Pharmacy Program NH Healthy Families is committed to providing appropriate, high quality, and cost effective drug therapy to all NH Healthy Families members. NH Healthy Families works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NH Healthy Families covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Preferred Drug List The NH Healthy Families Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The NH Healthy Families PDL is continually evaluated by the NH Healthy Families Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost- effective use of medications. The Committee is composed of the NH Healthy Families Medical Director, NH Healthy Families Pharmacy Director, and several New Hampshire physicians, pharmacists, and other healthcare professionals.

Pharmacy Benefit Manager NH Healthy Families works with Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Some drugs on the NH Healthy Families PDL may require PA, and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager (PBM).

Specialty Drugs NH Healthy Families contracts with a number of specialty pharmacies, such as AcariaHealth Specialty Pharmacy, to ensure members have adequate access to the specialty drugs they require. Specialty drugs, such as biopharmaceuticals and injectables, may require PA to be approved for payment by NH Healthy Families. PA requirements are programmed specific to the drug.

Dispensing Limits Drugs may be dispensed up to a maximum of thirty-four (34) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for PDL drugs except for ophthalmic drugs.

Appropriate Use and Safety Edits The health and safety of the member are top priorities for NH Healthy Families. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Prior Authorizations Some medications listed on the NH Healthy Families PDL may require PA. The information should be submitted by the practitioner to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document can be found on the NH Healthy Families website. NH Healthy Families will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the NH Healthy Families P&T Committee. If the request is approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NH Healthy Families will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Quantity Limits NH Healthy Families may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If NH Healthy Families does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits Some medications on the NH Healthy Families PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Non-Preferred NH Healthy Families incorporates a Preferred Drug List. A notation of ‘Non-Preferred’ corresponds to drugs identified on the NH Healthy Families PDL indicating the trial and failure of preferred alternatives. The number of preferred drugs that must be tried prior to approval of non-preferred drugs varies by therapeutic . To request the approval of a non-preferred drug please submit rationale via prior authorization request form to Envolve Pharmacy Solutions (fax 1-866-399-0929).

Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions. For a MN request NH Healthy Families requires: - Documentation of failure of PDL agent(s) within the same therapeutic class (provided agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or - Documented intolerance or contraindication to PDL agent(s) within the same therapeutic class (provided agents exist in the therapeutic category with comparable labeled indications); or - Documented clinical history or presentation where the patient is not a candidate for PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the NH Healthy Families P&T Committee. If the request is approved, Envolve Pharmacy Solutions will notify the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, the member and their practitioner will be notified of alternatives and provide information regarding the appeal process.

72-Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense at least a 72-hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. A provision of a 72-hour supply does not guarantee that the medication will be approved after a PA review. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call Envolve Pharmacy Solutions at 1-866-862-8615 for a prescription override to submit the 72-hour medication supply for payment.

Newly Approved Products New Hampshire Healthy Families reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If NH Healthy Families does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications NH Healthy Families covers some OTC medications. These medications can be found throughout the NH Healthy Families PDL. NH Healthy Families covers OTC products listed on the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

CMS Labeler Requirements NH Healthy Families requires manufacturers to enter into the federal rebate agreement program as outlined in the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) in order to be eligible for coverage under the NH Healthy Families preferred drug list. Manufacturers and products which do not engage in this rebate program will be ineligible for coverage under the preferred drug list.

Drug Efficacy Study and Implementation (DESI) Drugs DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by NH Healthy Families.

Filling a Prescription A member can have prescriptions filled at a NH Healthy Families network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting NH Healthy Families Member Services. At the pharmacy, the member will need to provide the pharmacist with the prescription and their NH Healthy Families ID card.

Step Therapy Some medications listed on the NH Healthy Families’ PDL may require specific medications to be used before the member can receive the step therapy medication. If NH Healthy Families has a record that the required medication was tried first the step therapy medications are automatically covered. If NH Healthy Families does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, NH Healthy Families will notify the member and their practitioner and provide information regarding the appeal process.

Trial and Failure of 1 Preferred Product Required Prior to Non-Preferred Products Antibiotics - 3rd Generation Quinolones Anticonvulsants - Carbamazepine Derivatives Behavioral Health - Atypical & Combos Cardiovascular - Oral Pulmonary Hypertension Agents - Calcitonin Gene-Related Peptide Inhibitors, Multiple Sclerosis – Other Endocrinology - Biguanides & Combos, Dipeptidyl Peptidase-4 Inhibitors and Comboos, Insulins Endocrinology - Meglitinides, SGLT-2 Inhibitors and Combos, Thiazolidinediones & Combos Gastrointestinal - Hepatitis C Agents Genitourinary/Renal - Androgen Hormone Inhibitors, Electrolyte Depleters Immunologic - Systemic Immunomodulators Miscellaneous - Smoking Cessation, Topical Androgenic Agents Osteoporosis - Nasal Calcitonins Respiratory - Long/Short Acting Beta & Combos - Inhalers/Nebs Topical - Antiparasitics, Very High Steroids, Topical Combination Benzoyl Peroxide & Clindamycin Products

Trial and Failure of 2 Preferred Products Required Prior to Non-Preferred Products Analagesic - Non-Selective NSAIDs, Long Acting , & Tramadol Like Derivatives Antibiotics - 2nd/3rd Generation Cepahlosporins, 2nd Generation Quinolones, Herpetic Antivirals, Macrolides Anticonvulsants - 1st/2nd Generation Antifungals - Onychomycosis Antivirals - Treatment/Prophylaxis of Influenza Behavioral Health - Alzheimer's Agents, Antihyperkinesis, Reuptake Inhibitors & Combos Cardiovascular - Angiotensin Receptor Blockers & Combos, Calcium Channel Blockers & Combos, High Potenency Statins & Combos, Platelet Inhibitors, Triglyceride Lowering Agents Central Nervous System - Endocrinology - 2nd Generation Sulfonylureas & Combos, Alpha-Glucosidase Inhibitors, Growth Hormone Gastrointestinal - , Proton Pump Inhibitors & Combos, Ulcerative Colitis Genitourinary/Renal - Alpha Blockers for Benign Prostatic Hyperplasia Hematologic - Anticoagulants Miscellaneous - Pancreatic Enzymes Ophthalmic - Nonsteroidal Antiinflammatory, Quinolones, , Carbonic Anhydrase Inhibitors, Prostaglandin Osteoporosis - Bisphosphonates Otic/Antibiotic - Quinolones and Combos Respiratory - COPD Agents, Leukotriene Modifiers, Nasal Antihistamines, Nasal Corticosteroids Topical - High/Medium/Low Potency Steroids, Topical Agents for Psoriasis, Antibiotics, Antivirals, Retinoids

Trial and Failure of 3 Preferred Products Required Prior to Non-Preferred Products Behavioral Health - Cardiovascular - ACE Inhibitors & Combos, Beta Blockers & Combos, Calcium Channel Blockers & Combos Central Nervous System - Multiple Sclerosis - Disease Modifying Therapy Genitourinary/Renal - Urinary Antispasmodics Miscellaneous - Skeletal Muscle Relaxants Respiratory - Inhaled Corticosteroids and Combinations, Low-Sedating Antihistamines & Combos

Trial and Failure of 5 Preferred Products Required Prior to Non-Preferred Products Ophthalmic/Glaucoma - Agents

Trial and Failure of All Preferred Products Required Prior to Non-Preferred Products Ophthalmic/Glaucoma - Alpha-2 Adrenergic Agents

Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column.

DS/DU: Day Supply per Dosage Unit Max Days Sply: Maximum Day Supply Max Fills: Maximum Fills (per a designated time period) Max Qty: Maximum Quantity (per claim or designated time period) Min DS: Minimum Day Supply PA: Prior Authorization Pkg Size: Package Size SP Specialty Drug PV Preventative QL Quantity Limit ST Step Therapy AL Age Limit RX/OTC Over-the-Counter Medication (prescription required)

Tier Definitions

0 $0 Copay 1 Preferred Generic 2 Preferred Brand CO Carve-Out Drug - Covered by State NP Non- Preferred

Contact Information NH Healthy Families: 1-866-769-3085, www.nhhealthyfamilies.com Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- QL(1 ea daily); dextroamphetamine sulfate 1 AL(At least 6 OBESITY/ANOREXIANTS - Drugs to Treat cp24 5 mg ADHD, Sleep and Eating Disorders yrs old) dextroamphetamine sulfate PA; 1 soln 5 mg/5ml ADDERALL TABS (Use QL(90 ea per - 2 90 days retail) dextroamphetamine sulfate 1 AL(At least 3 dextroamphetamine) tabs 10 mg, 5 mg yrs old) ADDERALL XR CP24 (Use QL(1 ea daily); EVEKEO TABS (Use NP PA; amphetamine- 2 AL(At least 6 amphetamine sulfate) dextroamphetamine) yrs old) methamphetamine hcl tabs 1 PA; amphetamine suer 1 VYVANSE CAPS 10 MG, PA; QL(1 ea PA; 20 MG, 30 MG, 40 MG, 50 2 daily) amphetamine sulfate tabs 1 MG, 60 MG, 70 MG amphetamine- QL(1 ea daily); VYVANSE CHEW 10 MG, PA; dextroamphetamine cp24 AL(At least 6 20 MG, 30 MG, 40 MG, 50 2 1.25 mg-1.25 mg-1.25 mg- yrs old) MG, 60 MG 1.25 mg, 2.5 mg-2.5 mg- Analeptics 2.5 mg-2.5 mg, 3.75 mg- 1 caffeine citrate soln or 20 1 QL(45 ml per 3.75 mg-3.75 mg-3.75 mg, mg/ml, 60 mg/3ml fill retail) 5 mg-5 mg-5 mg-5 mg, 6.25 mg-6.25 mg-6.25 mg- Attention-Deficit/Hyperactivity Disorder (ADHD) 6.25 mg, 7.5 mg-7.5 mg- AL(At least 6 atomoxetine hcl caps 1 7.5 mg-7.5 mg yrs old) amphetamine- QL(90 ea per dextroamphetamine tabs 90 days retail) hcl (adhd) tb12 1 1.25 mg-1.25 mg-1.25 mg- QL(1 ea daily); 1.25 mg, 1.875 mg-1.875 hcl (adhd) tb24 1 AL(At least 6 mg-1.875 mg-1.875 mg, yrs old) 2.5 mg-2.5 mg-2.5 mg-2.5 1 mg, 3.125 mg-3.125 mg- QL(1 ea daily); INTUNIV TB24 (Use NP 3.125 mg-3.125 mg, 3.75 guanfacine hcl (adhd)) AL(At least 6 mg-3.75 mg-3.75 mg-3.75 yrs old) mg, 5 mg-5 mg-5 mg-5 mg, KAPVAY TB12 (Use NP 7.5 mg-7.5 mg-7.5 mg-7.5 clonidine hcl (adhd)) mg, STRATTERA CAPS (Use NP AL(At least 6 atomoxetine hcl) yrs old) DESOXYN TABS (Use NP PA; methamphetamine hcl) Stimulants - Misc. DEXEDRINE CP24 10 MG, QL(2 ea daily); APTENSIO XR CP24 (Use 2 PA; 15 MG (Use NP AL(At least 6 methylphenidate hcl) dextroamphetamine yrs old) sulfate) CONCERTA TBCR (Use 2 AL(At least 6 methylphenidate hcl) yrs old) DEXEDRINE CP24 5 MG QL(1 ea daily); (Use dextroamphetamine NP AL(At least 6 dexmethylphenidate hcl PA; sulfate) yrs old) cp24 35 mg, 10 mg, 15 mg, 1 20 mg, 25 mg, 30 mg, 40 QL(2 ea daily); mg, 5 mg dextroamphetamine sulfate 1 AL(At least 6 cp24 10 mg, 15 mg yrs old)

New Hampshire Healthy Families Updated October 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); ginger (zingiber officinalis) 1 QL(4 ea daily) dexmethylphenidate hcl 1 AL(At least 6 tabs 2.5 mg, 10 mg, 5 mg caps 250 mg yrs old) Alternative - M's QL(2 ea daily); FOCALIN TABS (Use 2 tabs or 3 mg, 5 1 QL(1 ea daily) dexmethylphenidate hcl) AL(At least 6 mg yrs old) AMINOGLYCOSIDES - Drugs to Treat Bacterial FOCALIN XR CP24 (Use 2 PA; dexmethylphenidate hcl) Infections METHYLIN SOLN (Use 2 PA; Aminoglycosides methylphenidate hcl) BETHKIS NEBU (Use 2 PA; SP tobramycin) methylphenidate hcl chew 1 PA; or 10 mg, 2.5 mg, 5 mg KITABIS PAK NEBU (Use 2 PA; SP methylphenidate hcl cp24 PA; tobramycin) or 10 mg, 15 mg, 20 mg, 1 30 mg, 40 mg, 50 mg, 60 neomycin sulfate tabs or 1 mg tobramycin nebu in 300 1 PA; SP methylphenidate hcl cpcr or AL(At least 6 mg/4ml, 300 mg/5ml 40 mg, 60 mg, 10 mg, 20 1 yrs old) tobramycin sulfate soln ij PA mg, 30 mg, 50 mg 1.2 gm/30ml, 10 mg/ml, 40 1 methylphenidate hcl soln or 1 PA; mg/ml, 80 mg/2ml 10 mg/5ml, 5 mg/5ml tobramycin sulfate solr ij 1 PA methylphenidate hcl tabs or 1 AL(At least 3 1.2 gm 10 mg, 20 mg, 5 mg yrs old) - ANTI-INFLAMMATORY - Drugs methylphenidate hcl tb24 to Treat Pain, Swelling, Muscle and Joint or 18 mg, 27 mg, 36 mg, 1 Conditions 54 mg methylphenidate hcl tbcr or AL(At least 6 Anti-TNF-alpha - Monoclonal Antibodies 10 mg, 20 mg, 36 mg, 54 1 yrs old) HUMIRA PEDIATRIC PA; SP mg, 18 mg, 27 mg CROHNS DISEASE 2 STARTER PACK PSKT RITALIN LA CP24 (Use NP PA; methylphenidate hcl) HUMIRA PEN PNKT 2 PA; SP RITALIN TABS (Use NP AL(At least 3 methylphenidate hcl) yrs old) HUMIRA PEN-CD/UC/HS 2 PA; SP STARTER PNKT ALLERGENIC EXTRACTS/BIOLOGICALS MISC HUMIRA PEN-PEDIATRIC PA; SP UC STARTER PACK 2 Allergenic Extracts PNKT ORALAIR ADULT SAMPLE PA; SP 2 HUMIRA PEN-PS/UV 2 PA; SP KIT SUBL STARTER PNKT ORALAIR ADULT 2 PA; SP HUMIRA PSKT 10 PA; SP STARTER PACK SUBL MG/0.1ML, 20 MG/0.2ML, 2 ORALAIR SUBL 2 PA; SP 40 MG/0.4ML, 40 MG/0.8ML ALTERNATIVE Antirheumatic Antimetabolites METHOTREXATE TABS 2 Alternative Medicine - G's OR

New Hampshire Healthy Families Updated October 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OTREXUP SOAJ 2 PA; SP indomethacin caps or 25 1 mg, 50 mg PA; SP RASUVO SOAJ 2 indomethacin cpcr or 75 1 mg Nonsteroidal Anti-inflammatory Agents (NSAIDs) INFANTS ADVIL SUSP 0 (Use ibuprofen) ADVIL TABS (Use 0 ibuprofen) ketoprofen caps or 50 mg, 1 75 mg ALEVE ARTHRITIS TABS NP QL(2 ea daily) (Use naproxen sodium) ketoprofen cp24 or 200 mg 1 ALEVE TABS (Use NP QL(2 ea daily) naproxen sodium) QL(20 ea per ketorolac tromethamine fill retail); AL(At CELEBREX CAPS (Use NP PA; QL(2 ea 1 celecoxib) daily) tabs or 10 mg least 17 yrs old) celecoxib caps or 100 mg, 1 PA; QL(2 ea 200 mg, 400 mg, 50 mg daily) LODINE TABS (Use NP etodolac) CHILDRENS ADVIL SUSP 0 RX/OTC (Use ibuprofen) meloxicam tabs or 15 mg, 1 7.5 mg CHILDRENS MOTRIN 0 RX/OTC SUSP (Use ibuprofen) MOBIC TABS (Use NP meloxicam) DAYPRO TABS (Use NP oxaprozin) MOTRIN CHILDRENS 0 CHEW (Use ibuprofen) diclofenac potassium tabs 1 MOTRIN INFANTS DROPS SUSP (Use 0 diclofenac sodium tb24 or 1 100 mg ibuprofen) nabumetone tabs or 500 diclofenac sodium tbec or 1 1 25 mg, 50 mg, 75 mg mg, 750 mg NAPROSYN SUSP (Use EC-NAPROSYN TBEC NP QL(2 ea daily) NP (Use naproxen) naproxen) NAPROSYN TABS (Use NP etodolac caps 1 naproxen) naproxen sodium tabs or 1 QL(2 ea daily) etodolac tabs 1 220 mg etodolac tb24 1 naproxen sodium tabs or 1 550 mg, 275 mg FELDENE CAPS (Use NP naproxen susp or 125 1 piroxicam) mg/5ml flurbiprofen tabs or 100 mg, 1 naproxen tabs or 250 mg, 1 50 mg 375 mg, 500 mg ibuprofen chew or 100 mg 0 naproxen tbec or 375 mg, 1 QL(2 ea daily) 500 mg ibuprofen susp or 100 RX/OTC 0 naproxen-esomeprazole 1 mg/5ml magnesium tbec ibuprofen susp or 40 0 mg/ml, 50 mg/1.25ml oxaprozin tabs 1 ibuprofen tabs or 400 mg, 0 600 mg, 800 mg, 200 mg New Hampshire Healthy Families Updated October 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits piroxicam caps or 10 mg, 1 FIORINAL CAPS (Use NP QL(4 ea daily) 20 mg butalbital-aspirin-caffeine) sulindac tabs or 150 mg, 1 Analgesics Other 200 mg acetaminophen chew or 80 0 tolmetin sodium caps 1 mg, 160 mg acetaminophen elix or 160 0 tolmetin sodium tabs 1 mg/5ml, 80 mg/2.5ml VIMOVO TBEC (Use acetaminophen liqd or 160 0 naproxen-esomeprazole NP mg/5ml magnesium) acetaminophen soln or 100 0 QL(30 ml per mg/ml fill retail) Pyrimidine Synthesis Inhibitors acetaminophen soln or 160 ARAVA TABS (Use NP QL(1 ea daily) mg/5ml, 325 mg/10.15ml, 0 leflunomide) 650 mg/20.3ml leflunomide tabs or 10 mg, QL(1 ea daily) 1 acetaminophen supp re 0 QL(12 ea per 20 mg 650 mg, 120 mg fill retail) Soluble Tumor Necrosis Factor Receptor Agents acetaminophen susp or PA; SP 160 mg/5ml, 650 1 ENBREL MINI SOCT 2 mg/20.3ml, 80 mg/2.5ml PA; SP ENBREL SOLN 2 acetaminophen tabs or 325 1 mg, 500 mg PA; SP ENBREL SOLR 2 FEVERALL JUNIOR 0 QL(12 ea per STRENGTH SUPP fill retail) ENBREL SOSY 2 PA; SP NORTEMP INFANTS 0 SUSP ENBREL SURECLICK 2 PA; SP SOAJ TYLENOL CHILDRENS CHEWABLES/PAIN + 0 ANALGESICS - NonNarcotic - Drugs to Treat FEVER CHEW (Use Pain, Muscle and Joint Conditions acetaminophen) Combinations TYLENOL CHILDRENS SUSP (Use NP butalbital-acetaminophen 1 tabs 50 mg-325 mg acetaminophen) butalbital-acetaminophen- QL(4 ea daily) TYLENOL EXTRA caffeine caps 40 mg-50 1 STRENGTH TABS (Use NP mg-325 mg acetaminophen) butalbital-acetaminophen- QL(4 ea daily) TYLENOL FOR caffeine tabs 40 mg-50 mg- 1 CHILDREN/ADULTS NP 325 mg SUSP (Use acetaminophen) butalbital-aspirin-caffeine 1 QL(4 ea daily) caps TYLENOL INFANTS PAIN+FEVER SUSP (Use NP BUTALBITAL/ASPIRIN/CA 2 QL(4 ea daily) acetaminophen) FFEINE TABS TYLENOL INFANTS SUSP NP ESGIC TABS (Use QL(4 ea daily) (Use acetaminophen) butalbital-acetaminophen- NP caffeine) TYLENOL TABS (Use NP acetaminophen)

New Hampshire Healthy Families Updated October 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Analgesics-Peptide Channel Blockers fentanyl pt72 td 100 10 per mcg/hr, 12 mcg/hr, 25 month;QL(0.34 PA; SP 1 PRIALT SOLN 2 mcg/hr, 50 mcg/hr, 75 ea daily) mcg/hr Salicylates fentanyl pt72 td 37.5 PA aspirin buffered (cal carb- 1 mcg/hr, 62.5 mcg/hr, 87.5 1 mag carb-mag oxide) tabs mcg/hr aspirin chew or 81 mg 0 hydrocodone bitartrate cp12 or 10 mg, 15 mg, 30 1 ASPIRIN SUPP RE 300 0 QL(12 ea per mg, 40 mg, 50 mg MG, 600 MG fill retail) HYDROCODONE 2 aspirin tabs or 325 mg 0 BITARTRATE ER CP12 HYDROMORPHONE HCL 2 QL(12 ea per aspirin tbec or 325 mg, 81 0 SUPP RE 3 MG fill retail) mg hydromorphone hcl tabs or 1 QL(8 ea daily) BUFFERIN TABS (Use 2 mg, 4 mg, 8 mg aspirin buffered (cal carb- NP mag carb-mag oxide)) hydromorphone hcl tb24 or 1 PA 32 mg, 12 mg, 16 mg, 8 mg diflunisal tabs 1 KADIAN CP24 (Use NP PA sulfate) ECOTRIN MAXIMUM 0 STRENGTH TBEC meperidine hcl soln or 50 1 QL(500 ml per mg/5ml fill retail) ECOTRIN REGULAR STRENGTH TBEC (Use 0 meperidine hcl tabs or 50 1 QL(6 ea daily) aspirin) mg methadone hcl tabs or 10 PA; QL(10 ea ECOTRIN TBEC (Use 0 1 aspirin) mg daily) methadone hcl tabs or 5 PA; QL(4 ea salsalate tabs or 500 mg, 1 1 750 mg mg daily) ANALGESICS - - Drugs to Treat Pain, morphine sulfate beads 1 PA cp24 Muscle and Joint Conditions morphine sulfate cp24 or PA Opioid Agonists 10 mg, 100 mg, 20 mg, 30 1 CODEINE SULFATE TABS 2 QL(2 ea daily) mg, 40 mg, 50 mg, 60 mg, 15 MG, 60 MG 80 mg codeine sulfate tabs 30 mg 1 QL(2 ea daily) morphine sulfate soln or 10 1 QL(16.67 ml mg/5ml, 20 mg/5ml daily) DILAUDID TABS OR 2 QL(8 ea daily) morphine sulfate soln or 1 QL(240 ml per MG, 4 MG, 8 MG (Use NP 100 mg/5ml, 20 mg/ml fill retail) hydromorphone hcl) morphine sulfate supp re 1 QL(24 ea per 10 per 10 mg, 20 mg, 30 mg, 5 mg fill retail) DURAGESIC PT72 (Use NP month;QL(0.34 fentanyl) morphine sulfate tabs or 15 1 QL(6 ea daily) ea daily) mg, 30 mg EMBEDA CPCR 2 PA morphine sulfate tbcr or QL(3 ea daily) 100 mg, 15 mg, 200 mg, 30 1 mg, 60 mg MS CONTIN TBCR (Use NP QL(3 ea daily) morphine sulfate) New Hampshire Healthy Families Updated October 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXAYDO TABS 5 MG 2 QL(6 ea daily) FIORINAL/CODEINE #3 QL(4 ea daily) CAPS (Use butalbital- NP aspirin-caffeine w/cod) oxycodone hcl caps or 5 1 QL(6 ea daily) mg hydrocodone- QL(180 ml acetaminophen soln 2.5 daily) oxycodone hcl conc or 100 1 QL(6 ml daily) mg/5ml mg/5ml-108 mg/5ml, 5 1 mg/10ml-217 mg/10ml, 7.5 oxycodone hcl soln or 5 1 mg/5ml mg/15ml-325 mg/15ml oxycodone hcl t12a or 15 PA; QL(2 ea hydrocodone- QL(6 ea daily) mg, 30 mg, 60 mg, 80 mg, 1 daily) acetaminophen tabs 10 1 10 mg, 20 mg, 40 mg mg-325 mg oxycodone hcl tabs or 10 QL(6 ea daily) hydrocodone- QL(12 ea daily) mg, 20 mg, 15 mg, 30 mg, 1 acetaminophen tabs 5 mg- 1 5 mg 325 mg oxymorphone hcl tb12 10 hydrocodone- QL(8 ea daily) mg, 20 mg, 30 mg, 40 mg, 1 acetaminophen tabs 7.5 1 5 mg, 7.5 mg mg-325 mg NORCO TABS 10 MG-325 QL(6 ea daily) oxymorphone hcl tb12 15 1 PA mg MG (Use hydrocodone- NP acetaminophen) ROXICODONE TABS (Use NP QL(6 ea daily) oxycodone hcl) NORCO TABS 5 MG-325 QL(12 ea daily) MG (Use hydrocodone- NP tramadol hcl cp24 or 100 PA acetaminophen) mg, 200 mg, 300 mg, 150 1 mg NORCO TABS 7.5 MG-325 QL(8 ea daily) MG (Use hydrocodone- NP tramadol hcl tabs or 100 1 acetaminophen) mg oxycodone w/ QL(6 ea daily) QL(8 ea daily) tramadol hcl tabs or 50 mg 1 acetaminophen tabs 10 1 mg-325 mg, 5 mg-325 mg, tramadol hcl tb24 or 100 1 PA 7.5 mg-325 mg mg, 200 mg, 300 mg oxycodone-aspirin tabs 1 QL(6 ea daily) ULTRAM TABS (Use NP QL(8 ea daily) tramadol hcl) PERCOCET TABS 10 MG- QL(6 ea daily) ZOHYDRO ER CP12 NP 325 MG, 5 MG-325 MG, 7.5 MG-325 MG (Use NP Opioid Combinations oxycodone w/ acetaminophen w/ codeine QL(30 ml daily) acetaminophen) soln 12 mg/5ml-120 1 tramadol-acetaminophen 1 QL(4 ea daily) mg/5ml tabs acetaminophen w/ codeine QL(6 ea daily) TYLENOL/CODEINE #3 QL(6 ea daily) tabs 15 mg-300 mg, 60 1 TABS (Use acetaminophen NP mg-300 mg, 30 mg-300 mg w/ codeine) butalbital-acetaminophen- QL(4 ea daily) TYLENOL/CODEINE #4 QL(6 ea daily) TABS (Use acetaminophen NP caffeine w/ codeine caps 1 30 mg-40 mg-50 mg-325 w/ codeine) mg ULTRACET TABS (Use NP QL(4 ea daily) tramadol-acetaminophen) butalbital-aspirin-caffeine 1 QL(4 ea daily) w/cod caps Opioid Partial Agonists New Hampshire Healthy Families Updated October 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits buprenorphine hcl subl sl 2 1 PA PA; Generic mg, 8 mg SUBOXONE FILM 2 MG-8 Alternative MG (Use buprenorphine 2 buprenorphine hcl- QL(8 ea daily) hcl-naloxone hcl dihydrate) Preferred;QL(2 naloxone hcl dihydrate film 1 ea daily) 0.5 mg-2 mg PA; Generic SUBOXONE FILM 3 MG- Alternative buprenorphine hcl- QL(4 ea daily) 12 MG (Use buprenorphine 2 naloxone hcl dihydrate film 1 hcl-naloxone hcl dihydrate) Preferred;QL(1. 1 mg-4 mg 33 ea daily) buprenorphine hcl- QL(2 ea daily) ANDROGENS-ANABOLIC - Drugs to Regulate naloxone hcl dihydrate film 1 Hormones 2 mg-8 mg Androgens buprenorphine hcl- QL(1.33 ea ANDROGEL GEL 20.25 PA naloxone hcl dihydrate film 1 daily) MG/1.25GM, 40.5 NP 3 mg-12 mg MG/2.5GM (Use buprenorphine hcl- QL(8 ea daily) testosterone) naloxone hcl dihydrate subl 1 ANDROGEL GEL 25 0.5 mg-2 mg MG/2.5GM, 50 MG/5GM NP buprenorphine hcl- QL(2 ea daily) (Use testosterone) naloxone hcl dihydrate subl 1 ANDROGEL PUMP GEL NP PA 2 mg-8 mg (Use testosterone) buprenorphine ptwk td 10 PA PA; SP mcg/hr, 15 mcg/hr, 20 1 AVEED SOLN 2 mcg/hr, 5 mcg/hr DEPO-TESTOSTERONE QL(4 ml per 30 buprenorphine ptwk td 7.5 1 SOLN 200 MG/ML (Use NP days retail) mcg/hr testosterone cypionate) BUTRANS PTWK 10 PA FORTESTA GEL (Use NP PA MCG/HR, 15 MCG/HR, 20 NP testosterone) MCG/HR, 5 MCG/HR (Use buprenorphine) METHITEST TABS 2 BUTRANS PTWK 7.5 TESTIM GEL (Use NP MCG/HR (Use NP testosterone) buprenorphine) TESTOPEL PLLT 2 PA; SP PROBUPHINE IMPLANT 2 PA KIT IMPL testosterone cypionate soln 1 QL(4 ml per 30 PA; 1 rtl MAX im 200 mg/ml days retail) SUBLOCADE SOSY 2 fill,30 rtl day(s) testosterone gel td 10 PA supply, mg/act, 20.25 mg/1.25gm, 1 PA; Generic SUBOXONE FILM 0.5 MG- 40.5 mg/2.5gm, 1.62 % Alternative 2 MG (Use buprenorphine 2 testosterone gel td 25 1 hcl-naloxone hcl dihydrate) Preferred;QL(8 mg/2.5gm, 1 %, 50 mg/5gm ea daily) testosterone soln td 30 PA PA; Generic 1 SUBOXONE FILM 1 MG-4 mg/act Alternative MG (Use buprenorphine 2 VOGELXO GEL (Use hcl-naloxone hcl dihydrate) Preferred;QL(4 NP ea daily) testosterone) VOGELXO PUMP GEL NP (Use testosterone)

New Hampshire Healthy Families Updated October 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANORECTAL AND RELATED PRODUCTS - Antacids - Aluminum Salts Rectal Drugs to Treat Pain, Swelling and Itching ALUMINUM HYDROXIDE 2 Intrarectal Steroids SUSP OR CORTENEMA ENEM (Use NP QL(420 ml per Antacids - Bicarbonate hydrocortisone (intrarectal)) fill retail) sodium bicarbonate 1 QL(16.53 ea (antacid) tabs daily) hydrocortisone (intrarectal) 1 QL(420 ml per enem fill retail) Antacids - Calcium Salts Rectal Combinations calcium carbonate (antacid) 1 chew 500 mg -shark 1 QL(48 ea per oil-cocoa butter supp fill retail) TUMS CHEW (Use calcium NP phenylephrine-shark liver QL(12 gm per carbonate (antacid)) oil-mineral oil-petrolatum 1 fill retail) TUMS LASTING EFFECTS oint CHEW (Use calcium NP Rectal Local Anesthetics carbonate (antacid)) QL(15 gm per pramoxine hcl (rectal) foam 1 Antacids - Magnesium Salts fill retail) magnesium oxide tabs 400 1 PROCTOFOAM FOAM QL(15 gm per mg (Use pramoxine hcl NP fill retail) (rectal)) ANTHELMINTICS - Drugs to Treat Worm Infections Rectal Steroids Anthelmintics Use QL(30 gm per ANUSOL-HC CREA ( 2 PA; SP hydrocortisone (rectal)) fill retail) BENZNIDAZOLE TABS 2 hydrocortisone (rectal) crea 1 EMVERM CHEW 2 QL(1 ea per 14 1 % days retail) hydrocortisone (rectal) crea QL(30 gm per QL(60 ml per 1 pyrantel pamoate susp or 1 2.5 % fill retail) fill retail) PROCTOCORT CREA EX 1 % (Use hydrocortisone 2 ANTI-INFECTIVE AGENTS - MISC. - Drugs to (rectal)) Treat Bacterial Infections Anti-infective Agents - Misc. ANTACIDS FLAGYL TABS 500 MG NP Antacid Combinations (Use metronidazole) alum & mag hydrox- QL(16.53 ml metronidazole tabs or 250 1 mg, 500 mg simethicone liqd 20 1 daily) mg/5ml-200 mg/5ml-200 trimethoprim tabs or 1 mg/5ml alum & mag hydrox- QL(16.53 ml Anti-infective Misc. - Combinations simethicone susp 0.2 %-40 daily) BACTRIM DS TABS (Use mg/10ml-400 mg/10ml-400 sulfamethoxazole- NP mg/10ml, 120 mg/30ml- trimethoprim) 1200 mg/30ml-1200 1 mg/30ml, 20 mg/5ml-20 BACTRIM TABS (Use mg/5ml-200 mg/5ml-200 sulfamethoxazole- NP mg/5ml-200 mg/5ml-200 trimethoprim) mg/5ml

New Hampshire Healthy Families Updated October 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methenamine-hyosc- clindamycin palmitate 1 QL(100 ml per methylene blue-sod phos- hydrochloride solr fill retail) phenyl sal tabs 0.12 mg- 1 10.8 mg-36.2 mg-40.8 mg- Monobactams 81.6 mg CAYSTON SOLR NP PA; SP sulfamethoxazole- trimethoprim susp or 40 1 Oxazolidinones mg/5ml-200 mg/5ml PA; QL(6 ea SIVEXTRO TABS OR 2 sulfamethoxazole- per fill retail) trimethoprim tabs or 80 1 Urinary Anti-infectives mg-400 mg, 160 mg-800 mg FURADANTIN SUSP (Use NP QL(40 ml daily) nitrofurantoin) Carbapenems MACROBID CAPS (Use ertapenem sodium solr 1 PA; SP nitrofurantoin monohyd NP macro) INVANZ SOLR (Use NP PA; SP MACRODANTIN CAPS 50 ertapenem sodium) MG, 100 MG (Use NP Glycopeptides nitrofurantoin macrocrystal) methenamine mandelate FIRVANQ SOLR 25 2 QL(300 ml per MG/ML fill retail) tabs or 1 gm, 0.5 gm, 500 1 mg VANCOCIN CAPS (Use NP QL(8 ea daily) vancomycin hcl) nitrofurantoin macrocrystal 1 caps or 50 mg, 100 mg VANCOCIN HCL CAPS NP QL(4 ea daily) (Use vancomycin hcl) nitrofurantoin monohyd 1 macro caps vancomycin hcl caps or 1 QL(4 ea daily) 125 mg nitrofurantoin susp or 1 QL(40 ml daily) vancomycin hcl caps or 1 QL(8 ea daily) 250 mg AGENTS - Drugs to Treat Chest Pain vancomycin hcl solr iv 1 1 QL(14 ea per gm, 1000 mg fill retail) -Other vancomycin hcl solr iv 500 QL(0.467 ea 1 RANEXA TB12 (Use NP mg daily) ) Leprostatics ranolazine tb12 1 dapsone tabs or 100 mg, 1 25 mg Nitrates Lincosamides ISORDIL TITRADOSE TABS 5 MG (Use NP CLEOCIN CAPS OR 150 isosorbide dinitrate) MG, 300 MG (Use NP clindamycin hcl) isosorbide dinitrate tabs 30 1 mg, 10 mg, 20 mg, 5 mg CLEOCIN PEDIATRIC QL(100 ml per isosorbide dinitrate tbcr 40 GRANULES SOLR (Use NP fill retail) 1 clindamycin palmitate mg hydrochloride) isosorbide mononitrate tabs 1 QL(2 ea daily) 10 mg, 20 mg clindamycin hcl caps or 1 150 mg, 300 mg isosorbide mononitrate 1 QL(1 ea daily) tb24 120 mg, 30 mg, 60 mg

New Hampshire Healthy Families Updated October 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITRO-BID OINT 2 ATIVAN TABS OR 1 MG NP QL(4 ea daily) (Use ) NITRO-DUR PT24 0.1 hcl caps 1 QL(4 ea daily) MG/HR, 0.2 MG/HR, 0.4 NP MG/HR, 0.6 MG/HR (Use dipotassium 1 QL(3 ea daily) nitroglycerin) tabs nitroglycerin cpcr or 6.5 1 mg, 9 mg, 2.5 mg conc or 5 mg/ml 1 nitroglycerin pt24 td 0.1 DIAZEPAM SOAJ IM 10 2 mg/hr, 0.2 mg/hr, 0.4 1 MG/2ML mg/hr, 0.6 mg/hr DIAZEPAM SOLN IJ 5 2 nitroglycerin subl sl 0.3 mg, 1 MG/ML 0.4 mg, 0.6 mg diazepam soln ij 5 mg/ml, 1 NITROSTAT SUBL (Use NP 50 mg/10ml nitroglycerin) QL(500 ml per diazepam soln or 5 mg/5ml 1 ANTIANXIETY AGENTS - Drugs to Treat fill retail) diazepam tabs or 10 mg, 2 1 QL(4 ea daily) Antianxiety Agents - Misc. mg, 5 mg hcl tabs or 10 lorazepam conc or 2 mg/ml 1 mg, 30 mg, 5 mg, 7.5 mg, 1 15 mg lorazepam tabs or 0.5 mg, 1 QL(3 ea daily) 2 mg soln ij 1 lorazepam tabs or 1 mg 1 QL(4 ea daily) hydroxyzine hcl soln im 25 1 mg/ml, 50 mg/ml caps 1 QL(4 ea daily) hydroxyzine hcl syrp or 10 1 mg/5ml TRANXENE T TABS (Use NP QL(3 ea daily) clorazepate dipotassium) hydroxyzine hcl tabs or 10 1 mg, 25 mg, 50 mg VALIUM TABS (Use NP QL(4 ea daily) diazepam) hydroxyzine pamoate caps 1 or 100 mg, 25 mg, 50 mg XANAX TABS (Use NP QL(4 ea daily) ) tabs 1 XANAX XR TB24 (Use NP alprazolam) VISTARIL CAPS (Use NP hydroxyzine pamoate) ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms ALPRAZOLAM INTENSOL 2 Antiarrhythmics Type I-A CONC disopyramide phosphate 1 alprazolam tabs or 0.25 1 QL(4 ea daily) caps mg, 0.5 mg, 1 mg, 2 mg NORPACE CAPS (Use 2 alprazolam tb24 or 0.5 mg, 1 disopyramide phosphate) 1 mg, 2 mg, 3 mg gluconate tbcr 1 alprazolam tbdp or 0.25 1 mg, 0.5 mg, 1 mg, 2 mg quinidine sulfate tabs 1 ATIVAN TABS OR 0.5 MG, NP QL(3 ea daily) 2 MG (Use lorazepam) Antiarrhythmics Type I-B

New Hampshire Healthy Families Updated October 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mexiletine hcl caps 1 montelukast sodium pack 1 QL(1 ea daily) or 4 mg Antiarrhythmics Type I-C montelukast sodium tabs or 1 QL(1 ea daily) 10 mg flecainide acetate tabs 1 SINGULAIR CHEW (Use NP QL(1 ea daily) montelukast sodium) hcl tabs 150 1 mg, 225 mg, 300 mg SINGULAIR PACK (Use NP QL(1 ea daily) Antiarrhythmics Type III montelukast sodium) SINGULAIR TABS (Use QL(1 ea daily) amiodarone hcl tabs or 200 1 NP mg montelukast sodium) dofetilide caps 1 PA; SP zafirlukast tabs 1

TIKOSYN CAPS (Use NP PA; SP zileuton tb12 1 dofetilide) Steroid Inhalants ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions ASMANEX TWISTHALER 120 METERED DOSES 2 Anti-Inflammatory Agents AEPB cromolyn sodium nebu in 1 QL(8 ml daily) ASMANEX TWISTHALER 14 METERED DOSES 2 Antiasthmatic - Monoclonal Antibodies AEPB ASMANEX TWISTHALER CINQAIR SOLN 2 PA; SP 30 METERED DOSES 2 AEPB NUCALA SOAJ 2 PA; SP ASMANEX TWISTHALER NUCALA SOLR 2 PA; SP 60 METERED DOSES 2 AEPB NUCALA SOSY 2 PA; SP ASMANEX TWISTHALER 7 METERED DOSES 2 XOLAIR SOLR 2 PA; SP AEPB QL(4 ml daily); PA; SP XOLAIR SOSY 2 budesonide (inhalation) 1 AL(At least 1 susp yrs old - Up to Bronchodilators - 8 yrs old) QL(0.867 gm QL(2 ea daily) ATROVENT HFA AERS 2 FLOVENT DISKUS AEPB 2 daily) QL(15 ml daily) FLOVENT HFA AERO 110 2 QL(12 gm per ipratropium soln in 1 MCG/ACT, 220 MCG/ACT 30 days retail) FLOVENT HFA AERO 44 QL(11 gm per SPIRIVA HANDIHALER 2 2 CAPS MCG/ACT 30 days retail) Leukotriene Modulators PULMICORT FLEXHALER 2 QL(1 ea per 25 AEPB days retail) ACCOLATE TABS (Use NP zafirlukast) QL(4 ml daily); PULMICORT SUSP (Use NP AL(At least 1 montelukast sodium chew 1 QL(1 ea daily) budesonide (inhalation)) yrs old - Up to or 4 mg, 5 mg 8 yrs old) Sympathomimetics New Hampshire Healthy Families Updated October 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVAIR DISKUS AEPB QL(2 ea daily) levalbuterol hcl nebu in (Use fluticasone- 2 1.25 mg/0.5ml, 0.31 1 ) mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml ADVAIR HFA AERO 2 levalbuterol tartrate aero 1 Limit 2 inhalers albuterol sulfate aers in 0 per Limit 2 inhalers 108 mcg/act month;QL(0.45 PROAIR HFA AERS (Use 0 per gm daily) albuterol sulfate) month;QL(0.57 Limit 2 inhalers gm daily) albuterol sulfate aers in 0 per Limit 2 inhalers 108 mcg/act month;QL(1.2 PROVENTIL HFA AERS 0 per gm daily) (Use albuterol sulfate) month;QL(0.45 Limit 2 inhalers gm daily) albuterol sulfate aers in 0 per SEREVENT DISKUS 2 QL(2 ea daily) 108 mcg/act month;QL(0.57 AEPB gm daily) STIOLTO RESPIMAT 2 albuterol sulfate nebu in 1 QL(375 ml per AERS 0.083 % 25 days retail) SYMBICORT AERO (Use QL(11 gm per ALBUTEROL SULFATE 2 QL(2 ml daily) budesonide- 2 30 days retail) NEBU IN 0.5 % fumarate dihydrate) albuterol sulfate nebu in 1 QL(2 ml daily) sulfate tabs or 1 0.5 %, 2.5 mg/0.5ml 2.5 mg, 5 mg albuterol sulfate nebu in 1 QL(375 ml per Limit 2 inhalers 0.63 mg/3ml, 1.25 mg/3ml 30 days retail) VENTOLIN HFA AERS 0 per (Use albuterol sulfate) month;QL(0.54 albuterol sulfate syrp or 2 1 mg/5ml gm daily) Limit 2 inhalers albuterol sulfate tabs or 2 1 mg, 4 mg VENTOLIN HFA AERS 0 per (Use albuterol sulfate) month;QL(1.2 albuterol sulfate tb12 or 4 1 gm daily) mg, 8 mg XOPENEX BEVESPI AEROSPHERE 2 CONCENTRATE NEBU NP AERO (Use levalbuterol hcl) budesonide-formoterol QL(11 gm per 1 XOPENEX NEBU (Use NP fumarate dihydrate aero 30 days retail) levalbuterol hcl) COMBIVENT RESPIMAT 2 QL(4 gm per 30 AERS days retail) Xanthines DULERA AERO 5 QL(13 gm per ELIXOPHYLLIN ELIX 2 MCG/ACT-100 MCG/ACT, 2 30 days retail) 5 MCG/ACT-200 THEO-24 CP24 2 MCG/ACT theophylline soln 80 QL(475 ml per DULERA AERO 5 2 1 MCG/ACT-50 MCG/ACT mg/15ml fill retail) QL(2 ea daily) theophylline tb12 300 mg, 1 fluticasone-salmeterol aepb 1 450 mg QL(12 ml daily) theophylline tb24 400 mg, 1 ipratropium-albuterol soln 1 600 mg

New Hampshire Healthy Families Updated October 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOVENOX SOLN SC 100 QL(60 ml per ANTICOAGULANTS - Blood Thinners MG/ML, 150 MG/ML (Use NP 30 days retail) Coumarin Anticoagulants enoxaparin sodium) LOVENOX SOLN SC 120 QL(48 ml per COUMADIN TABS (Use NP warfarin sodium) MG/0.8ML, 80 MG/0.8ML NP 30 days retail) (Use enoxaparin sodium) warfarin sodium tabs 1 LOVENOX SOLN SC 30 QL(18 ml per MG/0.3ML (Use enoxaparin NP 30 days retail) Direct Factor Xa Inhibitors sodium) ELIQUIS STARTER PACK 2 QL(4 ea daily) LOVENOX SOLN SC 40 QL(24 ml per TBPK MG/0.4ML (Use enoxaparin NP 30 days retail) ELIQUIS TABS 2 QL(4 ea daily) sodium) LOVENOX SOLN SC 60 QL(36 ml per XARELTO STARTER 2 MG/0.6ML (Use enoxaparin NP 30 days retail) PACK TBPK sodium) QL(1 ea XARELTO TABS 10 MG 2 daily,35 ea per Thrombin Inhibitors 180 days retail) PRADAXA CAPS 2 XARELTO TABS 15 MG 2 QL(2 ea daily) ANTICONVULSANTS - Drugs to Treat Seizures XARELTO TABS 2.5 MG 2 Anticonvulsants - Benzodiazepines XARELTO TABS 20 MG 2 QL(1 ea daily) susp 1

Heparins And Heparinoid-Like Agents clobazam tabs 1 ARIXTRA SOLN (Use NP PA; SP fondaparinux sodium) tabs or 0.5 1 QL(4 ea daily) mg, 1 mg, 2 mg enoxaparin sodium soln ij 1 QL(180 ml per 300 mg/3ml 30 days retail) clonazepam tbdp or 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1 enoxaparin sodium soln sc 1 QL(60 ml per 2 mg 100 mg/ml, 150 mg/ml 30 days retail) QL(1 ea per fill enoxaparin sodium soln sc QL(48 ml per diazepam (anticonvulsant) 1 retail); AL(At 1 gel 120 mg/0.8ml, 80 mg/0.8ml 30 days retail) least 2 yrs old) enoxaparin sodium soln sc QL(18 ml per 1 KLONOPIN TABS (Use NP QL(4 ea daily) 30 mg/0.3ml 30 days retail) clonazepam) enoxaparin sodium soln sc QL(24 ml per 1 ONFI SUSP (Use NP 40 mg/0.4ml 30 days retail) clobazam) enoxaparin sodium soln sc QL(36 ml per 1 ONFI TABS (Use NP 60 mg/0.6ml 30 days retail) clobazam) fondaparinux sodium soln 1 PA; SP PA; QL(10 ea VALTOCO LIQD 2 per 30 days heparin sodium (porcine) 1 retail) soln PA; QL(10 ea LOVENOX SOLN IJ 300 QL(180 ml per VALTOCO LQPK 2 per 30 days MG/3ML (Use enoxaparin NP 30 days retail) retail) sodium) Anticonvulsants - Misc.

New Hampshire Healthy Families Updated October 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRIVIACT SOLN 2 PA; SP LAMICTAL STARTER/TAKING NP VALPROATE KIT (Use carbamazepine chew or 1 100 mg lamotrigine) LAMICTAL TABS (Use carbamazepine cp12 or 1 NP 100 mg, 200 mg, 300 mg lamotrigine) LAMICTAL XR TB24 (Use carbamazepine susp or 1 NP 100 mg/5ml lamotrigine) lamotrigine chew or 25 mg, carbamazepine tabs or 200 1 1 mg 5 mg carbamazepine tb12 or 100 1 lamotrigine kit or 25 mg, 1 mg, 200 mg, 400 mg lamotrigine tabs or 100 mg, CARBATROL CP12 (Use NP 1 carbamazepine) 150 mg, 200 mg, 25 mg QL(9 ea daily) lamotrigine tb24 or 100 mg, caps or 100 mg 1 200 mg, 250 mg, 300 mg, 1 25 mg, 50 mg gabapentin caps or 300 1 mg, 400 mg lamotrigine tbdp or 100 mg, 1 200 mg, 25 mg, 50 mg gabapentin soln or 250 1 mg/5ml, 300 mg/6ml levetiracetam soln or 100 1 QL(30 ml daily) mg/ml, 500 mg/5ml gabapentin tabs or 600 mg, 1 800 mg levetiracetam tabs or 250 mg, 1000 mg, 750 mg, 500 1 KEPPRA SOLN OR 100 NP QL(30 ml daily) MG/ML (Use levetiracetam) mg KEPPRA TABS OR 250 levetiracetam tb24 or 500 1 mg, 750 mg MG, 1000 MG, 750 MG, NP 500 MG (Use LYRICA CAPS (Use NP PA levetiracetam) ) LYRICA SOLN (Use PA KEPPRA XR TB24 (Use NP NP levetiracetam) pregabalin) LAMICTAL CHEWABLE MYSOLINE TABS (Use NP DISPERSIBLE CHEW (Use NP primidone) lamotrigine) NEURONTIN CAPS 100 NP QL(9 ea daily) MG (Use gabapentin) LAMICTAL ODT KIT (Use NP lamotrigine) NEURONTIN CAPS 300 MG, 400 MG (Use NP LAMICTAL ODT TBDP NP (Use lamotrigine) gabapentin) LAMICTAL STARTER/NOT NEURONTIN SOLN 250 NP MG/5ML (Use gabapentin) TAKING NP CARBAMAZEPINE KIT NEURONTIN TABS 600 (Use lamotrigine) MG, 800 MG (Use NP LAMICTAL gabapentin) STARTER/TAKING CARBAMAZEPINE/NOT NP oxcarbazepine susp 1 TAKING VALPROATE KIT (Use lamotrigine) oxcarbazepine tabs 1

New Hampshire Healthy Families Updated October 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pregabalin caps or 100 mg, PA FELBATOL TABS (Use NP 150 mg, 200 mg, 225 mg, 1 felbamate) 25 mg, 300 mg, 50 mg, 75 mg GABA Modulators PA GABITRIL TABS (Use 2 pregabalin soln or 20 1 hcl) mg/ml SABRIL PACK (Use NP PA; SP primidone tabs or 250 mg, 1 vigabatrin) 50 mg SABRIL TABS (Use NP PA; SP TEGRETOL SUSP (Use NP ) carbamazepine) vigabatrin tiagabine hcl tabs 1 TEGRETOL TABS (Use NP carbamazepine) vigabatrin pack 1 PA; SP TEGRETOL-XR TB12 (Use NP carbamazepine) vigabatrin tabs 1 PA; SP TOPAMAX SPRINKLE NP CPSP (Use topiramate) Hydantoins TOPAMAX TABS 100 MG, DILANTIN CAPS (Use 200 MG, 50 MG (Use NP phenytoin sodium NP topiramate) extended) TOPAMAX TABS 25 MG QL(6 ea daily) NP DILANTIN INFATABS 2 (Use topiramate) CHEW (Use phenytoin) topiramate cpsp or 15 mg, 1 DILANTIN-125 SUSP (Use NP 25 mg phenytoin) topiramate cs24 or 100 mg, PHENYTEK CAPS (Use 150 mg, 200 mg, 25 mg, 50 1 phenytoin sodium NP mg extended) topiramate tabs or 100 mg, 1 200 mg, 50 mg phenytoin chew or 50 mg 1 QL(6 ea daily) topiramate tabs or 25 mg 1 phenytoin sodium extended 1 caps TRILEPTAL SUSP (Use NP phenytoin susp or 100 1 oxcarbazepine) mg/4ml, 125 mg/5ml TRILEPTAL TABS (Use NP oxcarbazepine) Succinimides ZONEGRAN CAPS (Use NP CELONTIN CAPS 2 zonisamide) ethosuximide caps or 250 1 zonisamide caps or 100 1 mg mg, 25 mg, 50 mg ethosuximide soln or 250 1 mg/5ml felbamate susp 1 ZARONTIN CAPS (Use NP ethosuximide) felbamate tabs 1 ZARONTIN SOLN (Use NP ethosuximide) FELBATOL SUSP (Use NP felbamate) Valproic Acid

New Hampshire Healthy Families Updated October 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPAKENE CAPS (Use NP hcl tabs 1 valproic acid) WELLBUTRIN SR TB12 QL(4 ea daily) DEPAKOTE ER TB24 (Use NP divalproex sodium) 100 MG (Use NP DEPAKOTE SPRINKLES hcl) CSDR (Use divalproex 2 WELLBUTRIN SR TB12 QL(3 ea daily) sodium) 150 MG (Use bupropion NP hcl) DEPAKOTE TBEC (Use NP divalproex sodium) WELLBUTRIN SR TB12 QL(2 ea daily) 200 MG (Use bupropion NP divalproex sodium csdr 1 hcl) WELLBUTRIN XL TB24 QL(3 ea daily) divalproex sodium tb24 1 150 MG (Use bupropion NP hcl) divalproex sodium tbec 1 WELLBUTRIN XL TB24 QL(1 ea daily) 300 MG (Use bupropion NP valproate sodium soln or 1 250 mg/5ml hcl) valproic acid caps or 1 GABA - Neuroactive Steroid ZULRESSO SOLN 2 PA; SP - Drugs to Treat Depression Monoamine Oxidase Inhibitors (MAOIs) Alpha-2 Receptor Antagonists (Tetracyclics) NARDIL TABS (Use NP sulfate) tabs or 15 mg, 1 30 mg, 45 mg, 7.5 mg PARNATE TABS (Use NP tranylcypromine sulfate) mirtazapine tbdp or 15 mg, 1 30 mg, 45 mg phenelzine sulfate tabs or 1 REMERON SOLTAB TBDP NP (Use mirtazapine) tranylcypromine sulfate 1 tabs REMERON TABS (Use NP mirtazapine) Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants - Misc. CELEXA TABS (Use NP hydrobromide) bupropion hcl tabs or 100 1 mg, 75 mg citalopram hydrobromide 1 soln bupropion hcl tb12 or 100 1 QL(4 ea daily) mg citalopram hydrobromide 1 tabs bupropion hcl tb12 or 150 1 QL(3 ea daily) mg oxalate soln 1 bupropion hcl tb12 or 200 1 QL(2 ea daily) mg escitalopram oxalate tabs 1 bupropion hcl tb24 or 150 1 QL(3 ea daily) mg hcl caps or 10 1 mg, 40 mg, 20 mg bupropion hcl tb24 or 300 1 QL(1 ea daily) mg fluoxetine hcl cpdr or 90 mg 1 bupropion hcl tb24 or 450 1 fluoxetine hcl soln or 20 1 mg mg/5ml

New Hampshire Healthy Families Updated October 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 7 QL(4 ea daily) fluoxetine hcl tabs or 10 mg 1 desvenlafaxine succinate 1 yrs old) tb24 100 mg QL(4 ea daily); desvenlafaxine succinate 1 QL(1 ea daily) fluoxetine hcl tabs or 20 mg 1 AL(At least 7 tb24 25 mg, 50 mg yrs old) desvenlafaxine tb24 1 fluoxetine hcl tabs or 60 mg 1 QL(1 ea daily); hcl cpep or 20 1 AL(At least 7 FLUOXETINE mg, 40 mg, 60 mg, 30 mg HYDROCHLORIDE TABS 2 yrs old) (Use fluoxetine hcl) EFFEXOR XR CP24 150 NP QL(2 ea daily) maleate cp24 1 MG (Use hcl) EFFEXOR XR CP24 37.5 NP QL(4 ea daily) fluvoxamine maleate tabs 1 MG (Use venlafaxine hcl) EFFEXOR XR CP24 75 NP QL(5 ea daily) LEXAPRO TABS (Use NP MG (Use venlafaxine hcl) escitalopram oxalate) PRISTIQ TB24 100 MG QL(4 ea daily) hcl tabs 1 (Use desvenlafaxine NP succinate) paroxetine hcl tb24 1 PRISTIQ TB24 25 MG, 50 QL(1 ea daily) MG (Use desvenlafaxine NP PAXIL CR TB24 (Use NP succinate) paroxetine hcl) venlafaxine hcl cp24 150 1 QL(2 ea daily) PAXIL TABS (Use NP mg paroxetine hcl) venlafaxine hcl cp24 37.5 1 QL(4 ea daily) PROZAC CAPS (Use NP mg fluoxetine hcl) venlafaxine hcl cp24 75 mg 1 QL(5 ea daily) hcl conc or 20 1 mg/ml venlafaxine hcl tabs 100 sertraline hcl tabs or 100 1 mg, 25 mg, 37.5 mg, 50 1 mg, 25 mg, 50 mg mg, 75 mg ZOLOFT CONC (Use NP venlafaxine hcl tb24 150 QL(1 ea daily) sertraline hcl) mg, 225 mg, 75 mg, 37.5 1 ZOLOFT TABS (Use NP mg sertraline hcl) Agents Serotonin Modulators hcl tabs or 10 hcl tabs 1 mg, 50 mg, 100 mg, 150 1 mg, 25 mg, 75 mg hcl tabs or 300 mg, 100 mg, 150 mg, 50 1 tabs 1 mg ANAFRANIL CAPS (Use NP Serotonin- Reuptake Inhibitors hcl) QL(1 ea daily); clomipramine hcl caps or 1 CYMBALTA CPEP (Use NP 25 mg, 50 mg, 75 mg duloxetine hcl) AL(At least 7 yrs old) hcl tabs or 100 mg, 150 mg, 75 mg, 10 mg, 1 DESVENLAFAXINE ER 2 TB24 25 mg, 50 mg

New Hampshire Healthy Families Updated October 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl caps or 150 glipizide-metformin hcl tabs 1 mg, 25 mg, 100 mg, 75 mg, 1 10 mg, 50 mg glyburide-metformin tabs 1 doxepin hcl conc or 10 1 mg/ml GLYXAMBI TABS 2 hcl tabs or 10 1 mg, 25 mg, 50 mg JANUMET TABS 2 imipramine pamoate caps 1 JANUMET XR TB24 2 NORPRAMIN TABS (Use NP desipramine hcl) QL(2 ea daily); JENTADUETO TABS 2 AL(At least 18 hcl caps or 10 1 yrs old) mg, 50 mg, 25 mg, 75 mg KAZANO TABS (Use 2 QL(2 ea daily) nortriptyline hcl soln or 10 1 alogliptin-metformin hcl) mg/5ml KOMBIGLYZE XR TB24 2 PAMELOR CAPS (Use NP nortriptyline hcl) pioglitazone hcl-glimepiride 1 hcl tabs 1 tabs pioglitazone hcl-metformin 1 QL(2 ea daily) TOFRANIL TABS (Use NP hcl tabs imipramine hcl) repaglinide-metformin hcl 1 maleate caps 1 tabs or 100 mg, 25 mg, 50 mg Biguanides ANTIDIABETICS - Drugs to Regulate Blood FORTAMET TB24 (Use NP Sugar metformin hcl) Alpha-Glucosidase Inhibitors GLUMETZA TB24 (Use NP acarbose tabs 1 metformin hcl) metformin hcl soln or 500 1 GLYSET TABS (Use NP mg/5ml miglitol) metformin hcl tabs or 1000 1 miglitol tabs 1 mg, 500 mg, 850 mg metformin hcl tb24 or 1000 1 PRECOSE TABS (Use NP mg, 500 mg, 750 mg acarbose) RIOMET SOLN (Use NP Antidiabetic Combinations metformin hcl) ACTOPLUS MET TABS QL(2 ea daily) Diabetic Other (Use pioglitazone hcl- NP metformin hcl) BAQSIMI ONE PACK 2 QL(0.069 ea POWD daily) alogliptin-metformin hcl 1 QL(2 ea daily) tabs BAQSIMI TWO PACK 2 QL(0.069 ea POWD daily) QL(1 ea daily) alogliptin-pioglitazone tabs 1 QL(1.67 ea BD GLUCOSE CHEW 2 DUETACT TABS (Use daily) pioglitazone hcl- NP CVS GLUCOSE CHEW 4 2 QL(1.67 ea glimepiride) GM daily)

New Hampshire Healthy Families Updated October 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS SOFT GLUCOSE 2 QL(1.67 ea QL(2 ml per 30 CHEW daily) BYETTA SOPN 10 2 days retail); MCG/0.04ML AL(At least 18 DEX4 QUICK DISSOLVE 2 QL(1.67 ea GLUCOSE CHEW daily) yrs old) QL(1 ml per 30 diazoxide susp or 1 BYETTA SOPN 5 2 days retail); MCG/0.02ML AL(At least 18 GLUCAGEN HYPOKIT 2 SOLR yrs old) QL(1 ea per fill QL(0.3 ml glucagon (rdna) kit 1 VICTOZA SOPN 2 retail) daily) GLUCAGON QL(1 ea per fill Insulin Sensitizing Agents EMERGENCY KIT KIT NP retail) ACTOS TABS (Use NP QL(1 ea daily) (Use glucagon (rdna)) pioglitazone hcl) GLUCOSE CHEW 4 GM 2 QL(1.67 ea QL(1 ea daily) daily) pioglitazone hcl tabs 1 GNP GLUCOSE CHEW 4 2 QL(1.67 ea Insulin GM daily) HUMALOG JUNIOR 2 GNP QUICK DISSOLVE 2 QL(1.67 ea KWIKPEN SOPN GLUCOSE CHEW daily) HUMALOG KWIKPEN 2 KORLYM TABS 2 PA; SP SOPN HUMALOG MIX 50/50 2 QL(30 ml per LEADER QUICK QL(1.67 ea KWIKPEN SUPN 30 days retail) DISSOLVE GLUCOSE 2 daily) CHEW HUMALOG MIX 50/50 2 QL(40 ml per SUSP 30 days retail) PROGLYCEM SUSP (Use 2 diazoxide) HUMALOG MIX 75/25 2 QL(30 ml per KWIKPEN SUPN 30 days retail) SM GLUCOSE CHEW 4 2 QL(1.67 ea GM daily) HUMALOG MIX 75/25 2 QL(40 ml per SUSP 30 days retail) WALGREENS GLUCOSE 2 QL(1.67 ea CHEW 4 GM daily) HUMULIN 70/30 SUSP 2 QL(40 ml per 30 days retail) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors QL(40 ml per HUMULIN N SUSP 2 alogliptin benzoate tabs 1 QL(1 ea daily) 30 days retail) QL(40 ml per HUMULIN R SOLN 2 JANUVIA TABS 2 30 days retail) HUMULIN R U-500 2 ONGLYZA TABS 2 (CONCENTRATED) SOLN QL(1 ea daily); HUMULIN R U-500 2 TRADJENTA TABS 2 AL(At least 18 KWIKPEN SOPN yrs old) INSULIN ASPART QL(30 ml per PROTAMINE/INSULIN 2 30 days retail) Incretin Mimetic Agents (GLP-1 Receptor ASPART FLEXPEN SUPN QL(4 ea per 28 INSULIN ASPART QL(40 ml per days retail); BYDUREON PEN PEN 2 PROTAMINE/INSULIN 2 30 days retail) AL(At least 18 ASPART SUSP yrs old) INSULIN LISPRO JUNIOR 2 KWIKPEN SOPN

New Hampshire Healthy Families Updated October 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN LISPRO 2 glipizide tabs or 10 mg, 5 1 KWIKPEN SOPN mg INSULIN LISPRO QL(30 ml per glipizide tb24 or 10 mg, 2.5 1 PROTAMINE/INSULIN 2 30 days retail) mg, 5 mg LISPRO KWIKPEN SUPN GLUCOTROL TABS (Use NP INSULIN LISPRO SOLN 2 glipizide) GLUCOTROL XL TB24 NP LANTUS SOLOSTAR 2 (Use glipizide) SOPN glyburide micronized tabs 1 LEVEMIR FLEXTOUCH 2 SOPN glyburide tabs or 1.25 mg, 1 LEVEMIR SOLN 2 2.5 mg, 5 mg GLYNASE TABS (Use NP NOVOLOG MIX 70/30 QL(30 ml per glyburide micronized) PREFILLED FLEXPEN 2 30 days retail) RELION SUPN ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 2 30 days retail) Antidiarrheal/Probiotic Agents - Misc. SUPN ACIDOPHILUS HIGH- 2 RX/OTC POTENCY CAPS NOVOLOG MIX 70/30 2 QL(40 ml per RELION SUSP 30 days retail) ACIDOPHILUS PEARLS 2 RX/OTC CAPS NOVOLOG MIX 70/30 2 QL(40 ml per SUSP 30 days retail) ACIDOPHILUS 2 RX/OTC Meglitinide Analogues PROBIOTIC BLEND CAPS QL(3 ea daily) ACIDOPHILUS SUPER 2 RX/OTC nateglinide tabs 1 PROBIOTIC CAPS ACIDOPHILUS/GOAT RX/OTC repaglinide tabs 1 2 MILK CAPS STARLIX TABS (Use NP QL(3 ea daily) ACTIPHLORA CAPS 2 RX/OTC nateglinide) Sodium-Glucose Co-Transporter 2 (SGLT2) ADVANCED PROBIOTIC 2 RX/OTC 10 CAPS FARXIGA TABS 2 ADVANCED PROBIOTIC 2 RX/OTC CAPS INVOKANA TABS 2 ADVANCED PROBIOTIC- 2 RX/OTC 14 CAPS JARDIANCE TABS 2 QL(1 ea daily) ALIGN CAPS 2 RX/OTC Sulfonylureas ALIGN EXTRA RX/OTC AMARYL TABS 1 MG, 2 NP QL(4 ea daily) 2 MG (Use glimepiride) STRENGTH CAPS ALOE 10000 & RX/OTC AMARYL TABS 4 MG (Use NP QL(2 ea daily) 2 glimepiride) PROBIOTICS CAPS BACICAP CAPS 2 RX/OTC glimepiride tabs 1 mg, 2 1 QL(4 ea daily) mg BACID CAPS 2 RX/OTC glimepiride tabs 4 mg 1 QL(2 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BIO-KULT CAPS 2 RX/OTC CVS MOOD SUPPORT 2 RX/OTC PROBIOTIC CAPS BIOHM PROBIOTIC 2 RX/OTC RX/OTC SUPPLEMENT CAPS CVS PROBIOTIC CAPS 2 BIOHM PROBIOTIC RX/OTC CVS PROBIOTIC RX/OTC SUPPLEMENT/VITAMIN C 2 MAXIMUM STRENGTH 2 CAPS CAPS bismuth subsalicylate chew 1 CVS PROBIOTIC PEARLS 2 RX/OTC or 262 mg EXTRA STRENGTH CAPS bismuth subsalicylate susp CVS SENIOR PROBIOTIC 2 RX/OTC or 1050 mg/30ml, 525 1 CAPS mg/15ml, 262 mg/15ml, DAILY DIGESTIVE 2 RX/OTC 525 mg/30ml, 527 mg/30ml PROBIOTIC CAPS CHILDRENS PROBIOTIC 2 RX/OTC RX/OTC PEARLS CAPS DAILY PROBIOTIC CAPS 2 CULTURELLE RX/OTC DERMACINRX 2 RX/OTC ADVANCED IMMUNE 2 PROBITRAN CAPS DEFENSE CAPS DIFF-STAT CAPS 2 RX/OTC CULTURELLE KIDS 2 CHEW DIGESTIVE ADVANTAGE RX/OTC ADVANCED PROBIOTICS 2 2 CULTURELLE KIDS PACK MULTI-STRAIN SUPPORT CULTURELLE KIDS CAPS PURELY PRBIOTICS 2 DIGESTIVE ADVANTAGE 2 RX/OTC CHEW CAPS CULTURELLE KIDS DIGESTIVE ADVANTAGE RX/OTC PURELY PROBIOTICS 2 DAILYDIGESTIVE & 2 PACK IMMUNE SUPPORT CAPS CULTURELLE KIDS 2 DIGESTIVE ADVANTAGE RX/OTC REGULARITY PACK DAILYPROBIOTICS+GAS 2 CULTURELLE RX/OTC DEFENSE CAPS METABOLISM/WEIGHT 2 DIGESTIVE ADVANTAGE RX/OTC MANAGEMENT CAPS DAILYPROBIOTICS+INTE 2 CULTURELLE PRO-WELL RX/OTC NSIVE BOWEL SUPPORT CAPS 5 MG-8 MG-70 MG- 2 CAPS 240 MG DIGESTIVE ADVANTAGE RX/OTC DAILYPROBIOTICS+LACT 2 CULTURELLE 2 PROBIOTICS KIDS PACK OSE SUPPORT CAPS DIGESTIVE ADVANTAGE RX/OTC CVS ADULT 50+ 2 RX/OTC PROBIOTIC CAPS LACTOSE SUPPORT 2 CAPS CVS ADULT PROBIOTIC 2 RX/OTC CAPS ENVIVE CAPS 2 RX/OTC CVS DIGESTIVE 2 RX/OTC PROBIOTIC CAPS EQ PROBIOTIC RX/OTC DIGESTIVE SYSTEM 2 CVS EVERYDAY CARE 2 RX/OTC SUPPORT CAPS PROBIOTIC CAPS EQL DAILY PROBIOTIC 2 RX/OTC CAPS New Hampshire Healthy Families Updated October 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL PROBIOTIC COLON 2 RX/OTC PEPTO-BISMOL SUSP NP SUPPORT CAPS (Use bismuth subsalicylate) FLORA VANCE CAPS 2 RX/OTC PEPTO-BISMOL TO-GO CHEW (Use bismuth NP subsalicylate) FLORAJEN DIGESTION 2 RX/OTC CAPS PHILLIPS COLON 2 RX/OTC FLORAJEN3 CAPS 2 RX/OTC HEALTH CAPS PREORBOTIC CAPS 2 RX/OTC FLORAJEN4KIDS CAPS 2 RX/OTC PRO-FLORA IMMUNE 2 RX/OTC FLORASTOR PLUS CAPS 2 RX/OTC CAPS PROBINATE CAPS 2 RX/OTC FLORASTOR PRE CAPS 2 RX/OTC PROBIOMAX DAILY DF 2 RX/OTC FOLIKA PROBIOTIC 2 RX/OTC CAPS CAPS PROBIOTIC & RX/OTC FORTIFY DAILY 2 RX/OTC ACIDOPHILUS FORMULA 2 PROBIOTIC CAPS EXTRA STRENGTH CAPS GNP ACIDOPHILUS HIGH RX/OTC 2 PROBIOTIC + OMEGA-3 2 RX/OTC POTENCY CAPS CAPS GNP PROBIOTIC COLON 2 RX/OTC PROBIOTIC RX/OTC SUPPORT CAPS ACIDOPHILUS BEADS 2 GNP PROBIOTIC RX/OTC CAPS DIGESTIVE SUPPORT 2 PROBIOTIC 2 RX/OTC CAPS ACIDOPHILUS CAPS HIGH POTENCY RX/OTC 2 PROBIOTIC ADVANCED 2 RX/OTC PROBIOTIC CAPS ULTRAPOTENCY CAPS RX/OTC HM ACIDOPHILUS CAPS 2 PROBIOTIC BLEND CAPS 2 RX/OTC RX/OTC LACTEROL CAPS 2 PROBIOTIC CAPS 2 RX/OTC RX/OTC LACTO-PECTIN CAPS 2 PROBIOTIC COLON 2 RX/OTC SUPPORT CAPS MEGA PROBIOTIC CAPS 2 RX/OTC PROBIOTIC RX/OTC COMPLEX/ACIDOPHILUS 2 META BIOTIC/BIO- 2 RX/OTC CAPS ACTIVE 12 CAPS PROBIOTIC DAILY CAPS 2 RX/OTC MOMMYS BLISS 2 PROBIOTIC PACK PROBIOTIC DIGESTIVE 2 RX/OTC NATRUL PROBIOTIC 2 RX/OTC SUPPORT CAPS CAPS PROBIOTIC MATURE 2 RX/OTC PEARLS IC CAPS 2 RX/OTC ADULT CAPS PROBIOTIC PEARLS 2 RX/OTC PEPTO-BISMOL CHEW NP ADVANTAGE CAPS (Use bismuth subsalicylate) PROBIOTIC PEARLS 2 RX/OTC PEPTO-BISMOL MAX CAPS STRENGTH SUSP (Use NP bismuth subsalicylate) New Hampshire Healthy Families Updated October 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROBIOTIC+TURMERIC 2 RX/OTC TRUBIOTICS CAPS 2 RX/OTC EXTRACT CAPS TRUNATURE DIGESTIVE RX/OTC PROBIOTIC-10 ULTIMATE 2 RX/OTC 2 CAPS PROBIOTIC CAPS ULTRAFLORA IMMUNE RX/OTC PROBIOTIC/PREBIOTIC/C 2 RX/OTC 2 RANBERRY CAPS HEALTH CAPS RX/OTC UP4 PROBIOTICS ADULT 2 RX/OTC PROBITROL CAPS 2 CAPS PRODIGEN CAPS 2 RX/OTC UP4 PROBIOTICS ULTRA 2 RX/OTC CAPS PROMELLA IN RX/OTC 2 UP4 PROBIOTICS 2 RX/OTC PREBIOTIC CAPS WOMENS CAPS RX/OTC PROMEROL CAPS 2 VISBIOME PROBIOTIC 2 RX/OTC HIGH POTENCY CAPS RX/OTC PROVAD CAPS 2 VSL#3 CAPS 2 RX/OTC RX/OTC QUAD-PROBIOTIC CAPS 2 WOMENS 50 BILLION 2 RX/OTC CAPS RA PROBIOTIC COLON 2 RX/OTC CARE CAPS ZELAC CAPS 2 RX/OTC RA PROBIOTIC 2 RX/OTC COMPLEX CAPS Antidiarrheal/Probiotic Combinations RA PROBIOTIC RX/OTC CULTURELLE ADULT DIGESTIVE SUPPORT 2 ULTIMATEBALANCE 2 CAPS CAPS CULTURELLE DIGESTIVE RA PROBIOTIC MAXIMUM 2 RX/OTC 2 STRENGTH CAPS DAILY PROBIOTIC CAPS RX/OTC CULTURELLE DIGESTIVE 2 RESTORA CAPS 2 HEALTH CAPS RX/OTC CULTURELLE DIGESTIVE 2 RISAQUAD CAPS 2 HEALTH CHEW RISAQUAD-2 CAPS 2 RX/OTC CULTURELLE DIGESTIVE HEALTH PROBIOTIC 2 CAPS SD PROBIOTIC-10 2 RX/OTC COMPLEXULTRA CAPS CULTURELLE HEALTH & 2 WELLNESS CAPS SM ACIDOPHILUS 2 RX/OTC PEARLS CAPS CULTURELLE ULTIMATE SM ADVANCED RX/OTC STRENGTH PROBIOTIC 2 PROBIOTIC ULTRA 2 CAPS POTENCY CAPS PROBIOTIC DIGESTIVE SUPPORT EXTRA 2 2 RX/OTC SUPER PROBIOTIC CAPS STRENGTH CAPS SUPER PROBIOTIC RX/OTC VIACTIV DIGESTIVE 2 DIGESTIVE SUPPORT 2 HEALTH CHEW CAPS Antiperistaltic Agents SUPERIOR PROBIOTIC 2 RX/OTC CAPS ANTI-DIARRHEAL LIQD 2 QL(40 ml daily)

New Hampshire Healthy Families Updated October 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diphenoxylate w/ 1 deferoxamine mesylate solr 1 PA; SP liqd DESFERAL SOLR (Use PA; SP diphenoxylate w/ atropine 1 NP tabs deferoxamine mesylate) IMODIUM A-D CAPS 2 MG NP QL(8 ea daily); SM IPECAC SYRUP SYRP 2 (Use loperamide hcl) RX/OTC IMODIUM A-D TABS 2 MG NP QL(8 ea daily) VISTOGARD PACK 2 (Use loperamide hcl) Opioid Antagonists LOMOTIL TABS (Use NP diphenoxylate w/ atropine) naloxone hcl soct ij 0.4 1 QL(4 ml per 90 mg/ml days retail) loperamide hcl caps or 2 1 QL(8 ea daily); mg RX/OTC naloxone hcl soln ij 0.4 0 QL(2 ml per 90 mg/ml days retail) loperamide hcl tabs or 2 1 QL(8 ea daily) mg naloxone hcl soln ij 4 1 QL(4 ml per 90 mg/10ml days retail) paregoric tinc 1 naloxone hcl sosy ij 2 1 QL(4 ml per 30 mg/2ml days retail) ANTIDOTES AND SPECIFIC ANTAGONISTS naltrexone hcl tabs or 1 Antidotes - Chelating Agents PA CHEMET CAPS 2 NALTREXONE IMPL SC 2 PA; SP NARCAN LIQD 2 QL(2 ea per 90 deferasirox pack 1 days retail) deferasirox tabs 1 PA; SP VIVITROL SUSR 2 deferasirox tbso 1 PA; SP ANTIEMETICS - Drugs to Treat and Vomiting PA; SP deferiprone tabs 1 5-HT3 Receptor Antagonists hcl tabs or 1 EXJADE TBSO (Use NP PA; SP 1 deferasirox) mg hcl soln or 4 QL(50 ml per FERRIPROX SOLN 100 2 PA; SP 1 MG/ML mg/5ml fill retail) ondansetron hcl tabs or 4 QL(2 ea daily) FERRIPROX TABS 1000 2 PA; SP 1 MG mg, 8 mg QL(2 ea daily) FERRIPROX TABS 500 NP PA; SP ondansetron tbdp 1 MG (Use deferiprone) ZOFRAN TABS (Use NP QL(2 ea daily) JADENU SPRINKLE PACK NP PA; SP ondansetron hcl) (Use deferasirox) Antiemetics - JADENU TABS (Use NP PA; SP deferasirox) hcl chew or 25 1 RX/OTC mg Antidotes and Specific Antagonists meclizine hcl tabs or 12.5 1 RX/OTC ANDEXXA SOLR 2 PA; SP mg, 25 mg

BRIDION SOLN 2 PA; SP Antiemetics - Miscellaneous

New Hampshire Healthy Families Updated October 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DICLEGIS TBEC (Use NP fluconazole tabs or 200 mg 1 -pyridoxine) QL(7 ea per fill fluconazole tabs or 50 mg 1 doxylamine-pyridoxine tbec 1 retail) Substance P/Neurokinin 1 (NK1) Receptor caps or 100 1 PA; QL(1 ea mg daily) caps 1 itraconazole soln or 10 1 PA mg/ml aprepitant misc 1 SPORANOX CAPS 100 NP PA; QL(1 ea EMEND CAPS OR 125 MG (Use itraconazole) daily) MG, 40 MG, 80 MG (Use NP SPORANOX PULSEPAK NP PA; QL(1 ea aprepitant) CAPS (Use itraconazole) daily) EMEND TRIPACK CAPS NP SPORANOX SOLN 10 NP PA (Use aprepitant) MG/ML (Use itraconazole) ANTIFUNGALS - Drugs to Treat Fungal Infections ANTIHISTAMINES - Drugs to Treat Antifungals Antihistamines - Alkylamines griseofulvin microsize susp 1 CHLOR-TRIMETON SYRP QL(60 ml daily) 2 MG/5ML (Use NP griseofulvin microsize tabs 1 chlorpheniramine maleate) CHLOR-TRIMETON TABS QL(120 ea per griseofulvin ultramicrosize 1 4 MG (Use NP fill retail) tabs chlorpheniramine maleate) QL(6 ea daily) nystatin tabs or 1 chlorpheniramine maleate 1 QL(60 ml daily) syrp or 2 mg/5ml QL(1 ea chlorpheniramine maleate 1 QL(120 ea per terbinafine hcl tabs or 1 daily,90 ea per tabs or 4 mg fill retail) 120 days retail) 1 -Related Antifungals maleate soln or DIFLUCAN SUSR 10 QL(70 ml per Antihistamines - Ethanolamines MG/ML, 40 MG/ML (Use NP fill retail) fluconazole) ALER-DRYL TABS 2 QL(4 ea daily) DIFLUCAN TABS 100 MG NP QL(1 ea daily) (Use fluconazole) BENADRYL QL(4 ea daily) CAPS (Use NP DIFLUCAN TABS 150 MG NP QL(2 ea daily) hcl) (Use fluconazole) BENADRYL ALLERGY QL(240 ml per DIFLUCAN TABS 200 MG NP CHILDRENS LIQD 12.5 NP fill retail) (Use fluconazole) MG/5ML (Use diphenhydramine hcl) DIFLUCAN TABS 50 MG NP QL(7 ea per fill (Use fluconazole) retail) BENADRYL ALLERGY QL(4 ea daily) TABS (Use NP fluconazole susr or 10 1 QL(70 ml per mg/ml, 40 mg/ml fill retail) diphenhydramine hcl) fluconazole tabs or 100 mg 1 QL(1 ea daily) BENADRYL ALLERGY QL(4 ea daily) ULTRATABS TABS (Use NP diphenhydramine hcl) fluconazole tabs or 150 mg 1 QL(2 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fumarate tabs 1 QL(2 ea daily) tbdp 1 or 1.34 mg hcl susp or 30 diphenhydramine hcl caps 1 QL(4 ea daily) 1 or 50 mg, 25 mg mg/5ml fexofenadine hcl tabs or QL(1 ea daily) diphenhydramine hcl elix or 1 QL(240 ml per 1 12.5 mg/5ml fill retail) 180 mg diphenhydramine hcl liqd or QL(240 ml per fexofenadine hcl tabs or 60 1 QL(2 ea daily) 12.5 mg/5ml, 25 mg/10ml, 1 fill retail) mg 50 mg/20ml 1 RX/OTC dihydrochloride soln or diphenhydramine hcl tabs 1 QL(4 ea daily) or 25 mg caps or 10 mg 1 Antihistamines - Non-Sedating ALLEGRA ALLERGY loratadine chew or 5 mg 1 CHILDRENS SUSP (Use NP QL(240 ml per loratadine soln or 5 mg/5ml 1 fexofenadine hcl) fill retail) ALLEGRA ALLERGY QL(1 ea daily) QL(240 ml per loratadine syrp or 5 mg/5ml 1 TABS 180 MG (Use NP fill retail) fexofenadine hcl) ALLEGRA ALLERGY QL(2 ea daily) loratadine tabs or 10 mg 1 TABS 60 MG (Use NP fexofenadine hcl) XYZAL ALLERGY 24HR RX/OTC CHILDRENS SOLN (Use NP hcl caps 10 mg 1 levocetirizine dihydrochloride) cetirizine hcl chew 5 mg, QL(1 ea daily) 1 ZYRTEC ALLERGY CAPS NP 10 mg (Use cetirizine hcl) QL(240 ml per ZYRTEC ALLERGY TABS QL(1 ea daily) cetirizine hcl soln 1 mg/ml, 1 fill retail); NP 5 mg/5ml (Use cetirizine hcl) RX/OTC ZYRTEC CHILDRENS QL(240 ml per QL(240 ml per ALLERGY SOLN (Use NP fill retail); cetirizine hcl syrp 1 mg/ml, 1 fill retail); 5 mg/5ml cetirizine hcl) RX/OTC RX/OTC Antihistamines - cetirizine hcl tabs 5 mg, 10 1 QL(1 ea daily) mg QL(240 ml per hcl soln or 1 fill retail); AL(At CLARITIN ALLERGY QL(240 ml per 6.25 mg/5ml CHILDRENS SYRP (Use NP fill retail) least 2 yrs old) loratadine) QL(12 ea per promethazine hcl supp re 1 fill retail); AL(At CLARITIN CAPS 10 MG NP 50 mg, 12.5 mg, 25 mg (Use loratadine) least 2 yrs old) CLARITIN CHEW 5 MG QL(240 ml per NP promethazine hcl syrp or 1 fill retail); AL(At (Use loratadine) 6.25 mg/5ml least 2 yrs old) CLARITIN CHILDRENS NP CHEW (Use loratadine) promethazine hcl tabs or 1 AL(At least 2 25 mg, 12.5 mg, 50 mg yrs old) CLARITIN SYRP 5 NP QL(240 ml per MG/5ML (Use loratadine) fill retail) Antihistamines - Piperidines hcl syrp or CLARITIN TABS 10 MG NP 1 (Use loratadine) 2 mg/5ml

New Hampshire Healthy Families Updated October 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyproheptadine hcl tabs or 1 fenofibrate micronized caps 1 QL(1 ea daily) 4 mg 134 mg, 200 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High fenofibrate micronized caps 1 QL(2 ea daily) Cholesterol 67 mg fenofibrate tabs or 120 mg, Antihyperlipidemics - Combinations 1 40 mg ezetimibe-simvastatin tabs 1 fenofibrate tabs or 54 mg 1 QL(3 ea daily) VYTORIN TABS (Use NP ezetimibe-simvastatin) FENOFIBRIC ACID TABS NP 105 MG Antihyperlipidemics - Misc. fenofibric acid tabs 105 mg, 1 LOVAZA CAPS (Use NP 35 mg omega-3-acid ethyl esters) FENOGLIDE TABS (Use NP omega-3-acid ethyl esters 1 fenofibrate) caps FIBRICOR TABS (Use NP Bile Acid Sequestrants fenofibric acid) QL(2 ea daily) cholestyramine light pack 1 gemfibrozil tabs or 1 LOPID TABS (Use NP QL(2 ea daily) cholestyramine light powd 1 gemfibrozil) cholestyramine pack or 4 1 HMG CoA Reductase Inhibitors gm atorvastatin calcium tabs or QL(1 ea daily) cholestyramine powd or 4 1 10 mg, 20 mg, 40 mg, 80 1 gm/dose mg COLESTID FLAVORED CRESTOR TABS (Use NP QL(1 ea daily) GRAN 5 GM (Use NP rosuvastatin calcium) colestipol hcl) fluvastatin sodium caps 1 COLESTID GRAN 5 GM NP (Use colestipol hcl) fluvastatin sodium tb24 1 COLESTID TABS 1 GM NP (Use colestipol hcl) LESCOL XL TB24 (Use NP fluvastatin sodium) colestipol hcl gran 5 gm 1 LIPITOR TABS (Use NP QL(1 ea daily) colestipol hcl tabs 1 gm 1 atorvastatin calcium) lovastatin tabs 10 mg, 20 1 QL(1 ea daily) QUESTRAN LIGHT POWD NP mg (Use cholestyramine light) lovastatin tabs 40 mg 1 QL(2 ea daily) QUESTRAN PACK (Use NP cholestyramine) PRAVACHOL TABS (Use NP QL(1 ea daily) QUESTRAN POWD (Use NP pravastatin sodium) cholestyramine) pravastatin sodium tabs 1 QL(1 ea daily) Fibric Acid Derivatives QL(1 ea daily) fenofibrate caps or 150 mg, 1 rosuvastatin calcium tabs 1 50 mg simvastatin tabs or 5 mg, 1 QL(1 ea daily) fenofibrate micronized caps 1 10 mg, 20 mg, 40 mg 130 mg, 43 mg

New Hampshire Healthy Families Updated October 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits simvastatin tabs or 80 mg 1 lisinopril tabs or 2.5 mg, 10 mg, 20 mg, 30 mg, 40 mg, 1 ZOCOR TABS 5 MG, 10 QL(1 ea daily) 5 mg MG, 20 MG, 40 MG (Use NP LOTENSIN TABS 10 MG, NP QL(1 ea daily) simvastatin) 20 MG (Use benazepril hcl) ZOCOR TABS 80 MG (Use NP LOTENSIN TABS 40 MG NP QL(2 ea daily) simvastatin) (Use benazepril hcl) Intestinal Cholesterol Absorption Inhibitors moexipril hcl tabs 1 ezetimibe tabs 1 perindopril erbumine tabs 1 ZETIA TABS (Use NP ezetimibe) PRINIVIL TABS (Use NP lisinopril) Microsomal Triglyceride Transfer Protein (MTP) quinapril hcl tabs 1 QL(1 ea daily) JUXTAPID CAPS 2 PA; SP ramipril caps 1 QL(2 ea daily) Nicotinic Acid Derivatives trandolapril tabs 1 mg, 2 QL(1 ea daily) niacin (antihyperlipidemic) 1 1 tbcr mg QL(2 ea daily) NIASPAN TBCR (Use 2 trandolapril tabs 4 mg 1 niacin (antihyperlipidemic)) VASOTEC TABS (Use NP QL(2 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 enalapril maleate) PRALUENT SOAJ 2 PA; SP ZESTRIL TABS (Use NP lisinopril) PA; SP REPATHA SOSY 2 Agents for Pheochromocytoma REPATHA SURECLICK PA; SP 2 DEMSER CAPS (Use NP PA; SP SOAJ metyrosine) ANTIHYPERTENSIVES - Drugs to Treat High metyrosine caps 1 PA; SP Blood Pressure ACE Inhibitors Angiotensin II Receptor Antagonists ATACAND TABS (Use ACCUPRIL TABS (Use NP QL(1 ea daily) NP quinapril hcl) candesartan cilexetil) AVAPRO TABS (Use QL(1 ea daily) ALTACE CAPS (Use NP QL(2 ea daily) NP ramipril) irbesartan) BENICAR TABS (Use benazepril hcl tabs or 10 1 QL(1 ea daily) NP mg, 20 mg, 5 mg olmesartan medoxomil) benazepril hcl tabs or 40 1 QL(2 ea daily) candesartan cilexetil tabs 1 mg COZAAR TABS (Use NP QL(1 ea daily) captopril tabs or 100 mg, 1 QL(3 ea daily) losartan potassium) 12.5 mg, 25 mg, 50 mg DIOVAN TABS (Use 2 QL(1 ea daily) enalapril maleate tabs or QL(2 ea daily) valsartan) 10 mg, 2.5 mg, 20 mg, 5 1 mg eprosartan mesylate tabs 1 fosinopril sodium tabs 1 QL(1 ea daily) irbesartan tabs 1 QL(1 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits losartan potassium tabs or 1 QL(1 ea daily) amlodipine-valsartan- 1 100 mg, 25 mg, 50 mg hydrochlorothiazide tabs MICARDIS TABS (Use NP ATACAND HCT TABS telmisartan) (Use candesartan cilexetil- NP hydrochlorothiazide) olmesartan medoxomil tabs 1 & chlorthalidone 1 QL(1 ea daily) telmisartan tabs 1 tabs AVALIDE TABS (Use QL(1 ea daily) valsartan tabs 1 QL(1 ea daily) irbesartan- NP hydrochlorothiazide) Antiadrenergic Antihypertensives AZOR TABS (Use amlodipine besylate- NP CARDURA TABS (Use NP mesylate) olmesartan medoxomil) benazepril & QL(1 ea daily) CATAPRES TABS (Use NP 1 clonidine hcl) hydrochlorothiazide tabs BENAZEPRIL QL(1 ea daily) clonidine hcl tabs or 0.1 1 mg, 0.2 mg, 0.3 mg HCL/HYDROCHLOROTHI 2 AZIDE TABS doxazosin mesylate tabs or 1 1 mg, 2 mg, 4 mg, 8 mg BENICAR HCT TABS (Use olmesartan medoxomil- NP guanfacine hcl tabs 1 hydrochlorothiazide) & 1 QL(1 ea daily) TABS 2 hydrochlorothiazide tabs candesartan cilexetil- MINIPRESS CAPS (Use NP 1 hcl) hydrochlorothiazide tabs captopril & QL(2 ea daily) prazosin hcl caps 1 1 hydrochlorothiazide tabs hcl caps 1 DIOVAN HCT TABS (Use QL(1 ea daily) valsartan- NP Antihypertensive Combinations hydrochlorothiazide) ACCURETIC TABS 10 QL(3 ea daily) enalapril maleate & 1 QL(2 ea daily) hydrochlorothiazide tabs MG-12.5 MG (Use NP quinapril- EXFORGE HCT TABS 2 hydrochlorothiazide) ACCURETIC TABS 12.5 QL(4 ea daily) EXFORGE TABS (Use MG-20 MG (Use quinapril- NP amlodipine besylate- NP hydrochlorothiazide) valsartan) ACCURETIC TABS 20 QL(2 ea daily) fosinopril sodium & 1 QL(1 ea daily) MG-25 MG (Use quinapril- NP hydrochlorothiazide tabs hydrochlorothiazide) HYZAAR TABS (Use QL(1 ea daily) losartan potassium & NP amlodipine besylate- 1 QL(1 ea daily) benazepril hcl caps hydrochlorothiazide) irbesartan- QL(1 ea daily) amlodipine besylate- 1 1 olmesartan medoxomil tabs hydrochlorothiazide tabs lisinopril & amlodipine besylate- 1 1 valsartan tabs hydrochlorothiazide tabs

New Hampshire Healthy Families Updated October 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPRESSOR HCT TABS QL(2 ea daily) TRANDOLAPRIL/VERAPA 2 (Use & NP MIL HCL ER TBCR hydrochlorothiazide) TRIBENZOR TABS (Use losartan potassium & 1 QL(1 ea daily) olmesartan medoxomil- NP hydrochlorothiazide tabs amlodipine- LOTENSIN HCT TABS QL(1 ea daily) hydrochlorothiazide) (Use benazepril & NP TWYNSTA TABS (Use NP hydrochlorothiazide) telmisartan-amlodipine) LOTREL CAPS (Use QL(1 ea daily) valsartan- 1 QL(1 ea daily) amlodipine besylate- NP hydrochlorothiazide tabs benazepril hcl) VASERETIC TABS (Use QL(2 ea daily) metoprolol & 1 QL(2 ea daily) enalapril maleate & NP hydrochlorothiazide tabs hydrochlorothiazide) MICARDIS HCT TABS QL(1 ea daily) ZESTORETIC TABS (Use (Use telmisartan- NP lisinopril & NP hydrochlorothiazide) hydrochlorothiazide) olmesartan medoxomil- ZIAC TABS (Use bisoprolol NP QL(1 ea daily) amlodipine- 1 & hydrochlorothiazide) hydrochlorothiazide tabs Antihypertensives - Misc. olmesartan medoxomil- 1 PA; SP hydrochlorothiazide tabs VECAMYL TABS 2 & 1 QL(2 ea daily) hydrochlorothiazide tabs Vasodilators quinapril- QL(3 ea daily) hydralazine hcl tabs or 100 1 hydrochlorothiazide tabs 10 1 mg, 25 mg, 50 mg, 10 mg mg-12.5 mg minoxidil tabs or 10 mg, 2.5 1 quinapril- QL(4 ea daily) mg hydrochlorothiazide tabs 1 ANTIMALARIALS - Drugs to Treat Malaria 12.5 mg-20 mg (Parasitic Infections) quinapril- QL(2 ea daily) Antimalarial Combinations hydrochlorothiazide tabs 20 1 mg-25 mg COARTEM TABS 2 QL(24 ea per fill retail) TARKA TBCR (Use NP trandolapril-verapamil hcl) Antimalarials chloroquine phosphate tabs 0 QL(2 ea daily) telmisartan-amlodipine tabs 1 or 250 mg chloroquine phosphate tabs QL(8 ea per 56 telmisartan- 1 QL(1 ea daily) 0 hydrochlorothiazide tabs or 500 mg days retail) TENORETIC 100 TABS QL(1 ea daily) DARAPRIM TABS (Use NP PA; SP (Use atenolol & NP pyrimethamine) chlorthalidone) hydroxychloroquine sulfate 0 TENORETIC 50 TABS QL(1 ea daily) tabs or 200 mg (Use atenolol & NP KRINTAFEL TABS 2 QL(2 ea per 30 chlorthalidone) days retail) trandolapril-verapamil hcl 1 tbcr mefloquine hcl tabs 1

New Hampshire Healthy Families Updated October 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLAQUENIL TABS (Use 0 ALKERAN TABS OR 2 MG NP hydroxychloroquine sulfate) (Use melphalan) pyrimethamine tabs or 1 PA; SP BELRAPZO SOLN 2 PA; SP

BENDAMUSTINE 2 PA; SP ANTIMYASTHENIC/CHOLINERGIC AGENTS HYDROCHLORIDE SOLN Antimyasthenic/Cholinergic Agents BENDEKA SOLN 2 PA; SP PA; SP FIRDAPSE TABS 2 carboplatin soln 450 PA; SP MESTINON TABS 60 MG mg/45ml, 50 mg/5ml, 600 1 (Use pyridostigmine NP mg/60ml, 150 mg/15ml bromide) cisplatin soln 200 PA; SP MESTINON TIMESPAN mg/200ml, 100 mg/100ml, 1 TBCR (Use pyridostigmine NP 50 mg/50ml bromide) CISPLATIN SOLR 50 MG 2 PA; SP pyridostigmine bromide 1 tabs or 60 mg CYCLOPHOSPHAMIDE 2 TABS OR 25 MG, 50 MG pyridostigmine bromide 1 tbcr or 180 mg EVOMELA SOLR 2 PA; SP RUZURGI TABS 2 PA; QL(10 ea daily); SP LEUKERAN TABS 2 ANTIMYCOBACTERIAL AGENTS - Drugs to PA; SP Treat Tuberculosis (Bacterial Infections) melphalan hcl solr 1 Antimycobacterial Agents melphalan tabs 1 ethambutol hcl tabs or 100 1 mg, 400 mg MYLERAN TABS 2 isoniazid syrp or 50 mg/5ml 1 TEMODAR CAPS OR 100 PA; SP MG, 140 MG, 180 MG, 20 NP isoniazid tabs or 100 mg, 1 MG, 250 MG, 5 MG (Use 300 mg temozolomide) MYAMBUTOL TABS (Use NP TEMODAR SOLR IV 100 2 PA; SP ethambutol hcl) MG pyrazinamide tabs or 1 temozolomide caps 1 PA; SP RIFADIN CAPS OR 150 TEPADINA SOLR (Use 2 PA; SP MG, 300 MG (Use NP thiotepa) rifampin) thiotepa solr ij 1 PA; SP rifampin caps or 150 mg, 1 300 mg TREANDA SOLR 2 PA; SP TRECATOR TABS 2 YONDELIS SOLR 2 PA; SP ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Antimetabolites Alkylating Agents ALIMTA SOLR 2 PA; SP ALKERAN SOLR IV 50 MG NP PA; SP (Use melphalan hcl) New Hampshire Healthy Families Updated October 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azacitidine susr 1 PA; SP LENVIMA 18 MG DAILY 2 PA; SP DOSE CPPK PA; SP capecitabine tabs 1 LENVIMA 20 MG DAILY 2 PA; SP DOSE CPPK PA; SP cladribine soln 1 LENVIMA 24 MG DAILY 2 PA; SP DOSE CPPK cytarabine soln 1 PA; SP LENVIMA 4 MG DAILY 2 PA; SP DOSE CPPK DACOGEN SOLR (Use NP PA; SP decitabine) LENVIMA 8 MG DAILY 2 PA; SP DOSE CPPK decitabine solr 1 PA; SP MVASI SOLN 2 PA; SP fludarabine phosphate soln 1 PA; SP ZALTRAP SOLN 2 PA; SP fludarabine phosphate solr 1 PA; SP Antineoplastic - Anti-HER2 Agents PA; SP FOLOTYN SOLN 2 KANJINTI SOLR 420 MG 2 PA; SP mercaptopurine tabs or 1 PERJETA SOLN 2 PA; SP methotrexate sodium soln ij Antineoplastic - Antibodies 250 mg/10ml, 50 mg/2ml, 1 1 gm/40ml ADCETRIS SOLR 2 PA; SP methotrexate sodium tabs 1 PA; SP or 2.5 mg ARZERRA CONC 2 PURIXAN SUSP 2 BLINCYTO SOLR 2 PA; SP PA; SP TABLOID TABS 2 DARZALEX SOLN 2 PA; SP

TREXALL TABS 2 EMPLICITI SOLR 2 PA; SP VIDAZA SUSR (Use NP PA; SP PA; SP azacitidine) GAZYVA SOLN 2 XELODA TABS (Use NP PA; SP PA; SP capecitabine) KADCYLA SOLR 2 Antineoplastic - Angiogenesis Inhibitors KEYTRUDA SOLN 2 PA; SP AVASTIN SOLN 2 PA; SP LIBTAYO SOLN 2 PA; SP CYRAMZA SOLN 2 PA; SP LUMOXITI SOLR 2 PA; SP INLYTA TABS 2 PA; SP OPDIVO SOLN 100 2 PA; SP MG/10ML, 40 MG/4ML LENVIMA 10 MG DAILY 2 PA; SP DOSE CPPK POLIVY SOLR 140 MG 2 PA; SP LENVIMA 12MG DAILY PA; SP 2 PA; SP DOSE CPPK POTELIGEO SOLN 2 LENVIMA 14 MG DAILY 2 PA; SP PA; SP DOSE CPPK RITUXAN SOLN 2

New Hampshire Healthy Families Updated October 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECENTRIQ SOLN 2 PA; SP ARIMIDEX TABS (Use NP anastrozole) PA; SP UNITUXIN SOLN 2 AROMASIN TABS (Use NP SP exemestane) PA; SP YERVOY SOLN 2 bicalutamide tabs 1 QL(1 ea daily) PA; SP ZEVALIN Y-90 KIT 2 CASODEX TABS (Use NP QL(1 ea daily) bicalutamide) Antineoplastic - BCL-2 Inhibitors ELIGARD KIT 2 PA; SP VENCLEXTA STARTING 2 PA; SP PACK TBPK EMCYT CAPS 2 PA; SP VENCLEXTA TABS 2 PA; SP ERLEADA TABS 2 PA; SP Antineoplastic - Cellular Immunotherapy exemestane tabs 1 SP PROVENGE SUSP 2 PA; SP FARESTON TABS (Use NP PA Antineoplastic - EGFR Inhibitors toremifene citrate) PA; SP ERBITUX SOLN 2 FEMARA TABS (Use NP letrozole) PA; SP erlotinib hcl tabs 1 FIRMAGON SOLR 2 PA; SP PA; SP GILOTRIF TABS 2 flutamide caps 1 IRESSA TABS 2 PA; SP PA; QL(41.67 hydroxyprogesterone 1 ml daily); AL(At PA; SP caproate (antineoplastic) least 16 yrs PORTRAZZA SOLN 2 soln old); SP TAGRISSO TABS 2 PA; SP letrozole tabs or 1 TARCEVA TABS (Use NP PA; SP erlotinib hcl) leuprolide acetate kit ij 1 PA; SP VECTIBIX SOLN 2 PA; SP LEUPROLIDE PA; SP ACETATE/BUPIVACAINE 2 VIZIMPRO TABS 2 PA; SP HYDROCHLORIDE SOLN LUPRON DEPOT (1- 2 PA; SP Antineoplastic - Hedgehog Pathway Inhibitors MONTH) KIT PA; SP DAURISMO TABS 2 LUPRON DEPOT (3- 2 PA; SP MONTH) KIT PA; SP ERIVEDGE CAPS 2 LUPRON DEPOT (4- 2 PA; SP MONTH) KIT ODOMZO CAPS 2 PA; SP LUPRON DEPOT (6- 2 PA; SP MONTH) KIT Antineoplastic - Hormonal and Related Agents LYSODREN TABS 2 PA; SP abiraterone acetate tabs 1 PA; SP megestrol acetate susp or 1 anastrozole tabs or 1 40 mg/ml, 400 mg/10ml

New Hampshire Healthy Families Updated October 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits megestrol acetate tabs or 1 Antineoplastic Enzyme Inhibitors 40 mg, 20 mg AFINITOR DISPERZ TBSO 2 PA; SP tamoxifen citrate tabs or 20 1 mg, 10 mg AFINITOR TABS 10 MG 2 PA; SP toremifene citrate tabs 1 PA AFINITOR TABS 2.5 MG, 5 PA; SP TRELSTAR MIXJECT 2 PA; SP MG, 7.5 MG (Use NP SUSR everolimus) VANTAS KIT 2 PA; SP ALECENSA CAPS 2 PA; SP

XTANDI CAPS 40 MG 2 PA; SP BELEODAQ SOLR 2 PA; SP

ZOLADEX IMPL 2 PA; SP BORTEZOMIB SOLR 2 PA; SP

ZYTIGA TABS (Use NP PA; SP BOSULIF TABS 2 PA; SP abiraterone acetate) Antineoplastic - Immunomodulators BRAFTOVI CAPS 2 PA; SP PA; SP POMALYST CAPS 2 CABOMETYX TABS 2 PA; SP Antineoplastic - PDGFR-alpha Inhibitors CAPRELSA TABS 2 PA; SP LARTRUVO SOLN 2 PA; SP COMETRIQ KIT 2 PA; SP Antineoplastic Antibiotics PA; SP daunorubicin hcl soln 1 PA; SP COTELLIC TABS 2 DAUNORUBICIN PA; SP everolimus tabs 1 PA; SP HYDROCHLORIDE SOLN NP 20 MG/4ML (Use FARYDAK CAPS 2 PA; SP daunorubicin hcl) GLEEVEC TABS (Use NP PA; SP DAUNORUBICIN PA; SP mesylate) HYDROCHLORIDE SOLN 2 50 MG/10ML IBRANCE CAPS 100 MG, 2 PA; SP 125 MG, 75 MG ELLENCE SOLN (Use NP PA; SP epirubicin hcl) ICLUSIG TABS 15 MG, 45 2 PA; SP MG epirubicin hcl soln 1 PA; SP imatinib mesylate tabs 1 PA; SP mitoxantrone hcl conc 1 PA; SP IMBRUVICA CAPS 140 2 PA; SP MG valrubicin soln 1 PA; SP IMBRUVICA CAPS 70 MG 2 PA; QL(1 ea daily); SP VALSTAR SOLN (Use NP PA; SP valrubicin) IMBRUVICA TABS 140 PA; QL(1 ea Antineoplastic Combinations MG, 280 MG, 420 MG, 560 2 daily); SP MG HERCEPTIN HYLECTA 2 PA; SP SOLN ISTODAX (OVERFILL) 2 PA; SP SOLR LONSURF TABS 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JAKAFI TABS 2 PA; SP VOTRIENT TABS 2 PA; SP

KYPROLIS SOLR 2 PA; SP XALKORI CAPS 2 PA; SP lapatinib ditosylate tabs 1 PA; SP XOSPATA TABS 2 PA; SP

LORBRENA TABS 2 PA; SP ZELBORAF TABS 2 PA; SP

MEKINIST TABS 2 PA; SP ZOLINZA CAPS 2 PA; SP

MEKTOVI TABS 2 PA; SP ZYDELIG TABS 2 PA; SP

NEXAVAR TABS 2 PA; SP ZYKADIA CAPS 2 PA; SP

NINLARO CAPS 2 PA; SP Antineoplastic Enzymes ERWINASE SOLR 2 PA; SP ROMIDEPSIN SOLR 10 2 PA; SP MG ERWINAZE SOLR 2 PA; SP RUBRACA TABS 2 PA; SP ONCASPAR SOLN 2 PA; SP SPRYCEL TABS 2 PA; SP Antineoplastic Radiopharmaceuticals STIVARGA TABS 2 PA; SP AZEDRA DOSIMETRIC 2 PA; SP SOLN sunitinib malate caps 1 PA; SP AZEDRA THERAPEUTIC 2 PA; SP SOLN SUTENT CAPS (Use NP PA; SP sunitinib malate) LUTATHERA SOLN 2 PA; SP TAFINLAR CAPS 2 PA; SP Antineoplastics Misc. PA; SP TALZENNA CAPS 2 ACTIMMUNE SOLN 2 PA; SP PA; SP TASIGNA CAPS 2 ALFERON N SOLN 2 PA; SP PA; SP temsirolimus soln 1 arsenic trioxide soln iv 12 1 PA; SP mg/6ml TIBSOVO TABS 2 PA; SP bexarotene caps 1 PA; SP TORISEL SOLN (Use NP PA; SP temsirolimus) HYDREA CAPS (Use NP hydroxyurea) TYKERB TABS (Use NP PA; SP lapatinib ditosylate) hydroxyurea caps or 1 PA; SP VELCADE SOLR 2 INTRON A SOLN 2 PA; SP PA; SP VITRAKVI CAPS 2 INTRON A SOLR 2 PA; SP PA; SP VITRAKVI SOLN 2 MATULANE CAPS 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHOTOFRIN SOLR 2 PA; SP docetaxel conc 160 PA; SP mg/8ml, 20 mg/ml, 80 1 PROLEUKIN SOLR 2 PA; SP mg/4ml DOCETAXEL CONC 160 PA; SP SYLATRON KIT 2 PA; SP MG/8ML, 20 MG/ML, 80 2 MG/4ML SYNRIBO SOLR 2 PA; SP DOCETAXEL CONC 160 PA; SP MG/8ML, 20 MG/ML, 80 NP TARGRETIN CAPS OR 75 NP PA; SP MG/4ML (Use docetaxel) MG (Use bexarotene) docetaxel soln 160 PA; SP tretinoin (chemotherapy) 1 PA; SP mg/16ml, 20 mg/2ml, 80 1 caps mg/8ml TRISENOX SOLN (Use NP PA; SP DOCETAXEL SOLN 160 PA; SP arsenic trioxide) MG/16ML, 20 MG/2ML, 80 2 Chemotherapy Adjuncts MG/8ML PA; SP DOCETAXEL SOLN 160 PA; SP KEPIVANCE SOLR 2 MG/16ML, 20 MG/2ML, 80 NP MG/8ML (Use docetaxel) Chemotherapy Rescue/Antidote/Protective Agents etoposide caps or 50 mg 1 PA; SP dexrazoxane hcl solr 1 PA; SP etoposide soln iv 1 PA; SP FUSILEV SOLR (Use NP PA; SP gm/50ml, 100 mg/5ml, 500 1 levoleucovorin calcium) mg/25ml PA; SP KHAPZORY SOLR 2 HALAVEN SOLN 2 PA; SP leucovorin calcium tabs or 1 PA; SP 10 mg, 15 mg, 25 mg, 5 mg IXEMPRA KIT SOLR 2 PA; SP levoleucovorin calcium soln 1 JEVTANA SOLN 2 PA; SP PA; SP levoleucovorin calcium solr 1 MARQIBO SUSP 2 PA; SP PA; SP mesna soln 1 TAXOTERE CONC (Use NP PA; SP docetaxel) MESNEX SOLN IV 100 NP PA; SP PA; SP MG/ML (Use mesna) vincristine sulfate soln 1 MESNEX TABS OR 400 2 PA; SP Oncolytic Viral Agents MG IMLYGIC SUSP 2 PA; SP TOTECT SOLR 2 PA; SP Topoisomerase I Inhibitors VORAXAZE SOLR 2 PA; SP CAMPTOSAR SOLN (Use NP PA; SP irinotecan hcl) ZINECARD SOLR (Use NP PA; SP dexrazoxane hcl) HYCAMTIN CAPS OR 0.25 2 PA; SP Mitotic Inhibitors MG, 1 MG PA; SP HYCAMTIN SOLR IV 4 MG NP PA; SP ABRAXANE SUSR 2 (Use topotecan hcl) irinotecan hcl soln 1 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPOTECAN HCL SOLN 2 PA; SP MIRAPEX TABS (Use QL(3 ea daily); 4 MG/4ML NP AL(At least 18 dihydrochloride) yrs old) topotecan hcl soln 4 1 PA; SP mg/4ml PARLODEL CAPS (Use NP TOPOTECAN HCL SOLN PA; SP mesylate) 4 MG/4ML (Use topotecan NP PARLODEL TABS (Use NP hcl) bromocriptine mesylate) topotecan hcl solr 4 mg 1 PA; SP pramipexole QL(3 ea daily); dihydrochloride tabs 0.125 1 AL(At least 18 ANTIPARKINSON AND RELATED THERAPY mg, 0.25 mg, 0.5 mg, 0.75 yrs old) AGENTS - Drugs to Treat Parkinson's Disease mg, 1 mg, 1.5 mg pramipexole Antiparkinson Adjunctive Therapy dihydrochloride tb24 0.375 1 carbidopa tabs or 1 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg LODOSYN TABS (Use NP REQUIP XL TB24 (Use NP carbidopa) hydrochloride) Antiparkinson Anticholinergics ropinirole hydrochloride 1 QL(6 ea daily) tabs 0.25 mg, 3 mg, 4 mg benztropine mesylate tabs 1 or 0.5 mg, 1 mg, 2 mg ropinirole hydrochloride QL(3 ea daily) tabs 1 mg, 2 mg, 5 mg, 0.5 1 trihexyphenidyl hcl soln 1 mg trihexyphenidyl hcl tabs 1 ropinirole hydrochloride tb24 12 mg, 2 mg, 4 mg, 6 1 Antiparkinson mg, 8 mg SINEMET CR TBCR (Use hcl caps or 1 NP 100 mg carbidopa-levodopa) SINEMET TABS (Use amantadine hcl syrp or 50 1 NP mg/5ml carbidopa-levodopa) Antiparkinson Monoamine Oxidase Inhibitors amantadine hcl tabs or 100 1 mg selegiline hcl caps or 1 APOKYN SOCT 2 PA; SP selegiline hcl tabs or 1 bromocriptine mesylate 1 caps or 5 mg ANTIPSYCHOTICS/ANTIMANIC AGENTS - bromocriptine mesylate 1 Drugs to Treat Mood Disorders tabs or 2.5 mg Antimanic Agents carbidopa-levodopa tabs 10 mg-100 mg, 25 mg-100 1 carbonate caps or 1 mg, 25 mg-250 mg 150 mg, 300 mg, 600 mg lithium carbonate tabs or carbidopa-levodopa tbcr 25 1 1 mg-100 mg, 50 mg-200 mg 300 mg MIRAPEX ER TB24 (Use lithium carbonate tbcr or 1 pramipexole NP 300 mg, 450 mg dihydrochloride) LITHIUM SOLN 2

New Hampshire Healthy Families Updated October 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITHOBID TBCR (Use 2 HALDOL DECANOATE 50 lithium carbonate) SOLN (Use NP decanoate) Antipsychotics - Misc. HALDOL SOLN (Use NP GEODON CAPS (Use NP ) hcl) haloperidol lactate soln 1 GEODON SOLR (Use NP ziprasidone mesylate) im 100 mg/ml, 50 mg/ml haloperidol lactate conc 1 NUPLAZID CAPS 2 PA; QL(1 ea daily) PA; QL(1 ea haloperidol lactate soln 1 NUPLAZID TABS 2 daily) haloperidol tabs or 0.5 mg, ziprasidone hcl caps 1 1 mg, 10 mg, 2 mg, 20 mg, 1 5 mg ziprasidone mesylate solr 1 Dibenzapines Benzisoxazoles tabs 0 INVEGA SUSTENNA 2 AL(At least 18 SUSY yrs old); SP clozapine tbdp 0 INVEGA TB24 (Use NP CLOZARIL TABS (Use NP ) clozapine) 1 rtl MAX fill,84 FAZACLO TBDP (Use NP rtl day(s) clozapine) INVEGA TRINZA SUSY 2 supply,; AL(At least 18 yrs succinate caps 1 old); SP solr im 10 mg 1 paliperidone tb24 1 olanzapine tabs or 10 mg, AL(At least 10 1 rtl MAX fill,28 15 mg, 2.5 mg, 20 mg, 5 1 yrs old) rtl day(s) mg, 7.5 mg RISPERDAL CONSTA 2 supply,; AL(At SRER olanzapine tbdp or 10 mg, 1 least 18 yrs 15 mg, 20 mg, 5 mg old); SP fumarate tabs 1 RISPERDAL SOLN (Use NP ) quetiapine fumarate tb24 1 RISPERDAL TABS (Use NP risperidone) SEROQUEL TABS (Use NP risperidone soln 1 quetiapine fumarate) SEROQUEL XR TB24 (Use NP risperidone tabs 1 quetiapine fumarate) ZYPREXA RELPREVV 2 SP risperidone tbdp 1 SUSR ZYPREXA SOLR IM 10 NP Butyrophenones MG (Use olanzapine) HALDOL DECANOATE 100 SOLN (Use haloperidol NP decanoate)

New Hampshire Healthy Families Updated October 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZYPREXA TABS OR 10 AL(At least 10 tabs 10 mg, 15 QL(1 ea daily) 1 MG, 15 MG, 2.5 MG, 20 NP yrs old) mg, 2 mg, 20 mg, 30 mg, 5 MG, 5 MG, 7.5 MG (Use mg olanzapine) aripiprazole tbdp 10 mg, 15 1 QL(2 ea daily) ZYPREXA ZYDIS TBDP NP mg (Use olanzapine) QL(1 ml per 28 Dihydroindolones 2 days retail); ARISTADA PRSY AL(At least 18 hcl tabs 10 mg 1 yrs old); SP Phenothiazines hcl tabs or thiothixene caps 1 10 mg, 100 mg, 200 mg, 25 1 mg, 50 mg ANTIVIRALS - Drugs to Treat Viral Infections decanoate 1 soln ij Antiretrovirals abacavir sulfate soln 20 QL(30 ml daily) fluphenazine hcl tabs or 1 1 0 mg, 10 mg, 2.5 mg, 5 mg mg/ml abacavir sulfate tabs 300 QL(2 ea daily) tabs or 2 mg, 1 0 4 mg, 8 mg, 16 mg mg abacavir sulfate-lamivudine QL(1 ea daily) edisylate 1 0 soln ij 10 mg/2ml tabs abacavir sulfate- QL(2 ea daily) prochlorperazine maleate 1 0 tabs or 10 mg, 5 mg lamivudine-zidovudine tabs QL(4 ea daily) prochlorperazine supp 1 APTIVUS CAPS 250 MG 0 APTIVUS SOLN 100 QL(10 ml daily) hcl tabs or 10 1 0 mg, 100 mg, 25 mg, 50 mg MG/ML QL(2 ea daily) hcl tabs 1 atazanavir sulfate caps 0 Quinolinone Derivatives ATRIPLA TABS (Use QL(1 ea daily) -emtricitabine- 0 QL(1 ea per 28 tenofovir disoproxil ABILIFY MAINTENA PRSY 2 days retail); fumarate) 300 MG, 400 MG AL(At least 18 yrs old); SP BIKTARVY TABS 0 QL(1 ea daily) QL(1 ea per 28 COMBIVIR TABS (Use 0 QL(2 ea daily) ABILIFY MAINTENA SRER 2 days retail); lamivudine-zidovudine) 300 MG AL(At least 18 yrs old); SP COMPLERA TABS 0 QL(1 ea daily) ABILIFY MAINTENA SRER 2 SP QL(9 ea daily) 400 MG CRIXIVAN CAPS 200 MG 0 ABILIFY TABS (Use NP QL(1 ea daily) QL(6 ea daily) aripiprazole) CRIXIVAN CAPS 400 MG 0 QL(30 ml daily) aripiprazole soln 1 mg/ml 1 DELSTRIGO TABS 0 QL(1 ea daily)

DESCOVY TABS 0 PA; QL(1 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits didanosine cpdr 0 QL(1 ea daily) INTELENCE TABS 100 NP QL(4 ea daily) MG (Use etravirine) DOVATO TABS 0 INTELENCE TABS 200 NP QL(2 ea daily) MG (Use etravirine) QL(1 ea daily) EDURANT TABS 0 INTELENCE TABS 25 MG 0 QL(4 ea daily) QL(1 ea daily) efavirenz caps 200 mg 0 INVIRASE TABS 0 QL(4 ea daily) QL(2 ea daily) efavirenz caps 50 mg 0 ISENTRESS CHEW 100 0 QL(6 ea daily) MG efavirenz tabs 600 mg 0 QL(1 ea daily) ISENTRESS CHEW 25 MG 0 QL(12 ea daily) efavirenz-emtricitabine- QL(1 ea daily) tenofovir disoproxil 0 ISENTRESS PACK 100 0 QL(2 ea daily) fumarate tabs MG efavirenz-lamivudine- QL(1 ea daily) ISENTRESS TABS 400 0 QL(2 ea daily) tenofovir disoproxil 0 MG fumarate tabs KALETRA SOLN 400 QL(160 ml per QL(1 ea daily) MG/5ML-100 MG/5ML 0 fill retail) emtricitabine caps 0 (Use lopinavir-ritonavir) KALETRA TABS 25 MG- QL(4 ea daily) emtricitabine-tenofovir 0 QL(1 ea daily) disoproxil fumarate tabs 100 MG (Use lopinavir- NP ritonavir) EMTRIVA CAPS 200 MG 0 QL(1 ea daily) (Use emtricitabine) KALETRA TABS 50 MG- QL(6 ea daily) 200 MG (Use lopinavir- NP EMTRIVA SOLN 10 0 QL(24 ml daily) ritonavir) MG/ML lamivudine soln 10 mg/ml 0 QL(30 ml daily) EPIVIR SOLN 10 MG/ML 0 QL(30 ml daily) (Use lamivudine) lamivudine tabs 150 mg 0 QL(2 ea daily) EPIVIR TABS 150 MG 0 QL(2 ea daily) (Use lamivudine) lamivudine tabs 300 mg 0 QL(1 ea daily) EPIVIR TABS 300 MG 0 QL(1 ea daily) (Use lamivudine) lamivudine-zidovudine tabs 0 QL(2 ea daily) EPZICOM TABS (Use QL(1 ea daily) abacavir sulfate- 0 LEXIVA SUSP 50 MG/ML 0 QL(56 ml daily) lamivudine) QL(4 ea daily) LEXIVA TABS 700 MG QL(4 ea daily) etravirine tabs 100 mg 0 (Use fosamprenavir 0 calcium) etravirine tabs 200 mg 0 QL(2 ea daily) lopinavir-ritonavir soln 100 0 QL(160 ml per EVOTAZ TABS 0 QL(1 ea daily) mg/5ml-400 mg/5ml fill retail) lopinavir-ritonavir tabs 25 0 QL(4 ea daily) fosamprenavir calcium tabs 0 QL(4 ea daily) mg-100 mg lopinavir-ritonavir tabs 50 0 QL(6 ea daily) FUZEON SOLR 0 PA; SP mg-200 mg nevirapine susp 50 mg/5ml 0 QL(40 ml daily) GENVOYA TABS 0 QL(1 ea daily) nevirapine tabs 200 mg 0 QL(2 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nevirapine tb24 100 mg 0 QL(3 ea daily) STAVUDINE CAPS 15 MG, 0 QL(2 ea daily) 20 MG, 30 MG, 40 MG QL(1 ea daily) nevirapine tb24 400 mg 0 stavudine caps 15 mg, 20 0 QL(2 ea daily) mg, 30 mg, 40 mg NORVIR PACK 100 MG 0 STRIBILD TABS 0 QL(15 ml daily) NORVIR SOLN 80 MG/ML 0 SUSTIVA CAPS 200 MG 0 QL(1 ea daily) (Use efavirenz) NORVIR TABS 100 MG 0 QL(12 ea daily) (Use ritonavir) SUSTIVA CAPS 50 MG 0 QL(2 ea daily) (Use efavirenz) ODEFSEY TABS 0 PA SUSTIVA TABS 600 MG 0 QL(1 ea daily) (Use efavirenz) QL(1 ea daily) PIFELTRO TABS 0 SYMFI LO TABS (Use QL(1 ea daily) QL(1 ea daily) efavirenz-lamivudine- 0 PREZCOBIX TABS 0 tenofovir disoproxil fumarate) PREZISTA SUSP 100 0 QL(12 ml daily) MG/ML SYMFI TABS (Use QL(1 ea daily) QL(3 ea daily) efavirenz-lamivudine- 0 PREZISTA TABS 150 MG 0 tenofovir disoproxil fumarate) PREZISTA TABS 600 MG, 0 QL(2 ea daily) 75 MG, 800 MG SYMTUZA TABS 0 QL(1 ea daily) RESCRIPTOR TABS 0 QL(6 ea daily) tenofovir disoproxil 0 QL(1 ea daily) fumarate tabs RETROVIR CAPS 100 MG 0 QL(6 ea daily) (Use zidovudine) TIVICAY PD TBSO 0 RETROVIR IV INFUSION 0 PA SOLN TIVICAY TABS 0 RETROVIR SYRP 50 0 QL(60 ml daily) MG/5ML (Use zidovudine) TRIUMEQ TABS 0 REYATAZ CAPS 150 MG, QL(2 ea daily) TRIZIVIR TABS (Use QL(2 ea daily) 200 MG, 300 MG (Use 0 abacavir sulfate- 0 atazanavir sulfate) lamivudine-zidovudine) REYATAZ PACK 50 MG 0 QL(6 ea daily) TRUVADA TABS (Use QL(1 ea daily) emtricitabine-tenofovir 0 ritonavir tabs 0 QL(12 ea daily) disoproxil fumarate) TYBOST TABS 0 QL(1 ea daily) RUKOBIA TB12 0 PA VIDEX EC CPDR 125 MG 0 QL(1 ea daily) SELZENTRY SOLN 20 0 QL(35 ml daily) MG/ML VIDEX EC CPDR 200 MG, QL(1 ea daily) SELZENTRY TABS 150 0 QL(2 ea daily) 250 MG, 400 MG (Use 0 MG didanosine) SELZENTRY TABS 25 0 QL(20 ml daily) MG, 75 MG VIDEXPEDIATRIC SOLR 0 QL(9 ea daily) SELZENTRY TABS 300 0 QL(4 ea daily) VIRACEPT TABS 250 MG 0 MG

New Hampshire Healthy Families Updated October 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRACEPT TABS 625 MG 0 QL(4 ea daily) SOFOSBUVIR/VELPATAS 2 PA; SP VIR TABS VIRAMUNE SUSP 50 0 QL(40 ml daily) PA; SP MG/5ML (Use nevirapine) VOSEVI TABS 2 VIRAMUNE TABS 200 MG 0 QL(2 ea daily) Herpes Agents ) (Use nevirapine QL(50 ea per acyclovir caps or 200 mg 1 VIRAMUNE XR TB24 (Use 0 QL(1 ea daily) 30 days retail) nevirapine) acyclovir susp or 200 1 QL(400 ml per VIREAD POWD 40 MG/GM 0 mg/5ml 30 days retail) acyclovir tabs or 400 mg 1 QL(3 ea daily) VIREAD TABS 150 MG, 0 QL(1 ea daily) 200 MG, 250 MG QL(50 ea per acyclovir tabs or 800 mg 1 VIREAD TABS 300 MG QL(1 ea daily) 30 days retail) (Use tenofovir disoproxil 0 fumarate) famciclovir tabs or 125 mg, 1 250 mg, 500 mg ZIAGEN SOLN 20 MG/ML 0 QL(30 ml daily) valacyclovir hcl tabs or 1 QL(42 ea per (Use abacavir sulfate) 1 gm, 1000 mg 21 days retail) ZIAGEN TABS 300 MG 0 QL(2 ea daily) valacyclovir hcl tabs or 500 QL(2 ea daily) (Use abacavir sulfate) 1 mg zidovudine caps 100 mg 0 QL(6 ea daily) VALTREX TABS 1 GM NP QL(42 ea per (Use valacyclovir hcl) 21 days retail) zidovudine syrp 50 mg/5ml 0 QL(60 ml daily) VALTREX TABS 500 MG NP QL(2 ea daily) (Use valacyclovir hcl) zidovudine tabs 300 mg 0 QL(2 ea daily) ZOVIRAX CAPS OR 200 NP QL(50 ea per CMV Agents MG (Use acyclovir) 30 days retail) PA; SP ZOVIRAX SUSP OR 200 NP QL(400 ml per PREVYMIS SOLN 2 MG/5ML (Use acyclovir) 30 days retail) PA; SP ZOVIRAX TABS OR 400 NP QL(3 ea daily) PREVYMIS TABS 2 MG (Use acyclovir) ZOVIRAX TABS OR 800 QL(50 ea per VALCYTE TABS 450 MG NP QL(2 ea daily) NP (Use valganciclovir hcl) MG (Use acyclovir) 30 days retail) valganciclovir hcl tabs 450 1 QL(2 ea daily) Influenza Agents mg oseltamivir phosphate caps 1 QL(20 ea per Hepatitis Agents or 30 mg fill retail) oseltamivir phosphate caps QL(10 ea per LEDIPASVIR/SOFOSBUVI 2 PA; SP 1 R TABS or 45 mg, 75 mg fill retail) MAVYRET TABS 2 PA; SP oseltamivir phosphate susr 1 QL(120 ml per or 6 mg/ml fill retail) PEGASYS PROCLICK PA; SP 2 hydrochloride 1 PA SOLN tabs PEGASYS SOLN 2 PA; SP TAMIFLU CAPS 30 MG QL(20 ea per (Use oseltamivir 2 fill retail) ribavirin (hepatitis c) caps 1 PA; SP phosphate) TAMIFLU CAPS 45 MG, 75 QL(10 ea per ribavirin (hepatitis c) tabs 1 PA; SP MG (Use oseltamivir 2 fill retail) phosphate) New Hampshire Healthy Families Updated October 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAMIFLU SUSR 6 MG/ML QL(120 ml per metoprolol tartrate tabs or 1 QL(4 ea daily) (Use oseltamivir 2 fill retail) 25 mg, 50 mg phosphate) metoprolol tartrate tabs or 1 BETA BLOCKERS - Drugs to Treat High Blood 75 mg, 37.5 mg Pressure TENORMIN TABS (Use NP QL(2 ea daily) atenolol) Alpha-Beta Blockers QL(1 ea daily) TOPROL XL TB24 100 QL(4 ea daily) phosphate cp24 1 MG, 25 MG, 50 MG (Use NP metoprolol succinate) carvedilol tabs 12.5 mg, 1 QL(3 ea daily) 3.125 mg, 6.25 mg TOPROL XL TB24 200 MG NP QL(2 ea daily) (Use metoprolol succinate) carvedilol tabs 25 mg 1 QL(4 ea daily) Beta Blockers Non-Selective COREG CR CP24 (Use QL(1 ea daily) NP BETAPACE AF TABS (Use NP QL(2 ea daily) carvedilol phosphate) hcl (afib/afl)) COREG TABS 12.5 MG, QL(3 ea daily) BETAPACE TABS (Use NP QL(2 ea daily) 3.125 MG, 6.25 MG (Use NP sotalol hcl) carvedilol) CORGARD TABS (Use NP COREG TABS 25 MG (Use NP QL(4 ea daily) ) carvedilol) INDERAL LA CP24 (Use NP QL(2 ea daily) hcl tabs or 100 mg 1 QL(3 ea daily) propranolol hcl) nadolol tabs or 20 mg, 40 1 labetalol hcl tabs or 200 mg 1 QL(6 ea daily) mg, 80 mg tabs 1 labetalol hcl tabs or 300 mg 1 QL(8 ea daily) propranolol hcl cp24 or 60 QL(2 ea daily) Beta Blockers Cardio-Selective mg, 80 mg, 120 mg, 160 1 hcl caps or 400 1 mg mg, 200 mg propranolol hcl soln or 20 1 atenolol tabs or 100 mg, 25 1 QL(2 ea daily) mg/5ml, 40 mg/5ml mg, 50 mg propranolol hcl tabs or 10 hcl tabs 1 mg, 20 mg, 80 mg, 40 mg, 1 60 mg bisoprolol fumarate tabs or 1 QL(1 ea daily) QL(2 ea daily) 10 mg, 5 mg sotalol hcl (afib/afl) tabs 1 LOPRESSOR TABS 100 QL(4.5 ea sotalol hcl tabs 120 mg, 1 QL(2 ea daily) MG (Use metoprolol NP daily) 160 mg, 80 mg tartrate) sotalol hcl tabs 240 mg 1 LOPRESSOR TABS 50 QL(4 ea daily) MG (Use metoprolol NP maleate tabs or 20 1 tartrate) mg, 5 mg, 10 mg metoprolol succinate tb24 1 QL(4 ea daily) CALCIUM CHANNEL BLOCKERS - Drugs to 100 mg, 25 mg, 50 mg Treat High Blood Pressure metoprolol succinate tb24 1 QL(2 ea daily) 200 mg Calcium Channel Blockers ADALAT CC TB24 30 MG, QL(1 ea daily) metoprolol tartrate tabs or 1 QL(4.5 ea NP 100 mg daily) 90 MG (Use nifedipine)

New Hampshire Healthy Families Updated October 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADALAT CC TB24 60 MG NP QL(2 ea daily) nifedipine caps or 10 mg, 1 QL(4 ea daily) (Use nifedipine) 20 mg amlodipine besylate tabs or 1 QL(1 ea daily) nifedipine tb24 or 30 mg, 1 QL(1 ea daily) 10 mg, 2.5 mg, 5 mg 90 mg CALAN SR TBCR (Use NP QL(2 ea daily) nifedipine tb24 or 60 mg 1 QL(2 ea daily) verapamil hcl) CALAN TABS (Use NP QL(3 ea daily) nimodipine caps or 1 verapamil hcl) CARDIZEM CD CP24 120 QL(1 ea daily) nisoldipine tb24 1 MG, 180 MG, 300 MG (Use NP diltiazem hcl coated beads) NORVASC TABS (Use NP QL(1 ea daily) amlodipine besylate) CARDIZEM CD CP24 240 QL(2 ea daily) MG (Use diltiazem hcl NP PROCARDIA CAPS (Use NP QL(4 ea daily) coated beads) nifedipine) CARDIZEM CD CP24 360 PROCARDIA XL TB24 30 QL(1 ea daily) MG (Use diltiazem hcl NP MG, 90 MG (Use NP coated beads) nifedipine) PROCARDIA XL TB24 60 QL(2 ea daily) CARDIZEM LA TB24 (Use NP NP diltiazem hcl coated beads) MG (Use nifedipine) SULAR TB24 (Use CARDIZEM TABS (Use NP QL(3 ea daily) NP diltiazem hcl) nisoldipine) diltiazem hcl coated beads QL(1 ea daily) TIAZAC CP24 (Use QL(1 ea daily) cp24 120 mg, 180 mg, 300 1 diltiazem hcl extended NP mg release beads) verapamil hcl cp24 or 100 QL(2 ea daily) diltiazem hcl coated beads 1 QL(2 ea daily) cp24 240 mg mg, 120 mg, 180 mg, 240 1 mg diltiazem hcl coated beads 1 cp24 360 mg verapamil hcl cp24 or 300 1 mg diltiazem hcl coated beads tb24 180 mg, 240 mg, 300 1 verapamil hcl cp24 or 360 1 QL(1 ea daily) mg, 360 mg, 420 mg mg verapamil hcl tabs or 40 QL(3 ea daily) diltiazem hcl cp12 or 120 1 QL(2 ea daily) 1 mg, 60 mg, 90 mg mg, 120 mg, 80 mg verapamil hcl tbcr or 120 QL(2 ea daily) diltiazem hcl cp24 or 120 1 QL(1 ea daily) 1 mg, 240 mg mg, 180 mg, 240 mg VERELAN CP24 (Use QL(2 ea daily) diltiazem hcl cp24 or 180 1 NP mg verapamil hcl) VERELAN PM CP24 100 QL(2 ea daily) diltiazem hcl extended 1 QL(1 ea daily) NP release beads cp24 MG (Use verapamil hcl) VERELAN PM CP24 300 diltiazem hcl tabs or 120 1 QL(3 ea daily) NP mg, 30 mg, 60 mg, 90 mg MG (Use verapamil hcl) felodipine tb24 1 QL(1 ea daily) CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm isradipine caps 1 Cardiac Glycosides digoxin soln or 0.05 mg/ml 1 nicardipine hcl caps or 20 1 mg, 30 mg New Hampshire Healthy Families Updated October 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits digoxin tabs or 0.25 mg, REVATIO SUSR OR 10 SP 1 250 mcg, 0.125 mg, 125 MG/ML (Use NP mcg citrate (pulmonary LANOXIN TABS OR 250 hypertension)) MCG, 125 MCG (Use 2 REVATIO TABS OR 20 PA; SP digoxin) MG (Use sildenafil citrate NP (pulmonary hypertension)) CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions sildenafil citrate (pulmonary PA; SP hypertension) soln iv 10 1 Cardiovascular Agents Misc. - Combinations mg/12.5ml amlodipine besylate- 1 sildenafil citrate (pulmonary SP atorvastatin calcium tabs hypertension) susr or 10 1 CADUET TABS (Use mg/ml amlodipine besylate- NP sildenafil citrate (pulmonary PA; SP atorvastatin calcium) hypertension) tabs or 20 1 ENTRESTO TABS 2 mg tadalafil (pulmonary 1 PA; SP Prostaglandin Vasodilators hypertension) tabs epoprostenol sodium solr 1 PA; SP Transthyretin Stabilizers PA; QL(1 ea VYNDAMAX CAPS 2 FLOLAN SOLR (Use NP PA; SP daily); SP epoprostenol sodium) PA; QL(4 ea VYNDAQEL CAPS 2 REMODULIN SOLN NP PA; SP daily); SP PA; SP CEPHALOSPORINS - Drugs to Treat Bacterial treprostinil soln 1 Infections VELETRI SOLR (Use NP PA; SP Cephalosporins - 1st Generation epoprostenol sodium) cefadroxil caps 1 Pulmonary Hypertension - Endothelin Receptor ambrisentan tabs 1 PA; SP cefadroxil susr 1 bosentan tabs 1 PA; SP cefadroxil tabs 1 cephalexin caps 250 mg, LETAIRIS TABS (Use 2 PA; SP 1 ambrisentan) 500 mg cephalexin susr 125 TRACLEER TABS (Use NP PA; SP 1 bosentan) mg/5ml, 250 mg/5ml Pulmonary Hypertension - Phosphodiesterase KEFLEX CAPS 250 MG, NP 500 MG (Use cephalexin) ADCIRCA TABS (Use PA; SP tadalafil (pulmonary NP Cephalosporins - 2nd Generation hypertension)) cefaclor caps 1 REVATIO SOLN IV 10 PA; SP MG/12.5ML (Use sildenafil NP CEFACLOR ER TB12 2 citrate (pulmonary hypertension)) cefaclor susr 1

New Hampshire Healthy Families Updated October 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(75 ml per Up to 12-month cefprozil susr 125 mg/5ml, 1 fill retail); supply of 250 mg/5ml AL(Up to 12 yrs desogestrel-ethinyl 0 contraceptives old ) estradiol (biphasic) tabs and devices allowed; $0 cefprozil tabs 250 mg, 500 1 QL(20 ea per mg fill retail) copay;PV QL(20 ea per Up to 12-month cefuroxime axetil tabs 1 fill retail) supply of contraceptives Cephalosporins - 3rd Generation desogestrel-ethinyl 0 and devices QL(20 ea per estradiol (triphasic) tabs allowed; $0 cefdinir caps 300 mg 1 fill retail) copay;QL(4 ea per fill retail); cefdinir susr 125 mg/5ml, 1 QL(60 ml per 250 mg/5ml fill retail) PV Up to 12-month cefditoren pivoxil tabs 1 supply of drospirenone-ethinyl 0 contraceptives cefixime caps 1 estradiol tabs and devices allowed; $0 cefixime susr 1 copay;PV Up to 12-month cefpodoxime proxetil susr 1 supply of drospirenone-ethinyl 0 contraceptives cefpodoxime proxetil tabs 1 estradiol-levomefolate and devices calcium tabs allowed; $0 ceftriaxone sodium solr ij 1 1 QL(3 ea per fill gm, 250 mg, 500 mg retail) copay;PV Up to 12-month SUPRAX CAPS (Use NP cefixime) supply of ESTROSTEP FE TABS contraceptives SUPRAX SUSR (Use (Use norethindrone NP NP acetate-ethinyl estradiol-fe) and devices cefixime) allowed; $0 CONTRACEPTIVES - Drugs to Prevent copay;PV Pregnancy Up to 12-month supply of Combination Contraceptives - Oral contraceptives Up to 12-month ethynodiol diacet & eth 0 and devices BEYAZ TABS (Use supply of estrad tabs allowed; $0 drospirenone-ethinyl NP contraceptives copay;QL(12 estradiol-levomefolate and devices ea per fill calcium) allowed; $0 retail); PV copay;PV Up to 12-month Up to 12-month supply of supply of FALESSA KIT 0.1 MG-1 0 contraceptives desogestrel & ethinyl 0 contraceptives MG-20 MCG and devices estradiol tabs and devices allowed; $0 allowed; $0 copay;PV copay;PV

New Hampshire Healthy Families Updated October 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Up to 12-month Up to 12-month supply of supply of GENERESS FE CHEW contraceptives contraceptives (Use norethindrone & NP ethinyl estradiol-fe) and devices and devices allowed; $0 LOSEASONIQUE TABS allowed; $0 copay;PV (Use levonorgestrel-ethinyl NP copay;4 rtl pack Up to 12-month estradiol (91-day)) lmt amt,365 rtl supply of pack lmt day(s),4 rtl levonorgestrel & eth 0 contraceptives estradiol tabs and devices pack lmt per allowed; $0 fill,; PV copay;PV Up to 12-month Up to 12-month supply of MINASTRIN 24 FE CHEW contraceptives supply of (Use norethin acet & NP and devices levonorgestrel-eth estradiol 0 contraceptives estrad-fe) (triphasic) tabs and devices allowed; $0 allowed; $0 copay;PV copay;PV Up to 12-month supply of Up to 12-month MIRCETTE TABS (Use supply of desogestrel-ethinyl NP contraceptives contraceptives estradiol (biphasic)) and devices and devices allowed; $0 allowed; $0 copay;PV levonorgestrel-ethinyl 0 copay;4 rtl pack estradiol (91-day) tabs Up to 12-month lmt amt,365 rtl supply of pack lmt NATAZIA TABS 0 contraceptives day(s),4 rtl and devices pack lmt per allowed; $0 fill,; PV copay;PV Up to 12-month Up to 12-month supply of supply of levonorgestrel-ethinyl 0 contraceptives norethin acet & estrad-fe 0 contraceptives estradiol (91-day) tabs and devices caps 1 mg-20 mcg-75 mg and devices allowed; $0 allowed; $0 copay;PV copay;PV Up to 12-month Up to 12-month supply of supply of levonorgestrel-ethinyl 0 contraceptives norethin acet & estrad-fe 0 contraceptives estradiol (continuous) tabs and devices chew 1 mg-20 mcg-75 mg and devices allowed; $0 allowed; $0 copay;PV copay;PV Up to 12-month norethin acet & estrad-fe 0 supply of tabs 1 mg-20 mcg-75 mg contraceptives LO LOESTRIN FE TABS 0 Up to 12-month and devices supply of allowed; $0 norethin acet & estrad-fe 0 contraceptives copay;PV tabs 1 mg-20 mcg-75 mg, and devices 1.5 mg-30 mcg-75 mg allowed; $0 copay;PV

New Hampshire Healthy Families Updated October 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Up to 12-month Up to 12-month supply of supply of norethindrone & eth ORTHO TRI-CYCLEN LO 0 contraceptives NP contraceptives estradiol tabs 0.5 mg-35 and devices TABS (Use norgestimate- mcg, 0.4 mg-35 mcg ethinyl estradiol (triphasic)) and devices allowed; $0 allowed; $0 copay;PV copay;PV norethindrone & eth 0 ORTHO-NOVUM 1/35 estradiol tabs 1 mg-35 mcg TABS (Use norethindrone NP Up to 12-month & eth estradiol) supply of Up to 12-month contraceptives norethindrone & ethinyl 0 ORTHO-NOVUM 7/7/7 supply of estradiol-fe chew and devices NP contraceptives allowed; $0 TABS (Use norethindrone- eth estradiol (triphasic)) and devices copay;PV allowed; $0 Up to 12-month copay;PV supply of Up to 12-month norethindrone acet & eth contraceptives supply of 0 QUARTETTE TABS (Use estra tabs and devices NP contraceptives allowed; $0 levonorgestrel-ethinyl estradiol (91-day)) and devices copay;PV allowed; $0 Up to 12-month copay;PV supply of Up to 12-month norethindrone acetate- 0 contraceptives SAFYRAL TABS (Use supply of ethinyl estradiol-fe tabs and devices drospirenone-ethinyl NP contraceptives allowed; $0 estradiol-levomefolate and devices copay;PV calcium) allowed; $0 Up to 12-month copay;PV supply of Up to 12-month norethindrone-eth estradiol contraceptives supply of 0 SEASONIQUE TABS (Use (triphasic) tabs and devices NP contraceptives allowed; $0 levonorgestrel-ethinyl estradiol (91-day)) and devices copay;PV allowed; $0 Up to 12-month copay;PV supply of Up to 12-month norgestimate-ethinyl 0 contraceptives supply of estradiol (triphasic) tabs and devices TAYTULLA CAPS (Use NP contraceptives allowed; $0 norethin acet & estrad-fe) and devices copay;PV allowed; $0 Up to 12-month copay;PV supply of Up to 12-month norgestimate-ethinyl 0 contraceptives supply of estradiol tabs and devices TYBLUME CHEW 0 contraceptives allowed; $0 and devices copay;PV allowed; $0 Up to 12-month copay;PV supply of norgestrel & ethinyl 0 contraceptives estradiol tabs 0.3 mg-30 and devices mcg allowed; $0 copay;PV New Hampshire Healthy Families Updated October 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Up to 12-month Up to 12-month Use supply of supply of YASMIN 28 TABS ( contraceptives contraceptives drospirenone-ethinyl NP ELLA TABS 0 estradiol) and devices and devices allowed; $0 allowed; $0 copay;PV copay;PV Up to 12-month Up to 12-month supply of supply of YAZ TABS (Use NP contraceptives levonorgestrel (emergency 0 contraceptives drospirenone-ethinyl and devices estradiol) and devices oc) tabs allowed; $0 allowed; $0 copay;PV copay;PV Combination Contraceptives - Transdermal Up to 12-month Up to 12-month supply of PLAN B ONE-STEP TABS contraceptives supply of (Use levonorgestrel NP and devices norelgestromin-ethinyl 0 contraceptives (emergency oc)) and devices allowed; $0 estradiol ptwk copay;PV allowed; $0 copay;PV Progestin Contraceptives - IUD Combination Contraceptives - Vaginal Up to 12-month Up to 12-month supply of contraceptives supply of KYLEENA IUD 0 contraceptives and devices etonogestrel-ethinyl and devices allowed; $0 0 copay;SP; PV estradiol ring allowed; $0 copay;QL(12 Up to 12-month ea per fill supply of retail); PV 0 contraceptives LILETTA IUD and devices Up to 12-month allowed; $0 supply of copay;SP; PV contraceptives NUVARING RING (Use Up to 12-month etonogestrel-ethinyl NP and devices allowed; $0 supply of estradiol) contraceptives copay;QL(12 MIRENA IUD 0 ea per fill and devices retail); PV allowed; $0 copay;SP; PV Copper Contraceptives - IUD Up to 12-month Up to 12-month supply of PARAGARD supply of contraceptives SKYLA IUD 0 INTRAUTERINE COPPER 0 contraceptives and devices CONTRACEPTIVE T380A and devices allowed; $0 IUD allowed; $0 copay;SP; PV copay;PV Progestin Contraceptives - Implants Emergency Contraceptives

New Hampshire Healthy Families Updated October 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Up to 12-month Up to 12-month supply of supply of norethindrone contraceptives NEXPLANON IMPL 0 contraceptives 0 and devices (contraceptive) tabs and devices allowed; $0 allowed; $0 copay;SP; PV copay;PV Progestin Contraceptives - Injectable Up to 12-month supply of Up to 12-month ORTHO MICRONOR NP contraceptives supply of TABS (Use norethindrone and devices DEPO-PROVERA contraceptives (contraceptive)) allowed; $0 CONTRACEPTIVE SUSP NP and devices copay;PV (Use medroxyprogesterone allowed; $0 acetate (contraceptive)) copay;QL(4 ml CORTICOSTEROIDS - Steroid Hormone Drugs to per fill retail); Treat Systemic Swelling Conditions PV Glucocorticosteroids Up to 12-month supply of budesonide tb24 or 9 mg 1 DEPO-PROVERA contraceptives CORTEF TABS (Use CONTRACEPTIVE SUSY NP and devices NP (Use medroxyprogesterone allowed; $0 hydrocortisone) acetate (contraceptive)) copay;QL(4 ml cortisone acetate tabs or 1 per fill retail); PV elix or 0.5 1 Up to 12-month mg/5ml supply of DEXAMETHASONE 2 contraceptives INTENSOL CONC DEPO-SUBQ PROVERA 0 and devices dexamethasone sodium QL(150 ml per 104 SUSY allowed; $0 phosphate soln ij 120 1 30 days retail) copay;QL(4 ml mg/30ml, 20 mg/5ml, 4 per fill retail); mg/ml PV DEXAMETHASONE QL(150 ml per Up to 12-month SODIUM PHOSPHATE 2 30 days retail) supply of SOLN IJ 4 MG/ML contraceptives medroxyprogesterone and devices dexamethasone soln or 0.5 1 acetate (contraceptive) 0 mg/5ml allowed; $0 susp copay;QL(4 ml dexamethasone tabs or 1 per fill retail); mg, 1.5 mg, 2 mg, 4 mg, 1 PV 0.5 mg, 0.75 mg, 6 mg Up to 12-month EMFLAZA SUSP 2 PA; SP supply of contraceptives PA; SP medroxyprogesterone EMFLAZA TABS 2 and devices acetate (contraceptive) 0 allowed; $0 hydrocortisone tabs or 10 1 susy copay;QL(4 ml mg, 20 mg, 5 mg per fill retail); MEDROL DOSEPAK TBPK NP PV (Use methylprednisolone) Progestin Contraceptives - Oral

New Hampshire Healthy Families Updated October 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDROL TABS 8 MG, 4 HYCODAN SYRP (Use MG (Use NP hydrocodone w/ NP methylprednisolone) homatropine) methylprednisolone tabs or 1 hydrocodone w/ 8 mg, 4 mg homatropine syrp 1.5 1 mg/5ml-5 mg/5ml methylprednisolone tbpk or 1 4 mg TESSALON PERLES NP AL(At least 10 PEDIAPRED SOLN (Use CAPS (Use benzonatate) yrs old) prednisolone sodium NP Cough/Cold/Allergy Combinations phosphate) ADVIL COLD & SINUS prednisolone sodium QL(240 ml per TABS (Use NP phosphate soln or 15 1 fill retail) - mg/5ml ibuprofen) prednisolone sodium QL(150 ml per & QL(120 ml per phosphate soln or 20 1 fill retail) phenyleph elix 1 mg/5ml-1 1 fill retail) mg/5ml mg/5ml-2.5 mg/5ml-2.5 prednisolone sodium mg/5ml phosphate soln or 5 1 brompheniramine & 1 QL(120 ml per mg/5ml, 6.7 mg/5ml pseudoeph elix fill retail) prednisolone soln or 1 brompheniramine & 1 QL(120 ml per pseudoeph liqd fill retail) PREDNISONE INTENSOL 2 CHERACOL PLUS LIQD QL(240 ml per CONC (Use dextromethorphan- NP fill retail) prednisone soln or 5 1 ) mg/5ml CHERACOL-D COUGH QL(240 ml per prednisone tabs or 1 mg, LIQD (Use NP fill retail) 10 mg, 2.5 mg, 5 mg, 50 1 dextromethorphan- mg, 20 mg guaifenesin) prednisone tbpk or 10 mg, 1 dextromethorphan- QL(240 ml per 5 mg guaifenesin liqd 10 mg/5ml- fill retail) 100 mg/5ml, 15 mg/7.5ml- 1 UCERIS TB24 (Use NP budesonide) 150 mg/7.5ml, 20 mg/10ml- PA; SP 200 mg/10ml ZILRETTA SRER 2 DIMETAPP COLD & QL(120 ml per Mineralocorticoids ALLERGY ELIX (Use NP fill retail) brompheniramine & fludrocortisone acetate 1 phenyleph) tabs or guaifenesin-codeine liqd 10 1 QL(240 ml per COUGH/COLD/ALLERGY - Drugs to Treat mg/5ml-100 mg/5ml fill retail) Cough, Cold and Allergy Symptoms guaifenesin-codeine soln 1 QL(240 ml per Antitussives 10 mg/5ml-100 mg/5ml fill retail) AL(At least 10 guaifenesin-codeine syrp QL(240 ml per benzonatate caps 100 mg 1 1 yrs old) 10 mg/5ml-100 mg/5ml fill retail) QL(1 ea daily); MAXI-TUSS PE LIQD 2 benzonatate caps 200 mg 1 AL(At least 10 QL(240 ml per yrs old) phenylephrine-dm liqd 1 fill retail)

New Hampshire Healthy Families Updated October 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per RX/OTC phenylephrine-dm soln 1 adapalene gel 0.1 % 1 fill retail) QL(240 ml per adapalene gel 0.3 % 1 promethazine & 1 fill retail); AL(At phenylephrine syrp least 2 yrs old) adapalene lotn 0.1 % 1 QL(240 ml per promethazine w/codeine 1 fill retail); AL(At soln ADAPALENE SOLN 0.1 % 2 least 6 yrs old) QL(240 ml per adapalene-benzoyl 1 promethazine w/codeine 1 fill retail); AL(At peroxide gel syrp least 6 yrs old) ATRALIN GEL (Use NP promethazine- QL(240 ml per tretinoin) phenylephrine-codeine 1 fill retail); AL(At BENZAC AC WASH LIQD NP RX/OTC syrp least 6 yrs old) (Use benzoyl peroxide) BENZACLIN GEL (Use pseudoephedrine-ibuprofen 1 tabs clindamycin phosphate- 2 benzoyl peroxide) VIRTUSSIN DAC SOLN 1 QL(240 ml per fill retail) BENZACLIN WITH PUMP GEL (Use clindamycin 2 Misc. Respiratory Inhalants phosphate-benzoyl HYPER-SAL NEBU (Use NP peroxide) sodium chloride (inhalant)) benzoyl peroxide gel ex 2.5 1 HYPERSAL NEBU 7 % %, 5 %, 10 % (Use sodium chloride NP benzoyl peroxide liqd ex 10 1 (inhalant)) % sodium chloride (inhalant) QL(240 ml per 1 benzoyl peroxide liqd ex 5 1 RX/OTC aers 0.9 % fill retail) % sodium chloride (inhalant) 1 CLEOCIN-T GEL (Use QL(75 ml per nebu 0.9 %, 7 % clindamycin phosphate NP fill retail) Mucolytics (topical)) CLEOCIN-T LOTN (Use QL(60 ml per acetylcysteine soln in 10 1 %, 20 % clindamycin phosphate NP fill retail) (topical)) DERMATOLOGICALS - Drugs to Treat Skin Conditions CLINDAGEL GEL (Use QL(75 ml per clindamycin phosphate NP fill retail) Acne Products (topical)) ABSORICA CAPS 10 MG, QL(2 ea daily); clindamycin phosphate 1 QL(75 ml per 20 MG, 40 MG (Use NP AL(At least 12 (topical) gel fill retail) isotretinoin) yrs old) clindamycin phosphate 1 QL(60 ml per ACANYA GEL (Use (topical) lotn fill retail) clindamycin phosphate- NP clindamycin phosphate 1 benzoyl peroxide) (topical) soln ACNE MEDICATION 10 2 clindamycin phosphate- LOTN benzoyl peroxide 1 ACNE MEDICATION 5 2 (refrigerate) gel LOTN clindamycin phosphate- 1 adapalene crea 0.1 % 1 benzoyl peroxide gel

New Hampshire Healthy Families Updated October 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate- 1 SODIUM QL(30 gm per tretinoin gel SULFACETAMIDE/SULFU 2 fill retail) R SUSP 5 %-10 % DIFFERIN CREA 0.1 % 2 (Use adapalene) sulfacetamide sodium 1 QL(120 ml per (acne) lotn fill retail) DIFFERIN GEL 0.1 % (Use NP RX/OTC adapalene) sulfacetamide sodium w/ 1 QL(60 gm per sulfur lotn 5 %-10 % fill retail) DIFFERIN GEL 0.3 % (Use 2 ) AL(Up to 35 yrs adapalene tretinoin crea ex 0.025 % 1 old ) DIFFERIN LOTN 0.1 % 2 QL(20 gm per DUAC GEL (Use tretinoin crea ex 0.05 %, 1 fill retail); 0.1 %, 0.025 % AL(Up to 35 yrs clindamycin phosphate- NP benzoyl peroxide old ) (refrigerate)) QL(15 gm per fill retail); EPIDUO GEL (Use tretinoin gel ex 0.01 % 1 adapalene-benzoyl NP AL(Up to 35 yrs peroxide) old ) AL(Up to 35 yrs ERYGEL GEL (Use NP QL(60 gm per tretinoin gel ex 0.025 % 1 erythromycin (acne aid)) fill retail) old ) QL(60 gm per tretinoin gel ex 0.05 %, erythromycin (acne aid) gel 1 1 fill retail) 0.025 % erythromycin (acne aid) 1 tretinoin microsphere gel 1 soln QL(2 ea daily); VELTIN GEL (Use isotretinoin caps or 10 mg, 1 AL(At least 12 clindamycin phosphate- NP 20 mg, 40 mg yrs old) tretinoin) KLARON LOTN (Use QL(120 ml per ZIANA GEL (Use sulfacetamide sodium NP fill retail) clindamycin phosphate- NP (acne)) tretinoin) Anti-inflammatory Agents - Topical RETIN-A CREA 0.025 % 2 AL(Up to 35 yrs (Use tretinoin) old ) diclofenac sodium (topical) 1 QL(6.68 gm QL(20 gm per gel 1 % daily); RX/OTC RETIN-A CREA 0.05 %, fill retail); 0.1 %, 0.025 % (Use 2 VOLTAREN GEL (Use NP QL(6.68 gm tretinoin) AL(Up to 35 yrs diclofenac sodium (topical)) daily); RX/OTC old ) Antibiotics - Topical QL(15 gm per BACIGUENT OINT EX QL(453.9 gm RETIN-A GEL 0.01 % (Use 2 fill retail); NP tretinoin) AL(Up to 35 yrs (Use bacitracin (topical)) per fill retail) QL(453.9 gm old ) bacitracin (topical) oint 1 per fill retail) RETIN-A GEL 0.025 % 2 AL(Up to 35 yrs ) QL(453.6 gm (Use tretinoin old ) bacitracin zinc oint ex 1 per fill retail) RETIN-A MICRO GEL (Use NP tretinoin microsphere) QL(30 gm per CENTANY OINT NP RETIN-A MICRO PUMP fill retail) GEL (Use tretinoin NP gentamicin sulfate (topical) 1 QL(30 gm per microsphere) crea fill retail)

New Hampshire Healthy Families Updated October 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gentamicin sulfate (topical) 1 QL(30 gm per LAMISIL AT JOCK QL(42 gm per oint fill retail) CREA (Use terbinafine hcl NP fill retail) (topical)) mupirocin calcium (topical) 1 crea QL(60 gm per LOTRIMIN AF CREA (Use QL(30 gm per NP fill retail); mupirocin oint ex 1 clotrimazole (topical)) fill retail) RX/OTC LOTRIMIN AF JOCK ITCH QL(60 gm per neomycin-bacitracin- 1 QL(56 gm per polymyxin oint fill retail) CREA (Use clotrimazole NP fill retail); (topical)) RX/OTC neomycin-polymyxin w/ 1 QL(28.3 gm per pramoxine crea fill retail) LOTRISONE CREA (Use QL(45 gm per clotrimazole w/ NP fill retail) NEOSPORIN ORIGINAL QL(56 gm per betamethasone) OINT (Use neomycin- NP fill retail) bacitracin-polymyxin) luliconazole crea 1 NEOSPORIN PLUS PAIN QL(28.3 gm per RELIEF MAXIMUM fill retail) MICATIN CREA (Use NP QL(92 ml per STRENGTH CREA (Use NP miconazole nitrate (topical)) fill retail) neomycin-polymyxin w/ miconazole nitrate (topical) 1 QL(92 ml per pramoxine) crea fill retail) Antifungals - Topical NIZORAL A-D SHAM 2 QL(200 ml per fill retail) CICLODAN SOLUTION NP KIT KIT (Use ciclopirox) NIZORAL SHAM (Use NP QL(120 ml per ketoconazole (topical)) fill retail) ciclopirox kit ex 8 % 1 QL(30 gm per nystatin (topical) crea 1 fill retail) ciclopirox soln ex 8 % 1 QL(30 gm per nystatin (topical) oint 1 QL(60 gm per fill retail) clotrimazole (topical) crea 1 fill retail); nystatin (topical) powd 1 RX/OTC QL(60 gm per QL(60 ml per nystatin-triamcinolone crea 1 clotrimazole (topical) soln 1 fill retail); fill retail) RX/OTC QL(60 gm per nystatin-triamcinolone oint 1 clotrimazole w/ QL(45 gm per fill retail) betamethasone crea 0.05 1 fill retail) oxiconazole nitrate crea 1 %-1 %, 1 %-0.05 % clotrimazole w/ QL(30 ml per OXISTAT CREA (Use NP betamethasone lotn 0.05 1 fill retail) oxiconazole nitrate) %-1 % PENLAC NAIL LACQUER NP QL(85 gm per SOLN (Use ciclopirox) econazole nitrate crea ex 1 fill retail) QL(42 gm per terbinafine hcl (topical) crea 1 fill retail) ketoconazole (topical) crea 1 QL(60 gm per 2 % fill retail) TINACTIN CREA (Use NP QL(30 gm per tolnaftate) fill retail) ketoconazole (topical) 1 QL(200 ml per sham 1 % fill retail) QL(30 gm per tolnaftate crea ex 1 fill retail) ketoconazole (topical) 1 QL(120 ml per sham 2 % fill retail) Antihistamines-Topical LAMISIL AT CREA (Use NP QL(42 gm per terbinafine hcl (topical)) fill retail) ITCH RELIEF CREA 2 New Hampshire Healthy Families Updated October 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antineoplastic or Premalignant Lesion Agents - OVACE PLUS WASH LIQD QL(480 ml per (Use sulfacetamide NP fill retail) CARAC CREA (Use 2 QL(30 gm per sodium) fluorouracil (topical)) fill retail) OVACE WASH LIQD (Use NP QL(480 ml per EFUDEX CREA (Use NP QL(40 gm per sulfacetamide sodium) fill retail) fluorouracil (topical)) fill retail) QL(240 ml per fluorouracil (topical) crea QL(30 gm per selenium sulfide lotn ex 1 1 1 % fill retail) 0.5 % fill retail) QL(120 ml per fluorouracil (topical) crea 5 QL(40 gm per selenium sulfide lotn ex 2.5 1 1 % fill retail) % fill retail) QL(240 ml per fluorouracil (topical) soln 2 QL(10 ml per selenium sulfide sham ex 1 1 1 % fill retail) %, 5 % fill retail) SELSUN BLUE DAILY QL(240 ml per LEVULAN KERASTICK 2 PA; SP NP SOLR LOTN (Use selenium fill retail) sulfide) TARGRETIN GEL EX 1 % 2 PA; SP SELSUN BLUE LOTN (Use NP QL(240 ml per selenium sulfide) fill retail) - Topical SELSUN BLUE QL(240 ml per camphor & menthol lotn 0.5 1 QL(59 ml per MEDICATED LOTN (Use NP fill retail) %-0.5 % fill retail) selenium sulfide) SARNA LOTN (Use NP QL(59 ml per SELSUN BLUE QL(240 ml per camphor & menthol) fill retail) MOISTURIZING LOTN NP fill retail) Antipsoriatics (Use selenium sulfide) QL(60 gm per sulfacetamide sodium liqd QL(480 ml per calcipotriene crea ex 1 1 fill retail) ex fill retail) calcipotriene oint ex 1 Antivirals - Topical QL(1 gm daily) QL(60 ml per acyclovir topical crea 1 calcipotriene soln ex 1 fill retail) acyclovir topical oint 1 calcitriol (topical) oint 1 DENAVIR CREA 2 COSENTYX 2 SP SENSOREADY PEN SOAJ ZOVIRAX CREA EX 5 % 2 QL(1 gm daily) (Use acyclovir topical) COSENTYX SOSY 150 2 SP MG/ML ZOVIRAX OINT EX 5 % 2 (Use acyclovir topical) DOVONEX CREA (Use NP QL(60 gm per calcipotriene) fill retail) Burn Products QL(60 gm per SILVADENE CREA (Use QL(85 gm per fill retail); NP tazarotene crea ex 1 silver sulfadiazine) fill retail) AL(Up to 21 yrs QL(85 gm per old ) silver sulfadiazine crea ex 1 fill retail) QL(60 gm per Corticosteroids - Topical TAZORAC CREA (Use NP fill retail); tazarotene) AL(Up to 21 yrs alclometasone dipropionate 1 old ) crea Antiseborrheic Products alclometasone dipropionate 1 oint

New Hampshire Healthy Families Updated October 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amcinonide crea 1 clobetasol propionate gel 1 QL(60 gm per ex fill retail) amcinonide lotn 1 clobetasol propionate liqd 1 ex AMCINONIDE OINT 2 clobetasol propionate lotn 1 ex 1 rtl pack lmt betamethasone 1 amt,30 rtl pack clobetasol propionate oint QL(60 gm per dipropionate (topical) crea 1 lmt day(s), ex fill retail) clobetasol propionate sham betamethasone 1 1 dipropionate (topical) lotn ex clobetasol propionate soln QL(50 ml per betamethasone 1 1 dipropionate (topical) oint ex fill retail) betamethasone QL(50 gm per CLOBEX LIQD (Use NP dipropionate augmented 1 fill retail) clobetasol propionate) crea CLOBEX LOTN (Use NP betamethasone clobetasol propionate) dipropionate augmented 1 CLOBEX SHAM (Use NP gel clobetasol propionate) betamethasone clocortolone pivalate crea 1 dipropionate augmented 1 lotn CLODERM CREA (Use NP betamethasone clocortolone pivalate) dipropionate augmented 1 CORDRAN CREA (Use NP oint flurandrenolide) CORDRAN LOTN (Use betamethasone valerate 1 QL(45 gm per NP crea ex 0.1 % fill retail) flurandrenolide) CORDRAN OINT (Use betamethasone valerate 1 NP foam ex 0.12 % flurandrenolide) CUTIVATE LOTN (Use betamethasone valerate 1 QL(60 ml per NP lotn ex 0.1 % fill retail) fluticasone propionate) DERMA-SMOOTHE/FS betamethasone valerate 1 QL(45 gm per oint ex 0.1 % fill retail) BODY OIL (Use NP calcipotriene- fluocinolone acetonide) betamethasone 1 DERMA-SMOOTHE/FS dipropionate oint SCALP OIL (Use NP calcipotriene- fluocinolone acetonide) 1 rtl pack lmt betamethasone 1 desonide crea ex 1 dipropionate susp per fill, clobetasol propionate crea 1 QL(60 gm per desonide lotn ex 1 ex fill retail) 1 rtl pack lmt clobetasol propionate 1 QL(60 gm per desonide oint ex 1 emollient base crea fill retail) per fill, DESOWEN CREA (Use 1 rtl pack lmt clobetasol propionate 1 NP emulsion foam desonide) per fill, desoximetasone crea ex QL(60 gm per clobetasol propionate foam 1 1 ex 0.05 % fill retail)

New Hampshire Healthy Families Updated October 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desoximetasone crea ex 1 flurandrenolide oint 1 0.25 % fluticasone propionate crea QL(60 gm per desoximetasone gel ex 1 1 0.05 % ex 0.05 % fill retail) fluticasone propionate lotn desoximetasone liqd ex 1 1 0.25 % ex 0.05 % fluticasone propionate oint QL(60 gm per desoximetasone oint ex 1 1 0.05 %, 0.25 % ex 0.005 % fill retail) diflorasone diacetate crea 1 halcinonide crea 1 QL(60 gm per halobetasol propionate diflorasone diacetate oint 1 1 fill retail) crea DIPROLENE AF CREA QL(50 gm per HALOBETASOL 2 (Use betamethasone NP fill retail) PROPIONATE FOAM dipropionate augmented) halobetasol propionate oint 1 DIPROLENE OINT (Use betamethasone NP HALOG CREA (Use NP dipropionate augmented) halcinonide) hydrocortisone (topical) QL(30 gm per ELOCON CREA (Use NP QL(50 gm per 1 mometasone furoate) fill retail) crea 0.5 % fill retail) QL(85.2 gm per EPIFOAM FOAM 2 hydrocortisone (topical) 1 fill retail); crea 1 % RX/OTC fluocinolone acetonide crea 1 ex 0.01 %, 0.025 % hydrocortisone (topical) 1 QL(453.6 gm crea 2.5 % per fill retail) fluocinolone acetonide oil 1 ex 0.01 % hydrocortisone (topical) lotn 1 QL(99 ml per 1 % fill retail) fluocinolone acetonide oint 1 ex 0.025 % hydrocortisone (topical) lotn 1 QL(59 ml per 2.5 % fill retail) fluocinolone acetonide soln 1 ex 0.01 % hydrocortisone (topical) oint 1 0.5 % fluocinonide crea ex 0.05 1 QL(60 gm per % fill retail) QL(2 gm hydrocortisone (topical) oint 1 daily,56 gm per fluocinonide crea ex 0.1 % 1 1 % fill retail); RX/OTC fluocinonide emulsified 1 QL(60 gm per base crea fill retail) hydrocortisone (topical) oint 1 QL(454 gm per QL(60 gm per 2.5 % fill retail) fluocinonide gel ex 0.05 % 1 fill retail) hydrocortisone (topical) 1 QL(60 gm per soln 1 % fluocinonide oint ex 0.05 % 1 fill retail) hydrocortisone acetate 1 QL(60 ml per (topical) crea fluocinonide soln ex 0.05 % 1 fill retail) hydrocortisone butyrate 1 crea flurandrenolide crea 1 hydrocortisone butyrate 1 flurandrenolide lotn 1 hydrophilic lipo base crea hydrocortisone butyrate 1 lotn New Hampshire Healthy Families Updated October 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(60 gm per hydrocortisone butyrate 1 prednicarbate crea 1 oint fill retail) QL(60 ml per QL(60 gm per hydrocortisone butyrate 1 prednicarbate oint 1 soln fill retail) fill retail) HYDROCORTISONE OINT 2 PSORCON CREA 2 EX 1 % SYNALAR CREA (Use hydrocortisone valerate 1 NP crea fluocinolone acetonide) SYNALAR OINT (Use hydrocortisone valerate 1 NP oint fluocinolone acetonide) SYNALAR SOLN (Use hydrocortisone-aloe vera 1 NP crea 0.5 % fluocinolone acetonide) TACLONEX OINT (Use hydrocortisone-aloe vera 1 QL(56.8 gm per crea 1 % fill retail) calcipotriene- NP KENALOG AERS (Use betamethasone triamcinolone acetonide NP dipropionate) (topical)) TACLONEX SUSP (Use calcipotriene- LOCOID CREA (Use NP NP hydrocortisone butyrate) betamethasone dipropionate) LOCOID LIPOCREAM TEMOVATE CREA (Use QL(60 gm per CREA (Use hydrocortisone NP NP butyrate hydrophilic lipo clobetasol propionate) fill retail) base) TEMOVATE OINT (Use NP QL(60 gm per clobetasol propionate) fill retail) LOCOID LOTN (Use NP hydrocortisone butyrate) TOPICORT CREA 0.05 % NP QL(60 gm per (Use desoximetasone) fill retail) LOCOID SOLN (Use NP QL(60 ml per hydrocortisone butyrate) fill retail) TOPICORT CREA 0.25 % NP (Use desoximetasone) LUXIQ FOAM (Use NP betamethasone valerate) TOPICORT GEL 0.05 % NP (Use desoximetasone) MICORT-HC CREA 2 TOPICORT LIQD 0.25 % NP (Use desoximetasone) mometasone furoate crea 1 QL(50 gm per ex fill retail) TOPICORT OINT 0.05 %, 0.25 % (Use NP mometasone furoate oint 1 QL(45 gm per ex fill retail) desoximetasone) triamcinolone acetonide mometasone furoate soln 1 QL(60 ml per 1 ex fill retail) (topical) aers 0.147 mg/gm MONISTAT SOOTHING QL(85.2 gm per triamcinolone acetonide 1 QL(160 gm per (topical) crea 0.025 % fill retail) CARE ITCH RELIEF CREA NP fill retail); (Use hydrocortisone RX/OTC triamcinolone acetonide 1 QL(85.2 gm per (topical)) (topical) crea 0.1 % fill retail) OLUX FOAM (Use NP triamcinolone acetonide 1 QL(15 gm per clobetasol propionate) (topical) crea 0.5 % fill retail) OLUX-E FOAM (Use triamcinolone acetonide QL(60 ml per clobetasol propionate NP (topical) lotn 0.025 %, 0.1 1 fill retail) emulsion) %

New Hampshire Healthy Families Updated October 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits triamcinolone acetonide QL(80 gm per PA; QL(1 gm 1 fill retail) ELIDEL CREA (Use NP (topical) oint 0.025 %, 0.1 pimecrolimus) daily); AL(At % least 2 yrs old) triamcinolone acetonide 1 PA; QL(1 gm (topical) oint 0.05 % pimecrolimus crea 1 daily); AL(At least 2 yrs old) triamcinolone acetonide 1 QL(15 gm per (topical) oint 0.5 % fill retail) PA; QL(1 gm PROTOPIC OINT 0.03 % 2 daily); AL(At triamcinolone acetonide- 1 (Use tacrolimus (topical)) dimethicone-silicone kit least 2 yrs old) PROTOPIC OINT 0.1 % PA TRIDESILON CREA (Use NP 1 rtl pack lmt 2 desonide) per fill, (Use tacrolimus (topical)) VANOS CREA (Use PA; QL(1 gm NP tacrolimus (topical) oint 1 daily); AL(At fluocinonide) 0.03 % least 2 yrs old) Emollient/Keratolytic Agents tacrolimus (topical) oint 0.1 1 PA QL(85.05 gm % urea crea ex 40 % 1 per fill retail); RX/OTC Keratolytic/Antimitotic Agents QL(325 ml per KERALYT GEL 6 % (Use QL(40 gm per urea lotn ex 40 % 1 NP fill retail) salicylic acid) fill retail) QL(4 ml per fill podofilox soln ex 1 Emollients retail) LAC-HYDRIN CREA (Use QL(385 gm per QL(40 gm per lactic acid (ammonium NP fill retail); salicylic acid gel ex 6 % 1 fill retail) lactate)) RX/OTC LAC-HYDRIN TWELVE QL(57 ml per Local Anesthetics - Topical LOTN (Use lactic acid NP fill retail); ARTHRITIS PAIN 2 QL(60 gm per (ammonium lactate)) RX/OTC RELIEVING CREA fill retail) QL(385 gm per 1 QL(60 ml per lactic acid (ammonium 1 fill retail); capsaicin crea ex 0.025 % fill retail) lactate) crea 12 % RX/OTC 1 QL(60 gm per QL(57 ml per capsaicin crea ex 0.075 % fill retail) lactic acid (ammonium 1 fill retail); QL(56.6 gm per lactate) lotn 12 % capsaicin crea ex 0.1 % 1 RX/OTC fill retail) Hair Growth Agents CAPZASIN-HP CREA (Use NP QL(56.6 gm per capsaicin) fill retail) bimatoprost (topical) soln 1 CAPZASIN-P CREA 2 QL(42.5 gm per fill retail) LATISSE SOLN (Use NP bimatoprost (topical)) CASTIVA WARMING 2 QL(113 gm per Immunomodulating Agents - Topical LOTN fill retail) QL(56.7 gm per ALDARA CREA (Use NP QL(48 ea per dibucaine oint ex 1 imiquimod) 180 days retail) fill retail) QL(48 ea per QL(85 gm per imiquimod crea ex 5 % 1 LIDOCAINE CREA EX 3 % 2 180 days retail) fill retail) QL(76.5 gm per lidocaine crea ex 4 % 1 Immunosuppressive Agents - Topical fill retail)

New Hampshire Healthy Families Updated October 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(85 gm per metronidazole (topical) gel 1 QL(45 gm per lidocaine hcl crea ex 3 % 1 fill retail); 0.75 % fill retail) RX/OTC metronidazole (topical) lotn 1 QL(63 ml per lidocaine hcl crea ex 4 % 1 0.75 % fill retail) Scabicides & Pediculicides QL(85 ml per lidocaine hcl gel ex 2 % 1 CVS LICE SOLUTION KIT fill retail) 2 3-STEP KIT QL(85 ml per 1 fill retail); ELIMITE CREA (Use NP QL(60 gm per lidocaine hcl gel ex 2 % permethrin) fill retail) RX/OTC QL(85 ml per LICEMD GEL 2 lidocaine hcl prsy ex 2 % 1 fill retail) QL(5800 gm lindane sham 1 lidocaine-prilocaine crea 1 per fill retail) QL(59 ml per malathion lotn 1 LMX 4 CREA (Use NP QL(76.5 gm per fill retail) lidocaine) fill retail) NATROBA SUSP ( QL(120 ml per PREDATOR CREA (Use QL(63 ml per Use 2 fill retail); AL(At NP spinosad) lidocaine hcl) fill retail) least 2 yrs old) Misc. Topical NIX CREME RINSE LIQD NP (Use permethrin) HYDRO-LAN CREA 2 OVIDE LOTN (Use NP QL(59 ml per malathion) fill retail) lanolin (topical) crea 1 permethrin aero xx 0.5 % 1 lanolin (topical) oint 1 QL(60 gm per permethrin crea ex 5 % 1 LANOLOR CREA 2 fill retail) permethrin liqd ex 1 % 1 OFF DEEP WOODS AERO 2 QL(59 ml per permethrin lotn ex 1 % 1 OFF DEEP WOODS DRY 2 fill retail) AERO pyrethrins-piperonyl ULTRATHON INSECT 2 butoxide liqd 0.3 %-0.3 %- 1 REPELLENT 8 AERO 1.2 %-2.4 %-3 % ULTRATHON INSECT 2 pyrethrins-piperonyl 1 QL(59 ml per REPELLENT LOTN butoxide liqd 0.33 %-4 % fill retail) zinc oxide (topical) oint 20 1 QL(60 gm per pyrethrins-piperonyl % fill retail) butoxide sham 0.3 %-0.33 1 Rosacea Agents %-4 % METROCREAM CREA QL(45 gm per pyrethrins-piperonyl 1 QL(59 ml per (Use metronidazole NP fill retail) butoxide sham 0.33 %-4 % fill retail) (topical)) pyrethrins-piperonyl METROLOTION LOTN butoxide-permethrin-nit 1 (Use metronidazole NP remover kit (topical)) RID AERO XX 0.5 % (Use NP permethrin) metronidazole (topical) 1 QL(45 gm per crea 0.75 % fill retail)

New Hampshire Healthy Families Updated October 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RID COMPLETE LICE KETONE STRP 2 ELIMINATION KIT (Use pyrethrins-piperonyl NP KETONE TEST STRIPS 2 butoxide-permethrin-nit STRP remover) KETOSTIX STRP 2 RID ESSENTIAL LICE 2 ELIMINATION KIT KIT RELION KETONE TEST 2 RID LIQD EX 0.33 %-4 % QL(59 ml per STRIPS STRP (Use pyrethrins-piperonyl NP fill retail) INSULIN butoxide) USERS SCHOOLTIME SHAMPOO LIMITED TO 2 200 PER 30 SHAM RELION TRUE METRIX QL(120 ml per 2 DAYS, NON- BLOODGLUCOSE TEST INSULIN spinosad susp 1 fill retail); AL(At STRIPS STRP least 2 yrs old) USERS LIMITED TO Tar Products 100 PER 90 DAYS;RX/OTC coal tar extract sham 0.5 % 1 INSULIN DHS TAR GEL SHAM (Use NP USERS coal tar extract) LIMITED TO 200 PER 30 DHS TAR SHAM (Use coal NP TRUE METRIX BLOOD tar extract) 2 DAYS, NON- GLUCOSETEST STRIPS INSULIN NEUTROGENA T/GEL STRP NP USERS SHAM (Use coal tar LIMITED TO extract) 100 PER 90 NEUTROGENA T/GEL DAYS;RX/OTC STUBBORN ITCH NP INSULIN CONTROL SHAM (Use USERS coal tar extract) LIMITED TO 200 PER 30 Wound Care Products TRUE METRIX SELF PA; SP MONITORING BLOOD 2 DAYS, NON- APLIGRAF DISK 2 INSULIN GLUCOSE STRIPS STRP PA; SP USERS DERMAGRAFT SHEE 2 LIMITED TO 100 PER 90 DIAGNOSTIC PRODUCTS DAYS;RX/OTC INSULIN Diagnostic Drugs USERS CORTROSYN SOLR (Use NP PA; SP LIMITED TO cosyntropin) 200 PER 30 cosyntropin solr 1 PA; SP TRUETRACK BLOOD 2 DAYS, NON- GLUCOSE TEST STRP INSULIN USERS 2 PA; SP THYROGEN SOLR LIMITED TO Diagnostic Tests 100 PER 90 DAYS;RX/OTC CHEMSTRIP-K STRP 2

New Hampshire Healthy Families Updated October 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN triamterene & 1 QL(1 ea daily) USERS hydrochlorothiazide caps LIMITED TO triamterene & 1 QL(1 ea daily) 200 PER 30 hydrochlorothiazide tabs TRUETRACK TEST STRP 2 DAYS, NON- INSULIN Loop Diuretics USERS bumetanide tabs or 0.5 mg, 1 LIMITED TO 1 mg, 2 mg 100 PER 90 BUMEX TABS (Use NP DAYS;RX/OTC bumetanide) DIGESTIVE AIDS - Drugs to Treat Low Digestive furosemide soln or 10 1 Enzymes mg/ml, 8 mg/ml Digestive Enzymes furosemide tabs or 20 mg, 1 40 mg, 80 mg CREON CPEP 2 LASIX TABS (Use NP furosemide) SUCRAID SOLN 2 PA; SP torsemide tabs 10 mg, 100 1 QL(1 ea daily) ZENPEP CPEP 2 mg, 5 mg torsemide tabs 20 mg 1 DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure Potassium Sparing Diuretics Carbonic Anhydrase Inhibitors ALDACTONE TABS (Use NP spironolactone) acetazolamide cp12 or 500 1 mg amiloride hcl tabs or 1 QL(4 ea daily) acetazolamide tabs or 125 1 mg, 250 mg spironolactone tabs or 100 1 mg, 25 mg, 50 mg methazolamide tabs or 50 1 mg, 25 mg Thiazides and Thiazide-Like Diuretics Diuretic Combinations chlorthalidone tabs 1 ALDACTAZIDE TABS 25 hydrochlorothiazide caps or MG-25 MG (Use NP 1 spironolactone & 12.5 mg hydrochlorothiazide) hydrochlorothiazide tabs or 1 25 mg, 50 mg amiloride & 1 QL(1 ea daily) hydrochlorothiazide tabs indapamide tabs 1 DYAZIDE CAPS (Use QL(1 ea daily) triamterene & NP metolazone tabs 1 hydrochlorothiazide) MAXZIDE TABS (Use QL(1 ea daily) ENDOCRINE AND METABOLIC AGENTS - triamterene & NP MISC. - Drugs to Treat Bone Disease and hydrochlorothiazide) Regulate Hormones MAXZIDE-25 TABS (Use QL(1 ea daily) Bone Density Regulators triamterene & NP ACTONEL TABS 150 MG NP hydrochlorothiazide) (Use risedronate sodium) spironolactone & 1 hydrochlorothiazide tabs

New Hampshire Healthy Families Updated October 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 4 per 28 RECLAST SOLN (Use NP PA; SP ACTONEL TABS 35 MG NP days;QL(4 ea zoledronic acid) (Use risedronate sodium) per 28 days risedronate sodium tabs 1 retail) 150 mg ACTONEL TABS 5 MG QL(1 ea daily) NP risedronate sodium tabs 30 1 QL(1 ea daily) (Use risedronate sodium) mg, 5 mg alendronate sodium soln 1 QL(10.8 ml 4 per 28 70 mg/75ml daily) risedronate sodium tabs 35 1 days;QL(4 ea alendronate sodium tabs 1 QL(0.15 ea mg per 28 days 35 mg, 70 mg daily) retail) alendronate sodium tabs 1 QL(1 ea daily) risedronate sodium tbec 35 1 40 mg, 5 mg, 10 mg mg ATELVIA TBEC (Use NP XGEVA SOLN 2 PA; SP risedronate sodium) BONIVA SOLN IV 3 PA; SP zoledronic acid conc 4 1 PA; SP MG/3ML (Use ibandronate NP mg/5ml sodium) ZOLEDRONIC ACID SOLN 2 PA; SP 4 MG/100ML BONIVA TABS OR 150 MG NP PA (Use ibandronate sodium) zoledronic acid soln 4 1 PA; SP mg/100ml, 5 mg/100ml calcitonin (salmon) soln ij 1 QL(2 ml per 30 200 unit/ml days retail) ZOLEDRONIC ACID SOLR 2 PA; SP 4 MG calcitonin (salmon) soln na 1 QL(4 ml per 30 200 unit/act days retail) Corticotropin etidronate disodium tabs 1 ACTHAR GEL 2 PA; SP PA; SP EVENITY SOSY 2 Fertility Regulators CHORIONIC PA; SP FOSAMAX TABS (Use NP QL(0.15 ea alendronate sodium) daily) GONADOTROPIN SOLR 2 IM ibandronate sodium soln iv 1 PA; SP 3 mg/3ml HCG SOLR 2 PA; SP ibandronate sodium tabs or 1 PA 150 mg NOVAREL SOLR 2 PA; SP MIACALCIN SOLN (Use NP QL(2 ml per 30 PREGNYL W/DILUENT PA; SP calcitonin (salmon)) days retail) BENZYLALCOHOL/NACL 2 NATPARA CART 2 PA; SP SOLR GnRH/LHRH Antagonists pamidronate disodium soln 1 PA; SP 30 mg/10ml, 90 mg/10ml CETROTIDE KIT 2 PA; SP PAMIDRONATE PA; SP DISODIUM SOLN 6 2 ganirelix acetate sosy 1 PA; SP MG/ML GANIRELIX ACETATE PA; SP pamidronate disodium solr 1 PA; SP SOSY (Use ganirelix NP 30 mg, 90 mg acetate) PA; SP PROLIA SOSY 2 ORILISSA TABS 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Growth Hormone Receptor Antagonists CARNITOR SF SOLN (Use QL(30 ml daily) levocarnitine (metabolic NP SOMAVERT SOLR 2 PA; SP modifiers)) CARNITOR SOLN OR 1 QL(30 ml daily) Growth Hormone Releasing Hormones (GHRH) GM/10ML (Use NP EGRIFTA SOLR 2 PA; SP levocarnitine (metabolic modifiers)) Growth Hormones CARNITOR TABS OR 330 QL(3 ea daily) MG (Use levocarnitine NP GENOTROPIN MINIQUICK 2 PA; SP SOLR (metabolic modifiers)) PA; SP GENOTROPIN SOLR 2 PA; SP cinacalcet hcl tabs 1 Hormone Receptor Modulators CRYSVITA SOLN 2 PA; SP EVISTA TABS (Use NP QL(1 ea daily) PA; SP raloxifene hcl) CYSTADANE POWD 2 QL(1 ea daily) raloxifene hcl tabs 1 ELAPRASE SOLN 2 PA; SP

Insulin-Like Growth Factors (Somatomedins) FABRAZYME SOLR 2 PA; SP PA; SP INCRELEX SOLN 2 PA; QL(0.5 ea GALAFOLD CAPS 2 LHRH/GnRH Analog Pituitary daily); SP PA; SP FENSOLVI KIT 2 PA; SP KANUMA SOLN 2 PA; SP KUVAN PACK (Use PA; SP LUPANETA PACK KIT 2 sapropterin NP dihydrochloride) LUPRON DEPOT-PED (1- 2 PA; SP MONTH) KIT KUVAN TABS (Use PA; SP sapropterin NP LUPRON DEPOT-PED (3- 2 PA; SP dihydrochloride) MONTH) KIT levocarnitine (metabolic 1 QL(30 ml daily) SUPPRELIN LA KIT 2 PA; SP modifiers) soln 1 gm/10ml PA; SP levocarnitine (metabolic 1 QL(3 ea daily) SYNAREL SOLN 2 modifiers) tabs 330 mg Metabolic Modifiers LUMIZYME SOLR 2 PA; SP PA; SP ALDURAZYME SOLN 2 MYALEPT SOLR 2 PA; SP BUPHENYL POWD (Use NP PA; SP PA; SP sodium phenylbutyrate) NAGLAZYME SOLN 2 BUPHENYL TABS (Use NP PA; SP PA; SP sodium phenylbutyrate) nitisinone caps 1 calcitriol caps or 0.25 mcg, 1 ORFADIN CAPS 10 MG, 2 NP PA; SP 0.5 mcg MG, 5 MG (Use nitisinone) CARBAGLU TABS CO ORFADIN CAPS 20 MG 2 PA; SP

ORFADIN SUSP 4 MG/ML 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PALYNZIQ SOSY 2 PA; SP desmopressin acetate 1 QL(5 ml per fill spray refrigerated soln retail) paricalcitol soln iv 2 PA; SP 1 desmopressin acetate 1 QL(5 ml per fill mcg/ml, 5 mcg/ml spray soln retail) PA; SP PARSABIV SOLN 2 desmopressin acetate tabs 1 QL(6 ea daily) or 0.1 mg, 0.2 mg RAVICTI LIQD CO STIMATE SOLN CO PA; SP REVCOVI SOLN 2 Somatostatic Agents ROCALTROL CAPS 0.25 octreotide acetate soln 1 PA; SP MCG, 0.5 MCG (Use NP calcitriol) SANDOSTATIN LAR 2 PA; SP DEPOT KIT sapropterin dihydrochloride 1 PA; SP pack SANDOSTATIN SOLN NP PA; SP (Use octreotide acetate) sapropterin dihydrochloride 1 PA; SP tabs SIGNIFOR LAR SRER 2 PA; SP SENSIPAR TABS (Use NP PA; SP cinacalcet hcl) SIGNIFOR SOLN 2 PA; SP sodium phenylbutyrate 1 PA; SP SOMATULINE DEPOT PA; SP powd or 3 gm/tsp 2 SOLN sodium phenylbutyrate tabs 1 PA; SP or 500 mg Vasopressin Receptor Antagonists PA; SP JYNARQUE TABS 15 MG, 2 PA; SP STRENSIQ SOLN 2 30 MG VIMIZIM SOLN 2 PA; SP JYNARQUE TBPK 2 PA; SP

ZEMPLAR SOLN IV 2 PA; SP SAMSCA TABS (Use NP PA; SP MCG/ML, 5 MCG/ML (Use NP tolvaptan) paricalcitol) tolvaptan tabs 1 PA; SP Posterior Pituitary Hormones DDAVP SOLN IJ 4 PA; SP ESTROGENS - Hormone Replacement/Modifying MCG/ML (Use NP Drugs desmopressin acetate) Estrogen Combinations QL(5 ml per fill DDAVP SOLN NA 0.01 % 2 ACTIVELLA TABS (Use retail) estradiol & norethindrone NP DDAVP SOLN NA 0.01 % QL(5 ml per fill acetate) (Use desmopressin acetate NP retail) COMBIPATCH PTTW 2 QL(8 ea per 28 spray) days retail) DDAVP TABS OR 0.1 MG, QL(6 ea daily) estradiol & norethindrone 1 0.2 MG (Use desmopressin NP acetate tabs acetate) FEMHRT TABS (Use desmopressin acetate soln 1 PA; SP norethindrone acetate- NP ij 4 mcg/ml ethinyl estradiol) DESMOPRESSIN norethindrone acetate- 0 ACETATE SOLN NA 1.5 CO ethinyl estradiol tabs MG/ML

New Hampshire Healthy Families Updated October 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMPHASE TABS 2 QL(1 ea daily) levofloxacin soln or 25 1 mg/ml PREMPRO TABS 2 QL(1 ea daily) QL(1 ea levofloxacin tabs or 250 1 daily,14 ea per mg, 500 mg, 750 mg Estrogens fill retail) ALORA PTTW 2 QL(0.29 ea moxifloxacin hcl tabs or 1 daily) QL(56 ea per CLIMARA PTWK (Use NP QL(12 ea per ofloxacin tabs 1 estradiol) 90 days retail) fill retail) ESTRACE TABS OR 0.5 GASTROINTESTINAL AGENTS - MISC. - MG, 1 MG, 2 MG (Use NP Miscellaneous Gastrointestinal Drugs estradiol) Antiflatulents estradiol pttw td 0.025 QL(0.29 ea GAS-X CHEW (Use NP mg/24hr, 0.0375 mg/24hr, 1 daily) simethicone) 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr MYLICON INFANTS GAS QL(45 ml per RELIEF DYE FREE SUSP NP fill retail) estradiol ptwk td 0.025 QL(12 ea per (Use simethicone) mg/24hr, 0.075 mg/24hr, 90 days retail) 0.1 mg/24hr, 0.05 mg/24hr, 1 MYLICON INFANTS GAS QL(45 ml per 0.06 mg/24hr, 37.5 RELIEF SUSP (Use NP fill retail) mcg/24hr simethicone) estradiol tabs or 0.5 mg, 1 1 simethicone chew or 80 mg 1 mg, 2 mg simethicone liqd or 20 QL(30 ml per MINIVELLE PTTW (Use NP QL(0.29 ea 1 estradiol) daily) mg/0.3ml, 40 mg/0.6ml fill retail) PREMARIN TABS OR 0.3 QL(1 ea daily) simethicone susp or 20 1 QL(45 ml per MG, 0.45 MG, 0.625 MG, 2 mg/0.3ml, 40 mg/0.6ml fill retail) 0.9 MG, 1.25 MG Bile Acid Synthesis Disorder Agents VIVELLE-DOT PTTW (Use QL(0.29 ea NP CHOLBAM CAPS 2 PA; QL(5 ea estradiol) daily) daily); SP FLUOROQUINOLONES - Drugs to Treat Bacterial Farnesoid X Receptor (FXR) Agonists Infections OCALIVA TABS 2 PA; SP Fluoroquinolones Gallstone Solubilizing Agents CIPRO SUSR 5 2 GM/100ML, 500 MG/5ML ACTIGALL CAPS (Use NP QL(3 ea daily) ursodiol) CIPRO TABS 250 MG, 500 NP MG (Use hcl) CHENODAL TABS 2 PA; SP ciprofloxacin hcl tabs or 1 QL(6 ea per fill 100 mg retail) URSO 250 TABS (Use NP QL(7 ea daily) ursodiol) ciprofloxacin hcl tabs or 1 250 mg, 500 mg, 750 mg ursodiol caps or 300 mg 1 QL(3 ea daily) ciprofloxacin susr or 1 ursodiol tabs or 250 mg 1 QL(7 ea daily) QL(1 ea LEVAQUIN TABS (Use NP Gastrointestinal Stimulants levofloxacin) daily,14 ea per fill retail)

New Hampshire Healthy Families Updated October 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl soln or 1 LOTRONEX TABS (Use 2 10 mg/10ml, 5 mg/5ml hcl) metoclopramide hcl tabs or 1 Peripheral Opioid Receptor Antagonists 10 mg, 5 mg MOVANTIK TABS 2 REGLAN TABS (Use NP metoclopramide hcl) Phosphate Binder Agents Inflammatory Bowel Agents calcium acetate (phosphate 1 ASACOL HD TBEC (Use NP binder) caps mesalamine) calcium acetate (phosphate 1 RX/OTC AZULFIDINE EN-TABS NP binder) tabs TBEC (Use sulfasalazine) FOSRENOL CHEW (Use NP AZULFIDINE TABS (Use NP lanthanum carbonate) sulfasalazine) lanthanum carbonate chew 1 balsalazide disodium caps 1 QL(9 ea daily) RENAGEL TABS (Use NP CANASA SUPP (Use NP sevelamer hcl) mesalamine) RENVELA PACK (Use NP COLAZAL CAPS (Use NP QL(9 ea daily) sevelamer carbonate) balsalazide disodium) RENVELA TABS (Use NP LIALDA TBEC (Use 2 sevelamer carbonate) mesalamine) sevelamer carbonate pack 1 mesalamine enem re 4 gm 1 QL(60 ml daily) sevelamer carbonate tabs 1 mesalamine supp re 1000 1 mg sevelamer hcl tabs 1 mesalamine tbec or 1.2 1 gm, 800 mg Short Bowel Syndrome (SBS) Agents mesalamine w/ cleanser kit 1 GATTEX KIT 2 PA; SP

ROWASA KIT (Use NP GENITOURINARY AGENTS - MISCELLANEOUS mesalamine w/ cleanser) - Miscellaneous Drugs to Treat Reproductive sulfasalazine tabs or 1 Organs and Urinary System Alkalinizers sulfasalazine tbec or 1 potassium citrate (alkalinizer) tbcr 540 mg, 1 Intestinal Acidifiers 10 meq, 1080 mg lactulose (encephalopathy) 1 soln potassium citrate-citric acid 1 pack 1002 mg-3300 mg Irritable Bowel Syndrome (IBS) Agents sodium citrate & citric acid QL(16.67 ml alosetron hcl tabs 1 soln 334 mg/5ml-334 1 daily); RX/OTC mg/5ml-500 mg/5ml-500 mg/5ml LINZESS CAPS 145 MCG, 2 PA; SP 290 MCG UROCIT-K 10 TBCR (Use LINZESS CAPS 72 MCG 2 potassium citrate NP (alkalinizer))

New Hampshire Healthy Families Updated October 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UROCIT-K 5 TBCR (Use THIOLA TABS (Use NP PA; SP potassium citrate NP tiopronin) (alkalinizer)) tiopronin tabs or 1 PA; SP Cystinosis Agents Vesicoureteral Reflux (VUR) Agents CYSTAGON CAPS 2 PA; SP DEFLUX PRSY 2 PA; SP PROCYSBI CPDR 25 MG, 2 PA; SP 75 MG GOUT AGENTS - Drugs to Treat Gout Genitourinary Irrigants Gout Agent Combinations sodium chloride (gu 1 irrigant) soln colchicine w/ probenecid 1 tabs Agents Gout Agents ELMIRON CAPS 2 QL(3 ea daily) allopurinol tabs or 100 mg, 1 Prostatic Hypertrophy Agents 300 mg 1 fill per 30 hcl tb24 1 colchicine tabs or 1 days;QL(6 ea per fill retail) AVODART CAPS (Use NP dutasteride) 1 fill per 30 COLCRYS TABS (Use NP colchicine) days;QL(6 ea dutasteride caps or 1 per fill retail) PA; SP dutasteride- hcl 1 KRYSTEXXA SOLN 2 caps ZYLOPRIM TABS ( QL(1 ea daily) Use NP finasteride tabs or 1 allopurinol) Uricosurics FLOMAX CAPS (Use NP QL(2 ea daily) tamsulosin hcl) probenecid tabs 1 JALYN CAPS (Use NP dutasteride-tamsulosin hcl) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders PROSCAR TABS (Use NP QL(1 ea daily) finasteride) Antihemophilic Products RAPAFLO CAPS (Use NP ) ADVATE SOLR CO silodosin caps 1 ADYNOVATE SOLR CO QL(2 ea daily) tamsulosin hcl caps 1 AFSTYLA KIT CO UROXATRAL TB24 (Use NP alfuzosin hcl) ALPHANATE SOLR CO Urinary Analgesics ALPHANATE/VON WILLEBRANDFACTOR CO phenazopyridine hcl tabs or 1 100 mg, 200 mg COMPLEX/HUMAN SOLR PYRIDIUM TABS (Use NP ALPHANINE SD SOLR CO phenazopyridine hcl) Urinary Stone Agents ALPROLIX SOLR CO

New Hampshire Healthy Families Updated October 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENEFIX KIT CO OBIZUR SOLR CO

COAGADEX SOLR CO PROFILNINE SD SOLR CO

CORIFACT KIT CO PROFILNINE SOLR CO

ELOCTATE SOLR CO REBINYN SOLR CO SP

ESPEROCT SOLR CO RECOMBINATE SOLR CO

FEIBA SOLR CO RIASTAP SOLR CO

FIBRYGA SOLR CO RIXUBIS SOLR CO

HELIXATE FS KIT CO SEVENFACT SOLR CO

HEMLIBRA SOLN CO TRETTEN SOLR CO

HEMOFIL M SOLR CO VONVENDI SOLR CO

HUMATE-P SOLR CO WILATE KIT CO

IDELVION SOLR 1000 XYNTHA KIT CO UNIT, 2000 UNIT, 250 CO UNIT, 500 UNIT XYNTHA SOLOFUSE KIT CO IDELVION SOLR 3500 CO SP UNIT Bradykinin B2 Receptor Antagonists IXINITY SOLR CO FIRAZYR SOLN (Use NP PA; SP icatibant acetate) SP KCENTRA KIT CO icatibant acetate soln 1 PA; SP KOATE SOLR CO Complement Inhibitors PA; SP KOATE-DVI SOLR CO BERINERT KIT 2 PA; SP KOGENATE FS KIT CO CINRYZE SOLR 2 PA; SP KOVALTRY SOLR CO RUCONEST SOLR 2 PA; SP MONONINE SOLR CO SOLIRIS SOLN 2 ULTOMIRIS SOLN 300 2 PA; SP NOVOEIGHT SOLR CO MG/30ML NOVOSEVEN RT SOLR CO Hemataologic - Kinase Inhibitors TAVALISSE TABS 2 PA; SP NUWIQ KIT CO Hematorheologic Agents NUWIQ SOLR CO pentoxifylline tbcr or 1

New Hampshire Healthy Families Updated October 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Human Protein C CEREZYME SOLR 2 PA; SP CEPROTIN SOLR 2 PA; SP ELELYSO SOLR 2 PA; SP Plasma Kallikrein Inhibitors miglustat caps 1 PA; SP KALBITOR SOLN 2 PA; SP VPRIV SOLR 2 PA; SP TAKHZYRO SOLN 2 PA; SP ZAVESCA CAPS (Use NP PA; SP Plasma Proteins miglustat) THROMBATE III SOLR 2 PA; SP Agents for Sickle Cell Disease DROXIA CAPS 2 THROMBATE III W/10 ML 2 PA; SP STERILE WATER SOLR SIKLOS TABS 2 PA THROMBATE III W/20 ML 2 PA; SP STERILE WATER SOLR Cobalamins Platelet Aggregation Inhibitors cyanocobalamin soln ij 1 1000 mcg/ml AGGRENOX CP12 (Use 2 aspirin-dipyridamole) Folic Acid/Folates aspirin-dipyridamole cp12 1 folic acid tabs or 1 mg 1 RX/OTC QL(2 ea daily) BRILINTA TABS 2 folic acid tabs or 800 mcg, 1 QL(1 ea daily) 400 mcg QL(2 ea daily) cilostazol tabs 1 Hematopoietic Growth Factors clopidogrel bisulfate tabs 1 DOPTELET TABS 2 PA; SP 300 mg PA; SP clopidogrel bisulfate tabs 1 QL(1 ea daily) EPOGEN SOLN 2 75 mg PA; SP dipyridamole tabs or 25 1 FULPHILA SOSY 2 mg, 50 mg, 75 mg GRANIX SOLN 2 PA; SP EFFIENT TABS (Use NP QL(1 ea daily) prasugrel hcl) GRANIX SOSY 2 PA; SP PLAVIX TABS (Use NP QL(1 ea daily) clopidogrel bisulfate) LEUKINE SOLR 2 PA; SP prasugrel hcl tabs 1 QL(1 ea daily) MULPLETA TABS 2 PA; SP Thrombolytic Agent - Misc PA; SP NEULASTA ONPRO KIT 2 PA; SP DEFITELIO SOLN 2 PSKT HEMATOPOIETIC AGENTS - Drugs to Treat NEULASTA SOSY 2 PA; SP Blood Disorders PA; SP Agents for Gaucher Disease NEUPOGEN SOLN 2 CERDELGA CAPS 2 PA; SP NEUPOGEN SOSY 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVESTYM SOLN 2 PA; SP ferrous sulfate tbec or 325 1 mg PA; SP NIVESTYM SOSY 2 HEMOCYTE TABS (Use NP QL(2 ea daily) ferrous fumarate) NPLATE SOLR 250 MCG, PA; SP 2 IRON CHEWS PEDIATRIC 2 500 MCG CHEW PROMACTA PACK 12.5 PA; SP 2 polysaccharide iron 1 QL(1 ea daily) MG complex caps PROMACTA TABS 12.5 2 PA; SP MG, 25 MG, 50 MG, 75 MG Stem Cell Mobilizers RETACRIT SOLN 10000 PA; SP MOZOBIL SOLN 2 PA; SP UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 3000 2 HEMOSTATICS - Drugs to Stop Bleeding/Treat UNIT/ML, 4000 UNIT/ML, Blood Disorders 40000 UNIT/ML Hemostatics - Systemic RETACRIT SOLN 20000 2 SP AMICAR SOLN 0.25 PA; SP UNIT/ML GM/ML (Use aminocaproic NP UDENYCA SOSY 2 PA; SP acid) AMICAR TABS 1000 MG NP PA; SP ZARXIO SOSY 2 PA; SP (Use aminocaproic acid) PA; QL(24 ea Hematopoietic Mixtures AMICAR TABS 500 MG NP per fill retail); (Use aminocaproic acid) ferrous fumarate-fa-b QL(1 ea daily) SP complex-c-zn-mg-mn-cu 1 aminocaproic acid soln iv 1 PA; SP tabs 250 mg/ml Iron aminocaproic acid soln or 1 PA; SP 0.25 gm/ml FER-IN-SOL SOLN (Use NP QL(3.4 ml ferrous sulfate) daily) aminocaproic acid tabs or 1 PA; SP 1000 mg FERRETTS TABS 2 QL(2 ea daily) PA; QL(24 ea ferrous fumarate tabs or QL(2 ea daily) aminocaproic acid tabs or 1 per fill retail); 1 500 mg 324 mg SP ferrous gluconate tabs or 1 QL(30 ea per 5 240 mg, 27 mg LYSTEDA TABS (Use NP days retail); tranexamic acid) AL(At least 12 FERROUS GLUCONATE 2 TABS OR 324 MG yrs old) QL(30 ea per 5 ferrous sulfate dried tbcr 1 160 mg tranexamic acid tabs or 650 1 days retail); mg AL(At least 12 ferrous sulfate elix or 220 1 QL(16 ml daily) yrs old) mg/5ml //SLEEP DISORDER ferrous sulfate soln or 15 1 QL(3.4 ml mg/ml daily) AGENTS Hypnotics ferrous sulfate tabs or 28 1 mg, 325 mg, 65 mg ADVIL PM CAPS (Use ibuprofen-diphenhydramine NP FERROUS SULFATE 2 TBEC OR 324 MG hcl)

New Hampshire Healthy Families Updated October 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL PM TABS (Use UNISOM SLEEPTABS ibuprofen-diphenhydramine NP TABS (Use doxylamine NP citrate) succinate (sleep)) ALEVE PM TABS (Use ZZZQUIL CAPS (Use naproxen sodium- NP diphenhydramine hcl NP diphenhydramine hcl) (sleep)) diphenhydramine hcl 1 ZZZQUIL LIQD (Use (sleep) caps 25 mg, 50 mg diphenhydramine hcl NP (sleep)) diphenhydramine hcl 1 (sleep) liqd 50 mg/30ml Hypnotics diphenhydramine hcl QL(1 ea daily) 1 elix or 20 1 (sleep) tabs 25 mg mg/5ml diphenhydramine hcl 1 phenobarbital soln or 20 1 (sleep) tabs 50 mg mg/5ml diphenhydramine hcl 1 phenobarbital tabs or 100 (sleep) tbdp 25 mg mg, 16.2 mg, 32.4 mg, 60 1 diphenhydramine- mg, 64.8 mg, 97.2 mg, 15 acetaminophen (sleep) 1 mg, 30 mg tabs Hypnotics - Tricyclic Agents doxylamine succinate 1 (sleep) tabs doxepin hcl (sleep) tabs 1 EXCEDRIN PM TABS (Use SILENOR TABS (Use NP diphenhydramine- NP doxepin hcl (sleep)) acetaminophen (sleep)) Non-Barbiturate Hypnotics ibuprofen-diphenhydramine 1 citrate tabs AMBIEN CR TBCR (Use NP tartrate) ibuprofen-diphenhydramine 1 hcl caps AMBIEN TABS (Use NP QL(1 ea daily) zolpidem tartrate) naproxen sodium- 1 diphenhydramine hcl tabs hcl in 1 sodium chloride soln NYTOL MAXIMUM dexmedetomidine hcl soln STRENGTH TABS (Use NP 1 diphenhydramine hcl 200 mcg/2ml (sleep)) tabs 1 TYLENOL PM EXTRA STRENGTH TABS 25 MG- tabs 1 500 MG (Use NP diphenhydramine- hcl caps 1 QL(1 ea daily) acetaminophen (sleep)) UNISOM SLEEPGELS HALCION TABS (Use NP QL(1 ea daily) ) CAPS (Use NP diphenhydramine hcl INTERMEZZO SUBL (Use NP (sleep)) zolpidem tartrate) UNISOM SLEEPMELTS LUNESTA TABS (Use NP TBDP (Use NP eszopiclone) diphenhydramine hcl (sleep))

New Hampshire Healthy Families Updated October 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl soln ij 5 EVAC POWD (Use NP mg/5ml, 10 mg/2ml, 2 psyllium) mg/2ml, 5 mg/ml, 10 1 FIBERCON TABS (Use NP QL(10 ea daily) mg/10ml, 50 mg/10ml, 25 calcium polycarbophil) mg/5ml KONSYL DAILY FIBER PRECEDEX SOLN 0.9 %- POWD 100 % (Use NP 200 MCG/50ML, 0.9 %-400 psyllium) MCG/100ML, 0.9 %-80 NP MCG/20ML (Use METAMUCIL CAPS 0.52 NP dexmedetomidine hcl in GM (Use psyllium) sodium chloride) METAMUCIL ORIGINAL PRECEDEX SOLN 200 TEXTURE POWD (Use NP MCG/2ML (Use NP psyllium) dexmedetomidine hcl) METAMUCIL POWD 48.57 NP QL(1 ea daily); % (Use psyllium) RESTORIL CAPS 15 MG, NP psyllium caps 0.52 gm, 520 30 MG (Use ) AL(At least 18 1 yrs old) mg RESTORIL CAPS 22.5 psyllium powd 33 %, 68 %, MG, 7.5 MG (Use NP 30 %, 100 %, 30.9 %, 1 temazepam) 48.57 %, 58.6 %, 28.3 % QL(1 ea daily); Laxative Combinations temazepam caps 15 mg, 1 AL(At least 18 30 mg COLYTE-FLAVOR PACKS QL(4000 ml per yrs old) SOLR (Use peg 3350-kcl- NP fill retail) temazepam caps 22.5 mg, 1 sod bicarb-sod chloride-sod 7.5 mg sulfate) triazolam tabs 1 QL(1 ea daily) GOLYTELY SOLR 2.97 QL(4000 ml per GM-5.86 GM-6.74 GM- fill retail) caps 1 QL(1 ea daily) 22.74 GM-236 GM (Use NP peg 3350-kcl-sod bicarb- sod chloride-sod sulfate) zolpidem tartrate subl sl 1 1.75 mg, 3.5 mg NULYTELY SOLR (Use QL(4000 ml per peg 3350-potassium fill retail) zolpidem tartrate tabs or 10 1 QL(1 ea daily) NP mg, 5 mg chloride-sod bicarbonate- sod chloride) zolpidem tartrate tbcr or 1 6.25 mg, 12.5 mg NULYTELY/FLAVOR QL(4000 ml per PACKS SOLR (Use peg fill retail) Selective Agonists 3350-potassium chloride- NP HETLIOZ CAPS 2 PA; SP sod bicarbonate-sod chloride) tabs 1 peg 3350-kcl-sod bicarb- QL(4000 ml per sod chloride-sod sulfate 1 fill retail) ROZEREM TABS (Use NP solr ramelteon) peg 3350-potassium QL(4000 ml per LAXATIVES - Bowel Treatment Drugs chloride-sod bicarbonate- 1 fill retail) sod chloride solr Bulk Laxatives sennosides-docusate 1 QL(4 ea daily) sodium tabs calcium polycarbophil tabs 1 QL(10 ea daily)

New Hampshire Healthy Families Updated October 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENOKOT S TABS (Use QL(4 ea daily) DULCOLAX SUPP RE 10 NP QL(12 ea per sennosides-docusate NP MG (Use bisacodyl) fill retail) sodium) DULCOLAX TBEC OR 5 NP QL(1 ea daily) Laxatives - Miscellaneous MG (Use bisacodyl) glycerin (laxative) supp 2 1 sennosides tabs 8.6 mg 1 gm SENOKOT TABS (Use GLYCERIN ADULT SUPP NP NP (Use glycerin (laxative)) sennosides) Surfactant Laxatives lactulose soln 10 gm/15ml, 1 20 gm/30ml COLACE CAPS (Use NP QL(3 ea daily) MIRALAX MIX-IN PAX docusate sodium) PACK (Use polyethylene NP COLACE CLEAR CAPS NP glycol 3350) (Use docusate sodium) MIRALAX PACK 17 GM docusate sodium caps or 1 QL(3 ea daily) (Use polyethylene glycol NP 250 mg, 100 mg 3350) docusate sodium caps or 1 MIRALAX POWD 17 QL(34 gm 50 mg GM/SCOOP (Use NP daily) docusate sodium liqd or polyethylene glycol 3350) 100 mg/10ml, 150 1 polyethylene glycol 3350 1 mg/15ml, 50 mg/5ml pack or 17 gm docusate sodium syrp or 60 1 polyethylene glycol 3350 1 QL(34 gm mg/15ml powd or 17 gm/scoop daily) docusate sodium tabs or 1 SORBITOL SOLN OR 70 2 100 mg % MACROLIDES - Drugs to Treat Bacterial Saline Laxatives Infections FLEET ENEMA ENEM NP Azithromycin (Use sodium phosphates) FLEET ENEMA SIX PACK azithromycin pack or 1 gm 1 ENEM (Use sodium NP azithromycin susr or 100 0 QL(15 ml per phosphates) mg/5ml fill retail) FLEET PEDIATRIC ENEM NP azithromycin susr or 200 0 QL(30 ml per (Use sodium phosphates) mg/5ml fill retail) magnesium citrate soln or 1 azithromycin tabs or 250 0 QL(6 ea per fill 1.745 gm/30ml, mg retail) magnesium hydroxide susp QL(33 ml daily) azithromycin tabs or 500 0 QL(4 ea daily) or 1200 mg/15ml, 2400 1 mg mg/30ml, 400 mg/5ml, 7.75 % azithromycin tabs or 600 0 QL(8 ea per 28 mg days retail) sodium phosphates enem 1 ZITHROMAX SUSR OR QL(15 ml per 100 MG/5ML (Use NP fill retail) Stimulant Laxatives azithromycin) QL(12 ea per bisacodyl supp re 10 mg 1 ZITHROMAX SUSR OR QL(30 ml per fill retail) 200 MG/5ML (Use NP fill retail) bisacodyl tbec or 5 mg 1 QL(1 ea daily) azithromycin)

New Hampshire Healthy Families Updated October 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZITHROMAX TABS OR NP QL(6 ea per fill Diabetic Supplies 250 MG (Use azithromycin) retail) 1ST TIER UNILET 200 / ZITHROMAX TABS OR NP QL(4 ea daily) COMFORTOUCH 2 month;QL(6.67 500 MG (Use azithromycin) LANCETS 28G MISC ea daily) ZITHROMAX TABS OR NP QL(8 ea per 28 1ST TIER UNILET 200 / 600 MG (Use azithromycin) days retail) COMFORTOUCH 2 month;QL(6.67 LANCETS 30G MISC ea daily) ZITHROMAX TRI-PAK NP QL(4 ea daily) TABS (Use azithromycin) ACCUTREND PLUS DEVI 2 ZITHROMAX Z-PAK TABS NP QL(6 ea per fill (Use azithromycin) retail) 200 per ADVANCED MOBILE 2 Clarithromycin LANCET 30G MISC month;QL(6.67 ea daily) clarithromycin susr or 125 1 QL(200 ml per mg/5ml, 250 mg/5ml fill retail) 200 / AGAMATRIX ULTRA-THIN 2 month;QL(6.67 LANCETS 33G MISC clarithromycin tabs or 250 1 QL(28 ea per ea daily) mg, 500 mg fill retail) 200 / clarithromycin tb24 or 500 QL(14 ea per AIMSCO TWIST LANCETS 2 1 32G MISC month;QL(6.67 mg fill retail) ea daily) Erythromycins 200 / AIMSCO TWIST LANCETS 2 month;QL(6.67 E.E.S. GRANULES SUSR 33G MISC (Use erythromycin 2 ea daily) ethylsuccinate) 200 / AURORA LANCET SUPER 2 month;QL(6.67 ERYPED 200 SUSR (Use THIN30G MISC erythromycin 2 ea daily) ethylsuccinate) 200 / AURORA LANCET THIN 2 month;QL(6.67 ERYPED 400 SUSR (Use 23G MISC erythromycin NP ea daily) ethylsuccinate) 200 / BD LANCET ULTRAFINE 2 30G MISC month;QL(6.67 erythromycin base cpep 1 ea daily) erythromycin base tabs 1 200 / CAREONE LANCET 2 month;QL(6.67 SUPER THIN/30G MISC erythromycin ea daily) ethylsuccinate susr or 200 1 200 / mg/5ml, 400 mg/5ml CAREONE LANCET THIN 2 month;QL(6.67 MISC erythromycin ea daily) ethylsuccinate tabs or 400 1 CARESENS LANCETS 2 QL(6.67 ea mg MISC daily) MEDICAL DEVICES AND SUPPLIES 200 / CLEANLET LANCETS 28G 2 month;QL(6.67 MISC Bandages-Dressings-Tape ea daily) COMFORT ASSURED 200 / PREP PADS- 2 OTC MISC LANCETS SUPER THIN 2 month;QL(6.67 28G MISC ea daily) Contraceptives 200 / QL(36 ea per COMFORT LANCETS 2 CONDOMS-MISC 2 MISC month;QL(6.67 fill retail) ea daily)

New Hampshire Healthy Families Updated October 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 200 / 200 / CVS LANCETS 21G MISC 2 month;QL(6.67 E-Z JECT LANCETS 21G 2 MISC month;QL(6.67 ea daily) ea daily) CVS LANCETS MICRO 200 / 200 / 2 month;QL(6.67 E-Z JECT LANCETS 2 month;QL(6.67 THIN 33G MISC COLOR MISC ea daily) ea daily) CVS LANCETS MICRO- 200 / 200 / 2 month;QL(6.67 E-Z JECT LANCETS MISC 2 month;QL(6.67 THIN 33G MISC ea daily) ea daily) CVS LANCETS ORIGINAL 200 / 200 / 2 month;QL(6.67 E-Z JECT LANCETS 2 month;QL(6.67 MISC SUPER THIN 30G MISC ea daily) ea daily) CVS LANCETS THIN 26G 200 / 200 / 2 month;QL(6.67 E-Z JECT LANCETS THIN 2 month;QL(6.67 MISC 26G MISC ea daily) ea daily) CVS LANCETS ULTRA 200 / 200 / 2 month;QL(6.67 E-ZJECT LANCETS 2 month;QL(6.67 THIN 30G MISC MICRO-THIN 33G MISC ea daily) ea daily) CVS LANCETS ULTRA- 200 / 200 / 2 month;QL(6.67 EASY TOUCH LANCETS 2 month;QL(6.67 THIN 30G MISC 26G/PULL-TOP MISC ea daily) ea daily) CVS ULTRA THIN 200 / 200 / 2 month;QL(6.67 EASY TOUCH LANCETS 2 month;QL(6.67 LANCETS MISC 28G/PULL-TOP MISC ea daily) ea daily) DIATHRIVE LANCETS 2 QL(6.67 ea 200 / MISC daily) EASY TOUCH LANCETS 2 28G/TWIST MISC month;QL(6.67 ea daily) DIATHRIVE LANCETS 200 / 2 month;QL(6.67 200 / ULTRA THIN 30G MISC ea daily) EASY TOUCH LANCETS 2 30G/PULL-TOP MISC month;QL(6.67 ea daily) DIATHRIVE LANCETS 2 QL(6.67 ea ULTRA THIN 30G MISC daily) 200 / EASY TOUCH LANCETS 2 month;QL(6.67 200 / 30G/TWIST MISC DROPLET LANCETS 2 ea daily) ULTRA THIN 30G MISC month;QL(6.67 ea daily) 200 / EASY TOUCH LANCETS 2 month;QL(6.67 200 / 32G/PULL-TOP MISC DRUG MART LANCETS 2 ea daily) THIN MISC month;QL(6.67 ea daily) 200 / EASY TOUCH LANCETS 2 month;QL(6.67 DRUG MART UNILET 200 / 32G/TWIST MISC LANCETSSUPER THIN 2 month;QL(6.67 ea daily) 30G MISC ea daily) 200 / EASY TOUCH LANCETS 2 month;QL(6.67 DRUG MART UNILET 200 / 33G/TWIST MISC LANCETSULTRA THIN 2 month;QL(6.67 ea daily) 28G MISC ea daily) 200 / EQL COLOR LANCETS 2 month;QL(6.67 DRUG MART UNILET 200 per 21G MISC MICRO THIN LANCETS 2 month;QL(6.67 ea daily) 33G MISC ea daily) 200 / EQL COLOR LANCETS 2 month;QL(6.67 MICRO THIN 33G MISC ea daily) New Hampshire Healthy Families Updated October 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL SUPER THIN 200 / 200 / 2 month;QL(6.67 GNP LANCETS SUPER 2 month;QL(6.67 LANCETS 30G MISC THIN 30G MISC ea daily) ea daily) EQL THIN LANCETS 26G 200 / 200 / 2 month;QL(6.67 GNP LANCETS THIN 26G 2 month;QL(6.67 MISC MISC ea daily) ea daily) EZ-LETS LANCETS 26G 200 / 200 / 2 month;QL(6.67 GNP LANCETS THIN 2 month;QL(6.67 SUPER-SOFT MISC MISC ea daily) ea daily) EZ-LETS LANCETS 28G 200 / GOJJI STERILE LANCETS 2 QL(6.67 ea 2 month;QL(6.67 30G MISC daily) ULTRA-SOFT MISC ea daily) GOODSENSE COLOR QL(6.67 ea 2 EZ-LETS LANCETS 30G 200 / LANCETS MICRO-THIN daily) 2 month;QL(6.67 33G UNIVERSAL MISC MISC ea daily) GOODSENSE LANCETS 200 per 200 / MICRO-THIN 33G 2 month;QL(6.67 FORA LANCETS MISC 2 month;QL(6.67 UNIVERSAL MISC ea daily) ea daily) GOODSENSE LANCETS QL(6.67 ea FREDS PHARMACY 200 / MICRO-THIN 33G 2 daily) UNILET LANCETS SUPER 2 month;QL(6.67 UNIVERSAL MISC THIN 30G MISC ea daily) GOODSENSE LANCETS 200 per FREDS PHARMACY 200 / ULTRA-THIN 26G 2 month;QL(6.67 UNILET LANCETS ULTRA 2 month;QL(6.67 UNIVERSAL MISC ea daily) THIN 28G MISC ea daily) GOODSENSE LANCETS QL(6.67 ea GAUZE SPONGES 2 RX/OTC ULTRA-THIN 30G 2 daily) UNIVERSAL MISC 200 / H-E-B INCONTROL 200 / GENTLE-LET GP 2 month;QL(6.67 LANCETS MISC LANCETS MICRO THIN 2 month;QL(6.67 ea daily) 33G MISC ea daily) GENTLE-LET LANCETS 200 / H-E-B INCONTROL 200 / GENERAL PURPOSE 2 month;QL(6.67 LANCETS SUPER THIN 2 month;QL(6.67 STYLE/FINE POINT MISC ea daily) 30G MISC ea daily) GENTLE-LET LANCETS 200 / H-E-B INCONTROL 200 / GENERAL PURPOSE 2 month;QL(6.67 LANCETS ULTRA THIN 2 month;QL(6.67 STYLE/MEDIUM POINT ea daily) 28G MISC ea daily) MISC HEALTHY ACCENTS 200 / GENTLE-LET LANCETS 200 / UNILET LANCETS SUPER 2 month;QL(6.67 SAFETY STYLE/FINE 2 month;QL(6.67 THIN 30G MISC ea daily) POINT MISC ea daily) 200 / GENTLE-LET LANCETS 200 / HY-VEE LANCETS MISC 2 month;QL(6.67 SAFETY STYLE/MEDIUM 2 month;QL(6.67 ea daily) POINT MISC ea daily) 200 / 200 / HY-VEE THIN LANCETS 2 MISC month;QL(6.67 GNP LANCETS 21G MISC 2 month;QL(6.67 ea daily) ea daily) 200 / 200 / KINNEY LANCETS MISC 2 month;QL(6.67 GNP LANCETS MICRO 2 THIN 33G MISC month;QL(6.67 ea daily) ea daily) New Hampshire Healthy Families Updated October 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINNEY THIN LANCETS 200 / 200 per 2 month;QL(6.67 LANCETS SUPER THIN 2 month;QL(6.67 MISC 28G MISC ea daily) ea daily) KROGER HEALTHPRO 200 / 200 / TWIST LANCETS/26G 2 month;QL(6.67 LANCETS THIN MISC 2 month;QL(6.67 MISC ea daily) ea daily) KROGER LANCETS 21G 200 / 200 / 2 month;QL(6.67 LANCETS ULTRA THIN 2 month;QL(6.67 MISC MISC ea daily) ea daily) KROGER LANCETS 200 / 200 / 2 month;QL(6.67 LIVE BETTER LANCET 2 month;QL(6.67 MICRO THIN33G MISC SUPERTHIN 30G MISC ea daily) ea daily) 200 / 200 / KROGER LANCETS MISC 2 month;QL(6.67 LIVE BETTER LANCET 2 ULTRATHIN 28G MISC month;QL(6.67 ea daily) ea daily) KROGER LANCETS 200 / 200 / 2 month;QL(6.67 LONGS LANCETS 2 month;QL(6.67 SUPER THIN MISC STANDARD MISC ea daily) ea daily) KROGER LANCETS THIN 200 / 200 / 2 month;QL(6.67 LONGS LANCETS THIN 2 month;QL(6.67 26G MISC MISC ea daily) ea daily) KROGER LANCETS THIN 200 / 200 / 2 month;QL(6.67 MEDISENSE THIN 2 month;QL(6.67 MISC LANCETS MISC ea daily) ea daily) KROGER LANCETS 200 / MEIJER COLOR 200 / 2 month;QL(6.67 LANCETS UNIVERSAL 2 month;QL(6.67 ULTRATHIN30G MISC ea daily) 33G MISC ea daily) LANCETS 26G TWIST 200 / 200 / 2 month;QL(6.67 MEIJER LANCETS MISC 2 month;QL(6.67 TOP MISC ea daily) ea daily) 200 / 200 / LANCETS 28G MISC 2 month;QL(6.67 MEIJER LANCETS THIN 2 MISC month;QL(6.67 ea daily) ea daily) 200 / 200 / LANCETS 30G MISC 2 month;QL(6.67 MEIJER LANCETS 2 UNIVERSAL21G MISC month;QL(6.67 ea daily) ea daily) 200 / 200 / LANCETS MISC 2 month;QL(6.67 MEIJER LANCETS 2 UNIVERSAL30G MISC month;QL(6.67 ea daily) ea daily) LANCETS SAFETY SEAL 200 / 200 / 2 month;QL(6.67 MEIJER LANCETS 2 month;QL(6.67 21G MISC UNIVERSAL33G MISC ea daily) ea daily) LANCETS SAFETY SEAL 200 / 200 / 2 month;QL(6.67 MEIJER SUPER THIN 2 month;QL(6.67 26G MISC LANCETS MISC ea daily) ea daily) LANCETS SAFETY SEAL 200 / 200 / 2 month;QL(6.67 MONOLET LANCETS 2 month;QL(6.67 28G MISC MISC ea daily) ea daily) New Hampshire Healthy Families Updated October 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOLET OPD LANCETS 200 / 200 / 2 month;QL(6.67 QC UNILET LANCETS 2 month;QL(6.67 MISC 28G/ULTRA THIN MISC ea daily) ea daily) NOVA SUREFLEX 200 / 200 / 2 month;QL(6.67 QC UNILET LANCETS 2 month;QL(6.67 LANCETS MISC 33G/MICRO THIN MISC ea daily) ea daily) PC LANCETS SUPER 200 / 200 / 2 month;QL(6.67 RA E-ZJECT LANCETS 2 month;QL(6.67 THIN 30G MISC 28G MISC ea daily) ea daily) PERFECT LANCETS 30G 200 / 200 / 2 month;QL(6.67 RA E-ZJECT LANCETS 2 month;QL(6.67 MISC THIN 26G MISC ea daily) ea daily) PHARMACY COUNTER 200 / 200 / 2 month;QL(6.67 RA E-ZJECT LANCETS 2 month;QL(6.67 LANCETS MISC THIN 28G MISC ea daily) ea daily) PRECISION THINS GP 200 / 200 / 2 month;QL(6.67 RA E-ZJECT LANCETS 2 month;QL(6.67 LANCET MISC ULTRATHIN 30G MISC ea daily) ea daily) PREFERRED PLUS 200 / 200 / LANCETS COLORED 21G 2 month;QL(6.67 REALITY LANCETS MISC 2 month;QL(6.67 MISC ea daily) ea daily) PREFERRED PLUS 200 / 200 / LANCETS SUPER THIN 2 month;QL(6.67 RELION LANCETS 2 MICRO-THIN33G MISC month;QL(6.67 30G MISC ea daily) ea daily) PREFERRED PLUS 200 / 200 / 2 month;QL(6.67 RELION LANCETS THIN 2 month;QL(6.67 LANCETS THIN 26G MISC 26G MISC ea daily) ea daily) PRODIGY TWIST TOP 200 / 200 / 2 month;QL(6.67 RELION LANCETS 2 month;QL(6.67 LANCETS MISC ULTRA-THIN30G MISC ea daily) ea daily) PSS SELECT GP 200 / RELION ULTRA THIN 2 QL(6.67 ea 2 month;QL(6.67 LANCETS/30G MISC daily) LANCETS MISC ea daily) 200 / RELION ULTRA THIN 2 PSS SELECT SAFETY 200 / month;QL(6.67 2 month;QL(6.67 LANCETS30G MISC ea daily) LANCETS MISC ea daily) RELION ULTRA THIN 200 / 2 PX LANCETS MICROTHIN 200 / PLUS LANCETS 32G month;QL(6.67 2 month;QL(6.67 MISC ea daily) 33G MISC ea daily) RELION ULTRA THIN 200 / 2 PX LANCETS ULTRA 200 / PLUS LANCETS 33G month;QL(6.67 2 month;QL(6.67 MISC ea daily) THIN MISC ea daily) 200 / REXALL LANCETS ULTRA 2 QC LANCETS SUPER 200 / month;QL(6.67 2 month;QL(6.67 THIN MISC ea daily) THIN MISC ea daily) 200 / 200 / RIGHTEST GL300 2 month;QL(6.67 QC LANCETS ULTRA 2 month;QL(6.67 LANCETS MISC THIN MISC ea daily) ea daily) New Hampshire Healthy Families Updated October 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY SEAL LANCETS 200 / 200 / 2 month;QL(6.67 TECHLITE LANCETS 2 month;QL(6.67 28G MISC MISC ea daily) ea daily) SAFETY SEAL LANCETS 200 / 200 / 2 month;QL(6.67 TGT LANCET MICRO 2 month;QL(6.67 30G MISC THIN 33G MISC ea daily) ea daily) 200 / 200 / SB LANCETS THIN MISC 2 month;QL(6.67 TGT LANCET THIN 26G 2 MISC month;QL(6.67 ea daily) ea daily) SB LANCETS ULTRA 200 / 200 / 2 month;QL(6.67 TGT LANCET ULTRA 2 month;QL(6.67 THIN MISC THIN 30G MISC ea daily) ea daily) SHOPKO UNILET 200 / 200 / LANCETS SUPER THIN 2 month;QL(6.67 THINLETS GP LANCETS 2 MISC month;QL(6.67 30G MISC ea daily) ea daily) SHOPKO UNILET 200 / 200 / LANCETS ULTRA THIN 2 month;QL(6.67 TODAYS HEALTH SUPER 2 THINLANCETS 30G MISC month;QL(6.67 28G MISC ea daily) ea daily) SM MICRO THIN 200 / 200 / 2 month;QL(6.67 TODAYS HEALTH ULTRA 2 month;QL(6.67 LANCETS 33G MISC THINLANCETS 28G MISC ea daily) ea daily) SMART SENSE COLOR 200 / TRUE METRIX CONTROL LANCETS UNIVERSAL 2 month;QL(6.67 SOLUTION LEVEL 1 2 33G MISC ea daily) SOLN SMART SENSE 200 / TRUE METRIX CONTROL STANDARD LANCETS 2 month;QL(6.67 SOLUTION LEVEL 2 2 UNIVERSAL 21G MISC ea daily) SOLN SMART SENSE SUPER 200 / TRUE METRIX CONTROL THIN LANCETS 2 month;QL(6.67 SOLUTION LEVEL 3 2 UNIVERSAL 30G MISC ea daily) SOLN SMART SENSE THIN 200 / TRUEPLUS LANCETS 200 / LANCETSUNIVERSAL 2 month;QL(6.67 2 month;QL(6.67 26G MISC 26G MISC ea daily) ea daily) 200 / TRUEPLUS LANCETS 200 / STERILANCE TL MISC 2 month;QL(6.67 2 month;QL(6.67 28G MISC ea daily) ea daily) 200 / TRUEPLUS LANCETS 200 / SUPER THIN LANCETS 2 month;QL(6.67 2 month;QL(6.67 MISC 28G SUPER THIN MISC ea daily) ea daily) 200 / TRUEPLUS LANCETS 200 / SURELITE LANCETS 2 month;QL(6.67 2 month;QL(6.67 MISC 30G MISC ea daily) ea daily) 200 / TRUEPLUS LANCETS 200 / TECHLITE AST LANCETS 2 month;QL(6.67 2 month;QL(6.67 MISC 30G ULTRA THIN MISC ea daily) ea daily) 200 / TRUEPLUS LANCETS 200 / TECHLITE LANCETS 30G 2 month;QL(6.67 2 month;QL(6.67 MISC 33G MISC ea daily) ea daily) New Hampshire Healthy Families Updated October 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET CLASSIC 200 / 200 / 2 month;QL(6.67 VALUE PLUS LANCETS 2 month;QL(6.67 LANCETS MISC SUPERTHIN 30G MISC ea daily) ea daily) UNILET COMFORTOUCH 200 / 200 / 2 month;QL(6.67 VALUE PLUS LANCETS 2 month;QL(6.67 LANCET MISC THIN 26G MISC ea daily) ea daily) 200 / 200 / UNILET EXCELITE II MISC 2 month;QL(6.67 VALUMARK LANCET 2 SUPER THIN 30G MISC month;QL(6.67 ea daily) ea daily) 200 / 200 / UNILET EXCELITE MISC 2 month;QL(6.67 VALUMARK LANCET 2 ULTRA THIN 28G MISC month;QL(6.67 ea daily) ea daily) UNILET G.P. LANCET 200 / VIDA MIA UNILET 200 / 2 month;QL(6.67 LANCETS SUPER THIN 2 month;QL(6.67 MISC ea daily) 30G MISC ea daily) UNILET G.P. SUPERLITE 200 / VIDA MIA UNILET 200 / 2 month;QL(6.67 LANCETS ULTRA THIN 2 month;QL(6.67 LANCET MISC ea daily) 28G MISC ea daily) UNILET GP 28 ULTRA 200 / WALGREENS COMFORT 200 / 2 month;QL(6.67 ASSUREDLANCETS 2 month;QL(6.67 THIN MISC ea daily) MICRO THIN/33G MISC ea daily) 200 / WALGREENS COMFORT 200 / UNILET LANCET MISC 2 month;QL(6.67 ASSUREDLANCETS 2 month;QL(6.67 ea daily) SUPER THIN/28G MISC ea daily) UNILET LANCETS 200 / 200 / 2 month;QL(6.67 WALGREENS THIN 2 month;QL(6.67 MICRO-THIN33G MISC LANCETS MISC ea daily) ea daily) 200 / Misc. Devices UNILET LANCETS 2 month;QL(6.67 SUPER-THIN30G MISC ALCOHOL PREP PADS RX/OTC ea daily) 2 PADS 200 / UNILET LANCETS 2 ALCOHOL SWABS PADS 2 RX/OTC ULTRA-THIN 28G MISC month;QL(6.67 ea daily) ALCOHOL SWABSTICK 2 RX/OTC 200 / PADS UNILET SUPERLITE 2 month;QL(6.67 LANCET MISC ea daily) APLICARE ALCOHOL 2 RX/OTC SWABSTICK PADS 200 / UNIVERSAL 1 LANCETS 2 BD SWABS SINGLE USE RX/OTC THIN26G MISC month;QL(6.67 2 ea daily) BUTTERFLY PADS 200 / BD SWABS SINGLE USE 2 RX/OTC UNIVERSAL 1 LANCETS 2 PADS ULTRA THIN 30G MISC month;QL(6.67 ea daily) CURITY ALCOHOL RX/OTC UNIVERSAL 1 200 / PREPS/MEDIUM 2 PLY 2 LANCETS/33G/MICRO- 2 month;QL(6.67 PADS THIN MISC ea daily) CURITY ALCOHOL 2 RX/OTC 200 / SWABS PADS VALUE PLUS LANCETS 2 month;QL(6.67 RX/OTC STANDARD 21G MISC CVS PREP PADS PADS 2 ea daily) New Hampshire Healthy Families Updated October 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH ALCOHOL RX/OTC BD PEN QL(5 ea daily) PREP PADS/MEDIUM 2 NEEDLE/MICRO/ULTRA- 2 PADS FINE/32G X 6MM MISC FIFTY50 ALCOHOL PREP 2 RX/OTC BD PEN QL(5 ea daily); PADS PADS NEEDLE/MINI/ULTRA- 2 RX/OTC FINE/31G X 5MM MISC GNP ALCOHOL SWABS 2 RX/OTC PADS BD PEN NEEDLE/NANO QL(5 ea daily); 2ND GEN/32G X 5/32" 2 RX/OTC HM STERILE ALCOHOL 2 RX/OTC PREP PADS PADS MISC MEIJER ALCOHOL RX/OTC BD PEN QL(5 ea daily); SWABS EXTRA-THICK 2 NEEDLE/NANO/ULTRA- 2 RX/OTC PADS FINE/32G X 4MM MISC BD PEN QL(5 ea daily) PRO COMFORT 2 RX/OTC ALCOHOL PADS PADS NEEDLE/ORIGINAL/ULTR 2 A-FINE/29G X 12.7MM QC ALCOHOL SWABS 2 RX/OTC MISC PADS BD PEN QL(5 ea daily); RA ALCOHOL SWABS 2 RX/OTC NEEDLE/SHORT/ULTRA- 2 RX/OTC PADS FINE/31G X 8MM MISC REALITY SWABS PADS 2 RX/OTC BD PEN NEEDLES 2 QL (5 ea daily); RX/OTC RELION ALCOHOL 2 RX/OTC SWABS PADS INSULIN SYRINGES 2 QL (5 ea daily); RX/OTC SB ALCOHOL PREP 2 RX/OTC PADS PADS Respiratory Therapy Supplies SHOPKO ALCOHOL RX/OTC QL(1 ea per 2 ACE AEROSOL CLOUD 2 SWABS PADS ENHANCER MISC 360 days retail); RX/OTC SM ALCOHOL PREP 2 RX/OTC PADS PADS QL(1 ea per ACTIVITY POUCH MISC 2 360 days TGT ALCOHOL SWABS 2 RX/OTC PADS retail); RX/OTC WEBCOL ALCOHOL RX/OTC QL(1 ea per ADULT AEROSOL MASK 2 360 days PREP LARGE 1 PLY 2 MISC PADS retail); RX/OTC WEBCOL ALCOHOL RX/OTC QL(1 ea per ADULT MASK LARGE 2 360 days PREP LARGE 2 PLY 2 MISC PADS retail); RX/OTC WEBCOL ALCOHOL RX/OTC QL(1 ea per PREP MEDIUM 2 PLY 2 ADULT MASK MISC 2 360 days PADS retail); RX/OTC AEROCHAMBER MINI QL(2 ea per Parenteral Therapy Supplies AEROSOLCHAMBER 2 360 days BD AUTOSHIELD 29G X 2 QL(5 ea daily) DEVI retail); RX/OTC 3/16" MISC QL(2 ea per BD AUTOSHIELD 29G X QL(5 ea daily) AEROCHAMBER MV 2 2 MISC 360 days 5/16" MISC retail); RX/OTC BD AUTOSHIELD DUO 2 QL(5 ea daily) 30G X 5MM MISC

New Hampshire Healthy Families Updated October 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AEROCHAMBER PLUS QL(2 ea per ALL FLOW 1000 QL(1 ea per 2 360 days PULMONARY FUNCTION 2 360 days FLOW VU MISC retail); RX/OTC FILTER MISC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per 2 360 days ARIAL CHAMBER DEVI 2 360 days FLOW-VU MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per BREATHE EASE QL(1 ea per FLOW-VU/LARGE MASK 2 360 days NEBULIZER MASK/CHILD 2 360 days MISC retail); RX/OTC MISC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per BREATHE EASE QL(1 ea per 2 360 days NEBULIZER 2 360 days FLOW-VU/MASK MISC retail); RX/OTC MASK/INFANT MISC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per FLOW-VU/MEDIUM MASK 2 360 days BREATHE EASE/LARGE 2 MASK DEVI 360 days MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per FLOW-VU/SMALL MASK 2 360 days BREATHE EASE/MEDIUM 2 MASK DEVI 360 days MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER Z-STAT QL(2 ea per QL(2 ea per PLUS VALVED HOLDING 360 days BREATHE EASE/SMALL 2 2 MASK DEVI 360 days CHAMBER W/FLOW VU retail); RX/OTC retail); RX/OTC MISC BREATHERITE QL(2 ea per 2 AEROCHAMBER Z-STAT QL(2 ea per COLLAPSIBLEADULT 360 days 2 360 days SPACER W/MASK MISC retail); RX/OTC PLUS/FLOWSIGNAL MISC retail); RX/OTC BREATHERITE QL(2 ea per 2 AEROCHAMBER Z-STAT QL(2 ea per COLLAPSIBLECHILD 360 days 2 360 days SPACER W/MASK MISC retail); RX/OTC PLUS/LARGE MASK MISC retail); RX/OTC BREATHERITE QL(2 ea per AEROCHAMBER Z-STAT QL(2 ea per COLLAPSIBLEINFANT 2 360 days PLUS/MEDIUM MASK 2 360 days SPACER W/MASK MISC retail); RX/OTC MISC retail); RX/OTC BREATHERITE QL(2 ea per AEROCHAMBER Z-STAT QL(2 ea per COLLAPSIBLESMALL 2 360 days 2 360 days CHILD SPACER W/MASK retail); RX/OTC PLUS/SMALL MASK MISC retail); RX/OTC MISC AEROCHAMBER/FLOWSI QL(2 ea per BREATHERITE QL(2 ea per 2 360 days COLLAPSIBLESPACER 2 360 days GNAL MISC retail); RX/OTC W/ NEONATE MASK MISC retail); RX/OTC QL(1 ea per QL(2 ea per AEROTRACH PLUS MISC 2 360 days BREATHERITE MISC 2 360 days retail); RX/OTC retail); RX/OTC AEROVENT PLUS QL(2 ea per QL(2 ea per HOLDING 360 days BREATHERITE RIGID 2 2 SPACERW/MASK MISC 360 days CHAMBER/COLLAPSIBLE retail); RX/OTC retail); RX/OTC DEVI QL(2 ea per QL(1 ea per BREATHERITE W/LARGE 2 360 days AIRS PEDIATRIC 2 MASK MISC AEROSOL MASK MISC 360 days retail); RX/OTC retail); RX/OTC

New Hampshire Healthy Families Updated October 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHERITE QL(2 ea per COMPACT SPACE QL(2 ea per 2 360 days CHAMBER/ANTI- 360 days W/MEDIUM MASK MISC 2 retail); RX/OTC STATIC/SMALL MASK retail); RX/OTC DEVI BREATHERITE W/SMALL QL(2 ea per 2 360 days QL(2 ea per MASK MISC retail); RX/OTC EASIVENT MISC 2 360 days BUBBLES THE FISH II QL(1 ea per retail); RX/OTC PEDIATRIC MASK/PVC 2 360 days EASIVENT/MASK-LARGE QL(2 ea per MISC retail); RX/OTC 2 360 days MISC CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED 360 days QL(2 ea per HOLDING 2 retail); RX/OTC EASIVENT/MASK- 2 MEDIUM MISC 360 days CHAMBER/ADULT LARGE retail); RX/OTC DEVI QL(2 ea per CLEVER CHOICE ANTI- QL(2 ea per EASIVENT/MASK-SMALL 2 360 days MISC STATICVALVED 2 360 days retail); RX/OTC HOLDING retail); RX/OTC QL(1 ea per CHAMBER/MEDIUM DEVI EBASE CONTROLLER KIT 2 MISC 360 days CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED 360 days QL(1 ea per HOLDING 2 retail); RX/OTC EFLOW SCF AEROSOL 2 HEAD MISC 360 days CHAMBER/MEDIUM/3 retail); RX/OTC YEA DEVI QL(1 ea per CLEVER CHOICE ANTI- QL(2 ea per ELITE DC AUTO 2 360 days ADAPTER MISC STATICVALVED 2 360 days retail); RX/OTC HOLDING retail); RX/OTC CHAMBER/SMALL DEVI QL(2 ea per EQ SPACE CHAMBER 2 ANTI-STATIC DEVI 360 days CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED 360 days HOLDING 2 retail); RX/OTC EQ SPACE CHAMBER QL(2 ea per CHAMBER/SMALL ANTI-STATIC/LARGE 2 360 days INFANT DEVI MASK DEVI retail); RX/OTC CO MONITOR QL(1 ea per EQ SPACE CHAMBER QL(2 ea per REPLACEMENT TPIECES 2 360 days ANTI-STATIC/MEDIUM 2 360 days MISC retail); RX/OTC MASK DEVI retail); RX/OTC COMPACT SPACE QL(2 ea per EQ SPACE CHAMBER QL(2 ea per CHAMBER/ANTI-STATIC 2 360 days ANTI-STATIC/SMALL 2 360 days DEVI retail); RX/OTC MASK DEVI retail); RX/OTC COMPACT SPACE QL(2 ea per QL(1 ea per FILTER AIR PP MISC 2 360 days CHAMBER/ANTI- 2 360 days STATIC/LARGE MASK retail); RX/OTC retail); RX/OTC DEVI QL(2 ea per COMPACT SPACE QL(2 ea per FLEXICHAMBER DEVI 2 360 days retail); RX/OTC CHAMBER/ANTI- 2 360 days STATIC/MEDIUM MASK retail); RX/OTC QL(1 ea per FLYP HYPERSONIQ 2 DEVI CARTRIDGE MISC 360 days retail); RX/OTC

New Hampshire Healthy Families Updated October 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FULL KIT NEBULIZER QL(1 ea per QL(1 ea per 2 360 days MICROELITE FILTER 2 360 days SET MISC REPLACEMENTS MISC retail); RX/OTC retail); RX/OTC HUDSON RCI SEE-THRU QL(1 ea per MICROELITE QL(1 ea per AEROSOL MASK 2 360 days RECHARGEABLE 2 360 days ELONGATED/ADULT retail); RX/OTC BATTERY MISC retail); RX/OTC MISC QL(2 ea per INNOSPIRE QL(1 ea per MICROSPACER MISC 2 360 days REPLACEMENT FILTER 2 360 days retail); RX/OTC MISC retail); RX/OTC QL(1 ea per INSPIRACHAMBER/ANTI- QL(2 ea per MINIELITE FILTER 2 360 days REPLACEMENTS MISC STATIC 2 360 days retail); RX/OTC VALVED/MOUTHPIECE retail); RX/OTC MINIELITE QL(1 ea per DEVI RECHARGEABLE 2 360 days QL(2 ea per BATTERY MISC retail); RX/OTC INSPIRACHAMBER/LARG 2 360 days E DEVI QL(1 ea per retail); RX/OTC NEBULIZER AIR 2 TUBE/PLUGS MISC 360 days INSPIRACHAMBER/SOOT QL(2 ea per retail); RX/OTC HERMASK/INSPIRAMASK 2 360 days QL(1 ea per /MEDIUM DEVI retail); RX/OTC NEBULIZER PEDIATRIC 2 MASK MISC 360 days INSPIRACHAMBER/SOOT QL(2 ea per retail); RX/OTC HERMASK/INSPIRAMASK 2 360 days QL(1 ea per /SMALL DEVI retail); RX/OTC NOSE CLIP MISC 2 360 days QL(2 ea per retail); RX/OTC INSPIREASE DRUG 2 360 days DELIVERYSYSTEM MISC OPTICHAMBER QL(2 ea per retail); RX/OTC ADVANTAGE/LARGE 2 360 days INSPIREASE RESERVOIR 2 QL(3 ea per MASK MISC retail); RX/OTC BAGS MISC 180 days retail) OPTICHAMBER QL(2 ea per QL(2 ea per ADVANTAGE/MEDIUM 2 360 days LITEAIRE DEVI 2 360 days FACE MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per 2 LITETOUCH MASK QL(1 ea per ADVANTAGE/SMALL 360 days 2 360 days FACE MASK MISC retail); RX/OTC LARGE MISC retail); RX/OTC QL(2 ea per OPTICHAMBER 2 LITETOUCH MASK QL(1 ea per 360 days 2 360 days DIAMOND MISC retail); RX/OTC MEDIUM MISC retail); RX/OTC OPTICHAMBER QL(2 ea per 2 LITETOUCH MASK QL(1 ea per DIAMOND/LARGEFACE 360 days 2 360 days MASK DEVI retail); RX/OTC SMALL MISC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(2 ea per DIAMOND/MEDIUM FACE 2 360 days MICROCHAMBER DEVI 2 360 days MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(2 ea per DIAMOND/SMALLFACE 2 360 days MICROCHAMBER MISC 2 360 days MASK MISC retail); RX/OTC retail); RX/OTC QL(2 ea per OPTICHAMBER FACE 2 360 days MASK/LARGE MISC retail); RX/OTC New Hampshire Healthy Families Updated October 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER FACE QL(2 ea per PHARMACIST CHOICE QL(1 ea per 2 360 days NEBULIZER/CPAP/INHAL 360 days MASK/MEDIUM MISC 2 retail); RX/OTC ER CHAMBER MASK retail); RX/OTC QL(2 ea per WIPES MISC OPTICHAMBER FACE 2 360 days MASK/SMALL MISC PILLOW MASK/ADULT QL(1 ea per retail); RX/OTC 2 360 days MISC QL(2 ea per retail); RX/OTC OPTIHALER MDI DRUG 2 360 days DELIVERY SYSTEM DEVI PILLOW MASK/CHILD QL(1 ea per retail); RX/OTC 2 360 days MISC QL(2 ea per retail); RX/OTC OPTIHALER MISC 2 360 days PILLOW QL(1 ea per retail); RX/OTC 2 360 days MASK/PEDIATRIC MISC PARI ALTERA QL(1 ea per retail); RX/OTC NEBULIZER HANDSET 2 360 days QL(2 ea per MISC retail); RX/OTC POCKET CHAMBER DEVI 2 360 days retail); RX/OTC PARI BABY CONVERSION QL(1 ea per 2 360 days QL(2 ea per KITSIZE 1 MISC retail); RX/OTC POCKET SPACER DEVI 2 360 days retail); RX/OTC PARI BABY CONVERSION QL(1 ea per 2 360 days PRO COMFORT INHALER QL(2 ea per KITSIZE 2 MISC retail); RX/OTC SPACER CHAMBER 2 360 days ADULT MISC retail); RX/OTC PARI BABY CONVERSION QL(1 ea per 2 360 days PRO COMFORT INHALER QL(2 ea per KITSIZE 3 MISC retail); RX/OTC SPACER CHAMBER 2 360 days CHILD MISC retail); RX/OTC PARI ERAPID NEBULIZER QL(1 ea per 2 360 days PRO COMFORT INHALER QL(2 ea per HANDSET MISC retail); RX/OTC SPACER CHAMBER 2 360 days QL(1 ea per INFANT DEVI retail); RX/OTC PARI EXPIRATORY 2 FILTER VALVE SET DEVI 360 days PROCARE SPACER QL(2 ea per retail); RX/OTC CHAMBER W/ADULT 2 360 days QL(1 ea per MASK DEVI retail); RX/OTC PARI MASK SET MISC 2 360 days PROCARE SPACER QL(2 ea per retail); RX/OTC CHAMBER W/CHILD 2 360 days QL(1 ea per MASK DEVI retail); RX/OTC PARI SOFT PLASTIC 2 360 days ADULT MASK MISC PRONEB ULTRA FILTER QL(1 ea per retail); RX/OTC 2 360 days SET MISC QL(1 ea per retail); RX/OTC PARI SOFT PLASTIC 2 360 days PEDIATRIC MASK MISC REPLACEMENT AIR QL(1 ea per retail); RX/OTC 2 360 days FILTER MISC QL(1 ea per retail); RX/OTC PARI VORTEX ADULT 2 360 days MASK MISC REPLACEMENT FILTERS QL(1 ea per retail); RX/OTC 2 360 days MISC PEDIATRIC QL(1 ea per retail); RX/OTC MOUTHPIECE/DISPOSAB 2 360 days QL(2 ea per LE MISC retail); RX/OTC RITEFLO DEVI 2 360 days QL(1 ea per retail); RX/OTC PFLEX MISC 2 360 days retail); RX/OTC New Hampshire Healthy Families Updated October 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAMI THE SEAL QL(1 ea per QL(1 ea per REPLACEMENTFILTERS 2 360 days TUBING/WING TIP MISC 2 360 days MISC retail); RX/OTC retail); RX/OTC SIDESTREAM ADULT QL(1 ea per QL(2 ea per 2 360 days VALVED HOLDING 2 360 days FACE MASK MISC CHAMBER DEVI retail); RX/OTC retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per VORTEX VALVED QL(2 ea per 2 360 days HOLDING CHAMBER 2 360 days FACEMASK MISC retail); RX/OTC DEVI retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per QL(2 ea per FACEMASK/SAMI THE 2 360 days WATCHHALER DEVI 2 360 days SEAL MISC retail); RX/OTC retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per QL(1 ea per FACEMASK/TUCKER THE 2 360 days WINDMILL TRAINER 2 MISC 360 days TURTLE MISC retail); RX/OTC retail); RX/OTC QL(1 ea per MIGRAINE PRODUCTS - Drugs to Treat Migraine SIDESTREAM PLUS 2 ADULT FACE MASK MISC 360 days Headaches retail); RX/OTC Calcitonin Gene-Related Peptide (CGRP) SILICONE MASK FOR QL(1 ea per BREATHERITE 2 360 days AJOVY SOAJ 2 SP CHAMBER/ADULT MISC retail); RX/OTC SILICONE MASK FOR QL(1 ea per AJOVY SOSY 2 SP BREATHERITE 2 360 days CHAMBER/INFANT MISC retail); RX/OTC EMGALITY SOAJ 2 PA; SP SILICONE MASK FOR QL(1 ea per EMGALITY SOSY 2 PA; SP BREATHERITE 2 360 days CHAMBER/PEDIATRIC retail); RX/OTC MISC Migraine Combinations SILICONE MASK FOR QL(1 ea per CAFERGOT TABS (Use NP BREATHRITE 2 360 days w/ caffeine) CHAMBER/ADULT MISC retail); RX/OTC ergotamine w/ caffeine tabs 1 QL(1 ea per or 1 mg-100 mg SOOTHENEB NBL 100 2 360 days CHILD MASK MISC -naproxen 1 retail); RX/OTC sodium tabs QL(1 ea per TREXIMET TABS (Use SOOTHENEB NBL 100 2 360 days MEDICATION CUP MISC sumatriptan-naproxen NP retail); RX/OTC sodium) QL(1 ea per Migraine Products SOOTHENEB NBL 100 2 MESH CAP MISC 360 days retail); RX/OTC D.H.E. 45 SOLN (Use NP QL(1 ea per mesylate) SOOTHENEB NBL100 2 360 days ADULT MASK MISC retail); RX/OTC dihydroergotamine 1 mesylate soln ij 1 mg/ml QL(1 ea per THRESHOLD IMT MISC 2 360 days dihydroergotamine 1 retail); RX/OTC mesylate soln na 4 mg/ml

New Hampshire Healthy Families Updated October 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIGRANAL SOLN (Use QL(0.3 ea dihydroergotamine NP 1 daily); AL(At mesylate) hcl tabs least 18 yrs old) Serotonin Agonists RELPAX TABS (Use NP QL(0.2 ea malate tabs 1 hydrobromide) daily) QL(0.3 ea QL(12 ea per benzoate tabs 30 days retail); AMERGE TABS (Use NP daily); AL(At 1 naratriptan hcl) least 18 yrs 10 mg, 5 mg AL(At least 6 old) yrs old) rizatriptan benzoate tbdp eletriptan hydrobromide 1 QL(0.2 ea 1 tabs daily) 10 mg, 5 mg sumatriptan soln na 20 QL(6 ea per 30 FROVA TABS (Use NP 1 succinate) mg/act, 5 mg/act days retail) sumatriptan succinate soaj 1 frovatriptan succinate tabs 1 sc 4 mg/0.5ml IMITREX SOLN NA 20 QL(6 ea per 30 sumatriptan succinate soaj 1 QL(0.67 ml MG/ACT, 5 MG/ACT (Use NP days retail) sc 6 mg/0.5ml daily) sumatriptan) sumatriptan succinate soct 1 QL(2.5 ml per sc 4 mg/0.5ml IMITREX SOLN SC 6 30 days retail); MG/0.5ML (Use NP sumatriptan succinate soct 1 QL(0.67 ml sumatriptan succinate) AL(At least 12 sc 6 mg/0.5ml daily) yrs old) QL(2.5 ml per IMITREX STATDOSE sumatriptan succinate soln 1 30 days retail); REFILL SOCT 4 MG/0.5ML NP sc 6 mg/0.5ml AL(At least 12 (Use sumatriptan yrs old) succinate) sumatriptan succinate sosy 1 IMITREX STATDOSE QL(0.67 ml sc 6 mg/0.5ml REFILL SOCT 6 MG/0.5ML daily) NP sumatriptan succinate tabs 1 QL(9 ea per 30 (Use sumatriptan or 50 mg, 100 mg, 25 mg days retail) succinate) tabs or 2.5 mg, 1 QL(6 ea per 30 IMITREX STATDOSE 5 mg days retail) SYSTEM SOAJ 4 NP MG/0.5ML (Use zolmitriptan tbdp or 2.5 mg, 1 QL(6 ea per 30 sumatriptan succinate) 5 mg days retail) IMITREX STATDOSE QL(0.67 ml ZOMIG TABS (Use NP QL(6 ea per 30 zolmitriptan) days retail) SYSTEM SOAJ 6 NP daily) MG/0.5ML (Use ZOMIG ZMT TBDP (Use NP QL(6 ea per 30 sumatriptan succinate) zolmitriptan) days retail) IMITREX TABS OR 50 MG, QL(9 ea per 30 MINERALS & ELECTROLYTES 100 MG, 25 MG (Use NP days retail) sumatriptan succinate) Calcium QL(12 ea per oyster shell tabs 1 MAXALT TABS (Use NP 30 days retail); rizatriptan benzoate) AL(At least 6 yrs old) Fluoride MAXALT-MLT TBDP (Use NP rizatriptan benzoate) New Hampshire Healthy Families Updated October 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium fluoride chew or penicillamine tabs or 1 0.25 mg, 0.5 mg, 1 mg, 2.2 1 mg SYPRINE CAPS (Use NP PA; SP sodium fluoride soln or trientine hcl) 1 0.25 mg/drop, 0.125 trientine hcl caps 1 PA; SP mg/drop sodium fluoride soln or 0.5 1 RX/OTC Enzymes mg/ml XIAFLEX SOLR 2 PA; SP Phosphate K-PHOS NEUTRAL TABS QL(8 ea daily) Fecal Incontinence Bulking Agents (Use pot phosphate PA; SP monobasic w/ sod NP SOLESTA GEL 2 phosphate dibasic & monobasic) Immunomodulators pot phosphate monobasic QL(8 ea daily) REVLIMID CAPS 2 PA; SP w/ sod phosphate dibasic & 1 monobasic tabs THALOMID CAPS 2 PA; SP Potassium Immunosuppressive Agents K-TAB TBCR 10 MEQ (Use NP PA; SP potassium chloride) ASTAGRAF XL CP24 2 K-TAB TBCR 8 MEQ (Use 2 PA; SP potassium chloride) ATGAM INJ 2 potassium bicarbonate tbef 1 AZASAN TABS 2 or potassium chloride cpcr or 1 azathioprine tabs or 50 mg 1 10 meq CELLCEPT CAPS (Use PA; SP potassium chloride cpcr or 1 QL(1 ea daily) NP 8 meq mycophenolate mofetil) potassium chloride CELLCEPT PA; SP INTRAVENOUS SOLR microencapsulated crystals 1 NP er tbcr 15 meq, 20 meq, 10 (Use mycophenolate meq mofetil hcl) CELLCEPT SUSR (Use PA; SP potassium chloride pack or 1 NP 20 meq mycophenolate mofetil) CELLCEPT TABS (Use PA; SP potassium chloride soln or 1 NP 20 %, 10 % mycophenolate mofetil) cyclosporine caps or 100 PA; SP potassium chloride tbcr or 1 1 10 meq, 8 meq mg, 25 mg cyclosporine modified (for 1 PA; SP Zinc microemulsion) caps zinc sulfate caps or 220 mg 1 cyclosporine modified (for 1 PA; SP microemulsion) soln MISCELLANEOUS THERAPEUTIC CLASSES cyclosporine soln iv 50 1 PA; SP mg/ml Chelating Agents everolimus 1 PA; SP DEPEN TITRATABS TABS NP (immunosuppressant) tabs (Use penicillamine) New Hampshire Healthy Families Updated October 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAMIFANT SOLN 10 2 PA; SP tacrolimus caps or 0.5 mg, 1 PA; SP MG/2ML, 50 MG/10ML 1 mg, 5 mg IMURAN TABS (Use NP THYMOGLOBULIN SOLR 2 PA; SP azathioprine) ZORTRESS TABS 0.25 PA; SP mycophenolate mofetil 1 PA; SP caps or 250 mg MG, 0.5 MG, 0.75 MG (Use NP everolimus mycophenolate mofetil hcl 1 PA; SP solr (immunosuppressant)) ZORTRESS TABS 1 MG 2 PA mycophenolate mofetil susr 1 PA; SP or 200 mg/ml Lymphatic Agents mycophenolate mofetil tabs 1 PA; SP or 500 mg SYLVANT SOLR 2 PA; SP mycophenolate sodium 1 PA; SP tbec Potassium Removing Agents MYFORTIC TBEC (Use NP PA; SP LOKELMA PACK 2 mycophenolate sodium) NEORAL CAPS (Use PA; SP sodium polystyrene 1 QL(454 gm per cyclosporine modified (for NP sulfonate powd fill retail) microemulsion)) sodium polystyrene 1 NEORAL SOLN (Use PA; SP sulfonate susp cyclosporine modified (for NP Systemic Lupus Erythematosus Agents microemulsion)) BENLYSTA SOLR 2 PA; SP NULOJIX SOLR 2 PA; SP PROGRAF CAPS OR 0.5 PA; SP MOUTH/THROAT/DENTAL AGENTS MG, 1 MG, 5 MG (Use NP tacrolimus) Anesthetics Topical Oral lidocaine hcl (mouth-throat) QL(100 ml per PROGRAF PACK OR 0.2 2 PA; SP 1 MG, 1 MG soln 2 % fill retail) Anti-infectives - Throat PROGRAF SOLN IV 5 2 PA; SP MG/ML nystatin (mouth-throat) 1 QL(100 ml per susp fill retail) RAPAMUNE SOLN (Use NP PA; SP sirolimus) Antiseptics - Mouth/Throat RAPAMUNE TABS (Use PA; SP NP chlorhexidine gluconate 1 sirolimus) (mouth-throat) soln SANDIMMUNE CAPS OR PA; SP PERIDEX SOLN (Use 100 MG, 25 MG (Use 2 chlorhexidine gluconate NP cyclosporine) (mouth-throat)) SANDIMMUNE SOLN IV PA; SP Dental Products 50 MG/ML (Use NP cyclosporine) PREVIDENT 5000 DRY QL(60 ml per MOUTH GEL (Use sodium NP fill retail) SANDIMMUNE SOLN OR 2 PA; SP fluoride (dental)) 100 MG/ML PREVIDENT 5000 PLUS QL(57 gm per sirolimus soln or 1 mg/ml 1 PA; SP CREA (Use sodium fluoride NP fill retail) (dental)) sirolimus tabs or 0.5 mg, 1 1 PA; SP mg, 2 mg New Hampshire Healthy Families Updated October 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREVIDENT FLUORIDE QL(60 ml per QL(900 ml per GEL (Use sodium fluoride NP fill retail) NUMOISYN LIQD 2 fill retail); (dental)) RX/OTC PREVIDENT RINSE SOLN ORAL RELIEF SPRAY QL(900 ml per (Use sodium fluoride NP FOR DRYMOUTH & 2 fill retail); (dental)) DISCOMFORT SOLN RX/OTC sodium fluoride (dental) 1 QL(57 gm per pilocarpine hcl (oral) tabs 5 1 QL(6 ea daily) crea dt 1.1 % fill retail) mg sodium fluoride (dental) gel 1 QL(60 ml per QL(900 ml per dt 1.1 % fill retail) RA DRY MOUTH SOLN 2 fill retail); RX/OTC sodium fluoride (dental) 1 soln mt 0.2 % SALAGEN TABS 5 MG NP QL(6 ea daily) (Use pilocarpine hcl (oral)) stannous fluoride conc mt 1 RX/OTC 0.63 % QL(900 ml per RELIEF 2 SPRAY SOLN fill retail); Periodontal Products RX/OTC ARESTIN MISC 2 PA; SP MULTIVITAMINS Steroids - Mouth/Throat/Dental B-Complex Vitamins triamcinolone acetonide 1 QL(5 gm per fill retail) b-complex vitamins caps or QL(1 ea daily) (mouth) pste 0.5 mg-1 mcg-3 mg-3 mg-5 Throat Products - Misc. mg-20 mg-60 mg-60 mg, 1 1 QL(900 ml per mg-1.5 mg-2 mg-10 mg-70 AQUORAL SOLN 2 fill retail); mg-100 mcg-100 mg RX/OTC b-complex vitamins tabs or QL(1 ea daily) BIOTENE DRY MOUTH QL(900 ml per 0.1 mg-1 mg-2 mg-3 mg-5 MOISTURIZING SPRAY 2 fill retail); mcg-20 mg, 0.2 mg-1.5 SOLN RX/OTC mg-2 mg-10 mg-10 mg, 1 mcg-1 mg-4.6 mg-5 mg-5 QL(900 ml per mg-10 mg-20 mg-40 mg-50 CAPHOSOL SOLN 2 fill retail); mg-100 mg, 1 mg-2 mg-3 RX/OTC mg-5 mcg-20 mg-83 mg, 2 QL(900 ml per mcg-2 mg-2 mg-2 mg-5 1 CVS DRY MOUTH SPRAY 2 fill retail); SOLN mg-15 mg, 2 mg-2 mg-3 RX/OTC mg-3 mg-3 mg-3 mg-6 QL(900 ml per mcg-6 mcg-10 mg-10 mg- EQL DRY MOUTH ORAL 2 20 mg-20 mg, 2 mg-3 mg-3 RINSE SOLN fill retail); RX/OTC mg-6 mcg-10 mg-20 mg, 4 QL(900 ml per mg-5 mg-7 mg-10 mg-25 MOI-STIR SOLN 2 fill retail); mcg, 4.5 mg-7 mg-10 mg- RX/OTC 14 mg-25 mcg QL(900 ml per B-Complex w/ C MOUTH KOTE REMINT 2 fill retail); SOLN b complex w/ c caps 5 mg- QL(1 ea daily) RX/OTC 10 mg-10 mg-15 mg-50 QL(900 ml per mg-300 mg, 5 mg-10 mg- 1 MOUTH KOTE SOLN 2 fill retail); 10.2 mg-15 mg-50 mg-300 RX/OTC mg B-Complex w/ Folic Acid

New Hampshire Healthy Families Updated October 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits b-complex w/ c & folic acid QL(1 ea daily); multiple vitamins tabs- 1 QL(1 ea daily) caps 1 mg-1.5 mg-1.7 mg- 1 RX/OTC assorted generic 5 mg-6 mcg-10 mg-20 mg- 100 mg-150 mcg Ped MV w/ Fluoride QL(1 ea daily); b-complex w/ c & folic acid QL(1 ea daily); pediatric multivitamins w/fl 2 AL(Up to 13 yrs tabs 0.006 mg-0.3 mg-1 RX/OTC chew-assorted brand old) mg-1.5 mg-1.7 mg-10 mg- 10 mg-20 mg-100 mg, 0.01 QL(1 ea daily); pediatric multivitamins w/fl 1 AL(Up to 13 yrs mcg-1 mg-1.5 mg-1.7 mg- chew-assorted generic 10 mg-10 mg-20 mg-60 old) mg-300 mcg, 1 mg-1 mg- QL(50ml per fill 1.5 mg-1.5 mg-1.7 mg-1.7 pediatric multivitamins w/fl 2 retail); AL(Up to soln-assorted brand mg-6 mcg-6 mcg-10 mg-10 13 yrs old) mg-10 mg-10 mg-20 mg-20 QL(50ml per fill mg-100 mg-100 mg-300 pediatric multivitamins w/fl 1 retail); AL(Up to soln-assorted generic mcg-300 mcg, 1 mg-1 mg- 13 yrs old) 1.5 mg-1.7 mg-8 mg-20 1 mg-30 mcg-200 mg-300 pediatric vitamins acd w/ QL(50 ml per mcg, 1 mg-1.5 mg-1.7 mg- fluoride soln 0.25 mg/ml-35 1 fill retail); 6 mcg-10 mg-10 mg-20 mg/ml-400 unit/ml-1500 AL(Up to 13 yrs mg-100 mg-300 mcg, 1 unit/ml old ); RX/OTC mg-1.5 mg-1.7 mg-6 mcg- pediatric vitamins acd w/ QL(50 ml per 10 mg-10 mg-20 mg-60 fluoride soln 0.5 mg/ml-35 1 fill retail); mg-300 mcg, 1.5 mg-1.7 mg/ml-400 unit/ml-1500 AL(Up to 13 yrs mg-5 mg-6 mcg-10 mg-20 unit/ml old ) mg-100 mg-150 mcg-1000 Ped MV w/ Iron mcg, 1.5 mg-1.7 mg-6 mcg-10 mg-10 mg-20 mg- BPROTECTED PEDIA 2 QL(60 ml per 100 mg-300 mcg-1000 mcg POLY-VITE/IRON SOLN fill retail) NEPHRO-VITE RX TABS QL(1 ea daily); PC PEDIATRIC POLY- QL(60 ml per (Use b-complex w/ c & folic NP RX/OTC VITAMIN DROPS/IRON 2 fill retail) acid) SOLN POLY-VITA/IRON SOLN 2 QL(60 ml per Multiple Vitamins w/ Iron fill retail) multiple vitamins w/ iron 1 QL(1 ea daily) tabs Ped Multi Vitamins w/Fl & FE TAB-A-VITE QL(1 ea daily) ped multivitamins w/fl & QL(50 ml per MULTIVITAMIN/IRON AND 2 iron soln 0.25 mg/ml-0.4 fill retail); BETA-CAROTENE TABS mg/ml-0.5 mg/ml-0.6 1 AL(Up to 13 yrs mg/ml-5 unit/ml-8 mg/ml-10 old ); RX/OTC Multiple Vitamins w/ Minerals mg/ml-35 mg/ml-400 multiple vitamins w/ RX/OTC unit/ml-1500 unit/ml minerals tabs-assorted 2 Ped Multiple Vitamins w/ Minerals brand RX/OTC multiple vitamins w/ RX/OTC AQUADEKS LIQD 2 minerals tabs-assorted 1 generic Multivitamins multiple vitamins tabs- 2 QL(1 ea daily) assorted brand

New Hampshire Healthy Families Updated October 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multiple vitamin w/ RX/OTC Central Muscle Relaxants minerals & c soln 0.5 AMRIX CP24 (Use NP mg/ml-0.6 mg/ml-0.6 ) mg/ml-3 mg/ml-4 mcg/ml-5 hcl mg/ml-6 mg/ml-15 mcg/ml- soln it 20000 PA; SP 45 mg/ml-50 unit/ml-400 mcg/20ml, 40 mg/20ml, 1 mcg/ml-500 unit/ml-4627 1 500 mcg/ml unit/ml, 0.5 mg/ml-0.6 baclofen tabs or 10 mg, 20 1 mg/ml-0.6 mg/ml-3 mg/ml-4 mg mcg/ml-6 mg/ml-7.5 mg/ml- PA 15 mcg/ml-45 mg/ml-50 baclofen tabs or 5 mg 1 unit/ml-300 mcg/ml-400 tabs or 250 1 PA unit/ml-3170 unit/ml mg Pediatric Multiple Vitamins carisoprodol tabs or 350 1 ONE-A-DAY VITACRAVES QL(1 ea daily) mg GUMMIES+OMEGA-3 NP chlorzoxazone tabs 500 DHA CHEW (Use pediatric mg, 750 mg, 250 mg, 375 1 multiple vitamin w/ c & fa) mg pediatric multiple vitamin w/ QL(1 ea daily) 1 cyclobenzaprine hcl cp24 1 c & fa chew or 15 mg, 30 mg Prenatal Vitamins cyclobenzaprine hcl tabs or 1 QL(3 ea daily) QL(30 ea per 10 mg, 5 mg prenatal vitamins-assorted 2 30 days retail); cyclobenzaprine hcl tabs or QL(4 ea daily) brand 1 RX/OTC 7.5 mg QL(30 ea per GABLOFEN SOLN 10000 PA; SP prenatal vitamins-assorted 1 30 days retail); MCG/20ML, 40000 2 generic RX/OTC MCG/20ML Vitamins w/ Lipotropics GABLOFEN SOLN 20000 NP PA; SP MCG/20ML (Use baclofen) vitamins w/ lipotropics caps QL(1 ea daily) 0.5 mg-0.5 mg-1 mg-2 LIORESAL INTRATHECAL PA; SP mcg-2 mg-2 unit-2.5 mg-3 SOLN 0.05 MG/ML, 10 2 mg-4 mg-5 mg-15 mg-30 MG/5ML mg-31.4 mg-40 mg-58 mg- LIORESAL INTRATHECAL PA; SP 75 mg-75 mg-400 unit- SOLN 10 MG/20ML, 40 NP 10000 unit, 1.65 mg-2 mcg- MG/20ML (Use baclofen) 2 mg-3 mg-3 mg-10 mg-83 1 tabs 400 mg, 1 mg-86 mg-110 mg-240 mg, 800 mg 50 mcg-50 mcg-50 mcg-50 mg-50 mg-50 mg-50 mg-50 tabs or 500 1 mg, 50 mcg-50 mcg-50 mg, 750 mg mg-50 mg-50 mg-50 mg-50 citrate tb12 or 1 mg-50 mg-50 mg-50 mg- 100 mg 100 mcg ROBAXIN-750 TABS (Use NP MUSCULOSKELETAL THERAPY AGENTS - methocarbamol) Drugs to Treat Spasms SKELAXIN TABS (Use NP metaxalone) Articular Cartilage Repair Therapy SOMA TABS 250 MG (Use NP PA MACI SHEE 2 PA; SP carisoprodol)

New Hampshire Healthy Families Updated October 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOMA TABS 350 MG (Use NP TRIVISC SOSY 2 PA; SP carisoprodol) PA; SP hcl caps or 2 mg, 1 VISCO-3 SOSY 2 4 mg, 6 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - tizanidine hcl tabs or 4 mg, 1 2 mg Drugs to treat the Nose or Sinus ZANAFLEX CAPS (Use NP Nasal Agent Combinations tizanidine hcl) hcl-fluticasone 1 ZANAFLEX TABS (Use NP propionate susp tizanidine hcl) DYMISTA SUSP (Use Direct Muscle Relaxants azelastine hcl-fluticasone NP propionate) DANTRIUM CAPS (Use NP dantrolene sodium) Nasal Agents - Misc. dantrolene sodium caps or 1 OCEAN NASAL SPRAY NP QL(90 ml per 100 mg, 25 mg, 50 mg SOLN (Use saline) fill retail) Combinations saline soln na 0.002 %- 1 QL(90 ml per 0.65 % fill retail) carisoprodol w/ aspirin tabs 1 Nasal Antiallergy Viscosupplements azelastine hcl soln na 0.1 1 QL(30 ml per %, 0.15 %, 137 mcg/spray fill retail) EUFLEXXA SOSY 2 PA; SP cromolyn sodium (nasal) 1 QL(26 ml per GEL-ONE PRSY 2 PA; SP aers fill retail) NASALCROM AERS (Use NP QL(26 ml per GELSYN-3 SOSY 2 PA; SP cromolyn sodium (nasal)) fill retail) hcl (nasal) soln 1 GENVISC 850 SOSY 2 PA; SP PATANASE SOLN (Use NP HYALGAN SOLN 2 PA; SP olopatadine hcl (nasal)) Nasal Anticholinergics HYALGAN SOSY 2 PA; SP ipratropium bromide (nasal) 1 QL(30 ml per HYMOVIS SOSY 2 PA; SP soln 0.03 % 30 days retail) ipratropium bromide (nasal) 1 QL(15 ml per MONOVISC SOSY 2 PA; SP soln 0.06 % 30 days retail) Nasal Steroids ORTHOVISC SOSY 2 PA; SP budesonide (nasal) susp 1 SODIUM HYALURONATE 2 PA; SP SOSY IX FLONASE ALLERGY QL(16 ml per PA; SP RELIEF CHILDRENS NP fill retail); SUPARTZ FX SOSY 2 SUSP (Use fluticasone RX/OTC propionate (nasal)) PA; SP SYNVISC ONE SOSY 2 FLONASE ALLERGY QL(16 ml per PA; SP RELIEF SUSP (Use NP fill retail); SYNVISC SOSY 2 fluticasone propionate RX/OTC (nasal)) TRILURON SOSY 2 PA; SP

New Hampshire Healthy Families Updated October 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(25 ml per PA; SP flunisolide (nasal) soln 1 TIGLUTIK SUSP 2 fill retail) QL(16 ml per Muscular Dystrophy Agents fluticasone propionate 1 fill retail); (nasal) susp PA; SP RX/OTC EXONDYS 51 SOLN 2 QL(17 gm per Neuromuscular Blocking Agent - Neurotoxins mometasone furoate 1 fill retail); AL(At (nasal) susp least 2 yrs old) BOTOX SOLR 2 PA; SP NASONEX SUSP (Use QL(17 gm per PA; SP mometasone furoate NP fill retail); AL(At DYSPORT SOLR 2 (nasal)) least 2 yrs old) MYOBLOC SOLN 2 PA; SP Sympathomimetic Decongestants PA; SP ADRENALIN SOLN NA 0.1 2 XEOMIN SOLR 2 % Spinal Muscular Atrophy Agents (SMA) epinephrine hcl (nasal) soln 1 SPINRAZA SOLN 2 PA; SP phenylephrine hcl (oral) 1 QL(24 ea per tabs fill retail) ZOLGENSMA 10.1-10.5 CO KG KIT pseudoephedrine hcl liqd 1 or 15 mg/5ml ZOLGENSMA 10.6-11.0 CO KG KIT pseudoephedrine hcl tabs 1 or 60 mg, 30 mg ZOLGENSMA 11.1-11.5 CO KG KIT pseudoephedrine hcl tb12 1 QL(2 ea daily) or 120 mg ZOLGENSMA 11.6-12.0 CO KG KIT SUDAFED CHILDRENS 2 LIQD ZOLGENSMA 12.1-12.5 CO SUDAFED CONGESTION KG KIT TABS (Use NP ZOLGENSMA 12.6-13.0 CO pseudoephedrine hcl) KG KIT SUDAFED PE QL(120 ml per ZOLGENSMA 13.1-13.5 CO CHILDRENS NASAL 2 fill retail) KG KIT DECONGESTANT SOLN ZOLGENSMA 2.6-3.0 KG CO SUDAFED PE SINUS QL(24 ea per KIT CONGESTION TABS (Use NP fill retail) ZOLGENSMA 3.1-3.5 KG CO phenylephrine hcl (oral)) KIT SUDAFED SINUS ZOLGENSMA 3.6-4.0 KG CO CONGESTION TABS (Use NP KIT pseudoephedrine hcl) ZOLGENSMA 4.1-4.5 KG CO NEUROMUSCULAR AGENTS - Drugs to KIT Relax/Paralyze Muscles ZOLGENSMA 4.6-5.0 KG CO ALS Agents KIT ZOLGENSMA 5.1-5.5 KG RILUTEK TABS (Use NP PA CO riluzole) KIT riluzole tabs 1 PA ZOLGENSMA 5.6-6.0 KG CO KIT

New Hampshire Healthy Families Updated October 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOLGENSMA 6.1-6.5 KG CO timolol maleate (ophth) solg 1 KIT 0.25 % ZOLGENSMA 6.6-7.0 KG CO timolol maleate (ophth) solg 1 QL(5 ml per fill KIT 0.5 % retail) ZOLGENSMA 7.1-7.5 KG CO timolol maleate (ophth) soln 1 QL(5 ml per fill KIT 0.25 %, 0.5 % retail) ZOLGENSMA 7.6-8.0 KG CO timolol maleate (ophth) soln 1 KIT 0.5 % ZOLGENSMA 8.1-8.5 KG CO TIMOLOL/BRIMONIDE/DO 2 KIT RZOLAMIDE SOLN ZOLGENSMA 8.6-9.0 KG CO TIMOPTIC SOLN (Use NP QL(5 ml per fill KIT timolol maleate (ophth)) retail) ZOLGENSMA 9.1-9.5 KG CO TIMOPTIC-XE SOLG (Use NP KIT timolol maleate (ophth)) ZOLGENSMA 9.6-10.0 KG CO Cycloplegic Mydriatics KIT atropine sulfate 1 QL(4 gm per fill OPHTHALMIC AGENTS - Drugs to Treat the Eye (ophthalmic) oint retail) ATROPINE SULFATE 2 QL(5 ml per fill Artificial Tears and Lubricants SOLN OP 1 % retail) QL(15 ml per polyvinyl alcohol soln op 1 CYCLOGYL SOLN 0.5 % NP QL(15 ml per fill retail) (Use cyclopentolate hcl) fill retail) white petrolatum-mineral oil QL(5 gm per fill 1 CYCLOGYL SOLN 1 % NP QL(5 ml per fill oint retail) (Use cyclopentolate hcl) retail) Beta-blockers - Ophthalmic cyclopentolate hcl soln op 1 QL(15 ml per QL(5 ml per fill 0.5 % fill retail) betaxolol hcl (ophth) soln 1 retail) cyclopentolate hcl soln op 1 1 QL(5 ml per fill % retail) hcl (ophth) soln 1 ISOPTO ATROPINE SOLN 2 QL(5 ml per fill retail) COMBIGAN SOLN 2 MYDRIACYL SOLN (Use NP QL(3 ml per fill COSOPT PF SOLN (Use tropicamide) retail) dorzolamide hcl-timolol NP phenylephrine hcl 1 QL(5 ml per fill maleate) (mydriatic) soln 2.5 % retail) COSOPT SOLN (Use QL(10 ml per QL(15 ml per tropicamide soln op 0.5 % 1 dorzolamide hcl-timolol NP fill retail) fill retail) maleate) QL(3 ml per fill tropicamide soln op 1 % 1 dorzolamide hcl-timolol 1 retail) maleate soln 0.5 %-2 % dorzolamide hcl-timolol QL(10 ml per Miotics ISOPTO CARPINE SOLN maleate soln 0.5 %-2 %, 5 1 fill retail) NP mg/ml-20 mg/ml, 6.8 (Use pilocarpine hcl) mg/ml-22.3 mg/ml pilocarpine hcl soln op 1 %, 1 2 %, 4 % ISTALOL SOLN (Use NP timolol maleate (ophth)) Ophthalmic - Angiogenesis Inhibitors hcl soln 1

New Hampshire Healthy Families Updated October 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BEVACIZUMAB SOSY IO PA; SP levofloxacin (ophth) soln 1 2.75 MG/0.11ML, 3.75 2 MG/0.15ML MOXEZA SOLN (Use NP BEVACIZUMAB SOSY IZ PA; SP moxifloxacin hcl (ophth)) 2.5 MG/0.1ML, 3.25 2 moxifloxacin hcl (ophth) 1 QL(3 ml per fill MG/0.13ML, 3.75 soln retail) MG/0.15ML moxifloxacin hcl (ophth) 1 EYLEA SOLN 2 PA; SP soln neomycin-bacitracin zn- 1 QL(4 gm per fill LUCENTIS SOLN 2 PA; SP polymyxin oint retail) neomycin-polymyxin- 1 QL(10 ml per LUCENTIS SOSY 2 PA; SP gramicidin soln fill retail) PA; SP OCUFLOX SOLN (Use NP QL(5 ml per fill MACUGEN SOLN 2 ofloxacin (ophth)) retail) QL(5 ml per fill Ophthalmic Adrenergic Agents ofloxacin (ophth) soln 1 retail) ALPHAGAN P SOLN 0.1 % 2 polymyxin b-trimethoprim 1 QL(10 ml per ALPHAGAN P SOLN 0.15 soln fill retail) % (Use 2 POLYTRIM SOLN (Use NP QL(10 ml per tartrate) polymyxin b-trimethoprim) fill retail) sulfacetamide sodium 1 QL(15 ml per hcl soln 1 (ophth) soln fill retail) QL(5 ml per fill brimonidine tartrate soln op 1 tobramycin (ophth) soln 1 0.15 % retail) QL(4 gm per fill brimonidine tartrate soln op 1 QL(5 ml per fill TOBREX OINT 2 0.2 % retail) retail) SIMBRINZA SUSP 2 TOBREX SOLN (Use NP QL(5 ml per fill tobramycin (ophth)) retail) QL(8 ml per fill Ophthalmic Anti-infectives trifluridine soln 1 retail) bacitracin-polymyxin b 1 QL(4 gm per fill (ophth) oint retail) VIGAMOX SOLN (Use 2 QL(3 ml per fill BLEPH-10 SOLN (Use QL(15 ml per moxifloxacin hcl (ophth)) retail) sulfacetamide sodium NP fill retail) ZYMAXID SOLN (Use NP (ophth)) gatifloxacin (ophth)) CILOXAN SOLN (Use NP QL(5 ml per fill Ophthalmic Decongestants ciprofloxacin hcl (ophth)) retail) w/ ciprofloxacin hcl (ophth) 1 QL(5 ml per fill soln 0.025 %- 1 soln retail) 0.3 % QL(4 gm per fill erythromycin (ophth) oint 1 naphazoline w/ QL(0.5 ml retail) pheniramine soln 0.027 %- 1 daily) 0.315 % gatifloxacin (ophth) soln 1 NAPHCON-A SOLN (Use gentamicin sulfate (ophth) 1 QL(4 gm per fill naphazoline w/ NP oint retail) pheniramine) gentamicin sulfate (ophth) 1 QL(5 ml per fill soln retail)

New Hampshire Healthy Families Updated October 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPCON-A SOLN (Use QL(0.5 ml MAXITROL SUSP 0.1 %- QL(5 ml per fill naphazoline w/ NP daily) 3.5 MG/ML-10000 NP retail) pheniramine) UNIT/ML (Use neomycin- polymy-dexameth) tetrahydrozoline hcl (ophth) 1 QL(30 ml per soln fill retail) neomycin-polymy- QL(4 gm per fill VISINE RED EYE QL(30 ml per dexameth oint 0.1 %-3.5 1 retail) mg/gm-10000 unit/gm COMFORT SOLN (Use NP fill retail) tetrahydrozoline hcl neomycin-polymy- QL(5 ml per fill (ophth)) dexameth susp 0.1 %-3.5 1 retail) VISINE SOLN (Use QL(30 ml per mg/ml-10000 unit/ml tetrahydrozoline hcl NP fill retail) neomycin-polymyxin-hc 1 QL(8 ml per fill (ophth)) (ophth) susp retail) Ophthalmic Kinase Inhibitors OZURDEX IMPL 2 PA; SP ROCKLATAN SOLN 2 PRED FORTE SUSP (Use QL(5 ml per fill prednisolone acetate NP retail) Ophthalmic Local Anesthetics (ophth)) tetracaine hcl (ophth) soln 1 PRED MILD SUSP 2 QL(10 ml per fill retail) Ophthalmic Nerve Growth Factors QL(5 ml per fill PRED-G SUSP 2 OXERVATE SOLN 2 PA; SP retail) prednisolone acetate 1 QL(5 ml per fill Ophthalmic Photodynamic Therapy Agents (ophth) susp retail) VISUDYNE SOLR 2 PA; SP PREDNISOLONE 2 QL(5 ml per fill ACETATE P-F SUSP retail) Ophthalmic Steroids PREDNISOLONE SODIUM QL(10 ml per PHOSPHATE SOLN OP 1 2 fill retail) BLEPHAMIDE S.O.P. 2 QL(4 gm per fill OINT retail) % PA; SP BLEPHAMIDE SUSP 2 QL(5 ml per fill RETISERT IMPL 2 retail) sulfacetamide sod- 1 QL(5 ml per fill dexamethasone sodium 1 QL(5 ml per fill prednisolone soln retail) phosphate (ophth) soln retail) TOBRADEX OINT 2 QL(4 gm per fill DEXTENZA INST 2 PA; SP retail) TOBRADEX SUSP (Use QL(5 ml per fill fluorometholone (ophth) 1 QL(5 ml per fill susp retail) tobramycin- NP retail) dexamethasone) FML LIQUIFILM SUSP QL(5 ml per fill (Use fluorometholone NP retail) tobramycin- 1 QL(5 ml per fill (ophth)) dexamethasone susp retail) SP FML OINT 2 QL(4 gm per fill YUTIQ IMPL 2 retail) Ophthalmics - Misc. ILUVIEN IMPL 2 PA; SP ACULAR LS SOLN (Use MAXITROL OINT 0.1 %- QL(4 gm per fill ketorolac tromethamine NP (ophth)) 3.5 MG/GM-10000 NP retail) UNIT/GM (Use neomycin- polymy-dexameth)

New Hampshire Healthy Families Updated October 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACULAR SOLN (Use QL(5 ml per fill TRAVATAN Z SOLN (Use 2 ketorolac tromethamine NP retail) travoprost) (ophth)) travoprost soln 1 QL(6 ml per fill azelastine hcl (ophth) soln 1 retail) OTIC AGENTS - Drugs to Treat the Ear bromfenac sodium (ophth) 1 soln Otic Agents - Miscellaneous cromolyn sodium (ophth) QL(10 ml per QL(15 ml per 1 acetic acid (otic) soln 1 soln fill retail) fill retail) PA; SP CYSTARAN SOLN 2 carbamide peroxide (otic) 1 QL(0.5 ml soln daily) diclofenac sodium (ophth) QL(5 ml per fill 1 DEBROX SOLN (Use NP QL(0.5 ml soln retail) carbamide peroxide (otic)) daily) QL(10 ml per dorzolamide hcl soln 1 fill retail) Otic Anti-infectives CETRAXAL SOLN (Use DORZOLAMIDE HCL 2 QL(10 ml per NP SOLN fill retail) ciprofloxacin hcl (otic)) hcl (ophth) soln 1 ciprofloxacin hcl (otic) soln 1 QL(3 ml per fill FLOXIN OTIC SOLN (Use QL(5 ml per fill flurbiprofen sodium soln 1 NP retail) ofloxacin (otic)) retail) QL(5 ml per fill ofloxacin (otic) soln 1 ILEVRO SUSP 2 retail) Otic Combinations ketorolac tromethamine 1 (ophth) soln 0.4 % QL(7.5 ml per CIPRODEX SUSP (Use fill retail)1 rtl ketorolac tromethamine 1 QL(5 ml per fill ciprofloxacin- 2 (ophth) soln 0.5 % retail) dexamethasone) MAX fill,30 rtl day(s) supply, fumarate (ophth) 1 QL(5 ml per fill soln retail) QL(7.5 ml per RX/OTC ciprofloxacin- 1 fill retail)1 rtl olopatadine hcl soln 1 dexamethasone susp MAX fill,30 rtl day(s) supply, PATADAY EXTRA 2 RX/OTC STRENGTH SOLN neomycin-polymyxin-hc 1 QL(10 ml per (otic) soln fill retail) PATADAY SOLN (Use NP RX/OTC olopatadine hcl) neomycin-polymyxin-hc 1 QL(10 ml per (otic) susp fill retail) PATANOL SOLN (Use NP RX/OTC olopatadine hcl) OTICIN HC NR SOLN (Use QL(15 ml per RX/OTC pramoxine-hc- NP fill retail) PAZEO SOLN 2 chloroxylenol) pramoxine-hc-chloroxylenol QL(15 ml per TRUSOPT SOLN (Use NP QL(10 ml per 1 dorzolamide hcl) fill retail) soln fill retail) ZADITOR SOLN (Use NP QL(5 ml per fill Otic Steroids ketotifen fumarate (ophth)) retail) DERMOTIC OIL (Use QL(20 ml per Prostaglandins - Ophthalmic fluocinolone acetonide NP fill retail) (otic)) bimatoprost soln op 1 fluocinolone acetonide 1 QL(20 ml per (otic) oil fill retail) New Hampshire Healthy Families Updated October 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone w/acetic 1 QL(10 ml per NABI-HB SOLN 2 PA; SP acid soln fill retail) OXYTOCICS - Drugs to Prevent/Control Uterine OCTAGAM SOLN 1 PA; SP Bleeding GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 Oxytocics GM/20ML, 2.5 GM/50ML, 2 20 GM/200ML, 25 methylergonovine maleate 1 tabs or 0.2 mg GM/500ML, 5 GM/100ML, 5 GM/50ML PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune OCTAGAM SOLN 30 2 PA System GM/300ML PA; SP Immune Serums PANZYGA SOLN 2 PA; SP BIVIGAM SOLN 2 PRIVIGEN SOLN 2 PA; SP CARIMUNE PA; SP 2 RHOGAM ULTRA- 2 PA; SP NANOFILTERED SOLR FILTERED PLUS SOSY PA; SP CUVITRU SOLN 2 RHOPHYLAC SOSY 2 PA; SP PA; SP CYTOGAM INJ 2 WINRHO SDF SOLN 2 PA; SP FLEBOGAMMA DIF SOLN 2 PA; SP Monoclonal Antibodies PA; SP REGEN-COV SOLN IV GAMASTAN INJ 2 1332 MG/11.1ML-1332 MG/11.1ML, 300 CO GAMMAGARD LIQUID 2 PA; SP MG/2.5ML-1332 SOLN MG/11.1ML, 300 GAMMAGARD S/D IGA PA; SP MG/2.5ML-300 MG/2.5ML LESS THAN 1MCG/ML 2 PA; SP SOLR SYNAGIS SOLN 2 PA; SP GAMMAKED SOLN 2 ZINPLAVA SOLN 2 PA; SP PA; SP GAMMAPLEX SOLN 2 Passive Immunizing Agents - Combinations PA; SP GAMUNEX-C SOLN 2 PA; SP HYQVIA KIT 2

HEPAGAM B SOLN 2 PA; SP PENICILLINS - Drugs to Treat Bacterial Infections HIZENTRA SOLN 1 PA; SP Aminopenicillins GM/5ML, 10 GM/50ML, 2 2 amoxicillin caps 250 mg, 1 GM/10ML, 4 GM/20ML 500 mg PA; SP HYPERHEP B SOLN 2 amoxicillin chew 125 mg, 1 250 mg HYPERRHO S/D MINI- 2 PA; SP amoxicillin susr 125 DOSE SOSY mg/5ml, 200 mg/5ml, 250 1 HYPERRHO S/D SOSY 2 PA; SP mg/5ml, 400 mg/5ml amoxicillin tabs 875 mg 1 MICRHOGAM ULTRA- 2 PA; SP FILTEREDPLUS SOSY New Hampshire Healthy Families Updated October 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin caps 1 PHARMACEUTICAL ADJUVANTS Natural Penicillins Internal Vehicle Ingredients/Agents penicillin v potassium solr 1 QL(1816 ml per SIMPLYTHICK EASY MIX 2 fill retail); AL(At GEL penicillin v potassium tabs 1 least 2 yrs old) QL(1816 ml per SIMPLYTHICK EASYMIX 2 fill retail); AL(At Penicillin Combinations GEL amoxicillin & pot QL(20 ea per least 2 yrs old) clavulanate chew 28.5 mg- 1 fill retail) QL(1816 ml per 200 mg, 57 mg-400 mg SIMPLYTHICK GEL 2 fill retail); AL(At amoxicillin & pot QL(75 ml per least 2 yrs old) clavulanate susr 28.5 1 fill retail) Liquid Vehicles mg/5ml-200 mg/5ml, 62.5 PA; SP mg/5ml-250 mg/5ml glycine diluent soln 1 amoxicillin & pot QL(400 ml per PH 12 STERILE DILUENT PA; SP clavulanate susr 42.9 1 fill retail) FORFLOLAN SOLN (Use NP mg/5ml-600 mg/5ml, 600 glycine diluent) mg/5ml-42.9 mg/5ml STERILE DILUENT FOR PA; SP amoxicillin & pot QL(200 ml per FLOLAN SOLN (Use NP clavulanate susr 57 1 fill retail) glycine diluent) mg/5ml-400 mg/5ml STERILE DILUENT FOR PA; SP amoxicillin & pot QL(30 ea per TREPROSTINIL 2 clavulanate tabs 125 mg- 1 fill retail) INJECTION SOLN 250 mg, 250 mg-125 mg Semi Solid Vehicles amoxicillin & pot QL(20 ea per RX/OTC clavulanate tabs 125 mg- 1 fill retail) lanolin oint ex 1 500 mg, 125 mg-875 mg, 875 mg-125 mg lanolin oint xx 1 RX/OTC amoxicillin & pot QL(1.34 ea clavulanate tb12 62.5 mg- 1 daily) PROGESTINS - Hormone Replacement/Modifying 1000 mg Drugs AUGMENTIN ES-600 QL(400 ml per Progestins SUSR (Use amoxicillin & NP fill retail) AYGESTIN TABS (Use NP pot clavulanate) norethindrone acetate) AUGMENTIN SUSR 62.5 QL(75 ml per hydroxyprogesterone 1 PA; SP MG/5ML-250 MG/5ML NP fill retail) caproate oil im (Use amoxicillin & pot clavulanate) MAKENA OIL IM 250 PA; SP MG/ML (Use 2 AUGMENTIN TABS 125 QL(20 ea per hydroxyprogesterone MG-500 MG (Use NP fill retail) caproate) amoxicillin & pot clavulanate) MAKENA SOAJ SC 275 2 PA; SP MG/1.1ML Penicillinase-Resistant Penicillins medroxyprogesterone dicloxacillin sodium caps 1 acetate tabs or 10 mg, 2.5 1 mg, 5 mg

New Hampshire Healthy Families Updated October 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone acetate tabs 1 galantamine hydrobromide 1 QL(1 ea daily) or cp24 16 mg, 24 mg, 8 mg caps or 100 1 QL(1 ea daily) galantamine hydrobromide 1 QL(6 ml daily) mg soln 4 mg/ml progesterone caps or 200 1 galantamine hydrobromide 1 QL(2 ea daily) mg tabs 12 mg, 4 mg, 8 mg PROMETRIUM CAPS 100 NP QL(1 ea daily) hcl cp24 14 mg, 1 MG (Use progesterone) 21 mg, 28 mg, 7 mg PROMETRIUM CAPS 200 NP memantine hcl soln 10 1 QL(10 ml daily) MG (Use progesterone) mg/5ml, 2 mg/ml QL(1 ea per 28 PROVERA TABS (Use memantine hcl tabs 1 medroxyprogesterone NP days retail) acetate) memantine hcl tabs 10 mg, 1 QL(2 ea daily) PSYCHOTHERAPEUTIC AND NEUROLOGICAL 5 mg AGENTS - MISC. - Drugs to Treat Mental and NAMENDA TABS (Use NP QL(2 ea daily) Emotional Conditions memantine hcl) Agents for Chemical Dependency NAMENDA TITRATION QL(1 ea per 28 PAK TABS (Use NP days retail) acamprosate calcium tbec 1 memantine hcl) NAMENDA XR CP24 (Use ANTABUSE TABS 250 MG NP NP (Use disulfiram) memantine hcl) RAZADYNE ER CP24 (Use NP QL(1 ea daily) disulfiram tabs or 250 mg 1 galantamine hydrobromide) Anti-Cataplectic Agents RAZADYNE TABS (Use NP QL(2 ea daily) galantamine hydrobromide) XYREM SOLN 2 PA; SP rivastigmine pt24 13.3 1 mg/24hr Antidementia Agents rivastigmine pt24 4.6 1 QL(1 ea daily) ARICEPT TABS 23 MG mg/24hr, 9.5 mg/24hr (Use donepezil NP hydrochloride) rivastigmine tartrate caps 1 QL(2 ea daily) ARICEPT TABS 5 MG, 10 QL(1 ea daily) MG (Use donepezil NP Combination Psychotherapeutics hydrochloride) perphenazine-amitriptyline 1 QL(4 ea daily) tabs donepezil hydrochloride 1 tabs 23 mg Fibromyalgia Agents donepezil hydrochloride QL(1 ea daily) 1 SAVELLA TABS 2 PA; QL(2 ea tabs 5 mg, 10 mg daily) donepezil hydrochloride 1 PA; QL(55 ea tbdp 10 mg, 5 mg SAVELLA TITRATION 2 per 365 days PACK MISC EXELON PT24 13.3 retail) MG/24HR (Use 2 Movement Disorder Drug Therapy rivastigmine) PA; SP EXELON PT24 4.6 QL(1 ea daily) AUSTEDO TABS 2 MG/24HR, 9.5 MG/24HR 2 PA; SP (Use rivastigmine) tetrabenazine tabs 1

New Hampshire Healthy Families Updated October 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XENAZINE TABS (Use NP PA; SP CHANTIX STARTING 0 AL(At least 18 tetrabenazine) MONTH PAK TABS yrs old) Multiple Sclerosis Agents QL(2 ea daily); CHANTIX TABS 0 AL(At least 18 AMPYRA TB12 (Use NP PA; SP dalfampridine) yrs old) Use AL(At least 18 PA; SP NICODERM CQ PT24 ( NP AVONEX PEN AJKT 2 ) yrs old) PA; SP NICORETTE GUM (Use NP AL(At least 18 AVONEX PSKT 2 nicotine polacrilex) yrs old) NICORETTE LOZG (Use AL(At least 18 COPAXONE SOSY (Use 2 PA; SP NP glatiramer acetate) nicotine polacrilex) yrs old) PA; SP NICORETTE MINI LOZG NP AL(At least 18 dalfampridine tb12 or 1 (Use nicotine polacrilex) yrs old) dimethyl fumarate cpdr or 1 PA; SP NICORETTE STARTER AL(At least 18 120 mg, 240 mg KIT GUM (Use nicotine NP yrs old) polacrilex) dimethyl fumarate misc or 1 PA; SP nicotine polacrilex gum mt 0 AL(At least 18 GILENYA CAPS 2 PA; SP 4 mg, 2 mg yrs old) nicotine polacrilex lozg mt 2 0 AL(At least 18 glatiramer acetate sosy 1 PA; SP mg, 4 mg yrs old) AL(At least 18 nicotine pt24 0 TECFIDERA CPDR (Use 2 PA; SP yrs old) dimethyl fumarate) NICOTINE AL(At least 18 TECFIDERA STARTER PA; SP TRANSDERMAL SYSTEM 0 yrs old) PACK MISC (Use dimethyl 2 KIT fumarate) NICOTROL INHALER 0 PA; AL(At least Premenstrual Dysphoric Disorder (PMDD) Agents INHA 18 yrs old) fluoxetine hcl (pmdd) caps 1 NICOTROL NS SOLN 0 PA; AL(At least 18 yrs old) fluoxetine hcl (pmdd) tabs 1 QL(2 ea daily); varenicline tartrate tabs 0 AL(At least 18 SARAFEM TABS (Use NP yrs old) fluoxetine hcl (pmdd)) Transthyretin Amyloidosis Agents Psychotherapeutic and Neurological Agents - ONPATTRO SOLN 2 PA; SP mesylates tabs or 1 TEGSEDI SOSY 2 PA; SP Smoking Deterrents QL(2 ea daily); Vasomotor Symptom Agents APO-VARENICLINE TABS 0 AL(At least 18 BRISDELLE CAPS (Use yrs old) paroxetine mesylate NP bupropion hcl (smoking 0 AL(At least 18 (vasomotor)) deterrent) tb12 yrs old) paroxetine mesylate 1 QL(2 ea daily); (vasomotor) caps CHANTIX CONTINUING 0 MONTHPAK TABS AL(At least 18 yrs old) RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions

New Hampshire Healthy Families Updated October 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Alpha-Proteinase Inhibitor (Human) VIBRAMYCIN CAPS 100 MG (Use doxycycline NP ARALAST NP SOLR 2 PA; SP hyclate) GLASSIA SOLN 2 PA; SP THYROID AGENTS - Drugs to Regulate Thyroid Hormones PROLASTIN-C SOLR 2 PA; SP Antithyroid Agents PA; SP methimazole tabs or 10 1 ZEMAIRA SOLR 2 mg, 5 mg Cystic Fibrosis Agents propylthiouracil tabs or 1 KALYDECO PACK 50 MG, PA; SP 2 TAPAZOLE TABS (Use NP 75 MG methimazole) PA; SP KALYDECO TABS 150 MG 2 Thyroid Hormones ARMOUR THYROID TABS ORKAMBI PACK 2 PA; SP 120 MG, 15 MG, 30 MG, 2 PA; SP 60 MG, 90 MG (Use ORKAMBI TABS 2 thyroid) PA; SP ARMOUR THYROID TABS 2 PULMOZYME SOLN 2 180 MG, 240 MG, 300 MG PA; SP SYMDEKO TBPK 2 CYTOMEL TABS (Use NP liothyronine sodium) TRIKAFTA TBPK 50 MG- 2 PA; QL(3 ea levothyroxine sodium caps 100 MG daily); SP or 100 mcg, 112 mcg, 125 Pulmonary Fibrosis Agents mcg, 13 mcg, 137 mcg, 1 150 mcg, 25 mcg, 50 mcg, ESBRIET CAPS 2 PA; SP 75 mcg, 88 mcg PA; SP levothyroxine sodium tabs OFEV CAPS 2 or 300 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 1 TETRACYCLINES - Drugs to Treat Bacterial 150 mcg, 175 mcg, 200 Infections mcg, 25 mcg, 50 mcg, 75 Tetracyclines mcg, 88 mcg liothyronine sodium tabs or doxycycline (monohydrate) 1 1 caps 50 mg, 100 mg 25 mcg, 5 mcg, 50 mcg NATURE-THROID TABS doxycycline (monohydrate) 1 2 tabs 50 mg, 100 mg 130 MG, 65 MG SYNTHROID TABS (Use doxycycline hyclate caps or 1 2 50 mg, 100 mg levothyroxine sodium) thyroid tabs or 120 mg, 15 doxycycline hyclate tabs or 1 1 100 mg mg, 30 mg, 60 mg, 90 mg TIROSINT CAPS 100 MINOCIN CAPS OR 50 NP MG (Use minocycline hcl) MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 minocycline hcl caps or 1 2 100 mg, 50 mg, 75 mg MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG (Use levothyroxine sodium)

New Hampshire Healthy Families Updated October 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIROSINT CAPS 75 MCG 2 LEVSIN TABS OR 0.125 MG (Use NP sulfate) WESTHROID TABS 130 2 MG, 65 MG LEVSIN/SL SUBL (Use NP hyoscyamine sulfate) WP THYROID TABS 130 2 MG, 65 MG SYMAX DUOTAB TBCR 2 TOXOIDS H-2 Antagonists Toxoid Combinations tabs or 200 mg 1 RX/OTC QL(1 ml per 999 days cimetidine tabs or 300 mg, 1 ADACEL SUSP 0 retail); AL(At 400 mg least 18 yrs QL(500 ea per cimetidine tabs or 800 mg 1 old) fill retail) QL(1 ml per RX/OTC 999 days tabs or 20 mg 1 BOOSTRIX SUSP 0 retail); AL(At famotidine tabs or 40 mg, 1 least 18 yrs 10 mg old) GNP ACID CONTROL 150 QL(2 ea daily); ULCER DRUGS - Drugs to Treat Bowel, Intestine MAXIMUM STRENGTH 2 RX/OTC and Stomach Conditions TABS Antispasmodics PEPCID AC MAXIMUM RX/OTC STRENGTH TABS (Use NP ANASPAZ TBDP (Use NP hyoscyamine sulfate) famotidine) PEPCID AC TABS 10 MG dicyclomine hcl caps or 10 1 NP mg (Use famotidine) PEPCID AC TABS 20 MG RX/OTC dicyclomine hcl soln or 10 1 QL(40 ml daily) NP mg/5ml (Use famotidine) PEPCID TABS 20 MG (Use RX/OTC dicyclomine hcl tabs or 20 1 NP mg famotidine) PEPCID TABS 40 MG (Use glycopyrrolate tabs or 1 1 QL(4 ea daily) NP mg, 2 mg famotidine) hcl caps or 150 QL(2 ea daily) hyoscyamine sulfate elix or 1 1 0.125 mg/5ml mg ranitidine hcl caps or 300 QL(1 ea daily) hyoscyamine sulfate soln 1 1 or 0.125 mg/ml mg ranitidine hcl syrp or 15 QL(40 ml daily) hyoscyamine sulfate subl sl 1 0.125 mg mg/ml, 150 mg/10ml, 75 1 mg/5ml hyoscyamine sulfate tabs 1 or 0.125 mg ranitidine hcl tabs or 150 1 QL(2 ea daily); mg RX/OTC hyoscyamine sulfate tb12 1 or 0.375 mg ranitidine hcl tabs or 300 1 QL(2 ea daily) mg, 75 mg hyoscyamine sulfate tbdp 1 or 0.125 mg TAGAMET HB TABS (Use NP RX/OTC cimetidine) LEVBID TB12 (Use NP hyoscyamine sulfate)

New Hampshire Healthy Families Updated October 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); ZANTAC 150 MAXIMUM QL(2 ea daily); omeprazole cpdr or 20 mg 1 STRENGTH TABS (Use NP RX/OTC RX/OTC ranitidine hcl) omeprazole tbec or 20 mg 1 QL(1 ea daily) ZANTAC 75 TABS (Use NP QL(2 ea daily) ranitidine hcl) pantoprazole sodium pack 1 Misc. Anti-Ulcer or 40 mg pantoprazole sodium tbec QL(1 ea daily) CARAFATE SUSP 1 NP QL(420 ml per 1 GM/10ML (Use sucralfate) fill retail) or 20 mg pantoprazole sodium tbec QL(2 ea daily) CARAFATE TABS 1 GM NP QL(4 ea daily) 1 (Use sucralfate) or 40 mg PREVACID 24HR CPDR RX/OTC sucralfate susp or 1 1 QL(420 ml per NP gm/10ml fill retail) (Use lansoprazole) QL(4 ea daily) PREVACID CPDR 15 MG NP RX/OTC sucralfate tabs or 1 gm 1 (Use lansoprazole) Proton Pump Inhibitors PREVACID CPDR 30 MG NP (Use lansoprazole) ACIPHEX TBEC (Use NP rabeprazole sodium) PREVACID SOLUTAB PA; RX/OTC TBDD 15 MG (Use NP esomeprazole magnesium 1 RX/OTC lansoprazole) cpdr 20 mg PREVACID SOLUTAB PA esomeprazole magnesium 1 TBDD 30 MG (Use NP pack 10 mg, 20 mg, 40 mg lansoprazole) ESOMEPRAZOLE 2 PROTONIX PACK OR 40 STRONTIUM CPDR MG (Use pantoprazole 2 lansoprazole cpdr or 15 mg 1 RX/OTC sodium) PROTONIX TBEC OR 20 QL(1 ea daily) lansoprazole cpdr or 30 mg 1 MG (Use pantoprazole NP sodium) lansoprazole tbdd or 15 mg 1 PA; RX/OTC PROTONIX TBEC OR 40 QL(2 ea daily) MG (Use pantoprazole NP lansoprazole tbdd or 30 mg 1 PA sodium) NEXIUM 24HR CLEAR RX/OTC rabeprazole sodium tbec 1 MINIS CPDR (Use NP esomeprazole magnesium) Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use NEXIUM 24HR CPDR (Use NP RX/OTC NP esomeprazole magnesium) misoprostol) NEXIUM CPDR 20 MG RX/OTC misoprostol tabs or 100 1 (Use esomeprazole NP mcg, 200 mcg magnesium) Ulcer Therapy Combinations NEXIUM PACK 10 MG, 20 omeprazole-sodium RX/OTC MG, 40 MG (Use 2 bicarbonate caps 20 mg- 1 esomeprazole magnesium) 1100 mg NEXIUM PACK 2.5 MG, 5 2 omeprazole-sodium MG bicarbonate caps 40 mg- 1 omeprazole cpdr or 10 mg, 1 QL(2 ea daily) 1100 mg 40 mg

New Hampshire Healthy Families Updated October 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omeprazole-sodium trospium chloride cp24 60 1 bicarbonate pack 20 mg- 1 mg 1680 mg, 40 mg-1680 mg trospium chloride tabs 20 1 QL(2 ea daily) ZEGERID CAPS 20 MG- RX/OTC mg 1100 MG (Use NP VESICARE TABS (Use NP omeprazole-sodium solifenacin succinate) bicarbonate) ZEGERID CAPS 40 MG- Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 1100 MG (Use NP omeprazole-sodium or 10 mg, 25 mg, 5 mg, 50 1 bicarbonate) mg ZEGERID OTC CAPS (Use RX/OTC URECHOLINE TABS (Use NP omeprazole-sodium NP bethanechol chloride) bicarbonate) Urinary Antispasmodics - Direct Muscle Relaxants ZEGERID PACK 20 MG- flavoxate hcl tabs 1 1680 MG, 40 MG-1680 MG NP (Use omeprazole-sodium bicarbonate) VACCINES URINARY ANTISPASMODICS - Drugs to Treat Bacterial Vaccines Miscellaneous Bladder Spasms QL(1 ml per Urinary Antispasmodic - Antimuscarinics 999 days BEXSERO SUSY 0 retail); AL(At darifenacin hydrobromide 1 tb24 least 18 yrs old) DETROL LA CP24 (Use NP QL(1 ea daily) tolterodine tartrate) QL(1 ml per 999 days DETROL TABS (Use NP QL(2 ea daily) MENACTRA INJ 0 retail); AL(At tolterodine tartrate) least 18 yrs DITROPAN XL TB24 (Use NP QL(2 ea daily) old) oxybutynin chloride) QL(1 ml per ENABLEX TB24 (Use NP 999 days darifenacin hydrobromide) MENQUADFI INJ 0 retail); AL(At least 18 yrs oxybutynin chloride syrp or 1 QL(16 ml daily) 5 mg/5ml old) QL(1 ea per oxybutynin chloride tabs or 1 QL(3 ea daily) 5 mg 999 days MENVEO SOLR 0 retail); AL(At oxybutynin chloride tb24 or 1 QL(2 ea daily) 10 mg, 15 mg, 5 mg least 18 yrs old) solifenacin succinate tabs 1 2 rtl pack lmt amt,999 rtl tolterodine tartrate cp24 2 QL(1 ea daily) 1 0 pack lmt mg, 4 mg PNEUMOVAX 23 INJ day(s),; AL(At tolterodine tartrate tabs 1 1 QL(2 ea daily) least 19 yrs mg, 2 mg old) TOVIAZ TB24 2

New Hampshire Healthy Families Updated October 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2 rtl pack lmt 1 rtl pack lmt amt,999 rtl amt,180 rtl PNEUMOVAX 23/1 DOSE 0 pack lmt FLUZONE HIGH-DOSE PF 0 pack lmt INJ day(s),; AL(At 2020-2021 SUSY day(s),; AL(At least 19 yrs least 65 yrs old) old) AL(At least 19 1 rtl pack lmt PREVNAR 13 SUSP 0 yrs old) amt,180 rtl FLUZONE HIGH-DOSE PF 0 pack lmt PREVNAR 20 SUSY 0 2021-2022 SUSY day(s),; AL(At QL(1 ml per least 65 yrs 999 days old) TRUMENBA SUSY 0 retail); AL(At QL(2 ml per least 18 yrs 999 days old) HAVRIX SUSP 0 retail); AL(At least 18 yrs Viral Vaccines old) ASTRAZENECA COVID-19 CO JANSSEN COVID-19 CO VACCINE SUSP VACCINE SUSP QL(3 ml per AL(At least 18 M-M-R II SOLR 0 999 days yrs old) ENGERIX-B INJ 0 retail); AL(At least 18 yrs MODERNA COVID-19 CO old) VACCINE SUSP QL(3 ml per NOVAVAX COVID-19 CO 999 days VACCINE SUSP ENGERIX-B SUSP 0 retail); AL(At -BIONTECH CO least 18 yrs COVID-19VACCINE SUSP old) QL(3 ml per 1 rtl pack lmt 999 days amt,180 rtl RECOMBIVAX HB SUSP 0 retail); AL(At least 18 yrs FLUAD QUADRIVALENT 0 pack lmt 2021-2022 PRSY day(s),; AL(At old) least 65 yrs QL (1 ea per old) Seasonal Influenza 0 180 days 1 rtl pack lmt Vaccine retail); AL: At amt,180 rtl least 7 yrs old FLUAD QUADRIVALENT 0 pack lmt QL (1 ea per INFLUENZA VACCINE day(s),; AL(At FOR ADULTS PRSY Seasonal Influenza 0 180 days least 65 yrs Vaccine-High Dose retail); AL: At old) least 65 yrs old limit 0.5 per QL(2 ml per 180 days;1 rtl 999 days pack lmt VAQTA SUSP 0 retail); AL(At FLUMIST 0 amt,180 rtl QUADRIVALENT SUSP least 18 yrs pack lmt old) day(s),; AL(At least 4 yrs old)

New Hampshire Healthy Families Updated October 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea per miconazole nitrate vaginal 1 QL(45 gm per 999 days crea 2 % fill retail) ZOSTAVAX SUSR 0 retail); AL(At miconazole nitrate vaginal 1 QL(15 gm least 60 yrs crea 4 % daily) old) miconazole nitrate vaginal 1 QL(24 gm per VAGINAL AND RELATED PRODUCTS kit fill retail) miconazole nitrate vaginal 1 QL(7 ea per fill Spermicides supp 100 mg retail) QL(12 ea per ENCARE SUPP 2 miconazole nitrate vaginal 1 QL(3 ea per fill fill retail) supp 200 mg retail) OPTIONS CONCEPTROL MONISTAT 3 QL(24 gm per VAGINAL NP COMBINATION PACK KIT NP fill retail) CONTRACEPTIVE GEL (Use miconazole nitrate OPTIONS GYNOL II QL(86 gm per vaginal) VAGINALCONTRACEPTIV 2 fill retail) MONISTAT 3 CREA (Use NP QL(15 gm E GEL miconazole nitrate vaginal) daily) QL(24 gm per SHUR-SEAL GEL 2 MONISTAT 7 SIMPLY QL(45 gm per fill retail) CURE CREA (Use NP fill retail) VCF VAGINAL QL(9 ea per fill miconazole nitrate vaginal) CONTRACEPTIVE FILM 2 retail) FILM NUVESSA GEL 2 VCF VAGINAL terconazole vaginal crea 1 QL(45 gm per CONTRACEPTIVEGEL 2 0.4 % fill retail) GEL terconazole vaginal crea 1 QL(20 gm per Vaginal Anti-infectives 0.8 % fill retail) CLEOCIN CREA VA 2 % QL(40 gm per terconazole vaginal supp 1 QL(3 ea per fill (Use clindamycin NP fill retail) 80 mg retail) phosphate vaginal) QL(5 gm per fill tioconazole vaginal oint 1 retail) clindamycin phosphate 1 QL(40 gm per vaginal crea fill retail) Vaginal Estrogens CLINDESSE CREA 2 ESTRACE CREA VA 0.1 QL(43 gm per MG/GM (Use estradiol NP 30 days retail) clotrimazole vaginal crea 1 1 QL(45 gm per vaginal) % fill retail) estradiol vaginal crea 0.1 1 QL(43 gm per clotrimazole vaginal crea 2 1 QL(21 gm per mg/gm 30 days retail) % fill retail) estradiol vaginal tabs 10 1 GYNAZOLE-1 CREA 2 mcg PREMARIN CREA VA 2 QL(43 gm per GYNE-LOTRIMIN 3 CREA NP QL(21 gm per 0.625 MG/GM 30 days retail) (Use clotrimazole vaginal) fill retail) VAGIFEM TABS (Use NP GYNE-LOTRIMIN CREA NP QL(45 gm per estradiol vaginal) (Use clotrimazole vaginal) fill retail) METROGEL-VAGINAL QL(70 gm per Vaginal Progestins AL(At least 15 GEL (Use metronidazole NP fill retail) CRINONE GEL 2 vaginal) yrs old) QL(70 gm per metronidazole vaginal gel 1 fill retail) New Hampshire Healthy Families Updated October 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRST-PROGESTERONE AL(At least 15 ergocalciferol caps or 1.25 1 VGS 100 COMPOUNDING 2 yrs old) mg, 50000 unit KIT SUPP KEY-E CHEW OR 2 QL(2 ea daily) FIRST-PROGESTERONE AL(At least 15 VGS 200 yrs old) 2 MEPHYTON TABS (Use NP COMPOUNDING KIT phytonadione) SUPP phytonadione tabs or 5 mg 1 VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions vitamin e caps or 180 mg, QL(2 ea daily) 100 unit, 45 mg, 200 unit, 1 Anaphylaxis Therapy Agents 90 mg, 400 unit 2/30 VITAMIN E CHEW OR 400 2 QL(2 ea daily) NP DAYS;QL(2 ea UNIT AUVI-Q SOAJ per 30 days retail) Water Soluble Vitamins 2/30 ascorbic acid tabs or 250 QL(100 ea per mg, 1000 mg, 37 mg-1000 34 days retail) epinephrine (anaphylaxis) 1 DAYS;QL(2 ea soaj 0.15 mg/0.15ml per 30 days mg, 10 mg-500 mg, 14 mg- 1 retail) 25 mg-500 mg, 25 mg-35 mg-500 mg, 37 mg-500 mg Neurogenic Orthostatic (NOH) - B-1 TABS 2 QL(2.94 ea caps 1 PA; SP daily) niacin cpcr or 500 mg, 250 NORTHERA CAPS (Use NP PA; SP 1 droxidopa) mg Vasopressors niacin tabs or 500 mg 1 hcl tabs 1 niacin tbcr or 750 mg, 250 1 mg, 500 mg VITAMINS NIACIN TR TBCR 2 Oil Soluble Vitamins pyridoxine hcl tabs or 25 1 BABY DDROPS LIQD 400 mg, 50 mg, 100 mg UT/0.028ML (Use NP riboflavin tabs or 25 mg, 50 1 QL(2.94 ea cholecalciferol) mg, 100 mg daily) cholecalciferol caps or 1.25 QL(0.267 ea 1 SLO-NIACIN TBCR (Use NP mg, 50000 unit daily) niacin) cholecalciferol caps or thiamine hcl tabs or 250 1 QL(2.94 ea 1000 unit, 25 mcg, 2000 1 mg, 50 mg, 100 mg daily) unit, 50 mcg QL(2.94 ea thiamine mononitrate tabs 1 cholecalciferol caps or 125 1 QL(2 ea daily) daily) mcg, 5000 unit cholecalciferol liqd or 400 ut/0.028ml, 5000 unit/ml, 1 10 mcg/ml, 400 unit/ml D-VI-SOL LIQD (Use NP cholecalciferol) DRISDOL CAPS (Use NP ergocalciferol)

New Hampshire Healthy Families Updated October 1, 2021

110 Index 1ST TIER UNILET ACULAR 99 AEROCHAMBER Z-STAT COMFORTOUCH LANCETS ACULAR LS 98 PLUS/LARGE MASK 83 28G 75 AEROCHAMBER Z-STAT 1ST TIER UNILET acyclovir 42 PLUS/MEDIUM MASK 83 COMFORTOUCH LANCETS acyclovir topical 55 AEROCHAMBER Z-STAT 30G 75 ADACEL 105 PLUS/SMALL MASK 83 abacavir sulfate 39 AEROCHAMBER/FLOWSIGNAL ADALAT CC 43,44 83 abacavir sulfate-lamivudine 39 adapalene 52 abacavir sulfate-lamivudine- AEROTRACH PLUS 83 zidovudine 39 ADAPALENE 52 AEROVENT PLUS HOLDING ABILIFY 39 adapalene-benzoyl CHAMBER/COLLAPSIBLE 83 peroxide 52 AFINITOR 34 ABILIFY MAINTENA 39 ADCETRIS 32 AFINITOR DISPERZ 34 abiraterone acetate 33 ADCIRCA 45 AFSTYLA 68 ABRAXANE 36 ADDERALL 1 AGAMATRIX ULTRA-THIN ABSORICA 52 ADDERALL XR 1 LANCETS 33G 75 acamprosate calcium 102 ADRENALIN 95 AGGRENOX 70 ACANYA 52 ADULT AEROSOL MASK 82 AIMSCO TWIST LANCETS acarbose 18 32G 75 ADULT MASK 82 AIMSCO TWIST LANCETS ACCOLATE 11 ADULT MASK LARGE 82 33G 75 ACCUPRIL 28 ADVAIR DISKUS 12 AIRS PEDIATRIC AEROSOL MASK 83 ACCURETIC 29 ADVAIR HFA 12 AJOVY 87 ACCUTREND PLUS 75 ADVANCED MOBILE LANCET ACE AEROSOL CLOUD 30G 75 albuterol sulfate 12 ENHANCER 82 ADVANCED PROBIOTIC 20 ALBUTEROL SULFATE 12 acebutolol hcl 43 ADVANCED PROBIOTIC albuterol sulfate 12 acetaminophen 4 10 20 alclometasone dipropionate 55 acetaminophen w/ codeine 6 ADVANCED PROBIOTIC- 14 20 ALCOHOL PREP PADS 81 acetazolamide 62 ADVATE 68 ALCOHOL PREP PADS- acetic acid (otic) 99 MISC 75 ADVIL 3 acetylcysteine 52 ALCOHOL SWABS 81 ADVIL COLD & SINUS 51 ACIDOPHILUS HIGH- ALCOHOL SWABSTICK 81 POTENCY 20 ADVIL PM 71 ALDACTAZIDE 62 ACIDOPHILUS PEARLS 20 ADYNOVATE 68 ALDACTONE 62 AEROCHAMBER MINI ACIDOPHILUS PROBIOTIC ALDARA 59 BLEND 20 AEROSOLCHAMBER 82 ACIDOPHILUS SUPER AEROCHAMBER MV 82 ALDURAZYME 64 PROBIOTIC 20 AEROCHAMBER PLUS FLOW ALECENSA 34 ACIDOPHILUS/GOAT MILK 20 VU 83 alendronate sodium 63 ACIPHEX 106 AEROCHAMBER PLUS ALER-DRYL 25 FLOW-VU 83 ACNE MEDICATION 10 52 AEROCHAMBER PLUS ALEVE 3 ACNE MEDICATION 5 52 FLOW-VU/LARGE MASK 83 ALEVE ARTHRITIS 3 ACTHAR 63 AEROCHAMBER PLUS ALEVE PM 72 FLOW-VU/MASK 83 ACTIGALL 66 AEROCHAMBER PLUS ALFERON N 35 ACTIMMUNE 35 FLOW-VU/MEDIUM MASK83 alfuzosin hcl 68 ACTIPHLORA 20 AEROCHAMBER PLUS ALIGN 20 ACTIVELLA 65 FLOW-VU/SMALL MASK 83 ALIGN EXTRA STRENGTH 20 AEROCHAMBER Z-STAT ACTIVITY POUCH 82 PLUS VALVED HOLDING ALIMTA 31 ACTONEL 62,63 CHAMBER W/FLOW VU 83 ALKERAN 31 ACTOPLUS MET 18 AEROCHAMBER Z-STAT ALL FLOW 1000 PULMONARY ACTOS 19 PLUS/FLOWSIGNAL 83 FUNCTION FILTER 83

Index 1 ALLEGRA ALLERGY 26 amoxapine 17 ASMANEX TWISTHALER 120 ALLEGRA ALLERGY amoxicillin 100 METERED DOSES 11 ASMANEX TWISTHALER 14 CHILDRENS 26 amoxicillin & pot allopurinol 68 METERED DOSES 11 clavulanate 101 ASMANEX TWISTHALER 30 almotriptan malate 88 amphetamine 1 METERED DOSES 11 ALOE 10000 & amphetamine sulfate 1 ASMANEX TWISTHALER 60 PROBIOTICS 20 amphetamine- METERED DOSES 11 alogliptin benzoate 19 dextroamphetamine 1 ASMANEX TWISTHALER 7 alogliptin-metformin hcl 18 ampicillin 101 METERED DOSES 11 alogliptin-pioglitazone 18 AMPYRA 103 aspirin 5 ALORA 66 AMRIX 93 ASPIRIN 5 alosetron hcl 67 ANAFRANIL 17 aspirin 5 aspirin buffered (cal carb-mag ALPHAGAN P 97 ANASPAZ 105 carb-mag oxide) 5 ALPHANATE 68 anastrozole 33 aspirin-dipyridamole 70 ALPHANATE/VON ANDEXXA 24 ASTAGRAF XL 89 WILLEBRANDFACTOR ANDROGEL 7 ASTRAZENECA COVID-19 COMPLEX/HUMAN 68 VACCINE 108 ALPHANINE SD 68 ANDROGEL PUMP 7 ATACAND 28 alprazolam 10 ANTABUSE 102 ATACAND HCT 29 ALPRAZOLAM INTENSOL 10 ANTI-DIARRHEAL 23 atazanavir sulfate 39 ALPROLIX 68 ANUSOL-HC 8 APLICARE ALCOHOL ATELVIA 63 ALTACE 28 SWABSTICK 81 atenolol 43 alum & mag hydrox- APLIGRAF 61 simethicone 8 atenolol & chlorthalidone 29 ALUMINUM HYDROXIDE 8 APO-VARENICLINE 103 ATGAM 89 amantadine hcl 37 APOKYN 37 ATIVAN 10 AMARYL 20 apraclonidine hcl 97 atomoxetine hcl 1 AMBIEN 72 aprepitant 25 atorvastatin calcium 27 AMBIEN CR 72 APTENSIO XR 1 ATRALIN 52 ambrisentan 45 APTIVUS 39 ATRIPLA 39 amcinonide 56 AQUADEKS 92 ATROPINE SULFATE 96 AMCINONIDE 56 AQUORAL 91 atropine sulfate (ophthalmic) 96 AMERGE 88 ARALAST NP 104 ATROVENT HFA 11 AMICAR 71 ARAVA 4 AUGMENTIN 101 amiloride & ARESTIN 91 AUGMENTIN ES-600 101 hydrochlorothiazide 62 ARIAL CHAMBER 83 AURORA LANCET SUPER amiloride hcl 62 ARICEPT 102 THIN30G 75 aminocaproic acid 71 ARIMIDEX 33 AURORA LANCET THIN 23G 75 amiodarone hcl 11 aripiprazole 39 AUSTEDO 102 amitriptyline hcl 17 ARISTADA 39 AUVI-Q 110 amlodipine besylate 44 ARIXTRA 13 AVALIDE 29 amlodipine besylate-atorvastatin ARMOUR THYROID 104 calcium 45 AVAPRO 28 amlodipine besylate-benazepril AROMASIN 33 AVASTIN 32 hcl 29 arsenic trioxide 35 AVEED 7 amlodipine besylate-olmesartan ARTHRITIS PAIN medoxomil 29 RELIEVING 59 AVODART 68 amlodipine besylate- ARZERRA 32 AVONEX 103 valsartan 29 ASACOL HD 67 AVONEX PEN 103 amlodipine-valsartan- AYGESTIN 101 hydrochlorothiazide 29 ascorbic acid 110

Index 2 azacitidine 32 BD PEN bexarotene 35 AZASAN 89 NEEDLE/ORIGINAL/ULTRA- BEXSERO 107 FINE/29G X 12.7MM 82 azathioprine 89 BD PEN BEYAZ 46 AZEDRA DOSIMETRIC 35 NEEDLE/SHORT/ULTRA- bicalutamide 33 AZEDRA THERAPEUTIC 35 FINE/31G X 8MM 82 BIKTARVY 39 azelastine hcl 94 BD PEN NEEDLES 82 bimatoprost 99 azelastine hcl (ophth) 99 BD SWABS SINGLE USE 81 bimatoprost (topical) 59 BD SWABS SINGLE USE azelastine hcl-fluticasone BIO-KULT 21 propionate 94 BUTTERFLY 81 BELEODAQ 34 BIOHM PROBIOTIC azithromycin 74 SUPPLEMENT 21 AZOR 29 BELRAPZO 31 BIOHM PROBIOTIC AZULFIDINE 67 BENADRYL ALLERGY 25 SUPPLEMENT/VITAMIN C 21 BENADRYL ALLERGY BIOTENE DRY MOUTH AZULFIDINE EN-TABS 67 CHILDRENS 25 MOISTURIZING SPRAY 91 b complex w/ c 91 BENADRYL ALLERGY bisacodyl 74 B-1 110 ULTRATABS 25 bismuth subsalicylate 21 b-complex vitamins 91 benazepril & bisoprolol & hydrochlorothiazide 29 b-complex w/ c & folic acid 92 hydrochlorothiazide 29 benazepril hcl 28 bisoprolol fumarate 43 BABY DDROPS 110 BENAZEPRIL BACICAP 20 HCL/HYDROCHLOROTHIAZID BIVIGAM 100 BACID 20 E 29 BLEPH-10 97 BENDAMUSTINE BACIGUENT 53 BLEPHAMIDE 98 HYDROCHLORIDE 31 BLEPHAMIDE S.O.P. 98 bacitracin (topical) 53 BENDEKA 31 BLINCYTO 32 bacitracin zinc 53 BENEFIX 69 BONIVA 63 bacitracin-polymyxin b BENICAR 28 (ophth) 97 BOOSTRIX 105 BENICAR HCT 29 baclofen 93 BORTEZOMIB 34 BENLYSTA 90 BACTRIM 8 bosentan 45 BENZAC AC WASH 52 BACTRIM DS 8 BOSULIF 34 BENZACLIN 52 balsalazide disodium 67 BOTOX 95 BAQSIMI ONE PACK 18 BENZACLIN WITH PUMP 52 BPROTECTED PEDIA POLY- BAQSIMI TWO PACK 18 BENZNIDAZOLE 8 VITE/IRON 92 BD AUTOSHIELD 29G X benzonatate 51 BRAFTOVI 34 3/16" 82 benzoyl peroxide 52 BREATHE EASE NEBULIZER BD AUTOSHIELD 29G X benztropine mesylate 37 MASK/CHILD 83 5/16" 82 BREATHE EASE NEBULIZER BD AUTOSHIELD DUO 30G X BERINERT 69 MASK/INFANT 83 5MM 82 betamethasone dipropionate BREATHE EASE/LARGE BD GLUCOSE 18 (topical) 56 MASK 83 BD LANCET ULTRAFINE betamethasone dipropionate BREATHE EASE/MEDIUM augmented 56 30G 75 MASK 83 BD PEN betamethasone valerate 56 BREATHE EASE/SMALL NEEDLE/MICRO/ULTRA- BETAPACE 43 MASK 83 BREATHERITE 83 FINE/32G X 6MM 82 BETAPACE AF 43 BREATHERITE BD PEN NEEDLE/MINI/ULTRA- betaxolol hcl 43 FINE/31G X 5MM 82 COLLAPSIBLEADULT SPACER BD PEN NEEDLE/NANO 2ND betaxolol hcl (ophth) 96 W/MASK 83 GEN/32G X 5/32" 82 bethanechol chloride 107 BREATHERITE BD PEN BETHKIS 2 COLLAPSIBLECHILD SPACER NEEDLE/NANO/ULTRA- W/MASK 83 FINE/32G X 4MM 82 BEVACIZUMAB 97 BEVESPI AEROSPHERE 12

Index 3 BREATHERITE butalbital-aspirin-caffeine CARDIZEM LA 44 COLLAPSIBLEINFANT SPACER w/cod 6 CARDURA 29 W/MASK 83 BUTALBITAL/ASPIRIN/CAFFEI BREATHERITE NE 4 CAREONE LANCET SUPER THIN/30G 75 COLLAPSIBLESMALL CHILD BUTRANS 7 CAREONE LANCET THIN 75 SPACER W/MASK 83 BYDUREON PEN 19 BREATHERITE CARESENS LANCETS 75 COLLAPSIBLESPACER W/ BYETTA 19 CARIMUNE NEONATE MASK 83 CABOMETYX 34 NANOFILTERED 100 BREATHERITE RIGID CADUET 45 carisoprodol 93 SPACERW/MASK 83 BREATHERITE W/LARGE CAFERGOT 87 carisoprodol w/ aspirin 94 MASK 83 caffeine citrate 1 CARNITOR 64 BREATHERITE W/MEDIUM CALAN 44 CARNITOR SF 64 MASK 84 CALAN SR 44 carteolol hcl (ophth) 96 BREATHERITE W/SMALL MASK 84 calcipotriene 55 carvedilol 43 BRIDION 24 calcipotriene-betamethasone carvedilol phosphate 43 dipropionate 56 BRILINTA 70 CASODEX 33 calcitonin (salmon) 63 brimonidine tartrate 97 CASTIVA WARMING 59 calcitriol 64 BRISDELLE 103 CATAPRES 29 calcitriol (topical) 55 CAYSTON 9 BRIVIACT 14 calcium acetate (phosphate bromfenac sodium (ophth) 99 binder) 67 cefaclor 45 bromocriptine mesylate 37 calcium carbonate (antacid) 8 CEFACLOR ER 45 brompheniramine & calcium polycarbophil 73 cefadroxil 45 phenyleph 51 camphor & menthol 55 cefdinir 46 brompheniramine & pseudoeph 51 CAMPTOSAR 36 cefditoren pivoxil 46 BUBBLES THE FISH II CANASA 67 cefixime 46 PEDIATRIC MASK/PVC 84 candesartan cilexetil 28 cefpodoxime proxetil 46 budesonide 50 candesartan cilexetil- cefprozil 46 budesonide (inhalation) 11 hydrochlorothiazide 29 ceftriaxone sodium 46 budesonide (nasal) 94 capecitabine 32 cefuroxime axetil 46 budesonide-formoterol fumarate CAPHOSOL 91 CELEBREX 3 dihydrate 12 CAPRELSA 34 celecoxib 3 BUFFERIN 5 capsaicin 59 bumetanide 62 CELEXA 16 captopril 28 CELLCEPT 89 BUMEX 62 captopril & BUPHENYL 64 hydrochlorothiazide 29 CELLCEPT INTRAVENOUS 89 buprenorphine 7 CAPZASIN-HP 59 CELONTIN 15 buprenorphine hcl 7 CAPZASIN-P 59 CENTANY 53 buprenorphine hcl-naloxone hcl CARAC 55 cephalexin 45 dihydrate 7 CARAFATE 106 CEPROTIN 70 bupropion hcl 16 CARBAGLU 64 CERDELGA 70 bupropion hcl (smoking CEREZYME 70 deterrent) 103 carbamazepine 14 cetirizine hcl 26 buspirone hcl 10 carbamide peroxide (otic) 99 CETRAXAL 99 butalbital-acetaminophen 4 CARBATROL 14 butalbital-acetaminophen- carbidopa 37 CETROTIDE 63 caffeine 4 carbidopa-levodopa 37 CHANTIX 103 butalbital-acetaminophen- carboplatin 31 CHANTIX CONTINUING caffeine w/ codeine 6 MONTHPAK 103 butalbital-aspirin-caffeine 4 CARDIZEM 44 CHANTIX STARTING MONTH CARDIZEM CD 44 PAK 103

Index 4 CHEMET 24 CLARITIN CHILDRENS 26 clonidine hcl (adhd) 1 CHEMSTRIP-K 61 CLEANLET LANCETS clopidogrel bisulfate 70 CHENODAL 66 28G 75 clorazepate dipotassium 10 clemastine fumarate 26 CHERACOL PLUS 51 clotrimazole (topical) 54 CLEOCIN 9,109 CHERACOL-D COUGH 51 clotrimazole vaginal 109 CLEOCIN PEDIATRIC CHILDRENS ADVIL 3 GRANULES 9 clotrimazole w/ betamethasone 54 CHILDRENS MOTRIN 3 CLEOCIN-T 52 clozapine 38 CHILDRENS PROBIOTIC CLEVER CHOICE ANTI- PEARLS 21 STATICVALVED HOLDING CLOZARIL 38 CHLOR-TRIMETON 25 CHAMBER/ADULT CO MONITOR REPLACEMENT chlordiazepoxide hcl 10 LARGE 84 TPIECES 84 chlorhexidine gluconate (mouth- CLEVER CHOICE ANTI- COAGADEX 69 throat) 90 STATICVALVED HOLDING coal tar extract 61 CHAMBER/MEDIUM 84 chloroquine phosphate 30 CLEVER CHOICE ANTI- COARTEM 30 chlorpheniramine maleate 25 STATICVALVED HOLDING CODEINE SULFATE 5 chlorpromazine hcl 39 CHAMBER/MEDIUM/3 codeine sulfate 5 chlorthalidone 62 YEA 84 COLACE 74 CLEVER CHOICE ANTI- chlorzoxazone 93 STATICVALVED HOLDING COLACE CLEAR 74 CHOLBAM 66 CHAMBER/SMALL 84 COLAZAL 67 cholecalciferol 110 CLEVER CHOICE ANTI- colchicine 68 cholestyramine 27 STATICVALVED HOLDING colchicine w/ probenecid 68 CHAMBER/SMALL cholestyramine light 27 INFANT 84 COLCRYS 68 CHORIONIC CLIMARA 66 COLESTID 27 GONADOTROPIN 63 CLINDAGEL 52 COLESTID FLAVORED 27 CICLODAN SOLUTION KIT 54 clindamycin hcl 9 colestipol hcl 27 ciclopirox 54 clindamycin palmitate COLYTE-FLAVOR PACKS 73 cilostazol 70 hydrochloride 9 COMBIGAN 96 CILOXAN 97 clindamycin phosphate COMBIPATCH 65 cimetidine 105 (topical) 52 clindamycin phosphate COMBIVENT RESPIMAT 12 cinacalcet hcl 64 vaginal 109 COMBIVIR 39 CINQAIR 11 clindamycin phosphate-benzoyl COMETRIQ 34 52 CINRYZE 69 peroxide COMFORT ASSURED CIPRO 66 clindamycin phosphate-benzoyl peroxide (refrigerate) 52 LANCETS SUPER THIN CIPRODEX 99 clindamycin phosphate- 28G 75 ciprofloxacin 66 tretinoin 53 COMFORT LANCETS 75 ciprofloxacin hcl 66 CLINDESSE 109 COMPACT SPACE CHAMBER/ANTI-STATIC 84 ciprofloxacin hcl (ophth) 97 clobazam 13 COMPACT SPACE ciprofloxacin hcl (otic) 99 clobetasol propionate 56 CHAMBER/ANTI- ciprofloxacin-dexamethasone clobetasol propionate emollient STATIC/LARGE MASK 84 99 base 56 COMPACT SPACE cisplatin 31 clobetasol propionate CHAMBER/ANTI- emulsion 56 CISPLATIN 31 STATIC/MEDIUM MASK 84 CLOBEX 56 COMPACT SPACE citalopram hydrobromide 16 clocortolone pivalate 56 CHAMBER/ANTI-STATIC/SMALL cladribine 32 MASK 84 CLODERM 56 clarithromycin 75 COMPLERA 39 clomipramine hcl 17 CLARITIN 26 CONCERTA 1 clonazepam 13 CLARITIN ALLERGY CONDOMS-MISC 75 29 CHILDRENS 26 clonidine hcl COPAXONE 103

Index 5 CORDRAN 56 CULTURELLE ULTIMATE CYSTADANE 64 COREG 43 STRENGTH PROBIOTIC 23 CYSTAGON 68 CURITY ALCOHOL COREG CR 43 PREPS/MEDIUM 2 PLY 81 CYSTARAN 99 CORGARD 43 CURITY ALCOHOL cytarabine 32 CORIFACT 69 SWABS 81 CYTOGAM 100 CORTEF 50 CUTIVATE 56 CYTOMEL 104 CORTENEMA 8 CUVITRU 100 CYTOTEC 106 CVS ADULT 50+ cortisone acetate 50 PROBIOTIC 21 D-VI-SOL 110 CORTROSYN 61 CVS ADULT PROBIOTIC 21 D.H.E. 45 87 COSENTYX 55 CVS DIGESTIVE DACOGEN 32 COSENTYX SENSOREADY PROBIOTIC 21 DAILY DIGESTIVE PEN 55 CVS DRY MOUTH SPRAY91 PROBIOTIC 21 COSOPT 96 CVS EVERYDAY CARE DAILY PROBIOTIC 21 COSOPT PF 96 PROBIOTIC 21 dalfampridine 103 cosyntropin 61 CVS GLUCOSE 18 DANTRIUM 94 COTELLIC 34 CVS LANCETS 21G 76 dantrolene sodium 94 COUMADIN 13 CVS LANCETS MICRO THIN dapsone 9 33G 76 COZAAR 28 CVS LANCETS MICRO-THIN DARAPRIM 30 CREON 62 33G 76 darifenacin hydrobromide 107 CRESTOR 27 CVS LANCETS ORIGINAL76 DARZALEX 32 CRINONE 109 CVS LANCETS THIN 26G 76 daunorubicin hcl 34 CRIXIVAN 39 CVS LANCETS ULTRA THIN DAUNORUBICIN 30G 76 cromolyn sodium 11 HYDROCHLORIDE 34 CVS LANCETS ULTRA-THIN DAURISMO 33 cromolyn sodium (nasal) 94 30G 76 DAYPRO 3 cromolyn sodium (ophth) 99 CVS LICE SOLUTION KIT 3- STEP 60 DDAVP 65 CRYSVITA 64 CVS MOOD SUPPORT CULTURELLE ADULT DEBROX 99 PROBIOTIC 21 decitabine 32 ULTIMATEBALANCE 23 CVS PREP PADS 81 CULTURELLE ADVANCED deferasirox 24 CVS PROBIOTIC 21 IMMUNE DEFENSE 21 deferiprone 24 CULTURELLE DIGESTIVE CVS PROBIOTIC MAXIMUM DAILY PROBIOTIC 23 STRENGTH 21 deferoxamine mesylate 24 CULTURELLE DIGESTIVE CVS PROBIOTIC PEARLS DEFITELIO 70 HEALTH 23 EXTRA STRENGTH 21 DEFLUX 68 CULTURELLE DIGESTIVE CVS SENIOR PROBIOTIC 21 DELSTRIGO 39 HEALTH PROBIOTIC 23 CVS SOFT GLUCOSE 19 CULTURELLE HEALTH & DEMSER 28 CVS ULTRA THIN WELLNESS 23 LANCETS 76 DENAVIR 55 CULTURELLE KIDS 21 cyanocobalamin 70 DEPAKENE 16 CULTURELLE KIDS PURELY DEPAKOTE 16 PRBIOTICS 21 cyclobenzaprine hcl 93 CULTURELLE KIDS PURELY CYCLOGYL 96 DEPAKOTE ER 16 PROBIOTICS 21 cyclopentolate hcl 96 DEPAKOTE SPRINKLES 16 CULTURELLE KIDS DEPEN TITRATABS 89 REGULARITY 21 CYCLOPHOSPHAMIDE 31 cyclosporine 89 DEPO-PROVERA CULTURELLE CONTRACEPTIVE 50 METABOLISM/WEIGHT cyclosporine modified (for DEPO-SUBQ PROVERA MANAGEMENT 21 microemulsion) 89 104 50 CULTURELLE PRO-WELL 21 CYMBALTA 17 DEPO-TESTOSTERONE 7 CULTURELLE PROBIOTICS cyproheptadine hcl 26,27 DERMA-SMOOTHE/FS KIDS 21 CYRAMZA 32 BODY 56

Index 6 DERMA-SMOOTHE/FS dextromethorphan-guaifenesin DILAUDID 5 SCALP 56 51 diltiazem hcl 44 DERMACINRX PROBITRAN21 DHS TAR 61 diltiazem hcl coated beads 44 DERMAGRAFT 61 DHS TAR GEL 61 diltiazem hcl extended release DERMOTIC 99 DIATHRIVE LANCETS 76 beads 44 DESCOVY 39 DIATHRIVE LANCETS ULTRA DIMETAPP COLD & DESFERAL 24 THIN 30G 76 ALLERGY 51 diazepam 10 dimethyl fumarate 103 desipramine hcl 17 DIAZEPAM 10 DIOVAN 28 desloratadine 26 diazepam 10 DIOVAN HCT 29 desmopressin acetate 65 DESMOPRESSIN diazepam (anticonvulsant) 13 diphenhydramine hcl 26 ACETATE 65 diazoxide 19 diphenhydramine hcl (sleep) 72 desmopressin acetate 65 dibucaine 59 diphenhydramine-acetaminophen desmopressin acetate spray 65 DICLEGIS 25 (sleep) 72 diphenoxylate w/ atropine 24 desmopressin acetate spray diclofenac potassium 3 DIPROLENE 57 refrigerated 65 diclofenac sodium 3 desogestrel & ethinyl DIPROLENE AF 57 diclofenac sodium (ophth) 99 estradiol 46 dipyridamole 70 desogestrel-ethinyl estradiol diclofenac sodium (topical) 53 disopyramide phosphate 10 (biphasic) 46 dicloxacillin sodium 101 desogestrel-ethinyl estradiol disulfiram 102 dicyclomine hcl 105 (triphasic) 46 DITROPAN XL 107 didanosine 40 desonide 56 divalproex sodium 16 DIFF-STAT 21 DESOWEN 56 docetaxel 36 DIFFERIN 53 desoximetasone 56,57 DOCETAXEL 36 diflorasone diacetate 57 DESOXYN 1 docetaxel 36 DIFLUCAN 25 desvenlafaxine 17 DOCETAXEL 36 diflunisal 5 DESVENLAFAXINE ER 17 docusate sodium 74 DIGESTIVE ADVANTAGE 21 desvenlafaxine succinate 17 dofetilide 11 DETROL 107 DIGESTIVE ADVANTAGE ADVANCED PROBIOTICS donepezil hydrochloride 102 DETROL LA 107 MULTI-STRAIN DOPTELET 70 DEX4 QUICK DISSOLVE SUPPORT 21 dorzolamide hcl 99 GLUCOSE 19 DIGESTIVE ADVANTAGE dexamethasone 50 DAILYDIGESTIVE & IMMUNE DORZOLAMIDE HCL 99 DEXAMETHASONE SUPPORT 21 dorzolamide hcl-timolol INTENSOL 50 DIGESTIVE ADVANTAGE maleate 96 dexamethasone sodium DAILYPROBIOTICS+GAS DOVATO 40 phosphate 50 DEFENSE 21 DOVONEX 55 DEXAMETHASONE SODIUM DIGESTIVE ADVANTAGE doxazosin mesylate 29 PHOSPHATE 50 DAILYPROBIOTICS+INTENSI dexamethasone sodium VE BOWEL SUPPORT 21 doxepin hcl 18 phosphate (ophth) 98 DIGESTIVE ADVANTAGE doxepin hcl (sleep) 72 dexchlorpheniramine DAILYPROBIOTICS+LACTOS doxycycline (monohydrate) 104 maleate 25 E SUPPORT 21 doxycycline hyclate 104 DEXEDRINE 1 DIGESTIVE ADVANTAGE doxylamine succinate dexmedetomidine hcl 72 LACTOSE SUPPORT 21 digoxin 44,45 (sleep) 72 dexmedetomidine hcl in sodium doxylamine-pyridoxine 25 chloride 72 dihydroergotamine DRISDOL 110 dexmethylphenidate hcl 1,2 mesylate 87 DILANTIN 15 droperidol 10 dexrazoxane hcl 36 DILANTIN INFATABS 15 DROPLET LANCETS ULTRA DEXTENZA 98 DILANTIN-125 15 THIN 30G 76 dextroamphetamine sulfate 1

Index 7 drospirenone-ethinyl EASY TOUCH LANCETS emtricitabine-tenofovir disoproxil estradiol 46 32G/TWIST 76 fumarate 40 drospirenone-ethinyl estradiol- EASY TOUCH LANCETS EMTRIVA 40 levomefolate calcium 46 33G/TWIST 76 EMVERM 8 DROXIA 70 EBASE CONTROLLER ENABLEX 107 droxidopa 110 KIT 84 enalapril maleate 28 DRUG MART LANCETS EC-NAPROSYN 3 THIN 76 econazole nitrate 54 enalapril maleate & hydrochlorothiazide 29 DRUG MART UNILET ECOTRIN 5 ENBREL 4 LANCETSSUPER THIN 30G76 ECOTRIN MAXIMUM DRUG MART UNILET STRENGTH 5 ENBREL MINI 4 LANCETSULTRA THIN 28G 76 ECOTRIN REGULAR ENBREL SURECLICK 4 DRUG MART UNILET MICRO STRENGTH 5 ENCARE 109 THIN LANCETS 33G 76 EDURANT 40 DUAC 53 ENGERIX-B 108 efavirenz 40 enoxaparin sodium 13 DUETACT 18 efavirenz-emtricitabine- DULCOLAX 74 tenofovir disoproxil ENTRESTO 45 DULERA 12 fumarate 40 ENVIVE 21 duloxetine hcl 17 efavirenz-lamivudine-tenofovir EPIDUO 53 disoproxil fumarate 40 EPIFOAM 57 DURAGESIC 5 EFFEXOR XR 17 epinastine hcl (ophth) 99 dutasteride 68 EFFIENT 70 epinephrine (anaphylaxis) 110 dutasteride-tamsulosin hcl 68 EFLOW SCF AEROSOL DYAZIDE 62 HEAD 84 epinephrine hcl (nasal) 95 DYMISTA 94 EFUDEX 55 epirubicin hcl 34 DYSPORT 95 EGRIFTA 64 EPIVIR 40 E-Z JECT LANCETS 76 ELAPRASE 64 EPOGEN 70 E-Z JECT LANCETS 21G 76 ELELYSO 70 epoprostenol sodium 45 E-Z JECT LANCETS eletriptan hydrobromide 88 eprosartan mesylate 28 COLOR 76 ELIDEL 59 EPZICOM 40 E-Z JECT LANCETS SUPER ELIGARD 33 EQ PROBIOTIC DIGESTIVE THIN 30G 76 SYSTEM SUPPORT 21 E-Z JECT LANCETS THIN ELIMITE 60 EQ SPACE CHAMBER ANTI- 26G 76 ELIQUIS 13 STATIC 84 E-ZJECT LANCETS MICRO- ELIQUIS STARTER PACK 13 EQ SPACE CHAMBER ANTI- THIN 33G 76 ELITE DC AUTO STATIC/LARGE MASK 84 E.E.S. GRANULES 75 ADAPTER 84 EQ SPACE CHAMBER ANTI- EASIVENT 84 ELIXOPHYLLIN 12 STATIC/MEDIUM MASK 84 EASIVENT/MASK-LARGE 84 EQ SPACE CHAMBER ANTI- ELLA 49 STATIC/SMALL MASK 84 EASIVENT/MASK-MEDIUM 84 ELLENCE 34 EQL COLOR LANCETS 21G76 EASIVENT/MASK-SMALL 84 ELMIRON 68 EQL COLOR LANCETS MICRO EASY TOUCH ALCOHOL PREP ELOCON 57 THIN 33G 76 PADS/MEDIUM 82 ELOCTATE 69 EQL DAILY PROBIOTIC 21 EASY TOUCH LANCETS EQL DRY MOUTH ORAL 26G/PULL-TOP 76 EMBEDA 5 RINSE 91 EASY TOUCH LANCETS EMCYT 33 EQL PROBIOTIC COLON 28G/PULL-TOP 76 SUPPORT 22 EASY TOUCH LANCETS EMEND 25 EMEND TRIPACK 25 EQL SUPER THIN LANCETS 28G/TWIST 76 30G 77 EASY TOUCH LANCETS EMFLAZA 50 30G/PULL-TOP 76 EQL THIN LANCETS 26G 77 EASY TOUCH LANCETS EMGALITY 87 ERBITUX 33 30G/TWIST 76 EMPLICITI 32 ergocalciferol 110 EASY TOUCH LANCETS emtricitabine 40 ergoloid mesylates 103 32G/PULL-TOP 76

Index 8 ergotamine w/ caffeine 87 EXCEDRIN PM 72 ferrous sulfate 71 ERIVEDGE 33 EXELON 102 ferrous sulfate dried 71 ERLEADA 33 exemestane 33 FEVERALL JUNIOR erlotinib hcl 33 EXFORGE 29 STRENGTH 4 fexofenadine hcl 26 ertapenem sodium 9 EXFORGE HCT 29 FIBERCON 73 ERWINASE 35 EXJADE 24 FIBRICOR 27 ERWINAZE 35 EXONDYS 51 95 FIBRYGA 69 ERYGEL 53 EYLEA 97 FIFTY50 ALCOHOL PREP ERYPED 200 75 EZ-LETS LANCETS 26G PADS 82 ERYPED 400 75 SUPER-SOFT 77 EZ-LETS LANCETS 28G FILTER AIR PP 84 erythromycin (acne aid) 53 ULTRA-SOFT 77 finasteride 68 erythromycin (ophth) 97 EZ-LETS LANCETS 30G 77 FIORINAL 4 erythromycin base 75 ezetimibe 28 FIORINAL/CODEINE #3 6 erythromycin ethylsuccinate 75 ezetimibe-simvastatin 27 FIRAZYR 69 ESBRIET 104 FABRAZYME 64 FIRDAPSE 31 escitalopram oxalate 16 FALESSA 46 FIRMAGON 33 ESGIC 4 famciclovir 42 FIRST-PROGESTERONE VGS esomeprazole magnesium 106 famotidine 105 100 COMPOUNDING KIT 110 FIRST-PROGESTERONE VGS ESOMEPRAZOLE FARESTON 33 STRONTIUM 106 200 COMPOUNDING KIT 110 FARXIGA 20 ESPEROCT 69 FIRVANQ 9 FARYDAK 34 estazolam 72 FLAGYL 8 FAZACLO 38 ESTRACE 66,109 flavoxate hcl 107 FEIBA 69 estradiol 66 FLEBOGAMMA DIF 100 estradiol & norethindrone felbamate 15 flecainide acetate 11 acetate 65 FELBATOL 15 FLEET ENEMA 74 estradiol vaginal 109 FELDENE 3 FLEET ENEMA SIX PACK 74 ESTROSTEP FE 46 felodipine 44 FLEET PEDIATRIC 74 eszopiclone 72 FEMARA 33 FLEXICHAMBER 84 ethambutol hcl 31 FEMHRT 65 FLOLAN 45 ethosuximide 15 fenofibrate 27 FLOMAX 68 ethynodiol diacet & eth fenofibrate micronized 27 FLONASE ALLERGY estrad 46 FENOFIBRIC ACID 27 RELIEF 94 etidronate disodium 63 FLONASE ALLERGY RELIEF fenofibric acid 27 etodolac 3 CHILDRENS 94 FENOGLIDE 27 etonogestrel-ethinyl estradiol49 FLORA VANCE 22 FENSOLVI 64 etoposide 36 FLORAJEN DIGESTION 22 fentanyl 5 etravirine 40 FLORAJEN3 22 FER-IN-SOL 71 EUFLEXXA 94 FLORAJEN4KIDS 22 FERRETTS 71 EVAC 73 FLORASTOR PLUS 22 FERRIPROX 24 EVEKEO 1 FLORASTOR PRE 22 ferrous fumarate 71 EVENITY 63 FLOVENT DISKUS 11 ferrous fumarate-fa-b complex- FLOVENT HFA 11 everolimus 34 c-zn-mg-mn-cu 71 everolimus ferrous gluconate 71 FLOXIN OTIC 99 FLUAD QUADRIVALENT 2021- (immunosuppressant) 89 FERROUS GLUCONATE 71 EVISTA 64 2022 108 ferrous sulfate 71 FLUAD QUADRIVALENT EVOMELA 31 FERROUS SULFATE 71 INFLUENZA VACCINE FOR EVOTAZ 40 ADULTS 108

Index 9 fluconazole 25 fosinopril sodium 28 GENTLE-LET GP LANCETS 77 fludarabine phosphate 32 fosinopril sodium & GENTLE-LET LANCETS fludrocortisone acetate 51 hydrochlorothiazide 29 GENERAL PURPOSE FOSRENOL 67 STYLE/FINE POINT 77 FLUMIST QUADRIVALENT108 FREDS PHARMACY UNILET GENTLE-LET LANCETS flunisolide (nasal) 95 LANCETS SUPER THIN GENERAL PURPOSE fluocinolone acetonide 57 30G 77 STYLE/MEDIUM POINT 77 GENTLE-LET LANCETS fluocinolone acetonide (otic) 99 FREDS PHARMACY UNILET LANCETS ULTRA THIN SAFETY STYLE/FINE fluocinonide 57 28G 77 POINT 77 fluocinonide emulsified base 57 FROVA 88 GENTLE-LET LANCETS fluorometholone (ophth) 98 SAFETY STYLE/MEDIUM frovatriptan succinate 88 POINT 77 fluorouracil (topical) 55 FULL KIT NEBULIZER GENVISC 850 94 fluoxetine hcl 16,17 SET 85 GENVOYA 40 fluoxetine hcl (pmdd) 103 FULPHILA 70 GEODON 38 FLUOXETINE FURADANTIN 9 GILENYA 103 HYDROCHLORIDE 17 furosemide 62 GILOTRIF 33 fluphenazine decanoate 39 FUSILEV 36 ginger (zingiber officinalis) 2 fluphenazine hcl 39 FUZEON 40 GLASSIA 104 flurandrenolide 57 gabapentin 14 glatiramer acetate 103 flurazepam hcl 72 GABITRIL 15 GLEEVEC 34 flurbiprofen 3 GABLOFEN 93 glimepiride 20 flurbiprofen sodium 99 GALAFOLD 64 flutamide 33 galantamine glipizide 20 fluticasone propionate 57 hydrobromide 102 glipizide-metformin hcl 18 fluticasone propionate GAMASTAN 100 GLUCAGEN HYPOKIT 19 (nasal) 95 GAMIFANT 90 glucagon (rdna) 19 fluticasone-salmeterol 12 GAMMAGARD LIQUID 100 GLUCAGON EMERGENCY fluvastatin sodium 27 GAMMAGARD S/D IGA LESS KIT 19 fluvoxamine maleate 17 THAN 1MCG/ML 100 GLUCOSE 19 FLUZONE HIGH-DOSE PF 2020- GAMMAKED 100 GLUCOTROL 20 2021 108 GAMMAPLEX 100 GLUCOTROL XL 20 FLUZONE HIGH-DOSE PF 2021- GAMUNEX-C 100 2022 108 GLUMETZA 18 FLYP HYPERSONIQ ganirelix acetate 63 glyburide 20 CARTRIDGE 84 GANIRELIX ACETATE 63 glyburide micronized 20 FML 98 GAS-X 66 glyburide-metformin 18 FML LIQUIFILM 98 gatifloxacin (ophth) 97 glycerin (laxative) 74 FOCALIN 2 GATTEX 67 GLYCERIN ADULT 74 FOCALIN XR 2 GAUZE SPONGES 77 glycine diluent 101 folic acid 70 GAZYVA 32 glycopyrrolate 105 FOLIKA PROBIOTIC 22 GEL-ONE 94 GLYNASE 20 FOLOTYN 32 GELSYN-3 94 GLYSET 18 fondaparinux sodium 13 gemfibrozil 27 GLYXAMBI 18 FORA LANCETS 77 GENERESS FE 47 GNP ACID CONTROL 150 FORTAMET 18 GENOTROPIN 64 MAXIMUM STRENGTH 105 GNP ACIDOPHILUS HIGH FORTESTA 7 GENOTROPIN POTENCY 22 FORTIFY DAILY MINIQUICK 64 GNP ALCOHOL SWABS 82 PROBIOTIC 22 gentamicin sulfate (ophth) 97 GNP GLUCOSE 19 FOSAMAX 63 gentamicin sulfate (topical) 53 fosamprenavir calcium 40 GNP LANCETS 21G 77

Index 10 GNP LANCETS MICRO THIN haloperidol 38 HY-VEE LANCETS 77 33G 77 haloperidol decanoate 38 HY-VEE THIN LANCETS 77 GNP LANCETS SUPER THIN 30G 77 haloperidol lactate 38 HYALGAN 94 GNP LANCETS THIN 77 HAVRIX 108 HYCAMTIN 36 GNP LANCETS THIN 26G 77 HCG 63 HYCODAN 51 GNP PROBIOTIC COLON HEALTHY ACCENTS UNILET hydralazine hcl 30 SUPPORT 22 LANCETS SUPER THIN HYDREA 35 GNP PROBIOTIC DIGESTIVE 30G 77 SUPPORT 22 HELIXATE FS 69 HYDRO-LAN 60 GNP QUICK DISSOLVE HEMLIBRA 69 hydrochlorothiazide 62 GLUCOSE 19 HEMOCYTE 71 hydrocodone bitartrate 5 GOJJI STERILE LANCETS HYDROCODONE BITARTRATE 30G 77 HEMOFIL M 69 ER 5 GOLYTELY 73 HEPAGAM B 100 hydrocodone w/ GOODSENSE COLOR heparin sodium (porcine) 13 homatropine 51 LANCETS MICRO-THIN 33G HERCEPTIN HYLECTA 34 hydrocodone-acetaminophen 6 UNIVERSAL 77 hydrocortisone 50 GOODSENSE LANCETS HETLIOZ 73 MICRO-THIN 33G HIGH POTENCY HYDROCORTISONE 58 UNIVERSAL 77 PROBIOTIC 22 hydrocortisone (intrarectal) 8 GOODSENSE LANCETS HIZENTRA 100 hydrocortisone (rectal) 8 ULTRA-THIN 26G HM ACIDOPHILUS 22 hydrocortisone (topical) 57 UNIVERSAL 77 HM STERILE ALCOHOL PREP GOODSENSE LANCETS hydrocortisone acetate PADS 82 (topical) 57 ULTRA-THIN 30G HUDSON RCI SEE-THRU UNIVERSAL 77 hydrocortisone butyrate 57 AEROSOL MASK hydrocortisone butyrate granisetron hcl 24 ELONGATED/ADULT 85 GRANIX 70 HUMALOG JUNIOR hydrophilic lipo base 57 hydrocortisone valerate 58 griseofulvin microsize 25 KWIKPEN 19 HUMALOG KWIKPEN 19 hydrocortisone w/acetic griseofulvin ultramicrosize 25 acid 100 HUMALOG MIX 50/50 19 guaifenesin-codeine 51 hydrocortisone-aloe vera 58 HUMALOG MIX 50/50 guanfacine hcl 29 KWIKPEN 19 HYDROMORPHONE HCL 5 guanfacine hcl (adhd) 1 HUMALOG MIX 75/25 19 hydromorphone hcl 5 GYNAZOLE-1 109 HUMALOG MIX 75/25 hydroxychloroquine sulfate 30 GYNE-LOTRIMIN 109 KWIKPEN 19 hydroxyprogesterone GYNE-LOTRIMIN 3 109 HUMATE-P 69 caproate 101 hydroxyprogesterone caproate H-E-B INCONTROL LANCETS HUMIRA 2 (antineoplastic) 33 MICRO THIN 33G 77 HUMIRA PEDIATRIC CROHNS H-E-B INCONTROL LANCETS DISEASE STARTER PACK 2 hydroxyurea 35 SUPER THIN 30G 77 HUMIRA PEN 2 hydroxyzine hcl 10 H-E-B INCONTROL LANCETS HUMIRA PEN-CD/UC/HS hydroxyzine pamoate 10 ULTRA THIN 28G 77 STARTER 2 HYMOVIS 94 HALAVEN 36 HUMIRA PEN-PEDIATRIC UC hyoscyamine sulfate 105 halcinonide 57 STARTER PACK 2 HYPER-SAL 52 HALCION 72 HUMIRA PEN-PS/UV STARTER 2 HYPERHEP B 100 HALDOL 38 HUMULIN 70/30 19 HYPERRHO S/D 100 HALDOL DECANOATE 100 38 HUMULIN N 19 HYPERRHO S/D MINI- HALDOL DECANOATE 50 38 HUMULIN R 19 DOSE 100 halobetasol propionate 57 HUMULIN R U-500 HYPERSAL 52 HALOBETASOL (CONCENTRATED) 19 HYQVIA 100 PROPIONATE 57 HUMULIN R U-500 HYZAAR 29 HALOG 57 KWIKPEN 19 ibandronate sodium 63

Index 11 IBRANCE 34 INSULIN LISPRO 20 JANSSEN COVID-19 ibuprofen 3 INSULIN LISPRO JUNIOR VACCINE 108 ibuprofen-diphenhydramine KWIKPEN 19 JANUMET 18 citrate 72 INSULIN LISPRO JANUMET XR 18 ibuprofen-diphenhydramine KWIKPEN 20 JANUVIA 19 INSULIN LISPRO hcl 72 JARDIANCE 20 icatibant acetate 69 PROTAMINE/INSULIN LISPRO KWIKPEN 20 JENTADUETO 18 ICLUSIG 34 INSULIN SYRINGES 82 JEVTANA 36 IDELVION 69 INTELENCE 40 JUXTAPID 28 ILEVRO 99 INTERMEZZO 72 JYNARQUE 65 ILUVIEN 98 INTRON A 35 K-PHOS NEUTRAL 89 imatinib mesylate 34 INTUNIV 1 K-TAB 89 IMBRUVICA 34 INVANZ 9 KADCYLA 32 imipramine hcl 18 INVEGA 38 KADIAN 5 imipramine pamoate 18 INVEGA SUSTENNA 38 KALBITOR 70 imiquimod 59 INVEGA TRINZA 38 KALETRA 40 IMITREX 88 INVIRASE 40 KALYDECO 104 IMITREX STATDOSE REFILL 88 INVOKANA 20 KANJINTI 32 IMITREX STATDOSE ipratropium bromide 11 KANUMA 64 SYSTEM 88 ipratropium bromide KAPVAY 1 (nasal) 94 IMLYGIC 36 KAZANO 18 ipratropium-albuterol 12 IMODIUM A-D 24 KCENTRA 69 irbesartan 28 IMURAN 90 KEFLEX 45 INCRELEX 64 irbesartan-hydrochlorothiazide 29 KENALOG 58 indapamide 62 IRESSA 33 KEPIVANCE 36 INDERAL LA 43 irinotecan hcl 36 KEPPRA 14 indomethacin 3 IRON CHEWS KEPPRA XR 14 INFANTS ADVIL 3 PEDIATRIC 71 KERALYT 59 ISENTRESS 40 INLYTA 32 ketoconazole (topical) 54 INNOSPIRE REPLACEMENT isoniazid 31 KETONE 61 FILTER 85 ISOPTO ATROPINE 96 INSPIRACHAMBER/ANTI- KETONE TEST STRIPS 61 ISOPTO CARPINE 96 STATIC ketoprofen 3 ISORDIL TITRADOSE 9 VALVED/MOUTHPIECE 85 ketorolac tromethamine 3 INSPIRACHAMBER/LARGE isosorbide dinitrate 9 ketorolac tromethamine 85 isosorbide mononitrate 9 INSPIRACHAMBER/SOOTHER (ophth) 99 MASK/INSPIRAMASK/MEDIUM isotretinoin 53 KETOSTIX 61 85 isradipine 44 ketotifen fumarate (ophth) 99 INSPIRACHAMBER/SOOTHER ISTALOL 96 KEY-E 110 MASK/INSPIRAMASK/SMALL 85 ISTODAX (OVERFILL) 34 KEYTRUDA 32 INSPIREASE DRUG ITCH RELIEF 54 KHAPZORY 36 DELIVERYSYSTEM 85 itraconazole 25 KINNEY LANCETS 77 INSPIREASE RESERVOIR IXEMPRA KIT 36 KINNEY THIN LANCETS 78 BAGS 85 INSULIN ASPART IXINITY 69 KITABIS PAK 2 PROTAMINE/INSULIN JADENU 24 KLARON 53 ASPART 19 JADENU SPRINKLE 24 KLONOPIN 13 INSULIN ASPART PROTAMINE/INSULIN ASPART JAKAFI 35 KOATE 69 FLEXPEN 19 JALYN 68 KOATE-DVI 69

Index 12 KOGENATE FS 69 LANCETS 28G 78 LEUPROLIDE KOMBIGLYZE XR 18 LANCETS 30G 78 ACETATE/BUPIVACAINE HYDROCHLORIDE 33 LANCETS SAFETY SEAL KONSYL DAILY FIBER 73 levalbuterol hcl 12 KORLYM 19 21G 78 LANCETS SAFETY SEAL levalbuterol tartrate 12 KOVALTRY 69 26G 78 LEVAQUIN 66 KRINTAFEL 30 LANCETS SAFETY SEAL LEVBID 105 KROGER HEALTHPRO TWIST 28G 78 LANCETS/26G 78 LANCETS SUPER THIN LEVEMIR 20 KROGER LANCETS 78 28G 78 LEVEMIR FLEXTOUCH 20 KROGER LANCETS 21G 78 LANCETS THIN 78 levetiracetam 14 KROGER LANCETS MICRO LANCETS ULTRA THIN 78 levobunolol hcl 96 THIN33G 78 lanolin 101 levocarnitine (metabolic KROGER LANCETS SUPER lanolin (topical) 60 modifiers) 64 THIN 78 LANOLOR 60 levocetirizine dihydrochloride26 KROGER LANCETS THIN 78 LANOXIN 45 levofloxacin 66 KROGER LANCETS THIN levofloxacin (ophth) 97 26G 78 lansoprazole 106 KROGER LANCETS lanthanum carbonate 67 levoleucovorin calcium 36 levonorgestrel & eth ULTRATHIN30G 78 LANTUS SOLOSTAR 20 KRYSTEXXA 68 estradiol 47 lapatinib ditosylate 35 levonorgestrel (emergency KUVAN 64 LARTRUVO 34 oc) 49 KYLEENA 49 LASIX 62 levonorgestrel-eth estradiol KYPROLIS 35 (triphasic) 47 LATISSE 59 labetalol hcl 43 levonorgestrel-ethinyl estradiol LEADER QUICK DISSOLVE (91-day) 47 LAC-HYDRIN 59 GLUCOSE 19 levonorgestrel-ethinyl estradiol LAC-HYDRIN TWELVE 59 LEDIPASVIR/SOFOSBUVIR (continuous) 47 LACTEROL 22 42 levothyroxine sodium 104 lactic acid (ammonium leflunomide 4 LEVSIN 105 LENVIMA 10 MG DAILY lactate) 59 LEVSIN/SL 105 LACTO-PECTIN 22 DOSE 32 LENVIMA 12MG DAILY LEVULAN KERASTICK 55 lactulose 74 DOSE 32 LEXAPRO 17 lactulose (encephalopathy) 67 LENVIMA 14 MG DAILY LEXIVA 40 DOSE 32 LAMICTAL 14 LIALDA 67 LAMICTAL CHEWABLE LENVIMA 18 MG DAILY DISPERSIBLE 14 DOSE 32 LIBTAYO 32 LENVIMA 20 MG DAILY LICEMD 60 LAMICTAL ODT 14 DOSE 32 LAMICTAL STARTER/NOT LENVIMA 24 MG DAILY LIDOCAINE 59 TAKING CARBAMAZEPINE 14 DOSE 32 lidocaine 59 LAMICTAL STARTER/TAKING LENVIMA 4 MG DAILY lidocaine hcl 60 CARBAMAZEPINE/NOT TAKING DOSE 32 VALPROATE 14 LENVIMA 8 MG DAILY lidocaine hcl (mouth-throat) 90 LAMICTAL STARTER/TAKING DOSE 32 lidocaine-prilocaine 60 VALPROATE 14 LESCOL XL 27 LILETTA 49 LAMICTAL XR 14 LETAIRIS 45 lindane 60 LAMISIL AT 54 letrozole 33 LINZESS 67 LAMISIL AT JOCK ITCH 54 leucovorin calcium 36 LIORESAL INTRATHECAL 93 lamivudine 40 LEUKERAN 31 liothyronine sodium 104 lamivudine-zidovudine 40 LEUKINE 70 LIPITOR 27 lamotrigine 14 leuprolide acetate 33 lisinopril 28 LANCETS 78 lisinopril & LANCETS 26G TWIST TOP 78 hydrochlorothiazide 29

Index 13 LITEAIRE 85 luliconazole 54 medroxyprogesterone acetate LITETOUCH MASK LARGE 85 LUMIZYME 64 (contraceptive) 50 mefloquine hcl 30 LITETOUCH MASK LUMOXITI 32 MEGA PROBIOTIC 22 MEDIUM 85 LUNESTA 72 LITETOUCH MASK SMALL 85 megestrol acetate 33,34 LUPANETA PACK 64 MEIJER ALCOHOL SWABS LITHIUM 37 LUPRON DEPOT (1- lithium carbonate 37 EXTRA-THICK 82 MONTH) 33 MEIJER COLOR LANCETS LITHOBID 38 LUPRON DEPOT (3- UNIVERSAL 33G 78 MONTH) 33 LIVE BETTER LANCET MEIJER LANCETS 78 SUPERTHIN 30G 78 LUPRON DEPOT (4- LIVE BETTER LANCET MONTH) 33 MEIJER LANCETS THIN 78 ULTRATHIN 28G 78 LUPRON DEPOT (6- MEIJER LANCETS LMX 4 60 MONTH) 33 UNIVERSAL21G 78 LUPRON DEPOT-PED (1- MEIJER LANCETS LO LOESTRIN FE 47 MONTH) 64 UNIVERSAL30G 78 LOCOID 58 LUPRON DEPOT-PED (3- MEIJER LANCETS LOCOID LIPOCREAM 58 MONTH) 64 UNIVERSAL33G 78 MEIJER SUPER THIN LODINE 3 LUTATHERA 35 LUXIQ 58 LANCETS 78 LODOSYN 37 MEKINIST 35 LYRICA 14 LOKELMA 90 MEKTOVI 35 LYSODREN 33 LOMOTIL 24 melatonin 2 LYSTEDA 71 LONGS LANCETS meloxicam 3 STANDARD 78 M-M-R II 108 melphalan 31 LONGS LANCETS THIN 78 MACI 93 melphalan hcl 31 LONSURF 34 MACROBID 9 memantine hcl 102 loperamide hcl 24 MACRODANTIN 9 MENACTRA 107 LOPID 27 MACUGEN 97 MENQUADFI 107 lopinavir-ritonavir 40 magnesium citrate 74 MENVEO 107 LOPRESSOR 43 magnesium hydroxide 74 meperidine hcl 5 LOPRESSOR HCT 30 magnesium oxide 8 MEPHYTON 110 loratadine 26 MAKENA 101 meprobamate 10 lorazepam 10 malathion 60 mercaptopurine 32 LORBRENA 35 maprotiline hcl 16 mesalamine 67 losartan potassium 29 MARQIBO 36 mesalamine w/ cleanser 67 losartan potassium & MATULANE 35 hydrochlorothiazide 30 mesna 36 MAVYRET 42 LOSEASONIQUE 47 MESNEX 36 MAXALT 88 LOTENSIN 28 MESTINON 31 MAXALT-MLT 88 LOTENSIN HCT 30 MESTINON TIMESPAN 31 MAXI-TUSS PE 51 LOTREL 30 META BIOTIC/BIO-ACTIVE MAXITROL 98 LOTRIMIN AF 54 12 22 MAXZIDE 62 LOTRIMIN AF JOCK ITCH 54 METAMUCIL 73 MAXZIDE-25 62 METAMUCIL ORIGINAL LOTRISONE 54 meclizine hcl 24 TEXTURE 73 LOTRONEX 67 MEDISENSE THIN metaxalone 93 lovastatin 27 LANCETS 78 metformin hcl 18 LOVAZA 27 MEDROL 51 methadone hcl 5 LOVENOX 13 MEDROL DOSEPAK 50 methamphetamine hcl 1 loxapine succinate 38 medroxyprogesterone methazolamide 62 acetate 101 LUCENTIS 97 methenamine mandelate 9

Index 14 methenamine-hyosc-methylene MINIELITE RECHARGEABLE MOZOBIL 71 blue-sod phos-phenyl sal 9 BATTERY 85 MS CONTIN 5 methimazole 104 MINIPRESS 29 MULPLETA 70 METHITEST 7 MINIVELLE 66 multiple vitamins tabs-assorted methocarbamol 93 MINOCIN 104 brand 92 METHOTREXATE 2 minocycline hcl 104 multiple vitamins tabs-assorted methotrexate sodium 32 minoxidil 30 generic 92 multiple vitamins w/ iron 92 METHYLDOPA 29 MIRALAX 74 multiple vitamins w/ minerals methylergonovine maleate 100 MIRALAX MIX-IN PAX 74 tabs-assorted brand 92 METHYLIN 2 MIRAPEX 37 multiple vitamins w/ minerals methylphenidate hcl 2 MIRAPEX ER 37 tabs-assorted generic 92 methylprednisolone 51 MIRCETTE 47 mupirocin 54 metoclopramide hcl 67 MIRENA 49 mupirocin calcium (topical) 54 metolazone 62 mirtazapine 16 MVASI 32 metoprolol & misoprostol 106 MYALEPT 64 hydrochlorothiazide 30 mitoxantrone hcl 34 MYAMBUTOL 31 metoprolol succinate 43 MOBIC 3 mycophenolate mofetil 90 metoprolol tartrate 43 MODERNA COVID-19 mycophenolate mofetil hcl 90 METROCREAM 60 VACCINE 108 mycophenolate sodium 90 METROGEL-VAGINAL 109 moexipril hcl 28 MYDRIACYL 96 METROLOTION 60 MOI-STIR 91 MYFORTIC 90 metronidazole 8 molindone hcl 39 MYLERAN 31 metronidazole (topical) 60 mometasone furoate 58 MYLICON INFANTS GAS metronidazole vaginal 109 mometasone furoate RELIEF 66 MYLICON INFANTS GAS metyrosine 28 (nasal) 95 MOMMYS BLISS RELIEF DYE FREE 66 mexiletine hcl 11 PROBIOTIC 22 MYOBLOC 95 MIACALCIN 63 MONISTAT 3 109 MYSOLINE 14 MICARDIS 29 MONISTAT 3 COMBINATION NABI-HB 100 MICARDIS HCT 30 PACK 109 MONISTAT 7 SIMPLY nabumetone 3 MICATIN 54 CURE 109 nadolol 43 miconazole nitrate (topical) 54 MONISTAT SOOTHING CARE NAGLAZYME 64 miconazole nitrate vaginal 109 ITCH RELIEF 58 naloxone hcl 24 MONOLET LANCETS 78 MICORT-HC 58 NALTREXONE 24 MONOLET OPD MICRHOGAM ULTRA- naltrexone hcl 24 FILTEREDPLUS 100 LANCETS 79 MICROCHAMBER 85 MONONINE 69 NAMENDA 102 MICROELITE FILTER MONOVISC 94 NAMENDA TITRATION PAK 102 REPLACEMENTS 85 montelukast sodium 11 NAMENDA XR 102 MICROELITE RECHARGEABLE morphine sulfate 5 BATTERY 85 naphazoline w/ pheniramine 97 morphine sulfate beads 5 MICROSPACER 85 NAPHCON-A 97 MOTRIN CHILDRENS 3 midazolam hcl 73 NAPROSYN 3 MOTRIN INFANTS DROPS 3 midodrine hcl 110 naproxen 3 MOUTH KOTE 91 miglitol 18 naproxen sodium 3 miglustat 70 MOUTH KOTE REMINT 91 naproxen sodium- MIGRANAL 88 MOVANTIK 67 diphenhydramine hcl 72 naproxen-esomeprazole MINASTRIN 24 FE 47 MOXEZA 97 moxifloxacin hcl 66 magnesium 3 MINIELITE FILTER naratriptan hcl 88 REPLACEMENTS 85 moxifloxacin hcl (ophth) 97

Index 15 NARCAN 24 niacin (antihyperlipidemic) 28 norgestimate-ethinyl NARDIL 16 NIACIN TR 110 estradiol 48 norgestimate-ethinyl estradiol NASALCROM 94 NIASPAN 28 (triphasic) 48 NASONEX 95 nicardipine hcl 44 norgestrel & ethinyl estradiol 48 NATAZIA 47 NICODERM CQ 103 NORPACE 10 nateglinide 20 NICORETTE 103 NORPRAMIN 18 NATPARA 63 NICORETTE MINI 103 NORTEMP INFANTS 4 NATROBA 60 NICORETTE STARTER NORTHERA 110 KIT 103 NATRUL PROBIOTIC 22 nortriptyline hcl 18 nicotine 103 NATURE-THROID 104 NORVASC 44 nicotine polacrilex 103 NEBULIZER AIR NORVIR 41 TUBE/PLUGS 85 NICOTINE TRANSDERMAL NEBULIZER PEDIATRIC SYSTEM 103 NOSE CLIP 85 MASK 85 NICOTROL INHALER 103 NOVA SUREFLEX nefazodone hcl 17 NICOTROL NS 103 LANCETS 79 NOVAREL 63 neomycin sulfate 2 nifedipine 44 NOVAVAX COVID-19 neomycin-bacitracin zn- nimodipine 44 VACCINE 108 polymyxin 97 NINLARO 35 neomycin-bacitracin-polymyxin NOVOEIGHT 69 54 nisoldipine 44 NOVOLOG MIX 70/30 20 neomycin-polymy-dexameth 98 nitisinone 64 NOVOLOG MIX 70/30 neomycin-polymyxin w/ NITRO-BID 10 PREFILLED FLEXPEN 20 NOVOLOG MIX 70/30 pramoxine 54 NITRO-DUR 10 neomycin-polymyxin-gramicidin PREFILLED FLEXPEN 97 nitrofurantoin 9 RELION 20 neomycin-polymyxin-hc nitrofurantoin macrocrystal 9 NOVOLOG MIX 70/30 (ophth) 98 nitrofurantoin monohyd RELION 20 neomycin-polymyxin-hc macro 9 NOVOSEVEN RT 69 (otic) 99 nitroglycerin 10 NPLATE 71 NEORAL 90 NITROSTAT 10 NUCALA 11 NEOSPORIN ORIGINAL 54 NIVESTYM 71 NULOJIX 90 NEOSPORIN PLUS PAIN NIX CREME RINSE 60 NULYTELY 73 RELIEF MAXIMUM STRENGTH 54 NIZORAL 54 NULYTELY/FLAVOR PACKS 73 NEPHRO-VITE RX 92 NIZORAL A-D 54 NUMOISYN 91 NEULASTA 70 NORCO 6 NUPLAZID 38 NEULASTA ONPRO KIT 70 norelgestromin-ethinyl estradiol 49 NUVARING 49 NEUPOGEN 70 norethin acet & estrad-fe 47 NUVESSA 109 NEURONTIN 14 norethindrone & eth NUWIQ 69 NEUTROGENA T/GEL 61 estradiol 48 nystatin 25 NEUTROGENA T/GEL norethindrone & ethinyl STUBBORN ITCH estradiol-fe 48 nystatin (mouth-throat) 90 CONTROL 61 norethindrone nystatin (topical) 54 nevirapine 40,41 (contraceptive) 50 nystatin-triamcinolone 54 NEXAVAR 35 norethindrone acet & eth NYTOL MAXIMUM estra 48 NEXIUM 106 STRENGTH 72 norethindrone acetate 102 OBIZUR 69 NEXIUM 24HR 106 norethindrone acetate-ethinyl NEXIUM 24HR CLEAR estradiol 65 OCALIVA 66 MINIS 106 norethindrone acetate-ethinyl OCEAN NASAL SPRAY 94 NEXPLANON 50 estradiol-fe 48 OCTAGAM 100 niacin 110 norethindrone-eth estradiol octreotide acetate 65 (triphasic) 48

Index 16 OCUFLOX 97 OPTICHAMBER oxycodone-aspirin 6 ODEFSEY 41 DIAMOND/SMALLFACE oxymorphone hcl 6 MASK 85 ODOMZO 33 OPTICHAMBER FACE oyster shell 88 OFEV 104 MASK/LARGE 85 OZURDEX 98 OFF DEEP WOODS 60 OPTICHAMBER FACE paliperidone 38 MASK/MEDIUM 86 OFF DEEP WOODS DRY 60 OPTICHAMBER FACE PALYNZIQ 65 ofloxacin 66 MASK/SMALL 86 PAMELOR 18 ofloxacin (ophth) 97 OPTIHALER 86 pamidronate disodium 63 ofloxacin (otic) 99 OPTIHALER MDI DRUG PAMIDRONATE DISODIUM 63 olanzapine 38 DELIVERY SYSTEM 86 pamidronate disodium 63 OPTIONS CONCEPTROL olmesartan medoxomil 29 VAGINAL pantoprazole sodium 106 olmesartan medoxomil- CONTRACEPTIVE 109 PANZYGA 100 amlodipine-hydrochlorothiazide OPTIONS GYNOL II PARAGARD INTRAUTERINE 30 VAGINALCONTRACEPTIVE COPPER CONTRACEPTIVE olmesartan medoxomil- 109 T380A 49 hydrochlorothiazide 30 ORAL RELIEF SPRAY FOR paregoric 24 olopatadine hcl 99 DRYMOUTH & PARI ALTERA NEBULIZER olopatadine hcl (nasal) 94 DISCOMFORT 91 HANDSET 86 OLUX 58 ORALAIR 2 PARI BABY CONVERSION ORALAIR ADULT SAMPLE OLUX-E 58 KITSIZE 1 86 KIT 2 PARI BABY CONVERSION omega-3-acid ethyl esters 27 ORALAIR ADULT STARTER KITSIZE 2 86 omeprazole 106 PACK 2 PARI BABY CONVERSION omeprazole-sodium ORFADIN 64 KITSIZE 3 86 bicarbonate 106,107 ORILISSA 63 PARI ERAPID NEBULIZER ONCASPAR 35 HANDSET 86 ORKAMBI 104 PARI EXPIRATORY FILTER ondansetron 24 orphenadrine citrate 93 VALVE SET 86 ondansetron hcl 24 ORTHO MICRONOR 50 PARI MASK SET 86 ONE-A-DAY VITACRAVES ORTHO TRI-CYCLEN LO 48 PARI SOFT PLASTIC ADULT GUMMIES+OMEGA-3 DHA 93 MASK 86 ONFI 13 ORTHO-NOVUM 1/35 48 PARI SOFT PLASTIC ONGLYZA 19 ORTHO-NOVUM 7/7/7 48 PEDIATRIC MASK 86 ONPATTRO 103 ORTHOVISC 94 PARI VORTEX ADULT oseltamivir phosphate 42 MASK 86 OPCON-A 98 paricalcitol 65 OTICIN HC NR 99 OPDIVO 32 PARLODEL 37 OPTICHAMBER OTREXUP 3 PARNATE 16 ADVANTAGE/LARGE OVACE PLUS WASH 55 paroxetine hcl 17 MASK 85 OVACE WASH 55 OPTICHAMBER paroxetine mesylate ADVANTAGE/MEDIUM FACE OVIDE 60 (vasomotor) 103 MASK 85 oxaprozin 3 PARSABIV 65 OPTICHAMBER OXAYDO 6 PATADAY 99 ADVANTAGE/SMALL FACE oxazepam 10 PATADAY EXTRA MASK 85 oxcarbazepine 14 STRENGTH 99 OPTICHAMBER DIAMOND 85 PATANASE 94 OPTICHAMBER OXERVATE 98 DIAMOND/LARGEFACE oxiconazole nitrate 54 PATANOL 99 MASK 85 OXISTAT 54 PAXIL 17 OPTICHAMBER oxybutynin chloride 107 PAXIL CR 17 DIAMOND/MEDIUM FACE PAZEO 99 MASK 85 oxycodone hcl 6 oxycodone w/ PC LANCETS SUPER THIN acetaminophen 6 30G 79

Index 17 PC PEDIATRIC POLY-VITAMIN PHARMACIST CHOICE polymyxin b-trimethoprim 97 DROPS/IRON 92 NEBULIZER/CPAP/INHALER polysaccharide iron complex 71 PEARLS IC 22 CHAMBER MASK WIPES 86 POLYTRIM 97 ped multivitamins w/fl & iron 92 PHARMACY COUNTER LANCETS 79 polyvinyl alcohol 96 PEDIAPRED 51 phenazopyridine hcl 68 POMALYST 34 PEDIATRIC MOUTHPIECE/DISPOSABLE phenelzine sulfate 16 PORTRAZZA 33 86 phenobarbital 72 pot phosphate monobasic w/ sod pediatric multiple vitamin w/ c & phenylephrine hcl phosphate dibasic & fa 93 (mydriatic) 96 monobasic 89 pediatric multiple vitamin w/ phenylephrine hcl (oral) 95 potassium bicarbonate 89 minerals & c 93 phenylephrine-dm 51 potassium chloride 89 pediatric multivitamins w/fl chew- potassium chloride assorted brand 92 phenylephrine-shark liver oil- cocoa butter 8 microencapsulated crystals pediatric multivitamins w/fl chew- er 89 assorted generic 92 phenylephrine-shark liver oil- mineral oil-petrolatum 8 potassium citrate pediatric multivitamins w/fl soln- (alkalinizer) 67 assorted brand 92 PHENYTEK 15 pediatric multivitamins w/fl soln- phenytoin 15 potassium citrate-citric acid 67 assorted generic 92 phenytoin sodium POTELIGEO 32 pediatric vitamins acd w/ extended 15 PRADAXA 13 fluoride 92 PHILLIPS COLON PRALUENT 28 peg 3350-kcl-sod bicarb-sod HEALTH 22 pramipexole dihydrochloride 37 chloride-sod sulfate 73 PHOTOFRIN 36 peg 3350-potassium chloride-sod pramoxine hcl (rectal) 8 phytonadione 110 bicarbonate-sod chloride 73 pramoxine-hc-chloroxylenol 99 PIFELTRO 41 PEGASYS 42 prasugrel hcl 70 PILLOW MASK/ADULT 86 PEGASYS PROCLICK 42 PRAVACHOL 27 PILLOW MASK/CHILD 86 penicillamine 89 pravastatin sodium 27 penicillin v potassium 101 PILLOW MASK/PEDIATRIC 86 prazosin hcl 29 PENLAC NAIL LACQUER 54 pilocarpine hcl 96 PRECEDEX 73 pentoxifylline 69 pilocarpine hcl (oral) 91 PRECISION THINS GP PEPCID 105 pimecrolimus 59 LANCET 79 PRECOSE 18 PEPCID AC 105 pindolol 43 PEPCID AC MAXIMUM PRED FORTE 98 pioglitazone hcl 19 STRENGTH 105 PRED MILD 98 PEPTO-BISMOL 22 pioglitazone hcl- glimepiride 18 PRED-G 98 PEPTO-BISMOL MAX pioglitazone hcl-metformin STRENGTH 22 PREDATOR 60 hcl 18 prednicarbate 58 PEPTO-BISMOL TO-GO 22 piroxicam 4 prednisolone 51 PERCOCET 6 PLAN B ONE-STEP 49 prednisolone acetate (ophth) 98 PERFECT LANCETS 30G 79 PLAQUENIL 31 PERIDEX 90 PREDNISOLONE ACETATE P- PLAVIX 70 F 98 perindopril erbumine 28 PNEUMOVAX 23 107 prednisolone sodium PERJETA 32 PNEUMOVAX 23/1 phosphate 51 permethrin 60 DOSE 108 PREDNISOLONE SODIUM perphenazine 39 POCKET CHAMBER 86 PHOSPHATE 98 prednisone 51 perphenazine-amitriptyline 102 POCKET SPACER 86 PREDNISONE INTENSOL 51 PFIZER-BIONTECH COVID- podofilox 59 19VACCINE 108 PREFERRED PLUS LANCETS POLIVY 32 COLORED 21G 79 PFLEX 86 POLY-VITA/IRON 92 PREFERRED PLUS LANCETS PH 12 STERILE DILUENT SUPER THIN 30G 79 FORFLOLAN 101 polyethylene glycol 3350 74

Index 18 PREFERRED PLUS LANCETS PROBIOTIC PROLASTIN-C 104 THIN 26G 79 ACIDOPHILUS 22 PROLEUKIN 36 pregabalin 15 PROBIOTIC ACIDOPHILUS PROLIA 63 PREGNYL W/DILUENT BEADS 22 BENZYLALCOHOL/NACL 63 PROBIOTIC ADVANCED PROMACTA 71 PREMARIN 66,109 ULTRAPOTENCY 22 PROMELLA IN PREBIOTIC 23 PROBIOTIC BLEND 22 PREMPHASE 66 PROMEROL 23 PROBIOTIC COLON PREMPRO 66 promethazine & SUPPORT 22 phenylephrine 52 prenatal vitamins-assorted PROBIOTIC brand 93 COMPLEX/ACIDOPHILUS promethazine hcl 26 prenatal vitamins-assorted 22 promethazine w/codeine 52 generic 93 PROBIOTIC DAILY 22 promethazine-phenylephrine- PREORBOTIC 22 PROBIOTIC DIGESTIVE codeine 52 PREVACID 106 SUPPORT 22 PROMETRIUM 102 PREVACID 24HR 106 PROBIOTIC DIGESTIVE PRONEB ULTRA FILTER SUPPORT EXTRA SET 86 PREVACID SOLUTAB 106 STRENGTH 23 propafenone hcl 11 PREVIDENT 5000 DRY PROBIOTIC MATURE MOUTH 90 propranolol & ADULT 22 hydrochlorothiazide 30 PREVIDENT 5000 PLUS 90 PROBIOTIC PEARLS 22 propranolol hcl 43 PREVIDENT FLUORIDE 91 PROBIOTIC PEARLS propylthiouracil 104 PREVIDENT RINSE 91 ADVANTAGE 22 PROSCAR 68 PREVNAR 13 108 PROBIOTIC+TURMERIC EXTRACT 23 PROTONIX 106 PREVNAR 20 108 PROBIOTIC-10 PROTOPIC 59 PREVYMIS 42 ULTIMATE 23 protriptyline hcl 18 PREZCOBIX 41 PROBIOTIC/PREBIOTIC/CRA NBERRY 23 PROVAD 23 PREZISTA 41 PROBITROL 23 PROVENGE 33 PRIALT 5 PROBUPHINE IMPLANT PROVENTIL HFA 12 primidone 15 KIT 7 PROVERA 102 PRINIVIL 28 PROCARDIA 44 PROZAC 17 PRISTIQ 17 PROCARDIA XL 44 pseudoephedrine hcl 95 PRIVIGEN 100 PROCARE SPACER pseudoephedrine-ibuprofen 52 PRO COMFORT ALCOHOL CHAMBER W/ADULT PADS 82 MASK 86 PSORCON 58 PRO COMFORT INHALER PROCARE SPACER PSS SELECT GP LANCETS 79 SPACER CHAMBER CHAMBER W/CHILD PSS SELECT SAFETY ADULT 86 MASK 86 LANCETS 79 PRO COMFORT INHALER prochlorperazine 39 psyllium 73 SPACER CHAMBER CHILD 86 prochlorperazine edisylate 39 PULMICORT 11 PRO COMFORT INHALER prochlorperazine maleate 39 SPACER CHAMBER PULMICORT FLEXHALER 11 INFANT 86 PROCTOCORT 8 PULMOZYME 104 PRO-FLORA IMMUNE 22 PROCTOFOAM 8 PURIXAN 32 PROAIR HFA 12 PROCYSBI 68 PX LANCETS MICROTHIN probenecid 68 PRODIGEN 23 33G 79 PROBINATE 22 PRODIGY TWIST TOP PX LANCETS ULTRA THIN 79 LANCETS 79 PROBIOMAX DAILY DF 22 pyrantel pamoate 8 PROFILNINE 69 PROBIOTIC 22 pyrazinamide 31 PROFILNINE SD 69 PROBIOTIC & ACIDOPHILUS pyrethrins-piperonyl butoxide60 FORMULA EXTRA progesterone 102 pyrethrins-piperonyl butoxide- STRENGTH 22 PROGLYCEM 19 permethrin-nit remover 60 PROBIOTIC + OMEGA-3 22 PROGRAF 90 PYRIDIUM 68

Index 19 pyridostigmine bromide 31 REALITY SWABS 82 RETROVIR IV INFUSION 41 pyridoxine hcl 110 REBINYN 69 REVATIO 45 pyrimethamine 31 RECLAST 63 REVCOVI 65 QC ALCOHOL SWABS 82 RECOMBINATE 69 REVLIMID 89 QC LANCETS SUPER THIN 79 RECOMBIVAX HB 108 REXALL LANCETS ULTRA QC LANCETS ULTRA THIN 79 REGEN-COV 100 THIN 79 REYATAZ 41 QC UNILET LANCETS REGLAN 67 28G/ULTRA THIN 79 RHOGAM ULTRA-FILTERED RELION ALCOHOL PLUS 100 QC UNILET LANCETS SWABS 82 33G/MICRO THIN 79 RELION KETONE TEST RHOPHYLAC 100 QUAD-PROBIOTIC 23 STRIPS 61 RIASTAP 69 QUARTETTE 48 RELION LANCETS MICRO- ribavirin (hepatitis c) 42 QUESTRAN 27 THIN33G 79 riboflavin 110 RELION LANCETS THIN QUESTRAN LIGHT 27 26G 79 RID 60,61 quetiapine fumarate 38 RELION LANCETS ULTRA- RID COMPLETE LICE quinapril hcl 28 THIN30G 79 ELIMINATION 61 RELION TRUE METRIX RID ESSENTIAL LICE quinapril-hydrochlorothiazide ELIMINATION KIT 61 30 BLOODGLUCOSE TEST STRIPS 61 RIFADIN 31 quinidine gluconate 10 RELION ULTRA THIN rifampin 31 quinidine sulfate 10 LANCETS/30G 79 RIGHTEST GL300 RA ALCOHOL SWABS 82 RELION ULTRA THIN LANCETS 79 RA DRY MOUTH 91 LANCETS30G 79 RELION ULTRA THIN PLUS RILUTEK 95 RA E-ZJECT LANCETS 28G79 LANCETS 32G 79 riluzole 95 RA E-ZJECT LANCETS THIN RELION ULTRA THIN PLUS rimantadine hydrochloride 42 26G 79 LANCETS 33G 79 RIOMET 18 RA E-ZJECT LANCETS THIN RELPAX 88 28G 79 RISAQUAD 23 REMERON 16 RA E-ZJECT LANCETS RISAQUAD-2 23 REMERON SOLTAB 16 ULTRATHIN 30G 79 risedronate sodium 63 RA PROBIOTIC COLON REMODULIN 45 RISPERDAL 38 CARE 23 RENAGEL 67 RA PROBIOTIC COMPLEX 23 RISPERDAL CONSTA 38 RENVELA 67 RA PROBIOTIC DIGESTIVE risperidone 38 repaglinide 20 SUPPORT 23 RITALIN 2 RA PROBIOTIC MAXIMUM repaglinide-metformin hcl 18 RITALIN LA 2 STRENGTH 23 REPATHA 28 RITEFLO 86 rabeprazole sodium 106 REPATHA SURECLICK 28 ritonavir 41 raloxifene hcl 64 REPLACEMENT AIR ramelteon 73 FILTER 86 RITUXAN 32 ramipril 28 REPLACEMENT FILTERS 86 rivastigmine 102 RANEXA 9 REQUIP XL 37 rivastigmine tartrate 102 ranitidine hcl 105 RESCRIPTOR 41 RIXUBIS 69 ranolazine 9 RESTORA 23 rizatriptan benzoate 88 RAPAFLO 68 RESTORIL 73 ROBAXIN-750 93 RAPAMUNE 90 RETACRIT 71 ROCALTROL 65 RASUVO 3 RETIN-A 53 ROCKLATAN 98 RAVICTI 65 RETIN-A MICRO 53 ROMIDEPSIN 35 RAZADYNE 102 RETIN-A MICRO PUMP 53 ropinirole hydrochloride 37 RAZADYNE ER 102 RETISERT 98 rosuvastatin calcium 27 REALITY LANCETS 79 RETROVIR 41 ROWASA 67

Index 20 ROXICODONE 6 sennosides-docusate simethicone 66 ROZEREM 73 sodium 73 SIMPLYTHICK 101 SENOKOT 74 RUBRACA 35 SIMPLYTHICK EASY MIX 101 SENOKOT S 74 RUCONEST 69 SIMPLYTHICK EASYMIX 101 SENSIPAR 65 RUKOBIA 41 simvastatin 27,28 SEREVENT DISKUS 12 RUZURGI 31 SINEMET 37 SEROQUEL 38 SABRIL 15 SINEMET CR 37 SEROQUEL XR 38 SAFETY SEAL LANCETS SINGULAIR 11 sertraline hcl 17 28G 80 sirolimus 90 SAFETY SEAL LANCETS sevelamer carbonate 67 SIVEXTRO 9 30G 80 sevelamer hcl 67 SAFYRAL 48 SKELAXIN 93 SEVENFACT 69 SKYLA 49 SALAGEN 91 SHOPKO ALCOHOL salicylic acid 59 SWABS 82 SLO-NIACIN 110 saline 94 SHOPKO UNILET LANCETS SM ACIDOPHILUS PEARLS 23 salsalate 5 SUPER THIN 30G 80 SM ADVANCED PROBIOTIC SHOPKO UNILET LANCETS ULTRA POTENCY 23 SAMI THE SEAL ULTRA THIN 28G 80 REPLACEMENTFILTERS 87 SM ALCOHOL PREP PADS 82 SHUR-SEAL 109 SAMSCA 65 SM GLUCOSE 19 SIDESTREAM ADULT FACE SANDIMMUNE 90 MASK 87 SM IPECAC SYRUP 24 SANDOSTATIN 65 SIDESTREAM PEDIATRIC SM MICRO THIN LANCETS SANDOSTATIN LAR FACEMASK 87 33G 80 DEPOT 65 SIDESTREAM PEDIATRIC SMART SENSE COLOR LANCETS UNIVERSAL 33G 80 sapropterin dihydrochloride 65 FACEMASK/SAMI THE SEAL 87 SMART SENSE STANDARD SARAFEM 103 SIDESTREAM PEDIATRIC LANCETS UNIVERSAL 21G 80 SARNA 55 FACEMASK/TUCKER THE SMART SENSE SUPER THIN SAVELLA 102 TURTLE 87 LANCETS UNIVERSAL 30G 80 SIDESTREAM PLUS ADULT SMART SENSE THIN SAVELLA TITRATION LANCETSUNIVERSAL 26G 80 PACK 102 FACE MASK 87 sodium bicarbonate (antacid) 8 SB ALCOHOL PREP PADS 82 SIGNIFOR 65 sodium chloride (gu irrigant) 68 SB LANCETS THIN 80 SIGNIFOR LAR 65 sodium chloride (inhalant) 52 SB LANCETS ULTRA THIN 80 SIKLOS 70 sodium citrate & citric acid 67 SCHOOLTIME SHAMPOO 61 sildenafil citrate (pulmonary hypertension) 45 SD PROBIOTIC-10 sodium fluoride 89 COMPLEXULTRA 23 SILENOR 72 sodium fluoride (dental) 91 Seasonal Influenza SILICONE MASK FOR SODIUM HYALURONATE 94 BREATHERITE Vaccine 108 sodium phenylbutyrate 65 Seasonal Influenza Vaccine-High CHAMBER/ADULT 87 Dose 108 SILICONE MASK FOR sodium phosphates 74 SEASONIQUE 48 BREATHERITE sodium polystyrene CHAMBER/INFANT 87 sulfonate 90 selegiline hcl 37 SILICONE MASK FOR SODIUM selenium sulfide 55 BREATHERITE SULFACETAMIDE/SULFUR SELSUN BLUE 55 CHAMBER/PEDIATRIC 87 53 SELSUN BLUE DAILY 55 SILICONE MASK FOR SOFOSBUVIR/VELPATASVIR BREATHRITE 42 SELSUN BLUE CHAMBER/ADULT 87 MEDICATED 55 SOLESTA 89 SELSUN BLUE silodosin 68 solifenacin succinate 107 MOISTURIZING 55 SILVADENE 55 SOLIRIS 69 SELZENTRY 41 silver sulfadiazine 55 SOMA 93,94 sennosides 74 SIMBRINZA 97 SOMATULINE DEPOT 65

Index 21 SOMAVERT 64 sulfacetamide sod- tacrolimus 90 SOOTHENEB NBL 100 CHILD prednisolone 98 tacrolimus (topical) 59 MASK 87 sulfacetamide sodium 55 tadalafil (pulmonary SOOTHENEB NBL 100 sulfacetamide sodium hypertension) 45 MEDICATION CUP 87 (acne) 53 TAFINLAR 35 SOOTHENEB NBL 100 MESH sulfacetamide sodium CAP 87 (ophth) 97 TAGAMET HB 105 SOOTHENEB NBL100 ADULT sulfacetamide sodium w/ TAGRISSO 33 MASK 87 sulfur 53 TAKHZYRO 70 sulfamethoxazole- SORBITOL 74 TALZENNA 35 sotalol hcl 43 trimethoprim 9 sulfasalazine 67 TAMIFLU 42,43 sotalol hcl (afib/afl) 43 sulindac 4 tamoxifen citrate 34 spinosad 61 sumatriptan 88 tamsulosin hcl 68 SPINRAZA 95 sumatriptan succinate 88 TAPAZOLE 104 SPIRIVA HANDIHALER 11 sumatriptan-naproxen TARCEVA 33 spironolactone 62 sodium 87 TARGRETIN 36,55 spironolactone & sunitinib malate 35 hydrochlorothiazide 62 TARKA 30 SUPARTZ FX 94 SPORANOX 25 TASIGNA 35 SUPER PROBIOTIC 23 SPORANOX PULSEPAK 25 TAVALISSE 69 SUPER PROBIOTIC TAXOTERE 36 SPRYCEL 35 DIGESTIVE SUPPORT 23 stannous fluoride 91 SUPER THIN LANCETS 80 TAYTULLA 48 STARLIX 20 SUPERIOR PROBIOTIC 23 tazarotene 55 STAVUDINE 41 SUPPRELIN LA 64 TAZORAC 55 stavudine 41 SUPRAX 46 TECENTRIQ 33 STERILANCE TL 80 SURELITE LANCETS 80 TECFIDERA 103 TECFIDERA STARTER STERILE DILUENT FOR SUSTIVA 41 FLOLAN 101 PACK 103 STERILE DILUENT FOR SUTENT 35 TECHLITE AST LANCETS 80 TREPROSTINIL SYLATRON 36 TECHLITE LANCETS 80 INJECTION 101 SYLVANT 90 TECHLITE LANCETS 30G 80 STIMATE 65 SYMAX DUOTAB 105 TEGRETOL 15 STIOLTO RESPIMAT 12 SYMBICORT 12 TEGRETOL-XR 15 STIVARGA 35 SYMDEKO 104 TEGSEDI 103 STRATTERA 1 SYMFI 41 telmisartan 29 STRENSIQ 65 SYMFI LO 41 telmisartan-amlodipine 30 STRIBILD 41 SYMTUZA 41 telmisartan-hydrochlorothiazide SUBLOCADE 7 SYNAGIS 100 30 SUBOXONE 7 SYNALAR 58 temazepam 73 SUCRAID 62 SYNAREL 64 TEMODAR 31 sucralfate 106 SYNRIBO 36 TEMOVATE 58 SUDAFED CHILDRENS 95 SYNTHROID 104 temozolomide 31 SUDAFED CONGESTION 95 SYNVISC 94 temsirolimus 35 SUDAFED PE CHILDRENS SYNVISC ONE 94 tenofovir disoproxil fumarate 41 NASAL DECONGESTANT 95 TENORETIC 100 30 SUDAFED PE SINUS SYPRINE 89 CONGESTION 95 TAB-A-VITE TENORETIC 50 30 SUDAFED SINUS MULTIVITAMIN/IRON AND TENORMIN 43 CONGESTION 95 BETA-CAROTENE 92 TEPADINA 31 TABLOID 32 SULAR 44 terazosin hcl 29 TACLONEX 58

Index 22 terbinafine hcl 25 TINACTIN 54 trazodone hcl 17 terbinafine hcl (topical) 54 tioconazole vaginal 109 TREANDA 31 terbutaline sulfate 12 tiopronin 68 TRECATOR 31 terconazole vaginal 109 TIROSINT 104,105 TRELSTAR MIXJECT 34 TESSALON PERLES 51 TIVICAY 41 treprostinil 45 TESTIM 7 TIVICAY PD 41 tretinoin 53 TESTOPEL 7 tizanidine hcl 94 tretinoin (chemotherapy) 36 testosterone 7 TOBRADEX 98 tretinoin microsphere 53 testosterone cypionate 7 tobramycin 2 TRETTEN 69 tetrabenazine 102 tobramycin (ophth) 97 TREXALL 32 tetracaine hcl (ophth) 98 tobramycin sulfate 2 TREXIMET 87 tetrahydrozoline hcl (ophth) 98 tobramycin- triamcinolone acetonide TGT ALCOHOL SWABS 82 dexamethasone 98 (mouth) 91 triamcinolone acetonide TGT LANCET MICRO THIN TOBREX 97 TODAYS HEALTH SUPER (topical) 58,59 33G 80 triamcinolone acetonide- TGT LANCET THIN 26G 80 THINLANCETS 30G 80 TODAYS HEALTH ULTRA dimethicone-silicone 59 TGT LANCET ULTRA THIN THINLANCETS 28G 80 triamterene & 30G 80 TOFRANIL 18 hydrochlorothiazide 62 THALOMID 89 triazolam 73 tolmetin sodium 4 THEO-24 12 TRIBENZOR 30 tolnaftate 54 theophylline 12 TRIDESILON 59 tolterodine tartrate 107 thiamine hcl 110 trientine hcl 89 tolvaptan 65 thiamine mononitrate 110 trifluoperazine hcl 39 TOPAMAX 15 THINLETS GP LANCETS 80 trifluridine 97 TOPAMAX SPRINKLE 15 THIOLA 68 trihexyphenidyl hcl 37 TOPICORT 58 thioridazine hcl 39 TRIKAFTA 104 topiramate 15 thiotepa 31 TRILEPTAL 15 TOPOTECAN HCL 37 thiothixene 39 TRILURON 94 topotecan hcl 37 THRESHOLD IMT 87 trimethoprim 8 TOPROL XL 43 THROMBATE III 70 trimipramine maleate 18 toremifene citrate 34 THROMBATE III W/10 ML TRISENOX 36 STERILE WATER 70 TORISEL 35 TRIUMEQ 41 THROMBATE III W/20 ML torsemide 62 TRIVISC 94 STERILE WATER 70 TOTECT 36 THYMOGLOBULIN 90 TRIZIVIR 41 TOVIAZ 107 THYROGEN 61 tropicamide 96 TRACLEER 45 thyroid 104 trospium chloride 107 TRADJENTA 19 tiagabine hcl 15 TRUBIOTICS 23 tramadol hcl 6 TIAZAC 44 TRUE METRIX BLOOD tramadol-acetaminophen 6 TIBSOVO 35 GLUCOSETEST STRIPS 61 trandolapril 28 TRUE METRIX CONTROL TIGLUTIK 95 trandolapril-verapamil hcl 30 SOLUTION LEVEL 1 80 TIKOSYN 11 TRANDOLAPRIL/VERAPAMIL TRUE METRIX CONTROL timolol maleate 43 HCL ER 30 SOLUTION LEVEL 2 80 TRUE METRIX CONTROL timolol maleate (ophth) 96 tranexamic acid 71 SOLUTION LEVEL 3 80 TIMOLOL/BRIMONIDE/DORZOL TRANXENE T 10 TRUE METRIX SELF AMIDE 96 tranylcypromine sulfate 16 MONITORING BLOOD TIMOPTIC 96 TRAVATAN Z 99 GLUCOSE STRIPS 61 TIMOPTIC-XE 96 TRUEPLUS LANCETS 26G 80 travoprost 99

Index 23 TRUEPLUS LANCETS 28G 80 UNILET EXCELITE 81 VALTREX 42 TRUEPLUS LANCETS 28G UNILET EXCELITE II 81 VALUE PLUS LANCETS SUPER THIN 80 UNILET G.P. LANCET 81 STANDARD 21G 81 VALUE PLUS LANCETS TRUEPLUS LANCETS 30G 80 UNILET G.P. SUPERLITE TRUEPLUS LANCETS 30G SUPERTHIN 30G 81 LANCET 81 VALUE PLUS LANCETS THIN ULTRA THIN 80 UNILET GP 28 ULTRA TRUEPLUS LANCETS 33G 80 26G 81 THIN 81 VALUMARK LANCET SUPER TRUETRACK BLOOD UNILET LANCET 81 THIN 30G 81 GLUCOSE TEST 61 UNILET LANCETS MICRO- VALUMARK LANCET ULTRA TRUETRACK TEST 62 THIN33G 81 THIN 28G 81 TRUMENBA 108 UNILET LANCETS SUPER- VALVED HOLDING TRUNATURE DIGESTIVE THIN30G 81 CHAMBER 87 PROBIOTIC 23 UNILET LANCETS ULTRA- VANCOCIN 9 TRUSOPT 99 THIN 28G 81 UNILET SUPERLITE VANCOCIN HCL 9 TRUVADA 41 LANCET 81 vancomycin hcl 9 TUBING/WING TIP 87 UNISOM SLEEPGELS 72 VANOS 59 TUMS 8 UNISOM SLEEPMELTS 72 VANTAS 34 TUMS LASTING EFFECTS 8 UNISOM SLEEPTABS 72 VAQTA 108 TWYNSTA 30 UNITUXIN 33 varenicline tartrate 103 TYBLUME 48 UNIVERSAL 1 LANCETS VASERETIC 30 TYBOST 41 THIN26G 81 VASOTEC 28 UNIVERSAL 1 LANCETS TYKERB 35 ULTRA THIN 30G 81 VCF VAGINAL TYLENOL 4 UNIVERSAL 1 CONTRACEPTIVE FILM 109 VCF VAGINAL TYLENOL CHILDRENS 4 LANCETS/33G/MICRO-THIN 81 CONTRACEPTIVEGEL 109 TYLENOL CHILDRENS VECAMYL 30 CHEWABLES/PAIN + FEVER4 UP4 PROBIOTICS ADULT 23 TYLENOL EXTRA UP4 PROBIOTICS ULTRA 23 VECTIBIX 33 STRENGTH 4 UP4 PROBIOTICS VELCADE 35 TYLENOL FOR WOMENS 23 VELETRI 45 CHILDREN/ADULTS 4 urea 59 VELTIN 53 TYLENOL INFANTS 4 URECHOLINE 107 TYLENOL INFANTS VENCLEXTA 33 PAIN+FEVER 4 UROCIT-K 10 67 VENCLEXTA STARTING TYLENOL PM EXTRA UROCIT-K 5 68 PACK 33 STRENGTH 72 UROXATRAL 68 venlafaxine hcl 17 TYLENOL/CODEINE #3 6 URSO 250 66 VENTOLIN HFA 12 TYLENOL/CODEINE #4 6 ursodiol 66 verapamil hcl 44 UCERIS 51 VAGIFEM 109 VERELAN 44 UDENYCA 71 valacyclovir hcl 42 VERELAN PM 44 ULTILET CLASSIC VALCYTE 42 VESICARE 107 LANCETS 81 VIACTIV DIGESTIVE ULTOMIRIS 69 valganciclovir hcl 42 HEALTH 23 ULTRACET 6 VALIUM 10 VIBRAMYCIN 104 ULTRAFLORA IMMUNE valproate sodium 16 VICTOZA 19 HEALTH 23 valproic acid 16 VIDA MIA UNILET LANCETS ULTRAM 6 valrubicin 34 SUPER THIN 30G 81 ULTRATHON INSECT valsartan 29 VIDA MIA UNILET LANCETS REPELLENT 60 ULTRA THIN 28G 81 ULTRATHON INSECT valsartan-hydrochlorothiazide 30 VIDAZA 32 REPELLENT 8 60 VIDEX EC 41 UNILET COMFORTOUCH VALSTAR 34 LANCET 81 VALTOCO 13 VIDEXPEDIATRIC 41

Index 24 vigabatrin 15 WALGREENS THIN zafirlukast 11 VIGAMOX 97 LANCETS 81 zaleplon 73 warfarin sodium 13 VIMIZIM 65 ZALTRAP 32 WATCHHALER 87 VIMOVO 4 ZANAFLEX 94 WEBCOL ALCOHOL PREP vincristine sulfate 36 LARGE 1 PLY 82 ZANTAC 150 MAXIMUM VIRACEPT 41,42 WEBCOL ALCOHOL PREP STRENGTH 106 ZANTAC 75 106 VIRAMUNE 42 LARGE 2 PLY 82 WEBCOL ALCOHOL PREP ZARONTIN 15 VIRAMUNE XR 42 MEDIUM 2 PLY 82 ZARXIO 71 VIREAD 42 WELLBUTRIN SR 16 ZAVESCA 70 VIRTUSSIN DAC 52 WELLBUTRIN XL 16 ZEGERID 107 VISBIOME PROBIOTIC HIGH WESTHROID 105 POTENCY 23 ZEGERID OTC 107 white petrolatum-mineral VISCO-3 94 oil 96 ZELAC 23 VISINE 98 WILATE 69 ZELBORAF 35 VISINE RED EYE WINDMILL TRAINER 87 ZEMAIRA 104 COMFORT 98 ZEMPLAR 65 VISTARIL 10 WINRHO SDF 100 ZENPEP 62 VISTOGARD 24 WOMENS 50 BILLION 23 ZESTORETIC 30 VISUDYNE 98 WP THYROID 105 ZESTRIL 28 vitamin e 110 XALKORI 35 ZETIA 28 VITAMIN E 110 XANAX 10 ZEVALIN Y-90 33 vitamins w/ lipotropics 93 XANAX XR 10 ZIAC 30 VITRAKVI 35 XARELTO 13 XARELTO STARTER ZIAGEN 42 VIVELLE-DOT 66 PACK 13 ZIANA 53 VIVITROL 24 XELODA 32 zidovudine 42 VIZIMPRO 33 XENAZINE 103 zileuton 11 VOGELXO 7 XEOMIN 95 ZILRETTA 51 VOGELXO PUMP 7 XEROSTOMIA RELIEF zinc oxide (topical) 60 VOLTAREN 53 SPRAY 91 zinc sulfate 89 VONVENDI 69 XGEVA 63 ZINECARD 36 VORAXAZE 36 XIAFLEX 89 ZINPLAVA 100 VORTEX VALVED HOLDING XOLAIR 11 CHAMBER 87 XOPENEX 12 ziprasidone hcl 38 VOSEVI 42 XOPENEX ziprasidone mesylate 38 VOTRIENT 35 CONCENTRATE 12 ZITHROMAX 74,75 VPRIV 70 XOSPATA 35 ZITHROMAX TRI-PAK 75 VSL#3 23 XTANDI 34 ZITHROMAX Z-PAK 75 VYNDAMAX 45 XYNTHA 69 ZOCOR 28 VYNDAQEL 45 XYNTHA SOLOFUSE 69 ZOFRAN 24 VYTORIN 27 XYREM 102 ZOHYDRO ER 6 VYVANSE 1 XYZAL ALLERGY 24HR ZOLADEX 34 CHILDRENS 26 WALGREENS COMFORT zoledronic acid 63 YASMIN 28 49 ASSUREDLANCETS MICRO ZOLEDRONIC ACID 63 THIN/33G 81 YAZ 49 zoledronic acid 63 WALGREENS COMFORT YERVOY 33 ZOLEDRONIC ACID 63 ASSUREDLANCETS SUPER YONDELIS 31 THIN/28G 81 ZOLGENSMA 10.1-10.5 KG 95 YUTIQ 98 WALGREENS GLUCOSE 19 ZOLGENSMA 10.6-11.0 KG 95 ZADITOR 99

Index 25 ZOLGENSMA 11.1-11.5 KG 95 ZOLGENSMA 11.6-12.0 KG 95 ZOLGENSMA 12.1-12.5 KG 95 ZOLGENSMA 12.6-13.0 KG 95 ZOLGENSMA 13.1-13.5 KG 95 ZOLGENSMA 2.6-3.0 KG 95 ZOLGENSMA 3.1-3.5 KG 95 ZOLGENSMA 3.6-4.0 KG 95 ZOLGENSMA 4.1-4.5 KG 95 ZOLGENSMA 4.6-5.0 KG 95 ZOLGENSMA 5.1-5.5 KG 95 ZOLGENSMA 5.6-6.0 KG 95 ZOLGENSMA 6.1-6.5 KG 96 ZOLGENSMA 6.6-7.0 KG 96 ZOLGENSMA 7.1-7.5 KG 96 ZOLGENSMA 7.6-8.0 KG 96 ZOLGENSMA 8.1-8.5 KG 96 ZOLGENSMA 8.6-9.0 KG 96 ZOLGENSMA 9.1-9.5 KG 96 ZOLGENSMA 9.6-10.0 KG 96 ZOLINZA 35 zolmitriptan 88 ZOLOFT 17 zolpidem tartrate 73 ZOMIG 88 ZOMIG ZMT 88 ZONEGRAN 15 zonisamide 15 ZORTRESS 90 ZOSTAVAX 109 ZOVIRAX 42,55 ZULRESSO 16 ZYDELIG 35 ZYKADIA 35 ZYLOPRIM 68 ZYMAXID 97 ZYPREXA 38,39 ZYPREXA RELPREVV 38 ZYPREXA ZYDIS 39 ZYRTEC ALLERGY 26 ZYRTEC CHILDRENS ALLERGY 26 ZYTIGA 34 ZZZQUIL 72

Index 26