Single Preferred Drug List (SPDL)

Michigan Effective Date: 1/1/2021

Table of Contents Analgesics...... 3 Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 3 Anesthetics - Drugs for Numbing...... 18 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence...... 22 Antibacterials...... 23 Antibacterials - Drugs to Treat Bacterial Infections...... 23 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia...... 31 Antiemetics - Drugs to Treat Nausea and Vomiting...... 32 Antifungals...... 33 Antifungals - Drugs to Treat Fungal Infections...... 33 Antigout Agents - Drugs to Treat Gout...... 37 Anti-inflammatory Agents - Drugs to Treat Inflammation...... 38 Antimigraine Agents - Drugs to Treat Migraines...... 38 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis...... 39 Antimycobacterials - Drugs to Treat Infections...... 40 Antineoplastics...... 40 Antineoplastics - Drugs to Treat Cancer...... 41 Antiparasitics...... 43 Antiparasitics - Drugs to Treat Parasitic Infections...... 43 Antiparkinson Agents...... 45 Antiparkinson Agents - Drugs to Treat Parkinson's Disease...... 45 Antipsychotics - Drugs to Treat Mood Disorders...... 47 Antispasticity Agents...... 47 Antivirals - Drugs to Treat Viral Infections...... 47 Anxiolytics - Drugs to Treat Anxiety...... 48 Blood Glucose Regulators - Drugs to Regulate Blood Sugar...... 48 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders...... 52 Cardiovascular Agents...... 54 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions...... 54 Central Nervous System Agents...... 63 Central Nervous System Agents - Drugs to Treat Nerve Conditions...... 63 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions...... 65 Dermatological Agents - Drugs to Treat Skin Conditions...... 67 Electrolytes/Minerals/ Metals/ Vitamins...... 86 Electrolytes/Minerals/Metals/Vitamins...... 86 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions...... 113 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 136 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...... 136 1 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones...... 138 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones...... 140 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones...... 140 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones...... 141 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones...... 148 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones...... 150 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones...... 150 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones...... 151 Immunological Agents...... 151 Immunological Agents - Drugs that Stimulate or Suppress the Immune System...... 151 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease...... 154 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions...... 156 Metabolic Bone Disease Agents - Other...... 157 Miscellaneous Therapeutic Agents...... 157 Ophthalmic Agents - Drugs to Treat Eye Conditions...... 172 Otic Agents - Drugs to Treat Ear Conditions...... 180 Regulators - Drugs to Regulate Blood Sugar...... 182 Respiratory Tract Agents...... 182 Respiratory Tract/Pulmonary Agents...... 182 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 182 Sedatives/Hypnotics - Drugs for Sedation and Sleep...... 213 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm...... 213 Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 214 Sleep Disorder Agents - Drugs for Sedation and Sleep...... 215 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies...... 215

2 Preferred Agents Non-Preferred Agents Analgesics Nonsteroidal Anti-inflammatory Drugs GABAPENTIN-NAPROXEN CMPD KIT - Tier 2; PA; QL Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; A.A.G.C. KIT IN TERODERM - Tier 2; PA QL ACTIVE-PREP KIT IV - Tier 2; PA 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL active-tramadol - Tier 1; PA 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL added strength headache relief (generic for EXCEDRIN EXTRA 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL STRENGTH) - Tier 1; PA 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL ALLZITAL (brand for butalbital-acetaminophen) - Tier 2; PA; QL 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL AXSAIN - Tier 2; PA acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL BUPAP (brand for butalbital-acetaminophen) - Tier 2; PA acetaminophen childrens - Tier 1; QL butalbital-acetaminophen capsule 50-300 mg oral - Tier 1; PA acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL - Tier 2; acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP PA ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen ex st oral tablet 500 mg (generic for MEDI-TABS butalbital-acetaminophen oral tablet 25-325 mg (generic for ALLZITAL) - EXTRA STRENGTH) - Tier 1; QL Tier 1; PA; QL acetaminophen extra strength (generic for MEDI-TABS EXTRA butalbital-acetaminophen oral tablet 50-300 mg (generic for BUPAP) - STRENGTH) - Tier 1; QL Tier 1; PA acetaminophen infants (generic for PANADOL CHILDRENS) - Tier 1; butalbital-apap-caffeine oral capsule 50-300-40 mg (generic for QL FIORICET) - Tier 1; PA acetaminophen oral liquid 500 mg/15ml (generic for MAPAP butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - ACETAMINOPHEN EXTRA STR) - Tier 1 Tier 1; PA; QL butalbital-aspirin-caffeine oral tablet - Tier 1; PA; QL acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 CAPSAICIN-MENTHOL - Tier 2; PA mg/20.3ml - Tier 1; QL CASTIVA WARMING - Tier 2; PA; QL DOANS PM EXTRA STRENGTH - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 3 Preferred Agents Non-Preferred Agents acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic ELIXSURE FEVER/PAIN - Tier 2; PA for PANADOL CHILDRENS) - Tier 1; QL enovarx-tramadol - Tier 1; PA acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; eq headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL PA acetaminophen oral tablet 500 mg (generic for MEDI-TABS EXTRA eq migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; STRENGTH) - Tier 1; QL PA acetaminophen oral tablet chewable 160 mg (generic for MAPAP eql headache relief ex str (generic for EXCEDRIN EXTRA STRENGTH) - CHILDRENS) - Tier 1; QL Tier 1; PA acetaminophen rapid tabs child - Tier 1 acetaminophen rectal suppository 120 mg (generic for FEVERALL eql migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier CHILDRENS) - Tier 1; QL 1; PA acetaminophen rectal suppository 650 mg (generic for FEVERALL ESGIC ORAL CAPSULE (brand for butalbital-apap-caffeine) - Tier 2; PA; ADULTS) - Tier 1; QL QL aminofen (generic for PHARBETOL) - Tier 1; QL apra (generic for MEDI-TABS CHILDRENS) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for sm migraine relief) - Tier 2; arthritis pain oral tablet extended release 650 mg (generic for PA TYLENOL 8 HOUR) - Tier 1; QL EXCEDRIN MIGRAINE (brand for sm migraine relief) - Tier 2; PA arthritis pain relief oral tablet extended release 650 mg (generic for EXCEDRIN TENSION HEADACHE (brand for tension headache) - Tier 2; TYLENOL 8 HOUR) - Tier 1; QL PA arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL FIORICET (brand for butalbital-apap-caffeine) - Tier 2; PA aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL FIORINAL (brand for butalbital-aspirin-caffeine) - Tier 2; PA; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL FLEXIN - Tier 2; PA butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; - Tier 1; QL PA butalbital-apap-caffeine oral tablet (generic for ESGIC) - Tier 1; QL headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; PA butalbital-aspirin-caffeine oral capsule (generic for FIORINAL) - Tier 1; headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - QL Tier 1; PA capsaicin external cream 0.025 % (generic for DERMACINRX headrin ex strength pain rel (generic for EXCEDRIN EXTRA STRENGTH) PENETRAL) - Tier 1 - Tier 1; PA capzasin-p - Tier 1 childrens acetaminophen oral suspension 160 mg/5ml (generic for hm migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; PANADOL CHILDRENS) - Tier 1; QL PA childrens acetaminophen oral tablet dispersible - Tier 1 LEVATIO - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents childrens apap (generic for CHILDRENS MEDI-TABS) - Tier 1; QL mapap headache plus - Tier 1; PA childrens easy-melts - Tier 1 MEDI-DERM-RX - Tier 2; PA MEDROX-RX - Tier 2; PA childrens medi-tabs (generic for CHILDRENS MEDI-TABS) - Tier 1; MENCAPS - Tier 2; PA QL menstrual pain relief (generic for PAMPRIN MAX PAIN FORMULA) - Tier 1; PA childrens non-aspirin (generic for CHILDRENS MEDI-TABS) - Tier 1; migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL PA migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; PA childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier NEURAPTINE - Tier 2; PA; QL 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for childrens tactinal (generic for CHILDRENS MEDI-TABS) - Tier 1; QL EXCEDRIN EXTRA STRENGTH) - Tier 1; PA childs non-aspirin (generic for CHILDRENS MEDI-TABS) - Tier 1; QL pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; DERMACINRX PENETRAL (brand for capsaicin) - Tier 2 PA ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; PA eq 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL PANADOL EXTRA (brand for tension headache) - Tier 2; PA eq acetaminophen (generic for MEDI-TABS EXTRA STRENGTH) - qc headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; Tier 1; QL PA eq arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL QUTENZA - Tier 2; PA eq childrens pain reliever (generic for CHILDRENS MEDI-TABS) - Tier QUTENZA (2 PATCH) - Tier 2; PA 1; QL eq pain & fever childrens (generic for PANADOL CHILDRENS) - Tier ra headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL 1; PA eq pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; ra headache formula ex st (generic for EXCEDRIN EXTRA STRENGTH) - QL Tier 1; PA eq pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN ra menstrual pain relief (generic for PAMPRIN MAX PAIN FORMULA) - EXTRA STR) - Tier 1 Tier 1; PA eq pain reliever (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; ra migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; QL PA eq pain reliever junior (generic for MAPAP CHILDRENS) - Tier 1; QL eql acetaminophen (generic for PHARBETOL) - Tier 1; QL ra pain reliever ex st oral tablet (generic for EXCEDRIN EXTRA eql acetaminophen childrens (generic for PANADOL CHILDRENS) - STRENGTH) - Tier 1; PA Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents eql acetaminophen ex st (generic for MEDI-TABS EXTRA ra tension headache (generic for EXCEDRIN TENSION HEADACHE) - STRENGTH) - Tier 1; QL Tier 1; PA RENOVO - Tier 2; PA eql acetaminophen infants (generic for PANADOL CHILDRENS) - Tier sm migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; 1; QL PA eql arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL ESGIC ORAL TABLET (brand for butalbital-apap-caffeine) - Tier 2; QL tension headache (generic for EXCEDRIN TENSION HEADACHE) - Tier fever reducer childrens (generic for FEVERALL CHILDRENS) - Tier 1; 1; PA QL TURPENTINE EXTERNAL - Tier 2; PA fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier VANATOL LQ - Tier 2; PA 1; QL VTOL LQ - Tier 2; PA feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL ZEBUTAL (brand for butalbital-apap-caffeine) - Tier 2; PA; QL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL ZOSTRIX-HP - Tier 2; PA FEVERALL INFANTS - Tier 2; QL feverall junior strength - Tier 1; QL hm acetaminophen childrens (generic for MAPAP CHILDRENS) - Tier 1; QL hm arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL hm pain & fever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL hm pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL hm pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL hm pain relief extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL hm pain reliever (generic for PHARBETOL) - Tier 1; QL infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief oral suspension 80 mg/0.8ml - Tier 1; QL infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL kls acetaminophen ex st (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents kls rapid release pain (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL mapap oral capsule - Tier 1; QL medi-tabs extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1; QL non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL non-aspirin extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief extra st (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL pain relief extra strength oral capsule 500 mg - Tier 1; QL pain relief extra strength oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief extra strength oral tablet 500 mg (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 7 Preferred Agents Non-Preferred Agents pain relief oral tablet 500 mg (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain reliever extra strength oral tablet 500 mg (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL pain reliever oral tablet (generic for PHARBETOL) - Tier 1; QL PANADOL CHILDRENS (brand for acetaminophen) - Tier 2; QL PANADOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2; QL PANADOL INFANTS (brand for acetaminophen) - Tier 2; QL pharbetol extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL pharbetol oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL qc acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL qc acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; QL qc acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; QL qc arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL qc non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL qc non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL qc non-aspirin extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL qc pain relief (generic for PHARBETOL) - Tier 1; QL qc pain relief childrens (generic for PANADOL CHILDRENS) - Tier 1; QL qc pain relief extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL qc pain relief infants (generic for PANADOL CHILDRENS) - Tier 1; QL ra 8 hour pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL ra acetaminophen (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents ra acetaminophen ex st (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL ra acetaminophen rapid melts - Tier 1 ra arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL ra fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1; QL ra pain reliever ex st oral liquid (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sb pain reliever ex st (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL sm 8 hour pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sm arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sm arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL sm pain & fever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sm pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL sm pain relief extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL sm pain reliever (generic for PHARBETOL) - Tier 1; QL sm pain reliever ex st (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL sm rapid melts junior - Tier 1 sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1 tactinal (generic for PHARBETOL) - Tier 1; QL tactinal extra strength (generic for MEDI-TABS EXTRA STRENGTH) - Tier 1; QL tencon (generic for TENCON) - Tier 1; QL TYLENOL 8 HOUR (brand for cvs pain relief) - Tier 2; QL TYLENOL 8 HOUR ARTHRITIS PAIN (brand for cvs pain relief) - Tier 2; QL TYLENOL CHILDRENS CHEWABLES (brand for cvs pain relief childrens) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents TYLENOL CHILDRENS ORAL SUSPENSION (brand for acetaminophen) - Tier 2; QL TYLENOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2; QL TYLENOL INFANTS (brand for acetaminophen) - Tier 2; QL TYLENOL INFANTS PAIN+FEVER (brand for acetaminophen) - Tier 2; QL TYLENOL ORAL TABLET (brand for pain reliever) - Tier 2; QL Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs addaprin (generic for ADDAPRIN) - Tier 1 ACTIVE-KETOPROFEN - Tier 2; PA adult aspirin ec low strength oral tablet delayed release 81 mg (generic ACTIVE-PREP KIT I - Tier 2; PA for MINIPRIN LOW DOSE) - Tier 1; QL ACTIVE-PREP KIT II - Tier 2; PA adult aspirin low strength (generic for ST JOSEPH LOW DOSE) - Tier ACTIVE-PREP KIT III - Tier 2; PA 1; QL aif #2 drug preparation kit - Tier 1; PA adult aspirin regimen (generic for MINIPRIN LOW DOSE) - Tier 1; QL AIF #3 DRUG PREPARATION KIT - Tier 2; PA ADVIL (brand for sm ibuprofen ib) - Tier 2 ARTHROTEC (brand for diclofenac-misoprostol) - Tier 2; PA ADVIL JUNIOR STRENGTH (brand for sm ibuprofen jr) - Tier 2 BIIFENAC 1000 - Tier 2; PA; QL ADVIL LIQUI-GELS MINIS (brand for gnp ibuprofen) - Tier 2 BIIFENAC 500 - Tier 2; PA; QL ADVIL MIGRAINE (brand for gnp ibuprofen) - Tier 2 CAPSFENAC PAK - Tier 2; PA; QL ALEVE ORAL TABLET (brand for all day pain relief) - Tier 2 CAPSINAC - Tier 2; PA; QL all day pain relief (generic for MEDIPROXEN) - Tier 1 CELEBREX (brand for celecoxib) - Tier 2; PA; ST; QL all day relief (generic for MEDIPROXEN) - Tier 1 DAYPRO (brand for oxaprozin) - Tier 2; PA aspirin 81 oral tablet delayed release (generic for MINIPRIN LOW DERMACINRX ANALGESIC COMBOPAK - Tier 2; PA; QL DOSE) - Tier 1; QL aspirin adult (generic for BAYER ASPIRIN) - Tier 1; QL DERMACINRX LEXITRAL PHARMAPAK (brand for capsfenac pak) - Tier aspirin adult low dose (generic for ST JOSEPH LOW DOSE) - Tier 1; 2; PA; QL QL DFS DR/MS/MENTH/CAP PAK - Tier 2; PA; QL aspirin adult low st (generic for ST JOSEPH LOW DOSE) - Tier 1; QL DFS/MS/MENTH/CAP PAK - Tier 2; PA; QL aspirin adult low strength (generic for MINIPRIN LOW DOSE) - Tier 1; DICLOFENAC - Tier 2; PA QL DICLOFENAC EPOLAMINE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL diclofenac potassium - Tier 1; PA aspirin ec (generic for ECPIRIN) - Tier 1; QL diclofenac sodium er - Tier 1; PA aspirin ec low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL diclofenac-misoprostol (generic for ARTHROTEC) - Tier 1; PA aspirin ec low strength (generic for MINIPRIN LOW DOSE) - Tier 1; diclofex dc (generic for DICLOFEX DC) - Tier 1; PA; QL QL DICLOFONO - Tier 2; PA; QL aspirin low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL DICLOPR - Tier 2; PA; QL aspirin low strength (generic for ST JOSEPH LOW DOSE) - Tier 1; QL diclosaicin (generic for DICLOFEX DC) - Tier 1; PA; QL aspirin oral (generic for ST JOSEPH LOW DOSE) - Tier 1; QL DICLOSTREAM - Tier 2; PA; QL aspirin rectal - Tier 1 DICLOTREX - Tier 2; PA; QL aspirtab (generic for ECPIRIN) - Tier 1; QL DICLOVIX - Tier 2; PA; QL aspirtab maximum strength (generic for BAYER ADVANCED ASPIRIN DICLOVIX M - Tier 2; PA; QL EX ST) - Tier 1; QL diflunisal oral - Tier 1; PA BAYER ASPIRIN (brand for gnp aspirin) - Tier 2; QL DIMENTHO - Tier 2; PA; QL BAYER ASPIRIN EC LOW DOSE (brand for eql aspirin low dose) - DUAL COMPLEX FORMULA 1 KIT - Tier 2; PA Tier 2; QL DUEXIS - Tier 2; PA BUFFERIN (brand for ra tri-buffered aspirin) - Tier 2 EC-NAPROSYN (brand for naproxen) - Tier 2; PA celecoxib oral (generic for CELEBREX) - Tier 1; ST; QL ec-naproxen - Tier 1; PA childrens aspirin (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ENOVARX-DICLOFENAC SODIUM - Tier 2; PA childrens aspirin low strength (generic for ST JOSEPH LOW DOSE) - enovarx-ibuprofen - Tier 1; PA; QL Tier 1; QL enovarx-naproxen - Tier 1; PA diclofenac sodium external gel 1 % (generic for VOLTAREN) - Tier 1 EQUAPAX/IBUPROFEN/MINREX - Tier 2; PA diclofenac sodium external solution - Tier 1 etodolac - Tier 1; PA diclofenac sodium oral - Tier 1 etodolac er - Tier 1; PA dyspel (generic for ADDAPRIN) - Tier 1 FBL KIT - Tier 2; PA ECOTRIN MAXIMUM STRENGTH (brand for eq aspirin) - Tier 2; QL FELDENE (brand for piroxicam) - Tier 2; PA ecpirin (generic for ECPIRIN) - Tier 1; QL fenoprofen calcium oral (generic for FENORTHO) - Tier 1; PA fenortho (generic for FENORTHO) - Tier 1; PA eq adult aspirin low strength (generic for MINIPRIN LOW DOSE) - Tier FLEXIPAK - Tier 2; PA 1; QL flurbiprofen oral - Tier 1; PA eq all day pain relief (generic for MEDIPROXEN) - Tier 1 FROTEK - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents eq aspirin (generic for ECOTRIN MAXIMUM STRENGTH) - Tier 1; QL IBUPAK - Tier 2; PA; QL eq aspirin adult low dose (generic for MINIPRIN LOW DOSE) - Tier 1; inavix (generic for INFLAMMACIN) - Tier 1; PA QL INDOCIN - Tier 2; PA eq aspirin low dose (generic for ST JOSEPH LOW DOSE) - Tier 1; QL indomethacin er - Tier 1; PA eq buffered aspirin (generic for BUFFERIN) - Tier 1 INFLAMMACIN (brand for previdolrx plus analgesic) - Tier 2; PA eq childrens aspirin (generic for ST JOSEPH LOW DOSE) - Tier 1; QL INFLATHERM - Tier 2; PA; QL eq ibuprofen (generic for MEDI-PROFEN) - Tier 1 K.B.G.L IN TERODERM - Tier 2; PA eq ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 KETOPHENE RAPIDPAQ - Tier 2; PA eq ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ketoprofen er - Tier 1; PA eq naproxen sodium oral tablet (generic for MEDIPROXEN) - Tier 1 ketoprofen oral capsule 25 mg - Tier 1; PA; QL eql aspirin low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL KETOROLAC TROMETHAMINE EXTERNAL - Tier 2; PA eql ibuprofen (generic for ADDAPRIN) - Tier 1 KETOROLAC TROMETHAMINE NASAL - Tier 2; PA; QL eql ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 LICART - Tier 2; PA; QL eql ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) LODINE (brand for etodolac) - Tier 2; PA - Tier 1 meclofenamate sodium oral - Tier 1; PA eql naproxen sodium oral tablet (generic for MEDIPROXEN) - Tier 1 mefenamic acid oral - Tier 1; PA h-e-b aspirin (generic for MINIPRIN LOW DOSE) - Tier 1; QL MOBIC (brand for meloxicam) - Tier 2; PA hm aspirin (generic for BAYER ASPIRIN) - Tier 1; QL NALFON (brand for fenoprofen calcium) - Tier 2; PA hm aspirin ec (generic for ECPIRIN) - Tier 1; QL NAPRELAN (brand for naproxen sodium er) - Tier 2; PA hm aspirin ec low dose (generic for MINIPRIN LOW DOSE) - Tier 1; NAPROSYN (brand for naproxen) - Tier 2; PA QL naproxen dr (generic for EC-NAPROSYN) - Tier 1; PA hm ibuprofen (generic for ADDAPRIN) - Tier 1 naproxen oral suspension (generic for NAPROSYN) - Tier 1; PA hm ibuprofen ib (generic for ADDAPRIN) - Tier 1 naproxen sodium er (generic for NAPRELAN) - Tier 1; PA hm ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 naproxen sodium oral tablet 275 mg - Tier 1; PA hm naproxen sodium oral tablet (generic for MEDIPROXEN) - Tier 1 naproxen sodium oral tablet 550 mg (generic for ANAPROX DS) - Tier 1; ibu (generic for IBU) - Tier 1 PA ibu-200 (generic for ADDAPRIN) - Tier 1 naproxen-esomeprazole (generic for VIMOVO) - Tier 1; PA ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL NP #2 DRUG PREPARATION KIT - Tier 2; PA JUNIOR STRENGTH) - Tier 1 NUDICLO SOLUPAK (brand for capsfenac pak) - Tier 2; PA; QL ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 NUDICLO TABPAK (brand for previdolrx plus analgesic) - Tier 2; PA ibuprofen infants drops (generic for INFANTS ADVIL) - Tier 1 NUDROXIPAK - Tier 2; PA; QL ibuprofen junior st (generic for ADVIL JUNIOR STRENGTH) - Tier 1 NUDROXIPAK DSDR-50 - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 12 Preferred Agents Non-Preferred Agents ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - NUDROXIPAK DSDR-75 (brand for dfs dr/ms/menth/cap pak) - Tier 2; Tier 1 PA; QL ibuprofen oral capsule (generic for MEDI-PROFEN) - Tier 1 NUDROXIPAK E-400 - Tier 2; PA; QL ibuprofen oral suspension (generic for CHILDRENS ADVIL) - Tier 1 NUDROXIPAK I-800 - Tier 2; PA; QL ibuprofen oral tablet (generic for ADDAPRIN) - Tier 1 NUDROXIPAK M-15 - Tier 2; PA; QL INDOMETHACIN ORAL CAPSULE 20 MG - Tier 2 NUDROXIPAK N-500 - Tier 2; PA; QL indomethacin oral capsule 25 mg, 50 mg - Tier 1 ORMECA - Tier 2; PA; QL INFANTS ADVIL (brand for ibuprofen infants drops) - Tier 2 oxaprozin (generic for DAYPRO) - Tier 1; PA infants ibuprofen (generic for INFANTS ADVIL) - Tier 1 PENNSAID - Tier 2; PA ketoprofen oral capsule 50 mg, 75 mg - Tier 1 piroxicam oral (generic for FELDENE) - Tier 1; PA ketorolac tromethamine oral - Tier 1; QL PRASTERA - Tier 2; PA kls aspirin ec (generic for ECPIRIN) - Tier 1; QL PREVIDOLRX ANALGESIC - Tier 2; PA kls aspirin low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL previdolrx plus analgesic (generic for INFLAMMACIN) - Tier 1; PA kls ibuprofen (generic for ADDAPRIN) - Tier 1 QMIIZ ODT - Tier 2; PA kls naproxen sodium (generic for MEDIPROXEN) - Tier 1 RELAFEN (brand for nabumetone) - Tier 2; PA kp aspirin (generic for MINIPRIN LOW DOSE) - Tier 1; QL RELAFEN DS - Tier 2; PA ks ibuprofen (generic for MEDI-PROFEN) - Tier 1 REXAPHENAC - Tier 2; PA; QL medi-profen oral capsule (generic for MEDI-PROFEN) - Tier 1 salsalate oral - Tier 1; PA; QL medi-profen oral tablet (generic for ADDAPRIN) - Tier 1 SPRIX (brand for ketorolac tromethamine) - Tier 2; PA; QL mediproxen (generic for MEDIPROXEN) - Tier 1 sure result dss premium pack (generic for DICLOFEX DC) - Tier 1; PA; meloxicam oral (generic for MOBIC) - Tier 1 QL miniprin low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL TIVORBEX (brand for indomethacin) - Tier 2; PA MOTRIN CHILDRENS (brand for eq ibuprofen junior) - Tier 2 tolmetin sodium - Tier 1; PA MOTRIN IB (brand for sm ibuprofen ib) - Tier 2 TRIPLE COMPLEX FORMULA 3 KIT - Tier 2; PA; QL MOTRIN INFANTS DROPS (brand for ibuprofen infants drops) - Tier 2 VAROPHEN - Tier 2; PA; QL nabumetone oral (generic for RELAFEN) - Tier 1 VENNGEL ONE - Tier 2; PA; QL naproxen oral tablet - Tier 1 VIMOVO (brand for naproxen-esomeprazole) - Tier 2; PA naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier VIVLODEX - Tier 2; PA 1 VOLTAREN (brand for gnp arthritis pain) - Tier 2; PA provil (generic for ADDAPRIN) - Tier 1 VP FC KIT - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 13 Preferred Agents Non-Preferred Agents qc aspirin (generic for BAYER ASPIRIN) - Tier 1; QL VP GKL KIT - Tier 2; PA; QL qc aspirin low dose (generic for MINIPRIN LOW DOSE) - Tier 1; QL XRYLIX - Tier 2; PA qc childrens aspirin (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ZIPSOR - Tier 2; PA qc enteric aspirin (generic for ECPIRIN) - Tier 1; QL ZORVOLEX - Tier 2; PA qc ibuprofen (generic for MEDI-PROFEN) - Tier 1 qc ibuprofen ib (generic for ADDAPRIN) - Tier 1 qc ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 qc naproxen sodium (generic for MEDIPROXEN) - Tier 1 ra aspirin (generic for BAYER ADVANCED ASPIRIN EX ST) - Tier 1; QL ra aspirin adult low dose (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ra aspirin adult low strength (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ra aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ra aspirin ec (generic for ECPIRIN) - Tier 1; QL ra aspirin ec adult low st (generic for MINIPRIN LOW DOSE) - Tier 1; QL ra childrens aspirin (generic for ST JOSEPH LOW DOSE) - Tier 1; QL ra ibuprofen infants (generic for INFANTS ADVIL) - Tier 1 ra ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier 1 ra ibuprofen oral capsule (generic for MEDI-PROFEN) - Tier 1 ra ibuprofen oral tablet (generic for ADDAPRIN) - Tier 1 ra naproxen sodium oral tablet (generic for MEDIPROXEN) - Tier 1 ra tri-buffered aspirin (generic for BUFFERIN) - Tier 1 sb aspirin adult low strength (generic for MINIPRIN LOW DOSE) - Tier 1; QL sb aspirin oral tablet delayed release (generic for MINIPRIN LOW DOSE) - Tier 1; QL sm aspirin (generic for BAYER ASPIRIN) - Tier 1; QL sm aspirin adult low strength (generic for ST JOSEPH LOW DOSE) - Tier 1; QL sm aspirin ec (generic for ECPIRIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents sm aspirin ec low strength (generic for MINIPRIN LOW DOSE) - Tier 1; QL sm aspirin low dose (generic for ST JOSEPH LOW DOSE) - Tier 1; QL sm aspirin tri-buffered (generic for BUFFERIN) - Tier 1 sm childrens aspirin (generic for ST JOSEPH LOW DOSE) - Tier 1; QL sm ibuprofen (generic for MEDI-PROFEN) - Tier 1 sm ibuprofen ib (generic for ADVIL JUNIOR STRENGTH) - Tier 1 sm ibuprofen jr (generic for ADVIL JUNIOR STRENGTH) - Tier 1 sm infants ibuprofen (generic for INFANTS ADVIL) - Tier 1 sm naproxen sodium oral tablet (generic for MEDIPROXEN) - Tier 1 ST JOSEPH LOW DOSE (brand for sm aspirin adult low strength) - Tier 2; QL sulindac oral - Tier 1 tri-buffered aspirin (generic for BUFFERIN) - Tier 1 wal-profen oral capsule (generic for MEDI-PROFEN) - Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers fentanyl transdermal patch 72 hour 100 mcg/hr (generic for BELBUCA - Tier 2; PA; QL DURAGESIC-100) - Tier 1; QL buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL BUTRANS (brand for buprenorphine) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr (generic for CONZIP (brand for tramadol hcl er) - Tier 2; PA; QL DURAGESIC-12) - Tier 1; QL DOLOPHINE (brand for methadone hcl) - Tier 2; PA; QL DURAGESIC-100 (brand for fentanyl) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr (generic for DURAGESIC-12 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-25) - Tier 1; QL DURAGESIC-25 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-50 (brand for fentanyl) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr (generic for DURAGESIC-75 (brand for fentanyl) - Tier 2; PA; QL DURAGESIC-50) - Tier 1; QL fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr (generic for -hydrocodone Tier 1; PA; QL bitartrate er (generic for ZOHYDRO ER) - Tier 1; PA; QL DURAGESIC-75) - Tier 1; QL HYSINGLA ER - Tier 2; PA; QL levorphanol tartrate oral - Tier 1; PA; QL morphine sulfate er oral tablet extended release (generic for MS methadone hcl injection - Tier 1; PA; QL CONTIN) - Tier 1; QL methadone hcl intensol (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents methadone hcl oral - Tier 1; PA; QL methadose oral concentrate 10 mg/ml (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL methadose oral tablet soluble (generic for METHADOSE) - Tier 1; PA; QL methadose sugar-free (generic for METHADONE HCL INTENSOL) - Tier 1; PA; QL morphine sulfate er beads - Tier 1; PA; QL MS CONTIN (brand for morphine sulfate er) - Tier 2; PA; QL NUCYNTA ER - Tier 2; PA; QL OXYCODONE HCL ER - Tier 2; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL oxymorphone hcl er - Tier 1; PA; QL SYNAPRYN FUSEPAQ - Tier 2; PA; QL TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG - Tier 2; PA; QL tramadol hcl er oral capsule extended release 24 hour 150 mg - Tier 1; PA; QL XTAMPZA ER - Tier 2; PA; QL ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL

Opioid Analgesics, Short-acting - Opioid Pain Relievers acetaminophen-codeine - Tier 1; QL ACTIQ (brand for fentanyl citrate) - Tier 2; PA; QL acetaminophen-codeine #2 - Tier 1; QL APADAZ (brand for benzhydrocodone-acetaminophen) - Tier 2; PA; QL acetaminophen-codeine #3 - Tier 1; QL apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA; QL acetaminophen-codeine #4 - Tier 1; QL ARYMO ER - Tier 2; PA; QL codeine sulfate oral tablet 30 mg, 60 mg - Tier 1; QL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; PA; QL endocet (generic for ENDOCET) - Tier 1; QL BENZHYDROCODONE-ACETAMINOPHEN - Tier 2; PA; QL hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; butalbital-apap-caff-cod - Tier 1; PA; QL QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; PA; QL hydrocodone-acetaminophen oral tablet (generic for NORCO) - Tier 1; butorphanol tartrate nasal - Tier 1; PA; QL QL carisoprodol-aspirin-codeine - Tier 1; PA; QL hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL DILAUDID ORAL (brand for hydromorphone hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - fentanyl citrate buccal lozenge on a handle (generic for ACTIQ) - Tier 1; Tier 1; QL PA; QL morphine sulfate oral - Tier 1; QL FENTANYL CITRATE BUCCAL TABLET - Tier 2; PA; QL morphine sulfate rectal - Tier 1; QL FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL SYRINGE 100 MCG/2ML - Tier 2; PA oxycodone hcl oral solution - Tier 1; QL oxycodone hcl oral tablet 10 mg - Tier 1; QL FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 oxycodone hcl oral tablet 15 mg (generic for ROXICODONE) - Tier 1; MG/100ML-%, 2-0.9 MG/100ML-%, 2.5-0.9 MG/250ML-% - Tier 2; PA QL oxycodone hcl oral tablet 5 mg (generic for OXAYDO) - Tier 1; QL FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 SYRINGE 500-0.9 MCG/50ML-% - Tier 2; PA mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL FENTORA (brand for fentanyl citrate) - Tier 2; PA; QL tramadol hcl ir (generic for ULTRAM) - Tier 1; QL FIORICET/CODEINE (brand for butalbital-apap-caff-cod) - Tier 2; PA; QL FIORINAL/CODEINE #3 (brand for butalbital-asa-caff-codeine) - Tier 2; PA; QL hydrocodone-acetaminophen oral solution 10-325 mg/15ml - Tier 1; PA; QL hydrocodone-ibuprofen - Tier 1; PA; QL hydromorphone hcl er - Tier 1; PA hydromorphone hcl rectal - Tier 1; PA; QL HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 25-0.9 MG/50ML-%, 50-0.9 MG/50ML-% - Tier 2; PA HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-% - Tier 2; PA KADIAN (brand for morphine sulfate er) - Tier 2; PA; QL LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT - Tier 2; PA; QL LAZANDA NASAL SOLUTION 300 MCG/ACT - Tier 2; PA LORTAB - Tier 2; PA; QL meperidine hcl oral - Tier 1; PA; QL morphine sulfate er oral capsule extended release 24 hour (generic for KADIAN) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-0.9 MG/50ML-% - Tier 2; PA NALOCET - Tier 2; PA; QL NORCO (brand for hydrocodone-acetaminophen) - Tier 2; PA; QL NUCYNTA - Tier 2; PA; QL OXAYDO ORAL TABLET 7.5 MG - Tier 2; PA oxycodone hcl oral capsule - Tier 1; PA; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; PA; QL oxycodone hcl oral tablet 20 mg - Tier 1; PA; QL oxycodone hcl oral tablet 30 mg (generic for ROXICODONE) - Tier 1; PA; QL OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG - Tier 2; PA; QL oxycodone-aspirin - Tier 1; PA; QL oxymorphone hcl - Tier 1; PA; QL pentazocine-naloxone hcl - Tier 1; PA; QL PERCOCET (brand for oxycodone-acetaminophen) - Tier 2; PA; QL PRIMLEV (brand for oxycodone-acetaminophen) - Tier 2; PA; QL PROLATE (brand for oxycodone-acetaminophen) - Tier 2; PA; QL QDOLO - Tier 2; PA; QL ROXICODONE (brand for oxycodone hcl) - Tier 2; PA; QL SUBSYS - Tier 2; PA; QL tramadol hcl er (biphasic) - Tier 1; PA; QL tramadol hcl er oral tablet extended release 24 hour - Tier 1; PA; QL tramadol-acetaminophen (generic for ULTRACET) - Tier 1; PA; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL ULTRACET (brand for tramadol-acetaminophen) - Tier 2; PA; QL ULTRAM (brand for tramadol hcl) - Tier 2; PA; QL Anesthetics - Drugs for Numbing Local Anesthetics 7T LIDO - Tier 2 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 % - anecream external cream (generic for ANECREAM) - Tier 1; QL Tier 2; PA; QL blue tube/ aloe (generic for ANECREAM) - Tier 1; QL AGONEAZE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 18 Preferred Agents Non-Preferred Agents lidocaine cream 4 % external (generic for ANECREAM) - Tier 1; QL ANACAINE - Tier 2; PA lidocaine hcl external cream 3 % - Tier 1; QL ANODYNE LPT - Tier 2; PA lidocaine hcl urethral/mucosal (generic for GLYDO) - Tier 1 APRIZIO PAK (brand for prilovixil) - Tier 2; PA; QL lidocaine viscous hcl - Tier 1 APRIZIO PAK II (brand for prilovixil) - Tier 2; PA; QL lidocaine-prilocaine external cream - Tier 1; QL ASTERO - Tier 2; PA LIDOCANNA - Tier 2; QL BENZO-LIDOCAINE-TETRACAINE - Tier 2; PA; QL lidopin external cream 3 % - Tier 1; QL CADIRAMD - Tier 2; PA LMX 4 (brand for lidocaine) - Tier 2; QL CBD4 FREEZE PUMP MAXIMUM STR - Tier 2; PA PRIZOTRAL - Tier 2; PA; QL CETACAINE EXTERNAL AEROSOL - Tier 2; PA PRIZOTRAL-II - Tier 2; PA; QL cough drops mouth/throat lozenge 5.4 mg (generic for CEPACOL SORE THROAT) - Tier 1; PA DERMACINRX DUOPATCH PHARMAPAK - Tier 2; PA DERMACINRX EMPRICAINE (brand for lidocaine-prilocaine) - Tier 2; PA DERMACINRX NEUROTRAL PHARMAPAK - Tier 2; PA DERMACINRX PHN - Tier 2; PA DERMACINRX PRIZOPAK (brand for lidocaine-prilocaine) - Tier 2; PA DERMACINRX ZRM - Tier 2; PA EHA - Tier 2; PA EMPRICAINE-II (brand for prilovixil) - Tier 2; PA; QL enovarx-lidocaine hcl - Tier 1; PA eq pain relieving external cream 4 % (generic for NEUROMED7) - Tier 1; PA ethyl chloride - Tier 1; PA GEBAUERS PAIN EASE - Tier 2; PA GEBAUERS SPRAY AND STRETCH - Tier 2; PA GEN7T - Tier 2; PA; QL GEN7T PLUS - Tier 2; PA; QL LDO PLUS - Tier 2; PA lets - Tier 1; PA LIDO BDK (brand for lidocaine-prilocaine) - Tier 2; PA lidocaine external ointment - Tier 1; PA lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 19 Preferred Agents Non-Preferred Agents lidocaine hcl external cream 4 % (generic for NEUROMED7) - Tier 1; PA LIDOCAINE HCL EXTERNAL CREAM 4.12 % - Tier 2; PA; QL lidocaine hcl external lotion (generic for LIDO-SORB) - Tier 1; PA lidocaine hcl external solution - Tier 1; PA LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 100 MG/5ML - Tier 2; PA lidocaine hcl mouth/throat - Tier 1; PA lidocaine maximum strength (generic for NEUROMED7) - Tier 1; PA lidocaine pain relieving (generic for NEUROMED7) - Tier 1; PA lidocaine plus (generic for NEUROMED7) - Tier 1; PA lidocaine-prilocaine external kit (generic for DERMACINRX EMPRICAINE) - Tier 1; PA LIDOCAINE-TETRACAINE EXTERNAL CREAM 23-7 % - Tier 2; PA; QL LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 % - Tier 2; PA LIDODERM (brand for lidocaine) - Tier 2; PA LIDOPAC - Tier 2; PA; QL LIDOPIN EXTERNAL CREAM 3.25 % - Tier 2; PA LIDOPRIL - Tier 2; PA LIDOPRIL XR - Tier 2; PA LIDO-PRILO CAINE PACK (brand for lidocaine-prilocaine) - Tier 2; PA LIDOPURE PATCH - Tier 2; PA; QL LIDORX - Tier 2; PA LIDO-SORB (brand for lidocaine hcl) - Tier 2; PA LIDOSTREAM - Tier 2; PA; QL LIDOTHOL - Tier 2; PA; QL LIDOTRAL - Tier 2; PA LIDOVIX L - Tier 2; PA; QL LIDTOPIC MAX - Tier 2; PA LIVIXIL PAK (brand for lidocaine-prilocaine) - Tier 2; PA LMR PLUS - Tier 2; PA; QL LYDEXA (brand for lidocaine hcl) - Tier 2; PA; QL MEDI-DERM/L-RX - Tier 2; PA MEDI-PATCH RX - Tier 2; PA NEUROMED7 (brand for cvs lidocaine maximum strength) - Tier 2; PA NUVAKAAN (brand for lidocaine-prilocaine) - Tier 2; PA NUVAKAAN-II - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 20 Preferred Agents Non-Preferred Agents PAIN RELIEF EXTERNAL CREAM 4 % - Tier 2; PA pain relieving external cream 4 % (generic for NEUROMED7) - Tier 1; PA PAINGO KFT - Tier 2; PA; QL PLIAGLIS EXTERNAL CREAM (brand for lidocaine-tetracaine) - Tier 2; PA pramox - Tier 1; PA PREDATOR - Tier 2; PA premium lidocaine - Tier 1; PA PREMIUM SCAR - Tier 2; PA PRILO PATCH - Tier 2; PA; QL PRILOLID - Tier 2; PA PRILOVIX - Tier 2; PA PRILOVIX LITE - Tier 2; PA PRILOVIX LITE PLUS - Tier 2; PA PRILOVIX PLUS - Tier 2; PA prilovix ultralite (generic for DERMACINRX EMPRICAINE) - Tier 1; PA prilovix ultralite plus (generic for DERMACINRX EMPRICAINE) - Tier 1; PA PRILOVIXIL - Tier 2; PA; QL PRIZOPAK II (brand for prilovixil) - Tier 2; PA; QL ra aloe vera/lidocaine - Tier 1; PA RELADOR PAK (brand for lidocaine-prilocaine) - Tier 2; PA RELADOR PAK PLUS (brand for lidocaine-prilocaine) - Tier 2; PA SOLARAVIX - Tier 2; PA; QL SOOTHEE - Tier 2; PA SYNERA - Tier 2; PA SYNVEXIA TC - Tier 2; PA VEXATROL - Tier 2; PA WPR PLUS WOUND HEALING SYSTEM - Tier 2; PA; QL XARACOLL - Tier 2; PA XOLIDO XP - Tier 2; PA ZERUVIA - Tier 2; PA ZILACAINE PATCH - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents ZIONODIL - Tier 2; PA ZIONODIL 100 - Tier 2; PA ZTLIDO - Tier 2; PA; QL Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants LUCEMYRA - Tier 2; PA; QL Opioid Reversal Agents - Antidotes/Deterrents/Protectants naloxone hcl injection solution - Tier 1; QL naloxone hcl solution prefilled syringe 2 mg/2ml injection - Tier 1; PA; QL naloxone hcl injection solution cartridge - Tier 1; QL naloxone hcl solution prefilled syringe 2 mg/2ml injection - Tier 1; QL NARCAN - Tier 2; QL Smoking Cessation Agents - Deterrents bupropion hcl er (smoking det) - Tier 1; QL CHANTIX - Tier 2; QL CHANTIX CONTINUING MONTH PAK - Tier 2; QL CHANTIX STARTING MONTH PAK - Tier 2; QL eq nicotine (generic for KLS QUIT4) - Tier 1; QL eq nicotine polacrilex (generic for KLS QUIT2) - Tier 1; QL eq nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL eql nicotine polacrilex (generic for KLS QUIT2) - Tier 1; QL hm nicotine (generic for NICODERM CQ) - Tier 1; QL hm nicotine polacrilex (generic for KLS QUIT2) - Tier 1; QL kls quit2 (generic for KLS QUIT2) - Tier 1; QL kls quit4 (generic for KLS QUIT4) - Tier 1; QL NICODERM CQ (brand for cvs nicotine) - Tier 2; QL NICORETTE (brand for eq nicotine polacrilex) - Tier 2; QL NICORETTE MINI (brand for ra nicotine polacrilex) - Tier 2; QL NICORETTE STARTER KIT (brand for eq nicotine polacrilex) - Tier 2; QL nicotine (generic for NICODERM CQ) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 22 Preferred Agents Non-Preferred Agents nicotine gum (generic for KLS QUIT4) - Tier 1; QL nicotine mini (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL nicotine step 1 (generic for NICODERM CQ) - Tier 1; QL nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL NICOTROL - Tier 2; QL NICOTROL NS - Tier 2; QL ra mini nicotine (generic for KLS QUIT2) - Tier 1; QL ra nicotine (generic for NICODERM CQ) - Tier 1; QL ra nicotine polacrilex (generic for KLS QUIT2) - Tier 1; QL sm nicotine (generic for KLS QUIT4) - Tier 1; QL sm nicotine polacrilex (generic for KLS QUIT2) - Tier 1; QL thrive (generic for KLS QUIT2) - Tier 1; QL Antibacterials Antibacterials, Other fosfomycin tromethamine (generic for MONUROL) - Tier 1; PA HIPREX (brand for methenamine hippurate) - Tier 2; PA MACROBID (brand for nitrofurantoin monohyd macro) - Tier 2; PA; QL MACRODANTIN (brand for nitrofurantoin macrocrystal) - Tier 2; PA; QL methenamine hippurate (generic for HIPREX) - Tier 1; PA MONUROL (brand for fosfomycin tromethamine) - Tier 2; PA nitrofurantoin - Tier 1; PA nitrofurantoin macrocrystal oral (generic for MACRODANTIN) - Tier 1; PA; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - Tier 1; PA; QL Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics gentamicin sulfate external cream - Tier 1; QL ARIKAYCE - Tier 2; PA; SP; QL gentamicin sulfate external ointment - Tier 1 neomycin sulfate oral - Tier 1; PA paromomycin sulfate oral - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents Antibacterials, Other - Antibiotics alcohol prep pads external 70 % - Tier 1; QL AEMCOLO - Tier 2; PA; QL ALCOHOL PREP PADS EXTERNAL 70 % - Tier 2; QL ALTABAX - Tier 2; PA; QL antibioticbacitracin (generic external for (generic CURAD for TRIPLE BACITRAYCIN ANTIBIOTIC) PLUS) - -Tier Tier 1; 1 QL antibiotic pain/scar (generic for NEOSPORIN + PAIN RELIEF MAX ST) - bacitracin zinc external - Tier 1 Tier 1; PA CLEOCIN VAGINAL SUPPOSITORY - Tier 2 clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) - aplicare povidone-iodine external solution (generic for APLICARE Tier 1; QL POVIDONE-IODINE) - Tier 1; PA clindamycin hcl oral capsule 75 mg (generic for CLEOCIN) - Tier 1 clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL arzol silver nit applicators (generic for ARZOL SILVER NIT CLINDESSE - Tier 2 APPLICATORS) - Tier 1; PA BENZALKONIUM CHLORIDE EXTERNAL SOLUTION - Tier 2; PA CURAD TRIPLE ANTIBIOTIC (brand for sm triple antibiotic) - Tier 2; benzalkonium chloride external solution 50 % - Tier 1; PA QL BETADINE EXTERNAL SOLUTION 10 % (brand for qc povidone iodine) - eq bacitracin zinc - Tier 1 Tier 2; PA eq triple antibiotic (generic for CURAD TRIPLE ANTIBIOTIC) - Tier 1; BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2; PA QL CENTANY (brand for mupirocin) - Tier 2; PA eql bacitracin zinc - Tier 1 CENTANY AT - Tier 2; PA eql first aid antibiotic external ointment 3.5-400-5000 (generic for CLEOCIN ORAL CAPSULE 150 MG, 300 MG (brand for clindamycin hcl) CURAD TRIPLE ANTIBIOTIC) - Tier 1; QL - Tier 2; PA; QL first aid antibiotic external ointment 3.5-400-5000 mg-unit (generic for CLEOCIN ORAL CAPSULE 75 MG (brand for clindamycin hcl) - Tier 2; CURAD TRIPLE ANTIBIOTIC) - Tier 1; QL PA FIRVANQ - Tier 2 hm bacitracin zinc - Tier 1 CLEOCIN ORAL SOLUTION RECONSTITUTED (brand for clindamycin hm triple antibiotic (generic for CURAD TRIPLE ANTIBIOTIC) - Tier 1; palmitate hcl) - Tier 2; PA; QL QL kp bacitracin zinc - Tier 1 CLEOCIN VAGINAL CREAM (brand for clindamycin phosphate) - Tier 2; linezolid oral tablet (generic for ZYVOX) - Tier 1; QL PA clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; PA medi-first triple antibiotic (generic for CURAD TRIPLE ANTIBIOTIC) - double antibiotic (generic for POLYSPORIN) - Tier 1; PA Tier 1; QL eq first aid antiseptic (generic for APLICARE POVIDONE-IODINE) - Tier MEDPURA ALCOHOL PADS - Tier 2; QL 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents metronidazole external cream (generic for ROSADAN) - Tier 1; QL eq povidone-iodine (generic for APLICARE POVIDONE-IODINE) - Tier 1; metronidazole external gel 0.75 % (generic for ROSADAN) - Tier 1; QL PA metronidazole oral tablet - Tier 1 mupirocin external (generic for CENTANY) - Tier 1 eql first aid antibiotic external ointment 1 % (generic for NEOSPORIN + NEOSPORIN ORIGINAL (brand for sm triple antibiotic) - Tier 2; QL PAIN RELIEF MAX ST) - Tier 1; PA NUVESSA - Tier 2 FEM PH - Tier 2; PA qc bacitracin (generic for BACITRAYCIN PLUS) - Tier 1 FIRST-METRONIDAZOLE - Tier 2; PA ra bacitracin - Tier 1 FLAGYL (brand for metronidazole) - Tier 2; PA ra bacitracin zinc first aid - Tier 1 GLUTARALDEHYDE EXTERNAL - Tier 2; PA ra triple antibiotic external ointment (generic for CURAD TRIPLE grafco silver nit applicator (generic for ARZOL SILVER NIT ANTIBIOTIC) - Tier 1; QL APPLICATORS) - Tier 1; PA rosadan external cream (generic for ROSADAN) - Tier 1; QL hm double antibiotic (generic for POLYSPORIN) - Tier 1; PA rosadan external gel (generic for ROSADAN) - Tier 1; QL hm povidone-iodine (generic for APLICARE POVIDONE-IODINE) - Tier 1; sm antibiotic - Tier 1 PA sm triple antibiotic (generic for CURAD TRIPLE ANTIBIOTIC) - Tier 1; hm triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX QL ST) - Tier 1; PA iodine tincture external tincture 2 % - Tier 1; PA sm triple antibiotic original (generic for CURAD TRIPLE ANTIBIOTIC) - kp double antibiotic (generic for POLYSPORIN) - Tier 1; PA Tier 1; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA trimethoprim oral - Tier 1 mafenide acetate external (generic for SULFAMYLON) - Tier 1; PA triple antibiotic (generic for CURAD TRIPLE ANTIBIOTIC) - Tier 1; QL me/naphos/mb/hyo1 (generic for UROGESIC-BLUE) - Tier 1; PA vancomycin hcl oral capsule (generic for VANCOCIN HCL) - Tier 1 methenamine mandelate oral - Tier 1; PA vandazole (generic for VANDAZOLE) - Tier 1; GE METROCREAM (brand for metronidazole) - Tier 2; PA; QL METROGEL (brand for metronidazole) - Tier 2; PA; QL METROLOTION (brand for metronidazole) - Tier 2; PA; QL METRONIDAZOLE BENZO+SYRSPEND - Tier 2; PA metronidazole external gel 1 % (generic for METROGEL) - Tier 1; PA; QL metronidazole external lotion (generic for METROLOTION) - Tier 1; PA; QL metronidazole oral capsule (generic for FLAGYL) - Tier 1; PA metronidazole vaginal (generic for VANDAZOLE) - Tier 1; PA; GE mupirocin calcium - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 25 Preferred Agents Non-Preferred Agents NEOSPORIN + PAIN RELIEF MAX ST (brand for triple antibiotic plus) - Tier 2; PA NEO-SYNALAR EXTERNAL KIT - Tier 2; PA NORITATE - Tier 2; PA poly bacitracin (generic for POLYSPORIN) - Tier 1; PA POLYSPORIN (brand for ra double antibiotic) - Tier 2; PA povidone-iodine external solution (generic for APLICARE POVIDONE- IODINE) - Tier 1; PA POVIDONE-IODINE OPHTHALMIC - Tier 2; PA PRIMSOL - Tier 2; PA; QL pvp prep (generic for APLICARE POVIDONE-IODINE) - Tier 1; PA qc povidone iodine (generic for APLICARE POVIDONE-IODINE) - Tier 1; PA qc triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA ra antibiotic/pain relief (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA ra antiseptic (generic for APLICARE POVIDONE-IODINE) - Tier 1; PA ra double antibiotic (generic for POLYSPORIN) - Tier 1; PA ra triple antibiotic plus (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA SCRUB CARE POVIDONE-IODINE (brand for qc povidone iodine) - Tier 2; PA silver nitrate external solution 10 %, 25 %, 50 % - Tier 1; PA SIVEXTRO ORAL - Tier 2; PA; QL sm double antibiotic (generic for POLYSPORIN) - Tier 1; PA sm povidone-iodine (generic for APLICARE POVIDONE-IODINE) - Tier 1; PA sm triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA SOLOSEC - Tier 2; PA; QL SULFAMYLON - Tier 2; PA tinidazole oral - Tier 1; PA tri-biozene (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA TRIMO-SAN VAGINAL GEL 0.025-0.01 % - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 26 Preferred Agents Non-Preferred Agents triple antibiotic plus (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA triple antibiotic plus max st (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA triple antibiotic/pain (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA triple antibiotic+pain relief (generic for NEOSPORIN + PAIN RELIEF MAX ST) - Tier 1; PA UROGESIC-BLUE (brand for me/naphos/mb/hyo1) - Tier 2; PA VANCOCIN (brand for vancomycin hcl) - Tier 2; PA VANCOCIN HCL (brand for vancomycin hcl) - Tier 2; PA vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-% - Tier 1; PA vancomycin hcl oral solution reconstituted (generic for FIRVANQ) - Tier 1; PA VANCOMYCIN+SYRSPEND SF - Tier 2; PA XENLETA ORAL - Tier 2; PA; QL ZYVOX ORAL SUSPENSION RECONSTITUTED (brand for linezolid) - Tier 2; PA ZYVOX ORAL TABLET (brand for linezolid) - Tier 2; PA; QL

Beta-Lactam, Cephalosporins - Antibiotics cefadroxil oral capsule - Tier 1; QL cefaclor er - Tier 1; PA; QL cefadroxil oral suspension reconstituted - Tier 1 cefaclor oral capsule - Tier 1; PA; QL cefdinir oral capsule - Tier 1; QL cefaclor oral suspension reconstituted - Tier 1; PA cefdinir oral suspension reconstituted - Tier 1 cefadroxil oral tablet - Tier 1; PA; QL cefixime oral suspension reconstituted (generic for SUPRAX) - Tier 1 cefazolin sodium-dextrose intravenous solution 2-4 gm/100ml-% - Tier 1; cefprozil oral suspension reconstituted - Tier 1 PA cefprozil oral tablet - Tier 1; QL cefixime oral capsule (generic for SUPRAX) - Tier 1; PA cefuroxime axetil - Tier 1; QL cefpodoxime proxetil oral suspension reconstituted - Tier 1; PA cephalexin (generic for KEFLEX) - Tier 1 cefpodoxime proxetil oral tablet - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 27 Preferred Agents Non-Preferred Agents KEFLEX (brand for cephalexin) - Tier 2; PA SUPRAX (brand for cefixime) - Tier 2; PA

Beta-Lactam, Penicillins - Antibiotics amoxicillin oral capsule 250 mg - Tier 1 amoxicillin-potassium clavulanate er - Tier 1; PA amoxicillin oral capsule 500 mg - Tier 1; QL AUGMENTIN - Tier 2; PA; QL amoxicillin oral suspension reconstituted - Tier 1; QL AUGMENTIN ES-600 (brand for amoxicillin-pot clavulanate) - Tier 2; PA amoxicillin oral tablet - Tier 1 amoxicillin oral tablet chewable - Tier 1 amoxicillin-potassium clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 400-57 mg/5ml - Tier 1 amoxicillin-potassium clavulanate oral suspension reconstituted 250- 62.5 mg/5ml (generic for AUGMENTIN) - Tier 1; QL amoxicillin-potassium clavulanate oral suspension reconstituted 600- 42.9 mg/5ml (generic for AUGMENTIN ES-600) - Tier 1 amoxicillin-potassium clavulanate oral tablet 250-125 mg, 875-125 mg - Tier 1 amoxicillin-potassium clavulanate oral tablet 500-125 mg (generic for AUGMENTIN) - Tier 1; QL amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg - Tier 1 ampicillin - Tier 1 dicloxacillin sodium - Tier 1 penicillin v potassium - Tier 1

Macrolides - Antibiotics azithromycin oral packet (generic for ZITHROMAX) - Tier 1; QL clarithromycin er - Tier 1; PA azithromycin oral suspension reconstituted (generic for ZITHROMAX) - DIFICID ORAL TABLET - Tier 2; PA Tier 1 ERYPED 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA azithromycin oral tablet - Tier 1; QL ERY-TAB (brand for erythromycin) - Tier 2; PA clarithromycin oral suspension reconstituted - Tier 1 erythromycin base - Tier 1; PA clarithromycin oral tablet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 28 Preferred Agents Non-Preferred Agents E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2 erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2 PA ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2 erythromycin oral (generic for ERY-TAB) - Tier 1; PA ZITHROMAX ORAL PACKET (brand for azithromycin) - Tier 2; PA; QL ZITHROMAX ORAL SUSPENSION RECONSTITUTED (brand for azithromycin) - Tier 2; PA ZITHROMAX ORAL TABLET (brand for azithromycin) - Tier 2; PA; QL ZITHROMAX TRI-PAK (brand for azithromycin) - Tier 2; PA; QL ZITHROMAX Z-PAK (brand for azithromycin) - Tier 2; PA; QL Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2 BAXDELA - Tier 2; PA ciprofloxacin hcl oral - Tier 1; QL CIPRO ORAL TABLET (brand for ciprofloxacin hcl) - Tier 2; PA; QL levofloxacin oral solution - Tier 1 MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QL moxifloxacin hcl (2x day) (generic for MOXEZA) - Tier 1; PA VIGAMOX (brand for moxifloxacin hcl) - Tier 2 moxifloxacin hcl ophthalmic solution (generic for VIGAMOX) - Tier 1; PA moxifloxacin hcl oral - Tier 1; PA; QL ofloxacin oral - Tier 1; PA XEPI - Tier 2; PA; QL Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1 BACTRIM (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA ssd (generic for SSD) - Tier 1 BACTRIM DS (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA sulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1 BLEPH-10 (brand for sulfacetamide sodium) - Tier 2; PA sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1 SILVADENE (brand for silver sulfadiazine) - Tier 2; PA sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1 sulfadiazine oral - Tier 1; PA; QL Tetracyclines - Antibiotics avidoxy - Tier 1; QL ACTICLATE (brand for doxycycline hyclate) - Tier 2; PA; QL doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; QL AVIDOXY DK - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL BENZODOX - Tier 2; PA doxycycline monohydrate oral capsule 100 mg (generic for coremino (generic for COREMINO) - Tier 1; PA MONDOXYNE NL) - Tier 1 demeclocycline hcl - Tier 1; PA; QL doxycycline monohydrate oral capsule 50 mg - Tier 1 DORYX (brand for doxycycline hyclate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 29 Preferred Agents Non-Preferred Agents doxycycline monohydrate oral suspension reconstituted (generic for DORYX MPC - Tier 2; PA VIBRAMYCIN) - Tier 1 doxycycline (generic for ORACEA) - Tier 1; PA doxycycline monohydrate oral tablet 100 mg, 50 mg - Tier 1; QL minocycline hcl oral capsule (generic for MINOCIN) - Tier 1 doxycycline hyclate oral tablet 150 mg, 75 mg (generic for ACTICLATE) - mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; PA; QL Tier 1 doxycycline hyclate oral tablet 20 mg - Tier 1; PA morgidox oral (generic for MORGIDOX) - Tier 1; QL doxycycline hyclate oral tablet 50 mg (generic for TARGADOX) - Tier 1; PA doxycycline hyclate oral tablet delayed release 100 mg - Tier 1; PA; QL doxycycline hyclate oral tablet delayed release 150 mg, 75 mg - Tier 1; PA doxycycline hyclate oral tablet delayed release 200 mg, 50 mg (generic for DORYX) - Tier 1; PA; QL DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG - Tier 2; PA; QL doxycycline monohydrate oral capsule 150 mg - Tier 1; PA doxycycline monohydrate oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA doxycycline monohydrate oral tablet 150 mg - Tier 1; PA doxycycline monohydrate oral tablet 75 mg - Tier 1; PA; QL MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2; PA; QL minocycline hcl er oral tablet extended release 24 hour (generic for COREMINO) - Tier 1; PA minocycline hcl oral tablet 100 mg - Tier 1; PA; QL minocycline hcl oral tablet 50 mg, 75 mg - Tier 1; PA MINOLIRA - Tier 2; PA; QL mondoxyne nl oral capsule 75 mg (generic for MONDOXYNE NL) - Tier 1; PA MORGIDOX COMBINATION - Tier 2; PA NUTRIDOX - Tier 2; PA NUZYRA ORAL - Tier 2; PA; QL ORACEA (brand for doxycycline) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 30 Preferred Agents Non-Preferred Agents SEYSARA - Tier 2; PA; QL SOLODYN (brand for minocycline hcl er) - Tier 2; PA TARGADOX (brand for doxycycline hyclate) - Tier 2; PA tetracycline hcl oral - Tier 1; PA VIBRAMYCIN ORAL CAPSULE (brand for doxycycline hyclate) - Tier 2; PA; QL VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED (brand for doxycycline monohydrate) - Tier 2; PA VIBRAMYCIN ORAL SYRUP - Tier 2; PA XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1 ARICEPT (brand for donepezil hcl) - Tier 2; PA donepezil hcl oral tablet dispersible - Tier 1 donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; PA EXELON (brand for rivastigmine) - Tier 2 galantamine hydrobromide er (generic for RAZADYNE ER) - Tier 1; PA galantamine hydrobromide oral tablet - Tier 1; QL galantamine hydrobromide oral solution - Tier 1; PA rivastigmine tartrate - Tier 1 RAZADYNE ER (brand for galantamine hydrobromide er) - Tier 2; PA rivastigmine (generic for EXELON) - Tier 1; PA N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl oral solution 2 mg/ml - Tier 1 memantine hcl er (generic for NAMENDA XR) - Tier 1; PA memantine hcl oral tablet (generic for NAMENDA) - Tier 1 NAMENDA (brand for memantine hcl) - Tier 2; PA NAMENDA TITRATION PAK (brand for memantine hcl) - Tier 2; PA NAMENDA XR (brand for memantine hcl er) - Tier 2; PA NAMENDA XR TITRATION PACK - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs bonine (generic for BONINE) - Tier 1 anti-nausea (generic for EMETROL) - Tier 1; PA compro (generic for COMPRO) - Tier 1; QL anti-nausea/rekematol (generic for EMETROL) - Tier 1; PA DRAMAMINE ORAL TABLET (brand for cvs motion sickness) - Tier 2 BONJESTA - Tier 2; PA; QL driminate (generic for DRIMINATE) - Tier 1 DICLEGIS (brand for doxylamine-pyridoxine) - Tier 2; PA; QL eq motion sickness (generic for DRIMINATE) - Tier 1 doxylamine-pyridoxine (generic for DICLEGIS) - Tier 1; PA; QL eq motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - EMETROLformula em (brand(generic for for nausea EMETROL) relief) - Tier 1;2; PA Tier 1 GIMOTI - Tier 2; PA; QL hm motion sickness (generic for DRIMINATE) - Tier 1 hm anti-nausea (generic for EMETROL) - Tier 1; PA meclizine hcl oral tablet 12.5 mg - Tier 1 meclizine hcl oral tablet 50 mg - Tier 1; PA meclizine hcl oral tablet 25 mg (generic for DRAMAMINE LESS metoclopramide hcl oral tablet dispersible 10 mg - Tier 1; PA; QL DROWSY) - Tier 1 nausea control (generic for EMETROL) - Tier 1; PA meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 nausea relief (generic for EMETROL) - Tier 1; PA metoclopramide hcl oral solution - Tier 1 ra anti-nausea (generic for EMETROL) - Tier 1; PA motion sickness (generic for DRIMINATE) - Tier 1 scopolamine (generic for TRANSDERM SCOP (1.5 MG)) - Tier 1; PA; QL motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier sm anti-nausea (generic for EMETROL) - Tier 1; PA 1 TIGAN ORAL (brand for trimethobenzamide hcl) - Tier 2; PA; QL TRANSDERM SCOP (1.5 MG) (brand for scopolamine) - Tier 2; PA; QL motion sickness relief oral tablet chewable 25 mg (generic for TRANSDERM-SCOP (1.5 MG) (brand for scopolamine) - Tier 2; PA; QL BONINE) - Tier 1 trimethobenzamide hcl oral (generic for TIGAN) - Tier 1; PA; QL motion-time (generic for BONINE) - Tier 1 prochlorperazine (generic for COMPRO) - Tier 1; QL qc motion sickness relief (generic for DRIMINATE) - Tier 1 qc travel ease (generic for BONINE) - Tier 1 ra motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier 1 ra motion sickness relief oral tablet chewable (generic for BONINE) - Tier 1 sm motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1 sm motion sickness relief (generic for DRIMINATE) - Tier 1 travel sickness (generic for DRIMINATE) - Tier 1 wal-dram (generic for DRIMINATE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 32 Preferred Agents Non-Preferred Agents Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs dronabinol (generic for MARINOL) - Tier 1; PA AKYNZEO ORAL - Tier 2; PA; QL EMEND ORAL CAPSULE 80 MG (brand for aprepitant) - Tier 2; QL ANZEMET - Tier 2; PA; QL granisetron hcl oral - Tier 1 aprepitant (generic for EMEND) - Tier 1; PA; QL ondansetron hcl oral (generic for ZOFRAN) - Tier 1; QL EMEND ORAL SUSPENSION RECONSTITUTED - Tier 2; PA ondansetron odt - Tier 1; QL EMEND TRI-PACK (brand for aprepitant) - Tier 2; PA; QL MARINOL (brand for dronabinol) - Tier 2; PA SANCUSO - Tier 2; PA; QL SYNDROS - Tier 2; PA VARUBI (180 MG DOSE) - Tier 2; PA; QL ZOFRAN (brand for ondansetron hcl) - Tier 2; PA; QL ZUPLENZ - Tier 2; PA Antifungals ONYCHO-MED - Tier 2; PA; QL Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 ACTIVE-PREP KIT V - Tier 2; PA af spray powder (generic for ODOR EATERS FOOT/SNEAKER ala-quin - Tier 1; PA SPRAY) - Tier 1 ALCORTIN A (brand for iodoquinol-hc-aloe polysacch) - Tier 2; PA antifungal external cream 2 % (generic for CARRINGTON ALOE VESTA CLEAR ANTIFUNGAL (brand for triple paste af) - Tier 2; ANTIFUNGAL) - Tier 1 PA athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1 ANCOBON (brand for flucytosine) - Tier 2; PA athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1 antifungal external cream 1 % (generic for TINACTIN) - Tier 1; PA athletes foot powder spray external aerosol powder 1 % (generic for athletes foot external aerosol powder 2 % (generic for CRUEX ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 PRESCRIPTION STRENGTH) - Tier 1; PA carrington antifungal (generic for CARRINGTON ANTIFUNGAL) - Tier athletes foot powder spray external aerosol powder 2 % (generic for 1 CRUEX PRESCRIPTION STRENGTH) - Tier 1; PA cavilon (generic for CARRINGTON ANTIFUNGAL) - Tier 1 athletes foot spray (generic for TINACTIN) - Tier 1; PA ciclopirox olamine external suspension (generic for LOPROX) - Tier 1 AZOLEN TINCTURE - Tier 2; PA clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 BIO-STATIN ORAL CAPSULE - Tier 2; PA clotrimazole external (generic for DESENEX) - Tier 1 bio-statin oral powder - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents clotrimazole mouth/throat - Tier 1 ciclodan (generic for CICLODAN) - Tier 1; PA clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1 ciclopirox external (generic for CICLODAN) - Tier 1; PA eq athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1 ciclopirox olamine external cream (generic for LOPROX) - Tier 1; PA eq athletes foot external aerosol powder (generic for ODOR EATERS ciclopirox treatment - Tier 1; PA FOOT/SNEAKER SPRAY) - Tier 1 CRESEMBA ORAL - Tier 2; PA eq miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 eq miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CRUEX PRESCRIPTION STRENGTH (brand for athletes foot powder CURE) - Tier 1 spray) - Tier 2; PA eql miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 DERMACINRX THERAZOLE PAK - Tier 2; PA fluconazole oral suspension reconstituted (generic for DIFLUCAN) - dermafungal (generic for DERMAFUNGAL) - Tier 1; PA Tier 1 dermazene (generic for DERMAZENE) - Tier 1; PA DESENEX JOCK ITCH (brand for athletes foot powder spray) - Tier 2; PA fluconazole oral tablet 100 mg, 200 mg, 50 mg (generic for DIFLUCAN ORAL SUSPENSION RECONSTITUTED (brand for DIFLUCAN) - Tier 1 fluconazole) - Tier 2; PA fluconazole oral tablet 150 mg (generic for DIFLUCAN) - Tier 1; QL foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG (brand for SPRAY) - Tier 1 fluconazole) - Tier 2; PA griseofulvin microsize oral suspension - Tier 1 GYNE-LOTRIMIN (brand for clotrimazole-7) - Tier 2 DIFLUCAN ORAL TABLET 150 MG (brand for fluconazole) - Tier 2; PA; GYNE-LOTRIMIN 3 (brand for cvs clotrimazole 3) - Tier 2 QL jock itch (generic for LAMISIL AT) - Tier 1 DIFMETIOXRIME - Tier 2; PA; QL jock itch spray (generic for ODOR EATERS FOOT/SNEAKER SPRAY) ECONASIL - Tier 2; PA; QL - Tier 1 econazole nitrate external - Tier 1; PA ECONAZOLE NITRATE-NIACINAMIDE - Tier 2; PA; QL jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER ECOZA - Tier 2; PA SPRAY) - Tier 1 eq athletes foot spray (generic for CRUEX PRESCRIPTION STRENGTH) ketoconazole external cream - Tier 1 - Tier 1; PA ketoconazole external shampoo - Tier 1 eq miconazole 1 (generic for MONISTAT 1 COMBO PACK) - Tier 1; PA kp miconazole nitrate (generic for CARRINGTON ANTIFUNGAL) - Tier eq tioconazole 1 (generic for MONISTAT 1-DAY) - Tier 1; PA 1 eql antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; PA micaderm (generic for CARRINGTON ANTIFUNGAL) - Tier 1 ERTACZO - Tier 2; PA MICATIN (brand for podactin) - Tier 2 EXELDERM (brand for sulconazole nitrate) - Tier 2; PA exoderm external lotion - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents miconazole 3 applicator (generic for MONISTAT 3 COMBO PACK EXTINA (brand for ketoconazole) - Tier 2; PA APP) - Tier 1; QL FLUCON-IBUPROF-ITRACON-TERBINA - Tier 2; PA; QL flucytosine oral (generic for ANCOBON) - Tier 1; PA miconazole 3 combo pack (generic for MONISTAT 3 COMBINATION fungi-guard (generic for TINACTIN) - Tier 1; PA PACK) - Tier 1; QL FUNGIMEZ - Tier 2; PA FUNGOID TINCTURE - Tier 2; PA miconazole 3 combo pack app (generic for MONISTAT 3 COMBO griseofulvin microsize oral tablet - Tier 1; PA PACK APP) - Tier 1; QL griseofulvin ultramicrosize - Tier 1; PA miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 GYNAZOLE-1 - Tier 2; PA miconazole antifungal (generic for CARRINGTON ANTIFUNGAL) - hydrocortisone-iodoquinol (generic for DERMAZENE) - Tier 1; PA Tier 1 IMIOXIA - Tier 2; PA; QL IODOQUIMEZ-HC - Tier 2; PA miconazole nitrate external (generic for CARRINGTON ANTIFUNGAL) iodoquinol-hc-aloe polysacch (generic for ALCORTIN A) - Tier 1; PA - Tier 1 IODOQUINOL-HC-KETOCONAZOLE - Tier 2; PA; QL iodoquinol-hydrocortisone-aloe (generic for VYTONE) - Tier 1; PA miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL Tier 1 JUBLIA - Tier 2; PA nyamyc (generic for NYAMYC) - Tier 1 KERYDIN (brand for tavaborole) - Tier 2; PA nystatin external - Tier 1 ketoconazole external foam (generic for KETODAN) - Tier 1; PA nystatin mouth/throat - Tier 1 ketoconazole oral - Tier 1; PA nystatin-triamcinolone - Tier 1 KETOCONAZOLE-HYDROCORTISONE - Tier 2; PA; QL nystop (generic for NYAMYC) - Tier 1 ketodan external foam (generic for KETODAN) - Tier 1; PA podactin external cream (generic for CARRINGTON ANTIFUNGAL) - KETODAN EXTERNAL KIT - Tier 2; PA Tier 1 kp tolnaftate (generic for TINACTIN) - Tier 1; PA qc athletes foot (generic for LAMISIL AT) - Tier 1 LAMISIL AT EXTERNAL CREAM (brand for gnp terbinafine qc miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 hydrochloride) - Tier 2; PA ra antifungal external cream (generic for CARRINGTON LAMISIL AT JOCK ITCH (brand for gnp terbinafine hydrochloride) - Tier 2; ANTIFUNGAL) - Tier 1 PA ra antifungal foot care (generic for LAMISIL AT) - Tier 1 LOPROX (brand for ciclopirox olamine) - Tier 2; PA ra clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 LULICONAZOLE - Tier 2; PA ra clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1 LUZU (brand for luliconazole) - Tier 2; PA ra foot care (terbinafine) (generic for LAMISIL AT) - Tier 1 MENTAX (brand for butenafine hcl) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 35 Preferred Agents Non-Preferred Agents ra jock itch max st (generic for ODOR EATERS FOOT/SNEAKER miconazole 1 (generic for MONISTAT 1 COMBO PACK) - Tier 1; PA SPRAY) - Tier 1 miconazole 1 combo pack (generic for MONISTAT 1 COMBO PACK) - Tier 1; PA ra miconazole 3 combo pack app (generic for MONISTAT 3 COMBO miconazole 3 vaginal cream (generic for MONISTAT 3) - Tier 1; PA PACK APP) - Tier 1; QL miconazole 3 vaginal suppository - Tier 1; PA; QL ra miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1 MICONAZOLE-ZINC OXIDE-PETROLAT - Tier 2; PA remedy antifungal external cream (generic for CARRINGTON naftifine hcl - Tier 1; PA ANTIFUNGAL) - Tier 1 NAFTIN (brand for naftifine hcl) - Tier 2; PA sm 3-day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 NATACYN - Tier 2; PA sm antifungal miconazole (generic for CARRINGTON ANTIFUNGAL) - NOXAFIL ORAL - Tier 2; PA Tier 1 nystatin oral - Tier 1; PA sm athletes foot (generic for LAMISIL AT) - Tier 1 ORAVIG - Tier 2; PA sm clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1 oxiconazole nitrate (generic for OXISTAT) - Tier 1; PA sm miconazole 3 applicator (generic for MONISTAT 3 COMBO PACK OXISTAT (brand for oxiconazole nitrate) - Tier 2; PA APP) - Tier 1; QL PEDIZOLPAK - Tier 2; PA; QL sm miconazole 7 - Tier 1 PHEODOYO - Tier 2; PA; QL SOOTHE & COOL INZO ANTIFUNGAL (brand for podactin) - Tier 2 PHEYO - Tier 2; PA; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1 posaconazole (generic for NOXAFIL) - Tier 1; PA terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL qc 3 day (generic for MONISTAT 3) - Tier 1; PA terbinafine hydrochloride (generic for LAMISIL AT) - Tier 1 qc tolnaftate (generic for TINACTIN) - Tier 1; PA terconazole vaginal cream - Tier 1 QUINJA - Tier 2; PA ra antifungal external aerosol (generic for TINACTIN) - Tier 1; PA ra atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1; PA ra athletes foot (tolnaftate) (generic for TINACTIN) - Tier 1; PA ra tioconazole 1 (generic for MONISTAT 1-DAY) - Tier 1; PA RECURA - Tier 2; PA REMEDY PHYTOPLEX ANTIFUNGAL EXTERNAL OINTMENT (brand for triple paste af) - Tier 2; PA sm antifungal tolnaftate (generic for TINACTIN) - Tier 1; PA sm tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1; PA SPORANOX (brand for itraconazole) - Tier 2; PA; QL SPORANOX PULSEPAK (brand for itraconazole) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 36 Preferred Agents Non-Preferred Agents SULCONAZOLE NITRATE - Tier 2; PA tavaborole (generic for KERYDIN) - Tier 1; PA terconazole vaginal suppository - Tier 1; PA TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2; PA TINACTIN EXTERNAL CREAM (brand for eql antifungal (tolnaftate)) - Tier 2; PA tinaspore (generic for BLIS-TO-SOL) - Tier 1; PA tioconazole 1 vaginal ointment 6.5 % (generic for MONISTAT 1-DAY) - Tier 1; PA tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1; PA tolnaftate antifungal (generic for TINACTIN) - Tier 1; PA tolnaftate external cream (generic for TINACTIN) - Tier 1; PA TOLSURA - Tier 2; PA triple paste af (generic for DERMAFUNGAL) - Tier 1; PA VFEND (brand for voriconazole) - Tier 2; PA voriconazole oral (generic for VFEND) - Tier 1; PA VUSION (brand for miconazole-zinc oxide-petrolat) - Tier 2; PA VYTONE (brand for iodoquimez-hc) - Tier 2; PA XOLEGEL - Tier 2; PA XOLEGEL COREPAK - Tier 2; PA XOLEGEL DUO/HEAD & SHOULDERS - Tier 2; PA XOLEGEL DUO/XOLEX - Tier 2; PA ZOLPAK - Tier 2; PA; QL

Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1 COLCHICINE ORAL CAPSULE - Tier 2; PA colchicine-probenecid - Tier 1 colchicine oral tablet (generic for COLCRYS) - Tier 1; PA MITIGARE (brand for colchicine) - Tier 2 COLCRYS (brand for colchicine) - Tier 2; PA probenecid - Tier 1 febuxostat (generic for ULORIC) - Tier 1; PA GLOPERBA - Tier 2; PA ULORIC (brand for febuxostat) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents ZYLOPRIM (brand for allopurinol) - Tier 2; PA Anti-inflammatory Agents - Drugs to Treat Inflammation Glucocorticoids - Drugs to Treat Inflammation anucort-hc (generic for HEMMOREX-HC) - Tier 1; PA ANUSOL-HC RECTAL (brand for hydrocortisone acetate) - Tier 2; PA hemmorex-hc (generic for HEMMOREX-HC) - Tier 1; PA hemorrhoidal-hc rectal suppository 25 mg (generic for HEMMOREX-HC) - Tier 1; PA hydrocortisone acetate rectal (generic for HEMMOREX-HC) - Tier 1; PA PROCTOCORT RECTAL (brand for hydrocortisone acetate) - Tier 2; PA Antimigraine Agents - Drugs to Treat Migraines Antimigraine Agents, Other CAMBIA - Tier 2; PA; QL Ergot Alkaloids - Migraine Drugs CAFERGOT (brand for ergotamine-caffeine) - Tier 2; PA; QL D.H.E. 45 (brand for dihydroergotamine mesylate) - Tier 2; PA; QL dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; PA; QL dihydroergotamine mesylate nasal (generic for MIGRANAL) - Tier 1; PA; QL ERGOMAR - Tier 2; PA ergotamine-caffeine (generic for CAFERGOT) - Tier 1; PA; QL MIGERGOT - Tier 2; PA; QL MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA; QL Prophylactic - Migraine Drugs EMGALITY - Tier 2; PA; QL AIMOVIG - Tier 2; PA; QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; NURTEC - Tier 2; PA; QL; AL QL REYVOW - Tier 2; PA; QL; AL UBRELVY - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RELPAX (brand for eletriptan hydrobromide) - Tier 2; QL almotriptan malate - Tier 1; PA; QL rizatriptan benzoate - Tier 1; QL AMERGE (brand for naratriptan hcl) - Tier 2; PA; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL eletriptan hydrobromide (generic for RELPAX) - Tier 1; PA; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL - Tier 1; QL frovatriptan succinate (generic for FROVA) - Tier 1; PA; QL IMITREX (brand for sumatriptan succinate) - Tier 2; PA; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; IMITREX STATDOSE REFILL (brand for sumatriptan succinate refill) - QL Tier 2; PA; QL ZOMIG NASAL - Tier 2 IMITREX STATDOSE SYSTEM (brand for sumatriptan succinate) - Tier 2; PA; QL MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL MAXALT-MLT (brand for rizatriptan benzoate) - Tier 2; PA; QL MIGRAINE PACK - Tier 2; PA; QL MIGRANOW - Tier 2; PA; QL naratriptan hcl (generic for AMERGE) - Tier 1; PA; QL ONZETRA XSAIL - Tier 2; PA sumatriptan nasal (generic for IMITREX) - Tier 1; PA; QL sumatriptan-naproxen sodium (generic for TREXIMET) - Tier 1; PA TOSYMRA - Tier 2; PA TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA ZEMBRACE SYMTOUCH - Tier 2; PA zolmitriptan oral (generic for ZOMIG) - Tier 1; PA; QL ZOMIG ORAL (brand for zolmitriptan) - Tier 2; PA; QL ZOMIG ZMT (brand for zolmitriptan) - Tier 2; PA; QL

Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - GUANIDINE HCL - Tier 2; PA Tier 1 MESTINON ORAL SOLUTION (brand for pyridostigmine bromide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 39 Preferred Agents Non-Preferred Agents MESTINON ORAL TABLET (brand for pyridostigmine bromide) - Tier 2; PA MESTINON ORAL TABLET EXTENDED RELEASE (brand for pyridostigmine bromide er) - Tier 2; PA; QL NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 5 MG/5ML - Tier 2; PA pyridostigmine bromide er (generic for MESTINON) - Tier 1; PA; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; PA; QL pyridostigmine bromide oral tablet 30 mg - Tier 1; PA; QL Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1 MYCOBUTIN (brand for rifabutin) - Tier 2; PA PRETOMANID - Tier 2; PA; QL rifabutin (generic for MYCOBUTIN) - Tier 1 Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL MYAMBUTOL (brand for ethambutol hcl) - Tier 2; PA ethambutol hcl oral - Tier 1 PASER - Tier 2; PA isoniazid oral - Tier 1 RIFAMPIN+SYRSPEND SF - Tier 2; PA; QL PRIFTIN - Tier 2; QL SIRTURO ORAL TABLET 100 MG - Tier 2; PA; QL pyrazinamide oral - Tier 1 SIRTURO ORAL TABLET 20 MG - Tier 2; PA rifampin oral - Tier 1 TRECATOR - Tier 2

Antineoplastics Molecular Target Inhibitors INQOVI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide oral - Tier 1; PA ALKERAN ORAL (brand for melphalan) - Tier 2; PA GLEOSTINE - Tier 2; PA EVOMELA - Tier 2; PA LEUKERAN - Tier 2; PA TEMODAR ORAL (brand for temozolomide) - Tier 2; PA; SP MATULANE - Tier 2; PA; SP VALCHLOR - Tier 2; PA; SP; QL melphalan (generic for ALKERAN) - Tier 1; PA YONDELIS - Tier 2; PA MYLERAN - Tier 2; PA temozolomide (generic for TEMODAR) - Tier 1; PA; SP Antiandrogens - Hormone Suppressants abiraterone acetate oral tablet 250 mg (generic for ZYTIGA) - Tier 1; CASODEX (brand for bicalutamide) - Tier 2; PA PA; SP; QL YONSA - Tier 2; PA; SP; QL bicalutamide (generic for CASODEX) - Tier 1 ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL ERLEADA - Tier 2; PA; QL flutamide - Tier 1; PA nilutamide (generic for NILANDRON) - Tier 1; PA NUBEQA - Tier 2; PA; SP; QL XTANDI - Tier 2; PA; SP; QL Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP Antiestrogens/Modifiers - Chemotherapy Agents EMCYT - Tier 2; PA FARESTON (brand for toremifene citrate) - Tier 2; PA tamoxifen citrate oral - Tier 1; QL SOLTAMOX - Tier 2; PA; QL toremifene citrate (generic for FARESTON) - Tier 1; PA Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; PA; SP HYALUCIL-4 - Tier 2; PA DROXIA - Tier 2 HYDREA (brand for hydroxyurea) - Tier 2; PA hydroxyurea oral (generic for HYDREA) - Tier 1 PURIXAN - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents mercaptopurine oral - Tier 1; QL SIKLOS ORAL TABLET 100 MG - Tier 2; PA; QL TABLOID - Tier 2; PA; SP SIKLOS ORAL TABLET 1000 MG - Tier 2; PA XELODA (brand for capecitabine) - Tier 2; PA; SP Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral - Tier 1 IMLYGIC - Tier 2; PA LONSURF - Tier 2; PA; SP KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL TAZVERIK - Tier 2; PA; SP KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL XPOVIO (100 MG ONCE WEEKLY) - Tier 2; PA; SP; QL KISQALI FEMARA(200 MG DOSE) - Tier 2; PA; SP; QL XPOVIO (60 MG ONCE WEEKLY) - Tier 2; PA; SP; QL levoleucovorin calcium pf intravenous solution 250 mg/25ml - Tier 1; PA XPOVIO (80 MG ONCE WEEKLY) - Tier 2; PA; SP; QL ONIVYDE - Tier 2; PA XPOVIO (80 MG TWICE WEEKLY) - Tier 2; PA; SP; QL SYNRIBO - Tier 2; PA; SP ZOLINZA - Tier 2; PA; SP XPOVIO (40 MG ONCE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (40 MG TWICE WEEKLY) - Tier 2; PA; SP; QL XPOVIO (60 MG TWICE WEEKLY) - Tier 2; PA; SP; QL Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1 ARIMIDEX (brand for anastrozole) - Tier 2; PA exemestane (generic for AROMASIN) - Tier 1 AROMASIN (brand for exemestane) - Tier 2; PA letrozole oral (generic for FEMARA) - Tier 1; QL FEMARA (brand for letrozole) - Tier 2; PA; QL Enzyme Inhibitors - Chemotherapy Agents etoposide oral - Tier 1; PA HYCAMTIN ORAL - Tier 2; PA; SP Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL AFINITOR (brand for everolimus) - Tier 2; PA; SP; QL BRAFTOVI - Tier 2; PA; SP; QL IDHIFA - Tier 2; PA; SP DAURISMO - Tier 2; PA ERIVEDGE - Tier 2; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP; QL FARYDAK - Tier 2; PA; SP JAKAFI - Tier 2; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents ODOMZO - Tier 2; PA; SP TIBSOVO - Tier 2; PA; QL VENCLEXTA - Tier 2; PA; SP VENCLEXTA STARTING PACK - Tier 2; PA; SP

Monoclonal Antibodies/Antibody-Drug Conjugate - Chemotherapy Agents DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML - Tier 2; PA EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG - Tier 2; PA KEYTRUDA - Tier 2; PA OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML - Tier 2; PA PORTRAZZA - Tier 2; PA TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML - Tier 2; PA Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP PANRETIN - Tier 2; PA tretinoin oral - Tier 1; PA; SP; QL TARGRETIN (brand for bexarotene) - Tier 2; PA; SP Treatment Adjuncts - Supportive Chemotherapy Drugs MESNEX ORAL - Tier 2; PA; SP Antiparasitics Antiprotozoals LAMPIT - Tier 2; PA; QL Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; DX2RX; QL ALBENZA (brand for albendazole) - Tier 2; DX2RX; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL BILTRICIDE (brand for praziquantel) - Tier 2; PA; QL EGATEN - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 43 Preferred Agents Non-Preferred Agents EMVERM - Tier 2; PA; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; PA; QL SKLICE (brand for ivermectin) - Tier 2; PA; QL STROMECTOL (brand for ivermectin) - Tier 2; PA; QL

Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL TABLET (brand for nitazoxanide) - Tier 2; DX2RX; QL ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; QL atovaquone oral (generic for MEPRON) - Tier 1; PA ARAKODA - Tier 2; PA; QL BENZNIDAZOLE - Tier 2; DX2RX; QL atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; PA; QL chloroquine phosphate oral - Tier 1; QL COARTEM - Tier 2; PA hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1 DARAPRIM (brand for pyrimethamine) - Tier 2; PA; SP KRINTAFEL - Tier 2; PA; QL IMPAVIDO - Tier 2; PA mefloquine hcl - Tier 1; PA MALARONE (brand for atovaquone-proguanil hcl) - Tier 2; PA; QL primaquine phosphate - Tier 1 MEPRON (brand for atovaquone) - Tier 2; PA pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP NEBUPENT (brand for pentamidine isethionate) - Tier 2; PA pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1; PA PLAQUENIL (brand for hydroxychloroquine sulfate) - Tier 2; PA PYRIMETHAMINE-LEUCOVORIN - Tier 2; PA; QL QUALAQUIN (brand for quinine sulfate) - Tier 2; PA quinine sulfate oral (generic for QUALAQUIN) - Tier 1; PA

Pediculicides/Scabicides - Scabies and Lice Drugs eq lice killing max st (generic for LICIDE) - Tier 1; QL complete lice treatment (generic for CVS LICE SOLUTION) - Tier 1; PA eql lice killing max st (generic for LICIDE) - Tier 1; QL crotan - Tier 1; PA; QL hm lice killing max st (generic for LICIDE) - Tier 1; QL ELIMITE (brand for permethrin) - Tier 2; PA; QL hm lice treatment (generic for NIX CREME RINSE) - Tier 1; QL lice solution combination kit (generic for CVS LICE SOLUTION) - Tier 1; lice killing (generic for LICIDE) - Tier 1; QL PA lice killing maximum strength (generic for LICIDE) - Tier 1; QL NATROBA (brand for spinosad) - Tier 2; PA; ST; QL lice treatment - Tier 1; QL OVIDE (brand for malathion) - Tier 2; PA; ST; QL licide external (generic for LICIDE) - Tier 1; QL sm lice solution kit (generic for CVS LICE SOLUTION) - Tier 1; PA licide maximum strength (generic for LICIDE MAXIMUM STRENGTH) stop lice complete treatment (generic for CVS LICE SOLUTION) - Tier 1; - Tier 1; QL PA lindane - Tier 1; QL SULFURATED LIME - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 44 Preferred Agents Non-Preferred Agents malathion (generic for OVIDE) - Tier 1; ST; QL permethrin external (generic for ELIMITE) - Tier 1; QL ra lice maximum strength (generic for LICIDE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for sm lice killing max strength) - Tier 2; QL sb lice killing max st (generic for LICIDE) - Tier 1; QL sm lice killing (generic for LICIDE MAXIMUM STRENGTH) - Tier 1; QL sm lice killing max strength (generic for LICIDE) - Tier 1; QL sm lice treatment - Tier 1; QL spinosad (generic for NATROBA) - Tier 1; ST; QL

Antiparkinson Agents Antiparkinson Agents, Other ONGENTYS - Tier 2; PA; QL Antiparkinson Agents - Drugs to Treat Parkinson's Disease Antiparkinson Agents - Parkinson's Disease Drugs NOURIANZ - Tier 2; PA Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral capsule - Tier 1 amantadine hcl oral tablet - Tier 1; PA amantadine hcl oral syrup - Tier 1 COMTAN (brand for entacapone) - Tier 2; PA entacapone (generic for COMTAN) - Tier 1; PA GOCOVRI - Tier 2; PA OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK - Tier 2; PA; QL OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR - Tier 2; PA TASMAR (brand for tolcapone) - Tier 2; PA tolcapone (generic for TASMAR) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents Dopamine Agonists - Parkinson's Disease Drugs pramipexole dihydrochloride (generic for MIRAPEX) - Tier 1 APOKYN - Tier 2; PA; SP; QL ropinirole hcl - Tier 1 bromocriptine mesylate oral (generic for PARLODEL) - Tier 1; PA KYNMOBI - Tier 2; PA; SP; QL KYNMOBI TITRATION KIT - Tier 2; PA; SP; QL MIRAPEX (brand for pramipexole dihydrochloride) - Tier 2; PA MIRAPEX ER (brand for pramipexole dihydrochloride er) - Tier 2; PA NEUPRO - Tier 2; PA PARLODEL (brand for bromocriptine mesylate) - Tier 2; PA pramipexole dihydrochloride er (generic for MIRAPEX ER) - Tier 1; PA ropinirole hcl er - Tier 1; PA

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa oral tablet (generic for SINEMET) - Tier 1 carbidopa oral (generic for LODOSYN) - Tier 1; PA carbidopa-levodopa er - Tier 1; PA carbidopa-levodopa oral tablet dispersible - Tier 1; PA carbidopa-levodopa-entacapone (generic for STALEVO 50) - Tier 1; PA DUOPA - Tier 2; PA LODOSYN (brand for carbidopa) - Tier 2; PA RYTARY - Tier 2; PA SINEMET (brand for carbidopa-levodopa) - Tier 2; PA STALEVO 100 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA STALEVO 125 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA STALEVO 150 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA STALEVO 200 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA STALEVO 50 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA STALEVO 75 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs AZILECT (brand for rasagiline mesylate) - Tier 2; PA rasagiline mesylate oral (generic for AZILECT) - Tier 1; PA selegiline hcl oral - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 46 Preferred Agents Non-Preferred Agents XADAGO - Tier 2; PA ZELAPAR - Tier 2; PA Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs prochlorperazine maleate oral - Tier 1; QL Antispasticity Agents BACLOFEN EXTERNAL - Tier 2; PA enovarx-baclofen - Tier 1; PA XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 200 UNIT - Tier 2; PA Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; PA; QL PREVYMIS ORAL - Tier 2; PA; QL VALCYTE ORAL SOLUTION RECONSTITUTED (brand for valganciclovir hcl) - Tier 2; PA VALCYTE ORAL TABLET (brand for valganciclovir hcl) - Tier 2; PA; QL valganciclovir hcl oral solution reconstituted (generic for VALCYTE) - Tier 1; PA ZIRGAN - Tier 2; PA; QL Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs adefovir dipivoxil (generic for HEPSERA) - Tier 1; SP; QL BARACLUDE ORAL SOLUTION - Tier 2; PA; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; PA; QL EPIVIR HBV ORAL TABLET (brand for lamivudine) - Tier 2; PA; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; HEPSERA (brand for adefovir dipivoxil) - Tier 2; PA; SP; QL QL VEMLIDY - Tier 2; PA; SP; QL Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 47 Preferred Agents Non-Preferred Agents Antiherpetic Agents - Herpes Drugs acyclovir oral - Tier 1 ABREVA (brand for docosanol) - Tier 2; PA DENAVIR - Tier 2 acyclovir external (generic for ZOVIRAX) - Tier 1; PA docosanol external (generic for ABREVA) - Tier 1 SITAVIG - Tier 2; PA famciclovir oral - Tier 1 trifluridine - Tier 1; PA valacyclovir hcl oral (generic for VALTREX) - Tier 1 VALTREX (brand for valacyclovir hcl) - Tier 2; PA ZOVIRAX EXTERNAL CREAM (brand for acyclovir) - Tier 2 XERESE - Tier 2; PA ZOVIRAX EXTERNAL OINTMENT (brand for acyclovir) - Tier 2; PA ZOVIRAX ORAL (brand for acyclovir) - Tier 2; PA

Anti-Influenza Agents FAVIPIRAVIR - Tier 2; PA; QL Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral (generic for TAMIFLU) - Tier 1; QL RELENZA DISKHALER - Tier 2; QL rimantadine hcl - Tier 1 TAMIFLU (brand for oseltamivir phosphate) - Tier 2; QL XOFLUZA (40 MG DOSE) - Tier 2 XOFLUZA (80 MG DOSE) - Tier 2 Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs hydroxyzine hcl oral - Tier 1 Blood Glucose Regulators - Drugs to Regulate Blood Sugar Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1 ACTOPLUS MET (brand for pioglitazone hcl-metformin hcl) - Tier 2; PA BYDUREON - Tier 2 ACTOS (brand for pioglitazone hcl) - Tier 2; PA BYETTA 10 MCG PEN - Tier 2 ADLYXIN - Tier 2; PA BYETTA 5 MCG PEN - Tier 2 ADLYXIN STARTER PACK - Tier 2; PA FARXIGA - Tier 2; PA ALOGLIPTIN BENZOATE - Tier 2; PA glimepiride (generic for AMARYL) - Tier 1 ALOGLIPTIN-METFORMIN HCL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 48 Preferred Agents Non-Preferred Agents glipizide er (generic for GLUCOTROL XL) - Tier 1 ALOGLIPTIN-PIOGLITAZONE - Tier 2; PA glipizide ir (generic for GLUCOTROL) - Tier 1 AMARYL (brand for glimepiride) - Tier 2; PA glipizide xl (generic for GLUCOTROL XL) - Tier 1 AVANDIA - Tier 2; PA glyburide micronized (generic for GLYNASE) - Tier 1 BYDUREON BCISE AUTOINJECTOR - Tier 2; PA glyburide oral - Tier 1 CYCLOSET - Tier 2; PA glyburide-metformin - Tier 1 DUETACT (brand for pioglitazone hcl-glimepiride) - Tier 2; PA GLYXAMBI - Tier 2 FORTAMET (brand for metformin hcl er (osm)) - Tier 2; PA INVOKAMET - Tier 2 glipizide-metformin hcl - Tier 1; PA INVOKANA - Tier 2; PA GLUCOTROL (brand for glipizide) - Tier 2; PA JANUMET - Tier 2; QL GLUCOTROL XL (brand for glipizide xl) - Tier 2; PA JANUMET XR - Tier 2 GLUCOVANCE ORAL TABLET 5-500 MG (brand for glyburide- JANUVIA - Tier 2; QL metformin) - Tier 2; PA JARDIANCE - Tier 2; PA GLUMETZA (brand for metformin hcl er (mod)) - Tier 2; PA JENTADUETO - Tier 2 GLYNASE (brand for glyburide micronized) - Tier 2; PA metformin hcl er - Tier 1 GLYSET (brand for miglitol) - Tier 2; PA metformin hcl oral tablet - Tier 1 INVOKAMET XR - Tier 2; PA miglitol (generic for GLYSET) - Tier 1 JENTADUETO XR - Tier 2; PA nateglinide (generic for STARLIX) - Tier 1 KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA pioglitazone hcl (generic for ACTOS) - Tier 1 KOMBIGLYZE XR - Tier 2; PA; QL repaglinide - Tier 1 metformin hcl er (mod) (generic for GLUMETZA) - Tier 1; PA RIOMET (brand for metformin hcl) - Tier 2 metformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA SYMLINPEN 120 - Tier 2 metformin hcl oral solution (generic for RIOMET) - Tier 1; PA SYMLINPEN 60 - Tier 2 NESINA (brand for alogliptin benzoate) - Tier 2; PA TRADJENTA - Tier 2 ONGLYZA - Tier 2; PA; QL VICTOZA - Tier 2; PA OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA XIGDUO XR - Tier 2 OZEMPIC - Tier 2; PA pioglitazone hcl-glimepiride (generic for DUETACT) - Tier 1; PA pioglitazone hcl-metformin hcl (generic for ACTOPLUS MET) - Tier 1; PA PRECOSE (brand for acarbose) - Tier 2; PA QTERN - Tier 2; PA RIOMET ER - Tier 2; PA RYBELSUS - Tier 2; PA SEGLUROMET - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents SOLIQUA - Tier 2; PA STARLIX (brand for nateglinide) - Tier 2; PA STEGLATRO - Tier 2; PA STEGLUJAN - Tier 2; PA SYNJARDY - Tier 2; PA SYNJARDY XR - Tier 2; PA tolbutamide - Tier 1; PA TRIJARDY XR - Tier 2; PA TRULICITY - Tier 2; PA XULTOPHY - Tier 2; PA

Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL diazoxide oral (generic for PROGLYCEM) - Tier 1; PA BAQSIMI TWO PACK - Tier 2; QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - GLUCAGEN HYPOKIT - Tier 2; QL Tier 2; PA GLUCAGON EMERGENCY INJECTION KIT - Tier 2; QL glucose liquid shot oral liquid - Tier 1; PA GVOKE HYPOPEN 1-PACK - Tier 2; QL GLUCOSE NURSETTE - Tier 2; PA GVOKE HYPOPEN 2-PACK - Tier 2; QL GVOKE PFS - Tier 2; QL glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; PA; QL glucose oral tablet chewable 4-6 gm-mg (generic for DEX4) - Tier 1; PA GOOD START 5% GLUCOSE WATER - Tier 2; PA hm glucose (generic for DEX4) - Tier 1; PA INSTA-GLUCOSE - Tier 2; PA PROGLYCEM (brand for diazoxide) - Tier 2; PA ra glucose (generic for GLUCO BURST) - Tier 1; PA sm glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; PA; QL sm glucose oral tablet chewable 4-6 gm-mg (generic for DEX4) - Tier 1; PA soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; PA; QL TRUEPLUS GLUCOSE ORAL GEL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 50 Preferred Agents Non-Preferred Agents Insulins - Diabetic Drugs APIDRA SOLOSTAR - Tier 2; QL ADMELOG (brand for insulin lispro) - Tier 2; PA; QL APIDRA VIAL - Tier 2; QL ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; PA; QL HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- AFREZZA - Tier 2; PA; QL INJECTOR 100 UNIT/ML (brand for insulin lispro (1 unit dial)) - Tier 2; BASAGLAR KWIKPEN - Tier 2; PA; QL QL FIASP - Tier 2; PA; QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; QL FIASP FLEXTOUCH - Tier 2; PA; QL HUMALOG MIX 50/50 VIAL - Tier 2; QL FIASP PENFILL - Tier 2; PA; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR - Tier 2; QL 200 UNIT/ML - Tier 2; PA; QL HUMALOG MIX 75/25 VIAL - Tier 2; QL HUMULIN N KWIKPEN - Tier 2; PA; QL HUMALOG U-100 JUNIOR KWIKPEN (brand for insulin lispro junior INSULIN ASP PROT & ASP FLEXPEN - Tier 2; PA; QL kwikpen) - Tier 2; QL INSULIN ASPART - Tier 2; PA; QL INSULIN ASPART FLEXPEN - Tier 2; PA HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS INSULIN ASPART PENFILL - Tier 2; PA; QL SOLUTION 100 UNIT/ML (brand for insulin lispro) - Tier 2; PA; QL INSULIN ASPART PROT & ASPART - Tier 2; PA; QL INSULIN LISPRO - Tier 2; PA; QL HUMALOG U-100 VIAL AND CARTRIDGE SUBCUTANEOUS INSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QL SOLUTION CARTRIDGE 100 UNIT/ML - Tier 2; QL INSULIN LISPRO JUNIOR KWIKPEN - Tier 2; PA; QL HUMULIN 70/30 KWIKPEN - Tier 2; QL INSULIN LISPRO PROT & LISPRO - Tier 2; PA; QL HUMULIN 70/30 VIAL - Tier 2; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL HUMULIN N VIAL - Tier 2; QL NOVOLIN 70/30 FLEXPEN RELION - Tier 2; PA; QL HUMULIN R U-500 KWIKPEN - Tier 2; QL NOVOLIN 70/30 VIAL - Tier 2; PA; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; QL SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR - Tier 2; PA; HUMULIN R VIAL - Tier 2; QL QL LANTUS SOLOSTAR - Tier 2; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; QL TOUJEO SOLOSTAR - Tier 2; PA; QL LEVEMIR U-100 FLEXTOUCH - Tier 2; QL TRESIBA - Tier 2; PA; QL LEVEMIR U-100 VIAL - Tier 2; QL TRESIBA FLEXTOUCH - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents NOVOLIN 70/30 RELION - Tier 2; QL NOVOLIN N FLEXPEN - Tier 2; QL NOVOLIN N FLEXPEN RELION - Tier 2; QL NOVOLIN N RELION - Tier 2; QL NOVOLIN N VIAL - Tier 2; QL NOVOLIN R FLEXPEN - Tier 2; QL NOVOLIN R FLEXPEN RELION - Tier 2; QL NOVOLIN R RELION - Tier 2; QL NOVOLIN R VIAL - Tier 2; QL NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2 NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; QL SEMGLEE SUBCUTANEOUS SOLUTION - Tier 2; QL Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2 ACD-A NOCLOT-50 (brand for acd formula a) - Tier 2; PA enoxaparin sodium (generic for LOVENOX) - Tier 1 anticoagulant cit dext soln a (generic for ACD-A NOCLOT-50) - Tier 1; PA ARIXTRA (brand for fondaparinux sodium) - Tier 2; PA heparin sodium (porcine) injection solution 10000 unit/ml, 5000 unit/ml ELIQUIS DVT/PE STARTER PACK - Tier 2; PA - Tier 1 fondaparinux sodium (generic for ARIXTRA) - Tier 1; PA jantoven (generic for JANTOVEN) - Tier 1 FRAGMIN - Tier 2; PA PRADAXA - Tier 2 heparin sodium (porcine) pf injection solution 5000 unit/0.5ml - Tier 1; PA warfarin sodium oral (generic for JANTOVEN) - Tier 1 LOVENOX (brand for enoxaparin sodium) - Tier 2; PA XARELTO - Tier 2 SAVAYSA - Tier 2; PA; QL XARELTO STARTER PACK - Tier 2 TRICITRASOL - Tier 2; PA ZONTIVITY - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 AGRYLIN (brand for anagrelide hcl) - Tier 2; PA ARANESP (ALBUMIN FREE) - Tier 2; PA; SP DOPTELET - Tier 2; PA; SP; QL EPOGEN - Tier 2; PA; SP GRANIX SUBCUTANEOUS SOLUTION - Tier 2; PA FULPHILA - Tier 2; QL GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; NEUPOGEN - Tier 2; SP PA; SP OXBRYTA - Tier 2; PA; SP; QL LEUKINE - Tier 2; PA; SP PROMACTA ORAL PACKET 25 MG - Tier 2; PA; SP; QL MOZOBIL - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, MULPLETA - Tier 2; PA; QL 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP NEULASTA - Tier 2; PA; SP; QL UDENYCA - Tier 2; SP; QL NEULASTA ONPRO - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP ONUREG - Tier 2; PA; SP; QL PROCRIT - Tier 2; PA; SP PROMACTA ORAL PACKET 12.5 MG - Tier 2; PA PROMACTA ORAL TABLET 12.5 MG - Tier 2; PA; SP PROMACTA ORAL TABLET 25 MG, 50 MG, 75 MG - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA ZARXIO - Tier 2; PA; SP; QL ZIEXTENZO - Tier 2; PA; SP Hemostasis Agents - Drugs to Stop Bleeding ASTRINGYN - Tier 2; PA monsels ferric subsulfate - Tier 1; PA RECOTHROM - Tier 2; PA RECOTHROM SPRAY KIT - Tier 2; PA TAVALISSE - Tier 2; PA THROMBOGEN - Tier 2; PA Platelet Modifying Agents - Platelet Modifying Drugs BRILINTA - Tier 2 aspirin-dipyridamole er - Tier 1; PA cilostazol - Tier 1; QL ASPIRIN-OMEPRAZOLE - Tier 2; PA clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1 CABLIVI - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents prasugrel hcl (generic for EFFIENT) - Tier 1 dipyridamole oral - Tier 1; PA DURLAZA - Tier 2; PA EFFIENT (brand for prasugrel hcl) - Tier 2; PA PLAVIX (brand for clopidogrel bisulfate) - Tier 2; PA YOSPRALA (brand for aspirin-omeprazole) - Tier 2; PA Cardiovascular Agents Cardiovascular Agents, Other NEXLIZET - Tier 2; PA; QL Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs CATAPRES-TTS-1 (brand for clonidine) - Tier 2; QL CATAPRES (brand for clonidine hcl) - Tier 2; PA CATAPRES-TTS-2 (brand for clonidine) - Tier 2; QL NORTHERA - Tier 2; PA; SP; QL CATAPRES-TTS-3 (brand for clonidine) - Tier 2; QL clonidine (generic for CATAPRES-TTS-1) - Tier 1; QL PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED clonidine hcl oral (generic for CATAPRES) - Tier 1 SYRINGE 1-0.9 MG/10ML-%, 20-0.9 MG/50ML-% - Tier 2; PA guanfacine hcl - Tier 1 methyldopa - Tier 1 midodrine hcl - Tier 1; QL Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1 CARDURA (brand for doxazosin mesylate) - Tier 2; PA prazosin hcl oral (generic for MINIPRESS) - Tier 1 DIBENZYLINE (brand for phenoxybenzamine hcl) - Tier 2; PA; QL MINIPRESS (brand for prazosin hcl) - Tier 2; PA phenoxybenzamine hcl oral (generic for DIBENZYLINE) - Tier 1; PA; QL Angiotensin II Receptor Antagonists - Blood Pressure Drugs losartan potassium oral (generic for COZAAR) - Tier 1 ATACAND (brand for candesartan cilexetil) - Tier 2; PA valsartan (generic for DIOVAN) - Tier 1 AVAPRO (brand for irbesartan) - Tier 2; PA BENICAR (brand for olmesartan medoxomil) - Tier 2; PA candesartan cilexetil (generic for ATACAND) - Tier 1; PA COZAAR (brand for losartan potassium) - Tier 2; PA DIOVAN (brand for valsartan) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents EDARBI - Tier 2; PA; QL irbesartan (generic for AVAPRO) - Tier 1; PA MICARDIS (brand for telmisartan) - Tier 2; PA olmesartan medoxomil oral (generic for BENICAR) - Tier 1; PA telmisartan (generic for MICARDIS) - Tier 1; PA Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1 ACCUPRIL (brand for quinapril hcl) - Tier 2; PA enalapril maleate oral (generic for VASOTEC) - Tier 1 ALTACE (brand for ramipril) - Tier 2; PA lisinopril oral (generic for PRINIVIL) - Tier 1 captopril oral - Tier 1; PA EPANED - Tier 2; PA fosinopril sodium - Tier 1; PA LOTENSIN (brand for benazepril hcl) - Tier 2; PA moexipril hcl - Tier 1; PA perindopril erbumine - Tier 1; PA PRINIVIL (brand for lisinopril) - Tier 2; PA QBRELIS - Tier 2; PA quinapril hcl (generic for ACCUPRIL) - Tier 1; PA ramipril (generic for ALTACE) - Tier 1; PA trandolapril - Tier 1; PA VASOTEC (brand for enalapril maleate) - Tier 2; PA ZESTRIL (brand for lisinopril) - Tier 2; PA Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 100 mg (generic for PACERONE) - Tier 1; BETAPACE (brand for sotalol hcl) - Tier 2; PA QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA dofetilide (generic for TIKOSYN) - Tier 1; PA; QL amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - MULTAQ - Tier 2; PA; QL Tier 1 NORPACE (brand for disopyramide phosphate) - Tier 2; PA disopyramide phosphate (generic for NORPACE) - Tier 1 NORPACE CR - Tier 2; PA flecainide acetate - Tier 1 PACERONE ORAL TABLET 100 MG (brand for amiodarone hcl) - Tier 2; mexiletine hcl oral - Tier 1 PA; QL pacerone oral tablet 200 mg (generic for PACERONE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents propafenone hcl - Tier 1 PACERONE ORAL TABLET 400 MG (brand for amiodarone hcl) - Tier 2; quinidine sulfate - Tier 1 PA sotalol hcl (af) (generic for BETAPACE AF) - Tier 1 sotalol hcl oral (generic for BETAPACE) - Tier 1 propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg (generic for RYTHMOL SR) - Tier 1; PA; QL propafenone hcl er oral capsule extended release 12 hour 425 mg (generic for RYTHMOL SR) - Tier 1; PA quinidine gluconate er - Tier 1; PA; QL RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 225 MG, 325 MG (brand for propafenone hcl er) - Tier 2; PA; QL RYTHMOL SR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 425 MG (brand for propafenone hcl er) - Tier 2; PA SOTYLIZE - Tier 2; PA TIKOSYN (brand for dofetilide) - Tier 2; PA; QL Beta-adrenergic Blocking Agents - Blood Pressure Drugs atenolol oral (generic for TENORMIN) - Tier 1 acebutolol hcl oral - Tier 1; PA BYSTOLIC - Tier 2 ATENOLOL+SYRSPEND SF - Tier 2; PA; QL carvedilol (generic for COREG) - Tier 1 betaxolol hcl oral - Tier 1; PA labetalol hcl oral - Tier 1 bisoprolol fumarate - Tier 1; PA metoprolol succinate er (generic for TOPROL XL) - Tier 1 carvedilol phosphate er (generic for COREG CR) - Tier 1; PA metoprolol tartrate oral (generic for LOPRESSOR) - Tier 1 COREG (brand for carvedilol) - Tier 2; PA propranolol hcl er (generic for INDERAL LA) - Tier 1 COREG CR (brand for carvedilol phosphate er) - Tier 2; PA propranolol hcl oral - Tier 1 CORGARD (brand for nadolol) - Tier 2; PA FIRST - METOPROLOL - Tier 2; PA; QL FIRST-ATENOLOL - Tier 2; PA; QL HEMANGEOL - Tier 2; PA INDERAL LA (brand for propranolol hcl er) - Tier 2; PA INDERAL XL - Tier 2; PA INNOPRAN XL - Tier 2; PA KAPSPARGO SPRINKLE - Tier 2; PA LOPRESSOR (brand for metoprolol tartrate) - Tier 2; PA nadolol oral (generic for CORGARD) - Tier 1; PA pindolol - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents TENORMIN (brand for atenolol) - Tier 2; PA timolol maleate oral - Tier 1; PA TOPROL XL (brand for metoprolol succinate er) - Tier 2; PA Calcium Channel Blocking Agents - Blood Pressure Drugs amlodipine besylate oral (generic for NORVASC) - Tier 1 ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG cartia xt (generic for CARTIA XT) - Tier 1 (brand for nifedipine er) - Tier 2; PA diltiazem hcl er - Tier 1 AMLODIPINE BES+SYRSPEND SF - Tier 2; PA; QL diltiazem hcl er beads capsule extended release 24 hour 240 mg oral CALAN SR (brand for verapamil hcl er) - Tier 2; PA (generic for TAZTIA XT) - Tier 1 CARDIZEM (brand for diltiazem hcl) - Tier 2; PA CARDIZEM CD (brand for diltiazem hcl er coated beads) - Tier 2; PA diltiazem hcl er beads capsule extended release 24 hour 240 mg oral CARDIZEM LA - Tier 2; PA (generic for TAZTIA XT) - Tier 1; QL CONJUPRI - Tier 2; PA; QL diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 300 mg, 360 mg (generic for TAZTIA XT) - Tier 1 (generic for MATZIM LA) - Tier 1; PA felodipine er - Tier 1; PA diltiazem hcl er beads oral capsule extended release 24 hour 420 mg isradipine - Tier 1; PA (generic for TIADYLT ER) - Tier 1 KATERZIA - Tier 2; PA matzim la (generic for MATZIM LA) - Tier 1; PA diltiazem hcl er coated beads oral capsule extended release 24 hour nicardipine hcl oral - Tier 1; PA (generic for CARTIA XT) - Tier 1 nisoldipine er - Tier 1; PA diltiazem hcl oral (generic for CARDIZEM) - Tier 1 NORVASC (brand for amlodipine besylate) - Tier 2; PA dilt-xr - Tier 1 PROCARDIA (brand for nifedipine) - Tier 2; PA nifedipine er (generic for AFEDITAB CR) - Tier 1 PROCARDIA XL (brand for nifedipine er osmotic release) - Tier 2; PA nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1 SULAR (brand for nisoldipine er) - Tier 2; PA nifedipine oral (generic for PROCARDIA) - Tier 1 tiadylt er (generic for TAZTIA XT) - Tier 1; PA nimodipine oral - Tier 1; QL TIAZAC (brand for diltiazem hcl er beads) - Tier 2; PA NYMALIZE - Tier 2; QL taztia xt (generic for TAZTIA XT) - Tier 1 verapamil hcl er oral capsule extended release 24 hour (generic for verapamil hcl er oral tablet extended release (generic for CALAN SR) - VERELAN) - Tier 1; PA Tier 1 VERELAN (brand for verapamil hcl er) - Tier 2; PA verapamil hcl oral - Tier 1 VERELAN PM (brand for verapamil hcl er) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL ACCURETIC (brand for quinapril-hydrochlorothiazide) - Tier 2; PA amlodipine besylate-benazepril hcl - Tier 1 ALDACTAZIDE (brand for spironolactone-hctz) - Tier 2; PA; QL amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1 aliskiren fumarate (generic for TEKTURNA) - Tier 1; PA amlodipine-valsartan-hctz (generic for EXFORGE HCT) - Tier 1 amlodipine-atorvastatin (generic for CADUET) - Tier 1; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1 amlodipine-olmesartan (generic for AZOR) - Tier 1; PA benazepril-hydrochlorothiazide - Tier 1 ATACAND HCT (brand for candesartan cilexetil-hctz) - Tier 2; PA bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1 AVALIDE (brand for irbesartan-hydrochlorothiazide) - Tier 2; PA digitek (generic for DIGITEK) - Tier 1 AZOR (brand for amlodipine-olmesartan) - Tier 2; PA digox (generic for DIGITEK) - Tier 1 BENICAR HCT (brand for olmesartan medoxomil-hctz) - Tier 2; PA digoxin oral tablet (generic for DIGITEK) - Tier 1 BIDIL - Tier 2; PA ENTRESTO - Tier 2; QL CADUET (brand for amlodipine-atorvastatin) - Tier 2; PA; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1 candesartan cilexetil-hctz (generic for ATACAND HCT) - Tier 1; PA losartan potassium-hctz (generic for HYZAAR) - Tier 1 captopril-hydrochlorothiazide - Tier 1; PA pentoxifylline er - Tier 1 CONSENSI - Tier 2; PA; QL CORLANOR - Tier 2; PA; QL ranolazine er oral tablet extended release 12 hour 1000 mg (generic DEMSER (brand for metyrosine) - Tier 2; PA; QL for RANEXA) - Tier 1; PA digoxin oral solution - Tier 1; PA DIOVAN HCT (brand for valsartan-hydrochlorothiazide) - Tier 2; PA ranolazine er oral tablet extended release 12 hour 500 mg (generic for DUTOPROL - Tier 2; PA; QL RANEXA) - Tier 1; PA; QL DYAZIDE (brand for triamterene-hctz) - Tier 2; PA spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL EDARBYCLOR - Tier 2; PA triamterene-hctz (generic for MAXZIDE-25) - Tier 1 enalapril-hydrochlorothiazide - Tier 1; PA valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED VYNDAMAX - Tier 2; PA; SP; QL SYRINGE 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% - Tier 2; PA VYNDAQEL - Tier 2; PA; SP; QL EQUAPAX/ATORVASTATIN/COQ10 - Tier 2; PA EXFORGE (brand for amlodipine besylate-valsartan) - Tier 2; PA EXFORGE HCT (brand for amlodipine-valsartan-hctz) - Tier 2; PA fosinopril sodium-hctz - Tier 1; PA HYZAAR (brand for losartan potassium-hctz) - Tier 2; PA irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 58 Preferred Agents Non-Preferred Agents isoxsuprine hcl oral - Tier 1; PA LANOXIN ORAL TABLET 125 MCG, 250 MCG (brand for digoxin) - Tier 2; PA LANOXIN ORAL TABLET 62.5 MCG - Tier 2; PA; QL LOPRESSOR HCT (brand for metoprolol-hydrochlorothiazide) - Tier 2; PA LOTENSIN HCT (brand for benazepril-hydrochlorothiazide) - Tier 2; PA LOTREL (brand for amlodipine besy-benazepril hcl) - Tier 2; PA MAXZIDE (brand for triamterene-hctz) - Tier 2; PA MAXZIDE-25 (brand for triamterene-hctz) - Tier 2; PA methyldopa-hydrochlorothiazide - Tier 1; PA metoprolol-hydrochlorothiazide - Tier 1; PA metyrosine (generic for DEMSER) - Tier 1; PA; QL MICARDIS HCT (brand for telmisartan-hctz) - Tier 2; PA olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; PA olmesartan-amlodipine-hctz (generic for TRIBENZOR) - Tier 1; PA OMEGA-3/D-3 WELLNESS PACK (brand for sure result o3d3 system) - Tier 2; PA PRESTALIA - Tier 2; PA; QL propranolol-hctz - Tier 1; PA quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; PA RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG (brand for ranolazine er) - Tier 2; PA RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 500 MG (brand for ranolazine er) - Tier 2; PA; QL SURE RESULT O3D3 SYSTEM - Tier 2; PA TARKA (brand for trandolapril-verapamil hcl er) - Tier 2; PA TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA TEKTURNA HCT - Tier 2; PA telmisartan-amlodipine (generic for TWYNSTA) - Tier 1; PA telmisartan-hctz (generic for MICARDIS HCT) - Tier 1; PA TENORETIC 100 (brand for atenolol-chlorthalidone) - Tier 2; PA TENORETIC 50 (brand for atenolol-chlorthalidone) - Tier 2; PA trandolapril-verapamil hcl er - Tier 1; PA TRIBENZOR (brand for olmesartan-amlodipine-hctz) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents TWYNSTA (brand for telmisartan-amlodipine) - Tier 2; PA VASERETIC (brand for enalapril-hydrochlorothiazide) - Tier 2; PA VECAMYL - Tier 2; PA; QL ZESTORETIC (brand for lisinopril-hydrochlorothiazide) - Tier 2; PA ZIAC (brand for bisoprolol-hydrochlorothiazide) - Tier 2; PA Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs KEVEYIS - Tier 2; PA; SP methazolamide oral - Tier 1; PA Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1 BUMEX (brand for bumetanide) - Tier 2; PA furosemide oral solution - Tier 1 EDECRIN (brand for ethacrynic acid) - Tier 2; PA; QL furosemide oral tablet (generic for LASIX) - Tier 1; QL ethacrynic acid (generic for EDECRIN) - Tier 1; PA; QL torsemide - Tier 1; QL LASIX (brand for furosemide) - Tier 2; PA; QL Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL ALDACTONE (brand for spironolactone) - Tier 2; PA; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL CAROSPIR - Tier 2; PA; QL DYRENIUM (brand for triamterene) - Tier 2; PA eplerenone (generic for INSPRA) - Tier 1; PA; QL INSPRA (brand for eplerenone) - Tier 2; PA; QL triamterene oral (generic for DYRENIUM) - Tier 1; PA Diuretics, Thiazide - Cardiac Drugs chlorthalidone - Tier 1; QL DIURIL - Tier 2 hydrochlorothiazide oral - Tier 1 indapamide - Tier 1; QL metolazone - Tier 1; QL Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate oral tablet 145 mg, 48 mg (generic for TRICOR) - Tier 1 ANTARA - Tier 2; PA fenofibrate oral tablet 160 mg, 54 mg - Tier 1 fenofibrate micronized - Tier 1; PA gemfibrozil oral (generic for LOPID) - Tier 1 fenofibrate oral capsule - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents fenofibrate oral tablet 120 mg, 40 mg (generic for FENOGLIDE) - Tier 1; PA fenofibric acid (generic for FIBRICOR) - Tier 1; PA FENOGLIDE (brand for fenofibrate) - Tier 2; PA FIBRICOR (brand for fenofibric acid) - Tier 2; PA LIPOFEN (brand for fenofibrate) - Tier 2; PA LOPID (brand for gemfibrozil) - Tier 2; PA TRICOR (brand for fenofibrate) - Tier 2; PA TRILIPIX (brand for fenofibric acid) - Tier 2; PA Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL ALTOPREV - Tier 2; PA; QL lovastatin - Tier 1; QL CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL pravastatin sodium - Tier 1; QL EZALLOR SPRINKLE - Tier 2; PA; QL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL FLOLIPID - Tier 2; PA simvastatin oral (generic for ZOCOR) - Tier 1; QL fluvastatin sodium - Tier 1; PA; QL fluvastatin sodium er (generic for LESCOL XL) - Tier 1; PA; QL LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA; QL LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL LIVALO - Tier 2; PA; QL PRAVACHOL (brand for pravastatin sodium) - Tier 2; PA; QL ZOCOR (brand for simvastatin) - Tier 2; PA; QL ZYPITAMAG - Tier 2; PA; QL Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light (generic for PREVALITE) - Tier 1 colesevelam hcl (generic for WELCHOL) - Tier 1; PA cholestyramine oral (generic for QUESTRAN) - Tier 1 COLESTID (brand for colestipol hcl) - Tier 2; PA colestipol hcl oral tablet (generic for COLESTID) - Tier 1 COLESTID FLAVORED (brand for colestipol hcl) - Tier 2; PA ezetimibe (generic for ZETIA) - Tier 1 colestipol hcl oral granules (generic for COLESTID) - Tier 1; PA NIASPAN (brand for niacin er (antihyperlipidemic)) - Tier 2 colestipol hcl oral packet (generic for COLESTID) - Tier 1; PA prevalite (generic for PREVALITE) - Tier 1 ezetimibe-simvastatin (generic for VYTORIN) - Tier 1; PA; QL REPATHA - Tier 2; PA; SP; QL icosapent ethyl (generic for VASCEPA) - Tier 1; PA JUXTAPID - Tier 2; PA; SP; QL LOVAZA (brand for omega-3-acid ethyl esters) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents NEXLETOL - Tier 2; PA; AL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; PA; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; PA niacor (generic for NIACOR) - Tier 1; PA; QL OMEGA-3 RX COMPLETE - Tier 2; PA; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA PRALUENT - Tier 2; PA; SP; QL QUESTRAN (brand for cholestyramine) - Tier 2; PA QUESTRAN LIGHT (brand for cholestyramine light) - Tier 2; PA VASCEPA (brand for icosapent ethyl) - Tier 2; PA VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL WELCHOL (brand for colesevelam hcl) - Tier 2; PA ZETIA (brand for ezetimibe) - Tier 2; PA Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1 Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg - Tier 1 DILATRATE-SR - Tier 2; PA; QL isosorbide dinitrate oral tablet 5 mg (generic for ISORDIL GONITRO - Tier 2; PA TITRADOSE) - Tier 1 isosorbide mononitrate - Tier 1 ISORDIL TITRADOSE ORAL TABLET 40 MG (brand for isosorbide isosorbide mononitrate er - Tier 1; QL dinitrate) - Tier 2; PA; QL minitran (generic for MINITRAN) - Tier 1; QL NITRO-BID - Tier 2; QL ISORDIL TITRADOSE ORAL TABLET 5 MG (brand for isosorbide nitroglycerin sublingual (generic for NITROSTAT) - Tier 1 dinitrate) - Tier 2; PA nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; ST isosorbide dinitrate oral tablet 40 mg (generic for ISORDIL TITRADOSE) - NITROMIST - Tier 2 Tier 1; PA; QL nitro-time - Tier 1 NITRO-DUR (brand for nitroglycerin) - Tier 2; PA; QL NITROLINGUAL (brand for nitroglycerin) - Tier 2; PA; ST NITROSTAT (brand for nitroglycerin) - Tier 2; PA RECTIV - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; QL ZEPOSIA STARTER KIT - Tier 2; PA; SP; QL Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA; SP; QL KESIMPTA - Tier 2; PA; SP; QL Central Nervous System Agents - Drugs to Treat Nerve Conditions Central Nervous System, Other - Miscellaneous Central Nervous System Drugs caffeine citrate oral - Tier 1; QL ALLI - Tier 2; PA INGREZZA ORAL CAPSULE THERAPY PACK - Tier 2; PA; SP; QL AUSTEDO ORAL TABLET 12 MG, 9 MG - Tier 2; PA; SP AUSTEDO ORAL TABLET 6 MG - Tier 2; PA; SP; QL CONVENIENCE PAK - Tier 2; PA GRALISE - Tier 2; PA HORIZANT - Tier 2; PA INGREZZA ORAL CAPSULE 40 MG - Tier 2; PA; SP INGREZZA ORAL CAPSULE 80 MG - Tier 2; PA; QL LIPRITIN II - Tier 2; PA; QL NAMZARIC - Tier 2; PA NUEDEXTA - Tier 2; PA; QL RILUTEK (brand for riluzole) - Tier 2; PA riluzole (generic for RILUTEK) - Tier 1; PA SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 140 MG/7ML - Tier 2; PA tetrabenazine (generic for XENAZINE) - Tier 1; PA; SP; QL TIGLUTIK - Tier 2; PA; QL XENAZINE (brand for tetrabenazine) - Tier 2; PA; SP; QL XENICAL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain SAVELLA - Tier 2 SAVELLA TITRATION PACK - Tier 2 Multiple Sclerosis Agents - Multiple Sclerosis Drugs AVONEX PEN - Tier 2; SP AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL AVONEX PREFILLED - Tier 2; SP; QL AUBAGIO - Tier 2; PA; SP BETASERON - Tier 2; SP COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 20 MG/ML (brand for glatiramer acetate) - Tier 2; SP MG/ML (brand for glatiramer acetate) - Tier 2; PA; SP dalfampridine er (generic for AMPYRA) - Tier 1; PA; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; PA; SP dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; SP EXTAVIA - Tier 2; PA; SP GILENYA - Tier 2; SP glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP REBIF REBIDOSE - Tier 2; SP glatopa (generic for GLATOPA) - Tier 1; PA; SP REBIF REBIDOSE TITRATION PACK - Tier 2; SP MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL MCG/0.5ML - Tier 2; SP MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 44 MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL MCG/0.5ML - Tier 2; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; SP MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL TECFIDERA ORAL CAPSULE DELAYED RELEASE (brand for MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL dimethyl fumarate) - Tier 2; SP MAYZENT - Tier 2; PA; SP MAYZENT STARTER PACK - Tier 2; PA; SP PLEGRIDY - Tier 2; PA; SP PLEGRIDY STARTER PACK - Tier 2; PA; SP TECFIDERA STARTER PACK (brand for dimethyl fumarate starter pack) - Tier 2; PA; SP VUMERITY - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 64 Preferred Agents Non-Preferred Agents Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 ANBESOL MAXIMUM STRENGTH MOUTH/THROAT GEL (brand for chlorhexidine gluconate mouth/throat (generic for PAROEX) - Tier 1 goodsense oral pain relief) - Tier 2; PA denta 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL ANBESOL MOUTH/THROAT GEL - Tier 2; PA dentagel (generic for CAVAREST) - Tier 1 AQUORAL (brand for ra dry mouth) - Tier 2; PA; QL oralone (generic for ORALONE) - Tier 1; QL BABY ANBESOL (brand for baby teething) - Tier 2; PA paroex (generic for PAROEX) - Tier 1 baby teething oral pain (generic for BABY ANBESOL) - Tier 1; PA periogard (generic for PAROEX) - Tier 1 cevimeline hcl (generic for EVOXAC) - Tier 1; PA pilocarpine hcl oral (generic for SALAGEN) - Tier 1 cherry cough drops (generic for DENTIVA) - Tier 1; PA PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2 cherry menthol drops (generic for DENTIVA) - Tier 1; PA PREVIDENT 5000 PLUS (brand for sodium fluoride 5000 ppm) - Tier clinpro 5000 (generic for CLINPRO 5000) - Tier 1; PA 2; QL cold sore treatment external liquid 0.13 % - Tier 1; PA PREVIDENT DENTAL (brand for sf) - Tier 2 sf (generic for CAVAREST) - Tier 1 cough drops mouth/throat lozenge 8.4 mg (generic for DENTIVA) - Tier 1; sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL PA DEBACTEROL - Tier 2; PA sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; dry mouth (generic for AQUORAL) - Tier 1; PA; QL QL easygel - Tier 1; PA EPISIL - Tier 2; PA sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 eql cold sore treatment - Tier 1; PA PLUS) - Tier 1; QL EVOXAC (brand for cevimeline hcl) - Tier 2; PA FIRST-MOUTHWASH BLM - Tier 2; PA sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; fluoridex (generic for CLINPRO 5000) - Tier 1; PA QL fluoridex daily renewal - Tier 1; PA sodium fluoride dental gel (generic for CAVAREST) - Tier 1 fluoridex enhanced whitening (generic for CLINPRO 5000) - Tier 1; PA triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; fluoridex sensitivity relief (generic for FLUORIDEX SENSITIVITY RELIEF) QL - Tier 1; PA GELCLAIR - Tier 2; PA GELX - Tier 2; PA GLY-OXIDE (brand for ra antiseptic mouth cleanser) - Tier 2; PA honey lemon drops (generic for DENTIVA) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents HURRICAINE MOUTH/THROAT GEL (brand for goodsense oral pain relief) - Tier 2; PA larynex (generic for DENTIVA) - Tier 1; PA little teethers pain relief mouth/throat gel 7.5 % (generic for BABY ANBESOL) - Tier 1; PA menthol drops (generic for DENTIVA) - Tier 1; PA MOUTH KOTE REMINT (brand for ra dry mouth) - Tier 2; PA; QL MUCOSITISRX - Tier 2; PA MUCOTROL - Tier 2; PA MUGARD - Tier 2; PA NAFRINSE DAILY ACIDULATED - Tier 2; PA NAFRINSE DAILY/NEUTRAL - Tier 2; PA NAFRINSE WEEKLY - Tier 2; PA natural herb cough drops (generic for DENTIVA) - Tier 1; PA nycoff (generic for DENTIVA) - Tier 1; PA oral analgesic max st mouth/throat gel (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA oral anesthetic max str (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA oral pain relief mouth/throat gel 20 % (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA ORAMAGICRX - Tier 2; PA PERIDEX (brand for chlorhexidine gluconate) - Tier 2; PA PREVIDENT 5000 BOOSTER PLUS (brand for sodium fluoride 5000 ppm) - Tier 2; PA PREVIDENT 5000 ENAMEL PROTECT (brand for sodium fluoride 5000 sensitive) - Tier 2; PA PREVIDENT 5000 ORTHO DEFENSE (brand for sodium fluoride 5000 ppm) - Tier 2; PA PREVIDENT 5000 SENSITIVE (brand for sodium fluoride 5000 sensitive) - Tier 2; PA qc sore throat (generic for DENTIVA) - Tier 1; PA ra anesthetic oral (generic for ANBESOL MAXIMUM STRENGTH) - Tier 1; PA ra antiseptic mouth cleanser (generic for GLY-OXIDE) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 66 Preferred Agents Non-Preferred Agents ra baby care oral pain relief (generic for BABY ANBESOL) - Tier 1; PA ra cold sore treatment - Tier 1; PA ra dry mouth (generic for AQUORAL) - Tier 1; PA; QL SALAGEN (brand for pilocarpine hcl) - Tier 2; PA SALICEPT - Tier 2; PA SALIVAMAX - Tier 2; PA sodium fluoride 5000 ppm dental paste (generic for CLINPRO 5000) - Tier 1; PA sodium fluoride 5000 sensitive (generic for FLUORIDEX SENSITIVITY RELIEF) - Tier 1; PA TOPEX TOPICAL ANESTHETIC - Tier 2; PA XEROSTOMIA RELIEF SPRAY (brand for ra dry mouth) - Tier 2; PA; QL ZILACTIN BABY - Tier 2; PA Dermatological Agents - Drugs to Treat Skin Conditions acitretin (generic for SORIATANE) - Tier 1; PA ABSORICA LD - Tier 2; PA; QL ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1 ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG (brand for ammonium lactate external (generic for AL12) - Tier 1; QL isotretinoin) - Tier 2; PA amnesteem oral capsule 10 mg, 20 mg (generic for AMNESTEEM) - ABSORICA ORAL CAPSULE 25 MG, 35 MG - Tier 2; PA Tier 1; PA ABSORICA ORAL CAPSULE 40 MG (brand for isotretinoin) - Tier 2; PA; QL amnesteem oral capsule 40 mg (generic for AMNESTEEM) - Tier 1; ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA PA; QL acne (generic for CLEARSKIN) - Tier 1; PA avar cleanser (generic for AVAR CLEANSER) - Tier 1 acne control cleanser (generic for CLEARSKIN) - Tier 1; PA BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2 acne medication 10 external lotion - Tier 1; PA; QL benzoyl peroxide-erythromycin (generic for BENZAMYCIN) - Tier 1; acne medication 5 external lotion - Tier 1; PA QL betamethasone valerate external cream - Tier 1 acne treatment external cream 10 % (generic for CLEARSKIN) - Tier 1; betamethasone valerate external lotion - Tier 1 PA betamethasone valerate external ointment - Tier 1 ACZONE (brand for dapsone) - Tier 2; PA; QL calcipotriene external ointment (generic for CALCITRENE) - Tier 1; adapalene external cream (generic for DIFFERIN) - Tier 1; PA; QL PA; QL adapalene external gel (generic for DIFFERIN) - Tier 1; PA; QL calcipotriene external solution - Tier 1; PA; QL ADAPALENE EXTERNAL PAD - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 67 Preferred Agents Non-Preferred Agents CARAC (brand for fluorouracil) - Tier 2; PA; QL ADAPALENE EXTERNAL SOLUTION - Tier 2; PA; QL claravis capsule 30 mg oral (generic for CLARAVIS) - Tier 1; PA ADAPALENE-BENZOYL PER-CLINDAMY - Tier 2; PA; QL claravis capsule 30 mg oral (generic for CLARAVIS) - Tier 1; PA; QL ADAPALENE-BENZOYL PER-NIACINAM - Tier 2; PA; QL claravis oral capsule 10 mg, 20 mg, 40 mg (generic for AMNESTEEM) adapalene-benzoyl peroxide (generic for EPIDUO) - Tier 1; PA; QL - Tier 1; PA; QL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL WASH) - Tier 1; PA clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL advanced acne spot treat (generic for CLEAN & CLEAR ACNE SCRUB) - clindamycin phosphate-benzoyl peroxide (generic for BENZACLIN) - Tier 1; PA Tier 1; PA ADVANCED ALLERGY COLLECTION - Tier 2; PA; QL clindamycin phosphate external solution - Tier 1; QL advanced healing (generic for DERMAPHOR) - Tier 1; PA clindamycin phosphate external swab (generic for CLINDACIN ETZ) - AKLIEF - Tier 2; PA; QL Tier 1; QL ALA SCALP - Tier 2; PA clobetasol propionate external cream (generic for TEMOVATE) - Tier 1 alclometasone dipropionate - Tier 1; PA clobetasol propionate external gel - Tier 1 ALDARA (brand for imiquimod) - Tier 2; PA; QL ALEVAMAX - Tier 2; PA clobetasol propionate external ointment (generic for TEMOVATE) - ALOE VESTA DAILY MOISTURIZER - Tier 2; PA Tier 1 ALTRENO - Tier 2; PA clobetasol propionate external solution - Tier 1 alum sulfate-ca acetate (generic for DOMEBORO) - Tier 1; PA clotrimazole-betamethasone external cream - Tier 1 amcinonide - Tier 1; PA COSENTYX - Tier 2; SP AMELUZ - Tier 2; PA diclofenac sodium external gel 3 % - Tier 1; PA americerin (generic for AMERICERIN) - Tier 1; PA DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene) - Tier 2; QL AMZEEQ - Tier 2; PA; QL DRYSOL - Tier 2 ana-lex (generic for ANA-LEX) - Tier 1; PA ELIDEL (brand for pimecrolimus) - Tier 2; PA; QL anti-dandruff (generic for SELSUN BLUE) - Tier 1; PA erythromycin external solution - Tier 1; QL APEXICON E - Tier 2; PA FLUOROURACIL EXTERNAL CREAM 0.5 % - Tier 2; PA; QL AQUAPHILIC (brand for cvs advanced healing) - Tier 2; PA fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; PA AQUAPHOR (brand for cvs advanced healing) - Tier 2; PA fluticasone propionate external cream - Tier 1 ARAZLO - Tier 2; PA; QL fluticasone propionate external ointment - Tier 1 ARTHRITIS PAIN RELIEVING - Tier 2; PA; QL halobetasol propionate external cream - Tier 1 astringent solution (generic for DOMEBORO) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents halobetasol propionate external ointment - Tier 1 ATOPADERM - Tier 2; PA hm hydrocortisone plus (generic for CORTIZONE-10 INTENSIVE ATOPICLAIR (brand for alevamax) - Tier 2; PA HEALING) - Tier 1 ATRALIN (brand for tretinoin) - Tier 2; PA; QL hm hydrocortisone-aloe max st (generic for CORTIZONE-10 AVAR LS CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; INTENSIVE HEALING) - Tier 1 PA hydrocortisone acetate external ointment - Tier 1 AVAR-E EMOLLIENT (brand for sulfacetamide sodium-sulfur) - Tier 2; PA hydrocortisone anti-itch external cream 0.5 % - Tier 1 AVAR-E GREEN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA hydrocortisone external cream - Tier 1 AVAR-E LS (brand for sulfacetamide sodium-sulfur) - Tier 2; PA hydrocortisone external lotion 2.5 % - Tier 1 AVEIDAOXIA - Tier 2; PA; QL hydrocortisone external ointment - Tier 1 avita (generic for AVITA) - Tier 1; PA; QL hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE azelaic acid external (generic for FINACEA) - Tier 1; PA; QL HEALING) - Tier 1 AZELAIC ACID-NIACINAMIDE - Tier 2; PA; QL hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE AZELEX - Tier 2; PA; QL HEALING) - Tier 1 BASLE (brand for coconut oil beauty) - Tier 2; PA hydrocortisone-aloe - Tier 1 BEAU RX - Tier 2; PA imiquimod external (generic for ALDARA) - Tier 1; QL beauty 360 pure glycerin - Tier 1; PA instacort 5 - Tier 1 BENSAL HP - Tier 2; PA isotretinoin capsule 10 mg oral (generic for AMNESTEEM) - Tier 1; PA BENZ PER-CLIND-NIACIN-TRETIN - Tier 2; PA; QL isotretinoin capsule 10 mg oral (generic for AMNESTEEM) - Tier 1; BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA PA; QL BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - isotretinoin capsule 20 mg oral (generic for AMNESTEEM) - Tier 1; PA Tier 2; PA isotretinoin capsule 20 mg oral (generic for AMNESTEEM) - Tier 1; BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL PA; QL benzepro creamy wash (generic for BENZEPRO CREAMY WASH) - Tier isotretinoin capsule 30 mg oral (generic for CLARAVIS) - Tier 1; PA 1; PA isotretinoin capsule 30 mg oral (generic for CLARAVIS) - Tier 1; PA; BENZEPRO EXTERNAL - Tier 2; PA; QL QL BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % - Tier 2; PA; QL benzepro external foam 5.3 % - Tier 1; PA; QL isotretinoin capsule 40 mg oral (generic for AMNESTEEM) - Tier 1; BENZEPRO EXTERNAL LIQUID - Tier 2; PA; QL PA; QL benzepro foaming cloths - Tier 1; PA kls hydrocortisone plus (generic for CORTIZONE-10 INTENSIVE BENZEPRO SHORT CONTACT (brand for benzoyl peroxide) - Tier 2; PA; HEALING) - Tier 1 QL kp hydrocortisone-aloe - Tier 1 BENZOIN - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents mometasone furoate external - Tier 1 benzoin compound (generic for STERI-STRIP COMPOUND BENZOIN) - myorisan oral capsule 10 mg, 20 mg (generic for AMNESTEEM) - Tier Tier 1; PA 1; PA BENZOYL PEROX-HYDROCORTISONE - Tier 2; PA myorisan oral capsule 30 mg (generic for CLARAVIS) - Tier 1; PA benzoyl peroxide external foam (generic for BENZEPRO SHORT myorisan oral capsule 40 mg (generic for AMNESTEEM) - Tier 1; PA; CONTACT) - Tier 1; PA; QL QL BENZOYL PEROXIDE EXTERNAL GEL 6.5 % - Tier 2; PA; QL podofilox external - Tier 1; QL BENZOYL PEROXIDE EXTERNAL GEL 8 % - Tier 2; PA ra hydrocortisone plus (generic for CORTIZONE-10 INTENSIVE BENZOYL PEROXIDE FORTE- HC - Tier 2; PA; QL HEALING) - Tier 1 BESER EXTERNAL KIT - Tier 2; PA REGRANEX - Tier 2; QL beser external lotion (generic for BESER) - Tier 1; PA SANTYL - Tier 2; QL betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier 1; selenium sulfide external lotion - Tier 1 PA selenium sulfide external shampoo 2.25 % - Tier 1 betamethasone dipropionate external - Tier 1; PA sm hydrocortisone external cream 0.5 % - Tier 1 betamethasone valerate external foam (generic for LUXIQ) - Tier 1; PA sm hydrocortisone external ointment - Tier 1 sm hydrocortisone plus (generic for CORTIZONE-10 INTENSIVE betasept surgical scrub (generic for BETASEPT SURGICAL SCRUB) - HEALING) - Tier 1 Tier 1; PA boro-packs (generic for DOMEBORO) - Tier 1; PA sm hydrocortisone-aloe max st (generic for CORTIZONE-10 BOUDREAUXS BABY BUTT SMOOTH (brand for cvs advanced healing) INTENSIVE HEALING) - Tier 1 - Tier 2; PA sulfacetamide sodium-sulfur external emulsion (generic for AVAR boudreauxs butt paste external ointment 40 % (generic for CLEANSER) - Tier 1 BOUDREAUXS BUTT PASTE) - Tier 1; PA; QL triamcinolone acetonide external cream - Tier 1 bp 10-1 - Tier 1; PA triamcinolone acetonide external lotion - Tier 1 bp cleansing wash - Tier 1; PA triamcinolone acetonide external ointment - Tier 1 bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1; PA triderm (generic for TRIDERM) - Tier 1 zenatane oral capsule 10 mg, 20 mg (generic for AMNESTEEM) - Tier bp wash external liquid 7 % (generic for BENZEPRO CREAMY WASH) - 1; PA Tier 1; PA zenatane oral capsule 30 mg (generic for CLARAVIS) - Tier 1; PA BRYHALI - Tier 2; PA zenatane oral capsule 40 mg (generic for AMNESTEEM) - Tier 1; PA; calamine external lotion - Tier 1; PA QL calcipotriene external cream (generic for DOVONEX) - Tier 1; PA; QL CALCIPOTRIENE EXTERNAL FOAM - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents calcipotriene-betameth diprop (generic for TACLONEX) - Tier 1; PA; QL CALCIPOTRIENE-CLOBETASOL PROP - Tier 2; PA; QL CALCITRENE (brand for calcipotriene) - Tier 2; PA; QL calcitriol external (generic for VECTICAL) - Tier 1; PA; QL calicylic (generic for ATOPICLAIR) - Tier 1; PA CAPEX - Tier 2; PA capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; PA; QL capsaicin hp (generic for ZOSTRIX HP) - Tier 1; PA; QL capzix (generic for ZOSTRIX HP) - Tier 1; PA; QL CARRINGTON MOIST BARRIER/ZINC (brand for kerodex-51) - Tier 2; PA CARRINGTON MOISTURE BARRIER (brand for kerodex-51) - Tier 2; PA CEM-UREA - Tier 2; PA CERACADE (brand for iliderm) - Tier 2; PA cerovel (generic for CEROVEL) - Tier 1; PA; QL CHLOOXIA - Tier 2; PA; QL chlorhexidine gluconate external liquid 4 % (generic for BETASEPT SURGICAL SCRUB) - Tier 1; PA CICLOPIROX-CLOBETASOL - Tier 2; PA; QL CICLOPIROX-CLOBETASOL-SAL ACID - Tier 2; PA; QL CICLOPIROX-SALICYLIC ACID - Tier 2; PA; QL CIMETIDINE-LIDO-SALICYLIC ACID - Tier 2; PA; QL clearskin (generic for CLEARSKIN) - Tier 1; PA CLEOCIN-T (brand for clindamycin phosphate) - Tier 2; PA; QL CLINDACIN ETZ EXTERNAL KIT - Tier 2; PA CLINDACIN PAC - Tier 2; PA CLINDAGEL (brand for clindamycin phosphate) - Tier 2; PA; QL CLINDAMY-BENZOYL PER-NIACINAM - Tier 2; PA; QL CLINDAMYCIN PHOS-NIACINAMIDE - Tier 2; PA; QL clindamycin phosphate external foam (generic for EVOCLIN) - Tier 1; PA; QL clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1; PA; QL CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents clindamycin phosphate gel 1 % external (generic for CLINDAGEL) - Tier 1; PA; QL CLINDAMYCIN-NIACIN-TRETINOIN - Tier 2; PA; QL clindamycin-tretinoin (generic for VELTIN) - Tier 1; PA; QL CLIND-NIACIN-SPIRONOLAC-TRETIN - Tier 2; PA; QL CLINOIN - Tier 2; PA clobetasol prop emollient base - Tier 1; PA clobetasol propionate e - Tier 1; PA clobetasol propionate emulsion (generic for TOVET) - Tier 1; PA clobetasol propionate external foam (generic for OLUX) - Tier 1; PA clobetasol propionate external liquid (generic for CLOBEX SPRAY) - Tier 1; PA clobetasol propionate external lotion (generic for CLOBEX) - Tier 1; PA clobetasol propionate external shampoo (generic for CLODAN) - Tier 1; PA CLOBETASOL PROP-LEVOCETIRIZINE - Tier 2; PA; QL CLOBETASOL PROP-NIACINAMIDE - Tier 2; PA; QL CLOBEX (brand for clobetasol propionate) - Tier 2; PA CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA clocortolone pivalate (generic for CLODERM) - Tier 1; PA CLODAN EXTERNAL KIT - Tier 2; PA clodan external shampoo (generic for CLODAN) - Tier 1; PA CLODERM (brand for clocortolone pivalate) - Tier 2; PA clotrimazole-betamethasone external lotion - Tier 1; PA COAL TAR EXTERNAL - Tier 2; PA CONDYLOX - Tier 2; PA COPADERM (brand for scar gel) - Tier 2; PA COPASIL EXTERNAL (brand for scar gel) - Tier 2; PA CORDRAN EXTERNAL CREAM 0.025 % - Tier 2; PA; QL CORDRAN EXTERNAL CREAM 0.05 % (brand for flurandrenolide) - Tier 2; PA CORDRAN EXTERNAL LOTION (brand for flurandrenolide) - Tier 2; PA CORDRAN EXTERNAL OINTMENT (brand for flurandrenolide) - Tier 2; PA CORDRAN EXTERNAL TAPE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents corn & callus remover (generic for COMPOUND W) - Tier 1; PA CORTANE-B - Tier 2; PA cortisone maximum strength external gel (generic for CORTIZONE-10) - Tier 1; PA CORTISPORIN - Tier 2; PA cure-all (generic for ATOPICLAIR) - Tier 1; PA CUTIVATE (brand for fluticasone propionate) - Tier 2; PA daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1; PA dandruff shampoo external lotion (generic for SELSUN BLUE) - Tier 1; PA dapsone external gel 5 % (generic for ACZONE) - Tier 1; PA; QL DAPSONE EXTERNAL GEL 7.5 % - Tier 2; PA; QL DAPSONE-NIACINAMIDE - Tier 2; PA; QL DAPSONE-NIACINAMIDE-SPIRONOLAC - Tier 2; PA; QL DEOXIA - Tier 2; PA; QL dermacerin (generic for AMERICERIN) - Tier 1; PA DERMACINRX CLORHEXACIN - Tier 2; PA DERMACINRX SURGICAL PHARMAPAK - Tier 2; PA dermaphor (generic for DERMAPHOR) - Tier 1; PA DERMA-SMOOTHE/FS BODY (brand for fluocinolone acetonide body) - Tier 2; PA DERMA-SMOOTHE/FS SCALP (brand for fluocinolone acetonide scalp) - Tier 2; PA DESONATE (brand for desonide) - Tier 2; PA desonide external (generic for DESOWEN) - Tier 1; PA DESOWEN (brand for desonide) - Tier 2; PA desoximetasone external (generic for TOPICORT) - Tier 1; PA DEXERYL (brand for alevamax) - Tier 2; PA DIADIMAXIA - Tier 2; PA; QL DIAOXIA - Tier 2; PA; QL diaper rash creamy (generic for DR SMITHS ADULT BARRIER) - Tier 1; PA; QL diaper rash external ointment (generic for BOUDREAUXS BUTT PASTE) - Tier 1; PA; QL DIASDIMAXIA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents DIASOXIA - Tier 2; PA; QL dibucaine (perianal) (generic for NUPERCAINAL) - Tier 1; PA DICLOFENAC-NA HYALURON-NIACIN - Tier 2; PA; QL DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL DIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QL DIFFERIN EXTERNAL LOTION - Tier 2; PA; QL diflorasone diacetate - Tier 1; PA DIMOXIA - Tier 2; PA; QL DIPROLENE (brand for betamethasone dipropionate aug) - Tier 2; PA DIPROLENE AF (brand for betamethasone dipropionate aug) - Tier 2; PA DOVONEX (brand for calcipotriene) - Tier 2; PA; QL doxepin hcl external (generic for PRUDOXIN) - Tier 1; PA DR SMITHS ADULT BARRIER EXTERNAL OINTMENT (brand for gnp diaper rash creamy) - Tier 2; PA; QL DR SMITHS DIAPER (brand for gnp diaper rash creamy) - Tier 2; PA; QL DRAXACE - Tier 2; PA; QL DRAXACE LOTION CLEANSER - Tier 2; PA; QL DRITHO-CREME HP - Tier 2; PA DRIXECE - Tier 2; PA; QL DUOBRII - Tier 2; PA; QL duofilm (generic for DUOFILM) - Tier 1; PA DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR - Tier 2; PA; SP; QL DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP ECEOXIA - Tier 2; PA; QL EFUDEX (brand for fluorouracil) - Tier 2; PA ELETONE (brand for alevamax) - Tier 2; PA ELLZIA PAK - Tier 2; PA EMULSION SB (brand for iliderm) - Tier 2; PA ENSTILAR - Tier 2; PA ENTTY SPRAY (brand for iliderm) - Tier 2; PA ENZOCLEAR (brand for benzoyl peroxide) - Tier 2; PA; QL EPICERAM (brand for iliderm) - Tier 2; PA EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents EPIDUO FORTE - Tier 2; PA; QL EPIFOAM - Tier 2; PA eq wart remover (generic for COMPOUND W) - Tier 1; PA eql baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - Tier 1; PA; QL ery - Tier 1; PA; QL ERYGEL (brand for erythromycin) - Tier 2; PA; QL erythromycin external gel (generic for ERYGEL) - Tier 1; PA; QL ETHOXIA - Tier 2; PA; QL EUCRISA - Tier 2; PA; QL EVOCLIN (brand for clindamycin phosphate) - Tier 2; PA; QL FABIOR - Tier 2; PA; QL FINACEA EXTERNAL FOAM - Tier 2; PA FINACEA EXTERNAL GEL (brand for azelaic acid) - Tier 2; PA; QL flanders buttocks (generic for DERMAPHOR) - Tier 1; PA FLUOCINOLONE ACET-NIACINAMIDE - Tier 2; PA; QL fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; PA fluocinolone acetonide external - Tier 1; PA fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; PA fluocinonide emulsified base - Tier 1; PA fluocinonide external - Tier 1; PA FLUOPAR - Tier 2; PA; QL FLUOROPLEX - Tier 2; PA fluorouracil external solution - Tier 1; PA FLUOVIX - Tier 2; PA; QL FLUOVIX PLUS - Tier 2; PA; QL flurandrenolide (generic for NOLIX) - Tier 1; PA fluticasone propionate external lotion (generic for BESER) - Tier 1; PA formaldehyde external solution 10 % - Tier 1; PA FORMALDEHYDE EXTERNAL SOLUTION 37 % - Tier 2; PA GENADUR EXTERNAL (brand for strip ease adhesive remover) - Tier 2; PA glycerin external - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 75 Preferred Agents Non-Preferred Agents glycerin external liquid 99.5 % - Tier 1; PA GORDOFILM - Tier 2; PA gormel - Tier 1; PA gormel 10 (generic for NUTRAPLUS) - Tier 1; PA halcinonide (generic for HALOG) - Tier 1; PA HALOBETASOL PROPIONATE EXTERNAL FOAM - Tier 2; PA HALOG EXTERNAL CREAM (brand for halcinonide) - Tier 2; PA HALOG EXTERNAL OINTMENT - Tier 2; PA HALOG EXTERNAL SOLUTION - Tier 2; PA; QL HALUCORT - Tier 2; PA heal aid plus (generic for ATOPICLAIR) - Tier 1; PA HIBICLENS (brand for chlorhexidine gluconate) - Tier 2; PA hm glycerin external liquid - Tier 1; PA HPR PLUS EXTERNAL CREAM (brand for alevamax) - Tier 2; PA hpr plus external foam - Tier 1; PA HPR PLUS HYDROGEL - Tier 2; PA HYALURONATE-NIACINAM-TRETINOIN - Tier 2; PA; QL HYALURONATE-NIACIN-TACROLIMUS - Tier 2; PA; QL HYDRO 40 - Tier 2; PA hydrocerin (generic for AMERICERIN) - Tier 1; PA hydrocortisone ace-pramoxine external cream 2.5-1 % (generic for PRAMOSONE) - Tier 1; PA hydrocortisone acetate external cream (generic for GYNECORT 10) - Tier 1; PA hydrocortisone butyr lipo base (generic for LOCOID LIPOCREAM) - Tier 1; PA hydrocortisone butyrate - Tier 1; PA hydrocortisone valerate - Tier 1; PA hydrolatum (generic for DERMAPHOR) - Tier 1; PA hydrophor (generic for DERMAPHOR) - Tier 1; PA HYLATOPIC PLUS (brand for alevamax) - Tier 2; PA ILUMYA - Tier 2; PA IMIQUIMOD PUMP - Tier 2; PA; QL IMIQUIMOD-LEVOCETIRIZIN-NIACIN - Tier 2; PA; QL IMIQUIMOD-LEVOCET-TRETINOIN - Tier 2; PA; QL IMPEKLO - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents IMPOYZ - Tier 2; PA; QL INOVA - Tier 2; PA INOVA 4/1 ACNE CONTROL THERAPY - Tier 2; PA INOVA 8/2 ACNE CONTROL THERAPY - Tier 2; PA ionil-t - Tier 1; PA ITHOXIA - Tier 2; PA; QL IVERMECTIN-METRONIDAZOL-NIACIN - Tier 2; PA; QL KAMDOY (brand for iliderm) - Tier 2; PA KELARX (brand for scar gel) - Tier 2; PA KENALOG EXTERNAL (brand for triamcinolone acetonide) - Tier 2; PA KERALAC (brand for urea) - Tier 2; PA KERALYT EXTERNAL GEL 6 % (brand for salicylic acid) - Tier 2; PA; QL KERALYT SCALP - Tier 2; PA KIVIK (brand for iliderm) - Tier 2; PA KLARON (brand for sulfacetamide sodium (acne)) - Tier 2; PA; QL LAC-HYDRIN FIVE - Tier 2; PA lactic acid e - Tier 1; PA lactic acid external - Tier 1; PA LANAPHILIC (brand for cvs advanced healing) - Tier 2; PA lavare wound wash (generic for MICROCYN) - Tier 1; PA LEVULAN KERASTICK - Tier 2; PA LEXETTE (brand for halobetasol propionate) - Tier 2; PA lidocaine-hydrocort (perianal) (generic for LIDOCORT) - Tier 1; PA LIDOCAINE-HYDROCORTISONE ACE EXTERNAL - Tier 2; PA; QL LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL - Tier 2; PA lidocaine-hydrocortisone ace rectal kit - Tier 1; PA LIDOCORT (brand for lidocaine-hydrocort (perianal)) - Tier 2; PA LIDOTREX - Tier 2; PA LOCOID (brand for hydrocortisone butyrate) - Tier 2; PA LOCOID LIPOCREAM (brand for hydrocortisone butyr lipo base) - Tier 2; PA LUXIQ (brand for betamethasone valerate) - Tier 2; PA MEDERMA (brand for scar gel) - Tier 2; PA MEDERMA FOR KIDS (brand for scar gel) - Tier 2; PA MEDERMA SPF 30 (brand for scarcin) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 77 Preferred Agents Non-Preferred Agents medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1; PA methoxsalen rapid (generic for OXSORALEN ULTRA) - Tier 1; PA methyl salicylate external liquid - Tier 1; PA MIMYX (brand for alevamax) - Tier 2; PA minerin creme (generic for AMERICERIN) - Tier 1; PA MIRVASO - Tier 2; PA; QL moisturel - Tier 1; PA NEOCERA (brand for alevamax) - Tier 2; PA NEOSALUS - Tier 2; PA NEOSALUS CP (brand for alevamax) - Tier 2; PA NEO-SYNALAR EXTERNAL CREAM - Tier 2; PA; QL neuac external gel (generic for NEUAC) - Tier 1; PA NEUAC EXTERNAL KIT - Tier 2; PA NEUTROGENA HAND (brand for coconut oil beauty) - Tier 2; PA NEUTROGENA OIL-FREE ACNE WASH (brand for cvs daily acne wash) - Tier 2; PA NIACINAMIDE-SPIRONOLACTONE - Tier 2; PA; QL NIACINAMIDE-SULFACETAMIDE - Tier 2; PA; QL NIACINAMIDE-TACROLIMUS - Tier 2; PA; QL NIACINAMIDE-TAZAROTENE - Tier 2; PA; QL NIACINAMIDE-TRETINOIN - Tier 2; PA; QL NIACINAMIDE-TRIAMCINOLONE ACET - Tier 2; PA; QL NIACIN-SPIRONOLACTON-TRETINOIN - Tier 2; PA; QL NIVATOPIC PLUS (brand for alevamax) - Tier 2; PA nolix (generic for NOLIX) - Tier 1; PA NOVACORT - Tier 2; PA NUCARACLINPAK - Tier 2; PA; QL NUCARARXPAK - Tier 2; PA; QL NUCORT - Tier 2; PA NUDERMRXPAK 120 - Tier 2; PA; QL NUDERMRXPAK 60 - Tier 2; PA; QL NUPERCAINAL (brand for dibucaine (perianal)) - Tier 2; PA NUSURGEPAK SURGICAL PREP/CARE - Tier 2; PA NUTRAPLUS EXTERNAL CREAM (brand for urea 10 hydrating) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents nutraplus lotion 10 % external (generic for NUTRAPLUS) - Tier 1; PA NUTRAPLUS LOTION 10 % EXTERNAL (brand for urea 10 hydrating) - Tier 2; PA NUTRASEB - Tier 2; PA NUTRIARX CREAMPAK (brand for sanadermrx skin repair) - Tier 2; PA NUVAIL - Tier 2; PA OINTMENT BASE - Tier 2; PA OLUX (brand for clobetasol propionate) - Tier 2; PA OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA ONEXTON - Tier 2; PA OVACE PLUS EXTERNAL CREAM - Tier 2; PA OVACE PLUS EXTERNAL FOAM - Tier 2; PA; QL OVACE PLUS EXTERNAL LOTION - Tier 2; PA OVACE PLUS EXTERNAL SHAMPOO (brand for sodium sulfacetamide) - Tier 2; PA OVACE PLUS WASH (brand for sulfacetamide sodium) - Tier 2; PA OVACE WASH (brand for sulfacetamide sodium) - Tier 2; PA OXSORALEN ULTRA (brand for methoxsalen rapid) - Tier 2; PA PACQUIN PLUS EXTERNAL CREAM (brand for coconut oil beauty) - Tier 2; PA PACQUIN PLUS/ALOE EXTERNAL CREAM (brand for coconut oil beauty) - Tier 2; PA PANDEL - Tier 2; PA PANOXYL (brand for bp wash) - Tier 2; PA PENLEN (brand for iliderm) - Tier 2; PA PHLAG SPRAY (brand for iliderm) - Tier 2; PA PICATO - Tier 2; PA; QL pimecrolimus (generic for ELIDEL) - Tier 1; PA; QL PLEXION (brand for sulfacetamide sodium-sulfur) - Tier 2; PA PLEXION CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2; PA PLEXION CLEANSING CLOTH - Tier 2; PA podocon - Tier 1; PA PR BENZOYL PEROXIDE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents pr benzoyl peroxide wash (generic for BENZEPRO CREAMY WASH) - Tier 1; PA PR CREAM - Tier 2; PA pramosone external cream 1-1 % - Tier 1; PA PRAMOSONE EXTERNAL CREAM 1-2.5 % (brand for hydrocortisone ace-pramoxine) - Tier 2; PA PRAMOSONE EXTERNAL LOTION - Tier 2; PA PRAMOSONE EXTERNAL OINTMENT - Tier 2; PA PRE & POST SX POUCH - Tier 2; PA; QL prednicarbate - Tier 1; PA PRESERA - Tier 2; PA PROMISEB - Tier 2; PA PROSILK EXTERNAL - Tier 2; PA PROTEXA - Tier 2; PA; QL PROTOPIC (brand for tacrolimus) - Tier 2; PA; QL PRUCLAIR (brand for alevamax) - Tier 2; PA PRUDOXIN (brand for doxepin hcl) - Tier 2; PA PRUMYX (brand for alevamax) - Tier 2; PA PSORCON - Tier 2; PA PYROGALLIC ACID - Tier 2; PA QBREXZA - Tier 2; PA; QL qc calamine - Tier 1; PA qc glycerin - Tier 1; PA QUINIXIL - Tier 2; PA; QL ra acne cleanser oil-free (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1; PA ra acne treatment (generic for CLEARSKIN) - Tier 1; PA ra advanced healing external lotion (generic for THERASEAL HAND PROTECTION) - Tier 1; PA ra apricot scrub (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1; PA ra dandruff shampoo external lotion (generic for SELSUN BLUE) - Tier 1; PA ra diaper rash (generic for BOUDREAUXS BUTT PASTE) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents ra glycerin - Tier 1; PA ra hemorrhoidal rectal - Tier 1; PA ra hydrating healing (generic for DERMAPHOR) - Tier 1; PA ra renewal dandruff (generic for SELSUN BLUE) - Tier 1; PA ra renewal soothing bath (generic for AVEENO BABY BATH TREATMENT) - Tier 1; PA ra scalp itch/dandruff relief (generic for PSORIASIN) - Tier 1; PA ra scar (generic for COPADERM) - Tier 1; PA ra vanishing acne treatment (generic for CLEARSKIN) - Tier 1; PA ra wart remover external solution (generic for DUOFILM) - Tier 1; PA REA-LO - Tier 2; PA RECEDO (brand for scar gel) - Tier 2; PA REGENECARE - Tier 2; PA REMIGEN - Tier 2; PA RESORCINOL-SULFUR - Tier 2; PA RETIN-A (brand for tretinoin) - Tier 2; PA; QL RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) - Tier 2; PA; QL RETIN-A MICRO PUMP (brand for tretinoin microsphere) - Tier 2; PA; QL REXASIL PATCH & VITAMIN E LIQ - Tier 2; PA; QL RHOFADE - Tier 2; PA RIAX - Tier 2; PA ROSADAN EXTERNAL KIT - Tier 2; PA SALEX (brand for salicylic acid) - Tier 2; PA salicylic acid er (generic for ULTRASAL-ER) - Tier 1; PA salicylic acid external cream - Tier 1; PA salicylic acid external foam (generic for SALVAX) - Tier 1; PA salicylic acid external gel (generic for KERALYT) - Tier 1; PA; QL salicylic acid external liquid (generic for VIRASAL) - Tier 1; PA; QL salicylic acid external lotion - Tier 1; PA; QL salicylic acid external shampoo (generic for SALEX) - Tier 1; PA salicylic acid external solution - Tier 1; PA salicylic acid wart remover (generic for VIRASAL) - Tier 1; PA; QL salicylic acid-cleanser - Tier 1; PA SALICYLIC ACID-SULFACETAMIDE - Tier 2; PA; QL salimez - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 81 Preferred Agents Non-Preferred Agents SALIMEZ FORTE - Tier 2; PA SALVAX (brand for salicylic acid) - Tier 2; PA SALVAX DUO PLUS - Tier 2; PA SANADERMRX SKIN REPAIR - Tier 2; PA SCALACORT DK - Tier 2; PA scalp relief (generic for PSORIASIN) - Tier 1; PA scar (generic for COPADERM) - Tier 1; PA SCARCARE GEL-PAD KIT/LARGE - Tier 2; PA; QL SCARCIN - Tier 2; PA SCARSILK EXTERNAL - Tier 2; PA SCARZEN SKIN REPAIR - Tier 2; PA; QL selenium sulfide external shampoo 2.3 % (generic for SELRX) - Tier 1; PA SELRX (brand for selenium sulfide) - Tier 2; PA SERNIVO - Tier 2; PA SILA III - Tier 2; PA; QL SILIPAC - Tier 2; PA SILIQ - Tier 2; PA; SP skarjel (generic for COPADERM) - Tier 1; PA sm calamine - Tier 1; PA sm glycerin - Tier 1; PA sodium hyaluronate external - Tier 1; PA sodium sulfacetamide (generic for OVACE PLUS) - Tier 1; PA sodium sulfacetamide wash - Tier 1; PA SODIUM SULFACETAMIDE-BAKUCHIOL - Tier 2; PA SOOLANTRA - Tier 2; PA soothing bath treatment (generic for AVEENO BABY BATH TREATMENT) - Tier 1; PA SORBIDON HYDRATE (brand for kerodex-51) - Tier 2; PA SORIATANE (brand for acitretin) - Tier 2; PA SORILUX (brand for calcipotriene) - Tier 2; PA; QL sss 10-5 - Tier 1; PA STRATA CTX - Tier 2; PA STRATA MARK - Tier 2; PA STRATA TRIZ (brand for scar gel) - Tier 2; PA STRATA XRT - Tier 2; PA sulfacetamide sodium (acne) (generic for KLARON) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents sulfacetamide sodium external (generic for OVACE PLUS WASH) - Tier 1; PA sulfacetamide sodium-sulfur external cream (generic for AVAR-E EMOLLIENT) - Tier 1; PA sulfacetamide sodium-sulfur external liquid (generic for SUMADAN WASH) - Tier 1; PA sulfacetamide sodium-sulfur external lotion - Tier 1; PA sulfacetamide sodium-sulfur external pad (generic for SUMAXIN) - Tier 1; PA sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; PA; QL sulfacetamide sodium-sulfur external suspension 8-4 % (generic for SULFACLEANSE 8/4) - Tier 1; PA sulfacetamide sod-sulfur wash (generic for SUMADAN) - Tier 1; PA sulfacetamide-sulfur in urea - Tier 1; PA sulfacleanse 8/4 (generic for SULFACLEANSE 8/4) - Tier 1; PA sulfamez wash - Tier 1; PA SUMADAN (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA SUMADAN XLT - Tier 2; PA SUMAXIN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA SUMAXIN CP - Tier 2; PA SUMAXIN WASH (brand for sulfacetamide sodium-sulfur) - Tier 2; PA SUVICORT - Tier 2; PA SYNALAR (brand for fluocinolone acetonide) - Tier 2; PA SYNALAR (CREAM) - Tier 2; PA SYNALAR (OINTMENT) - Tier 2; PA SYNALAR TS - Tier 2; PA SYNERDERM (brand for iliderm) - Tier 2; PA TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL TACROLIMUS EXTERNAL CREAM - Tier 2; PA; QL tacrolimus external ointment (generic for PROTOPIC) - Tier 1; PA; QL TALTZ - Tier 2; PA; SP TARDEOXIA - Tier 2; PA; QL TARDIMAXIA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents TAROXIA - Tier 2; PA; QL TASOPROL - Tier 2; PA; QL tazarotene external (generic for TAZORAC) - Tier 1; PA; QL TAZORAC - Tier 2; PA; QL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA TETRIX (brand for alevamax) - Tier 2; PA TEXACORT - Tier 2; PA THERASEAL HAND PROTECTION (brand for ra advanced healing) - Tier 2; PA TOLAK - Tier 2; PA TOPICORT (brand for desoximetasone) - Tier 2; PA TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA tovet external foam (generic for TOVET) - Tier 1; PA TOVET EXTERNAL KIT - Tier 2; PA TREMFYA - Tier 2; PA; SP tretinoin external (generic for AVITA) - Tier 1; PA; QL tretinoin microsphere (generic for RETIN-A MICRO) - Tier 1; PA; QL tretinoin microsphere pump (generic for RETIN-A MICRO) - Tier 1; PA; QL triamcinolone acetonide external aerosol solution (generic for KENALOG) - Tier 1; PA TRIAMSIL COMBIPAK - Tier 2; PA TRIAMSIL MULTIPAK - Tier 2; PA trianex (generic for TRIANEX) - Tier 1; PA TRI-CHLOR - Tier 2; PA TRIDESILON (brand for desonide) - Tier 2; PA TRIVIX (brand for sanadermrx skin repair) - Tier 2; PA ULTRASAL-ER (brand for salicylic acid er) - Tier 2; PA ULTRAVATE - Tier 2; PA UMECTA MOUSSE - Tier 2; PA URAMAXIN (brand for urea nail) - Tier 2; PA urea 20 intensive hydrating - Tier 1; PA urea external cream 39 % (generic for UREDEB) - Tier 1; PA urea external cream 40 % - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents urea external cream 41 % (generic for UTOPIC) - Tier 1; PA urea external cream 45 % - Tier 1; PA urea external cream 47 % (generic for KERALAC) - Tier 1; PA UREA EXTERNAL FOAM - Tier 2; PA; QL urea external lotion (generic for CEROVEL) - Tier 1; PA; QL urea external suspension - Tier 1; PA urea hydrating - Tier 1; PA urea nail (generic for URAMAXIN) - Tier 1; PA urea-c40 (generic for CEROVEL) - Tier 1; PA; QL ureacin-10 (generic for NUTRAPLUS) - Tier 1; PA ureacin-20 - Tier 1; PA uredeb (generic for UREDEB) - Tier 1; PA uremez-40 - Tier 1; PA; QL URESOL - Tier 2; PA; QL UTOPIC (brand for urea) - Tier 2; PA VANICREAM EXTERNAL OINTMENT (brand for cvs advanced healing) - Tier 2; PA VANOS (brand for fluocinonide) - Tier 2; PA VANOXIDE-HC (brand for benzoyl perox-hydrocortisone) - Tier 2; PA VARDIMAXIA - Tier 2; PA; QL VAROXIA - Tier 2; PA; QL VECTICAL (brand for calcitriol) - Tier 2; PA; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL VERDESO - Tier 2; PA; QL VEREGEN - Tier 2; PA; QL VIRASAL (brand for salicylic acid wart remover) - Tier 2; PA; QL wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1; PA wart remover maximum strength external liquid (generic for COMPOUND W) - Tier 1; PA XALIX - Tier 2; PA; QL XERAC AC - Tier 2; PA XERALUX (brand for alevamax) - Tier 2; PA xurea (generic for UREDEB) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents ZACARE - Tier 2; PA zaclir cleansing - Tier 1; PA ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; PA; QL ZITHRANOL - Tier 2; PA ZONALON (brand for doxepin hcl) - Tier 2; PA ZOSTRIX HP (brand for capsaicin hp) - Tier 2; PA; QL ZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL ZYCLARA PUMP EXTERNAL CREAM 2.5 % - Tier 2; PA ZYCLARA PUMP EXTERNAL CREAM 3.75 % (brand for imiquimod pump) - Tier 2; PA; QL Dermatological Agents - Skin Agents CLOBETAVIX - Tier 2; PA; QL ZILXI - Tier 2; PA; QL Electrolytes/Minerals/ Metals/ Vitamins Vitamins NEONATAL FE - Tier 2; PA; QL Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement UPNEEQ - Tier 2; PA; QL Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs ABATRON - Tier 2 aspartate mg & k - Tier 1; PA abatron af (generic for ABATRON AF) - Tier 1 cal-citrate - Tier 1; PA active fe - Tier 1 calcium 1200 - Tier 1; PA aqueous vitamin e (generic for SOLUVITA E) - Tier 1 calcium citrate oral tablet 1040 mg - Tier 1; PA BEELITH - Tier 2 calcium oral tablet 600 mg - Tier 1; PA cal-glu - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 86 Preferred Agents Non-Preferred Agents bprotected pedia iron (generic for BPROTECTED PEDIA IRON) - Tier cal-lac - Tier 1; PA 1 EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ - Tier 2; PA cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM) eql anticavity fluoride rinse (generic for ACT ANTICAVITY FLUORIDE - Tier 1 RINSE) - Tier 1; PA calcitrate oral tablet 950 mg - Tier 1 FERRO-PLEX HEMATINIC - Tier 2; PA calcium 500 +d3 (generic for OS-CAL EXTRA D3) - Tier 1 FERROTRIN - Tier 2; PA calcium 500/d (generic for RA HI CAL) - Tier 1 FLORICAL - Tier 2; PA calcium 600 - Tier 1 FLORIVA ORAL LIQUID - Tier 2; PA calcium 600/d - Tier 1 FLUORABON - Tier 2; PA calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1 fluoritab oral solution (generic for NAFRINSE DROPS) - Tier 1; PA; QL calcium carbonate oral tablet 600 mg - Tier 1 FLURA-DROPS - Tier 2; PA; QL calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1 GALZIN ORAL CAPSULE 25 MG - Tier 2; PA calcium carbonate-vitamin d oral tablet 600-400 mg-unit - Tier 1 GALZIN ORAL CAPSULE 50 MG - Tier 2; PA; QL calcium carbonate-vitamin d3 - Tier 1 glutamine oral capsule - Tier 1; PA calcium citrate + d oral tablet 315-250 mg-unit (generic for IROFOL - Tier 2; PA CALCITRATE) - Tier 1 kelp oral tablet 0.15 mg - Tier 1; PA calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1 KLOR-CON M15 - Tier 2; PA; QL calcium citrate + oral tablet 315-200 mg-unit - Tier 1 K-MAG - Tier 2; PA calcium citrate +d3 (generic for CALCITRATE) - Tier 1 K-MAG-70 - Tier 2; PA calcium citrate malate-vit d - Tier 1 kp mag-oxide magnesium (generic for MAG-OXIDE) - Tier 1; PA calcium citrate+d maximum (generic for CALCITRATE) - Tier 1 K-PHOS-NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; PA; QL calcium citrate+d3 (generic for CALCITRATE) - Tier 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 8 MEQ (brand for potassium chloride er) - Tier 2; PA calcium citrate+d3 petites (generic for CITRACAL PETITES/VITAMIN K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ (brand for D) - Tier 1 potassium chloride er) - Tier 2; PA; QL m2 magnesium - Tier 1; PA calcium citrate+d3 w/magne (generic for ADVANCED MAG-200 (brand for kp mag-oxide magnesium) - Tier 2; PA CALCIUM/D/MAGNESIUM) - Tier 1 MAGIMIN - Tier 2; PA magnacaps - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents calcium citrate-vitamin d oral tablet 200-125 mg-unit, 315-200 mg-unit magnesium sulfate oral - Tier 1; PA - Tier 1 mag-oxide (generic for MAG-OXIDE) - Tier 1; PA calcium high potency - Tier 1 MANGIMIN - Tier 2; PA calcium high potency/vitamin d - Tier 1 mn-50 - Tier 1; PA calcium oral tablet 600 mg - Tier 1 MONOCAL - Tier 2; PA calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1 nafrinse drops (generic for NAFRINSE DROPS) - Tier 1; PA; QL calcium plus 600 +d - Tier 1 ORACIT - Tier 2; PA calcium plus vitamin d oral tablet (generic for OYSCO 500+D) - Tier 1 ORAZINC ORAL TABLET - Tier 2; PA calcium/vitamin d/minerals - Tier 1 OS-CAL - Tier 2; PA calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5 OS-CAL ULTRA - Tier 2; PA mg - Tier 1 oysco 500+d oral tablet chewable - Tier 1; PA calcium-vitamin d oral tablet 500-200 mg-unit (generic for OYSCO oyster shell calcium oral tablet 500-400 mg-unit (generic for 500+D) - Tier 1 OYSTERCAL-D) - Tier 1; PA; QL calcium-vitamin d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1 oyster shell calcium/d oral tablet 250-250 mg-unit - Tier 1; PA calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1 oyster shell/vitamin d - Tier 1; PA; QL cal-mag aspartate - Tier 1 phospha 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; PA; CALTRATE GUMMY BITES (brand for cvs calcium-vitamin d) - Tier 2 QL CENTRATEX - Tier 2 phosphorous (generic for PHOSPHA 250 NEUTRAL) - Tier 1; PA; QL chromagen - Tier 1 phospho-trin 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; PA; QL citrus calcium/vitamin d (generic for CITRACAL PETITES/VITAMIN D) PHOXILLUM BK4/2.5 - Tier 2; PA - Tier 1 potassium chloride er oral tablet extended release 20 meq (generic for K- COLAMINE (brand for multi-minerals) - Tier 2 TAB) - Tier 1; PA; QL coral calcium oral capsule 185-50-100 mg-mg-unit - Tier 1 potassium citrate er oral tablet extended release 15 meq (1620 mg) corvita 150 - Tier 1 (generic for UROCIT-K 15) - Tier 1; PA CORVITE 150 - Tier 2 PREVIDENT MOUTH/THROAT - Tier 2; PA corvite fe (generic for CORVITE 150) - Tier 1 ra anticavity fluoride rinse (generic for ACT ANTICAVITY FLUORIDE cytra k crystals (generic for TARON-CRYSTALS) - Tier 1 RINSE) - Tier 1; PA cytra-2 - Tier 1 ra calcium hi-cal/vitamin d - Tier 1; PA; QL effer-k oral tablet effervescent 25 meq - Tier 1 ra calcium high potency - Tier 1; PA electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1 ra tooth shield (generic for CREST PRO-HEALTH COMPLETE) - Tier 1; ENDARI - Tier 2; PA PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 88 Preferred Agents Non-Preferred Agents ENFAMIL ENFALYTE (brand for ra pediatric electrolyte) - Tier 2 ra zinc - Tier 1; PA ezfe 200 - Tier 1 sm anticavity fluoride rinse (generic for ACT ANTICAVITY FLUORIDE fa-8 oral tablet (generic for FA-8) - Tier 1 RINSE) - Tier 1; PA fe c tab (generic for ICAR-C) - Tier 1 sm zinc - Tier 1; PA FERAHEME - Tier 2 sodium chloride oral solution 4 meq/ml - Tier 1; PA ferate (generic for FERATE) - Tier 1 sodium chloride oral tablet 1 gm - Tier 1; PA FER-IN-SOL (brand for iron supplement childrens) - Tier 2 sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1; PA FERIVA 21/7 - Tier 2 sodium fluoride oral tablet 2.2 (1 f) mg - Tier 1; PA; QL FERIVAFA - Tier 2 tricitrates - Tier 1; PA ferocon (generic for TRICON) - Tier 1 UROCIT-K 10 (brand for potassium citrate er) - Tier 2; PA; QL ferosul (generic for FEROSUL) - Tier 1 UROCIT-K 15 (brand for potassium citrate er) - Tier 2; PA ferotrinsic (generic for TRICON) - Tier 1 UROCIT-K 5 (brand for potassium citrate er) - Tier 2; PA FERRALET 90 - Tier 2; QL virt-phos 250 neutral (generic for PHOSPHA 250 NEUTRAL) - Tier 1; PA; ferraplus 90 - Tier 1 QL ferretts - Tier 1 ZINC 15 - Tier 2; PA ferretts ips - Tier 1 zinc chelated oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; PA; QL ferrex 150 (generic for FERREX 150) - Tier 1 zinc gluconate oral tablet 100 mg, 50 mg - Tier 1; PA ferric x-150 (generic for FERREX 150) - Tier 1 zinc methionate - Tier 1; PA FERRIMIN 150 - Tier 2 zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; PA; QL FERRLECIT (brand for na ferric gluc cplx in sucrose) - Tier 2 zinc sulfate oral tablet 220 (50 zn) mg - Tier 1; PA ferrocite plus (generic for FERROCITE PLUS) - Tier 1 zn-50 - Tier 1; PA ferrous fumarate oral tablet 324 (106 fe) mg (generic for HEMOCYTE) - Tier 1 ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 ferrous gluconate oral tablet 324 (37.5 fe) mg, 324 (38 fe) mg - Tier 1 ferrous sulfate oral elixir - Tier 1 ferrous sulfate oral solution (generic for BPROTECTED PEDIA IRON) - Tier 1 ferrous sulfate oral syrup - Tier 1; QL ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 89 Preferred Agents Non-Preferred Agents ferrous sulfate oral tablet delayed release - Tier 1 fluoritab oral tablet chewable - Tier 1; QL folic acid oral tablet 1 mg - Tier 1 folic acid oral tablet 400 mcg - Tier 1; QL folic acid oral tablet 800 mcg (generic for FA-8) - Tier 1 FOLIVANE-F - Tier 2 FOLIVANE-PLUS (brand for virt-fefa plus) - Tier 2 foltrin (generic for TRICON) - Tier 1 FUSION PLUS - Tier 2 hematinic plus vit/minerals (generic for FERROCITE PLUS) - Tier 1 hematinic/folic acid (generic for HEMOCYTE-F) - Tier 1 HEMATOGEN (brand for iron complex) - Tier 2 HEMATOGEN FA - Tier 2 HEMATRON-AF (brand for tl-hem 150) - Tier 2 hemax (generic for ABATRON AF) - Tier 1 HEMOCYTE (brand for ferrous fumarate) - Tier 2 HEMOCYTE PLUS - Tier 2 hemocyte-f (generic for HEMOCYTE-F) - Tier 1 hemocyte-plus (generic for FERROCITE PLUS) - Tier 1 ICAR (brand for wee care) - Tier 2 ICAR-C (brand for fe c tab) - Tier 2 ICAR-C PLUS (brand for iron 100 plus) - Tier 2 iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1 INFED - Tier 2 INTEGRA - Tier 2 INTEGRA F - Tier 2 INTEGRA PLUS (brand for virt-fefa plus) - Tier 2 iron 100/c (generic for ICAR-C) - Tier 1 iron chews pediatric - Tier 1 iron oral tablet 200 (65 fe) mg (generic for FEOSOL) - Tier 1 iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1 iron oral tablet extended release 142 (45 fe) mg (generic for SLOW FE) - Tier 1 iron supplement - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 90 Preferred Agents Non-Preferred Agents iron supplement childrens (generic for BPROTECTED PEDIA IRON) - Tier 1 IROSPAN 24/6 - Tier 2 klor-con (generic for KLOR-CON) - Tier 1 klor-con 10 (generic for KLOR-CON 10) - Tier 1 klor-con m10 (generic for KLOR-CON M10) - Tier 1 klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL klor-con sprinkle (generic for KLOR-CON SPRINKLE) - Tier 1 klor-con/ef - Tier 1 kp calcium 600+d oral capsule - Tier 1 kp calcium 600+d oral tablet 600-400 mg-unit - Tier 1 kp calcium 600+d3 - Tier 1 kp calcium citrate+d (generic for CALCITRATE) - Tier 1 kp calcium-magnesium-zinc - Tier 1 kp ferrous gluconate - Tier 1 kp ferrous sulfate (generic for FEROSUL) - Tier 1 kp folic acid (generic for FA-8) - Tier 1 K-PHOS - Tier 2; QL K-PHOS NO 2 - Tier 2 k-prime - Tier 1 k-tan plus (generic for K-TAN PLUS) - Tier 1 liquid calcium with d3 oral capsule 600-500 mg-unit - Tier 1 liquid calcium/vitamin d - Tier 1 mag-g - Tier 1 MAGNEBIND 300 - Tier 2 magnesium chloride oral tablet delayed release (generic for MAG64) - Tier 1 magnesium lactate (generic for MAG-TAB SR) - Tier 1 magnesium oral capsule 300 mg - Tier 1 magnesium oral tablet 250 mg, 30 mg, 500 mg - Tier 1 magnesium oxide oral tablet 400 (241.3 mg) mg (generic for MAGNESIUM-OXIDE) - Tier 1 magnesium oxide oral tablet 500 mg - Tier 1 magnesium sulfate intravenous - Tier 1 magnesium sulfate solution 50 % injection - Tier 1 MAGNESIUM SULFATE SOLUTION 50 % INJECTION - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 91 Preferred Agents Non-Preferred Agents magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 MAGONATE - Tier 2 MAG-TAB SR (brand for magnesium lactate) - Tier 2 MULTIGEN - Tier 2 MULTIGEN FOLIC - Tier 2 MULTIGEN PLUS - Tier 2 myferon 150 (generic for FERREX 150) - Tier 1 na ferric gluc cplx in sucrose (generic for FERRLECIT) - Tier 1 nafrinse (generic for NAFRINSE) - Tier 1; QL NEPHRON FA - Tier 2 NIFEREX (brand for corvite fe) - Tier 2 NUFERA (brand for corvite fe) - Tier 2 nu-iron (generic for FERREX 150) - Tier 1 NU-MAG - Tier 2 nutr-e-sol - Tier 1 oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1 oscal 500/200 d-3 (generic for RA HI CAL) - Tier 1 OS-CAL CALCIUM + D3 (brand for calcium 500 + d) - Tier 2 OS-CAL EXTRA D3 (brand for gnp calcium 500 +d3) - Tier 2 OSTEO-PORETICAL - Tier 2 oysco 500+d oral tablet (generic for OYSCO 500+D) - Tier 1 oyster calcium + d - Tier 1 oyster shell calcium + d oral tablet 500-400 mg-unit (generic for OYSTERCAL-D) - Tier 1 oyster shell calcium + d3 (generic for OYSTERCAL-D) - Tier 1 oyster shell calcium 500 + d - Tier 1 oyster shell calcium oral tablet 500 mg (generic for RA HI-CAL) - Tier 1 oyster shell calcium plus d oral tablet 500-200 mg-unit (generic for OYSCO 500+D) - Tier 1 oyster shell calcium/d oral tablet 250-125 mg-unit, 500-400 mg-unit - Tier 1 oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1 oyster shell calcium/vitamin d oral tablet (generic for OYSCO 500+D) - Tier 1 pa calcium/vitamin d - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 92 Preferred Agents Non-Preferred Agents pa oyster shell calcium (generic for RA HI CAL) - Tier 1 ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - Tier 1 ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1 PEDIALYTE FREEZER POPS (brand for ra pediatric electrolyte) - Tier 2 PEDIALYTE ORAL SOLUTION (brand for ra pediatric electrolyte) - Tier 2 PEDIALYTE SINGLES (brand for ra pediatric electrolyte) - Tier 2 pediatric electrolyte oral solution (generic for ORALYTE FREEZER POPS) - Tier 1 PHOS-NAK - Tier 2 phosphorus supplement - Tier 1 phosphorus w/sod & potassium - Tier 1 poly-iron 150 (generic for FERREX 150) - Tier 1 poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide-iron complex (generic for FERREX 150) - Tier 1 potassium chloride crys er oral tablet extended release 10 meq (generic for KLOR-CON M10) - Tier 1 potassium chloride crys er oral tablet extended release 20 meq (generic for KLOR-CON M20) - Tier 1; QL potassium chloride er oral capsule extended release (generic for KLOR-CON SPRINKLE) - Tier 1 potassium chloride er oral tablet extended release 10 meq (generic for KLOR-CON 10) - Tier 1 potassium chloride er oral tablet extended release 8 meq (generic for KLOR-CON) - Tier 1 potassium chloride oral packet (generic for KLOR-CON) - Tier 1 potassium chloride oral solution 20 meq/15ml (10%) - Tier 1; QL potassium chloride oral solution 40 meq/15ml (20%) - Tier 1 potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 93 Preferred Agents Non-Preferred Agents potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 potassium citrate-citric acid - Tier 1 PROFE - Tier 2 PROFERRIN ES - Tier 2; QL purevit dualfe plus (generic for K-TAN PLUS) - Tier 1 qc calcium fast dissolution - Tier 1 qc calcium/minerals/vitamin d - Tier 1 qc ferrous sulfate (generic for FEROSUL) - Tier 1 ra ca/mg/zn/cu (generic for COLAMINE) - Tier 1 ra calcium - Tier 1 ra calcium 600 - Tier 1 ra calcium 600/vit d/minerals - Tier 1 ra calcium 600/vitamin d-3 - Tier 1 ra calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1 ra calcium citrate plus vit d - Tier 1 ra calcium cit-vit d-3 petites (generic for CITRACAL PETITES/VITAMIN D) - Tier 1 ra calcium hi-cal - Tier 1 ra calcium plus vitamin d - Tier 1 ra calcium plus vitamin d3 - Tier 1 ra calcium soft chews - Tier 1 ra calcium/vitamin d/minerals - Tier 1 ra calcium-boron - Tier 1 ra calcium-magnesium-zinc - Tier 1 ra coral calcium - Tier 1 ra folic acid oral tablet 400 mcg - Tier 1; QL ra folic acid oral tablet 800 mcg (generic for FA-8) - Tier 1 ra hi cal (generic for RA HI CAL) - Tier 1 ra hi-cal (generic for RA HI-CAL) - Tier 1 ra hi-cal plus vitamin d (generic for RA HI CAL) - Tier 1 ra high potency iron - Tier 1 ra iron (generic for FEROSUL) - Tier 1 ra magnesium - Tier 1 ra natural magnesium - Tier 1 ra oyster shell calcium (generic for RA HI-CAL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 94 Preferred Agents Non-Preferred Agents ra oyster shell calcium/d - Tier 1 ra ped electrolyte freezer pop (generic for ORALYTE FREEZER POPS) - Tier 1 ra pediatric electrolyte (generic for ORALYTE FREEZER POPS) - Tier 1 ra slow release iron oral tablet extended release 47.5 mg - Tier 1 rehydralyte (generic for ORALYTE FREEZER POPS) - Tier 1 risacal-d - Tier 1 se-tan plus (generic for K-TAN PLUS) - Tier 1 SLOW FE (brand for iron slow release) - Tier 2 slow release iron oral tablet extended release 47.5 mg - Tier 1 SLOW-MAG - Tier 2 SLOWMAG MG MUSCLE/HEART - Tier 2 sm calcium 500/vitamin d3 - Tier 1 sm calcium 600/vitamin d - Tier 1 sm calcium citrate w/vit d3 (generic for CALCITRATE) - Tier 1 sm calcium citrate-vit d - Tier 1 sm calcium soft chews - Tier 1 sm calcium-magnesium-zinc oral tablet 333-133-5 mg - Tier 1 SM CORAL CALCIUM - Tier 2 sm folic acid - Tier 1; QL sm iron (generic for FEROSUL) - Tier 1 sm iron slow release - Tier 1 sm magnesium - Tier 1 sm oyster shell calcium/vit d - Tier 1 sm oyster shell calcium/vit d3 (generic for OYSTERCAL-D) - Tier 1 sm pediatric electrolyte (generic for ORALYTE FREEZER POPS) - Tier 1 sm slow release iron oral tablet extended release 143 (45 fe) mg - Tier 1 sod citrate-citric acid - Tier 1 sodium fluoride oral solution - Tier 1; QL sodium fluoride oral tablet chewable - Tier 1; QL soluvita e (generic for SOLUVITA E) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 95 Preferred Agents Non-Preferred Agents TARON FORTE - Tier 2 taron-crystals (generic for TARON-CRYSTALS) - Tier 1 tl-hem 150 (generic for ABATRON AF) - Tier 1 tricon (generic for TRICON) - Tier 1 VENOFER - Tier 2; QL VIRT-FEFA PLUS - Tier 2 vitamin e oral solution 15 unit/0.3ml (generic for SOLUVITA E) - Tier 1 wee care (generic for ICAR) - Tier 1 Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2; QL clovique (generic for CLOVIQUE) - Tier 1; PA; SP kionex (generic for KIONEX) - Tier 1; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP sodium polystyrene sulfonate oral powder - Tier 1 deferasirox oral tablet (generic for JADENU) - Tier 1; PA; SP; QL sodium polystyrene sulfonate oral suspension (generic for KIONEX) - deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; PA; SP Tier 1; QL deferiprone (generic for FERRIPROX) - Tier 1; PA; SP; QL sodium polystyrene sulfonate rectal - Tier 1 EXJADE (brand for deferasirox) - Tier 2; PA; SP sps (generic for KIONEX) - Tier 1; QL FERRIPROX ORAL SOLUTION - Tier 2; PA; SP FERRIPROX ORAL TABLET (brand for deferiprone) - Tier 2; PA; SP; QL FERRIPROX TWICE-A-DAY - Tier 2; PA; SP; QL JADENU (brand for deferasirox) - Tier 2; PA; SP; QL JADENU SPRINKLE (brand for deferasirox granules) - Tier 2; PA; SP JYNARQUE ORAL TABLET (brand for tolvaptan) - Tier 2; PA; SP JYNARQUE ORAL TABLET THERAPY PACK - Tier 2; PA; SP; QL LOKELMA - Tier 2; PA; QL OVEEZA - Tier 2; PA; QL SAMSCA (brand for tolvaptan) - Tier 2; PA; SP SYPRINE (brand for trientine hcl) - Tier 2; PA; SP TOLVAPTAN ORAL TABLET 15 MG - Tier 2; PA; SP tolvaptan oral tablet 30 mg (generic for JYNARQUE) - Tier 1; PA; SP trientine hcl (generic for CLOVIQUE) - Tier 1; PA; SP VELTASSA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 96 Preferred Agents Non-Preferred Agents Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; PA AURYXIA - Tier 2; PA calcium acetate oral (generic for CALPHRON) - Tier 1; PA FOSRENOL (brand for lanthanum carbonate) - Tier 2; PA sevelamer carbonate (generic for RENVELA) - Tier 1; PA lanthanum carbonate (generic for FOSRENOL) - Tier 1; PA sevelamer hcl - Tier 1; PA PHOSLYRA - Tier 2; PA RENAGEL (brand for sevelamer hcl) - Tier 2; PA RENVELA (brand for sevelamer carbonate) - Tier 2; PA VELPHORO - Tier 2; PA Vitamins ACTIFLOVIT EAR HEALTH (brand for b-50) - Tier 2 a-25 - Tier 1; PA; QL ACTIVITE - Tier 2; QL a-caro-25 - Tier 1; PA adc/f (0.5mg/ml) - Tier 1; QL ACEROLA C 500 - Tier 2; PA advanced stress formula/zinc - Tier 1 ACTITROM (brand for vasoflex forte) - Tier 2; PA airavite (generic for AIRAVITE) - Tier 1 ACTITROM-D (brand for vasoflex forte) - Tier 2; PA AIRSHIELD IMMUNITY SUPPORT (brand for multi adult gummies) - ADRENALalgal-900 dha C FORMULA (generic for (brand ALGAL-900 for hi c-500) DHA) - Tier 1;2; PA Tier 2 aminobenzoate potassium - Tier 1; PA airshield oral tablet chewable (generic for CVS AIRSHIELD) - Tier 1 alba-lybe nr - Tier 1 animal shapes plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; alph-e (generic for ESTER-E) - Tier 1; QL PA alph-e-mixed 1000 - Tier 1 alph-e-mixed oral capsule 200 unit - Tier 1 animal shapes plus iron (generic for LAND BEFORE TIME alph-e-mixed oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL MULTIVITAMIN) - Tier 1; PA AMINOPMRMS (brand for pros-tech plus) - Tier 2 animal shapes/iron (generic for CEROVITE JR) - Tier 1; PA; QL animal shapes (generic for ANIMAL SHAPES) - Tier 1 ASCOCID (brand for ascorbic acid) - Tier 2; PA ANIMI-3 - Tier 2 ASCOCID-1000 (brand for c1000 tr/rose hip/bioflavonoid) - Tier 2; PA ANIMI-3/VITAMIN D - Tier 2 ASCOCID-500-D (brand for c1000 tr/rose hip/bioflavonoid) - Tier 2; PA APETEX (brand for biopetit) - Tier 2 ascocid-iso-ph - Tier 1; PA APETIGEN (brand for biopetit) - Tier 2 ascorbic acid oral powder (generic for ASCOCID) - Tier 1; PA APETIGEN-PLUS - Tier 2 AQUADEKS - Tier 2 ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; PA; aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier QL 1; QL asco-tabs-1000 - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 97 Preferred Agents Non-Preferred Agents asilnasalrms (generic for ASILNASALRMS) - Tier 1 ATABEX EC - Tier 2; PA; QL ATABEX OB - Tier 2; QL azec - Tier 1; PA b complex formula 1 - Tier 1 AZESCHEW PRENATAL/POSTNATAL - Tier 2; PA; QL b complex oral capsule - Tier 1 AZESCO - Tier 2; PA; QL b complex plus c (generic for ALLBEE/C) - Tier 1 b complex-folic acid - Tier 1; PA b complex vitamins - Tier 1 b-1 - Tier 1; PA b complex-biotin-fa (generic for BIG 100) - Tier 1 b12 - Tier 1; PA b complex-c oral capsule - Tier 1 b12 gummies - Tier 1; PA; QL b-100 balanced tr - Tier 1 b-12 oral liquid 1000 mcg/15ml - Tier 1; PA b-100 complex cr (generic for ENDUR-B) - Tier 1 b-12 oral tablet 1000 mcg, 500 mcg - Tier 1; PA b-50 balanced (generic for BIG 100) - Tier 1 b12 quick dissolve - Tier 1; PA BACMIN (brand for sm one daily mens) - Tier 2 b-12 sublingual tablet sublingual 2500 mcg, 5000 mcg - Tier 1; PA balance b-100 (generic for CVS BALANCED B50) - Tier 1 B-2-400 - Tier 2; PA balance b-50 (generic for BIG 100) - Tier 1 b6 - Tier 1; PA balanced b50 (generic for CVS BALANCED B50) - Tier 1 b-6 folic acid - Tier 1; PA b-complex/b-12 oral - Tier 1 balanced b100 - Tier 1; PA biocel (generic for LYSIPLEX PLUS) - Tier 1 b-caro-t - Tier 1; PA bio-immunex (generic for ASILNASALRMS) - Tier 1 beta carotene oral capsule 25000 unit - Tier 1; PA biopetit (generic for APETEX) - Tier 1 bioflavonoid-1000 - Tier 1; PA biotin forte oral tablet 5 mg - Tier 1 bioflex (generic for ESTER-C) - Tier 1; PA biotin high potency - Tier 1; QL biotin forte oral tablet 3 mg - Tier 1; PA biotin oral capsule 5000 mcg (generic for MERIBIN) - Tier 1 b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; PA biotin oral tablet 1000 mcg - Tier 1; QL bprotected pedia poly-vite/fe - Tier 1; PA biotin oral tablet 5 mg - Tier 1 bp vit 3 (generic for TALIVA) - Tier 1 bprotected vitamin c (generic for BPROTECTED VITAMIN C) - Tier 1; PA; b-plex - Tier 1 QL c 1000-bioflavonoids-rose hips (generic for ACTITROM) - Tier 1; PA bprotected pedia d-vite (generic for BPROTECTED PEDIA D-VITE) - c 250 oral tablet - Tier 1; PA; QL Tier 1; QL c 500/rose hips (generic for PUREWAY-C) - Tier 1; PA; QL c complex (generic for ASCOCID-1000) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents bprotected pedia poly-vite (generic for BPROTECTED PEDIA POLY- c-1000/rose hips - Tier 1; PA; QL VITE) - Tier 1; QL CADEAU DHA - Tier 2; PA brewers yeast oral tablet 487.5 mg - Tier 1 calcidol (generic for CALCIDOL) - Tier 1; PA; QL bromase (generic for ASILNASALRMS) - Tier 1 calciferol (generic for CALCIDOL) - Tier 1; PA; QL b-stress - Tier 1 CALCIFOL - Tier 2; PA CENTRUM FLAVOR BURST (brand for multi adult gummies) - Tier 2 calcium-folic acid plus d - Tier 1; PA CENTRUM FLAVOR BURST ADULT (brand for multi adult gummies) - CALNA - Tier 2; PA Tier 2 caroguard - Tier 1; PA CENFOL - Tier 2; PA CENTRUM FRESH/FRUITY 50+ (brand for multi adult gummies) - Tier CENTRUM FLAVOR BURST KIDS (brand for complete multi-vitamin) - 2 Tier 2; PA; QL CENTRUM MULTI + OMEGA 3 (brand for multi adult gummies) - Tier CENTRUM SPECIALISTKIDS (brand forPRENATAL complete multi-vitamin)- Tier 2; PA - Tier 2; PA; QL 2 cerovite jr (generic for CEROVITE JR) - Tier 1; PA; QL CHEW-12 - Tier 2; PA CENTRUM ORAL TABLET CHEWABLE (brand for multi adult chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; PA; gummies) - Tier 2 QL chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; PA; QL CENTRUM SILVER ORAL TABLET CHEWABLE (brand for multi adult chew-c (generic for SUNKIST VITAMIN C) - Tier 1; PA; QL gummies) - Tier 2 child chewable vitamins/iron (generic for LAND BEFORE TIME CENTRUM VITAMINTS (brand for multi adult gummies) - Tier 2 MULTIVITAMIN) - Tier 1; PA CEREFOLIN (brand for l-methyl-mc) - Tier 2 childrens animal shapes (generic for CEROVITE JR) - Tier 1; PA; QL cerefolin nac (generic for CEREFOLIN NAC) - Tier 1 childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1; childrens chewable vitamins (generic for ANIMAL SHAPES) - Tier 1 PA CHOICEFUL MULTIVITAMIN ORAL TABLET CHEWABLE (brand for childrens chewables/iron (generic for LAND BEFORE TIME multi adult gummies) - Tier 2 MULTIVITAMIN) - Tier 1; PA classic prenatal - Tier 1; QL COMPLETENATE - Tier 2; QL childrens complete (generic for CENTRUM FLAVOR BURST KIDS) - Tier complex b-100 - Tier 1 1; PA; QL CO-NATAL FA (brand for pretab) - Tier 2; QL corvita - Tier 1 childrens vitamins/iron (generic for LAND BEFORE TIME creatine oral capsule (generic for ASILNASALRMS) - Tier 1 MULTIVITAMIN) - Tier 1; PA cyanocobalamin injection solution 1000 mcg/ml - Tier 1 chlorella oral capsule - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1 CHOLECAL DF - Tier 2; PA; QL d 400 oral tablet - Tier 1 CIFEREX (brand for ortho df) - Tier 2; PA CIFRAZOL - Tier 2; PA d 400 oral tablet chewable (generic for HEALTHY KIDS VITAMIN D3) - CITRANATAL 90 DHA - Tier 2; PA Tier 1 CITRANATAL ASSURE - Tier 2; PA; QL CITRANATAL B-CALM - Tier 2; PA d 5000 oral tablet (generic for RADIANCE PLATINUM VITAMIN D3) - CITRANATAL BLOOM - Tier 2; PA; QL Tier 1 CITRANATAL BLOOM DHA - Tier 2; PA d3 - Tier 1 CITRANATAL DHA - Tier 2; PA; QL d3 high potency oral capsule 25 mcg (1000 ut) (generic for CITRANATAL HARMONY - Tier 2; PA PRONUTRIENTS VITAMIN D3) - Tier 1 CITRANATAL MEDLEY - Tier 2; PA; QL d3 super strength - Tier 1 CITRANATAL RX - Tier 2; PA; QL d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 C-NATE DHA - Tier 2; PA d3-50 (generic for D3-50) - Tier 1 cod liver oil oral capsule 1250-135 unit, 4000-200 unit - Tier 1; PA daily gummies (generic for CVS AIRSHIELD) - Tier 1 COD LIVER OIL ORAL OIL - Tier 2; PA daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - COMPLETE NATAL DHA - Tier 2; PA; QL Tier 1 CONCEPT DHA (brand for virt-c dha) - Tier 2; PA daily vitamin formula+iron - Tier 1 CONCEPT OB - Tier 2; PA daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 C-PLEX (brand for vasoflex forte) - Tier 2; PA daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 crush vitamin c drops (generic for CRUSH VITAMIN C DROPS) - Tier 1; daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 PA daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 c-time - Tier 1; PA decara oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1 d 10000 (generic for DECARA) - Tier 1; PA dexifol (generic for DEXIFOL) - Tier 1 daflonex-xl (generic for ASCOCID-1000) - Tier 1; PA DIAB EXTRA (brand for bladder 2.2) - Tier 2 daily prenatal (generic for ONE-A-DAY WOMENS PRENATAL) - Tier 1; DIAB NUTRI (brand for bladder 2.2) - Tier 2 PA dialyvite (generic for DIALYVITE) - Tier 1; QL DIALYVITE 3000 - Tier 2 decara oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1; DIALYVITE 5000 - Tier 2 PA DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2; PA DIALYVITE 800 ORAL TABLET (brand for west-vite w/folic acid) - Tier DERMACINRX PUREFOLIX - Tier 2; PA 2 dino-life w/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; PA DIALYVITE 800/IRON - Tier 2 DINO-LIFE W/IRON-ZINC - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents DIALYVITE 800/ZINC - Tier 2 d-natural-5 - Tier 1; PA DIALYVITE 800-ZINC 15 - Tier 2 DOC OMEGA - Tier 2; PA DIALYVITE SUPREME D - Tier 2 DRISDOL (brand for vitamin d (ergocalciferol)) - Tier 2; PA DIALYVITE VITAMIN D 5000 (brand for d 5000) - Tier 2 DUET DHA 400 - Tier 2; PA DIALYVITE/ZINC - Tier 2 DUET DHA BALANCED - Tier 2; PA dino-life (generic for ANIMAL SHAPES) - Tier 1 DURACHOL - Tier 2; PA D-VI-SOL (brand for vitamin d3) - Tier 2; QL ELFOLATE (brand for l-methylfolate) - Tier 2; PA d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1; ELITE-OB - Tier 2; PA QL ENBRACE HR - Tier 2; PA e - Tier 1 ENFAMIL EXPECTA - Tier 2; PA e-400-clear (generic for ESTER-E) - Tier 1; QL ERGOCAL - Tier 2; PA; QL e-400-mixed (generic for ESTER-E) - Tier 1; QL ergocalciferol oral solution (generic for CALCIDOL) - Tier 1; PA; QL ecee plus - Tier 1 ester-c oral tablet (generic for ESTER-C) - Tier 1; PA eldertonic (generic for ELDERTONIC) - Tier 1 EXTRESS-30 - Tier 2; PA ELFOLATE PLUS (brand for l-methylfolate-b6-b12) - Tier 2 fa-8 oral capsule - Tier 1; PA e-max-1000 - Tier 1 fa-vitamin b-6-vitamin b-12 - Tier 1; PA ergocalciferol oral capsule (generic for DRISDOL) - Tier 1 flexgen (generic for ESTER-C) - Tier 1; PA FLORIVA ORAL TABLET CHEWABLE - Tier 2; PA essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier folic acid oral capsule 20 mg, 5 mg - Tier 1; PA 1 FOLIC D3 - Tier 2; PA estro support es (generic for DIAB EXTRA) - Tier 1 FOLIC-K - Tier 2; PA; QL ex-l (generic for DIAB EXTRA) - Tier 1 FOLI-D - Tier 2; PA; QL extress (generic for BIG 100) - Tier 1 FOLITE - Tier 2; PA; QL extress-super (generic for BIG 100) - Tier 1 FOLIVANE-OB - Tier 2; PA fabb (generic for VIRT-GARD) - Tier 1 FOLIXAPURE - Tier 2; PA FLORIVA PLUS (brand for multi-vitamin/fluoride) - Tier 2; QL folplex 2.2 - Tier 1; PA folbee (generic for AIRAVITE) - Tier 1 FOLTANX RF (brand for l-methylfolate-algae-b12-b6) - Tier 2; PA folbee plus (generic for DEXIFOL) - Tier 1 FOLTREXYL - Tier 2; PA folbee plus cz - Tier 1 FOLVITE-D - Tier 2; PA; QL FOLBIC RF - Tier 2 FOSTEUM - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents FOLGARD OS - Tier 2 fruity c - Tier 1; PA; QL FOLGARD RX (brand for fabb) - Tier 2 GENICIN VITA-D - Tier 2; PA; QL foltabs 800 - Tier 1 GENICIN VITA-Q - Tier 2; PA foltanx (generic for FOLTANX) - Tier 1 geravine - Tier 1; PA FOLTX - Tier 2 geriatric vitamin - Tier 1; PA full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1 GERM DEFENSE PM (brand for ra effervescent formula) - Tier 2; PA GENICIN VITA-S (brand for vitasure) - Tier 2; QL gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; glyco-tech (generic for APETIGEN-PLUS) - Tier 1 PA; QL HARD NAILS (brand for ra biotin) - Tier 2 healthy hair/skin/nails (generic for TAB-A-VITE/BETA CAROTENE) - gummy multivitamin kids (generic for CENTRUM FLAVOR BURST KIDS) Tier 1 - Tier 1; PA; QL HYLAVITE - Tier 2 HONEY BEARS - Tier 2; PA INATAL GT - Tier 2; QL HONEY BEARS W/IRON-ZINC - Tier 2; PA INFUVITE ADULT - Tier 2 HYLAZINC - Tier 2; PA INFUVITE PEDIATRIC - Tier 2 kosher prenatal plus iron - Tier 1; PA inner ear plus (generic for CVS BALANCED B50) - Tier 1 kp vitamin b-12 - Tier 1; PA KIDNEY (brand for pros-tech plus) - Tier 2 kp vitamin b-6 - Tier 1; PA kp prenatal multivitamins - Tier 1; QL lexinal - Tier 1; PA kp vitamin d (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 LIPOTRIAD (brand for b-50) - Tier 2; PA kp vitamin d3 - Tier 1 l-methylfolate (generic for ELFOLATE) - Tier 1; PA kp vitamin e - Tier 1 l-methylfolate calcium oral (generic for ELFOLATE) - Tier 1; PA lipoflavonoid (generic for CVS BALANCED B50) - Tier 1 l-methylfolate-algae-b12-b6 (generic for FOLTANX RF) - Tier 1; PA lipoflavovit (generic for CVS BALANCED B50) - Tier 1 lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; PA lipo-key (generic for CVS BALANCED B50) - Tier 1 MARNATAL-F - Tier 2; PA LITHATE (brand for pros-tech plus) - Tier 2 MEPHYTON (brand for phytonadione) - Tier 2; PA; QL little ones childrens (generic for ANIMAL SHAPES) - Tier 1 METANX (brand for l-methylfolate-algae-b12-b6) - Tier 2; PA l-methylfolate ca me-cbl nac (generic for CEREFOLIN NAC) - Tier 1 l-methylfolate-b6-b12 (generic for FOLTANX) - Tier 1 multiple vitamins-iron oral tablet chewable (generic for LAND BEFORE l-methyl-mc (generic for METAFOLBIC) - Tier 1 TIME MULTIVITAMIN) - Tier 1; PA l-methyl-mc nac (generic for METAFOLBIC PLUS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents LORID - Tier 2; QL MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, M.V.I. ADULT - Tier 2 0.5-0.3 MG, 1-0.3 MG - Tier 2; PA M.V.I. PEDIATRIC - Tier 2 MYNATAL - Tier 2; PA MAGNEBIND 400 - Tier 2 n-acetyl-l-cysteine oral (generic for NF FORMULAS NAC) - Tier 1; PA malic b6 (generic for ASILNASALRMS) - Tier 1 nail-ex - Tier 1; PA NASCOBAL - Tier 2; PA mega multiple/chelated mineral (generic for CVS BALANCED B50) - NATACHEW - Tier 2; PA Tier 1 NATALVIT - Tier 2; PA mens daily gummies (generic for CVS AIRSHIELD) - Tier 1 NEEVO DHA - Tier 2; PA meribin (generic for MERIBIN) - Tier 1 NEONATAL + DHA - Tier 2; PA; QL metafolbic (generic for METAFOLBIC) - Tier 1 NEONATAL 19 - Tier 2; PA; QL metafolbic plus (generic for METAFOLBIC PLUS) - Tier 1 NEOVITE - Tier 2; PA metafolbic plus rf (generic for CEREFOLIN NAC) - Tier 1 NESTABS ONE - Tier 2; PA; QL METHIONINE-200 (brand for pros-tech plus) - Tier 2 NEURO-K-250 T.D. - Tier 2; PA methylfol-algae-b12-acetylcyst (generic for CEREFOLIN NAC) - Tier 1 neuro-k-250 vitamin b6 - Tier 1; PA; QL M-NATAL PLUS - Tier 2; QL neuro-k-50 - Tier 1; PA multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 neuro-k-500 - Tier 1; PA; QL niacin er oral capsule extended release 500 mg - Tier 1; PA multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier niacin er oral tablet extended release 500 mg (generic for SLO-NIACIN) - 1 Tier 1; PA multiple vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 niacin oral tablet 100 mg - Tier 1; PA multiple vitamin-folic acid (generic for TAB-A-VITE/BETA CAROTENE) NICADAN (brand for sm one daily mens) - Tier 2; PA - Tier 1 NICAZEL (brand for sm one daily mens) - Tier 2; PA multiple vitamins/iron - Tier 1 NICAZEL FORTE (brand for sm one daily mens) - Tier 2; PA MULTIPRO - Tier 2 nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; PA multi-vit/iron/fluoride - Tier 1; QL OB COMPLETE - Tier 2; PA multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 OB COMPLETE ONE - Tier 2; PA multi-vitamin hp/minerals - Tier 1 OB COMPLETE PETITE - Tier 2; PA multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL OB COMPLETE PREMIER - Tier 2; PA OB COMPLETE/DHA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 103 Preferred Agents Non-Preferred Agents multivitamin/fluoride oral solution (generic for FLORIVA PLUS) - Tier 1; OBSTETRIX ONE - Tier 2; PA QL O-CAL PRENATAL - Tier 2; PA; QL OCUVEL - Tier 2; PA multivitamin/fluoride oral tablet chewable 0.25 mg, 1 mg (generic for ORTHO DF - Tier 2; PA QUFLORA PEDIATRIC) - Tier 1 p-1000 - Tier 1; PA pa prenatal formula - Tier 1; PA multivitamin/fluoride tablet chewable 0.5 mg oral (generic for pa vitamin b-12 tr - Tier 1; PA QUFLORA PEDIATRIC) - Tier 1 panto-250 - Tier 1; PA pantothenic acid - Tier 1; PA multivitamin/fluoride tablet chewable 0.5 mg oral (generic for PERIDIN-C (brand for hi c-500) - Tier 2; PA QUFLORA PEDIATRIC) - Tier 1; QL PERRY PRENATAL - Tier 2; PA multi-vitamin/fluoride/iron - Tier 1; QL pnv-dha (generic for ZATEAN-PN DHA) - Tier 1; PA multi-vitamin/iron - Tier 1 pnv-dha+docusate - Tier 1; PA multivitamins/fluoride (generic for QUFLORA PEDIATRIC) - Tier 1 pnv-omega (generic for ZATEAN-PN PLUS) - Tier 1; PA MYNATAL PLUS - Tier 2; QL pnv-select - Tier 1; PA MYNATAL-Z - Tier 2; QL POLY-VI-FLOR FS - Tier 2; PA mynephrocaps (generic for MYNEPHRON) - Tier 1 POLY-VI-FLOR ORAL SUSPENSION - Tier 2; PA mynephron (generic for MYNEPHRON) - Tier 1 POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG - Tier 2; PA; QL NEOMULTIVITE (brand for healthy hair/skin/nails) - Tier 2 POLY-VI-FLOR ORAL TABLET CHEWABLE 0.5 MG, 1 MG - Tier 2; PA NEONATAL COMPLETE - Tier 2; QL POLY-VI-FLOR/IRON - Tier 2; PA POTABA - Tier 2; PA NEONATAL PLUS (brand for prenatal vitamin plus low iron) - Tier 2; PREGENNA - Tier 2; PA; QL QL PREMESISRX - Tier 2; PA; QL NEONATAL VITAMIN (brand for prenatal vitamin) - Tier 2; QL PRENA 1 TRUE - Tier 2; PA NEPHPLEX RX - Tier 2 PRENA1 - Tier 2; PA nephro vitamins (generic for DIALYVITE 800) - Tier 1 PRENA1 PEARL - Tier 2; PA nephronex oral tablet (generic for DIALYVITE) - Tier 1; QL PRENAISSANCE - Tier 2; PA NEPHRO-VITE (brand for west-vite w/folic acid) - Tier 2 PRENAISSANCE PLUS - Tier 2; PA NEPHRO-VITE RX (brand for vitasure) - Tier 2; QL PRENARA - Tier 2; PA; QL NESTABS - Tier 2; QL prenatal formula - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents NESTABS DHA (brand for tri-tabs dha) - Tier 2; QL prenatal multi+dha - Tier 1; PA niacin er oral capsule extended release 250 mg - Tier 1 prenatal/iron oral tablet - Tier 1; PA niacin er oral tablet extended release 1000 mg - Tier 1 PRENATE - Tier 2; PA niacin er oral tablet extended release 250 mg, 750 mg (generic for PRENATE AM - Tier 2; PA; QL SLO-NIACIN) - Tier 1 PRENATE DHA - Tier 2; PA niacin flush free oral capsule 400-100 mg - Tier 1 PRENATE ELITE - Tier 2; PA niacin oral tablet 250 mg, 50 mg - Tier 1 PRENATE ENHANCE - Tier 2; PA niacin tr (generic for SLO-NIACIN) - Tier 1 PRENATE ESSENTIAL - Tier 2; PA niacin-50 - Tier 1 PRENATE MINI - Tier 2; PA NICOMIDE - Tier 2 PRENATE PIXIE - Tier 2; PA NIVA-PLUS (brand for prenatal vitamin plus low iron) - Tier 2; QL PRENATE RESTORE - Tier 2; PA no flush niacin oral capsule - Tier 1 PRENATVITE COMPLETE - Tier 2; PA; QL novamv pediatric multi-vitamin - Tier 1 PRENATVITE PLUS - Tier 2; PA; QL nufol (generic for AIRAVITE) - Tier 1 PRENATVITE RX - Tier 2; PA NUTRICAP (brand for sm one daily mens) - Tier 2 PRIMACARE - Tier 2; PA; QL NUTRIVIT - Tier 2 PRONUTRIENTS SUPER B COMPLEX - Tier 2; PA OBSTETRIX DHA - Tier 2; QL PROVIDA OB - Tier 2; PA OBSTETRIX EC - Tier 2; QL pyridoxine hcl oral - Tier 1; PA OBTREX - Tier 2; QL qc childrens complete (generic for CEROVITE JR) - Tier 1; PA; QL once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 qc childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier once daily/iron - Tier 1 1; PA one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 qc childrens vitamins/iron (generic for LAND BEFORE TIME one daily plus iron - Tier 1 MULTIVITAMIN) - Tier 1; PA QUFLORA FE - Tier 2; PA one daily womens health (generic for HM VITA-MINI MULTI QUFLORA FE PEDIATRIC - Tier 2; PA; QL COMPLETE) - Tier 1 QUFLORA GUMMIES - Tier 2; PA; QL ONE VITE WOMENS - Tier 2; QL ra beta carotene - Tier 1; PA ONE VITE WOMENS PLUS - Tier 2; QL ra childrens chewable vit/iron (generic for LAND BEFORE TIME one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - MULTIVITAMIN) - Tier 1; PA Tier 1 ra cod liver oil oral capsule - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA ra effervescent formula (generic for GERM DEFENSE PM) - Tier 1; PA CAROTENE) - Tier 1 RA GERM DEFENSE ORAL (brand for ra effervescent formula) - Tier 2; one-daily multi-vitamin/iron - Tier 1 PA one-daily/iron - Tier 1 ra gummy vitamins & minerals (generic for CENTRUM FLAVOR BURST ONEVITE - Tier 2 KIDS) - Tier 1; PA; QL OVARY (brand for pros-tech plus) - Tier 2 ra niacin oral tablet 100 mg - Tier 1; PA pa b-complex with b-12 - Tier 1 ra one daily (generic for ONE-A-DAY WOMENS PRENATAL) - Tier 1; PA pa biotin oral capsule (generic for MERIBIN) - Tier 1 ra vitamin a - Tier 1; PA; QL pa biotin oral tablet - Tier 1; QL ra vitamin a & d oral - Tier 1; PA pa vitamin d-3 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 ra vitamin b-1 - Tier 1; PA pa vitamin d-3 gummy (generic for HEALTHY KIDS VITAMIN D3) - ra vitamin b12 - Tier 1; PA Tier 1 ra vitamin b-12 - Tier 1; PA pa vitamin e (generic for ESTER-E) - Tier 1; QL ra vitamin b-12 tr - Tier 1; PA pediavit - Tier 1 ra vitamin b-6 - Tier 1; PA phytonadione oral (generic for MEPHYTON) - Tier 1; QL ra vitamin b-6 cr - Tier 1; PA; QL pnv tabs 29-1 (generic for PRENATABS RX) - Tier 1; QL ra vitamin c - Tier 1; PA; QL poly-vite pediatric (generic for BPROTECTED PEDIA POLY-VITE) - ra vitamin c cr oral tablet extended release (generic for ASCOCID-1000) - Tier 1; QL Tier 1; PA prenatabs rx (generic for PRENATABS RX) - Tier 1; QL ra vitamin c cr oral tablet extended release 500 mg (generic for ENDUR- prenatal 19 - Tier 1; QL C) - Tier 1; PA; QL prenatal gummy oral tablet chewable 0.4-113.5 mg - Tier 1; QL prenatal low iron (generic for NEONATAL VITAMIN) - Tier 1; QL ra vitamin c drops mouth/throat lozenge 60 mg (generic for CRUSH prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier VITAMIN C DROPS) - Tier 1; PA 1; QL ra vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; PA; QL prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; ra vitamin c/rose hips (generic for PUREWAY-C) - Tier 1; PA; QL QL ra vitamin c/rose hips cr (generic for ENDUR-C) - Tier 1; PA; QL prenatal oral tablet 28-0.8 mg - Tier 1; QL prenatal plus iron (generic for PRENATABS RX) - Tier 1; QL ra vitamins complete childrens (generic for CEROVITE JR) - Tier 1; PA; prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; QL QL RELNATE DHA - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents prenatal vitamins - Tier 1; QL REMEDIENT - Tier 2; PA prenatal/iron oral tablet 28-0.8 mg - Tier 1; QL RENATABS - Tier 2; PA PRENATAL-U - Tier 2; QL RENATABS WITH IRON - Tier 2; PA PRENATRIX (brand for prenatal vitamin plus low iron) - Tier 2; QL REQ 49+ (brand for sm one daily mens) - Tier 2; PA PRENATRYL (brand for prenatal vitamin plus low iron) - Tier 2; QL REVESTA - Tier 2; PA preplus (generic for NEONATAL PLUS) - Tier 1; QL riboflavin oral capsule 50 mg - Tier 1; PA pretab (generic for CO-NATAL FA) - Tier 1; QL SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG - Tier 2; PA pronutrients vitamin d3 (generic for PRONUTRIENTS VITAMIN D3) - SELECT-OB ORAL TABLET CHEWABLE 29-1 MG - Tier 2; PA; QL Tier 1 SELECT-OB+DHA - Tier 2; PA prostate oral capsule 140 mg (generic for ASILNASALRMS) - Tier 1 SLO-NIACIN ORAL TABLET EXTENDED RELEASE 500 MG (brand for pros-tech plus (generic for ASILNASALRMS) - Tier 1 niacin er) - Tier 2; PA qc daily multivitamins/iron - Tier 1 sm animal shapes complete (generic for CEROVITE JR) - Tier 1; PA; QL qc essentials (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 sm chewable c (generic for SUNKIST VITAMIN C) - Tier 1; PA; QL qc prenatal - Tier 1; QL sm cod liver oil - Tier 1; PA sm vit c/rose hips - Tier 1; PA; QL QUFLORA PEDIATRIC ORAL SOLUTION (brand for multi- sm vitamin b-12 - Tier 1; PA vitamin/fluoride) - Tier 2; QL sm vitamin b-6 - Tier 1; PA sm vitamin c oral tablet 1000 mg, 250 mg - Tier 1; PA; QL QUFLORA PEDIATRIC ORAL TABLET CHEWABLE (brand for sm vitamin c oral tablet chewable (generic for SUNKIST VITAMIN C) - multivitamin/fluoride) - Tier 2 Tier 1; PA; QL ra balanced b-100 (generic for BIG 100) - Tier 1 sm vitamin c/rose hips (generic for PUREWAY-C) - Tier 1; PA; QL ra balanced b-100 cr (generic for ENDUR-B) - Tier 1 STROVITE FORTE ORAL SYRUP - Tier 2; PA ra balanced b-50 (generic for BIG 100) - Tier 1 STUART ONE - Tier 2; PA ra balanced b-50 tr (generic for ENDUR-B) - Tier 1 SUPER B-50 B COMPLEX (brand for super b-50 complex) - Tier 2; PA ra b-complex - Tier 1 SYNAGEX - Tier 2; PA ra b-complex with b-12 - Tier 1 TARON-C DHA (brand for virt-c dha) - Tier 2; PA ra b-complex/vitamin c cr - Tier 1 TARON-PREX - Tier 2; PA ra biotin oral capsule (generic for HARD NAILS) - Tier 1 thiamine - Tier 1; PA ra biotin oral tablet - Tier 1; QL thiamine hcl oral - Tier 1; PA ra melatonin/b-6 (generic for DIAB EXTRA) - Tier 1 TRICARE PRENATAL DHA ONE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 107 Preferred Agents Non-Preferred Agents ra natural vitamin e (generic for ESTER-E) - Tier 1; QL TRINAZ - Tier 2; PA; QL ra one daily essential (generic for TAB-A-VITE/BETA CAROTENE) - TRISTART DHA - Tier 2; PA Tier 1 TRISTART ONE - Tier 2; PA; QL ra one daily gummy vites (generic for CVS AIRSHIELD) - Tier 1 TRI-VI-FLOR (brand for tri-vi-floro) - Tier 2; PA ra one daily multi-vit plus fe - Tier 1 TRI-VI-FLORO - Tier 2; PA TROMBONEX (brand for vasoflex forte) - Tier 2; PA ra one daily multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) TROMBONEX-D (brand for vasoflex forte) - Tier 2; PA - Tier 1 vasoflex forte (generic for ACTITROM) - Tier 1; PA ra prenatal - Tier 1; QL vasoflex hd (generic for ESTER-C) - Tier 1; PA ra prenatal formula - Tier 1; QL VASOFLEX ORAL CAPSULE (brand for vasoflex forte) - Tier 2; PA ra vitamin d-3 - Tier 1 vasoflex oral tablet (generic for ESTER-C) - Tier 1; PA ra vitamin e blend (generic for ESTER-E) - Tier 1; QL VINATE DHA RF - Tier 2; PA ra vitamin e natural - Tier 1 virt-c dha (generic for CONCEPT DHA) - Tier 1; PA ra vitamin e oral capsule 1000 unit, 200 unit - Tier 1 virt-nate dha (generic for VIVA DHA) - Tier 1; PA ra vitamin e oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL virt-pn dha (generic for ZATEAN-PN DHA) - Tier 1; PA radiance platinum vitamin d3 (generic for RADIANCE PLATINUM virt-pn plus (generic for ZATEAN-PN PLUS) - Tier 1; PA VITAMIN D3) - Tier 1 vita s forte (generic for LYSIPLEX PLUS) - Tier 1; PA renal (generic for MYNEPHRON) - Tier 1 RENAL MULTIVITAMIN FORMULA (brand for west-vite w/folic acid) - vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST KIDS) Tier 2 - Tier 1; PA; QL renal-vite (generic for DIALYVITE 800) - Tier 1 VITAFOL FE+ - Tier 2; PA; QL rena-vite (generic for DIALYVITE 800) - Tier 1 VITAFOL GUMMIES - Tier 2; PA RIGHT STEP PRENATAL (brand for prenatal vitamin) - Tier 2; QL VITAFOL STRIPS - Tier 2; PA; QL risanoid plus (generic for CVS BALANCED B50) - Tier 1 VITAFOL ULTRA - Tier 2; PA SE-NATAL 19 - Tier 2; QL VITAFOL-NANO - Tier 2; PA senior tonic (generic for ELDERTONIC) - Tier 1 VITAFOL-OB+DHA - Tier 2; PA SIDEROL (brand for sm one daily mens) - Tier 2 VITAFOL-ONE - Tier 2; PA silica oral (generic for ASILNASALRMS) - Tier 1 VITAMAX (brand for complete multi-vitamin) - Tier 2; PA; QL SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG (brand VITAMEDMD ONE RX/QUATREFOLIC - Tier 2; PA for gnp niacin tr) - Tier 2 VITAMEDMD REDICHEW RX (brand for prena1) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents SLO-NIACIN ORAL TABLET EXTENDED RELEASE 750 MG (brand VITAMIN A FISH - Tier 2; PA for niacin er) - Tier 2 vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1; PA; sm animal shapes kids first (generic for ANIMAL SHAPES) - Tier 1 QL sm balanced b-100 - Tier 1 vitamin b1 - Tier 1; PA sm balanced b-50 - Tier 1 vitamin b-1 oral tablet 100 mg, 50 mg - Tier 1; PA sm estro vital nutrients ex st (generic for DIAB EXTRA) - Tier 1 vitamin b-1 oral tablet 250 mg - Tier 1; PA; QL sm multiple vitamins essential (generic for TAB-A-VITE/BETA vitamin b-12 er oral tablet extended release 1000 mcg, 2000 mcg - Tier 1; CAROTENE) - Tier 1 PA sm multiple vitamins/iron - Tier 1 sm prenatal vitamins - Tier 1; QL vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg - Tier 1; sm super b complex/c (generic for ALLBEE/C) - Tier 1 PA vitamin b-12 oral tablet extended release 2000 mcg - Tier 1; PA sm vitamin d3 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier vitamin b12 sublingual liquid - Tier 1; PA 1 vitamin b-12 sublingual tablet sublingual 2500 mcg, 5000 mcg - Tier 1; PA sm vitamin e oral capsule 1000 unit, 200 unit - Tier 1 vitamin b-12 tr - Tier 1; PA sm vitamin e oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL vitamin b-2 oral tablet 100 mg, 25 mg - Tier 1; PA sodium benzoate oral (generic for ASILNASALRMS) - Tier 1 vitamin b-6 er - Tier 1; PA; QL vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg - Tier 1; PA spectravite adult 50+ oral tablet chewable (generic for CVS vitamin b-6 oral tablet 500 mg - Tier 1; PA; QL AIRSHIELD) - Tier 1 vitamin c cr (generic for ENDUR-C) - Tier 1; PA; QL stress formula - Tier 1 vitamin c drops (generic for CRUSH VITAMIN C DROPS) - Tier 1; PA stress formula/iron - Tier 1 vitamin c er oral capsule extended release - Tier 1; PA stress formula/zinc - Tier 1 vitamin c er oral tablet extended release 1500 mg - Tier 1; PA; QL STROVITE FORTE ORAL TABLET (brand for sm one daily mens) - vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN C) - Tier 2 Tier 1; PA; QL STROVITE ONE (brand for sm one daily mens) - Tier 2 vitamin c oral tablet 1000 mg, 250 mg - Tier 1; PA; QL super b complex/c (generic for ALLBEE/C) - Tier 1 vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; PA; QL super b complex/vitamin c (generic for ALLBEE/C) - Tier 1 vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; PA; QL super b/c - Tier 1 SUPERVITE - Tier 2 vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN C) support (generic for ALIVE MULTI-VITAMIN) - Tier 1; QL - Tier 1; PA; QL SUPPORT-500 (brand for bilberry plus) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 109 Preferred Agents Non-Preferred Agents SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE (brand for vitamin c w/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier multi adult gummies) - Tier 2 1; PA; QL tab-a-vite (generic for LYSIPLEX PLUS) - Tier 1 vitamin c/bioflavonoids (generic for ESTER-C) - Tier 1; PA tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - vitamin c/rose hips tr (generic for ENDUR-C) - Tier 1; PA; QL Tier 1 vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; PA; QL tab-a-vite/iron - Tier 1 TALIVA (brand for bp vit 3) - Tier 2 vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 1; PA vitamin d3 oral liquid 125 mcg/ml - Tier 1; PA therapeutic oral tablet (generic for TAB-A-VITE/BETA CAROTENE) - vitamin k (phytonadione) - Tier 1; PA Tier 1 VITAPEARL (brand for prena1 pearl) - Tier 2; PA thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 VITAROCA PLUS (brand for sm one daily mens) - Tier 2; PA THRIVITE 19 - Tier 2 VITATRUE (brand for prena 1 true) - Tier 2; PA THRIVITE RX - Tier 2; QL VITONIC - Tier 2; PA totalday multiple (generic for ENDUR-VM) - Tier 1 VITREXATE (brand for sm one daily mens) - Tier 2; PA TRICARE (brand for prenatal vitamin plus low iron) - Tier 2; QL VITREXATE FE (brand for sm one daily mens) - Tier 2; PA TRINATAL RX 1 - Tier 2; QL VITREXYL (brand for sm one daily mens) - Tier 2; PA trinate - Tier 1; QL VITREXYL + IRON (brand for sm one daily mens) - Tier 2; PA triphrocaps (generic for MYNEPHRON) - Tier 1 VIVA DHA (brand for virt-nate dha) - Tier 2; PA TRI-TABS DHA - Tier 2; QL vp-heme ob + dha - Tier 1; PA vp-pnv-dha - Tier 1; PA tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1; WESTGEL DHA - Tier 2; PA QL womens prenatal+dha - Tier 1; PA tri-vite/fluoride - Tier 1; QL XAQUIL XR - Tier 2; PA TRONVITE - Tier 2; QL ZALVIT - Tier 2; PA; QL UDAMIN SP (brand for thrivite 19) - Tier 2 ZATEAN-PN DHA (brand for virt-pn dha) - Tier 2; PA ultra energy (generic for DIAB EXTRA) - Tier 1 ZATEAN-PN PLUS (brand for pnv-omega) - Tier 2; PA ultra-mega (generic for ENDUR-VM) - Tier 1 zinc oral lozenge - Tier 1; PA urosex (generic for ALLERWELL ALLERGY FORMULA) - Tier 1 zoo friends (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1; PA; v-c forte (generic for VIC-FORTE) - Tier 1 QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 110 Preferred Agents Non-Preferred Agents vic-forte (generic for VIC-FORTE) - Tier 1 zoo friends complete (generic for CENTRUM FLAVOR BURST KIDS) - vinate ii - Tier 1; QL Tier 1; PA; QL vinate one (generic for VINATE ONE) - Tier 1; QL zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; PA virt-caps (generic for MYNEPHRON) - Tier 1 zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) - virt-gard (generic for VIRT-GARD) - Tier 1 Tier 1; PA vitacel (generic for LYSIPLEX PLUS) - Tier 1 VITAFOL - Tier 2 zoochews gummies (generic for CENTRUM FLAVOR BURST KIDS) - VITAFOL-OB (brand for mynatal-z) - Tier 2; QL Tier 1; PA; QL VITAL-D RX - Tier 2 VITAMAX PEDIATRIC - Tier 2 VITAMEZ (brand for bp vit 3) - Tier 2 vita-min (generic for VIC-FORTE) - Tier 1 vitamin b complex 100 - Tier 1 vitamin b complex-c - Tier 1 vitamin b-complex 100 - Tier 1 vitamin d (cholecalciferol) oral tablet - Tier 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1 vitamin d oral capsule 400 unit - Tier 1 vitamin d oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1 vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1 vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1 vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1 vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 super strength oral tablet (generic for THERA-D 2000) - Tier 1 vitamin d-400 - Tier 1 vitamin e oral capsule 100 unit, 1000 unit, 200 unit - Tier 1 vitamin e oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL vitamin-b complex - Tier 1 vitamins acd-fluoride - Tier 1; QL VITA-RX DIABETIC VITAMIN - Tier 2 VITASURE - Tier 2; QL VITATHELY WITH GINGER (brand for prenatal vitamin plus low iron) - Tier 2; QL VOL-PLUS - Tier 2; QL VOL-TAB RX - Tier 2; QL vp-vite rx (generic for DIALYVITE) - Tier 1; QL weekly-d (generic for D3-50) - Tier 1 westab max (generic for FOLBIC) - Tier 1 westab mini (generic for VIRT-GARD) - Tier 1 westab one (generic for AIRAVITE) - Tier 1 WESTAB PLUS - Tier 2; QL WEST-VITE W/FOLIC ACID - Tier 2 WHEAT GERM OIL - Tier 2 womens daily gummies (generic for CVS AIRSHIELD) - Tier 1 XVITE - Tier 2; QL ZE-PLUS (brand for antioxidant formula) - Tier 2 zoo friends gummies (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs ANASPAZ (brand for ed-spaz) - Tier 2 belladonna alkaloids-opium - Tier 1; PA; QL dicyclomine hcl oral - Tier 1 chlordiazepoxide-clidinium (generic for LIBRAX) - Tier 1; PA ed-spaz (generic for ANASPAZ) - Tier 1 CUVPOSA - Tier 2; PA; QL glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 DONNATAL (brand for phenobarbital-belladonna alk) - Tier 2; PA hyoscyamine sulfate er (generic for SYMAX-SR) - Tier 1 GLYCATE (brand for glycopyrrolate) - Tier 2; PA hyoscyamine sulfate oral elixir - Tier 1 GLYCOPYRROLATE ORAL TABLET 1.5 MG - Tier 2; PA hyoscyamine sulfate oral solution - Tier 1; QL LIBRAX (brand for chlordiazepoxide-clidinium) - Tier 2; PA hyoscyamine sulfate oral tablet (generic for LEVSIN) - Tier 1 methscopolamine bromide oral - Tier 1; PA pb-hyoscy-atropine-scopolamine (generic for PHENOHYTRO) - Tier 1; PA hyoscyamine sulfate oral tablet dispersible (generic for ANASPAZ) - phenobarbital-belladonna alk (generic for PHENOHYTRO) - Tier 1; PA Tier 1 phenohytro (generic for PHENOHYTRO) - Tier 1; PA hyoscyamine sulfate sl (generic for SYMAX-SL) - Tier 1 propantheline bromide oral - Tier 1; PA; QL hyoscyamine sulfate sublingual (generic for SYMAX-SL) - Tier 1 SYMAX DUOTAB - Tier 2; PA hyosyne oral elixir - Tier 1 hyosyne oral solution - Tier 1; QL LEVBID (brand for hyoscyamine sulfate er) - Tier 2 LEVSIN ORAL (brand for hyoscyamine sulfate) - Tier 2 LEVSIN/SL (brand for oscimin) - Tier 2 NULEV (brand for ed-spaz) - Tier 2 oscimin (generic for LEVSIN) - Tier 1 oscimin sr (generic for SYMAX-SR) - Tier 1 symax-sl (generic for SYMAX-SL) - Tier 1 symax-sr (generic for SYMAX-SR) - Tier 1 Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs acid gone (generic for ACID GONE) - Tier 1 abatinex (generic for ABATINEX) - Tier 1; PA almacone double strength (generic for ALMACONE DOUBLE acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1; PA STRENGTH) - Tier 1 acidophilus oral capsule (generic for ABATINEX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 113 Preferred Agents Non-Preferred Agents alum & mag hydroxide-simeth (generic for MI-ACID) - Tier 1 acidophilus probiotic (generic for FLORANEX) - Tier 1; PA alumina-magnesia-simethicone (generic for MI-ACID) - Tier 1 acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier 1; PA antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MI- acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1; PA; QL ACID) - Tier 1 ACTIGALL (brand for ursodiol) - Tier 2; PA ACTIPHLORA (brand for probiotic acidophilus biobeads) - Tier 2; PA; QL antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for adult 50+ probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL ALMACONE DOUBLE STRENGTH) - Tier 1 adult probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL antacid advanced (generic for ALMACONE DOUBLE STRENGTH) - amoxicill-clarithro-lansoprazanti-diarr/ant-gas (generic for - IMODIUMTier 1; PA; MULTI-SYMPTOM QL RELIEF) - Tier 1 Tier 1; PA antacid anti-gas (generic for MI-ACID) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1; PA antacid anti-gas max strength (generic for ALMACONE DOUBLE anti-gas (generic for GAS-X ULTRA STRENGTH) - Tier 1; PA STRENGTH) - Tier 1 BACICAP - Tier 2; PA; QL antacid anti-gas reg strength (generic for MI-ACID) - Tier 1 biotinex (generic for ABATINEX) - Tier 1; PA antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 calcium carbonate antacid oral tablet - Tier 1; PA antacid calcium extra strength (generic for CVS CHEWY NOT CHENODAL - Tier 2; PA; SP CHALKY FLAVOR) - Tier 1 cromolyn sodium oral (generic for GASTROCROM) - Tier 1; PA; QL antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 DIGESTIVE ADV LACTOSE DEFENSE (brand for probiotic acidophilus antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier biobeads) - Tier 2; PA; QL 1 antacid extra strength oral suspension (generic for ALMACONE digestive probiotic oral capsule (generic for ACTIPHLORA) - Tier 1; PA; DOUBLE STRENGTH) - Tier 1 QL antacid extra strength oral tablet chewable 160-105 mg (generic for digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier ACID GONE) - Tier 1 1; PA ENTEREG (brand for alvimopan) - Tier 2; PA antacid extra strength oral tablet chewable 750 mg (generic for CVS eq anti-diarrheal oral liquid - Tier 1; PA CHEWY NOT CHALKY FLAVOR) - Tier 1 eq gas relief oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier antacid fast relief (generic for MI-ACID) - Tier 1 1; PA antacid i (generic for MI-ACID) - Tier 1 eql gas relief (generic for GAS-X EXTRA STRENGTH) - Tier 1; PA antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 eql gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 114 Preferred Agents Non-Preferred Agents antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier FLORA VANCE (brand for probiotic acidophilus biobeads) - Tier 2; PA; 1 QL antacid liquid (generic for MI-ACID) - Tier 1 floranex oral tablet (generic for FLORANEX) - Tier 1; PA antacid m (generic for MI-ACID) - Tier 1 FOLIKA PROBIOTIC - Tier 2; PA; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1; PA antacid maximum strength (generic for ALMACONE DOUBLE gas relief extra strength oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 STRENGTH) - Tier 1; PA antacid maximum strength oral tablet chewable 1000 mg (generic for gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - TUMS ULTRA 1000) - Tier 1 Tier 1; PA antacid oral suspension (generic for MI-ACID) - Tier 1 antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA gas relief oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - 1000) - Tier 1 Tier 1; PA antacid oral tablet chewable 500 mg (generic for CAL-GEST gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1; ANTACID) - Tier 1 PA GASTROCROM (brand for cromolyn sodium) - Tier 2; PA; QL antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for ra gas relief CHALKY FLAVOR) - Tier 1 extra strength) - Tier 2; PA GAS-X ULTRA STRENGTH (brand for simethicone) - Tier 2; PA antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - GATTEX - Tier 2; PA; SP; QL Tier 1 HELIDAC THERAPY - Tier 2; PA antacid plus anti-gas fast act (generic for MI-ACID) - Tier 1 high potency probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE hm anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM STRENGTH) - Tier 1 RELIEF) - Tier 1; PA antacid regular strength (generic for MI-ACID) - Tier 1 antacid supreme - Tier 1 hm gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS Tier 1; PA ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - IMODIUM MULTI-SYMPTOM RELIEF (brand for hm anti-diarrheal anti- Tier 1 gas) - Tier 2; PA intestinex (generic for ABATINEX) - Tier 1; PA antacid/simethicone ds (generic for ALMACONE DOUBLE lactobacillus oral tablet (generic for FLORANEX) - Tier 1; PA STRENGTH) - Tier 1 LACTOJEN - Tier 2; PA lacto-key-100 (generic for ABATINEX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 115 Preferred Agents Non-Preferred Agents anti-diarrheal oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier lacto-key-600 (generic for ABATINEX) - Tier 1; PA 1 lacto-pectin (generic for ACTIPHLORA) - Tier 1; PA; QL LOMOTIL (brand for diphenoxylate-atropine) - Tier 2; PA anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - mega probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL Tier 1 metoclopramide hcl oral tablet dispersible 5 mg - Tier 1; PA; QL anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1 mood support probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL bismatrol maximum strength (generic for SOOTHE MAXIMUM MOTEGRITY - Tier 2; PA STRENGTH) - Tier 1 MOTOFEN - Tier 2; PA bismatrol oral suspension (generic for SOOTHE) - Tier 1 MYTESI - Tier 2; PA; QL bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL OCALIVA - Tier 2; PA; SP bismuth (generic for SOOTHE) - Tier 1; QL OMECLAMOX-PAK - Tier 2; PA bismuth subsalicylate oral suspension (generic for SOOTHE) - Tier 1 opium - Tier 1; PA; QL bismuth subsalicylate oral tablet chewable (generic for SOOTHE) - PHAZYME ORAL CAPSULE (brand for simethicone) - Tier 2; PA Tier 1; QL PHAZYME ULTRA STRENGTH (brand for simethicone) - Tier 2; PA calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 PROBICHEW - Tier 2; PA calcium antacid extra strength (generic for CVS CHEWY NOT pro-biotic blend (generic for ACTIPHLORA) - Tier 1; PA; QL CHALKY FLAVOR) - Tier 1 probiotic maximum strength (generic for ACTIPHLORA) - Tier 1; PA; QL calcium antacid ultra max st (generic for TUMS ULTRA 1000) - Tier 1 probiotic oral capsule (generic for ACTIPHLORA) - Tier 1; PA; QL calcium antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1 probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1; PA calcium carbonate antacid oral suspension - Tier 1 probiotic pearls ex st (generic for ACTIPHLORA) - Tier 1; PA; QL PRODIGEN - Tier 2; PA; QL calcium carbonate antacid oral tablet chewable (generic for CAL- PROMELLA IN PREBIOTIC - Tier 2; PA; QL GEST ANTACID) - Tier 1 PROVAD - Tier 2; PA; QL qc anti-gas (generic for GAS-X ULTRA STRENGTH) - Tier 1; PA calcium carbonate oral tablet chewable 500 mg (generic for CAL- qc gas relief extra strength oral capsule (generic for GAS-X EXTRA GEST ANTACID) - Tier 1 STRENGTH) - Tier 1; PA cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY qc gas relief oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier FLAVOR) - Tier 1 1; PA childrens soothe (generic for CHILDRENS SOOTHE) - Tier 1 QUAD-PROBIOTIC - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents comfort gel (generic for MI-ACID) - Tier 1 ra acidophilus (generic for ABATINEX) - Tier 1; PA comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml ra anti-diarrheal oral liquid - Tier 1; PA (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 diamode (generic for IMODIUM A-D) - Tier 1 ra gas relief extra strength oral capsule (generic for GAS-X EXTRA diarrhea (generic for SOOTHE) - Tier 1 STRENGTH) - Tier 1; PA diotame instydose (generic for SOOTHE) - Tier 1 diphenoxylate-atropine - Tier 1 ra gas relief oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier eq antacid (generic for CAL-GEST ANTACID) - Tier 1 1; PA eq antacid antigas multi-sympt - Tier 1 eq antacid extra strength oral tablet chewable 160-105 mg (generic for ra gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier ACID GONE) - Tier 1 1; PA ra probiotic colon care (generic for ACTIPHLORA) - Tier 1; PA; QL eq antacid extra strength oral tablet chewable 750 mg (generic for ra probiotic complex oral capsule (generic for ACTIPHLORA) - Tier 1; PA; CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 QL eq antacid maximum strength (generic for ALMACONE DOUBLE REGLAN ORAL TABLET 5 MG (brand for metoclopramide hcl) - Tier 2; STRENGTH) - Tier 1 PA eq antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1 RELISTOR - Tier 2; PA eq antacid/anti-gas (generic for MI-ACID) - Tier 1 RESTORA (brand for probiotic acidophilus biobeads) - Tier 2; PA; QL eq anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1 RESTORA RX - Tier 2; PA RISAQUAD (brand for probiotic acidophilus biobeads) - Tier 2; PA; QL eq gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - RISAQUAD-2 (brand for probiotic acidophilus biobeads) - Tier 2; PA; QL Tier 1 saccharomyces boulardii (generic for FLORASTOR) - Tier 1; PA senior probiotic (generic for ACTIPHLORA) - Tier 1; PA; QL eq gas relief oral tablet chewable (generic for GAS-X EXTRA SEROSTIM - Tier 2; PA; SP STRENGTH) - Tier 1 simethicone oral capsule (generic for GAS-X EXTRA STRENGTH) - Tier 1; PA eq infants gas relief (generic for LITTLE TUMMYS GAS RELIEF) - Tier sm acidophilus oral capsule 10 mg (generic for ABATINEX) - Tier 1; PA 1 sm gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier eq loperamide hcl (generic for IMODIUM A-D) - Tier 1 1; PA eq pink-bismuth (generic for SOOTHE) - Tier 1; QL sm gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - eq stomach relief oral suspension (generic for SOOTHE) - Tier 1 Tier 1; PA SODIUM BICARBONATE ORAL POWDER - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 117 Preferred Agents Non-Preferred Agents eq stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1; SYMPROIC - Tier 2; PA QL TRULANCE - Tier 2; PA URSO 250 (brand for ursodiol) - Tier 2; PA eql antacid advanced max st (generic for ALMACONE DOUBLE URSO FORTE (brand for ursodiol) - Tier 2; PA STRENGTH) - Tier 1 ursodiol oral capsule (generic for ACTIGALL) - Tier 1; PA URSODIOL+SYRSPEND SF - Tier 2; PA; QL eql antacid extra strength (generic for CVS CHEWY NOT CHALKY VISBIOME (brand for probiotic) - Tier 2; PA FLAVOR) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for probiotic eql antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1 acidophilus biobeads) - Tier 2; PA; QL eql antacid/anti-gas (generic for MI-ACID) - Tier 1 XERMELO - Tier 2; PA; SP eql anti-diarrheal (generic for IMODIUM A-D) - Tier 1 ZELAC - Tier 2; PA; QL ZELNORM - Tier 2; PA eql infants gas relief (generic for LITTLE TUMMYS GAS RELIEF) - ZORBTIVE - Tier 2; PA; SP Tier 1 eql loperamide hcl (generic for IMODIUM A-D) - Tier 1 eql stomach relief oral tablet (generic for SOOTHE) - Tier 1 eql stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1; QL fast acting antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 foaming antacid (generic for ACID GONE) - Tier 1 gas relief drops infants (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 gas relief extra strength oral tablet chewable 125 mg (generic for GAS- X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 gas relief max st (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension 20 mg/0.3ml (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 gas relief oral tablet chewable 80 mg - Tier 1 GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for sm gas relief) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 118 Preferred Agents Non-Preferred Agents gavis-care (generic for ACID GONE) - Tier 1 GAVISCON EXTRA RELIEF FORMULA (brand for heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for gnp antacid extra strength) - Tier 2 GAVISCON ORAL SUSPENSION (brand for gnp foaming antacid) - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MI-ACID) - Tier 1 geri-lanta supreme - Tier 1 geri-mox (generic for MI-ACID) - Tier 1 geri-pectate (generic for SOOTHE) - Tier 1 heartburn antacid ex st (generic for ACID GONE) - Tier 1 heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1 heartburn relief oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 hm advanced antacid max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 hm antacid (generic for MI-ACID) - Tier 1 hm antacid anti-gas ex st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 hm antacid/antigas (generic for MI-ACID) - Tier 1 hm anti-diarrheal oral liquid (generic for IMODIUM A-D) - Tier 1 hm anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1 hm calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 hm calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 hm calcium antacid ultra st (generic for TUMS ULTRA 1000) - Tier 1 hm gas relief (generic for GAS-X EXTRA STRENGTH) - Tier 1 hm gas relief infants drops (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 hm loperamide hcl oral liquid (generic for IMODIUM A-D) - Tier 1 hm loperamide hcl oral suspension (generic for IMODIUM A-D) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents hm stomach relief max strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 hm stomach relief oral suspension (generic for SOOTHE) - Tier 1 hm stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1; QL hm stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 IMODIUM A-D ORAL LIQUID (brand for eq loperamide hcl) - Tier 2 IMODIUM A-D ORAL TABLET (brand for anti-diarrheal) - Tier 2 infant gas relief (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 infants gas relief (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 infants simethicone (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 kls anti-diarrheal (generic for IMODIUM A-D) - Tier 1 k-pec (generic for SOOTHE) - Tier 1 little tummys gas relief (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1 loperamide hcl oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1 loperamide hcl oral suspension (generic for IMODIUM A-D) - Tier 1 loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1 MAALOX - Tier 2 MAALOX CHILDRENS (brand for childrens pepto) - Tier 2 MAALOX MAX ORAL SUSPENSION (brand for meijer antacid) - Tier 2 MAALOX MULTI SYMPTOM MAX ST (brand for meijer antacid) - Tier 2 mag-al plus (generic for MI-ACID) - Tier 1 mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 magnesium oxide oral tablet 400 mg - Tier 1 magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1 MAOX (brand for magnesium oxide) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 120 Preferred Agents Non-Preferred Agents medi-bismuth (generic for SOOTHE) - Tier 1; QL meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1 metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1 mi-acid (generic for MI-ACID) - Tier 1 mi-acid gas relief - Tier 1 mi-acid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 milantex (generic for MI-ACID) - Tier 1 milantex extra strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 mintox plus - Tier 1 MOVANTIK - Tier 2; PA peptic relief (generic for SOOTHE) - Tier 1; QL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for gnp stomach relief) - Tier 2 PEPTO-BISMOL ORAL TABLET (brand for gnp pink bismuth) - Tier 2 PEPTO-BISMOL TO-GO (brand for eq stomach relief) - Tier 2; QL PHAZYME ORAL TABLET CHEWABLE (brand for sm gas relief) - Tier 2 pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1 pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL PYLERA - Tier 2 qc antacid (generic for MI-ACID) - Tier 1 qc antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 qc antacid multi-symptom - Tier 1 qc antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents qc antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 qc anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1 qc diarrhea relief (generic for SOOTHE) - Tier 1 qc gas relief extra strength oral tablet chewable (generic for GAS-X EXTRA STRENGTH) - Tier 1 qc gas relief oral tablet chewable - Tier 1 qc heartburn antacid (generic for ACID GONE) - Tier 1 qc pink bismuth oral suspension (generic for SOOTHE) - Tier 1 qc pink bismuth oral tablet (generic for SOOTHE) - Tier 1 qc pink bismuth oral tablet chewable (generic for SOOTHE) - Tier 1; QL ra antacid (generic for CAL-GEST ANTACID) - Tier 1 ra antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 ra antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1 ra antacid/anti-gas (generic for MI-ACID) - Tier 1 ra antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 ra antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 ra anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1 ra gas relief extra strength oral tablet chewable (generic for GAS-X EXTRA STRENGTH) - Tier 1 ra gas relief maximum strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 ra gas relief oral suspension (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 ra gas relief oral tablet chewable - Tier 1 ra gas relief/infants (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 ra k-pec (generic for SOOTHE) - Tier 1 ra liquid antacid (generic for MI-ACID) - Tier 1 ra loperamide hcl (generic for IMODIUM A-D) - Tier 1 ra pink bismuth oral tablet (generic for SOOTHE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents ra pink bismuth oral tablet chewable (generic for SOOTHE) - Tier 1; QL ra smooth antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 ra stomach relief kids (generic for CHILDRENS SOOTHE) - Tier 1 ra stomach relief max st (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 ra stomach relief oral suspension (generic for SOOTHE) - Tier 1 ra stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1; QL REGLAN ORAL TABLET 10 MG (brand for metoclopramide hcl) - Tier 2 simeped (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 simethicone oral suspension (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 simethicone oral tablet chewable (generic for GAS-X EXTRA STRENGTH) - Tier 1 sm antacid (generic for CAL-GEST ANTACID) - Tier 1 sm antacid advanced (generic for MI-ACID) - Tier 1 sm antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 sm antacid anti-gas (generic for MI-ACID) - Tier 1 sm antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1 sm antacid/antigas (generic for MI-ACID) - Tier 1 sm anti-diarrheal oral liquid (generic for IMODIUM A-D) - Tier 1 sm anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1 sm calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 sm calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sm foaming antacid - Tier 1 sm gas relief - Tier 1 sm gas relief infants (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents sm gas relief infants drops (generic for LITTLE TUMMYS GAS RELIEF) - Tier 1 sm loperamide hcl (generic for IMODIUM A-D) - Tier 1 sm smooth antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sm stomach relief oral suspension (generic for SOOTHE) - Tier 1 sm stomach relief oral tablet (generic for SOOTHE) - Tier 1 sm stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1; QL smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sodium bicarbonate oral tablet - Tier 1 soothe maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 soothe oral suspension (generic for SOOTHE) - Tier 1 soothe oral tablet (generic for SOOTHE) - Tier 1 soothe oral tablet chewable (generic for SOOTHE) - Tier 1; QL stomach relief extra strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max st (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527 mg/30ml (generic for SOOTHE) - Tier 1 stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1 stomach relief oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 TITRALAC - Tier 2 TUMS (brand for ra antacid) - Tier 2 TUMS CHEWY BITES (brand for cvs antacid kids) - Tier 2 TUMS E-X 750 (brand for cvs antacid kids) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents TUMS EXTRA STRENGTH 750 (brand for cvs antacid kids) - Tier 2 TUMS LASTING EFFECTS (brand for ra antacid) - Tier 2 TUMS SMOOTHIES (brand for cvs antacid kids) - Tier 2 TUMS ULTRA 1000 (brand for cvs antacid maximum strength) - Tier 2 ursodiol oral tablet (generic for URSO 250) - Tier 1 Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1 cimetidine hcl - Tier 1; PA acid reducer oral tablet (generic for PEPCID AC) - Tier 1 nizatidine - Tier 1; PA cimetidine oral (generic for TAGAMET HB) - Tier 1 eq acid reducer (generic for PEPCID AC) - Tier 1 PEPCID ORAL TABLET 20 MG (brand for acid controller max st) - Tier 2; eq cimetidine (generic for TAGAMET HB) - Tier 1 PA eq heartburn relief (generic for TAGAMET HB) - Tier 1 PEPCID ORAL TABLET 40 MG (brand for famotidine) - Tier 2; PA; QL eql heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1 famotidine oral suspension reconstituted - Tier 1; QL; AL famotidine oral tablet 20 mg (generic for PEPCID) - Tier 1 famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL heartburn relief 200 (generic for TAGAMET HB) - Tier 1 heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1 heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1 hm famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1 qc acid controller (generic for PEPCID AC) - Tier 1 ra acid reducer (generic for PEPCID AC) - Tier 1 sm acid reducer (generic for PEPCID AC) - Tier 1 Irritable Bowel Syndrome Agents - Bowel Treatment Drugs AMITIZA - Tier 2; PA alosetron hcl (generic for LOTRONEX) - Tier 1; PA LINZESS ORAL CAPSULE 145 MCG, 290 MCG - Tier 2; PA LINZESS ORAL CAPSULE 72 MCG - Tier 2; PA; QL LOTRONEX (brand for alosetron hcl) - Tier 2; PA TALICIA - Tier 2; PA VIBERZI - Tier 2; PA; QL XIFAXAN ORAL TABLET 200 MG - Tier 2; PA; QL XIFAXAN ORAL TABLET 550 MG - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 125 Preferred Agents Non-Preferred Agents Laxatives - Bowel Treatment Drugs SUTAB - Tier 2; PA Laxatives - Drugs to treat Constipation bisacodyl ec (generic for GNP BISA-LAX) - Tier 1 cascara sagrada oral fluid extract - Tier 1; PA bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1 CLENPIQ - Tier 2; PA; QL bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1 COLACE ORAL LIQUID† 150 MG/15ML (brand for docu) - Tier 2; PA; QL bisa-lax (generic for GNP BISA-LAX) - Tier 1 docusate sodium-casanthranol oral capsule 100-30 mg - Tier 1; PA; QL calcium polycarbophil (generic for FIBERCON) - Tier 1 GIALAX - Tier 2; PA chocolate laxative pieces - Tier 1 laxacin (generic for SENEXON-S) - Tier 1; PA chocolated laxative - Tier 1 MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA citrate of magnesia (generic for CITROMA) - Tier 1; QL PCP 100 - Tier 2; PA citroma (generic for CITROMA) - Tier 1; QL PLENVU - Tier 2; PA; QL CITRUCEL - Tier 2 psyldex - Tier 1; PA c-lax laxative (generic for GNP BISA-LAX) - Tier 1 sorbitol oral - Tier 1; PA clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; QL COLACE ORAL CAPSULE (brand for gnp stool softener) - Tier 2 constulose - Tier 1; QL correct (generic for GNP BISA-LAX) - Tier 1 daily fiber (generic for MEDI-MUCIL) - Tier 1 diocto - Tier 1; QL docu - Tier 1; QL docusate calcium (generic for SURFAK) - Tier 1 docusate mini (generic for DOCUSOL MINI) - Tier 1; QL docusate sodium oral capsule (generic for DOCUSIL) - Tier 1 docusate sodium oral liquid 50 mg/5ml - Tier 1; QL docusate sodium oral syrup - Tier 1 docusate sodium oral tablet (generic for DOK) - Tier 1 docusil (generic for DOCUSIL) - Tier 1 DOCUSOL MINI (brand for docusate mini) - Tier 2; QL docuzen (generic for SENEXON-S) - Tier 1 dok (generic for DOCUSIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents dss (generic for DOCUSIL) - Tier 1 ducodyl (generic for GNP BISA-LAX) - Tier 1 easy-lax plus (generic for SENEXON-S) - Tier 1 enema (generic for PURE & GENTLE ENEMA) - Tier 1 enema disposable (generic for PURE & GENTLE ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for PURE & GENTLE ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL eq clearlax (generic for CLEARLAX) - Tier 1; QL eq fiber laxative (generic for FIBERCON) - Tier 1 eq fiber therapy (generic for CITRUCEL) - Tier 1 eq gentle laxative (generic for GNP BISA-LAX) - Tier 1 eq laxative - Tier 1 eq laxative maximum strength - Tier 1 eq magnesium citrate (generic for CITROMA) - Tier 1; QL eq mineral oil - Tier 1 eq natural fiber laxative (generic for WAL-MUCIL) - Tier 1 eq natural laxative (generic for SENNO) - Tier 1 eq natural vegetable laxative (generic for SENNO) - Tier 1 eq senna-s (generic for SENEXON-S) - Tier 1 eq stool softener (generic for DOCUSIL) - Tier 1 eq stool softener/laxative (generic for SENEXON-S) - Tier 1 eq vegetable laxative (generic for SENNO) - Tier 1 eq womens laxative (generic for GNP BISA-LAX) - Tier 1 eql clearlax (generic for CLEARLAX) - Tier 1; QL eql fiber laxative (generic for FIBERCON) - Tier 1 eql fiber therapy oral powder 28.3 % (generic for WAL-MUCIL) - Tier 1 eql gentle laxative (generic for GNP BISA-LAX) - Tier 1 eql laxative oral tablet - Tier 1 eql laxative oral tablet chewable - Tier 1 eql magnesium citrate (generic for CITROMA) - Tier 1; QL eql milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 eql ready-to-use enema rectal enema (generic for PURE & GENTLE ENEMA) - Tier 1 eql stool softener (generic for DOCUSIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 127 Preferred Agents Non-Preferred Agents eql stool softener/stimulant (generic for SENEXON-S) - Tier 1 EVAC (brand for natural psyllium seed) - Tier 2 EX-LAX ULTRA (brand for gentle laxative) - Tier 2 fiber (generic for FIBERCON) - Tier 1 fiber laxative (generic for FIBERCON) - Tier 1 fiber therapy (generic for CITRUCEL) - Tier 1 fiber-caps (generic for FIBERCON) - Tier 1 FIBERCON (brand for eql fiber laxative) - Tier 2 fiber-lax (generic for FIBERCON) - Tier 1 FLEET BISACODYL - Tier 2 FLEET ENEMA (brand for gnp enema) - Tier 2 FLEET OIL (brand for enema mineral oil) - Tier 2 FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; QL gavilyte-c - Tier 1 gavilyte-g (generic for GAVILYTE-G) - Tier 1 gavilyte-h - Tier 1 gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1 gentle laxative (generic for GNP BISA-LAX) - Tier 1 gentle laxative womens (generic for GNP BISA-LAX) - Tier 1 gentlelax (generic for CLEARLAX) - Tier 1; QL geri-kot (generic for SENNO) - Tier 1 geri-mucil - Tier 1 glycerin (adult) rectal suppository 2 gm - Tier 1 glycerin (infant) - Tier 1 glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin adult rectal suppository 2 gm - Tier 1 glycerin child (generic for PEDIA-LAX) - Tier 1 glycerin childrens (generic for PEDIA-LAX) - Tier 1 glycolax (generic for CLEARLAX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 128 Preferred Agents Non-Preferred Agents GOLYTELY (brand for peg-3350/electrolytes) - Tier 2 hm clearlax oral powder (generic for CLEARLAX) - Tier 1; QL hm enema (generic for PURE & GENTLE ENEMA) - Tier 1 hm enema mineral oil (generic for FLEET OIL) - Tier 1 hm fiber oral powder 28.3 %, 48.57 %, 58.6 % (generic for WAL- MUCIL) - Tier 1 hm fiber oral powder 30.9 % - Tier 1 hm fiber oral tablet (generic for CITRUCEL) - Tier 1 hm laxative (generic for THE MAGIC BULLET) - Tier 1 hm magnesium citrate (generic for CITROMA) - Tier 1; QL hm milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 HM MINERAL OIL - Tier 2 hm senna (generic for SENNO) - Tier 1 hm senna-s (generic for SENEXON-S) - Tier 1 hm stool softener (generic for DOCUSIL) - Tier 1 hm stool softener/laxative (generic for SENEXON-S) - Tier 1 kls laxaclear (generic for CLEARLAX) - Tier 1; QL kls natural psyllium fiber (generic for WAL-MUCIL) - Tier 1 kls stool softener (generic for DOCUSIL) - Tier 1 KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for WAL-MUCIL) - Tier 1 kp bisacodyl (generic for GNP BISA-LAX) - Tier 1 kp senna (generic for SENNO) - Tier 1 KRISTALOSE ORAL PACKET 20 GM - Tier 2 ks stool softener (generic for DOCUSIL) - Tier 1 lactulose (generic for KRISTALOSE) - Tier 1; QL laxa basic (generic for DOCUSIL) - Tier 1 laxative (generic for GNP BISA-LAX) - Tier 1 laxative max str - Tier 1 laxative pills - Tier 1 laxative regular strength (generic for SENNA SMOOTH) - Tier 1 magnesium citrate oral solution (generic for CITROMA) - Tier 1; QL medi-mucil (generic for MEDI-MUCIL) - Tier 1 medi-natural (generic for SENNO) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents METAMUCIL ORAL CAPSULE 0.52 GM (brand for ra fiber therapy) - Tier 2 METAMUCIL ORAL POWDER 48.57 % (brand for sb fiber laxative) - Tier 2 milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 milk of magnesia concentrate - Tier 1 mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral - Tier 1 MIRALAX ORAL POWDER (brand for ra laxative) - Tier 2; QL mm stool softener laxative (generic for DOCUSIL) - Tier 1 natural daily fiber (generic for WAL-MUCIL) - Tier 1 natural fiber (generic for WAL-MUCIL) - Tier 1 natural fiber laxative oral powder 28.3 %, 58.6 % (generic for WAL- MUCIL) - Tier 1 natural fiber laxative oral powder 30.9 % - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 %, 48.57 % (generic for WAL-MUCIL) - Tier 1 natural fiber supplement oral powder (generic for WAL-MUCIL) - Tier 1 natural senna laxative (generic for SENNO) - Tier 1 natural vegetable fiber (generic for WAL-MUCIL) - Tier 1 NULYTELY LEMON-LIME (brand for peg 3350-kcl-na bicarb-nacl) - Tier 2 NULYTELY WITH FLAVOR PACKS (brand for peg 3350-kcl-na bicarb- nacl) - Tier 2 OSMOPREP - Tier 2; QL PEDIA-LAX ORAL LIQUID - Tier 2 PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for cvs glycerin child) - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1 peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1 peg-3350/electrolytes/ascorbat (generic for MOVIPREP) - Tier 1 peg-kcl-nacl-nasulf-na asc-c (generic for MOVIPREP) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 130 Preferred Agents Non-Preferred Agents peg-prep - Tier 1 PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for eql milk of magnesia) - Tier 2 polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; QL PROMOLAXIN (brand for stool softener) - Tier 2 pure & gentle enema (generic for PURE & GENTLE ENEMA) - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; QL qc docusate calcium (generic for SURFAK) - Tier 1 qc enema (generic for PURE & GENTLE ENEMA) - Tier 1 qc fiber laxative (generic for MEDI-MUCIL) - Tier 1 qc fiber therapy (generic for CITRUCEL) - Tier 1 qc gentle laxative (generic for GNP BISA-LAX) - Tier 1 qc laxative - Tier 1 qc magnesium citrate (generic for CITROMA) - Tier 1; QL qc milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 qc mineral oil heavy - Tier 1 qc natural vegetable (generic for HYDROCIL) - Tier 1 qc natural vegetable laxative (generic for SENNO) - Tier 1 qc natura-lax (generic for CLEARLAX) - Tier 1; QL qc senna (generic for SENNO) - Tier 1 qc senna-s (generic for SENEXON-S) - Tier 1 qc stool softener (generic for DOCUSIL) - Tier 1 qc stool softener pls laxative (generic for SENEXON-S) - Tier 1 ra col-rite oral capsule 250 mg - Tier 1 ra col-rite oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 ra enema (generic for PURE & GENTLE ENEMA) - Tier 1 ra fast relief laxative (generic for THE MAGIC BULLET) - Tier 1 ra fiber (generic for MEDI-MUCIL) - Tier 1 ra fiber laxative (generic for WAL-MUCIL) - Tier 1 ra fiber supplement (generic for WAL-MUCIL) - Tier 1 ra fiber therapy (generic for MEDI-MUCIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 131 Preferred Agents Non-Preferred Agents ra fiber-cap (generic for FIBERCON) - Tier 1 ra fiber-tab (generic for FIBERCON) - Tier 1 ra laxative & stool softener (generic for SENEXON-S) - Tier 1 ra laxative extra strength (generic for SENOKOT EXTRA STRENGTH) - Tier 1 ra laxative maximum strength - Tier 1 ra laxative oral powder (generic for CLEARLAX) - Tier 1; QL ra laxative oral tablet - Tier 1 ra laxative oral tablet chewable - Tier 1 ra laxative oral tablet delayed release (generic for GNP BISA-LAX) - Tier 1 ra magnesium citrate (generic for CITROMA) - Tier 1; QL ra milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 ra mineral oil - Tier 1 ra p col-rite (generic for SENEXON-S) - Tier 1 ra saline enema (generic for PURE & GENTLE ENEMA) - Tier 1 ra senna (generic for SENNO) - Tier 1 ra senna plus (generic for SENEXON-S) - Tier 1 ra soluble fiber (generic for CITRUCEL) - Tier 1 ra stimulant laxative (generic for THE MAGIC BULLET) - Tier 1 ra stool softener (generic for DOCUSIL) - Tier 1 ra womens laxative (generic for GNP BISA-LAX) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENNO) - Tier 1 senna laxative (generic for SENNO) - Tier 1 senna oral (generic for SENNO) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1 senna-lax (generic for SENNO) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 132 Preferred Agents Non-Preferred Agents senna-tabs (generic for SENNO) - Tier 1 senna-time (generic for SENNO) - Tier 1 senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1 senno (generic for SENNO) - Tier 1 sennosides-docusate sodium (generic for SENEXON-S) - Tier 1 SENOKOT (brand for senna-time) - Tier 2 SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2 SENOKOT S (brand for senna-docusate sodium) - Tier 2 silace oral liquid - Tier 1; QL silace oral syrup - Tier 1 sm clearlax (generic for CLEARLAX) - Tier 1; QL sm docusate calcium (generic for SURFAK) - Tier 1 sm enema (generic for PURE & GENTLE ENEMA) - Tier 1 sm fiber laxative (generic for CITRUCEL) - Tier 1 sm fiber oral powder 28.3 %, 48.57 %, 58.6 % (generic for WAL- MUCIL) - Tier 1 sm fiber oral tablet (generic for FIBERCON) - Tier 1 sm gentle laxative (generic for GNP BISA-LAX) - Tier 1 sm glycerin pediatric rectal suppository 1.2 gm - Tier 1 sm laxative (generic for THE MAGIC BULLET) - Tier 1 sm laxative maximum strength - Tier 1 sm magnesium citrate (generic for CITROMA) - Tier 1; QL sm milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 sm mineral oil rectal (generic for FLEET OIL) - Tier 1 sm natural laxative/stool soft (generic for SENEXON-S) - Tier 1 sm senna laxative (generic for SENNO) - Tier 1 sm senna-s (generic for SENEXON-S) - Tier 1 sm stool softener (generic for DOCUSIL) - Tier 1 sm stool softener/laxative (generic for SENEXON-S) - Tier 1 smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL soluble fiber therapy - Tier 1 stimulant laxative (generic for SENEXON-S) - Tier 1 stool softener laxative (generic for SENEXON-S) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 133 Preferred Agents Non-Preferred Agents stool softener oral capsule 100 mg (generic for DOCUSIL) - Tier 1 stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral capsule 250 mg - Tier 1 stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral liquid 50 mg/5ml - Tier 1; QL stool softener oral syrup 60 mg/15ml - Tier 1 stool softener oral tablet 100 mg (generic for DOK) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 SUPREP BOWEL PREP KIT - Tier 2 the magic bullet (generic for THE MAGIC BULLET) - Tier 1 trilyte (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1 vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 veracolate (generic for GNP BISA-LAX) - Tier 1 wal-mucil (generic for MEDI-MUCIL) - Tier 1 womans laxative (generic for GNP BISA-LAX) - Tier 1 womens gentle laxative (generic for GNP BISA-LAX) - Tier 1 womens laxative (generic for GNP BISA-LAX) - Tier 1

Protectants - Ulcer and Stomach Acid Drugs misoprostol oral (generic for CYTOTEC) - Tier 1; QL CARAFATE (brand for sucralfate) - Tier 2; PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL CYTOTEC (brand for misoprostol) - Tier 2; PA; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; PA; QL Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg - Tier acid reducer oral capsule delayed release - Tier 1; PA 1 acid reducer oral tablet delayed release (generic for PRILOSEC OTC) - Tier 1; PA; QL pantoprazole sodium oral tablet delayed release (generic for ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA PROTONIX) - Tier 1 ACIPHEX SPRINKLE - Tier 2; PA DEXILANT - Tier 2; PA eq lansoprazole (generic for PREVACID) - Tier 1; PA eq omeprazole magnesium - Tier 1; PA eq omeprazole oral tablet delayed release - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 134 Preferred Agents Non-Preferred Agents eql omeprazole - Tier 1; PA ESOMEP-EZS - Tier 2; PA esomeprazole magnesium (generic for NEXIUM) - Tier 1; PA ESOMEPRAZOLE STRONTIUM - Tier 2; PA; QL FIRST-LANSOPRAZOLE - Tier 2; PA FIRST-OMEPRAZOLE - Tier 2; PA hm lansoprazole (generic for PREVACID) - Tier 1; PA hm omeprazole - Tier 1; PA kls lansoprazole (generic for PREVACID) - Tier 1; PA kls omeprazole - Tier 1; PA kp omeprazole magnesium - Tier 1; PA lansoprazole oral (generic for PREVACID) - Tier 1; PA NEXIUM (brand for esomeprazole magnesium) - Tier 2; PA omeprazole magnesium oral capsule delayed release - Tier 1; PA omeprazole magnesium oral tablet delayed release (generic for PRILOSEC OTC) - Tier 1; PA; QL omeprazole oral capsule delayed release 20.6 (20 base) mg - Tier 1; PA omeprazole oral tablet delayed release 20 mg - Tier 1; PA OMEPRAZOLE+SYRSPEND SF ALKA - Tier 2; PA omeprazole-sod bicarbonate (generic for ZEGERID) - Tier 1; PA omeprazole-sodium bicarbonate (generic for ZEGERID) - Tier 1; PA pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA PREVACID (brand for lansoprazole) - Tier 2; PA PREVACID 24HR (brand for lansoprazole) - Tier 2; PA PREVACID SOLUTAB (brand for lansoprazole) - Tier 2; PA PRILOSEC - Tier 2; PA PRILOSEC OTC (brand for omeprazole magnesium) - Tier 2; PA; QL PROTONIX ORAL (brand for pantoprazole sodium) - Tier 2; PA qc lansoprazole (generic for PREVACID) - Tier 1; PA qc omeprazole magnesium - Tier 1; PA ra omeprazole - Tier 1; PA ra omeprazole-sodium bicarb (generic for ZEGERID) - Tier 1; PA RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE - Tier 2; PA rabeprazole sodium oral tablet delayed release (generic for ACIPHEX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 135 Preferred Agents Non-Preferred Agents sm lansoprazole (generic for PREVACID) - Tier 1; PA sm omeprazole - Tier 1; PA ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA ZEGERID OTC (brand for omeprazole-sodium bicarbonate) - Tier 2; PA

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CREON - Tier 2; PA CHOLBAM - Tier 2; PA; SP; QL ZENPEP - Tier 2; PA CYSTAGON - Tier 2; PA; SP; QL EVRYSDI - Tier 2; PA; SP; QL KANUMA - Tier 2; PA PALYNZIQ - Tier 2; PA; SP; QL PANCREAZE - Tier 2; PA PERTZYE - Tier 2; PA PROCYSBI ORAL CAPSULE DELAYED RELEASE - Tier 2; PA; SP; QL PROCYSBI ORAL PACKET - Tier 2; PA; SP STRENSIQ - Tier 2; PA; SP TEGSEDI - Tier 2; PA; SP; QL VIOKACE - Tier 2; PA XURIDEN - Tier 2; PA; SP Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs flavoxate hcl - Tier 1 darifenacin hydrobromide er (generic for ENABLEX) - Tier 1; PA oxybutynin chloride er (generic for DITROPAN XL) - Tier 1 DETROL (brand for tolterodine tartrate) - Tier 2; PA oxybutynin chloride oral - Tier 1 DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA solifenacin succinate (generic for VESICARE) - Tier 1 DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA TOVIAZ - Tier 2 ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG (brand for darifenacin hydrobromide er) - Tier 2; PA GELNIQUE - Tier 2; PA MYRBETRIQ - Tier 2; PA OXYTROL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 136 Preferred Agents Non-Preferred Agents OXYTROL FOR WOMEN - Tier 2; PA tolterodine tartrate (generic for DETROL) - Tier 1; PA tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA trospium chloride - Tier 1; PA trospium chloride er - Tier 1; PA VESICARE (brand for solifenacin succinate) - Tier 2; PA Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1 AVODART (brand for dutasteride) - Tier 2; PA dutasteride oral (generic for AVODART) - Tier 1 CARDURA XL - Tier 2; PA finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1 CIALIS ORAL TABLET 5 MG (brand for tadalafil) - Tier 2; PA; QL tamsulosin hcl (generic for FLOMAX) - Tier 1 dutasteride-tamsulosin hcl (generic for JALYN) - Tier 1; PA terazosin hcl - Tier 1 FLOMAX (brand for tamsulosin hcl) - Tier 2; PA JALYN (brand for dutasteride-tamsulosin hcl) - Tier 2; PA PROSCAR (brand for finasteride) - Tier 2; PA RAPAFLO (brand for silodosin) - Tier 2; PA silodosin (generic for RAPAFLO) - Tier 1; PA tadalafil oral tablet 5 mg (generic for CIALIS) - Tier 1; PA; QL UROXATRAL (brand for alfuzosin hcl er) - Tier 2; PA Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs bethanechol chloride oral - Tier 1; QL azo tabs (generic for PHENAZO) - Tier 1; PA ELMIRON - Tier 2; PA; QL CERVIDIL - Tier 2; PA OPTIONS GYNOL II CONTRACEPTIVE - Tier 2 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier eq urinary pain relief (generic for PHENAZO) - Tier 1; PA 1 hyophen - Tier 1; PA phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier OPTIONS CONCEPTROL - Tier 2; PA 1 penicillamine oral (generic for CUPRIMINE) - Tier 1; PA; SP PYRIDIUM (brand for phenazopyridine hcl) - Tier 2 PENTOSAN POLYSULFATE SODIUM ORAL - Tier 2; PA; QL VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2 phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1; PA PHEXXI - Tier 2; PA; QL phosphasal (generic for PHOSPHASAL) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 137 Preferred Agents Non-Preferred Agents PREPIDIL - Tier 2; PA PROSTIN E2 - Tier 2; PA qc azo (generic for PHENAZO) - Tier 1; PA qc urinary pain relief (generic for PHENAZO) - Tier 1; PA ra urinary pain relief (generic for PHENAZO) - Tier 1; PA ra urinary tract pain relief (generic for PHENAZO) - Tier 1; PA SHUR-SEAL CONTRACEPTIVE - Tier 2; PA sm urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1; PA THIOLA - Tier 2; PA; SP THIOLA EC - Tier 2; PA; SP; QL URELLE (brand for uroav-81) - Tier 2; PA uretron d/s (generic for PHOSPHASAL) - Tier 1; PA; QL URIBEL (brand for uro-mp) - Tier 2; PA URIMAR-T - Tier 2; PA urin ds (generic for PHOSPHASAL) - Tier 1; PA; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1; PA URO-458 - Tier 2; PA uro-mp (generic for VILAMIT MB) - Tier 1; PA ustell (generic for USTELL) - Tier 1; PA uticap (generic for USTELL) - Tier 1; PA utira-c (generic for PHOSPHASAL) - Tier 1; PA; QL utrona-c (generic for PHOSPHASAL) - Tier 1; PA; QL VCF VAGINAL CONTRACEPTIVE VAGINAL FILM - Tier 2; PA vcf vaginal contraceptive vaginal gel - Tier 1; PA vilamit mb (generic for VILAMIT MB) - Tier 1; PA VILEVEV MB (brand for uroav-81) - Tier 2; PA Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs DECADRON (brand for dexamethasone) - Tier 2 ALKINDI SPRINKLE - Tier 2; PA; QL dexamethasone oral elixir - Tier 1 CONTRAST ALLERGY PREMED PACK - Tier 2; PA; QL dexamethasone oral solution - Tier 1 CORTEF (brand for hydrocortisone) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 138 Preferred Agents Non-Preferred Agents dexamethasone oral tablet (generic for DECADRON) - Tier 1 cortisone acetate oral - Tier 1; PA; QL EMFLAZA - Tier 2; PA; SP; AL DEXABLISS - Tier 2; PA; QL fludrocortisone acetate oral - Tier 1 dexamethasone intensol - Tier 1; PA hydrocortisone oral (generic for CORTEF) - Tier 1 dexamethasone oral tablet therapy pack (generic for HIDEX 6-DAY) - Tier methylprednisolone oral tablet 16 mg, 4 mg, 8 mg (generic for 1; PA MEDROL) - Tier 1 DXEVO 11-DAY (brand for dexabliss) - Tier 2; PA; QL methylprednisolone oral tablet 32 mg (generic for MEDROL) - Tier 1; HEMADY - Tier 2; PA; QL QL HIDEX 6-DAY (brand for dexamethasone) - Tier 2; PA methylprednisolone oral tablet therapy pack (generic for MEDROL) - MEDROL ORAL TABLET 16 MG, 8 MG (brand for methylprednisolone) - Tier 1 Tier 2; PA prednisolone oral solution - Tier 1; QL MEDROL ORAL TABLET 2 MG - Tier 2; PA prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1 MEDROL ORAL TABLET 32 MG (brand for methylprednisolone) - Tier 2; prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml PA; QL (generic for PEDIAPRED) - Tier 1; QL prednisone oral solution - Tier 1; QL MEDROL ORAL TABLET 4 MG (brand for methylprednisolone) - Tier 2; prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg, 50 mg - Tier 1 PA prednisone oral tablet 20 mg - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL MEDROL ORAL TABLET THERAPY PACK (brand for prednisone oral tablet therapy pack 10 mg (48), 5 mg (21) - Tier 1 methylprednisolone) - Tier 2; PA MILLIPRED - Tier 2; PA MILLIPRED DP 12-DAY - Tier 2; PA ORAPRED ODT (brand for prednisolone sodium phosphate) - Tier 2; PA PEDIAPRED (brand for prednisolone sodium phosphate) - Tier 2; PA; QL prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml - Tier 1; PA; QL prednisolone sodium phosphate oral solution 25 mg/5ml - Tier 1; PA prednisolone sodium phosphate oral tablet dispersible (generic for ORAPRED ODT) - Tier 1; PA prednisone intensol - Tier 1; PA; QL prednisone oral tablet therapy pack 5 mg (48) - Tier 1; PA RAYOS - Tier 2; PA; QL TAPERDEX 12-DAY - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 139 Preferred Agents Non-Preferred Agents TAPERDEX 6-DAY (brand for dexamethasone) - Tier 2; PA TAPERDEX 7-DAY - Tier 2; PA; QL ZCORT 7-DAY - Tier 2; PA; QL Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP NASAL (brand for desmopressin acetate spray) - Tier 2; PA; chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; PA QL DDAVP ORAL (brand for desmopressin acetate) - Tier 2; PA; QL DDAVP RHINAL TUBE - Tier 2; PA; QL HUMATROPE - Tier 2; PA; SP desmopressin ace spray refrig - Tier 1; PA NOCDURNA - Tier 2; PA desmopressin acetate oral (generic for DDAVP) - Tier 1; QL novarel intramuscular solution reconstituted 10000 unit (generic for desmopressin acetate spray (generic for DDAVP) - Tier 1; PA; QL NOVAREL) - Tier 1; PA GENOTROPIN - Tier 2; PA; SP NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 GENOTROPIN MINIQUICK - Tier 2; PA; SP UNIT - Tier 2; PA; SP INCRELEX - Tier 2; PA; SP NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP NORDITROPIN FLEXPRO - Tier 2; PA; SP NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP STIMATE - Tier 2; PA NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP OMNITROPE - Tier 2; PA; SP pregnyl (generic for NOVAREL) - Tier 1; PA SAIZEN - Tier 2; PA; SP SAIZENPREP - Tier 2; PA; SP ZOMACTON - Tier 2; PA; SP ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL MIFEPREX (brand for mifepristone) - Tier 2; PA mifepristone (generic for MIFEPREX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 140 Preferred Agents Non-Preferred Agents Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs danazol oral - Tier 1 ANADROL-50 - Tier 2; PA testosterone cypionate intramuscular solution 100 mg/ml (generic for ANDRODERM - Tier 2; PA DEPO-TESTOSTERONE) - Tier 1; QL ANDROGEL (brand for testosterone) - Tier 2; PA testosterone cypionate intramuscular solution 200 mg/ml (generic for ANDROGEL PUMP (brand for testosterone) - Tier 2; PA DEPO-TESTOSTERONE) - Tier 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML testosterone transdermal (generic for ANDROGEL PUMP) - Tier 1; PA (brand for testosterone cypionate) - Tier 2; PA; QL DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML (brand for testosterone cypionate) - Tier 2; PA EC-RX TESTOSTERONE - Tier 2; PA FORTESTA (brand for testosterone) - Tier 2; PA INTRAROSA - Tier 2; PA JATENZO - Tier 2; PA; QL METHITEST - Tier 2; PA; QL methyltestosterone oral - Tier 1; PA; QL NATESTO - Tier 2; PA; QL oxandrolone oral - Tier 1; PA; QL TESTIM (brand for testosterone) - Tier 2; PA TESTONE CIK - Tier 2; PA; QL TESTOSTERONE COMPOUNDING KIT - Tier 2; PA TESTOSTERONE CYPIONATE INJECTION - Tier 2; PA; QL testosterone enanthate intramuscular - Tier 1; PA; QL VOGELXO (brand for testosterone) - Tier 2; PA VOGELXO PUMP (brand for testosterone) - Tier 2; PA XYOSTED - Tier 2; PA; QL Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA ALORA (brand for estradiol) - Tier 2; QL amethia (generic for AMETHIA) - Tier 1; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL amethia lo (generic for AMETHIA LO) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 141 Preferred Agents Non-Preferred Agents alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL ANGELIQ - Tier 2; PA alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL ANNOVERA - Tier 2; PA; QL amabelz (generic for AMABELZ) - Tier 1 ashlyna (generic for AMETHIA) - Tier 1; PA; QL amethyst (generic for AMETHYST) - Tier 1; QL BALCOLTRA - Tier 2; PA; QL apri - Tier 1; QL BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL aranelle - Tier 1; QL BI-EST 80:20 PROGESTERONE - Tier 2; PA aubra (generic for AFIRMELLE) - Tier 1; QL BIEST/PROGESTERONE (brand for bi-est 80:20 progesterone) - Tier 2; aubra eq (generic for AFIRMELLE) - Tier 1; QL PA aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL BIJUVA - Tier 2; PA; QL aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL camrese (generic for AMETHIA) - Tier 1; PA; QL aurovela 24 fe - Tier 1; QL camrese lo (generic for AMETHIA LO) - Tier 1; PA; QL aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL CLIMARA (brand for estradiol) - Tier 2; PA; QL aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL CLIMARA PRO - Tier 2; PA aviane (generic for AFIRMELLE) - Tier 1; QL COMBIPATCH - Tier 2; PA; QL ayuna (generic for ALTAVERA) - Tier 1; QL covaryx (generic for COVARYX) - Tier 1; PA azurette (generic for AZURETTE) - Tier 1; QL covaryx hs (generic for COVARYX HS) - Tier 1; PA balziva (generic for BALZIVA) - Tier 1; QL daysee (generic for AMETHIA) - Tier 1; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL DEPO-ESTRADIOL - Tier 2; PA blisovi 24 fe - Tier 1; QL DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25 blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL MG/1.25GM - Tier 2; PA; QL blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM - Tier 2; PA briellyn (generic for BALZIVA) - Tier 1; QL drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg (generic for caziant - Tier 1; QL BEYAZ) - Tier 1; PA; QL charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL DUAVEE - Tier 2; PA; QL chateal (generic for ALTAVERA) - Tier 1; QL EC-RX ESTRADIOL - Tier 2; PA chateal eq (generic for ALTAVERA) - Tier 1; QL eemt (generic for COVARYX) - Tier 1; PA cryselle-28 - Tier 1; QL eemt hs (generic for COVARYX HS) - Tier 1; PA cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL ELESTRIN - Tier 2; PA cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL est estrogens-methyltest (generic for COVARYX) - Tier 1; PA cyred - Tier 1; QL est estrogens-methyltest ds (generic for COVARYX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 142 Preferred Agents Non-Preferred Agents cyred eq - Tier 1; QL est estrogens-methyltest hs (generic for COVARYX HS) - Tier 1; PA dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL ESTRACE ORAL (brand for estradiol) - Tier 2; PA dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL ESTRACE VAGINAL (brand for estradiol) - Tier 2; PA; QL delyla (generic for AFIRMELLE) - Tier 1; QL ESTRING - Tier 2; PA; QL desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL ESTROGEL - Tier 2; PA dotti (generic for DOTTI) - Tier 1; QL ESTROSTEP FE - Tier 2; PA; QL drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg (generic for EVAMIST - Tier 2; PA TYDEMY) - Tier 1; QL FALESSA - Tier 2; PA; QL drospirenone-ethinyl estradiol (generic for OCELLA) - Tier 1; QL fayosim (generic for FAYOSIM) - Tier 1; PA; QL elinest - Tier 1; QL FEMHRT LOW DOSE (brand for norethindrone-eth estradiol) - Tier 2; PA; eluryng (generic for ELURYNG) - Tier 1; QL QL emoquette - Tier 1; QL FEMRING - Tier 2; PA; QL enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL gemmily (generic for GEMMILY) - Tier 1; PA; QL enskyce - Tier 1; QL GENERESS FE (brand for norethin-eth estradiol-fe) - Tier 2; PA; QL estarylla (generic for ESTARYLLA) - Tier 1; QL jaimiess (generic for AMETHIA) - Tier 1; PA; QL estradiol oral (generic for ESTRACE) - Tier 1 kaitlib fe (generic for KAITLIB FE) - Tier 1; PA; QL estradiol transdermal (generic for DOTTI) - Tier 1; QL layolis fe (generic for KAITLIB FE) - Tier 1; PA; QL estradiol vaginal cream (generic for ESTRACE) - Tier 1; QL levonorgest-eth est & eth est (generic for FAYOSIM) - Tier 1; PA; QL estradiol vaginal tablet (generic for YUVAFEM) - Tier 1 levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg (generic for estradiol-norethindrone acet (generic for AMABELZ) - Tier 1 AMETHIA LO) - Tier 1; PA; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg (generic for falmina (generic for AFIRMELLE) - Tier 1; QL AMETHIA) - Tier 1; PA; QL femynor (generic for ESTARYLLA) - Tier 1; QL LO LOESTRIN FE - Tier 2; PA; QL fyavolv oral tablet 0.5-2.5 mg-mcg (generic for FYAVOLV) - Tier 1; QL LOESTRIN 1.5/30 (21) (brand for norethindrone acet-ethinyl est) - Tier 2; fyavolv oral tablet 1-5 mg-mcg (generic for FYAVOLV) - Tier 1 PA; QL gianvi (generic for GIANVI) - Tier 1; QL hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL LOESTRIN 1/20 (21) (brand for norethindrone acet-ethinyl est) - Tier 2; hailey 24 fe - Tier 1; QL PA; QL hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL LOESTRIN FE 1.5/30 (brand for norethin ace-eth estrad-fe) - Tier 2; PA; introvale (generic for INTROVALE) - Tier 1; QL QL isibloom - Tier 1; QL LOESTRIN FE 1/20 (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 143 Preferred Agents Non-Preferred Agents jasmiel (generic for GIANVI) - Tier 1; QL lojaimiess (generic for AMETHIA LO) - Tier 1; PA; QL jinteli (generic for FYAVOLV) - Tier 1 LOSEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; PA; jolessa (generic for INTROVALE) - Tier 1; QL QL juleber - Tier 1; QL MENOSTAR - Tier 2; PA; QL junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL MINASTRIN 24 FE (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL MINIVELLE (brand for estradiol) - Tier 2; PA; QL junel fe (generic for AUROVELA FE 1/20) - Tier 1; QL MIRCETTE (brand for viorele) - Tier 2; PA; QL kalliga - Tier 1; QL NATAZIA - Tier 2; PA; QL kariva (generic for AZURETTE) - Tier 1; QL kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL norethin ace-eth estrad-fe oral capsule (generic for GEMMILY) - Tier 1; kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL PA; QL kurvelo (generic for ALTAVERA) - Tier 1; QL larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg (generic for larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL KAITLIB FE) - Tier 1; PA; QL larin 24 fe - Tier 1; QL NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; PA; QL larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL PREFEST - Tier 2; PA; QL larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL PREMARIN VAGINAL - Tier 2; PA; QL larissia (generic for AFIRMELLE) - Tier 1; QL QUARTETTE (brand for levonorgest-eth est & eth est) - Tier 2; PA; QL leena - Tier 1; QL rivelsa (generic for FAYOSIM) - Tier 1; PA; QL lessina (generic for AFIRMELLE) - Tier 1; QL SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL levonest (generic for ENPRESSE-28) - Tier 1; QL SEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; PA; QL levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg (generic for simpesse (generic for AMETHIA) - Tier 1; PA; QL INTROVALE) - Tier 1; QL TAYTULLA (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL levonorgestrel-ethinyl estrad (generic for ALTAVERA) - Tier 1; QL TWIRLA - Tier 2; PA; QL levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; QL lillow (generic for ALTAVERA) - Tier 1; QL YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; QL loryna (generic for GIANVI) - Tier 1; QL low-ogestrel - Tier 1; QL lo-zumandimine (generic for GIANVI) - Tier 1; QL lutera (generic for AFIRMELLE) - Tier 1; QL lyllana (generic for DOTTI) - Tier 1; QL marlissa (generic for ALTAVERA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 144 Preferred Agents Non-Preferred Agents melodetta 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL MENEST - Tier 2 mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL mili (generic for ESTARYLLA) - Tier 1; QL mimvey (generic for AMABELZ) - Tier 1 mono-linyah (generic for ESTARYLLA) - Tier 1; QL necon 0.5/35 (28) - Tier 1; QL nikki (generic for GIANVI) - Tier 1; QL norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL norethin ace-eth estrad-fe oral tablet chewable (generic for CHARLOTTE 24 FE) - Tier 1; QL norethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg (generic for FYAVOLV) - Tier 1; QL norethindrone-eth estradiol oral tablet 1-5 mg-mcg (generic for FYAVOLV) - Tier 1 norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg (generic for WYMZYA FE) - Tier 1; QL norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL norgestimate-ethinyl estradiol triphasic (generic for TRI-LO- ESTARYLLA) - Tier 1; QL nortrel 0.5/35 (28) - Tier 1; QL nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL ocella (generic for OCELLA) - Tier 1; QL orsythia (generic for AFIRMELLE) - Tier 1; QL philith (generic for BALZIVA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 145 Preferred Agents Non-Preferred Agents pimtrea (generic for AZURETTE) - Tier 1; QL pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL portia-28 (generic for ALTAVERA) - Tier 1; QL PREMARIN ORAL - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1; QL reclipsen - Tier 1; QL setlakin (generic for INTROVALE) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1; QL sprintec 28 (generic for ESTARYLLA) - Tier 1; QL sronyx (generic for AFIRMELLE) - Tier 1; QL syeda (generic for OCELLA) - Tier 1; QL tarina 24 fe - Tier 1; QL tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL tilia fe - Tier 1; QL tri femynor (generic for TRI FEMYNOR) - Tier 1; QL tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL tri-legest fe - Tier 1; QL tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1; QL tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1; QL tri-mili (generic for TRI FEMYNOR) - Tier 1; QL tri-previfem (generic for TRI FEMYNOR) - Tier 1; QL tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL trivora (28) (generic for ENPRESSE-28) - Tier 1; QL tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL tyblume (generic for AFIRMELLE) - Tier 1; QL tydemy (generic for TYDEMY) - Tier 1; QL VAGIFEM (brand for estradiol) - Tier 2 velivet - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 146 Preferred Agents Non-Preferred Agents vienva (generic for AFIRMELLE) - Tier 1; QL viorele (generic for AZURETTE) - Tier 1; QL volnea (generic for AZURETTE) - Tier 1; QL vyfemla (generic for BALZIVA) - Tier 1; QL vylibra (generic for ESTARYLLA) - Tier 1; QL wera - Tier 1; QL wymzya fe (generic for WYMZYA FE) - Tier 1; QL xulane - Tier 1; QL yuvafem (generic for YUVAFEM) - Tier 1 zarah (generic for OCELLA) - Tier 1; QL zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL zovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL zumandimine (generic for OCELLA) - Tier 1; QL

Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL AYGESTIN (brand for norethindrone acetate) - Tier 2; PA camila (generic for CAMILA) - Tier 1; QL CRINONE - Tier 2; PA deblitaneecontra ez (generic (generic for for CAMILA) AFTERA) - Tier- Tier 1; 1; QL QL DEPO-PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; econtra one-step (generic for AFTERA) - Tier 1; QL QL ELLA - Tier 2; QL DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL errin (generic for CAMILA) - Tier 1; QL EC-RX PROGESTERONE - Tier 2; PA heather (generic for CAMILA) - Tier 1; QL FIRST-PROGESTERONE VGS - Tier 2; PA incassia (generic for CAMILA) - Tier 1; QL jencycla (generic for CAMILA) - Tier 1; QL hydroxyprogesterone caproate intramuscular (generic for MAKENA) - Tier levonorgestrel (generic for AFTERA) - Tier 1; QL 1; PA lyza (generic for CAMILA) - Tier 1; QL KYLEENA - Tier 2; PA; QL medroxyprogesterone acetate intramuscular (generic for DEPO- MAKENA (brand for hydroxyprogesterone caproate) - Tier 2; PA PROVERA) - Tier 1; QL megestrol acetate oral suspension 625 mg/5ml - Tier 1; PA medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1 ORTHO MICRONOR (brand for norethindrone) - Tier 2; PA; QL megestrol acetate oral suspension 40 mg/ml - Tier 1 PROGESTERONE COMPOUNDING KIT - Tier 2; PA megestrol acetate oral tablet 20 mg - Tier 1 progesterone intramuscular - Tier 1; PA megestrol acetate oral tablet 40 mg - Tier 1; QL PROGESTERONE MICRONIZED TRANSDERMAL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 147 Preferred Agents Non-Preferred Agents my choice (generic for AFTERA) - Tier 1; QL PROMETRIUM (brand for progesterone micronized) - Tier 2; PA my way (generic for AFTERA) - Tier 1; QL PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA new day (generic for AFTERA) - Tier 1; QL SLYND - Tier 2; PA; QL nora-be (generic for CAMILA) - Tier 1; QL norethindrone acetate oral (generic for AYGESTIN) - Tier 1 norethindrone oral (generic for CAMILA) - Tier 1; QL norlyda (generic for CAMILA) - Tier 1; QL norlyroc (generic for CAMILA) - Tier 1; QL opcicon one-step (generic for AFTERA) - Tier 1; QL option 2 (generic for AFTERA) - Tier 1; QL PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL progesterone micronized oral (generic for PROMETRIUM) - Tier 1 react (generic for AFTERA) - Tier 1; QL sharobel (generic for CAMILA) - Tier 1; QL take action (generic for AFTERA) - Tier 1; QL tulana (generic for CAMILA) - Tier 1; QL

Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs raloxifene hcl (generic for EVISTA) - Tier 1 EVISTA (brand for raloxifene hcl) - Tier 2; PA OSPHENA - Tier 2; PA; QL Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYROID ORAL TABLET 120 MG, 60 MG (brand for np CYTOMEL (brand for liothyronine sodium) - Tier 2; PA; QL thyroid) - Tier 2; QL ARMOUR THYROID ORAL TABLET 15 MG, 30 MG, 90 MG (brand for LEVOTHYROXINE SODIUM ORAL CAPSULE 100 MCG, 112 MCG, 125 np thyroid) - Tier 2 MCG, 13 MCG, 137 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG - Tier 2; ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG - Tier PALEVOTHYROXINE SODIUM ORAL CAPSULE 150 MCG, 175 MCG, 200 2 MCG - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 148 Preferred Agents Non-Preferred Agents euthyrox oral tablet 100 mcg, 75 mcg (generic for EUTHYROX) - Tier SYNTHROID ORAL TABLET 100 MCG, 75 MCG (brand for levothyroxine 1; QL sodium) - Tier 2; PA; QL euthyrox oral tablet 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, SYNTHROID ORAL TABLET 112 MCG, 125 MCG, 137 MCG, 150 MCG, 200 mcg, 25 mcg, 50 mcg, 88 mcg (generic for EUTHYROX) - Tier 1 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 88 MCG (brand for levo-t oral tablet 100 mcg, 75 mcg (generic for EUTHYROX) - Tier 1; levothyroxineTIROSINT ORAL sodium) CAPSULE - Tier 2; 100 PA MCG, 112 MCG, 125 MCG, 13 MCG, QL 137 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG (brand for levothyroxine levo-t oral tablet 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 sodium)TIROSINT - Tier ORAL 2; PA CAPSULE 150 MCG, 175 MCG, 200 MCG (brand for mcg, 25 mcg, 50 mcg, 88 mcg (generic for EUTHYROX) - Tier 1 levothyroxine sodium) - Tier 2; PA; QL levo-t oral tablet 300 mcg (generic for LEVO-T) - Tier 1 TIROSINT-SOL - Tier 2; PA; QL levothyroxine sodium oral tablet 100 mcg, 75 mcg (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium oral tablet 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 88 mcg (generic for EUTHYROX) - Tier 1 levothyroxine sodium oral tablet 300 mcg (generic for LEVO-T) - Tier 1 levoxyl oral tablet 100 mcg, 75 mcg (generic for EUTHYROX) - Tier 1; QL levoxyl oral tablet 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 88 mcg (generic for EUTHYROX) - Tier 1 liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 195 MG, 32.5 MG, 48.75 MG, 81.25 MG, 97.5 MG - Tier 2; PA NATURE-THROID ORAL TABLET 146.25 MG, 162.5 MG, 260 MG, 325 MG - Tier 2 NATURE-THROID ORAL TABLET 65 MG (brand for thyroid) - Tier 2; PA np thyroid oral tablet 120 mg, 60 mg (generic for ARMOUR THYROID) - Tier 1; QL np thyroid oral tablet 15 mg, 30 mg, 90 mg (generic for ARMOUR THYROID) - Tier 1 unithroid oral tablet 100 mcg, 75 mcg (generic for EUTHYROX) - Tier 1; QL unithroid oral tablet 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 88 mcg (generic for EUTHYROX) - Tier 1 unithroid oral tablet 300 mcg (generic for LEVO-T) - Tier 1

Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2; PA ISTURISA - Tier 2; PA; SP; QL Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL BYNFEZIA PEN - Tier 2; PA; SP leuprolide acetate injection - Tier 1; PA; SP EGRIFTA SV - Tier 2; PA; SP; QL ELIGARD - Tier 2; PA; SP; QL octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml (generic FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL for SANDOSTATIN) - Tier 1; PA; SP LUPANETA PACK - Tier 2; PA; SP octreotide acetate injection solution 1000 mcg/ml - Tier 1; PA; SP; QL LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL octreotide acetate injection solution 200 mcg/ml - Tier 1; PA; SP LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL ORILISSA - Tier 2; PA; QL LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; PA; SP; QL LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP MYCAPSSA - Tier 2; PA; SP; QL octreotide acetate injection solution 500 mcg/ml (generic for SANDOSTATIN) - Tier 1; PA; SP; QL ORIAHNN - Tier 2; PA; QL SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML (brand for octreotide acetate) - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 150 Preferred Agents Non-Preferred Agents SANDOSTATIN INJECTION SOLUTION 500 MCG/ML (brand for octreotide acetate) - Tier 2; PA; SP; QL SIGNIFOR - Tier 2; PA; SP; QL SIGNIFOR LAR - Tier 2; PA SOMAVERT - Tier 2; PA; SP; QL SYNAREL - Tier 2; PA TRIPTODUR - Tier 2; PA; SP

Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1 TAPAZOLE (brand for methimazole) - Tier 2; PA propylthiouracil oral - Tier 1 Immunological Agents Immunomodulators ENSPRYNG - Tier 2; PA; SP; QL Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL icatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL Immune Suppressants - Immune System Drugs azathioprine oral (generic for IMURAN) - Tier 1; QL ASTAGRAF XL - Tier 2; PA; QL cyclosporine modified (generic for GENGRAF) - Tier 1 AZASAN - Tier 2; PA cyclosporine oral (generic for SANDIMMUNE) - Tier 1 CELLCEPT (brand for mycophenolate mofetil) - Tier 2; PA ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML - Tier 2; SP; CIMZIA - Tier 2; PA; SP; QL QL ENVARSUS XR - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 151 Preferred Agents Non-Preferred Agents ENBREL SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for ZORTRESS) SP - Tier 1; PA; QL ENBREL SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; SP IMURAN (brand for azathioprine) - Tier 2; PA; QL ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier methotrexate sodium injection solution reconstituted - Tier 1; PA 2; SP MYFORTIC (brand for mycophenolate sodium) - Tier 2; PA; ST NEORAL (brand for cyclosporine modified) - Tier 2; PA ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED - Tier 2; OLUMIANT - Tier 2; PA; SP SP ORENCIA CLICKJECT - Tier 2; PA; SP; QL gengraf (generic for GENGRAF) - Tier 1 ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 80 OTREXUP - Tier 2; PA; QL MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; SP PROGRAF ORAL (brand for tacrolimus) - Tier 2; PA RAPAMUNE ORAL SOLUTION (brand for sirolimus) - Tier 2; PA HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML - Tier RAPAMUNE ORAL TABLET 0.5 MG (brand for sirolimus) - Tier 2; PA; QL 2; PA; SP; QL RAPAMUNE ORAL TABLET 1 MG, 2 MG (brand for sirolimus) - Tier 2; HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT - Tier 2; SP PA methotrexate oral - Tier 1 RASUVO - Tier 2; PA; QL methotrexate sodium (pf) - Tier 1 REDITREX - Tier 2; PA methotrexate sodium injection solution - Tier 1 SANDIMMUNE ORAL (brand for cyclosporine) - Tier 2; PA methotrexate sodium oral - Tier 1 SIMPONI - Tier 2; PA; SP mycophenolate mofetil (generic for CELLCEPT) - Tier 1 sirolimus oral solution (generic for RAPAMUNE) - Tier 1; PA mycophenolate sodium (generic for MYFORTIC) - Tier 1; ST SKYRIZI (150 MG DOSE) - Tier 2; PA; SP sirolimus oral tablet 0.5 mg (generic for RAPAMUNE) - Tier 1; QL STELARA INTRAVENOUS - Tier 2; PA sirolimus oral tablet 1 mg, 2 mg (generic for RAPAMUNE) - Tier 1 STELARA SUBCUTANEOUS - Tier 2; PA; SP tacrolimus oral (generic for PROGRAF) - Tier 1 TREXALL - Tier 2; PA XATMEP - Tier 2; PA XELJANZ - Tier 2; PA; SP XELJANZ XR - Tier 2; PA; SP ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG (brand for everolimus) - Tier 2; PA; QL ZORTRESS ORAL TABLET 1 MG - Tier 2; PA Immunizing Agents, Passive - Immune System Drugs CUVITRU SUBCUTANEOUS SOLUTION 8 GM/40ML - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 152 Preferred Agents Non-Preferred Agents Immunomodulators - Immune System Drugs leflunomide oral (generic for ARAVA) - Tier 1; QL ACTEMRA ACTPEN - Tier 2; PA; SP SYNAGIS - Tier 2; PA; SP ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL XOLAIR - Tier 2; PA; SP; QL ACTIMMUNE - Tier 2; PA; SP ARAVA (brand for leflunomide) - Tier 2; PA; QL BENLYSTA SUBCUTANEOUS - Tier 2; PA; SP ENTYVIO - Tier 2; PA KEVZARA - Tier 2; PA; SP OTEZLA - Tier 2; PA; SP RIDAURA - Tier 2; PA; QL RINVOQ - Tier 2; PA; SP SIMPONI ARIA - Tier 2; PA Vaccines ADACEL - Tier 2; QL GARDASIL 9 SUSPENSION INTRAMUSCULAR - Tier 2; PA AFLURIA QUADRIVALENT - Tier 2; QL GARDASIL 9 SUSPENSION PREFILLED SYRINGE INTRAMUSCULAR - BEXSERO - Tier 2; QL Tier 2; PA BOOSTRIX - Tier 2; QL HEPLISAV-B - Tier 2; PA DAPTACEL - Tier 2; QL PNEUMOVAX 23 INJECTABLE 25 MCG/0.5ML INJECTION - Tier 2; PA ENGERIX-B SUSPENSION 20 MCG/ML INJECTION - Tier 2; QL FLUAD - Tier 2; QL FLUAD QUADRIVALENT - Tier 2; QL FLUARIX QUADRIVALENT - Tier 2; QL FLUCELVAX QUADRIVALENT - Tier 2; QL FLULAVAL QUADRIVALENT - Tier 2; QL FLUMIST QUADRIVALENT - Tier 2; QL FLUZONE QUADRIVALENT - Tier 2; QL GARDASIL 9 SUSPENSION INTRAMUSCULAR - Tier 2; QL GARDASIL 9 SUSPENSION PREFILLED SYRINGE INTRAMUSCULAR - Tier 2; QL HAVRIX - Tier 2; QL INFANRIX - Tier 2; QL MENACTRA - Tier 2; QL M-M-R II - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 153 Preferred Agents Non-Preferred Agents PNEUMOVAX 23 INJECTABLE 25 MCG/0.5ML INJECTION - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL TENIVAC - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL

Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs APRISO (brand for mesalamine er) - Tier 2 ASACOL HD (brand for mesalamine) - Tier 2; PA LIALDA (brand for mesalamine) - Tier 2 balsalazide disodium (generic for COLAZAL) - Tier 1; PA mesalamine rectal enema - Tier 1 CANASA (brand for mesalamine) - Tier 2; PA COLAZAL (brand for balsalazide disodium) - Tier 2; PA DELZICOL (brand for mesalamine) - Tier 2; PA DIPENTUM - Tier 2; PA mesalamine er (generic for APRISO) - Tier 1; PA mesalamine oral (generic for LIALDA) - Tier 1; PA mesalamine rectal suppository (generic for CANASA) - Tier 1; PA mesalamine-cleanser (generic for ROWASA) - Tier 1; PA PENTASA - Tier 2; PA ROWASA (brand for mesalamine-cleanser) - Tier 2; PA SFROWASA - Tier 2; PA; QL

Glucocorticoids - Drugs to Treat Inflammation ANALPRAM HC (brand for hydrocort-pramoxine (perianal)) - Tier 2; PA ANALPRAM HC SINGLES (brand for hydrocort-pramoxine (perianal)) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 154 Preferred Agents Non-Preferred Agents ANALPRAM-HC (brand for hydrocortisone ace-pramoxine) - Tier 2; PA ANUSOL-HC EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; PA; QL budesonide er (generic for UCERIS) - Tier 1; PA budesonide oral (generic for ENTOCORT EC) - Tier 1; PA; QL CORTENEMA (brand for hydrocortisone) - Tier 2; PA CORTIFOAM - Tier 2; PA ENTOCORT EC (brand for budesonide) - Tier 2; PA; QL hydrocortisone (perianal) external cream 1 % (generic for PROCTO-PAK) - Tier 1; PA hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO- MED HC) - Tier 1; PA; QL hydrocortisone ace-pramoxine external cream 1-1 % (generic for ANALPRAM-HC) - Tier 1; PA hydrocortisone rectal (generic for CORTENEMA) - Tier 1; PA hydrocort-pramoxine (perianal) (generic for ANALPRAM HC) - Tier 1; PA ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 6 MG - Tier 2; PA; QL PROCORT - Tier 2; PA PROCTOCORT EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2; PA PROCTOFOAM HC - Tier 2; PA procto-med hc (generic for PROCTO-MED HC) - Tier 1; PA; QL procto-pak (generic for PROCTO-PAK) - Tier 1; PA proctozone-hc (generic for PROCTO-MED HC) - Tier 1; PA; QL UCERIS (brand for budesonide er) - Tier 2; PA Sulfonamides - Antibiotics sulfasalazine oral (generic for AZULFIDINE) - Tier 1 AZULFIDINE (brand for sulfasalazine) - Tier 2; PA AZULFIDINE EN-TABS (brand for sulfasalazine) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 155 Preferred Agents Non-Preferred Agents Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium oral tablet 10 mg, 5 mg - Tier 1 ACTONEL ORAL TABLET 150 MG (brand for risedronate sodium) - Tier alendronate sodium oral tablet 35 mg - Tier 1; QL 2; PA alendronate sodium oral tablet 70 mg (generic for FOSAMAX) - Tier 1; ACTONEL ORAL TABLET 35 MG (brand for risedronate sodium) - Tier 2; QL PA; QL calcitonin (salmon) (generic for MIACALCIN) - Tier 1 alendronate sodium oral solution - Tier 1; PA cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL ATELVIA (brand for risedronate sodium) - Tier 2; PA; QL BINOSTO - Tier 2; PA BONIVA INTRAVENOUS (brand for ibandronate sodium) - Tier 2; PA BONIVA ORAL (brand for ibandronate sodium) - Tier 2; PA; QL FORTEO - Tier 2; PA; SP FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL FOSAMAX PLUS D - Tier 2; PA; QL ibandronate sodium intravenous (generic for BONIVA) - Tier 1; PA ibandronate sodium oral (generic for BONIVA) - Tier 1; PA; QL MIACALCIN INJECTION - Tier 2; PA RAYALDEE - Tier 2; PA risedronate sodium oral tablet 150 mg (generic for ACTONEL) - Tier 1; PA risedronate sodium oral tablet 30 mg, 5 mg - Tier 1; PA risedronate sodium oral tablet 35 mg (generic for ACTONEL) - Tier 1; PA; QL risedronate sodium oral tablet delayed release (generic for ATELVIA) - Tier 1; PA; QL SENSIPAR (brand for cinacalcet hcl) - Tier 2; PA; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL TYMLOS - Tier 2; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 156 Preferred Agents Non-Preferred Agents Metabolic Bone Disease Agents - Other calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL NATPARA - Tier 2; PA; SP; QL calcitriol oral solution (generic for ROCALTROL) - Tier 1 ROCALTROL ORAL CAPSULE (brand for calcitriol) - Tier 2; PA; QL doxercalciferol oral - Tier 1 ROCALTROL ORAL SOLUTION (brand for calcitriol) - Tier 2; PA paricalcitol (generic for ZEMPLAR) - Tier 1 ZEMPLAR INTRAVENOUS (brand for paricalcitol) - Tier 2; PA ZEMPLAR ORAL (brand for paricalcitol) - Tier 2 Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA IN VITRO (brand for element compact control 3) - ACCU-CHEK AVIVA DEVICE (brand for verasens blood glucose meter) - Tier 2; QL Tier 2; PA; QL ACCU-CHEK COMPACT PLUS CONTROL (brand for element ACCU-CHEK AVIVA CONNECT (brand for meijer premium blood compact control 3) - Tier 2; QL glucose) - Tier 2; PA; QL ACCU-CHEK GUIDE CONTROL (brand for element compact control ACCU-CHEK AVIVA PLUS KIT W/DEVICE (brand for element compact 3) - Tier 2; QL test) - Tier 2; PA; QL ACCU-CHEK CLIP FOR PUMP SKIN - Tier 2; PA ACCU-CHEK SMARTVIEW CONTROL (brand for element compact ACCU-CHEK COMPACT PLUS (brand for element compact test) - Tier 2; control 3) - Tier 2; QL PA; QL ACCU-CHEK COMPACT PLUS CARE - Tier 2; PA; QL ACCU-CHEK SOFTCLIX LANCETS (brand for lancets ultra thin 30g) - ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite Tier 2; QL device/lancets) - Tier 2; PA ACCUTREND GLUCOSE CONTROL (brand for element compact ACCU-CHEK GUIDE KIT W/DEVICE (brand for meijer premium blood control 3) - Tier 2; QL glucose) - Tier 2; PA; QL ACCU-CHEK LINKASSIST - Tier 2; PA ACE AEROSOL CLOUD ENHANCER (brand for co monitor ACCU-CHEK MULTICLIX LANCET DEVICE KIT (brand for select-lite replacement pieces) - Tier 2; QL device/lancets) - Tier 2; PA ADULT AEROSOL MASK - Tier 2; QL ADULT MASK - Tier 2; QL ACCU-CHEK NANO SMARTVIEW (brand for meijer premium blood AEROCHAMBER PLUS FLO-VU (brand for procare spacer/adult glucose) - Tier 2; PA; QL mask) - Tier 2; QL AEROCHAMBER PLUS FLO-VU LARGE (brand for procare ACCU-CHEK SMARTVIEW (brand for element compact test) - Tier 2; PA; spacer/adult mask) - Tier 2; QL QL AEROCHAMBER PLUS FLO-VU SMALL (brand for procare ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite spacer/adult mask) - Tier 2; QL device/lancets) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 157 Preferred Agents Non-Preferred Agents AEROCHAMBER PLUS FLO-VU W/MASK (brand for procare ACCU-CHEK SOFTCLIX LANCETS (brand for lancets ultra thin 30g) - spacer/adult mask) - Tier 2; QL Tier 2; PA; QL ACCU-CHEK SPIRIT ADAPTER KIT - Tier 2; PA AIRZONE PEAK FLOW METER (brand for pure comfort flow meter ACCU-CHEK SPIRIT BATTERY KIT - Tier 2; PA adult) - Tier 2; QL ACCU-CHEK SPIRIT COMBO PACK - Tier 2; PA ALCOHOL PREP PADS PAD , 70 % - Tier 2; QL ACCU-CHEK TENDER 1 INFUSION - Tier 2; PA anti-fungal external powder (generic for ODOR EATERS ACCUTREND GLUCOSE (brand for element compact test) - Tier 2; PA; ANTIFUNGAL) - Tier 1 QL ACESO AG - Tier 2; PA ASSESS FULL RANGE PEAK METER (brand for pure comfort flow ACTIFOAM COLLAGEN SPONGE - Tier 2; PA meter adult) - Tier 2; QL ACTIPOCHOL PLUS (brand for lipochol plus) - Tier 2; PA ADJUSTABLE LANCING DEVICE - Tier 2; PA ASSESS LOW RANGE PEAK METER (brand for pure comfort flow ADVANCED GLUCOSE TEST (brand for element compact test) - Tier 2; meter adult) - Tier 2; QL PA; QL atabex dha 200 - Tier 1 AZALGIA - Tier 2 AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; BD ULTRA-FINE INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for PA; QL vp insulin syringe) - Tier 2; QL alga - Tier 1; PA BREATHE EASE HUMIDIFIER - Tier 2; QL amino action (generic for PRE PROTEIN) - Tier 1; PA BREATHE EASE NEB MASK/CHILD - Tier 2; QL aminoamrms - Tier 1; PA BREATHE EASE NEB MASK/INFANT - Tier 2; QL aminoreliefrms - Tier 1; PA BUBBLES THE FISH II PEDI MASK (brand for co monitor replacement aminos (generic for PRE PROTEIN) - Tier 1; PA pieces) - Tier 2; QL antifungal external powder (generic for REMEDY ANTIFUNGAL) - Tier 1; PA; QL CARETOUCH 2 CPAP HOSE HANGER (brand for co monitor arginine - Tier 1; PA replacement pieces) - Tier 2; QL ARIDA (brand for cvs silver) - Tier 2; PA ASPARTAME - Tier 2; PA CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact ASPARTAME (NUTRASWEET) (brand for aspartame) - Tier 2; PA control 3) - Tier 2; QL AUTOJECT 2 (brand for inject-ease) - Tier 2; PA AUTOLET II CLINISAFE (brand for select-lite device/lancets) - Tier 2; PA CARETOUCH CPAP & BIPAP HOSE (brand for co monitor AUTOLET LANCING DEVICE (brand for live better adv lancing device) - replacement pieces) - Tier 2; QL Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 158 Preferred Agents Non-Preferred Agents CARETOUCH CPAP MASK WIPES (brand for co monitor replacement AUTOLET LITE STARTER PACK (brand for select-lite device/lancets) - pieces) - Tier 2; QL Tier 2; PA AUTOLET MINI (brand for live better adv lancing device) - Tier 2; PA CARETOUCH CPAP PRE-WASH SOLN (brand for co monitor AUTOPEN - Tier 2; PA replacement pieces) - Tier 2; QL AVAILNEX - Tier 2; PA AVITENE - Tier 2; PA CARETOUCH CPAP TUBE BRUSH (brand for co monitor AVITENE FLOUR - Tier 2; PA replacement pieces) - Tier 2; QL avo cream (generic for AVO CREAM) - Tier 1; PA AXONA (brand for pro-critic) - Tier 2; PA CARETOUCH UNIVERSL CPAP FILTER (brand for co monitor AZADROX (brand for cvs silver) - Tier 2; PA replacement pieces) - Tier 2; QL BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 0.3 ML (brand for CAYA - Tier 2 global inject ease insulin syr) - Tier 2; PA; QL CHEMSTRIP K (brand for ketone test) - Tier 2; QL bee pollen oral capsule 580 mg - Tier 1; PA CHEMSTRIP UGK - Tier 2; QL BEHAVIORAL HEALTH APP - Tier 2; PA CONDOMS - Tier 2; QL BIAFINE (brand for foraxa) - Tier 2; PA COOL MIST HUMIDIFER - Tier 2; QL BIONECT EXTERNAL CREAM - Tier 2; PA dha - Tier 1 BIONECT EXTERNAL FOAM - Tier 2; PA EASIVENT (brand for procare spacer/adult mask) - Tier 2; QL EASIVENT MASK LARGE (brand for procare spacer/adult mask) - Tier BLOOD GLUCOSE TEST STRIPS (brand for element compact test) - Tier 2; QL 2; PA; QL BLUESTAR - Tier 2; PA EASIVENT MASK MEDIUM (brand for procare spacer/adult mask) - borage - Tier 1; PA Tier 2; QL CAMINO PRO COMPLETE/GLYTACTIN - Tier 2; PA CANTHARIDIN EXTERNAL - Tier 2; PA; QL EASIVENT MASK SMALL (brand for procare spacer/adult mask) - Tier CARDIOVID PLUS - Tier 2; PA 2; QL CAREONE ADVANCED LANCING DEV - Tier 2; PA EASYMAX 15 LEVEL 2 CONTROL (brand for element compact CARETOUCH LANCING/EJECTOR (brand for live better adv lancing control 3) - Tier 2; QL device) - Tier 2; PA EASYMAX 15 LEVEL 2-3 CONTROL (brand for element compact CARETOUCH MONITOR SYSTEM (brand for meijer premium blood control 3) - Tier 2; QL glucose) - Tier 2; PA; QL CARETOUCH TEST (brand for element compact test) - Tier 2; PA; QL EASYMAX CONTROL NORMAL/HIGH (brand for element compact carnitine oral capsule 250 mg - Tier 1; PA control 3) - Tier 2; QL CEQUR SIMPLICITY 2U (brand for autopen) - Tier 2; PA CHEMSTRIP 10 MD - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 159 Preferred Agents Non-Preferred Agents EBASE CONTROLLER KIT (brand for co monitor replacement pieces) CHEMSTRIP 10/SG - Tier 2; PA - Tier 2; QL CHEMSTRIP 2 GP - Tier 2; PA CHEMSTRIP 5 OB - Tier 2; PA EFLOW SCF AEROSOL HEAD (brand for co monitor replacement CHEMSTRIP 7 - Tier 2; PA pieces) - Tier 2; QL CHEMSTRIP 9 - Tier 2; PA enteric fish oil - Tier 1 CHOICE DM DIABETES RISK TEST - Tier 2; PA; QL FILTER AIR PP - Tier 2; QL choline - Tier 1; PA FIRDAPSE - Tier 2; SP; QL CITRULLINE 1000 - Tier 2; PA co q 10 oral capsule 60 mg (generic for Q-GEL ULTRA) - Tier 1; PA fish oil concentrate oral capsule 1000 mg (generic for SEA-OMEGA) - co q-10 oral capsule 100 mg (generic for H2Q) - Tier 1; PA Tier 1 co q-10 oral capsule 150 mg (generic for Q-SORB) - Tier 1; PA fish oil half-the-size (generic for OVEGA-3) - Tier 1 co q-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier 1; PA fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1 coenzyme q-10 (generic for H2Q) - Tier 1; PA fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH OIL co-enzyme q10 (generic for H2Q) - Tier 1; PA CONC) - Tier 1 coenzyme q10 oral capsule 100 mg (generic for H2Q) - Tier 1; PA fish oil oral capsule 500 mg (generic for OVEGA-3) - Tier 1 coenzyme q-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - fish oil oral capsule delayed release 1000 mg, 1200 mg - Tier 1 Tier 1; PA FLEXICHAMBER (brand for procare spacer/adult mask) - Tier 2; QL coenzyme q10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA FLEXICHAMBER ADULT MASK/SMALL - Tier 2; QL co-enzyme q-10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA FLEXICHAMBER CHILD MASK/LARGE - Tier 2; QL coenzyme q10 oral tablet 200 mg (generic for VITALINE COQ10) - Tier 1; FLEXICHAMBER CHILD MASK/SMALL - Tier 2; QL PA GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for COLLATYL (brand for cvs silver) - Tier 2; PA element compact control 3) - Tier 2; QL CONTOUR MONITOR (brand for meijer premium blood glucose) - Tier 2; PA; QL INSPIRACHAMBER/LARGE (brand for procare spacer/adult mask) - CONTOUR CONTROL (brand for easy plus ii control) - Tier 2; PA Tier 2; QL CONTOUR MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL INSPIRACHAMBER/MEDIUM (brand for procare spacer/adult mask) - CONTOUR NEXT EZ (brand for meijer premium blood glucose) - Tier 2; Tier 2; QL PA; QL INSPIRACHAMBER/MOUTHPIECE (brand for procare spacer/adult CONTOUR NEXT LINK (brand for meijer premium blood glucose) - Tier 2; mask) - Tier 2; QL PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 160 Preferred Agents Non-Preferred Agents INSPIRACHAMBER/SMALL (brand for procare spacer/adult mask) - CONTOUR NEXT MONITOR (brand for meijer premium blood glucose) - Tier 2; QL Tier 2; PA; QL INSPIREASE (brand for procare spacer/adult mask) - Tier 2; QL CONTOUR NEXT ONE - Tier 2; PA; QL INSPIREASE RESERVOIR BAGS - Tier 2; QL CONTOUR NEXT TEST (brand for element compact test) - Tier 2; PA; QL INSULIN PEN NEEDLES 29G X 12MM - Tier 2; QL CONTOUR TEST (brand for element compact test) - Tier 2; PA; QL coq-10 & fish oil - Tier 1; PA INSULIN PEN NEEDLES 30G X 8 MM (brand for sure comfort pen coq-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier 1; PA needles) - Tier 2; QL coq10 oral capsule 30 mg (generic for Q-GEL FORTE) - Tier 1; PA coq-10 oral capsule 50 mg (generic for Q-SORB) - Tier 1; PA INSULIN PEN NEEDLES 31G X 6 MM (brand for px extra short pen creatine oral powder (generic for CYTOTINE) - Tier 1; PA needles) - Tier 2; QL CYSTECH - Tier 2; PA cystine - Tier 1; PA INSULIN SYRINGES 27G X 1/2" 1 ML (brand for insulin syringe) - Tier D-CARE BLOOD GLUCOSE (brand for element compact test) - Tier 2; 2; QL PA; QL INSULIN SYRINGES 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML (brand for D-CARE GLUCOMETER (brand for meijer premium blood glucose) - Tier preferred plus insulin syringe) - Tier 2; QL 2; PA; QL DEPLIN 15 (brand for l-methylfolate-algae) - Tier 2; PA INSULIN SYRINGES 28G X 1/2" 1 ML (brand for insulin DEPLIN 7.5 (brand for l-methylfolate forte) - Tier 2; PA syringe/needle) - Tier 2; QL DESENEX EXTERNAL POWDER (brand for gnp miconazorb af) - Tier 2; PA; QL INSULIN SYRINGES 28G X 5/16" 1 ML, 29G X 5/16" 1 ML, 30G X DIALYVITE OMEGA-3 CONCENTRATE (brand for fish oil) - Tier 2; PA 3/8" 0.5 ML - Tier 2; QL DIASTIX - Tier 2; PA diuretic maximum strength - Tier 1; PA INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for vp insulin syringe) - dl-pa-500 - Tier 1; PA Tier 2; QL DOJOLVI - Tier 2; PA DUROLANE - Tier 2; PA INSULIN SYRINGES 29G X 1/2" 1 ML (brand for global inject ease DX1 ORAGENOMIC DNA SCREEN (brand for professional dna insulin syr) - Tier 2; QL collection) - Tier 2; PA INSULIN SYRINGES 30G X 5/16" 0.3 ML, 30G X 5/16" 1 ML (brand DX2 ORAGENOMIC DNA SCREEN (brand for professional dna for kroger insulin syringe) - Tier 2; QL collection) - Tier 2; PA EASY TOUCH TEST (brand for element compact test) - Tier 2; PA; QL INSULIN SYRINGES 30G X 5/16" 0.5 ML (brand for leader insulin EASYMAX 15 TEST (brand for element compact test) - Tier 2; PA; QL syringe) - Tier 2; QL EASYMAX CONTROL (brand for easy trak control) - Tier 2; PA kelp-b6-lecithin-vinegar - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 161 Preferred Agents Non-Preferred Agents KETO-DIASTIX - Tier 2; QL EASYMAX NG BLOOD GLUCOSE (brand for meijer premium blood KETONE CARE - Tier 2; QL glucose) - Tier 2; PA; QL KETONE TEST - Tier 2; QL EASYMAX TEST (brand for element compact test) - Tier 2; PA; QL KETOSTIX (brand for ketone test) - Tier 2; QL EASYMAX V BLOOD GLUCOSE (brand for meijer premium blood kp fish oil (generic for THERAGRAN-M FISH OIL CONC) - Tier 1 glucose) - Tier 2; PA; QL kp omega-3 fish oil - Tier 1 EC-RX DHEA - Tier 2; PA; QL LANCETS - Tier 2; QL ENDO AVITENE - Tier 2; PA MASK VORTEX - Tier 2; QL enovarx-amitriptyline - Tier 1; PA EQ BLOOD GLUCOSE TEST - Tier 2; PA; QL MEDISENSE GLUCOSE KETONE CONTR (brand for element ergoloid mesylates oral - Tier 1; PA; QL compact control 3) - Tier 2; QL evening primrose oil oral capsule 500 mg - Tier 1; PA MEDISENSE HI/MID/LOW CONTROL (brand for element compact EXACTECH R-S-G TEST (brand for element compact test) - Tier 2; PA; control 3) - Tier 2; QL QL EXACTECH TEST (brand for element compact test) - Tier 2; PA; QL MEDISENSE HIGH/LOW CONTROL (brand for element compact fish oil extra strength oral capsule 435 mg - Tier 1; PA control 3) - Tier 2; QL fish oil oral capsule 435 mg - Tier 1; PA flogen - Tier 1; PA MEDISENSE MID CONTROL (brand for element compact control 3) - FLUID ADMINISTRATION SET - Tier 2; PA Tier 2; QL FORA GD50 BLOOD GLUCOSE SYSTEM (brand for verasens blood methergine (generic for METHERGINE) - Tier 1; QL glucose meter) - Tier 2; PA; QL methylergonovine maleate oral (generic for METHERGINE) - Tier 1; FORA GD50 BLOOD GLUCOSE TEST (brand for element compact test) - QL Tier 2; PA; QL MICRODOT PEN NEEDLE 31G X 6 MM (brand for px extra short pen FORA TEST N' GO MONITOR (brand for verasens blood glucose meter) needles) - Tier 2; QL - Tier 2; PA; QL FORAXA - Tier 2; PA MINI WRIGHT PEAK FLOW METER (brand for pure comfort flow FORTISCARE CONTROL (brand for easy plus ii control) - Tier 2; PA meter adult) - Tier 2; QL FORTISCARE GLUCOSE SYSTEM (brand for meijer premium blood MISTASSIST (brand for co monitor) - Tier 2; QL glucose) - Tier 2; PA; QL natural fish oil (generic for SEA-OMEGA) - Tier 1 FORTISCARE T1 GLUCOSE SYSTEM (brand for verasens blood NEODOT THERMOMETER - Tier 2; QL glucose meter) - Tier 2; PA; QL FORTISCARE TEST (brand for element compact test) - Tier 2; PA; QL NEUTEK 2TEK CONTROL (brand for element compact control 3) - FREESTYLE PRECISION NEO SYSTEM (brand for meijer premium Tier 2; QL blood glucose) - Tier 2; PA; QL odorless coated fish oil - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 162 Preferred Agents Non-Preferred Agents omega-3 fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - FREESTYLE PRECISION NEO TEST (brand for element compact test) - Tier 1 Tier 2; PA; QL GELFILM EXTERNAL - Tier 2; PA omega-3 fish oil oral capsule 1200 mg (generic for THERAGRAN-M GELFOAM - Tier 2; PA FISH OIL CONC) - Tier 1 GELFOAM COMPRESSED SIZE 100 - Tier 2; PA omega-3 oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1 GELFOAM DENTAL PACK SIZE 4 - Tier 2; PA OMNIFLEX DIAPHRAGM - Tier 2; QL GELFOAM SPONGE SIZE 200 - Tier 2; PA ONETOUCH ULTRA (brand for element compact test) - Tier 2; QL GELFOAM SPONGE SIZE 50 - Tier 2; PA GELSYN-3 - Tier 2; PA ONETOUCH ULTRA 2 KIT W/DEVICE (brand for meijer premium GENADUR COMBINATION - Tier 2; PA blood glucose) - Tier 2; QL GENTLE-LET PLATFORMS (brand for lancet transporter case) - Tier 2; PA; QL ONETOUCH ULTRA CONTROL (brand for element compact control ginseng oral capsule 100 mg (generic for GIN-ZING) - Tier 1; PA 3) - Tier 2; QL gla-45 - Tier 1; PA ONETOUCH ULTRA MINI KIT W/DEVICE (brand for meijer premium GLUCOSE CONTROL SOLUTION IN VITRO LIQUID (brand for easy trak blood glucose) - Tier 2; QL control) - Tier 2; PA ONETOUCH VERIO KIT W/DEVICE (brand for meijer premium blood GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION HIGH , LOW glucose) - Tier 2; QL (brand for easy plus ii control) - Tier 2; PA ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for meijer GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION NORMAL premium blood glucose) - Tier 2; QL (brand for easy trak control) - Tier 2; PA GLUCOSE METER TEST STRIPS - Tier 2; PA; QL ONETOUCH VERIO IN VITRO SOLUTION (brand for element GLYTACTIN COMPLETE 10PE - Tier 2; PA compact control 3) - Tier 2; QL G-PREPROTEIN - Tier 2; PA h2q oral capsule (generic for H2Q) - Tier 1; PA ONETOUCH VERIO TEST STRIPS (brand for element compact test) - H2Q ORAL POWDER - Tier 2; PA Tier 2; QL HUMATROPEN FOR 12MG (brand for inject-ease) - Tier 2; PA HUMATROPEN FOR 24MG (brand for inject-ease) - Tier 2; PA ONETOUCH VERIO IQ SYSTEM (brand for meijer premium blood HUMATROPEN FOR 6MG (brand for inject-ease) - Tier 2; PA glucose) - Tier 2; QL hydro-tabs - Tier 1; PA HYMOVIS - Tier 2; PA ONETOUCH VERIO SYNC SYSTEM (brand for meijer premium blood INBRIJA - Tier 2; PA; SP glucose) - Tier 2; QL INOSITOL-5 - Tier 2; PA OPTICHAMBER ADVANTAGE-LG MASK (brand for procare INSULIN PEN NEEDLES 29G X 12.7MM (brand for sure comfort pen spacer/adult mask) - Tier 2; QL needles) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 163 Preferred Agents Non-Preferred Agents OPTICHAMBER ADVANTAGE-MED MASK (brand for procare INSULIN PEN NEEDLES 29G X 5MM , 29G X 8MM , 31G X 5 MM , 31G spacer/adult mask) - Tier 2; QL X 8 MM - Tier 2; PA; QL OPTICHAMBER ADVANTAGE-SM MASK (brand for procare INSULIN PEN NEEDLES 32G X 4 MM (brand for 1st tier unifine pentips spacer/adult mask) - Tier 2; QL plus) - Tier 2; PA; QL OPTICHAMBER FACE MASK-LARGE (brand for procare spacer/adult INSULIN PEN NEEDLES 32G X 5 MM (brand for pure comfort pen mask) - Tier 2; QL needle) - Tier 2; PA OPTICHAMBER FACE MASK-MEDIUM (brand for procare INSULIN PEN NEEDLES 32G X 6 MM (brand for pure comfort pen spacer/adult mask) - Tier 2; QL needle) - Tier 2; PA; QL OPTICHAMBER FACE MASK-SMALL (brand for procare spacer/adult INSULIN PEN NEEDLES 33G X 4 MM (brand for easy glide pen needles) mask) - Tier 2; QL - Tier 2; PA OPTIHALER DEVICE (brand for procare spacer/adult mask) - Tier 2; INSULIN SYRINGES 27G X 1/2" 0.5 ML (brand for insulin syringe) - Tier QL 2; PA; QL pa fish oil (generic for SEA-OMEGA) - Tier 1 PALFORZIA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL INSULIN SYRINGES 30G X 1/2" 0.3 ML (brand for global inject ease PALFORZIA (120 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL insulin syr) - Tier 2; PA; QL PALFORZIA (160 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL PALFORZIA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL INSULIN SYRINGES 30G X 1/2" 0.5 ML (brand for px insulin syringe) - PALFORZIA (200 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL Tier 2; PA; QL PALFORZIA (240 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL PALFORZIA (3 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL INSULIN SYRINGES 30G X 1/2" 1 ML (brand for sure comfort insulin PALFORZIA (300 MG MAINTENANCE) - Tier 2; PA; SP; QL; AL syringe) - Tier 2; PA; QL PALFORZIA (300 MG TITRATION) - Tier 2; PA; SP; QL; AL PALFORZIA (40 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL INSULIN SYRINGES 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML (brand PALFORZIA (6 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL for global easy glide insulin syr) - Tier 2; PA; QL PALFORZIA (80 MG DAILY DOSE) - Tier 2; PA; SP; QL; AL PALFORZIA INITIAL ESCALATION - Tier 2; PA; SP; QL; AL INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for ms insulin syringe) - PARI ALTERA NEBULIZER HANDSET (brand for co monitor Tier 2; PA; QL replacement pieces) - Tier 2; QL INSULIN SYRINGES 31G X 5/16" 0.5 ML - Tier 2; PA; QL PARI BABY CONVERSION KIT (brand for co monitor replacement INSULIN SYRINGES 31G X 5/16" 1 ML (brand for insulin syringe-needle pieces) - Tier 2; QL u-100) - Tier 2; PA; QL IODINE STRONG ORAL - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 164 Preferred Agents Non-Preferred Agents PARI ERAPID NEBULIZER HANDSET (brand for co monitor IOSAT - Tier 2; PA replacement pieces) - Tier 2; QL isoleucine - Tier 1; PA PARI TREK S COMBO PACK (brand for co monitor) - Tier 2; QL ISOLEUCINE 1000 - Tier 2; PA PARI VORTEX ADULT MASK (brand for co monitor replacement kaminos (generic for PRE PROTEIN) - Tier 1; PA pieces) - Tier 2; QL KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-0.9 MG/5ML-% - Tier 2; PA podactin external powder (generic for ODOR EATERS ANTIFUNGAL) KEY OMEGA - Tier 2; PA - Tier 1 korean ginseng oral capsule 250 mg, 350 mg - Tier 1; PA KROGER BLOOD GLUCOSE KIT - Tier 2; PA; QL PRECISION GLUCOSE CONTROL (brand for element compact KROGER TEST - Tier 2; PA; QL control 3) - Tier 2; QL LANCETS (brand for lancets ultra thin 30g) - Tier 2; PA; QL LANCETS KIT - Tier 2; PA PRECISION GLUCOSE CONTROL SOLN (brand for element compact LANCING DEVICE - Tier 2; PA control 3) - Tier 2; QL l-arginine oral capsule - Tier 1; PA l-arginine-500 - Tier 1; PA PRECISION GLUCOSE KETONE CONTR (brand for element l-carnitine oral capsule 250 mg - Tier 1; PA compact control 3) - Tier 2; QL L-CYSTINE - Tier 2; PA LEADER ADVANCED LANCING DEVICE - Tier 2; PA PRECISION GLUCOSE/KETONE CONTR (brand for element lecithin oral capsule - Tier 1; PA compact control 3) - Tier 2; QL lecithin-19 - Tier 1; PA PREMIUM CONDOMS LUBRICATED - Tier 2; QL leucine oral - Tier 1; PA prenatal dha - Tier 1 LIMBREL - Tier 2; PA PRONEB ULTRA FILTER SET (brand for co monitor replacement LIMBREL250 - Tier 2; PA pieces) - Tier 2; QL LIMBREL500 - Tier 2; PA QUINTET CONTROL HIGH/NORMAL (brand for element compact lipochol nr - Tier 1; PA control 3) - Tier 2; QL lipochol plus (generic for ACTIPOCHOL PLUS) - Tier 1; PA ra expecting dha - Tier 1 L-ISOLEUCINE - Tier 2; PA ra fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1 LIVE BETTER ADV LANCING DEVICE - Tier 2; PA ra fish oil oral capsule delayed release 1000 mg - Tier 1 liver - Tier 1; PA RELION KETONE (brand for ketone test) - Tier 2; QL l-lysine hcl oral tablet 500 mg - Tier 1; PA REPLACEMENT FILTERS - Tier 2; QL l-lysine oral tablet 1000 mg, 500 mg - Tier 1; PA sam-e.p.a. (generic for OVEGA-3) - Tier 1 l-methylfolate forte (generic for DEPLIN 7.5) - Tier 1; PA sea-omega (generic for SEA-OMEGA) - Tier 1 l-methylfolate-algae (generic for DEPLIN 15) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 165 Preferred Agents Non-Preferred Agents sm fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1 LOTRIMIN AF EXTERNAL POWDER (brand for gnp miconazorb af) - Tier sm omega-3 fish oil (generic for THERAGRAN-M FISH OIL CONC) - 2; PA; QL Tier 1 SOLARTEK GLUCOSE CONTROL (brand for element compact LTXF PRIM CNV PIN MICRODRIP (brand for iv extension set) - Tier 2; control 3) - Tier 2; QL PA SUPREME II HIGH/LOW CONTROL - Tier 2; QL LTXF PRIM IV SET/CNVT PIN (brand for iv extension set) - Tier 2; PA tolnaftate external powder (generic for ODOR EATERS ANTIFUNGAL) LTXF SECONDARY/CNV PIN/32INC (brand for iv extension set) - Tier 2; - Tier 1 PA l-tyrosine oral capsule - Tier 1; PA TRUECONTROL GLUCOSE CONT LEV 0 (brand for element lysine hcl oral tablet 1000 mg - Tier 1; PA compact control 3) - Tier 2; QL lysine oral capsule - Tier 1; PA MACRILEN - Tier 2; PA; SP; QL TRUECONTROL GLUCOSE CONT LEV 1 (brand for element MACUTEK - Tier 2; PA compact control 3) - Tier 2; QL ME-500 - Tier 2; PA LANCETS (brand for lancets ultra thin 30g) - Tier 2; QL MEDICATED DNA COLLECTION - Tier 2; PA TUBING/WING TIP - Tier 2; QL MEDICATED DNA COLLECTION 2 - Tier 2; PA VAPORIZER WARM STEAM - Tier 2; QL METABOLIC DISEASE APP - Tier 2; PA METHACHOLINE CHLORIDE INHALATION - Tier 2; PA VORTEX HOLDING CHAMBER/MASK (brand for co monitor) - Tier 2; methionine oral - Tier 1; PA QL METHOHEXITAL SODIUM - Tier 2; PA METOPIRONE - Tier 2; PA VORTEX VALVED HOLDING CHAMBER (brand for procare miconazorb af (generic for REMEDY ANTIFUNGAL) - Tier 1; PA; QL spacer/adult mask) - Tier 2; QL MICRODOT PEN NEEDLE 32G X 4 MM (brand for 1st tier unifine pentips WATCHHALER (brand for procare spacer/adult mask) - Tier 2; QL plus) - Tier 2; PA; QL WIDE-SEAL DIAPHRAGM 60 - Tier 2 MICRODOT PEN NEEDLE 33G X 4 MM (brand for easy glide pen WIDE-SEAL DIAPHRAGM 65 - Tier 2 needles) - Tier 2; PA WIDE-SEAL DIAPHRAGM 70 - Tier 2 MICRODOT TEST (brand for element compact test) - Tier 2; PA; QL WIDE-SEAL DIAPHRAGM 75 - Tier 2 MICROLET NEXT LANCING DEVICE (brand for live better adv lancing WIDE-SEAL DIAPHRAGM 80 - Tier 2 device) - Tier 2; PA WIDE-SEAL DIAPHRAGM 85 - Tier 2 MINI LANCING DEVICE - Tier 2; PA WIDE-SEAL DIAPHRAGM 90 - Tier 2 MINILINK REAL-TIME TRANSMITTER - Tier 2; PA WIDE-SEAL DIAPHRAGM 95 - Tier 2 MM EASY TOUCH GLUCOSE METER (brand for meijer premium blood XYZMUNE - Tier 2 glucose) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 166 Preferred Agents Non-Preferred Agents MM LANCING DEVICE (brand for live better adv lancing device) - Tier 2; PA NEUTEK 2TEK TEST (brand for element compact test) - Tier 2; PA; QL NICAPRIN (brand for xyzbac) - Tier 2; PA NICAZYME - Tier 2; PA NORDIPEN 5 INJECTION DEVICE (brand for inject-ease) - Tier 2; PA NORDIPEN DELIVERY SYSTEM (brand for inject-ease) - Tier 2; PA NOVOPEN ECHO (brand for autopen) - Tier 2; PA NOVOTWIST PEN NEEDLE (brand for pure comfort pen needle) - Tier 2; PA OASIS ULTRA MATRIX FENESTRATED - Tier 2; PA OASIS ULTRA TRI-LAYER MATRIX - Tier 2; PA OASIS WOUND MATRIX FENESTRATED - Tier 2; PA OCEAN BLUE MINICAPS OMEGA-3 - Tier 2; PA omega-3 fish oil oral capsule 300 mg (generic for FISH OIL PEARLS) - Tier 1; PA omega-3 oral capsule 1400 mg - Tier 1; PA OMNITROPE PEN 5 INJ DEVICE (brand for inject-ease) - Tier 2; PA OMNIVEX - Tier 2; PA ONETOUCH DELICA LANCING DEV (brand for live better adv lancing device) - Tier 2; PA ONETOUCH DELICA PLUS LANCING (brand for live better adv lancing device) - Tier 2; PA ONETOUCH SURESOFT LANCING DEVICE (brand for lancet transporter case) - Tier 2; PA; QL ONETOUCH ULTRALINK (brand for meijer premium blood glucose) - Tier 2; PA; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for meijer premium blood glucose) - Tier 2; PA; QL ONETOUCH VERIO IN VITRO SOLUTION HIGH (brand for easy plus ii control) - Tier 2; PA ONETOUCH VERIO REFLECT (brand for meijer premium blood glucose) - Tier 2; PA; QL OPTIUM BLOOD GLUCOSE MONITOR (brand for meijer premium blood glucose) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 167 Preferred Agents Non-Preferred Agents OPTIUM GLUCOSE MONITOR SYSTEM (brand for verasens blood glucose meter) - Tier 2; PA; QL OPTIUM TEST (brand for element compact test) - Tier 2; PA; QL OPTIUMEZ TEST (brand for element compact test) - Tier 2; PA; QL ornithine - Tier 1; PA PA CLA - Tier 2; PA PARADIGM REAL-TIME TRANSMITTER - Tier 2; PA PARAGARD INTRAUTERINE COPPER - Tier 2; PA; QL PENLET II BLOOD SAMPLER (brand for select-lite device/lancets) - Tier 2; PA PENLET II REPLACEMENT CAP (brand for lancet transporter case) - Tier 2; PA; QL phenylalanine - Tier 1; PA pre protein oral tablet (generic for PRE PROTEIN) - Tier 1; PA PRECISION LINK (brand for meijer premium blood glucose) - Tier 2; PA; QL PRECISION PCX (brand for element compact test) - Tier 2; PA; QL PRECISION PCX PLUS TEST (brand for element compact test) - Tier 2; PA; QL PRECISION POINT OF CARE TEST (brand for element compact test) - Tier 2; PA; QL PRECISION QID MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION QID TEST (brand for element compact test) - Tier 2; PA; QL PRECISION SOF-TACT MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION SOF-TACT TEST (brand for element compact test) - Tier 2; PA; QL PRECISION XTRA (brand for verasens blood glucose meter) - Tier 2; PA; QL PRECISION XTRA BLOOD GLUCOSE (brand for element compact test) - Tier 2; PA; QL PRECISION XTRA KETONE - Tier 2; PA PRECISION XTRA MONITOR (brand for verasens blood glucose meter) - Tier 2; PA; QL PREMIUM BLOOD GLUCOSE TEST - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 168 Preferred Agents Non-Preferred Agents PREPROTEIN - Tier 2; PA PREPROTEIN 20 - Tier 2; PA PRO DNA COLLECTION (brand for professional dna collection) - Tier 2; PA PRO NUTRIENTS OMEGA 3 - Tier 2; PA PRO-CRITIC - Tier 2; PA PROFESSIONAL DNA COLLECTION - Tier 2; PA PROLEVA - Tier 2; PA PROMACTIN AA PLUS 20PE - Tier 2; PA pronutrients coq10 (generic for H2Q) - Tier 1; PA PROTEINEX ORAL LIQUID - Tier 2; PA proteinex oral tablet (generic for PRE PROTEIN) - Tier 1; PA PROTEINEX P100 - Tier 2; PA PROTEINEX P18 - Tier 2; PA PROTEINEX-18 - Tier 2; PA PROTYL AG (brand for cvs silver) - Tier 2; PA PSS SELECT PLATFORMS (brand for lancet transporter case) - Tier 2; PA; QL pure l-arginine hcl - Tier 1; PA pure l-citrulline oral capsule - Tier 1; PA pure l-tyrosine - Tier 1; PA PX ADVANCED LANCING DEVICE - Tier 2; PA QC ADVANCED LANCING DEVICE - Tier 2; PA q-gel forte (generic for Q-GEL FORTE) - Tier 1; PA q-gel mega (generic for H2Q) - Tier 1; PA q-gel ultra (generic for Q-GEL ULTRA) - Tier 1; PA QUINTET AC BLOOD GLUCOSE (brand for verasens blood glucose meter) - Tier 2; PA; QL QUINTET AC BLOOD GLUCOSE TEST (brand for element compact test) - Tier 2; PA; QL QUINTET BLOOD GLUCOSE SYSTEM (brand for verasens blood glucose meter) - Tier 2; PA; QL QUINTET BLOOD GLUCOSE TEST (brand for element compact test) - Tier 2; PA; QL ra bee pollen - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 169 Preferred Agents Non-Preferred Agents RA BLOOD GLUCOSE MONITOR - Tier 2; PA; QL ra coenzyme q-10 (generic for H2Q) - Tier 1; PA RA FISH OIL EXTRA STRENGTH - Tier 2; PA ra fish oil oral capsule 900 mg - Tier 1; PA ra fish oil oral capsule delayed release 1400 mg (generic for OMEGAPURE 780 EC) - Tier 1; PA ra fish oil oral capsule delayed release 600 mg - Tier 1; PA RA LANCING DEVICE - Tier 2; PA ra l-carnitine - Tier 1; PA ra l-lysine - Tier 1; PA ra saccharin - Tier 1; PA RA TRUE2GO BLOOD GLUCOSE (brand for meijer premium blood glucose) - Tier 2; PA; QL RA TRUERESULT BLOOD GLUCOSE (brand for meijer premium blood glucose) - Tier 2; PA; QL RA TRUETEST TEST (brand for element compact test) - Tier 2; PA; QL RADIOGARDASE - Tier 2; PA RELION ULTIMA GLUCOSE SYSTEM (brand for meijer premium blood glucose) - Tier 2; PA; QL RELION ULTIMA TEST (brand for element compact test) - Tier 2; PA; QL remedy antifungal external powder (generic for REMEDY ANTIFUNGAL) - Tier 1; PA; QL remedy phytoplex antifungal external powder (generic for REMEDY ANTIFUNGAL) - Tier 1; PA; QL rutin-50 - Tier 1; PA RUZURGI - Tier 2; PA; SP; QL salmon oil-1000 (generic for SALMON) - Tier 1; PA sam-g.l.a. - Tier 1; PA SILTREX (brand for cellpad) - Tier 2; PA SILVERSEAL HYDROGEL DRESSING - Tier 2; PA SLEEP APPLICATION - Tier 2; PA sm coenzyme q-10 (generic for H2Q) - Tier 1; PA sm l-lysine - Tier 1; PA sm soya lecithin - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 170 Preferred Agents Non-Preferred Agents SOLOX (brand for cvs silver) - Tier 2; PA SOLUTION TRANSFER DEVICE - Tier 2; PA SOLVIL - Tier 2; PA sonafine (generic for AVO CREAM) - Tier 1; PA SSKI - Tier 2; PA; QL SUPREME TEST (brand for element compact test) - Tier 2; PA; QL SYRINGE AVITENE - Tier 2; PA taurine oral - Tier 1; PA TEGADERM AG MESH - Tier 2; PA TGT LANCING DEVICE - Tier 2; PA THE ELIMINATOR (brand for lecithin-kelp-b6-cider vinegar) - Tier 2; PA THERAMINE PLUS (brand for pro-critic) - Tier 2; PA THERATEARS NUTRITION - Tier 2; PA THROMBI-GEL 10 - Tier 2; PA THROMBI-GEL 100 - Tier 2; PA THROMBI-GEL 40 - Tier 2; PA THROMBI-PAD - Tier 2; PA TRUE FOCUS BLOOD GLUCOSE STRIP - Tier 2; PA; QL TRUE METRIX AIR GLUCOSE METER (brand for meijer premium blood glucose) - Tier 2; PA; QL TRUE METRIX GO GLUCOSE METER (brand for meijer premium blood glucose) - Tier 2; PA; QL TRUE METRIX METER KIT (brand for meijer premium blood glucose) - Tier 2; PA; QL TRUEDRAW LANCING DEVICE (brand for live better adv lancing device) - Tier 2; PA LANCETS (brand for lancets ultra thin 30g) - Tier 2; PA; QL TRUETRACK BLOOD GLUCOSE (brand for verasens blood glucose meter) - Tier 2; PA; QL TRUETRACK TEST (brand for element compact test) - Tier 2; PA; QL TYLACTIN COMPLETE 15 PE - Tier 2; PA tyrosine - Tier 1; PA ULTIMA - Tier 2; PA; QL ULTIMA TEST (brand for element compact test) - Tier 2; PA; QL ULTRAFOAM SPONGE 2X6.25X7CM - Tier 2; PA ULTRAFOAM SPONGE 8X12.5X1CM - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 171 Preferred Agents Non-Preferred Agents ULTRAFOAM SPONGE 8X12.5X3CM - Tier 2; PA ULTRAFOAM SPONGE 8X25X1CM - Tier 2; PA ULTRAFOAM SPONGE 8X6.25X1CM - Tier 2; PA UNISTRIP CONTROL (brand for easy plus ii control) - Tier 2; PA UNISTRIP1 GENERIC (brand for element compact test) - Tier 2; PA; QL VALINE 1000 - Tier 2; PA valine oral - Tier 1; PA VASCULERA (brand for xyzbac) - Tier 2; PA VASOFLEX D1 - Tier 2; PA venaliv - Tier 1; PA VISTOGARD - Tier 2; PA water tabs - Tier 1; PA WELLNESS APPLICATION - Tier 2; PA XYZBAC - Tier 2; PA ZEASORB-AF (brand for gnp miconazorb af) - Tier 2; PA; QL zincolate - Tier 1; PA ZYVEXOL - Tier 2; PA ZYVIT - Tier 2; PA Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1; QL akwa tears ophthalmic ointment 83-15 % (generic for ALTALUBE) - Tier altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 1; PA; QL altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL ALCAINE (brand for proparacaine hcl) - Tier 2; PA altafrin ophthalmic solution 2.5 % (generic for ALTAFRIN) - Tier 1 altafrin ophthalmic solution 10 % (generic for ALTAFRIN) - Tier 1; PA artificial tears ophthalmic solution 1.4 % - Tier 1 altalube (generic for ALTALUBE) - Tier 1; PA; QL artificial tears ophthalmic solution 1-0.3 % (generic for MOISTURE artificial tears ophthalmic solution 0.5-0.6 %, 5-6 mg/ml (generic for EYES) - Tier 1 CLEAR EYES ALL SEASONS) - Tier 1; PA atropine sulfate ophthalmic ointment - Tier 1 astringent eye drops (generic for VISINE-AC) - Tier 1; PA; QL atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % - Tier 2; PA; QL ATROPINE) - Tier 1; QL bio glo - Tier 1; PA bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1; QL CEQUA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 172 Preferred Agents Non-Preferred Agents bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (brand for 1 cyclopentolate hcl) - Tier 2; PA biolle tears (generic for BIOLLE TEARS) - Tier 1 bion tears pf (generic for BION TEARS PF) - Tier 1 CYCLOGYL OPHTHALMIC SOLUTION 1 % (brand for cyclopentolate BLEPHAMIDE (brand for sulfacetamide-prednisolone) - Tier 2; QL hcl) - Tier 2; PA; QL BLEPHAMIDEcyclopentolate hclS.O.P. ophthalmic - Tier 2 solution 1 % (generic for CYCLOGYL) - cyclopentolate hcl ophthalmic solution 0.5 % (generic for CYCLOGYL) - Tier 1; QL Tier 1; PA CYCLOSPORINE IN KLARITY - Tier 2; PA; QL cyclopentolate hcl ophthalmic solution 2 % (generic for CYCLOGYL) - CYSTADROPS - Tier 2; PA; SP; QL Tier 1 CYSTARAN - Tier 2; PA; SP; QL eq artificial tears (generic for MOISTURE EYES) - Tier 1 dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; PA; QL eq restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1 eq gentle lubricant - Tier 1; PA eq revive plus (generic for BIOLLE TEARS) - Tier 1 eq lubricant eye drops (generic for SYSTANE) - Tier 1; PA; QL eq lubricating eye drops (generic for REFRESH OPTIVE) - Tier 1; PA eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - eq restore pm (generic for ALTALUBE) - Tier 1; PA; QL Tier 1 eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - GENTEAL TEARS (brand for just tears eye drops) - Tier 2 Tier 1; PA; QL GENTEAL TEARS MODERATE PF (brand for ra lubricant eye) - Tier 2 eye drops allergy relief (generic for VISINE-AC) - Tier 1; PA; QL GENTEAL TEARS PF (brand for ra lubricant eye) - Tier 2 eye drops ar (generic for VISINE-AC) - Tier 1; PA; QL hm lubricating plus (generic for BIOLLE TEARS) - Tier 1 eye drops long lasting (generic for SYSTANE) - Tier 1; PA; QL homatropaire - Tier 1 eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL ADVANCED RELIEF) - Tier 1; PA; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; TEARS) - Tier 1 PA; QL eye lubricant (generic for ALTALUBE) - Tier 1; PA; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA flucaine (generic for FLUCAINE) - Tier 1; PA FRESH) - Tier 1 fluor-i-strips a.t. - Tier 1; PA lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 FLURA-SAFE - Tier 2; PA lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 for sty relief (generic for ALTALUBE) - Tier 1; PA; QL lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 FRESHKOTE - Tier 2; PA FUL-GLO OPHTHALMIC STRIP 0.6 MG - Tier 2; PA MURO 128 OPHTHALMIC OINTMENT (brand for sodium chloride ful-glo ophthalmic strip 1 mg - Tier 1; PA (hypertonic)) - Tier 2 GELFILM OPHTHALMIC - Tier 2; PA GENTEAL SEVERE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 173 Preferred Agents Non-Preferred Agents MURO 128 OPHTHALMIC SOLUTION 5 % (brand for sodium chloride GENTEAL TEARS NIGHT-TIME (brand for artificial tears) - Tier 2; PA; QL (hypertonic)) - Tier 2; QL glostrips ophthalmic strip 1 mg - Tier 1; PA natural tears pf (generic for BION TEARS PF) - Tier 1 GONAK - Tier 2; PA neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 goniotaire - Tier 1; PA neomycin-polymyxin-dexameth ophthalmic ointment (generic for goniovisc ophthalmic solution 2.5 % - Tier 1; PA MAXITROL) - Tier 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 green glo lissamine green (generic for GREEN GLO LISSAMINE GREEN) (generic for MAXITROL) - Tier 1 - Tier 1; PA neomycin-polymyxin-gramicidin - Tier 1 neo-polycin (generic for NEO-POLYCIN) - Tier 1 hm eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1 Tier 1; PA; QL OXERVATE - Tier 2; PA; QL hm lubricating tears (generic for SYSTANE) - Tier 1; PA; QL phenylephrine hcl ophthalmic solution 2.5 % (generic for ALTAFRIN) - HYPOCYN - Tier 2; PA Tier 1 HYPOTEARS (brand for artificial tears) - Tier 2; PA; QL polycin (generic for POLYCIN) - Tier 1; QL ISOPTO TEARS - Tier 2; PA polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1 LACRISERT - Tier 2; PA polyvinyl alcohol ophthalmic - Tier 1 LASTACAFT - Tier 2; PA proparacaine hcl ophthalmic (generic for ALCAINE) - Tier 1 ra artificial tears (generic for MOISTURE EYES) - Tier 1 lissamine green (generic for GREEN GLO LISSAMINE GREEN) - Tier 1; ra lubricant eye ophthalmic solution 0.1-0.3 % (generic for BION PA TEARS PF) - Tier 1 lubricant drops fast act (generic for SYSTANE) - Tier 1; PA; QL ra lubricant eye ophthalmic solution 1-0.3 % (generic for MOISTURE lubricant drops long last (generic for SYSTANE) - Tier 1; PA; QL EYES) - Tier 1 lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; PA; QL ra ophthalmic (generic for ALTACHLORE) - Tier 1; QL REFRESH PLUS (brand for gnp lubricating plus eye drops) - Tier 2 lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - REFRESH TEARS (brand for ra lubricant eye drops) - Tier 2 Tier 1; PA; QL RESTASIS - Tier 2; PA; QL RESTASIS MULTIDOSE - Tier 2; PA; QL; AL lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for RHOPRESSA - Tier 2 SYSTANE HYDRATION PF) - Tier 1; PA; QL ROCKLATAN - Tier 2 sm artificial tears (generic for GENTEAL TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) sm lubricating plus (generic for BIOLLE TEARS) - Tier 1 - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 174 Preferred Agents Non-Preferred Agents sodium chloride (hypertonic) ophthalmic ointment (generic for lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE ALTACHLORE) - Tier 1 COMPLETE) - Tier 1; PA; QL lubricant eye nighttime (generic for ALTALUBE) - Tier 1; PA; QL sodium chloride (hypertonic) ophthalmic solution (generic for lubricant eye pm (generic for ALTALUBE) - Tier 1; PA; QL ALTACHLORE) - Tier 1; QL lubricant pm (generic for ALTALUBE) - Tier 1; PA; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for - Tier 1 SYSTANE) - Tier 1; PA; QL sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - lubricating eye drops ophthalmic solution 0.5-0.9 % (generic for Tier 1; QL REFRESH OPTIVE) - Tier 1; PA sulfacetamide-prednisolone ophthalmic solution - Tier 1 lubricating eye/overnight (generic for ALTALUBE) - Tier 1; PA; QL SYSTANE CONTACTS (brand for just tears eye drops) - Tier 2 lubricating/dry eye (generic for REFRESH OPTIVE) - Tier 1; PA SYSTANE OPHTHALMIC GEL - Tier 2; QL lubrifresh p.m. (generic for ALTALUBE) - Tier 1; PA; QL MAXITROL (brand for neomycin-polymyxin-dexameth) - Tier 2; PA TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for just MEMBRANEBLUE - Tier 2; PA tears eye drops) - Tier 2 MYDRIACYL (brand for tropicamide) - Tier 2; PA tears pure (generic for GENTEAL TEARS) - Tier 1 neomycin-polymyxin-hc ophthalmic - Tier 1; PA TOBRADEX OPHTHALMIC OINTMENT - Tier 2 nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; PA; QL tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; QL PAREMYD - Tier 2; PA tropicamide ophthalmic - Tier 1 ultra fresh (generic for ULTRA FRESH) - Tier 1 phenylephrine hcl ophthalmic solution 10 % (generic for ALTAFRIN) - Tier 1; PA POLYTRIM (brand for polymyxin b-trimethoprim) - Tier 2; PA PRED-G - Tier 2; PA PRED-G S.O.P. - Tier 2; PA PREDNISOLONE-BROMFENAC - Tier 2; PA; QL proparacaine-fluorescein (generic for FLUCAINE) - Tier 1; PA puralube (generic for ALTALUBE) - Tier 1; PA; QL pure & gentle lubricant - Tier 1; PA qc artificial tears (generic for CLEAR EYES ALL SEASONS) - Tier 1; PA qc eye drops (generic for VISINE ADVANCED RELIEF) - Tier 1; PA; QL ra lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; PA; QL REFRESH LACRI-LUBE (brand for artificial tears) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 175 Preferred Agents Non-Preferred Agents REFRESH OPTIVE OPHTHALMIC SOLUTION (brand for cvs lubricating/dry eye) - Tier 2; PA REFRESH OPTIVE PF - Tier 2; PA REFRESH P.M. (brand for artificial tears) - Tier 2; PA; QL REFRESH RELIEVA (brand for cvs lubricating/dry eye) - Tier 2; PA REFRESH RELIEVA PF OPHTHALMIC SOLUTION 0.5-0.9 % - Tier 2; PA relief eye drops (generic for VISINE-AC) - Tier 1; PA; QL ROSE GLO - Tier 2; PA sm eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; PA; QL sm lubricant eye drops (generic for SYSTANE) - Tier 1; PA; QL sm lubricating tears (generic for SYSTANE) - Tier 1; PA; QL SYSTANE COMPLETE (brand for lubricant eye drops) - Tier 2; PA; QL SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) - Tier 2; PA; QL SYSTANE NIGHTTIME (brand for artificial tears) - Tier 2; PA; QL SYSTANE OPHTHALMIC SOLUTION (brand for ultra lubricating eye drops) - Tier 2; PA; QL SYSTANE OVERNIGHT THERAPY - Tier 2; PA; QL SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops (pf)) - Tier 2; PA; QL SYSTANE ULTRA (brand for ultra lubricating eye drops) - Tier 2; PA; QL SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2; PA; QL tears again (generic for ALTALUBE) - Tier 1; PA; QL TOBRADEX OPHTHALMIC SUSPENSION (brand for tobramycin- dexamethasone) - Tier 2; PA; QL TOBRADEX ST - Tier 2; PA; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; PA; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; PA; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; PA; QL VISINE ADVANCED RELIEF (brand for sm eye drops) - Tier 2; PA; QL VISIONBLUE - Tier 2; PA XIIDRA - Tier 2; PA ZYLET - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 176 Preferred Agents Non-Preferred Agents Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs cromolyn sodium ophthalmic - Tier 1 ALOCRIL - Tier 2; PA eq eye allergy relief (generic for OPCON-A) - Tier 1 ALOMIDE - Tier 2; PA eye allergy relief (generic for OPCON-A) - Tier 1 azelastine hcl ophthalmic - Tier 1; PA NAPHCON-A (brand for allergy eye) - Tier 2 BEPREVE - Tier 2; PA olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1 CLEAR EYES REDNESS RELIEF (brand for eql redness relief) - Tier 2; ra eye allergy relief (generic for OPCON-A) - Tier 1 PA; QL VISINE (brand for allergy eye) - Tier 2 CYCLOMYDRIL - Tier 2; PA epinastine hcl - Tier 1; PA eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1; PA hm eye drops (generic for VISINE RED EYE COMFORT) - Tier 1; PA PATADAY (brand for olopatadine hcl) - Tier 2; PA PAZEO OPHTHALMIC SOLUTION 0.7 % - Tier 2; PA sm eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1; PA sm redness relief (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; PA; QL TROPICAMIDE-CYCLOPENTOLATE-PE - Tier 2; PA; QL VASOCLEAR-A - Tier 2; PA; QL ZERVIATE - Tier 2; PA Ophthalmic Antibiotics - Drugs to treat Eye Infections bacitracin ophthalmic - Tier 1 AZASITE - Tier 2; PA ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1 BESIVANCE - Tier 2; PA erythromycin ophthalmic - Tier 1 CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA gentak - Tier 1 gatifloxacin ophthalmic (generic for ZYMAXID) - Tier 1; PA gentamicin sulfate ophthalmic - Tier 1; QL KLARITY-A - Tier 2; PA ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1 levofloxacin ophthalmic - Tier 1; PA tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL OCUFLOX (brand for ofloxacin) - Tier 2; PA TOBREX - Tier 2; PA; QL ZYMAXID (brand for gatifloxacin) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 177 Preferred Agents Non-Preferred Agents Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA acetazolamide oral - Tier 1; QL betaxolol hcl ophthalmic - Tier 1; PA apraclonidine hcl - Tier 1 BETIMOL - Tier 2; PA; QL AZOPT - Tier 2 brimonidine tartrate ophthalmic solution 0.15 % (generic for ALPHAGAN BETOPTIC-S - Tier 2 P) - Tier 1; PA brimonidine tartrate ophthalmic solution 0.2 % - Tier 1 BRIMONIDINE-DORZOLAMIDE - Tier 2; PA; QL carteolol hcl - Tier 1 COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA COMBIGAN - Tier 2 COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2 IOPIDINE - Tier 2; PA dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISOPTO CARPINE (brand for pilocarpine hcl) - Tier 2; PA 1 ISTALOL (brand for timolol maleate) - Tier 2; PA dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1 LATANOPROST-TIMOLOL MALEATE - Tier 2; PA; QL dorzolamide hcl-timolol mal pf (generic for COSOPT PF) - Tier 1 levobunolol hcl - Tier 1; PA PHOSPHOLINE IODIDE - Tier 2 timolol maleate ophthalmic solution 0.5 % (daily) (generic for ISTALOL) - pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1 Tier 1; PA SIMBRINZA - Tier 2 timolol maleate pf (generic for TIMOPTIC OCUDOSE) - Tier 1; PA timolol maleate ophthalmic gel forming solution (generic for TIMOLOL-BRIMON-DORZOL-LATANOPR - Tier 2; PA; QL TIMOPTIC-XE) - Tier 1 TIMOLOL-BRIMONIDINE-DORZOLAMID - Tier 2; PA; QL timolol maleate ophthalmic solution 0.25 %, 0.5 % (generic for TIMOLOL-DORZOLAMID-LATANOPROST - Tier 2; PA; QL TIMOPTIC) - Tier 1 TIMOPTIC (brand for timolol maleate) - Tier 2; PA TIMOPTIC OCUDOSE - Tier 2; PA TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ACULAR (brand for ketorolac tromethamine) - Tier 2 ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA ALAWAY (brand for cvs allergy eye drops) - Tier 2 ALREX - Tier 2; PA bromfenac sodium (once-daily) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 178 Preferred Agents Non-Preferred Agents ALAWAY CHILDRENS ALLERGY (brand for cvs allergy eye drops) - BROMSITE - Tier 2; PA Tier 2 DOUBLE PM - Tier 2; PA allergy eye drops (generic for ALAWAY) - Tier 1 DUREZOL - Tier 2; PA; QL CLARITIN EYE (brand for cvs allergy eye drops) - Tier 2 EYSUVIS - Tier 2; PA dexamethasone sodium phosphate ophthalmic - Tier 1 FML LIQUIFILM (brand for fluorometholone) - Tier 2; PA; QL diclofenac sodium ophthalmic - Tier 1 ILEVRO - Tier 2; PA eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - ILUVIEN - Tier 2; PA Tier 1 INVELTYS - Tier 2; PA; QL FLAREX - Tier 2 KLARITY-L - Tier 2; PA; QL fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL LOTEMAX OPHTHALMIC GEL - Tier 2; PA; QL flurbiprofen sodium - Tier 1 LOTEMAX OPHTHALMIC OINTMENT - Tier 2; PA FML - Tier 2 FML FORTE - Tier 2; QL LOTEMAX OPHTHALMIC SUSPENSION (brand for loteprednol hm eye itch relief (generic for ALAWAY) - Tier 1 etabonate) - Tier 2; PA ketorolac tromethamine ophthalmic (generic for ACULAR) - Tier 1 LOTEMAX SM - Tier 2; PA; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1 loteprednol etabonate (generic for LOTEMAX) - Tier 1; PA kp ketotifen fumarate (generic for ALAWAY) - Tier 1 MAXIDEX - Tier 2; PA PRED MILD - Tier 2; QL MITOSOL - Tier 2; PA prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; NEVANAC - Tier 2; PA QL PRED FORTE (brand for prednisolone acetate) - Tier 2; PA; QL prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL PREDNISOL ACE-MOXIFLOX-BROMFEN - Tier 2; PA; QL prednisolone sodium phosphate ophthalmic - Tier 1 PREDNISOLONE ACETATE-NEPAFENAC - Tier 2; PA; QL ra antihistamine eye drops (generic for ALAWAY) - Tier 1 PREDNISOLONE ACET-MOXIFLOXACIN - Tier 2; PA; QL ra eye itch relief (generic for ALAWAY) - Tier 1 PREDNISOLONE-GATIFLOXACIN - Tier 2; PA; QL sm eye itch relief (generic for ALAWAY) - Tier 1 PREDNISOLONE-MOXIFLOXACIN - Tier 2; PA ZADITOR (brand for cvs allergy eye drops) - Tier 2 PREDNISOLON-GATIFLOX-BROMFENAC - Tier 2; PA; QL PREDNISOLON-MOXIFLOX-BROMFENAC - Tier 2; PA; QL PREDNISOLON-MOXIFLOX-NEPAFENAC - Tier 2; PA; QL PROLENSA - Tier 2; PA TRIPLE PMB - Tier 2; PA TRIPLE PMK - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 179 Preferred Agents Non-Preferred Agents Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1 bimatoprost ophthalmic - Tier 1; PA TRAVATAN Z (brand for travoprost (bak free)) - Tier 2 LUMIGAN - Tier 2; PA travoprost (bak free) (generic for TRAVATAN Z) - Tier 1; PA VYZULTA - Tier 2; PA XALATAN (brand for latanoprost) - Tier 2; PA XELPROS - Tier 2; PA ZIOPTAN - Tier 2; PA

Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1 CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA ciprofloxacin hcl otic (generic for CETRAXAL) - Tier 1; PA CIPROFLOXACIN-FLUOCINOLONE PF - Tier 2; PA OTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA Otic Agents - Drugs for the Ear acetic acid otic - Tier 1; QL auraphene-b (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; CIPRODEX (brand for ciprofloxacin-dexamethasone) - Tier 2 PA hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1; QL CIPRO HC - Tier 2; PA neomycin-polymyxin-hc otic solution - Tier 1 ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; PA neomycin-polymyxin-hc otic suspension - Tier 1; QL clearcanal earwax softener (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA cortic-nd (generic for CORTIC-ND) - Tier 1; PA DERMOTIC (brand for fluocinolone acetonide) - Tier 2; PA ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear drops earwax aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear systems (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 180 Preferred Agents Non-Preferred Agents ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA earwax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA eq ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA exotic-hc (generic for CORTIC-ND) - Tier 1; PA flac (generic for FLAC) - Tier 1; PA fluocinolone acetonide otic (generic for FLAC) - Tier 1; PA hm earwax removal aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA hm earwax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA OTICIN HC NR (brand for exotic-hc) - Tier 2; PA PRAMOTIC - Tier 2; PA qc ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA qc earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA qc earwax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ra ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA ra earwax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA sm ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 181 Preferred Agents Non-Preferred Agents Regulators - Drugs to Regulate Blood Sugar Insulins - Diabetic Drugs LYUMJEV - Tier 2; PA; QL LYUMJEV KWIKPEN - Tier 2; PA; QL Respiratory Tract Agents Respiratory Tract Agents, Other DUAKLIR PRESSAIR - Tier 2; PA Respiratory Tract/Pulmonary Agents BREZTRI AEROSPHERE - Tier 2; PA; QL Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release (generic for CHLOR-TRIMETON CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2; PA; ALLERGY) - Tier 1 QL ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; PA; QL allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1 chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1 CHLOR-TRIMETON ALLERGY (brand for cvs allergy relief) - Tier 2 Antihistamines - Drugs to Treat Allergies ALAVERT (brand for ra loratadine) - Tier 2 24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; PA all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1 aler-dryl - Tier 1; PA; QL aller-chlor (generic for WAL-FINATE) - Tier 1 ALLEGRA ALLERGY (brand for ra allergy relief) - Tier 2; PA allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1 ALLEGRA ALLERGY CHILDRENS - Tier 2; PA allergy antihistamine (generic for NARAMIN) - Tier 1 aller-ease (generic for ALLEGRA ALLERGY) - Tier 1; PA allergy childrens (generic for NARAMIN) - Tier 1 allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 182 Preferred Agents Non-Preferred Agents allergy oral capsule (generic for BANOPHEN) - Tier 1 allergy relief childrens oral suspension 30 mg/5ml (generic for ALLEGRA allergy oral tablet (generic for WAL-FINATE) - Tier 1 ALLERGY CHILDRENS) - Tier 1; PA allergy rel child (loratadine) (generic for WAL-ITIN) - Tier 1 allergy relief adult (generic for NARAMIN) - Tier 1 allergy relief childrens oral tablet chewable 10 mg (generic for WAL-ZYR allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1 CHILDRENS) - Tier 1; PA allergy relief child (generic for WAL-ITIN) - Tier 1 allergy relief childrens oral liquid 12.5 mg/5ml (generic for NARAMIN) - allergy relief oral capsule 10 mg (generic for ZYRTEC ALLERGY) - Tier 1; Tier 1 PA allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; PA allergy relief childrens oral syrup 5 mg/5ml (generic for WAL-ITIN) - allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier 1; Tier 1 PA allergy relief childrens oral tablet chewable 5 mg (generic for allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL CLARITIN) - Tier 1 ALLERGY CHILDRENS) - Tier 1; PA; QL allergy relief loratadine (generic for KLS ALLERCLEAR) - Tier 1 allergy relief oral capsule 10 mg (generic for CLARITIN) - Tier 1 allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS ALLER- allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1 FEX) - Tier 1; PA allergy relief oral liquid 25 mg/10ml (generic for NARAMIN) - Tier 1 allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE (brand allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1 for gnp allergy relief) - Tier 2; PA; QL allergy relief oral tablet 4 mg (generic for WAL-FINATE) - Tier 1 allergy relief oral tablet dispersible 10 mg (generic for WAL-ITIN carbinoxamine maleate oral tablet 6 mg (generic for RYVENT) - Tier 1; ALLER-MELTS) - Tier 1 PA allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- cetirizine hcl childrens oral tablet chewable (generic for WAL-ZYR TEC) - Tier 1 CHILDRENS) - Tier 1; PA allergy-time (generic for WAL-FINATE) - Tier 1 anti-hist allergy (generic for BANOPHEN) - Tier 1 cetirizine hcl oral tablet chewable (generic for WAL-ZYR CHILDRENS) - aurodryl allergy childrens (generic for NARAMIN) - Tier 1 Tier 1; PA azelastine hcl nasal - Tier 1 CLARINEX (brand for desloratadine) - Tier 2; PA banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1 CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG - Tier 2; PA banophen oral tablet (generic for BANOPHEN) - Tier 1 desloratadine oral tablet (generic for CLARINEX) - Tier 1; PA desloratadine oral tablet dispersible 5 mg - Tier 1; PA BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for eq dexchlorpheniramine maleate oral (generic for RYCLORA) - Tier 1; PA; allergy relief childrens) - Tier 2 QL DICOPANOL FUSEPAQ - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 183 Preferred Agents Non-Preferred Agents BENADRYL ALLERGY ORAL TABLET (brand for sm allergy relief) - DICOPANOL RAPIDPAQ - Tier 2; PA Tier 2 eq allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; carbinoxamine maleate oral solution - Tier 1 PA carbinoxamine maleate oral tablet 4 mg - Tier 1 eq cetirizine hcl (generic for WAL-ZYR CHILDRENS) - Tier 1; PA cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) eql aller-ease (generic for KLS ALLER-FEX) - Tier 1; PA - Tier 1 fexofenadine hcl oral (generic for KLS ALLER-FEX) - Tier 1; PA cetirizine hcl oral tablet - Tier 1 HISTEX PD (brand for triprolidine hcl) - Tier 2; PA childrens allergy (generic for NARAMIN) - Tier 1 hm fexofenadine hcl (generic for KLS ALLER-FEX) - Tier 1; PA childrens loratadine (generic for WAL-ITIN) - Tier 1 KARBINAL ER - Tier 2; PA chlorpheniramine maleate oral (generic for WAL-FINATE) - Tier 1 kls aller-fex (generic for KLS ALLER-FEX) - Tier 1; PA CHLOR-TRIMETON ORAL TABLET (brand for qc allergy relief 4-hour) kp fexofenadine hcl (generic for ALLEGRA ALLERGY) - Tier 1; PA - Tier 2 CLARITIN ALLERGY CHILDRENS (brand for allergy relief childrens) - levocetirizine dihydrochloride oral solution (generic for XYZAL ALLERGY Tier 2 24HR CHILDRENS) - Tier 1; PA CLARITIN CHILDRENS (brand for ra allergy relief childrens) - Tier 2 m-hist pd (generic for PEDIACLEAR PD CHILDRENS) - Tier 1; PA CLARITIN ORAL CAPSULE (brand for goodsense allergy relief) - Tier MICLARA LQ - Tier 2; PA; QL 2 olopatadine hcl nasal (generic for PATANASE) - Tier 1; PA PATANASE (brand for olopatadine hcl) - Tier 2; PA CLARITIN ORAL TABLET (brand for qc loratadine allergy relief) - Tier pediaclear pd childrens (generic for PEDIACLEAR PD CHILDRENS) - 2 Tier 1; PA CLARITIN ORAL TABLET CHEWABLE (brand for ra allergy relief qc allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; childrens) - Tier 2 PA qc fexofenadine hydrochloride (generic for KLS ALLER-FEX) - Tier 1; PA CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand ra allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; for ra loratadine) - Tier 2 PA clemastine fumarate oral tablet 2.68 mg - Tier 1 ra cetirizine childrens (generic for WAL-ZYR CHILDRENS) - Tier 1; PA cold multi-symptom severe day oral tablet 5-10-200-325 mg (generic RYCLORA (brand for dexchlorpheniramine maleate) - Tier 2; PA; QL for MUCINEX FAST-MAX CLD FLU THRT) - Tier 1 ryvent (generic for RYVENT) - Tier 1; PA sm fexofenadine hcl (generic for KLS ALLER-FEX) - Tier 1; PA complete allergy medicine oral capsule (generic for BANOPHEN) - triprolidine hcl oral liquid 0.313 mg/ml (generic for VANACLEAR PD) - Tier Tier 1 1; PA; QL complete allergy relief (generic for BANOPHEN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 184 Preferred Agents Non-Preferred Agents cyproheptadine hcl oral - Tier 1 triprolidine hcl oral liquid 0.625 mg/ml (generic for PEDIACLEAR PD dayhist allergy 12 hour relief (generic for DAYHIST ALLERGY 12 CHILDRENS) - Tier 1; PA HOUR RELIEF) - Tier 1 diphen - Tier 1 triprolidine hcl oral liquid 0.938 mg/ml (generic for HISTEX PD) - Tier 1; DI-PHEN - Tier 2 PA diphenhist (generic for BANOPHEN) - Tier 1 triprolidine hcl oral liquid 2.5 mg/5ml - Tier 1; PA; QL diphenhydramine hcl injection - Tier 1; QL VANACLEAR PD (brand for triprolidine hcl) - Tier 2; PA; QL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1 VISTARIL (brand for hydroxyzine pamoate) - Tier 2; PA diphenhydramine hcl oral elixir - Tier 1 diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for NARAMIN) - wal-fex allergy oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1; Tier 1 PA diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1 dye-free allergy relief (generic for NARAMIN) - Tier 1 wal-zyr childrens oral tablet chewable 5 mg (generic for WAL-ZYR eq allergy (generic for BANOPHEN) - Tier 1 CHILDRENS) - Tier 1; PA eq allergy childrens (generic for WAL-ITIN) - Tier 1 ZYRTEC ALLERGY CHILDRENS - Tier 2; PA eq allergy relief (cetirizine) oral tablet (generic for KLS ALLER-TEC) - ZYRTEC ALLERGY ORAL CAPSULE (brand for cvs allergy relief) - Tier Tier 1 2; PA eq allergy relief childrens oral liquid (generic for NARAMIN) - Tier 1 ZYRTEC ALLERGY ORAL TABLET DISPERSIBLE - Tier 2; PA eq allergy relief childrens oral syrup (generic for WAL-ITIN) - Tier 1 eq allergy relief oral capsule (generic for BANOPHEN) - Tier 1 eq allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1 eq allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1 eq chlortabs (generic for WAL-FINATE) - Tier 1 eq dayhist allergy (generic for DAYHIST ALLERGY 12 HOUR RELIEF) - Tier 1 eq loratadine (generic for KLS ALLERCLEAR) - Tier 1 eq loratadine childrens (generic for CLARITIN) - Tier 1 eql all day allergy (generic for KLS ALLER-TEC) - Tier 1 eql allergy relief (generic for KLS ALLERCLEAR) - Tier 1 eql childrens allergy (generic for NARAMIN) - Tier 1 geri-dryl oral capsule 25 mg (generic for BANOPHEN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 185 Preferred Agents Non-Preferred Agents h-e-b childrens allergy (generic for NARAMIN) - Tier 1 hm all day allergy oral tablet (generic for KLS ALLER-TEC) - Tier 1 hm allergy relief childrens (generic for NARAMIN) - Tier 1 hm allergy relief oral (generic for WAL-ITIN ALLER-MELTS) - Tier 1 hm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1 hm loratadine (generic for KLS ALLERCLEAR) - Tier 1 hm loratadine childrens (generic for WAL-ITIN) - Tier 1 hydroxyzine pamoate oral - Tier 1 indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1 kls allerclear (generic for KLS ALLERCLEAR) - Tier 1 kls allergy medicine (generic for BANOPHEN) - Tier 1 kls aller-tec (generic for KLS ALLER-TEC) - Tier 1 levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1 loradamed (generic for KLS ALLERCLEAR) - Tier 1 loratadine childrens (generic for WAL-ITIN) - Tier 1 loratadine oral (generic for KLS ALLERCLEAR) - Tier 1 loratadine oral tablet dispersible 10 mg (generic for WAL-ITIN ALLER- MELTS) - Tier 1 m-dryl (generic for NARAMIN) - Tier 1 medi-phedryl (generic for BANOPHEN) - Tier 1 mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1 naramin (generic for NARAMIN) - Tier 1 pharbechlor (generic for WAL-FINATE) - Tier 1 pharbedryl (generic for BANOPHEN) - Tier 1 promethazine hcl oral - Tier 1 promethazine hcl rectal suppository 12.5 mg (generic for PROMETHEGAN) - Tier 1 promethazine hcl rectal suppository 25 mg (generic for PROMETHEGAN) - Tier 1; QL promethegan rectal suppository 12.5 mg (generic for PROMETHEGAN) - Tier 1 promethegan rectal suppository 25 mg (generic for PROMETHEGAN) - Tier 1; QL promethegan rectal suppository 50 mg - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 186 Preferred Agents Non-Preferred Agents qc all day allergy (generic for KLS ALLER-TEC) - Tier 1 qc allergy childrens (generic for NARAMIN) - Tier 1 qc allergy relief 4-hour (generic for WAL-FINATE) - Tier 1 qc allergy relief childrens oral syrup 5 mg/5ml (generic for WAL-ITIN) - Tier 1 qc allergy relief oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1 qc allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1 qc allergy relief oral tablet dispersible (generic for WAL-ITIN ALLER- MELTS) - Tier 1 qc chlor-pheniramine (generic for WAL-FINATE) - Tier 1 qc complete allergy medicine (generic for BANOPHEN) - Tier 1 qc loratadine allergy relief (generic for KLS ALLERCLEAR) - Tier 1 ra allergy medication (generic for BANOPHEN) - Tier 1 ra allergy oral (generic for BANOPHEN) - Tier 1 ra allergy relief (cetirizine) (generic for KLS ALLER-TEC) - Tier 1 ra allergy relief childrens oral liquid (generic for NARAMIN) - Tier 1 ra allergy relief oral capsule (generic for BANOPHEN) - Tier 1 ra allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1 ra allergy relief oral tablet dispersible (generic for WAL-ITIN ALLER- MELTS) - Tier 1 ra cetirizine (generic for KLS ALLER-TEC) - Tier 1 ra chlorpheniramine maleate (generic for WAL-FINATE) - Tier 1 ra complete allergy (generic for BANOPHEN) - Tier 1 ra diphedryl allergy (generic for NARAMIN) - Tier 1 ra loratadine (generic for KLS ALLERCLEAR) - Tier 1 ra loratadine childrens (generic for WAL-ITIN) - Tier 1 sb allergy medicine oral tablet (generic for BANOPHEN) - Tier 1 siladryl allergy (generic for NARAMIN) - Tier 1 sm all day allergy (generic for KLS ALLER-TEC) - Tier 1 sm allergy 4 hour (generic for WAL-FINATE) - Tier 1 sm allergy childrens (generic for WAL-ITIN) - Tier 1 sm allergy relief childrens (generic for NARAMIN) - Tier 1 sm allergy relief oral (generic for BANOPHEN) - Tier 1 sm childrens loratadine (generic for WAL-ITIN) - Tier 1 sm loratadine (generic for WAL-ITIN) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 187 Preferred Agents Non-Preferred Agents sm loratadine allergy relief (generic for WAL-ITIN ALLER-MELTS) - Tier 1 total allergy (generic for BANOPHEN) - Tier 1 total allergy medicine (generic for NARAMIN) - Tier 1 TRIAMINIC ALLERCHEWS (brand for ra loratadine) - Tier 2 wal-dryl allergy (generic for BANOPHEN) - Tier 1 wal-dryl allergy childrens (generic for NARAMIN) - Tier 1 wal-finate (generic for WAL-FINATE) - Tier 1 wal-itin aller-melts (generic for WAL-ITIN ALLER-MELTS) - Tier 1 wal-itin childrens (generic for WAL-ITIN) - Tier 1 wal-itin oral syrup (generic for WAL-ITIN) - Tier 1 wal-itin oral tablet (generic for KLS ALLERCLEAR) - Tier 1 wal-vert (generic for WAL-ITIN ALLER-MELTS) - Tier 1 wal-zyr oral tablet (generic for KLS ALLER-TEC) - Tier 1 ZYRTEC ALLERGY ORAL TABLET (brand for eql all day allergy) - Tier 2 Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX (120 METERED DOSES) - Tier 2; QL 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; PA ASMANEX (14 METERED DOSES) - Tier 2; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - Tier 1; PA ASMANEX (30 METERED DOSES) INHALATION AEROSOL ALVESCO - Tier 2; PA POWDER BREATH ACTIVATED 110 MCG/INH - Tier 2 ARMONAIR DIGIHALER - Tier 2; PA; QL ASMANEX (30 METERED DOSES) INHALATION AEROSOL ARNUITYASMANEX ELLIPTA (7 METERED - Tier DOSES)2; PA - Tier 2; PA POWDER BREATH ACTIVATED 220 MCG/INH - Tier 2; QL ASMANEX HFA - Tier 2; PA; QL ASMANEX (60 METERED DOSES) - Tier 2; QL BECONASE AQ - Tier 2; PA budesonide inhalation (generic for PULMICORT) - Tier 1 DERMACINRX TICANASE PAK - Tier 2; PA FLOVENT HFA - Tier 2; QL eq nasal allergy (generic for KLS ALLER-CORT) - Tier 1; PA FLOVENT DISKUS - Tier 2; PA flunisolide nasal - Tier 1; PA fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; PA kls aller-cort (generic for KLS ALLER-CORT) - Tier 1; PA mometasone furoate nasal (generic for NASONEX) - Tier 1; PA NASACORT ALLERGY 24HR (brand for allergy spray 24 hour) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 188 Preferred Agents Non-Preferred Agents NASACORT ALLERGY 24HR CHILDREN (brand for allergy spray 24 hour) - Tier 2; PA nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; PA nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; PA NASONEX (brand for mometasone furoate) - Tier 2; PA OMNARIS - Tier 2; PA PULMICORT FLEXHALER - Tier 2; PA; QL PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA QNASL - Tier 2; PA QNASL CHILDRENS - Tier 2; PA QVAR REDIHALER - Tier 2; PA XHANCE - Tier 2; PA ZETONNA - Tier 2; PA

Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral tablet (generic for SINGULAIR) - Tier 1 ACCOLATE (brand for zafirlukast) - Tier 2; PA montelukast sodium oral tablet chewable (generic for SINGULAIR) - montelukast sodium oral packet (generic for SINGULAIR) - Tier 1; PA Tier 1 SINGULAIR (brand for montelukast sodium) - Tier 2; PA zafirlukast (generic for ACCOLATE) - Tier 1; PA zileuton er - Tier 1; PA ZYFLO - Tier 2; PA Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL INCRUSE ELLIPTA - Tier 2; PA ipratropium bromide inhalation - Tier 1 LONHALA MAGNAIR REFILL KIT - Tier 2; PA ipratropium bromide nasal - Tier 1 LONHALA MAGNAIR STARTER KIT - Tier 2; PA SPIRIVA HANDIHALER - Tier 2; QL SEEBRI NEOHALER - Tier 2; PA SPIRIVA RESPIMAT - Tier 2; PA TUDORZA PRESSAIR - Tier 2; PA YUPELRI - Tier 2; PA Bronchodilators, Sympathomimetic - Asthma/Lung Drugs albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, ADRENALIN INJECTION SOLUTION 1 MG/ML - Tier 2; PA; QL 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml - Tier 1 ADYPHREN (brand for epinephrine professional) - Tier 2; PA; QL ADYPHREN AMP (brand for epinephrine professional) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 189 Preferred Agents Non-Preferred Agents ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% ADYPHREN AMP II (brand for epinephrine professional) - Tier 2; PA; QL INHALATION - Tier 2 ADYPHREN II (brand for epinephrine professional) - Tier 2; PA; QL albuterol sulfate er - Tier 1; PA albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 1 (generic for PROAIR HFA) - Tier 1; PA; QL epinephrine injection solution auto-injector 0.15 mg/0.3ml (generic for ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) EPIPEN JR 2-PAK) - Tier 1; QL MCG/ACT INHALATION - Tier 2; PA; QL albuterol sulfate oral - Tier 1; PA epinephrine injection solution auto-injector 0.3 mg/0.3ml (generic for ARCAPTA NEOHALER - Tier 2; PA AUVI-Q) - Tier 1; QL asthmanefrin refill - Tier 1; PA PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; QL AUVI-Q (brand for epinephrine) - Tier 2; PA; QL PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; QL BROVANA - Tier 2; PA SEREVENT DISKUS - Tier 2; QL epinephrine injection solution auto-injector 0.15 mg/0.15ml (generic for terbutaline sulfate oral - Tier 1 AUVI-Q) - Tier 1; PA; QL EPINEPHRINE PROFESSIONAL - Tier 2; PA; QL EPINEPHRINESNAP-EMS (brand for epinephrine professional) - Tier 2; PA; QL EPINEPHRINESNAP-V (brand for epinephrine professional) - Tier 2; PA; QL EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL EPISNAP (brand for epinephrine professional) - Tier 2; PA; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; PA LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT - Tier 2; PA; QL PERFOROMIST - Tier 2; PA PROAIR DIGIHALER - Tier 2; PA; QL PROAIR RESPICLICK - Tier 2; PA; QL S2 (RACEPINEPHRINE) - Tier 2; PA STRIVERDI RESPIMAT - Tier 2; PA SYMJEPI - Tier 2; PA VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 190 Preferred Agents Non-Preferred Agents XOPENEX (brand for levalbuterol hcl) - Tier 2; PA XOPENEX CONCENTRATE (brand for levalbuterol hcl) - Tier 2; PA XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis CAYSTON - Tier 2; PA; SP BETHKIS (brand for tobramycin) - Tier 2; PA; SP KITABIS PAK (brand for tobramycin) - Tier 2; SP ORKAMBI ORAL PACKET - Tier 2; PA TOBI PODHALER - Tier 2; SP TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP tobramycin inhalation nebulization solution 300 mg/4ml (generic for tobramycin nebulization solution 300 mg/5ml inhalation (generic for BETHKIS) - Tier 1; SP KITABIS PAK) - Tier 1; PA; SP TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1 cromolyn sodium nasal (generic for NASALCROM) - Tier 1 NASALCROM (brand for cromolyn sodium) - Tier 2 Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN - Tier 2 DALIRESP - Tier 2; PA theophylline - Tier 1 difil-g forte - Tier 1; PA theophylline er - Tier 1 THEO-24 - Tier 2; PA Pulmonary Antihypertensives - Asthma/Lung Drugs LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP OPSUMIT - Tier 2; PA; SP ADEMPAS - Tier 2; PA; SP alyq (generic for ALYQ) - Tier 1; PA; SP sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA; ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP SP bosentan (generic for TRACLEER) - Tier 1; PA; SP TRACLEER 62.5 MG, 125 MG (brand for bosentan) - Tier 2; PA; SP ORENITRAM - Tier 2; PA; SP UPTRAVI - Tier 2; PA; SP REVATIO ORAL (brand for sildenafil citrate) - Tier 2; PA; SP sildenafil citrate oral suspension reconstituted (generic for REVATIO) - Tier 1; PA; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 191 Preferred Agents Non-Preferred Agents tadalafil (pah) (generic for ALYQ) - Tier 1; PA; SP TRACLEER 32 MG - Tier 2; PA TYVASO - Tier 2; PA TYVASO REFILL - Tier 2; PA TYVASO STARTER - Tier 2; PA VENTAVIS - Tier 2; PA Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis ESBRIET ORAL CAPSULE - Tier 2; PA; SP; QL ESBRIET ORAL TABLET - Tier 2; PA; SP OFEV - Tier 2; PA; SP; QL Respiratory Tract Agents, Other - Asthma/Lung Drugs acetylcysteine inhalation - Tier 1 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; QL 12 hour decongestant (generic for WAL-PHED 12 HOUR) - Tier 1; PA ADVAIR HFA - Tier 2; QL AFRIN SALINE NASAL MIST (brand for ra saline nasal spray) - Tier 2 12 hour nasal decongestant (generic for WAL-PHED 12 HOUR) - Tier 1; altamist spray (generic for NASAL MOIST) - Tier 1 PA AYR (brand for ra saline nasal spray) - Tier 2 BABY AYR SALINE (brand for ra saline nasal spray) - Tier 2 12 hour nasal relief spray (generic for MUCINEX SINUS-MAX CLEAR & benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - COOL) - Tier 1; PA Tier 1; QL benzonatate oral capsule 200 mg - Tier 1; QL 12 hour nasal spray (generic for MUCINEX SINUS-MAX CLEAR & BEVESPI AEROSPHERE - Tier 2 COOL) - Tier 1; PA cold & flu oral liquid (generic for WAL-FLU SEVERE COLD & COUGH) 12hr allergy & congestion (generic for WAL-FEX D ALLERGY & - Tier 1; QL CONGESTION) - Tier 1; PA; QL 4-WAY FAST ACTING (brand for ephrine nose drops) - Tier 2; PA cold/flu relief (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 4-WAY MENTHOL (brand for ephrine nose drops) - Tier 2; PA 1; QL ADRENALIN NASAL (brand for epinephrine hcl (nasal)) - Tier 2; PA COMBIVENT RESPIMAT - Tier 2 ADVIL COLD/SINUS (brand for qc ibuprofen cold/sinus) - Tier 2; PA day time cold/flu relief (generic for WAL-FLU SEVERE COLD & AFRIN NODRIP ORIGINAL (brand for 12 hour nasal spray) - Tier 2; PA COUGH) - Tier 1; QL AFRIN SINUS (brand for 12 hour nasal spray) - Tier 2; PA AIRDUO DIGIHALER - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 192 Preferred Agents Non-Preferred Agents daytime cold & flu relief oral liquid (generic for WAL-FLU SEVERE AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; COLD & COUGH) - Tier 1; QL PA; QL day-time cold/flu relief (generic for WAL-FLU SEVERE COLD & AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; COUGH) - Tier 1; QL PA; QL daytime cold/flu relief oral liquid (generic for WAL-FLU SEVERE COLD AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; & COUGH) - Tier 1; QL PA; QL deep sea nasal spray (generic for NASAL MOIST) - Tier 1 ALAHIST CF - Tier 2; PA; QL DULERA - Tier 2; QL ALAHIST DM - Tier 2; PA; QL eq daytime cold/flu ms relief oral liquid (generic for WAL-FLU SEVERE ALAVERT ALLERGY/SINUS (brand for px allergy relief d (loratid)) - Tier COLD & COUGH) - Tier 1; QL 2; PA eq suphedrine (generic for SUDOGEST) - Tier 1; QL all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL eql daytime cold & flu relief (generic for WAL-FLU SEVERE COLD & all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; PA; QL COUGH) - Tier 1; QL all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL eql nasal decongestant (generic for SUDOGEST) - Tier 1; QL ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED FASENRA PEN - Tier 2; PA; SP; QL RELEASE 12 HOUR (brand for fexofenadine-pseudoephed er) - Tier 2; PA; QL flu/severe cold daytime oral liquid 10-5-325 mg/15ml (generic for WAL- ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED FLU SEVERE COLD & COUGH) - Tier 1; QL RELEASE 24 HOUR (brand for fexofenadine-pseudoephed er) - Tier 2; genaphed (generic for SUDOGEST) - Tier 1; QL PA hm daytime cold & flu oral liquid (generic for WAL-FLU SEVERE allergy & congestion (generic for KLS ALLERCLEAR D-24HR) - Tier 1; COLD & COUGH) - Tier 1; QL PA hm nasal decongestant (generic for SUDOGEST) - Tier 1; QL allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; PA; QL hm saline nasal spray (generic for NASAL MOIST) - Tier 1 allergy relief d (generic for WAL-FEX D ALLERGY & CONGESTION) - HYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for Tier 1; PA; QL sodium chloride) - Tier 2 allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA ipratropium-albuterol - Tier 1 allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA kp pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - allergy relief/nasal decongest oral tablet extended release 12 hour Tier 1; QL (generic for KLS ALLER-TEC D) - Tier 1; PA; QL nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL allergy relief/nasal decongest oral tablet extended release 24 hour nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 193 Preferred Agents Non-Preferred Agents nasal moist nasal solution (generic for NASAL MOIST) - Tier 1 allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for nasal moisturizing (generic for NASAL MOIST) - Tier 1 KLS ALLER-TEC D) - Tier 1; PA; QL nasal moisturizing spray (generic for NASAL MOIST) - Tier 1 NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for PA; SP; QL KLS ALLERCLEAR D-12HR) - Tier 1; PA NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic 2; PA; SP; QL for KLS ALLERCLEAR D-24HR) - Tier 1; PA OCEAN FOR KIDS (brand for ra saline nasal spray) - Tier 2 allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA OCEAN NASAL SPRAY (brand for ra saline nasal spray) - Tier 2 allergy/congestion relief (generic for KLS ALLERCLEAR D-12HR) - Tier 1; pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier PA 1; QL PULMOZYME - Tier 2; PA; SP allergy-d allergy & conges (generic for WAL-FEX D ALLERGY & qc daytime cold/flu oral liquid (generic for WAL-FLU SEVERE COLD & CONGESTION) - Tier 1; PA; QL COUGH) - Tier 1; QL altarussin (generic for DIABETIC TUSSIN EX) - Tier 1; PA ra day time cold/flu formula (generic for WAL-FLU SEVERE COLD & altarussin dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; COUGH) - Tier 1; QL PA; QL ra saline nasal spray (generic for NASAL MOIST) - Tier 1 altarussin-pe - Tier 1; PA ra suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL ALZAIR ALLERGY NASAL SPRAY - Tier 2; PA; QL saline mist spray (generic for NASAL MOIST) - Tier 1 anefrin spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier saline nasal spray (generic for NASAL MOIST) - Tier 1 1; PA severe cold/cough (generic for WAL-FLU SEVERE COLD & COUGH) ANORO ELLIPTA - Tier 2; PA - Tier 1; QL antihistamine & nasal deconges (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA; QL severe cold/flu daytime (generic for WAL-FLU SEVERE COLD & aprodine - Tier 1; PA COUGH) - Tier 1; QL AYR NASAL MIST ALLERGY/SINUS - Tier 2; PA sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL AYR SALINE NASAL (brand for saline) - Tier 2; PA sm day time cold & flu relief (generic for WAL-FLU SEVERE COLD & AYR SALINE NASAL DROPS - Tier 2; PA COUGH) - Tier 1; QL AYR SALINE NASAL NO-DRIP (brand for saline) - Tier 2; PA sm nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL azelastine-fluticasone (generic for DYMISTA) - Tier 1; PA sm nasal spray saline (generic for NASAL MOIST) - Tier 1 benzonatate oral capsule 150 mg - Tier 1; PA sodium chloride inhalation nebulization solution 0.9 % - Tier 1 bidex (generic for BIDEX) - Tier 1; PA BREO ELLIPTA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 194 Preferred Agents Non-Preferred Agents sodium chloride inhalation nebulization solution 7 % (generic for bromfed dm (generic for BROMFED DM) - Tier 1; PA; QL HYPERSAL) - Tier 1 BUDESONIDE-FORMOTEROL FUMARATE - Tier 2; PA; QL STIOLTO RESPIMAT - Tier 2 capcof - Tier 1; PA; QL SUDAFED (brand for pseudoephedrine hcl) - Tier 2; QL cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; SUDAFED CONGESTION (brand for pseudoephedrine hcl) - Tier 2; PA; QL QL SUDAFED SINUS CONGESTION (brand for pseudoephedrine hcl) - chest congest/cough child (generic for DELSYM CGH/CHEST CONG DM Tier 2; QL CHILD) - Tier 1; PA sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL chest congestion relief (generic for BIDEX) - Tier 1; PA sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL chest congestion relief dm (generic for WAL-TUSSIN COUGH/CHEST SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; QL DM) - Tier 1; PA; QL THERAFLU EXPRESSMAX (brand for hm daytime cold & flu) - Tier 2; childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier QL 1; PA TYLENOL COLD MAX ORAL LIQUID (brand for hm daytime cold & childrens cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - flu) - Tier 2; QL Tier 1; PA wal-flu severe cold & cough oral liquid (generic for WAL-FLU SEVERE childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG COLD & COUGH) - Tier 1; QL DM CHILD) - Tier 1; PA wal-phed (generic for SUDOGEST) - Tier 1; QL CINQAIR - Tier 2; PA CLARINEX-D 12 HOUR - Tier 2; PA CLARITIN-D 12 HOUR (brand for px allergy relief d (loratid)) - Tier 2; PA CLARITIN-D 24 HOUR (brand for sm lorata-dine d) - Tier 2; PA CLEAR COUGH PM MULTI-SYMPTOM (brand for ra nite time cold/flu formula) - Tier 2; PA coditussin ac - Tier 1; PA; QL cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA cold & flu relief daytime (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA cold & sinus relief (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA cold head congestion daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 195 Preferred Agents Non-Preferred Agents cold max (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA cold max daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA cold multi-symptom daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA cold/allergy childrens (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA cold/cough dm childrens oral elixir 2.5-1-5 mg/5ml - Tier 1; PA cold/flu daytime relief (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA COMTREX COLD & COUGH MAX ST (brand for cold head congestion daytime) - Tier 2; PA CORICIDIN HBP COUGH/COLD (brand for cough & cold hbp) - Tier 2; PA cough & chest congestion (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; PA cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; PA cough & sore throat nighttime (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA cough dm (generic for DELSYM) - Tier 1; PA cough dm childrens (generic for DELSYM) - Tier 1; PA cough dm er (generic for DELSYM) - Tier 1; PA cough/chest congestion dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML - Tier 2; PA day time cold & flu oral capsule (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 196 Preferred Agents Non-Preferred Agents day time cold/flu (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA daytime (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA daytime cold & flu relief oral capsule (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA daytime cold/flu relief oral capsule (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA day-time pe cold/flu relief (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA decongestant 12hour max st (generic for WAL-PHED 12 HOUR) - Tier 1; PA DELSYM (brand for eql cough dm) - Tier 2; PA delsym cgh/chest cong dm child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA DELSYM COUGH CHILDRENS (brand for eql cough dm) - Tier 2; PA DERMACINRX AZENASE PAK - Tier 2; PA desgen dm oral liquid (generic for DESGEN DM) - Tier 1; PA despec dm - Tier 1; PA despec dm-g - Tier 1; PA dextromethorphan polistirex er (generic for DELSYM) - Tier 1; PA dextromethorphan-guaifenesin oral syrup (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL diabetic tussin ex (generic for DIABETIC TUSSIN EX) - Tier 1; PA diabetic tussin max st (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA DIMETAPP COLD RELIEF CHILDRENS (brand for eq cold/cough dm childrens) - Tier 2; PA DIMETAPP COLD/ALLERGY (brand for cold & allergy) - Tier 2; PA DIMETAPP DM COLD/COUGH (brand for eq cold/cough dm childrens) - Tier 2; PA DIMETAPP LONG ACT COUGH/COLD - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 197 Preferred Agents Non-Preferred Agents dm maximum adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA DRISTAN SPRAY (brand for 12 hour nasal spray) - Tier 2; PA DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; PA; QL ed bron gp - Tier 1; PA endacof-dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA ENTSOL NASAL - Tier 2; PA ephrine nose drops (generic for WAL-FOUR) - Tier 1; PA epinephrine hcl (nasal) (generic for ADRENALIN) - Tier 1; PA eq allergy relief d 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA eq allergy relief oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; PA; QL eq cold multi-symptom daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA eq cold/allergy childrens - Tier 1; PA eq cold/cough dm childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA eq cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA eq cough dm (generic for DELSYM) - Tier 1; PA eq daytime cold/flu ms relief oral capsule (generic for MUCINEX FAST- MAX CONG HEADACHE) - Tier 1; PA eq mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL eq mucus relief dm (generic for MUCINEX DM) - Tier 1; PA; QL eq mucus-d (generic for MUCINEX D) - Tier 1; PA eq nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA eq nasal spray fast acting (generic for WAL-FOUR) - Tier 1; PA eq sinus relief max st - Tier 1; PA eq tussin cf cough & cold (generic for DESGEN DM) - Tier 1; PA eq tussin dm cough/chest (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL eq tussin dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 198 Preferred Agents Non-Preferred Agents eq tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA eq tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA eql all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL eql allergy/congestion relief (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA eql cold multi-symptom daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA eql cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA eql cough dm (generic for DELSYM) - Tier 1; PA eql flu/severe cold daytime (generic for THERAFLU SEVERE COLD) - Tier 1; PA eql mucus-dm (generic for MUCINEX DM) - Tier 1; PA; QL eql nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA eql nasal spray 12 hour (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA eql nasal spray fast acting (generic for WAL-FOUR) - Tier 1; PA eql nasal spray no drip (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA eql tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1; PA eql tussin dm cough/chest cong (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL fenesin ir (generic for BIDEX) - Tier 1; PA fexofenadine/pse er (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA; QL fexofenadine-pseudoephed er oral tablet extended release 12 hour (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA; QL fexofenadine-pseudoephed er oral tablet extended release 24 hour (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA flu/cold/daytime (generic for THERAFLU SEVERE COLD) - Tier 1; PA flu/severe cold & cough day (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA flu/severe cold/cough day (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 199 Preferred Agents Non-Preferred Agents fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; PA; QL g tussin ac - Tier 1; PA; QL geri-tussin dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL geri-tussin oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; PA GILPHEX TR - Tier 2; PA GILTUSS TR - Tier 2; PA GRASTEK - Tier 2; PA; QL guaiatussin ac - Tier 1; PA; QL guaicon dms (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL guaifenesin ac - Tier 1; PA; QL guaifenesin dac - Tier 1; PA; QL guaifenesin er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL guaifenesin oral tablet 400 mg (generic for BIDEX) - Tier 1; PA guaifenesin-codeine - Tier 1; PA; QL guaifenesin-dm oral syrup (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL herbiomed fast acting - Tier 1; PA; QL HISTEX-AC - Tier 2; PA; QL hm adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA hm allergy & congestion (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA hm allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL hm allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA hm chest congestion relief (generic for BIDEX) - Tier 1; PA hm cold & allergy childrens (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 200 Preferred Agents Non-Preferred Agents hm cold & cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA hm cold & sinus relief (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA hm cough dm (generic for DELSYM) - Tier 1; PA hm day time (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA hm mucus er (generic for EQ MUCUS ER) - Tier 1; PA; QL hm mucus relief d (generic for MUCINEX D) - Tier 1; PA hm nasal decongestant 12 hour (generic for WAL-PHED 12 HOUR) - Tier 1; PA hm nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA hm nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA hm nose drops (generic for WAL-FOUR) - Tier 1; PA hm severe cold/cough/flu (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA hm sinus nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA hm tussin adult dm oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA hm tussin adult multi-symptom (generic for DESGEN DM) - Tier 1; PA hycodan (generic for HYCODAN) - Tier 1; PA; QL hydrocodone polst-cpm polst er - Tier 1; PA; QL hydrocodone-homatropine (generic for HYCODAN) - Tier 1; PA; QL hydromet (generic for HYCODAN) - Tier 1; PA; QL HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 % - Tier 2; PA ibuprofen cold & sinus (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA kls allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA kls allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA kls aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL kls mucus relief chest (generic for BIDEX) - Tier 1; PA kls nasal decongestant spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA kls suphedrine pe (generic for SUDOGEST PE) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 201 Preferred Agents Non-Preferred Agents liquibid (generic for BIDEX) - Tier 1; PA long acting nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA long lasting nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA mapap cold formula multi-sympt (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA MAR-COF BP - Tier 2; PA; QL MAR-COF CG EXPECTORANT (brand for trymine cg) - Tier 2; PA maxi-tuss ac - Tier 1; PA; QL maxi-tuss cd - Tier 1; PA; QL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA maxi-tuss pe max - Tier 1; PA m-clear wc - Tier 1; PA medi-tussin dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA M-END PE - Tier 2; PA; QL MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for cvs chest congest/cough child) - Tier 2; PA MUCINEX CHILDRENS STUFFY NOSE (brand for 12 hour nasal spray) - Tier 2; PA mucinex cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA MUCINEX D (brand for sm mucus relief d) - Tier 2; PA MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) - Tier 2; PA MUCINEX DM (brand for ra mucus relief dm) - Tier 2; PA; QL mucinex fast-max cong headache (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA mucinex fast-max dm max liquid 20-400 mg/20ml oral (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 202 Preferred Agents Non-Preferred Agents MUCINEX FAST-MAX DM MAX LIQUID 20-400 MG/20ML ORAL (brand for cvs chest congest/cough child) - Tier 2; PA MUCINEX MAXIMUM STRENGTH (brand for guaifenesin er) - Tier 2; PA; QL mucinex sinus-max clear & cool (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA mucinex sinus-max cong & pain oral capsule (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA mucinex sinus-max sinus/allrgy (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA mucosa (generic for BIDEX) - Tier 1; PA mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA mucus d (generic for MUCINEX D) - Tier 1; PA mucus d extended release (generic for MUCINEX D) - Tier 1; PA mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1; PA mucus dm (generic for MUCINEX DM) - Tier 1; PA; QL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL mucus relief cough child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA mucus relief d oral tablet extended release 12 hour (generic for MUCINEX D) - Tier 1; PA mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 203 Preferred Agents Non-Preferred Agents mucus relief er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL mucus relief max st (generic for EQ MUCUS ER) - Tier 1; PA; QL mucus relief oral tablet (generic for BIDEX) - Tier 1; PA mucus-d (generic for MUCINEX D) - Tier 1; PA mucus-dm (generic for MUCINEX DM) - Tier 1; PA; QL mucus-er max (generic for EQ MUCUS ER) - Tier 1; PA; QL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; PA; QL multi symptom flu/severe cold (generic for THERAFLU SEVERE COLD) - Tier 1; PA nasal decongestant 12hr (generic for WAL-PHED 12 HOUR) - Tier 1; PA nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA nasal decongestant pe max st (generic for SUDOGEST PE) - Tier 1; PA nasal decongestant spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal four (generic for WAL-FOUR) - Tier 1; PA nasal mist nasal solution (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal relief (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray 12 hour (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray anti-drip (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray extra moist (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray extra moisturizing (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nasal spray fast acting (generic for WAL-FOUR) - Tier 1; PA nasal spray no drip (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 204 Preferred Agents Non-Preferred Agents nasal spray sinus (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2; PA NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for ephrine nose drops) - Tier 2; PA NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2; PA NEOTUSS PLUS - Tier 2; PA night time cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for CLEAR COUGH PM MULTI-SYMPTOM) - Tier 1; PA nighttime cold medicine (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA NINJACOF-XG - Tier 2; PA; QL nite time cold/flu relief (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA no drip nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA nohist-lq (generic for ED A-HIST) - Tier 1; PA; QL non-pseudo sinus decongestant (generic for SUDOGEST PE) - Tier 1; PA nose drops (generic for WAL-FOUR) - Tier 1; PA nose drops extra strength (generic for WAL-FOUR) - Tier 1; PA NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED - Tier 2; PA ORALAIR - Tier 2; PA; QL ORALAIR ADULT SAMPLE KIT - Tier 2; PA; QL ORALAIR ADULT STARTER PACK - Tier 2; PA; QL ORALAIR CHILDRENS SAMPLE KIT - Tier 2; PA; QL ORALAIR CHILDRENS STARTER PACK - Tier 2; PA; QL pharbinex (generic for BIDEX) - Tier 1; PA phenylephrine hcl oral (generic for SUDOGEST PE) - Tier 1; PA poly-tussin ac - Tier 1; PA; QL PONARIS - Tier 2; PA promethazine-codeine - Tier 1; PA; QL promethazine-dm - Tier 1; PA; QL promethazine-phenyleph-codeine - Tier 1; PA; QL promethazine-phenylephrine - Tier 1; PA; QL PRO-RED AC - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 205 Preferred Agents Non-Preferred Agents pseudoephedrine hcl 12 hr (generic for WAL-PHED 12 HOUR) - Tier 1; PA pseudoephedrine hcl er (generic for WAL-PHED 12 HOUR) - Tier 1; PA pseudoephedrine-bromphen-dm (generic for BROMFED DM) - Tier 1; PA; QL pseudoephedrine-bromphen-dm oral liquid 30-2-10 mg/5ml - Tier 1; PA; QL pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1; PA qc cold relief (generic for PERCOGESIC EXTRA STRENGTH) - Tier 1; PA qc cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; PA qc cough/sore throat nighttime (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA qc daytime cold/flu oral capsule (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA qc ibuprofen cold/sinus (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA qc loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA qc medifin 400 (generic for BIDEX) - Tier 1; PA qc mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA qc mucus relief dm max (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA qc mucus relief er (generic for EQ MUCUS ER) - Tier 1; PA; QL qc mucus relief max st (generic for EQ MUCUS ER) - Tier 1; PA; QL qc nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA qc nasal relief moisturizing (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA qc nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA qc nighttime cold/flu relief (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA qc no drip nasal relief (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 206 Preferred Agents Non-Preferred Agents qc severe allergy (generic for PERCOGESIC EXTRA STRENGTH) - Tier 1; PA qc severe cold/cough daytime (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA qc suphedrine maximum strength (generic for WAL-PHED 12 HOUR) - Tier 1; PA qc tussin cf (generic for DESGEN DM) - Tier 1; PA ra 12 hour nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra allergy relief-d (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA; QL ra allergy/congestion relief (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA ra cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL ra childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA ra cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA ra cold & cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA ra cold multi-symptom daytime oral tablet 10-5-325 mg (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1; PA ra cold/cough dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA ra cold/flu relief daytime (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA ra cough dm (generic for DELSYM) - Tier 1; PA ra daytime multi-symp cold/flu (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA ra daytime multi-symptom cold (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA ra ibu-profen cold/sinus (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA ra lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA ra mucus relief chest (generic for BIDEX) - Tier 1; PA ra mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 207 Preferred Agents Non-Preferred Agents ra mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; PA ra mucus relief oral tablet (generic for BIDEX) - Tier 1; PA ra nasal decongestant (generic for WAL-FOUR) - Tier 1; PA ra nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA ra nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra nasal spray max st (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra nasal spray/moisturizing (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra nasal spray/sinus (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra nighttime cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for CLEAR COUGH PM MULTI-SYMPTOM) - Tier 1; PA ra nite time cold/flu formula (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA ra nose drops extra strength (generic for WAL-FOUR) - Tier 1; PA ra severe cold & cough day (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA ra severe congestion spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA ra sinus/congestion relief pe (generic for SUDOGEST PE) - Tier 1; PA ra suphedrine oral tablet extended release 12 hour (generic for WAL- PHED 12 HOUR) - Tier 1; PA ra tussin (generic for DIABETIC TUSSIN EX) - Tier 1; PA ra tussin cf (generic for DESGEN DM) - Tier 1; PA ra tussin chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; PA ra tussin cough dm sugar free (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL ra tussin cough/chest dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA ra tussin maximum strength (generic for WAL-TUSSIN COUGH) - Tier 1; PA RAGWITEK - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 208 Preferred Agents Non-Preferred Agents recofen d (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA refenesen 400 (generic for BIDEX) - Tier 1; PA ribavirin inhalation (generic for VIRAZOLE) - Tier 1; PA robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1; PA ROBITUSSIN 12 HOUR COUGH (brand for eql cough dm) - Tier 2; PA ROBITUSSIN 12 HOUR COUGH CHILD (brand for eql cough dm) - Tier 2; PA ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; PA robitussin childrens cough la - Tier 1; PA ROBITUSSIN COLD+FLU DAYTIME (brand for hm day time) - Tier 2; PA ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for cvs chest congest/cough child) - Tier 2; PA ROBITUSSIN NIGHTTIME COUGH - Tier 2; PA ROBITUSSIN PEAK COLD MULTI-SYM (brand for goodsense tussin cf) - Tier 2; PA rydex - Tier 1; PA; QL rymed - Tier 1; PA; QL rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; PA rynex pse - Tier 1; PA sb cough control dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA sb mucus relief (generic for BIDEX) - Tier 1; PA SEMPREX-D - Tier 2; PA severe allergy (generic for PERCOGESIC EXTRA STRENGTH) - Tier 1; PA siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1; PA siltussin-dm alcohol free (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL sinus 12 hour (generic for WAL-PHED 12 HOUR) - Tier 1; PA sinus nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA sinus pe decongestant (generic for SUDOGEST PE) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 209 Preferred Agents Non-Preferred Agents sinus relief extra strength (generic for WAL-FOUR) - Tier 1; PA sm all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL sm chest congestion relief (generic for BIDEX) - Tier 1; PA sm cold & allergy childrens - Tier 1; PA sm cold & cough dm childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; PA sm cold & sinus relief (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA sm cough relief (generic for WAL-TUSSIN COUGH) - Tier 1; PA sm cough/sore throat daytime - Tier 1; PA sm cough/sore throat nighttime (generic for CLEAR COUGH PM MULTI- SYMPTOM) - Tier 1; PA sm day time non drowsy (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA sm day time pe cold/flu relief (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA sm daytime liquid (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1; PA sm lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA sm loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA sm mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA sm mucus relief d (generic for MUCINEX D) - Tier 1; PA sm mucus relief max strength (generic for EQ MUCUS ER) - Tier 1; PA; QL sm nasal decongestant (generic for WAL-PHED 12 HOUR) - Tier 1; PA sm nasal decongestant pe (generic for SUDOGEST PE) - Tier 1; PA sm nasal spray (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA sm nasal spray 12 hour (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA sm nasal spray moisturizing (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 210 Preferred Agents Non-Preferred Agents sm nasal spray sinus (generic for MUCINEX SINUS-MAX CLEAR & COOL) - Tier 1; PA sm nose drops nasal decongest (generic for WAL-FOUR) - Tier 1; PA sm tussin cf - Tier 1; PA sm tussin cough/chest congest (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL sm tussin dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL sm tussin dm max (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA sodium chloride inhalation nebulization solution 10 %, 3 % - Tier 1; PA SUDAFED CHILDRENS (brand for gnp suphedrin) - Tier 2; PA; QL SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for nasal decongestant pe max st) - Tier 2; PA SUDAFED PE SINUS CONGESTION (brand for nasal decongestant pe max st) - Tier 2; PA SUDAFED SINUS CONGESTION 12HR (brand for sinus 12 hour) - Tier 2; PA sudogest 12 hour (generic for WAL-PHED 12 HOUR) - Tier 1; PA sudogest pe (generic for SUDOGEST PE) - Tier 1; PA suphedrin (generic for SUDAFED CHILDRENS) - Tier 1; PA; QL tab tussin (generic for BIDEX) - Tier 1; PA TESSALON PERLES (brand for benzonatate) - Tier 2; PA; QL THERAFLU EXPRESSMAX SEV CLD/CG ORAL TABLET 10-5-325 MG (brand for cold head congestion daytime) - Tier 2; PA THERAFLU POWERPODS SEVERE COLD ORAL 20-10-650 MG - Tier 2; PA; QL THERAFLU SEVERE COLD (brand for eql flu/severe cold daytime) - Tier 2; PA THERAFLU SEVERE COLD DAYTIME - Tier 2; PA THERAFLU SEVERE COLD/CGH DAY (brand for cold head congestion daytime) - Tier 2; PA TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 211 Preferred Agents Non-Preferred Agents TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH - Tier 2; PA; QL trymine cg (generic for MAR-COF CG EXPECTORANT) - Tier 1; PA tusnel c - Tier 1; PA TUSSICAPS - Tier 2; PA; QL tussin cf (generic for DESGEN DM) - Tier 1; PA tussin cf cough & cold - Tier 1; PA tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1; PA tussin cough long acting (generic for WAL-TUSSIN COUGH) - Tier 1; PA tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1; PA tussin dm cough + chest oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA tussin dm max (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA tussin dm max adult (generic for DIABETIC TUSSIN MAX ST) - Tier 1; PA tussin dm max st (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; PA tussin dm oral syrup 100-10 mg/5ml (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL tussin maximum strength (generic for WAL-TUSSIN COUGH) - Tier 1; PA tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; PA tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; PA TUXARIN ER - Tier 2; PA; QL TUZISTRA XR - Tier 2; PA; QL TYLENOL COLD MAX ORAL TABLET (brand for cold head congestion daytime) - Tier 2; PA UTIBRON NEOHALER - Tier 2; PA VIRAZOLE (brand for ribavirin) - Tier 2; PA virtussin a/c - Tier 1; PA; QL virtussin ac w/alc - Tier 1; PA; QL virtussin dac - Tier 1; PA; QL wal-act - Tier 1; PA wal-fex d allergy & congestion oral tablet extended release 12 hour (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA; QL wal-fex d allergy & congestion oral tablet extended release 24 hour (generic for WAL-FEX D ALLERGY & CONGESTION) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 212 Preferred Agents Non-Preferred Agents wal-flu severe cold & cough oral packet (generic for WAL-FLU SEVERE COLD & COUGH) - Tier 1; PA wal-four (generic for WAL-FOUR) - Tier 1; PA wal-itin d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; PA wal-itin d 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; PA wal-phed 12 hour (generic for WAL-PHED 12 HOUR) - Tier 1; PA wal-phed pe (generic for SUDOGEST PE) - Tier 1; PA wal-profen cold & sinus (generic for WAL-PROFEN COLD & SINUS) - Tier 1; PA wal-tap cold/allergy oral elixir - Tier 1; PA wal-tussin (generic for DIABETIC TUSSIN EX) - Tier 1; PA wal-tussin cf - Tier 1; PA wal-tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1; PA wal-tussin cough/chest dm (generic for WAL-TUSSIN COUGH/CHEST DM) - Tier 1; PA; QL wal-zyr d (generic for KLS ALLER-TEC D) - Tier 1; PA; QL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL xpect (generic for BIDEX) - Tier 1; PA ZYRTEC-D ALLERGY & CONGESTION (brand for sm all day allergy-d) - Tier 2; PA; QL

Sedatives/Hypnotics - Drugs for Sedation and Sleep Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs XYWAV - Tier 2; PA; QL Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1 active-cyclobenzaprine (generic for CYCLOPHENE RAPIDPAQ) - Tier 1; chlorzoxazone - Tier 1 PA cyclobenzaprine hcl oral - Tier 1 AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 213 Preferred Agents Non-Preferred Agents orphenadrine citrate er - Tier 1 carisoprodol oral (generic for SOMA) - Tier 1; PA; QL tizanidine hcl oral tablet - Tier 1 CYCLO/GABA 10/300 - Tier 2; PA cyclobenzaprine hcl er (generic for AMRIX) - Tier 1; PA CYCLOPHENE RAPIDPAQ (brand for active-cyclobenzaprine) - Tier 2; PA DANTRIUM ORAL (brand for dantrolene sodium) - Tier 2; PA dantrolene sodium oral - Tier 1; PA enovarx-cyclobenzaprine hcl - Tier 1; PA FEXMID (brand for cyclobenzaprine hcl) - Tier 2; PA FIRST-BACLOFEN - Tier 2; PA LORZONE (brand for chlorzoxazone) - Tier 2; PA METAXALL CP - Tier 2; PA metaxalone - Tier 1; PA methocarbamol oral - Tier 1; PA NORGESIC FORTE - Tier 2; PA orphenadrine-asa-caffeine (generic for ORPHENGESIC FORTE) - Tier 1; PA ORPHENGESIC FORTE (brand for orphenadrine-asa-caffeine) - Tier 2; PA OZOBAX - Tier 2; PA; QL ROBAXIN-750 (brand for methocarbamol) - Tier 2; PA SKELAXIN (brand for metaxalone) - Tier 2; PA SOMA (brand for carisoprodol) - Tier 2; PA; QL TABRADOL FUSEPAQ - Tier 2; PA; QL TABRADOL RAPIDPAQ - Tier 2; PA; QL tizanidine hcl oral capsule (generic for ZANAFLEX) - Tier 1; PA VANADOM (brand for carisoprodol) - Tier 2; PA; QL ZANAFLEX (brand for tizanidine hcl) - Tier 2; PA Skeletal Muscle Relaxants - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Skeletal Muscle Relaxants - Pain/Swelling Management Drugs NOPIOID-LMC KIT - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 214 Preferred Agents Non-Preferred Agents Sleep Disorder Agents - Drugs for Sedation and Sleep Sleep Disorders, Other - Drugs for Sleeping XYREM - Tier 2; PA; SP; QL Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs prenatal gummy oral tablet chewable 0.4 mg - Tier 1; PA; QL PRENATAL GUMMY ORAL TABLET CHEWABLE 0.4-25 MG - Tier 2; PA; QL Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs CITRANATAL ESSENCE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 216 Index of Drugs 12 hour allergy-d...... 192 ACCU-CHEK AVIVA DEVICE...... 157 acetaminophen ex st oral liquid 500 12 hour decongestant...... 192 ACCU-CHEK AVIVA IN VITRO...... 157 mg/15ml...... 3 12 hour nasal decongestant...... 192 ACCU-CHEK AVIVA PLUS KIT W/DEVICE acetaminophen ex st oral tablet 500 mg...... 3 12 hour nasal relief spray...... 192 ...... 157 acetaminophen extra strength...... 3 12 hour nasal spray...... 192 ACCU-CHEK CLIP FOR PUMP SKIN...... 157 acetaminophen infants...... 3 12hr allergy & congestion...... 192 ACCU-CHEK COMPACT PLUS...... 157 acetaminophen oral liquid 500 mg/15ml...... 3 1ST MEDX-PATCH/ LIDOCAINE ACCU-CHEK COMPACT PLUS CARE..... 157 acetaminophen oral solution 160 mg/5ml, EXTERNAL PATCH 4-0.0375-5-20 %...... 18 ACCU-CHEK COMPACT PLUS 325 mg/10.15ml, 650 mg/20.3ml...... 3 24 hour nasal allergy...... 188 CONTROL...... 157 acetaminophen oral suspension 160 24hr allergy relief...... 182 ACCU-CHEK FASTCLIX LANCET KIT...... 157 mg/5ml, 650 mg/20.3ml...... 3 3 day vaginal...... 33 ACCU-CHEK GUIDE CONTROL...... 157 acetaminophen oral tablet 325 mg...... 4 4-WAY FAST ACTING...... 192 ACCU-CHEK GUIDE KIT W/DEVICE...... 157 acetaminophen oral tablet 500 mg...... 4 4-WAY MENTHOL...... 192 ACCU-CHEK LINKASSIST...... 157 acetaminophen oral tablet chewable 160 7T LIDO...... 18 ACCU-CHEK MULTICLIX LANCET mg...... 4 8 hour arthritis pain reliever...... 3 DEVICE KIT...... 157 acetaminophen rapid tabs child...... 4 8 hour arthritis relief...... 3 ACCU-CHEK NANO SMARTVIEW...... 157 acetaminophen rectal suppository 120 mg.... 4 8 hour pain reliever...... 3 ACCU-CHEK SMARTVIEW...... 157 acetaminophen rectal suppository 650 mg.... 4 8 hr arthritis pain relief...... 3 ACCU-CHEK SMARTVIEW CONTROL.... 157 acetaminophen-codeine...... 16 8hr arthritis pain relief...... 3 ACCU-CHEK SOFTCLIX LANCET acetaminophen-codeine #2...... 16 8hr muscle aches & pain...... 3 DEVICE KIT...... 157 acetaminophen-codeine #3...... 16 A.A.G.C. KIT IN TERODERM...... 3 ACCU-CHEK SOFTCLIX LANCETS...... 157 acetaminophen-codeine #4...... 16 a-25...... 97 ACCU-CHEK SPIRIT ADAPTER KIT...... 158 acetazolamide er...... 178 abatinex...... 113 ACCU-CHEK SPIRIT BATTERY KIT...... 158 acetazolamide oral...... 178 ABATRON...... 86 ACCU-CHEK SPIRIT COMBO PACK...... 158 acetic acid otic...... 180 abatron af...... 86 ACCU-CHEK TENDER 1 INFUSION...... 158 acetylcysteine inhalation...... 192 abiraterone acetate oral tablet 250 mg...... 41 ACCUPRIL...... 55 acid controller...... 125 ABREVA...... 48 ACCURETIC...... 58 acid gone...... 113 ABSORICA LD...... 67 ACCUTREND GLUCOSE...... 158 acid reducer oral capsule delayed release.134 ABSORICA ORAL CAPSULE 10 MG, 20 ACCUTREND GLUCOSE CONTROL...... 158 acid reducer oral tablet...... 125 MG, 30 MG...... 67 ACD-A NOCLOT-50...... 52 acid reducer oral tablet delayed release.... 134 ABSORICA ORAL CAPSULE 25 MG, 35 ACE AEROSOL CLOUD ENHANCER...... 158 acidophilus lactobacillus oral...... 113 MG...... 67 acebutolol hcl oral...... 56 acidophilus oral capsule...... 113 ABSORICA ORAL CAPSULE 40 MG...... 67 ACEROLA C 500...... 97 acidophilus probiotic...... 113 ACANYA...... 67 ACESO AG...... 158 acidophilus probiotic oral capsule 10 mg... 114 acarbose oral...... 48 acetaminophen 8 hour...... 3 acidophilus/l-sporogenes...... 114 a-caro-25...... 97 acetaminophen childrens...... 3 ACIPHEX...... 134 ACCOLATE...... 189 acetaminophen er...... 3 ACIPHEX SPRINKLE...... 134 ACCU-CHEK AVIVA CONNECT...... 157 acitretin...... 67

217 acne...... 67 ADALAT CC ORAL TABLET EXTENDED advanced stress formula/zinc...... 97 acne control cleanser...... 67 RELEASE 24 HOUR 60 MG...... 57 ADVIL...... 10 acne medication 10 external lotion...... 67 adapalene external cream...... 67 ADVIL COLD/SINUS...... 192 acne medication 5 external lotion...... 67 adapalene external gel...... 67 ADVIL JUNIOR STRENGTH...... 10 acne treatment external cream 10 %...... 67 ADAPALENE EXTERNAL PAD...... 67 ADVIL LIQUI-GELS MINIS...... 10 ACTEMRA ACTPEN...... 153 ADAPALENE EXTERNAL SOLUTION...... 67 ADVIL MIGRAINE...... 10 ACTEMRA SUBCUTANEOUS...... 153 ADAPALENE-BENZOYL PER-CLINDAMY. 68 ADYPHREN...... 189 ACTICLATE...... 29 ADAPALENE-BENZOYL PER-NIACINAM.. 68 ADYPHREN AMP...... 189 ACTIFLOVIT EAR HEALTH...... 97 adapalene-benzoyl peroxide...... 68 ADYPHREN AMP II...... 189 ACTIFOAM COLLAGEN SPONGE...... 158 adc/f (0.5mg/ml)...... 97 ADYPHREN II...... 190 ACTIGALL...... 114 ADCIRCA...... 191 AEMCOLO...... 24 ACTIMMUNE...... 153 addaprin...... 10 AEROCHAMBER PLUS FLO-VU...... 158 ACTIPHLORA...... 114 added strength headache relief...... 4 AEROCHAMBER PLUS FLO-VU LARGE. 158 ACTIPOCHOL PLUS...... 158 adefovir dipivoxil...... 47 AEROCHAMBER PLUS FLO-VU SMALL..158 ACTIQ...... 16 ADEMPAS...... 191 AEROCHAMBER PLUS FLO-VU W/MASK ACTITROM...... 97 ADJUSTABLE LANCING DEVICE...... 158 ...... 158 ACTITROM-D...... 97 ADLYXIN...... 48 af spray powder...... 33 active fe...... 86 ADLYXIN STARTER PACK...... 48 AFINITOR...... 42 active-cyclobenzaprine...... 213 ADMELOG...... 51 AFINITOR DISPERZ...... 42 ACTIVE-KETOPROFEN...... 10 ADMELOG SOLOSTAR...... 51 afirmelle...... 141 ACTIVELLA...... 141 ADRENAL C FORMULA...... 97 AFLURIA QUADRIVALENT...... 153 ACTIVE-PREP KIT I...... 10 ADRENALIN INJECTION SOLUTION 1 AFREZZA...... 51 ACTIVE-PREP KIT II...... 10 MG/ML...... 189 AFRIN NODRIP ORIGINAL...... 192 ACTIVE-PREP KIT III...... 10 ADRENALIN NASAL...... 192 AFRIN SALINE NASAL MIST...... 192 ACTIVE-PREP KIT IV...... 4 adult 50+ probiotic...... 114 AFRIN SINUS...... 192 ACTIVE-PREP KIT V...... 33 ADULT AEROSOL MASK...... 158 aftera...... 147 active-tramadol...... 4 adult aspirin ec low strength oral tablet AGONEAZE...... 18 ACTIVITE...... 97 delayed release 81 mg...... 10 AGRYLIN...... 53 ACTONEL ORAL TABLET 150 MG...... 156 adult aspirin low strength...... 10 aif #2 drug preparation kit...... 10 ACTONEL ORAL TABLET 35 MG...... 156 adult aspirin regimen...... 10 AIF #3 DRUG PREPARATION KIT...... 10 ACTOPLUS MET...... 48 ADULT MASK...... 158 AIMOVIG...... 38 ACTOS...... 48 adult probiotic...... 114 airavite...... 97 ACULAR...... 178 adv acne spot treatment...... 68 AIRDUO DIGIHALER...... 192 ACULAR LS...... 178 ADVAIR DISKUS...... 192 AIRDUO RESPICLICK 113/14...... 192 acyclovir external...... 48 ADVAIR HFA...... 192 AIRDUO RESPICLICK 232/14...... 193 acyclovir oral...... 48 advanced acne spot treat...... 68 AIRDUO RESPICLICK 55/14...... 193 ACZONE...... 67 ADVANCED ALLERGY COLLECTION...... 68 AIRSHIELD IMMUNITY SUPPORT...... 97 ADACEL...... 153 ADVANCED GLUCOSE TEST...... 158 airshield oral tablet chewable...... 97 advanced healing...... 68 AIRZONE PEAK FLOW METER...... 158

218 AJOVY SUBCUTANEOUS SOLUTION ALCOHOL PREP PADS PAD , 70 %...... 158 allergy 24hour indoor/outdoor...... 182 AUTO-INJECTOR...... 38 ALCORTIN A...... 33 allergy 24-hr...... 182 AJOVY SUBCUTANEOUS SOLUTION ALDACTAZIDE...... 58 allergy antihistamine...... 182 PREFILLED SYRINGE...... 158 ALDACTONE...... 60 allergy childrens...... 182 AKLIEF...... 68 ALDARA...... 68 allergy d-12...... 193 ak-poly-bac...... 172 alendronate sodium oral solution...... 156 allergy eye drops...... 179 akwa tears ophthalmic ointment 83-15 %.. 172 alendronate sodium oral tablet 10 mg, 5 allergy oral capsule...... 182 AKYNZEO ORAL...... 33 mg...... 156 allergy oral tablet...... 183 ALA SCALP...... 68 alendronate sodium oral tablet 35 mg...... 156 allergy oral tablet extended release...... 182 ala-cort...... 68 alendronate sodium oral tablet 70 mg...... 156 allergy rel child (loratadine)...... 183 ALAHIST CF...... 193 aler-dryl...... 182 allergy relief adult...... 183 ALAHIST DM...... 193 ALEVAMAX...... 68 allergy relief cetirizine...... 183 ala-quin...... 33 ALEVE ORAL TABLET...... 10 allergy relief child...... 183 ALAVERT...... 182 alfuzosin hcl er...... 137 allergy relief childrens oral liquid 12.5 ALAVERT ALLERGY/SINUS...... 193 alga...... 158 mg/5ml...... 183 ALAWAY...... 178 algal-900 dha...... 97 allergy relief childrens oral suspension 30 ALAWAY CHILDRENS ALLERGY...... 178 ALINIA ORAL SUSPENSION mg/5ml...... 183 alba-lybe nr...... 97 RECONSTITUTED...... 44 allergy relief childrens oral syrup 5 mg/5ml 183 albendazole oral...... 43 ALINIA ORAL TABLET...... 44 allergy relief childrens oral tablet chewable ALBENZA...... 43 aliskiren fumarate...... 58 10 mg...... 183 albuterol sulfate er...... 190 ALKERAN ORAL...... 41 allergy relief childrens oral tablet chewable albuterol sulfate hfa aerosol solution 108 ALKINDI SPRINKLE...... 138 5 mg...... 183 (90 base) mcg/act inhalation...... 190 all day allergy d...... 193 allergy relief d...... 193 ALBUTEROL SULFATE HFA AEROSOL all day allergy d-12...... 193 allergy relief d-12...... 193 SOLUTION 108 (90 BASE) MCG/ACT all day allergy oral tablet 10 mg...... 182 allergy relief d-24...... 193 INHALATION...... 190 all day allergy-d...... 193 allergy relief loratadine...... 183 albuterol sulfate inhalation nebulization all day pain relief...... 10 allergy relief oral capsule 10 mg...... 183 solution (2.5 mg/3ml) 0.083%, 0.63 all day relief...... 10 allergy relief oral capsule 25 mg...... 183 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml...... 190 ALLEGRA ALLERGY...... 182 allergy relief oral liquid 25 mg/10ml...... 183 ALBUTEROL SULFATE NEBULIZATION ALLEGRA ALLERGY CHILDRENS...... 182 allergy relief oral tablet 10 mg...... 183 SOLUTION (5 MG/ML) 0.5% INHALATION ALLEGRA-D ALLERGY & CONGESTION allergy relief oral tablet 180 mg...... 183 ...... 190 ORAL TABLET EXTENDED RELEASE 12 allergy relief oral tablet 25 mg...... 183 albuterol sulfate nebulization solution (5 HOUR...... 193 allergy relief oral tablet 4 mg...... 183 mg/ml) 0.5% inhalation...... 190 ALLEGRA-D ALLERGY & CONGESTION allergy relief oral tablet 60 mg...... 183 albuterol sulfate oral...... 190 ORAL TABLET EXTENDED RELEASE 24 allergy relief oral tablet chewable 12.5 mg.183 ALCAINE...... 172 HOUR...... 193 allergy relief oral tablet dispersible 10 mg..183 alclometasone dipropionate...... 68 aller-chlor...... 182 allergy relief oral tablet extended release alcohol prep pads external 70 %...... 24 aller-ease...... 182 12 mg...... 182 ALCOHOL PREP PADS EXTERNAL 70 %. 24 allergy & congestion...... 193

219 allergy relief/indoor/outdoor oral tablet 10 altachlore ophthalmic ointment...... 172 AMINOPMRMS...... 97 mg...... 183 altachlore ophthalmic solution...... 172 aminoreliefrms...... 158 allergy relief/indoor/outdoor oral tablet 180 altafrin ophthalmic solution 10 %...... 172 aminos...... 158 mg...... 183 altafrin ophthalmic solution 2.5 %...... 172 amiodarone hcl oral tablet 100 mg...... 55 allergy relief/nasal decongest oral tablet altalube...... 172 amiodarone hcl oral tablet 200 mg, 400 mg.55 extended release 12 hour...... 193 altamist spray...... 194 AMITIZA...... 125 allergy relief/nasal decongest oral tablet altarussin...... 194 AMLODIPINE BES+SYRSPEND SF...... 57 extended release 24 hour...... 193 altarussin dm...... 194 amlodipine besylate oral...... 57 allergy relief-d oral tablet extended release altarussin-pe...... 194 amlodipine besylate-benazepril hcl...... 58 12 hour 5-120 mg...... 193, 194 altavera...... 141 amlodipine besylate-valsartan...... 58 allergy relief-d oral tablet extended release ALTOPREV...... 61 amlodipine-atorvastatin...... 58 24 hour 10-240 mg...... 194 ALTRENO...... 68 amlodipine-olmesartan...... 58 allergy relief-d12...... 194 alum & mag hydroxide-simeth...... 114 amlodipine-valsartan-hctz...... 58 allergy spray 24 hour nasal aerosol...... 188 alum sulfate-ca acetate...... 68 ammonium lactate external...... 68 allergy/congestion relief...... 194 alumina-magnesia-simethicone...... 114 amnesteem oral capsule 10 mg, 20 mg...... 68 allergy-d allergy & conges...... 194 ALVESCO...... 188 amnesteem oral capsule 40 mg...... 68 allergy-time...... 183 alyacen 1/35...... 141 amoxicill-clarithro-lansopraz...... 114 ALLI...... 63 alyacen 7/7/7...... 142 amoxicillin oral capsule 250 mg...... 28 allopurinol oral...... 37 alyq...... 191 amoxicillin oral capsule 500 mg...... 28 ALLZITAL...... 4 ALZAIR ALLERGY NASAL SPRAY...... 194 amoxicillin oral suspension reconstituted.....28 almacone double strength...... 114 amabelz...... 142 amoxicillin oral tablet...... 28 almotriptan malate...... 39 amantadine hcl oral capsule...... 45 amoxicillin oral tablet chewable...... 28 ALOCRIL...... 177 amantadine hcl oral syrup...... 45 amoxicillin-potassium clavulanate er...... 28 ALOE VESTA CLEAR ANTIFUNGAL...... 33 amantadine hcl oral tablet...... 45 amoxicillin-potassium clavulanate oral ALOE VESTA DAILY MOISTURIZER...... 68 AMARYL...... 49 suspension reconstituted 200-28.5 mg/5ml, ALOGLIPTIN BENZOATE...... 48 ambrisentan...... 191 400-57 mg/5ml...... 28 ALOGLIPTIN-METFORMIN HCL...... 48 amcinonide...... 68 amoxicillin-potassium clavulanate oral ALOGLIPTIN-PIOGLITAZONE...... 48 AMELUZ...... 68 suspension reconstituted 250-62.5 mg/5ml. 28 ALOMIDE...... 177 AMERGE...... 39 amoxicillin-potassium clavulanate oral ALORA...... 141 americerin...... 68 suspension reconstituted 600-42.9 mg/5ml. 28 alosetron hcl...... 125 amethia...... 142 amoxicillin-potassium clavulanate oral ALPHAGAN P...... 178 amethia lo...... 142 tablet 250-125 mg, 875-125 mg...... 28 alph-e...... 97 amethyst...... 142 amoxicillin-potassium clavulanate oral alph-e-mixed 1000...... 97 amiloride hcl oral...... 60 tablet 500-125 mg...... 28 alph-e-mixed oral capsule 200 unit...... 97 amiloride-hydrochlorothiazide...... 58 amoxicillin-potassium clavulanate oral alph-e-mixed oral capsule 400 unit...... 97 amino action...... 158 tablet chewable 200-28.5 mg, 400-57 mg....28 ALREX...... 179 aminoamrms...... 158 ampicillin...... 28 ALTABAX...... 24 aminobenzoate potassium...... 97 AMPYRA...... 64 ALTACE...... 55 aminofen...... 4 AMRIX...... 213

220 AMZEEQ...... 68 antacid calcium rich...... 114 anti-diarrheal oral suspension 262 mg/15ml ANACAINE...... 18 antacid extra...... 114 ...... 116 ANADROL-50...... 141 antacid extra strength oral suspension...... 114 anti-diarrheal oral tablet 2 mg...... 116 anagrelide hcl...... 53 antacid extra strength oral tablet chewable antifungal external cream 1 %...... 33 ana-lex...... 68 160-105 mg...... 114 antifungal external cream 2 %...... 33 ANALPRAM HC...... 154 antacid extra strength oral tablet chewable antifungal external powder...... 158 ANALPRAM HC SINGLES...... 154 750 mg...... 114 anti-fungal external powder...... 158 ANALPRAM-HC...... 154 antacid fast relief...... 114 anti-gas...... 116 ANASPAZ...... 113 antacid i...... 114 anti-hist allergy...... 183 anastrozole oral...... 42 antacid iii...... 114 antihistamine & nasal deconges...... 194 ANBESOL MAXIMUM STRENGTH antacid kids...... 114 anti-nausea...... 32 MOUTH/THROAT GEL...... 65 antacid liquid...... 115 anti-nausea/rekematol...... 32 ANBESOL MOUTH/THROAT GEL...... 65 antacid m...... 115 anucort-hc...... 38 ANCOBON...... 33 antacid maximum...... 115 ANUSOL-HC EXTERNAL...... 155 ANDRODERM...... 141 antacid maximum strength...... 115 ANUSOL-HC RECTAL...... 38 ANDROGEL...... 141 antacid maximum strength oral tablet ANZEMET...... 33 ANDROGEL PUMP...... 141 chewable 1000 mg...... 115 APADAZ...... 16 anecream external cream...... 19 antacid oral suspension...... 115 apap-caff-dihydrocodeine...... 16 anefrin spray...... 194 antacid oral tablet chewable 1000 mg...... 115 APETEX...... 97 ANGELIQ...... 142 antacid oral tablet chewable 500 mg...... 115 APETIGEN...... 97 animal shapes...... 97 antacid oral tablet chewable 750 mg...... 115 APETIGEN-PLUS...... 97 animal shapes plus extra c...... 97 antacid plus antigas...... 115 APEXICON E...... 68 animal shapes plus iron...... 97 antacid plus anti-gas fast act...... 115 APIDRA SOLOSTAR...... 51 animal shapes/iron...... 97 antacid plus anti-gas relief...... 115 APIDRA VIAL...... 51 ANIMI-3...... 97 antacid regular strength...... 115 aplicare povidone-iodine external solution... 24 ANIMI-3/VITAMIN D...... 97 antacid supreme...... 115 APOKYN...... 46 ANNOVERA...... 142 antacid ultra strength oral tablet chewable apra...... 4 ANODYNE LPT...... 19 1000 mg...... 115 apraclonidine hcl...... 178 ANORO ELLIPTA...... 194 antacid/anti-gas...... 115 aprepitant...... 33 antacid & anti-gas oral suspension 200- antacid/simethicone ds...... 115 apri...... 142 200-20 mg/5ml...... 114 ANTARA...... 60 APRISO...... 154 antacid & anti-gas oral suspension 400- antibiotic...... 24 APRIZIO PAK...... 19 400-40 mg/5ml...... 114 antibiotic pain/scar...... 24 APRIZIO PAK II...... 19 antacid advanced...... 114 anticoagulant cit dext soln a...... 52 aprodine...... 194 antacid anti-gas...... 114 anti-dandruff...... 68 AQUADEKS...... 97 antacid anti-gas max strength...... 114 anti-diarr/ant-gas...... 115 AQUAPHILIC...... 68 antacid anti-gas reg strength...... 114 anti-diarrheal oral liquid 1 mg/5ml...... 115 AQUAPHOR...... 68 antacid calcium...... 114 anti-diarrheal oral liquid 1 mg/7.5ml...... 115 aqueous vitamin d...... 97 antacid calcium extra strength...... 114 aqueous vitamin e...... 86

221 AQUORAL...... 65 ascocid-iso-ph...... 97 ASSESS LOW RANGE PEAK METER...... 158 ARAKODA...... 44 ascomp-codeine...... 16 ASTAGRAF XL...... 151 aranelle...... 142 ascorbic acid oral powder...... 97 ASTERO...... 19 ARANESP (ALBUMIN FREE)...... 53 ascorbic acid oral tablet 500 mg...... 97 asthmanefrin refill...... 190 ARAVA...... 153 asco-tabs-1000...... 97 astringent eye drops...... 172 ARAZLO...... 68 ashlyna...... 142 astringent solution...... 68 ARCAPTA NEOHALER...... 190 asilnasalrms...... 97 ASTRINGYN...... 53 arginine...... 158 ASMANEX (120 METERED DOSES)...... 188 atabex dha 200...... 158 ARICEPT...... 31 ASMANEX (14 METERED DOSES)...... 188 ATABEX EC...... 98 ARIDA...... 158 ASMANEX (30 METERED DOSES) ATABEX OB...... 98 ARIKAYCE...... 23 INHALATION AEROSOL POWDER ATACAND...... 54 ARIMIDEX...... 42 BREATH ACTIVATED 110 MCG/INH...... 188 ATACAND HCT...... 58 ARIXTRA...... 52 ASMANEX (30 METERED DOSES) ATELVIA...... 156 ARMONAIR DIGIHALER...... 188 INHALATION AEROSOL POWDER atenolol oral...... 56 ARMOUR THYROID ORAL TABLET 120 BREATH ACTIVATED 220 MCG/INH...... 188 ATENOLOL+SYRSPEND SF...... 56 MG, 60 MG...... 148 ASMANEX (60 METERED DOSES)...... 188 atenolol-chlorthalidone...... 58 ARMOUR THYROID ORAL TABLET 15 ASMANEX (7 METERED DOSES)...... 188 athletes foot (terbinafine)...... 33 MG, 30 MG, 90 MG...... 148 ASMANEX HFA...... 188 athletes foot external aerosol powder 2 %... 33 ARMOUR THYROID ORAL TABLET 180 ASPARTAME...... 158 athletes foot external cream 1 %...... 33 MG, 240 MG, 300 MG...... 148 ASPARTAME (NUTRASWEET)...... 158 athletes foot powder spray external aerosol ARNUITY ELLIPTA...... 188 aspartate mg & k...... 86 powder 1 %...... 33 AROMASIN...... 42 aspirin 81 oral tablet delayed release...... 10 athletes foot powder spray external aerosol arthritis pain oral tablet extended release aspirin adult...... 10 powder 2 %...... 33 650 mg...... 4 aspirin adult low dose...... 10 athletes foot spray...... 33 arthritis pain relief oral tablet extended aspirin adult low st...... 10 ATOPADERM...... 68 release 650 mg...... 4 aspirin adult low strength...... 10 ATOPICLAIR...... 69 arthritis pain reliever oral...... 4 aspirin childrens...... 10 atorvastatin calcium oral...... 61 ARTHRITIS PAIN RELIEVING...... 68 aspirin ec...... 11 atovaquone oral...... 44 ARTHROTEC...... 10 aspirin ec low dose...... 11 atovaquone-proguanil hcl...... 44 artificial tears ophthalmic solution 0.5-0.6 aspirin ec low strength...... 11 ATRALIN...... 69 %, 5-6 mg/ml...... 172 aspirin low dose...... 11 atropine sulfate ophthalmic ointment...... 172 artificial tears ophthalmic solution 1.4 %.... 172 aspirin low strength...... 11 ATROPINE SULFATE OPHTHALMIC artificial tears ophthalmic solution 1-0.3 %.172 aspirin oral...... 11 SOLUTION 0.01 %...... 172 ARYMO ER...... 16 aspirin rectal...... 11 atropine sulfate ophthalmic solution 1 %....172 arzol silver nit applicators...... 24 aspirin-dipyridamole er...... 53 ATROVENT HFA...... 189 ASACOL HD...... 154 ASPIRIN-OMEPRAZOLE...... 53 AUBAGIO...... 64 ASCOCID...... 97 aspirtab...... 11 aubra...... 142 ASCOCID-1000...... 97 aspirtab maximum strength...... 11 aubra eq...... 142 ASCOCID-500-D...... 97 ASSESS FULL RANGE PEAK METER..... 158 AUGMENTIN...... 28

222 AUGMENTIN ES-600...... 28 AXONA...... 159 b complex-c oral capsule...... 98 auraphene-b...... 180 AXSAIN...... 4 b complex-folic acid...... 98 aurodryl allergy childrens...... 183 AYGESTIN...... 147 b-1...... 98 aurophen childrens...... 4 AYR...... 194 b-100 balanced tr...... 98 aurovela 1.5/30...... 142 AYR NASAL MIST ALLERGY/SINUS...... 194 b-100 complex cr...... 98 aurovela 1/20...... 142 AYR SALINE NASAL...... 194 b12...... 98 aurovela 24 fe...... 142 AYR SALINE NASAL DROPS...... 194 b12 gummies...... 98 aurovela fe 1.5/30...... 142 AYR SALINE NASAL NO-DRIP...... 194 b-12 oral liquid 1000 mcg/15ml...... 98 aurovela fe 1/20...... 142 ayuna...... 142 b-12 oral tablet 1000 mcg, 500 mcg...... 98 AURYXIA...... 97 AZADROX...... 159 b12 quick dissolve...... 98 AUSTEDO ORAL TABLET 12 MG, 9 MG....63 AZALGIA...... 159 b-12 sublingual tablet sublingual 2500 AUSTEDO ORAL TABLET 6 MG...... 63 AZASAN...... 151 mcg, 5000 mcg...... 98 AUTOJECT 2...... 158 AZASITE...... 177 B-2-400...... 98 AUTOLET II CLINISAFE...... 158 azathioprine oral...... 151 b-50 balanced...... 98 AUTOLET LANCING DEVICE...... 158 azec...... 98 b6...... 98 AUTOLET LITE STARTER PACK...... 158 azelaic acid external...... 69 b-6 folic acid...... 98 AUTOLET MINI...... 159 AZELAIC ACID-NIACINAMIDE...... 69 BABY ANBESOL...... 65 AUTOPEN...... 159 azelastine hcl nasal...... 183 BABY AYR SALINE...... 194 AUVI-Q...... 190 azelastine hcl ophthalmic...... 177 baby teething oral pain...... 65 AVAILNEX...... 159 azelastine-fluticasone...... 194 BACICAP...... 116 AVALIDE...... 58 AZELEX...... 69 bacitracin external...... 24 AVANDIA...... 49 AZESCHEW PRENATAL/POSTNATAL...... 98 bacitracin ophthalmic...... 177 AVAPRO...... 54 AZESCO...... 98 bacitracin zinc external...... 24 avar cleanser...... 69 AZILECT...... 46 bacitracin-polymyxin b ophthalmic...... 172 AVAR LS CLEANSER...... 69 azithromycin oral packet...... 28 bacitra-neomycin-polymyxin-hc...... 172 AVAR-E EMOLLIENT...... 69 azithromycin oral suspension reconstituted. 28 BACLOFEN EXTERNAL...... 47 AVAR-E GREEN...... 69 azithromycin oral tablet...... 28 baclofen oral...... 213 AVAR-E LS...... 69 azo tabs...... 137 BACMIN...... 98 AVEIDAOXIA...... 69 AZOLEN TINCTURE...... 33 BACTRIM...... 29 aviane...... 142 AZOPT...... 178 BACTRIM DS...... 29 avidoxy...... 29 AZOR...... 58 BAFIERTAM...... 63 AVIDOXY DK...... 29 AZULFIDINE...... 155 balance b-100...... 98 avita...... 69 AZULFIDINE EN-TABS...... 155 balance b-50...... 98 AVITENE...... 159 azurette...... 142 balanced b100...... 98 AVITENE FLOUR...... 159 b complex formula 1...... 98 balanced b50...... 98 avo cream...... 159 b complex oral capsule...... 98 BALCOLTRA...... 142 AVODART...... 137 b complex plus c...... 98 balsalazide disodium...... 154 AVONEX PEN...... 64 b complex vitamins...... 98 balziva...... 142 AVONEX PREFILLED...... 64 b complex-biotin-fa...... 98 banophen oral capsule 25 mg...... 183

223 banophen oral tablet...... 183 BENZALKONIUM CHLORIDE EXTERNAL betamethasone dipropionate external...... 70 BAQSIMI ONE PACK...... 50 SOLUTION...... 24 betamethasone valerate external cream...... 70 BAQSIMI TWO PACK...... 50 benzalkonium chloride external solution 50 betamethasone valerate external foam...... 70 BARACLUDE ORAL SOLUTION...... 47 %...... 24 betamethasone valerate external lotion...... 70 BASAGLAR KWIKPEN...... 51 BENZAMYCIN...... 69 betamethasone valerate external ointment.. 70 BASLE...... 69 benzepro creamy wash...... 69 BETAPACE...... 55 BAXDELA...... 29 BENZEPRO EXTERNAL...... 69 BETAPACE AF...... 55 BAYER ASPIRIN...... 11 BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 betasept surgical scrub...... 70 BAYER ASPIRIN EC LOW DOSE...... 11 %...... 69 BETASERON...... 64 b-caro-t...... 98 benzepro external foam 5.3 %...... 69 betatemp childrens...... 4 b-complex/b-12 oral...... 98 BENZEPRO EXTERNAL LIQUID...... 69 betaxolol hcl ophthalmic...... 178 BD ULTRA-FINE INSULIN SYRINGES benzepro foaming cloths...... 69 betaxolol hcl oral...... 56 29G X 1/2" 0.3 ML...... 159 BENZEPRO SHORT CONTACT...... 69 bethanechol chloride oral...... 137 BD ULTRA-FINE INSULIN SYRINGES BENZHYDROCODONE- BETHKIS...... 191 30G X 1/2" 0.3 ML...... 159 ACETAMINOPHEN...... 16 BETIMOL...... 178 BEAU RX...... 69 BENZNIDAZOLE...... 44 BETOPTIC-S...... 178 beauty 360 pure glycerin...... 69 BENZODOX...... 29 BEVESPI AEROSPHERE...... 194 BECONASE AQ...... 188 BENZOIN...... 69 bexarotene...... 43 bee pollen oral capsule 580 mg...... 159 benzoin compound...... 69 BEXSERO...... 153 BEELITH...... 86 BENZO-LIDOCAINE-TETRACAINE...... 19 BEYAZ...... 142 BEHAVIORAL HEALTH APP...... 159 benzonatate oral capsule 100 mg...... 194 BIAFINE...... 159 bekyree...... 142 benzonatate oral capsule 150 mg...... 194 bicalutamide...... 41 BELBUCA...... 15 benzonatate oral capsule 200 mg...... 194 bidex...... 194 belladonna alkaloids-opium...... 113 BENZOYL PEROX-HYDROCORTISONE... 70 BIDIL...... 58 BENADRYL ALLERGY CHILDRENS benzoyl peroxide external foam...... 70 BI-EST 80:20 PROGESTERONE...... 142 ORAL LIQUID...... 183 BENZOYL PEROXIDE EXTERNAL GEL BIEST/PROGESTERONE...... 142 BENADRYL ALLERGY CHILDRENS 6.5 %...... 70 BIIFENAC 1000...... 11 ORAL TABLET CHEWABLE...... 183 BENZOYL PEROXIDE EXTERNAL GEL 8 BIIFENAC 500...... 11 BENADRYL ALLERGY ORAL TABLET.....183 %...... 70 BIJUVA...... 142 benazepril hcl oral...... 55 BENZOYL PEROXIDE FORTE- HC...... 70 BILTRICIDE...... 43 benazepril-hydrochlorothiazide...... 58 benzoyl peroxide-erythromycin...... 70 bimatoprost ophthalmic...... 180 BENICAR...... 54 BEPREVE...... 177 BINOSTO...... 156 BENICAR HCT...... 58 BESER EXTERNAL KIT...... 70 bio glo...... 173 BENLYSTA SUBCUTANEOUS...... 153 beser external lotion...... 70 biocel...... 98 BENSAL HP...... 69 BESIVANCE...... 177 bioflavonoid-1000...... 98 BENZ PER-CLIND-NIACIN-TRETIN...... 69 beta carotene oral capsule 25000 unit...... 98 bioflex...... 98 BENZAC AC WASH...... 69 BETADINE EXTERNAL SOLUTION 10 %...24 bio-immunex...... 98 BENZACLIN...... 69 BETADINE OPHTHALMIC PREP...... 24 biolle tears...... 173 BENZACLIN WITH PUMP...... 69 betamethasone dipropionate aug...... 70 bion tears pf...... 173

224 BIONECT EXTERNAL CREAM...... 159 boro-packs...... 70 BUBBLES THE FISH II PEDI MASK...... 159 BIONECT EXTERNAL FOAM...... 159 bosentan...... 191 budesonide er...... 155 biopetit...... 98 BOUDREAUXS BABY BUTT SMOOTH...... 70 budesonide inhalation...... 188 BIO-STATIN ORAL CAPSULE...... 33 boudreauxs butt paste external ointment budesonide oral...... 155 bio-statin oral powder...... 33 40 %...... 70 BUDESONIDE-FORMOTEROL biotin forte oral tablet 3 mg...... 98 bp 10-1...... 70 FUMARATE...... 195 biotin forte oral tablet 5 mg...... 98 bp cleansing wash...... 70 BUFFERIN...... 11 biotin high potency...... 98 bp vit 3...... 98 bumetanide oral...... 60 biotin oral capsule 5000 mcg...... 98 bp wash external liquid 2.5 %...... 70 BUMEX...... 60 biotin oral tablet 1000 mcg...... 98 bp wash external liquid 7 %...... 70 BUPAP...... 4 biotin oral tablet 5 mg...... 98 b-plex...... 98 buprenorphine transdermal...... 15 biotinex...... 116 b-plex plus...... 98 bupropion hcl er (smoking det)...... 22 bisacodyl ec...... 126 bprotected pedia d-vite...... 98 butalbital-acetaminophen capsule 50-300 bisacodyl laxative...... 126 bprotected pedia iron...... 86 mg oral...... 4 bisacodyl rectal...... 126 bprotected pedia poly-vite...... 98 BUTALBITAL-ACETAMINOPHEN bisa-lax...... 126 bprotected pedia poly-vite/fe...... 99 CAPSULE 50-300 MG ORAL...... 4 bismatrol maximum strength...... 116 bprotected vitamin c...... 99 butalbital-acetaminophen oral tablet 25- bismatrol oral suspension...... 116 BRAFTOVI...... 42 325 mg...... 4 bismatrol oral tablet chewable...... 116 BREATHE EASE HUMIDIFIER...... 159 butalbital-acetaminophen oral tablet 50- bismuth...... 116 BREATHE EASE NEB MASK/CHILD...... 159 300 mg...... 4 bismuth subsalicylate oral suspension...... 116 BREATHE EASE NEB MASK/INFANT...... 159 butalbital-acetaminophen oral tablet 50- bismuth subsalicylate oral tablet chewable 116 BREO ELLIPTA...... 194 325 mg...... 4 bisoprolol fumarate...... 56 brewers yeast oral tablet 487.5 mg...... 99 butalbital-apap-caff-cod...... 16 bisoprolol-hydrochlorothiazide...... 58 BREZTRI AEROSPHERE...... 182 butalbital-apap-caffeine oral capsule 50- BLEPH-10...... 29 briellyn...... 142 300-40 mg...... 4 BLEPHAMIDE...... 173 BRILINTA...... 53 butalbital-apap-caffeine oral capsule 50- BLEPHAMIDE S.O.P...... 173 brimonidine tartrate ophthalmic solution 325-40 mg...... 4 blisovi 24 fe...... 142 0.15 %...... 178 butalbital-apap-caffeine oral tablet...... 4 blisovi fe 1.5/30...... 142 brimonidine tartrate ophthalmic solution 0.2 butalbital-asa-caff-codeine...... 16 blisovi fe 1/20...... 142 %...... 178 butalbital-aspirin-caffeine oral capsule...... 4 BLOOD GLUCOSE TEST STRIPS...... 159 BRIMONIDINE-DORZOLAMIDE...... 178 butalbital-aspirin-caffeine oral tablet...... 4 blue tube/ aloe...... 19 bromase...... 99 butorphanol tartrate nasal...... 16 BLUESTAR...... 159 bromfed dm...... 194 BUTRANS...... 15 bonine...... 32 bromfenac sodium (once-daily)...... 179 BYDUREON...... 49 BONIVA INTRAVENOUS...... 156 bromocriptine mesylate oral...... 46 BYDUREON BCISE AUTOINJECTOR...... 49 BONIVA ORAL...... 156 BROMSITE...... 179 BYETTA 10 MCG PEN...... 49 BONJESTA...... 32 BROVANA...... 190 BYETTA 5 MCG PEN...... 49 BOOSTRIX...... 153 BRYHALI...... 70 BYNFEZIA PEN...... 150 borage...... 159 b-stress...... 99 BYSTOLIC...... 56

225 c 1000-bioflavonoids-rose hips...... 99 calcium acetate oral...... 97 calcium/vitamin d/minerals...... 88 c 250 oral tablet...... 99 calcium antacid...... 116 calcium-folic acid plus d...... 99 c 500/rose hips...... 99 calcium antacid extra strength...... 116 calcium-magnesium-zinc oral tablet 333- c complex...... 99 calcium antacid ultra max st...... 116 133-5 mg, 333.33-133.33-5 mg...... 88 c-1000/rose hips...... 99 calcium antacid ultra strength...... 116 calcium-vitamin d oral tablet 500-200 mg- cabergoline...... 150 calcium carbonate antacid oral suspension116 unit...... 88 CABLIVI...... 53 calcium carbonate antacid oral tablet...... 116 calcium-vitamin d oral tablet 600-200 mg- CADEAU DHA...... 99 calcium carbonate antacid oral tablet unit, 600-400 mg-unit...... 88 CADIRAMD...... 19 chewable...... 116 calcium-vitamin d3 oral tablet 600-400 mg- CADUET...... 58 calcium carbonate oral tablet 600 mg...... 87 unit...... 88 CAFERGOT...... 38 calcium carbonate oral tablet chewable cal-gest antacid...... 116 caffeine citrate oral...... 63 1250 (500 ca) mg...... 87 cal-glu...... 88 cal mag zinc +d3...... 87 calcium carbonate oral tablet chewable calicylic...... 71 calamine external lotion...... 70 500 mg...... 116 cal-lac...... 88 CALAN SR...... 57 calcium carbonate-vitamin d oral tablet cal-mag aspartate...... 88 calcidol...... 99 600-400 mg-unit...... 87 CALNA...... 99 calciferol...... 99 calcium carbonate-vitamin d3...... 87 CALTRATE GUMMY BITES...... 88 CALCIFOL...... 99 calcium citrate + d oral tablet 315-250 mg- CAMBIA...... 38 calcipotriene external cream...... 70 unit...... 87 camila...... 147 CALCIPOTRIENE EXTERNAL FOAM...... 70 calcium citrate + d3 maximum...... 87 CAMINO PRO COMPLETE/GLYTACTIN.. 159 calcipotriene external ointment...... 70 calcium citrate + oral tablet 315-200 mg- camrese...... 142 calcipotriene external solution...... 70 unit...... 87 camrese lo...... 142 calcipotriene-betameth diprop...... 70 calcium citrate +d3...... 87 CANASA...... 154 CALCIPOTRIENE-CLOBETASOL PROP....71 calcium citrate malate-vit d...... 87 candesartan cilexetil...... 54 calcitonin (salmon)...... 156 calcium citrate oral tablet 1040 mg...... 87 candesartan cilexetil-hctz...... 58 cal-citrate...... 87 calcium citrate+d maximum...... 87 CANTHARIDIN EXTERNAL...... 159 calcitrate oral tablet 950 mg...... 87 calcium citrate+d3...... 87 capcof...... 195 CALCITRENE...... 71 calcium citrate+d3 petites...... 87 capecitabine...... 41 calcitriol external...... 71 calcium citrate+d3 w/magne...... 87 CAPEX...... 71 calcitriol oral capsule...... 157 calcium citrate-vitamin d oral tablet 200- capsaicin external cream 0.025 %...... 4 calcitriol oral solution...... 157 125 mg-unit, 315-200 mg-unit...... 87 capsaicin external cream 0.1 %...... 71 calcium 1200...... 87 calcium high potency...... 88 capsaicin hp...... 71 calcium 500 +d3...... 87 calcium high potency/vitamin d...... 88 CAPSAICIN-MENTHOL...... 4 calcium 500/d...... 87 calcium oral tablet 600 mg...... 88 CAPSFENAC PAK...... 11 calcium 600...... 87 calcium oyster shell oral tablet 1250 (500 CAPSINAC...... 11 calcium 600/d...... 87 ca) mg...... 88 captopril oral...... 55 calcium 600+d oral tablet 600-200 mg-unit, calcium plus 600 +d...... 88 captopril-hydrochlorothiazide...... 58 600-400 mg-unit...... 87 calcium plus vitamin d oral tablet...... 88 capzasin-p...... 4 calcium acetate (phos binder)...... 97 calcium polycarbophil...... 126 capzix...... 71

226 CARAC...... 71 cascara sagrada oral fluid extract...... 126 CENTRUM FLAVOR BURST...... 99 CARAFATE...... 134 CASODEX...... 41 CENTRUM FLAVOR BURST ADULT...... 99 carbidopa oral...... 46 CASTIVA WARMING...... 4 CENTRUM FLAVOR BURST KIDS...... 99 carbidopa-levodopa er...... 46 CATAPRES...... 54 CENTRUM FRESH/FRUITY 50+...... 99 carbidopa-levodopa oral tablet...... 46 CATAPRES-TTS-1...... 54 CENTRUM KIDS...... 99 carbidopa-levodopa oral tablet dispersible...46 CATAPRES-TTS-2...... 54 CENTRUM MULTI + OMEGA 3...... 99 carbidopa-levodopa-entacapone...... 46 CATAPRES-TTS-3...... 54 CENTRUM ORAL TABLET CHEWABLE.....99 carbinoxamine maleate oral solution...... 184 cavarest...... 65 CENTRUM SILVER ORAL TABLET carbinoxamine maleate oral tablet 4 mg.... 184 cavilon...... 33 CHEWABLE...... 99 carbinoxamine maleate oral tablet 6 mg.... 184 CAYA...... 159 CENTRUM SPECIALIST PRENATAL...... 99 CARDIOVID PLUS...... 159 CAYSTON...... 191 CENTRUM VITAMINTS...... 99 CARDIZEM...... 57 caziant...... 142 cephalexin...... 27 CARDIZEM CD...... 57 CBD4 FREEZE PUMP MAXIMUM STR...... 19 CEQUA...... 173 CARDIZEM LA...... 57 cefaclor er...... 27 CEQUR SIMPLICITY 2U...... 159 CARDURA...... 54 cefaclor oral capsule...... 27 CERACADE...... 71 CARDURA XL...... 137 cefaclor oral suspension reconstituted...... 27 CEREFOLIN...... 99 CAREONE ADVANCED LANCING DEV... 159 cefadroxil oral capsule...... 27 cerefolin nac...... 99 CARETOUCH 2 CPAP HOSE HANGER... 159 cefadroxil oral suspension reconstituted...... 27 cerovel...... 71 CARETOUCH CONTROL SOL LEVEL 2.. 159 cefadroxil oral tablet...... 27 cerovite jr...... 99 CARETOUCH CPAP & BIPAP HOSE...... 159 cefazolin sodium-dextrose intravenous CERVIDIL...... 137 CARETOUCH CPAP MASK WIPES...... 159 solution 2-4 gm/100ml-%...... 27 CETACAINE EXTERNAL AEROSOL...... 19 CARETOUCH CPAP PRE-WASH SOLN.. 159 cefdinir oral capsule...... 27 cetirizine hcl childrens oral tablet chewable CARETOUCH CPAP TUBE BRUSH...... 159 cefdinir oral suspension reconstituted...... 27 ...... 184 CARETOUCH LANCING/EJECTOR...... 159 cefixime oral capsule...... 27 cetirizine hcl oral solution...... 184 CARETOUCH MONITOR SYSTEM...... 159 cefixime oral suspension reconstituted...... 27 cetirizine hcl oral tablet...... 184 CARETOUCH TEST...... 159 cefpodoxime proxetil oral suspension cetirizine hcl oral tablet chewable...... 184 CARETOUCH UNIVERSL CPAP FILTER. 159 reconstituted...... 27 cetirizine-pseudoephedrine er...... 195 carisoprodol oral...... 213 cefpodoxime proxetil oral tablet...... 27 CETRAXAL...... 180 carisoprodol-aspirin-codeine...... 16 cefprozil oral suspension reconstituted...... 27 cevimeline hcl...... 65 carnitine oral capsule 250 mg...... 159 cefprozil oral tablet...... 27 CHANTIX...... 22 caroguard...... 99 cefuroxime axetil...... 27 CHANTIX CONTINUING MONTH PAK...... 22 CAROSPIR...... 60 CELEBREX...... 11 CHANTIX STARTING MONTH PAK...... 22 carrington antifungal...... 33 celecoxib oral...... 11 charlotte 24 fe...... 142 CARRINGTON MOIST BARRIER/ZINC...... 71 CELLCEPT...... 151 chateal...... 142 CARRINGTON MOISTURE BARRIER...... 71 CEM-UREA...... 71 chateal eq...... 142 carteolol hcl...... 178 CENFOL...... 99 CHEMET...... 96 cartia xt...... 57 CENTANY...... 24 CHEMSTRIP 10 MD...... 159 carvedilol...... 56 CENTANY AT...... 24 CHEMSTRIP 10/SG...... 159 carvedilol phosphate er...... 56 CENTRATEX...... 88 CHEMSTRIP 2 GP...... 160

227 CHEMSTRIP 5 OB...... 160 childrens tactinal...... 5 cilostazol...... 53 CHEMSTRIP 7...... 160 childrens vitamins/iron...... 99 CILOXAN...... 177 CHEMSTRIP 9...... 160 childs non-aspirin...... 5 cimetidine hcl...... 125 CHEMSTRIP K...... 160 CHLOOXIA...... 71 cimetidine oral...... 125 CHEMSTRIP UGK...... 160 chlordiazepoxide-clidinium...... 113 CIMETIDINE-LIDO-SALICYLIC ACID...... 71 CHENODAL...... 116 chlorella oral capsule...... 99 CIMZIA...... 151 cherry cough drops...... 65 chlorhexidine gluconate external liquid 4 %. 71 cinacalcet hcl...... 156 cherry menthol drops...... 65 chlorhexidine gluconate mouth/throat...... 65 CINQAIR...... 195 chest congest/cough child...... 195 chloroquine phosphate oral...... 44 CIPRO HC...... 180 chest congestion relief...... 195 chlorpheniramine maleate er...... 182 CIPRO ORAL SUSPENSION chest congestion relief dm...... 195 chlorpheniramine maleate oral...... 184 RECONSTITUTED...... 29 CHEW-12...... 99 chlorthalidone...... 60 CIPRO ORAL TABLET...... 29 chewable c with rose hips...... 99 CHLOR-TRIMETON ALLERGY...... 182 CIPRODEX...... 180 chewable childrens vitamin...... 99 CHLOR-TRIMETON ORAL SYRUP...... 182 ciprofloxacin hcl ophthalmic...... 177 chew-c...... 99 CHLOR-TRIMETON ORAL TABLET...... 184 ciprofloxacin hcl oral...... 29 chewy not chalky flavor...... 116 chlorzoxazone...... 214 ciprofloxacin hcl otic...... 180 child chewable vitamins/iron...... 99 chocolate laxative pieces...... 126 ciprofloxacin-dexamethasone...... 180 childrens acetaminophen oral suspension chocolated laxative...... 126 CIPROFLOXACIN-FLUOCINOLONE PF...180 160 mg/5ml...... 4 CHOICE DM DIABETES RISK TEST...... 160 CITRANATAL 90 DHA...... 100 childrens acetaminophen oral tablet CHOICEFUL MULTIVITAMIN ORAL CITRANATAL ASSURE...... 100 dispersible...... 4 TABLET CHEWABLE...... 99 CITRANATAL B-CALM...... 100 childrens allergy...... 184 CHOLBAM...... 136 CITRANATAL BLOOM...... 100 childrens animal shapes...... 99 CHOLECAL DF...... 99 CITRANATAL BLOOM DHA...... 100 childrens apap...... 4 cholestyramine light...... 61 CITRANATAL DHA...... 100 childrens aspirin...... 11 cholestyramine oral...... 61 CITRANATAL ESSENCE...... 215 childrens aspirin low strength...... 11 choline...... 160 CITRANATAL HARMONY...... 100 childrens chewable vitamins...... 99 chorionic gonadotropin intramuscular...... 140 CITRANATAL MEDLEY...... 100 childrens chewables/ex c...... 99 chromagen...... 88 CITRANATAL RX...... 100 childrens chewables/iron...... 99 CIALIS ORAL TABLET 5 MG...... 137 citrate of magnesia...... 126 childrens cold & allergy...... 195 ciclodan...... 33 citroma...... 126 childrens complete...... 99 ciclopirox external...... 34 CITRUCEL...... 126 childrens cough...... 195 ciclopirox olamine external cream...... 34 CITRULLINE 1000...... 160 childrens easy-melts...... 5 ciclopirox olamine external suspension...... 34 citrus calcium/vitamin d...... 88 childrens loratadine...... 184 ciclopirox treatment...... 34 claravis capsule 30 mg oral...... 71 childrens medi-tabs...... 5 CICLOPIROX-CLOBETASOL...... 71 claravis oral capsule 10 mg, 20 mg, 40 mg..71 childrens mucus relief cough...... 195 CICLOPIROX-CLOBETASOL-SAL ACID.... 71 CLARINEX...... 184 childrens non-aspirin...... 5 CICLOPIROX-SALICYLIC ACID...... 71 CLARINEX-D 12 HOUR...... 195 childrens silapap...... 5 CIFEREX...... 100 clarithromycin er...... 28 childrens soothe...... 116 CIFRAZOL...... 100

228 clarithromycin oral suspension CLINDAMY-BENZOYL PER-NIACINAM..... 71 clodan external shampoo...... 72 reconstituted...... 28 clindamycin hcl oral capsule 150 mg, 300 CLODERM...... 72 clarithromycin oral tablet...... 28 mg...... 24 clonidine...... 54 CLARITIN ALLERGY CHILDRENS...... 184 clindamycin hcl oral capsule 75 mg...... 24 clonidine hcl oral...... 54 CLARITIN CHILDRENS...... 184 clindamycin palmitate hcl...... 24 clopidogrel bisulfate oral...... 53 CLARITIN EYE...... 179 CLINDAMYCIN PHOS-NIACINAMIDE...... 71 clotrimazole 3...... 34 CLARITIN ORAL CAPSULE...... 184 clindamycin phosphate external foam...... 71 clotrimazole external...... 34 CLARITIN ORAL TABLET...... 184 clindamycin phosphate external lotion...... 71 clotrimazole mouth/throat...... 34 CLARITIN ORAL TABLET CHEWABLE.... 184 clindamycin phosphate external solution..... 71 clotrimazole vaginal...... 34 CLARITIN REDITABS ORAL TABLET clindamycin phosphate external swab...... 71 clotrimazole-betamethasone external DISPERSIBLE 10 MG...... 184 CLINDAMYCIN PHOSPHATE GEL 1 % cream...... 72 CLARITIN REDITABS ORAL TABLET EXTERNAL...... 71 clotrimazole-betamethasone external lotion.72 DISPERSIBLE 5 MG...... 184 clindamycin phosphate gel 1 % external...... 71 clovique...... 96 CLARITIN-D 12 HOUR...... 195 clindamycin phosphate vaginal...... 24 C-NATE DHA...... 100 CLARITIN-D 24 HOUR...... 195 clindamycin phosphate-benzoyl peroxide.... 71 co q 10 oral capsule 60 mg...... 160 classic prenatal...... 100 CLINDAMYCIN-NIACIN-TRETINOIN...... 72 co q-10 oral capsule 100 mg...... 160 c-lax laxative...... 126 clindamycin-tretinoin...... 72 co q-10 oral capsule 150 mg...... 160 CLEAR COUGH PM MULTI-SYMPTOM... 195 CLINDESSE...... 24 co q-10 oral capsule 200 mg...... 160 CLEAR EYES REDNESS RELIEF...... 177 CLIND-NIACIN-SPIRONOLAC-TRETIN...... 72 COAL TAR EXTERNAL...... 72 clearcanal earwax softener...... 180 CLINOIN...... 72 COARTEM...... 44 clearlax oral powder 17 gm/scoop...... 126 clinpro 5000...... 65 cod liver oil oral capsule 1250-135 unit, clearskin...... 71 clobetasol prop emollient base...... 72 4000-200 unit...... 100 clemastine fumarate oral tablet 2.68 mg.... 184 clobetasol propionate e...... 72 COD LIVER OIL ORAL OIL...... 100 CLENPIQ...... 126 clobetasol propionate emulsion...... 72 codeine sulfate oral tablet 30 mg, 60 mg..... 16 CLEOCIN ORAL CAPSULE 150 MG, 300 clobetasol propionate external cream...... 72 coditussin ac...... 195 MG...... 24 clobetasol propionate external foam...... 72 coenzyme q-10...... 160 CLEOCIN ORAL CAPSULE 75 MG...... 24 clobetasol propionate external gel...... 72 co-enzyme q10...... 160 CLEOCIN ORAL SOLUTION clobetasol propionate external liquid...... 72 coenzyme q10 oral capsule 100 mg...... 160 RECONSTITUTED...... 24 clobetasol propionate external lotion...... 72 coenzyme q-10 oral capsule 200 mg...... 160 CLEOCIN VAGINAL CREAM...... 24 clobetasol propionate external ointment...... 72 coenzyme q10 oral capsule 50 mg...... 160 CLEOCIN VAGINAL SUPPOSITORY...... 24 clobetasol propionate external shampoo..... 72 co-enzyme q-10 oral capsule 50 mg...... 160 CLEOCIN-T...... 71 clobetasol propionate external solution...... 72 coenzyme q10 oral tablet 200 mg...... 160 CLIMARA...... 142 CLOBETASOL PROP-LEVOCETIRIZINE... 72 COLACE ORAL CAPSULE...... 126 CLIMARA PRO...... 142 CLOBETASOL PROP-NIACINAMIDE...... 72 COLACE ORAL LIQUID† 150 MG/15ML...126 CLINDACIN ETZ EXTERNAL KIT...... 71 CLOBETAVIX...... 86 COLAMINE...... 88 clindacin etz external swab...... 71 CLOBEX...... 72 COLAZAL...... 154 CLINDACIN PAC...... 71 CLOBEX SPRAY...... 72 COLCHICINE ORAL CAPSULE...... 37 clindacin-p...... 71 clocortolone pivalate...... 72 colchicine oral tablet...... 37 CLINDAGEL...... 71 CLODAN EXTERNAL KIT...... 72 colchicine-probenecid...... 37

229 COLCRYS...... 37 compro...... 32 CORDRAN EXTERNAL LOTION...... 72 cold & allergy...... 195 COMTAN...... 45 CORDRAN EXTERNAL OINTMENT...... 72 cold & cough childrens oral liquid 2.5-1-5 COMTREX COLD & COUGH MAX ST...... 196 CORDRAN EXTERNAL TAPE...... 72 mg/5ml...... 195 CO-NATAL FA...... 100 COREG...... 56 cold & flu oral liquid...... 195 CONCEPT DHA...... 100 COREG CR...... 56 cold & flu relief daytime...... 195 CONCEPT OB...... 100 coremino...... 29 cold & sinus relief...... 195 CONDOMS...... 160 CORGARD...... 56 cold head congestion daytime...... 195 CONDYLOX...... 72 CORICIDIN HBP COUGH/COLD...... 196 cold max...... 195 CONJUPRI...... 57 CORLANOR...... 58 cold max daytime...... 196 CONSENSI...... 58 corn & callus remover...... 72 cold multi-symptom daytime...... 196 constulose...... 126 correct...... 126 cold multi-symptom severe day oral tablet CONTOUR CONTROL...... 160 CORTANE-B...... 73 5-10-200-325 mg...... 184 CONTOUR MONITOR...... 160 CORTEF...... 138 cold sore treatment external liquid 0.13 %... 65 CONTOUR NEXT EZ...... 160 CORTENEMA...... 155 cold/allergy childrens...... 196 CONTOUR NEXT LINK...... 160 cortic-nd...... 180 cold/cough childrens...... 196 CONTOUR NEXT MONITOR...... 160 CORTIFOAM...... 155 cold/cough dm childrens oral elixir 2.5-1-5 CONTOUR NEXT ONE...... 161 cortisone acetate oral...... 138 mg/5ml...... 196 CONTOUR NEXT TEST...... 161 cortisone maximum strength external gel.... 73 cold/flu daytime relief...... 196 CONTOUR TEST...... 161 CORTISPORIN...... 73 cold/flu relief...... 196 CONTRAST ALLERGY PREMED PACK...138 corvita...... 100 colesevelam hcl...... 61 CONVENIENCE PAK...... 63 corvita 150...... 88 COLESTID...... 61 CONZIP...... 15 CORVITE 150...... 88 COLESTID FLAVORED...... 61 COOL MIST HUMIDIFER...... 161 corvite fe...... 88 colestipol hcl oral granules...... 61 COPADERM...... 72 COSENTYX...... 73 colestipol hcl oral packet...... 61 COPASIL EXTERNAL...... 72 COSOPT...... 178 colestipol hcl oral tablet...... 61 COPAXONE SUBCUTANEOUS COSOPT PF...... 178 COLLATYL...... 160 SOLUTION PREFILLED SYRINGE 20 cough & chest congestion...... 196 COMBIGAN...... 178 MG/ML...... 64 cough & cold...... 196 COMBIPATCH...... 142 COPAXONE SUBCUTANEOUS cough & cold hbp...... 196 COMBIVENT RESPIMAT...... 196 SOLUTION PREFILLED SYRINGE 40 cough & sore throat nighttime...... 196 comfort gel...... 116 MG/ML...... 64 cough dm...... 196 comfort gel antacid anti-gas oral coq-10 & fish oil...... 161 cough dm childrens...... 196 suspension 400-400-40 mg/5ml...... 117 coq-10 oral capsule 200 mg...... 161 cough dm er...... 196 complete allergy medicine oral capsule..... 184 coq10 oral capsule 30 mg...... 161 cough drops mouth/throat lozenge 5.4 mg...19 complete allergy relief...... 184 coq-10 oral capsule 50 mg...... 161 cough drops mouth/throat lozenge 8.4 mg...65 complete lice treatment...... 44 coral calcium oral capsule 185-50-100 mg- cough/chest congestion dm...... 196 COMPLETE NATAL DHA...... 100 mg-unit...... 88 cough/chest dm childrens oral liquid...... 196 COMPLETENATE...... 100 CORDRAN EXTERNAL CREAM 0.025 %...72 covaryx...... 142 complex b-100...... 100 CORDRAN EXTERNAL CREAM 0.05 %.....72 covaryx hs...... 142

230 COZAAR...... 54 cyclopentolate hcl ophthalmic solution 0.5 daily multiple vitamins...... 100 C-PLEX...... 100 %...... 173 daily prenatal...... 100 creatine oral capsule...... 100 cyclopentolate hcl ophthalmic solution 1 %173 daily vitamin formula+iron...... 100 creatine oral powder...... 161 cyclopentolate hcl ophthalmic solution 2 %173 daily vitamins...... 100 CREON...... 136 CYCLOPHENE RAPIDPAQ...... 214 daily vite...... 100 CRESEMBA ORAL...... 34 cyclophosphamide oral...... 41 daily vites...... 100 CRESTOR...... 61 cycloserine oral...... 40 daily-vite...... 100 CRINONE...... 147 CYCLOSET...... 49 dalfampridine er...... 64 cromolyn sodium inhalation...... 191 CYCLOSPORINE IN KLARITY...... 173 DALIRESP...... 191 cromolyn sodium nasal...... 191 cyclosporine modified...... 151 danazol oral...... 141 cromolyn sodium ophthalmic...... 177 cyclosporine oral...... 151 dandruff shampoo external lotion...... 73 cromolyn sodium oral...... 117 cyproheptadine hcl oral...... 184 DANTRIUM ORAL...... 214 crotan...... 44 cyred...... 142 dantrolene sodium oral...... 214 CRUEX PRESCRIPTION STRENGTH...... 34 cyred eq...... 142 dapsone external gel 5 %...... 73 crush vitamin c drops...... 100 CYSTADROPS...... 173 DAPSONE EXTERNAL GEL 7.5 %...... 73 cryselle-28...... 142 CYSTAGON...... 136 dapsone oral...... 40 c-time...... 100 CYSTARAN...... 173 DAPSONE-NIACINAMIDE...... 73 CUPRIMINE...... 137 CYSTECH...... 161 DAPSONE-NIACINAMIDE-SPIRONOLAC.. 73 CURAD TRIPLE ANTIBIOTIC...... 24 cystine...... 161 DAPTACEL...... 153 cure-all...... 73 CYTOMEL...... 148 DARAPRIM...... 44 CUROSURF INTRATRACHEAL CYTOTEC...... 134 darifenacin hydrobromide er...... 136 SUSPENSION 120 MG/1.5ML...... 196 cytra k crystals...... 88 DARZALEX INTRAVENOUS SOLUTION CUTIVATE...... 73 cytra-2...... 88 100 MG/5ML...... 43 CUVITRU SUBCUTANEOUS SOLUTION d 1000 oral tablet...... 100 dasetta 1/35...... 143 8 GM/40ML...... 152 d 10000...... 100 dasetta 7/7/7...... 143 CUVPOSA...... 113 d 400 oral tablet...... 100 DAURISMO...... 42 cyanocobalamin injection solution 1000 d 400 oral tablet chewable...... 100 day time cold & flu oral capsule...... 196 mcg/ml...... 100 d 5000 oral tablet...... 100 day time cold/flu...... 196 cyclafem 1/35...... 142 D.H.E. 45...... 38 day time cold/flu relief...... 197 cyclafem 7/7/7...... 142 d3...... 100 dayhist allergy 12 hour relief...... 185 CYCLO/GABA 10/300...... 214 d3 high potency oral capsule 25 mcg (1000 DAYPRO...... 11 cyclobenzaprine hcl er...... 214 ut)...... 100 daysee...... 143 cyclobenzaprine hcl oral...... 214 d3 super strength...... 100 daytime...... 197 CYCLOGYL OPHTHALMIC SOLUTION d-3-5...... 100 daytime cold & flu relief oral capsule...... 197 0.5 %, 2 %...... 173 d3-50...... 100 daytime cold & flu relief oral liquid...... 197 CYCLOGYL OPHTHALMIC SOLUTION 1 daflonex-xl...... 100 day-time cold/flu relief...... 197 %...... 173 daily acne wash...... 73 daytime cold/flu relief oral capsule...... 197 CYCLOMYDRIL...... 177 daily fiber...... 126 daytime cold/flu relief oral liquid...... 197 daily gummies...... 100 day-time pe cold/flu relief...... 197

231 D-CARE BLOOD GLUCOSE...... 161 DEPO-TESTOSTERONE despec dm...... 197 D-CARE GLUCOMETER...... 161 INTRAMUSCULAR SOLUTION 200 despec dm-g...... 197 DDAVP NASAL...... 140 MG/ML...... 141 DETROL...... 136 DDAVP ORAL...... 140 dermacerin...... 73 DETROL LA...... 136 DDAVP RHINAL TUBE...... 140 DERMACINRX ANALGESIC COMBOPAK..11 DEXABLISS...... 139 DEBACTEROL...... 65 DERMACINRX AZENASE PAK...... 197 dexamethasone intensol...... 139 deblitane...... 147 DERMACINRX CLORHEXACIN...... 73 dexamethasone oral elixir...... 139 DECADRON...... 139 DERMACINRX DUOPATCH PHARMAPAK 19 dexamethasone oral solution...... 139 decara oral capsule 1.25 mg (50000 ut).... 100 DERMACINRX EMPRICAINE...... 19 dexamethasone oral tablet...... 139 decara oral capsule 250 mcg (10000 ut)....100 DERMACINRX LEXITRAL PHARMAPAK... 11 dexamethasone oral tablet therapy pack... 139 DECARA ORAL CAPSULE 625 MCG DERMACINRX NEUROTRAL dexamethasone sodium phosphate (25000 UT)...... 100 PHARMAPAK...... 19 ophthalmic...... 179 decongestant 12hour max st...... 197 DERMACINRX PENETRAL...... 5 dexchlorpheniramine maleate oral...... 185 deep sea nasal spray...... 197 DERMACINRX PHN...... 19 DEXERYL...... 73 deferasirox granules...... 96 DERMACINRX PRIZOPAK...... 19 dexifol...... 100 deferasirox oral tablet...... 96 DERMACINRX PUREFOLIX...... 100 DEXILANT...... 134 deferasirox oral tablet soluble...... 96 DERMACINRX SURGICAL PHARMAPAK.. 73 dextromethorphan polistirex er...... 197 deferiprone...... 96 DERMACINRX THERAZOLE PAK...... 34 dextromethorphan-guaifenesin oral syrup..197 DELSYM...... 197 DERMACINRX TICANASE PAK...... 188 DFS DR/MS/MENTH/CAP PAK...... 11 delsym cgh/chest cong dm child...... 197 DERMACINRX ZRM...... 19 DFS/MS/MENTH/CAP PAK...... 11 DELSYM COUGH CHILDRENS...... 197 dermafungal...... 34 dha...... 161 delyla...... 143 dermaphor...... 73 DIAB EXTRA...... 100 DELZICOL...... 154 DERMA-SMOOTHE/FS BODY...... 73 DIAB NUTRI...... 100 demeclocycline hcl...... 29 DERMA-SMOOTHE/FS SCALP...... 73 diabetic tussin ex...... 197 DEMSER...... 58 dermazene...... 34 diabetic tussin max st...... 197 DENAVIR...... 48 DERMOTIC...... 180 DIADIMAXIA...... 73 denta 5000 plus...... 65 DESENEX EXTERNAL POWDER...... 161 dialyvite...... 100 dentagel...... 65 DESENEX JOCK ITCH...... 34 DIALYVITE 3000...... 100 DEOXIA...... 73 desgen dm oral liquid...... 197 DIALYVITE 5000...... 100 DEPEN TITRATABS...... 137 desloratadine oral tablet...... 185 DIALYVITE 800 ORAL TABLET...... 100 DEPLIN 15...... 161 desloratadine oral tablet dispersible 5 mg..185 DIALYVITE 800/IRON...... 100 DEPLIN 7.5...... 161 desmopressin ace spray refrig...... 140 DIALYVITE 800/ZINC...... 100 DEPO-ESTRADIOL...... 143 desmopressin acetate oral...... 140 DIALYVITE 800-ZINC 15...... 101 DEPO-PROVERA...... 147 desmopressin acetate spray...... 140 DIALYVITE OMEGA-3 CONCENTRATE...161 DEPO-SUBQ PROVERA 104...... 147 desogestrel-ethinyl estradiol...... 143 DIALYVITE SUPREME D...... 101 DEPO-TESTOSTERONE DESONATE...... 73 DIALYVITE VITAMIN D 5000...... 101 INTRAMUSCULAR SOLUTION 100 desonide external...... 73 DIALYVITE/ZINC...... 101 MG/ML...... 141 DESOWEN...... 73 diamode...... 117 desoximetasone external...... 73 DIAOXIA...... 73

232 diaper rash creamy...... 73 diflorasone diacetate...... 74 dimethyl fumarate oral...... 64 diaper rash external ointment...... 73 DIFLUCAN ORAL SUSPENSION dimethyl fumarate starter pack...... 64 diarrhea...... 117 RECONSTITUTED...... 34 DIMOXIA...... 74 DIASDIMAXIA...... 73 DIFLUCAN ORAL TABLET 100 MG, 200 dino-life...... 101 DIASOXIA...... 73 MG, 50 MG...... 34 dino-life w/extra c...... 101 DIASTIX...... 161 DIFLUCAN ORAL TABLET 150 MG...... 34 DINO-LIFE W/IRON-ZINC...... 101 diazoxide oral...... 50 diflunisal oral...... 11 diocto...... 126 DIBENZYLINE...... 54 DIFMETIOXRIME...... 34 diotame instydose...... 117 dibucaine (perianal)...... 74 DIGESTIVE ADV LACTOSE DEFENSE....117 DIOVAN...... 54 DICLEGIS...... 32 digestive probiotic oral capsule...... 117 DIOVAN HCT...... 58 DICLOFENAC...... 11 digestive probiotic oral capsule 250 mg..... 117 DIPENTUM...... 154 DICLOFENAC EPOLAMINE...... 11 digitek...... 58 diphen...... 185 diclofenac potassium...... 11 digox...... 58 DI-PHEN...... 185 diclofenac sodium er...... 11 digoxin oral solution...... 58 diphenhist...... 185 diclofenac sodium external gel 1 %...... 11 digoxin oral tablet...... 58 diphenhydramine hcl injection...... 185 diclofenac sodium external gel 3 %...... 74 dihydroergotamine mesylate injection...... 38 diphenhydramine hcl oral capsule...... 185 diclofenac sodium external solution...... 11 dihydroergotamine mesylate nasal...... 38 diphenhydramine hcl oral elixir...... 185 diclofenac sodium ophthalmic...... 179 DILATRATE-SR...... 62 diphenhydramine hcl oral liquid 12.5 diclofenac sodium oral...... 11 DILAUDID ORAL...... 16 mg/5ml...... 185 diclofenac-misoprostol...... 11 diltiazem hcl er...... 57 diphenhydramine hcl oral tablet...... 185 DICLOFENAC-NA HYALURON-NIACIN..... 74 diltiazem hcl er beads capsule extended diphenoxylate-atropine...... 117 diclofex dc...... 11 release 24 hour 240 mg oral...... 57 DIPROLENE...... 74 DICLOFONO...... 11 diltiazem hcl er beads oral capsule DIPROLENE AF...... 74 DICLOPR...... 11 extended release 24 hour 120 mg, 180 mg, dipyridamole oral...... 53 diclosaicin...... 11 300 mg, 360 mg...... 57 disopyramide phosphate...... 55 DICLOSTREAM...... 11 diltiazem hcl er beads oral capsule DITROPAN XL...... 136 DICLOTREX...... 11 extended release 24 hour 420 mg...... 57 diuretic maximum strength...... 161 DICLOVIX...... 11 diltiazem hcl er coated beads oral capsule DIURIL...... 60 DICLOVIX M...... 11 extended release 24 hour...... 57 DIVIGEL TRANSDERMAL GEL 0.25 dicloxacillin sodium...... 28 diltiazem hcl er coated beads oral tablet MG/0.25GM, 0.75 MG/0.75GM, 1.25 DICOPANOL FUSEPAQ...... 185 extended release 24 hour...... 57 MG/1.25GM...... 143 DICOPANOL RAPIDPAQ...... 185 diltiazem hcl oral...... 57 DIVIGEL TRANSDERMAL GEL 0.5 dicyclomine hcl oral...... 113 dilt-xr...... 57 MG/0.5GM, 1 MG/GM...... 143 DIFFERIN EXTERNAL CREAM...... 74 dimaphen dm cold/cough...... 197 dl-pa-500...... 161 DIFFERIN EXTERNAL GEL 0.1 %...... 74 DIMENTHO...... 11 dm maximum adult...... 197 DIFFERIN EXTERNAL GEL 0.3 %...... 74 DIMETAPP COLD RELIEF CHILDRENS.. 197 d-natural-5...... 101 DIFFERIN EXTERNAL LOTION...... 74 DIMETAPP COLD/ALLERGY...... 197 DOANS PM EXTRA STRENGTH...... 5 DIFICID ORAL TABLET...... 28 DIMETAPP DM COLD/COUGH...... 197 DOC OMEGA...... 101 difil-g forte...... 191 DIMETAPP LONG ACT COUGH/COLD.... 197 docosanol external...... 48

233 docu...... 126 doxycycline hyclate oral tablet 150 mg, 75 dronabinol...... 33 docusate calcium...... 126 mg...... 30 drospiren-eth estrad-levomefol oral tablet docusate mini...... 126 doxycycline hyclate oral tablet 20 mg...... 30 3-0.02-0.451 mg...... 143 docusate sodium oral capsule...... 126 doxycycline hyclate oral tablet 50 mg...... 30 drospiren-eth estrad-levomefol oral tablet docusate sodium oral liquid 50 mg/5ml...... 126 doxycycline hyclate oral tablet delayed 3-0.03-0.451 mg...... 143 docusate sodium oral syrup...... 126 release 100 mg...... 30 drospirenone-ethinyl estradiol...... 143 docusate sodium oral tablet...... 126 doxycycline hyclate oral tablet delayed DROXIA...... 41 docusate sodium-casanthranol oral release 150 mg, 75 mg...... 30 dry mouth...... 65 capsule 100-30 mg...... 126 doxycycline hyclate oral tablet delayed dry-eye relief nighttime...... 173 docusil...... 126 release 200 mg, 50 mg...... 30 DRYSOL...... 74 DOCUSOL MINI...... 126 DOXYCYCLINE HYCLATE ORAL TABLET dss...... 126 docuzen...... 126 DELAYED RELEASE 80 MG...... 30 DUAKLIR PRESSAIR...... 182 dofetilide...... 55 doxycycline monohydrate oral capsule 100 DUAL COMPLEX FORMULA 1 KIT...... 11 DOJOLVI...... 161 mg...... 30 DUAVEE...... 143 dok...... 126 doxycycline monohydrate oral capsule 150 ducodyl...... 127 DOLOPHINE...... 15 mg...... 30 DUET DHA 400...... 101 donepezil hcl oral tablet 10 mg, 5 mg...... 31 doxycycline monohydrate oral capsule 50 DUET DHA BALANCED...... 101 donepezil hcl oral tablet 23 mg...... 31 mg...... 30 DUETACT...... 49 donepezil hcl oral tablet dispersible...... 31 doxycycline monohydrate oral capsule 75 DUEXIS...... 11 DONNATAL...... 113 mg...... 30 DULERA...... 198 DOPTELET...... 53 doxycycline monohydrate oral suspension DUOBRII...... 74 DORYX...... 29 reconstituted...... 30 duofilm...... 74 DORYX MPC...... 29 doxycycline monohydrate oral tablet 100 DUOPA...... 46 DORZOLAMIDE HCL SOLUTION 2 % mg, 50 mg...... 30 DUPIXENT SUBCUTANEOUS SOLUTION OPHTHALMIC...... 178 doxycycline monohydrate oral tablet 150 PEN-INJECTOR...... 74 dorzolamide hcl solution 2 % ophthalmic... 178 mg...... 30 DUPIXENT SUBCUTANEOUS SOLUTION dorzolamide hcl-timolol mal...... 178 doxycycline monohydrate oral tablet 75 mg.30 PREFILLED SYRINGE...... 74 dorzolamide hcl-timolol mal pf...... 178 doxylamine-pyridoxine...... 32 DURACHOL...... 101 dotti...... 143 DR SMITHS ADULT BARRIER DURAGESIC-100...... 15 double antibiotic...... 24 EXTERNAL OINTMENT...... 74 DURAGESIC-12...... 15 DOUBLE PM...... 179 DR SMITHS DIAPER...... 74 DURAGESIC-25...... 15 DOVONEX...... 74 DRAMAMINE ORAL TABLET...... 32 DURAGESIC-50...... 15 doxazosin mesylate oral...... 54 DRAXACE...... 74 DURAGESIC-75...... 15 doxepin hcl external...... 74 DRAXACE LOTION CLEANSER...... 74 DUREZOL...... 179 doxercalciferol oral...... 157 driminate...... 32 DURLAZA...... 54 doxycycline...... 30 DRISDOL...... 101 DUROLANE...... 161 doxycycline hyclate oral capsule...... 30 DRISTAN SPRAY...... 198 dutasteride oral...... 137 doxycycline hyclate oral tablet 100 mg...... 30 DRITHO-CREME HP...... 74 dutasteride-tamsulosin hcl...... 137 DRIXECE...... 74 DUTOPROL...... 58

234 D-VI-SOL...... 101 EASYMAX V BLOOD GLUCOSE...... 162 ELESTRIN...... 143 d-vite pediatric...... 101 EBASE CONTROLLER KIT...... 162 ELETONE...... 74 DX1 ORAGENOMIC DNA SCREEN...... 161 ecee plus...... 101 eletriptan hydrobromide...... 39 DX2 ORAGENOMIC DNA SCREEN...... 161 ECEOXIA...... 74 ELFOLATE...... 101 DXEVO 11-DAY...... 139 EC-NAPROSYN...... 11 ELFOLATE PLUS...... 101 DYAZIDE...... 58 ec-naproxen...... 11 ELIDEL...... 74 dye-free allergy relief...... 185 ECONASIL...... 34 ELIGARD...... 150 DYMISTA...... 198 econazole nitrate external...... 34 ELIMITE...... 44 DYRENIUM...... 60 ECONAZOLE NITRATE-NIACINAMIDE...... 34 elinest...... 143 dyspel...... 11 econtra ez...... 147 ELIQUIS...... 52 e...... 101 econtra one-step...... 147 ELIQUIS DVT/PE STARTER PACK...... 52 E.E.S. GRANULES...... 28 ECOTRIN MAXIMUM STRENGTH...... 11 ELITE-OB...... 101 e-400-clear...... 101 ECOZA...... 34 ELIXOPHYLLIN...... 191 e-400-mixed...... 101 ecpirin...... 11 ELIXSURE FEVER/PAIN...... 5 ear drops...... 180 EC-RX DHEA...... 162 ELLA...... 147 ear drops earwax aid...... 180 EC-RX ESTRADIOL...... 143 ELLZIA PAK...... 74 ear systems...... 180 EC-RX PROGESTERONE...... 147 ELMIRON...... 137 ear wax kit...... 180 EC-RX TESTOSTERONE...... 141 eluryng...... 143 ear wax removal...... 180 ED A-HIST ORAL LIQUID...... 198 e-max-1000...... 101 ear wax removal drops...... 180 ed bron gp...... 198 EMCYT...... 41 ear wax removal kit...... 181 ed chlorped jr...... 182 EMEND ORAL CAPSULE 80 MG...... 33 ear wax removal system...... 181 ed-apap...... 5 EMEND ORAL SUSPENSION earwax removal...... 181 EDARBI...... 54 RECONSTITUTED...... 33 earwax removal drops...... 181 EDARBYCLOR...... 58 EMEND TRI-PACK...... 33 earwax removal kit...... 181 EDECRIN...... 60 EMETROL...... 32 EASIVENT...... 161 ed-spaz...... 113 EMFLAZA...... 139 EASIVENT MASK LARGE...... 161 eemt...... 143 EMGALITY...... 38 EASIVENT MASK MEDIUM...... 161 eemt hs...... 143 EMGALITY (300 MG DOSE)...... 38 EASIVENT MASK SMALL...... 161 EFFER-K ORAL TABLET emoquette...... 143 EASY TOUCH TEST...... 161 EFFERVESCENT 10 MEQ, 20 MEQ...... 88 EMPLICITI INTRAVENOUS SOLUTION easygel...... 65 effer-k oral tablet effervescent 25 meq...... 88 RECONSTITUTED 300 MG...... 43 easy-lax plus...... 127 EFFIENT...... 54 EMPRICAINE-II...... 19 EASYMAX 15 LEVEL 2 CONTROL...... 161 EFLOW SCF AEROSOL HEAD...... 162 EMULSION SB...... 74 EASYMAX 15 LEVEL 2-3 CONTROL...... 161 EFUDEX...... 74 EMVERM...... 43 EASYMAX 15 TEST...... 161 EGATEN...... 43 ENABLEX ORAL TABLET EXTENDED EASYMAX CONTROL...... 161 EGRIFTA SV...... 150 RELEASE 24 HOUR 7.5 MG...... 136 EASYMAX CONTROL NORMAL/HIGH.....161 EHA...... 19 enalapril maleate oral...... 55 EASYMAX NG BLOOD GLUCOSE...... 161 eldertonic...... 101 enalapril-hydrochlorothiazide...... 58 EASYMAX TEST...... 162 electrolyte solution...... 88 ENBRACE HR...... 101

235 ENBREL SUBCUTANEOUS SOLUTION enteric fish oil...... 162 eq acid reducer...... 125 25 MG/0.5ML...... 151 ENTOCORT EC...... 155 eq adult aspirin low strength...... 11 ENBREL SUBCUTANEOUS SOLUTION ENTRESTO...... 58 eq all day pain relief...... 11 AUTO-INJECTOR...... 151 ENTSOL NASAL...... 198 eq allergy...... 185 ENBREL SUBCUTANEOUS SOLUTION ENTTY SPRAY...... 74 eq allergy childrens...... 185 CARTRIDGE...... 152 ENTYVIO...... 153 eq allergy relief (cetirizine) oral tablet...... 185 ENBREL SUBCUTANEOUS SOLUTION ENVARSUS XR...... 152 eq allergy relief childrens oral liquid...... 185 PREFILLED SYRINGE...... 152 ENZOCLEAR...... 74 eq allergy relief childrens oral syrup...... 185 ENBREL SUBCUTANEOUS SOLUTION EPANED...... 55 eq allergy relief d 24 hour...... 198 RECONSTITUTED...... 152 EPHEDRINE SULFATE-NACL eq allergy relief oral capsule...... 185 endacof-dm...... 198 INTRAVENOUS SOLUTION PREFILLED eq allergy relief oral tablet 10 mg...... 185 ENDARI...... 88 SYRINGE 50-0.9 MG/10ML-%, 50-0.9 eq allergy relief oral tablet 180 mg...... 185 ENDO AVITENE...... 162 MG/5ML-%...... 58 eq allergy relief oral tablet 25 mg...... 185 endocet...... 16 ephrine nose drops...... 198 eq allergy relief oral tablet extended enema...... 127 EPICERAM...... 74 release 12 hour...... 198 enema disposable...... 127 EPIDUO...... 74 eq antacid...... 117 enema mineral oil...... 127 EPIDUO FORTE...... 74 eq antacid antigas multi-sympt...... 117 enema ready-to-use...... 127 EPIFOAM...... 75 eq antacid extra strength oral tablet ENEMEEZ MINI...... 127 epinastine hcl...... 177 chewable 160-105 mg...... 117 ENFAMIL ENFALYTE...... 88 epinephrine hcl (nasal)...... 198 eq antacid extra strength oral tablet ENFAMIL EXPECTA...... 101 epinephrine injection solution auto-injector chewable 750 mg...... 117 ENGERIX-B SUSPENSION 20 MCG/ML 0.15 mg/0.15ml...... 190 eq antacid maximum strength...... 117 INJECTION...... 153 epinephrine injection solution auto-injector eq antacid ultra strength...... 117 enovarx-amitriptyline...... 162 0.15 mg/0.3ml...... 190 eq antacid/anti-gas...... 117 enovarx-baclofen...... 47 epinephrine injection solution auto-injector eq anti-diarrheal oral liquid...... 117 enovarx-cyclobenzaprine hcl...... 214 0.3 mg/0.3ml...... 190 eq anti-diarrheal oral tablet...... 117 ENOVARX-DICLOFENAC SODIUM...... 11 EPINEPHRINE PROFESSIONAL...... 190 eq arthritis pain...... 5 enovarx-ibuprofen...... 11 EPINEPHRINESNAP-EMS...... 190 eq artificial tears...... 173 enovarx-lidocaine hcl...... 19 EPINEPHRINESNAP-V...... 190 eq aspirin...... 11 enovarx-naproxen...... 11 EPIPEN 2-PAK...... 190 eq aspirin adult low dose...... 12 enovarx-tramadol...... 5 EPIPEN JR 2-PAK...... 190 eq aspirin low dose...... 12 enoxaparin sodium...... 52 EPISIL...... 65 eq athletes foot (terbinafine)...... 34 enpresse-28...... 143 EPISNAP...... 190 eq athletes foot external aerosol powder..... 34 enskyce...... 143 EPIVIR HBV ORAL SOLUTION...... 47 eq athletes foot spray...... 34 ENSPRYNG...... 151 EPIVIR HBV ORAL TABLET...... 47 eq bacitracin zinc...... 24 ENSTILAR...... 74 eplerenone...... 60 EQ BLOOD GLUCOSE TEST...... 162 entacapone...... 45 EPOGEN...... 53 eq buffered aspirin...... 12 entecavir...... 47 eq 8hr arthritis pain relief...... 5 eq cetirizine hcl...... 185 ENTEREG...... 117 eq acetaminophen...... 5 eq childrens aspirin...... 12

236 eq childrens pain reliever...... 5 eq miconazole 7...... 34 eq suphedrine...... 198 eq chlortabs...... 185 eq miconazole 7 day treatment...... 34 eq tioconazole 1...... 34 eq cimetidine...... 125 eq migraine relief...... 5 eq triple antibiotic...... 25 eq clearlax...... 127 eq mineral oil...... 127 eq tussin cf cough & cold...... 198 eq cold multi-symptom daytime...... 198 eq motion sickness...... 32 eq tussin dm cough/chest...... 198 eq cold/allergy childrens...... 198 eq motion sickness relief oral tablet 50 mg.. 32 eq tussin dm max...... 198 eq cold/cough dm childrens...... 198 eq mucus er oral tablet extended release eq tussin dm max adult...... 198 eq cough childrens...... 198 12 hour 1200 mg...... 198 eq tussin dm max daytime...... 199 eq cough dm...... 198 eq mucus relief dm...... 198 eq urinary pain relief...... 137 eq dayhist allergy...... 185 eq mucus-d...... 198 eq vegetable laxative...... 127 eq daytime cold/flu ms relief oral capsule.. 198 eq naproxen sodium oral tablet...... 12 eq wart remover...... 75 eq daytime cold/flu ms relief oral liquid...... 198 eq nasal allergy...... 188 eq womens laxative...... 127 eq ear drops...... 181 eq nasal spray...... 198 eql acetaminophen...... 5 eq eye allergy relief...... 177 eq nasal spray fast acting...... 198 eql acetaminophen childrens...... 5 eq fiber laxative...... 127 eq natural fiber laxative...... 127 eql acetaminophen ex st...... 5 eq fiber therapy...... 127 eq natural laxative...... 127 eql acetaminophen infants...... 6 eq first aid antiseptic...... 24 eq natural vegetable laxative...... 127 eql all day allergy...... 185 eq gas relief extra strength...... 117 eq nicotine...... 22 eql all day allergy-d...... 199 eq gas relief oral capsule...... 117 eq nicotine polacrilex...... 22 eql aller-ease...... 185 eq gas relief oral tablet chewable...... 117 eq nicotine step 3...... 22 eql allergy relief...... 185 eq gentle laxative...... 127 eq omeprazole magnesium...... 134 eql allergy/congestion relief...... 199 eq gentle lubricant...... 173 eq omeprazole oral tablet delayed release 134 eql antacid advanced max st...... 118 eq headache relief...... 5 eq pain & fever childrens...... 5 eql antacid extra strength...... 118 eq heartburn relief...... 125 eq pain & fever infants...... 5 eql antacid ultra strength...... 118 eq ibuprofen...... 12 eq pain relief/rapid burst...... 5 eql antacid/anti-gas...... 118 eq ibuprofen infants...... 12 eq pain reliever...... 5 eql anticavity fluoride rinse...... 89 eq ibuprofen junior...... 12 eq pain reliever junior...... 5 eql anti-diarrheal...... 118 eq infants gas relief...... 117 eq pain relieving external cream 4 %...... 19 eql antifungal (tolnaftate)...... 34 eq lansoprazole...... 134 eq pink-bismuth...... 117 eql arthritis pain relief...... 6 eq laxative...... 127 eq povidone-iodine...... 24 eql aspirin low dose...... 12 eq laxative maximum strength...... 127 eq restore plus lubricant eye...... 173 eql baby basics diaper rash...... 75 eq lice killing max st...... 44 eq restore pm...... 173 eql bacitracin zinc...... 25 eq loperamide hcl...... 117 eq revive plus...... 173 eql childrens allergy...... 185 eq loratadine...... 185 eq senna-s...... 127 eql clearlax...... 127 eq loratadine childrens...... 185 eq sinus relief max st...... 198 eql cold multi-symptom daytime...... 199 eq lubricant eye drops...... 173 eq stomach relief oral suspension...... 117 eql cold sore treatment...... 65 eq lubricating eye drops...... 173 eq stomach relief oral tablet chewable...... 117 eql cold/cough...... 199 eq magnesium citrate...... 127 eq stool softener...... 127 eql cough dm...... 199 eq miconazole 1...... 34 eq stool softener/laxative...... 127 eql daytime cold & flu relief...... 199

237 eql fiber laxative...... 127 EQUAPAX/ATORVASTATIN/COQ10...... 58 estradiol oral...... 143 eql fiber therapy oral powder 28.3 %...... 127 EQUAPAX/IBUPROFEN/MINREX...... 12 estradiol transdermal...... 143 eql first aid antibiotic external ointment 1 %.25 ERGOCAL...... 101 estradiol vaginal cream...... 143 eql first aid antibiotic external ointment 3.5- ergocalciferol oral capsule...... 101 estradiol vaginal tablet...... 143 400-5000...... 25 ergocalciferol oral solution...... 101 estradiol-norethindrone acet...... 143 eql flu/severe cold daytime...... 199 ergoloid mesylates oral...... 162 ESTRING...... 143 eql gas relief...... 118 ERGOMAR...... 38 estro support es...... 101 eql gas relief ultra strength...... 118 ergotamine-caffeine...... 38 ESTROGEL...... 143 eql gentle laxative...... 127 ERIVEDGE...... 42 ESTROSTEP FE...... 143 eql headache relief ex str...... 6 ERLEADA...... 41 ethacrynic acid...... 60 eql heartburn prevention oral tablet 10 mg 125 errin...... 147 ethambutol hcl oral...... 40 eql ibuprofen...... 12 ERTACZO...... 34 ETHOXIA...... 75 eql ibuprofen infants...... 12 ery...... 75 ethyl chloride...... 19 eql ibuprofen junior strength...... 12 ERYGEL...... 75 ethynodiol diac-eth estradiol...... 143 eql infants gas relief...... 118 ERYPED 200...... 29 etodolac...... 12 eql laxative oral tablet...... 127 ERYPED 400...... 29 etodolac er...... 12 eql laxative oral tablet chewable...... 127 ERY-TAB...... 29 etonogestrel-ethinyl estradiol...... 143 eql lice killing max st...... 44 ERYTHROCIN STEARATE...... 29 etoposide oral...... 42 eql loperamide hcl...... 118 erythromycin base...... 29 EUCRISA...... 75 eql magnesium citrate...... 127 erythromycin ethylsuccinate oral...... 29 euthyrox oral tablet 100 mcg, 75 mcg...... 148 eql miconazole 7...... 34 erythromycin external gel...... 75 euthyrox oral tablet 112 mcg, 125 mcg, eql migraine formula...... 6 erythromycin external solution...... 75 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 eql milk of magnesia...... 127 erythromycin ophthalmic...... 177 mcg, 50 mcg, 88 mcg...... 149 eql mucus-dm...... 199 erythromycin oral...... 29 EVAC...... 128 eql naproxen sodium oral tablet...... 12 ESBRIET ORAL CAPSULE...... 192 EVAMIST...... 143 eql nasal decongestant...... 199 ESBRIET ORAL TABLET...... 192 evening primrose oil oral capsule 500 mg..162 eql nasal decongestant pe...... 199 ESGIC ORAL CAPSULE...... 6 everolimus oral tablet 0.25 mg, 0.5 mg, eql nasal spray 12 hour...... 199 ESGIC ORAL TABLET...... 6 0.75 mg...... 152 eql nasal spray fast acting...... 199 ESOMEP-EZS...... 135 everolimus oral tablet 2.5 mg, 5 mg, 7.5 eql nasal spray no drip...... 199 esomeprazole magnesium...... 135 mg...... 42 eql nicotine polacrilex...... 22 ESOMEPRAZOLE STRONTIUM...... 135 EVISTA...... 148 eql omeprazole...... 134 essential one daily...... 101 EVOCLIN...... 75 eql ready-to-use enema rectal enema...... 127 est estrogens-methyltest...... 143 EVOMELA...... 41 eql stomach relief oral tablet...... 118 est estrogens-methyltest ds...... 143 EVOXAC...... 65 eql stomach relief oral tablet chewable...... 118 est estrogens-methyltest hs...... 143 EVRYSDI...... 136 eql stool softener...... 127 estarylla...... 143 EXACTECH R-S-G TEST...... 162 eql stool softener/stimulant...... 127 ester-c oral tablet...... 101 EXACTECH TEST...... 162 eql tussin cough long-acting...... 199 ESTRACE ORAL...... 143 EXCEDRIN EXTRA STRENGTH...... 6 eql tussin dm cough/chest cong...... 199 ESTRACE VAGINAL...... 143 EXCEDRIN MIGRAINE...... 6

238 EXCEDRIN TENSION HEADACHE...... 6 famciclovir oral...... 48 FENTANYL CITRATE-NACL EXELDERM...... 34 famotidine oral suspension reconstituted...125 INTRAVENOUS SOLUTION 1-0.9 EXELON...... 31 famotidine oral tablet 20 mg...... 125 MG/100ML-%, 2-0.9 MG/100ML-%, 2.5-0.9 exemestane...... 42 famotidine oral tablet 40 mg...... 125 MG/250ML-%...... 17 EXFORGE...... 58 FARESTON...... 41 FENTANYL CITRATE-NACL EXFORGE HCT...... 58 FARXIGA...... 49 INTRAVENOUS SOLUTION PREFILLED EXJADE...... 96 FARYDAK...... 42 SYRINGE 500-0.9 MCG/50ML-%...... 17 ex-l...... 101 FASENRA PEN...... 199 fentanyl transdermal patch 72 hour 100 EX-LAX ULTRA...... 128 fast acting antacid/anti-gas...... 118 mcg/hr...... 15 exoderm external lotion...... 34 FAVIPIRAVIR...... 48 fentanyl transdermal patch 72 hour 12 exotic-hc...... 181 fa-vitamin b-6-vitamin b-12...... 101 mcg/hr...... 15 EXTAVIA...... 64 fayosim...... 143 fentanyl transdermal patch 72 hour 25 EXTINA...... 34 FBL KIT...... 12 mcg/hr...... 15 extress...... 101 fe c tab...... 89 fentanyl transdermal patch 72 hour 37.5 EXTRESS-30...... 101 febuxostat...... 37 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr...... 15 extress-super...... 101 FELDENE...... 12 fentanyl transdermal patch 72 hour 50 eye allergy relief...... 177 felodipine er...... 57 mcg/hr...... 15 eye drops advanced relief...... 173 FEM PH...... 25 fentanyl transdermal patch 72 hour 75 eye drops allergy relief...... 173 FEMARA...... 42 mcg/hr...... 15 eye drops ar...... 173 FEMHRT LOW DOSE...... 143 FENTORA...... 17 eye drops long lasting...... 173 FEMRING...... 143 FERAHEME...... 89 eye drops ophthalmic solution 0.05 %...... 177 femynor...... 143 ferate...... 89 eye drops ophthalmic solution 0.05-0.1-1-1 fenesin ir...... 199 FER-IN-SOL...... 89 %...... 173 fenofibrate micronized...... 60 FERIVA 21/7...... 89 eye drops ophthalmic solution 0.4-0.3 %... 173 fenofibrate oral capsule...... 60 FERIVAFA...... 89 eye drops ophthalmic solution 0.5 %...... 173 fenofibrate oral tablet 120 mg, 40 mg...... 60 ferocon...... 89 eye itch relief ophthalmic solution 0.025 % 179 fenofibrate oral tablet 145 mg, 48 mg...... 61 ferosul...... 89 eye lubricant...... 173 fenofibrate oral tablet 160 mg, 54 mg...... 61 ferotrinsic...... 89 EYSUVIS...... 179 fenofibric acid...... 61 FERRALET 90...... 89 EZALLOR SPRINKLE...... 61 FENOGLIDE...... 61 ferraplus 90...... 89 ezetimibe...... 61 fenoprofen calcium oral...... 12 ferretts...... 89 ezetimibe-simvastatin...... 61 fenortho...... 12 ferretts ips...... 89 ezfe 200...... 89 FENSOLVI (6 MONTH)...... 150 ferrex 150...... 89 fa-8 oral capsule...... 101 fentanyl citrate buccal lozenge on a handle. 16 ferric x-150...... 89 fa-8 oral tablet...... 89 FENTANYL CITRATE BUCCAL TABLET....17 FERRIMIN 150...... 89 fabb...... 101 FENTANYL CITRATE INTRAVENOUS FERRIPROX ORAL SOLUTION...... 96 FABIOR...... 75 SOLUTION PREFILLED SYRINGE 100 FERRIPROX ORAL TABLET...... 96 FALESSA...... 143 MCG/2ML...... 17 FERRIPROX TWICE-A-DAY...... 96 falmina...... 143 FERRLECIT...... 89

239 ferrocite plus...... 89 finasteride oral tablet 5 mg...... 137 FLEXICHAMBER ADULT MASK/SMALL.. 162 FERRO-PLEX HEMATINIC...... 89 FIORICET...... 6 FLEXICHAMBER CHILD MASK/LARGE... 162 FERROTRIN...... 89 FIORICET/CODEINE...... 17 FLEXICHAMBER CHILD MASK/SMALL... 162 ferrous fumarate oral tablet 324 (106 fe) FIORINAL...... 6 FLEXIN...... 6 mg...... 89 FIORINAL/CODEINE #3...... 17 FLEXIPAK...... 12 ferrous gluconate oral tablet 240 (27 fe) mg 89 FIRAZYR...... 151 flogen...... 162 ferrous gluconate oral tablet 324 (37.5 fe) FIRDAPSE...... 162 FLOLIPID...... 61 mg, 324 (38 fe) mg...... 89 FIRST - METOPROLOL...... 56 FLOMAX...... 137 ferrous sulfate oral elixir...... 89 first aid antibiotic external ointment 3.5- FLORA VANCE...... 118 ferrous sulfate oral solution...... 89 400-5000 mg-unit...... 25 floranex oral tablet...... 118 ferrous sulfate oral syrup...... 89 FIRST-ATENOLOL...... 56 FLORICAL...... 90 ferrous sulfate oral tablet 325 (65 fe) mg..... 89 FIRST-BACLOFEN...... 214 FLORIVA ORAL LIQUID...... 90 ferrous sulfate oral tablet delayed release... 89 FIRST-LANSOPRAZOLE...... 135 FLORIVA ORAL TABLET CHEWABLE..... 101 fever reducer childrens...... 6 FIRST-METRONIDAZOLE...... 25 FLORIVA PLUS...... 101 fever reducing childrens...... 6 FIRST-MOUTHWASH BLM...... 65 FLOVENT DISKUS...... 188 feverall adults...... 6 FIRST-OMEPRAZOLE...... 135 FLOVENT HFA...... 188 feverall childrens...... 6 FIRST-PROGESTERONE VGS...... 147 flu/cold/daytime...... 199 FEVERALL INFANTS...... 6 FIRVANQ...... 25 flu/severe cold & cough day...... 199 feverall junior strength...... 6 fish oil concentrate oral capsule 1000 mg..162 flu/severe cold daytime oral liquid 10-5-325 FEXMID...... 214 fish oil extra strength oral capsule 435 mg.162 mg/15ml...... 199 fexofenadine hcl oral...... 185 fish oil half-the-size...... 162 flu/severe cold/cough day...... 199 fexofenadine/pse er...... 199 fish oil oral capsule 1000 mg...... 162 FLUAD...... 153 fexofenadine-pseudoephed er oral tablet fish oil oral capsule 1200 mg...... 162 FLUAD QUADRIVALENT...... 153 extended release 12 hour...... 199 fish oil oral capsule 435 mg...... 162 FLUARIX QUADRIVALENT...... 153 fexofenadine-pseudoephed er oral tablet fish oil oral capsule 500 mg...... 162 flucaine...... 173 extended release 24 hour...... 199 fish oil oral capsule delayed release 1000 FLUCELVAX QUADRIVALENT...... 153 FIASP...... 51 mg, 1200 mg...... 162 fluconazole oral suspension reconstituted... 35 FIASP FLEXTOUCH...... 51 flac...... 181 fluconazole oral tablet 100 mg, 200 mg, 50 FIASP PENFILL...... 51 FLAGYL...... 25 mg...... 35 fiber...... 128 flanders buttocks...... 75 fluconazole oral tablet 150 mg...... 35 fiber laxative...... 128 FLAREX...... 179 FLUCON-IBUPROF-ITRACON-TERBINA... 35 fiber therapy...... 128 flavoxate hcl...... 136 flucytosine oral...... 35 fiber-caps...... 128 flecainide acetate...... 55 fludrocortisone acetate oral...... 139 FIBERCON...... 128 FLEET BISACODYL...... 128 FLUID ADMINISTRATION SET...... 162 fiber-lax...... 128 FLEET ENEMA...... 128 FLULAVAL QUADRIVALENT...... 153 FIBRICOR...... 61 FLEET OIL...... 128 FLUMIST QUADRIVALENT...... 153 FILTER AIR PP...... 162 FLEET PEDIATRIC...... 128 flunisolide nasal...... 188 FINACEA EXTERNAL FOAM...... 75 flexgen...... 101 FLUOCINOLONE ACET-NIACINAMIDE..... 75 FINACEA EXTERNAL GEL...... 75 FLEXICHAMBER...... 162 fluocinolone acetonide body...... 75

240 fluocinolone acetonide external...... 75 fluvastatin sodium...... 61 FORA GD50 BLOOD GLUCOSE SYSTEM fluocinolone acetonide otic...... 181 fluvastatin sodium er...... 61 ...... 162 fluocinolone acetonide scalp...... 75 FLUZONE QUADRIVALENT...... 153 FORA GD50 BLOOD GLUCOSE TEST.... 162 fluocinonide emulsified base...... 75 FML...... 179 FORA TEST N' GO MONITOR...... 162 fluocinonide external...... 75 FML FORTE...... 179 FORAXA...... 162 FLUOPAR...... 75 FML LIQUIFILM...... 179 formaldehyde external solution 10 %...... 75 FLUORABON...... 90 foaming antacid...... 118 FORMALDEHYDE EXTERNAL fluoridex...... 65 folbee...... 101 SOLUTION 37 %...... 75 fluoridex daily renewal...... 65 folbee plus...... 101 formula em...... 32 fluoridex enhanced whitening...... 65 folbee plus cz...... 101 FORTAMET...... 49 fluoridex sensitivity relief...... 65 FOLBIC RF...... 101 FORTEO...... 156 fluor-i-strips a.t...... 173 FOLGARD OS...... 101 FORTESTA...... 141 fluoritab oral solution...... 90 FOLGARD RX...... 102 FORTISCARE CONTROL...... 162 fluoritab oral tablet chewable...... 90 folic acid oral capsule 20 mg, 5 mg...... 102 FORTISCARE GLUCOSE SYSTEM...... 162 fluorometholone...... 179 folic acid oral tablet 1 mg...... 90 FORTISCARE T1 GLUCOSE SYSTEM.... 162 FLUOROPLEX...... 75 folic acid oral tablet 400 mcg...... 90 FORTISCARE TEST...... 162 FLUOROURACIL EXTERNAL CREAM 0.5 folic acid oral tablet 800 mcg...... 90 FOSAMAX...... 156 %...... 75 FOLIC D3...... 102 FOSAMAX PLUS D...... 156 fluorouracil external cream 5 %...... 75 FOLIC-K...... 102 fosfomycin tromethamine...... 23 fluorouracil external solution...... 75 FOLI-D...... 102 fosinopril sodium...... 55 FLUOVIX...... 75 FOLIKA PROBIOTIC...... 118 fosinopril sodium-hctz...... 58 FLUOVIX PLUS...... 75 FOLITE...... 102 FOSRENOL...... 97 FLURA-DROPS...... 90 FOLIVANE-F...... 90 FOSTEUM...... 102 flurandrenolide...... 75 FOLIVANE-OB...... 102 FRAGMIN...... 52 FLURA-SAFE...... 173 FOLIVANE-PLUS...... 90 FREESTYLE PRECISION NEO SYSTEM.162 flurbiprofen oral...... 12 FOLIXAPURE...... 102 FREESTYLE PRECISION NEO TEST...... 162 flurbiprofen sodium...... 179 folplex 2.2...... 102 freeze dried acidophilus...... 118 flutamide...... 41 foltabs 800...... 102 FRESHKOTE...... 173 fluticasone propionate external cream...... 75 foltanx...... 102 FROTEK...... 12 fluticasone propionate external lotion...... 75 FOLTANX RF...... 102 FROVA...... 39 fluticasone propionate external ointment..... 75 FOLTREXYL...... 102 frovatriptan succinate...... 39 fluticasone propionate nasal...... 188 foltrin...... 90 fruity c...... 102 fluticasone-salmeterol inhalation aerosol FOLTX...... 102 FUL-GLO OPHTHALMIC STRIP 0.6 MG...173 powder breath activated 100-50 mcg/dose, FOLVITE-D...... 102 ful-glo ophthalmic strip 1 mg...... 173 250-50 mcg/dose, 500-50 mcg/dose...... 199 fondaparinux sodium...... 52 full spectrum b/vitamin c...... 102 FLUTICASONE-SALMETEROL foot & sneaker...... 35 FULPHILA...... 53 INHALATION AEROSOL POWDER for sty relief...... 173 fungi-guard...... 35 BREATH ACTIVATED 113-14 MCG/ACT, FUNGIMEZ...... 35 232-14 MCG/ACT, 55-14 MCG/ACT...... 200 FUNGOID TINCTURE...... 35

241 furosemide oral solution...... 60 gavilyte-h...... 128 GENTEAL TEARS...... 173 furosemide oral tablet...... 60 gavilyte-n with flavor pack...... 128 GENTEAL TEARS MODERATE PF...... 173 FUSION PLUS...... 90 gavis-care...... 118 GENTEAL TEARS NIGHT-TIME...... 173 fyavolv oral tablet 0.5-2.5 mg-mcg...... 143 GAVISCON EXTRA RELIEF FORMULA... 119 GENTEAL TEARS PF...... 174 fyavolv oral tablet 1-5 mg-mcg...... 143 GAVISCON EXTRA STRENGTH...... 119 gentle laxative...... 128 g tussin ac...... 200 GAVISCON ORAL SUSPENSION...... 119 gentle laxative womens...... 128 GABAPENTIN-NAPROXEN CMPD KIT...... 3 GEBAUERS PAIN EASE...... 19 gentlelax...... 128 galantamine hydrobromide er...... 31 GEBAUERS SPRAY AND STRETCH...... 19 GENTLE-LET PLATFORMS...... 163 galantamine hydrobromide oral solution...... 31 GELCLAIR...... 65 geravine...... 102 galantamine hydrobromide oral tablet...... 31 GELFILM EXTERNAL...... 163 geriatric vitamin...... 102 GALZIN ORAL CAPSULE 25 MG...... 90 GELFILM OPHTHALMIC...... 173 geri-dryl oral capsule 25 mg...... 185 GALZIN ORAL CAPSULE 50 MG...... 90 GELFOAM...... 163 geri-kot...... 128 GARDASIL 9 SUSPENSION GELFOAM COMPRESSED SIZE 100...... 163 geri-lanta...... 119 INTRAMUSCULAR...... 153 GELFOAM DENTAL PACK SIZE 4...... 163 geri-lanta supreme...... 119 GARDASIL 9 SUSPENSION PREFILLED GELFOAM SPONGE SIZE 200...... 163 geri-mox...... 119 SYRINGE INTRAMUSCULAR...... 153 GELFOAM SPONGE SIZE 50...... 163 geri-mucil...... 128 gas relief drops infants...... 118 GELNIQUE...... 136 geri-pectate...... 119 gas relief extra strength oral capsule 125 GELSYN-3...... 163 geri-tussin dm...... 200 mg...... 118 GELUSIL...... 119 geri-tussin oral syrup...... 200 gas relief extra strength oral tablet GELX...... 65 GERM DEFENSE PM...... 102 chewable 125 mg...... 118 gemfibrozil oral...... 61 GIALAX...... 128 gas relief infants...... 118 gemmily...... 143 gianvi...... 143 gas relief max st...... 118 GEN7T...... 19 GILENYA...... 64 gas relief oral capsule 125 mg...... 118 GEN7T PLUS...... 19 GILPHEX TR...... 200 gas relief oral capsule 180 mg...... 118 GENADUR COMBINATION...... 163 GILTUSS TR...... 200 gas relief oral suspension 20 mg/0.3ml...... 118 GENADUR EXTERNAL...... 75 GIMOTI...... 32 gas relief oral tablet chewable 80 mg...... 118 genaphed...... 200 ginseng oral capsule 100 mg...... 163 gas relief ultra strength...... 118 GENERESS FE...... 143 gla-45...... 163 GASTROCROM...... 118 gengraf...... 152 glatiramer acetate...... 64 GAS-X EXTRA STRENGTH ORAL GENICIN VITA-D...... 102 glatopa...... 64 CAPSULE...... 118 GENICIN VITA-Q...... 102 GLEOSTINE...... 41 GAS-X EXTRA STRENGTH ORAL GENICIN VITA-S...... 102 glimepiride...... 49 TABLET CHEWABLE...... 118 GENOTROPIN...... 140 glipizide er...... 49 GAS-X ULTRA STRENGTH...... 118 GENOTROPIN MINIQUICK...... 140 glipizide ir...... 49 gatifloxacin ophthalmic...... 177 gentak...... 177 glipizide xl...... 49 GATTEX...... 118 gentamicin sulfate external cream...... 23 glipizide-metformin hcl...... 49 gavilax oral powder...... 128 gentamicin sulfate external ointment...... 23 GLOPERBA...... 37 gavilyte-c...... 128 gentamicin sulfate ophthalmic...... 177 glostrips ophthalmic strip 1 mg...... 174 gavilyte-g...... 128 GENTEAL SEVERE...... 173 GLUCAGEN HYPOKIT...... 50

242 GLUCAGON EMERGENCY INJECTION GLYCOPYRROLATE ORAL TABLET 1.5 guanfacine hcl...... 54 KIT...... 50 MG...... 113 GUANIDINE HCL...... 39 GLUCAGON EMERGENCY INJECTION glyco-tech...... 102 gummy dinos...... 102 SOLUTION RECONSTITUTED...... 50 GLYNASE...... 49 gummy multivitamin kids...... 102 GLUCOSE CONTROL SOLUTION IN GLY-OXIDE...... 65 GVOKE HYPOPEN 1-PACK...... 50 VITRO LIQUID...... 163 GLYSET...... 49 GVOKE HYPOPEN 2-PACK...... 50 GLUCOSE CONTROL SOLUTION IN GLYTACTIN COMPLETE 10PE...... 163 GVOKE PFS...... 50 VITRO SOLUTION...... 163 GLYXAMBI...... 49 GYNAZOLE-1...... 35 GLUCOSE CONTROL SOLUTION IN GOCOVRI...... 45 GYNE-LOTRIMIN...... 35 VITRO SOLUTION HIGH , LOW...... 163 GOLYTELY...... 128 GYNE-LOTRIMIN 3...... 35 GLUCOSE CONTROL SOLUTION IN GONAK...... 174 h2q oral capsule...... 163 VITRO SOLUTION NORMAL...... 163 goniotaire...... 174 H2Q ORAL POWDER...... 163 glucose liquid shot oral liquid...... 50 goniovisc ophthalmic solution 2.5 %...... 174 hailey 1.5/30...... 143 GLUCOSE METER TEST STRIPS...... 163 GONITRO...... 62 hailey 24 fe...... 143 GLUCOSE NURSETTE...... 50 GOOD START 5% GLUCOSE WATER...... 50 hailey fe 1.5/30...... 143 glucose oral tablet chewable 4 gm...... 50 GORDOFILM...... 76 hailey fe 1/20...... 143 glucose oral tablet chewable 4-6 gm-mg..... 50 gormel...... 76 halcinonide...... 76 GLUCOTROL...... 49 gormel 10...... 76 halobetasol propionate external cream...... 76 GLUCOTROL XL...... 49 G-PREPROTEIN...... 163 HALOBETASOL PROPIONATE GLUCOVANCE ORAL TABLET 5-500 MG..49 grafco silver nit applicator...... 25 EXTERNAL FOAM...... 76 GLUMETZA...... 49 GRALISE...... 63 halobetasol propionate external ointment.... 76 glutamine oral capsule...... 90 granisetron hcl oral...... 33 HALOG EXTERNAL CREAM...... 76 GLUTARALDEHYDE EXTERNAL...... 25 GRANIX SUBCUTANEOUS SOLUTION..... 53 HALOG EXTERNAL OINTMENT...... 76 glyburide micronized...... 49 GRANIX SUBCUTANEOUS SOLUTION HALOG EXTERNAL SOLUTION...... 76 glyburide oral...... 49 PREFILLED SYRINGE...... 53 HALUCORT...... 76 glyburide-metformin...... 49 GRASTEK...... 200 HARD NAILS...... 102 GLYCATE...... 113 green glo lissamine green...... 174 HAVRIX...... 153 glycerin (adult) rectal suppository 2 gm..... 128 griseofulvin microsize oral suspension...... 35 headache formula...... 6 glycerin (infant)...... 128 griseofulvin microsize oral tablet...... 35 headache relief...... 6 glycerin (infants & children) rectal griseofulvin ultramicrosize...... 35 headache relief extra str...... 6 suppository 1 gm...... 128 guaiatussin ac...... 200 headrin ex strength pain rel...... 6 glycerin (pediatric) rectal suppository 1 gm128 guaicon dms...... 200 heal aid plus...... 76 glycerin adult rectal suppository 2 gm...... 128 guaifenesin ac...... 200 healthy hair/skin/nails...... 102 glycerin child...... 128 guaifenesin dac...... 200 heartburn antacid ex st...... 119 glycerin childrens...... 128 guaifenesin er oral tablet extended release heartburn relief 200...... 125 glycerin external...... 75 12 hour 1200 mg...... 200 heartburn relief ex st...... 119 glycerin external liquid 99.5 %...... 75 guaifenesin oral tablet 400 mg...... 200 heartburn relief oral tablet 10 mg...... 125 glycolax...... 128 guaifenesin-codeine...... 200 heartburn relief oral tablet 200 mg...... 125 glycopyrrolate oral tablet 1 mg, 2 mg...... 113 guaifenesin-dm oral syrup...... 200

243 heartburn relief oral tablet chewable 160- hm allergy relief childrens...... 186 hm fiber oral powder 30.9 %...... 129 105 mg...... 119 hm allergy relief oral...... 186 hm fiber oral tablet...... 129 heather...... 147 hm allergy relief/nasal decong...... 200 hm gas relief...... 119 h-e-b aspirin...... 12 hm antacid...... 119 hm gas relief extra strength...... 119 h-e-b childrens allergy...... 185 hm antacid anti-gas ex st...... 119 hm gas relief infants drops...... 119 HELIDAC THERAPY...... 119 hm antacid/antigas...... 119 hm glucose...... 50 HEMADY...... 139 hm anti-diarrheal anti-gas...... 119 hm glycerin external liquid...... 76 HEMANGEOL...... 56 hm anti-diarrheal oral liquid...... 119 hm hydrocortisone plus...... 76 hematinic plus vit/minerals...... 90 hm anti-diarrheal oral tablet...... 119 hm hydrocortisone-aloe max st...... 76 hematinic/folic acid...... 90 hm anti-nausea...... 32 hm ibuprofen...... 12 HEMATOGEN...... 90 hm arthritis pain relief...... 6 hm ibuprofen ib...... 12 HEMATOGEN FA...... 90 hm aspirin...... 12 hm ibuprofen infants...... 12 HEMATRON-AF...... 90 hm aspirin ec...... 12 hm lansoprazole...... 135 hemax...... 90 hm aspirin ec low dose...... 12 hm laxative...... 129 hemmorex-hc...... 38 hm bacitracin zinc...... 25 hm lice killing max st...... 44 HEMOCYTE...... 90 hm calcium antacid...... 119 hm lice treatment...... 44 HEMOCYTE PLUS...... 90 hm calcium antacid ex st...... 119 hm loperamide hcl oral liquid...... 119 hemocyte-f...... 90 hm calcium antacid ultra st...... 119 hm loperamide hcl oral suspension...... 119 hemocyte-plus...... 90 hm cetirizine hcl...... 186 hm loratadine...... 186 hemorrhoidal-hc rectal suppository 25 mg... 38 hm chest congestion relief...... 200 hm loratadine childrens...... 186 heparin sodium (porcine) injection solution hm clearlax oral powder...... 129 hm lubricating plus...... 174 10000 unit/ml, 5000 unit/ml...... 52 hm cold & allergy childrens...... 200 hm lubricating tears...... 174 heparin sodium (porcine) pf injection hm cold & cough childrens...... 200 hm magnesium citrate...... 129 solution 5000 unit/0.5ml...... 52 hm cold & sinus relief...... 201 hm migraine relief...... 6 HEPLISAV-B...... 153 hm cough dm...... 201 hm milk of magnesia...... 129 HEPSERA...... 47 hm day time...... 201 HM MINERAL OIL...... 129 herbiomed fast acting...... 200 hm daytime cold & flu oral liquid...... 201 hm motion sickness...... 32 HIBICLENS...... 76 hm double antibiotic...... 25 hm mucus er...... 201 HIDEX 6-DAY...... 139 hm earwax removal aid...... 181 hm mucus relief d...... 201 high potency probiotic...... 119 hm earwax removal kit...... 181 hm naproxen sodium oral tablet...... 12 HIPREX...... 23 hm enema...... 129 hm nasal decongestant...... 201 HISTEX PD...... 186 hm enema mineral oil...... 129 hm nasal decongestant 12 hour...... 201 HISTEX-AC...... 200 hm eye drops...... 177 hm nasal decongestant pe...... 201 hm acetaminophen childrens...... 6 hm eye drops advanced relief...... 174 hm nasal spray...... 201 hm adult tussin cough & chest...... 200 hm eye itch relief...... 179 hm nicotine...... 22 hm advanced antacid max st...... 119 hm famotidine oral tablet 10 mg...... 125 hm nicotine polacrilex...... 22 hm all day allergy oral tablet...... 186 hm fexofenadine hcl...... 186 hm nose drops...... 201 hm allergy & congestion...... 200 hm fiber oral powder 28.3 %, 48.57 %, hm omeprazole...... 135 hm allergy complete-d...... 200 58.6 %...... 129 hm pain & fever childrens...... 6

244 hm pain & fever infants...... 6 HUMALOG U-100 VIAL AND CARTRIDGE hydrocodone-acetaminophen oral solution hm pain relief...... 6 SUBCUTANEOUS SOLUTION 100 10-325 mg/15ml...... 17 hm pain relief extra strength...... 6 UNIT/ML...... 51 hydrocodone-acetaminophen oral solution hm pain reliever...... 6 HUMALOG U-100 VIAL AND CARTRIDGE 7.5-325 mg/15ml...... 17 hm povidone-iodine...... 25 SUBCUTANEOUS SOLUTION hydrocodone-acetaminophen oral tablet...... 17 hm saline nasal spray...... 201 CARTRIDGE 100 UNIT/ML...... 51 hydrocodone-homatropine...... 201 hm senna...... 129 HUMATROPE...... 140 hydrocodone-ibuprofen...... 17 hm senna-s...... 129 HUMATROPEN FOR 12MG...... 163 hydrocortisone (perianal) external cream 1 hm severe cold/cough/flu...... 201 HUMATROPEN FOR 24MG...... 163 %...... 155 hm sinus nasal spray...... 201 HUMATROPEN FOR 6MG...... 163 hydrocortisone (perianal) external cream hm stomach relief max strength...... 119 HUMIRA SUBCUTANEOUS PEN- 2.5 %...... 155 hm stomach relief oral suspension...... 120 INJECTOR KIT 40 MG/0.4ML, 80 hydrocortisone ace-pramoxine external hm stomach relief oral tablet chewable...... 120 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML. 152 cream 1-1 %...... 155 hm stomach relief ultra...... 120 HUMIRA SUBCUTANEOUS PEN- hydrocortisone ace-pramoxine external hm stool softener...... 129 INJECTOR KIT 40 MG/0.8ML...... 152 cream 2.5-1 %...... 76 hm stool softener/laxative...... 129 HUMIRA SUBCUTANEOUS PREFILLED hydrocortisone acetate external cream...... 76 hm triple antibiotic...... 25 SYRINGE KIT...... 152 hydrocortisone acetate external ointment.... 76 hm triple antibiotic max st...... 25 HUMULIN 70/30 KWIKPEN...... 51 hydrocortisone acetate rectal...... 38 hm tussin adult dm oral liquid 10-200 HUMULIN 70/30 VIAL...... 51 hydrocortisone anti-itch external cream 0.5 mg/5ml...... 201 HUMULIN N KWIKPEN...... 51 %...... 76 hm tussin adult multi-symptom...... 201 HUMULIN N VIAL...... 51 hydrocortisone butyr lipo base...... 76 homatropaire...... 174 HUMULIN R U-500 KWIKPEN...... 51 hydrocortisone butyrate...... 76 HONEY BEARS...... 102 HUMULIN R U-500 VIAL hydrocortisone external cream...... 76 HONEY BEARS W/IRON-ZINC...... 102 (CONCENTRATED)...... 51 hydrocortisone external lotion 2.5 %...... 76 honey lemon drops...... 65 HUMULIN R VIAL...... 51 hydrocortisone external ointment...... 76 HORIZANT...... 63 HURRICAINE MOUTH/THROAT GEL...... 65 hydrocortisone oral...... 139 HPR PLUS EXTERNAL CREAM...... 76 HYALUCIL-4...... 41 hydrocortisone rectal...... 155 hpr plus external foam...... 76 HYALURONATE-NIACINAM-TRETINOIN...76 hydrocortisone valerate...... 76 HPR PLUS HYDROGEL...... 76 HYALURONATE-NIACIN-TACROLIMUS.... 76 hydrocortisone/aloe...... 76 HUMALOG KWIKPEN SUBCUTANEOUS HYCAMTIN ORAL...... 42 hydrocortisone/aloe max str...... 76 SOLUTION PEN-INJECTOR 100 UNIT/ML.51 hycodan...... 201 hydrocortisone-acetic acid...... 181 HUMALOG KWIKPEN SUBCUTANEOUS hydralazine hcl oral...... 62 hydrocortisone-aloe...... 76 SOLUTION PEN-INJECTOR 200 UNIT/ML.51 HYDREA...... 41 hydrocortisone-iodoquinol...... 35 HUMALOG MIX 50/50 KWIKPEN...... 51 HYDRO 40...... 76 hydrocort-pramoxine (perianal)...... 155 HUMALOG MIX 50/50 VIAL...... 51 hydrocerin...... 76 hydrolatum...... 76 HUMALOG MIX 75/25 KWIKPEN...... 51 hydrochlorothiazide oral...... 60 hydromet...... 201 HUMALOG MIX 75/25 VIAL...... 51 hydrocodone bitartrate er...... 15 hydromorphone hcl er...... 17 HUMALOG U-100 JUNIOR KWIKPEN...... 51 hydrocodone polst-cpm polst er...... 201 hydromorphone hcl oral...... 17 hydromorphone hcl rectal...... 17

245 HYDROMORPHONE HCL-NACL ibu-200...... 12 inavix...... 13 INTRAVENOUS SOLUTION 25-0.9 IBUPAK...... 12 INBRIJA...... 163 MG/50ML-%, 50-0.9 MG/50ML-%...... 17 ibuprofen childrens oral tablet chewable incassia...... 147 HYDROMORPHONE HCL-NACL 100 mg...... 12 INCRELEX...... 140 INTRAVENOUS SOLUTION PREFILLED ibuprofen cold & sinus...... 201 INCRUSE ELLIPTA...... 189 SYRINGE 10-0.9 MG/50ML-%...... 17 ibuprofen infants...... 12 indapamide...... 60 hydrophor...... 76 ibuprofen infants drops...... 12 INDERAL LA...... 56 hydro-tabs...... 163 ibuprofen junior st...... 12 INDERAL XL...... 56 hydroxychloroquine sulfate oral...... 44 ibuprofen junior strength...... 12 INDOCIN...... 13 hydroxyprogesterone caproate ibuprofen oral capsule...... 13 indomethacin er...... 13 intramuscular...... 147 ibuprofen oral suspension...... 13 INDOMETHACIN ORAL CAPSULE 20 MG. 13 hydroxyurea oral...... 41 ibuprofen oral tablet...... 13 indomethacin oral capsule 25 mg, 50 mg.... 13 hydroxyzine hcl oral...... 48 ICAR...... 90 indoor/outdoor allergy rlf...... 186 hydroxyzine pamoate oral...... 186 ICAR-C...... 90 INFANRIX...... 153 HYLATOPIC PLUS...... 76 ICAR-C PLUS...... 90 infant gas relief...... 120 HYLAVITE...... 102 icatibant acetate...... 151 INFANTS ADVIL...... 13 HYLAZINC...... 102 icosapent ethyl...... 61 infants gas relief...... 120 HYMOVIS...... 163 IDHIFA...... 42 infants ibuprofen...... 13 hyophen...... 137 iferex 150 forte...... 90 infants pain & fever...... 6 hyoscyamine sulfate er...... 113 ILEVRO...... 179 infants pain relief drops...... 6 hyoscyamine sulfate oral elixir...... 113 ILUMYA...... 76 infants pain relief oral suspension 80 hyoscyamine sulfate oral solution...... 113 ILUVIEN...... 179 mg/0.8ml...... 6 hyoscyamine sulfate oral tablet...... 113 IMIOXIA...... 35 infants pain/fever...... 6 hyoscyamine sulfate oral tablet dispersible113 imiquimod external...... 76 infants simethicone...... 120 hyoscyamine sulfate sl...... 113 IMIQUIMOD PUMP...... 76 INFED...... 90 hyoscyamine sulfate sublingual...... 113 IMIQUIMOD-LEVOCETIRIZIN-NIACIN...... 76 INFLAMMACIN...... 13 hyosyne oral elixir...... 113 IMIQUIMOD-LEVOCET-TRETINOIN...... 76 INFLATHERM...... 13 hyosyne oral solution...... 113 IMITREX...... 39 INFUVITE ADULT...... 102 HYPERSAL INHALATION NEBULIZATION IMITREX STATDOSE REFILL...... 39 INFUVITE PEDIATRIC...... 102 SOLUTION 3.5 %...... 201 IMITREX STATDOSE SYSTEM...... 39 INGREZZA ORAL CAPSULE 40 MG...... 63 HYPERSAL INHALATION NEBULIZATION IMLYGIC...... 42 INGREZZA ORAL CAPSULE 80 MG...... 63 SOLUTION 7 %...... 201 IMODIUM A-D ORAL LIQUID...... 120 INGREZZA ORAL CAPSULE THERAPY HYPOCYN...... 174 IMODIUM A-D ORAL TABLET...... 120 PACK...... 63 HYPOTEARS...... 174 IMODIUM MULTI-SYMPTOM RELIEF...... 120 inner ear plus...... 102 HYSINGLA ER...... 15 IMPAVIDO...... 44 INNOPRAN XL...... 56 HYZAAR...... 58 IMPEKLO...... 76 INOSITOL-5...... 163 ibandronate sodium intravenous...... 156 IMPOYZ...... 76 INOVA...... 77 ibandronate sodium oral...... 156 IMURAN...... 152 INOVA 4/1 ACNE CONTROL THERAPY.... 77 ibu...... 12 INATAL GT...... 102 INOVA 8/2 ACNE CONTROL THERAPY.... 77

246 INQOVI...... 40 INSULIN SYRINGES 30G X 1/2" 0.5 ML...164 iron oral tablet 240 (27 fe) mg...... 90 INSPIRACHAMBER/LARGE...... 163 INSULIN SYRINGES 30G X 1/2" 1 ML...... 164 iron oral tablet 325 (65 fe) mg...... 90 INSPIRACHAMBER/MEDIUM...... 163 INSULIN SYRINGES 30G X 5/16" 0.3 ML, iron oral tablet extended release 142 (45 INSPIRACHAMBER/MOUTHPIECE...... 163 30G X 5/16" 1 ML...... 164 fe) mg...... 90 INSPIRACHAMBER/SMALL...... 163 INSULIN SYRINGES 30G X 5/16" 0.5 ML.164 iron supplement...... 90 INSPIREASE...... 163 INSULIN SYRINGES 31G X 15/64" 0.3 iron supplement childrens...... 90 INSPIREASE RESERVOIR BAGS...... 163 ML, 31G X 15/64" 0.5 ML...... 164 IROSPAN 24/6...... 91 INSPRA...... 60 INSULIN SYRINGES 31G X 5/16" 0.3 ML.164 isibloom...... 143 instacort 5...... 77 INSULIN SYRINGES 31G X 5/16" 0.5 ML.164 isoleucine...... 165 INSTA-GLUCOSE...... 50 INSULIN SYRINGES 31G X 5/16" 1 ML....164 ISOLEUCINE 1000...... 165 INSULIN ASP PROT & ASP FLEXPEN...... 51 INTEGRA...... 90 isoniazid oral...... 40 INSULIN ASPART...... 51 INTEGRA F...... 90 ISOPTO ATROPINE...... 174 INSULIN ASPART FLEXPEN...... 51 INTEGRA PLUS...... 90 ISOPTO CARPINE...... 178 INSULIN ASPART PENFILL...... 51 intestinex...... 120 ISOPTO TEARS...... 174 INSULIN ASPART PROT & ASPART...... 51 INTRAROSA...... 141 ISORDIL TITRADOSE ORAL TABLET 40 INSULIN LISPRO...... 51 INTRON A...... 47 MG...... 62 INSULIN LISPRO (1 UNIT DIAL)...... 51 introvale...... 143 ISORDIL TITRADOSE ORAL TABLET 5 INSULIN LISPRO JUNIOR KWIKPEN...... 51 INVELTYS...... 179 MG...... 62 INSULIN LISPRO PROT & LISPRO...... 51 INVOKAMET...... 49 isosorbide dinitrate oral tablet 10 mg, 20 INSULIN PEN NEEDLES 29G X 12.7MM..163 INVOKAMET XR...... 49 mg, 30 mg...... 62 INSULIN PEN NEEDLES 29G X 12MM.....163 INVOKANA...... 49 isosorbide dinitrate oral tablet 40 mg...... 62 INSULIN PEN NEEDLES 29G X 5MM , IODINE STRONG ORAL...... 164 isosorbide dinitrate oral tablet 5 mg...... 62 29G X 8MM , 31G X 5 MM , 31G X 8 MM..163 iodine tincture external tincture 2 %...... 25 isosorbide mononitrate...... 62 INSULIN PEN NEEDLES 30G X 8 MM...... 164 IODOQUIMEZ-HC...... 35 isosorbide mononitrate er...... 62 INSULIN PEN NEEDLES 31G X 6 MM...... 164 iodoquinol-hc-aloe polysacch...... 35 isotretinoin capsule 10 mg oral...... 77 INSULIN PEN NEEDLES 32G X 4 MM...... 164 IODOQUINOL-HC-KETOCONAZOLE...... 35 isotretinoin capsule 20 mg oral...... 77 INSULIN PEN NEEDLES 32G X 5 MM...... 164 iodoquinol-hydrocortisone-aloe...... 35 isotretinoin capsule 30 mg oral...... 77 INSULIN PEN NEEDLES 32G X 6 MM...... 164 ionil-t...... 77 isotretinoin capsule 40 mg oral...... 77 INSULIN PEN NEEDLES 33G X 4 MM...... 164 IOPIDINE...... 178 isoxsuprine hcl oral...... 58 INSULIN SYRINGES 27G X 1/2" 0.5 ML...164 IOSAT...... 164 isradipine...... 57 INSULIN SYRINGES 27G X 1/2" 1 ML...... 164 ipratropium bromide inhalation...... 189 ISTALOL...... 178 INSULIN SYRINGES 28G X 1/2" 0.5 ML, ipratropium bromide nasal...... 189 ISTURISA...... 150 29G X 1/2" 0.5 ML...... 164 ipratropium-albuterol...... 201 ITHOXIA...... 77 INSULIN SYRINGES 28G X 1/2" 1 ML...... 164 irbesartan...... 55 itraconazole oral...... 35 INSULIN SYRINGES 28G X 5/16" 1 ML, irbesartan-hydrochlorothiazide...... 58 ivermectin oral...... 44 29G X 5/16" 1 ML, 30G X 3/8" 0.5 ML...... 164 IROFOL...... 90 IVERMECTIN-METRONIDAZOL-NIACIN....77 INSULIN SYRINGES 29G X 1/2" 0.3 ML...164 iron 100/c...... 90 JADENU...... 96 INSULIN SYRINGES 29G X 1/2" 1 ML...... 164 iron chews pediatric...... 90 JADENU SPRINKLE...... 96 INSULIN SYRINGES 30G X 1/2" 0.3 ML...164 iron oral tablet 200 (65 fe) mg...... 90 jaimiess...... 143

247 JAKAFI...... 42 KELARX...... 77 KIDNEY...... 102 JALYN...... 137 kelnor 1/35...... 144 kionex...... 96 jantoven...... 52 kelnor 1/50...... 144 KISQALI FEMARA (400 MG DOSE)...... 42 JANUMET...... 49 kelp oral tablet 0.15 mg...... 91 KISQALI FEMARA (600 MG DOSE)...... 42 JANUMET XR...... 49 kelp-b6-lecithin-vinegar...... 165 KISQALI FEMARA(200 MG DOSE)...... 42 JANUVIA...... 49 KENALOG EXTERNAL...... 77 KITABIS PAK...... 191 JARDIANCE...... 49 KERALAC...... 77 KIVIK...... 77 jasmiel...... 143 KERALYT EXTERNAL GEL 6 %...... 77 KLARITY-A...... 177 JATENZO...... 141 KERALYT SCALP...... 77 KLARITY-L...... 179 jencycla...... 147 KERYDIN...... 35 KLARON...... 77 JENTADUETO...... 49 KESIMPTA...... 63 klor-con...... 91 JENTADUETO XR...... 49 KETAMINE HCL-SODIUM CHLORIDE klor-con 10...... 91 jinteli...... 144 INTRAVENOUS SOLUTION PREFILLED klor-con m10...... 91 jock itch...... 35 SYRINGE 50-0.9 MG/5ML-%...... 165 KLOR-CON M15...... 91 jock itch spray...... 35 ketoconazole external cream...... 35 klor-con m20...... 91 jock itch spray powder...... 35 ketoconazole external foam...... 35 klor-con sprinkle...... 91 jolessa...... 144 ketoconazole external shampoo...... 35 klor-con/ef...... 91 JUBLIA...... 35 ketoconazole oral...... 35 kls acetaminophen ex st...... 6 juleber...... 144 KETOCONAZOLE-HYDROCORTISONE.... 35 kls allerclear...... 186 junel 1.5/30...... 144 ketodan external foam...... 35 kls allerclear d-12hr...... 201 junel 1/20...... 144 KETODAN EXTERNAL KIT...... 35 kls allerclear d-24hr...... 201 junel fe...... 144 KETO-DIASTIX...... 165 kls aller-cort...... 188 JUXTAPID...... 61 KETONE CARE...... 165 kls aller-fex...... 186 JYNARQUE ORAL TABLET...... 96 KETONE TEST...... 165 kls allergy medicine...... 186 JYNARQUE ORAL TABLET THERAPY KETOPHENE RAPIDPAQ...... 13 kls aller-tec...... 186 PACK...... 96 ketoprofen er...... 13 kls aller-tec d...... 201 K.B.G.L IN TERODERM...... 13 ketoprofen oral capsule 25 mg...... 13 kls anti-diarrheal...... 120 KADIAN...... 17 ketoprofen oral capsule 50 mg, 75 mg...... 13 kls aspirin ec...... 13 kaitlib fe...... 144 KETOROLAC TROMETHAMINE kls aspirin low dose...... 13 kalliga...... 144 EXTERNAL...... 13 kls hydrocortisone plus...... 77 KAMDOY...... 77 KETOROLAC TROMETHAMINE NASAL.... 13 kls ibuprofen...... 13 kaminos...... 165 ketorolac tromethamine ophthalmic...... 179 kls lansoprazole...... 135 KANUMA...... 136 ketorolac tromethamine oral...... 13 kls laxaclear...... 129 KAPSPARGO SPRINKLE...... 56 KETOSTIX...... 165 kls mucus relief chest...... 201 KARBINAL ER...... 186 ketotifen fumarate ophthalmic...... 179 kls naproxen sodium...... 13 kariva...... 144 KEVEYIS...... 60 kls nasal decongestant spray...... 201 KATERZIA...... 57 KEVZARA...... 153 kls natural psyllium fiber...... 129 KAZANO...... 49 KEY OMEGA...... 165 kls omeprazole...... 135 KEFLEX...... 27 KEYTRUDA...... 43 kls quit2...... 22

248 kls quit4...... 22 kp vitamin b-12...... 102 LAMPIT...... 43 kls rapid release pain...... 6 kp vitamin b-6...... 102 LANAPHILIC...... 77 kls stool softener...... 129 kp vitamin d...... 102 LANCETS...... 165, 171 kls suphedrine pe...... 201 kp vitamin d3...... 102 LANCETS KIT...... 165 K-MAG...... 91 kp vitamin e...... 102 LANCING DEVICE...... 165 K-MAG-70...... 91 k-pec...... 120 LANOXIN ORAL TABLET 125 MCG, 250 KOMBIGLYZE XR...... 49 K-PHOS...... 91 MCG...... 59 KONSYL DAILY FIBER ORAL POWDER K-PHOS NO 2...... 91 LANOXIN ORAL TABLET 62.5 MCG...... 59 100 %...... 129 K-PHOS-NEUTRAL...... 91 lansoprazole oral...... 135 konsyl daily fiber oral powder 28.3 %...... 129 k-prime...... 91 lanthanum carbonate...... 97 korean ginseng oral capsule 250 mg, 350 KRINTAFEL...... 44 LANTUS SOLOSTAR...... 51 mg...... 165 KRISTALOSE ORAL PACKET 20 GM...... 129 LANTUS U-100 VIAL...... 51 KORLYM...... 140 KROGER BLOOD GLUCOSE KIT...... 165 l-arginine oral capsule...... 165 kosher prenatal plus iron...... 102 KROGER TEST...... 165 l-arginine-500...... 165 kp aspirin...... 13 ks ibuprofen...... 13 larin 1.5/30...... 144 kp bacitracin zinc...... 25 ks stool softener...... 129 larin 1/20...... 144 kp bisacodyl...... 129 K-TAB ORAL TABLET EXTENDED larin 24 fe...... 144 kp calcium 600+d oral capsule...... 91 RELEASE 10 MEQ, 8 MEQ...... 91 larin fe 1.5/30...... 144 kp calcium 600+d oral tablet 600-400 mg- K-TAB ORAL TABLET EXTENDED larin fe 1/20...... 144 unit...... 91 RELEASE 20 MEQ...... 91 larissia...... 144 kp calcium 600+d3...... 91 k-tan plus...... 91 larynex...... 66 kp calcium citrate+d...... 91 kurvelo...... 144 LASIX...... 60 kp calcium-magnesium-zinc...... 91 KYLEENA...... 147 LASTACAFT...... 174 kp double antibiotic...... 25 KYNMOBI...... 46 latanoprost ophthalmic...... 180 kp ferrous gluconate...... 91 KYNMOBI TITRATION KIT...... 46 LATANOPROST-TIMOLOL MALEATE...... 178 kp ferrous sulfate...... 91 labetalol hcl oral...... 56 lavare wound wash...... 77 kp fexofenadine hcl...... 186 LAC-HYDRIN FIVE...... 77 laxa basic...... 129 kp fish oil...... 165 LACRISERT...... 174 laxacin...... 129 kp folic acid...... 91 lactic acid e...... 77 laxative...... 129 kp hydrocortisone-aloe...... 77 lactic acid external...... 77 laxative max str...... 129 kp ketotifen fumarate...... 179 lactobacillus oral tablet...... 120 laxative pills...... 129 kp mag-oxide magnesium...... 91 LACTOJEN...... 120 laxative regular strength...... 129 kp miconazole nitrate...... 35 lacto-key-100...... 120 layolis fe...... 144 kp omega-3 fish oil...... 165 lacto-key-600...... 120 LAZANDA NASAL SOLUTION 100 kp omeprazole magnesium...... 135 lacto-pectin...... 120 MCG/ACT, 400 MCG/ACT...... 17 kp prenatal multivitamins...... 102 lactulose...... 129 LAZANDA NASAL SOLUTION 300 kp pseudoephedrine hcl oral tablet 30 mg. 201 LAMISIL AT EXTERNAL CREAM...... 35 MCG/ACT...... 17 kp senna...... 129 LAMISIL AT JOCK ITCH...... 35 l-carnitine oral capsule 250 mg...... 165 kp tolnaftate...... 35 lamivudine oral tablet 100 mg...... 47 L-CYSTINE...... 165

249 LDO PLUS...... 19 levonorgest-eth estrad 91-day oral tablet lice treatment...... 44 LEADER ADVANCED LANCING DEVICE 165 0.15-0.03 mg...... 144 licide external...... 44 lecithin oral capsule...... 165 levonorgestrel...... 147 licide maximum strength...... 44 lecithin-19...... 165 levonorgestrel-ethinyl estrad...... 144 LIDO BDK...... 19 leena...... 144 levonorg-eth estrad triphasic...... 144 lidocaine cream 4 % external...... 19 leflunomide oral...... 153 levora 0.15/30 (28)...... 144 lidocaine external ointment...... 19 LENVIMA (4 MG DAILY DOSE)...... 42 levorphanol tartrate oral...... 15 lidocaine external patch 5 %...... 19 LESCOL XL...... 61 levo-t oral tablet 100 mcg, 75 mcg...... 149 lidocaine hcl external cream 3 %...... 19 lessina...... 144 levo-t oral tablet 112 mcg, 125 mcg, 137 lidocaine hcl external cream 4 %...... 19 LETAIRIS...... 191 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, LIDOCAINE HCL EXTERNAL CREAM letrozole oral...... 42 50 mcg, 88 mcg...... 149 4.12 %...... 20 lets...... 19 levo-t oral tablet 300 mcg...... 149 lidocaine hcl external lotion...... 20 leucine oral...... 165 LEVOTHYROXINE SODIUM ORAL lidocaine hcl external solution...... 20 leucovorin calcium oral...... 42 CAPSULE 100 MCG, 112 MCG, 125 MCG, LIDOCAINE HCL INJECTION SOLUTION LEUKERAN...... 41 13 MCG, 137 MCG, 25 MCG, 50 MCG, 75 PREFILLED SYRINGE 100 MG/5ML...... 20 LEUKINE...... 53 MCG, 88 MCG...... 149 lidocaine hcl mouth/throat...... 20 leuprolide acetate injection...... 150 LEVOTHYROXINE SODIUM ORAL lidocaine hcl urethral/mucosal...... 20 levalbuterol hcl inhalation...... 190 CAPSULE 150 MCG, 175 MCG, 200 MCG149 lidocaine maximum strength...... 20 LEVALBUTEROL HFA INHALATION levothyroxine sodium oral tablet 100 mcg, lidocaine pain relieving...... 20 AEROSOL 45 MCG/ACT...... 190 75 mcg...... 149 lidocaine plus...... 20 LEVATIO...... 7 levothyroxine sodium oral tablet 112 mcg, lidocaine viscous hcl...... 20 LEVBID...... 113 125 mcg, 137 mcg, 150 mcg, 175 mcg, lidocaine-hydrocort (perianal)...... 77 LEVEMIR U-100 FLEXTOUCH...... 51 200 mcg, 25 mcg, 50 mcg, 88 mcg...... 149 LIDOCAINE-HYDROCORTISONE ACE LEVEMIR U-100 VIAL...... 51 levothyroxine sodium oral tablet 300 mcg..149 EXTERNAL...... 77 levobunolol hcl...... 178 levoxyl oral tablet 100 mcg, 75 mcg...... 149 LIDOCAINE-HYDROCORTISONE ACE levocetirizine dihydrochloride oral solution.186 levoxyl oral tablet 112 mcg, 125 mcg, 137 RECTAL GEL...... 77 levocetirizine dihydrochloride oral tablet.... 186 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, lidocaine-hydrocortisone ace rectal kit...... 77 levofloxacin ophthalmic...... 177 50 mcg, 88 mcg...... 149 lidocaine-prilocaine external cream...... 20 levofloxacin oral solution...... 29 LEVSIN ORAL...... 113 lidocaine-prilocaine external kit...... 20 levofloxacin oral tablet...... 29 LEVSIN/SL...... 113 LIDOCAINE-TETRACAINE EXTERNAL levoleucovorin calcium pf intravenous LEVULAN KERASTICK...... 77 CREAM 23-7 %...... 20 solution 250 mg/25ml...... 42 LEXETTE...... 77 LIDOCAINE-TETRACAINE EXTERNAL levonest...... 144 lexinal...... 102 CREAM 7-7 %...... 20 levonorgest-eth est & eth est...... 144 LIALDA...... 154 LIDOCANNA...... 20 levonorgest-eth estrad 91-day oral tablet LIBRAX...... 113 LIDOCORT...... 77 0.1-0.02 & 0.01 mg...... 144 LICART...... 13 LIDODERM...... 20 levonorgest-eth estrad 91-day oral tablet lice killing...... 44 LIDOPAC...... 20 0.15-0.03 &0.01 mg...... 144 lice killing maximum strength...... 44 lidopin external cream 3 %...... 20 lice solution combination kit...... 44 LIDOPIN EXTERNAL CREAM 3.25 %...... 20

250 LIDOPRIL...... 20 lisinopril-hydrochlorothiazide...... 59 long lasting nasal spray...... 202 LIDOPRIL XR...... 20 L-ISOLEUCINE...... 165 LONHALA MAGNAIR REFILL KIT...... 189 LIDO-PRILO CAINE PACK...... 20 lissamine green...... 174 LONHALA MAGNAIR STARTER KIT...... 189 LIDOPURE PATCH...... 20 LITHATE...... 102 LONSURF...... 42 LIDORX...... 20 little ones childrens...... 102 loperamide hcl oral capsule...... 120 LIDO-SORB...... 20 little teethers pain relief mouth/throat gel loperamide hcl oral liquid 1 mg/7.5ml...... 120 LIDOSTREAM...... 20 7.5 %...... 66 loperamide hcl oral suspension...... 120 LIDOTHOL...... 20 little tummys gas relief...... 120 loperamide hcl oral tablet...... 120 LIDOTRAL...... 20 LIVALO...... 61 LOPID...... 61 LIDOTREX...... 77 LIVE BETTER ADV LANCING DEVICE.... 165 LOPRESSOR...... 56 LIDOVIX L...... 20 liver...... 165 LOPRESSOR HCT...... 59 LIDTOPIC MAX...... 20 LIVIXIL PAK...... 20 LOPROX...... 35 lillow...... 144 l-lysine hcl oral tablet 500 mg...... 165 loradamed...... 186 LIMBREL...... 165 l-lysine oral tablet 1000 mg, 500 mg...... 165 loratadine childrens...... 186 LIMBREL250...... 165 l-methylfolate...... 102 loratadine oral...... 186 LIMBREL500...... 165 l-methylfolate ca me-cbl nac...... 102 loratadine oral tablet dispersible 10 mg..... 186 lindane...... 44 l-methylfolate calcium oral...... 102 loratadine-d 12hr...... 202 linezolid oral suspension reconstituted...... 25 l-methylfolate forte...... 165 loratadine-d 24hr...... 202 linezolid oral tablet...... 25 l-methylfolate-algae...... 165 LORID...... 102 LINZESS ORAL CAPSULE 145 MCG, 290 l-methylfolate-algae-b12-b6...... 102 LORTAB...... 17 MCG...... 125 l-methylfolate-b6-b12...... 102 loryna...... 144 LINZESS ORAL CAPSULE 72 MCG...... 125 l-methyl-mc...... 102 LORZONE...... 214 liothyronine sodium oral...... 149 l-methyl-mc nac...... 102 losartan potassium oral...... 55 LIPITOR...... 61 LMR PLUS...... 20 losartan potassium-hctz...... 59 lipochol nr...... 165 LMX 4...... 20 LOSEASONIQUE...... 144 lipochol plus...... 165 LO LOESTRIN FE...... 144 LOTEMAX OPHTHALMIC GEL...... 179 LIPOFEN...... 61 LOCOID...... 77 LOTEMAX OPHTHALMIC OINTMENT...... 179 lipoflavonoid...... 102 LOCOID LIPOCREAM...... 77 LOTEMAX OPHTHALMIC SUSPENSION.179 lipoflavovit...... 102 LODINE...... 13 LOTEMAX SM...... 179 lipo-key...... 102 LODOSYN...... 46 LOTENSIN...... 55 LIPOTRIAD...... 102 LOESTRIN 1.5/30 (21)...... 144 LOTENSIN HCT...... 59 LIPRITIN II...... 63 LOESTRIN 1/20 (21)...... 144 loteprednol etabonate...... 179 liquibid...... 201 LOESTRIN FE 1.5/30...... 144 LOTREL...... 59 liquid acetaminophen...... 7 LOESTRIN FE 1/20...... 144 LOTRIMIN AF EXTERNAL POWDER...... 165 liquid calcium with d3 oral capsule 600-500 lojaimiess...... 144 LOTRONEX...... 125 mg-unit...... 91 LOKELMA...... 96 lovastatin...... 61 liquid calcium/vitamin d...... 91 LOMOTIL...... 120 LOVAZA...... 61 liquid pain relief...... 7 long acting nasal spray...... 202 LOVENOX...... 52 lisinopril oral...... 55 long lasting antacid...... 120 low-ogestrel...... 144

251 lo-zumandimine...... 144 LUPRON DEPOT (4-MONTH) magnesium chloride oral tablet delayed LTXF PRIM CNV PIN MICRODRIP...... 166 INTRAMUSCULAR KIT 30MG...... 150 release...... 91 LTXF PRIM IV SET/CNVT PIN...... 166 LUPRON DEPOT (6-MONTH) magnesium citrate oral solution...... 129 LTXF SECONDARY/CNV PIN/32INC...... 166 INTRAMUSCULAR KIT 45MG...... 150 magnesium lactate...... 91 l-tyrosine oral capsule...... 166 LUPRON DEPOT-PED (1-MONTH)...... 150 magnesium oral capsule 300 mg...... 91 lubricant drops fast act...... 174 LUPRON DEPOT-PED (3-MONTH)...... 150 magnesium oral tablet 250 mg, 30 mg, 500 lubricant drops long last...... 174 lutera...... 144 mg...... 91 lubricant drops ophthalmic gel 0.25-0.3 %. 174 LUXIQ...... 77 magnesium oxide oral tablet 400 (241.3 lubricant drops ophthalmic solution...... 174 LUZU...... 35 mg) mg...... 91 lubricant eye drops (pf) ophthalmic solution LYDEXA...... 20 magnesium oxide oral tablet 400 mg...... 120 0.4-0.3 %...... 174 lyllana...... 144 magnesium oxide oral tablet 420 mg...... 120 lubricant eye drops (pf) ophthalmic solution lysine hcl oral tablet 1000 mg...... 166 magnesium oxide oral tablet 500 mg...... 91 0.5 %...... 174 lysine oral capsule...... 166 magnesium sulfate intravenous...... 91 lubricant eye drops ophthalmic solution lysiplex plus oral tablet...... 103 magnesium sulfate oral...... 91 0.4-0.3 %...... 174 LYSODREN...... 150 magnesium sulfate solution 50 % injection.. 91 lubricant eye drops ophthalmic solution 0.5 LYUMJEV...... 182 MAGNESIUM SULFATE SOLUTION 50 % %...... 174 LYUMJEV KWIKPEN...... 182 INJECTION...... 91 lubricant eye drops ophthalmic solution 0.6 lyza...... 147 magnesium-oxide...... 91 %...... 174 M.V.I. ADULT...... 103 MAGONATE...... 92 lubricant eye drops pf...... 175 M.V.I. PEDIATRIC...... 103 mag-oxide...... 92 lubricant eye nighttime...... 175 m2 magnesium...... 91 MAG-TAB SR...... 92 lubricant eye pm...... 175 MAALOX...... 120 MAKENA...... 147 lubricant pm...... 175 MAALOX CHILDRENS...... 120 MALARONE...... 44 lubricating eye drop...... 175 MAALOX MAX ORAL SUSPENSION...... 120 malathion...... 44 lubricating eye drops ophthalmic solution MAALOX MULTI SYMPTOM MAX ST...... 120 malic b6...... 103 0.4-0.3 %...... 175 MACRILEN...... 166 MANGIMIN...... 92 lubricating eye drops ophthalmic solution MACROBID...... 23 MAOX...... 120 0.5-0.9 %...... 175 MACRODANTIN...... 23 mapap acetaminophen extra str...... 7 lubricating eye/overnight...... 175 MACUTEK...... 166 mapap arthritis pain...... 7 lubricating plus eye drops...... 175 mafenide acetate external...... 25 mapap childrens...... 7 lubricating/dry eye...... 175 MAG-200...... 91 mapap cold formula multi-sympt...... 202 lubrifresh p.m...... 175 mag-al plus...... 120 mapap headache plus...... 7 LUCEMYRA...... 22 mag-al plus xs...... 120 mapap oral capsule...... 7 LULICONAZOLE...... 35 mag-g...... 91 MAR-COF BP...... 202 LUMIGAN...... 180 MAGIMIN...... 91 MAR-COF CG EXPECTORANT...... 202 LUPANETA PACK...... 150 magnacaps...... 91 MARINOL...... 33 LUPRON DEPOT (1-MONTH)...... 150 MAGNEBIND 300...... 91 marlissa...... 144 LUPRON DEPOT (3-MONTH)...... 150 MAGNEBIND 400...... 103 MARNATAL-F...... 103 MASK VORTEX...... 166

252 MATULANE...... 41 medi-first triple antibiotic...... 25 melodetta 24 fe...... 144 matzim la...... 57 medi-mucil...... 129 meloxicam oral...... 13 MAVENCLAD (10 TABS)...... 64 medi-natural...... 129 melphalan...... 41 MAVENCLAD (4 TABS)...... 64 MEDI-PATCH RX...... 20 memantine hcl er...... 31 MAVENCLAD (5 TABS)...... 64 medi-phedryl...... 186 memantine hcl oral solution 2 mg/ml...... 31 MAVENCLAD (6 TABS)...... 64 medi-profen oral capsule...... 13 memantine hcl oral tablet...... 31 MAVENCLAD (7 TABS)...... 64 medi-profen oral tablet...... 13 MEMBRANEBLUE...... 175 MAVENCLAD (8 TABS)...... 64 mediproxen...... 13 MENACTRA...... 153 MAVENCLAD (9 TABS)...... 64 MEDISENSE GLUCOSE KETONE MENCAPS...... 7 MAXALT...... 39 CONTR...... 166 M-END PE...... 202 MAXALT-MLT...... 39 MEDISENSE HI/MID/LOW CONTROL...... 166 MENEST...... 145 MAXIDEX...... 179 MEDISENSE HIGH/LOW CONTROL...... 166 MENOSTAR...... 145 MAXITROL...... 175 MEDISENSE MID CONTROL...... 166 mens daily gummies...... 103 maxi-tuss ac...... 202 medi-tabs extra strength...... 7 menstrual pain relief...... 7 maxi-tuss cd...... 202 medi-tussin dm...... 202 MENTAX...... 35 maxi-tuss gmx...... 202 MEDPURA ALCOHOL PADS...... 25 menthol drops...... 66 maxi-tuss pe max...... 202 MEDROL ORAL TABLET 16 MG, 8 MG....139 meperidine hcl oral...... 17 MAXZIDE...... 59 MEDROL ORAL TABLET 2 MG...... 139 MEPHYTON...... 103 MAXZIDE-25...... 59 MEDROL ORAL TABLET 32 MG...... 139 MEPRON...... 44 MAYZENT...... 64 MEDROL ORAL TABLET 4 MG...... 139 mercaptopurine oral...... 41 MAYZENT STARTER PACK...... 64 MEDROL ORAL TABLET THERAPY meribin...... 103 m-clear wc...... 202 PACK...... 139 mesalamine er...... 154 m-dryl...... 186 MEDROX-RX...... 7 mesalamine oral...... 154 me/naphos/mb/hyo1...... 25 medroxyprogesterone acetate mesalamine rectal enema...... 154 ME-500...... 166 intramuscular...... 147 mesalamine rectal suppository...... 154 meclizine hcl oral tablet 12.5 mg...... 32 medroxyprogesterone acetate oral...... 147 mesalamine-cleanser...... 154 meclizine hcl oral tablet 25 mg...... 32 mefenamic acid oral...... 13 MESNEX ORAL...... 43 meclizine hcl oral tablet 50 mg...... 32 mefloquine hcl...... 44 MESTINON ORAL SOLUTION...... 39 meclizine hcl oral tablet chewable...... 32 mega multiple/chelated mineral...... 103 MESTINON ORAL TABLET...... 39 meclofenamate sodium oral...... 13 mega probiotic...... 121 MESTINON ORAL TABLET EXTENDED MEDERMA...... 77 megestrol acetate oral suspension 40 RELEASE...... 40 MEDERMA FOR KIDS...... 77 mg/ml...... 147 METABOLIC DISEASE APP...... 166 MEDERMA SPF 30...... 77 megestrol acetate oral suspension 625 metafolbic...... 103 medi-bismuth...... 120 mg/5ml...... 147 metafolbic plus...... 103 MEDICATED DNA COLLECTION...... 166 megestrol acetate oral tablet 20 mg...... 147 metafolbic plus rf...... 103 MEDICATED DNA COLLECTION 2...... 166 megestrol acetate oral tablet 40 mg...... 147 METAMUCIL ORAL CAPSULE 0.52 GM...129 medicated spot...... 77 meijer allergy relief-d...... 202 METAMUCIL ORAL POWDER 48.57 %....130 MEDI-DERM/L-RX...... 20 meijer antacid...... 121 METANX...... 103 MEDI-DERM-RX...... 7 meijer anti-diarrheal...... 121 METAXALL CP...... 214

253 metaxalone...... 214 methylprednisolone oral tablet 32 mg...... 139 miconazole 1...... 35 metformin hcl er...... 49 methylprednisolone oral tablet therapy miconazole 1 combo pack...... 36 metformin hcl er (mod)...... 49 pack...... 139 miconazole 3 applicator...... 36 metformin hcl er (osm)...... 49 methyltestosterone oral...... 141 miconazole 3 combo pack...... 36 metformin hcl oral solution...... 49 metoclopramide hcl oral solution...... 32 miconazole 3 combo pack app...... 36 metformin hcl oral tablet...... 49 metoclopramide hcl oral tablet...... 121 miconazole 3 vaginal cream...... 36 METHACHOLINE CHLORIDE metoclopramide hcl oral tablet dispersible miconazole 3 vaginal suppository...... 36 INHALATION...... 166 10 mg...... 32 miconazole 7...... 36 methadone hcl injection...... 15 metoclopramide hcl oral tablet dispersible miconazole antifungal...... 36 methadone hcl intensol...... 15 5 mg...... 121 miconazole nitrate external...... 36 methadone hcl oral...... 15 metolazone...... 60 miconazole nitrate vaginal...... 36 methadose oral concentrate 10 mg/ml...... 16 METOPIRONE...... 166 MICONAZOLE-ZINC OXIDE-PETROLAT... 36 methadose oral tablet soluble...... 16 metoprolol succinate er...... 56 miconazorb af...... 166 methadose sugar-free...... 16 metoprolol tartrate oral...... 56 MICRODOT PEN NEEDLE 31G X 6 MM...166 methazolamide oral...... 60 metoprolol-hydrochlorothiazide...... 59 MICRODOT PEN NEEDLE 32G X 4 MM...166 methenamine hippurate...... 23 METROCREAM...... 25 MICRODOT PEN NEEDLE 33G X 4 MM...166 methenamine mandelate oral...... 25 METROGEL...... 25 MICRODOT TEST...... 166 methergine...... 166 METROLOTION...... 25 microgestin 1.5/30...... 145 methimazole oral...... 151 METRONIDAZOLE BENZO+SYRSPEND...25 microgestin 1/20...... 145 methionine oral...... 166 metronidazole external cream...... 25 microgestin fe 1.5/30...... 145 METHIONINE-200...... 103 metronidazole external gel 0.75 %...... 25 microgestin fe 1/20...... 145 METHITEST...... 141 metronidazole external gel 1 %...... 25 MICROLET NEXT LANCING DEVICE...... 166 methocarbamol oral...... 214 metronidazole external lotion...... 25 midodrine hcl...... 54 METHOHEXITAL SODIUM...... 166 metronidazole oral capsule...... 25 MIFEPREX...... 140 methotrexate oral...... 152 metronidazole oral tablet...... 25 mifepristone...... 140 methotrexate sodium (pf)...... 152 metronidazole vaginal...... 25 MIGERGOT...... 38 methotrexate sodium injection solution...... 152 metyrosine...... 59 miglitol...... 49 methotrexate sodium injection solution mexiletine hcl oral...... 55 migraine formula...... 7 reconstituted...... 152 m-hist pd...... 186 MIGRAINE PACK...... 39 methotrexate sodium oral...... 152 MIACALCIN INJECTION...... 156 migraine relief...... 7 methoxsalen rapid...... 78 mi-acid...... 121 MIGRANAL...... 38 methscopolamine bromide oral...... 113 mi-acid gas relief...... 121 MIGRANOW...... 39 methyl salicylate external liquid...... 78 mi-acid maximum strength...... 121 milantex...... 121 methyldopa...... 54 mibelas 24 fe...... 145 milantex extra strength...... 121 methyldopa-hydrochlorothiazide...... 59 micaderm...... 35 mili...... 145 methylergonovine maleate oral...... 166 MICARDIS...... 55 milk of magnesia...... 130 methylfol-algae-b12-acetylcyst...... 103 MICARDIS HCT...... 59 milk of magnesia concentrate...... 130 methylprednisolone oral tablet 16 mg, 4 MICATIN...... 35 MILLIPRED...... 139 mg, 8 mg...... 139 MICLARA LQ...... 186 MILLIPRED DP 12-DAY...... 139

254 mimvey...... 145 M-M-R II...... 153 MOTRIN CHILDRENS...... 13 MIMYX...... 78 mn-50...... 92 MOTRIN IB...... 13 MINASTRIN 24 FE...... 145 M-NATAL PLUS...... 103 MOTRIN INFANTS DROPS...... 13 mineral oil enema...... 130 MOBIC...... 13 MOUTH KOTE REMINT...... 66 mineral oil heavy oral...... 130 moexipril hcl...... 55 MOVANTIK...... 121 mineral oil oral...... 130 moisturel...... 78 MOVIPREP...... 130 minerin creme...... 78 mometasone furoate external...... 78 MOXEZA...... 29 MINI LANCING DEVICE...... 166 mometasone furoate nasal...... 188 moxifloxacin hcl (2x day)...... 29 MINI WRIGHT PEAK FLOW METER...... 166 mondoxyne nl oral capsule 100 mg...... 30 moxifloxacin hcl ophthalmic solution...... 29 MINILINK REAL-TIME TRANSMITTER.....166 mondoxyne nl oral capsule 75 mg...... 30 moxifloxacin hcl oral...... 29 MINIPRESS...... 54 MONOCAL...... 92 MOZOBIL...... 53 miniprin low dose...... 13 mono-linyah...... 145 m-pap...... 7 minitran...... 62 monsels ferric subsulfate...... 53 MS CONTIN...... 16 MINIVELLE...... 145 montelukast sodium oral packet...... 189 MUCINEX CHILDRENS FREEFROM MINOCYCLINE HCL ER ORAL CAPSULE montelukast sodium oral tablet...... 189 ORAL LIQUID 5-100 MG/5ML...... 202 EXTENDED RELEASE 24 HOUR...... 30 montelukast sodium oral tablet chewable.. 189 MUCINEX CHILDRENS STUFFY NOSE...202 minocycline hcl er oral tablet extended MONUROL...... 23 mucinex cough childrens...... 202 release 24 hour...... 30 mood support probiotic...... 121 MUCINEX D...... 202 minocycline hcl oral capsule...... 30 MORGIDOX COMBINATION...... 30 MUCINEX D MAX STRENGTH...... 202 minocycline hcl oral tablet 100 mg...... 30 morgidox oral...... 30 MUCINEX DM...... 202 minocycline hcl oral tablet 50 mg, 75 mg..... 30 morphine sulfate (concentrate) oral mucinex fast-max cong headache...... 202 MINOLIRA...... 30 solution 100 mg/5ml, 20 mg/ml...... 17 mucinex fast-max dm max liquid 20-400 minoxidil oral...... 62 morphine sulfate er beads...... 16 mg/20ml oral...... 202 mintox maximum strength...... 121 morphine sulfate er oral capsule extended MUCINEX FAST-MAX DM MAX LIQUID mintox plus...... 121 release 24 hour...... 17 20-400 MG/20ML ORAL...... 202 MIRALAX ORAL POWDER...... 130 morphine sulfate er oral tablet extended MUCINEX MAXIMUM STRENGTH...... 203 MIRAPEX...... 46 release...... 16 mucinex sinus-max clear & cool...... 203 MIRAPEX ER...... 46 morphine sulfate oral...... 17 mucinex sinus-max cong & pain oral MIRCETTE...... 145 morphine sulfate rectal...... 17 capsule...... 203 MIRVASO...... 78 MORPHINE SULFATE-NACL mucinex sinus-max sinus/allrgy...... 203 misoprostol oral...... 134 INTRAVENOUS SOLUTION PREFILLED mucosa...... 203 MISTASSIST...... 166 SYRINGE 50-0.9 MG/50ML-%...... 17 MUCOSITISRX...... 66 MITIGARE...... 37 MOTEGRITY...... 121 MUCOTROL...... 66 MITOSOL...... 179 motion sickness...... 32 mucus & cough relief childrens...... 203 mm arthritis pain...... 7 motion sickness relief oral tablet 50 mg...... 32 mucus d...... 203 mm cetirizine hcl...... 186 motion sickness relief oral tablet chewable mucus d extended release...... 203 MM EASY TOUCH GLUCOSE METER.....166 25 mg...... 32 mucus d max st er...... 203 MM LANCING DEVICE...... 166 motion-time...... 32 mucus dm...... 203 mm stool softener laxative...... 130 MOTOFEN...... 121

255 mucus er oral tablet extended release 12 multivitamin/fluoride oral solution...... 103 n-acetyl-l-cysteine oral...... 104 hour 1200 mg...... 203 multivitamin/fluoride oral tablet chewable nadolol oral...... 56 mucus extended release oral tablet 0.25 mg, 1 mg...... 104 nafrinse...... 92 extended release 12 hour 1200 mg...... 203 MULTIVITAMIN/FLUORIDE ORAL NAFRINSE DAILY ACIDULATED...... 66 mucus relief cough child...... 203 TABLET CHEWABLE 0.25-0.3 MG, 0.5-0.3 NAFRINSE DAILY/NEUTRAL...... 66 mucus relief cough childrens...... 203 MG, 1-0.3 MG...... 104 nafrinse drops...... 92 mucus relief d oral tablet extended release multivitamin/fluoride tablet chewable 0.5 NAFRINSE WEEKLY...... 66 12 hour...... 203 mg oral...... 104 naftifine hcl...... 36 mucus relief dm max oral liquid...... 203 multi-vitamin/fluoride/iron...... 104 NAFTIN...... 36 mucus relief dm oral liquid...... 203 multi-vitamin/iron...... 104 nail-ex...... 104 mucus relief dm oral tablet extended multivitamins/fluoride...... 104 NALFON...... 13 release 12 hour 30-600 mg...... 203 mupirocin calcium...... 25 NALOCET...... 18 mucus relief er oral tablet extended release mupirocin external...... 25 naloxone hcl injection solution...... 22 12 hour 1200 mg...... 203 MURO 128 OPHTHALMIC OINTMENT.....175 naloxone hcl injection solution cartridge...... 22 mucus relief max st...... 204 MURO 128 OPHTHALMIC SOLUTION 5 naloxone hcl solution prefilled syringe 2 mucus relief oral tablet...... 204 %...... 175 mg/2ml injection...... 22 mucus-d...... 204 my choice...... 147 NAMENDA...... 31 mucus-dm...... 204 my way...... 148 NAMENDA TITRATION PAK...... 31 mucus-er max...... 204 MYAMBUTOL...... 40 NAMENDA XR...... 31 mucus-er oral tablet extended release 12 MYCAPSSA...... 150 NAMENDA XR TITRATION PACK...... 31 hour 1200 mg...... 204 MYCOBUTIN...... 40 NAMZARIC...... 63 MUGARD...... 66 mycophenolate mofetil...... 152 NAPHCON-A...... 177 MULPLETA...... 53 mycophenolate sodium...... 152 NAPRELAN...... 13 MULTAQ...... 55 MYDRIACYL...... 175 NAPROSYN...... 13 multi symptom flu/severe cold...... 204 myferon 150...... 92 naproxen dr...... 13 multi vitamin...... 103 MYFORTIC...... 152 naproxen oral suspension...... 13 multi vitamin w/d-3...... 103 MYLERAN...... 41 naproxen oral tablet...... 13 MULTIGEN...... 92 MYNATAL...... 104 naproxen sodium er...... 13 MULTIGEN FOLIC...... 92 MYNATAL PLUS...... 104 naproxen sodium oral tablet 220 mg...... 13 MULTIGEN PLUS...... 92 MYNATAL-Z...... 104 naproxen sodium oral tablet 275 mg...... 13 multiple vitamin...... 103 mynephrocaps...... 104 naproxen sodium oral tablet 550 mg...... 13 multiple vitamin-folic acid...... 103 mynephron...... 104 naproxen-esomeprazole...... 13 multiple vitamins/iron...... 103 myorisan oral capsule 10 mg, 20 mg...... 78 naramin...... 186 multiple vitamins-iron oral tablet chewable 103 myorisan oral capsule 30 mg...... 78 naratriptan hcl...... 39 MULTIPRO...... 103 myorisan oral capsule 40 mg...... 78 NARCAN...... 22 multi-vit/iron/fluoride...... 103 MYRBETRIQ...... 136 NASACORT ALLERGY 24HR...... 188 multi-vitamin...... 103 MYTESI...... 121 NASACORT ALLERGY 24HR CHILDREN 188 multi-vitamin hp/minerals...... 103 na ferric gluc cplx in sucrose...... 92 nasal allergy 24 hour...... 189 multi-vitamin/fluoride...... 103 nabumetone oral...... 13 nasal allergy spray...... 189

256 nasal decongestant 12hr...... 204 natural fish oil...... 167 NEOSALUS CP...... 78 nasal decongestant max st...... 204 natural herb cough drops...... 66 NEOSPORIN + PAIN RELIEF MAX ST...... 25 nasal decongestant oral tablet 30 mg...... 204 natural senna laxative...... 130 NEOSPORIN ORIGINAL...... 26 nasal decongestant pe...... 204 natural tears pf...... 175 NEOSTIGMINE METHYLSULFATE nasal decongestant pe max st...... 204 natural vegetable fiber...... 130 INTRAVENOUS SOLUTION PREFILLED nasal decongestant spray...... 204 NATURE-THROID ORAL TABLET 113.75 SYRINGE 5 MG/5ML...... 40 nasal four...... 204 MG, 130 MG, 16.25 MG, 195 MG, 32.5 NEO-SYNALAR EXTERNAL CREAM...... 78 nasal mist nasal solution...... 204 MG, 48.75 MG, 81.25 MG, 97.5 MG...... 149 NEO-SYNALAR EXTERNAL KIT...... 26 nasal moist nasal solution...... 204 NATURE-THROID ORAL TABLET 146.25 NEO-SYNEPHRINE COLD/ALLRG MILD. 205 nasal moisturizing...... 204 MG, 162.5 MG, 260 MG, 325 MG...... 149 NEO-SYNEPHRINE COLD/ALLRGY EXT.205 nasal moisturizing spray...... 204 NATURE-THROID ORAL TABLET 65 MG 149 NEO-SYNEPHRINE COLD/ALLRGY REG 205 nasal relief...... 204 nausea control...... 32 NEOTUSS PLUS...... 205 nasal spray...... 204 nausea relief...... 32 NEOVITE...... 104 nasal spray 12 hour...... 204 NEBUPENT...... 44 NEPHPLEX RX...... 104 nasal spray anti-drip...... 204 necon 0.5/35 (28)...... 145 nephro vitamins...... 104 nasal spray extra moist...... 204 NEEVO DHA...... 104 NEPHRON FA...... 92 nasal spray extra moisturizing...... 204 NEOCERA...... 78 nephronex oral tablet...... 104 nasal spray fast acting...... 204 NEODOT THERMOMETER...... 167 NEPHRO-VITE...... 104 nasal spray no drip...... 204 NEOMULTIVITE...... 104 NEPHRO-VITE RX...... 104 nasal spray sinus...... 204 neomycin sulfate oral...... 23 NESINA...... 49 NASALCROM...... 191 neomycin-bacitracin zn-polymyx...... 175 NESTABS...... 104 NASCOBAL...... 104 neomycin-polymyxin-dexameth ophthalmic NESTABS DHA...... 104 NASONEX...... 189 ointment...... 175 NESTABS ONE...... 105 NATACHEW...... 104 neomycin-polymyxin-dexameth ophthalmic neuac external gel...... 78 NATACYN...... 36 suspension 3.5-10000-0.1...... 175 NEUAC EXTERNAL KIT...... 78 NATALVIT...... 104 neomycin-polymyxin-gramicidin...... 175 NEULASTA...... 53 NATAZIA...... 145 neomycin-polymyxin-hc ophthalmic...... 175 NEULASTA ONPRO...... 53 nateglinide...... 49 neomycin-polymyxin-hc otic solution...... 181 NEUPOGEN...... 53 NATESTO...... 141 neomycin-polymyxin-hc otic suspension....181 NEUPRO...... 46 NATPARA...... 157 NEONATAL + DHA...... 104 NEURAPTINE...... 7 NATROBA...... 45 NEONATAL 19...... 104 NEURO-K-250 T.D...... 105 natural daily fiber...... 130 NEONATAL COMPLETE...... 104 neuro-k-250 vitamin b6...... 105 natural fiber...... 130 NEONATAL FE...... 86 neuro-k-50...... 105 natural fiber laxative oral powder 28.3 %, NEONATAL PLUS...... 104 neuro-k-500...... 105 58.6 %...... 130 NEONATAL VITAMIN...... 104 NEUROMED7...... 20 natural fiber laxative oral powder 30.9 %... 130 neo-polycin...... 175 NEUTEK 2TEK CONTROL...... 167 natural fiber oral capsule 0.52 gm...... 130 neo-polycin hc...... 175 NEUTEK 2TEK TEST...... 167 natural fiber oral powder 28.3 %, 48.57 %. 130 NEORAL...... 152 NEUTROGENA HAND...... 78 natural fiber supplement oral powder...... 130 NEOSALUS...... 78 NEUTROGENA OIL-FREE ACNE WASH... 78

257 NEVANAC...... 179 NICORETTE...... 22 NIVATOPIC PLUS...... 78 new day...... 148 NICORETTE MINI...... 22 NIVESTYM...... 53 NEXIUM...... 135 NICORETTE STARTER KIT...... 22 nizatidine...... 125 NEXLETOL...... 61 nicotine...... 22 no drip nasal spray...... 205 NEXLIZET...... 54 nicotine gum...... 22 no flush niacin oral capsule...... 105 niacin (antihyperlipidemic)...... 62 nicotine mini...... 23 NOCDURNA...... 140 niacin er (antihyperlipidemic)...... 62 nicotine polacrilex mouth/throat...... 23 nohist-lq...... 205 niacin er oral capsule extended release nicotine step 1...... 23 nolix...... 78 250 mg...... 105 nicotine step 2...... 23 non-aspirin...... 7 niacin er oral capsule extended release nicotine step 3...... 23 non-aspirin childrens...... 7 500 mg...... 105 NICOTROL...... 23 non-aspirin extra strength...... 7 niacin er oral tablet extended release 1000 NICOTROL NS...... 23 non-aspirin jr strength...... 7 mg...... 105 nifedipine er...... 57 non-aspirin pain relief...... 7 niacin er oral tablet extended release 250 nifedipine er osmotic release...... 57 non-pseudo sinus decongestant...... 205 mg, 750 mg...... 105 nifedipine oral...... 57 NOPIOID-LMC KIT...... 214 niacin er oral tablet extended release 500 NIFEREX...... 92 nora-be...... 148 mg...... 105 night time cold/flu relief oral liquid 15-6.25- NORCO...... 18 niacin flush free oral capsule 400-100 mg. 105 500 mg/15ml...... 205 NORDIPEN 5 INJECTION DEVICE...... 167 niacin oral tablet 100 mg...... 105 nighttime cold medicine...... 205 NORDIPEN DELIVERY SYSTEM...... 167 niacin oral tablet 250 mg, 50 mg...... 105 nighttime dry-eye relief...... 175 NORDITROPIN FLEXPRO...... 140 niacin tr...... 105 nikki...... 145 norethin ace-eth estrad-fe oral capsule...... 145 niacin-50...... 105 nilutamide...... 41 norethin ace-eth estrad-fe oral tablet...... 145 NIACINAMIDE-SPIRONOLACTONE...... 78 nimodipine oral...... 57 norethin ace-eth estrad-fe oral tablet NIACINAMIDE-SULFACETAMIDE...... 78 NINJACOF-XG...... 205 chewable...... 145 NIACINAMIDE-TACROLIMUS...... 78 nisoldipine er...... 57 norethindrone acetate oral...... 148 NIACINAMIDE-TAZAROTENE...... 78 nite time cold/flu relief...... 205 norethindrone acet-ethinyl est...... 145 NIACINAMIDE-TRETINOIN...... 78 NITRO-BID...... 62 norethindrone oral...... 148 NIACINAMIDE-TRIAMCINOLONE ACET....78 NITRO-DUR...... 62 norethindrone-eth estradiol oral tablet 0.5- NIACIN-SPIRONOLACTON-TRETINOIN.... 78 nitrofurantoin...... 23 2.5 mg-mcg...... 145 niacor...... 62 nitrofurantoin macrocrystal oral...... 23 norethindrone-eth estradiol oral tablet 1-5 NIASPAN...... 62 nitrofurantoin monohydrate macrocrystals... 23 mg-mcg...... 145 NICADAN...... 105 nitroglycerin sublingual...... 62 norethin-eth estradiol-fe oral tablet NICAPRIN...... 167 nitroglycerin transdermal...... 62 chewable 0.4-35 mg-mcg...... 145 nicardipine hcl oral...... 57 nitroglycerin translingual...... 62 norethin-eth estradiol-fe oral tablet NICAZEL...... 105 NITROLINGUAL...... 62 chewable 0.8-25 mg-mcg...... 145 NICAZEL FORTE...... 105 NITROMIST...... 62 NORGESIC FORTE...... 214 NICAZYME...... 167 NITROSTAT...... 62 norgestimate-eth estradiol...... 145 NICODERM CQ...... 22 nitro-time...... 62 norgestimate-ethinyl estradiol triphasic...... 145 NICOMIDE...... 105 NIVA-PLUS...... 105 NORITATE...... 26

258 norlyda...... 148 NP #2 DRUG PREPARATION KIT...... 13 NUTRAPLUS LOTION 10 % EXTERNAL....79 norlyroc...... 148 np thyroid oral tablet 120 mg, 60 mg...... 149 NUTRASEB...... 79 NORPACE...... 55 np thyroid oral tablet 15 mg, 30 mg, 90 mg149 nutr-e-sol...... 92 NORPACE CR...... 55 NUBEQA...... 41 NUTRIARX CREAMPAK...... 79 NORTHERA...... 54 NUCALA SUBCUTANEOUS SOLUTION NUTRICAP...... 105 nortrel 0.5/35 (28)...... 145 AUTO-INJECTOR...... 205 NUTRIDOX...... 30 nortrel 1/35 (21)...... 145 NUCALA SUBCUTANEOUS SOLUTION nutrifac zx...... 105 nortrel 1/35 (28)...... 145 PREFILLED SYRINGE...... 205 NUTRIVIT...... 105 nortrel 7/7/7...... 145 NUCALA SUBCUTANEOUS SOLUTION NUTROPIN AQ NUSPIN 10...... 140 NORVASC...... 57 RECONSTITUTED...... 205 NUTROPIN AQ NUSPIN 20...... 140 nose drops...... 205 NUCARACLINPAK...... 78 NUTROPIN AQ NUSPIN 5...... 140 nose drops extra strength...... 205 NUCARARXPAK...... 78 NUVAIL...... 79 NOURIANZ...... 45 NUCORT...... 78 NUVAKAAN...... 20 NOVACORT...... 78 NUCYNTA...... 18 NUVAKAAN-II...... 20 novamv pediatric multi-vitamin...... 105 NUCYNTA ER...... 16 NUVARING...... 145 novarel intramuscular solution NUDERMRXPAK 120...... 78 NUVESSA...... 26 reconstituted 10000 unit...... 140 NUDERMRXPAK 60...... 78 NUZYRA ORAL...... 30 NOVAREL INTRAMUSCULAR SOLUTION NUDICLO SOLUPAK...... 13 nyamyc...... 36 RECONSTITUTED 5000 UNIT...... 140 NUDICLO TABPAK...... 13 nycoff...... 66 NOVOLIN 70/30 FLEXPEN...... 51 NUDROXIPAK...... 13 NYMALIZE...... 57 NOVOLIN 70/30 FLEXPEN RELION...... 51 NUDROXIPAK DSDR-50...... 13 nystatin external...... 36 NOVOLIN 70/30 RELION...... 51 NUDROXIPAK DSDR-75...... 13 nystatin mouth/throat...... 36 NOVOLIN 70/30 VIAL...... 52 NUDROXIPAK E-400...... 13 nystatin oral...... 36 NOVOLIN N FLEXPEN...... 52 NUDROXIPAK I-800...... 13 nystatin-triamcinolone...... 36 NOVOLIN N FLEXPEN RELION...... 52 NUDROXIPAK M-15...... 13 nystop...... 36 NOVOLIN N RELION...... 52 NUDROXIPAK N-500...... 13 OASIS ULTRA MATRIX FENESTRATED. 167 NOVOLIN N VIAL...... 52 NUEDEXTA...... 63 OASIS ULTRA TRI-LAYER MATRIX...... 167 NOVOLIN R FLEXPEN...... 52 NUFERA...... 92 OASIS WOUND MATRIX FENESTRATED167 NOVOLIN R FLEXPEN RELION...... 52 nufol...... 105 OB COMPLETE...... 105 NOVOLIN R RELION...... 52 nu-iron...... 92 OB COMPLETE ONE...... 105 NOVOLIN R VIAL...... 52 NULEV...... 113 OB COMPLETE PETITE...... 105 NOVOLOG FLEXPEN...... 52 NULYTELY LEMON-LIME...... 130 OB COMPLETE PREMIER...... 105 NOVOLOG MIX 70/30 FLEXPEN...... 52 NULYTELY WITH FLAVOR PACKS...... 130 OB COMPLETE/DHA...... 105 NOVOLOG MIX 70/30 VIAL...... 52 NU-MAG...... 92 OBSTETRIX DHA...... 105 NOVOLOG PENFILL...... 52 NUPERCAINAL...... 78 OBSTETRIX EC...... 105 NOVOLOG U-100 VIAL...... 52 NURTEC...... 38 OBSTETRIX ONE...... 105 NOVOPEN ECHO...... 167 NUSURGEPAK SURGICAL PREP/CARE...78 OBTREX...... 105 NOVOTWIST PEN NEEDLE...... 167 NUTRAPLUS EXTERNAL CREAM...... 78 O-CAL PRENATAL...... 105 NOXAFIL ORAL...... 36 nutraplus lotion 10 % external...... 78 OCALIVA...... 121

259 OCEAN BLUE MINICAPS OMEGA-3...... 167 omeprazole magnesium oral capsule ONETOUCH ULTRALINK...... 167 OCEAN FOR KIDS...... 205 delayed release...... 135 ONETOUCH VERIO FLEX SYSTEM KIT OCEAN NASAL SPRAY...... 205 omeprazole magnesium oral tablet delayed W/DEVICE...... 167 ocella...... 145 release...... 135 ONETOUCH VERIO IN VITRO SOLUTION octreotide acetate injection solution 100 omeprazole oral capsule delayed release ...... 167 mcg/ml, 50 mcg/ml...... 150 10 mg, 20 mg, 40 mg...... 135 ONETOUCH VERIO IN VITRO SOLUTION octreotide acetate injection solution 1000 omeprazole oral capsule delayed release HIGH...... 167 mcg/ml...... 150 20.6 (20 base) mg...... 135 ONETOUCH VERIO IQ SYSTEM...... 167 octreotide acetate injection solution 200 omeprazole oral tablet delayed release 20 ONETOUCH VERIO KIT W/DEVICE...... 167 mcg/ml...... 150 mg...... 135 ONETOUCH VERIO REFLECT...... 167 octreotide acetate injection solution 500 OMEPRAZOLE+SYRSPEND SF ALKA.....135 ONETOUCH VERIO SYNC SYSTEM...... 167 mcg/ml...... 150 omeprazole-sod bicarbonate...... 135 ONETOUCH VERIO TEST STRIPS...... 167 OCUFLOX...... 177 omeprazole-sodium bicarbonate...... 135 ONEVITE...... 106 OCUVEL...... 105 OMNARIS...... 189 ONEXTON...... 79 ODOMZO...... 42 OMNIFLEX DIAPHRAGM...... 167 ONGENTYS...... 45 odorless coated fish oil...... 167 OMNITROPE...... 140 ONGLYZA...... 49 OFEV...... 192 OMNITROPE PEN 5 INJ DEVICE...... 167 ONIVYDE...... 42 ofloxacin ophthalmic...... 177 OMNIVEX...... 167 ONUREG...... 53 ofloxacin oral...... 29 once daily...... 105 ONYCHO-MED...... 33 ofloxacin otic...... 180 once daily/iron...... 105 ONZETRA XSAIL...... 39 OINTMENT BASE...... 79 ondansetron hcl oral...... 33 opcicon one-step...... 148 olmesartan medoxomil oral...... 55 ondansetron odt...... 33 OPDIVO INTRAVENOUS SOLUTION 100 olmesartan medoxomil-hctz...... 59 one daily...... 105 MG/10ML, 40 MG/4ML...... 43 olmesartan-amlodipine-hctz...... 59 one daily plus iron...... 105 opium...... 121 olopatadine hcl nasal...... 186 one daily womens health...... 105 OPSUMIT...... 191 olopatadine hcl ophthalmic...... 177 ONE VITE WOMENS...... 105 OPTICHAMBER ADVANTAGE-LG MASK 167 OLUMIANT...... 152 ONE VITE WOMENS PLUS...... 105 OPTICHAMBER ADVANTAGE-MED OLUX...... 79 one-daily multi vitamins...... 105 MASK...... 167 OLUX-E...... 79 one-daily multi-vitamin oral tablet...... 105 OPTICHAMBER ADVANTAGE-SM MASK 167 OMECLAMOX-PAK...... 121 one-daily multi-vitamin/iron...... 106 OPTICHAMBER FACE MASK-LARGE...... 167 omega-3 fish oil oral capsule 1000 mg...... 167 one-daily/iron...... 106 OPTICHAMBER FACE MASK-MEDIUM... 167 omega-3 fish oil oral capsule 1200 mg...... 167 ONETOUCH DELICA LANCING DEV...... 167 OPTICHAMBER FACE MASK-SMALL...... 167 omega-3 fish oil oral capsule 300 mg...... 167 ONETOUCH DELICA PLUS LANCING..... 167 OPTIHALER DEVICE...... 167 omega-3 oral capsule 1000 mg...... 167 ONETOUCH SURESOFT LANCING option 2...... 148 omega-3 oral capsule 1400 mg...... 167 DEVICE...... 167 OPTIONS CONCEPTROL...... 137 OMEGA-3 RX COMPLETE...... 62 ONETOUCH ULTRA...... 167 OPTIONS GYNOL II CONTRACEPTIVE...137 OMEGA-3/D-3 WELLNESS PACK...... 59 ONETOUCH ULTRA 2 KIT W/DEVICE..... 167 OPTIUM BLOOD GLUCOSE MONITOR... 167 omega-3-acid ethyl esters...... 62 ONETOUCH ULTRA CONTROL...... 167 OPTIUM GLUCOSE MONITOR SYSTEM.167 ONETOUCH ULTRA MINI KIT W/DEVICE 167 OPTIUM TEST...... 168

260 OPTIUMEZ TEST...... 168 oscimin sr...... 113 oxycodone hcl oral tablet 10 mg...... 18 ORACEA...... 30 oseltamivir phosphate oral...... 48 oxycodone hcl oral tablet 15 mg...... 18 ORACIT...... 92 OSENI...... 49 oxycodone hcl oral tablet 20 mg...... 18 oral analgesic max st mouth/throat gel...... 66 OSMOLEX ER ORAL TABLET ER 24 oxycodone hcl oral tablet 30 mg...... 18 oral anesthetic max str...... 66 HOUR THERAPY PACK...... 45 oxycodone hcl oral tablet 5 mg...... 18 oral pain relief mouth/throat gel 20 %...... 66 OSMOLEX ER ORAL TABLET OXYCODONE-ACETAMINOPHEN ORAL ORALAIR...... 205 EXTENDED RELEASE 24 HOUR...... 45 TABLET 10-300 MG, 2.5-300 MG, 5-300 ORALAIR ADULT SAMPLE KIT...... 205 OSMOPREP...... 130 MG...... 18 ORALAIR ADULT STARTER PACK...... 205 OSPHENA...... 148 oxycodone-acetaminophen oral tablet 10- ORALAIR CHILDRENS SAMPLE KIT...... 205 OSTEO-PORETICAL...... 92 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 ORALAIR CHILDRENS STARTER PACK. 205 OTEZLA...... 153 mg...... 18 oralone...... 66 OTICIN HC NR...... 181 oxycodone-aspirin...... 18 oralyte freezer pops...... 92 OTOVEL...... 180 OXYCONTIN...... 16 ORAMAGICRX...... 66 OTREXUP...... 152 oxymorphone hcl...... 18 ORAPRED ODT...... 139 OVACE PLUS EXTERNAL CREAM...... 79 oxymorphone hcl er...... 16 ORAVIG...... 36 OVACE PLUS EXTERNAL FOAM...... 79 OXYTROL...... 136 ORAZINC ORAL TABLET...... 92 OVACE PLUS EXTERNAL LOTION...... 79 OXYTROL FOR WOMEN...... 136 ORENCIA CLICKJECT...... 152 OVACE PLUS EXTERNAL SHAMPOO...... 79 oysco 500+d oral tablet...... 92 ORENCIA SUBCUTANEOUS...... 152 OVACE PLUS WASH...... 79 oysco 500+d oral tablet chewable...... 92 ORENITRAM...... 191 OVACE WASH...... 79 oyster calcium + d...... 92 ORIAHNN...... 150 OVARY...... 106 oyster shell calcium + d oral tablet 500-400 ORILISSA...... 150 OVEEZA...... 96 mg-unit...... 92 ORKAMBI ORAL PACKET...... 191 OVIDE...... 45 oyster shell calcium + d3...... 92 ORMECA...... 13 oxandrolone oral...... 141 oyster shell calcium 500 + d...... 92 ornithine...... 168 oxaprozin...... 13 oyster shell calcium oral tablet 500 mg...... 92 orphenadrine citrate er...... 214 OXAYDO ORAL TABLET 5 MG...... 18 oyster shell calcium oral tablet 500-400 orphenadrine-asa-caffeine...... 214 OXAYDO ORAL TABLET 7.5 MG...... 18 mg-unit...... 92 ORPHENGESIC FORTE...... 214 OXBRYTA...... 53 oyster shell calcium plus d oral tablet 500- orsythia...... 145 OXERVATE...... 175 200 mg-unit...... 92 ORTHO DF...... 106 oxiconazole nitrate...... 36 oyster shell calcium/d oral tablet 250-125 ORTHO MICRONOR...... 148 OXISTAT...... 36 mg-unit, 500-400 mg-unit...... 92 ORTIKOS ORAL CAPSULE EXTENDED OXSORALEN ULTRA...... 79 oyster shell calcium/d oral tablet 250-250 RELEASE 24 HOUR 6 MG...... 155 oxybutynin chloride er...... 136 mg-unit...... 92 OS-CAL...... 92 oxybutynin chloride oral...... 136 oyster shell calcium/d oral tablet 500-200 oscal 500/200 d-3...... 92 OXYCODONE HCL ER...... 16 mg-unit...... 92 OS-CAL CALCIUM + D3...... 92 oxycodone hcl oral capsule...... 18 oyster shell calcium/vitamin d oral tablet...... 92 OS-CAL EXTRA D3...... 92 oxycodone hcl oral concentrate 100 oyster shell/vitamin d...... 92 OS-CAL ULTRA...... 92 mg/5ml...... 18 OZEMPIC...... 49 oscimin...... 113 oxycodone hcl oral solution...... 18 OZOBAX...... 214

261 p-1000...... 106 pain reliever extra strength oral tablet 500 PARI ERAPID NEBULIZER HANDSET..... 168 pa b-complex with b-12...... 106 mg...... 8 PARI TREK S COMBO PACK...... 168 pa biotin oral capsule...... 106 pain reliever oral tablet...... 8 PARI VORTEX ADULT MASK...... 168 pa biotin oral tablet...... 106 pain reliever plus...... 8 paricalcitol...... 157 pa calcium/vitamin d...... 92 pain relieving external cream 4 %...... 21 PARLODEL...... 46 PA CLA...... 168 PAINGO KFT...... 21 paroex...... 66 pa fish oil...... 168 pain-off...... 8 paromomycin sulfate oral...... 23 pa oyster shell calcium...... 92 PALFORZIA (12 MG DAILY DOSE)...... 168 PASER...... 40 pa prenatal formula...... 106 PALFORZIA (120 MG DAILY DOSE)...... 168 PATADAY...... 177 pa vitamin b-12 tr...... 106 PALFORZIA (160 MG DAILY DOSE)...... 168 PATANASE...... 186 pa vitamin d-3...... 106 PALFORZIA (20 MG DAILY DOSE)...... 168 PAZEO OPHTHALMIC SOLUTION 0.7 %.177 pa vitamin d-3 gummy...... 106 PALFORZIA (200 MG DAILY DOSE)...... 168 pb-hyoscy-atropine-scopolamine...... 113 pa vitamin e...... 106 PALFORZIA (240 MG DAILY DOSE)...... 168 PCP 100...... 130 PACERONE ORAL TABLET 100 MG...... 55 PALFORZIA (3 MG DAILY DOSE)...... 168 ped electrolyte freeze pop...... 93 pacerone oral tablet 200 mg...... 55 PALFORZIA (300 MG MAINTENANCE)....168 ped electrolyte freezer pops...... 93 PACERONE ORAL TABLET 400 MG...... 55 PALFORZIA (300 MG TITRATION)...... 168 pediaclear pd childrens...... 186 PACQUIN PLUS EXTERNAL CREAM...... 79 PALFORZIA (40 MG DAILY DOSE)...... 168 PEDIA-LAX ORAL LIQUID...... 130 PACQUIN PLUS/ALOE EXTERNAL PALFORZIA (6 MG DAILY DOSE)...... 168 PEDIA-LAX RECTAL SUPPOSITORY 1 CREAM...... 79 PALFORZIA (80 MG DAILY DOSE)...... 168 GM...... 130 pain & fever child...... 7 PALFORZIA INITIAL ESCALATION...... 168 PEDIALYTE FREEZER POPS...... 93 pain & fever childrens...... 7 PALYNZIQ...... 136 PEDIALYTE ORAL SOLUTION...... 93 pain & fever infants...... 7 PANADOL CHILDRENS...... 8 PEDIALYTE SINGLES...... 93 pain relief childrens...... 7 PANADOL EXTRA...... 8 PEDIAPRED...... 139 PAIN RELIEF EXTERNAL CREAM 4 %...... 20 PANADOL EXTRA STRENGTH...... 8 pediatric electrolyte oral solution...... 93 pain relief extra st...... 7 PANADOL INFANTS...... 8 pediavit...... 106 pain relief extra strength oral capsule 500 PANCREAZE...... 136 PEDIZOLPAK...... 36 mg...... 7 PANDEL...... 79 peg 3350 oral powder...... 130 pain relief extra strength oral liquid 500 PANOXYL...... 79 peg 3350-kcl-na bicarb-nacl...... 130 mg/15ml...... 7 PANRETIN...... 43 peg-3350/electrolytes...... 130 pain relief extra strength oral tablet 500 mg...7 panto-250...... 106 peg-3350/electrolytes/ascorbat...... 130 pain relief oral liquid 500 mg/15ml...... 7 pantoprazole sodium oral packet...... 135 peg-kcl-nacl-nasulf-na asc-c...... 130 pain relief oral tablet 325 mg...... 7 pantoprazole sodium oral tablet delayed peg-prep...... 130 pain relief oral tablet 500 mg...... 7 release...... 135 penicillamine oral...... 137 pain relief oral tablet extended release 650 pantothenic acid...... 106 penicillin v potassium...... 28 mg...... 8 PARADIGM REAL-TIME TRANSMITTER. 168 PENLEN...... 79 pain relief regular st...... 8 PARAGARD INTRAUTERINE COPPER... 168 PENLET II BLOOD SAMPLER...... 168 pain relief regular strength...... 8 PAREMYD...... 175 PENLET II REPLACEMENT CAP...... 168 pain reliever extra strength oral tablet 250- PARI ALTERA NEBULIZER HANDSET.... 168 PENNSAID...... 13 250-65 mg...... 8 PARI BABY CONVERSION KIT...... 168 pentamidine isethionate inhalation...... 44

262 PENTASA...... 154 phenylephrine hcl ophthalmic solution 10 pioglitazone hcl-glimepiride...... 49 pentazocine-naloxone hcl...... 18 %...... 175 pioglitazone hcl-metformin hcl...... 49 PENTOSAN POLYSULFATE SODIUM phenylephrine hcl ophthalmic solution 2.5 pirmella 1/35...... 146 ORAL...... 137 %...... 175 pirmella 7/7/7...... 146 pentoxifylline er...... 59 phenylephrine hcl oral...... 205 piroxicam oral...... 13 PEPCID ORAL TABLET 20 MG...... 125 PHENYLEPHRINE HCL-NACL PLAN B ONE-STEP...... 148 PEPCID ORAL TABLET 40 MG...... 125 INTRAVENOUS SOLUTION PREFILLED PLAQUENIL...... 44 peptic relief...... 121 SYRINGE 1-0.9 MG/10ML-%, 20-0.9 PLAVIX...... 54 PEPTO-BISMOL ORAL SUSPENSION MG/50ML-%...... 54 PLEGRIDY...... 64 524 MG/30ML...... 121 PHEODOYO...... 36 PLEGRIDY STARTER PACK...... 64 PEPTO-BISMOL ORAL TABLET...... 121 PHEXXI...... 137 PLENVU...... 131 PEPTO-BISMOL TO-GO...... 121 PHEYO...... 36 PLEXION...... 79 PERCOCET...... 18 philith...... 145 PLEXION CLEANSER...... 79 PERDIEM OVERNIGHT RELIEF...... 131 PHILLIPS MILK OF MAGNESIA ORAL PLEXION CLEANSING CLOTH...... 79 PERFOROMIST...... 190 SUSPENSION 400 MG/5ML...... 131 PLIAGLIS EXTERNAL CREAM...... 21 PERIDEX...... 66 PHLAG SPRAY...... 79 PNEUMOVAX 23 INJECTABLE 25 PERIDIN-C...... 106 PHOSLYRA...... 97 MCG/0.5ML INJECTION...... 153, 154 perindopril erbumine...... 55 PHOS-NAK...... 93 pnv tabs 29-1...... 106 periogard...... 66 phospha 250 neutral...... 93 pnv-dha...... 106 permethrin external...... 45 phosphasal...... 137 pnv-dha+docusate...... 106 PERRY PRENATAL...... 106 PHOSPHOLINE IODIDE...... 178 pnv-omega...... 106 PERTZYE...... 136 phosphorous...... 93 pnv-select...... 106 pharbechlor...... 186 phosphorus supplement...... 93 podactin external cream...... 36 pharbedryl...... 186 phosphorus w/sod & potassium...... 93 podactin external powder...... 168 pharbetol extra strength...... 8 phospho-trin 250 neutral...... 93 podocon...... 79 pharbetol oral tablet 325 mg...... 8 PHOXILLUM BK4/2.5...... 93 podofilox external...... 79 pharbinex...... 205 phytonadione oral...... 106 poly bacitracin...... 26 PHAZYME ORAL CAPSULE...... 121 PICATO...... 79 polycin...... 175 PHAZYME ORAL TABLET CHEWABLE... 121 pilocarpine hcl ophthalmic...... 178 polyethylene glycol 3350 oral powder...... 131 PHAZYME ULTRA STRENGTH...... 121 pilocarpine hcl oral...... 66 polyethylene glycol 3350-grx oral powder..131 phenazo oral tablet 200 mg...... 137 pimecrolimus...... 79 poly-iron 150...... 93 phenazo oral tablet 95 mg...... 137 pimtrea...... 145 poly-iron 150 forte...... 93 phenazopyridine hcl oral tablet 100 mg..... 137 pindolol...... 56 polymyxin b-trimethoprim...... 175 phenazopyridine hcl oral tablet 200 mg..... 137 pink bismuth maximum strength...... 121 polysaccharide iron complex...... 93 phenobarbital-belladonna alk...... 113 pink bismuth oral suspension 262 mg/15ml polysaccharide-iron complex...... 93 phenohytro...... 113 ...... 121 POLYSPORIN...... 26 phenoxybenzamine hcl oral...... 54 pink bismuth oral tablet 262 mg...... 121 POLYTRIM...... 175 phenylalanine...... 168 pink bismuth oral tablet chewable 262 mg. 121 poly-tussin ac...... 205 pioglitazone hcl...... 49 POLY-VI-FLOR FS...... 106

263 POLY-VI-FLOR ORAL SUSPENSION...... 106 POVIDONE-IODINE OPHTHALMIC...... 26 PRECOSE...... 49 POLY-VI-FLOR ORAL TABLET PR BENZOYL PEROXIDE...... 79 PRED FORTE...... 179 CHEWABLE 0.25 MG...... 106 pr benzoyl peroxide wash...... 79 PRED MILD...... 179 POLY-VI-FLOR ORAL TABLET PR CREAM...... 80 PREDATOR...... 21 CHEWABLE 0.5 MG, 1 MG...... 106 PRADAXA...... 52 PRED-G...... 175 POLY-VI-FLOR/IRON...... 106 PRALUENT...... 62 PRED-G S.O.P...... 175 polyvinyl alcohol ophthalmic...... 175 pramipexole dihydrochloride...... 46 prednicarbate...... 80 poly-vite pediatric...... 106 pramipexole dihydrochloride er...... 46 PREDNISOL ACE-MOXIFLOX-BROMFEN POMALYST...... 41 pramosone external cream 1-1 %...... 80 ...... 179 PONARIS...... 205 PRAMOSONE EXTERNAL CREAM 1-2.5 prednisolone acetate ophthalmic...... 179 portia-28...... 146 %...... 80 prednisolone acetate p-f...... 179 PORTRAZZA...... 43 PRAMOSONE EXTERNAL LOTION...... 80 PREDNISOLONE ACETATE- posaconazole...... 36 PRAMOSONE EXTERNAL OINTMENT...... 80 NEPAFENAC...... 179 POTABA...... 106 PRAMOTIC...... 181 PREDNISOLONE ACET-MOXIFLOXACIN 179 potassium chloride crys er oral tablet pramox...... 21 prednisolone oral solution...... 139 extended release 10 meq...... 93 PRASTERA...... 13 prednisolone sodium phosphate potassium chloride crys er oral tablet prasugrel hcl...... 54 ophthalmic...... 179 extended release 20 meq...... 93 PRAVACHOL...... 61 prednisolone sodium phosphate oral potassium chloride er oral capsule pravastatin sodium...... 61 solution 10 mg/5ml, 20 mg/5ml...... 139 extended release...... 93 praziquantel oral...... 44 prednisolone sodium phosphate oral potassium chloride er oral tablet extended prazosin hcl oral...... 54 solution 15 mg/5ml...... 139 release 10 meq...... 93 PRE & POST SX POUCH...... 80 prednisolone sodium phosphate oral potassium chloride er oral tablet extended pre protein oral tablet...... 168 solution 25 mg/5ml...... 139 release 20 meq...... 93 PRECISION GLUCOSE CONTROL...... 168 prednisolone sodium phosphate oral potassium chloride er oral tablet extended PRECISION GLUCOSE CONTROL SOLN168 solution 6.7 (5 base) mg/5ml...... 139 release 8 meq...... 93 PRECISION GLUCOSE KETONE CONTR168 prednisolone sodium phosphate oral tablet potassium chloride oral packet...... 93 PRECISION GLUCOSE/KETONE CONTR168 dispersible...... 139 potassium chloride oral solution 20 PRECISION LINK...... 168 PREDNISOLONE-BROMFENAC...... 175 meq/15ml (10%)...... 93 PRECISION PCX...... 168 PREDNISOLONE-GATIFLOXACIN...... 179 potassium chloride oral solution 40 PRECISION PCX PLUS TEST...... 168 PREDNISOLONE-MOXIFLOXACIN...... 179 meq/15ml (20%)...... 93 PRECISION POINT OF CARE TEST...... 168 PREDNISOLON-GATIFLOX- potassium citrate er oral tablet extended PRECISION QID MONITOR...... 168 BROMFENAC...... 179 release 10 meq (1080 mg)...... 93 PRECISION QID TEST...... 168 PREDNISOLON-MOXIFLOX- potassium citrate er oral tablet extended PRECISION SOF-TACT MONITOR...... 168 BROMFENAC...... 179 release 15 meq (1620 mg)...... 93 PRECISION SOF-TACT TEST...... 168 PREDNISOLON-MOXIFLOX- potassium citrate er oral tablet extended PRECISION XTRA...... 168 NEPAFENAC...... 179 release 5 meq (540 mg)...... 93 PRECISION XTRA BLOOD GLUCOSE.....168 prednisone intensol...... 139 potassium citrate-citric acid...... 94 PRECISION XTRA KETONE...... 168 prednisone oral solution...... 139 povidone-iodine external solution...... 26 PRECISION XTRA MONITOR...... 168

264 prednisone oral tablet 1 mg, 10 mg, 2.5 prenatal oral tablet 27-0.8 mg...... 106 PREVIDENT 5000 PLUS...... 66 mg, 5 mg, 50 mg...... 139 prenatal oral tablet 27-1 mg...... 106 PREVIDENT 5000 SENSITIVE...... 66 prednisone oral tablet 20 mg...... 139 prenatal oral tablet 28-0.8 mg...... 106 PREVIDENT DENTAL...... 66 prednisone oral tablet therapy pack 10 mg prenatal plus iron...... 106 PREVIDENT MOUTH/THROAT...... 94 (21)...... 139 prenatal vitamin plus low iron...... 106 PREVIDOLRX ANALGESIC...... 13 prednisone oral tablet therapy pack 10 mg prenatal vitamins...... 106 previdolrx plus analgesic...... 13 (48), 5 mg (21)...... 139 prenatal/iron oral tablet...... 107 previfem...... 146 prednisone oral tablet therapy pack 5 mg prenatal/iron oral tablet 28-0.8 mg...... 107 PREVNAR 13...... 154 (48)...... 139 PRENATAL-U...... 107 PREVYMIS ORAL...... 47 PREFEST...... 146 PRENATE...... 107 PRIFTIN...... 40 PREGENNA...... 106 PRENATE AM...... 107 PRILO PATCH...... 21 pregnyl...... 140 PRENATE DHA...... 107 PRILOLID...... 21 PREMARIN ORAL...... 146 PRENATE ELITE...... 107 PRILOSEC...... 135 PREMARIN VAGINAL...... 146 PRENATE ENHANCE...... 107 PRILOSEC OTC...... 135 PREMESISRX...... 106 PRENATE ESSENTIAL...... 107 PRILOVIX...... 21 PREMIUM BLOOD GLUCOSE TEST...... 168 PRENATE MINI...... 107 PRILOVIX LITE...... 21 PREMIUM CONDOMS LUBRICATED...... 168 PRENATE PIXIE...... 107 PRILOVIX LITE PLUS...... 21 premium lidocaine...... 21 PRENATE RESTORE...... 107 PRILOVIX PLUS...... 21 PREMIUM SCAR...... 21 PRENATRIX...... 107 prilovix ultralite...... 21 PREMPHASE...... 146 PRENATRYL...... 107 prilovix ultralite plus...... 21 PREMPRO...... 146 PRENATVITE COMPLETE...... 107 PRILOVIXIL...... 21 PRENA 1 TRUE...... 106 PRENATVITE PLUS...... 107 PRIMACARE...... 107 PRENA1...... 106 PRENATVITE RX...... 107 primaquine phosphate...... 44 PRENA1 PEARL...... 106 PREPIDIL...... 137 PRIMLEV...... 18 PRENAISSANCE...... 106 preplus...... 107 PRIMSOL...... 26 PRENAISSANCE PLUS...... 106 PREPROTEIN...... 168 PRINIVIL...... 55 PRENARA...... 106 PREPROTEIN 20...... 169 PRIZOPAK II...... 21 prenatabs rx...... 106 PRESERA...... 80 PRIZOTRAL...... 21 prenatal 19...... 106 PRESTALIA...... 59 PRIZOTRAL-II...... 21 prenatal dha...... 168 pretab...... 107 PRO DNA COLLECTION...... 169 prenatal formula...... 106 PRETOMANID...... 40 PRO NUTRIENTS OMEGA 3...... 169 prenatal gummy oral tablet chewable 0.4 PREVACID...... 135 PROAIR DIGIHALER...... 190 mg...... 215 PREVACID 24HR...... 135 PROAIR HFA...... 190 prenatal gummy oral tablet chewable 0.4- PREVACID SOLUTAB...... 135 PROAIR RESPICLICK...... 190 113.5 mg...... 106 prevalite...... 62 probenecid...... 37 PRENATAL GUMMY ORAL TABLET PREVIDENT 5000 BOOSTER PLUS...... 66 PROBICHEW...... 121 CHEWABLE 0.4-25 MG...... 215 PREVIDENT 5000 DRY MOUTH...... 66 pro-biotic blend...... 121 prenatal low iron...... 106 PREVIDENT 5000 ENAMEL PROTECT...... 66 probiotic maximum strength...... 121 prenatal multi+dha...... 106 PREVIDENT 5000 ORTHO DEFENSE...... 66 probiotic oral capsule...... 121

265 probiotic oral capsule 250 mg...... 121 promethazine hcl oral...... 186 PROTEINEX P18...... 169 probiotic pearls ex st...... 121 promethazine hcl rectal suppository 12.5 PROTEINEX-18...... 169 PROCARDIA...... 57 mg...... 186 PROTEXA...... 80 PROCARDIA XL...... 57 promethazine hcl rectal suppository 25 mg186 PROTONIX ORAL...... 135 prochlorperazine...... 32 promethazine-codeine...... 205 PROTOPIC...... 80 prochlorperazine maleate oral...... 47 promethazine-dm...... 205 PROTYL AG...... 169 PROCORT...... 155 promethazine-phenyleph-codeine...... 205 PROVAD...... 121 PROCRIT...... 53 promethazine-phenylephrine...... 205 PROVENTIL HFA...... 190 PRO-CRITIC...... 169 promethegan rectal suppository 12.5 mg...186 PROVERA...... 148 PROCTOCORT EXTERNAL...... 155 promethegan rectal suppository 25 mg...... 186 PROVIDA OB...... 107 PROCTOCORT RECTAL...... 38 promethegan rectal suppository 50 mg...... 186 provil...... 13 PROCTOFOAM HC...... 155 PROMETRIUM...... 148 PRUCLAIR...... 80 procto-med hc...... 155 PROMISEB...... 80 PRUDOXIN...... 80 procto-pak...... 155 PROMOLAXIN...... 131 PRUMYX...... 80 proctozone-hc...... 155 PRONEB ULTRA FILTER SET...... 169 pseudoephedrine hcl 12 hr...... 205 PROCYSBI ORAL CAPSULE DELAYED pronutrients coq10...... 169 pseudoephedrine hcl er...... 206 RELEASE...... 136 PRONUTRIENTS SUPER B COMPLEX... 107 pseudoephedrine hcl oral tablet 30 mg...... 206 PROCYSBI ORAL PACKET...... 136 pronutrients vitamin d3...... 107 pseudoephedrine-bromphen-dm...... 206 PRODIGEN...... 121 propafenone hcl...... 56 pseudoephedrine-bromphen-dm oral liquid PROFE...... 94 propafenone hcl er oral capsule extended 30-2-10 mg/5ml...... 206 PROFERRIN ES...... 94 release 12 hour 225 mg, 325 mg...... 56 pseudoephedrine-guaifenesin er...... 206 PROFESSIONAL DNA COLLECTION...... 169 propafenone hcl er oral capsule extended PSORCON...... 80 PROGESTERONE COMPOUNDING KIT. 148 release 12 hour 425 mg...... 56 PSS SELECT PLATFORMS...... 169 progesterone intramuscular...... 148 propantheline bromide oral...... 113 psyldex...... 131 progesterone micronized oral...... 148 proparacaine hcl ophthalmic...... 175 PULMICORT FLEXHALER...... 189 PROGESTERONE MICRONIZED proparacaine-fluorescein...... 175 PULMICORT SUSPENSION...... 189 TRANSDERMAL...... 148 propranolol hcl er...... 56 PULMOZYME...... 206 PROGLYCEM...... 50 propranolol hcl oral...... 56 puralube...... 175 PROGRAF ORAL...... 152 propranolol-hctz...... 59 pure & gentle enema...... 131 PROLATE...... 18 propylthiouracil oral...... 151 pure & gentle lubricant...... 175 PROLENSA...... 179 PRO-RED AC...... 205 pure l-arginine hcl...... 169 PROLEVA...... 169 PROSCAR...... 137 pure l-citrulline oral capsule...... 169 PROMACTA ORAL PACKET 12.5 MG...... 53 PROSILK EXTERNAL...... 80 pure l-tyrosine...... 169 PROMACTA ORAL PACKET 25 MG...... 53 prostate oral capsule 140 mg...... 107 purelax oral powder...... 131 PROMACTA ORAL TABLET 12.5 MG...... 53 pros-tech plus...... 107 purevit dualfe plus...... 94 PROMACTA ORAL TABLET 25 MG, 50 PROSTIN E2...... 138 PURIXAN...... 42 MG, 75 MG...... 53 PROTEINEX ORAL LIQUID...... 169 pvp prep...... 26 PROMACTIN AA PLUS 20PE...... 169 proteinex oral tablet...... 169 PX ADVANCED LANCING DEVICE...... 169 PROMELLA IN PREBIOTIC...... 121 PROTEINEX P100...... 169 PYLERA...... 121

266 pyrazinamide oral...... 40 qc azo...... 138 qc ibuprofen...... 14 PYRIDIUM...... 138 qc bacitracin...... 26 qc ibuprofen cold/sinus...... 206 pyridostigmine bromide er...... 40 qc calamine...... 80 qc ibuprofen ib...... 14 pyridostigmine bromide oral solution...... 40 qc calcium fast dissolution...... 94 qc ibuprofen infants...... 14 pyridostigmine bromide oral tablet 30 mg.... 40 qc calcium/minerals/vitamin d...... 94 qc lansoprazole...... 135 pyridostigmine bromide oral tablet 60 mg.... 40 qc childrens aspirin...... 14 qc laxative...... 131 pyridoxine hcl oral...... 107 qc childrens complete...... 107 qc loratadine allergy relief...... 187 pyrimethamine oral...... 44 qc childrens vitamins/extra c...... 107 qc loratadine-d...... 206 PYRIMETHAMINE-LEUCOVORIN...... 44 qc childrens vitamins/iron...... 107 qc magnesium citrate...... 131 PYROGALLIC ACID...... 80 qc chlor-pheniramine...... 187 qc medifin 400...... 206 QBRELIS...... 55 qc cold relief...... 206 qc miconazole 7...... 36 QBREXZA...... 80 qc complete allergy medicine...... 187 qc milk of magnesia...... 131 qc 3 day...... 36 qc cough/cold hbp...... 206 qc mineral oil heavy...... 131 qc acetaminophen 8 hours...... 8 qc cough/sore throat nighttime...... 206 qc motion sickness relief...... 32 qc acetaminophen 8hr arth pain...... 8 qc daily multivitamins/iron...... 107 qc mucus & cough relief child...... 206 qc acetaminophen 8hr musc ache...... 8 qc daytime cold/flu oral capsule...... 206 qc mucus relief dm max...... 206 qc acid controller...... 125 qc daytime cold/flu oral liquid...... 206 qc mucus relief er...... 206 QC ADVANCED LANCING DEVICE...... 169 qc diarrhea relief...... 122 qc mucus relief max st...... 206 qc all day allergy...... 186 qc docusate calcium...... 131 qc naproxen sodium...... 14 qc allergy childrens...... 187 qc ear wax removal...... 181 qc nasal decongestant pe...... 206 qc allergy relief 4-hour...... 187 qc earwax removal...... 181 qc nasal relief moisturizing...... 206 qc allergy relief childrens oral syrup 5 qc earwax removal kit...... 181 qc nasal spray...... 206 mg/5ml...... 187 qc enema...... 131 qc natural vegetable...... 131 qc allergy relief oral tablet 10 mg...... 187 qc enteric aspirin...... 14 qc natural vegetable laxative...... 131 qc allergy relief oral tablet 180 mg...... 187 qc essentials...... 107 qc natura-lax...... 131 qc allergy relief oral tablet 25 mg...... 187 qc eye drops...... 175 qc nighttime cold/flu relief...... 206 qc allergy relief oral tablet dispersible...... 187 qc ferrous sulfate...... 94 qc no drip nasal relief...... 206 qc antacid...... 121 qc fexofenadine hydrochloride...... 187 qc non-aspirin 8 hour...... 8 qc antacid extra strength...... 121 qc fiber laxative...... 131 qc non-aspirin childrens...... 8 qc antacid multi-symptom...... 121 qc fiber therapy...... 131 qc non-aspirin extra strength...... 8 qc antacid ultra strength...... 121 qc gas relief extra strength oral capsule.... 122 qc omeprazole magnesium...... 135 qc antacid/anti-gas...... 121 qc gas relief extra strength oral tablet qc pain relief...... 8 qc anti-diarrheal oral tablet...... 122 chewable...... 122 qc pain relief childrens...... 8 qc anti-gas...... 122 qc gas relief oral capsule...... 122 qc pain relief extra strength...... 8 qc arthritis pain relief...... 8 qc gas relief oral tablet chewable...... 122 qc pain relief infants...... 8 qc artificial tears...... 175 qc gentle laxative...... 131 qc pink bismuth oral suspension...... 122 qc aspirin...... 13 qc glycerin...... 80 qc pink bismuth oral tablet...... 122 qc aspirin low dose...... 14 qc headache relief...... 8 qc pink bismuth oral tablet chewable...... 122 qc athletes foot...... 36 qc heartburn antacid...... 122 qc povidone iodine...... 26

267 qc prenatal...... 107 QUINJA...... 36 ra anti-diarrheal oral liquid...... 122 qc senna...... 131 QUINTET AC BLOOD GLUCOSE...... 169 ra anti-diarrheal oral tablet...... 122 qc senna-s...... 131 QUINTET AC BLOOD GLUCOSE TEST... 169 ra antifungal external aerosol...... 36 qc severe allergy...... 206 QUINTET BLOOD GLUCOSE SYSTEM... 169 ra antifungal external cream...... 36 qc severe cold/cough daytime...... 207 QUINTET BLOOD GLUCOSE TEST...... 169 ra antifungal foot care...... 36 qc sore throat...... 66 QUINTET CONTROL HIGH/NORMAL...... 169 ra antihistamine eye drops...... 179 qc stool softener...... 131 QUTENZA...... 8 ra anti-nausea...... 32 qc stool softener pls laxative...... 131 QUTENZA (2 PATCH)...... 8 ra antiseptic...... 26 qc suphedrine maximum strength...... 207 QVAR REDIHALER...... 189 ra antiseptic mouth cleanser...... 66 qc tolnaftate...... 36 ra 12 hour nasal spray...... 207 ra apricot scrub...... 80 qc travel ease...... 32 ra 8 hour pain relief...... 8 ra arthritis pain relief...... 9 qc triple antibiotic max st...... 26 ra acetaminophen...... 8 ra artificial tears...... 175 qc tussin cf...... 207 ra acetaminophen ex st...... 8 ra aspirin...... 14 qc urinary pain relief...... 138 ra acetaminophen rapid melts...... 9 ra aspirin adult low dose...... 14 QDOLO...... 18 ra acid reducer...... 125 ra aspirin adult low strength...... 14 q-gel forte...... 169 ra acidophilus...... 122 ra aspirin childrens...... 14 q-gel mega...... 169 ra acne cleanser oil-free...... 80 ra aspirin ec...... 14 q-gel ultra...... 169 ra acne treatment...... 80 ra aspirin ec adult low st...... 14 QMIIZ ODT...... 14 ra advanced healing external lotion...... 80 ra atheletes foot...... 36 QNASL...... 189 ra allergy medication...... 187 ra athletes foot (tolnaftate)...... 36 QNASL CHILDRENS...... 189 ra allergy oral...... 187 ra baby care oral pain relief...... 66 QTERN...... 49 ra allergy relief (cetirizine)...... 187 ra bacitracin...... 26 QUAD-PROBIOTIC...... 122 ra allergy relief childrens oral liquid...... 187 ra bacitracin zinc first aid...... 26 QUALAQUIN...... 44 ra allergy relief oral capsule...... 187 ra balanced b-100...... 107 QUARTETTE...... 146 ra allergy relief oral tablet 180 mg...... 187 ra balanced b-100 cr...... 107 QUESTRAN...... 62 ra allergy relief oral tablet 25 mg...... 187 ra balanced b-50...... 107 QUESTRAN LIGHT...... 62 ra allergy relief oral tablet dispersible...... 187 ra balanced b-50 tr...... 107 QUFLORA FE...... 107 ra allergy relief-d...... 207 ra b-complex...... 107 QUFLORA FE PEDIATRIC...... 107 ra allergy/congestion relief...... 207 ra b-complex with b-12...... 107 QUFLORA GUMMIES...... 107 ra aloe vera/lidocaine...... 21 ra b-complex/vitamin c cr...... 107 QUFLORA PEDIATRIC ORAL SOLUTION107 ra anesthetic oral...... 66 ra bee pollen...... 169 QUFLORA PEDIATRIC ORAL TABLET ra antacid...... 122 ra beta carotene...... 107 CHEWABLE...... 107 ra antacid extra strength...... 122 ra biotin oral capsule...... 107 quinapril hcl...... 55 ra antacid ultra strength...... 122 ra biotin oral tablet...... 107 quinapril-hydrochlorothiazide...... 59 ra antacid/anti-gas...... 122 RA BLOOD GLUCOSE MONITOR...... 169 quinidine gluconate er...... 56 ra antacid/anti-gas max st...... 122 ra ca/mg/zn/cu...... 94 quinidine sulfate...... 56 ra antacid/gas relief max st...... 122 ra calcium...... 94 quinine sulfate oral...... 44 ra antibiotic/pain relief...... 26 ra calcium 600...... 94 QUINIXIL...... 80 ra anticavity fluoride rinse...... 94 ra calcium 600/vit d/minerals...... 94

268 ra calcium 600/vitamin d-3...... 94 ra daytime multi-symptom cold...... 207 ra gas relief ultra strength...... 122 ra calcium cit plus vit d-3...... 94 ra diaper rash...... 80 ra gas relief/infants...... 122 ra calcium citrate plus vit d...... 94 ra diphedryl allergy...... 187 RA GERM DEFENSE ORAL...... 107 ra calcium cit-vit d-3 petites...... 94 ra double antibiotic...... 26 ra glucose...... 50 ra calcium hi-cal...... 94 ra dry mouth...... 67 ra glycerin...... 80 ra calcium hi-cal/vitamin d...... 94 ra ear drops...... 181 ra gummy vitamins & minerals...... 107 ra calcium high potency...... 94 ra earwax removal kit...... 181 ra headache formula...... 9 ra calcium plus vitamin d...... 94 ra effervescent formula...... 107 ra headache formula ex st...... 9 ra calcium plus vitamin d3...... 94 ra enema...... 131 ra hemorrhoidal rectal...... 81 ra calcium soft chews...... 94 ra expecting dha...... 170 ra hi cal...... 94 ra calcium/vitamin d/minerals...... 94 ra eye allergy relief...... 177 ra hi-cal...... 94 ra calcium-boron...... 94 ra eye itch relief...... 179 ra hi-cal plus vitamin d...... 94 ra calcium-magnesium-zinc...... 94 ra fast relief laxative...... 131 ra high potency iron...... 94 ra cetiri-d...... 207 ra fever reducer/pain reliever...... 9 ra hydrating healing...... 81 ra cetirizine...... 187 ra fiber...... 131 ra hydrocortisone plus...... 81 ra cetirizine childrens...... 187 ra fiber laxative...... 131 ra ibu-profen cold/sinus...... 207 ra childrens aspirin...... 14 ra fiber supplement...... 131 ra ibuprofen infants...... 14 ra childrens chewable vit/iron...... 107 ra fiber therapy...... 131 ra ibuprofen junior strength...... 14 ra childrens cold & allergy...... 207 ra fiber-cap...... 131 ra ibuprofen oral capsule...... 14 ra chlorpheniramine maleate...... 187 ra fiber-tab...... 132 ra ibuprofen oral tablet...... 14 ra clotrimazole 3...... 36 RA FISH OIL EXTRA STRENGTH...... 170 ra iron...... 94 ra clotrimazole 7...... 36 ra fish oil oral capsule 1000 mg...... 170 ra jock itch max st...... 36 ra cod liver oil oral capsule...... 107 ra fish oil oral capsule 900 mg...... 170 ra k-pec...... 122 ra coenzyme q-10...... 170 ra fish oil oral capsule delayed release RA LANCING DEVICE...... 170 ra cold & allergy...... 207 1000 mg...... 170 ra laxative & stool softener...... 132 ra cold & cough childrens...... 207 ra fish oil oral capsule delayed release ra laxative extra strength...... 132 ra cold multi-symptom daytime oral tablet 1400 mg...... 170 ra laxative maximum strength...... 132 10-5-325 mg...... 207 ra fish oil oral capsule delayed release 600 ra laxative oral powder...... 132 ra cold sore treatment...... 67 mg...... 170 ra laxative oral tablet...... 132 ra cold/cough dm...... 207 ra folic acid oral tablet 400 mcg...... 94 ra laxative oral tablet chewable...... 132 ra cold/flu relief daytime...... 207 ra folic acid oral tablet 800 mcg...... 94 ra laxative oral tablet delayed release...... 132 ra col-rite oral capsule 250 mg...... 131 ra foot care (terbinafine)...... 36 ra l-carnitine...... 170 ra col-rite oral capsule 50 mg...... 131 ra gas relief extra strength oral capsule..... 122 ra lice maximum strength...... 45 ra complete allergy...... 187 ra gas relief extra strength oral tablet ra liquid antacid...... 122 ra coral calcium...... 94 chewable...... 122 ra l-lysine...... 170 ra cough dm...... 207 ra gas relief maximum strength...... 122 ra loperamide hcl...... 122 ra dandruff shampoo external lotion...... 80 ra gas relief oral capsule...... 122 ra lorata-d...... 207 ra day time cold/flu formula...... 207 ra gas relief oral suspension...... 122 ra loratadine...... 187 ra daytime multi-symp cold/flu...... 207 ra gas relief oral tablet chewable...... 122 ra loratadine childrens...... 187

269 ra lubricant eye ophthalmic solution 0.1-0.3 ra nose drops extra strength...... 208 ra stomach relief kids...... 123 %...... 175 ra omeprazole...... 135 ra stomach relief max st...... 123 ra lubricant eye ophthalmic solution 0.4-0.3 ra omeprazole-sodium bicarb...... 135 ra stomach relief oral suspension...... 123 %...... 175 ra one daily...... 108 ra stomach relief oral tablet chewable...... 123 ra lubricant eye ophthalmic solution 1-0.3 ra one daily essential...... 108 ra stool softener...... 132 %...... 175 ra one daily gummy vites...... 108 ra suphedrine oral tablet 30 mg...... 208 ra magnesium...... 94 ra one daily multi-vit plus fe...... 108 ra suphedrine oral tablet extended release ra magnesium citrate...... 132 ra one daily multi-vitamin...... 108 12 hour...... 208 ra melatonin/b-6...... 107 ra ophthalmic...... 175 ra tension headache...... 9 ra menstrual pain relief...... 9 ra oyster shell calcium...... 94 ra tioconazole 1...... 36 ra miconazole 3 combo pack app...... 36 ra oyster shell calcium/d...... 94 ra tooth shield...... 95 ra miconazole 7...... 36 ra p col-rite...... 132 ra tri-buffered aspirin...... 14 ra migraine relief...... 9 ra pain reliever ex st oral liquid...... 9 ra triple antibiotic external ointment...... 26 ra milk of magnesia...... 132 ra pain reliever ex st oral tablet...... 9 ra triple antibiotic plus...... 26 ra mineral oil...... 132 ra ped electrolyte freezer pop...... 95 RA TRUE2GO BLOOD GLUCOSE...... 170 ra mini nicotine...... 23 ra pediatric electrolyte...... 95 RA TRUERESULT BLOOD GLUCOSE..... 170 ra motion sickness relief oral tablet 50 mg...32 ra pink bismuth oral tablet...... 122 RA TRUETEST TEST...... 170 ra motion sickness relief oral tablet ra pink bismuth oral tablet chewable...... 122 ra tussin...... 208 chewable...... 32 ra prenatal...... 108 ra tussin cf...... 208 ra mucus relief chest...... 207 ra prenatal formula...... 108 ra tussin chest congestion oral syrup...... 208 ra mucus relief d max strength...... 207 ra probiotic colon care...... 123 ra tussin cough dm sugar free...... 208 ra mucus relief d oral tablet extended ra probiotic complex oral capsule...... 123 ra tussin cough/chest dm max...... 208 release 12 hour 60-600 mg...... 207 ra renewal dandruff...... 81 ra tussin maximum strength...... 208 ra mucus relief oral tablet...... 208 ra renewal soothing bath...... 81 ra urinary pain relief...... 138 ra naproxen sodium oral tablet...... 14 ra saccharin...... 170 ra urinary tract pain relief...... 138 ra nasal decongestant...... 208 ra saline enema...... 132 ra vanishing acne treatment...... 81 ra nasal decongestant pe...... 208 ra saline nasal spray...... 208 ra vitamin a...... 108 ra nasal spray...... 208 ra scalp itch/dandruff relief...... 81 ra vitamin a & d oral...... 108 ra nasal spray max st...... 208 ra scar...... 81 ra vitamin b-1...... 108 ra nasal spray/moisturizing...... 208 ra senna...... 132 ra vitamin b12...... 108 ra nasal spray/sinus...... 208 ra senna plus...... 132 ra vitamin b-12...... 108 ra natural magnesium...... 94 ra severe cold & cough day...... 208 ra vitamin b-12 tr...... 108 ra natural vitamin e...... 107 ra severe congestion spray...... 208 ra vitamin b-6...... 108 ra niacin oral tablet 100 mg...... 108 ra sinus/congestion relief pe...... 208 ra vitamin b-6 cr...... 108 ra nicotine...... 23 ra slow release iron oral tablet extended ra vitamin c...... 108 ra nicotine polacrilex...... 23 release 47.5 mg...... 95 ra vitamin c cr oral tablet extended release108 ra nighttime cold/flu relief oral liquid 15- ra smooth antacid ex st...... 123 ra vitamin c cr oral tablet extended release 6.25-500 mg/15ml...... 208 ra soluble fiber...... 132 500 mg...... 108 ra nite time cold/flu formula...... 208 ra stimulant laxative...... 132

270 ra vitamin c drops mouth/throat lozenge 60 RAYOS...... 139 RELAFEN DS...... 14 mg...... 108 RAZADYNE ER...... 31 RELENZA DISKHALER...... 48 ra vitamin c/acerola...... 108 react...... 148 relief eye drops...... 176 ra vitamin c/rose hips...... 108 REA-LO...... 81 RELION KETONE...... 170 ra vitamin c/rose hips cr...... 108 REBIF REBIDOSE...... 64 RELION ULTIMA GLUCOSE SYSTEM..... 170 ra vitamin d-3...... 108 REBIF REBIDOSE TITRATION PACK...... 64 RELION ULTIMA TEST...... 170 ra vitamin e blend...... 108 REBIF SUBCUTANEOUS SOLUTION RELISTOR...... 123 ra vitamin e natural...... 108 PREFILLED SYRINGE 22 MCG/0.5ML...... 64 RELNATE DHA...... 108 ra vitamin e oral capsule 1000 unit, 200 REBIF SUBCUTANEOUS SOLUTION RELPAX...... 39 unit...... 108 PREFILLED SYRINGE 44 MCG/0.5ML...... 64 REMEDIENT...... 108 ra vitamin e oral capsule 400 unit...... 108 REBIF TITRATION PACK...... 64 remedy antifungal external cream...... 36 ra vitamins complete childrens...... 108 RECEDO...... 81 remedy antifungal external powder...... 170 ra wart remover external solution...... 81 reclipsen...... 146 REMEDY PHYTOPLEX ANTIFUNGAL ra womens laxative...... 132 recofen d...... 208 EXTERNAL OINTMENT...... 36 ra zinc...... 95 RECOMBIVAX HB...... 154 remedy phytoplex antifungal external RABEPRAZOLE SODIUM ORAL RECOTHROM...... 53 powder...... 170 CAPSULE SPRINKLE...... 135 RECOTHROM SPRAY KIT...... 53 REMIGEN...... 81 rabeprazole sodium oral tablet delayed RECTIV...... 62 RENAGEL...... 97 release...... 135 RECURA...... 36 renal...... 108 radiance platinum vitamin d3...... 108 REDITREX...... 152 RENAL MULTIVITAMIN FORMULA...... 108 RADIOGARDASE...... 170 refenesen 400...... 209 renal-vite...... 108 RAGWITEK...... 208 REFRESH LACRI-LUBE...... 175 RENATABS...... 108 raloxifene hcl...... 148 REFRESH OPTIVE OPHTHALMIC RENATABS WITH IRON...... 108 ramipril...... 55 SOLUTION...... 175 rena-vite...... 108 RANEXA ORAL TABLET EXTENDED REFRESH OPTIVE PF...... 176 RENOVO...... 9 RELEASE 12 HOUR 1000 MG...... 59 REFRESH P.M...... 176 RENVELA...... 97 RANEXA ORAL TABLET EXTENDED REFRESH PLUS...... 176 repaglinide...... 49 RELEASE 12 HOUR 500 MG...... 59 REFRESH RELIEVA...... 176 REPATHA...... 62 ranolazine er oral tablet extended release REFRESH RELIEVA PF OPHTHALMIC REPLACEMENT FILTERS...... 170 12 hour 1000 mg...... 59 SOLUTION 0.5-0.9 %...... 176 REQ 49+...... 108 ranolazine er oral tablet extended release REFRESH TEARS...... 176 RESORCINOL-SULFUR...... 81 12 hour 500 mg...... 59 REGENECARE...... 81 RESTASIS...... 176 RAPAFLO...... 137 REGLAN ORAL TABLET 10 MG...... 123 RESTASIS MULTIDOSE...... 176 RAPAMUNE ORAL SOLUTION...... 152 REGLAN ORAL TABLET 5 MG...... 123 RESTORA...... 123 RAPAMUNE ORAL TABLET 0.5 MG...... 152 REGRANEX...... 81 RESTORA RX...... 123 RAPAMUNE ORAL TABLET 1 MG, 2 MG.152 rehydralyte...... 95 RETACRIT INJECTION SOLUTION 10000 rasagiline mesylate oral...... 46 RELADOR PAK...... 21 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, RASUVO...... 152 RELADOR PAK PLUS...... 21 4000 UNIT/ML, 40000 UNIT/ML...... 53 RAYALDEE...... 156 RELAFEN...... 14

271 RETACRIT INJECTION SOLUTION 20000 rivastigmine tartrate...... 31 RYTHMOL SR ORAL CAPSULE UNIT/ML...... 53 rivelsa...... 146 EXTENDED RELEASE 12 HOUR 425 MG..56 RETIN-A...... 81 rizatriptan benzoate...... 39 ryvent...... 187 RETIN-A MICRO GEL 0.04 %, 0.1 %...... 81 robafen cf multi-symptom cold...... 209 S2 (RACEPINEPHRINE)...... 190 RETIN-A MICRO PUMP...... 81 ROBAXIN-750...... 214 saccharomyces boulardii...... 123 REVATIO ORAL...... 191 ROBITUSSIN 12 HOUR COUGH...... 209 SAFYRAL...... 146 REVESTA...... 108 ROBITUSSIN 12 HOUR COUGH CHILD.. 209 SAIZEN...... 140 REVLIMID...... 41 ROBITUSSIN CHILD COUGH/COLD LA...209 SAIZENPREP...... 140 REXAPHENAC...... 14 robitussin childrens cough la...... 209 SALAGEN...... 67 REXASIL PATCH & VITAMIN E LIQ...... 81 ROBITUSSIN COLD+FLU DAYTIME...... 209 SALEX...... 81 REYVOW...... 38 ROBITUSSIN COUGH+CHEST CONG SALICEPT...... 67 RHOFADE...... 81 DM ORAL LIQUID 20-400 MG/20ML...... 209 salicylic acid er...... 81 RHOPRESSA...... 176 ROBITUSSIN NIGHTTIME COUGH...... 209 salicylic acid external cream...... 81 RIAX...... 81 ROBITUSSIN PEAK COLD MULTI-SYM...209 salicylic acid external foam...... 81 ribavirin inhalation...... 209 ROCALTROL ORAL CAPSULE...... 157 salicylic acid external gel...... 81 riboflavin oral capsule 50 mg...... 108 ROCALTROL ORAL SOLUTION...... 157 salicylic acid external liquid...... 81 RID LICE KILLING SHAMPOO...... 45 ROCKLATAN...... 176 salicylic acid external lotion...... 81 RIDAURA...... 153 ropinirole hcl...... 46 salicylic acid external shampoo...... 81 rifabutin...... 40 ropinirole hcl er...... 46 salicylic acid external solution...... 81 rifampin oral...... 40 rosadan external cream...... 26 salicylic acid wart remover...... 81 RIFAMPIN+SYRSPEND SF...... 40 rosadan external gel...... 26 salicylic acid-cleanser...... 81 RIGHT STEP PRENATAL...... 108 ROSADAN EXTERNAL KIT...... 81 SALICYLIC ACID-SULFACETAMIDE...... 81 RILUTEK...... 63 ROSE GLO...... 176 salimez...... 81 riluzole...... 63 rosuvastatin calcium...... 61 SALIMEZ FORTE...... 81 rimantadine hcl...... 48 ROWASA...... 154 saline mist spray...... 209 RINVOQ...... 153 ROXICODONE...... 18 saline nasal spray...... 209 RIOMET...... 49 rutin-50...... 170 SALIVAMAX...... 67 RIOMET ER...... 49 RUZURGI...... 170 salmon oil-1000...... 170 risacal-d...... 95 RYBELSUS...... 49 salsalate oral...... 14 risanoid plus...... 108 RYCLORA...... 187 SALVAX...... 82 RISAQUAD...... 123 rydex...... 209 SALVAX DUO PLUS...... 82 RISAQUAD-2...... 123 rymed...... 209 sam-e.p.a...... 170 risedronate sodium oral tablet 150 mg...... 156 rynex dm...... 209 sam-g.l.a...... 170 risedronate sodium oral tablet 30 mg, 5 mg rynex pe...... 209 SAMSCA...... 96 ...... 156 rynex pse...... 209 SANADERMRX SKIN REPAIR...... 82 risedronate sodium oral tablet 35 mg...... 156 RYTARY...... 46 SANCUSO...... 33 risedronate sodium oral tablet delayed RYTHMOL SR ORAL CAPSULE SANDIMMUNE ORAL...... 152 release...... 156 EXTENDED RELEASE 12 HOUR 225 MG, SANDOSTATIN INJECTION SOLUTION rivastigmine...... 31 325 MG...... 56 100 MCG/ML, 50 MCG/ML...... 150

272 SANDOSTATIN INJECTION SOLUTION SEMGLEE SUBCUTANEOUS SOLUTION. 52 SEYSARA...... 30 500 MCG/ML...... 150 SEMGLEE SUBCUTANEOUS SOLUTION sf...... 67 SANTYL...... 82 PEN-INJECTOR...... 52 sf 5000 plus...... 67 SAVAYSA...... 52 SEMPREX-D...... 209 SFROWASA...... 154 SAVELLA...... 64 SE-NATAL 19...... 108 sharobel...... 148 SAVELLA TITRATION PACK...... 64 senexon-s...... 132 SHINGRIX...... 154 sb allergy medicine oral tablet...... 187 senior probiotic...... 123 SHUR-SEAL CONTRACEPTIVE...... 138 sb arthritis pain relief...... 9 senior tonic...... 108 SIDEROL...... 108 sb aspirin adult low strength...... 14 senna lax...... 132 SIGNIFOR...... 151 sb aspirin oral tablet delayed release...... 14 senna laxative...... 132 SIGNIFOR LAR...... 151 sb cough control dm max...... 209 senna oral...... 132 SIKLOS ORAL TABLET 100 MG...... 42 sb docusate sodium/senna...... 132 senna plus oral tablet...... 132 SIKLOS ORAL TABLET 1000 MG...... 42 sb lice killing max st...... 45 senna s...... 132 SILA III...... 82 sb mucus relief...... 209 senna smooth...... 132 silace oral liquid...... 133 sb pain reliever childrens...... 9 senna-docusate sodium...... 132 silace oral syrup...... 133 sb pain reliever ex st...... 9 senna-extra...... 132 siladryl allergy...... 187 SCALACORT DK...... 82 senna-lax...... 132 sildenafil citrate oral suspension scalp relief...... 82 senna-plus...... 132 reconstituted...... 191 scar...... 82 senna-s...... 132 sildenafil citrate oral tablet 20 mg...... 191 SCARCARE GEL-PAD KIT/LARGE...... 82 senna-tabs...... 132 silica oral...... 108 SCARCIN...... 82 senna-time...... 133 SILIPAC...... 82 SCARSILK EXTERNAL...... 82 senna-time s...... 133 SILIQ...... 82 SCARZEN SKIN REPAIR...... 82 sennazon...... 133 silodosin...... 137 scopolamine...... 32 senno...... 133 SILTREX...... 170 SCRUB CARE POVIDONE-IODINE...... 26 sennosides-docusate sodium...... 133 siltussin sa...... 209 sea-omega...... 170 SENOKOT...... 133 siltussin-dm alcohol free...... 209 SEASONIQUE...... 146 SENOKOT EXTRA STRENGTH...... 133 SILVADENE...... 29 SEEBRI NEOHALER...... 189 SENOKOT S...... 133 silver nitrate external solution 10 %, 25 %, SEGLUROMET...... 49 SENSIPAR...... 156 50 %...... 26 SELECT-OB ORAL TABLET CHEWABLE SEREVENT DISKUS...... 190 silver sulfadiazine external...... 29 29-0.6-0.4 MG...... 108 SERNIVO...... 82 SILVERSEAL HYDROGEL DRESSING.... 170 SELECT-OB ORAL TABLET CHEWABLE SEROSTIM...... 123 SIMBRINZA...... 178 29-1 MG...... 108 se-tan plus...... 95 simeped...... 123 SELECT-OB+DHA...... 108 setlakin...... 146 simethicone oral capsule...... 123 selegiline hcl oral...... 46 sevelamer carbonate...... 97 simethicone oral suspension...... 123 selenium sulfide external lotion...... 82 sevelamer hcl...... 97 simethicone oral tablet chewable...... 123 selenium sulfide external shampoo 2.25 %..82 severe allergy...... 209 simliya...... 146 selenium sulfide external shampoo 2.3 %....82 severe cold/cough...... 209 simpesse...... 146 SELRX...... 82 severe cold/flu daytime...... 209 SIMPONI...... 152

273 SIMPONI ARIA...... 153 sm allergy 4 hour...... 187 sm calcium-magnesium-zinc oral tablet simvastatin oral...... 61 sm allergy childrens...... 187 333-133-5 mg...... 95 SINEMET...... 46 sm allergy relief childrens...... 187 sm chest congestion relief...... 210 SINGULAIR...... 189 sm allergy relief oral...... 187 sm chewable c...... 109 sinus 12 hour...... 209 sm animal shapes complete...... 109 sm childrens aspirin...... 15 sinus congestion max strength...... 209 sm animal shapes kids first...... 109 sm childrens loratadine...... 187 sinus nasal spray...... 209 sm antacid...... 123 sm clearlax...... 133 sinus pe decongestant...... 209 sm antacid advanced...... 123 sm clotrimazole vaginal...... 36 sinus relief extra strength...... 209 sm antacid advanced max st...... 123 sm cod liver oil...... 109 sirolimus oral solution...... 152 sm antacid anti-gas...... 123 sm coenzyme q-10...... 170 sirolimus oral tablet 0.5 mg...... 152 sm antacid maximum strength...... 123 sm cold & allergy childrens...... 210 sirolimus oral tablet 1 mg, 2 mg...... 152 sm antacid/antigas...... 123 sm cold & cough dm childrens...... 210 SIRTURO ORAL TABLET 100 MG...... 40 sm antibiotic...... 26 sm cold & sinus relief...... 210 SIRTURO ORAL TABLET 20 MG...... 40 sm anticavity fluoride rinse...... 95 SM CORAL CALCIUM...... 95 SITAVIG...... 48 sm anti-diarrheal oral liquid...... 123 sm cough relief...... 210 SIVEXTRO ORAL...... 26 sm anti-diarrheal oral tablet...... 123 sm cough/sore throat daytime...... 210 skarjel...... 82 sm antifungal miconazole...... 36 sm cough/sore throat nighttime...... 210 SKELAXIN...... 214 sm antifungal tolnaftate...... 36 sm day time cold & flu relief...... 210 SKLICE...... 44 sm anti-nausea...... 32 sm day time non drowsy...... 210 SKYRIZI (150 MG DOSE)...... 152 sm arthritis pain relief...... 9 sm day time pe cold/flu relief...... 210 SLEEP APPLICATION...... 170 sm arthritis pain reliever...... 9 sm daytime liquid...... 210 SLO-NIACIN ORAL TABLET EXTENDED sm artificial tears...... 176 sm docusate calcium...... 133 RELEASE 250 MG...... 108 sm aspirin...... 14 sm double antibiotic...... 26 SLO-NIACIN ORAL TABLET EXTENDED sm aspirin adult low strength...... 14 sm ear drops...... 181 RELEASE 500 MG...... 108 sm aspirin ec...... 14 sm enema...... 133 SLO-NIACIN ORAL TABLET EXTENDED sm aspirin ec low strength...... 14 sm estro vital nutrients ex st...... 109 RELEASE 750 MG...... 108 sm aspirin low dose...... 15 sm eye drops ophthalmic solution 0.05 %..177 SLOW FE...... 95 sm aspirin tri-buffered...... 15 sm eye drops ophthalmic solution 0.05-0.1- slow release iron oral tablet extended sm athletes foot...... 36 1-1 %...... 176 release 47.5 mg...... 95 sm balanced b-100...... 109 sm eye itch relief...... 179 SLOW-MAG...... 95 sm balanced b-50...... 109 sm fexofenadine hcl...... 187 SLOWMAG MG MUSCLE/HEART...... 95 sm calamine...... 82 sm fiber laxative...... 133 SLYND...... 148 sm calcium 500/vitamin d3...... 95 sm fiber oral powder 28.3 %, 48.57 %, 58.6 sm 3-day vaginal...... 36 sm calcium 600/vitamin d...... 95 %...... 133 sm 8 hour pain relief...... 9 sm calcium antacid...... 123 sm fiber oral tablet...... 133 sm acid reducer...... 125 sm calcium antacid ex st...... 123 sm fish oil oral capsule 1000 mg...... 170 sm acidophilus oral capsule 10 mg...... 123 sm calcium citrate w/vit d3...... 95 sm foaming antacid...... 123 sm all day allergy...... 187 sm calcium citrate-vit d...... 95 sm folic acid...... 95 sm all day allergy-d...... 210 sm calcium soft chews...... 95 sm gas relief...... 123

274 sm gas relief antiflatuent...... 123 sm miconazole 3 applicator...... 36 sm senna laxative...... 133 sm gas relief extra strength...... 123 sm miconazole 7...... 36 sm senna-s...... 133 sm gas relief infants...... 123 sm migraine relief...... 9 sm slow release iron oral tablet extended sm gas relief infants drops...... 123 sm milk of magnesia...... 133 release 143 (45 fe) mg...... 95 sm gentle laxative...... 133 sm mineral oil rectal...... 133 sm smooth antacid ex st...... 124 sm glucose oral tablet chewable 4 gm...... 50 sm motion sickness oral tablet 50 mg...... 32 sm soya lecithin...... 170 sm glucose oral tablet chewable 4-6 gm- sm motion sickness relief...... 32 sm stomach relief oral suspension...... 124 mg...... 50 sm mucus relief cough children...... 210 sm stomach relief oral tablet...... 124 sm glycerin...... 82 sm mucus relief d...... 210 sm stomach relief oral tablet chewable...... 124 sm glycerin pediatric rectal suppository 1.2 sm mucus relief max strength...... 210 sm stool softener...... 133 gm...... 133 sm multiple vitamins essential...... 109 sm stool softener/laxative...... 133 sm hydrocortisone external cream 0.5 %.....82 sm multiple vitamins/iron...... 109 sm super b complex/c...... 109 sm hydrocortisone external ointment...... 82 sm naproxen sodium oral tablet...... 15 sm tioconazole-1...... 36 sm hydrocortisone plus...... 82 sm nasal decongestant...... 210 sm triple antibiotic...... 26 sm hydrocortisone-aloe max st...... 82 sm nasal decongestant max st...... 210 sm triple antibiotic max st...... 26 sm ibuprofen...... 15 sm nasal decongestant pe...... 210 sm triple antibiotic original...... 26 sm ibuprofen ib...... 15 sm nasal spray...... 210 sm tussin cf...... 211 sm ibuprofen jr...... 15 sm nasal spray 12 hour...... 210 sm tussin cough/chest congest...... 211 sm infants ibuprofen...... 15 sm nasal spray moisturizing...... 210 sm tussin dm...... 211 sm iron...... 95 sm nasal spray saline...... 210 sm tussin dm max...... 211 sm iron slow release...... 95 sm nasal spray sinus...... 210 sm urinary pain relief oral tablet 95 mg...... 138 sm lansoprazole...... 135 sm natural laxative/stool soft...... 133 sm vit c/rose hips...... 109 sm laxative...... 133 sm nicotine...... 23 sm vitamin b-12...... 109 sm laxative maximum strength...... 133 sm nicotine polacrilex...... 23 sm vitamin b-6...... 109 sm lice killing...... 45 sm nose drops nasal decongest...... 211 sm vitamin c oral tablet 1000 mg, 250 mg. 109 sm lice killing max strength...... 45 sm omega-3 fish oil...... 170 sm vitamin c oral tablet chewable...... 109 sm lice solution kit...... 45 sm omeprazole...... 136 sm vitamin c/rose hips...... 109 sm lice treatment...... 45 sm oyster shell calcium/vit d...... 95 sm vitamin d3 oral tablet...... 109 sm l-lysine...... 170 sm oyster shell calcium/vit d3...... 95 sm vitamin e oral capsule 1000 unit, 200 sm loperamide hcl...... 124 sm pain & fever childrens...... 9 unit...... 109 sm loratadine...... 187 sm pain & fever infants...... 9 sm vitamin e oral capsule 400 unit...... 109 sm loratadine allergy relief...... 187 sm pain relief extra strength...... 9 sm zinc...... 95 sm lorata-dine d...... 210 sm pain reliever...... 9 smooth antacid extra st...... 124 sm loratadine d 12hr...... 210 sm pain reliever ex st...... 9 smooth lax oral powder...... 133 sm lubricant eye drops...... 176 sm pediatric electrolyte...... 95 sod citrate-citric acid...... 95 sm lubricating plus...... 176 sm povidone-iodine...... 26 sodium benzoate oral...... 109 sm lubricating tears...... 176 sm prenatal vitamins...... 109 SODIUM BICARBONATE ORAL sm magnesium...... 95 sm rapid melts junior...... 9 POWDER...... 124 sm magnesium citrate...... 133 sm redness relief...... 177 sodium bicarbonate oral tablet...... 124

275 sodium chloride (hypertonic) ophthalmic SOLOX...... 170 ST JOSEPH LOW DOSE...... 15 ointment...... 176 SOLTAMOX...... 41 STALEVO 100...... 46 sodium chloride (hypertonic) ophthalmic soluble fiber therapy...... 133 STALEVO 125...... 46 solution...... 176 SOLUTION TRANSFER DEVICE...... 171 STALEVO 150...... 46 sodium chloride inhalation nebulization soluvita e...... 95 STALEVO 200...... 46 solution 0.9 %...... 211 SOLVIL...... 171 STALEVO 50...... 46 sodium chloride inhalation nebulization SOMA...... 214 STALEVO 75...... 46 solution 10 %, 3 %...... 211 SOMAVERT...... 151 STARLIX...... 50 sodium chloride inhalation nebulization sonafine...... 171 STEGLATRO...... 50 solution 7 %...... 211 SOOLANTRA...... 82 STEGLUJAN...... 50 sodium chloride ophthalmic ointment 5 %..176 SOOTHE & COOL INZO ANTIFUNGAL...... 36 STELARA INTRAVENOUS...... 152 sodium chloride ophthalmic solution 5 %... 176 soothe maximum strength...... 124 STELARA SUBCUTANEOUS...... 152 sodium chloride oral solution 4 meq/ml...... 95 soothe oral suspension...... 124 STIMATE...... 140 sodium chloride oral tablet 1 gm...... 95 soothe oral tablet...... 124 stimulant laxative...... 133 sodium fluoride 5000 plus...... 67 soothe oral tablet chewable...... 124 STIOLTO RESPIMAT...... 211 sodium fluoride 5000 ppm dental cream...... 67 SOOTHEE...... 21 stomach relief extra strength...... 124 sodium fluoride 5000 ppm dental paste...... 67 soothing bath treatment...... 82 stomach relief max st...... 124 sodium fluoride 5000 sensitive...... 67 SORBIDON HYDRATE...... 82 stomach relief oral suspension 1050 sodium fluoride dental cream...... 67 sorbitol oral...... 133 mg/30ml, 525 mg/15ml...... 124 sodium fluoride dental gel...... 67 SORIATANE...... 82 stomach relief oral suspension 262 sodium fluoride oral solution...... 95 SORILUX...... 82 mg/15ml, 525 mg/30ml, 527 mg/30ml...... 124 sodium fluoride oral tablet 1.1 (0.5 f) mg...... 95 sotalol hcl (af)...... 56 stomach relief oral tablet 262 mg...... 124 sodium fluoride oral tablet 2.2 (1 f) mg...... 95 sotalol hcl oral...... 56 stomach relief oral tablet chewable 262 mg sodium fluoride oral tablet chewable...... 95 SOTYLIZE...... 56 ...... 124 sodium hyaluronate external...... 82 spectravite adult 50+ oral tablet chewable.109 stomach relief plus...... 124 sodium polystyrene sulfonate oral powder...96 spinosad...... 45 stomach relief ultra...... 124 sodium polystyrene sulfonate oral SPIRIVA HANDIHALER...... 189 stool softener laxative...... 133 suspension...... 96 SPIRIVA RESPIMAT...... 189 stool softener oral capsule 100 mg...... 133 sodium polystyrene sulfonate rectal...... 96 spironolactone oral...... 60 stool softener oral capsule 240 mg...... 134 sodium sulfacetamide...... 82 spironolactone-hctz...... 59 stool softener oral capsule 250 mg...... 134 sodium sulfacetamide wash...... 82 SPORANOX...... 36 stool softener oral capsule 50 mg...... 134 SODIUM SULFACETAMIDE-BAKUCHIOL..82 SPORANOX PULSEPAK...... 36 stool softener oral liquid 50 mg/5ml...... 134 soft glucose...... 50 sprintec 28...... 146 stool softener oral syrup 60 mg/15ml...... 134 SOLARAVIX...... 21 SPRIX...... 15 stool softener oral tablet 100 mg...... 134 SOLARTEK GLUCOSE CONTROL...... 170 sps...... 96 stool softener plus laxative...... 134 solifenacin succinate...... 137 sronyx...... 146 stool softener/laxative...... 134 SOLIQUA...... 49 ssd...... 29 stop lice complete treatment...... 45 SOLODYN...... 31 SSKI...... 171 STRATA CTX...... 82 SOLOSEC...... 26 sss 10-5...... 82 STRATA MARK...... 82

276 STRATA TRIZ...... 82 sulfacetamide sodium-sulfur external liquid. 83 SUPRAX...... 28 STRATA XRT...... 82 sulfacetamide sodium-sulfur external lotion. 83 SUPREME II HIGH/LOW CONTROL...... 171 STRENSIQ...... 136 sulfacetamide sodium-sulfur external pad....83 SUPREME TEST...... 171 stress formula...... 109 sulfacetamide sodium-sulfur external SUPREP BOWEL PREP KIT...... 134 stress formula/iron...... 109 suspension 10-5 %...... 83 sure result dss premium pack...... 15 stress formula/zinc...... 109 sulfacetamide sodium-sulfur external SURE RESULT O3D3 SYSTEM...... 59 STRIVERDI RESPIMAT...... 190 suspension 8-4 %...... 83 sure result sr relief...... 9 STROMECTOL...... 44 sulfacetamide sod-sulfur wash...... 83 SUTAB...... 126 STROVITE FORTE ORAL SYRUP...... 109 sulfacetamide-prednisolone ophthalmic SUVICORT...... 83 STROVITE FORTE ORAL TABLET...... 109 solution...... 176 syeda...... 146 STROVITE ONE...... 109 sulfacetamide-sulfur in urea...... 83 SYMAX DUOTAB...... 113 STUART ONE...... 109 sulfacleanse 8/4...... 83 symax-sl...... 113 SUBSYS...... 18 sulfadiazine oral...... 29 symax-sr...... 113 SUCCINYLCHOLINE CHLORIDE sulfamethoxazole-trimethoprim oral...... 29 SYMBICORT...... 211 INTRAVENOUS SOLUTION PREFILLED sulfamez wash...... 83 SYMJEPI...... 190 SYRINGE 140 MG/7ML...... 63 SULFAMYLON...... 26 SYMLINPEN 120...... 50 sucralfate oral suspension...... 134 sulfasalazine oral...... 155 SYMLINPEN 60...... 50 sucralfate oral tablet...... 134 sulfatrim pediatric...... 29 SYMPROIC...... 124 SUDAFED...... 211 SULFURATED LIME...... 45 SYNAGEX...... 109 SUDAFED CHILDRENS...... 211 sulindac oral...... 15 SYNAGIS...... 153 SUDAFED CONGESTION...... 211 SUMADAN...... 83 SYNALAR...... 83 SUDAFED PE CONGESTION ORAL SUMADAN WASH...... 83 SYNALAR (CREAM)...... 83 TABLET 10 MG...... 211 SUMADAN XLT...... 83 SYNALAR (OINTMENT)...... 83 SUDAFED PE SINUS CONGESTION...... 211 sumatriptan nasal...... 39 SYNALAR TS...... 83 SUDAFED SINUS CONGESTION...... 211 sumatriptan succinate oral...... 39 SYNAPRYN FUSEPAQ...... 16 SUDAFED SINUS CONGESTION 12HR...211 sumatriptan succinate refill...... 39 SYNAREL...... 151 sudogest 12 hour...... 211 sumatriptan succinate subcutaneous...... 39 SYNDROS...... 33 sudogest maximum strength...... 211 sumatriptan-naproxen sodium...... 39 SYNERA...... 21 sudogest oral tablet 30 mg...... 211 SUMAXIN...... 83 SYNERDERM...... 83 sudogest pe...... 211 SUMAXIN CP...... 83 SYNJARDY...... 50 SULAR...... 57 SUMAXIN WASH...... 83 SYNJARDY XR...... 50 SULCONAZOLE NITRATE...... 36 super b complex/c...... 109 SYNRIBO...... 42 sulfacetamide sodium (acne)...... 82 super b complex/vitamin c...... 109 SYNTHROID ORAL TABLET 100 MCG, 75 sulfacetamide sodium external...... 82 super b/c...... 109 MCG...... 149 sulfacetamide sodium ophthalmic...... 29 SUPER B-50 B COMPLEX...... 109 SYNTHROID ORAL TABLET 112 MCG, sulfacetamide sodium-sulfur external SUPERVITE...... 109 125 MCG, 137 MCG, 150 MCG, 175 MCG, cream...... 83 suphedrin...... 211 200 MCG, 25 MCG, 300 MCG, 50 MCG, sulfacetamide sodium-sulfur external support...... 109 88 MCG...... 149 emulsion...... 83 SUPPORT-500...... 109 SYNVEXIA TC...... 21

277 SYPRINE...... 96 TAPERDEX 7-DAY...... 140 telmisartan-hctz...... 59 SYRINGE AVITENE...... 171 TARDEOXIA...... 83 TEMODAR ORAL...... 41 SYSTANE COMPLETE...... 176 TARDIMAXIA...... 83 TEMOVATE...... 84 SYSTANE CONTACTS...... 176 TARGADOX...... 31 temozolomide...... 41 SYSTANE HYDRATION PF...... 176 TARGRETIN...... 43 tencon...... 9 SYSTANE ICAPS AREDS2 ORAL tarina 24 fe...... 146 TENIVAC...... 154 TABLET CHEWABLE...... 109 tarina fe 1/20...... 146 TENORETIC 100...... 59 SYSTANE NIGHTTIME...... 176 tarina fe 1/20 eq...... 146 TENORETIC 50...... 59 SYSTANE OPHTHALMIC GEL...... 176 TARKA...... 59 TENORMIN...... 56 SYSTANE OPHTHALMIC SOLUTION...... 176 TARON FORTE...... 95 tension headache...... 9 SYSTANE OVERNIGHT THERAPY...... 176 TARON-C DHA...... 110 terazosin hcl...... 137 SYSTANE PRESERVATIVE FREE...... 176 taron-crystals...... 96 terbinafine hcl external...... 37 SYSTANE ULTRA...... 176 TARON-PREX...... 110 terbinafine hcl oral...... 37 SYSTANE ULTRA PF...... 176 TAROXIA...... 83 terbinafine hydrochloride...... 37 tab tussin...... 211 TASMAR...... 45 terbutaline sulfate oral...... 190 tab-a-vite...... 110 TASOPROL...... 84 terconazole vaginal cream...... 37 tab-a-vite/beta carotene...... 110 taurine oral...... 171 terconazole vaginal suppository...... 37 tab-a-vite/iron...... 110 tavaborole...... 37 TERIPARATIDE (RECOMBINANT)...... 156 TABLOID...... 42 TAVALISSE...... 53 TESSALON PERLES...... 211 TABRADOL FUSEPAQ...... 214 TAYTULLA...... 146 TESTIM...... 141 TABRADOL RAPIDPAQ...... 214 tazarotene external...... 84 TESTONE CIK...... 141 TACLONEX...... 83 TAZORAC...... 84 TESTOSTERONE COMPOUNDING KIT.. 141 TACROLIMUS EXTERNAL CREAM...... 83 taztia xt...... 57 TESTOSTERONE CYPIONATE tacrolimus external ointment...... 83 TAZVERIK...... 42 INJECTION...... 141 tacrolimus oral...... 152 tears again...... 176 testosterone cypionate intramuscular tactinal...... 9 TEARS AGAIN ADVANCED EYELID solution 100 mg/ml...... 141 tactinal extra strength...... 9 OPHTHALMIC...... 176 testosterone cypionate intramuscular tadalafil (pah)...... 191 tears pure...... 176 solution 200 mg/ml...... 141 tadalafil oral tablet 5 mg...... 137 TECENTRIQ INTRAVENOUS SOLUTION testosterone enanthate intramuscular...... 141 take action...... 148 1200 MG/20ML...... 43 testosterone transdermal...... 141 TALICIA...... 125 TECFIDERA ORAL CAPSULE DELAYED tetrabenazine...... 63 TALIVA...... 110 RELEASE...... 64 tetracycline hcl oral...... 31 TALTZ...... 83 TECFIDERA STARTER PACK...... 64 TETRIX...... 84 TAMIFLU...... 48 TEGADERM AG MESH...... 171 TEXACORT...... 84 tamoxifen citrate oral...... 41 TEGSEDI...... 136 TGT LANCING DEVICE...... 171 tamsulosin hcl...... 137 TEKTURNA...... 59 THALOMID...... 41 TAPAZOLE...... 151 TEKTURNA HCT...... 59 THE ELIMINATOR...... 171 TAPERDEX 12-DAY...... 139 telmisartan...... 55 the magic bullet...... 134 TAPERDEX 6-DAY...... 139 telmisartan-amlodipine...... 59 THEO-24...... 191

278 theophylline...... 191 timolol maleate ophthalmic solution 0.5 % TOBRAMYCIN NEBULIZATION theophylline er...... 191 (daily)...... 178 SOLUTION 300 MG/5ML INHALATION.... 191 thera...... 110 timolol maleate oral...... 57 tobramycin ophthalmic...... 177 THERAFLU EXPRESSMAX...... 211 timolol maleate pf...... 178 tobramycin-dexamethasone...... 176 THERAFLU EXPRESSMAX SEV CLD/CG TIMOLOL-BRIMON-DORZOL-LATANOPR TOBREX...... 177 ORAL TABLET 10-5-325 MG...... 211 ...... 178 TOLAK...... 84 THERAFLU POWERPODS SEVERE TIMOLOL-BRIMONIDINE-DORZOLAMID. 178 tolbutamide...... 50 COLD ORAL 20-10-650 MG...... 211 TIMOLOL-DORZOLAMID-LATANOPROST tolcapone...... 45 THERAFLU SEVERE COLD...... 211 ...... 178 tolmetin sodium...... 15 THERAFLU SEVERE COLD DAYTIME.....211 TIMOPTIC...... 178 tolnaftate antifungal...... 37 THERAFLU SEVERE COLD/CGH DAY.... 211 TIMOPTIC OCUDOSE...... 178 tolnaftate external cream...... 37 THERAMINE PLUS...... 171 TIMOPTIC-XE...... 178 tolnaftate external powder...... 171 therapeutic oral tablet...... 110 TINACTIN EXTERNAL AEROSOL...... 37 TOLSURA...... 37 THERASEAL HAND PROTECTION...... 84 TINACTIN EXTERNAL CREAM...... 37 tolterodine tartrate...... 137 thera-tabs...... 110 tinaspore...... 37 tolterodine tartrate er...... 137 THERATEARS NUTRITION...... 171 tinidazole oral...... 26 TOLVAPTAN ORAL TABLET 15 MG...... 96 thiamine...... 110 tioconazole 1 vaginal ointment 6.5 %...... 37 tolvaptan oral tablet 30 mg...... 96 thiamine hcl oral...... 110 tioconazole-1...... 37 TOPEX TOPICAL ANESTHETIC...... 67 THIOLA...... 138 TIROSINT ORAL CAPSULE 100 MCG, TOPICORT...... 84 THIOLA EC...... 138 112 MCG, 125 MCG, 13 MCG, 137 MCG, TOPICORT SPRAY...... 84 thrive...... 23 25 MCG, 50 MCG, 75 MCG, 88 MCG...... 149 TOPROL XL...... 57 THRIVITE 19...... 110 TIROSINT ORAL CAPSULE 150 MCG, toremifene citrate...... 41 THRIVITE RX...... 110 175 MCG, 200 MCG...... 149 torsemide...... 60 THROMBI-GEL 10...... 171 TIROSINT-SOL...... 149 TOSYMRA...... 39 THROMBI-GEL 100...... 171 TITRALAC...... 124 total allergy...... 188 THROMBI-GEL 40...... 171 TIVORBEX...... 15 total allergy medicine...... 188 THROMBI-PAD...... 171 tizanidine hcl oral capsule...... 214 totalday multiple...... 110 THROMBOGEN...... 53 tizanidine hcl oral tablet...... 214 TOUJEO MAX SOLOSTAR...... 52 tiadylt er...... 57 tl-hem 150...... 96 TOUJEO SOLOSTAR...... 52 TIAZAC...... 57 TOBI NEBULIZER...... 191 tovet external foam...... 84 TIBSOVO...... 43 TOBI PODHALER...... 191 TOVET EXTERNAL KIT...... 84 TIGAN ORAL...... 32 TOBRADEX OPHTHALMIC OINTMENT... 176 TOVIAZ...... 137 TIGLUTIK...... 63 TOBRADEX OPHTHALMIC SUSPENSION TRACLEER 32 MG...... 192 TIKOSYN...... 56 ...... 176 TRACLEER 62.5 MG, 125 MG...... 192 tilia fe...... 146 TOBRADEX ST...... 176 TRADJENTA...... 50 timolol maleate ophthalmic gel forming tobramycin inhalation nebulization solution tramadol hcl er (biphasic)...... 18 solution...... 178 300 mg/4ml...... 191 TRAMADOL HCL ER ORAL CAPSULE timolol maleate ophthalmic solution 0.25 tobramycin nebulization solution 300 EXTENDED RELEASE 24 HOUR 100 MG, %, 0.5 %...... 178 mg/5ml inhalation...... 191 200 MG, 300 MG...... 16

279 tramadol hcl er oral capsule extended TRIAMSIL MULTIPAK...... 84 triple antibiotic/pain...... 27 release 24 hour 150 mg...... 16 triamterene oral...... 60 triple antibiotic+pain relief...... 27 tramadol hcl er oral tablet extended triamterene-hctz...... 59 TRIPLE COMPLEX FORMULA 3 KIT...... 15 release 24 hour...... 18 trianex...... 84 triple paste af...... 37 tramadol hcl ir...... 18 TRIBENZOR...... 59 TRIPLE PMB...... 179 tramadol-acetaminophen...... 18 tri-biozene...... 26 TRIPLE PMK...... 179 trandolapril...... 55 tri-buffered aspirin...... 15 tri-previfem...... 146 trandolapril-verapamil hcl er...... 59 TRICARE...... 110 triprolidine hcl oral liquid 0.313 mg/ml...... 188 TRANSDERM SCOP (1.5 MG)...... 32 TRICARE PRENATAL DHA ONE...... 110 triprolidine hcl oral liquid 0.625 mg/ml...... 188 TRANSDERM-SCOP (1.5 MG)...... 32 TRI-CHLOR...... 84 triprolidine hcl oral liquid 0.938 mg/ml...... 188 TRAVATAN Z...... 180 TRICITRASOL...... 52 triprolidine hcl oral liquid 2.5 mg/5ml...... 188 travel sickness...... 32 tricitrates...... 96 TRIPTODUR...... 151 travoprost (bak free)...... 180 tricon...... 96 tri-sprintec...... 146 TRECATOR...... 40 TRICOR...... 61 TRISTART DHA...... 110 TRELEGY ELLIPTA INHALATION triderm...... 84 TRISTART ONE...... 110 AEROSOL POWDER BREATH TRIDESILON...... 84 TRI-TABS DHA...... 110 ACTIVATED 100-62.5-25 MCG/INH...... 211 trientine hcl...... 96 TRI-VI-FLOR...... 110 TRELEGY ELLIPTA INHALATION tri-estarylla...... 146 TRI-VI-FLORO...... 110 AEROSOL POWDER BREATH trifluridine...... 48 tri-vite pediatric...... 110 ACTIVATED 200-62.5-25 MCG/INH...... 211 TRIJARDY XR...... 50 tri-vite/fluoride...... 110 TREMFYA...... 84 tri-legest fe...... 146 TRIVIX...... 84 TRESIBA...... 52 tri-linyah...... 146 trivora (28)...... 146 TRESIBA FLEXTOUCH...... 52 TRILIPIX...... 61 tri-vylibra...... 146 tretinoin external...... 84 tri-lo-estarylla...... 146 tri-vylibra lo...... 146 tretinoin microsphere...... 84 tri-lo-marzia...... 146 TROMBONEX...... 110 tretinoin microsphere pump...... 84 tri-lo-mili...... 146 TROMBONEX-D...... 110 tretinoin oral...... 43 tri-lo-sprintec...... 146 TRONVITE...... 110 TREXALL...... 152 trilyte...... 134 tropicamide ophthalmic...... 176 TREXIMET...... 39 trimethobenzamide hcl oral...... 32 TROPICAMIDE-CYCLOPENTOLATE-PE. 177 TREZIX...... 18 trimethoprim oral...... 26 trospium chloride...... 137 tri femynor...... 146 tri-mili...... 146 trospium chloride er...... 137 triamcinolone acetonide external aerosol TRIMO-SAN VAGINAL GEL 0.025-0.01 %..26 TRUE FOCUS BLOOD GLUCOSE STRIP 171 solution...... 84 TRINATAL RX 1...... 110 TRUE METRIX AIR GLUCOSE METER....171 triamcinolone acetonide external cream...... 84 trinate...... 110 TRUE METRIX GO GLUCOSE METER.... 171 triamcinolone acetonide external lotion...... 84 TRINAZ...... 110 TRUE METRIX METER KIT...... 171 triamcinolone acetonide external ointment...84 triphrocaps...... 110 TRUECONTROL GLUCOSE CONT LEV 0171 triamcinolone acetonide mouth/throat...... 67 triple antibiotic...... 26 TRUECONTROL GLUCOSE CONT LEV 1171 TRIAMINIC ALLERCHEWS...... 188 triple antibiotic plus...... 26 TRUEDRAW LANCING DEVICE...... 171 TRIAMSIL COMBIPAK...... 84 triple antibiotic plus max st...... 27 TRUEPLUS GLUCOSE ORAL GEL...... 50

280 TRUETRACK BLOOD GLUCOSE...... 171 tyblume...... 146 ULTRASAL-ER...... 84 TRUETRACK TEST...... 171 tydemy...... 146 ULTRAVATE...... 84 TRULANCE...... 124 TYLACTIN COMPLETE 15 PE...... 171 UMECTA MOUSSE...... 84 TRULICITY...... 50 TYLENOL 8 HOUR...... 9 UNISTRIP CONTROL...... 172 TRUMENBA...... 154 TYLENOL 8 HOUR ARTHRITIS PAIN...... 9 UNISTRIP1 GENERIC...... 172 TRUSOPT...... 178 TYLENOL CHILDRENS CHEWABLES...... 9 unithroid oral tablet 100 mcg, 75 mcg...... 149 trymine cg...... 212 TYLENOL CHILDRENS ORAL unithroid oral tablet 112 mcg, 125 mcg, TUBING/WING TIP...... 171 SUSPENSION...... 9 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 TUDORZA PRESSAIR...... 189 TYLENOL COLD MAX ORAL LIQUID...... 212 mcg, 50 mcg, 88 mcg...... 149 tulana...... 148 TYLENOL COLD MAX ORAL TABLET...... 212 unithroid oral tablet 300 mcg...... 149 TUMS...... 124 TYLENOL EXTRA STRENGTH...... 10 UPNEEQ...... 86 TUMS CHEWY BITES...... 124 TYLENOL INFANTS...... 10 UPTRAVI...... 192 TUMS E-X 750...... 124 TYLENOL INFANTS PAIN+FEVER...... 10 URAMAXIN...... 84 TUMS EXTRA STRENGTH 750...... 124 TYLENOL ORAL TABLET...... 10 urea 20 intensive hydrating...... 84 TUMS LASTING EFFECTS...... 125 TYMLOS...... 156 urea external cream 39 %...... 84 TUMS SMOOTHIES...... 125 tyrosine...... 171 urea external cream 40 %...... 84 TUMS ULTRA 1000...... 125 TYVASO...... 192 urea external cream 41 %...... 84 TURPENTINE EXTERNAL...... 9 TYVASO REFILL...... 192 urea external cream 45 %...... 85 tusnel c...... 212 TYVASO STARTER...... 192 urea external cream 47 %...... 85 TUSSICAPS...... 212 UBRELVY...... 38 UREA EXTERNAL FOAM...... 85 tussin cf...... 212 UCERIS...... 155 urea external lotion...... 85 tussin cf cough & cold...... 212 UDAMIN SP...... 110 urea external suspension...... 85 tussin cf multi-symptom cold...... 212 UDENYCA...... 53 urea hydrating...... 85 tussin cough long acting...... 212 ULORIC...... 37 urea nail...... 85 tussin cough oral syrup...... 212 ULTIMA...... 171 urea-c40...... 85 tussin dm cough + chest oral liquid 10-200 ULTIMA TEST...... 171 ureacin-10...... 85 mg/5ml...... 212 ultra energy...... 110 ureacin-20...... 85 tussin dm max...... 212 ultra fresh...... 176 uredeb...... 85 tussin dm max adult...... 212 ultra fresh pm...... 176 URELLE...... 138 tussin dm max st...... 212 ultra lubricant drop...... 176 uremez-40...... 85 tussin dm oral syrup 100-10 mg/5ml...... 212 ultra lubricating eye drops...... 176 URESOL...... 85 tussin maximum strength...... 212 ULTRACET...... 18 uretron d/s...... 138 tussin mucus+chest congestion oral syrup 212 ULTRAFOAM SPONGE 2X6.25X7CM...... 171 URIBEL...... 138 tussin multi-symptom cold cf...... 212 ULTRAFOAM SPONGE 8X12.5X1CM...... 171 URIMAR-T...... 138 TUXARIN ER...... 212 ULTRAFOAM SPONGE 8X12.5X3CM...... 171 urin ds...... 138 TUZISTRA XR...... 212 ULTRAFOAM SPONGE 8X25X1CM...... 172 urinary pain relief oral tablet 95 mg...... 138 TWINRIX...... 154 ULTRAFOAM SPONGE 8X6.25X1CM...... 172 URO-458...... 138 TWIRLA...... 146 ULTRAM...... 18 UROCIT-K 10...... 96 TWYNSTA...... 59 ultra-mega...... 110 UROCIT-K 15...... 96

281 UROCIT-K 5...... 96 VANCOMYCIN+SYRSPEND SF...... 27 VENNGEL ONE...... 15 UROGESIC-BLUE...... 27 vandazole...... 27 VENOFER...... 96 uro-mp...... 138 VANICREAM EXTERNAL OINTMENT...... 85 VENTAVIS...... 192 urosex...... 110 VANOS...... 85 VENTOLIN HFA...... 190 UROXATRAL...... 137 VANOXIDE-HC...... 85 veracolate...... 134 URSO 250...... 125 VAPORIZER WARM STEAM...... 172 verapamil hcl er oral capsule extended URSO FORTE...... 125 VAQTA...... 154 release 24 hour...... 57 ursodiol oral capsule...... 125 VARDIMAXIA...... 85 verapamil hcl er oral tablet extended ursodiol oral tablet...... 125 VARIVAX...... 154 release...... 57 URSODIOL+SYRSPEND SF...... 125 VAROPHEN...... 15 verapamil hcl oral...... 57 ustell...... 138 VAROXIA...... 85 VERDESO...... 85 UTIBRON NEOHALER...... 212 VARUBI (180 MG DOSE)...... 33 VEREGEN...... 85 uticap...... 138 VASCEPA...... 62 VERELAN...... 57 utira-c...... 138 VASCULERA...... 172 VERELAN PM...... 57 UTOPIC...... 85 VASERETIC...... 60 VESICARE...... 137 utrona-c...... 138 VASOCLEAR-A...... 177 VEXATROL...... 21 VAGIFEM...... 146 VASOFLEX D1...... 172 VFEND...... 37 valacyclovir hcl oral...... 48 vasoflex forte...... 110 VIBERZI...... 125 VALCHLOR...... 41 vasoflex hd...... 110 VIBRAMYCIN ORAL CAPSULE...... 31 VALCYTE ORAL SOLUTION VASOFLEX ORAL CAPSULE...... 110 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED...... 47 vasoflex oral tablet...... 110 RECONSTITUTED...... 31 VALCYTE ORAL TABLET...... 47 VASOTEC...... 55 VIBRAMYCIN ORAL SYRUP...... 31 valganciclovir hcl oral solution v-c forte...... 110 vic-forte...... 110 reconstituted...... 47 VCF VAGINAL CONTRACEPTIVE VICTOZA...... 50 valganciclovir hcl oral tablet...... 47 VAGINAL FILM...... 138 vienva...... 146 VALINE 1000...... 172 VCF VAGINAL CONTRACEPTIVE VIGAMOX...... 29 valine oral...... 172 VAGINAL FOAM...... 138 vilamit mb...... 138 valsartan...... 55 vcf vaginal contraceptive vaginal gel...... 138 VILEVEV MB...... 138 valsartan-hydrochlorothiazide...... 60 VECAMYL...... 60 VIMOVO...... 15 VALTREX...... 48 VECTICAL...... 85 VINATE DHA RF...... 111 VANACLEAR PD...... 188 vegetable lax+stool softener...... 134 vinate ii...... 111 VANADOM...... 214 velivet...... 146 vinate one...... 111 VANATOL LQ...... 10 VELPHORO...... 97 VIOKACE...... 136 VANCOCIN...... 27 VELTASSA...... 96 viorele...... 147 VANCOCIN HCL...... 27 VELTIN...... 85 VIRASAL...... 85 vancomycin hcl in nacl intravenous solution VEMLIDY...... 47 VIRAZOLE...... 212 1-0.9 gm/200ml-%...... 27 venaliv...... 172 virt-c dha...... 111 vancomycin hcl oral capsule...... 27 VENCLEXTA...... 43 virt-caps...... 111 vancomycin hcl oral solution reconstituted...27 VENCLEXTA STARTING PACK...... 43 VIRT-FEFA PLUS...... 96

282 virt-gard...... 111 vitamin b complex-c...... 111 vitamin d oral liquid 10 mcg/ml...... 111 virt-nate dha...... 111 vitamin b1...... 111 vitamin d oral tablet 25 mcg (1000 ut)...... 111 virt-phos 250 neutral...... 96 vitamin b-1 oral tablet 100 mg, 50 mg...... 111 vitamin d oral tablet 50 mcg (2000 ut)...... 111 virt-pn dha...... 111 vitamin b-1 oral tablet 250 mg...... 111 vitamin d3 oral capsule 1.25 mg (50000 ut) virt-pn plus...... 111 vitamin b-12 er oral tablet extended ...... 111 virtussin a/c...... 212 release 1000 mcg, 2000 mcg...... 111 vitamin d3 oral capsule 125 mcg (5000 ut) 111 virtussin ac w/alc...... 212 vitamin b-12 oral tablet 100 mcg, 1000 vitamin d3 oral capsule 25 mcg (1000 ut).. 111 virtussin dac...... 212 mcg, 250 mcg, 500 mcg...... 111 vitamin d3 oral capsule 250 mcg (10000 ut) VISBIOME...... 125 vitamin b-12 oral tablet extended release ...... 111 VISBIOME HIGH POTENCY ORAL 2000 mcg...... 111 vitamin d3 oral capsule 50 mcg (2000 ut).. 111 CAPSULE...... 125 vitamin b12 sublingual liquid...... 111 vitamin d3 oral liquid 10 mcg/ml...... 111 VISINE...... 177 vitamin b-12 sublingual tablet sublingual vitamin d3 oral liquid 125 mcg/ml...... 111 VISINE ADVANCED RELIEF...... 176 2500 mcg, 5000 mcg...... 111 vitamin d3 oral tablet 10 mcg (400 unit)..... 111 VISIONBLUE...... 176 vitamin b-12 tr...... 111 vitamin d3 oral tablet 125 mcg (5000 ut)....111 VISTARIL...... 188 vitamin b-2 oral tablet 100 mg, 25 mg...... 111 vitamin d3 oral tablet 25 mcg (1000 ut)...... 112 VISTOGARD...... 172 vitamin b-6 er...... 111 vitamin d3 oral tablet 50 mcg (2000 ut)...... 112 vita s forte...... 111 vitamin b-6 oral tablet 100 mg, 25 mg, 50 vitamin d3 oral tablet chewable 10 mcg vitacel...... 111 mg...... 111 (400 unit)...... 112 vitachew multiple vitamin...... 111 vitamin b-6 oral tablet 500 mg...... 111 vitamin d3 super strength oral tablet...... 112 VITAFOL...... 111 vitamin b-complex 100...... 111 vitamin d-400...... 112 VITAFOL FE+...... 111 vitamin c cr...... 111 vitamin e oral capsule 100 unit, 1000 unit, VITAFOL GUMMIES...... 111 vitamin c drops...... 111 200 unit...... 112 VITAFOL STRIPS...... 111 vitamin c er oral capsule extended release 111 vitamin e oral capsule 400 unit...... 112 VITAFOL ULTRA...... 111 vitamin c er oral tablet extended release vitamin e oral solution 15 unit/0.3ml...... 96 VITAFOL-NANO...... 111 1500 mg...... 111 vitamin k (phytonadione)...... 112 VITAFOL-OB...... 111 vitamin c oral liquid 500 mg/5ml...... 111 vitamin-b complex...... 112 VITAFOL-OB+DHA...... 111 vitamin c oral tablet 1000 mg, 250 mg...... 111 vitamins acd-fluoride...... 112 VITAFOL-ONE...... 111 vitamin c oral tablet 500 mg...... 111 VITAPEARL...... 112 VITAL-D RX...... 111 vitamin c oral tablet chewable 100 mg, 250 VITAROCA PLUS...... 112 VITAMAX...... 111 mg...... 111 VITA-RX DIABETIC VITAMIN...... 112 VITAMAX PEDIATRIC...... 111 vitamin c oral tablet chewable 500 mg...... 111 VITASURE...... 112 VITAMEDMD ONE RX/QUATREFOLIC.... 111 vitamin c w/rose hips oral tablet 500 mg.... 111 VITATHELY WITH GINGER...... 112 VITAMEDMD REDICHEW RX...... 111 vitamin c/bioflavonoids...... 111 VITATRUE...... 112 VITAMEZ...... 111 vitamin c/rose hips tr...... 111 VITONIC...... 112 vita-min...... 111 vitamin c-rose hips oral tablet...... 111 VITREXATE...... 112 VITAMIN A FISH...... 111 vitamin d (cholecalciferol) oral tablet...... 111 VITREXATE FE...... 112 vitamin a oral capsule 2400 mcg (8000 ut), vitamin d (ergocalciferol) oral capsule 1.25 VITREXYL...... 112 3 mg (10000 ut)...... 111 mg (50000 ut)...... 111 VITREXYL + IRON...... 112 vitamin b complex 100...... 111 vitamin d oral capsule 400 unit...... 111 VIVA DHA...... 112

283 VIVELLE-DOT...... 147 wal-itin aller-melts...... 188 WEST-VITE W/FOLIC ACID...... 112 VIVLODEX...... 15 wal-itin childrens...... 188 WHEAT GERM OIL...... 112 VOGELXO...... 141 wal-itin d...... 213 WIDE-SEAL DIAPHRAGM 60...... 172 VOGELXO PUMP...... 141 wal-itin d 24 hour...... 213 WIDE-SEAL DIAPHRAGM 65...... 172 volnea...... 147 wal-itin oral syrup...... 188 WIDE-SEAL DIAPHRAGM 70...... 172 VOL-PLUS...... 112 wal-itin oral tablet...... 188 WIDE-SEAL DIAPHRAGM 75...... 172 VOL-TAB RX...... 112 wal-mucil...... 134 WIDE-SEAL DIAPHRAGM 80...... 172 VOLTAREN...... 15 wal-phed...... 213 WIDE-SEAL DIAPHRAGM 85...... 172 voriconazole oral...... 37 wal-phed 12 hour...... 213 WIDE-SEAL DIAPHRAGM 90...... 172 VORTEX HOLDING CHAMBER/MASK.....172 wal-phed pe...... 213 WIDE-SEAL DIAPHRAGM 95...... 172 VORTEX VALVED HOLDING CHAMBER.172 wal-profen cold & sinus...... 213 wixela inhub...... 213 VP FC KIT...... 15 wal-profen oral capsule...... 15 womans laxative...... 134 VP GKL KIT...... 15 wal-tap cold/allergy oral elixir...... 213 womens daily gummies...... 112 vp-heme ob + dha...... 112 wal-tussin...... 213 womens gentle laxative...... 134 vp-pnv-dha...... 112 wal-tussin cf...... 213 womens laxative...... 134 vp-vite rx...... 112 wal-tussin cough oral syrup...... 213 womens prenatal+dha...... 112 VTOL LQ...... 10 wal-tussin cough/chest dm...... 213 WP THYROID...... 150 VUMERITY...... 64 wal-vert...... 188 WPR PLUS WOUND HEALING SYSTEM...21 VUSION...... 37 wal-zyr childrens oral tablet chewable 5 mg wymzya fe...... 147 vyfemla...... 147 ...... 188 XADAGO...... 46 vylibra...... 147 wal-zyr d...... 213 XALATAN...... 180 VYNDAMAX...... 60 wal-zyr oral tablet...... 188 XALIX...... 85 VYNDAQEL...... 60 warfarin sodium oral...... 52 XAQUIL XR...... 112 VYTONE...... 37 wart remover external liquid 17 %...... 85 XARACOLL...... 21 VYTORIN...... 62 wart remover maximum strength external XARELTO...... 52 VYZULTA...... 180 liquid...... 85 XARELTO STARTER PACK...... 52 wal-act...... 212 WATCHHALER...... 172 XATMEP...... 152 wal-dram...... 32 water tabs...... 172 XELJANZ...... 152 wal-dryl allergy...... 188 wee care...... 96 XELJANZ XR...... 152 wal-dryl allergy childrens...... 188 weekly-d...... 112 XELODA...... 42 wal-fex allergy oral tablet 180 mg...... 188 WELCHOL...... 62 XELPROS...... 180 wal-fex d allergy & congestion oral tablet WELLNESS APPLICATION...... 172 XENAZINE...... 63 extended release 12 hour...... 212 wera...... 147 XENICAL...... 63 wal-fex d allergy & congestion oral tablet westab max...... 112 XENLETA ORAL...... 27 extended release 24 hour...... 212 westab mini...... 112 XEOMIN INTRAMUSCULAR SOLUTION wal-finate...... 188 westab one...... 112 RECONSTITUTED 200 UNIT...... 47 wal-flu severe cold & cough oral liquid...... 212 WESTAB PLUS...... 112 XEPI...... 29 wal-flu severe cold & cough oral packet.....212 WESTGEL DHA...... 112 XERAC AC...... 85 wal-four...... 213 WESTHROID...... 149 XERALUX...... 85

284 XERESE...... 48 XYZBAC...... 172 ZERVIATE...... 177 XERMELO...... 125 XYZMUNE...... 172 ZESTORETIC...... 60 XEROSTOMIA RELIEF SPRAY...... 67 YASMIN 28...... 147 ZESTRIL...... 55 XHANCE...... 189 YAZ...... 147 ZETIA...... 62 XIFAXAN ORAL TABLET 200 MG...... 125 YONDELIS...... 41 ZETONNA...... 189 XIFAXAN ORAL TABLET 550 MG...... 125 YONSA...... 41 ZIAC...... 60 XIGDUO XR...... 50 YOSPRALA...... 54 ZIANA...... 86 XIIDRA...... 176 YUPELRI...... 189 ZIEXTENZO...... 53 XIMINO...... 31 yuvafem...... 147 ZILACAINE PATCH...... 21 XOFLUZA (40 MG DOSE)...... 48 ZACARE...... 85 ZILACTIN BABY...... 67 XOFLUZA (80 MG DOSE)...... 48 zaclir cleansing...... 86 zileuton er...... 189 XOLAIR...... 153 ZADITOR...... 179 ZILXI...... 86 XOLEGEL...... 37 zafirlukast...... 189 ZINC 15...... 96 XOLEGEL COREPAK...... 37 ZALVIT...... 112 zinc chelated oral tablet 50 mg...... 96 XOLEGEL DUO/HEAD & SHOULDERS...... 37 ZANAFLEX...... 214 zinc gluconate oral tablet 100 mg, 50 mg.... 96 XOLEGEL DUO/XOLEX...... 37 zarah...... 147 zinc methionate...... 96 XOLIDO XP...... 21 ZARXIO...... 53 zinc oral lozenge...... 112 XOPENEX...... 190 ZATEAN-PN DHA...... 112 zinc oral tablet 50 mg...... 96 XOPENEX CONCENTRATE...... 191 ZATEAN-PN PLUS...... 112 zinc oxide external ointment 40 %...... 86 XOPENEX HFA...... 191 ZCORT 7-DAY...... 140 zinc sulfate oral tablet 220 (50 zn) mg...... 96 xpect...... 213 ZEASORB-AF...... 172 zincolate...... 172 XPOVIO (100 MG ONCE WEEKLY)...... 42 ZEBUTAL...... 10 ZIONODIL...... 21 XPOVIO (40 MG ONCE WEEKLY)...... 42 ZEGERID...... 136 ZIONODIL 100...... 22 XPOVIO (40 MG TWICE WEEKLY)...... 42 ZEGERID OTC...... 136 ZIOPTAN...... 180 XPOVIO (60 MG ONCE WEEKLY)...... 42 ZELAC...... 125 ZIPSOR...... 15 XPOVIO (60 MG TWICE WEEKLY)...... 42 ZELAPAR...... 47 ZIRGAN...... 47 XPOVIO (80 MG ONCE WEEKLY)...... 42 ZELNORM...... 125 ZITHRANOL...... 86 XPOVIO (80 MG TWICE WEEKLY)...... 42 ZEMBRACE SYMTOUCH...... 39 ZITHROMAX ORAL PACKET...... 29 XRYLIX...... 15 ZEMPLAR INTRAVENOUS...... 157 ZITHROMAX ORAL SUSPENSION XTAMPZA ER...... 16 ZEMPLAR ORAL...... 157 RECONSTITUTED...... 29 XTANDI...... 41 zenatane oral capsule 10 mg, 20 mg...... 86 ZITHROMAX ORAL TABLET...... 29 xulane...... 147 zenatane oral capsule 30 mg...... 86 ZITHROMAX TRI-PAK...... 29 XULTOPHY...... 50 zenatane oral capsule 40 mg...... 86 ZITHROMAX Z-PAK...... 29 xurea...... 85 ZENPEP...... 136 zn-50...... 96 XURIDEN...... 136 ZE-PLUS...... 112 ZOCOR...... 61 XVITE...... 112 ZEPOSIA...... 63 ZOFRAN...... 33 XYOSTED...... 141 ZEPOSIA 7-DAY STARTER PACK...... 63 ZOHYDRO ER...... 16 XYREM...... 215 ZEPOSIA STARTER KIT...... 63 ZOLINZA...... 42 XYWAV...... 213 ZERUVIA...... 21 zolmitriptan oral...... 39

285 ZOLPAK...... 37 ZYRTEC ALLERGY CHILDRENS...... 188 ZOMACTON...... 140 ZYRTEC ALLERGY ORAL CAPSULE...... 188 ZOMACTON (FOR ZOMA-JET 10)...... 140 ZYRTEC ALLERGY ORAL TABLET...... 188 ZOMIG NASAL...... 39 ZYRTEC ALLERGY ORAL TABLET ZOMIG ORAL...... 39 DISPERSIBLE...... 188 ZOMIG ZMT...... 39 ZYRTEC-D ALLERGY & CONGESTION...213 ZONALON...... 86 ZYTIGA...... 41 ZONTIVITY...... 52 ZYVEXOL...... 172 zoo friends...... 112 ZYVIT...... 172 zoo friends complete...... 112 ZYVOX ORAL SUSPENSION zoo friends gummies...... 112 RECONSTITUTED...... 27 zoo friends plus extra c...... 112 ZYVOX ORAL TABLET...... 27 zoo friends plus iron...... 112 zoochews gummies...... 112 ZORBTIVE...... 125 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG...... 152 ZORTRESS ORAL TABLET 1 MG...... 152 ZORVOLEX...... 15 ZOSTRIX HP...... 86 ZOSTRIX-HP...... 10 zovia 1/35 (28)...... 147 zovia 1/35e (28)...... 147 ZOVIRAX EXTERNAL CREAM...... 48 ZOVIRAX EXTERNAL OINTMENT...... 48 ZOVIRAX ORAL...... 48 ZTLIDO...... 22 zumandimine...... 147 ZUPLENZ...... 33 ZYCLARA...... 86 ZYCLARA PUMP EXTERNAL CREAM 2.5 %...... 86 ZYCLARA PUMP EXTERNAL CREAM 3.75 %...... 86 ZYFLO...... 189 ZYLET...... 176 ZYLOPRIM...... 37 ZYMAXID...... 177 ZYPITAMAG...... 61

286