2020 Drug Formulary

CHPW_RX_311_10_2020_Medicaid_Formulary_NOV COMMUNITY HEALTH PLAN of WASHINGTON

2020 DRUG FORMULARY

The Community Health Plan of Washington (CHPW) drug formulary is developed by a Pharmacy and Therapeutics Committee. For medications included in the Apple Health Preferred Drug List, formulary status and coverage criteria are developed and approved by the Washington State Authority (HCA) Pharmacy and Therapeutics Committee before adoption by CHPW. All other medications’ formulary status and coverage criteria are developed and approved by the CHPW Pharmacy and Therapeutics Committee. The formulary is searchable on the website at http:// chpw.org/for-members/pharmacy. For more information on the Apple Health Preferred Drug List, please visit: https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple- health-preferred-drug-list-pdl. The Formulary may change at any time.

For updates regarding periodic changes to the Formulary and other pharmaceutical management programs please check our website at www.chpw.org/for-members/pharmacy.

This Drug Formulary is intended for use by our providers and pharmacies and applies only to medications prescribed to our members and dispensed by participating network pharmacies. The Formulary does not apply to inpatient medications.

Generic Drug Policy

Community Health Plan of Washington utilizes a mandatory generic policy. This means that unless specified, the brand product won’t be covered without adequate trial and documented failure of the formulary generic product. Only when generic substitution conflicts with state regulations or restrictions, the pharmacist must gain approval from the prescriber to use the generic equivalent.

OTC Medication Policy Some Over-The-Counter (OTC) products are covered with a written prescription. If a prescription product is available in the identical strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In these instances, providers and pharmacists should refer members to the OTC equivalent product. If the member or provider insists on the prescription equivalent product, the member must pay the entire cost of the prescription.

Age Restrictions

Age restrictions apply to selected drugs. These drugs are covered without prior authorization for specific age ranges but otherwise require prior authorization.

 Mental health medications outside of HCA mandated age/dose limits  Tretinoin—covered for members under 30 years old  Opioid prescriptions outside of HCA mandated age/dose limits

1 Second Opinion Network (SON) Community Health Plan of Washington has adopted Washington State Health Care Authority medication review thresholds for certain psychotropic medications for children under 18 years old. Clients currently receiving medications outside of these medication review thresholds will be allowed to continue, regardless of previous payer (whether HCA FFS, the plan themselves, or a previous payer prior to the client becoming a Medicaid enrollee). Clients being prescribed medications for the first time, or receiving prescriptions for dose escalations which exceed thresholds, will have those prescriptions denied by the managed care plans, and referred to HCA for initiation of the second opinion review process. After completion of the second opinion review, the managed care plan will receive a copy of the SON written recommendation, and approve or deny future prescriptions accordingly.

Exception Request

The health care professionals consulted in the development of this Formulary attempted to include medications for all therapeutic needs. Providers are expected to comply with the Drug Formulary when prescribing medications for plan members. If a patient requires a medication that is not covered, the provider may request an exception to allow payment for the non-covered medication. It is anticipated that such exceptions will be rare, and that most of the time, providers should be able to find a Formulary medication for the vast majority of therapeutic needs. However, if providers desire a non-covered product for members, they must call or submit a request explaining the necessity, past therapeutic failures and patient identification (name, address and Community Health Plan of Washington member number).

Prior Authorization To promote the most appropriate utilization, selected high-risk or high-cost medications require prior authorization to be eligible for coverage. Prior authorization criteria have been developed using current, published, peer-reviewed, medical literature, as well as input from local providers. The prior authorization criteria are approved by the P&T Committee. The Formulary medications that require prior authorization are identified by a “PA” following their name. Most authorizations are good for one year; after that, the drugs listed here will need to be reauthorized. Drugs may be added or deleted from this list as deemed necessary.

Prior Authorization Requests:

Non Formulary and Prior Authorization requests must be directed to:

Express Scripts Attn: Prior Authorization Mail Stop B401-03 8640 Evans Road St. Louis, MO 63134 Phone: 844-605-8168 Fax: 877-251-5896

Electronic Prior Authorization requests can be submitted through: www.express-scripts.com/PA

2 Step Therapy Step-­­therapy promotes appropriate utilization of first line drugs and/or therapeutic categories. Step-­­ therapy requires that participants receive one or more first-­­line drug(s), as defined by program criteria, before prescriptions are covered for second-­­line drugs. All step-­­therapy programs are supported by prior authorization criteria to determine coverage in the event that a participant does not meet the automated, on-­­line step-­­therapy criteria and coverage of a second line product is medically necessary.

Benefit Exclusions Drugs in the following categories are not available as benefits of the plan:  Non-­­FDA approved drug products Medications will be eligible for coverage only if they are FDA-­­ approved prescription medications used for non-­­experimental indications.  Experimental and Investigational (E & I) drugs These are drugs that do not have FDA-­­ approved indication(s) for use, or other indications that are considered effective based on published scientific evidence.  Compounded drugs with non-­­FDA approved ingredients (e.g. Estriol used in Bi-­­Est and Tri-­­Est)  Samples Members started on samples of a non-­­formulary drug are not guaranteed coverage for that drug.  Drugs for weight loss or appetite suppression (e.g. Xenical)  Drugs for impotence or sexual dysfunction (e.g.Viagra)  Drugs to treat cosmetic issues (e.g.Rogaine)  Infertility drugs  Prescription drugs that are equivalent to OTC medications or with an OTC add on (Some OTC medications are covered for Apple Health.)

Benefit Information:

Retail Pharmacy A 30 day supply is allowed at all network retail pharmacies and a 90-day supply of select generic maintenance medications at select pharmacies. Mail Order Pharmacy Contact Walmart pharmacy at 1-800-273-3455 to get your medications sent to you. Copay Determinations There is no copay or deductible for formulary products for Apple Health. OTC products: Only certain OTC products are covered for Community Health Plan of Washington members as determined by the Apple Health Preferred Drug List.

3 Formulary Legend: Generic drugs are listed in lower case BRAND drugs are listed in UPPER case

Tier 1: Preferred. No limits. Tier 2: Preferred. With limits. Tier 3: Non Preferred. Tier 4: Medical Benefit.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, there are limits on the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

4 COMMUNITY HEALTH PLAN OF WASHINGTON

FORMULARIO DE MEDICAMENTOS 2020

El Formulario de medicamentos de Community Health Plan of Washington (CHPW) es desarrollado por el Comité de Farmacia y Terapéutica (P&T). Para los medicamentos incluidos en la Lista de medicamentos preferidos de Apple Health, el Comité de Farmacia y Terapéutica de la Autoridad de Atención Médica de Washington (HCA) desarrolla y aprueba el estado del formulario y el criterio de cobertura antes de que CHPW los adopte. El resto de los criterios de cobertura y de los estados de los formularios de medicamentos son desarrollados y aprobados por el Comité de Farmacia y Terapéutica de CHPW. El formulario se puede consultar en el sitio web http://chpw.org/for-members/pharmacy. Para obtener más información sobre la Lista de medicamentos preferidos de Apple Health, visite https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple-health- preferred-drug-list-pdl. El Formulario puede cambiar en cualquier momento.

Para acceder a los cambios periódicos en el Formulario y otros programas de administración de productos farmacéuticos, visite nuestro sitio web en www.chpw.org/for-members/pharmacy.

Este Formulario de medicamentos está destinado a nuestros proveedores y farmacias, y se aplica solo a los medicamentos recetados a nuestros miembros y proporcionados por las farmacias de la red participantes. El Formulario no se aplica a medicamentos para pacientes internados.

Política de medicamentos genéricos

Community Health Plan of Washington utiliza una política genérica obligatoria. Esto significa que, a menos que se especifique lo contrario, el producto de marca no estará cubierto sin un estudio adecuado y un registro del fracaso del producto genérico del formulario. Solo cuando la sustitución por un genérico entre en conflicto con las restricciones o regulaciones estatales, el farmacéutico debe obtener la aprobación de la persona autorizada a dar recetas para usar el equivalente genérico.

Política de medicamentos de venta libre (OTC) Algunos productos de venta libre (OTC, por sus siglas en inglés) están cubiertos con una receta escrita. Si un producto con receta está disponible con los mismos ingredientes activos, potencia y dosificación que un producto de venta libre, el producto con receta no estará cubierto. En estos casos, los proveedores y farmacéuticos deberían ofrecer a los miembros el producto equivalente de venta libre. Si el miembro o proveedor insisten en el producto equivalente con receta, el miembro debe pagar el costo total de la receta.

Restricciones de edad A ciertos medicamentos seleccionados se les aplican restricciones de edad. Estos medicamentos están cubiertos sin autorización previa en grupos de edad específicos, pero, en otros casos, se requiere autorización previa.

• Medicamentos para la salud mental no contemplados en los límites de dosis y edad indicados por la HCA • Tretinoína: cubierta para miembros menores de 30 años • Medicamentos con receta opiáceos no contemplados en los límites de dosis y edad indicados por la HCA 5 Red de segunda opinión (SON) Community Health Plan of Washington ha adoptado la revisión de los límites de medicamentos de la Autoridad de Atención Médica de Washington (Washington Health Care Authority, HCA) para ciertos medicamentos psicotrópicos para niños menores de 18 años. Los clientes que actualmente reciben los medicamentos fuera de esta revisión de medicamentos podrán continuar, independientemente del pagador anterior (ya sea HCA FFS, el plan mismo o un pagador anterior previo a que el cliente se inscribiera en Medicaid). Los planes de atención administrada rechazarán las recetas de los clientes a quienes se les recetan medicamentos por primera vez o quienes reciben medicamentos con receta con aumentos de dosis que superen los umbrales, y los derivarán a la HCA para que inicien el proceso de revisión de segunda opinión. Luego de finalizar la revisión de segunda opinión, el plan de atención administrada recibirá una copia de la recomendación escrita correspondiente a la red de segunda opinión (SON, por sus siglas en inglés) y aprobará o denegará las futuras recetas en consecuencia.

Solicitud de excepción Los profesionales de la atención médica consultados durante el desarrollo de este Formulario intentaron incluir medicamentos para todas las necesidades terapéuticas. Se espera que los proveedores cumplan con el Formulario de medicamentos cuando receten medicamentos a los miembros del plan. Si un paciente requiere un medicamento que no está cubierto, el proveedor puede solicitar una excepción para permitir el pago del medicamento no cubierto. Está previsto que dichas excepciones sean poco frecuentes y, la mayoría de las veces, los proveedores deberían poder encontrar un medicamento dentro del Formulario para la amplia mayoría de las necesidades terapéuticas. No obstante, si un proveedor desea un producto no cubierto para los miembros, debe llamar o presentar una solicitud en la que detalle la necesidad, los fracasos terapéuticos anteriores y la identificación del paciente (nombre, dirección y número de miembro de Community Health Plan of Washington).

Autorización previa A fin de promover la utilización más adecuada, los medicamentos de alto riesgo o alto costo seleccionados requieren autorización previa para calificar para la cobertura. Los criterios de autorización previa se han desarrollado con documentación médica actual, publicada y revisada por pares, así como también mediante aportes de proveedores locales. Los criterios de autorización previa son aprobados por el Comité de Farmacia y Terapéutica. Los medicamentos del Formulario que requieren autorización previa están identificados con las letras "PA" luego del nombre. La mayoría de las autorizaciones tienen validez durante un año; después se deberán volver a autorizar los medicamentos incluidos aquí. Community Health Plan of Washington puede agregar o eliminar medicamentos de la lista, según lo considere necesario.

Solicitudes de autorización previa: Las solicitudes de autorización previa y de medicamentos externos al Formulario deben dirigirse a: Express Scripts Attn: Prior Authorization Mail Stop B401-03 8640 Evans Road St. Louis, MO 63134 Teléfono: 844-605-8168 Fax: 877-251-5896

6 Las solicitudes de autorización previa electrónicas deben enviarse a: www.express-scripts.com/PA

Tratamiento escalonado El tratamiento escalonado promociona una utilización adecuada de medicamentos de primera línea o categorías terapéuticas. El tratamiento escalonado requiere que los participantes reciban uno o más medicamentos de primera línea, según lo definan los criterios del programa, antes de que se cubran las recetas de medicamentos de segunda línea. Todos los programas de tratamiento escalonado están respaldados por los criterios de autorización previa para determinar la cobertura en caso de que un participante no cumpla con los criterios de tratamiento escalonado automatizados y en línea, y la cobertura de un medicamento de segunda línea sea médicamente necesario.

Exclusiones de los beneficios Los medicamentos en las siguientes categorías no están disponibles como beneficios del plan: • Productos farmacológicos no aprobados por la FDA: los medicamentos calificarán para la cobertura solo si son medicamentos con receta aprobados por la FDA utilizados con indicaciones no experimentales. • Medicamentos experimentales y de investigación: estos son medicamentos que no tienen indicaciones aprobadas por la FDA para el uso u otras indicaciones que se consideran efectivas sobre la base de evidencia científica publicada. • Medicamentos compuestos con ingredientes no aprobados por la FDA: (p. ej., Estriol utilizado en Biest y Triest) • Muestras: los miembros que comenzaron con una muestra de un medicamento externo al formulario no tienen garantía de cobertura para ese medicamento. • Medicamentos para la pérdida de peso o suspensión del apetito: (p. ej., Xenical) • Medicamentos para la impotencia o disfunción sexual: (p. ej., Viagra) • Medicamentos para tratar problemas estéticos: (p. ej., Rogaine) • Medicamentos contra la infertilidad • Medicamentos con receta que son equivalentes a medicamentos de venta libre o con un complemento de venta libre: (algunos medicamentos de venta libre están cubiertos para Apple Health).

7 Información sobre los beneficios:

Farmacia minorista Se permite un suministro de 30 días en todas las farmacias minoristas de la red y un suministro de 90 días de medicamentos genéricos de mantenimiento seleccionados en farmacias seleccionadas. Farmacias de venta por correo Póngase en contacto con la farmacia de Walmart al 1-800-273-3455 para que le envíen los medicamentos. Determinaciones de copago No hay copago ni deducible para los productos del formulario de Apple Health. Productos de venta libre Solo ciertos productos de venta libre incluidos en la Lista de medicamentos preferidos de Apple Health están cubiertos para los miembros de Community Health Plan of Washington.

Texto del formulario Los medicamentos genéricos están en minúscula. Los medicamentos de MARCA están en MAYÚSCULA.

Nivel 1: Preferido. Sin límites. Nivel 2: Preferido. Con límites. Nivel 3: No preferido. Nivel 4: Beneficio médico.

PA (Prior Authorization): autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener aprobación antes de surtir sus recetas. Si usted no obtiene la aprobación, puede que no cubramos el medicamento. QL (Quantity Limit): límite de cantidades. Para ciertos medicamentos, existen límites a la cantidad del medicamento que cubriremos. ST (Step Therapy): tratamiento escalonado. En algunos casos, el Plan requiere que usted pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica, es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.

8 Community Health Plan of Washington 2020 Apple Health Drug Formulary

Table of Contents ALTERNATIVE THERAPY ...... 11 ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC ...... 13 ANESTHETICS ...... 24 ANORECTAL PREPARATIONS ...... 27 ANTIDOTES AND OTHER REVERSAL AGENTS ...... 28 ANTI-INFECTIVE AGENTS ...... 30 ANTINEOPLASTICS ...... 46 ANTISEPTICS AND DISINFECTANTS ...... 58 BIOLOGICALS ...... 58 CARDIOVASCULAR THERAPY AGENTS ...... 62 CENTRAL NERVOUS SYSTEM AGENTS ...... 77 CHEMICAL DEPENDENCY, AGENTS TO TREAT ...... 95 CHEMICALS-PHARMACEUTICAL ADJUVANTS...... 96 COGNITIVE DISORDER THERAPY ...... 110 CONTRACEPTIVES ...... 110 DERMATOLOGICAL ...... 114 DIAGNOSTIC AGENTS ...... 132 DRUGS TO TREAT ERECTILE DYSFUNCTION ...... 135 EATING DISORDER THERAPY ...... 136 ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS ...... 136 ENDOCRINE ...... 170 ENZYMES ...... 184 FDB CLASS OBSOLETE-NOT USED ...... 184 GASTROINTESTINAL THERAPY AGENTS ...... 184 GENITOURINARY THERAPY ...... 193 GOUT AND HYPERURICEMIA THERAPY ...... 197 HEMATOLOGICAL AGENTS ...... 197 HEPATOBILIARY SYSTEM TREATMENT AGENTS ...... 203 HISTAMINE PREPARATIONS FOR DESENSITIZATION ...... 203 IMMUNOSUPPRESSIVE AGENTS ...... 203 LOCOMOTOR SYSTEM ...... 204 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME) ...... 207 MEDICAL SUPPLY, FDB SUPERSET ...... 215 METABOLIC DISEASE ENZYME REPLACEMENT AGENTS ...... 222 METABOLIC MODIFIERS ...... 222 MOUTH-THROAT-DENTAL - PREPARATIONS ...... 224 MULTIPLE SCLEROSIS AGENTS ...... 226 OPHTHALMIC AGENTS ...... 227 OTIC (EAR)...... 234 RESPIRATORY THERAPY AGENTS ...... 234 VAGINAL PRODUCTS ...... 241

9 Community Health Plan of Washington 2020 AppleHealth Drug Formulary

Table of Contents ALTERNATIVE THERAPY...... 12 ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC...... 14 ANESTHETICS...... 27 ANORECTAL PREPARATIONS...... 29 ANTIDOTES AND OTHER REVERSAL AGENTS...... 30 ANTI-INFECTIVE AGENTS...... 32 ANTINEOPLASTICS...... 48 ANTISEPTICS AND DISINFECTANTS...... 61 BIOLOGICALS...... 61 CARDIOVASCULAR THERAPY AGENTS...... 66 CENTRAL NERVOUS SYSTEM AGENTS...... 82 CHEMICAL DEPENDENCY, AGENTS TO TREAT...... 104 CHEMICALS-PHARMACEUTICAL ADJUVANTS...... 105 COGNITIVE DISORDER THERAPY...... 118 CONTRACEPTIVES...... 119 DERMATOLOGICAL...... 123 DIAGNOSTIC AGENTS...... 142 DRUGS TO TREAT ERECTILE DYSFUNCTION...... 144 EATING DISORDER THERAPY...... 145 ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS...... 145 ENDOCRINE...... 179 ENZYMES...... 193 FDB CLASS OBSOLETE-NOT USED...... 193 GASTROINTESTINAL THERAPY AGENTS...... 194 GENITOURINARY THERAPY...... 204 GOUT AND HYPERURICEMIA THERAPY...... 208 HEMATOLOGICAL AGENTS...... 209 HEPATOBILIARY SYSTEM TREATMENT AGENTS...... 215 HISTAMINE PREPARATIONS FOR DESENSITIZATION...... 215 IMMUNOSUPPRESSIVE AGENTS...... 215 LOCOMOTOR SYSTEM...... 217 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)...... 219 MEDICAL SUPPLY, FDB SUPERSET...... 228 METABOLIC DISEASE ENZYME REPLACEMENT AGENTS...... 234 METABOLIC MODIFIERS...... 235 MOUTH-THROAT-DENTAL - PREPARATIONS...... 236 MULTIPLE SCLEROSIS AGENTS...... 238 OPHTHALMIC AGENTS...... 239 OTIC (EAR)...... 246 RESPIRATORY THERAPY AGENTS...... 247 VAGINAL PRODUCTS...... 255

10 11 2020 AppleHealth Drug Formulary Drug Name Drug Tier Limits GLUCOSAMINE- CHONDROITIN CURRENT AS OF 11/01/2020 1 COMPLX ORAL Drug Name Drug Tier Limits CAPSULE ALTERNATIVE GLUCOSAMINE- CHONDROITIN DS 1 THERAPY ORAL CAPSULE ALTERNATIVE glucosamine- THERAPY - chondroitin oral tablet 1 ANDROGENIC 250-200 mg, 500-400 AGENTS mg, 750-600 mg DEHYDROEPIANDR glucosamine-chondroit- 3 1 OSTERONE (MICRO) vit c-mn oral tablet DHEA ORAL methylsulfonylmethane 3 3 CAPSULE 50 MG oral capsule 900 mg DHEA ORAL TABLET methylsulfonylmethane 3 3 50 MG oral tablet 1,000 mg prasterone (dhea), N-ACETYL-ALPHA- 3 3 micro(bulk) D-GLUCOSAMINE ALTERNATIVE OSTEO BI-FLEX 1 THERAPY - ALTERNATIVE ANTIARTHRITIC THERAPY - S ANTIOXIDANT CIDAFLEX 1 HEALTHY EYES LUTEIN- 3 glucosam-chon-msm1- ZEAXANTHIN c-mang-bosw oral tablet 1 750-625-30 mg LIPOIC ACID 3 GLUCOSAMINE lutein oral tablet 10 mg 1 1 COMPLEX-MSM PROSIGHT 3 GLUCOSAMINE tetrahydrocurcumin 3 RELIEF ORAL 1 (bulk) TABLET ALTERNATIVE glucosamine su 2kcl- THERAPY - chondroit oral capsule 3 250-200 mg DIETARY SUPPLEMENT, glucosamine su 2kcl- chondroit oral tablet 3 STEROID 750-600 mg STRUCTURE glucosamine sulfate oral 7-KETO DHEA, 1 3 tablet 500 mg, 750 mg MICRONIZED GLUCOSAMINE 1 SULF-CHONDROITIN

You can find information on what the symbols and abbreviationson this table mean on page 4. 12 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CRANBERRY ALTERNATIVE 1 THERAPY - URINARY COMFORT echinacea oral capsule PINEAL 1 HORMONE 400 mg AGENTS evening primrose oil 1 flaxseed oil oral capsule TOPROPHAN 1 3 1,000 mg ALTERNATIVE garlic oral capsule 1,500 THERAPY - 1 mg, 500 mg SEDATIVE/HYPN gelatin oral capsule 650 OTICS 1 mg LYDIA PINKHAM ginseng oral capsule 100 HERBAL ORAL 3 1 mg ELIXIR GLUCOLESS 1 tryptophan 3 LECITHIN-KELP-B6 3 ALTERNATIVE mag oxide-d3-turmeric THERAPY - 3 rt xt UNCLASSIFIED MANNXTRA 3 AIRSHIELD IMMUNE 3 MENS POTENT 3 aloe vera (bulk) powder 3 FORMULA AZO CRANBERRY + 1 MG-PLUS-PROTEIN 1 PROBIOTIC milk thistle oral tablet 1 CHEW Q 1 milk thistle seed extract CHILDREN'S 1 3 oral capsule 175 mg MIGRELIEF milk thistle seed extract CO Q-10 (WITH VIT 3 1 oral tablet E) ODORLESS GARLIC CO Q-10 ORAL 1 1 ORAL CAPSULE CAPSULE 150 MG ORTHODIET 1 coenzyme q10 (bulk) 3 PROSTATE powder 100 % 3 CONTROL coenzyme q10 oral capsule 200 mg, 30 mg, 3 Q-GEL MEGA 1 400 mg, 50 mg, 60 mg REFEX 1 coenzyme q10 oral SAW PALMETTO 3 1 tablet 100 mg EXTRACT (W-ZINC) coenzyme q10-vitamin e saw palmetto oral 1 oral capsule 100-5 mg- 3 capsule 160 mg, 450 mg unit saw palmetto-pumpkin 1 cranberry extract- seed oil 3 vitamin c saw palmto frt xtr-zinc 1 cranberry fruit oral picoli 1 tablet 400 mg You can find information on what the symbols and abbreviationson this table mean on page 4. 13 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TEARS AGAIN DEMEROL (PF) HYDRATE ORAL INJECTION SYRINGE 3 4 CAPSULE 250-125-10 25 MG/ML, 50 MG MG/ML, 75 MG/ML thymus gland,calf (bulk) 3 DEMEROL turmeric 3 INJECTION 4 SOLUTION 50 MG/ML turmeric-turmeric ext- DEMEROL ORAL pepper oral capsule 900- 3 3 100-5 mg TABLET 100 MG VALINEX 1 DILAUDID 3 ANALGESIC, DISKETS 3 ANTI- DOLOPHINE ORAL 3 INFLAMMATOR DSUVIA 3 PA Y OR DURAGESIC 3 ANTIPYRETIC DURAMORPH (PF) 4 ANALGESIC - EXALGO ER ORAL TABLET EXTENDED 3 CENTRAL RELEASE 24 HR 16 ALPHA-2 MG RECEPTOR fentanyl citrate 3 AGONISTS fentanyl citrate (bulk) 3 clonidine (pf) 2 fentanyl citrate (pf) ANALGESIC intravenous pt controlled analgesia OPIOID 4 AGONISTS syring 1,500 mcg/30 ml (50 mcg/ml), 2,750 ACTIQ 3 mcg/55 ml (50 mcg/ml) alfentanil 4 fentanyl citrate (pf) ARYMO ER 3 intravenous syringe 100 4 ASTRAMORPH-PF mcg/2 ml (50 mcg/ml) INJECTION 4 fentanyl citrate (pf)- SOLUTION 0.5 0.9%nacl injection pt 4 MG/ML controlled analgesia codeine phosphate syring 550 mcg/55 ml 3 (bulk) fentanyl citrate (pf)- codeine sulfate oral 0.9%nacl intravenous 1 4 tablet solution 10 mcg/ml, 20 mcg/ml, 5 mcg/ml CONZIP 3 fentanyl citrate (pf)- DEMEROL (PF) 0.9%nacl intravenous INJECTION 4 4 syringe 50 mcg/5 ml (10 SOLUTION 100 MG/2 mcg/ml) ML

You can find information on what the symbols and abbreviationson this table mean on page 4. 14 Drug Name Drug Tier Limits Drug Name Drug Tier Limits fentanyl transdermal hydromorphone patch 72 hour 100 injection syringe 1 1 mcg/hr, 12 mcg/hr, 25 2 PA mg/ml, 4 mg/ml mcg/hr, 50 mcg/hr, 75 hydromorphone oral 3 mcg/hr liquid fentanyl transdermal hydromorphone oral 1 patch 72 hour 37.5 tablet mcg/hour, 62.5 3 PA mcg/hour, 87.5 hydromorphone oral mcg/hour tablet extended release 3 24 hr FENTORA 3 hydromorphone rectal 1 hydromorphone (bulk) 3 HYSINGLA ER 3 hydromorphone (pf) in 4 water injection INFUMORPH P/F 4 hydromorphone (pf) KADIAN ORAL injection solution 10 CAPSULE,EXTEND.R 4 mg/ml, 2 mg/ml, 4 ELEASE PELLETS 10 mg/ml MG, 100 MG, 20 MG, 3 200 MG, 30 MG, 40 hydromorphone (pf)-0.9 MG, 50 MG, 60 MG, 80 % nacl intravenous 4 MG patient control.analgesia soln LAZANDA 3 hydromorphone (pf)-0.9 levorphanol tartrate 3 PA % nacl intravenous pt levorphanol tartrate 3 controlled analgesia (bulk) syring 10 mg/50 ml (0.2 4 meperidine (pf) mg/ml), 50 mg/50 ml (1 injection solution 100 4 mg/ml), 55 mg/55 ml (1 mg/ml, 25 mg/ml, 50 mg/ml) mg/ml hydromorphone (pf)-0.9 meperidine injection % nacl intravenous 4 4 cartridge solution 0.5 mg/ml, 1 mg/ml meperidine oral 3 hydromorphone (pf)-0.9 methadone (bulk) 3 % nacl intravenous methadone injection 4 syringe 1 mg/5 ml (0.2 4 solution mg/ml), 1 mg/ml, 2 METHADONE QL (60 ML per 3 mg/ml INTENSOL 23 days) hydromorphone methadone oral 3 injection solution 1 4 concentrate mg/ml, 2 mg/ml methadone oral solution 3 hydromorphone injection syringe 0.5 4 methadone oral tablet 3 mg/0.5 ml, 2 mg/ml methadone oral 3 tablet,soluble

You can find information on what the symbols and abbreviationson this table mean on page 4. 15 Drug Name Drug Tier Limits Drug Name Drug Tier Limits METHADOSE ORAL morphine in 0.9 % 3 CONCENTRATE sodium chlor 4 METHADOSE ORAL intravenous solution 1 3 TABLET,SOLUBLE mg/ml, 5 mg/ml morphine (bulk) 3 morphine injection solution 2 mg/ml, 4 4 morphine (pf) in 0.9 % mg/ml, 8 mg/ml sod chl intravenous pt controlled analgesia morphine injection syringe 10 mg/ml, 2 syring 30 mg/30 ml (1 4 4 mg/ml), 50 mg/50 ml (1 mg/ml, 4 mg/ml, 5 mg/ml), 55 mg/55 ml (1 mg/ml, 8 mg/ml mg/ml) morphine intramuscular 4 morphine (pf) in 0.9 % morphine intravenous pt sod chl intravenous controlled analgesia 4 syringe 2 mg/2 ml (1 4 syring mg/ml), 2 mg/ml, 5 morphine intravenous mg/5 ml (1 mg/ml) solution 10 mg/ml, 100 4 morphine (pf) injection mg/4 ml, 25 mg/ml, 250 solution 0.5 mg/ml, 1 4 mg/10 ml, 50 mg/ml mg/ml morphine intravenous morphine (pf) syringe 10 mg/ml, 2 4 4 intravenous syringe mg/ml, 4 mg/ml, 8 morphine concentrate mg/ml 1 oral solution morphine oral capsule, 3 morphine concentrate er multiphase 24 hr oral syringe 10 mg/0.5 3 morphine oral ml capsule,extend.release 3 morphine in 0.9 % pellets sodium chlor injection morphine oral solution 3 pt controlled analgesia 4 PA; QL (42 EA morphine oral tablet 15 syring 55 mg/55 ml (1 1 Max Qty Per mg mg/ml) Fill Retail) morphine in 0.9 % morphine oral tablet 30 1 LA sodium chlor mg intravenous prefilled 4 morphine oral tablet pump reservoir 50 2 PA mg/50 ml (1 mg/ml) extended release morphine in 0.9 % morphine rectal 1 sodium chlor MS CONTIN 3 intravenous pt NUCYNTA 3 PA controlled analgesia syring 150 mg/30 ml (5 4 NUCYNTA ER 3 mg/ml), 275 mg/55 ml OXAYDO 3 (5 mg/ml), 50 mg/50 ml oxycodone (bulk) 3 (1 mg/ml), 60 mg/30 ml (2 mg/ml) oxycodone oral capsule 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 16 Drug Name Drug Tier Limits Drug Name Drug Tier Limits oxycodone oral 3 ANALGESIC concentrate OPIOID oxycodone oral solution 1 CODEINE oxycodone oral syringe 3 COMBINATIONS oxycodone oral tablet 1 acetaminophen-codeine oxycodone oral oral solution 120-12 tablet,oral 3 mg/5 ml, 240 mg-24 mg 1 only,ext.rel.12 hr /10 ml (10 ml), 300 mg- 30 mg /12.5 ml OXYCONTIN ORAL TABLET,ORAL acetaminophen-codeine 3 1 ONLY,EXT.REL.12 oral tablet HR ASCOMP WITH 1 oxymorphone oral tablet 3 CODEINE oxymorphone oral tablet BUTALBITAL extended release 12 hr COMPOUND 1 2 PA 10 mg, 20 mg, 30 mg, W/CODEINE 40 mg, 5 mg, 7.5 mg butalbital-acetaminop- 1 oxymorphone oral tablet caf-cod extended release 12 hr 3 PA codeine-butalbital-asa- 2 15 mg caff ROXICODONE 3 FIORINAL-CODEINE 3 SUBSYS 3 #3 tramadol oral capsule,er ANALGESIC biphase 24 hr 25-75 150 3 OPIOID mg DIHYDROCODEI tramadol oral tablet 50 NE 1 mg COMBINATIONS tramadol oral tablet acetaminophen-caff- 2 PA 3 extended release 24 hr dihydrocod oral capsule tramadol oral tablet, er 3 DVORAH 1 multiphase 24 hr TREZIX ORAL ULTRAM 3 CAPSULE 320.5-30-16 3 ULTRAM ER ORAL MG TABLET EXTENDED 3 ANALGESIC RELEASE 24 HR 300 OPIOID MG DIHYDROCODEI XTAMPZA ER 3 NE, NON- ZOHYDRO ER ORAL SALICYLATE CAPSULE, ORAL 3 ANALGESIC,XAN ONLY, ER 12HR THINE acetaminophen-caff- 3 dihydrocod oral capsule

You can find information on what the symbols and abbreviationson this table mean on page 4. 17 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DVORAH 1 LORTAB ELIXIR TREZIX ORAL ORAL SOLUTION 10- 3 CAPSULE 320.5-30-16 3 300 MG/15 ML MG NORCO 3 ANALGESIC VERDROCET 2 OPIOID VICODIN HP 3 FENTANYL ANALGESIC COMBINATIONS OPIOID fentanyl-ropivacaine- HYDROCODONE nacl (pf) epidural 4 AND NSAID prefilled pump reservoir COMBINATIONS 2-0.2 mcg/ml-% hydrocodone-ibuprofen fentanyl-ropivacaine- oral tablet 10-200 mg, 2 nacl (pf) injection 4 5-200 mg, 7.5-200 mg solution 2-0.2 mcg/ml- IBUDONE ORAL % 3 TABLET 10-200 MG ANALGESIC REPREXAIN ORAL OPIOID 3 TABLET 2.5-200 MG HYDROCODONE AND NON- XYLON 10 2 SALICYLATE ANALGESIC COMBINATIONS OPIOID APADAZ ORAL HYDROCODONE 3 PA TABLET 4.08-325 MG COMBINATIONS APADAZ ORAL HYCET 1 TABLET 6.12-325 MG, 3 hydrocodone- 8.16-325 MG acetaminophen oral 3 benzhydrocodone- solution 7.5-325 mg/15 3 acetaminophen ml HYCET 1 hydrocodone- acetaminophen oral hydrocodone- tablet 10-300 mg, 10- acetaminophen oral 1 3 325 mg, 5-300 mg, 5- solution 7.5-325 mg/15 325 mg, 7.5-300 mg, ml 7.5-325 mg hydrocodone- hydrocodone- acetaminophen oral acetaminophen oral 2 tablet 10-300 mg, 10- 1 tablet 2.5-325 mg 325 mg, 5-300 mg, 5- 325 mg, 7.5-300 mg, hydrocodone-ibuprofen 7.5-325 mg oral tablet 10-200 mg, 2 5-200 mg, 7.5-200 mg hydrocodone- IBUDONE ORAL acetaminophen oral 2 3 tablet 2.5-325 mg TABLET 10-200 MG LORCET HD 3 LORCET HD 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 18 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LORTAB ELIXIR ANALGESIC ORAL SOLUTION 10- 3 OPIOID 300 MG/15 ML OXYCODONE NORCO 3 AND REPREXAIN ORAL 3 SALICYLATE TABLET 2.5-200 MG COMBINATIONS VERDROCET 2 oxycodone-aspirin 1 VICODIN HP 3 ANALGESIC XYLON 10 2 OPIOID ANALGESIC OXYCODONE OPIOID COMBINATIONS OXYCODONE ENDOCET ORAL AND NON- TABLET 10-325 MG, 1 SALICYLATE 2.5-325 MG, 5-325 MG, COMBINATIONS 7.5-325 MG ENDOCET ORAL ibuprofen-oxycodone 3 TABLET 10-325 MG, NALOCET 3 1 2.5-325 MG, 5-325 MG, oxycodone- 7.5-325 MG acetaminophen oral NALOCET 3 tablet 10-325 mg, 2.5- 1 oxycodone- 325 mg, 5-325 mg, 7.5- acetaminophen oral 325 mg tablet 10-325 mg, 2.5- 1 oxycodone-aspirin 1 325 mg, 5-325 mg, 7.5- PERCOCET ORAL 325 mg TABLET 10-325 MG, 3 PERCOCET ORAL 2.5-325 MG, 5-325 MG, TABLET 10-325 MG, 7.5-325 MG 3 2.5-325 MG, 5-325 MG, PRIMLEV 3 7.5-325 MG ANALGESIC PRIMLEV 3 OPIOID ANALGESIC PARTIAL-MIXED OPIOID AGONISTS OXYCODONE BELBUCA 3 PA AND NSAID COMBINATIONS BUPRENEX 4 buprenorphine hcl ibuprofen-oxycodone 3 3 (bulk) buprenorphine hcl 4 injection

You can find information on what the symbols and abbreviationson this table mean on page 4. 19 Drug Name Drug Tier Limits Drug Name Drug Tier Limits buprenorphine butalbital- transdermal patch acetaminophen oral 3 QL (4 EA per weekly 10 mcg/hour, 15 1 capsule 28 days) mcg/hour, 20 mcg/hour, butalbital- 5 mcg/hour acetaminophen oral 1 buprenorphine tablet 50-300 mg, 50- QL (0.29 EA transdermal patch 1 325 mg per 1 day) weekly 7.5 mcg/hour butalbital- butorphanol injection 4 acetaminophen-caff oral 3 QL (5 ML per capsule 50-300-40 mg butorphanol nasal 3 23 days) butalbital- BUTRANS 3 PA acetaminophen-caff oral 1 capsule 50-325-40 mg nalbuphine injection 4 solution 10 mg/ml butalbital- acetaminophen-caff oral 1 nalbuphine injection 1 tablet 50-325-40 mg solution 20 mg/ml ESGIC 3 pentazocine-naloxone 3 TENCON ORAL 3 ANALGESIC TABLET 50-325 MG OPIOID VANATOL LQ 3 TRAMADOL AND ZEBUTAL ORAL NON- CAPSULE 50-325-40 3 SALICYLATE MG COMBINATIONS ANALGESIC OR tramadol- 1 ANTIPYRETIC acetaminophen NON-OPIOID ULTRACET 3 acetaminophen (bulk) 3 ANALGESIC OFIRMEV 4 OPIOID ANTI- TRAMADOL INFLAMMATOR COMBINATIONS Y - tramadol- 1 INTERLEUKIN-1 acetaminophen BETA ULTRACET 3 BLOCKERS ANALGESIC OR ILARIS (PF) ANTIPYRETIC SUBCUTANEOUS 3 PA NON- SOLUTION OPIOID/SEDATIV E COMBINATIONS ALLZITAL 3 BUPAP ORAL 3 TABLET 50-300 MG You can find information on what the symbols and abbreviationson this table mean on page 4. 20 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HUMIRA PEN PSOR- ANTI- 2 PA INFLAMMATOR UVEITS-ADOL HS Y - HUMIRA INTERLEUKIN-1 SUBCUTANEOUS RECEPTOR SYRINGE KIT 10 2 PA MG/0.2 ML, 20 MG/0.4 ANTAGONIST ML ARCALYST 3 HUMIRA SUBCUTANEOUS PA; QL (2 EA ANTI- 2 INFLAMMATOR SYRINGE KIT 40 per 28 days) Y TUMOR MG/0.8 ML NECROSIS HUMIRA(CF) 2 PA HUMIRA(CF) PEDI FACTOR 2 PA INHIBITING CROHNS STARTER AGNTS,NON- HUMIRA(CF) PEN 2 PA SEIECTIVE INFLECTRA 4 PA ENBREL MINI 3 REMICADE 4 PA ENBREL RENFLEXIS 4 PA PA; QL (8 EA SUBCUTANEOUS 2 per 21 days) SIMPONI 3 PA RECON SOLN SIMPONI ARIA 4 PA ENBREL SUBCUTANEOUS 2 PA DMARD - ANTI- SYRINGE INFLAMMATOR PA; QL (8 ML Y TUMOR ENBREL SURECLICK 2 per 21 days) NECROSIS ANTI- FACTOR INFLAMMATOR INHIBITING Y TUMOR AGENTS NECROSIS CIMZIA 3 FACTOR CIMZIA POWDER 3 INHIBITING FOR RECONST AGNTS,TNF- CIMZIA STARTER 3 ALPHA SEL KIT CIMZIA 3 ENBREL MINI 3 ENBREL CIMZIA POWDER PA; QL (8 EA 3 SUBCUTANEOUS 2 FOR RECONST per 21 days) RECON SOLN CIMZIA STARTER 3 KIT ENBREL SUBCUTANEOUS 2 PA PA; QL (2 EA HUMIRA PEN 2 SYRINGE per 28 days) PA; QL (8 ML HUMIRA PEN ENBREL SURECLICK 2 per 21 days) CROHNS-UC-HS 2 PA START You can find information on what the symbols and abbreviationson this table mean on page 4. 21 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PA; QL (2 EA OTREXUP (PF) HUMIRA PEN 2 per 28 days) SUBCUTANEOUS HUMIRA PEN AUTO-INJECTOR 10 CROHNS-UC-HS 2 PA MG/0.4 ML, 12.5 START MG/0.4 ML, 15 MG/0.4 3 PA ML, 17.5 MG/0.4 ML, HUMIRA PEN PSOR- 2 PA 20 MG/0.4 ML, 22.5 UVEITS-ADOL HS MG/0.4 ML, 25 MG/0.4 HUMIRA ML SUBCUTANEOUS RASUVO (PF) SYRINGE KIT 10 2 PA SUBCUTANEOUS MG/0.2 ML, 20 MG/0.4 AUTO-INJECTOR 10 ML MG/0.2 ML, 12.5 HUMIRA MG/0.25 ML, 15 SUBCUTANEOUS PA; QL (2 EA MG/0.3 ML, 17.5 2 PA 2 SYRINGE KIT 40 per 28 days) MG/0.35 ML, 20 MG/0.8 ML MG/0.4 ML, 22.5 HUMIRA(CF) 2 PA MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 HUMIRA(CF) PEDI ML, 7.5 MG/0.15 ML CROHNS STARTER SUBCUTANEOUS 2 PA TREXALL 1 SYRINGE KIT 80 XATMEP 1 MG/0.8 ML DMARD - HUMIRA(CF) PEN 2 PA ANTINFLAMMAT INFLECTRA 4 PA ORY, SELECT. REMICADE 4 PA COSTIMULATIO RENFLEXIS 4 PA N SIMPONI 3 PA MODULATOR,T- CELL INHIB. SIMPONI ARIA 4 PA ORENCIA 3 PA DMARD - ORENCIA (WITH ANTIMALARIAL 4 PA MALTOSE) S ORENCIA 3 PA hydroxychloroquine 1 CLICKJECT hydroxychloroquine sulf 3 DMARD - B CELL (bulk) TARGETED PLAQUENIL 3 AGENTS DMARD - RITUXAN 4 PA ANTIMETABOLI TES DMARD - GOLD COMPOUNDS methotrexate sodium 1 oral RIDAURA 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 22 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DMARD - DMARD - IMMUNOSUPPRE INTERLEUKIN-1 SSIVES RECEPTOR AZASAN 3 ANTAGONIST azathioprine 1 (IL-1RA) azathioprine sodium 4 KINERET 3 PA CELLCEPT DMARD - 4 INTRAVENOUS INTERLEUKIN-6 CELLCEPT ORAL (IL-6) RECEPTOR 3 CAPSULE INHIBITORS, CELLCEPT ORAL MONOCLONAL SUSPENSION FOR 4 ANTIBODY RECONSTITUTION ACTEMRA ACTPEN 3 PA cyclophosphamide ACTEMRA 4 4 PA intravenous recon soln INTRAVENOUS cyclophosphamide oral ACTEMRA 1 3 PA capsule SUBCUTANEOUS cyclosporine modified KEVZARA oral capsule 100 mg, 25 1 SUBCUTANEOUS 3 PA mg PEN INJECTOR cyclosporine modified 3 PA KEVZARA oral capsule 50 mg SUBCUTANEOUS 3 cyclosporine modified SYRINGE 1 oral solution DMARD - JANUS cyclosporine oral 1 KINASE (JAK) capsule INHIBITORS GENGRAF ORAL OLUMIANT 3 PA CAPSULE 100 MG, 25 1 XELJANZ ORAL MG 3 TABLET 5 MG GENGRAF ORAL 1 SOLUTION XELJANZ XR ORAL TABLET EXTENDED IMURAN 3 3 RELEASE 24 HR 11 mycophenolate mofetil 1 MG mycophenolate mofetil 4 DMARD - OTHER (hcl) AZULFIDINE 3 NEORAL 3 AZULFIDINE EN- SANDIMMUNE ORAL 3 3 TABS CAPSULE CUPRIMINE 3 PA SANDIMMUNE ORAL 3 PA SOLUTION DEPEN TITRATABS 1 D-PENAMINE 3 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 23 Drug Name Drug Tier Limits Drug Name Drug Tier Limits minocycline oral 1 NSAID capsule ANALGESIC AND minocycline oral tablet 3 HISTAMINE H2 penicillamine (bulk) 3 RECEPTOR penicillamine oral ANTAGONIST 2 PA capsule COMBINATIONS PENICILLAMINE(D-) 3 DUEXIS 3 sulfasalazine 1 NSAID DMARD - ANALGESIC AND PHOSPHODIEST PROSTAGLANDI ERASE-4 (PDE4) N ANALOG INHIBITORS COMBINATIONS OTEZLA 3 ARTHROTEC 50 3 OTEZLA STARTER 3 ARTHROTEC 75 3 DMARD - diclofenac-misoprostol 3 PYRIMIDINE NSAID SYNTHESIS ANALGESIC AND INHIBITORS PROTON PUMP QL (30 EA per INHIBITOR ARAVA 3 23 days) COMBINATIONS QL (30 EA per VIMOVO 3 leflunomide 1 23 days) NSAID IMMUNOMODUL ANALGESIC AND ATOR B- TOPICAL LYMPHOCYTE IRRITANT STIMULATOR COUNTER- (BLYS)-SPECIFIC IRRITANT INHIBITOR COMBINATIONS MCAB FLEXIPAK 3 BENLYSTA NUDROXIPAK DSDR- 3 INTRAVENOUS 2 PA 50 RECON SOLN 120 MG NUDROXIPAK DSDR- 3 BENLYSTA 75 INTRAVENOUS 4 PA RECON SOLN 400 MG NUDROXIPAK E-400 3 NUDROXIPAK I-800 3 NUDROXIPAK N-500 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 24 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NSAID NSAID ANALGESIC, ANALGESICS CYCLOOXYGEN (COX NON- ASE-2 (COX-2) SPECIFIC) - SELECTIVE OXICAM INHIBITORS DERIVATIVES CELEBREX 3 FELDENE 3 celecoxib 2 PA meloxicam 1 celecoxib (bulk) 3 meloxicam (bulk) 3 NUDROXIPAK 3 MOBIC ORAL 3 NSAID TABLET ANALGESICS piroxicam 2 PA (COX NON- VIVLODEX 3 SPECIFIC) - NSAID ANTHRANILIC ANALGESICS ACID (COX NON- DERIVATIVES SPECIFIC) - meclofenamate 2 PA PHENYLACETIC mefenamic acid 2 PA ACID mefenamic acid (bulk) 3 DERIVATIVES NSAID CAMBIA 2 PA ANALGESICS diclofenac potassium 1 (COX NON- diclofenac sodium oral 1 SPECIFIC) - VOLTAREN-XR 3 OTHER ZIPSOR 3 ketorolac injection 4 ZORVOLEX 3 cartridge NSAID ketorolac injection 4 ANALGESICS solution (COX NON- ketorolac injection 4 SPECIFIC) - syringe 30 mg/ml PROPIONIC ketorolac intramuscular 4 ACID solution DERIVATIVES ketorolac intramuscular 4 syringe ANAPROX DS 3 ketorolac oral 2 PA CALDOLOR INTRAVENOUS 4 nabumetone 1 RECON SOLN SPRIX 3 DAYPRO 3 sulindac 1 EC-NAPROSYN 3 tolmetin 2 PA EC-NAPROXEN 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 25 Drug Name Drug Tier Limits Drug Name Drug Tier Limits fenoprofen 3 NSAID flurbiprofen oral tablet ANALGESICS 1 100 mg (CYCLOOXYGEN ibuprofen (bulk) 3 ASE ibuprofen oral tablet 400 INHIBITORS- 1 mg, 600 mg, 800 mg NON- ketoprofen oral capsule 1 SELECTIVE) ketoprofen oral CAMBIA 2 PA capsule,ext rel. pellets 3 NSAID 24 hr 200 mg ANALGESICS, NALFON ORAL 3 (COX NON- CAPSULE 400 MG SPECIFIC) - NALFON ORAL 3 INDOLE ACETIC TABLET ACID NAPRELAN CR 3 DERIVATIVES NAPROSYN ORAL 3 etodolac 1 SUSPENSION INDOCIN ORAL 1 NAPROSYN ORAL 3 TABLET 500 MG INDOCIN RECTAL 3 naproxen (bulk) 3 indomethacin (bulk) 3 naproxen oral indomethacin oral 1 1 suspension TIVORBEX ORAL 3 naproxen oral tablet 1 CAPSULE 20 MG naproxen oral SALICYLATE tablet,delayed release 3 ANALGESIC AND (dr/ec) SEDATIVE naproxen sodium (bulk) 3 COMBINATIONS naproxen sodium oral butalbital-aspirin- 1 1 tablet 275 mg, 550 mg caffeine oral capsule naproxen sodium oral FIORINAL 3 tablet, er multiphase 24 3 SALICYLATE hr ANALGESIC oxaprozin 1 COMBINATIONS NSAID choline,magnesium 1 ANALGESICS salicylate (COX NON- SALICYLATE SPECIFIC) - ANALGESICS PYRAZOLONE DERIVATIVES diflunisal 2 PA DISALCID 3 phenylbutazone (bulk) 3 DURLAZA 3 salsalate 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 26 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANESTHETICS midazolam (pf) in 0.9 % nacl intravenous syringe 3 ANESTHETIC, 2 mg/2 ml (1 mg/ml) NON- midazolam (pf) in 0.9 % PARENTERAL- nacl intravenous syringe 4 BENZODIAZEPIN 5 mg/5 ml (1 mg/ml) E-ANTI-EMETIC midazolam (pf) 1 LA COMBINATIONS injection MKO (MIDAZOLAM- 3 LA midazolam in 0.9 % sod KETAMINE-ONDAN) chlorid intravenous 4 LA ANESTHETICS solution 1 mg/ml dibucaine hcl (bulk) 3 midazolam in 0.9 % sod chlorid intravenous GENERAL syringe 2 mg/2 ml (1 3 LA ANESTHETIC - mg/ml), 5 mg/5 ml (1 INHALANT mg/ml) VOLATILE midazolam injection 1 LA desflurane 4 midazolam intravenous GENERAL syringe 150 mg/30 ml (5 1 LA mg/ml) ANESTHETIC - PARENTERAL, GENERAL ARYLCYCLOHE ANESTHETIC - XYLAMINES PARENTERAL, OTHERS ketamine (bulk) 3 AMIDATE ketamine in 0.9 % sod INTRAVENOUS 4 chloride intravenous 4 SOLUTION syringe 100 mg/10 ml (10 mg/ml) etomidate 4 ketamine in nacl, iso- GENERAL 4 osmotic ANESTHETIC - ketamine in sterile water PARENTERAL, 4 injection PHENOL ketamine injection DERIVATIVES solution 100 mg/ml, 50 4 ANESTHESIA S/I-40 4 mg/ml (PROPOFOL) GENERAL ANESTHESIA S/I-40A 4 ANESTHETIC - (PROPOFOL) PARENTERAL, ANESTHESIA S/I-40H 4 BENZODIAZEPIN (PROPOFOL) ES ANESTHESIA S/I-40S 4 midazolam (pf) in 0.9 % (PROPOFOL) nacl intravenous 1 LA ANESTHESIA S/I-60 4 solution (PROPOFOL)

You can find information on what the symbols and abbreviationson this table mean on page 4. 27 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIPRIVAN 4 bupivacaine in nacl(pf) propofol intravenous epidural syringe 25 4 4 emulsion mg/10 ml (2.5mg/ml)0.25% GENERAL bupivacaine in nacl(pf) ANESTHETIC injection syringe 50 4 ADJUNCTS - mg/20 ml NEUROLEPTIC, (2.5mg/ml)0.25% BUTYROPHENO CARBOCAINE NE DERIVATIVE INJECTION 4 droperidol injection CARTRIDGE 1 LA solution lidocaine (pf) injection 4 GENERAL solution ANESTHETIC lidocaine (pf) injection syringe 100 mg/5 ml (2 ADJUNCTS - 4 %), 200 mg/10 ml (2 OPIOID %), 50 mg/5 ml (1 %) fentanyl citrate (pf) 4 lidocaine hcl injection injection solution solution 10 mg/ml (1 4 fentanyl citrate (pf) %), 20 mg/ml (2 %) intravenous pt lidocaine hcl injection controlled analgesia 4 syringe 100 mg/5 ml (2 4 syring 1,500 mcg/30 ml %) (50 mcg/ml) lidocaine hcl fentanyl citrate (pf) 4 4 intradermal intravenous solution lidocaine topical QL (2 GM per 2 fentanyl citrate (pf) ointment 23 days) intravenous syringe 100 4 mcg/2 ml (50 mcg/ml) LTA PRE-ATTACHED 4 sufentanil citrate 4 NAROPIN (PF) 4 ULTIVA 4 prilocaine (bulk) 3 ropivacaine (pf) LOCAL 4 injection solution ANESTHETIC - ropivacaine (pf)- AMIDES 4 nacl,iso-osm bupivacaine 4 ropivacaine(pf)-0.9 % bupivacaine (bulk) 3 sodchlor epidural 4 bupivacaine (pf) prefilled pump reservoir 4 injection solution 0.2 % (2 mg/ml) bupivacaine in nacl(pf) ropivacaine(pf)-0.9 % epidural solution 0.125 4 sodchlor epidural 4 % (1,250 mcg/ml) solution 0.2 %

You can find information on what the symbols and abbreviationson this table mean on page 4. 28 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ropivacaine(pf)-0.9 % ANORECTAL sodchlor local PREPARATIONS infiltration elastomeric 4 pump,hi var rate 0.2 % ANAL FISSURE 545 ml, 0.2 % 745 ml PAIN/TREATMEN SCANDONEST PLAIN 4 T AGENTS - XYLOCAINE NITRATES 4 INJECTION RECTIV 2 PA XYLOCAINE-MPF ANORECTAL - INJECTION GLUCOCORTICO SOLUTION 10 MG/ML 4 (1 %), 15 MG/ML (1.5 IDS %), 20 MG/ML (2 %), 5 hydrocortisone topical MG/ML (0.5 %) cream with perineal 1 ZINGO 4 applicator PROCTOCORT LOCAL 3 TOPICAL ANESTHETIC - ESTERS PROCTO-MED HC 1 PROCTO-PAK 1 CLOROTEKAL 4 PROCTOSOL HC 1 LOCAL TOPICAL ANESTHETIC - PROCTOZONE-HC 1 SYMPATHOMIM ETIC ANORECTAL - COMBINATIONS HEMORRHOIDA L RECTAL bupivacaine-epinephrine 4 GLUCOCORTICO bupivacaine-epinephrine 4 ID-LOCAL (pf) ANESTHETIC lidocaine-epinephrine 4 COMB lidocaine-epineph- 4 ANA-LEX KIT 3 sodium chlor ANALPRAM-HC XYLOCAINE WITH 3 4 RECTAL CREAM EPINEPHRINE ANALPRAM-HC LOCAL SINGLES RECTAL 3 ANESTHETIC- CREAM 2.5-1 % (4G) NSAID-NMDA hydrocortisone- RECEPTOR pramoxine rectal cream 1 ANTAGONIST 2.5-1 % COMBINATIONS lidocaine hcl- QL (2 GM per bupivacaine-ketorolac- hydrocortison ac rectal 1 4 23 days) ketamine cream 3-0.5 %

You can find information on what the symbols and abbreviationson this table mean on page 4. 29 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lidocaine hcl- QL (2 GM per ANTIDOTE - hydrocortison ac rectal 3 23 days) ACETAMINOPHE gel N POISONING lidocaine hcl- ACETADOTE 4 hydrocortison ac rectal 3 PA kit 2 %-2 % (7 gram) acetylcysteine 1 acetylcysteine lidocaine hcl- 4 hydrocortison ac rectal QL (2 EA per intravenous 3 kit 3-0.5 %, 3-1 % (7 23 days) ANTIDOTE - gram) ALCOHOL lidocaine- QL (2 GM per DEHYDROGENA hydrocortisone-aloe 3 23 days) SE ENZYME rectal gel INHIBITOR lidocaine- hydrocortisone-aloe QL (2 EA per fomepizole 4 3 rectal kit 3-2.5 % (7 23 days) ANTIDOTE - gram) CHOLINESTERA PROCORT 3 SE PROCTOFOAM HC 3 REACTIVATING ANORECTAL - AGENT AND HEMORRHOIDA MUSCARINIC L SINGLE ANTAGONIST AGENTS OTHER DUODOTE 4 phenylephrine hcl (bulk) 3 ANTIDOTE - ANTIDOTES CYANIDE AND OTHER POISONING REVERSAL CYANOKIT 4 AGENTS NITHIODOTE 4 ANTICOAGULAN sodium nitrite 4 sodium thiosulfate T REVERSAL 3 AGENT FOR (bulk) powder DIRECT sodium thiosulfate intravenous solution THROMBIN 4 12.5 gram/50 ml (250 INHIBITORS mg/ml) PRAXBIND 4 ANTIDOTE - ANTICOAGULAN DIGITALIS T REVERSAL GLYCOSIDE AGENT FOR TOXICITY FACTOR XA AGENTS INHIBITORS DIGIFAB 4 ANDEXXA 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 30 Drug Name Drug Tier Limits Drug Name Drug Tier Limits deferoxamine injection ANTIDOTE - 4 METHEMOGLOB recon soln 500 mg INEMIA EXJADE 3 PA methylene blue FERRIPROX ORAL 4 3 PA (antidote) SOLUTION FERRIPROX ORAL ANTIDOTE - 3 PA RADIOACTIVE TABLET 500 MG AGENTS JADENU 2 RADIOGARDASE 3 JADENU SPRINKLE ORAL GRANULES IN 1 ANTIDOTE PACKET 180 MG, 360 OTHERS MG GALZIN 3 JADENU SPRINKLE RADIOGARDASE 3 ORAL GRANULES IN 3 PACKET 90 MG BENZODIAZEPIN E REVERSAL CHELATING AGENTS - AGENTS - LEAD BENZODIAZEPIN POISONING E ANTAGONISTS BAL IN OIL 4 CALCIUM DISODIUM flumazenil 4 4 VERSENATE CHELATING CHEMET 1 AGENTS - COPPER DMSA (BULK) 3 CLOVIQUE 2 PA CHELATING AGENTS - CUPRIMINE 3 PA OTHERS DEPEN TITRATABS 1 BAL IN OIL 4 D-PENAMINE 3 PA CA-DTPA 4 penicillamine (bulk) 3 pentetate calcium penicillamine oral 4 2 PA trisodium capsule ZN-DTPA 4 PENICILLAMINE(D-) 3 MU-OPIOID SYPRINE 3 RECEPTOR trientine 2 PA ANTAGONISTS, CHELATING PERIPHERALLY- AGENTS - IRON ACTING deferasirox oral tablet 1 ENTEREG 3 360 mg, 90 mg MOVANTIK 2 PA deferasirox oral tablet, 1 RELISTOR ORAL 3 PA dispersible

You can find information on what the symbols and abbreviationson this table mean on page 4. 31 Drug Name Drug Tier Limits Drug Name Drug Tier Limits RELISTOR gentamicin in nacl (iso- SUBCUTANEOUS 3 PA osm) intravenous SOLUTION piggyback 100 mg/100 ml, 100 mg/50 ml, 120 RELISTOR 4 SUBCUTANEOUS 3 PA mg/100 ml, 60 mg/50 SYRINGE ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 SYMPROIC 3 PA ml, 90 mg/100 ml OPIOID gentamicin injection 4 REVERSAL solution 20 mg/2 ml AGENTS - gentamicin sulfate (pf) OPIOID intravenous solution 100 4 ANTAGONISTS mg/10 ml, 60 mg/6 ml naloxone (bulk) 3 neomycin 1 naloxone injection streptomycin 4 1 solution tobramycin (bulk) 3 naloxone injection 1 tobramycin in 0.9 % syringe nacl intravenous 4 naltrexone 1 piggyback 60 mg/50 ml naltrexone hcl (bulk) 3 tobramycin sulfate 4 tobramycin sulfate NARCAN NASAL 3 SPRAY,NON- (bulk) 1 AEROSOL 4 ZEMDRI 4 MG/ACTUATION AMINOMETHYL REVIA 3 CYCLINE REVERSAL ANTIBIOTICS AGENTS - NUZYRA 4 PA HEPARIN INTRAVENOUS ANTAGONISTS NUZYRA ORAL 3 protamine 4 AMINOPENICILL ANTI- IN ANTIBIOTIC - INFECTIVE BETA- AGENTS LACTAMASE AMEBICIDES INHIBITOR COMBINATIONS iodoquinol (bulk) 3 amoxicillin-pot 1 paromomycin 1 clavulanate AMINOGLYCOSI ampicillin-sulbactam DE ANTIBIOTIC injection recon soln 1.5 4 PA ARIKAYCE 3 PA gram, 3 gram gentamicin (bulk) 3 ampicillin-sulbactam injection recon soln 15 4 gram You can find information on what the symbols and abbreviationson this table mean on page 4. 32 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ampicillin-sulbactam 4 ANTHELMINTIC intravenous AGENTS OTHER AUGMENTIN ES-600 3 BILTRICIDE 3 AUGMENTIN ORAL ivermectin oral 2 PA SUSPENSION FOR RECONSTITUTION 3 praziquantel 3 125-31.25 MG/5 ML, STROMECTOL 3 250-62.5 MG/5 ML ANTIBACTERIAL AUGMENTIN ORAL FOLATE TABLET 500-125 MG, 3 ANTAGONIST - 875-125 MG OTHER AUGMENTIN XR 3 COMBINATIONS UNASYN INJECTION 4 BACTRIM 3 AMINOPENICILL BACTRIM DS 3 IN ANTIBIOTIC sulfamethoxazole- amoxicillin oral capsule 1 trimethoprim 4 amoxicillin oral intravenous suspension for 1 sulfamethoxazole- 1 reconstitution trimethoprim oral amoxicillin oral tablet 1 SULFATRIM 1 amoxicillin oral ANTIBACTERIAL tablet,chewable 125 mg, 1 FOLATE 250 mg ANTAGONIST ampicillin oral capsule 1 OTHERS ampicillin sodium 4 PRIMSOL 3 MOXATAG 3 trimethoprim 1 ANTHELMINTIC trimethoprim (bulk) 3 AGENTS - trimethoprim, micro 3 BENZIMIDAZOL (bulk) E DERIVATIVES ANTIBACTERIAL albendazole 3 NITROFURAN ALBENZA 3 DERIVATIVES EMVERM 3 PA FURADANTIN 1 thiabendazole (bulk) 3 MACROBID 3 ANTHELMINTIC MACRODANTIN 3 AGENTS - nitrofurantoin 1 MACROCYCLIC nitrofurantoin (bulk) 3 LACTONES nitrofurantoin 1 ivermectin (bulk) 3 macrocrystal ivermectin oral 2 PA nitrofurantoin 1 STROMECTOL 3 monohyd/m-cryst You can find information on what the symbols and abbreviationson this table mean on page 4. 33 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIBACTERIAL econazole nitrate (bulk) 3 OTHER ketoconazole (bulk) 3 MONUROL 1 powder ANTIFUNGAL - ketoconazole oral 3 PA ALLYLAMINES ORAVIG 2 PA terbinafine (bulk) 3 ANTIFUNGAL - terbinafine hcl oral 1 TRIAZOLES CRESEMBA ANTIFUNGAL - 4 INTRAVENOUS AMPHOTERIC POLYENE CRESEMBA ORAL 3 MACROLIDES DIFLUCAN ORAL SUSPENSION FOR 3 ABELCET 4 RECONSTITUTION AMBISOME 4 DIFLUCAN ORAL amphotericin b 2 PA TABLET 100 MG, 200 3 nystatin (bulk) powder 1 MG, 50 MG billion unit, 10 billion DIFLUCAN ORAL QL (2 EA per 3 unit, 2 billion unit, 5 1 TABLET 150 MG 23 days) billion unit, 500 million fluconazole in nacl (iso- 4 unit osm) nystatin oral tablet 1 fluconazole oral ANTIFUNGAL - suspension for 1 FLUORINATED reconstitution fluconazole oral tablet PYRIMIDINE- 1 TYPE AGENTS 100 mg, 200 mg, 50 mg fluconazole oral tablet QL (2 EA per ANCOBON 3 2 150 mg 23 days) flucytosine 3 itraconazole oral 3 PA ANTIFUNGAL - capsule GLUCAN itraconazole oral 2 PA SYNTHESIS solution INHIBITORS NOXAFIL 4 (ECHINOCANDIN INTRAVENOUS S) NOXAFIL ORAL 3 PA CANCIDAS 4 SUSPENSION caspofungin 4 NOXAFIL ORAL ERAXIS(WATER TABLET,DELAYED 3 4 DILUENT) RELEASE (DR/EC) SPORANOX ORAL MYCAMINE 4 2 PA SOLUTION ANTIFUNGAL - SPORANOX 3 IMIDAZOLES PULSEPAK clotrimazole (bulk) 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 34 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TOLSURA 3 PA MALARONE 3 VFEND 3 MALARONE 3 VFEND IV 4 PEDIATRIC voriconazole ANTIMALARIAL 4 PA intravenous S voriconazole oral ARAKODA 3 suspension for 3 chloroquine phosphate 1 reconstitution chloroquine phosphate 3 voriconazole oral tablet 3 PA (bulk) ANTIFUNGAL DARAPRIM 3 PA OTHER hydroxychloroquine 1 ANCOBON 3 hydroxychloroquine sulf 3 benzoic acid (bulk) (bulk) 1 crystals KRINTAFEL 3 PA benzoic acid (bulk) 3 mefloquine 1 powder PLAQUENIL 3 clioquinol (bulk) 3 primaquine 3 PA flucytosine 3 pyrimethamine (bulk) 3 griseofulvin (bulk) 3 QUALAQUIN 3 griseofulvin microsize 1 quinacrine (bulk) 3 griseofulvin 1 ultramicrosize quinine sulfate 2 PA ANTI-INFECTIVE ANTIPROTOZOA IMMUNOLOGIC L AGENTS - ADJUVANTS - OTHER INTERFERONS ALINIA ORAL SUSPENSION FOR 2 PA ACTIMMUNE 2 RECONSTITUTION ANTILEPROTIC - ALINIA ORAL 3 IMMUNOMODUL TABLET ATORS atovaquone 1 THALOMID 3 IMPAVIDO 3 ANTILEPROTIC - MEPRON 3 SULFONE AGENTS dapsone oral 1 ANTIMALARIAL COMBINATIONS atovaquone-proguanil 2 PA COARTEM 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 35 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPROTOZOA ANTIRETROVIR L AGENTS AL - ANTI-CD4 (ANTIPARASITIC DOMAIN 2 ) - 5- MONOCLONAL NITROTHIAZOL ANTIBODY YL TROGARZO 4 DERIVATIVES ANTIRETROVIR ALINIA ORAL AL - CCR5 CO- SUSPENSION FOR 2 PA RECEPTOR RECONSTITUTION ANTAGONIST ALINIA ORAL 3 TABLET SELZENTRY 1 ANTIPROTOZOA ANTIRETROVIR L- AL - HIV-1 ANTIBACTERIAL FUSION 1ST INHIBITORS GENERATION 2- FUZEON METHYL-5- SUBCUTANEOUS 1 NITROIMIDAZO RECON SOLN LE ANTIRETROVIR FLAGYL 3 AL - HIV-1 INTEGRASE METRO I.V. 4 STRAND metronidazole in nacl 4 TRANSFER (iso-os) INHIBITORS metronidazole oral 3 capsule ISENTRESS 1 metronidazole oral ISENTRESS HD 1 1 tablet TIVICAY 1 ANTIPROTOZOA ANTIRETROVIR L- AL - INTEGRASE ANTIBACTERIAL INHIBITOR AND 2ND NNRTI GENERATION 2- COMBINATIONS METHYL-5- JULUCA 3 NITROIMIDAZO ANTIRETROVIR LE AL - INTEGRASE SOLOSEC 2 PA INHIBITOR AND tinidazole 1 NRTI tinidazole (bulk) 3 COMBINATIONS DOVATO 3 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 36 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIRETROVIR didanosine oral capsule,delayed AL - NON- 1 NUCLEOSIDE release(dr/ec) 250 mg, 400 mg REVERSE TRANSCRIPTASE EMTRIVA 1 INHIB (NNRTI) EPIVIR 3 EDURANT 1 lamivudine oral solution 1 lamivudine oral tablet efavirenz 1 1 150 mg, 300 mg INTELENCE 1 RETROVIR 4 nevirapine 1 INTRAVENOUS PIFELTRO 3 RETROVIR ORAL 3 SUSTIVA 3 CAPSULE VIRAMUNE ORAL RETROVIR ORAL 1 3 SUSPENSION SYRUP VIRAMUNE ORAL stavudine oral capsule 1 3 TABLET ZERIT ORAL 3 VIRAMUNE XR CAPSULE 30 MG ORAL TABLET ZIAGEN 3 EXTENDED 3 RELEASE 24 HR 400 zidovudine 1 MG ANTIRETROVIR ANTIRETROVIR AL - AL - NUCLEOTIDE NUCLEOSIDE ANALOG AND REVERSE NUCLEOTIDE TRANSCRIPTASE ANALOG RTIS INHIBITORS COMBINATIONS tenofovir disoproxil 1 CIMDUO 3 fumarate VIREAD ORAL DESCOVY 3 PA 1 POWDER TRUVADA 1 VIREAD ORAL ANTIRETROVIR TABLET 150 MG, 200 1 AL - MG, 250 MG NUCLEOSIDE VIREAD ORAL 3 REVERSE TABLET 300 MG TRANSCRIPTASE ANTIRETROVIR INHIBITORS AL (NRTI) COMBINATIONS abacavir 1 - PROTEASE INHIBITORS EVOTAZ 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 37 Drug Name Drug Tier Limits Drug Name Drug Tier Limits KALETRA ORAL COMBIVIR 3 3 SOLUTION EPZICOM 3 KALETRA ORAL 1 lamivudine-zidovudine 1 TABLET TRIZIVIR 3 lopinavir-ritonavir 1 ANTIRETROVIR PREZCOBIX 1 AL- ANTIRETROVIR NUCLEOSIDE, AL- NUCLEOTIDE NUCLEOSIDE ANALOGS AND AND NON- NUCLEOTIDE NUCLEOSIDE ANALOGS,PROT RTI EASE ATRIPLA 1 INHIBITORS COMPLERA 1 SYMTUZA 3 DELSTRIGO 3 ANTIRETROVIR ODEFSEY 1 AL-INTEGRASE INHIBITOR,NUC SYMFI 3 LEOSIDE AND SYMFI LO 3 NUCLEOTIDE ANTITUBERCUL RTIS COMB AR - BIKTARVY 3 AMINOBENZOIC GENVOYA 1 ACID ANALOGS aminosalicylic acid STRIBILD 1 3 (bulk) ANTIRETROVIR PASER 3 AL-NUCLEOSIDE ANALOGS AND ANTITUBERCUL INTEGRASE AR - CYCLIC INHIBITOR PEPTIDE COMBINATIONS ANTIBIOTICS TRIUMEQ 1 CAPASTAT 4 ANTIRETROVIR ANTITUBERCUL AL-NUCLEOSIDE AR - D-ALANINE REVERSE ANALOGS TRANSCRIPTASE cycloserine 2 PA INHIBITORS (NRTI) COMB abacavir-lamivudine 1 abacavir-lamivudine- 1 zidovudine

You can find information on what the symbols and abbreviationson this table mean on page 4. 38 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTITUBERCUL ANTITUBERCUL AR - AR AGENTS DIARYLQUINOLI OTHER NE ANTIBIOTICS ethambutol 1 SIRTURO ORAL MYAMBUTOL ORAL 1 3 TABLET 100 MG TABLET 400 MG ANTITUBERCUL TRECATOR 2 PA AR - ANTITUBERCUL ISONICOTINIC AR ACID COMBINATIONS DERIVATIVES RIFAMATE 3 PA isoniazid injection 4 RIFATER 3 PA isoniazid oral 1 CARBAPENEM ANTITUBERCUL ANTIBIOTIC AR - COMBINATIONS NIACINAMIDE imipenem-cilastatin 4 DERIVATIVES PRIMAXIN IV pyrazinamide 1 INTRAVENOUS 4 ANTITUBERCUL RECON SOLN 500 MG AR - VABOMERE 4 NITROIMIDAZO CARBAPENEM LE ANTIBIOTICS DERIVATIVES (THIENAMYCINS pretomanid 3 ) ANTITUBERCUL ertapenem 4 AR - RIFAMYCIN INVANZ INJECTION 4 AND meropenem 4 DERIVATIVES meropenem-0.9% 4 MYCOBUTIN 3 sodium chloride PRIFTIN 1 MERREM 4 rifabutin 2 PA CATHETER RIFADIN 4 LOCK - INTRAVENOUS AMINOGLYCOSI RIFADIN ORAL 3 DE rifampin intravenous 4 ANTIBIOTICS- rifampin oral 1 ANTICOAGULAN T COMB gentamicin-sodium citrate intra-catheter 4 solution

You can find information on what the symbols and abbreviationson this table mean on page 4. 39 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CEPHALOSPORI CEPHALOSPORI N ANTIBIOTIC N ANTIBIOTICS - AND BETA- 2ND LACTAMASE GENERATION INHIBITOR cefaclor oral capsule 1 COMBINATIONS cefaclor oral suspension AVYCAZ 4 for reconstitution 125 1 ZERBAXA 4 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml CEPHALOSPORI cefaclor oral tablet 3 PA N ANTIBIOTICS - extended release 12 hr 1ST CEFOTAN 2 PA GENERATION cefotetan 2 PA cefadroxil oral capsule 1 cefotetan in dextrose, 2 PA cefadroxil oral iso-osm suspension for 1 reconstitution 250 mg/5 cefoxitin 2 PA ml, 500 mg/5 ml cefoxitin in dextrose, 2 PA cefadroxil oral tablet 1 iso-osm cefazolin in 0.9% sod cefprozil 1 chloride intravenous cefuroxime axetil oral 4 1 piggyback 3 gram/100 tablet ml cefuroxime sodium cefazolin in 0.9% sod injection recon soln 750 2 PA chloride intravenous 4 mg solution cefuroxime sodium 2 PA cefazolin in dextrose intravenous (iso-os) intravenous MEFOXIN IN piggyback 1 gram/50 2 PA DEXTROSE (ISO- 4 ml, 2 gram/100 ml, 2 OSM) gram/50 ml CEPHALOSPORI cefazolin injection recon soln 1 gram, 10 gram, 2 PA N ANTIBIOTICS - 20 gram, 500 mg 3RD cefazolin injection recon GENERATION 4 soln 100 gram, 300 g cefdinir 1 cefazolin intravenous 2 PA cefditoren pivoxil 3 cephalexin 1 cefixime 1 KEFLEX ORAL cefotaxime injection 3 2 PA CAPSULE recon soln 1 gram cefpodoxime 1 ceftazidime 2 PA ceftazidime in d5w 2 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 40 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ceftriaxone in 2 PA CEPHALOSPORI dextrose,iso-os N ANTIBIOTICS - ceftriaxone injection SIDEROPHORE recon soln 1 gram, 10 2 PA FETROJA 2 PA gram, 2 gram, 250 mg, 500 mg CHLORAMPHENI ceftriaxone injection COL 1 recon soln 100 gram ANTIBIOTICS ceftriaxone intravenous 2 PA AND CLAFORAN DERIVATIVES - INJECTION RECON SINGLE AGENTS 4 SOLN 1 GRAM, 2 chloramphenicol (bulk) 3 GRAM chloramphenicol sod 4 CLAFORAN succinate INTRAVENOUS 4 RECON SOLN CMV ANTIVIRAL AGENT - SPECTRACEF ORAL 1 TABLET 400 MG INORGANIC PYROPHOSPHAT SUPRAX ORAL 3 PA CAPSULE E ANALOGS SUPRAX ORAL FOSCAVIR 4 SUSPENSION FOR 3 CMV ANTIVIRAL RECONSTITUTION AGENT - SUPRAX ORAL 1 NUCLEOSIDE TABLET,CHEWABLE ANALOGS TAZICEF INJECTION 2 PA CYTOVENE 4 TAZICEF ganciclovir sodium 4 PA 4 PA INTRAVENOUS intravenous recon soln CEPHALOSPORI ganciclovir sodium 4 N ANTIBIOTICS - intravenous solution 4TH VALCYTE 3 GENERATION valganciclovir 1 cefepime 2 PA CMV ANTIVIRAL cefepime in dextrose 5 2 PA AGENT - % NUCLEOTIDE cefepime in 2 PA ANALOGS dextrose,iso-osm cidofovir 4 CEPHALOSPORI N ANTIBIOTICS - 5TH GENERATION TEFLARO 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 41 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CMV ANTIVIRAL levofloxacin intravenous 4 AGENT - levofloxacin oral 3 TERMINASE solution COMPLEX levofloxacin oral tablet 1 INHIBITORS moxifloxacin oral 3 PA PREVYMIS moxifloxacin- 4 4 INTRAVENOUS sod.ace,sul-water CYCLIC moxifloxacin- 4 LIPOPEPTIDE sod.chloride(iso) ANTIBIOTICS ofloxacin oral tablet 300 3 CUBICIN 4 mg, 400 mg daptomycin 4 GLYCOPEPTIDE ANTIBIOTICS FLUOROCYCLIN E ANTIBIOTICS FIRVANQ 1 XERAVA VANCOCIN 3 PA INTRAVENOUS 4 vancomycin hcl in water 4 RECON SOLN 50 MG vancomycin in 0.9 % FLUOROQUINOL sodium chl intravenous 4 ONE piggyback ANTIBIOTICS vancomycin in dextrose 5 % intravenous 4 AVELOX IN NACL 4 piggyback (ISO-OSMOTIC) vancomycin in dextrose BAXDELA 4 5 % intravenous INTRAVENOUS solution 1 gram/250 ml, 4 CIPRO ORAL 1.25 gram/250 ml, 1.5 SUSPENSION,MICRO 3 PA gram/250 ml CAPSULE RECON vancomycin intravenous CIPRO ORAL recon soln 1,000 mg, TABLET 250 MG, 500 3 1.25 gram, 1.5 gram, 10 4 MG gram, 5 gram, 500 mg, CIPRO XR 3 750 mg vancomycin oral ciprofloxacin hcl oral 1 1 capsule ciprofloxacin in 5 % 4 vancomycin oral recon dextrose 1 soln ciprofloxacin oral suspension,microcapsul 4 vancomycin-water inject (peg) intravenous e recon 250 mg/5 ml 4 piggyback 1 gram/200 ciprofloxacin oral ml, 1.5 gram/300 ml suspension,microcapsul 1 e recon 500 mg/5 ml GLYCYLCYCLIN levofloxacin in d5w 4 E ANTIBIOTICS tigecycline 4 You can find information on what the symbols and abbreviationson this table mean on page 4. 42 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TYGACIL 4 VALTREX ORAL 3 HEPATITIS B TABLET 500 MG ZOVIRAX ORAL TREATMENT- 3 NUCLEOSIDE SUSPENSION ANALOGS HERPES (ANTIVIRAL) ANTIVIRAL BARACLUDE 3 AGENT - THYMIDINE entecavir 1 ANALOGS EPIVIR HBV ORAL 1 SOLUTION famciclovir 2 PA EPIVIR HBV ORAL INFLUENZA 3 TABLET ANTIVIRAL lamivudine oral tablet AGENTS - 1 100 mg NEURAMINIDAS HEPATITIS B E INHIBITORS TREATMENT- oseltamivir oral capsule 1 NUCLEOTIDE oseltamivir oral QL (180 ML ANALOGS suspension for 2 Max Qty Per (ANTIVIRAL) reconstitution Fill Retail) oseltamivir phosphate adefovir 2 PA 3 (bulk) HEPSERA 3 RAPIVAB (PF) 4 VEMLIDY 3 RELENZA QL (20 EA per 3 HERPES DISKHALER 23 days) ANTIVIRAL TAMIFLU ORAL 3 AGENT - PURINE CAPSULE ANALOGS TAMIFLU ORAL QL (180 ML acyclovir (bulk) 3 SUSPENSION FOR 3 Max Qty Per acyclovir oral capsule 1 RECONSTITUTION Fill Retail) acyclovir oral INFLUENZA 1 suspension 200 mg/5 ml ANTIVIRAL acyclovir oral tablet 1 AGENTS - PA acyclovir sodium 4 ENDONUCLEASE INHIBITOR SITAVIG 3 XOFLUZA 3 PA valacyclovir oral tablet QL (30 EA per 2 1 gram 23 days) INFLUENZA-A valacyclovir oral tablet ANTIVIRAL 1 500 mg AGENTS VALTREX ORAL QL (30 EA per FLUMADINE ORAL 3 3 TABLET 1 GRAM 23 days) TABLET rimantadine 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 43 Drug Name Drug Tier Limits Drug Name Drug Tier Limits clarithromycin oral LINCOSAMIDE 1 ANTIBIOTICS tablet CLEOCIN HCL 3 clarithromycin oral tablet extended release 3 CLEOCIN INJECTION 4 24 hr CLEOCIN PEDIATRIC 3 PA DIFICID 3 clindamycin hcl 1 E.E.S. 400 ORAL 3 clindamycin hcl (bulk) 3 TABLET clindamycin in 5 % E.E.S. GRANULES 3 4 dextrose ERYPED 200 3 clindamycin palmitate 1 ERYPED 400 3 hcl ERY-TAB 1 CLINDAMYCIN 1 PEDIATRIC ERYTHROCIN 4 clindamycin phosphate ERYTHROCIN (AS 1 (bulk) crystals STEARATE) ORAL 3 TABLET 250 MG clindamycin phosphate 3 (bulk) powder erythromycin ethylsuccinate oral clindamycin phosphate 1 4 suspension for injection reconstitution LINCOCIN 4 erythromycin lincomycin 4 ethylsuccinate oral 1 LIPOGLYCOPEP tablet TIDE erythromycin oral ANTIBIOTICS capsule,delayed 1 release(dr/ec) DALVANCE 4 erythromycin oral tablet 3 VIBATIV erythromycin oral INTRAVENOUS 4 tablet,delayed release 1 RECON SOLN 750 MG (dr/ec) 250 mg, 333 mg MACROLIDE ZITHROMAX 4 ANTIBIOTICS INTRAVENOUS azithromycin ZITHROMAX ORAL 4 3 PA intravenous PACKET azithromycin oral 2 PA ZITHROMAX ORAL packet SUSPENSION FOR 3 azithromycin oral RECONSTITUTION suspension for 1 ZITHROMAX ORAL reconstitution TABLET 250 MG, 500 3 azithromycin oral tablet 1 MG ZITHROMAX TRI- clarithromycin oral 3 suspension for 1 PAK reconstitution ZITHROMAX Z-PAK 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 44 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MISC ANTI- linezolid oral INFECTIVE suspension for 2 PA COMBINATIONS reconstitution linezolid oral tablet 1 HYOPHEN 3 linezolid-0.9% sodium methen-sod phos-meth 4 3 chloride blue-hyos SIVEXTRO PHOSPHASAL 1 4 INTRAVENOUS URELLE 3 SIVEXTRO ORAL 3 URETRON D-S ORAL ZYVOX TABLET 81.6-10.8- 1 4 INTRAVENOUS 40.8 MG ZYVOX ORAL 3 URIBEL 3 URIMAR-T 3 PENICILLIN ANTIBIOTIC - URIN DS 1 NATURAL UROGESIC-BLUE 3 BICILLIN L-A 4 URO-MP 3 penicillin g pot in 4 URYL 3 dextrose USTELL 3 penicillin g potassium UTIRA-C 3 injection recon soln 20 4 MISC ANTI- million unit INFECTIVE penicillin g procaine 4 HIPREX 3 penicillin g sodium 2 PA methenamine hippurate 1 penicillin v potassium 1 methenamine mandelate 3 PENICILLIN QL (1 EA per ANTIBIOTIC - NEBUPENT 2 23 days) PENICILLINASE- PENTAM 4 RESISTANT pentamidine inhalation 2 dicloxacillin 1 pentamidine injection 4 nafcillin 4 nafcillin in dextrose iso- UROQID-ACID NO.2 3 4 osm MONOBACTAM oxacillin 4 ANTIBIOTICS oxacillin in 4 AZACTAM 4 dextrose(iso-osm) aztreonam injection 4 recon soln 2 gram OXAZOLIDINON E ANTIBIOTICS linezolid in dextrose 5% 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 45 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PENICILLIN polymyxin b sulf,micron.(bulk) ANTIBIOTIC, 3 EXTENDED- powder 50 million unit, 6,000 unit/mg SPECTRUM AND BETA- PROTEASE LACTAMASE INHIBITORS INHIB COMB (NON-PEPTIDIC) ANTIRETROVIR piperacillin-tazobactam intravenous recon soln 4 AL 13.5 gram, 40.5 gram APTIVUS 1 piperacillin-tazobactam APTIVUS (WITH 1 intravenous recon soln VITAMIN E) 4 PA 2.25 gram, 3.375 gram, PREZCOBIX 1 4.5 gram PREZISTA ORAL 1 ZOSYN IN SUSPENSION DEXTROSE (ISO- 4 OSM) PREZISTA ORAL TABLET 150 MG, 600 1 PENICILLIN MG, 75 MG, 800 MG NATURAL PROTEASE ANTIBIOTIC INHIBITORS COMBINATIONS (PEPTIDIC) - EXTENDED ANTIRETROVIR RELEASE AL BICILLIN C-R 4 atazanavir 1 POLYMYXINS CRIXIVAN ORAL 1 AND CAPSULE 200 MG DERIVATIVES - EVOTAZ 1 SINGLE AGENTS fosamprenavir 1 bacitracin (bulk) powder 3 INVIRASE ORAL 5 million unit 1 TABLET bacitracin intramuscular 4 LEXIVA ORAL 1 bacitracin, micronized SUSPENSION (bulk) powder 75.7 3 LEXIVA ORAL unit/mg 3 PA TABLET colistin (colistimethate 4 NORVIR 3 PA na) REYATAZ ORAL colistin sulfate (bulk) 3 CAPSULE 150 MG, 3 COLY-MYCIN M 4 300 MG PARENTERAL REYATAZ ORAL 3 PA CAPSULE 200 MG REYATAZ ORAL 3 POWDER IN PACKET You can find information on what the symbols and abbreviationson this table mean on page 4. 46 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VIRACEPT ORAL 1 TETRACYCLINE TABLET AND RIFAMYCINS TETRACYCLINE AND RELATED ANTIBIOTIC DERIVATIVE COMBINATIONS ANTIBIOTICS AVIDOXY DK 3 AEMCOLO 3 BENZODOX 30 3 MYCOBUTIN 3 BENZODOX 60 3 PRIFTIN 1 TETRACYCLINE rifabutin 2 PA ANTIBIOTICS RIFADIN 4 ACTICLATE 3 INTRAVENOUS AVIDOXY 3 RIFADIN ORAL 3 COREMINO 3 rifampin (bulk) 3 demeclocycline 3 rifampin intravenous 4 DORYX MPC 3 rifampin oral 1 DORYX ORAL XIFAXAN 2 TABLET,DELAYED 3 STREPTOGRAMI RELEASE (DR/EC) N ANTIBIOTICS 200 MG, 50 MG DOXY-100 4 SYNERCID 4 doxycycline hyclate 3 SULFONAMIDE (bulk) ANTIBIOTIC doxycycline hyclate oral 1 sulfacetamide (bulk) 3 capsule sulfacetamide sod, 3 doxycycline hyclate oral mono (bulk) tablet 100 mg, 150 mg, 1 sulfacetamide sodium 50 mg 3 (bulk) doxycycline hyclate oral tablet,delayed release sulfadiazine 2 PA 3 (dr/ec) 100 mg, 150 mg, sulfadiazine (bulk) 3 200 mg, 50 mg, 75 mg sulfadiazine sodium 3 doxycycline (bulk) monohydrate oral 1 sulfamethoxazole (bulk) 3 capsule 100 mg, 50 mg sulfanilamide (bulk) 3 doxycycline sulfisoxazole (bulk) 1 monohydrate oral 3 capsule 150 mg, 75 mg doxycycline monohydrate oral 3 capsule,ir - delay rel,biphase

You can find information on what the symbols and abbreviationson this table mean on page 4. 47 Drug Name Drug Tier Limits Drug Name Drug Tier Limits doxycycline VIBRAMYCIN ORAL 3 monohydrate oral CAPSULE 100 MG 3 suspension for VIBRAMYCIN ORAL reconstitution SUSPENSION FOR 3 doxycycline RECONSTITUTION 1 monohydrate oral tablet VIBRAMYCIN ORAL 3 MINOCIN SYRUP 4 INTRAVENOUS XERAVA minocycline oral INTRAVENOUS 4 1 capsule RECON SOLN 50 MG minocycline oral tablet 3 ANTINEOPLAST minocycline oral tablet ICS extended release 24 hr 3 PA 105 mg, 65 mg, 80 mg ANP - HUMAN VASCULAR minocycline oral tablet extended release 24 hr ENDOTHELIAL 3 115 mg, 135 mg, 45 mg, GROWTH 55 mg, 90 mg FACTOR INHIB MINOLIRA ER 3 PA REC-MC MONDOXYNE NL ANTIBODY ORAL CAPSULE 100 3 AVASTIN 4 MG, 75 MG ZIRABEV 4 MONODOX 3 ANTINEOPLASIC MORGIDOX 2X100 3 - MORGIDOX ORAL 1 EPIDERM.GROW CAPSULE 100 MG TH FACTOR- NUZYRA 4 PA EGFR INTRAVENOUS (ERBB1),HER-2 NUZYRA ORAL 3 (ERBB2)R.INHIB ORACEA 3 TYKERB 2 oxytetracycline (bulk) 3 ANTINEOPLASTI SEYSARA 3 C - CYP17 (17 SOLODYN ORAL ALPHA- TABLET EXTENDED HYDROXYLASE/ RELEASE 24 HR 105 3 C17,20-LYASE) MG, 115 MG, 55 MG, INHIBITOR 65 MG, 80 MG abiraterone 1 tetracycline 1 YONSA 3 tetracycline hcl (bulk) 3 ZYTIGA 3 PA tigecycline 4 TYGACIL 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 48 Drug Name Drug Tier Limits Drug Name Drug Tier Limits thiotepa injection recon ANTINEOPLASTI 4 C - 1ST soln 15 mg GENERATION ANTINEOPLASTI EGFR TYROSINE C - ALKYLATING KINASE AGENT - INHIBITOR METHYLHYDRA erlotinib 1 PA ZINES IRESSA 2 MATULANE 3 PA TARCEVA 2 ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - 2ND AGENT - GENERATION NITROGEN EGFR TYROSINE MUSTARDS KINASE ALKERAN 1 INHIBITOR ALKERAN (AS HCL) 4 GILOTRIF 2 cyclophosphamide 4 NERLYNX 2 PA intravenous recon soln cyclophosphamide oral VIZIMPRO 2 PA 1 capsule ANTINEOPLASTI EVOMELA 4 C - 3RD GENERATION IFEX 4 EGFR TYROSINE ifosfamide 4 KINASE LEUKERAN 1 INHIBITOR melphalan hcl 4 TAGRISSO 2 ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - ALKYLATING AGENT - AGENT - ALKYL NITROSOUREAS SULFONATES BICNU 4 BUSULFEX 4 carmustine 3 MYLERAN 1 GLEOSTINE ORAL ANTINEOPLASTI CAPSULE 10 MG, 100 3 MG, 40 MG C - ALKYLATING AGENT - GLIADEL WAFER 4 ETHYLENIMINE ANTINEOPLASTI S AND C - ALKYLATING METHYLMELAM AGENT - OTHER INES BELRAPZO 4 TEPADINA 4 BENDEKA 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 49 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TREANDA XTANDI 2 INTRAVENOUS 4 YONSA 3 RECON SOLN ZYTIGA 3 PA ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - ANTIBODY- AGENT - DRUG TRIAZENES CONJUGATES dacarbazine 4 (ADCS) TEMODAR 4 ADCETRIS 4 PA INTRAVENOUS KADCYLA 4 PA TEMODAR ORAL 3 POLIVY temozolomide 1 INTRAVENOUS 4 ANTINEOPLASTI RECON SOLN 140 MG C - ANAPLASTIC ANTINEOPLASTI LYMPHOMA C - ANTI-GD2 KINASE (ALK) GANGLIOSIDE INHIBITORS MONOCLONAL ALECENSA 2 PA ANTIBODY ALUNBRIG 2 PA UNITUXIN 4 LORBRENA 2 PA ANTINEOPLASTI XALKORI 2 C - ZYKADIA ORAL ANTIMETABOLI 2 PA TABLET TE - FOLIC ACID ANTINEOPLASTI ANALOGS C - ALIMTA 4 PA ANTIADRENALS FOLOTYN 4 LYSODREN 1 methotrexate sodium 1 ANTINEOPLASTI (pf) methotrexate sodium C - 4 ANTIANDROGEN injection methotrexate sodium S 1 oral abiraterone 1 TREXALL 1 bicalutamide 1 XATMEP 1 CASODEX 3 PA ERLEADA 2 PA ANTINEOPLASTI C - flutamide 1 ANTIMETABOLI NILANDRON 3 TE - PURINE nilutamide 2 PA ANALOGS NUBEQA 2 PA ARRANON 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 50 Drug Name Drug Tier Limits Drug Name Drug Tier Limits cladribine 4 ANTINEOPLASTI clofarabine 4 C - CLOLAR 4 ANTIMETABOLI fludarabine 4 TES - PYRIMIDINE mercaptopurine 1 ANALOG NIPENT 4 COMBINATIONS PURIXAN 2 PA LONSURF 1 TABLOID 1 ANTINEOPLASTI ANTINEOPLASTI C - ANTI-SLAMF7 C - MONOCLONAL ANTIMETABOLI ANTIBODY TE - PYRIMIDINE AGENTS ANALOGS EMPLICITI 4 ADRUCIL INTRAVENOUS ANTINEOPLASTI 4 SOLUTION 2.5 C - AROMATASE GRAM/50 ML INHIBITORS azacitidine 4 anastrozole 1 capecitabine 1 PA ARIMIDEX 3 cytarabine 4 AROMASIN 3 PA cytarabine (pf) injection exemestane 1 4 solution FEMARA 3 DACOGEN 4 letrozole 1 decitabine 4 ANTINEOPLASTI floxuridine 4 C - ARSENIC fluorouracil (bulk) 3 COMPOUNDS fluorouracil intravenous 4 arsenic trioxide (bulk) 4 gemcitabine 4 arsenic trioxide INFUGEM 4 intravenous solution 1 4 mg/ml VIDAZA 4 TRISENOX XELODA 3 INTRAVENOUS 4 ANTINEOPLASTI SOLUTION 2 MG/ML C - ANTINEOPLASTI ANTIMETABOLI C - TE - UREA ASPARAGINASE DERIVATIVES ENZYME HYDREA 3 THERAPY hydroxyurea 1 AGENTS ERWINAZE 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 51 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONCASPAR 4 ANTINEOPLASTI ANTINEOPLASTI C - CD20 C - B-CELL SPECIFIC LYMPHOMA-2 RECOMBINANT (BCL-2) MONOCLONAL INHIBITORS ANTIBODY VENCLEXTA 2 PA AGENTS VENCLEXTA ARZERRA 4 3 STARTING PACK GAZYVA 4 ANTINEOPLASTI RITUXAN 4 PA C - BRAF KINASE RITUXAN HYCELA 4 PA INHIBITORS ANTINEOPLASTI BRAFTOVI 2 PA C - CD22 TAFINLAR 2 DIRECTED ZELBORAF 2 ANTIBODY AND ANTINEOPLASTI CYTOTOXIN C - BRUTON'S CONJUGATE TYROSINE LUMOXITI 4 KINASE (BTK) ANTINEOPLASTI INHIBITOR C - CD38 BRUKINSA 2 PA SPECIFIC CALQUENCE 2 PA RECOMBINANT MONOCLONAL IMBRUVICA 2 PA ANTIBODY ANTINEOPLASTI AGENTS C - CC DARZALEX 4 CHEMOKINE RECEPTOR 4 ANTINEOPLASTI (CCR4) C - CD52 ANTAGONIST, SPECIFIC REC-MAB RECOMBINANT MONOCLONAL POTELIGEO 4 ANTIBODY ANTINEOPLASTI AGENTS C - CD-19 CAMPATH 4 DIRECTED CAR- T CELL IMMUNOTHERA PY TECARTUS 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 52 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C - CYCLIN- C - ESTROGENS DEPENDENT diethylstilbestrol (bulk) 3 KINASE (CDK) EMCYT 1 4/6 INHIBITORS ANTINEOPLASTI IBRANCE ORAL 2 C - FIBROBLAST CAPSULE GROWTH KISQALI ORAL FACTOR TABLET 200 MG/DAY 2 PA (200 MG X 1) RECEPTOR (FGFR) KINASE VERZENIO 2 PA INHIB ANTINEOPLASTI BALVERSA 3 C - CYTOTOXIC T-LYMPHOCYTE ANTINEOPLASTI ANTIGEN (CTLA- C - FMS-LIKE 4),R-MC TYROSINE ANTIBODY KINASE 3 (FLT3) INHIBITORS YERVOY 4 PA XOSPATA 2 PA ANTINEOPLASTI C - ANTINEOPLASTI EPIPODOPHYLL C - OTOXINS HALICHONDRIN B ANALOGS, ETOPOPHOS 4 MICROTUBULE etoposide intravenous 4 INHIBITORS etoposide oral 2 PA HALAVEN 4 teniposide 4 ANTINEOPLASTI TOPOSAR 4 C - HEDGEHOG ANTINEOPLASTI PATHWAY C - INHIBITOR EPOTHILONES DAURISMO 2 PA AND ANALOGS ERIVEDGE 2 IXEMPRA 4 ODOMZO 2 PA ANTINEOPLASTI ANTINEOPLASTI C - ESTROGEN C - HISTONE RECEPTOR DEACETYLASE ANTAGONIST (HDAC) FASLODEX 3 INHIBITORS fulvestrant 4 BELEODAQ 4 FARYDAK 2 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 53 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ISTODAX 4 ANTINEOPLASTI romidepsin intravenous C - JANUS 4 solution KINASE(JAK),FM ZOLINZA 2 S-LIKE ANTINEOPLASTI TYROSINE C - KINASE(FLT) IMMUNOTHERA INHIB PY, INREBIC 2 PA THERAPEUTIC ANTINEOPLASTI VACCINES C - KINASE PROVENGE 4 INHIBITOR AND ANTINEOPLASTI AROMATASE C - INHIBITOR IMMUNOTHERA COMBINATION PY, VIRUS- KISQALI FEMARA BASED CO-PACK ORAL TABLET 200 2 PA IMLYGIC 4 MG/DAY(200 MG X ANTINEOPLASTI 1)-2.5 MG C - ANTINEOPLASTI IMMUNOTOXINS C - LHRH (GNRH) LUMOXITI 4 AGONIST ANTINEOPLASTI ANALOG C - PITUITARY INTERLEUKIN-6 SUPPRESSANTS (IL-6) ELIGARD 1 INHIBITORS, ELIGARD (3 MONTH) 1 MONOCLONAL ELIGARD (4 MONTH) 1 ANTIBODY ELIGARD (6 MONTH) 1 SYLVANT 4 leuprolide subcutaneous 4 ANTINEOPLASTI kit C - LUPRON DEPOT (3 INTERLEUKINS MONTH) INTRAMUSCULAR 4 PA PROLEUKIN 4 SYRINGE KIT 22.5 ANTINEOPLASTI MG C - JANUS LUPRON DEPOT (4 4 PA KINASE (JAK) MONTH) INHIBITORS LUPRON DEPOT (6 4 PA JAKAFI 2 MONTH)

You can find information on what the symbols and abbreviationson this table mean on page 4. 54 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LUPRON DEPOT everolimus 2 PA INTRAMUSCULAR 4 PA (antineoplastic) SYRINGE KIT 7.5 MG TORISEL 4 VANTAS 4 PA ANTINEOPLASTI ZOLADEX 4 PA C - ANTINEOPLASTI MULTIKINASE C - LHRH (GNRH) INHIBITORS ANTAGONIST CABOMETYX 2 PITUITARY COMETRIQ 2 PA SUPPRESSANTS ICLUSIG 2 PA FIRMAGON KIT W 2 NEXAVAR 2 DILUENT SYRINGE STIVARGA 2 ANTINEOPLASTI C - MAST CELL ANTINEOPLASTI STABILIZERS C - MUTANT ISOCITRATE cromolyn (bulk) 1 DEHYDROGENA cromolyn oral 1 SE 1 (MIDH1) GASTROCROM 1 INHIBITORS ANTINEOPLASTI TIBSOVO 2 PA C - MEK1 AND ANTINEOPLASTI MEK2 KINASE C - MUTANT INHIBITORS ISOCITRATE COTELLIC 2 DEHYDROGENA MEKINIST 2 SE 2 (MIDH2) MEKTOVI 2 PA INHIBITORS ANTINEOPLASTI IDHIFA 2 PA C - ANTINEOPLASTI MONOCLONAL C - OTHER ANTIBODIES levamisole (bulk) 3 FOR TICE BCG 4 RADIOPHARMA CEUTICAL ANTINEOPLASTI THERAPY C - PAN-CLASS I PI3K ZEVALIN (Y-90) 4 INHIBITORS ANTINEOPLASTI ALIQOPA 4 C - MTOR KINASE INHIBITORS AFINITOR 2 AFINITOR DISPERZ 2 You can find information on what the symbols and abbreviationson this table mean on page 4. 55 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C - C - POLY (ADP- PHOSPHATIDYLI RIBOSE) NOSITOL 3- POLYMERASE KINASE (PI3K) (PARP) INHIBITORS INHIBITORS ALIQOPA 4 LYNPARZA ORAL 2 PA COPIKTRA 2 PA TABLET 100 MG RUBRACA ORAL ZYDELIG 2 PA 2 PA TABLET 200 MG ANTINEOPLASTI TALZENNA 2 PA C - PHOTOSENSITIZ ZEJULA 2 PA ERS ANTINEOPLASTI methoxsalen (bulk) C - PROGESTINS 3 crystals DEPO-PROVERA INTRAMUSCULAR PHOTOFRIN 4 1 SUSPENSION 400 UVADEX 4 MG/ML ANTINEOPLASTI megestrol oral tablet 1 C - PI3K-ALPHA ANTINEOPLASTI INHIBITORS C - PIQRAY 2 PA PROTEASOME ANTINEOPLASTI ENZYME C - PI3K-DELTA INHIBITORS AND GAMMA bortezomib 4 INHIBITORS KYPROLIS 4 COPIKTRA 2 PA NINLARO 2 ANTINEOPLASTI VELCADE 4 C - PI3K-DELTA ANTINEOPLASTI INHIBITORS C - PROTEIN- ZYDELIG 2 PA TYROSINE ANTINEOPLASTI KINASE C - PLATINUM INHIBITORS COMPLEXES AYVAKIT 2 PA carboplatin 4 BOSULIF ORAL cisplatin 4 TABLET 100 MG, 500 2 PA MG oxaliplatin intravenous 4 recon soln BRUKINSA 2 PA oxaliplatin intravenous CALQUENCE 2 PA solution 100 mg/20 ml, 4 CAPRELSA 2 PA 50 mg/10 ml (5 mg/ml) You can find information on what the symbols and abbreviationson this table mean on page 4. 56 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GLEEVEC 3 ANTINEOPLASTI imatinib 1 C - SELECTIVE IMBRUVICA 2 PA RETINOID X INLYTA 2 RECEPTOR AGONISTS LENVIMA 2 PA bexarotene 1 OFEV 2 PA TARGRETIN ORAL 3 QINLOCK 2 PA ROZLYTREK 2 PA ANTINEOPLASTI C - TAXANES RYDAPT 2 PA ABRAXANE 4 PA SPRYCEL 2 DOCEFREZ 4 SUTENT 2 PA docetaxel intravenous TASIGNA 2 PA solution 160 mg/16 ml TURALIO 2 PA (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 VOTRIENT 2 4 ml (10 mg/ml), 20 ANTINEOPLASTI mg/ml (1 ml), 80 mg/4 C - ml (20 mg/ml), 80 mg/8 RADIOPHARMA ml (10 mg/ml) CEUTICALS JEVTANA 4 strontium-89 chloride 3 paclitaxel 4 PA XOFIGO 4 TAXOTERE ANTINEOPLASTI INTRAVENOUS C - RETINOIDS SOLUTION 20 MG/ML 4 (1 ML), 80 MG/4 ML tretinoin (antineoplastic) 1 (20 MG/ML) ANTINEOPLASTI ANTINEOPLASTI C - SELECTIVE C - ESTROGEN THALIDOMIDE RECEPTOR ANALOGS MODULATORS POMALYST 2 PA (SERMS) REVLIMID 2 FARESTON 1 THALOMID 3 SOLTAMOX 3 ANTINEOPLASTI tamoxifen 1 C - tamoxifen (bulk) 3 TOPOISOMERAS toremifene 3 E I INHIBITORS CAMPTOSAR 4 HYCAMTIN 4 INTRAVENOUS HYCAMTIN ORAL 2

You can find information on what the symbols and abbreviationson this table mean on page 4. 57 Drug Name Drug Tier Limits Drug Name Drug Tier Limits irinotecan intravenous ANTINEOPLASTI solution 100 mg/5 ml, 4 C ANTIBIOTIC - 40 mg/2 ml, 500 mg/25 ANTHRACYCLIN ml ES ONIVYDE 4 ADRIAMYCIN topotecan intravenous 4 INTRAVENOUS 4 recon soln SOLUTION topotecan intravenous daunorubicin 4 solution 4 mg/4 ml (1 4 mg/ml) DOXIL 4 doxorubicin intravenous ANTINEOPLASTI 4 recon soln 50 mg C - doxorubicin intravenous TROPOMYOSIN 4 solution RECEPTOR doxorubicin, peg- KINASE (TRK) 4 liposomal INHIBITOR ELLENCE 4 VITRAKVI 2 PA epirubicin 4 ANTINEOPLASTI IDAMYCIN PFS 4 C - VASC ENDOTHELIAL idarubicin 4 GROWTH mitoxantrone 4 FACTOR valrubicin 4 RECEPTOR VALSTAR 4 (VEGFR) ANTAG ANTINEOPLASTI CYRAMZA 4 PA C ANTIBIOTIC - ANTINEOPLASTI OTHERS C - VINCA bleomycin injection 4 ALKALOIDS AND recon soln 15 unit ANALOGS bleomycin injection 1 MARQIBO 4 recon soln 30 unit NAVELBINE 4 mitomycin intravenous 4 vinblastine intravenous mitomycin intravesical 4 4 solution syringe vincristine 4 ZANOSAR 4 vinorelbine 4 ANTINEOPLASTI C - ANTINEOPLASTI CEPHALOTAXIN C ANTIBIOTIC - ES ACTINOMYCINS SYNRIBO 3 COSMEGEN 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 58 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C-ALKYLATING C-CD79B DIRECT AGENT- ANTIBODY- TETRAHYDROIS MICROTUBULE OQUINOLINE DISRUPTING AND CONJUGATE DERIVATIVES POLIVY YONDELIS 4 INTRAVENOUS 4 RECON SOLN 140 MG ANTINEOPLASTI C-ANTI- ANTINEOPLASTI PROGRAMMED C-HER2 CELL DEATH TARGETED LIGAND-1 (PD- ANTIBODY- L1) MC ANTIB. MICROTUBULE INHIBITOR TECENTRIQ 4 CONJUGATE ANTINEOPLASTI KADCYLA 4 PA C-ANTI- PROGRAMMED ANTINEOPLASTI CELL DEATH C-VASC RECEPTOR-1 ENDOTHELIAL (PD-1) MC ANTIB. GROWTH FAC(VEGF-A,B KEYTRUDA INTRAVENOUS 4 PA AND SOLUTION PLGF)INHIBITO LIBTAYO 4 R OPDIVO 4 PA ZALTRAP 4 PA ANTINEOPLASTI BISPECIFIC C-CD123- CD19-DIRECTED DIRECTED CD3 T-CELL CYTOTOXIN (IL- ENGAGER, 3 AND DIPHTH.) MONOCLONAL CONJUGATE ANTIBODY BLINCYTO ELZONRIS 4 4 INTRAVENOUS KIT ANTINEOPLASTI C-CD30 DIRECTED ANTIBODY- MICROTUBULE DISRUPTING CONJUGATE ADCETRIS 4 PA You can find information on what the symbols and abbreviationson this table mean on page 4. 59 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CARDIAC FLUOROURACIL PROTECTIVE AND RELATED AGENTS USED IN RESCUE AGENTS CONJUNCTION VISTOGARD 3 WITH METHOTREXAT CHEMOTHERAP E RESCUE Y AGENTS - dexrazoxane hcl 4 CARBOXYPEPTI EPIDERMAL DASE G2 TYPE GROWTH VORAXAZE 4 FACTOR METHOTREXAT RECEPT (HER-2) E RESCUE SUBDOMAIN II AGENTS - FOLIC BLOCKER, REC- ACID MC AB ANTAGONIST PERJETA 4 PA TYPE EPIDERMAL FUSILEV 4 GROWTH KHAPZORY 4 FACTOR leucovorin calcium RECEPT injection recon soln 100 1 BLOCKER (HER- mg, 200 mg, 350 mg, 1 TYPE), REC-MC 500 mg ANTIBODY leucovorin calcium ERBITUX 4 PA injection recon soln 50 4 mg PORTRAZZA 4 leucovorin calcium VECTIBIX 4 PA 4 injection solution EPIDERMAL leucovorin calcium oral 3 PA GROWTH tablet 10 mg, 15 mg FACTOR leucovorin calcium oral 1 RECEPT tablet 25 mg, 5 mg BLOCKER (HER- levoleucovorin calcium 2 TYPE), REC-MC intravenous recon soln 4 ANTIBODY 50 mg HERCEPTIN levoleucovorin calcium 3 PA 4 HYLECTA intravenous solution HERCEPTIN METHOTREXAT INTRAVENOUS 4 PA E RESCUE RECON SOLN 150 MG AGENTS FUSILEV 4 KHAPZORY 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 60 Drug Name Drug Tier Limits Drug Name Drug Tier Limits leucovorin calcium ANTISEPTIC - injection recon soln 100 1 CHLORINE mg, 200 mg, 350 mg, RELEASING 500 mg DELUO 3 leucovorin calcium injection recon soln 50 4 HYCLODEX 3 mg ANTISEPTIC - leucovorin calcium 4 IODINE/IODOPH injection solution ORES leucovorin calcium oral 3 PA iodine (bulk) crystals 1 tablet 10 mg, 15 mg IODOFLEX 1 leucovorin calcium oral 1 tablet 25 mg, 5 mg IODOSORB 1 STRONG IODINE levoleucovorin calcium 1 intravenous recon soln 4 TOPICAL 50 mg ANTISEPTIC - levoleucovorin calcium OTHERS 4 intravenous solution silver protein mild 3 VORAXAZE 4 (bulk) URINARY TRACT ANTISEPTIC - PROTECTIVE PHENOL AGENTS USED IN DERIVATIVES CONJUNCTION phenol 1 WITH phenol (bulk) liquid 1 CHEMOTHERAP ANTISEPTIC Y AND mesna 4 DISINFECTANT MESNEX 4 COMBINATIONS INTRAVENOUS SQUARIC ACID IN 1 MESNEX ORAL 1 BUTANOL ANTISEPTICS BIOLOGICALS AND ALLERGENIC DISINFECTANT EXTRACT S OTHERS ANTISEPTIC - CANDIN 4 BIGUANIDES ALLERGENIC chlorhexidine gluconate 1 EXTRACTS - (bulk) GRASS POLLEN GRASTEK 2 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 61 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ORALAIR HEPATITIS A SUBLINGUAL 2 PA VACCINE - TABLET 300 INDX SINGLE AGENTS REACTIVITY HAVRIX (PF) ALLERGENIC INTRAMUSCULAR 1 EXTRACTS - SUSPENSION 1,440 MITE EXTRACTS ELISA UNIT/ML ODACTRA 3 HAVRIX (PF) ALLERGENIC INTRAMUSCULAR 1 SYRINGE EXTRACTS - WEED POLLEN VAQTA (PF) 1 RAGWITEK 2 PA HEPATITIS B VACCINE ANTIVENOMS - COMBINATIONS SCORPION ANTIVENOMS PEDIARIX (PF) 4 ANASCORP 4 HEPATITIS B VACCINES - ANTIVENOMS - SINGLE AGENTS SNAKE ANTIVENOMS ENGERIX-B (PF) 1 ENGERIX-B ANAVIP 4 PEDIATRIC (PF) 1 CROFAB 4 INTRAMUSCULAR ANTIVIRAL SYRINGE MONOCLONAL HEPLISAV-B (PF) ANTIBODIES - INTRAMUSCULAR 1 RESPIRATORY SYRINGE RECOMBIVAX HB SYNCYTIAL 1 VIRUS (RSV) (PF) SYNAGIS 2 PA IMMUNE GLOBULIN - ANTIVIRAL CYTOMEGALOV MONOCLONAL IRUS (CMV) ANTIBODIES CYTOGAM SYNAGIS 2 PA INTRAVENOUS 4 HEPATITIS A SOLUTION 50 MG/ML AND HEPATITIS IMMUNE B VACCINE GLOBULIN - COMBINATIONS GAMMA TWINRIX (PF) GLOBULIN INTRAMUSCULAR 1 (IGG), HUMAN SYRINGE BIVIGAM 4 PA CUTAQUIG 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 62 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CUVITRU IMMUNE SUBCUTANEOUS GLOBULIN - SOLUTION 1 GRAM/5 RABIES ML (20 %), 2 3 PA GRAM/10 ML (20 %), HYPERRAB (PF) 4 4 GRAM/20 ML (20 HYPERRAB S/D (PF) 1 %), 8 GRAM/40 ML IMOGAM RABIES-HT (20 %) 3 (PF) FLEBOGAMMA DIF 4 PA KEDRAB (PF) 4 GAMASTAN S/D 4 IMMUNE GAMMAGARD 4 PA GLOBULIN - LIQUID RHO(D) GAMMAGARD S-D 4 PA (IGA < 1 MCG/ML) WINRHO SDF 4 GAMMAKED IMMUNE INJECTION GLOBULIN - SOLUTION 1 TETANUS GRAM/10 ML (10 %), 4 PA HYPERTET S/D (PF) 1 10 GRAM/100 ML (10 %), 20 GRAM/200 ML IMMUNE (10 %), 5 GRAM/50 SERUMS ML (10 %) ATGAM 4 GAMMAPLEX (WITH 4 PA THYMOGLOBULIN 4 SORBITOL) GAMUNEX-C 4 PA LIVE VACCINE AND LIVE VIRUS HIZENTRA SUBCUTANEOUS 4 PA FORMULATIONS SOLUTION bcg vaccine, live (pf) 4 HYQVIA 3 IMLYGIC 4 HYQVIA IG M-M-R II (PF) 1 3 COMPONENT PROQUAD (PF) 1 OCTAGAM 4 PA ROTARIX 3 PANZYGA 4 ROTATEQ VACCINE 3 PRIVIGEN 4 PA TICE BCG 4 IMMUNE VARIVAX (PF) 4 GLOBULIN - ZOSTAVAX (PF) 1 HEPATITIS B PEANUT HEPAGAM B 4 DESENSITIZATI HYPERHEP B S/D 3 ON AGENTS HYPERHEP B S-D PALFORZIA (LEVEL 3 2 PA NEONATAL 1) NABI-HB 3 PALFORZIA (LEVEL 2 PA 2) You can find information on what the symbols and abbreviationson this table mean on page 4. 63 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PALFORZIA (LEVEL 2 PA VACCINE 3) BACTERIAL - PALFORZIA (LEVEL 2 PA GRAM 4) NEGATIVE PALFORZIA (LEVEL 2 PA BACILLI (NON- 5) ENTERIC) PALFORZIA (LEVEL 2 PA ACTHIB (PF) 1 6) HIBERIX (PF) 1 PALFORZIA (LEVEL 2 PA 7) PEDVAX HIB (PF) 1 PALFORZIA (LEVEL VACCINE 2 PA 8) BACTERIAL - PALFORZIA (LEVEL GRAM 2 PA 9) NEGATIVE PALFORZIA (LEVEL COCCI 2 PA 10) MENACTRA (PF) PALFORZIA (LEVEL INTRAMUSCULAR 4 2 PA 11 UP-DOSE) SOLUTION PALFORZIA INITIAL MENVEO A-C-Y-W- 2 PA 4 DOSE 135-DIP (PF) PALFORZIA LEVEL VACCINE 2 PA 11 MAINTENANCE BACTERIAL - TOXOID GRAM POSITIVE VACCINE COCCI COMBINATIONS PNEUMOVAX-23 ADACEL(TDAP INJECTION 1 ADOLESN/ADULT)(P 1 SOLUTION F) PNEUMOVAX-23 4 BOOSTRIX TDAP 1 INJECTION SYRINGE DAPTACEL (DTAP PREVNAR 13 (PF) 4 4 PEDIATRIC) (PF) VACCINE INFANRIX (DTAP) BACTERIAL - 4 (PF) MENINGOCOCC KINRIX (PF) 4 AL GROUP B PEDIARIX (PF) 4 VACCINES QUADRACEL (PF) 4 BEXSERO 4 TDVAX 1 TRUMENBA 4 TENIVAC (PF) 4 VACCINE tetanus,diphtheria tox BACTERIAL - 4 ped(pf) OTHER bcg vaccine, live (pf) 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 64 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VACCINE VACCINE VIRAL BACTERIAL - - MUMPS AND TOXIN- RELATED PRODUCING M-M-R II (PF) 1 BACILLI PROQUAD (PF) 1 BIOTHRAX 4 VACCINE VIRAL VACCINE MIXED - COMBINATIONS POLIOMYELITIS (BACTERIAL IPOL 1 AND VIRAL) VACCINE VIRAL PENTACEL (PF) - RABIES INTRAMUSCULAR 4 IMOVAX RABIES KIT 15 LF UNIT-20 3 MCG-5 LF/0.5 ML VACCINE (PF) VACCINE VIRAL RABAVERT (PF) 4 - HUMAN VACCINE VIRAL PAPILLOMAVIR - ROTAVIRUS US (HPV) ROTARIX 3 VACCINES ROTATEQ VACCINE 3 GARDASIL 9 (PF) 1 VACCINE VIRAL VACCINE VIRAL - RUBELLA - INFLUENZA A M-M-R II (PF) 1 AND B PROQUAD (PF) 1 FLUAD QUAD 2020- 1 21(65Y UP)(PF) VACCINE VIRAL - VARICELLA FLUZONE QUAD 2020-2021 VIAL PROQUAD (PF) 1 1 MUV,LATEX- SHINGRIX (PF) 2 FREE,INNER VARIVAX (PF) 4 VACCINE VIRAL ZOSTAVAX (PF) 1 - JAPANESE VACCINE VIRAL ENCEPHALITIS COMBINATIONS IXIARO (PF) 4 M-M-R II (PF) 1 VACCINE VIRAL PROQUAD (PF) 1 - MEASLES M-M-R II (PF) 1 PROQUAD (PF) 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 65 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CARDIOVASCU ALTACE 3 LAR THERAPY benazepril 1 AGENTS captopril 1 ACE INHIBITOR enalapril maleate 1 enalaprilat intravenous AND CALCIUM 3 CHANNEL solution EPANED ORAL BLOCKER 3 COMBINATIONS SOLUTION amlodipine-benazepril 2 PA fosinopril 1 LOTREL ORAL lisinopril 1 CAPSULE 10-20 MG, LOTENSIN ORAL 3 10-40 MG, 5-10 MG, 5- TABLET 10 MG, 20 3 20 MG MG, 40 MG PRESTALIA 3 moexipril 3 TARKA ORAL perindopril erbumine 3 TABLET, IR - ER, PRINIVIL ORAL BIPHASIC 24HR 2-180 3 TABLET 10 MG, 20 3 MG, 2-240 MG, 4-240 MG MG QBRELIS 3 trandolapril-verapamil 3 quinapril 3 ACE INHIBITOR ramipril 1 AND DIURETIC COMBINATIONS trandolapril 3 VASOTEC 3 ACCURETIC 3 ZESTRIL 3 benazepril- 1 hydrochlorothiazide ALDOSTERONE captopril- RECEPTOR 3 hydrochlorothiazide ANTAGONISTS enalapril- ALDACTONE 3 1 hydrochlorothiazide eplerenone 1 fosinopril- 1 INSPRA 3 hydrochlorothiazide spironolactone oral lisinopril- 4 1 tablet 100 mg hydrochlorothiazide spironolactone oral 1 LOTENSIN HCT 3 tablet 25 mg, 50 mg quinapril- 1 ALPHA-BETA hydrochlorothiazide BLOCKERS VASERETIC 3 carvedilol 1 ZESTORETIC 3 carvedilol phosphate 1 ACE INHIBITORS COREG 3 ACCUPRIL 3 COREG CR 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 66 Drug Name Drug Tier Limits Drug Name Drug Tier Limits labetalol intravenous BENICAR HCT 3 4 solution candesartan- 3 labetalol intravenous hydrochlorothiazid syringe 20 mg/4 ml (5 4 DIOVAN HCT ORAL mg/ml), 25 mg/5 ml (5 TABLET 160-12.5 MG, 1 mg/ml) 160-25 MG, 80-12.5 labetalol oral 1 MG ANGIOTENSIN II DIOVAN HCT ORAL RECEPTOR TABLET 320-12.5 MG, 3 BLOCKER (ARB)- 320-25 MG CALCIUM EDARBYCLOR 1 CHANNEL HYZAAR 1 BLOCKER irbesartan- 1 COMB. hydrochlorothiazide losartan- amlodipine-olmesartan 3 1 hydrochlorothiazide amlodipine-valsartan 1 MICARDIS HCT 3 AZOR 3 telmisartan- EXFORGE 3 3 hydrochlorothiazid telmisartan-amlodipine 1 valsartan- 1 TWYNSTA 1 hydrochlorothiazide ANGIOTENSIN II ANGIOTENSIN II RECEPTOR RECEPTOR BLOCKER (ARB)- BLOCKER- CALCIUM NEPRILYSIN CHANNEL INHIBITOR BLOCKER- COMB. (ARNI) DIURETIC ENTRESTO 2 PA amlodipine-valsartan- 1 ANGIOTENSIN II hcthiazid RECEPTOR EXFORGE HCT 3 BLOCKERS olmesartan-amlodipin- 3 (ARBS) hcthiazid ATACAND 3 TRIBENZOR 1 AVAPRO 3 ANGIOTENSIN II BENICAR ORAL 3 ST RECEPTOR TABLET 20 MG, 5 MG BLOCKER (ARB)- BENICAR ORAL 3 DIURETIC TABLET 40 MG COMBINATIONS candesartan 3 ATACAND HCT 1 COZAAR 3 AVALIDE 3 DIOVAN 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 67 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EDARBI 3 nitroglycerin eprosartan 3 transdermal patch 24 1 hour irbesartan 1 nitroglycerin losartan 1 translingual spray,non- 3 MICARDIS 3 aerosol olmesartan 1 NITROLINGUAL 3 telmisartan 3 NITROMIST 3 valsartan oral tablet 160 NITROSTAT 1 1 ST mg, 40 mg, 80 mg NITRO-TIME 3 valsartan oral tablet 320 2 ANTIANGINAL mg AND ANTI- ANTIANGINAL - ISCHEMIC CORONARY AGENTS, NON- VASODILATORS HEMODYNAMIC (NITRATES) RANEXA 3 PA DILATRATE-SR 3 PA ranolazine 2 PA ISOCHRON 3 ANTIARRHYTH ISORDIL 3 PA MIC - CLASS IA ISORDIL TITRADOSE 3 disopyramide phosphate ORAL TABLET 5 MG 1 oral capsule isosorbide dinitrate oral 1 NORPACE 3 isosorbide mononitrate 1 NORPACE CR 3 MINITRAN 1 procainamide injection 4 NITRO-BID 1 quinidine gluconate oral 1 NITRO-DUR quinidine sulfate (bulk) TRANSDERMAL 1 3 crystals PATCH 24 HOUR 0.1 quinidine sulfate oral MG/HR, 0.8 MG/HR 3 tablet NITRO-DUR TRANSDERMAL ANTIARRHYTH PATCH 24 HOUR 0.2 3 PA MIC - CLASS IB MG/HR, 0.3 MG/HR, lidocaine (pf) 0.4 MG/HR, 0.6 4 intravenous MG/HR lidocaine in 5 % nitroglycerin in 5 % 4 dextrose (pf) dextrose intravenous parenteral 4 nitroglycerin 4 solution 4 mg/ml (0.4 intravenous %), 8 mg/ml (0.8 %) nitroglycerin oral 1 mexiletine 1 nitroglycerin sublingual 1 phenytoin sodium (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 68 Drug Name Drug Tier Limits Drug Name Drug Tier Limits phenytoin sodium ibutilide fumarate 4 4 intravenous solution MULTAQ 3 phenytoin sodium 2 PA NEXTERONE 4 intravenous syringe PACERONE ORAL XYLOCAINE 4 TABLET 100 MG, 200 1 (CARDIAC) (PF) MG, 400 MG ANTIARRHYTH TIKOSYN 3 MIC - CLASS IC ANTIARRHYTH flecainide 1 MIC - CLASS IV propafenone 1 diltiazem hcl 4 RYTHMOL SR 3 intravenous ANTIARRHYTH verapamil intravenous 4 MIC - CLASS II verapamil oral tablet 1 BETAPACE 3 ANTIARRHYTH BETAPACE AF 3 MIC OTHERS BREVIBLOC IN adenosine (bulk) 3 4 NACL (ISO-OSM) adenosine intravenous 4 PA BREVIBLOC solution INTRAVENOUS adenosine intravenous 4 4 SOLUTION 100 MG/10 syringe ML (10 MG/ML) ANTIHYPERLIPI esmolol 4 DEMIC - ATP- esmolol in nacl (iso- 4 CITRATE LYASE osm) (ACLY) SORINE 3 INHIBITOR SOTALOL AF 1 NEXLETOL 2 PA sotalol intravenous 4 ANTIHYPERLIPI sotalol oral 1 DEMIC - BILE SOTYLIZE 1 ACID ANTIARRHYTH SEQUESTRANTS MIC - CLASS III cholestyramine (bulk) 3 amiodarone in dextrose cholestyramine (with 1 5 % intravenous sugar) solution 150 mg/100 ml 4 CHOLESTYRAMINE (1.5 mg/ml), 900 1 LIGHT mg/500 ml (1.8 mg/ml) colesevelam oral amiodarone intravenous 4 3 powder in packet amiodarone oral 1 colesevelam oral tablet 3 PA CORVERT 4 dofetilide 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 69 Drug Name Drug Tier Limits Drug Name Drug Tier Limits COLESTID TRILIPIX 3 FLAVORED ORAL 3 ANTIHYPERLIPI PACKET DEMIC - HMG COLESTID ORAL 3 COA GRANULES REDUCTASE COLESTID ORAL 3 INHIBITORS TABLET (STATINS) colestipol oral granules 3 ALTOPREV 3 colestipol oral packet 3 QL (30 EA per atorvastatin 1 colestipol oral tablet 1 30 days) PREVALITE 1 CRESTOR ORAL QL (30 EA per QUESTRAN 3 TABLET 10 MG, 20 3 23 days) QUESTRAN LIGHT MG, 5 MG 3 ORAL POWDER CRESTOR ORAL 3 WELCHOL 3 TABLET 40 MG ANTIHYPERLIPI EZALLOR SPRINKLE 3 DEMIC - FIBRIC fluvastatin oral capsule 3 fluvastatin oral tablet QL (30 EA per ACID 3 DERIVATIVES extended release 24 hr 23 days) LESCOL ORAL ANTARA ORAL 3 CAPSULE 30 MG, 90 3 CAPSULE 20 MG MG LESCOL ORAL QL (60 EA per 3 fenofibrate micronized CAPSULE 40 MG 23 days) oral capsule 130 mg, 3 QL (30 EA per LESCOL XL 3 134 mg, 43 mg 23 days) fenofibrate micronized QL (30 EA per LIPITOR 3 oral capsule 200 mg, 67 1 23 days) mg LIVALO 3 fenofibrate lovastatin oral tablet 10 QL (30 EA per 2 nanocrystallized oral 1 mg 23 days) tablet 145 mg, 48 mg lovastatin oral tablet 20 QL (120 EA 2 fenofibrate oral capsule 3 mg per 23 days) fenofibrate oral tablet 1 lovastatin oral tablet 40 QL (60 EA per 4 fenofibric acid 3 mg 23 days) fenofibric acid (choline) 3 PRAVACHOL ORAL QL (30 EA per 3 FENOGLIDE 3 TABLET 20 MG 23 days) PRAVACHOL ORAL QL (34 EA per FIBRICOR 3 3 TABLET 40 MG 23 days) gemfibrozil 1 pravastatin oral tablet 10 QL (30 EA per 2 LIPOFEN 3 mg, 20 mg, 80 mg 23 days) LOPID 3 pravastatin oral tablet 40 QL (60 EA per 2 TRICOR 3 mg 23 days) You can find information on what the symbols and abbreviationson this table mean on page 4. 70 Drug Name Drug Tier Limits Drug Name Drug Tier Limits rosuvastatin oral tablet QL (30 EA per 1 ANTIHYPERLIPI 10 mg, 20 mg, 5 mg 23 days) DEMIC AGENTS - rosuvastatin oral tablet 1 ST DIETARY 40 mg SOURCE QL (30 EA per simvastatin oral tablet 2 COMBINATIONS 23 days) FISH OIL EXTRA ZOCOR ORAL 1 QL (30 EA per STRENGTH TABLET 10 MG, 20 3 23 days) FISH OIL ORAL MG, 40 MG, 80 MG CAPSULE 360-1,200 1 ZYPITAMAG ORAL 3 MG TABLET 2 MG, 4 MG FISH OIL ORAL ANTIHYPERLIPI CAPSULE 900 MG-360 3 DEMIC - MG- 455 MG-1,000 NICOTINIC ACID MG DERIVATIVES FISH OIL ORAL CAPSULE,DELAYED niacin oral tablet 1 RELEASE(DR/EC) 120 extended release 24 hr 1 MG-180 MG- 60 MG- NIACOR 1 1,200 MG, 360-1,200 NIASPAN MG EXTENDED- 3 fish oil-dha-epa 3 RELEASE krill-om-3-dha-epa- ANTIHYPERLIPI phospho-ast oral capsule 3 DEMIC - OMEGA- 1,000-170-50-80 mg 3 FATTY ACID LIPOCHOL PLUS 3 TYPE OMEGA-3 (WITH 3 omega-3 acid ethyl DPA) 3 esters OMEGA-3 2100 3 VASCEPA ORAL 3 omega-3 fatty acids-fish CAPSULE 1 GRAM oil oral capsule 300- 3 ANTIHYPERLIPI 1,000 mg DEMIC - OMEGA-3 FISH OIL SELECTIVE ORAL CAPSULE 910- 3 CHOLESTEROL 1,400 MG ABSORPTION omega-3s-dha-epa-fish oil oral capsule,delayed INHIBITOR 3 release(dr/ec) 300-1,000 ezetimibe 1 mg ZETIA 3 vitamin e oral capsule 1 100 unit

You can find information on what the symbols and abbreviationson this table mean on page 4. 71 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERLIPI ANTIHYPERLIPI DEMIC AGENTS - DEMIC-HMG DIETARY COA REDUCT SOURCE INHIB AND ALGAL OMEGA-3 CHOLESTEROL 3 DHA ABSORP INHIBIT ALGAL-900 DHA ezetimibe-simvastatin ORAL CAPSULE 300 1 oral tablet 10-40 mg, 3 PA MG 10-80 mg DHA ALGAL-900 1 QL (30 EA per VYTORIN 10-10 3 FISH OIL ORAL 23 days) 1 CAPSULE 120-180 MG QL (30 EA per VYTORIN 10-20 3 fish oil-dha-epa 3 23 days) inositol oral tablet 650 QL (30 EA per 1 VYTORIN 10-40 3 mg 23 days) lecithin oral capsule VYTORIN 10-80 3 1 1,200 mg ANTIHYPERLIPI lecithin, soy oral DEMIC- 1 capsule 1,200 mg MICROSOMAL omega-3 acid ethyl TRIGLYCERIDE 3 esters TRANSFER VASCEPA ORAL PROTEIN 3 CAPSULE 1 GRAM (MTP)INHIB ANTIHYPERLIPI JUXTAPID 2 PA DEMIC HMG ANTI-PCSK9 COA REDUCT MONOCLONAL INHIB AND ANTIBODIES CALCIUM PRALUENT PEN 3 CHANNEL REPATHA BLOCKER 3 PA PUSHTRONEX QL (30 EA per amlodipine-atorvastatin 3 REPATHA 30 days) 3 PA SURECLICK CADUET ORAL REPATHA SYRINGE 3 PA TABLET 10-10 MG, 10-20 MG, 10-40 MG, QL (30 EA per BETA 3 10-80 MG, 5-10 MG, 5- 23 days) BLOCKERS 20 MG, 5-40 MG, 5-80 CARDIAC MG SELECTIVE, INTRINSIC SYMPATHOMIM ETIC ACTIVITY acebutolol 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 72 Drug Name Drug Tier Limits Drug Name Drug Tier Limits acebutolol (bulk) 3 BETA BETA BLOCKERS NON- BLOCKERS CARDIAC CARDIAC SELECTIVE SELECTIVE BETAPACE 3 atenolol 1 BETAPACE AF 3 betaxolol oral 1 CORGARD 3 bisoprolol fumarate 1 HEMANGEOL 3 BREVIBLOC IN INDERAL LA 3 4 NACL (ISO-OSM) INDERAL XL 3 BREVIBLOC INNOPRAN XL 3 INTRAVENOUS 4 SOLUTION 100 MG/10 nadolol 1 ML (10 MG/ML) propranolol intravenous 4 BYSTOLIC 3 propranolol oral capsule,extended release esmolol 4 1 24 hr 120 mg, 160 mg, esmolol in nacl (iso- 4 80 mg osm) propranolol oral KAPSPARGO 3 capsule,extended release 4 SPRINKLE 24 hr 60 mg LOPRESSOR propranolol oral 4 1 INTRAVENOUS solution LOPRESSOR ORAL 3 propranolol oral tablet 1 metoprolol succinate 1 SORINE 3 metoprolol tartrate 4 SOTALOL AF 1 intravenous solution sotalol intravenous 4 metoprolol tartrate oral 1 sotalol oral 1 TENORMIN 3 SOTYLIZE 1 TOPROL XL 3 timolol maleate oral 3 BETA BRADYKININ B2 BLOCKERS NON- RECEPTOR CARDIAC ANTAGONISTS SELECT., INTRINSIC FIRAZYR 3 PA SYMPATHOMIM icatibant 2 PA ETIC ACTIVITY CALCIUM pindolol 3 CHANNEL BLOCKERS - BENZOTHIAZEPI NES CARDIZEM CD 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 73 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CARDIZEM LA 3 CALCIUM CARDIZEM ORAL CHANNEL TABLET 120 MG, 30 3 BLOCKERS - MG, 60 MG DIHYDROPYRIDI CARTIA XT 3 NES diltiazem hcl in 0.9% ADALAT CC 3 nacl intravenous 4 amlodipine 1 solution 125 mg/125 ml (1 mg/ml) CARDENE IV 4 diltiazem hcl CARDENE IV IN 4 intravenous DEXTROSE INTRAVENOUS diltiazem hcl oral 4 PIGGYBACK 20 capsule,ext.rel 24h 1 MG/200 ML (0.1 degradable 180 mg, 240 MG/ML) mg CARDENE IV IN diltiazem hcl oral 4 SODIUM CHLORIDE capsule,extended release 1 12 hr CLEVIPREX 4 diltiazem hcl oral felodipine 1 capsule,extended release 1 isradipine 3 24 hr nicardipine in 0.9 % sod diltiazem hcl oral chlor intravenous 4 capsule,extended release 1 syringe 1 mg/10 ml 24hr nicardipine intravenous 4 diltiazem hcl oral tablet 1 solution DILT-XR 1 nicardipine oral 3 TIADYLT ER ORAL nifedipine 1 CAPSULE,EXTENDE 1 nifedipine (bulk) 3 D RELEASE 24 HR nifedipine, micronized 360 MG 3 (bulk) TIAZAC 3 nisoldipine 3 CALCIUM CHANNEL NORVASC 3 BLOCKERS - PROCARDIA 3 DIHYDROPYRIDI PROCARDIA XL 3 NES - SULAR ORAL TABLET EXTENDED CEREBROVASCU 3 LAR SPECIFIC RELEASE 24 HR 17 MG, 34 MG, 8.5 MG nimodipine 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 74 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CALCIUM TENORETIC 50 3 CHANNEL ZIAC 3 BLOCKERS - CARDIOVASCUL PHENYLAKYLA AR MINES SYMPATHOMIM CALAN SR 3 ETIC - verapamil (bulk) 3 ANAPHYLAXIS verapamil intravenous 4 THERAPY verapamil oral capsule, SINGLE AGENTS 3 24 hr er pellet ct ADRENALIN INJECTION QL (3 ML per verapamil oral 3 capsule,ext rel. pellets 3 SOLUTION 1 MG/ML 21 days) 24 hr (1 ML) verapamil oral tablet 1 AUVI-Q 3 verapamil oral tablet epinephrine (bulk) 3 1 extended release epinephrine injection auto-injector 0.15 PA; QL (4 EA VERELAN 3 3 mg/0.15 ml, 0.3 mg/0.3 per 21 days) VERELAN PM 3 ml CARDIAC epinephrine injection QL (4 EA per INOTROPES - auto-injector 0.15 1 21 days) PHOSPHODIEST mg/0.3 ml ERASE epinephrine injection QL (3 ML per 2 INHIBITORS solution 21 days) EPINEPHRINESNAP- milrinone 4 PA 3 EMS milrinone in 5 % 4 dextrose EPIPEN 2-PAK 3 CARDIAC EPIPEN JR 2-PAK 3 SELECTIVE SYMJEPI INJECTION BETA BLOCKER- SYRINGE 0.3 MG/0.3 1 THIAZIDE ML DIURETIC AND CARDIOVASCUL RELATED COMB. AR atenolol-chlorthalidone 1 SYMPATHOMIM ETIC - BETA- bisoprolol- 1 hydrochlorothiazide ADRENERGIC AGONISTS DUTOPROL 3 isoproterenol hcl 4 LOPRESSOR HCT 3 isoproterenol hcl (bulk) 4 metoprolol ta- 1 hydrochlorothiaz TENORETIC 100 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 75 Drug Name Drug Tier Limits Drug Name Drug Tier Limits epinephrine injection QL (3 ML per CARDIOVASCUL 2 AR solution 1 mg/ml (1 ml) 21 days) LEVOPHED SYMPATHOMIM 4 ETICS (BITARTRATE) ADRENALIN midodrine 1 INJECTION QL (3 ML per norepinephrine bitartrate 1 3 SOLUTION 1 MG/ML 21 days) norepinephrine (1 ML) bitartrate-d5w AKOVAZ 4 intravenous solution 16 BIORPHEN 4 mg/250 ml (64 mcg/ml), 4 4 mg/250 ml (16 dobutamine in d5w mcg/ml), 8 mg/250 ml intravenous parenteral (32 mcg/ml) solution 1,000 mg/250 ml (4,000 mcg/ml), 250 norepinephrine 4 mg/250 ml (1 mg/ml), bitartrate-nacl 500 mg/250 ml (2,000 intravenous solution 16 mcg/ml), 500 mg/500 mg/250 ml (64 mcg/ml), 4 ml (1,000 mcg/ml) 4 mg/250 ml (16 mcg/ml), 8 mg/250 ml dobutamine intravenous (32 mcg/ml) solution 250 mg/20 ml 4 (12.5 mg/ml) NORTHERA 3 PA dopamine in 5 % phenylephrine hcl (bulk) 3 4 dextrose phenylephrine hcl in dopamine intravenous 0.9% nacl intravenous 4 solution solution 20 mg/250 ml (80 mcg/ml), 40 mg/250 4 ephedrine hcl (bulk) 3 ml (160 mcg/ml), 50 ephedrine sulfate (bulk) 3 mg/250 ml (200 ephedrine sulfate mcg/ml), 80 mg/250 ml 4 injection solution (320 mcg/ml) ephedrine sulfate phenylephrine hcl in 4 intravenous 0.9% nacl intravenous syringe 0.4 mg/10 ml ephedrine sulfate- (40 mcg/ml), 0.5 mg/5 0.9%nacl(pf) 4 ml (100 mcg/ml), 0.8 4 intravenous syringe 50 mg/10 ml (80 mcg/ml), mg/5 ml (10 mg/ml) 1 mg/10 ml (100 epinephrine hcl in 5% mcg/ml), 20 mg/50 ml dextrose intravenous (400 mcg/ml) solution 2 mg/250 ml (8 phenylephrine hcl 4 4 PA mcg/ml), 4 mg/250 ml injection (16 mcg/ml), 8 mg/250 ml (32 mcg/ml) epinephrine in sod 4 chlor,iso

You can find information on what the symbols and abbreviationson this table mean on page 4. 76 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LANOXIN CENTRAL 4 ALPHA-2 PEDIATRIC AGONISTS- DIRECT ACTING THIAZIDE VASODILATORS DIURETIC AND hydralazine injection 4 RELATED COMB. hydralazine oral 1 CLORPRES 3 minoxidil (bulk) 3 methyldopa- 3 minoxidil oral 1 hydrochlorothiazide NIPRIDE RTU 4 CENTRAL NITROPRESS 4 ALPHA-2 RECEPTOR sodium nitroprusside 4 AGONISTS DIURETIC - CATAPRES 3 LA ALDOSTERONE RECEPTOR CATAPRES-TTS-1 3 LA ANTAGONIST, CATAPRES-TTS-2 3 LA NON-SELECTIVE CATAPRES-TTS-3 3 LA ALDACTONE 3 clonidine 1 LA spironolactone oral 4 clonidine hcl oral tablet 1 LA tablet 100 mg guanfacine oral tablet 1 LA spironolactone oral 1 methyldopa 2 LA tablet 25 mg, 50 mg methyldopate 4 LA DIURETIC - DIGITALIS ALDOSTERONE GLYCOSIDES RECEPTOR ANTAGONIST, DIGITEK 1 SELECTIVE DIGOX 1 eplerenone 1 digoxin injection 4 INSPRA 3 digoxin oral solution 50 2 PA mcg/ml (0.05 mg/ml) DIURETIC - digoxin oral tablet 1 ARGININE VASOPRESSIN digoxin, micronized 3 (bulk) V1A/V2 RECEPTOR LANOXIN INJECTION SOLUTION 250 ANTAGONISTS 4 MCG/ML (0.25 VAPRISOL IN 5 % 4 MG/ML) DEXTROSE LANOXIN ORAL TABLET 125 MCG (0.125 MG), 250 MCG 3 (0.25 MG), 62.5 MCG (0.0625 MG) You can find information on what the symbols and abbreviationson this table mean on page 4. 77 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIURETIC - DIURETIC - CARBONIC POTASSIUM ANHYDRASE SPARING INHIBITORS amiloride 1 acetazolamide 1 DYRENIUM 3 acetazolamide (bulk) 3 triamterene (bulk) 3 acetazolamide sodium 4 DIURETIC - methazolamide 1 POTASSIUM DIURETIC - SPARING- INORGANIC THIAZIDE AND SALT RELATED ammonium chloride 4 COMBINATIONS DIURETIC - ALDACTAZIDE 3 amiloride- LOOP 1 hydrochlorothiazide bumetanide injection 4 DYAZIDE 3 bumetanide oral 1 MAXZIDE 3 EDECRIN 3 MAXZIDE-25MG 3 ethacrynate sodium 4 spironolacton- 1 ethacrynic acid 1 hydrochlorothiaz furosemide in 0.9 % 4 triamterene- nacl hydrochlorothiazid oral 1 furosemide injection 4 capsule 37.5-25 mg furosemide oral 1 triamterene- LASIX 3 hydrochlorothiazid oral 1 tablet SODIUM EDECRIN 4 DIURETIC - torsemide oral 1 SELECTIVE DIURETIC - ARGININE OSMOTIC VASOPRESSIN V2 mannitol 10 % 4 RECEPTOR mannitol 20 % 4 ANTAGONISTS mannitol 25 % JYNARQUE ORAL 4 2 PA intravenous solution TABLET mannitol 5 % 4 JYNARQUE ORAL OSMITROL 10 % 4 TABLETS, SEQUENTIAL 45 MG OSMITROL 15 % 4 (AM)/ 15 MG (PM), 60 3 OSMITROL 20 % 4 MG (AM)/ 30 MG OSMITROL 5 % 4 (PM), 90 MG (AM)/ 30 MG (PM) SAMSCA 2 You can find information on what the symbols and abbreviationson this table mean on page 4. 78 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIURETIC - HYPERTROPHIC THIAZIDES AND CARDIOMYOPAT RELATED HY TREATMENT chlorothiazide oral AGENTS, 1 tablet 500 mg ABLATIVE chlorothiazide sodium 4 PA ABLYSINOL 4 chlorthalidone oral 1 MUSCARINIC tablet 25 mg, 50 mg RECEPTOR DIURIL 3 ANTAGONISTS DIURIL IV 4 (ANTICHOLINER hydrochlorothiazide 1 GIC) hydrochlorothiazide ATROPEN 3 (bulk) INTRAMUSCULAR PEN INJECTOR 0.5 4 indapamide 1 MG/0.7 ML, 1 MG/0.7 metolazone 1 ML DOPAMINE D1 atropine (bulk) 3 RECEPTOR atropine injection 4 AGONISTS, solution 1 mg/ml ANTIHYPERTEN atropine injection SIVE syringe 0.05 mg/ml, 0.1 4 CORLOPAM 4 mg/ml GANGLIONIC glycopyrrolate (bulk) 3 BLOCKING, NON-CARDIAC NON- SELECTIVE DEPOLARIZING BETA BLOCKER- VECAMYL 3 THIAZIDE DIURETIC AND HYPERPOLARIZ RELATED COMB. ATION- ACTIVATED nadolol- bendroflumethiazide 3 CYCLIC oral tablet 80-5 mg NUCLEOTIDE- propranolol- 1 GATED hydrochlorothiazid CHANNEL INHIBITORS PAH AGENTS - SELECTIVE CORLANOR 2 PA PROSTACYCLIN RECEPTOR (IP) AGONISTS UPTRAVI 2 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 79 Drug Name Drug Tier Limits Drug Name Drug Tier Limits terazosin oral capsule 1 QL (30 EA per PATENT DUCTUS 2 ARTERIOSUS mg, 2 mg, 5 mg 23 days) terazosin oral capsule 10 QL (60 EA per (PDA) 2 TREATMENT mg 23 days) AGENTS , NSAID- PERIPHERAL TYPE VASODILATORS, indomethacin sodium 4 SINGLE AGENTS isoxsuprine oral tablet NEOPROFEN 3 (IBUPROFEN 4 20 mg LYSN)(PF) nylidrin (bulk) 3 PATENT DUCTUS papaverine (bulk) 3 ARTERIOSUS papaverine injection 4 (PDA) solution TREATMENT PHEOCHROMOC AGENTS, YTOMA, AGENTS PROSTAGLANDI TO TREAT N-TYPE DEMSER 3 alprostadil 4 PLASMA PROSTIN VR 4 KALLIKREIN PEDIATRIC INHIBITOR PERIPHERAL AGENTS, ALPHA-1 RECOMBINANT RECEPTOR MONOCLONAL BLOCKERS ANTIBODY CARDURA ORAL QL (30 EA per TAKHZYRO 3 PA TABLET 1 MG, 2 MG, 3 23 days) 4 MG PLASMA CARDURA ORAL QL (60 EA per KALLIKREIN 3 TABLET 8 MG 23 days) INHIBITOR QL (30 EA per AGENTS, CARDURA XL 3 23 days) RECOMBINANT DIBENZYLINE 3 PROTEIN doxazosin oral tablet 1 QL (30 EA per KALBITOR 4 PA 2 mg, 2 mg, 4 mg 23 days) PLASMA doxazosin oral tablet 8 QL (60 EA per KALLIKREIN 2 mg 23 days) INHIBITOR MINIPRESS 3 LA AGENTS phenoxybenzamine 1 KALBITOR 4 PA phentolamine injection 4 recon soln prazosin 1 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 80 Drug Name Drug Tier Limits Drug Name Drug Tier Limits POSTGANGLION bosentan 2 PA IC BLOCKERS, LETAIRIS 2 PA ANTIHYPERTEN OPSUMIT 3 SIVE TRACLEER 3 PA guanethidine sulfate 3 PULMONARY (bulk) ARTERIAL PULMONARY HYPERTENSION ANTIHYPERTEN AGENTS- SIVE AGENTS - SELECTIVE PROSTACYCLIN- CGMP-PDE5 TYPE INHIBITORS epoprostenol (glycine) 4 PA ADCIRCA 3 FLOLAN 4 PA ALYQ 3 PA ORENITRAM 3 REVATIO 4 REMODULIN 4 PA INTRAVENOUS treprostinil sodium 4 REVATIO ORAL 3 TYVASO 2 PA sildenafil TYVASO (pulm.hypertension) 4 INSTITUTIONAL 2 PA intravenous START KIT sildenafil (pulm.hypertension) TYVASO REFILL KIT 2 PA 3 oral suspension for TYVASO STARTER 2 PA reconstitution KIT sildenafil VELETRI 4 PA (pulm.hypertension) 2 PA VENTAVIS 2 PA oral tablet tadalafil (pulm. PULMONARY 3 PA ANTIHYPERTEN hypertension) tadalafil oral tablet 20 SIVE AGENTS- 2 PA SOLUBLE mg GUANYLATE RENIN CYCLASE INHIBITOR, STIMULATOR DIRECT AND ADEMPAS 2 PA DIURETIC PULMONARY COMBINATIONS ARTERIAL TEKTURNA HCT 3 HYPERTENSION RENIN - ENDOTHELIN INHIBITOR, RECEPTOR DIRECT ANTAGONISTS aliskiren 3 PA ambrisentan 2 PA TEKTURNA 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 81 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SCLEROSING ANTIANXIETY AGENTS AGENT - ASCLERA 4 BENZODIAZEPIN ETHAMOLIN 4 ES ALPRAZOLAM SOTRADECOL 4 3 LA INTENSOL VARITHENA 4 alprazolam oral tablet 1 LA VASODILATOR alprazolam oral tablet 3 LA COMBINATIONS extended release 24 hr BIDIL 3 alprazolam oral 3 LA CENTRAL tablet,disintegrating NERVOUS ATIVAN ORAL 3 LA SYSTEM chlordiazepoxide hcl 1 LA AGENTS clonazepam oral tablet 1 LA clonazepam oral AGENTS TO 3 LA TREAT tablet,disintegrating EPISODIC clorazepate dipotassium 1 LA CLUSTER diazepam injection 1 LA HEADACHES DIAZEPAM 1 LA EMGALITY SYRINGE INTENSOL SUBCUTANEOUS diazepam oral 2 PA 1 LA SYRINGE 300 MG/3 concentrate ML (100 MG/ML X 3) diazepam oral solution 5 2 LA ANTIANXIETY mg/5 ml (1 mg/ml) AGENT - diazepam oral solution 5 ANTIHISTAMINE mg/5 ml (1 mg/ml, 5 1 LA TYPE ml) hydroxyzine hcl diazepam oral tablet 10 1 LA 2 LA intramuscular mg hydroxyzine hcl oral diazepam oral tablet 2 1 LA 1 LA solution 10 mg/5 ml mg, 5 mg hydroxyzine hcl oral KLONOPIN 3 LA solution 10 mg/5 ml (5 2 LA LORAZEPAM 1 LA ml) INTENSOL hydroxyzine hcl oral lorazepam oral 1 LA 1 LA tablet concentrate hydroxyzine pamoate 1 LA lorazepam oral tablet 1 LA VISTARIL 3 LA oxazepam 3 LA TRANXENE T-TAB ORAL TABLET 7.5 3 LA MG

You can find information on what the symbols and abbreviationson this table mean on page 4. 82 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VALIUM 3 LA clonazepam oral 3 LA XANAX 3 LA tablet,disintegrating XANAX XR 3 LA DIASTAT 1 LA ANTIANXIETY DIASTAT ACUDIAL 1 LA AGENT - diazepam rectal 1 LA DICARBAMATE KLONOPIN 3 LA TYPE NAYZILAM 3 LA meprobamate 3 LA ONFI ORAL 3 LA ANTIANXIETY SUSPENSION ONFI ORAL TABLET AGENT - NON- 3 LA BENZODIAZEPIN 10 MG, 20 MG E SYMPAZAN 3 LA buspirone 1 LA VALTOCO 3 LA ANTICONVULSA ANTICONVULSA NT - AMPA-TYPE NT - GLUTAMATE CANNABINOID RECEPTOR TYPE ANTAGONISTS EPIDIOLEX 3 PA FYCOMPA ORAL ANTICONVULSA 2 PA SUSPENSION NT - FYCOMPA ORAL CARBAMATES 2 PA TABLET felbamate oral 1 PA ANTICONVULSA suspension NT - felbamate oral tablet 2 PA BARBITURATES FELBATOL 3 AND ANTICONVULSA DERIVATIVES NT - butalbital (bulk) 3 CARBOXYLIC MYSOLINE 3 LA ACID phenobarbital 1 DERIVATIVES phenobarbital (bulk) 3 DEPAKOTE 3 LA phenobarbital sodium DEPAKOTE ER 3 LA 4 injection solution DEPAKOTE 3 LA primidone 1 LA SPRINKLES ANTICONVULSA divalproex 1 LA NT - valproate sodium 1 LA BENZODIAZEPIN valproic acid 1 LA ES valproic acid (as sodium clobazam 1 LA salt) oral solution 250 1 LA clonazepam oral tablet 1 LA mg/5 ml (5 ml) You can find information on what the symbols and abbreviationson this table mean on page 4. 83 Drug Name Drug Tier Limits Drug Name Drug Tier Limits valproic acid (as sodium ANTICONVULSA salt) oral solution 250 2 LA NT - GABA RE- mg/5 ml, 500 mg/10 ml UPTAKE (10 ml) INHIBITOR, ANTICONVULSA NIPECOTIC ACID NT - DERIVATIVES FUNCTIONALIZE GABITRIL ORAL D AMINO ACID TABLET 12 MG, 16 3 VIMPAT MG 2 PA; LA INTRAVENOUS GABITRIL ORAL 2 PA VIMPAT ORAL TABLET 2 MG, 4 MG 1 LA SOLUTION tiagabine 2 PA VIMPAT ORAL 1 LA ANTICONVULSA TABLET NT - GABA ANTICONVULSA TRANSAMINASE NT - GABA (GABA-T) ANALOGS INHIBITOR ACTIVE-PAC 3 SABRIL ORAL 3 gabapentin oral capsule 1 LA POWDER IN PACKET gabapentin oral solution SABRIL ORAL 2 LA 3 PA; LA 250 mg/5 ml TABLET gabapentin oral solution vigabatrin oral tablet 2 PA 250 mg/5 ml (5 ml), 300 1 LA VIGADRONE 2 PA mg/6 ml (6 ml) ANTICONVULSA gabapentin oral tablet 1 LA 600 mg NT - HYDANTOINS gabapentin oral tablet 2 LA 800 mg CEREBYX 2 PA LYRICA 3 LA DILANTIN 3 DILANTIN NEURONTIN 3 LA 3 EXTENDED pregabalin oral capsule 100 mg, 150 mg, 200 DILANTIN INFATABS 3 1 LA mg, 225 mg, 25 mg, 50 DILANTIN-125 3 mg, 75 mg fosphenytoin 2 PA pregabalin oral capsule 1 PEGANONE 3 300 mg PHENYTEK 3 pregabalin oral solution 1 LA phenytoin (bulk) 3 phenytoin oral 1 suspension phenytoin oral 1 tablet,chewable

You can find information on what the symbols and abbreviationson this table mean on page 4. 84 Drug Name Drug Tier Limits Drug Name Drug Tier Limits phenytoin sodium (bulk) 3 topiramate oral tablet 2 LA phenytoin sodium 200 mg, 25 mg 1 extended TROKENDI XR 1 LA phenytoin sodium 4 ANTICONVULSA intravenous solution NT - phenytoin sodium 2 PA PHENYLTRIAZIN intravenous syringe E DERIVATIVES ANTICONVULSA LAMICTAL ODT 3 LA NT - LAMICTAL ODT 3 LA IMINOSTILBENE STARTER (BLUE) DERIVATIVES LAMICTAL ODT 3 LA APTIOM 3 LA STARTER (GREEN) carbamazepine 1 LA LAMICTAL ODT 3 LA CARBATROL 3 LA STARTER (ORANGE) LAMICTAL ORAL EPITOL 1 LA 3 LA TABLET EQUETRO 2 PA; LA LAMICTAL ORAL oxcarbazepine oral TABLET, CHEWABLE 1 LA 3 LA suspension DISPERSIBLE 25 MG, oxcarbazepine oral 5 MG 2 LA tablet LAMICTAL STARTER 3 LA OXTELLAR XR 3 LA (BLUE) KIT TEGRETOL ORAL LAMICTAL STARTER 3 LA 3 LA SUSPENSION (GREEN) KIT TEGRETOL ORAL LAMICTAL STARTER 3 LA 3 LA TABLET (ORANGE) KIT TEGRETOL XR 3 LA LAMICTAL XR 3 LA TRILEPTAL 3 LA LAMICTAL XR 3 LA ANTICONVULSA STARTER (BLUE) LAMICTAL XR NT - 3 LA MONOSACCHAR STARTER (GREEN) LAMICTAL XR IDE 3 LA DERIVATIVES STARTER (ORANGE) lamotrigine oral tablet QUDEXY XR 3 LA 1 LA 100 mg, 150 mg, 25 mg TOPAMAX 3 LA lamotrigine oral tablet topiramate oral capsule, 2 LA 1 LA 200 mg sprinkle lamotrigine oral tablet topiramate oral 3 PA; LA 3 LA disintegrating, dose pk capsule,sprinkle,er 24hr lamotrigine oral tablet topiramate oral tablet 3 LA 1 LA extended release 24hr 100 mg, 50 mg

You can find information on what the symbols and abbreviationson this table mean on page 4. 85 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lamotrigine oral tablet, 3 LA ANTICONVULSA chewable dispersible NT - lamotrigine oral 3 LA SUCCINIMIDES tablet,disintegrating CELONTIN ORAL 3 PA SUBVENITE 1 LA CAPSULE 300 MG SUBVENITE 3 ethosuximide 1 STARTER (BLUE) KIT ZARONTIN 1 SUBVENITE STARTER (GREEN) 3 ANTICONVULSA KIT NT - SUBVENITE SULFONAMIDE STARTER (ORANGE) 3 DERIVATIVES KIT ZONEGRAN ORAL ANTICONVULSA CAPSULE 100 MG, 25 3 LA NT - MG zonisamide oral capsule PYRROLIDINE 2 LA DERIVATIVES 100 mg zonisamide oral capsule BRIVIACT 1 LA 2 PA; LA 25 mg, 50 mg INTRAVENOUS BRIVIACT ORAL 3 LA ANTICONVULSA NT - TRIAZOLE KEPPRA 3 LA DERIVATIVES KEPPRA XR 3 LA BANZEL 3 LA levetiracetam in nacl 2 PA; LA (iso-os) ANTICONVULSA levetiracetam NT OTHERS 2 PA; LA intravenous DIACOMIT 3 PA levetiracetam oral FINTEPLA 3 LA 1 solution 100 mg/ml XCOPRI 3 levetiracetam oral XCOPRI TITRATION 3 solution 500 mg/5 ml (5 2 LA PACK ml) ANTIDEPRESSAN levetiracetam oral tablet 1 LA T - ALPHA-2 levetiracetam oral tablet 1 LA RECEPTOR extended release 24 hr ANTAGONISTS ROWEEPRA 1 LA (NASSA) ROWEEPRA XR 1 LA mirtazapine oral tablet 1 LA SPRITAM 3 LA 15 mg, 30 mg, 7.5 mg mirtazapine oral tablet 2 LA 45 mg mirtazapine oral tablet,disintegrating 15 1 LA mg, 45 mg You can find information on what the symbols and abbreviationson this table mean on page 4. 86 Drug Name Drug Tier Limits Drug Name Drug Tier Limits mirtazapine oral ANTIDEPRESSAN tablet,disintegrating 30 2 LA T - SELECTIVE mg SEROTONIN REMERON ORAL REUPTAKE TABLET 15 MG, 30 3 LA INHIBITORS MG (SSRIS) REMERON SOLTAB 3 LA CELEXA ORAL LA; QL (40 EA 3 ANTIDEPRESSAN TABLET per 1 day) T - MAO LA; QL (40 citalopram oral solution 3 INHIBITOR ML per 1 day) NONSELECTIVE LA; QL (40 EA citalopram oral tablet 1 AND per 1 day) IRREVERSIBLE- escitalopram oxalate 3 LA TYPES A,B oral solution EMSAM 1 LA escitalopram oxalate 1 LA MARPLAN 3 LA oral tablet fluoxetine oral capsule NARDIL 3 LA 3 LA 10 mg, 20 mg PARNATE 3 LA fluoxetine oral capsule phenelzine 1 LA 1 LA 40 mg tranylcypromine 1 LA fluoxetine oral ANTIDEPRESSAN capsule,delayed 3 LA T - release(dr/ec) NEUROACTIVE fluoxetine oral solution 1 LA STEROID GABA- fluoxetine oral tablet 3 LA A RECEPTOR fluvoxamine oral MODULATOR capsule,extended release 3 LA ZULRESSO 4 24hr ANTIDEPRESSAN fluvoxamine oral tablet 1 LA LEXAPRO ORAL T - N-METHYL D- 3 LA ASPARTATE TABLET paroxetine hcl oral (NMDA) 1 LA RECEPTOR tablet ANTAGONIST paroxetine hcl oral tablet extended release 3 LA SPRAVATO 4 LA 24 hr PAXIL 3 LA PAXIL CR 3 LA PEXEVA 3 LA PROZAC ORAL 3 LA CAPSULE

You can find information on what the symbols and abbreviationson this table mean on page 4. 87 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SARAFEM ORAL venlafaxine oral tablet 3 LA TABLET 10 MG, 20 3 LA extended release 24hr MG ANTIDEPRESSAN sertraline oral 3 LA T - SSRI AND concentrate 5HT1A PARTIAL sertraline oral tablet 1 LA AGONIST ZOLOFT 3 LA VIIBRYD ORAL 3 LA ANTIDEPRESSAN TABLET T - SEROTONIN-2 VIIBRYD ORAL TABLETS,DOSE ANTAGONIST- 3 LA REUPTAKE PACK 10 MG (7)- 20 INHIBITORS MG (23) (SARIS) ANTIDEPRESSAN nefazodone 3 LA T - SSRI AND SEROTONIN (5- trazodone 1 LA HT) RECEPTOR ANTIDEPRESSAN MODULATOR T - SEROTONIN- TRINTELLIX 3 LA NOREPINEPHRIN E REUPTAKE ANTIDEPRESSAN INHIBITORS T - TRICYCLIC (SNRIS) AND ANTIPSYCHOTIC LA; QL (60 EA CYMBALTA 3 per 1 day) , PHENOTHIAZIN E COMB desvenlafaxine oral perphenazine- tablet extended release 3 LA 1 LA 24 hr amitriptyline desvenlafaxine ANTIDEPRESSAN 3 LA succinate T - TRICYCLIC- DRIZALMA BENZODIAZEPIN 3 LA SPRINKLE E LA; QL (60 EA COMBINATIONS duloxetine 1 per 1 day) amitriptyline- 3 LA EFFEXOR XR 3 LA chlordiazepoxide FETZIMA 3 LA ANTIDEPRESSAN PRISTIQ 3 LA T- SSRI AND SAVELLA 3 ATYPICAL venlafaxine oral ANTIPSYCH,DOP capsule,extended release 1 LA AMINE,SEROTO 24hr NIN ANTAGON venlafaxine oral tablet 1 LA olanzapine-fluoxetine 3 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 88 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SYMBYAX ORAL NORPRAMIN ORAL CAPSULE 12-50 MG, TABLET 10 MG, 25 3 LA 3 LA 3-25 MG, 6-25 MG, 6- MG 50 MG nortriptyline oral 1 LA ANTIDEPRESSAN capsule T- nortriptyline oral 3 LA NOREPINEPHRIN solution E AND PAMELOR 3 LA DOPAMINE protriptyline 3 LA REUPTAKE trimipramine 3 LA INHIBITORS ANTIPARKINSON (NDRIS) - APLENZIN 3 LA DOPAMINERGIC- bupropion hcl 1 LA PERIPH COMT- bupropion hcl (bulk) 1 DOPA- FORFIVO XL 3 LA DECARBOXYLAS WELLBUTRIN SR 3 LA E INHIB COMB carbidopa-levodopa- WELLBUTRIN XL 3 LA 3 LA entacapone ANTIDEPRESSAN T-TRICYCLICS STALEVO 100 3 LA AND RELATED STALEVO 125 3 LA (NON-SELECT STALEVO 150 3 LA REUPTAKE STALEVO 200 3 LA INHIBITORS) STALEVO 50 3 LA amitriptyline 1 LA STALEVO 75 3 LA amitriptyline (bulk) 3 ANTIPARKINSON amoxapine 1 LA - DOPAMINERG- ANAFRANIL 3 LA PERIPHERAL clomipramine 3 LA DOPA- desipramine 1 LA DECARBOXYLAS E INHIBIT COMB doxepin oral capsule 10 carbidopa-levodopa oral mg, 100 mg, 25 mg, 50 1 LA 1 LA mg, 75 mg tablet doxepin oral capsule carbidopa-levodopa oral 2 LA 1 LA 150 mg tablet extended release carbidopa-levodopa oral doxepin oral concentrate 1 LA 3 LA tablet,disintegrating imipramine hcl 1 LA DUOPA 3 LA imipramine pamoate 3 LA RYTARY 3 LA maprotiline 3 LA SINEMET 3 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 89 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPARKINSON INBRIJA ADJUVANT - INHALATION CENTRAL/PERIP CAPSULE, 3 PA W/INHALATION HERAL COMT DEVICE INHIBITORS ANTIPARKINSON TASMAR ORAL 3 THERAPY - TABLET 100 MG ERGOT tolcapone 1 ALKALOIDS AND ANTIPARKINSON DERIVATIVES ADJUVANT - bromocriptine 3 LA PERIPHERAL PARLODEL 3 LA COMT INHIBITORS ANTIPARKINSON THERAPY - COMTAN 3 MONOAMINE entacapone 1 OXIDASE ANTIPARKINSON INHIBITOR(MAO ADJUVANT - -B) PERIPHERAL AZILECT 3 LA DOPA- ELDEPRYL 3 LA DECARBOXYLAS E INHIBITORS rasagiline 3 LA selegiline hcl 1 LA carbidopa 1 LA XADAGO 3 LA carbidopa (bulk) 3 ZELAPAR 3 LA LODOSYN 3 LA ANTIPARKINSON ANTIPARKINSON THERAPY - THERAPY - NON- ANTICHOLINER ERGOT GIC AGENTS DOPAMINE AGONIST benztropine 1 LA AGENTS COGENTIN 1 LA amantadine hcl (bulk) 3 trihexyphenidyl 1 LA amantadine hcl oral 1 LA ANTIPARKINSON capsule THERAPY - amantadine hcl oral 1 LA DOPAMINE solution PRECURSORS amantadine hcl oral 3 LA INBRIJA tablet INHALATION 3 APOKYN 3 LA CAPSULE GOCOVRI 3 LA KYNMOBI 3 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 90 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MIRAPEX 3 LA ANTIPSYCHOTIC MIRAPEX ER 3 LA - ATYPICAL NEUPRO 3 LA DOPAMINE- OSMOLEX ER 3 LA SEROTONIN ANTAG- pramipexole oral tablet 0.125 mg, 0.25 mg, 0.75 1 LA BENZISOTHIAZO mg, 1 mg, 1.5 mg LONES pramipexole oral tablet GEODON LA; QL (40 EA 1 1 0.5 mg INTRAMUSCULAR per 1 day) pramipexole oral tablet GEODON ORAL 3 LA 3 LA extended release 24 hr LATUDA 1 LA REQUIP ORAL ziprasidone hcl 1 LA TABLET 0.25 MG, 3 3 ziprasidone mesylate 1 LA MG, 5 MG REQUIP XL ORAL ANTIPSYCHOTIC TABLET EXTENDED - ATYPICAL 3 LA RELEASE 24 HR 12 DOPAMINE- MG, 6 MG SEROTONIN REQUIP XL ORAL ANTAG- TABLET EXTENDED 3 BENZISOXAZOL RELEASE 24 HR 2 MG E DERIV ropinirole oral tablet 1 LA FANAPT ORAL 1 LA ropinirole oral tablet TABLET 3 LA extended release 24 hr FANAPT ORAL ANTIPSYCHOTIC TABLETS,DOSE 3 LA - ATYP PACK DOPAMINE- INVEGA 3 LA SEROTONIN LA; QL (1 ML INVEGA SUSTENNA 1 ANTAG per 30 days) DIBENZO- LA; QL (819 OXEPINO INVEGA TRINZA 1 ML per 90 PYRROLES days) SAPHRIS 1 LA paliperidone 1 LA SECUADO 3 LA PERSERIS 3 LA LA; QL (100 RISPERDAL CONSTA 1 EA per 30 days) RISPERDAL ORAL 3 LA SOLUTION RISPERDAL ORAL TABLET 0.5 MG, 1 3 LA MG, 2 MG, 3 MG, 4 MG You can find information on what the symbols and abbreviationson this table mean on page 4. 91 Drug Name Drug Tier Limits Drug Name Drug Tier Limits risperidone oral solution 1 LA ANTIPSYCHOTIC risperidone oral syringe 2 LA - risperidone oral tablet DIBENZOXAZEPI 0.25 mg, 1 mg, 2 mg, 3 1 LA NE mg DERIVATIVES risperidone oral tablet 2 LA ADASUVE 3 LA 0.5 mg, 4 mg loxapine succinate 1 LA risperidone oral 1 LA tablet,disintegrating ANTIPSYCHOTIC - ANTIPSYCHOTIC DIHYDROINDOL - ATYPICAL ONES DOPAMINE- SEROTONIN molindone 1 LA ANTAG- ANTIPSYCHOTIC BUTYROPHENO - NE DERIV DIPHENYLBUTY CAPLYTA 2 PA; LA LPIPERIDINE DERIVATIVES ANTIPSYCHOTIC pimozide oral tablet 1 - ATYPICAL 1 LA mg DOPAMINE- pimozide oral tablet 2 SEROTONIN 3 PA mg ANTAG- DIBENZODIAZEP ANTIPSYCHOTIC INE DER - PHENOTHIAZIN ES, ALIPHATIC clozapine oral tablet 1 LA chlorpromazine 1 LA clozapine oral 3 LA tablet,disintegrating ANTIPSYCHOTIC CLOZARIL 3 LA - PHENOTHIAZIN VERSACLOZ 3 LA ES, PIPERAZINE ANTIPSYCHOTIC COMPAZINE ORAL 3 LA - BUTYROPHENO fluphenazine decanoate 1 LA NE fluphenazine hcl 1 LA DERIVATIVES perphenazine 1 LA HALDOL 3 LA prochlorperazine HALDOL maleate oral tablet 10 1 LA 3 LA DECANOATE mg prochlorperazine haloperidol 1 LA 2 LA maleate oral tablet 5 mg haloperidol decanoate 1 LA trifluoperazine 1 LA haloperidol lactate 1 LA injection haloperidol lactate oral 1 LA You can find information on what the symbols and abbreviationson this table mean on page 4. 92 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSYCHOTIC ZYPREXA ZYDIS 3 LA - PHENOTHIAZIN ANTIPSYCHOTIC ES, PIPERIDINE -ATYP thioridazine 1 LA SELECTIVE ANTIPSYCHOTIC SEROTONIN 5- - HT2A INVERSE THIOXANTHENE AGONISTS (SSIA) NUPLAZID ORAL S 2 PA; LA CAPSULE thiothixene 1 LA NUPLAZID ORAL 2 PA; LA ANTIPSYCHOTIC TABLET 10 MG -ATYPICAL DOPAMINE- ANTIPSYCHOTIC SEROTONIN -ATYPICAL,D2 ANTAG- RECEPTOR DIBENZOTHIAZ PARTIAL EPINE DER AGONIST-5HT SEROTONIN quetiapine 1 LA MIXED SEROQUEL 3 LA LA; QL (400 SEROQUEL XR ORAL ABILIFY MAINTENA 1 EA per 30 TABLET EXTENDED 3 LA days) RELEASE 24 HR ABILIFY MYCITE 3 LA ANTIPSYCHOTIC ABILIFY ORAL 3 LA -ATYPICAL TABLET DOPAMINE- aripiprazole oral 1 LA SEROTONIN solution ANTAG- aripiprazole oral tablet 1 LA THIENOBENZOD aripiprazole oral 3 LA IAZEPINES tablet,disintegrating olanzapine LA; QL (10 EA 1 LA; QL (882 intramuscular per 1 day) ARISTADA 1 ML per 30 olanzapine oral 1 LA days) olanzapine-fluoxetine 3 LA ARISTADA INITIO 3 LA SYMBYAX ORAL REXULTI 1 LA CAPSULE 12-50 MG, 3 LA 3-25 MG, 6-25 MG, 6- 50 MG ZYPREXA LA; QL (10 EA 3 INTRAMUSCULAR per 1 day) ZYPREXA ORAL 3 LA ZYPREXA LA; QL (3 EA 3 RELPREVV per 10 days)

You can find information on what the symbols and abbreviationson this table mean on page 4. 93 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSYCHOTIC DESOXYN 3 LA - DEXEDRINE 3 LA ATYPICAL,D3/D2 SPANSULE RECEPTOR dexmethylphenidate 1 LA PARTIAL dextroamphetamine oral AGONIST- capsule, extended 1 LA SEROTONIN release MIXED dextroamphetamine oral 3 LA VRAYLAR 2 PA; LA tablet dextroamphetamine- ATTENTION 1 LA amphetamine DEFICIT- HYPERACT. DYANAVEL XR 3 LA DISORDER EVEKEO 3 LA (ADHD)- ALPHA- EVEKEO ODT 3 LA 2 RECEPTOR FOCALIN 3 LA AGONIST FOCALIN XR 3 LA clonidine hcl oral tablet 1 LA JORNAY PM 3 LA extended release 12 hr METADATE ER 1 LA guanfacine oral tablet 1 LA methamphetamine 3 LA extended release 24 hr METHYLIN ORAL INTUNIV ER 3 LA 1 LA SOLUTION KAPVAY 3 LA methylphenidate hcl ATTENTION oral cap,er 1 LA DEFICIT- sprinkle,biphasic 40-60 HYPERACTIVITY methylphenidate hcl (ADHD) oral capsule, er biphasic 1 LA THERAPY, 30-70 STIMULANT- methylphenidate hcl TYPE oral capsule,er biphasic 1 LA 50-50 ADDERALL 3 LA methylphenidate hcl 1 LA ADDERALL XR 3 LA oral solution ADHANSIA XR 3 LA methylphenidate hcl 1 LA ADZENYS ER 3 LA oral tablet ADZENYS XR-ODT 3 LA methylphenidate hcl amphetamine 3 LA oral tablet extended 1 LA release amphetamine sulfate 3 LA methylphenidate hcl APTENSIO XR 1 LA oral tablet extended 1 LA CONCERTA 3 LA release 24hr 18 mg, 27 COTEMPLA XR-ODT 3 LA mg, 36 mg, 54 mg DAYTRANA 3 LA You can find information on what the symbols and abbreviationson this table mean on page 4. 94 Drug Name Drug Tier Limits Drug Name Drug Tier Limits methylphenidate hcl chlordiazepoxide hcl 1 LA oral tablet extended 3 LA chlordiazepoxide- 3 release 24hr 72 mg clidinium methylphenidate hcl 1 LA clobazam 1 LA oral tablet,chewable clonazepam oral tablet 1 LA MYDAYIS 3 LA clonazepam oral 3 LA QUILLICHEW ER 3 LA tablet,disintegrating QUILLIVANT XR 3 LA clorazepate dipotassium 1 LA RELEXXII 3 LA DIASTAT 1 LA RITALIN 3 LA DIASTAT ACUDIAL 1 LA RITALIN LA ORAL diazepam injection 1 LA CAPSULE,ER DIAZEPAM BIPHASIC 50-50 10 3 LA 1 LA MG, 20 MG, 30 MG, 40 INTENSOL MG diazepam oral 1 LA LA; QL (30 EA concentrate VYVANSE 1 per 30 days) diazepam oral solution 5 2 LA ZENZEDI 3 LA mg/5 ml (1 mg/ml) ATTENTION diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 1 LA DEFICIT- ml) HYPERACTIVITY diazepam oral tablet 10 2 LA DISORDER mg (ADHD) diazepam oral tablet 2 1 LA THERAPY, NRI- mg, 5 mg TYPE diazepam rectal 1 LA LA; QL (120 atomoxetine 1 DORAL 3 LA EA per 1 day) estazolam 3 LA LA; QL (120 STRATTERA 3 EA per 1 day) flurazepam 3 LA HALCION ORAL BENZODIAZEPIN 3 LA ES TABLET 0.25 MG KLONOPIN 3 LA ALPRAZOLAM 3 LA LIBRAX (WITH INTENSOL 3 CLIDINIUM) alprazolam oral tablet 1 LA lorazepam injection alprazolam oral tablet 1 3 LA solution 2 mg/ml extended release 24 hr lorazepam injection alprazolam oral 1 LA 3 LA syringe tablet,disintegrating LORAZEPAM amitriptyline- 1 LA 3 LA INTENSOL chlordiazepoxide lorazepam oral ATIVAN 3 LA 1 LA concentrate

You can find information on what the symbols and abbreviationson this table mean on page 4. 95 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lorazepam oral tablet 1 LA triazolam oral tablet 1 LA midazolam (pf) in 0.9 % 0.125 mg nacl intravenous 1 LA triazolam oral tablet LA; QL (30 EA 1 solution 0.25 mg per 22 days) midazolam (pf) in 0.9 % VALIUM 3 LA nacl intravenous syringe 3 VALTOCO 3 LA 2 mg/2 ml (1 mg/ml) XANAX 3 LA midazolam (pf) in 0.9 % nacl intravenous syringe 4 XANAX XR 3 LA 5 mg/5 ml (1 mg/ml) BIPOLAR midazolam (pf) THERAPY 1 LA injection AGENTS - midazolam in 0.9 % sod ANTICONVULSA chlorid intravenous 4 LA NT TYPE solution 1 mg/ml carbamazepine oral midazolam in 0.9 % sod capsule, er multiphase 1 LA chlorid intravenous 12 hr syringe 2 mg/2 ml (1 3 LA carbamazepine oral mg/ml), 5 mg/5 ml (1 1 LA suspension mg/ml) carbamazepine oral midazolam injection 1 LA 1 LA tablet midazolam intravenous carbamazepine oral syringe 150 mg/30 ml (5 1 LA tablet extended release 1 LA mg/ml) 12 hr 200 mg, 400 mg midazolam oral syrup 2 3 LA carbamazepine oral mg/ml 1 LA tablet,chewable NAYZILAM 3 LA CARBATROL 3 LA ONFI ORAL 3 LA DEPAKOTE 3 LA SUSPENSION DEPAKOTE ER 3 LA ONFI ORAL TABLET 3 LA DEPAKOTE 10 MG, 20 MG 3 LA SPRINKLES oxazepam 3 LA divalproex 1 LA quazepam 2 EPITOL 1 LA RESTORIL 3 LA EQUETRO 2 PA; LA SYMPAZAN 3 LA LAMICTAL ODT 3 LA temazepam oral capsule 1 LA LAMICTAL ODT 15 mg, 30 mg, 7.5 mg 3 LA STARTER (BLUE) temazepam oral capsule 2 LA LAMICTAL ODT 22.5 mg 3 LA STARTER (GREEN) TRANXENE T-TAB LAMICTAL ODT ORAL TABLET 7.5 3 LA 3 LA MG STARTER (ORANGE)

You can find information on what the symbols and abbreviationson this table mean on page 4. 96 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LAMICTAL STARTER aripiprazole oral 3 LA 1 LA (BLUE) KIT solution LAMICTAL STARTER aripiprazole oral tablet 1 LA 3 LA (GREEN) KIT aripiprazole oral 3 LA LAMICTAL STARTER tablet,disintegrating 3 LA (ORANGE) KIT GEODON LA; QL (40 EA 1 lamotrigine oral tablet INTRAMUSCULAR per 1 day) 3 PA; LA disintegrating, dose pk GEODON ORAL 3 LA lamotrigine oral olanzapine LA; QL (10 EA 3 LA 1 tablet,disintegrating intramuscular per 1 day) SUBVENITE 3 olanzapine oral 1 LA STARTER (BLUE) KIT olanzapine-fluoxetine 3 LA SUBVENITE STARTER (GREEN) 3 quetiapine 1 LA KIT RISPERDAL ORAL 3 LA SUBVENITE SOLUTION STARTER (ORANGE) 3 RISPERDAL ORAL KIT TABLET 0.5 MG, 1 3 LA TEGRETOL ORAL MG, 2 MG, 3 MG, 4 3 LA SUSPENSION MG TEGRETOL ORAL risperidone oral solution 1 LA 3 LA TABLET risperidone oral syringe 2 LA TEGRETOL XR ORAL risperidone oral tablet TABLET EXTENDED 0.25 mg, 1 mg, 2 mg, 3 1 LA 3 LA RELEASE 12 HR 200 mg MG, 400 MG risperidone oral tablet 2 LA valproic acid 1 LA 0.5 mg, 4 mg valproic acid (as sodium risperidone oral 1 LA salt) oral solution 250 1 LA tablet,disintegrating mg/5 ml (5 ml) SAPHRIS 1 LA valproic acid (as sodium SEROQUEL 3 LA salt) oral solution 250 2 LA mg/5 ml, 500 mg/10 ml SEROQUEL XR ORAL (10 ml) TABLET EXTENDED 3 LA RELEASE 24 HR BIPOLAR SYMBYAX ORAL THERAPY CAPSULE 12-50 MG, 3 LA AGENTS - 3-25 MG, 6-25 MG, 6- ATYPICAL 50 MG ANTIPSYCHOTIC VRAYLAR 2 PA; LA S ziprasidone hcl 1 LA ABILIFY MYCITE 3 LA ziprasidone mesylate 1 LA ABILIFY ORAL ZYPREXA LA; QL (10 EA 3 LA 3 TABLET INTRAMUSCULAR per 1 day)

You can find information on what the symbols and abbreviationson this table mean on page 4. 97 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZYPREXA ORAL 3 LA CNS STIMULANT ZYPREXA ZYDIS 3 LA - BIPOLAR AMPHETAMINES THERAPY amphetamine sulfate 3 LA AGENTS - DESOXYN 3 LA LITHIUM DEXEDRINE 3 LA lithium carbonate 1 LA SPANSULE lithium citrate oral dextroamphetamine oral 1 LA solution 8 meq/5 ml capsule, extended 1 LA release LITHOBID 3 LA dextroamphetamine oral 3 LA CANNABIS AND solution CANNABINOID dextroamphetamine oral 3 LA RECEPTOR tablet AGONISTS EVEKEO 3 LA CESAMET 2 PA EVEKEO ODT 3 LA dronabinol oral capsule 3 methamphetamine 3 LA 10 mg PROCENTRA 3 LA dronabinol oral capsule 3 PA 2.5 mg, 5 mg ZENZEDI 3 LA SYNDROS 3 CNS STIMULANT CNS AND - ANALEPTICS, RESPIRATORY METHYLXANTHI STIMULANT NE-TYPE CAFCIT DOPRAM 4 4 INTRAVENOUS doxapram 4 caffeine (bulk) 3 CNS STIMULANT caffeine citrate (bulk) 3 - AMPHETAMINE caffeine citrate COMBINATIONS 4 intravenous ADDERALL 3 LA caffeine citrate oral 3 ADDERALL XR 3 LA caffeine-sodium 4 ADZENYS ER 3 LA benzoate ADZENYS XR-ODT 3 LA CNS STIMULANT amphetamine 3 LA - ANALEPTICS dextroamphetamine- CAFCIT 1 LA 4 amphetamine INTRAVENOUS DYANAVEL XR 3 LA caffeine (bulk) 3 MYDAYIS 3 LA caffeine citrate (bulk) 3 caffeine citrate 4 intravenous

You can find information on what the symbols and abbreviationson this table mean on page 4. 98 Drug Name Drug Tier Limits Drug Name Drug Tier Limits caffeine citrate oral 3 HYPNOTICS - caffeine-sodium MELATONIN 4 benzoate COMBINATIONS DOPRAM 4 melatonin-lemon balm doxapram 4 leaf extr oral tablet 3 3 mg- 500 mcg DIABETIC PERIPHERAL TOPROPHAN 1 NEUROPATHY HYPNOTICS - AGENTS MELATONIN LYRICA CR 3 M1/M2 RECEPTOR FIBROMYALGIA AGONISTS AGENTS - GABA ANALOGS HETLIOZ 3 LA ramelteon 2 PA; LA LYRICA 3 LA ROZEREM 3 LA pregabalin oral capsule 100 mg, 150 mg, 200 MIGRAINE 1 LA mg, 225 mg, 25 mg, 50 THERAPY - mg, 75 mg ANALGESIC- pregabalin oral capsule 1 VASOCONSTRIC 300 mg TOR-SEDATIVE pregabalin oral solution 1 LA COMBINATIONS FIBROMYALGIA isometh-dichloral- 3 AGENTS - acetaminophn SEROTONIN- MIGRAINE NOREPINEPHRIN THERAPY - E REUPTAKE- CALCITONIN INHIB (SNRIS) GENE-RELATED LA; QL (60 EA PEPTIDE CYMBALTA 3 per 1 day) INHIBITORS DRIZALMA AIMOVIG 3 LA 3 SPRINKLE AUTOINJECTOR LA; QL (60 EA duloxetine 1 AJOVY SYRINGE 3 PA per 1 day) EMGALITY PEN 2 PA SAVELLA 3 EMGALITY SYRINGE HSDD AGENTS- SUBCUTANEOUS 2 PA MIXED SYRINGE 120 MG/ML SEROTONIN AGONIST/ANTA GONISTS ADDYI 3 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 99 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dihydroergotamine MIGRAINE 4 THERAPY - injection QL (8 ML per CARBOXYLIC dihydroergotamine nasal 2 ACID 23 days) DERIVATIVES ERGOMAR 1 PA ergotamine tartrate DEPAKOTE ER 3 LA 3 (bulk) divalproex oral tablet 1 LA PA; QL (8 ML extended release 24 hr MIGRANAL 2 per 23 days) MIGRAINE THERAPY - MIGRAINE CGRP LIGAND THERAPY - BLOCKER, ERGOT MONOCLONAL COMBINATIONS ANTIBODY CAFERGOT 3 PA AJOVY SYRINGE 3 PA MIGERGOT 2 PA EMGALITY PEN 2 PA MIGRAINE EMGALITY SYRINGE THERAPY - SUBCUTANEOUS 2 PA NSAID SYRINGE 120 MG/ML ANALGESICS(CY MIGRAINE CLOOXYGENAS THERAPY - E INHIB-NON- CGRP SELECTIV) RECEPTOR CAMBIA 2 PA BLOCKERS MIGRAINE (GEPANTS) THERAPY - UBRELVY 3 SELECTIVE MIGRAINE SEROTONIN THERAPY - AGONISTS 5- CGRP HT(1) RECEPTOR QL (6 EA per almotriptan malate 3 BLOCKERS, 23 days) MONOCLONAL QL (4 ML per ALSUMA 3 ANTIBODY 30 days) AIMOVIG QL (9 EA per 3 AMERGE 3 AUTOINJECTOR 23 days) MIGRAINE eletriptan 3 QL (9 EA per THERAPY - FROVA 3 ERGOT 23 days) QL (9 EA per ALKALOIDS AND frovatriptan 3 DERIVATIVES 23 days) D.H.E.45 4 You can find information on what the symbols and abbreviationson this table mean on page 4. 100 Drug Name Drug Tier Limits Drug Name Drug Tier Limits QL (12 EA per IMITREX NASAL 3 MIGRAINE 23 days) THERAPY - QL (9 EA per IMITREX ORAL 3 SEROTONIN 23 days) AGONIST 5-HT(1) IMITREX STATDOSE QL (4 ML per 3 AND NSAID PEN 30 days) COMB. IMITREX STATDOSE QL (4 ML per 3 sumatriptan-naproxen 2 PA REFILL 30 days) TREXIMET ORAL IMITREX QL (4 ML per 2 PA 3 TABLET 85-500 MG SUBCUTANEOUS 30 days) MOVEMENT MAXALT ORAL 3 TABLET 10 MG DISORDER DRUG THERAPY MAXALT-MLT ORAL TABLET,DISINTEGR 3 AUSTEDO 2 ATING 10 MG INGREZZA 3 MIGRANOW 2 PA INITIATION PACK QL (9 EA per INGREZZA ORAL naratriptan 2 3 23 days) CAPSULE 40 MG ONZETRA XSAIL 3 tetrabenazine 2 RELPAX 3 XENAZINE 3 rizatriptan 1 ST MOVEMENT QL (12 EA per DISORDER sumatriptan 2 23 days) THERAPY - sumatriptan succinate QL (9 EA per HUNTINGTON'S 2 oral 23 days) DISEASE sumatriptan succinate QL (4 ML per AUSTEDO 2 2 subcutaneous cartridge 30 days) tetrabenazine 2 sumatriptan succinate QL (4 ML per XENAZINE 3 subcutaneous pen 2 30 days) injector MOVEMENT sumatriptan succinate QL (4 ML per DISORDER 1 subcutaneous solution 30 days) THERAPY - ZEMBRACE RESTLESS LEGS 3 SYMTOUCH SYNDROME zolmitriptan 3 HORIZANT 3 PA ZOMIG NASAL 3 MOVEMENT ZOMIG ORAL DISORDER 3 TABLET 5 MG THERAPY - ZOMIG ZMT 3 TARDIVE DYSKINESIA AUSTEDO 2

You can find information on what the symbols and abbreviationson this table mean on page 4. 101 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INGREZZA 3 NARCOLEPSY INITIATION PACK THERAPY INGREZZA ORAL 3 AGENTS - CAPSULE 40 MG STIMULANT- NARCOLEPSY TYPE, AND PIPERADINE CATAPLEXY DERIVATIVE THERAPY METHYLIN ORAL 1 LA AGENTS - SOLUTION SEDATIVE-TYPE methylphenidate hcl 1 LA XYREM 3 oral solution methylphenidate hcl NARCOLEPSY 1 LA THERAPY oral tablet methylphenidate hcl AGENTS - 1 LA DOPAMINE AND oral tablet,chewable NE REUPTAKE RITALIN 3 LA INHIBITOR NARCOLEPSY (DNRI) THERAPY SUNOSI 3 AGENTS- NARCOLEPSY STIMULANT- THERAPY TYPE,SYMPATH AGENTS - H3- OMIMETIC,AMP RECEPTOR HETAMINES ANTAGONIST/IN ADDERALL 3 LA VERSE AGONIST amphetamine sulfate 3 LA DEXEDRINE WAKIX 2 PA; LA 3 LA SPANSULE NARCOLEPSY THERAPY dextroamphetamine oral capsule, extended 1 LA AGENTS - NON- release SYMPATHOMIM dextroamphetamine oral 3 LA ETIC tablet armodafinil 2 PA; LA dextroamphetamine- 1 LA modafinil 2 PA; LA amphetamine oral tablet NUVIGIL 3 LA EVEKEO 3 LA PROVIGIL 3 LA ZENZEDI 3 LA NEUROPATHIC PAIN THERAPY LYRICA CR 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 102 Drug Name Drug Tier Limits Drug Name Drug Tier Limits POSTHERPETIC quazepam 2 NEURALGIA RESTORIL 3 LA AGENTS temazepam oral capsule 1 LA ACTIVE-PAC 3 15 mg, 30 mg, 7.5 mg temazepam oral capsule GRALISE 3 2 LA 22.5 mg LYRICA CR 3 triazolam oral tablet 1 LA PSEUDOBULBAR 0.125 mg AFFECT (PBA) triazolam oral tablet LA; QL (30 EA 1 AGENTS, NMDA 0.25 mg per 22 days) ANTAGONISTS SEDATIVE- TYPE HYPNOTIC - NUEDEXTA 3 LA GABA- SEDATIVE- RECEPTOR HYPNOTIC - MODULATORS BARBITURATES AMBIEN 3 LA AMYTAL 4 AMBIEN CR 3 LA butalbital (bulk) 3 EDLUAR 3 LA NEMBUTAL SODIUM 3 eszopiclone 3 LA phenobarbital 1 INTERMEZZO 3 LA phenobarbital (bulk) 3 LUNESTA 3 LA phenobarbital sodium 4 zaleplon 3 LA injection solution zolpidem oral tablet 10 LA; QL (15 EA 1 SECONAL SODIUM 3 mg per 22 days) SEDATIVE- zolpidem oral tablet 5 LA; QL (30 EA 1 HYPNOTIC - mg per 22 days) BENZODIAZEPIN zolpidem oral tablet,ext LA; QL (10 EA ES release multiphase 12.5 2 per 30 days) ATIVAN INJECTION 3 LA mg zolpidem oral tablet,ext DORAL 3 LA LA; QL (10 EA release multiphase 6.25 1 per 30 days) estazolam 3 LA mg flurazepam 3 LA LA; QL (10 EA zolpidem sublingual 1 HALCION ORAL per 30 days) 3 LA TABLET 0.25 MG ZOLPIMIST 3 LA lorazepam injection 1 SEDATIVE- solution 2 mg/ml HYPNOTIC - lorazepam injection 1 LA OREXIN syringe RECEPTOR midazolam oral syrup 2 3 LA ANTAGONIST mg/ml BELSOMRA 3 LA

You can find information on what the symbols and abbreviationson this table mean on page 4. 103 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SEDATIVE- CHEMICAL HYPNOTIC - DEPENDENCY, SELECTIVE AGENTS TO ALPHA2- TREAT ADRENORECEPT AGENTS FOR OR AGONISTS OPIOID dexmedetomidine 4 LA WITHDRAWAL, dexmedetomidine in 0.9 CENTRAL % nacl intravenous 4 ALPHA-2 solution ADRENERGIC dexmedetomidine in 4 AGONIST-TYPE dextrose 5% PA; QL (12 EA PRECEDEX 4 LA LUCEMYRA 3 per 1 day) PRECEDEX IN 0.9 % SODIUM CHLOR AGENTS FOR INTRAVENOUS OPIOID SOLUTION 200 WITHDRAWAL, MCG/50 ML (4 4 LA OPIOID-TYPE MCG/ML), 400 PA; QL (32 MCG/100 ML (4 BUNAVAIL 3 MG per 1 day) MCG/ML), 80 MCG/20 buprenorphine hcl PA; QL (32 ML (4 MCG/ML) 3 sublingual MG per 1 day) SEDATIVE- buprenorphine-naloxone PA; QL (32 HYPNOTIC - 3 sublingual film MG per 1 day) TRICYCLIC buprenorphine-naloxone QL (32 MG per ANTIDEPRESSAN 2 sublingual tablet 1 day) T TYPE PROBUPHINE 4 PA doxepin oral tablet 3 LA SUBLOCADE SILENOR 3 LA SUBCUTANEOUS SOLUTION, SEDATIVE- 1 PA; LA HYPNOTIC EXTENDED REL COMBINATIONS SYRINGE 100 MG/0.5 ML OTHER SUBLOCADE MKO (MIDAZOLAM- 3 LA SUBCUTANEOUS KETAMINE-ONDAN) SOLUTION, 1 PA EXTENDED REL SYRINGE 300 MG/1.5 ML QL (32 MG per SUBOXONE 2 1 day) PA; QL (32 ZUBSOLV 3 MG per 1 day)

You can find information on what the symbols and abbreviationson this table mean on page 4. 104 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ALCOHOL SMOKING ABSTINENCE DETERRENTS - THERAPY - NICOTINIC GLUTAMATE RECEPTOR AND GABA PARTIAL SYSTEM TYPE AGONIST, acamprosate 1 ALPHA4BETA2 ALCOHOL LA; QL (336 ABSTINENCE CHANTIX 1 EA per 273 days) THERAPY - CHANTIX OPIOID QL (336 EA CONTINUING 2 per 273 days) RECEPTOR MONTH BOX ANTAGONIST- CHANTIX STARTING QL (336 EA 2 TYPE MONTH BOX per 273 days) VIVITROL 2 LA CHEMICALS- ALCOHOL PHARMACEUTI DETERRENTS CAL ANTABUSE 3 ADJUVANTS disulfiram 1 BULK SMOKING CHEMICALS DETERRENTS - (d)-limonene flavor 1 NE AND (bulk) DOPAMINE 5-AMINOSALICYLIC 3 REUPTAKE ACID INHIBITOR 5-hydroxy-l-tryptophan 3 (NDRI)-TYPE (bulk) bupropion hcl (smoking 7-KETO DHEA, 1 LA 3 deter) MICRONIZED bupropion hcl oral tablet acacia (bulk) 3 sustained-release 12 hr 1 LA acebutolol (bulk) 3 150 mg acetaminophen (bulk) 3 SMOKING DETERRENTS - acetazolamide (bulk) 3 acetylcholine chloride NICOTINE-TYPE 3 (bulk) QL (112 EA NICOTROL 3 per 273 days) acyclovir (bulk) 3 NICOTROL NS 3 adenosine (bulk) 3 albuterol sulfate (bulk) 3 alginic acid (bulk) 3 alkyl (c12-15) benzoate 1 (bulk) You can find information on what the symbols and abbreviationson this table mean on page 4. 105 Drug Name Drug Tier Limits Drug Name Drug Tier Limits aloe vera (bulk) powder 3 BASE aluminum, (acetato- B,POLYETHYLENE 3 3 o)dih(bulk) GLYCOL3350 amantadine hcl (bulk) 3 BASE W301 1 aminobenzoic acid BASE X 1 3 (bulk) BASE, PCCA 3 aminophylline (bulk) 3 POLYPEG aminosalicylic acid BASE, PCCA 3 1 (bulk) VANPEN AMINOSALICYLIC beclomethasone diprop 3 3 ACID-5 (bulk) belladonna tincture amitriptyline (bulk) 3 1 (bulk) ammonium sulfate 1 benzoic acid (bulk) (bulk) 1 crystals anise flavor extract 1 benzoic acid (bulk) (bulk) 3 powder anthralin (bulk) 3 benzoin compound apple flavor (bulk) 1 1 (bulk) liquid benzoyl peroxide (bulk) 3 APPLE-ADE FLAVOR 1 betamethasone sod phos apricot flavor (bulk) 3 1 (bulk) liquid betamethasone valerate 3 arsenic trioxide (bulk) 4 (bulk) ATREVIS bethanechol chloride 3 3 HYDROGEL (bulk) atropine (bulk) 3 bioflavonoids, citrus 3 AZ 1 (bulk) powder 100 % bacitracin (bulk) powder biotin (bulk) 3 3 5 million unit bismuth citrate (bulk) 3 bacitracin, micronized bismuth subnitrate 3 (bulk) powder 75.7 3 (bulk) unit/mg bitter almond oil (bulk) 1 baclofen (bulk) 3 bitter mask flavoring BANANA 1 1 (bulk) CONCENTRATE BITTERNESS MASK BANANA CREAM 1 1 FLAVOR FLAVOR blackberry flavor (bulk) 1 banana creme flavor 1 BLUEBERRY (bulk) 1 FLAVOR banana flavor (bulk) 1 brompheniramine 3 barium sulfate (bulk) 3 maleate (bulk)

You can find information on what the symbols and abbreviationson this table mean on page 4. 106 Drug Name Drug Tier Limits Drug Name Drug Tier Limits BUBBLE GUM chocolate flavor (bulk) 1 1 CONCENTRATE liquid bubblegum flavor (bulk) 1 chocolate hazelnut flav 1 budesonide, micronized (bulk) 3 (bulk) cholestyramine (bulk) 3 bupivacaine (bulk) 3 ciclopirox olamine 3 buprenorphine hcl (bulk) 3 (bulk) citrulline (bulk) 3 bupropion hcl (bulk) 1 clindamycin hcl (bulk) 3 butalbital (bulk) 3 clindamycin phosphate 1 butter flavor (bulk) 1 (bulk) crystals clindamycin phosphate butter rum flavor (bulk) 1 3 (bulk) powder butterscotch flavor 1 (bulk) clioquinol (bulk) 3 BUTTERSCOTCH clomiphene citrate 1 3 FLAVORING (bulk) caffeine (bulk) 3 clotrimazole (bulk) 3 coal tar (crude) (bulk) caffeine citrate (bulk) 3 1 tar calcium glucon 3 cocoa butter (bulk) monohyd (bulk) 1 topical ointment calcium phos, tribasic 3 (bulk) coconut flavor (bulk) 1 calcium phosphate cod liver oil (bulk) 1 3 (bulk) codeine phosphate 3 caramel flavor (bulk) 1 (bulk) carbidopa (bulk) 3 coenzyme q10 (bulk) 3 carboxymethylcellul.sod coffee flavor (bulk) 1 3 .(bulk) granules cola flavor (bulk) 1 carisoprodol (bulk) 3 colchicine (bulk) 3 celecoxib (bulk) 3 colistin sulfate (bulk) 3 cheesecake flavor (bulk) 1 collodion (bulk) 1 cherry flavor (bulk) 1 corn starch (bulk) 3 chloramphenicol (bulk) 3 corticotropin (bulk) 3 chlorhexidine (bulk) 1 cortisone (bulk) 3 chlorhexidine gluconate cotton candy flavor 1 1 (bulk) (bulk) chlorobutanol (bulk) 1 cran-raspberry flavor 1 chloroquine phosphate (bulk) 3 (bulk) cream base no.64 (bulk) 1 cream de menthe (bulk) 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 107 Drug Name Drug Tier Limits Drug Name Drug Tier Limits cromolyn (bulk) 1 ephedrine sulfate (bulk) 3 cyclobenzaprine (bulk) 3 epinephrine (bulk) 3 cyclosporine (bulk) 3 ergocalciferol (vit d2) 3 dalfampridine (bulk) 3 (bulk) ergotamine tartrate dantrolene (bulk) 3 3 (bulk) DEHYDROEPIANDR 3 estradiol cypionate OSTERONE (MICRO) 3 (bulk) desmopressin acetate 3 estradiol hemihydrate (bulk) 3 (bulk) desoximetasone, micro 3 (bulk) estradiol valerate (bulk) 3 dexamethasone ac, estriol (bulk) 3 3 micro (bulk) estriol micronized 3 dexamethasone acetate (bulk) 3 (bulk) estrone (bulk) crystals 1 dexamethasone sod estrone (bulk) powder 3 3 phos (bulk) ethinyl estradiol (bulk) 3 dexamethasone,microni 3 FATTYBLEND 3 zed(bulk) fentanyl citrate (bulk) 3 dextromethorphan hbr 3 ferric chloride (bulk) (bulk) 3 powder dibucaine hcl (bulk) 3 ferrous fumarate (bulk) 3 diethylstilbestrol (bulk) 3 ferrous gluconate (bulk) 3 digoxin, micronized 3 FIXED OIL (bulk) 3 SUSPENSION diltiazem hcl (bulk) 3 FLAVORX 1 dimethyl sulfoxide 1 (bulk) liquid 99 % flunisolide (bulk) 3 dinitrochlorobenzen(2,4 fluocinolone acetonide 3 3 )(bulk) (bulk) diphencyprone (bulk) fluocinonide, 3 3 powder 98 % micronized(bulk) diphenhydramine (bulk) 3 fluorouracil (bulk) 3 DMSA (BULK) 3 gentamicin (bulk) 3 doxycycline hyclate glipizide (bulk) 3 3 (bulk) glycerol formal (bulk) 1 dutasteride (bulk) 3 glycolic acid (bulk) 1 econazole nitrate (bulk) 3 crystals ENGLISH TOFFEE glycopyrrolate (bulk) 3 1 FLAVOR grape flavor (bulk) 1 ephedrine hcl (bulk) 3 GRAPEFRUIT 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 108 Drug Name Drug Tier Limits Drug Name Drug Tier Limits griseofulvin (bulk) 3 ketoconazole (bulk) 3 guaifenesin (bulk) 3 powder guanethidine sulfate lactic acid (bulk) 1 3 (bulk) lactobacill.acidophilus guava flavor (bulk) 1 (bulk) powder , 10 3 billion unit/gram histamine phosphate 1 (bulk) crystals lactose (bulk) 3 homatropine L-ALANINE 3 3 methylbrom (bulk) lansoprazole (bulk) 3 honey flavor (bulk) 1 L-CARNITINE 3 hydrochlorothiazide lecithin (bulk) 3 3 (bulk) lemonade flavor oil 1 hydrocortisone (bulk) 3 (bulk) hydrocortisone acetate leucovorin calcium 3 3 (bulk) (bulk) hydromorphone (bulk) 3 levamisole (bulk) 3 HYDROPHILIC levorphanol tartrate 3 OINTMENT 1 (bulk) BASE(FAG) levothyroxine (bulk) 3 HYDROUS 1 L-GLUTAMINE 3 EMULSIFIED BASE licorice flavor (bulk) 1 hydroxychloroquine sulf 3 (bulk) LIME FLAVOR 1 hydroxyprogesterone liothyronine (bulk) 3 3 capr(bulk) powder 1 mg/gram hyoscyamine sulfate LIP BALM BASE 3 3 (bulk) (BULK) ibuprofen (bulk) 3 LIPOBASE REGULAR 1 indomethacin (bulk) 3 LIPOIC ACID 3 INOSITOL LIPOVAN CREAM 3 1 HEXANICOTINATE BASE iodine (bulk) crystals 1 L-ISOLEUCINE 3 iodoquinol (bulk) 3 loperamide (bulk) 3 iopanoic acid (bulk) 3 MAGNASWEET 110 1 ipratropium bromide magnesium carbonate 1 3 (bulk) (bulk) magnesium gluconate isoproterenol hcl (bulk) 4 3 (bulk) ivermectin (bulk) 3 magnesium glycinate 3 kahlua flavor (bulk) 1 (bulk) powder 10 % karaya gum (bulk) 3 magnesium hydroxide 3 ketamine (bulk) 3 (bulk) You can find information on what the symbols and abbreviationson this table mean on page 4. 109 Drug Name Drug Tier Limits Drug Name Drug Tier Limits maple flavor (bulk) 1 naproxen (bulk) 3 marshmallow flavor naproxen sodium (bulk) 3 1 (bulk) niacinamide (bulk) 1 mecobalamin (bulk) crystals 3 powder 100 %, 96 % nifedipine (bulk) 3 MEDIUM CREAM 1 nifedipine, micronized 3 mefenamic acid (bulk) 3 (bulk) meloxicam (bulk) 3 nitrofurantoin (bulk) 3 menthol (bulk) 1 nylidrin (bulk) 3 mesalamine (bulk) 3 nystatin (bulk) powder 1 methacholine chloride billion unit, 10 billion 3 (bulk) unit, 2 billion unit, 5 1 billion unit, 50 million methadone (bulk) 3 unit, 500 million unit methenamine mandelate 3 omeprazole (bulk) 3 (bulk) ORANGE 1 methoxsalen (bulk) 3 CONCENTRATE methylcellulose 1500cps orange cream flavor 3 1 (bulk) (bulk) methylcellulose 4000cps orange flavor (bulk) 3 1 (bulk) liquid methylprednisolon oseltamivir phosphate 3 3 ac,mic(bulk) (bulk) methylprednisolone, 3 oxalic acid (bulk) 1 mic (bulk) oxybutynin chloride methyltestosterone 3 3 (bulk) (bulk) oxycodone (bulk) 3 methyltestosterone,micr 3 o(bulk) oxytetracycline (bulk) 3 metoclopramide (bulk) 3 oxytocin (bulk) 3 mineral oil 1 papaverine (bulk) 3 minoxidil (bulk) 3 PCCA NATACREAM 1 mint chocolate chip flv PCCA T4 SODIUM 1 3 (bulk) DILUTION morphine (bulk) 3 peach flavor (bulk) 1 PEANUT BUTTER MULTIBASE 1 1 FLAVOR MULTIUSE BASE 1 peanut butter flavor N-ACETYL-ALPHA- 1 3 (bulk) D-GLUCOSAMINE pectin (bulk) 3 naloxone (bulk) 3 PEG OINTMENT 1 naltrexone hcl (bulk) 3 BASE (BULK)

You can find information on what the symbols and abbreviationson this table mean on page 4. 110 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PEGBLEND 3 potassium chloride 1 penicillamine (bulk) 3 (bulk) granules potassium chloride PENICILLAMINE(D-) 3 3 (bulk) powder PENSOMAL 3 potassium iodide (bulk) PEPPERMINT 1 1 crystals FLAVORING potassium iodide (bulk) 3 PHARMABASE 1 granules PHARMABASE potassium phosph, 1 1 COSMETIC mono (bulk) PHARMABASE potassium sorbate (bulk) 1 3 HEAVY powder PHARMABASE pralines and cream 1 1 LIGHT flavr(bulk) PHARMABASE 1 pramoxine hcl (bulk) 3 NATURAL prasterone (dhea), PHARMABASE 3 1 micro(bulk) VAGINAL prednisolone (bulk) 3 phenobarbital (bulk) 3 prednisolone ac, micro 3 phenol (bulk) crystals 3 (bulk) phenol (bulk) liquid 1 prednisolone sod phos 3 phenylbutazone (bulk) 3 (bulk) phenylephrine hcl (bulk) 3 prednisolone, micro 3 phenytoin (bulk) 3 (bulk) phenytoin sodium (bulk) 3 prednisone (bulk) 3 prednisone micronized pilocarpine hcl (bulk) 3 3 (bulk) pineapple flavor (bulk) 1 prilocaine (bulk) 3 polyethylene glycol 3 1000(bulk) procaine (bulk) 1 polyethylene glycol promethazine (bulk) 3 1 1450(bulk) powder pseudoephedrine hcl 3 polyethylene glycol (bulk) 3 1450(bulk) wax PUMPKIN FLAVOR 1 polyethylene glycol pyridostigmine bromide 1 3 3350(bulk) granules (bulk) polymyxin b pyridoxine (bulk) 1 sulf,micron.(bulk) crystals 3 powder 50 million unit, pyrilamine maleate 3 6,000 unit/mg (bulk) potassium bicarbonate 1 pyrimethamine (bulk) 3 (bulk) granules quinacrine (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 111 Drug Name Drug Tier Limits Drug Name Drug Tier Limits quinidine sulfate (bulk) sucrose (bulk) 3 1 crystals sulfacetamide (bulk) 3 raspberry flavor (bulk) sulfacetamide sod, 1 3 liquid mono (bulk) resorcinol (bulk) sulfacetamide sodium 1 3 crystals (bulk) RETINOIC ACID 3 sulfadiazine (bulk) 3 rifampin (bulk) 3 sulfadiazine sodium 3 root beer flavor (bulk) 1 (bulk) salicylic acid (bulk) sulfamethoxazole (bulk) 3 1 crystals sulfanilamide (bulk) 3 salicylic acid (bulk) 3 sulfisoxazole (bulk) 1 powder SWEET OIL 1 SALTSTABLE LO 3 SWEETNESS CREAM BASE 1 ENHANCER FLAVOR SALTSTABLE LS 1 talc (bulk) 3 silicon,colloidal (bulk) 3 tamoxifen (bulk) 3 silver protein mild 3 (bulk) tangerine oil (bulk) 1 TANGERINE OIL, sodium benzoate (bulk) 3 1 NATURAL sodium citrate (bulk) 3 teaberry oil flavor (bulk) 1 sodium citrate 1 dihydrate(bulk) granules terbinafine (bulk) 3 sodium fluoride (bulk) 3 terbutaline sulfate (bulk) 3 sodium saccharin (bulk) testosterone (bulk) 3 1 oral granules testosterone cypionate 3 sodium saccharin (bulk) (bulk) 3 oral powder testosterone propionate 3 sodium thiosulfate (bulk) 1 (bulk) crystals tetracycline hcl (bulk) 3 sodium thiosulfate tetrahydrocurcumin 3 3 (bulk) powder (bulk) squaric acid (bulk) 3 theophylline (bulk) 3 squaric acid thiabendazole (bulk) 3 3 dibutylest.(bulk) powder thymus gland,calf (bulk) 3 SQUARIC ACID IN thyroid, pork (bulk) 1 3 BUTANOL powder 100 % usp STEVIA 3 tinidazole (bulk) 3 strawberry flavor (bulk) 1 tobramycin (bulk) 3 SUBSOLV RDT 3 tobramycin sulfate 3 sucralfate (bulk) 3 (bulk)

You can find information on what the symbols and abbreviationson this table mean on page 4. 112 Drug Name Drug Tier Limits Drug Name Drug Tier Limits tranexamic acid (bulk) watermelon flavor 3 1 powder (bulk) tretinoin (bulk) 3 white petrolatum (bulk) 1 triamcin diacet, micro wild cherry flavor (bulk) 1 3 (bulk) CHEMICALS - triamcinolone (bulk) 3 ACIDS triamcinolone acetonide glycolic acid (bulk) 3 1 (bulk) crystals triamcinolone diacetate 3 lactic acid (bulk) 1 (bulk) oxalic acid (bulk) 1 triamterene (bulk) 3 CHEMICALS - trimethoprim (bulk) 3 ESSENTIAL OILS trimethoprim, micro 3 (bulk) tangerine oil (bulk) 1 TANGERINE OIL, TROCHIBASE 3 1 NATURAL TROCHIBASE S 1 CLASSIC CHEMICALS - tropical punch flavor FIXED OILS 1 (bulk) castor oil 1 tutti-frutti flavor (bulk) 1 olive oil 1 U-BASE 1 SWEET OIL 1 urea (bulk) beads 1 CHEMICALS - urea (bulk) powder 3 SOLVENTS ursodiol (bulk) 3 acetone 1 VANIBASE 1 ALCOHOL, 1 VANIBASE DENATURED TRADITIONAL 1 dimethyl sulfoxide 1 FORMULA (bulk) liquid 99 % VANILLA glycerol formal (bulk) 1 BUTTERNUT 1 LIP BALM BASE 3 FLAVOR (BULK) vanilla butternut 1 mineral oil 1 flavor(bulk) PEG OINTMENT vanilla extract flavor 1 1 BASE (BULK) (bulk) sodium succinate 3 VANISHING CREAM 1 TOPICAL PHARMACEUTIC VANISH-PEN CREAM AL ADJUVANT - 1 BASE ANTICORROSIV verapamil (bulk) 3 E AGENTS VERSATILE 1 sodium bisulfite (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 113 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PHARMACEUTIC MULTIUSE BASE 1 AL ADJUVANT - PCCA NATACREAM 1 CELLULOSE PEGBLEND 3 CAPSULES PENSOMAL 3 (EMPTY) PETROLATUM 1 CAPSULE #0 1 petrolatum, yellow (CELLULOSE) 1 (bulk) CAPSULE #00 1 PHARMABASE 1 (CELLULOSE) PHARMABASE CAPSULE #1 1 1 HEAVY (CELLULOSE) PHARMABASE CAPSULE #3 1 1 LIGHT (CELLULOSE) PHARMABASE 1 PHARMACEUTIC NATURAL AL ADJUVANT - PHARMABASE 1 CREAM/OINTME VAGINAL NT VEHICLES polyethylene glycol ATREVIS 3 3 1000(bulk) HYDROGEL polyethylene glycol 1 AZ 1 3350(bulk) granules BASE SALTSTABLE LO 3 B,POLYETHYLENE 3 CREAM BASE GLYCOL3350 SALTSTABLE LS 1 BASE W301 1 U-BASE 1 cocoa butter 1 VANISH-PEN CREAM cocoa butter (bulk) 1 1 BASE topical ointment VERSATILE 1 cream base no.64 (bulk) 1 white petrolatum (bulk) 1 hydrophilic 1 PHARMACEUTIC HYDROPHILIC AL ADJUVANT - OINTMENT 1 BASE(FAG) EXTERNAL VEHICLES HYDROPHILIC 1 BASE, PCCA PETROLATUM 3 POLYPEG HYDROUS 1 BASE, PCCA EMULSIFIED BASE 1 VANPEN LIPOBASE REGULAR 1 VANIBASE LIPOVAN CREAM 1 TRADITIONAL 1 BASE FORMULA MEDIUM CREAM 1 MULTIBASE 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 114 Drug Name Drug Tier Limits Drug Name Drug Tier Limits chocolate flavor (bulk) PHARMACEUTIC 1 AL ADJUVANT - liquid chocolate hazelnut flav FLAVORING 1 AGENTS (bulk) (d)-limonene flavor coconut flavor (bulk) 1 1 (bulk) coffee flavor (bulk) 1 anise flavor extract cola flavor (bulk) 1 1 (bulk) cotton candy flavor 1 apple flavor (bulk) (bulk) 1 liquid cran-raspberry flavor 1 APPLE-ADE FLAVOR 1 (bulk) apricot flavor (bulk) cream de menthe (bulk) 1 1 liquid ENGLISH TOFFEE 1 BANANA FLAVOR 1 CONCENTRATE FLAVORX 1 BANANA CREAM 1 grape flavor (bulk) 1 FLAVOR GRAPEFRUIT 1 banana creme flavor 1 (bulk) guava flavor (bulk) 1 banana flavor (bulk) 1 honey flavor (bulk) 1 bitter almond oil (bulk) 1 kahlua flavor (bulk) 1 bitter mask flavoring lemon flavor extract 1 1 (bulk) (bulk) BITTERNESS MASK lemonade flavor oil 1 1 FLAVOR (bulk) blackberry flavor (bulk) 1 licorice flavor (bulk) 1 BLUEBERRY LIME FLAVOR 1 1 FLAVOR MAGNASWEET 110 1 BUBBLE GUM maple flavor (bulk) 1 1 CONCENTRATE marshmallow flavor 1 bubblegum flavor (bulk) 1 (bulk) butter flavor (bulk) 1 mint chocolate chip flv 1 butter rum flavor (bulk) 1 (bulk) butterscotch flavor ORANGE 1 1 (bulk) CONCENTRATE BUTTERSCOTCH orange cream flavor 1 1 FLAVORING (bulk) caramel flavor (bulk) 1 peach flavor (bulk) 1 PEANUT BUTTER cheesecake flavor (bulk) 1 1 FLAVOR chlorhexidine (bulk) 1 peanut butter flavor 1 (bulk) You can find information on what the symbols and abbreviationson this table mean on page 4. 115 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PEPPERMINT CAPSULE #10 1 1 FLAVORING CAPSULE #13 1 pineapple flavor (bulk) 1 CAPSULE #2 1 pralines and cream 1 CAPSULE #3 1 flavr(bulk) CAPSULE #4 1 PUMPKIN FLAVOR 1 CAPSULE #5 1 raspberry flavor (bulk) 1 liquid CAPSULE #7 1 CAPSULE CONI- root beer flavor (bulk) 1 1 SNAP #0 (GELATIN) spearmint oil 1 CAPSULE CONI- 1 strawberry flavor (bulk) 1 SNAP #00 (GELATIN SWEET OIL 1 CAPSULE CONI- 1 SWEETNESS SNAP #000 1 ENHANCER FLAVOR CAPSULE CONI- 1 tangerine oil (bulk) 1 SNAP #1 (GELATIN) TANGERINE OIL, CAPSULE CONI- 1 1 NATURAL SNAP #2 (GELATIN) teaberry oil flavor (bulk) 1 CAPSULE CONI- 1 tropical punch flavor SNAP #3 (GELATIN) 1 (bulk) CAPSULE CONI- 1 tutti-frutti flavor (bulk) 1 SNAP #4 (GELATIN) VANILLA PHARMACEUTIC BUTTERNUT 1 AL ADJUVANT - FLAVOR HYPROMELLOS vanilla butternut E CAPSULES 1 flavor(bulk) (EMPTY) vanilla extract flavor 1 CAPSULE #0 1 (bulk) CAPSULE #0 watermelon flavor 1 1 (HYPROMELLOSE) (bulk) CAPSULE #0 DRCAPS 1 wild cherry flavor (bulk) 1 CAPSULE #00 1 PHARMACEUTIC (HYPROMELLOSE) AL ADJUVANT - CAPSULE #1 1 GELATIN (HYPROMELLOSE) CAPSULES CAPSULE #1 DRCAPS 1 (EMPTY) CAPSULE #3 1 CAPSULE #0 1 (HYPROMELLOSE) CAPSULE #00 1 CAPSULE #4 1 CAPSULE #000 1 CAPSULE CONI- CAPSULE #1 1 SNAP 1 #0(HYPROMEL)

You can find information on what the symbols and abbreviationson this table mean on page 4. 116 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CAPSULE CONI- FLAVOR SWEET 1 SNAP 1 FLAVOR SWEET-SF 1 #1(HYPROMEL) ORA-BLEND 3 CAPSULE CONI- SNAP 1 ORA-BLEND SF 3 #3(HYPROMEL) ORAL MIX 1 PHARMACEUTIC ORAL MIX SF 1 AL ADJUVANT - ORAL SUSPEND 1 INHALATION ORAL SYRUP 1 VEHICLES ORAL SYRUP SF 1 NEBUSAL 3 orange flavor (bulk) 1 PULMOSAL 3 liquid sodium chloride ORA-PLUS 1 1 inhalation ORA-SWEET 1 PHARMACEUTIC ORA-SWEET SF 1 AL ADJUVANT - simple syrup 1 ORAL SYRPALTA VEHICLE 1 THICKENING AGENTS SYRSPEND SF ALKA 1 SYRSPEND SF corn starch (bulk) 3 1 LIQUID DIAFOODS THICK-IT 3 VERSA FREE 1 DIAFOODS THICK-IT 3 VERSA PLUS 1 #2 SIMPLYTHICK ORAL PHARMACEUTIC GEL IN PACKET 12 AL ADJUVANT - 3 GRAM, 48 GRAM, 6 PARENTERAL GRAM, 96 GRAM VEHICLES SIMPLYTHICK ORAL BACTERIOSTATIC 4 GEL WITH PUMP 6 3 WATER(PARABENS) GRAM/ACTUATION DILUENT FOR THICK NOW 3 EPOPROSTENOL/FLO 4 PA THICK-IT #2 ORAL LA 3 POWDER DILUENT FOR 4 THICK-IT #2 ORAL IXEMPRA (15 MG) 1 POWDER IN PACKET DILUENT FOR 4 PHARMACEUTIC IXEMPRA (45 MG) diluent for treprostinil AL ADJUVANT - 4 ORAL VEHICLES (gly) cherry flavor (bulk) 1 FLAVOR BLEND 2 IN 1 1 FLAVOR PLUS 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 117 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PHARMACEUTIC SUSPENDOL-S 1 AL ADJUVANT - tragacanth 3 PRESERVATIVES PHARMACEUTIC benzoic acid (bulk) 1 AL ADJUVANT - crystals TABLETING chlorobutanol (bulk) 1 lactose (bulk) 3 sodium benzoate (bulk) 3 SUBSOLV RDT 3 PHARMACEUTIC PHARMACEUTIC AL ADJUVANT - AL ADJUVANT - SUPPOSITORY TROCHE/SOFT VEHICLES LOZENGE BASE BASE X 1 polyethylene glycol 1 FATTYBLEND 3 1450(bulk) powder polyethylene glycol PHARMACEUTIC 3 AL ADJUVANT - 1450(bulk) wax SURFACTANTS TROCHIBASE 3 LUMOXITI IV SOLN TROCHIBASE S 4 1 STABILIZER CLASSIC polysorbate 80 1 PHARMACEUTIC PHARMACEUTIC AL ADJUVANT - AL ADJUVANT - VEHICLE SUSPENDING EXCIPIENTS AGENTS stearyl alcohol 1 alginic acid (bulk) 3 COGNITIVE alkyl (c12-15) benzoate DISORDER 1 (bulk) THERAPY FIXED OIL 3 ALZHEIMER'S SUSPENSION DISEASE gelatin (bulk) gel 1 THERAPY - gelatin (bulk) powder 3 CHOLINESTERA LIP BALM BASE 3 SE INHIBITORS (BULK) ARICEPT ORAL METHOCEL E 4 M 3 1 TABLET 10 MG, 5 MG GRANULES ARICEPT ORAL methylcellulose 1500cps 3 LA 3 TABLET 23 MG (bulk) donepezil oral tablet 10 methylcellulose 4000cps 1 3 mg, 5 mg (bulk) donepezil oral tablet 23 PEG OINTMENT 3 LA 1 mg BASE (BULK)

You can find information on what the symbols and abbreviationson this table mean on page 4. 118 Drug Name Drug Tier Limits Drug Name Drug Tier Limits donepezil oral 2 LA CONTRACEPTI tablet,disintegrating VES EXELON 3 LA TRANSDERMAL CONTRACEPTIV E IMPLANT - galantamine 2 LA PROGESTIN RAZADYNE ER 3 LA NEXPLANON 1 rivastigmine 2 LA CONTRACEPTIV rivastigmine tartrate 2 E INJECTABLE - ALZHEIMER'S PROGESTIN DISEASE DEPO-PROVERA THERAPY - INTRAMUSCULAR 1 NMDA SUSPENSION 150 RECEPTOR MG/ML ANTAGONISTS DEPO-PROVERA memantine oral INTRAMUSCULAR 1 3 LA capsule,sprinkle,er 24hr SYRINGE DEPO-SUBQ memantine oral solution 2 LA 1 PROVERA 104 memantine oral tablet 2 LA medroxyprogesterone memantine oral 1 3 LA intramuscular tablets,dose pack NAMENDA ORAL CONTRACEPTIV 3 LA TABLET E NAMENDA INTRAUTERINE - 3 LA TITRATION PAK COPPER IUD NAMENDA XR 3 LA PARAGARD T 380A 1 ALZHEIMER'S CONTRACEPTIV THX - NMDA E RECEPTOR INTRAUTERINE - ANTAG. AND PROGESTERONE CHOLINESTERA IUD SE INHIB. COMB KYLEENA 1 NAMZARIC ORAL LILETTA 1 CAPSULE,SPRINKLE, 3 LA MIRENA 1 ER 24HR 14-10 MG, 28-10 MG SKYLA 1 COGNITIVE CONTRACEPTIV DISORDER E ORAL - THERAPY - BIPHASIC CEREBRAL AMETHIA 1 VASODILATORS AMETHIA LO 1 ergoloid 2 PA ASHLYNA 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 119 Drug Name Drug Tier Limits Drug Name Drug Tier Limits AZURETTE (28) 1 AVIANE 1 BEKYREE (28) 1 AYUNA 1 CAMRESE 1 BALCOLTRA 1 CAMRESE LO 1 BALZIVA (28) 1 DAYSEE 1 BEYAZ 1 desog- BLISOVI 24 FE 1 1 e.estradiol/e.estradiol BLISOVI FE 1.5/30 1 KARIVA (28) 1 (28) l norgest/e.estradiol- BLISOVI FE 1/20 (28) 1 e.estrad oral tablets,dose BRIELLYN 1 pack,3 month 0.10 mg- 1 20 mcg (84)/10 mcg (7), CHATEAL (28) 1 0.15 mg-30 mcg (84)/10 CHATEAL EQ (28) 1 mcg (7) CRYSELLE (28) 1 LO LOESTRIN FE 1 CYCLAFEM 1/35 (28) 1 LOSEASONIQUE 1 CYRED 1 MIRCETTE (28) 1 CYRED EQ 1 PIMTREA (28) 1 DASETTA 1/35 (28) 1 SEASONIQUE 1 desogestrel-ethinyl 1 SIMLIYA (28) 1 estradiol SIMPESSE 1 drospirenone- e.estradiol-lm.fa oral VIORELE (28) 1 1 tablet 3-0.03-0.451 mg CONTRACEPTIV (21) (7) E ORAL - drospirenone-ethinyl 1 MONOPHASIC estradiol AFIRMELLE 1 ELINEST 1 ALTAVERA (28) 1 ENSKYCE 1 ALYACEN 1/35 (28) 1 ESTARYLLA 1 AMETHYST (28) 1 ethynodiol diac-eth 1 APRI 1 estradiol AUBRA 1 FALMINA (28) 1 AUBRA EQ 1 GENERESS FE 1 AUROVELA 1.5/30 GIANVI (28) 1 1 (21) HAILEY 1 AUROVELA 1/20 (21) 1 HAILEY 24 FE 1 AUROVELA 24 FE 1 INTROVALE 1 AUROVELA FE 1.5/30 1 JASMIEL (28) 1 (28) JOLESSA 1 AUROVELA FE 1-20 1 JULEBER 1 (28) You can find information on what the symbols and abbreviationson this table mean on page 4. 120 Drug Name Drug Tier Limits Drug Name Drug Tier Limits JUNEL 1.5/30 (21) 1 MICROGESTIN FE 1 JUNEL 1/20 (21) 1 1.5/30 (28) MICROGESTIN FE JUNEL FE 1.5/30 (28) 1 1 1/20 (28) JUNEL FE 1/20 (28) 1 MILI 1 JUNEL FE 24 1 MINASTRIN 24 FE 1 KAITLIB FE 1 MONO-LINYAH 1 KALLIGA 1 NECON 0.5/35 (28) 1 KELNOR 1/35 (28) 1 NIKKI (28) 1 KELNOR 1-50 1 noreth-ethinyl estradiol- 1 KURVELO (28) 1 iron LARIN 1.5/30 (21) 1 norethindrone ac-eth LARIN 1/20 (21) 1 estradiol oral tablet 1-20 1 LARIN 24 FE 1 mg-mcg LARIN FE 1.5/30 (28) 1 norethindrone- e.estradiol-iron oral 1 LARIN FE 1/20 (28) 1 tablet 1 mg-20 mcg LAYOLIS FE 1 (21)/75 mg (7) LESSINA 1 norgestimate-ethinyl levonorgestrel-ethinyl estradiol oral tablet 1 1 estrad 0.25-35 mg-mcg LEVORA-28 1 NORTREL 0.5/35 (28) 1 LOESTRIN 1.5/30 (21) 1 NORTREL 1/35 (21) 1 LOESTRIN 1/20 (21) 1 OCELLA 1 LOESTRIN FE 1.5/30 ORSYTHIA 1 1 (28-DAY) PHILITH 1 LOESTRIN FE 1/20 PIRMELLA ORAL 1 (28-DAY) TABLET 1-35 MG- 1 LORYNA (28) 1 MCG LOW-OGESTREL (28) 1 PORTIA 28 1 LO-ZUMANDIMINE PREVIFEM 1 1 (28) RECLIPSEN (28) 1 LUTERA (28) 1 SAFYRAL 1 MARLISSA (28) 1 SETLAKIN 1 MELODETTA 24 FE 1 SPRINTEC (28) 1 MIBELAS 24 FE 1 SRONYX 1 MICROGESTIN 1.5/30 SYEDA 1 1 (21) TARINA 24 FE 1 MICROGESTIN 1/20 1 TARINA FE 1/20 (28) 1 (21) TARINA FE 1-20 EQ 1 (28) You can find information on what the symbols and abbreviationson this table mean on page 4. 121 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TYDEMY 1 CAZIANT (28) 1 VIENVA 1 CYCLAFEM 7/7/7 (28) 1 VYFEMLA (28) 1 DASETTA 7/7/7 (28) 1 VYLIBRA 1 ENPRESSE 1 WERA (28) 1 ESTROSTEP FE-28 1 WYMZYA FE 1 LEENA 28 1 YASMIN (28) 1 LEVONEST (28) 1 YAZ (28) 1 levonorg-eth estrad 1 ZARAH 1 triphasic ZOVIA 1/35E (28) 1 norgestimate-ethinyl estradiol oral tablet ZUMANDIMINE (28) 1 0.18/0.215/0.25 mg-25 1 CONTRACEPTIV mcg, 0.18/0.215/0.25 E ORAL - mg-35 mcg (28) PROGESTIN NORTREL 7/7/7 (28) 1 ORTHO TRI-CYCLEN CAMILA 1 1 (28) DEBLITANE 1 ORTHO-NOVUM 7/7/7 ERRIN 1 1 (28) HEATHER 1 PIRMELLA ORAL INCASSIA 1 TABLET 0.5/0.75/1 1 JENCYCLA 1 MG- 35 MCG LYZA 1 TILIA FE 1 NORA-BE 1 TRI-ESTARYLLA 1 norethindrone TRI-LEGEST FE 1 1 (contraceptive) TRI-LINYAH 1 ORTHO MICRONOR 1 TRI-LO-ESTARYLLA 1 SHAROBEL 1 TRI-LO-MARZIA 1 SLYND 1 TRI-LO-MILI 1 TULANA 1 TRI-LO-SPRINTEC 1 CONTRACEPTIV TRI-MILI 1 E ORAL - TRI-PREVIFEM (28) 1 QUADRAPHASIC TRI-SPRINTEC (28) 1 NATAZIA 1 TRIVORA (28) 1 QUARTETTE 1 TRI-VYLIBRA 1 CONTRACEPTIV TRI-VYLIBRA LO 1 E ORAL - VELIVET TRIPHASIC 1 TRIPHASIC REGIMEN (28) ALYACEN 7/7/7 (28) 1 ARANELLE (28) 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 122 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CONTRACEPTIV EMERGENCY E CONTRACEPTIV TRANSDERMAL ES COMBINATIONS ELLA 1 - ESTROGEN DERMATOLOGI AND PROGESTIN CAL COMB. XULANE 1 ACNE THERAPY SYSTEMIC - CONTRACEPTIV RETINOIDS AND E DERIVATIVES TRANSDERMAL COMBINATIONS ABSORICA 2 PA AMNESTEEM 2 PA XULANE 1 CLARAVIS 2 PA CONTRACEPTIV ES - isotretinoin 2 PA INTRAVAGINAL, MYORISAN 2 PA SYSTEMIC - ZENATANE 2 PA ESTROGEN AND ACNE THERAPY PROGESTIN SYSTEMIC - COMB. TETRACYCLINE ANNOVERA 1 ANTIBIOTIC ELURYNG 1 COREMINO 3 etonogestrel-ethinyl minocycline oral tablet 1 estradiol extended release 24 hr 3 PA NUVARING 1 105 mg, 65 mg, 80 mg CONTRACEPTIV minocycline oral tablet extended release 24 hr 3 ES - 115 mg, 135 mg, 45 mg, INTRAVAGINAL, 55 mg, 90 mg SYSTEMIC MINOLIRA ER 3 PA etonogestrel-ethinyl 1 SEYSARA 3 estradiol SOLODYN ORAL NUVARING 1 TABLET EXTENDED EMERGENCY RELEASE 24 HR 105 3 CONTRACEPTIV MG, 115 MG, 55 MG, ES - 65 MG, 80 MG PROGESTERONE AGONIST/ANTA GONIST TYPE ELLA 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 123 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ACNE THERAPY FINACEA 1 TOPICAL - ANTI- KLARON 1 INFECTIVE METROCREAM 3 COMBINATIONS METROLOTION 3 OTHER metronidazole topical CLINDACIN ETZ 1 3 cream TOPICAL KIT metronidazole topical 1 CLINDACIN PAC 3 lotion ACNE THERAPY NORITATE 3 TOPICAL - ANTI- ROSADAN TOPICAL 1 INFECTIVE CREAM ACZONE 3 sulfacetamide sodium 1 azelaic acid 1 (acne) AZELEX 3 ACNE THERAPY CLEOCIN T TOPICAL TOPICAL - ANTI- 3 GEL INFECTIVE- CLEOCIN T TOPICAL KERATOLYTIC 3 LOTION COMBINATIONS CLEOCIN T TOPICAL ACANYA TOPICAL 3 3 SOLUTION GEL WITH PUMP CLINDACIN P 3 AVAR LS 3 AVAR TOPICAL CLINDAGEL 3 3 CLEANSER clindamycin phosphate 3 AVAR TOPICAL topical foam 3 PADS, MEDICATED clindamycin phosphate 1 topical gel AVAR-E LS 3 clindamycin phosphate BENZACLIN 3 3 topical gel, once daily BENZACLIN PUMP 3 clindamycin phosphate 1 BENZAMYCIN 3 topical lotion BP 10-1 3 clindamycin phosphate 1 CLEANSING WASH topical solution 3 TOPICAL CLEANSER clindamycin phosphate 3 clindamycin-benzoyl topical swab 3 peroxide ERY PADS 1 erythromycin-benzoyl 1 ERYGEL 3 peroxide erythromycin with 1 NEUAC 1 ethanol topical gel ONEXTON TOPICAL erythromycin with 3 1 GEL WITH PUMP ethanol topical solution PLEXION 3 EVOCLIN 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 124 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PLEXION 3 ACNE THERAPY CLEANSING CLOTHS TOPICAL - ANTI- ROSANIL 3 INFECTIVE- ROSULA 3 RETINOID ROSULA CLEANSING COMBINATIONS 3 CLOTHS VELTIN 3 SSS 10-5 TOPICAL 3 ZIANA 3 FOAM ACNE THERAPY sulfacetamide sodium- 3 TOPICAL - sulfur topical cleanser KERATOLYTIC sulfacetamide sodium- COMBINATIONS sulfur topical cream 10- 3 2 %, 9.8-4.8 % OTHER sulfacetamide sodium- INOVA 4-1 3 sulfur topical lotion 10- INOVA 8-2 3 1 5 % (w/v), 10-5 % ACNE THERAPY (w/w) TOPICAL - sulfacetamide sodium- KERATOLYTIC sulfur topical lotion 9.8- 3 BENZEPRO 4.8 % 3 (MICROSPHERES) sulfacetamide sodium- BENZEPRO TOPICAL sulfur topical pads, 3 3 medicated 10-4 % TOWELETTE benzoyl peroxide topical sulfacetamide sodium- 3 sulfur topical 3 cleanser 7 % suspension INOVA 3 sulfacetamide sod- PACNEX 3 sulfur-urea topical 3 PR BENZOYL cleanser 3 PEROXIDE sulfacetamide-sulfur- 3 cleansr23 ACNE THERAPY TOPICAL - SULFACLEANSE 8-4 3 KERATOLYTIC- SUMADAN 3 GLUCOCORTICO SUMADAN XLT 3 ID SUMAXIN 3 COMBINATIONS SUMAXIN CP 3 VANOXIDE-HC 1 SUMAXIN TS 3 ACNE THERAPY TOPICAL - RETINOID COMBINATIONS OTHER EPIDUO FORTE 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 125 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EPIDUO TOPICAL 3 ANTIPSORIATIC GEL WITH PUMP - RETINOID ACNE THERAPY (VITAMIN A TOPICAL - DERIVATIVE) - RETINOIDS AND GLUCOCORTICO DERIVATIVES ID adapalene topical cream 1 DUOBRII 3 adapalene topical gel 3 ANTIPSORIATIC 0.3 % - VITAMIN D adapalene topical gel 3 ANALOG - with pump GLUCOCORTICO adapalene topical swab 3 ID ALTRENO 3 COMBINATIONS ATRALIN 3 calcipotriene- AVITA TOPICAL betamethasone topical 1 3 CREAM ointment DIFFERIN TOPICAL ENSTILAR 3 3 GEL 0.3 % TACLONEX TOPICAL 3 DIFFERIN TOPICAL SUSPENSION 3 GEL WITH PUMP ANTIPSORIATIC DIFFERIN TOPICAL AGENTS - 3 LOTION INTERLEUKIN 12 FABIOR 3 AND IL-23 RETIN-A 3 INHIBITORS,MC RETIN-A MICRO 3 ANTIBODY STELARA RETIN-A MICRO 3 PA PUMP TOPICAL GEL SUBCUTANEOUS 3 WITH PUMP 0.04 %, ANTIPSORIATIC 0.08 %, 0.1 % AGENTS - tretinoin microspheres 3 INTERLEUKIN-23 tretinoin topical cream 2 PA (IL-23) tretinoin topical gel 0.01 ANTAGONIST, 2 PA %, 0.025 % MC ANTIBODY tretinoin topical gel 0.05 3 SKYRIZI 3 % TREMFYA 3 PA TRETIN-X CREAM 3 KIT TRETIN-X TOPICAL 3 CREAM 0.075 %

You can find information on what the symbols and abbreviationson this table mean on page 4. 126 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSORIATIC DERMATOLOGI AGENTS- CAL - INTERLEUKIN-17 ANTIBACTERIAL (IL-17) AMINOGLYCOSI ANTAGONIST, DES MC ANTIBODY gentamicin topical 1 COSENTYX 3 DERMATOLOGI COSENTYX (2 3 CAL - SYRINGES) ANTIBACTERIAL COSENTYX PEN 3 OTHER COSENTYX PEN (2 3 CENTANY 3 PENS) CENTANY AT 3 SILIQ 3 mupirocin 1 TALTZ 3 mupirocin calcium 3 AUTOINJECTOR silver nitrate topical TALTZ 3 solution 10 % AUTOINJECTOR (2 3 PACK) SOLOX GEL 3 TALTZ DERMATOLOGI AUTOINJECTOR (3 3 CAL - PACK) ANTIBACTERIAL TALTZ SYRINGE 3 PLEUROMUTILI DERMATITIS OR N DERIVATIVES ECZEMA ALTABAX 1 AGENTS, DERMATOLOGI SYSTEMIC- CAL - INTERLEUKIN-4 ANTIBACTERIAL (IL-4RA) QUINOLONES ANTAG.MAB XEPI 3 DUPIXENT SYRINGE SUBCUTANEOUS DERMATOLOGI 3 PA SYRINGE 200 CAL - MG/1.14 ML ANTIBACTERIAL DUPIXENT SYRINGE SULFONAMIDES SUBCUTANEOUS 3 AVAR-E GREEN 3 SYRINGE 300 MG/2 SSS 10-5 TOPICAL ML 3 CREAM sulfacetamide sodium- sulfur topical cream 10- 3 5 % (w/w)

You can find information on what the symbols and abbreviationson this table mean on page 4. 127 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - CAL - ANTIBACTERIAL ANTIFUNGAL - HYDROXYPYRID GLUCOCORTICO INONE ID CICLODAN TOPICAL 1 COMBINATIONS CREAM CORTISPORIN CICLODAN TOPICAL 3 3 TOPICAL SOLUTION NEO-SYNALAR 3 ciclopirox olamine 3 NEO-SYNALAR KIT 3 (bulk) DERMATOLOGI ciclopirox topical cream 1 CAL - ciclopirox topical gel 3 ciclopirox topical ANTIFUNGAL 1 ALLYLAMINES shampoo ciclopirox topical naftifine topical cream 3 ST 3 solution naftifine topical gel 3 ciclopirox topical NAFTIN TOPICAL 1 3 suspension GEL ciclopirox-ure-camph- 3 DERMATOLOGI menth-euc CAL - LOPROX TOPICAL 3 ANTIFUNGAL SHAMPOO AMPHOTERIC DERMATOLOGI POLYENE CAL - MACROLIDES ANTIFUNGAL NYAMYC 1 IMIDAZOLE AND nystatin topical 1 RELATED NYSTOP 1 AGENTS DERMATOLOGI econazole 3 PA CAL - ECOZA 3 ANTIFUNGAL ERTACZO 3 PA BENZYLAMINES EXELDERM 3 MENTAX 3 PA EXTINA 3 DERMATOLOGI ketoconazole topical 1 CAL - cream ANTIFUNGAL ketoconazole topical 3 COMBINATIONS foam OTHER ketoconazole topical 1 EXODERM 3 shampoo luliconazole 3 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 128 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LUZU 3 DERMATOLOGI miconazole nitrate-zinc CAL - 3 ox-pet ANTINEOPLASTI oxiconazole 3 C OXISTAT TOPICAL ANTIMETABOLI 3 LOTION TES VUSION 3 CARAC 3 PA XOLEGEL 3 EFUDEX TOPICAL 3 PA DERMATOLOGI CREAM CAL - FLUOROPLEX 1 fluorouracil topical ANTIFUNGAL 3 OXABOROLE cream 0.5 % fluorouracil topical KERYDIN 3 PA 1 cream 5 % DERMATOLOGI fluorouracil topical 1 CAL - solution ANTIFUNGAL TOLAK 2 PA TRIAZOLE DERMATOLOGI JUBLIA 3 CAL - DERMATOLOGI ANTINEOPLASTI CAL - C OR PREMALIG. ANTIFUNGAL- LESIONS - GLUCOCORTICO DITERPENE ID ESTERS COMBINATIONS PICATO 2 PA clotrimazole- 1 betamethasone DERMATOLOGI CAL - hydrocortisone- 3 PA iodoquinol ANTINEOPLASTI C OR nystatin-triamcinolone 1 PREMALIGNANT DERMATOLOGI LESIONS - CAL - NSAID'S ANTIFUNGALS diclofenac sodium 1 OTHER topical gel 3 % triacetin 3 SOLARAZE 3 DERMATOLOGI DERMATOLOGI CAL - CAL - ANTINEOPLASTI ANTINEOPLASTI C ALKYLATING C RETINOIDS AGENTS PANRETIN 2 PA VALCHLOR 2 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 129 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcipotriene topical DERMATOLOGI 1 CAL - ointment ANTINEOPLASTI calcitriol topical 3 C SELECTIVE DOVONEX TOPICAL 3 RETINOID X DRITHOCREME HP 1 RECEPTOR halobetasol propionate 3 AGONIST topical foam TARGRETIN 1 IMPOYZ 3 TOPICAL LEXETTE 3 DERMATOLOGI SORILUX 3 CAL - tazarotene 3 ANTIPSORIATIC AGENTS TAZORAC 3 ULTRAVATE SYSTEMIC, 3 PHOTOSENSITIZ TOPICAL LOTION ING VECTICAL 3 methoxsalen 3 ZITHRANOL 3 methoxsalen (bulk) DERMATOLOGI 3 crystals CAL - OXSORALEN ULTRA 3 ANTIPSORIATIC S SYSTEMIC, DERMATOLOGI PHOSPHODIEST CAL - ERASE 4 INHIB. ANTIPSORIATIC AGENTS OTEZLA 3 SYSTEMIC, OTEZLA STARTER 3 VITAMIN A DERMATOLOGI DERIVATIVES CAL - acitretin 1 ANTISEBORRHEI SORIATANE ORAL C CAPSULE 10 MG, 25 3 ESKATA 3 MG LOUTREX 3 DERMATOLOGI OVACE 3 CAL - OVACE PLUS 3 ANTIPSORIATIC SHAMPOO AGENTS OVACE PLUS 3 TOPICAL TOPICAL CREAM anthralin (bulk) 3 OVACE PLUS 3 BRYHALI 3 PA TOPICAL FOAM OVACE PLUS calcipotriene scalp 1 3 calcipotriene topical TOPICAL LOTION 1 cream OVACE PLUS WASH 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 130 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PROMISEB 3 DERMATOLOGI selenium sulfide topical CAL - 1 lotion CALCINEURIN selenium sulfide topical INHIBITORS 3 shampoo 2.25 %, 2.3 % ELIDEL 2 PA; ST SELRX 3 pimecrolimus 2 PA sulfacetamide sodium 3 PROTOPIC 3 topical tacrolimus topical 3 PA; ST TERSI FOAM 3 DERMATOLOGI DERMATOLOGI CAL - CAL - EMOLLIENT ANTIVIRAL, COMBINATIONS HERPES OTHER acyclovir topical 3 PA ELON 1 DENAVIR 3 HPR PLUS ZOVIRAX TOPICAL 3 3 HYDROGEL CREAM HPR PLUS-MB 3 DERMATOLOGI HYDROGEL CAL - MB HYDROGEL 3 ANTIVIRAL- MB HYDROGEL GLUCOCORTICO (CYCLOMETHICONE 3 ID ) COMBINATIONS DERMATOLOGI XERESE 3 CAL - DERMATOLOGI EMOLLIENT CAL - COMBINATIONS ASTRINGENTS CERAVE TOPICAL 1 ferric chloride (bulk) CREAM 3 powder DERMATOLOGI DERMATOLOGI CAL - CAL - BURN EMOLLIENT PRODUCTS MIXTURES ANTI-INFECTIVE ALOE GRANDE 1 SILVADENE 3 ALPHABATH 1 silver sulfadiazine 1 AMERIPHOR 1 SSD 1 AMLACTIN TOPICAL 1 SULFAMYLON 1 CREAM ATOPADERM 3 ATOPICLAIR 3 ATRAPRO CP 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 131 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ATRAPRO PRUCLAIR 3 3 HYDROGEL PRUMYX 3 AVO CREAM 3 REMEDY AVOSIL 1 PHYTOPLEX 3 BALNEOL TOPICAL MOISTURIZER 1 LOTION SONAFINE 3 BETAMIDE 1 SOOTHE AND COOL 3 BIAFINE EMULSION 3 SKIN CREAM CELACYN 3 SORBOLENE 3 CERACADE 3 SWEEN CREAM 1 CERAMAX 3 THERA BATH 1 COCOA BUTTER VANIBASE 1 1 CREAM vitamin e-safflower oil 1 DERMACERIN 1 VITAMN E BEAUTY 1 ELETONE 3 WITH SAFFLOWER EMULSION SB 3 VITA-RAY 1 ENTTY 3 XCLAIR 3 EPICERAM 3 DERMATOLOGI EUCERIN 1 CAL - EMOLLIENTS HPR 3 AMERISTORE 1 HPR PLUS 3 AQUA CARE 1 HYDROCERIN 1 AQUANIL SKIN HYLATOPIC 3 1 CLEANSER HYLATOPICPLUS 3 DERMACLOUD 1 TOPICAL CREAM emollient 1 HYLATOPICPLUS 3 TOPICAL FOAM GORDONS-VITE E 1 HYPER-HEAL 1 GORMEL 1 LOUTREX 3 LAC-HYDRIN FIVE 1 LUXAMEND 3 MAPO BATH 1 MIADERM 1 RADIAGEL 1 NEOSALUS 3 SUPERSOFT 1 NIVATOPIC PLUS 3 ULTRA MIDE 25 1 UNSCENTED COLD PENLEN 3 1 CREAM PETROLATUM 1 urea topical cream 39 % 3 PHARMABASE 1 COSMETIC UREACIN-10 1 PRESERA 3 UREACIN-20 1 PROMISEB 3 UREDEB 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 132 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VANISHING CREAM clobetasol scalp 1 1 TOPICAL clobetasol topical cream 1 DERMATOLOGI clobetasol topical foam 3 CAL - ENZYMES clobetasol topical gel 1 SANTYL 3 PA clobetasol topical lotion 3 DERMATOLOGI clobetasol topical 1 CAL - EYELID ointment CLEANSERS clobetasol topical 3 ACUICYN 3 shampoo clobetasol topical HYPOCYN 3 3 spray,non-aerosol DERMATOLOGI CAL - clobetasol-emollient 3 PA GLUCOCORTICO CLOBEX 3 ID clocortolone pivalate 3 PA ADVANCED CLODAN 3 ALLERGY COLLECT 3 CLODERM 3 KIT CORDRAN TOPICAL ALA-CORT TOPICAL 3 3 CREAM 0.025 % CREAM 1 % CORDRAN TOPICAL 3 alclometasone 1 LOTION amcinonide topical CORDRAN TOPICAL 3 PA 3 cream OINTMENT amcinonide topical CUTIVATE TOPICAL 3 3 lotion CREAM beclomethasone diprop CUTIVATE TOPICAL 3 3 (bulk) LOTION BESER 3 PA DERMA- betamethasone SMOOTHE/FS BODY 3 PA 3 PA dipropionate OIL betamethasone valerate DERMA- 1 topical cream SMOOTHE/FS SCALP 3 PA OIL betamethasone valerate 3 topical foam DESONATE 3 betamethasone valerate desonide topical cream 1 3 PA topical lotion desonide topical lotion 3 betamethasone valerate desonide topical 1 1 topical ointment ointment betamethasone, 3 PA DESOWEN 3 augmented desoximetasone topical 3 PA BRYHALI 3 PA cream CAPEX 3 PA

You can find information on what the symbols and abbreviationson this table mean on page 4. 133 Drug Name Drug Tier Limits Drug Name Drug Tier Limits desoximetasone topical hydrocortisone topical 3 PA gel cream with perineal 1 desoximetasone topical applicator 3 PA ointment hydrocortisone topical 1 desoximetasone topical lotion 2.5 % 3 spray,non-aerosol hydrocortisone topical 1 diflorasone topical ointment 2.5 % 3 cream hydrocortisone valerate 3 PA diflorasone topical IMPOYZ 3 3 PA ointment KENALOG TOPICAL 3 DIPROLENE 3 LEXETTE 3 TOPICAL OINTMENT LOCOID LIPOCREAM 3 fluocinolone 3 PA LOCOID TOPICAL fluocinolone and shower 3 3 PA LOTION cap LUXIQ 3 fluocinonide 3 PA mometasone topical 2 PA FLUOCINONIDE-E 3 PA cream flurandrenolide topical mometasone topical 3 PA 2 PA cream ointment fluticasone propionate mometasone topical 1 1 topical cream solution fluticasone propionate NOLIX TOPICAL 3 3 topical lotion CREAM fluticasone propionate 1 OLUX 3 topical ointment OLUX-E 3 PA halobetasol propionate 1 topical cream PANDEL 3 halobetasol propionate prednicarbate topical 3 3 topical foam cream halobetasol propionate prednicarbate topical 1 3 PA topical ointment ointment HALOG TOPICAL PROCTOCORT 3 PA 3 CREAM TOPICAL HALOG TOPICAL PROCTO-MED HC 1 3 PA OINTMENT PROCTO-PAK 1 hydrocortisone butyrate 3 PROCTOSOL HC 1 hydrocortisone butyr- TOPICAL 3 emollient PROCTOZONE-HC 1 hydrocortisone topical PSORCON 3 1 cream 2.5 % SCALACORT 1 SCALACORT DK 3 SERNIVO 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 134 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SILAZONE-II 3 SYNALAR CREAM 3 SYNALAR TOPICAL KIT 3 SOLUTION SYNALAR 3 TEMOVATE OINTMENT KIT 3 TOPICAL CREAM WHYTEDERM 3 TEXACORT 1 TDPAK TOPICORT TOPICAL WHYTEDERM 3 3 OINTMENT 0.05 % TRILASIL PAK TOPICORT TOPICAL DERMATOLOGI SPRAY,NON- 3 CAL - AEROSOL GLUCOCORTICO triamcinolone acetonide ID-LOCAL 3 topical aerosol ANESTHETIC triamcinolone acetonide COMBINATIONS 1 topical cream ANALPRAM-HC 3 triamcinolone acetonide TOPICAL 1 topical lotion EPIFOAM 3 triamcinolone acetonide lidocaine hcl- QL (2 GM per 1 topical ointment 0.025 1 hydrocortison ac topical 23 days) %, 0.1 %, 0.5 % NOVACORT 3 TRIANEX 1 PA PRAMOSONE TRIDERM TOPICAL 1 TOPICAL CREAM 1-1 3 CREAM 0.1 % % ULTRAVATE 3 PRAMOSONE TOPICAL LOTION TOPICAL CREAM 2.5- 1 VANOS 3 1 % VERDESO 3 PRAMOSONE 3 DERMATOLOGI TOPICAL LOTION PRAMOSONE CAL - 1 GLUCOCORTICO TOPICAL OINTMENT ID-EMOLLIENT DERMATOLOGI COMBINATIONS CAL - BESER KIT 3 PA GLUCOCORTICO ID-SKIN DERMACINRX 3 SILAPAK CLEANSER COMBINATIONS DERMAWERX SDS 3 AQUA GLYCOLIC HC 3 NOXIPAK 3 SYNALAR TS 3 SANADERMRX 3 SURE RESULT TAC 3 PAK

You can find information on what the symbols and abbreviationson this table mean on page 4. 135 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - HAIR CAL - GROWTH KERATOLYTIC- AGENTS ANTIMITOTIC diphencyprone (bulk) COMBINATIONS 3 powder 98 % SALKERA 3 DERMATOLOGI SALVAX DUO PLUS 3 CAL - silver nitrate applicators 3 IMMUNOMODUL DERMATOLOGI ATOR - CAL - CATECHINS - KERATOLYTIC- GENITAL ANTIMITOTIC WART/HPV TX SINGLE AGENTS VEREGEN 3 PA BENSAL HP TOPICAL 3 DERMATOLOGI OINTMENT 3 % CAL - cantharidin in acetone 3 IMMUNOMODUL CEM-UREA 3 ATOR - CONDYLOX 1 IMIDAZOQUINO TOPICAL GEL LINAMINES HYDRO 35 3 ALDARA 3 HYDRO 40 3 imiquimod topical 1 KERAFOAM 3 cream in packet KERALAC 3 ZYCLARA 3 KERALYT RX 3 DERMATOLOGI KERALYT SCALP CAL - 3 COMPLETE IMMUNOMODUL ATOR - PODOCON 3 INTERFERONS podofilox 1 ALFERON N 4 RYNODERM 3 SALEX TOPICAL DERMATOLOGI 3 SHAMPOO CAL - salicylic acid (bulk) KERATOLYTIC 3 powder COMBINATIONS salicylic acid topical OTHER 3 cream URAMAXIN GT salicylic acid topical TOPICAL 3 3 cream,extended release KIT,CREAM AND GEL salicylic acid topical film forming liquid 3 w/appl

You can find information on what the symbols and abbreviationson this table mean on page 4. 136 Drug Name Drug Tier Limits Drug Name Drug Tier Limits salicylic acid topical DERMATOLOGI film-forming soln er w/ 3 CAL - appl KERATOPLASTI salicylic acid topical 3 C TAR foam PRODUCTS salicylic acid topical gel 3 coal tar 3 salicylic acid topical 3 coal tar (crude) (bulk) liquid 26 % 1 tar salicylic acid topical 3 lotion DERMATOLOGI CAL - LIVER salicylic acid topical 3 lotion,extended release DERIVATIVE COMPLEX salicylic acid topical 3 shampoo NEXAVIR 4 salicylic acid-ceramides DERMATOLOGI no.1 topical kit,cleanser 3 CAL - LOCAL and cream er ANESTHETIC SALVAX 3 COMBINATIONS ULTRASAL-ER 3 APRIZIO PAK 3 UMECTA TOPICAL CETACAINE 3 3 FOAM ANESTHETIC URAMAXIN GT 3 KAMDOY 3 TOPICAL GEL lidocaine-prilocaine QL (90 GM per URAMAXIN 2 3 topical cream 23 days) TOPICAL FOAM lidocaine-prilocaine URAMAXIN 1 3 topical kit TOPICAL GEL LIVIXIL PAK 3 urea (bulk) powder 3 NUVAKAAN 3 UREA NAIL STICK 3 PRIKAAN 3 urea topical cream 40 PRIKAAN LITE 3 %, 41 %, 45 %, 47 %, 3 50 % PRILOVIX LITE 3 urea topical foam 3 PRILOVIX PLUS 3 urea topical gel 45 % 3 RELADOR PAK 3 URE-K 3 RELADOR PAK PLUS 3 UREVAZ 3 WPR PLUS 3 UTOPIC 3 DERMATOLOGI VIRASAL 3 CAL - LOCAL ANESTHETIC GAS SINGLE AGENTS ethyl chloride 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 137 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI PENNSAID TOPICAL SOLUTION IN CAL - 3 MISCELLANEOU METERED-DOSE PUMP S SINGLE AGENTS VOLTAREN TOPICAL 3 XRYLIX NEURAPTINE (DICLOFENAC- 3 TOPICAL CREAM IN 3 KINES TAPE) PACKET squaric acid (bulk) 3 DERMATOLOGI CAL - squaric acid 3 dibutylest.(bulk) powder ORNITHINE DECARBOXYLAS DERMATOLOGI E (ODC) CAL - NSAID AND INHIBITORS LOCAL ANESTHETIC VANIQA 3 COMBINATION DERMATOLOGI DICLOVIX 3 CAL - PHOTODYNAMI DERMATOLOGI C THERAPY CAL - NSAID AGENTS COMBINATIONS TOPICAL CAPSFENAC PAK 3 AMELUZ 2 PA DERMACINRX 3 LEVULAN 2 PA LEXITRAL DICLOFEX DC 3 DERMATOLOGI CAL - DICLOPAK 3 PIGMENTING, DICLOTRAL 3 PHOTOSENSITIZ INFLAMMA-K 3 ING AGENTS SURE RESULT DSS methoxsalen (bulk) 3 3 PREMIUM PACK crystals XELITRAL 3 DERMATOLOGI DERMATOLOGI CAL - POWDERS CAL - NSAID VAGISIL TOPICAL 3 SINGLE AGENTS POWDER diclofenac epolamine 3 DERMATOLOGI diclofenac sodium 3 CAL - topical drops PROTECTANT DICLOFONO 3 COMBINATIONS FLECTOR 3 KELARX 3 FROTEK TOPICAL 3 SCARCIN GEL 3 CREAM IN PACKET SCARCIN ROLL-ON 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 138 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SCARSILK GEL 3 FINACEA 1 SILIPAC 3 METROCREAM 3 METROGEL TOPICAL DERMATOLOGI 3 CAL - GEL 1 % PROTECTANTS METROLOTION 3 ANTI MONKEY BUTT 1 metronidazole topical 1 benzoin compound MIRVASO TOPICAL 1 3 (bulk) GEL WITH PUMP BIONECT TOPICAL NORITATE 3 4 FOAM ROSADAN TOPICAL 1 SCARCARE 3 CREAM ROSADAN TOPICAL talc (bulk) 3 1 GEL zinc oxide topical paste 1 SOOLANTRA 3 DERMATOLOGI CAL - sulfacetamide sod- sulfur-urea topical 3 RETINOIDS cleanser (VITAMIN A SUMADAN XLT 3 DERIVATIVES) - TOPICAL DERMATOLOGI COSMETIC CAL - SHAMPOOS REFISSA 3 NEUTROGENA tazarotene 3 1 TOPICAL SHAMPOO tretinoin (emollient) 3 DERMATOLOGI DERMATOLOGI CAL - SKIN CAL - ROSACEA CONTACT THERAPY, SENSITIZING SYSTEMIC AGENTS doxycycline dinitrochlorobenzen(2,4 monohydrate oral 3 3 )(bulk) capsule,ir - delay rel,biphase DERMATOLOGI ORACEA 3 CAL - SOAP AND CLEANSER DERMATOLOGI SINGLE AGENTS CAL - ROSACEA THERAPY, green soap 1 TOPICAL azelaic acid 1 AZELEX 3 CLEANSING WASH 3 TOPICAL CLEANSER

You can find information on what the symbols and abbreviationson this table mean on page 4. 139 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI lidocaine hcl mucous CAL - SOAP membrane jelly in 3 AND/OR applicator lidocaine hcl topical QL (2 ML per CLEANSER 3 COMBINATIONS lotion 23 days) lidocaine topical BABY WASH 1 adhesive 2 PA CETA-KLENZ 1 patch,medicated 5 % GENTLE lidocaine topical QL (2 GM per CETAPHIL TOPICAL 2 1 ointment 23 days) BAR QL (2 GM per CETAPHIL TOPICAL lidocaine-tetracaine 1 1 23 days) CLEANSER LIDODERM 3 CONTI CASTILE 1 LIDO-K 3 SOAP LIDOPIN 3 GENTLE SKIN 1 CLEANSER LIDORX 3 NEUTROGENA ACNE LIDOTREX 3 1 CLEANSING SOAP LIDOVEX 3 NEUTROGENA 1 LIDOZION 3 FACIAL SOAP SUVICORT 3 PERIANAL 1 SYNERA 3 CLEANSING ZTLIDO 3 PERIFRESH 1 PROSHIELD DERMATOLOGI FOAM/SPRAY 1 CAL - TOPICAL CLEANSER LOCAL SAF-CLENS AF ANESTHETIC 1 DERMAL WOUND OTHERS SKIN CLEANSER 1 chlorobutanol (bulk) 1 TECNU 3 DERMATOLOGI DERMATOLOGI CAL - TOPICAL CAL - TOPICAL LOCAL LOCAL ANESTHETICS ANESTHETIC AND AMIDES COMBINATIONS GLYDO 3 NEURCAINE 3 L.E.T. (LIDO- DERMATOLOGI 3 EPINEPH-TETRA) CAL - TOPICAL lidocaine hcl mucous QL (2 ML per LOCAL 2 membrane jelly 23 days) ANESTHETICS dibucaine hcl (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 140 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI WOUND CARE - CAL CLEANSER ANTIPRURITICS COMBINATIONS - DELUO 3 ANTIHISTAMINE EPICYN 3 S HYCLODEX 3 doxepin topical 2 PA WOUND CARE - PRUDOXIN 2 PA CLEANSERS ZONALON 2 PA VASHE WOUND 3 DERMATOLOGI THERAPY CAL IRRITANTS- WOUND CARE - COUNTER- DRESSINGS IRRITANT ACTICOAT 7 SINGLE AGENTS DRESSING TOPICAL 1 menthol (bulk) 1 BANDAGE 4 X 5 " QUTENZA 4 ALLEVYN TOPICAL 1 WINTERGREEN OIL 1 BANDAGE 8 X 8 " HAIR GROWTH COLLATYL 3 AGENTS - PROTYL AG 3 TOPICAL RESTORE FOAM DRESSING SILVER minoxidil (bulk) 3 1 TOPICAL BANDAGE SCABICIDE AND 4 X 4 " PEDICULICIDE RESTORE TOPICAL 4 SINGLE AGENTS BANDAGE 2 X 2 " CROTAN 3 SPECTRAGEL 4 ELIMITE 3 WOUND CARE - EURAX 1 GROWTH LICE BEDDING FACTOR 1 SPRAY AGENTS lindane topical shampoo 1 QL (15 GM per REGRANEX 1 malathion 2 PA 23 days) NATROBA 3 WOUND CARE OVIDE 3 COMBINATIONS OTHER permethrin topical 1 cream balsam peru-castor oil 3 BPCO TOPICAL SKLICE 2 PA 3 OINTMENT spinosad 1 DERMULCERA 3 ULESFIA 1 VENELEX 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 141 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIAGNOSTIC CONTRAST AGENTS MEDIA - CONTRAST IODINATED OIL MEDIA - BARIUM BASED LIPIODOL 4 barium sulfate (bulk) 3 CONTRAST CONTRAST MEDIA - MEDIA - IODINATED MAGNETIC IONIC RESONANCE GADOLINIUM CONRAY-30 4 COMPLEXES CONRAY-43 4 DOTAREM 4 iopanoic acid (bulk) 3 EOVIST 4 SINOGRAFIN 4 GADAVIST 4 CONTRAST MAGNEVIST 4 MEDIA - MULTIHANCE 4 IODINATED MULTIHANCE NONIONIC 4 MULTIPACK ISOVUE-200 4 OMNISCAN 4 INTRAVENOUS PROHANCE 4 ISOVUE-250 4 ISOVUE-300 4 CONTRAST MEDIA - ISOVUE-370 4 MAGNETIC ISOVUE-M 300 4 RESONANCE OMNIPAQUE 3 IRON OMNIPAQUE 140 4 COMPOUNDS OMNIPAQUE 240 4 FERIDEX IV 4 OMNIPAQUE 300 4 CONTRAST OMNIPAQUE 350 4 MEDIA - OPTIRAY 240 ULTRASOUND INTRAVENOUS 4 AGENTS SOLUTION DEFINITY 4 OPTIRAY 300 4 OPTISON 4 OPTIRAY 320 4 DIAGNOSTIC OPTIRAY 350 4 DRUGS - VISIPAQUE 4 BILIARY IC GREEN 4 indocyanine green 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 142 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIAGNOSTIC DIAGNOSTIC DRUGS - DRUGS - CARDIOVASCUL PITUITARY AR FUNCTION ADENOSCAN 4 ACTHREL 4 adenosine (bulk) 3 CORTROSYN 4 adenosine (diagnostic) 4 cosyntropin 4 dipyridamole 4 DIAGNOSTIC intravenous DRUGS - LEXISCAN 4 PULMONARY DIAGNOSTIC methacholine chloride 3 DRUGS - (bulk) GASTROINTESTI PROVOCHOLINE 4 NAL DIAGNOSTIC RADIOLOGICAL DRUGS - ADJUNCT THYROID GLUCAGEN 4 FUNCTION DIAGNOSTIC KIT THYROGEN 4 glucagon hcl 4 DIAGNOSTIC DIAGNOSTIC RADIOPHARMA DRUGS - CEUTICALS - GLUCOSE BRAIN, TOLERANCE AMYLOID TEST, ORAL PLAQUE GLUTOL GEL 4 IMAGING DIAGNOSTIC AMYVID 4 DRUGS - IN VIVO DIAGNOSTIC OTHER RADIOPHARMA KINEVAC 4 CEUTICALS - DIAGNOSTIC CEREBRAL DRUGS - PERFUSION METABOLIC IMAGING FUNCTION CERETEC 4 CHIRHOSTIM 4 INTRAVENOUS KIT MACRILEN 3 NEUROLITE 4 METOPIRONE 4 R-GENE 10 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 143 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIAGNOSTIC DIAGNOSTIC RADIOPHARMA RADIOPHARMA CEUTICALS - CEUTICALS - DOPAMINE RADIOLABELIN TRANSPORTER G AUTOLOGOUS (DAT) IMAGING LEUKOCYTES DATSCAN 4 indium in-111 4 DIAGNOSTIC oxyquinoline RADIOPHARMA DIAGNOSTIC CEUTICALS - RADIOPHARMA ENDOCRINE CEUTICALS - ADREVIEW 4 RADIOLABELIN G FOR fludeoxyglucose f-18 intravenous solution 20 3 LYMPHATIC mci to 200 mci/ml MAPPING OCTREOSCAN 4 LYMPHOSEEK 4 DIAGNOSTIC DIAGNOSTIC RADIOPHARMA RADIOPHARMA CEUTICALS - CEUTICALS - HEPATOBILIAR RENAL IMAGING Y IMAGING DMSA 4 CHOLETEC 3 DRAXIMAGE DTPA 4 DIAGNOSTIC FLUORESCENCE RADIOPHARMA IMAGING CEUTICALS - AGENTS - MYOCARDIAL MALIGNANT PERFUSION BRAIN TISSUE IMAGING GLEOLAN 3 MYOVIEW KIT 4 DRUGS TO thallous chloride tl-201 TREAT intravenous solution 37 4 mbq/ml (1 mci/ml) ERECTILE DYSFUNCTION DIAGNOSTIC RADIOPHARMA ERECTILE CEUTICALS - DYSFUNCTION PROSTATIC (ED) DRUGS - PROSTAGLANDI AXUMIN 4 NS CAVERJECT QL (12 EA per 4 IMPULSE 23 days)

You can find information on what the symbols and abbreviationson this table mean on page 4. 144 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CAVERJECT dronabinol oral capsule QL (12 EA per 3 PA INTRACAVERNOSAL 4 2.5 mg, 5 mg 23 days) RECON SOLN SYNDROS 3 QL (12 EA per EDEX 4 APPETITE 23 days) STIMULANTS - IFE-PG20 3 PROGESTIN QL (12 EA per MUSE 3 HORMONE TYPE 23 days) megestrol oral ERECTILE suspension 400 mg/10 DYSFUNCTION ml (10 ml), 400 mg/10 1 (ED) DRUGS- ml (40 mg/ml), 625 ALPHA mg/5 ml (125 mg/ml) BLOCKER, ELECTROLYTE PERIPHERAL BALANCE- VASODILATOR NUTRITIONAL IFE-BIMIX 30/1 3 PRODUCTS ERECTILE AMINO ACID - DYSFUNCTION CARNITINE (ED) DRUGS- DERIVATIVES SEL.CGMP acetylcarnitine 3 PHOSPHODIEST AMINO ACID - ERASE TYPE5 TYROSINE INHIB tyrosine oral packet 1 CIALIS 3 LEVITRA ORAL AMINO ACID- TABLET 10 MG, 20 3 AMINO ACID MG COMBINATIONS, STAXYN 3 ORAL COMPLETE AMINO STENDRA 3 1 ACID MIX tadalafil 2 PA DAILY AMINO 1 vardenafil 3 PRE PROTEIN 1 QL (10 EA per VIAGRA 3 23 days) AMINO ACIDS, EATING SINGLE DISORDER INGREDIENT, THERAPY ORAL (NON- INJECTABLE) APPETITE arginine (l-arginine) oral STIMULANTS - powder in packet 500 1 CANNABINOIDS mg dronabinol oral capsule arginine (l-arginine) oral 3 1 10 mg tablet You can find information on what the symbols and abbreviationson this table mean on page 4. 145 Drug Name Drug Tier Limits Drug Name Drug Tier Limits arginine hcl (l-arginine) BALANCED B-100 1 oral tablet ORAL TABLET 0.4 1 ENDARI 3 MG glycine oral powder 3 BALANCED B-100 ORAL TABLET ISOLEUCINE AMINO 3 1 EXTENDED ACID SUPPLMNT RELEASE l-cystine 1 B-COMPLEX PLUS 3 leucine oral powder in VIT C (CALCIUM) 1 packet b-complex with vitamin 3 L-LYSINE ORAL c oral tablet 1 TABLET B-COMPLEX WITH lysine hcl oral tablet 500 VITAMIN C ORAL 1 3 mg TABLET 400-500 lysine oral tablet 1,000 MCG-MG 1 mg, 500 mg b-complex with vitamin PURE L-CITRULLINE c oral tablet extended 1 1 ORAL CAPSULE release VALINE AMINO B-STRESS 3 1 ACID SUPPLEMENT COMPLEX B-100 ORAL TABLET B-COMPLEX 3 EXTENDED VITAMIN RELEASE 400 MCG COMBINATIONS COMPLEX B-50 3 ACTIVITE 3 DEXIFOL 1 ALBA-LYBE 3 DIALYVITE 3000 3 APETEX 3 DIALYVITE 800 1 APETIGEN 3 ORAL TABLET B COMPLEX 100 1 DIALYVITE 800 ORAL ORAL 3 B COMPLEX PLUS TABLET,CHEWABLE 3 VITAMIN C DIALYVITE 800 3 b complex-vitamin c- WITH ZINC 15 folic acid oral tablet 3 DIALYVITE 800 3 extended release WITH ZINC 50 B-100 COMPLEX DIALYVITE 800- ORAL TABLET 3 1 ULTRA D EXTENDED DIALYVITE ORAL RELEASE 3 TABLET 100-1 MG BALANCED B-100 DIALYVITE COMPLEX ORAL 3 3 SUPREME D TABLET EXTENDED FATIGUE RELIEF RELEASE 100 MG 3 COMPLEX

You can find information on what the symbols and abbreviationson this table mean on page 4. 146 Drug Name Drug Tier Limits Drug Name Drug Tier Limits FOLBEE AR 4 SUPER QUINTS 1 FOLBEE PLUS 3 SUPERVITE 3 FULL SPECTRUM B- SUPPORT-500 3 1 VITAMIN C TRIPHROCAPS 1 GENICIN VITA-S 1 TRONVITE 1 HYLAVITE 3 VIRT-CAPS 3 KOBEE 1 VIRT-VITE PLUS 3 LORID 1 VITAMINS B MEDTYCHOLL-B COMPLEX ORAL 3 3 COMPLEX-LIVER TABLET 500 MG-400 MYNEPHROCAPS 1 MCG- 18 MG IRON NATURAL B-100 VITAMINS FOR HAIR 3 1 COMPLEX ORAL TABLET NEPHRONEX 3 VITASURE 1 NEPHRONEX-SL 1 XVITE 1 NEPHRO-VITE 1 B-COMPLEX NUTRIVIT 3 VITAMINS AND COMBINATIONS PRORENAL 3 APETIGEN PLUS QUIN B STRONG 3 3 ORAL LIQUID RENAL CAPS 1 DIALYVITE ORAL RENAL VITAMIN 3 TABLET 1-100-300-50 3 RENAPLEX 3 MG-MG-MCG-MG RENAPLEX-D 3 NEPHPLEX RX 3 RENA-VITE 1 NEPHRO-VITE RX 3 RENO CAPS 1 RENA-VITE RX 3 STRESS B PLUS ZINC 3 VP-VITE RX 3 STRESS B WITH B-COMPLEX 3 ZINC VITAMINS STRESS FORMULA 3 B COMPLEX 100 4 STRESS FORMULA INJECTION 1 600 C B COMPLEX 3 STRESS FORMULA SUBLINGUAL 3 WITH IRON BALANCED B-50 1 STRESS FORMULA ORAL TABLET 3 WITH IRON(SULF) COMPLEX B-100 STRESS FORMULA ORAL TABLET 3 1 WITH ZINC EXTENDED RELEASE SUPER B COMPLEX- 1 VITAMIN C PODIAPN 3 SUPER B/C 1 STRESS FORMULA 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 147 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SUPER QUINTS B-50 1 DEXTROSE VITAMINS B SOLUTIONS, COMPLEX ORAL 1 CONCENTRATED CAPSULE dextrose 20 % in water 4 VITAMINS B (d20w) COMPLEX ORAL 1 dextrose 25 % in water TABLET 4 (d25w) BIOFLAVONOID dextrose 30 % in water 4 COMBINATIONS (d30w) EAR CARE 1 dextrose 40 % in water 4 EAR HEALTH (d40w) 1 FORMULA dextrose 50 % in water 4 PERIDIN-C 1 (d50w) dextrose 70 % in water TROMBONEX 1 4 (d70w) VASOFLEX FORTE 1 DEXTROSE AND DEXTROSE LACTATED SOLUTIONS dextrose 10 % in water RINGER'S 4 SOLUTIONS (d10w) dextrose 20 % in water dextrose 5 %-lactated 4 4 (d20w) ringers dextrose 25 % in water 4 DEXTROSE AND (d25w) SODIUM dextrose 30 % in water 4 CHLORIDE (d30w) SOLUTIONS dextrose 40 % in water d10 %-0.45 % sodium 4 4 (d40w) chloride dextrose 5 % in water d2.5 %-0.45 % sodium 4 4 (d5w) chloride dextrose 50 % in water d5 % and 0.9 % sodium 4 4 (d50w) chloride dextrose 70 % in water d5 %-0.45 % sodium 4 4 (d70w) chloride DIETARY dextrose 10 % and 0.2 4 PRODUCT - % nacl DIETARY dextrose 5%-0.2 % sod 4 SUPPLEMENTS chloride 5-hydroxy-l-tryptophan dextrose 5%-0.3 % 3 4 (bulk) sod.chloride BRIGHT 1 BEGINNINGS SOY

You can find information on what the symbols and abbreviationson this table mean on page 4. 148 Drug Name Drug Tier Limits Drug Name Drug Tier Limits coenzyme q10 (bulk) ENFAMIL 3 powder GENTLEASE ORAL 1 CRANBERRY- POWDER 1 PROBIOTIC ENFAMIL INFANT 1 CYTOTINE 1 ORAL POWDER ENSURE CLEAR ENFAMIL NEURO 3 ORAL LIQUID ENFACARE NON- 3 GMO ENSURE ORIGINAL 3 ORAL POWDER ENFAMIL NEURO GENTLEASE 3 HYPROST 1 NONGMO NURETIN 3 ENFAMIL NUTRA PRO HIGH NEUROPRO NON- 1 1 PROTEIN GMO ORAL LIQUID NUTRISURE PLUS 3 ENFAMIL NEWBORN 1 PEDIASURE ORAL POWDER 3 HARVEST ENFAMIL PROSOBEE 1 PEDIASURE LIPIL SIDEKICKS ORAL ENFAMIL PROSOBEE 3 3 LIQUID 0.04-0.8 ORAL POWDER GRAM-KCAL/ML GERBER GOOD PHLEXY-VITS 1 START GENTLE 1 SIMILAC ORAL LIQUID 3 LAMEHADRIN GERBER GOOD TALIVA 3 START SOY ORAL 1 LIQUID TART CHERRY 1 GERBER GOOD TURKEY-SWEET 3 START SOY ORAL 1 POTATOES-PEACHES POWDER DIETARY infant formula with iron 1 PRODUCT - oral powder INFANT ISOMIL ADVANCE 1 FORMULAS ISOMIL DF 1 ADVANTAGE WITH 1 ISOMIL/IRON 1 IRON MSUD ANALOG 1 CALCILO XD 1 NUTRAMIGEN DHA- 1 ENFAGROW ARA TODDLR 1 TRANSITION SOY NUTRAMIGEN TODDLER ENFLORA- 1 ENFAMIL LGG GENTLEASE ORAL 1 PREGESTIMIL ORAL LIQUID 3 POWDER

You can find information on what the symbols and abbreviationson this table mean on page 4. 149 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PREMIUM INFANT XLYS- XTRP 1 1 FORMULA ANALOG RCF SOY PROTEIN XMET ANALOG 3 1 FORMULA BASE XMTVI ANALOG 1 SIMILAC ADVANCE XPHE, XTYR 3 1 LAMEHADRIN ANALOG SIMILAC ADVANCE XPTM ANALOG 1 ORAL 1 CONCENTRATE DIETARY SIMILAC ADVANCE PRODUCT - 1 ORAL LIQUID SWEETENERS SIMILAC ADVANCE saccharin 3 ORAL POWDER IN 1 sodium saccharin (bulk) 1 PACKET oral granules SIMILAC ADVANCE sodium saccharin (bulk) 1 3 WITH IRON oral powder SIMILAC EXPERT 1 STEVIA 3 CARE NEOSURE sucrose (bulk) 3 SIMILAC EXPERT 1 CARE ORAL LIQUID DILUENTS - SODIUM SIMILAC FOR SPIT- 1 UP ORAL POWDER CHLORIDE sodium chlor 0.9% SIMILAC HUMAN 4 MILK FORTIFIER bacteriostat 1 ORAL POWDER IN sodium chloride 0.9 % 4 PACKET (flush) SIMILAC LOW-IRON 1 sodium chloride 0.9 % 1 SIMILAC NEOSURE 1 injection SIMILAC PM 1 SWABFLUSH 4 SIMILAC PRO-TOTAL DILUENTS - 3 CMFT NON-GMO STERILE WATER SIMILAC SENSITIVE FOR INJECTION 1 ISOMIL SOY water for inject, 1 SIMILAC SOY bacteriostat 1 ISOMIL water for injection, 1 SIMILAC SPECIAL sterile injection solution 1 CARE 24 water for injection, 4 SIMILAC TOTAL sterile injection syringe 3 COMFORT NON-GMO DILUENTS - SIMILAC TOTAL VACCINE COMFORT ORAL 1 DILUENTS POWDER DILUENT FOR 1 XLEU ANALOG 1 HIBERIX You can find information on what the symbols and abbreviationson this table mean on page 4. 150 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DILUENT FOR 4 MINERALS AND RABAVERT ELECTROLYTES ELECTROLYTE - BICARBONATE DEPLETERS - PRODUCING OR ION EXCHANGE CONTAINING RESIN AGENTS LOKELMA 3 sodium acetate 4 sodium polystyrene sodium bicarbonate in 1 sulfonate oral powder d5w intravenous 4 SPS (WITH solution 150 meq/1,000 1 SORBITOL) ml sodium bicarbonate VELTASSA 1 4 intravenous GERIATRIC THAM 4 VITAMINS MINERALS AND DAILY MULTIVITAMIN- 3 ELECTROLYTES MINERALS - CALCIUM ELDERTONIC 1 REPLACEMENT COMBINATIONS GERITOL TONIC 1 ADVANCED WITH FERREX 18 3 CALCIUM IRRIGATION SOLUTIONS BIOCAL 3 BONE DENSITY AQUA CARE 3 3 CALCIUM + D SODIUM CHLORIDE BONE ESSENTIALS 3 AQUA CARE 3 ca-d3-mag ox-zinc-cop- STERILE WATER 3 mang-bor oral tablet lactated ringers 1 irrigation ca-d3-mag ox-zinc-cop- mang-bor oral PHYSIOLYTE 1 1 tablet,chewable 600 mg PHYSIOSOL 3 calcium- 400 unit-40 mg IRRIGATION ca-d3-mag ox-zinc-cop- ringer's irrigation 3 mang-bor oral 3 sodium chloride tablet,chewable 600 mg 1 irrigation calcium- 800 unit-40 mg TIS-U-SOL ca-d3-mag-zinc-cop- 1 3 PENTALYTE mang-bor water for irrigation, CAL MAG ZINC PLUS 1 3 sterile D3 CALCI-MAX 3 CALCIUM 600 + 1 MINERALS

You can find information on what the symbols and abbreviationson this table mean on page 4. 151 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcium carb-d3-mag CALTRATE + D3 3 3 cmb11-zinc PLUS MINERALS calcium carb-mag CALTRATE 600-D 3 oxide-zinc ox PLUS MINERALS 3 calcium carb-mag ox- ORAL 3 zinc gluc TABLET,CHEWABLE CITRACAL PLUS calcium carb-mag ox- 3 zinc sulf oral tablet 333- 3 BONE DENSITY 133-5 mg CITRACAL-D3 PLUS 3 calcium carbonate-vit HEART HEALTH 1 d3-min oral tablet CITRACAL-D3 PLUS 3 CALCIUM FOR MAGNESIUM 1 WOMEN CORAL CALCIUM CALCIUM ORAL CAPSULE 133 3 MAGNESIUM MG CALCIUM -133 UNIT-67 MG, 185-50- 3 CALCIUM 100 MG-MG-UNIT, MAGNESIUM + D 3 250-125-100 MG-MG- ORAL TABLET 400- UNIT, 250-200-125 167-133 MG-MG-UNIT MG-UNIT-MG CALCIUM SOFT FEM-CAL CITRATE 3 CHEW ORAL TABLET,CHEWABLE LOCALNESIUM 3 1 500-100-40 MG-UNIT- LOCALNESIUM-C 3 MCG, 500-200-40 MG- ORTHO-TABS 3 UNIT-MCG PRO-CAL ORAL CALCIUM WITH 3 3 TABLET BORON SOY FORMULA 3 CALCIUM-FOLIC 3 ACID-VITAMIN D VIACTIV ORAL TABLET,CHEWABLE 3 calcium-magnesium- 650 MG-12.5 MCG-40 zinc oral tablet 333-133- 1 MCG 5 mg MINERALS AND calcium-vitamin d3- vitamin k oral ELECTROLYTES tablet,chewable 500 mg- 3 - CALCIUM 1,000 unit-40 mcg, 500- REPLACEMENT/ 200-40 mg-unit-mcg VITAMIN D calcium-vitamin d3- COMBINATIONS vitamin k oral 1 CALCET PETITES 3 tablet,chewable 500- 500-40 mg-unit-mcg CAL-CITRATE 3 CALCIUM 500 + D CAL-MAG 3 1 ORAL TABLET CALMAG THINS 3 CALCIUM 500 WITH 3 D You can find information on what the symbols and abbreviationson this table mean on page 4. 152 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CALCIUM 600 + D(3) calcium citrate-vitamin 1 ORAL CAPSULE d3 oral tablet 200 mg- 6.25 mcg (250 unit), CALCIUM 600 + D(3) 3 ORAL TABLET 600 250 mg-5 mcg (200 1 MG(1,500MG) -400 unit), 315 mg-6.25 mcg UNIT (250 unit) CALCIUM 600 WITH calcium phosphate- VITAMIN D3 ORAL 1 vitamin d3 oral TABLET,CHEWABLE tablet,chewable 200 mg- 5 mcg (200 unit), 250 3 calcium carb and citrate- 3 mg-12.5 mcg (500 unit), vitd3 250 mg-5 mcg (200 calcium carbonate- unit) vitamin d3 oral capsule CALCIUM WITH 1 1 600 mg(1,500mg) -400 VITAMIN D unit CAL-QUICK 2 PA calcium carbonate- CALTRATE 600 PLUS vitamin d3 oral capsule 3 600 mg(1,500mg) -500 3 D unit, 600mg (1,500mg) - CALTRATE GUMMY 3 1,000 unit BITES calcium carbonate- CALTRATE WITH 3 vitamin d3 oral tablet VITAMIN D3 1,000 mg(2,500 mg)- CITRACAL + D 3 800 unit, 500 MAXIMUM mg(1,250mg) -200 unit, CITRACAL 500 mg(1,250mg) -400 3 3 unit, 600 mg(1,500mg) - REGULAR 200 unit, 600 CITRACAL-D3 mg(1,500mg) -400 unit, GUMMIES ORAL 600 mg(1,500mg) -800 TABLET,CHEWABLE 3 unit 250 MG-12.5 MCG calcium carbonate- (500 UNIT) vitamin d3 oral 3 CITRACAL-D3 3 tablet,chewable PETITES CALCIUM CITRATE + CITRACAL-D3 SLOW 3 3 D RELEASE calcium citrate malate- HI-CAL PLUS VIT D 1 3 vit d3 LIQUID CALCIUM 1 calcium citrate-vitamin WITH VITAMIN D 3 d3 oral liquid OS-CAL 500 + D3 calcium citrate-vitamin ORAL TABLET 500 1 d3 oral tablet 200 mg- 1 MG(1,250MG) -200 3.125 mcg (125 unit) UNIT

You can find information on what the symbols and abbreviationson this table mean on page 4. 153 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OS-CAL 500 + D3 calcium gluc in nacl, ORAL TABLET iso-osm intravenous 4 3 500MG (1,250MG) - solution 1 gram/50 ml 600 UNIT calcium gluconate in OYSCO 500/D ORAL 0.9% nacl intravenous 4 1 TABLET solution 1 gram/100 ml OYSTER SHELL calcium gluconate in 3 CALCIUM-VIT D3 water 3 ORAL POWDER IN calcium gluconate 4 PACKET intravenous PARVA-CAL 250 3 calcium phos, tribasic 3 PARVA-CAL 500 3 (bulk) PROSTEON 3 CALPHRON 1 RISACAL-D 3 OYSTER SHELL 1 THERACAL D2000 3 CALCIUM OYSTER SHELL THERACAL D4000 3 1 CALCIUM 500 UPCAL D 3 MINERALS AND MINERALS AND ELECTROLYTES ELECTROLYTES - - CALCIUM ELECTROLYTES REPLACEMENT AND DEXTROSE CALCIUM 500 ORAL 1 dextrose 5 % in ringer's 4 TABLET electrolyte-48 in d5w 4 calcium acetate oral tablet 668 mg (169 mg 3 IONOSOL-B IN D5W 4 calcium) IONOSOL-MB IN 4 calcium D5W acetate(phosphat bind) 1 ISOLYTE-P IN 5 % 4 oral tablet DEXTROSE calcium amino acid NORMOSOL-M IN 5 3 4 chelate % DEXTROSE calcium carbonate oral NORMOSOL-R IN 5 % 4 tablet 500 mg calcium DEXTROSE (1,250 mg), 600 mg 3 calcium (1,500 mg), 650 MINERALS AND mg calcium (1,625 mg) ELECTROLYTES calcium carbonate oral - IODINE tablet,chewable 500 mg 3 IODOPEN 4 calcium (1,250 mg) LUGOLS ORAL 1 calcium chloride 4 potassium iodide (bulk) 1 calcium citrate oral crystals 1 tablet 250 mg calcium SSKI 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 154 Drug Name Drug Tier Limits Drug Name Drug Tier Limits STRONG IODINE HEMATINIC PLUS 1 1 ORAL VIT/MINERALS HEMATINIC/FOLIC MINERALS AND 3 ELECTROLYTES ACID - IRON HEMATOGEN 1 COMBINATIONS HEMATOGEN FA 3 ABATRON 3 HEMATOGEN FORTE 1 ACTIVE FE 3 HEMAX 1 APETIGEN PLUS HEMETAB 3 3 ORAL TABLET HEMOCYTE-F 3 CENTRATEX 3 HEMOCYTE-PLUS 3 CHEWABLE IRON 3 I.L.X. B-12 3 CHROMAGEN(SUMA 1 ICAR-C 3 LATE-QUATREFOLI) IFEREX 150 FORTE 1 CORVITA 150 1 INTEGRA 3 CORVITE 150 ORAL TABLET 150 MG 3 INTEGRA F 3 IRON- 1 MG INTEGRA PLUS 3 CORVITE FE ORAL iron,carbonyl-vitamin c 1 TABLET 150 MG 3 IRO-PLEX (IRON 3 IRON- 1 MG CARBONYL) DUOFER 3 IRO-PLEX (IRON 3 FE C 1 POLYSACCHARIDE) FEOSOL BIFERA 3 IROSPAN 24/6 3 FEROCON 1 LYDIA PINKHAM FERRACTIV 3 HERBAL ORAL 3 TABLET FERREX 150 FORTE 3 MULTIGEN FOLIC 3 FERREX 150 FORTE 3 PLUS MULTIGEN PLUS 3 MYFERON 150 FERREX 150 PLUS 3 1 FORTE FERREX 28 3 NUFERA 3 FERROCITE PLUS 3 OB COMPLETE ORAL FERRO-SEQUELS 3 3 TABLET (IRON-VIT C) OB COMPLETE 3 FOLITAB 3 PREMIER FOLIVANE-F 3 PARVLEX 3 FOLIVANE-PLUS 3 POLY-IRON 150 1 FUSION 3 FORTE FUSION PLUS 3 PROFERRIN-FORTE 3 FUSION SPRINKLES 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 155 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SIDEROL ORAL ferrous gluconate oral 3 TABLET tablet 324 mg (37.5 mg 1 STRESS FORMULA 3 iron) ferrous sulfate oral TARON FORTE 3 1 drops TRICON 1 ferrous sulfate oral 1 TRIGELS-F FORTE 1 liquid VITAFOL 1 ferrous sulfate oral 1 VITRON-C 3 solution MINERALS AND ferrous sulfate oral tablet,delayed release ELECTROLYTES 1 - IRON (dr/ec) 324 mg (65 mg iron) AURYXIA 3 HEMOCYTE 3 CHILDREN'S IRON 1 HIGH POTENCY EZFE 200 1 IRON ORAL TABLET 3 FE C PLUS 1 27 MG IRON ICAR ORAL FEOSOL ORAL 3 TABLET 325 MG (65 1 SUSPENSION MG IRON) ICAR-C PLUS 3 FEOSOL ORAL 3 INFED 2 PA TABLET 45 MG INJECTAFER 2 PA FERAHEME 4 IRON (DRIED) 3 FERGON ORAL IRON 100 PLUS 1 TABLET 240 MG (27 3 MG IRON) IRON CHEWS 3 FER-IN-SOL 3 iron oral tablet 18 mg 3 FEROSUL ORAL IRON ORAL TABLET 1 1 TABLET 325 MG (65 MG IRON) FERRETTS IPS 3 IRONUP 3 FERRIMIN 150 3 NOVAFERRUM 125 3 FERRLECIT 4 NOVAFERRUM 50 3 NOVAFERRUM FERRO-TIME 1 3 ORAL DROPS ferrous fumarate 3 NU-IRON 3 ferrous fumarate (bulk) 3 PEDIA IRON 3 ferrous gluconate (bulk) 3 PERFECT IRON 3 ferrous gluconate oral tablet 236 mg (27 mg POLY-IRON 3 iron), 240 mg (27 mg 3 PRO FE 3 iron), 256 mg (28 mg PROFERRIN ES 3 iron), 324 mg (38 mg iron)

You can find information on what the symbols and abbreviationson this table mean on page 4. 156 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SLOW RELEASE magnesium oxide oral IRON ORAL TABLET tablet 250 mg 1 EXTENDED magnesium RELEASE 142 MG (45 3 magnesium oxide oral MG IRON), 159 MG tablet 400 mg 3 (45 MG IRON), 168 magnesium MG (50 MG IRON) magnesium oxide oral sodium ferric gluconat- 3 4 tablet,chewable sucrose magnesium sulfate in TANDEM DUAL 3 d5w intravenous ACTION piggyback 1 gram/100 4 VENOFER ml, 1 gram/50 ml, 2 INTRAVENOUS gram/100 ml, 2 gram/50 2 PA SOLUTION 100 MG ml IRON/5 ML magnesium sulfate in 4 VENOFER water INTRAVENOUS magnesium sulfate 4 SOLUTION 200 MG 4 injection IRON/10 ML, 50 MG IRON/2.5 ML PHILLIPS 1 WEE CARE 1 MINERALS AND MINERALS AND ELECTROLYTES ELECTROLYTES - MANGANESE - MAGNESIUM manganese chloride 4 COMBINATIONS manganese sulfate 4 BEELITH 1 MINERALS AND MINERALS AND ELECTROLYTES ELECTROLYTES - MULTIPLE - MAGNESIUM MINERAL COMBINATIONS magnesium amino acid chelate oral tablet 100 1 FLORICAL 1 mg magnesium, potassium 3 magnesium chloride aspartate 4 injection MEDI-LYTE 3 magnesium gluconate 3 MONOCAL 1 (bulk) MINERALS AND magnesium glycinate 3 ELECTROLYTES (bulk) powder 10 % - MULTIPLE magnesium l-lactate 3 MINERALS magnesium oral tablet 1 calcium-magnesium- 250 mg 3 copper-zinc magnesium oxide oral 3 powder in packet

You can find information on what the symbols and abbreviationson this table mean on page 4. 157 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MINERALS AND NORMOSOL-R 4 ELECTROLYTES NORMOSOL-R PH 7.4 4 - ORAL NUTRILYTE 4 ELECTROLYTES PLASMA-LYTE 148 4 CERALYTE 50 3 PLASMA-LYTE A 4 POTASSIUM FREE TPN ELECTROLYTES 4 CERALYTE 90 1 TPN ELECTROLYTES CERALYTE-70 ORAL 4 1 II PACKET MINERALS AND CERALYTE-70 ORAL POWDER IN PACKET ELECTROLYTES 1 2.3-1.5-2.9-160 G-G-G- - PHOSPHATE KCAL/50 G GLYCOPHOS 4 CERASPORT ORAL K-PHOS-NEUTRAL 3 LIQUID 115 MG-40 3 PHOS-NAK 1 MG- 40 KCAL/250 ML PHOSPHA 250 CERASPORT ORAL 1 3 NEUTRAL POWDER PHOSPHOROUS 1 electrolytes-dextrose 1 PHOSPHO-TRIN 250 ENFAMIL ENFALYTE 1 1 NEUTRAL ORALYTE 1 potassium phos in 0.9 % PEDIALYTE nacl intravenous 1 4 ADVANCED CARE solution 15 mmol/250 PEDIALYTE ml, 30 mmol/500 ml 1 FREEZER POPS potassium phosph, 1 PEDIALYTE ORAL mono (bulk) 1 SOLUTION potassium phosphate m- PEDIALYTE SINGLES 1 /d-basic intravenous 4 solution 3 mmol/ml PEDIATRIC potassium, sodium ELECTROLYTE 1 3 ORAL SOLUTION phosphates PEDIATRIC FREEZER sodium phosphate 4 1 POPS VIRT-PHOS 250 1 MINERALS AND NEUTRAL ELECTROLYTES MINERALS AND - PARENTERAL ELECTROLYTES ELECTROLYTE - POTASSIUM COMBINATIONS FOR INJECTION HYPERLYTE CR 4 potassium acetate ISOLYTE S PH 7.4 4 intravenous solution 2 2 PA meq/ml ISOLYTE-S 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 158 Drug Name Drug Tier Limits Drug Name Drug Tier Limits potassium chlorid-d5- 4 MINERALS AND 0.45%nacl ELECTROLYTES potassium chloride in - POTASSIUM, 0.9%nacl intravenous ORAL parenteral solution 20 4 meq/250 ml (80 meq/l), EFFER-K ORAL TABLET, 20 meq/l, 40 meq/l 1 EFFERVESCENT 10 potassium chloride in MEQ, 25 MEQ 0.9%nacl intravenous 4 syringe EFFER-K ORAL TABLET, 3 potassium chloride in 5 EFFERVESCENT 20 % dex intravenous MEQ parenteral solution 20 4 meq/l, 30 meq/l, 40 KLOR-CON 1 meq/l KLOR-CON 10 1 potassium chloride in lr- KLOR-CON 8 1 4 d5 KLOR-CON M10 1 potassium chloride in KLOR-CON M15 1 water intravenous 2 PA piggyback 10 meq/100 KLOR-CON M20 1 ml, 20 meq/100 ml KLOR-CON/EF 1 potassium chloride in K-TAB 3 water intravenous potassium chloride oral piggyback 10 meq/50 4 capsule, extended 1 ml, 20 meq/50 ml, 30 release meq/100 ml, 40 potassium chloride oral meq/100 ml 1 liquid potassium chloride 2 PA potassium chloride oral intravenous 3 packet potassium chloride-0.45 4 % nacl potassium chloride oral tablet extended release 1 potassium chloride-d5- 4 10 meq, 8 meq 0.2%nacl potassium chloride oral potassium chloride-d5- tablet extended release 3 0.3%nacl intravenous 4 20 meq parenteral solution 20 meq/l potassium chloride oral tablet,er 1 potassium chloride-d5- 4 particles/crystals 0.9%nacl potassium gluconate oral tablet 2.5 meq, 500 1 mg (83 mg), 550 mg (90 mg) potassium gluconate oral tablet 595 mg (99 3 mg) You can find information on what the symbols and abbreviationson this table mean on page 4. 159 Drug Name Drug Tier Limits Drug Name Drug Tier Limits zinc gluconate oral MINERALS AND 1 ELECTROLYTES tablet 100 mg, 30 mg zinc sulfate intravenous - POTASSIUM 4 solution 5 mg/ml potassium chloride 3 (bulk) powder ZINC-15 1 MINERALS AND MULTIVITAMIN ELECTROLYTES AND MINERAL - TRACE COMBINATIONS MINERAL A THRU Z SELECT COMBINATIONS ORAL TABLET 300- 3 600-300 MCG ADDAMEL N 4 ACTICAL 3 MULTITRACE-4 4 ADULT MULTITRACE-4 4 MULTIVITAMIN 3 CONCENTRATE GUMMIES MULTITRACE-4 4 ADULT ONE DAILY NEONATAL 3 GUMMIES MULTITRACE-4 4 AIRSHIELD ORAL PEDIATRIC TABLET, MULTITRACE-5 4 EFFERVESCENT 3 MULTITRACE-5 5,000-1000-30 UNIT- 4 CONCENTRATE MG-UNIT ALIVE ONCE DAILY PEDITRACE 4 3 WOMEN 50 PLUS TRACE ELEMENTS 4 ALIVE WOMEN'S 4/PEDIATRIC 3 ENERGY MINERALS AND AQUADEKS ORAL ELECTROLYTES 1 TABLET,CHEWABLE - TRACE MINERALS BACMIN 3 BEROCCA (FA- chromium chloride 4 3 GUARANA-CAFF) chromium picolinate 1 BIO-35, GLUTEN oral tablet 200 mcg 3 FREE COPPER CHLORIDE 4 BIOTECT PLUS 3 selenium intravenous 4 BIOTIN PLUS- selenium oral tablet 1 CALCIUM AND VIT 3 MINERALS AND D3 ELECTROLYTES BIOVOL 1 - ZINC BLADDER 2.2 3 ORAZINC ORAL BODY, HAIR, SKIN 1 3 TABLET AND NAILS zinc chloride 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 160 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CALCIUM CITRATE CONCEPT DHA 3 1 PLUS (VIT B6) CONCEPT OB 3 CENTRAL-VITE 3 CORVITA 3 WOMEN'S MATURE CORVITE 3 CENTRAVITES 3 CORVITE FREE 3 CENTRUM 3 CHEWABLES DAILY GUMMIES 3 CENTRUM MEN 3 DAILY MULTIPLE ORAL TABLET 400- 3 CENTRUM ORAL 120 MCG-MG LIQUID 9 MG 3 DAILY IRON/15 ML 3 MULTIVITAMIN CENTRUM SILVER 3 ORAL TABLET DAILY MULTIVITAMIN- 3 CENTRUM SILVER 3 MINERALS ULTRA MEN'S DEKAS BARIATRIC 3 CENTRUM SILVER 3 WOMEN DEKAS PLUS (FOLIC ACID) ORAL 3 CENTRUM 3 CAPSULE SPECIALIST ENERGY DIABETES HEALTH 3 CENTRUM ULTRA 3 DIABETES HEALTH MEN'S 3 FORMULA CENTURY ULTIMATE MEN'S DIALYVITE 5000 3 3 ORAL TABLET 300- ELON MATRIX 5000 3 600-300 MCG COMPLETE CENTURY ESSENTIAL ULTIMATE MEN'S BALANCE WITH 3 ORAL TABLET 8 MG 4 LUTEIN IRON- 200 MCG-600 ESSENTIAL MAN 3 MCG ESSENTIAL WOMAN 3 CERTA PLUS 3 50+ COMPLETE MULTI 3 FOLIVANE-OB 3 COMPLETE FOSFREE 3 MULTIVITAMIN 3 ORAL TABLET FREEDAVITE 3 COMPLETE GERITOL COMPLETE 1 MULTIVITAMIN- HAIR FORMULA 3 3 MINERAL ORAL HAIR, SKIN AND 3 LIQUID NAILS-ARGAN OIL COMPLETE MV 3 HAIR,SKIN AND ADULT 50 PLUS NAILS ORAL 3 COMPLETE TABLET 1 MG IRON- 3 PREMIUM VITAMIN 66.7 MCG-1,000 MCG

You can find information on what the symbols and abbreviationson this table mean on page 4. 161 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HAIR,SKIN AND MULTI FOR HER 3 3 NAILS(FA-BIOTIN) ORAL TABLET HAIR-SKIN-NAILS MULTI VITAMIN 3 3 (PABA) MULTI-DAY PLUS 3 HEARTBURN AND MINERALS 3 ACID REFLUX-ALOE MULTI-DELYN WITH 3 ICAPS 3 IRON ICAPS MV 3 MULTIPLE VITAMIN, 3 K-PAX IMMUNE WOMENS 3 SUPPORT MULTI-VITAMIN 3 K-PAX ORAL HP/MINERALS 3 POWDER MULTIVITAMIN 3 LIPOTRIAD (WITH WOMEN 50 PLUS 1 LUTEIN) MULTI-VITE 3 MAXIMIN PACK 3 mv-min-folic acid-lutein 3 MEGA NICOMIDE MULTIPLE/CHELATE 1 (SELENIUM- 3 D MINERAL CHROMIUM) MEGA NIVA-PLUS 1 MULTIVITAMIN FOR 3 OB COMPLETE ORAL 3 MEN TABLET MEGA O-CAL F.A. 1 MULTIVITAMIN WITH MINERAL OCUTABS 3 3 ORAL TABLET 13.5- OCUVITE EYE PLUS 3 200-250 MG-MCG- MULTI MCG ONE DAILY FOR 3 MEN'S 50 PLUS MEN 3 MULTIVITAMIN ONE DAILY FOR 3 MEN'S DAILY 3 WOMEN MEN'S DAILY ONE DAILY 3 3 GUMMIES HEALTHY WEIGHT MEN'S DAILY ONE DAILY MEN'S 50 3 3 MULTIVIT-MINERAL PLUS W-D3 MEN'S ONE DAILY MULTI- MULTIVITAMIN 3 VIT W-MINERAL 3 GUMMIES ORAL POWDER IN MEN'S ONE DAILY PACKET ORAL TABLET 400- 3 ONE DAILY 20-300 MCG MULTIVITAMIN- 3 MEN'S PACK 3 IRON ONE DAILY MONOCAPS 3 3 WOMENS 50 PLUS

You can find information on what the symbols and abbreviationson this table mean on page 4. 162 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONE-A-DAY PROTECT IRON 3 3 CHOLESTEROL PLUS PROTECT PLUS SO 3 ONE-A-DAY MEN 3 PUREFE OB PLUS 3 VITACRAVES PUREFE PLUS 3 ONE-A-DAY MENOPAUSE 3 QUINTABS-M 3 FORMULA SOLO 3 ONE-A-DAY MEN'S SPECTRAVITE 3 3 50 PLUS ULTRA MEN 50+ ONE-A-DAY MEN'S SPECTRAVITE 3 3 MULTIVITAMIN ULTRA MEN'S SR ONE-A-DAY STRESS B-COMPLEX 3 VITACRAVES ORAL TABLET 500- 3 ONE-A-DAY 400-23.9-3 MG-MCG- VITACRAVES 3 MG-MG IMMUNITY STROVITE FORTE 3 ONE-A-DAY STROVITE ONE 3 VITACRAVES 3 SUNVITE 3 OMEGA-3 SUPER GINSENG ONE-A-DAY 3 3 MULTIVITAMIN WEIGHTSMART SUPER MULTIPLE - ONE-A-DAY WOMEN 3 3 LOW IRON VITACRAVES SUPER MULTIPLE ONE-A-DAY 3 3 ORAL CAPSULE WOMEN'S ACTIVE TARON-C DHA 3 ONE-A-DAY THERAGRAN-M WOMENS FORMULA 3 ORAL TABLET 18 MG 3 PREMIER 50 PLUS IRON-400 MCG-500 THERANATAL ORAL 3 MG COMBO PACK ONE-A-DAY THERAPEUTIC-M 3 WOMEN'S HEALTHY 3 VITAMIN/MINERALS SKIN TRUEPLUS OPTISOURCE 3 DIABETIC 3 OPURITY MULTIVITAMIN 3 MULTIVITAMIN UDAMIN SP 3 PNV-OMEGA 3 ULTIMATE MEN'S 3 PRENATAL DAILY COMPLETE 50+ 3 DUO ULTIMATE PROCERV HP 3 WOMEN'S 3 COMPLETE 50+ PRORENAL QD 3 ULTRA FREEDA 3 PROTECT CARDIO 3 AF V-C FORTE 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 163 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VIC-FORTE 3 CRANBERRY 1 VIRT-C DHA 3 URINARY COMFORT DAILY MULTIPLE VIRT-PN PLUS 3 3 FOR WOMEN VITABEX PLUS 3 DAILY VITAL-D RX 3 MULTIVITAMIN 3 VITAMIN D-3 WITH WITH IRON 3 ALOE DAILY VALUE 1 VITAMINS A-D-E 3 DECUBI VITE 3 SELENIUM DEKAS ESSENTIAL 3 VITRUM SENIOR ORAL CAPSULE ORAL TABLET 500- 3 DIALYVITE 800 300-250 MCG 3 WITH IRON WOMEN'S 50 PLUS 3 MULTIVITAMIN ENBRACE HR 3 WOMEN'S DAILY ESSENTIAL 3 CAPLET BALANCE WITH 3 LUTEIN WOMENS DAILY 3 GUMMIES FORTAVIT 3 WOMEN'S DAILY HAIR-SKIN-NAILS 3 3 PACK (MV-FA-BIOTIN) WOMEN'S INFUVITE ADULT 4 MULTIVITAMIN 3 M.V.I. ADULT 4 GUMMIES M.V.I.-12 (WITHOUT 4 WOMEN'S VITAMIN K) MULTIVITAMIN METAFOLBIC 1 ORAL TABLET 18 3 multivitamin oral MG-400 MCG- 500 1 MG-50 MCG capsule NEEVODHA (WITH ZATEAN-PN PLUS 3 3 ALGAL OIL) MULTIVITAMINS NORWEGIAN COD 1 A THRU Z LIVER OIL ADVANCED 3 OMNIVEX 3 FORMULA ONCOVITE 3 ANIMI-3 WITH 3 VITAMIN D ONE DAILY ESSENTIAL ORAL 3 CALCIUM PNV 3 TABLET 400 MCG CENTRUM 3 ONE DAILY MEN'S 50 COMPLETE 3 PLUS MEMORY CEREFOLIN 3 ONE DAILY cod liver oil oral capsule 1 MULTIVITAMIN 3 cod liver oil oral oil 3 ORAL POWDER IN PACKET

You can find information on what the symbols and abbreviationson this table mean on page 4. 164 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONE DAILY WOMEN'S DAILY MULTIVITAMIN FORMULA ORAL 3 ORAL TABLET 400 TABLET 18 MG 3 MCG IRON-400 MCG-500 ONE DAILY MG CA 3 WOMEN'S HEALTH WOMEN'S ONE 1 ONE DAILY DAILY WOMEN'S ORAL XYZBAC 3 TABLET 18 MG 1 ZATEAN-PN DHA 3 IRON-400 MCG-450 MG CA NUTRITIONAL ONE-A-DAY ENERGY 3 PRODUCT - CARBOHYDRAT ONE-A-DAY WOMENS FORMULA ES, ORAL ORAL TABLET 18 MG 3 ENFAMIL GLUCOSE 1 IRON-400 MCG-500 NUTRITIONAL MG CA PRODUCT - ONE-A-DAY 3 GLUTARIC WOMEN'S PETITES ACIDURIA TYPE PNV-DHA 1 1 SPECIFIC PRENATAL-U 3 FORMULATION PRENATE AM 3 GLUTARADE JUNIOR 1 PRENATE XLYS- XTRP 3 1 CHEWABLE ANALOG PRENATE NUTRITIONAL ESSENTIAL(IRON- 3 ASP-GL) PRODUCT - ISOVALERIC PUREVIT DUALFE 1 PLUS ACIDEMIA SPECIFIC QUINTABS 3 FORMULATION SE-TAN PLUS 1 XLEU ANALOG 1 TANDEM PLUS 3 NUTRITIONAL TOBAKIENT 3 PRODUCT - VINATE CARE 3 KETOGENIC VINATE DHA RF 3 FORMULATION VIRT-PN DHA 3 KETOCAL 2.5:1 3 VIT 3 3 KETOQ10 5.5:1 3 vitamins a and d 3 MICROLIPID 1 VITAMINS FOR HAIR 1 ORAL TABLET

You can find information on what the symbols and abbreviationson this table mean on page 4. 165 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NUTRITIONAL NUTRITIONAL PRODUCT - PRODUCT - LIPID OTHERS PARENTERAL MCT OIL ORAL OIL AND OTHER 1 7.7 KCAL/ML AMINO ACIDS MICROLIPID 1 AMINOPROTECT 4 arginine-lysine in 0.9 % NUTRITIONAL 4 PRODUCT - nacl MEDICAL NUTRITIONAL CONDITION PRODUCT - SPECIFIC PHENYLKETON FORMULATION URIA (PKU) CHOLEXTRA T-F 3 SPECIFIC ENDARI 3 FORMULATION NUTRITIONAL GLYTACTIN 15PECOMPLETE- 3 PRODUCT - TAURINE METHIONINE- PERIFLEX INFANT 1 FREE SPECIFIC FORMULATION PERIFLEX LQ PKU 1 PHENYLADE 40 1 XMET ANALOG 3 PHENYLADE GMP NUTRITIONAL MIX-IN ORAL 3 PRODUCT - POWDER MSUD SPECIFIC PHENYLADE GMP 3 FORMULATION READY COMPLEX 1 PHENYLADE MTE ESSENTIAL AMINO ACIDS ORAL 1 COMPLEX MSUD POWDER 1 AMINO ACID BLEND PHENYL-FREE 1 1 ISOLEUCINE AMINO 1 XPHE MAXAMUM ACID SUPPLMNT ORAL POWDER IN 1 MSUD ANALOG 1 PACKET NUTRITIONAL NUTRITIONAL PRODUCT - PRODUCT - NUTRITIONAL PROPIONIC THERAPY ACIDEMIA PRONOURISH 3 SPECIFIC FORMULATION PURAMINO JR 3 XMTVI ANALOG 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 166 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NUTRITIONAL NUTRITIONAL PRODUCT - PRODUCT - PROTEIN UREA CYCLE REPLACEMENTS DISORDER citrulline (bulk) 3 SPECIFIC G-PREPROTEIN 1 FORMULATION ESSENTIAL AMINO L-ALANINE 3 1 ACID MIX L-GLUTAMINE 3 PARENTERAL L-ISOLEUCINE 3 NUTRITION - PRE-PROTEIN ORAL 1 AMINO ACID LIQUID AND DEXTROSE PROCEL 1 COMBINATIONS PROCEL 100 1 CLINIMIX 5%/D15W 4 PROCEL SINGLES 1 SULFITE FREE PROMOD PROTEIN 1 CLINIMIX 5%/D25W 4 PROSOURCE NO SULFITE-FREE 1 CARB CLINIMIX PROSOURCE ORAL 4.25%/D10W SULF 4 1 POWDER FREE PRO-STAT RENAL CLINIMIX 4.25%/D5W 1 4 CARE SULFIT FREE PRO-STAT SUGAR CLINIMIX 4.25%- 1 4 FREE D25W SULF-FREE PROSYNMINIC 1 CLINIMIX 5%- D20W(SULFITE- 4 protein oral powder 3 FREE) PROTEINEX ORAL 1 LIQUID PARENTERAL NUTRITION - PROTEINEX-18 1 AMINO ACID NUTRITIONAL AND PRODUCT - ELECTROLYTES TYROSINEMIA COMBINATION SPECIFIC AMINOSYN 7 % FORMULATION WITH 4 TYR LOPHLEX GMP 3 ELECTROLYTES MIX-IN AMINOSYN 8.5 %- XPHE, XTYR 4 1 ELECTROLYTES ANALOG AMINOSYN II 8.5 %- 4 XPTM ANALOG 1 ELECTROLYTES AMINOSYN M 3.5 % 4 PROCALAMINE 3% 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 167 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PARENTERAL PROSOL 20 % 4 NUTRITION - SYNTHAMIN 17 4 AMINO ACID WITHOUT ELYTE SOLUTIONS TRAVASOL 10 % 4 AMINOSYN 10 % 4 TROPHAMINE 10 % 4 AMINOSYN 3.5 % 4 PARENTERAL AMINOSYN 7 % 4 NUTRITION - AMINOSYN 8.5 % 4 AMINO ACID, AMINOSYN II 10 % 4 DEXTROSE, E- LYTES AND FAT AMINOSYN II 15 % 4 EMUL COMB AMINOSYN II 7 % 4 KABIVEN 4 AMINOSYN II 8.5 % 4 PERIKABIVEN 4 AMINOSYN M 3.5 % 4 PARENTERAL AMINOSYN-HBC 7% 4 NUTRITION - AMINOSYN-PF 10 % 4 INTRAVENOUS AMINOSYN-PF 7 % 4 FAT EMULSIONS (SULFITE-FREE) INTRALIPID AMINOSYN-RF 5.2 % 4 INTRAVENOUS 4 CLINIMIX E EMULSION 20 %, 30 2.75%/D5W SULF 4 % FREE LIPOSYN II 4 CLINIMIX E LIPOSYN III 4 4.25%/D10W SUL 4 FREE NUTRILIPID 4 CLINIMIX E OMEGAVEN 4 4.25%/D5W SULF 4 PARENTERAL FREE NUTRITION- CLINIMIX E AMINO ACID, 5%/D15W SULFIT 4 DEXTROSE AND FREE ELECTROLYTES CLINIMIX E COMBINATION 5%/D20W SULFIT 4 FREE CLINIMIX E 2.75%/D5W SULF 4 CLINISOL SF 15 % 4 FREE FREAMINE III 10 % 4 CLINIMIX E HEPATAMINE 8% 4 4.25%/D10W SUL 4 NEPHRAMINE 5.4 % 4 FREE PLENAMINE 4 CLINIMIX E 4.25%/D5W SULF 4 PREMASOL 10 % 4 FREE PROCALAMINE 3% 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 168 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CLINIMIX E FLINTSTONES PLUS 3 5%/D15W SULFIT 4 CALCIUM FREE FLINTSTONES TAB 3 CLINIMIX E CHEW 5%/D20W SULFIT 4 FLINTSTONES WITH 1 FREE IRON PEDIATRIC HONEY BEARS WITH 1 VITAMINS AND IRON-ZINC MINERAL LYSIPLEX PLUS 1 COMBINATIONS ORAL LIQUID ANIMAL SHAPES NANOVM 9-18 3 1 COMPLETE NANOVM T-F 3 AQUADEKS NOVAFERRUM 1 1 PEDIATRIC PEDIATRIC CEROVITE JR ORAL PEDIA POLY-VITE 1 TABLET,CHEWABLE 1 18 MG IRON- 10 MCG PEDIA POLY-VITE WITH IRON ORAL 1 CHILD CHEWABLE 1 DROPS VITAMN COMPLETE POLY-VI-SOL WITH CHILD COMPLETE 1 1 IRON MULTIVITAMIN SCOOBY-DOO ONE A CHILDREN'S CHEW 1 1 DAY MULTIVIT-IRON VITALETS ORAL CHILDREN'S TABLET,CHEWABLE 3 CHEWABLE 10 MG IRON COMPLETE ORAL 3 TABLET,CHEWABLE PEDIATRIC 9-200 MG IRON-MCG VITAMINS WITH CHILDREN'S FLUORIDE AND 1 MULTIVITAMIN MINERALS CHILD'S CHEWABLE COMBINATIONS 1 VITAMINS/IRON MULTI-VIT WITH 3 CHILDS/IRON 1 FLUORIDE-IRON DINO-LIFE WITH PEDIATRIC 1 IRON-ZINC VITAMINS WITH EMERGEN-C KIDZ 3 FLUORIDE FLINTSTONES COMBINATIONS 1 COMPLETE (IRON) FLORIVA 3 FLINTSTONES FLORIVA MULTI-VIT (FLUORIDE- 3 GUMMIES ORAL 3 VITAMIN D3) TABLET,CHEWABLE FLORIVA PLUS 3 100 MCG

You can find information on what the symbols and abbreviationson this table mean on page 4. 169 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MULTI-VIT WITH CHILDREN 3 1 FLUORIDE-IRON MULTIVITAMIN MULTIVITAMIN CHILDREN'S 3 WITH FLUORIDE CHEWABLE 1 MULTI-VITAMIN VITAMIN WITH FLUORIDE 1 CHILDREN'S 3 ORAL DROPS CHEWABLES MULTI-VITAMIN CHILDREN'S WITH FLUORIDE CHEWABLES EXTRA 3 3 ORAL C TABLET,CHEWABLE CHILDREN'S MULTI- 1 MULTIVITAMINS VIT GUMMIES 3 WITH FLUORIDE CHILDREN'S 1 MVC-FLUORIDE 3 MULTIVITAMIN POLY-VI-FLOR 3 DEKAS PLUS LIQUID 3 POLY-VI-FLOR WITH DINO-LIFE WITH 3 1 IRON IRON-ZINC QUFLORA 3 FLINTSTONES 3 QUFLORA FE COMPLETE 1 (FERROUS SULFATE) FLINTSTONES 1 QUFLORA GUMMIES 3 PEDIATRIC FLINTSTONES 3 QUFLORA GUMMIES OMEGA-3 3 PEDIATRIC DROPS FLINTSTONES TRI-VI-FLOR 3 MULTI-VIT GUMMIES ORAL 3 TRI-VITAMIN WITH 3 TABLET,CHEWABLE FLUORIDE 200 MCG TRI-VITE WITH FLINTSTONES 3 1 FLUORIDE MULTIVITAMIN VITAMINS A,C,D FLINTSTONES SOUR 3 3 AND FLUORIDE GUMMIES PEDIATRIC FLINTSTONES/EXTR 3 VITAMINS A C ANIMAL CHEWS 1 GUMMI BEAR 1 ANIMAL SHAPE MULTIVITAMIN 1 VITAMINS GUMMIES ANIMAL SHAPES CHILDREN 1 COMPLETE ORAL 1 MULTIVITAMIN TABLET,CHEWABLE GUMMY DINOS 1 CHILD HONEY BEARS WITH 3 1 MULTIVITAMINS IRON-ZINC

You can find information on what the symbols and abbreviationson this table mean on page 4. 170 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INFUVITE ONE-A-DAY TEEN 2 PA 3 PEDIATRIC HIM VITACRAVES KIDS COD LIVER OIL PEDIA POLY-VITE 1 3 AND VIT D PEDIA TRI-VITE 1 KIDS' GUMMY 1 POLY-VI-SOL ORAL 1 KIDS DROPS MULTIVITAMIN- 3 POLY-VITAMINS 1 MINERALS SCOOBY-DOO ONE A 3 LITTLE ANIMALS- DAY KIDS IRON ORAL 1 TABLET,CHEWABLE ZOO CHEWS 1 15 MG IRON ZOO FRIENDS ORAL 3 M.V.I. PEDIATRIC 2 PA TABLET,CHEWABLE MVW COMPLETE PRENATAL FORMUL MULTIVIT 3 VITAMINS AND ORAL CAPSULE MINERALS MVW COMPLETE BAL-CARE DHA 3 FORMUL MULTIVIT 1 BAL-CARE DHA ORAL 3 ESSENTIAL TABLET,CHEWABLE BRAINSTRONG MVW COMPLETE 3 3 PRENATAL FORMUL PEDIATRIC CADEAU DHA 3 MVW COMPLETE FORMULATION CALCIUM PNV 3 3 D3000 ORAL CITRANATAL B- 3 CAPSULE CALM (FE GLUC) MVW COMPLETE CLASSIC PRENATAL 1 FORMULATION 1 C-NATE DHA 3 D3000 ORAL COMPLETE NATAL TABLET,CHEWABLE 3 DHA MVW COMPLETE FORMULATION COMPLETENATE 1 3 D5000 ORAL CONCEPT DHA 3 CAPSULE CONCEPT OB 3 MVW COMPLETE DAILY PRENATAL 1 FORMULATION 1 D5000 ORAL DUET DHA TABLET,CHEWABLE BALANCED ORAL COMBO PACK 25 MG 3 NANO VM 1-3 ORAL 3 IRON-1 MG -267 MG- POWDER 233 MG NANO VM 4-8 ORAL 3 DUET DHA WITH POWDER OMEGA-3 ORAL 3 NOVAMV 3 COMBO PACK 25 MG ONE-A-DAY KID'S 3 IRON-1 MG -400 MG

You can find information on what the symbols and abbreviationson this table mean on page 4. 171 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ENBRACE HR 3 ONE-A-DAY EXPECTA WOMEN'S 3 1 PRENATAL PRENATAL 1 EXTRA-VIRT PLUS PERRY PRENATAL 3 3 DHA PNV 29-1 3 FOLIVANE-OB 3 PNV-DHA 1 KPN ORAL TABLET 1 PNV-FERROUS KPN ORAL TABLET 9 FUMARATE-DOCU- 3 3 MG IRON- 267 MCG FA MARNATAL-F 3 PNV-OMEGA 3 MINI PRENATAL 3 PNV-SELECT 3 M-NATAL PLUS 3 PR NATAL 400 3 MYNATAL ORAL PR NATAL 400 EC 3 1 CAPSULE PR NATAL 430 3 MYNATAL PLUS 1 PR NATAL 430 EC 3 MYNATAL-Z 1 PRENA1 CHEW 3 NATACHEW (FE BIS- PRENA1 PEARL 3 3 GLYCINATE) PRENA1 TRUE 3 NEEVODHA (WITH 3 PRENATA 3 ALGAL OIL) PRENATABS FA 1 NESTABS 3 PRENATABS RX 1 NESTABS ABC 3 PRENATAL + DHA NESTABS DHA 3 ORAL COMBO PACK 3 NEWGEN 3 28 MG IRON- 975 NIVA-PLUS 1 MCG-200 MG OB COMPLETE ONE 3 PRENATAL + DHA ORAL COMBO PACK OB COMPLETE ORAL 1 3 28 MG IRON-800 TABLET MCG-200 MG OB COMPLETE 3 PRENATAL 19 3 PETITE PRENATAL OB COMPLETE 3 3 COMPLETE PREMIER PRENATAL OB COMPLETE WITH 3 3 FORMULA DHA PRENATAL GUMMY 3 O-CAL PRENATAL 3 PRENATAL LOW 1 ONE A DAY IRON WOMEN'S 3 PRENATAL DHA PRENATAL MULTI 1 ONE DAILY PRENATAL MULTI- 3 3 PRENATAL DHA (ALGAL OIL)

You can find information on what the symbols and abbreviationson this table mean on page 4. 172 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PRENATAL PROVIDA OB 3 1 MULTIVITAMINS PUREFE OB PLUS 3 PRENATAL ONE 1 PUREFE PLUS 3 DAILY R-NATAL OB 3 PRENATAL ORAL TABLET 28 MG 1 SELECT-OB 3 IRON- 800 MCG SELECT-OB + DHA 3 PRENATAL PLUS 1 SE-NATAL 19 1 PRENATAL PLUS CHEWABLE 1 (CALCIUM CARB) SE-NATAL-19 1 PRENATAL TABLET 1 SIMILAC PRENATAL 3 PRENATAL VITAMIN STUART ONE 3 ORAL TABLET 27 MG 1 TARON-C DHA 3 IRON- 0.8 MG, 27 MG IRON- 800 MCG TENDERA-OB 3 PRENATAL VITAMIN THERANATAL 3 3 PLUS LOW IRON COMPLETE PRENATAL VITAMIN THERANATAL ONE 3 1 WITH MINERALS THERANATAL ORAL 1 prenatal vit-iron fum- TABLET 1 folic ac THERANATAL 3 prenatal vits96-iron OVAVITE 1 fum-folic THERANATAL PLUS 3 PRENATAL-U 3 THRIVITE RX 3 PRENATE AM 3 TRIADVANCE 1 PRENATE TRICARE 3 3 CHEWABLE TRINATAL RX 1 3 PRENATE DHA 3 TRINATE 3 (FERR ASP GLYCIN) TRISTART DHA 3 PRENATE ELITE 3 (IRON ASP GLYC) TRIVEEN-DUO DHA 3 PRENATE ENHANCE 3 VINACAL B 3 PRENATE VINATE CARE 3 ESSENTIAL(IRON- 3 VINATE DHA RF 3 ASP-GL) VINATE II 3 PRENATE MINI 3 VINATE M 1 (FERR ASP GLYCIN) VINATE ONE 1 PRENATE PIXIE 3 VINATE ULTRA 1 PRENATE RESTORE 3 VIRT-C DHA 3 PRENATE STAR 3 VIRT-NATE DHA 3 PREPLUS 1 VIRT-PN DHA 3 PRETAB 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 173 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VIRT-PN PLUS 3 SODIUM VITAFOL GUMMIES 3 CHLORIDE VITAFOL NANO 3 FLUSHES BD PRE-FILLED VITAFOL ULTRA 3 4 NORMAL SALINE VITAFOL-OB 1 MONOJECT 0.9% VITAFOL-OB+DHA 3 4 SODIUM CHLORIDE VITAFOL-ONE 3 MONOJECT PREFILL VITAMED MD ONE 4 3 ADVANCED NS RX NORMAL SALINE VITAMEDMD 4 3 FLUSH REDICHEW RX sodium chlor 0.9% 4 VITAPEARL 3 bacteriostat VITATRUE 3 sodium chloride 0.9 % 4 VIVA DHA 3 (flush) sodium chloride 0.9 % VP-CH PLUS 3 1 injection VP-CH-PNV 3 SWABFLUSH 4 VP-PNV-DHA 3 ZATEAN-PN DHA 3 SODIUM CHLORIDE ZATEAN-PN PLUS 3 SOLUTIONS, PRENATAL CONCENTRATED VITAMINS WITH sodium chloride 3 % 4 LOW OR NO IRON (LESS sodium chloride 5 % 4 THAN 27 MG) sodium chloride intravenous parenteral 4 ALIVE PRENATAL 3 solution 2.5 meq/ml AZESCO 3 sodium chloride PRENATAL ORAL intravenous parenteral 1 3 TABLET,CHEWABLE solution 4 meq/ml ZINGIBER 3 SODIUM RINGER'S AND CHLORIDE, LACTATED PARENTERAL RINGER'S BD PRE-FILLED 4 SOLUTIONS NORMAL SALINE lactated ringers LIQUIVIDA 4 4 intravenous HYDRATION KIT MONOJECT 0.9% ringer's intravenous 4 4 SODIUM CHLORIDE MONOJECT PREFILL 4 ADVANCED NS

You can find information on what the symbols and abbreviationson this table mean on page 4. 174 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NORMAL SALINE 4 VITAMINS - A FLUSH AND D sodium chloride 0.45 % COMBINATIONS, intravenous parenteral 4 SYSTEMIC solution cod liver oil (bulk) 1 sodium chloride 0.9 % 4 (flush) COD LIVER OIL ORAL CAPSULE 1 sodium chloride 0.9 % 4 1,250-135 UNIT intravenous NORWEGIAN COD 1 sodium chloride 3 % 4 LIVER OIL sodium chloride 5 % 4 vit a and d3 in cod liver 1 sodium chloride oil intravenous parenteral 4 VITAMINS - A solution 2.5 meq/ml AQUASOL A 4 sodium chloride intravenous parenteral 1 beta carotene 1 solution 4 meq/ml LUMITENE 1 SWABFLUSH 4 vitamin a oral capsule 1 STERILE WATER 10,000 unit, 8,000 unit FOR INJECTION VITAMINS - B water for injection, PREPARATION 4 sterile intravenous COMBINATIONS VITAMIN C APATATE 1 COMBINATIONS B COMPLEX W-VIT C 3 EMERGEN-C ORAL B-COMPLEX WITH B- 3 3 TABLET,CHEWABLE 12 VITAMIN C FIZZY CEREFOLIN NAC 3 3 DRINK (ALGAL OIL) VITAMIN D AND FABB 1 FOLIC ACID FOLBEE 3 COMBINATIONS FOLBIC 3 CIFEREX 3 folic acid-vit b6-vit b12 3 DERMACINRX oral tablet 0.5-5-0.2 mg 3 PUREFOLIX FOLINIC-PLUS 3 DURACHOL 3 FOLPLEX 2.2 1 FOLVITE-D 1 FOLTABS 800 3 GENICIN VITA-D 3 FOLTANX 1 NOXIFOL-D3 3 FOLTX 3 REVESTA 3 HOMOCYSTEINE 3 ZAVARA 3 FORMULA

You can find information on what the symbols and abbreviationson this table mean on page 4. 175 Drug Name Drug Tier Limits Drug Name Drug Tier Limits METANX (ALGAL VITAMIN B-12 ORAL 3 1 OIL) TABLET 100 MCG METHAVER 3 VITAMINS - B-2, NEURIN-SL 3 RIBOFLAVIN NIVA-FOL 3 AND VIRT-GARD 1 DERIVATIVES VIRT-VITE 3 VITAMIN B-2 ORAL TABLET 100 MG, 50 1 VITA-RESPA 3 MG WESTAB ONE 1 VITAMINS - B-3, ZINGIBER 3 NIACIN AND VITAMINS - B-1, DERIVATIVES THIAMINE AND ENDUR-ACIN ORAL DERIVATIVES TABLET EXTENDED 1 ARKALIOX 3 RELEASE 500 MG thiamine hcl (vitamin ENDUR-AMIDE 2 PA ORAL TABLET b1) injection 1 EXTENDED thiamine hcl (vitamin 1 RELEASE 500 MG b1) oral tablet 100 mg INOSITOL VITAMIN B-1 3 1 HEXANICOTINATE (MONONITRATE) niacin (inositol VITAMIN B-1 ORAL niacinate) oral capsule 1 TABLET 250 MG, 50 1 400 mg niacin (500 mg), MG 500 mg VITAMINS - B-12 niacin (inositol 1 AND FOLIC ACID niacinate) oral tablet COMBINATIONS NIACIN FLUSH FREE FOLTRATE 3 ORAL CAPSULE 400 1 MG NIACIN (500 MG) VITAMINS - B-12, CYANOCOBALA NIACIN NO FLUSH 1 MIN AND niacin oral capsule, DERIVATIVES extended release 250 1 mg, 500 mg B12 1 niacin oral tablet 250 1 B-12 DOTS 1 mg cyanocobalamin 1 niacin oral tablet (vitamin b-12) injection extended release 250 1 hydroxocobalamin 2 PA mg, 500 mg, 750 mg niacinamide (bulk) LIQUID B-12 1 1 crystals mecobalamin (bulk) 3 niacinamide oral tablet powder 100 %, 96 % 1 500 mg NEURIN-SL 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 176 Drug Name Drug Tier Limits Drug Name Drug Tier Limits niacinamide oral tablet ascorbic acid (vitamin c) 1 3 extended release oral powder in packet VITAMINS - B-5, VITAMINS - D PANTOTHENIC AND K ACID AND COMBINATIONS DERIVATIVES D3 + K2 DOTS 3 pantothenic acid (vit b5) 1 K2 PLUS D3 3 VITAMINS - B-6, VITAMINS - D PYRIDOXINE DERIVATIVES AND BABY DDROPS 3 DERIVATIVES BABY VITAMIN D3 3 pyridoxine (bulk) 1 BABY'S SUPER crystals 3 DAILY D3 pyridoxine (vitamin b6) 4 calcitriol intravenous injection 4 solution 1 mcg/ml pyridoxine (vitamin b6) 1 calcitriol oral capsule 1 oral tablet 50 mg calcitriol oral solution 3 VITAMIN B-6 ORAL 1 TABLET 50 MG cholecalciferol (vitamin d3) oral capsule 25 mcg 1 VITAMINS - (1,000 unit) BIOFLAVONOID cholecalciferol (vitamin S d3) oral tablet 25 mcg 1 bioflavonoids, citrus (1,000 unit) 3 (bulk) powder 100 % cholecalciferol (vitamin 3 VITAMINS - d3) sublingual BIOTIN CIFEREX 3 biotin (bulk) 3 D3-2000 1 biotin oral capsule 1 mg, DDROPS 3 3 10,000 mcg, 5 mg DECARA ORAL CYTO B7 3 CAPSULE 1,250 MCG 3 MEGA BIOTIN 3 (50,000 UNIT), 625 MCG (25,000 UNIT) MERIBIN 3 DERMACINRX 3 VB7 MAX 3 PUREFOLIX VITAMINS - C, DIALYVITE 3 ASCORBIC ACID VITAMIN D3 MAX AND DURACHOL 3 DERIVATIVES ergocalciferol (vit d2) 3 ASCOR 4 (bulk) ascorbic acid (vitamin c) ergocalciferol (vitamin 4 3 injection d2)

You can find information on what the symbols and abbreviationson this table mean on page 4. 177 Drug Name Drug Tier Limits Drug Name Drug Tier Limits KIDS FIRST VITAMIN folic acid oral tablet 400 3 3 D3 mcg KIDS VITAMIN D3 3 folic acid oral tablet 800 1 NOXIFOL-D3 3 mcg OPTIMAL D3 3 GENICIN VITA-Q 3 OPTIMAL D3 M 3 XAQUIL XR 3 PEDIA D-VITE ORAL VITAMINS - 3 DROPS FOLIC ACID REPLESTA NX 3 COMBINATIONS REVESTA 3 ENLYTE 3 ROCALTROL 3 FABB 1 SUPER DAILY D3 FOLBEE 3 ORAL DROPS 25 3 FOLBIC 3 MCG/DROP ( 1000 FOLPLEX 2.2 1 UNIT/DROP) NIVA-FOL 3 THERA-D 1 RESTORA RX 3 THERA-D 4000 3 VIRT-GARD 1 VITAL-D RX 3 VIRT-VITE 3 VITAMIN D3 ORAL CAPSULE 25 MCG 1 VITA-RESPA 3 (1,000 UNIT) WESTAB ONE 1 VITAMIN D3 ORAL VITAMINS - K, TABLET 25 MCG 1 PHYTONADIONE (1,000 UNIT) AND ZAVARA 3 DERIVATIVES VITAMINS - E MEPHYTON 3 vitamin e oral capsule phytonadione (vitamin 1 3 100 unit, 600 unit k1) injection solution VITAMINS - phytonadione (vitamin 1 FOLIC ACID AND k1) injection syringe DERIVATIVES phytonadione (vitamin 3 DENOVO 3 k1) oral tablet 100 mcg phytonadione (vitamin DEPLIN (ALGAL OIL) 3 1 k1) oral tablet 5 mg ELFOLATE 3 VITAMIN K 4 FA-8 1 VITAMIN K1 folic acid injection 2 PA 4 INJECTION folic acid oral capsule 1 vitamin k2 3 0.8 mg folic acid oral capsule 3 20 mg

You can find information on what the symbols and abbreviationson this table mean on page 4. 178 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VITAMINS - GLUCAGON PABA EMERGENCY KIT 1 (HUMAN) POTABA ORAL 3 CAPSULE glucagon hcl 4 ENDOCRINE GLUTOSE-45 1 GVOKE PFS 1-PACK ABORTIFACIENT SYRINGE S OR CERVICAL SUBCUTANEOUS 3 RIPENING SYRINGE 0.5 MG/0.1 AGENTS - ML PROSTAGLANDI PROGLYCEM 3 N ANALOGS SUGARUP 3 CERVIDIL 3 AMYLOIDOSIS PREPIDIL 3 AGENTS- PROSTIN E2 3 TRANSTHYRETI ABORTIFACIENT N (TTR) S- STABILIZER PROGESTERONE VYNDAQEL 3 RECEPTOR AMYLOIDOSIS ANTAGONIST AGENTS-TTR MIFEPREX 3 SUPPRESSION, mifepristone 1 ANTISENSE OLIGONUCLEOT ADRENOCORTIC IDE-BASED OTROPHIC HORMONES TEGSEDI 2 PA ACTHAR 2 PA AMYLOIDOSIS corticotropin (bulk) 3 AGENTS-TTR SUPPRESSION, AGENTS TO RNA TREAT INTERFERING HYPOGLYCEMIA (RNAI) BASED (HYPERGLYCEM ICS) ONPATTRO 4 DEX4 GLUCOSE BITS 1 ANABOLIC STEROID - DEX4 GLUCOSE 1 POUCH PACK SINGLE AGENTS DEX4 GLUCOSE ANADROL-50 2 PA 1 QUICK DISSOLVE OXANDRIN 3 GLUCAGEN oxandrolone 2 PA 1 HYPOKIT GLUCAGON (HCL) 3 EMERGENCY KIT You can find information on what the symbols and abbreviationson this table mean on page 4. 179 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANDROGEN - testosterone transdermal SINGLE AGENTS gel in metered-dose pump 10 mg/0.5 gram 3 PA ANDRODERM 2 PA /actuation, 20.25 ANDROGEL mg/1.25 gram (1.62 %) TRANSDERMAL GEL testosterone transdermal IN METERED-DOSE 3 gel in metered-dose 2 PA PUMP 20.25 MG/1.25 pump 12.5 mg/ 1.25 GRAM (1.62 %) gram (1 %) ANDROGEL testosterone transdermal TRANSDERMAL GEL 3 gel in packet 1 % (25 2 PA IN PACKET mg/2.5gram), 1 % (50 ANDROID 3 mg/5 gram) AVEED 3 testosterone transdermal DEPO- gel in packet 1.62 % 3 PA TESTOSTERONE (20.25 mg/1.25 gram), 3 PA 1.62 % (40.5 mg/2.5 FORTESTA 3 gram) METHITEST 3 PA TESTRED 3 methyltestosterone 3 VOGELXO 3 (bulk) XYOSTED 3 PA methyltestosterone oral 3 PA capsule ANTIDIURETIC methyltestosterone,micr AND 3 o(bulk) VASOPRESSOR NATESTO 3 HORMONES TESTIM 3 DDAVP ORAL 3 PA desmopressin acetate TESTONE CIK 4 3 (bulk) TESTOPEL 4 desmopressin injection 4 testosterone (bulk) 3 desmopressin nasal testosterone cypionate 1 3 spray with pump (bulk) desmopressin nasal 1 testosterone cypionate spray,non-aerosol intramuscular oil 100 2 PA mg/ml, 200 mg/ml desmopressin oral 1 testosterone enanthate 2 PA NOCDURNA (MEN) 3 testosterone propionate NOCDURNA 3 3 (bulk) (WOMEN) testosterone transdermal NOCTIVA 3 2 PA gel vasopressin in 0.9 % sod chlor intravenous 4 solution 20 unit/100 ml (0.2 unit/ml) VASOSTRICT 4 You can find information on what the symbols and abbreviationson this table mean on page 4. 180 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY ANTIHYPERGLY CEMIC - ALPHA- CEMIC - GLUCOSIDASE MEGLITINIDE INHIBITORS ANALOGS acarbose 1 nateglinide 1 GLYSET 1 PRANDIN ORAL 3 miglitol 3 TABLET 1 MG, 2 MG PRECOSE 3 repaglinide 1 ANTIHYPERGLY STARLIX 3 CEMIC - ANTIHYPERGLY DIPEPTIDYL CEMIC - SGLT-2 PEPTIDASE-4 INHIBITOR AND (DPP-4) BIGUANIDE INHIBITORS COMBINATIONS alogliptin 3 INVOKAMET 1 JANUVIA 1 SEGLUROMET 3 NESINA 3 SYNJARDY 3 ONGLYZA 3 SYNJARDY XR 3 TRADJENTA 1 XIGDUO XR 1 ANTIHYPERGLY ANTIHYPERGLY CEMIC - CEMIC - SGLT-2 DOPAMINE INHIBITOR AND RECEPTOR DPP-4 AGONISTS INHIBITOR CYCLOSET 3 COMBINATIONS ANTIHYPERGLY GLYXAMBI 3 CEMIC - QTERN 3 GLUCOCORTICO STEGLUJAN 3 ID (CORTISOL) ANTIHYPERGLY RECEPTOR CEMIC - SODIUM BLOCKER (GR- GLUCOSE II) COTRANSPORTE KORLYM 1 R-2 (SGLT2) ANTIHYPERGLY INHIBITORS CEMIC - FARXIGA 1 MEGLITINIDE INVOKANA 1 ANALOG AND JARDIANCE 1 BIGUANIDE STEGLATRO 3 COMBINATIONS repaglinide-metformin 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 181 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY ANTIHYPERGLY CEMIC - CEMIC, AMYLIN SULFONYLUREA ANALOG-TYPE AND BIGUANIDE SYMLINPEN 120 2 PA COMBINATIONS SYMLINPEN 60 2 PA glipizide-metformin 1 ANTIHYPERGLY glyburide-metformin 1 CEMIC, ANTIHYPERGLY INCRETIN CEMIC - MIMETIC,GLP-1 SULFONYLUREA RECEPTOR DERIVATIVES AGONIST AMARYL 3 ANALOG-TYPE glimepiride 1 ADLYXIN 3 glipizide 1 BYDUREON BCISE 3 PA glipizide (bulk) 3 BYDUREON SUBCUTANEOUS 1 GLUCOTROL 3 PEN INJECTOR GLUCOTROL XL 3 BYETTA glyburide 1 SUBCUTANEOUS QL (2.4 ML PEN INJECTOR 10 1 glyburide micronized 1 per 30 days) MCG/DOSE(250 GLYNASE 3 MCG/ML) 2.4 ML ANTIHYPERGLY BYETTA CEMIC - SUBCUTANEOUS QL (1.2 ML THIAZOLIDINED PEN INJECTOR 5 1 per 30 days) IONE AND MCG/DOSE (250 BIGUANIDE MCG/ML) 1.2 ML COMBINATIONS OZEMPIC 3 ACTOPLUS MET 3 TRULICITY SUBCUTANEOUS pioglitazone-metformin 1 PEN INJECTOR 0.75 3 ANTIHYPERGLY MG/0.5 ML, 1.5 CEMIC - MG/0.5 ML THIAZOLIDINED QL (6 ML per VICTOZA 2-PAK 1 IONE AND 30 days) SULFONYLUREA QL (9 ML per VICTOZA 3-PAK 1 COMBINATIONS 30 days) DUETACT 3 pioglitazone-glimepiride 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 182 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY ANTITHYROID CEMIC- AGENTS, DIPEPTIDYL THIONAMIDES - PEPTIDASE-4 THIOURACIL INHIBIT AND DERIVATIVES THIAZOLIDINED propylthiouracil 1 IONE BONE alogliptin-pioglitazone 2 PA FORMATION OSENI 3 AGENTS - ANTIHYPERGLY SCLEROSTIN CEMIC- INHIBITOR, DIPEPTIDYL MONOCLONAL PEPTIDASE- ANTIBODY 4(DPP- EVENITY 3 4)INHIBITOR BONE AND BIGUANIDE FORMATION alogliptin-metformin 3 STIMULATING JANUMET 1 AGENTS - JANUMET XR 1 PARATHYROID JENTADUETO 1 HORMONE REL PEPTIDES JENTADUETO XR 1 TYMLOS 3 PA KAZANO 3 KOMBIGLYZE XR 3 BONE FORMATION ANTIHYPERGLY STIMULATING CEMIC-INSULIN, AGENTS - LONG ACTING PARATHYROID AND GLP-1 HORMONE-TYPE RECEPTOR AGONIST COMB FORTEO 2 PA teriparatide 2 SOLIQUA 100/33 3 XULTOPHY 100/3.6 3 BONE RESORPTION ANTITHYROID INHIBITORS - AGENTS, BISPHOSPHONA THIONAMIDES - TE AND IMIDAZOLE VITAMIN D DERIVATIVES COMBINATIONS methimazole oral tablet 1 FOSAMAX PLUS D 3 10 mg, 5 mg TAPAZOLE 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 183 Drug Name Drug Tier Limits Drug Name Drug Tier Limits zoledronic ac-mannitol- BONE 4 PA RESORPTION 0.9nacl INHIBITORS - CALCIMIMETIC, BISPHOSPHONA PARATHYROID TES CALCIUM ACTONEL ORAL RECEPTOR TABLET 150 MG, 35 3 SENSITIVITY MG, 5 MG ENHANCER alendronate oral 1 cinacalcet 2 PA solution SENSIPAR 3 PA alendronate oral tablet 1 10 mg CALCITONINS alendronate oral tablet QL (5 EA per calcitonin (salmon) 1 2 35 mg 23 days) MIACALCIN 4 PA alendronate oral tablet 5 QL (30 EA per INJECTION 2 mg, 70 mg 23 days) ESTROGEN AND ATELVIA 3 PROGESTIN BINOSTO 3 WITH BONIVA ANTIMINERALO 4 PA INTRAVENOUS CORTICOID BONIVA ORAL 3 ACTIVITY,COMB INATION etidronate disodium oral 3 PA tablet 200 mg ANGELIQ 1 FOSAMAX ORAL QL (5 EA per ESTROGEN AND 3 TABLET 70 MG 23 days) SELECTIVE ibandronate intravenous ESTROGEN 4 solution RECEPTOR ibandronate intravenous MODULATOR 4 PA syringe (SERM) ibandronate oral 1 ST COMBINATIONS pamidronate 4 DUAVEE 2 PA RECLAST 4 PA ESTROGEN- risedronate oral tablet ANDROGEN 3 PA 150 mg, 30 mg, 5 mg COVARYX 3 risedronate oral tablet 3 COVARYX H.S. 3 35 mg EEMT 3 risedronate oral tablet,delayed release 3 EEMT HS 3 (dr/ec) estrogens- 1 zoledronic acid 4 PA methyltestosterone zoledronic acid- 4 PA mannitol-water You can find information on what the symbols and abbreviationson this table mean on page 4. 184 Drug Name Drug Tier Limits Drug Name Drug Tier Limits estradiol cypionate ESTROGEN- 3 PROGESTIN (bulk) ACTIVELLA ORAL estradiol hemihydrate 3 3 TABLET 1-0.5 MG (bulk) AMABELZ 1 estradiol oral 1 BIJUVA 3 estradiol transdermal patch semiweekly 0.025 QL (10 EA per CLIMARA PRO 1 mg/24 hr, 0.05 mg/24 1 23 days) COMBIPATCH 1 hr, 0.075 mg/24 hr, 0.1 estradiol-norethindrone mg/24 hr 1 acet estradiol transdermal FEMHRT LOW DOSE 3 PA patch semiweekly 1 0.0375 mg/24 hr FYAVOLV 1 estradiol transdermal JINTELI 1 patch weekly 0.025 LOPREEZA ORAL mg/24 hr, 0.0375 mg/24 1 1 TABLET 1-0.5 MG hr, 0.06 mg/24 hr, 0.075 MIMVEY 1 mg/24 hr estradiol transdermal norethindrone ac-eth QL (5 EA per estradiol oral tablet 0.5- patch weekly 0.05 1 1 23 days) 2.5 mg-mcg, 1-5 mg- mg/24 hr, 0.1 mg/24 hr mcg estradiol valerate (bulk) 3 PREFEST 3 estriol (bulk) 3 PREMPHASE 1 estriol micronized 3 PREMPRO 1 (bulk) ESTROGENS ESTROGEL 3 estrone (bulk) crystals 1 QL (10 EA per ALORA 3 23 days) estrone (bulk) powder 3 CLIMARA 3 ethinyl estradiol (bulk) 3 DELESTROGEN 4 PA EVAMIST 3 DEPO-ESTRADIOL 1 MENEST ORAL TABLET 0.3 MG, 1 DIVIGEL 0.625 MG, 1.25 MG TRANSDERMAL GEL IN PACKET 0.25 MENOSTAR 3 MG/0.25 GRAM (0.1 3 MINIVELLE %), 0.5 MG/0.5 GRAM TRANSDERMAL QL (10 EA per (0.1 %), 0.75 MG/0.75 PATCH 3 23 days) GRAM (0.1%), 1 SEMIWEEKLY 0.025 MG/GRAM (0.1 %) MG/24 HR DOTTI 1 ELESTRIN 3 ESTRACE ORAL 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 185 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MINIVELLE GLUCOCORTICO TRANSDERMAL IDS PATCH SEMIWEEKLY 0.0375 A-HYDROCORT 4 3 MG/24 HR, 0.05 ARISTOSPAN INTRA- 4 MG/24 HR, 0.075 ARTICULAR MG/24 HR, 0.1 MG/24 ARISTOSPAN 4 HR INTRALESIONAL PREMARIN beclomethasone diprop 4 PA 3 INJECTION (bulk) PREMARIN ORAL 1 betamethasone sod phos 3 VIVELLE-DOT 3 (bulk) betamethasone sod FERTILITY 4 ENHANCER - phosph-water betamethasone valerate LUTEAL PHASE 3 SUPPORTING, (bulk) budesonide, micronized PROGESTERONE 3 -TYPE (bulk) CRINONE VAGINAL CORTEF 3 3 GEL 8 % cortisone 1 FERTILITY cortisone (bulk) 3 ENHANCER - DECADRON ORAL 1 OVULATION TABLET STIMULANT - DEPO-MEDROL INJECTION SYNTHETIC 2 PA (NON-FSH) SUSPENSION 20 MG/ML clomiphene citrate 3 (bulk) DEPO-MEDROL INJECTION 3 PA GLUCOCORTICO SUSPENSION 40 ID SALT MG/ML, 80 MG/ML COMBINATIONS desoximetasone, micro 3 betamethasone acet,sod (bulk) 4 phos dexamethasone ac, 3 CELESTONE micro (bulk) 3 PA SOLUSPAN dexamethasone acetate 3 POD-CARE 100C 4 (bulk) DEXAMETHASONE POD-CARE 100CG 4 1 INTENSOL GLUCOCORTICO dexamethasone oral ID-ANESTHETIC 1 elixir COMBINATIONS dexamethasone oral triamcinol ace-bupiv- 2 PA 4 solution 0.9% nacl You can find information on what the symbols and abbreviationson this table mean on page 4. 186 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dexamethasone oral KENALOG tablet 0.5 mg, 0.75 mg, INJECTION 1 3 PA 1 mg, 1.5 mg, 2 mg, 4 SUSPENSION 40 mg MG/ML dexamethasone oral KENALOG-80 3 4 tablet 6 mg MAS CARE-PAK (PF) 4 dexamethasone oral 1 MEDROL 3 tablets,dose pack MEDROL (PAK) 3 dexamethasone sod 3 methylprednisolon phos (bulk) 3 ac,mic(bulk) dexamethasone sodium phos (pf) injection 2 PA methylprednisolone 1 solution methylprednisolone 1 dexamethasone sodium acetate phos (pf) injection 4 methylprednisolone syringe sodium succ injection 1 dexamethasone sodium recon soln 125 mg, 40 phosphate injection 1 PA mg solution 10 mg/ml methylprednisolone dexamethasone sodium sodium succ intravenous 1 phosphate injection 2 PA recon soln 1,000 mg solution 4 mg/ml methylprednisolone, 3 dexamethasone sodium mic (bulk) phosphate injection 2 PA MILLIPRED DP 3 syringe MILLIPRED ORAL 3 dexamethasone,microni TABLET 3 zed(bulk) ORAPRED ODT 3 DXEVO 3 POD-CARE 100K 4 EMFLAZA 3 POD-CARE 100KG 4 fluocinolone acetonide 3 prednisolone (bulk) 3 (bulk) prednisolone ac, micro fluocinonide, 3 3 (bulk) micronized(bulk) prednisolone oral 1 HIDEX 3 solution 15 mg/5 ml hydrocortisone (bulk) 3 prednisolone sod phos 3 hydrocortisone acetate (bulk) 3 (bulk) prednisolone sodium hydrocortisone oral 1 phosphate oral solution KENALOG 10 mg/5 ml, 15 mg/5 ml INJECTION (3 mg/ml), 20 mg/5 ml 1 2 PA SUSPENSION 10 (4 mg/ml), 25 mg/5 ml MG/ML (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

You can find information on what the symbols and abbreviationson this table mean on page 4. 187 Drug Name Drug Tier Limits Drug Name Drug Tier Limits prednisolone sodium triamcinolone acetonide phosphate oral 1 injection suspension 10 2 PA tablet,disintegrating mg/ml prednisolone, micro triamcinolone acetonide 3 (bulk) injection suspension 40 1 prednisone 1 mg/ml triamcinolone diacetate prednisone (bulk) 3 3 (bulk) PREDNISONE 1 INTENSOL VERIPRED 20 3 prednisone micronized ZILRETTA 4 PA 3 (bulk) GONADOTROPIN RAYOS 3 INHIBITOR SOLU-CORTEF 1 PITUITARY SOLU-CORTEF ACT- SUPPRESSANTS O-VIAL (PF) danazol 1 INJECTION RECON 2 PA GROWTH SOLN 1,000 MG/8 ML, 250 MG/2 ML, 500 HORMONE MG/4 ML RECEPTOR SOLU-CORTEF ACT- ANTAGONISTS O-VIAL (PF) SOMAVERT 1 INJECTION RECON SUBCUTANEOUS 1 SOLN 100 MG/2 ML RECON SOLN 15 MG, SOLU-MEDROL (PF) 3 PA 20 MG, 25 MG, 30 MG SOLU-MEDROL GROWTH INTRAVENOUS HORMONE 3 PA RECON SOLN 1,000 RELEASING MG, 500 MG HORMONES SOLU-MEDROL (GHRH) INTRAVENOUS 4 PA EGRIFTA SV 2 PA RECON SOLN 2 GRAM GROWTH TAPERDEX ORAL HORMONES TABLETS,DOSE GENOTROPIN 4 PA PACK 1.5 MG (21 1 GENOTROPIN TABS), 1.5 MG (49 4 PA MINIQUICK TABS) HUMATROPE 4 PA TAPERDEX ORAL TABLETS,DOSE NORDITROPIN 3 2 PA PACK 1.5 MG (27 FLEXPRO TABS) NUTROPIN AQ 3 triamcinolone (bulk) 3 NUSPIN triamcinolone acetonide OMNITROPE 3 3 (bulk) SAIZEN 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 188 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SAIZEN SAIZENPREP 3 HUMAN SEROSTIM INSULINS - SUBCUTANEOUS 4 PA SHORT ACTING RECON SOLN 4 MG, 5 AFREZZA MG, 6 MG INHALATION ZOMACTON 3 CARTRIDGE WITH INHALER 12 UNIT, 4 ZORBTIVE 4 PA 3 UNIT, 4 UNIT (90)/ 8 HUMAN UNIT (90), 4 UNIT/8 CHORIONIC UNIT/ 12 UNIT (60), 8 GONADOTROPIN UNIT (HCG) HUMULIN R U-500 QL (60 ML per 2 chorionic gonadotropin, (CONC) INSULIN 23 days) human injection recon HUMULIN R U-500 QL (60 ML per 4 2 soln 12,000 unit, 6,000 (CONC) KWIKPEN 23 days) unit INSULIN NOVAREL ANALOGS - INTRAMUSCULAR 3 RECON SOLN 10,000 FIXED UNIT COMBINATIONS HUMALOG MIX 50-50 QL (60 ML per OVIDREL 3 2 INSULN U-100 23 days) PREGNYL 3 HUMALOG MIX 50-50 QL (60 ML per 2 HUMAN KWIKPEN 23 days) INSULINS - HUMALOG MIX 75-25 QL (60 ML per 2 RAPID ACTING KWIKPEN 23 days) AFREZZA HUMALOG MIX 75- QL (60 ML per 2 INHALATION 25(U-100)INSULN 23 days) CARTRIDGE WITH INHALER 12 UNIT, 4 insulin lispro protamin- 3 3 UNIT, 4 UNIT (90)/ 8 lispro UNIT (90), 4 UNIT/8 NOVOLOG MIX 70-30 QL (60 ML per 2 UNIT/ 12 UNIT (60), 8 U-100 INSULN 23 days) UNIT NOVOLOG MIX 70- QL (60 ML per 2 AFREZZA 30FLEXPEN U-100 23 days) INHALATION INSULIN CARTRIDGE WITH 3 PA INHALER 8 UNIT ANALOGS - (90)/ 12 UNIT (90) LONG ACTING BASAGLAR QL (60 ML per KWIKPEN U-100 3 23 days) INSULIN LANTUS SOLOSTAR QL (60 ML per 1 U-100 INSULIN 23 days) LANTUS U-100 QL (60 ML per 2 INSULIN 23 days) You can find information on what the symbols and abbreviationson this table mean on page 4. 189 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LEVEMIR NOVOLOG U-100 QL (60 ML per QL (60 ML per 2 FLEXTOUCH U-100 2 INSULIN ASPART 23 days) 30 days) INSULN INSULIN LEVEMIR U-100 QL (60 ML per 2 RESPONSE INSULIN 23 days) ENHANCERS - TOUJEO MAX U-300 3 BIGUANIDES SOLOSTAR FORTAMET 3 TOUJEO SOLOSTAR QL (60 ML per 3 U-300 INSULIN 22 days) GLUCOPHAGE 3 TRESIBA GLUCOPHAGE XR 3 3 FLEXTOUCH U-100 GLUMETZA 3 TRESIBA metformin oral solution 3 3 FLEXTOUCH U-200 metformin oral tablet 1 TRESIBA U-100 metformin oral tablet 3 1 INSULIN extended release 24 hr INSULIN metformin oral tablet 3 PA ANALOGS - extended release 24hr RAPID ACTING metformin oral tablet,er 3 ADMELOG gast.retention 24 hr SOLOSTAR U-100 3 PA RIOMET 3 INSULIN INSULIN ADMELOG U-100 3 PA RESPONSE INSULIN LISPRO ENHANCERS - APIDRA SOLOSTAR QL (60 ML per 3 THIAZOLIDINED U-100 INSULIN 22 days) IONES (PPAR- APIDRA U-100 QL (60 ML per 3 GAMMA INSULIN 22 days) AGONISTS) FIASP FLEXTOUCH 3 ACTOS ORAL U-100 INSULIN 3 TABLET 15 MG FIASP U-100 INSULIN 3 ACTOS ORAL QL (30 EA per HUMALOG JUNIOR QL (60 ML per TABLET 30 MG, 45 3 2 23 days) KWIKPEN U-100 23 days) MG HUMALOG QL (60 ML per AVANDIA ORAL 2 3 KWIKPEN INSULIN 23 days) TABLET 2 MG, 4 MG HUMALOG U-100 QL (60 ML per pioglitazone oral tablet 2 1 ST INSULIN 23 days) 15 mg insulin lispro 3 pioglitazone oral tablet ST; QL (30 EA 1 NOVOLOG FLEXPEN QL (60 ML per 30 mg, 45 mg per 23 days) 2 U-100 INSULIN 23 days) NOVOLOG PENFILL QL (60 ML per 2 U-100 INSULIN 23 days)

You can find information on what the symbols and abbreviationson this table mean on page 4. 190 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INSULIN-LIKE SYNAREL 1 GROWTH LHRH (GNRH) FACTOR-1 (IGF- ANTAGONISTS 1) CETROTIDE INCRELEX 2 SUBCUTANEOUS KIT 3 LHRH (GNRH) 0.25 MG AGONIST ganirelix 3 ANALOG PIT ORILISSA 2 PA SUPPRES - MENOPAUSAL CENTRAL SYMPTOMS PRECOCIOUS SUPPRESSANT- PUBERTY SSRI LUPRON DEPOT-PED 4 PA ANTIDEPRESSAN LUPRON DEPOT-PED T TYPE 4 PA (3 MONTH) BRISDELLE 3 LA SUPPRELIN LA 4 PA MENOPAUSAL TRIPTODUR 4 PA SYMPTOMS LHRH (GNRH) SUPRESSANT - AGONIST HORMONAL ANALOG AGENTS PITUITARY IMVEXXY SUPP. AND MAINTENANCE 3 PROGESTIN PACK IMVEXXY STARTER COMB. 3 PACK LUPANETA PACK (1 2 PA MONTH) MINERALOCORT LUPANETA PACK (3 ICOIDS 2 PA MONTH) fludrocortisone 1 LHRH (GNRH) OXYTOCIC - AGONIST ERGOT ANALOG ALKALOIDS PITUITARY METHERGINE 1 SUPPRESSANTS methylergonovine 4 LUPRON DEPOT (3 injection MONTH) INTRAMUSCULAR 4 PA OXYTOCIC - SYRINGE KIT 11.25 OXYTOCIN AND MG ANALOGS LUPRON DEPOT oxytocin (bulk) 3 INTRAMUSCULAR 4 PA SYRINGE KIT 3.75 MG You can find information on what the symbols and abbreviationson this table mean on page 4. 191 Drug Name Drug Tier Limits Drug Name Drug Tier Limits oxytocin in 0.9 % sod RENIN- chloride intravenous ANGIOTENSIN- solution 10 unit/500 ml, ALDOSTERONE 15 unit/250 ml, 20 4 unit/1000 ml, 30 SYSTEM (RAAS) unit/500 ml, 40 HORMONES unit/1000 ml GIAPREZA 4 oxytocin injection 4 SELECTIVE solution ESTROGEN PARATHYROID RECEPTOR HORMONES MODULATORS NATPARA 4 (SERMS) PROGESTINS EVISTA 3 PA AYGESTIN 3 raloxifene 1 hydroxyprogesterone SOMATOSTATIC 3 capr(bulk) AGENTS medroxyprogesterone 1 octreotide acetate 4 oral SANDOSTATIN norethindrone acetate 1 INJECTION SOLUTION 100 progesterone 1 4 MCG/ML, 50 progesterone micronized 1 MCG/ML, 500 PROMETRIUM 3 MCG/ML PROVERA 3 SANDOSTATIN LAR PROLACTIN DEPOT INHIBITOR - INTRAMUSCULAR 3 SUSPENSION,EXTEN ERGOT DED REL RECON DERIVATIVE SIGNIFOR 3 DOPAMINE SOMATULINE RECEPTOR 3 DEPOT AGONISTS THYROID cabergoline 1 HORMONE RANK LIGAND COMBINATIONS (RANKL) - SYNTHETIC T3 INHIBITOR, MC AND T4 ANTIBODY THYROLAR-1 3 PROLIA 4 PA THYROLAR-1/2 3 XGEVA 4 PA THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 192 Drug Name Drug Tier Limits Drug Name Drug Tier Limits THYROID LEVOXYL ORAL HORMONES - TABLET 100 MCG, ANIMAL 112 MCG, 125 MCG, 137 MCG, 150 MCG, 1 SOURCE 175 MCG, 200 MCG, (PORCINE) 25 MCG, 50 MCG, 75 ARMOUR THYROID 3 MCG, 88 MCG PCCA T4 SODIUM NP THYROID ORAL 3 TABLET 15 MG, 30 3 DILUTION MG, 60 MG, 90 MG SYNTHROID 3 thyroid, pork (bulk) 3 TIROSINT ORAL powder 100 % usp CAPSULE 100 MCG, WESTHROID ORAL 112 MCG, 125 MCG, TABLET 130 MG, 195 13 MCG, 137 MCG, 3 3 MG, 32.5 MG, 65 MG, 150 MCG, 25 MCG, 50 97.5 MG MCG, 75 MCG, 88 MCG THYROID HORMONES - TIROSINT ORAL CAPSULE 175 MCG, 3 PA SYNTHETIC T3 200 MCG (TRIIODOTHYRO TIROSINT-SOL 3 NINE) UNITHROID 1 CYTOMEL 3 ENZYMES liothyronine (bulk) 3 powder 1 mg/gram ENZYMES liothyronine intravenous 4 AMPHADASE 4 liothyronine oral 1 carica papaya oral 1 TRIOSTAT 4 tablet,chewable THYROID HYLENEX 4 HYQVIA HY HORMONES - 3 SYNTHETIC T4 COMPONENT (THYROXINE) VITRASE 4 EUTHYROX 1 FDB CLASS LEVO-T 1 OBSOLETE- levothyroxine (bulk) 3 NOT USED levothyroxine ARGININE 4 intravenous VASOPRESSIN levothyroxine oral 1 (AVP) V2 RECEPTOR ANTAGONIST, SELECTIVE JYNARQUE ORAL 2 PA TABLET

You can find information on what the symbols and abbreviationson this table mean on page 4. 193 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SAMSCA 2 ANTIEMETIC - GASTROINTEST ANTIHISTAMINE INAL THERAPY S AGENTS ANTIVERT ORAL TABLET 12.5 MG, 25 3 ANTIDIARRHEA MG L - dimenhydrinate 3 ANTIPERISTALT injection solution IC AGENTS ANTIEMETIC - loperamide (bulk) 3 ANTIHISTAMINE opium tincture 3 -VITAMIN ANTIDIARRHEA COMBINATIONS L - BISMUTH BONJESTA 3 AGENTS DICLEGIS 3 PA bismuth citrate (bulk) 3 doxylamine-pyridoxine 3 ANTIDIARRHEA (vit b6) L ANTIEMETIC - ANTIPERISTALT CANNABINOID IC- TYPE ANTICHOLINER CESAMET 2 PA GIC dronabinol oral capsule 3 COMBINATIONS 10 mg diphenoxylate-atropine 1 dronabinol oral capsule 3 PA LOMOTIL 3 2.5 mg, 5 mg MOTOFEN 3 SYNDROS 3 ANTIDIARRHEA ANTIEMETIC - L DOPAMINE MISCELLANEOU (D2)/5-HT3 S ANTAGONISTS COMBINATIONS TIGAN 3 BANATROL PLUS 3 INTRAMUSCULAR TIGAN ORAL ANTIDIARRHEA 3 L OPIOID CAPSULE 300 MG AGENTS trimethobenzamide oral 1 opium tincture 3 ANTIEMETIC - OTHER ANTIEMETIC - ANTICHOLINER cola (syrup) 1 GICS QL (12 EA per TRANSDERM-SCOP 3 30 days)

You can find information on what the symbols and abbreviationson this table mean on page 4. 194 Drug Name Drug Tier Limits Drug Name Drug Tier Limits QL (6 EA per ANTIEMETIC - granisetron hcl oral 1 PHENOTHIAZIN 23 days) ES ondansetron 1 COMPAZINE ORAL 3 LA ondansetron hcl 1 COMPAZINE ondansetron hcl (pf) 1 3 RECTAL palonosetron 4 COMPRO 1 LA SANCUSO 3 PA PHENERGAN SUSTOL 3 INJECTION 3 ZOFRAN ORAL SOLUTION 25 MG/ML 3 TABLET PHENERGAN ZUPLENZ 3 INJECTION 1 SOLUTION 50 MG/ML ANTIEMETIC - prochlorperazine 1 LA SUBSTANCE P- prochlorperazine NEUROKININ 1 2 PA; LA edisylate (NK1) RECEPTOR prochlorperazine ANTAGONISTS maleate oral tablet 10 1 LA aprepitant 1 mg CINVANTI 4 PA prochlorperazine EMEND 2 LA 4 maleate oral tablet 5 mg (FOSAPREPITANT) promethazine (bulk) 3 EMEND ORAL promethazine injection CAPSULE 40 MG, 80 3 PA 3 solution 25 mg/ml MG promethazine injection EMEND ORAL 1 solution 50 mg/ml CAPSULE,DOSE 3 PA promethazine oral tablet 1 PACK promethazine rectal EMEND ORAL suppository 12.5 mg, 25 1 SUSPENSION FOR 3 PA mg RECONSTITUTION promethazine rectal fosaprepitant 4 3 suppository 50 mg VARUBI 4 PROMETHEGAN 1 INTRAVENOUS ANTIEMETIC - VARUBI ORAL 3 PA SELECTIVE SEROTONIN 5- HT3 ANTAGONISTS ALOXI 4 granisetron (pf) 1 granisetron hcl 1 intravenous You can find information on what the symbols and abbreviationson this table mean on page 4. 195 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIEMETIC - PANCREAZE ORAL SUBSTANCE P- CAPSULE,DELAYED NEUROKININ 1 RELEASE(DR/EC) 10,500-35,500- 61,500 AND 5-HT3 UNIT, 16,800-56,800- 3 RECEPT 98,400 UNIT, 2,600- ANTAGONIST 6,200- 10,850 UNIT, COMB 21,000-54,700- 83,900 UNIT, 4,200-14,200- AKYNZEO 24,600 UNIT (FOSNETUPITANT) 2 PA INTRAVENOUS PERTZYE 3 RECON SOLN VIOKACE 3 AKYNZEO 3 PA ZENPEP ORAL (NETUPITANT) CAPSULE,DELAYED BILE ACIDS RELEASE(DR/EC) 10,000-32,000 -42,000 CHOLBAM 3 UNIT, 15,000-47,000 - CHRONIC 63,000 UNIT, 20,000- IDIOPATHIC 63,000- 84,000 UNIT, 1 CONST. AGENTS 25,000-79,000- 105,000 UNIT, 3,000-10,000 - - GUANYLATE 14,000-UNIT, 40,000- CYCLASE-C (GC- 126,000- 168,000 C) AGONISTS UNIT, 5,000-17,000- LINZESS 2 PA 24,000 UNIT TRULANCE 3 PA DIGESTIVE COLONIC ENZYMES ACIDIFIER DAIRY AID 1 (AMMONIA DAIRY DIGESTIVE 1 INHIBITOR) DAIRY DIGESTIVE 1 ENULOSE 1 SUPPLEMENT GENERLAC 1 DAIRY RELIEF 1 lactulose oral solution lactase 1 1 10 gram/15 ml LACTASE FAST 1 DIGESTIVE ACTING LACTOSE FAST ENZYME 1 MIXTURES ACTING RELIEF SUCRAID 1 CREON 1 ULTRA DAIRY 1 DIGESTIVE

You can find information on what the symbols and abbreviationson this table mean on page 4. 196 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GALLSTONE GASTRIC ACID SOLUBILIZING SECRETION (LITHOLYSIS) REDUCING AGENTS AGENTS - ACTIGALL 3 PROTON PUMP CHENODAL 3 INHIBITORS (PPIS) URSO 250 3 ACIPHEX 3 URSO FORTE 3 QL (60 EA per ursodiol 1 ACIPHEX SPRINKLE 3 365 days) ursodiol (bulk) 3 QL (60 EA per DEXILANT 2 GASTRIC ACID 365 days) SECRETION ESOMEP-EZS 3 REDUCERS - esomeprazole HISTAMINE H2- magnesium oral QL (60 EA per 3 RECEPTOR capsule,delayed 365 days) ANTAGONISTS release(dr/ec) 40 mg cimetidine hcl oral 1 esomeprazole sodium intravenous recon soln 2 PA cimetidine oral tablet 1 20 mg 300 mg, 800 mg esomeprazole sodium cimetidine oral tablet 3 intravenous recon soln 4 400 mg 40 mg famotidine (pf) 3 lansoprazole (bulk) 3 famotidine (pf)-nacl 3 lansoprazole oral (iso-os) QL (60 EA per capsule,delayed 2 famotidine intravenous 365 days) 3 release(dr/ec) 30 mg solution QL (60 EA per famotidine oral NEXIUM 3 1 365 days) suspension NEXIUM IV famotidine oral tablet 40 1 INTRAVENOUS 2 PA mg RECON SOLN 40 MG nizatidine oral capsule 2 PA NEXIUM PACKET 3 nizatidine oral solution 3 omeprazole (bulk) 3 PEPCID ORAL omeprazole oral 3 QL (60 EA per TABLET capsule,delayed 3 365 days) ranitidine hcl oral syrup 1 release(dr/ec) 10 mg ranitidine hcl oral tablet omeprazole oral 1 capsule,delayed QL (60 EA per 300 mg 1 release(dr/ec) 20 mg, 40 365 days) mg pantoprazole 2 PA intravenous

You can find information on what the symbols and abbreviationson this table mean on page 4. 197 Drug Name Drug Tier Limits Drug Name Drug Tier Limits pantoprazole oral QL (60 EA per GASTRIC tablet,delayed release 1 365 days) MUCOSA - (dr/ec) CYTOPROTECTI PREVACID 3 VE QL (60 EA per PREVACID SOLUTAB 3 PROSTAGLANDI 365 days) N ANALOGS PRILOSEC ORAL CYTOTEC 3 SUSP,DELAYED 3 RELEASE FOR misoprostol 1 RECON GASTROINTESTI PROTONIX NAL - 2 PA INTRAVENOUS PROKINETIC PROTONIX ORAL AGENTS - 5-HT4 GRANULES DR FOR 3 RECEPTOR SUSP IN PACKET AGONISTS PROTONIX ORAL QL (60 EA per MOTEGRITY 3 TABLET,DELAYED 3 365 days) RELEASE (DR/EC) GASTROINTESTI rabeprazole oral NAL QL (60 EA per tablet,delayed release 1 ANTIFLATULEN 365 days) (dr/ec) TS activated charcoal oral GASTRIC ACID 1 SECRETION capsule 260 mg BEANO ORAL REDUCING- 1 PROTON PUMP TABLET INHIBITOR AND GASTROINTESTI ANTACID COMB NAL omeprazole-sodium PROKINETIC QL (60 EA per bicarbonate oral capsule 3 AGENTS - D2 365 days) 40-1.1 mg-gram ANTAGONIST/5- omeprazole-sodium HT4 AGONISTS bicarbonate oral packet 3 metoclopramide hcl 3 20-1,680 mg injection ZEGERID ORAL QL (60 EA per metoclopramide hcl oral 3 1 CAPSULE 365 days) solution ZEGERID ORAL QL (60 EA per metoclopramide hcl oral 1 1 PACKET 20-1,680 MG 365 days) tablet ZEGERID ORAL metoclopramide hcl oral 3 3 PACKET 40-1,680 MG tablet,disintegrating REGLAN ORAL 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 198 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GI GI ANTISPASMODIC ANTISPASMODIC - BELLADONNA - QUATERNARY ALKALOIDS AMMONIUM ANASPAZ 3 COMPOUNDS glycopyrrolate (pf) in atropine (bulk) 3 4 water injection atropine injection 4 solution glycopyrrolate (pf) in water intravenous atropine injection 4 4 syringe 0.4 mg/2 ml (0.2 syringe 0.05 mg/ml mg/ml) belladonna tincture 1 glycopyrrolate injection 1 (bulk) glycopyrrolate oral ED-SPAZ 1 1 tablet 1 mg, 2 mg homatropine 3 GLYRX-PF 4 methylbrom (bulk) propantheline 1 hyoscyamine sulfate 3 (bulk) GI hyoscyamine sulfate ANTISPASMODIC 1 oral - SYNTHETIC hyoscyamine sulfate TERTIARY 1 sublingual AMINES HYOSYNE 1 BENTYL 3 LEVBID 3 INTRAMUSCULAR dicyclomine LEVSIN 3 1 intramuscular LEVSIN/SL 3 dicyclomine oral 1 methscopolamine 1 capsule NULEV 1 dicyclomine oral 1 OSCIMIN ORAL solution 1 TABLET dicyclomine oral tablet 1 OSCIMIN SL 1 GI OSCIMIN SR 1 ANTISPASMODIC SYMAX DUOTAB 3 AND SYMAX FASTABS 1 BENZODIAZEPIN SYMAX-SL 1 E SYMAX-SR 1 COMBINATIONS chlordiazepoxide- 3 clidinium LIBRAX (WITH 3 CLIDINIUM)

You can find information on what the symbols and abbreviationson this table mean on page 4. 199 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GI IBS AGENT - ANTISPASMODIC MIXED OPIOID AND OPIOID RECEPTOR COMBINATIONS AGONIST AND belladonna alkaloids- ANTAGONIST 3 opium VIBERZI 3 GI IBS AGENT - ANTISPASMODIC SELECTIVE 5- COMBINATIONS HT3 RECEPTOR OTHER ANTAGONISTS belladonna alkaloids- 3 alosetron 3 PA opium LOTRONEX 3 chlordiazepoxide- 3 clidinium INFLAMMATOR Y BOWEL DONNATAL ORAL ELIXIR 16.2-0.1037 - 3 AGENT - 0.0194 MG/5 ML INTERLEUKIN-12 DONNATAL ORAL AND IL-23 3 TABLET INHIBITORS, MC LIBRAX (WITH AB 3 CLIDINIUM) STELARA 4 PA PHENOHYTRO ORAL INTRAVENOUS ELIXIR 16.2-0.1037 - 3 STELARA 0.0194 MG/5 ML SUBCUTANEOUS 3 PA PHENOHYTRO ORAL SOLUTION 3 TABLET STELARA IBS AGENT - SUBCUTANEOUS 3 PA SYRINGE 90 MG/ML GASTROINTESTI NAL CHLORIDE INFLAMMATOR CHANNEL Y BOWEL ACTIVATOR AGENT - AGENTS AMINOSALICYL ATES AND AMITIZA 3 RELATED IBS AGENT - AGENTS GUANYLATE APRISO 3 CYCLASE-C (GC- C) AGONISTS ASACOL HD 1 AZULFIDINE 3 LINZESS 2 PA AZULFIDINE EN- TRULANCE 3 PA 3 TABS balsalazide 1 CANASA 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 200 Drug Name Drug Tier Limits Drug Name Drug Tier Limits COLAZAL 3 INFLAMMATOR DELZICOL ORAL Y BOWEL CAPSULE (WITH DEL 3 PA AGENT - JANUS REL TABLETS) KINASE (JAK) DIPENTUM 3 ST INHIBITORS LIALDA 1 XELJANZ ORAL 3 PA mesalamine 1 TABLET 10 MG mesalamine with XELJANZ ORAL 3 3 cleansing wipe TABLET 5 MG PENTASA 1 XELJANZ XR ORAL TABLET EXTENDED ROWASA RECTAL 3 3 RELEASE 24 HR 22 ENEMA KIT MG SFROWASA 1 INFLAMMATOR sulfasalazine 1 Y BOWEL INFLAMMATOR AGENT - TUMOR Y BOWEL NECROSIS AGENT - FACTOR ALPHA GLUCOCORTICO BLOCKERS IDS CIMZIA 3 budesonide oral 1 CIMZIA POWDER 3 CORTENEMA 3 FOR RECONST CORTIFOAM 3 CIMZIA STARTER 3 ENTOCORT EC 3 KIT PA; QL (2 EA hydrocortisone rectal 1 HUMIRA PEN 2 per 28 days) UCERIS ORAL 3 HUMIRA PEN UCERIS RECTAL 3 PA CROHNS-UC-HS 2 PA INFLAMMATOR START Y BOWEL HUMIRA PEN PSOR- 2 PA AGENT - UVEITS-ADOL HS INTEGRIN HUMIRA RECEPTOR SUBCUTANEOUS ANTAGONIST, SYRINGE KIT 10 2 PA MC ANTIBODY MG/0.2 ML, 20 MG/0.4 ML ENTYVIO 4 PA HUMIRA SUBCUTANEOUS PA; QL (2 EA 2 SYRINGE KIT 40 per 28 days) MG/0.8 ML HUMIRA(CF) 2 PA HUMIRA(CF) PEDI 2 PA CROHNS STARTER

You can find information on what the symbols and abbreviationson this table mean on page 4. 201 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HUMIRA(CF) PEN 2 PA HIGH POTENCY 3 INFLECTRA 4 PA PROBIOTIC l.acidoph,saliva-b.bif- REMICADE 4 PA 1 s.therm RENFLEXIS 4 PA LACTINEX 1 SIMPONI SUBCUTANEOUS lactobacill.acidophilus 3 PA PEN INJECTOR 100 (bulk) powder , 10 3 MG/ML billion unit/gram SIMPONI lactobacillus acidophilus SUBCUTANEOUS 3 PA oral tablet 1 billion cell, 1 SYRINGE 100 MG/ML 500 million cell lactobacillus acidoph- INTESTINAL 3 l.bulgar FLORA MOOD SUPPORT MODIFIERS 3 PROBIOTIC ACIDOPHILUS EX 1 ONE-A-DAY STR (L. SPOROG) TRUBIOTICS ORAL 3 ACIDOPHILUS 1 CAPSULE PROBIOTIC BLEND PHILLIPS' COLON 1 acidophilus-pectin, HEALTH citrus oral capsule 100 3 PROBIOTIC million cell-10 mg COMPLEX (WITH 3 acidophilus-pectin, 1 FOS) citrus oral tablet PROBIOTIC-10 (WITH 3 BACID 1 INULIN) BIOGAIA PROTECTIS 3 PRODIGEN 3 WITH VIT D3 PROVAD 3 CULTURELLE PROVELLA 1 WOMEN HEALTH 3 BALANC RESTORA RX 3 DAILY PROBIOTIC RISA-BID 1 3 (10 STRAINS) SENIOR PROBIOTIC 1 EVIVO 3 ULTIMATE FLORA 3 EVIVO STARTER KIT 3 PROBIOTIC EVIVO WITH MCT VSL#3 DS 3 3 OIL ZELAC 3 FLORAJEN3 1 IRRITABLE FLORAJEN4KIDS 1 BOWEL GERBER GENTLE SYNDROME (IBS) 3 PROBIOTIC AGENTS GERBER SOOTHE 3 alosetron 3 PA VIT D-PROBIOTIC AMITIZA 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 202 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LINZESS 2 PA NULYTELY WITH 3 LOTRONEX 3 FLAVOR PACKS VIBERZI 3 OSMOPREP 3 KERATINOCYTE peg 3350-electrolytes oral recon soln 236- 1 GROWTH 22.74-6.74 -5.86 gram FACTOR (KGF) PEG-3350 WITH 1 KEPIVANCE 4 FLAVOR PACKS LAXATIVE - peg-electrolyte soln 1 BULK FORMING PLENVU 3 BENEFIBER SUPREP BOWEL 3 3 HEALTHY SHAPE PREP KIT COLOX 1 TRILYTE WITH 1 EASY FIBER ORAL FLAVOR PACKETS 1 POWDER LAXATIVE - FIBER (DEXTRIN) 1 STIMULANT AND karaya gum (bulk) 3 SALINE/OSMOTI METAMUCIL FREE 3 C METAMUCIL PLUS COMBINATIONS 1 CALCIUM CLENPIQ 3 LAXATIVE - PEG-PREP 3 SALINE AND PREPOPIK 2 PA OSMOTIC LAXATIVE - CONSTULOSE 1 STIMULANT KRISTALOSE 1 castor oil oral oil 1 lactulose oral packet 3 SENNA ORAL SYRUP 1 lactulose oral solution 176 MG/5 ML 10 gram/15 ml, 20 1 PEPTIC ULCER - gram/30 ml GASTRIC LAXATIVE - LUMEN SALINE/OSMOTI ADHERENT C MIXTURES CYTOPROTECTI GAVILYTE-C 1 VES GAVILYTE-G 1 CARAFATE ORAL 1 GAVILYTE-N 1 SUSPENSION CARAFATE ORAL GOLYTELY 3 3 TABLET MOVIPREP 3 sucralfate 1 NULYTELY LEMON- 3 LIME sucralfate (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 203 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PEPTIC ULCER - SANDOSTATIN LAR TREATMENT OF DEPOT INTRAMUSCULAR H. PYLORI: 3 SUSPENSION,EXTEN ANTIBIOTIC- DED REL RECON 10 BISMUTH MG, 20 MG COMBINATIONS ZORBTIVE 4 PA PYLERA 1 GENITOURINA PEPTIC ULCER- RY THERAPY TREATMENT H. BPH AGENT- 5- PYLORI-PROTON ALPHA PUMP REDUCTASE INHIBITOR AND INHIB AND ANTIBIOTICS ALPHA-1 amoxicil-clarithromy- QL (112 EA 3 ADRENOCEPTOR lansopraz per 23 days) ANTAG COMB OMECLAMOX-PAK 3 dutasteride-tamsulosin 3 SHORT BOWEL JALYN 3 SYNDROME (SBS) - CYSTINOSIS GLUCAGON- THERAPY LIKE PEPTIDE-2 (CYSTINE (GLP-2) ANALOG DEPLETING AGENTS) GATTEX 30-VIAL 2 PA CYSTAGON 1 GATTEX ONE-VIAL 2 PA PROCYSBI ORAL SHORT BOWEL CAPSULE, DELAYED 3 SYNDROME REL SPRINKLE (SBS) AGENTS G.U. IRRIGANTS - ENDARI 3 ANTI-INFECTIVE octreotide acetate 4 neomycin-polymyxin b 4 SAIZEN gu SUBCUTANEOUS 3 G.U. IRRIGANTS RECON SOLN 8.8 MG acetic acid irrigation 3 SANDOSTATIN INJECTION RENACIDIN SOLUTION 100 IRRIGATION 4 MCG/ML, 50 SOLUTION 1980.6 1 MCG/ML, 500 MG-59.4 MG- MCG/ML 980.4MG/30ML sorbitol irrigation 3 sorbitol-mannitol 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 204 Drug Name Drug Tier Limits Drug Name Drug Tier Limits FOSRENOL ORAL INTERSTITIAL 3 PA CYSTITIS POWDER IN PACKET FOSRENOL ORAL AGENTS 2 PA TABLET,CHEWABLE ELMIRON 2 lanthanum 3 PA KIDNEY STONE AGENTS MAGNEBIND 300 3 MAGNEBIND 400 3 THIOLA 2 PA PHOSLYRA 1 THIOLA EC 2 PA RENAGEL ORAL 3 OVERACTIVE TABLET 800 MG BLADDER RENVELA 2 PA AGENTS - BETA - 3 ADRENERGIC sevelamer carbonate 3 PA RECEPTOR sevelamer hcl 2 PA AGONIST VELPHORO 3 MYRBETRIQ 2 PA POLYCYSTIC PHOSPHATE KIDNEY BINDERS - DISEASE - CALCIUM- VASOPRESSIN V2 BASED RECEPTOR ANTAGONISTS calcium acetate oral JYNARQUE ORAL tablet 668 mg (169 mg 3 2 PA calcium) TABLET calcium JYNARQUE ORAL 1 acetate(phosphat bind) TABLETS, SEQUENTIAL 45 MG CALPHRON 1 (AM)/ 15 MG (PM), 60 3 PHOSLYRA 1 MG (AM)/ 30 MG PHOSPHATE (PM), 90 MG (AM)/ 30 BINDERS - IRON- MG (PM) BASED SAMSCA 2 AURYXIA 3 PROSTATIC VELPHORO 3 HYPERTROPHY AGENT - ALPHA- PHOSPHATE 1- BINDERS ADRENOCEPTOR AURYXIA 3 ANTAGONISTS calcium acetate oral alfuzosin 2 PA tablet 668 mg (169 mg 3 calcium) FLOMAX 3 calcium RAPAFLO 3 1 acetate(phosphat bind) silodosin 3 PA CALPHRON 1 tamsulosin 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 205 Drug Name Drug Tier Limits Drug Name Drug Tier Limits UROXATRAL 3 URINARY PROSTATIC ACIDIFIER - HYPERTROPHY OTHERS AGENT - TYPE II ammonium chloride 4 5-ALPHA URINARY REDUCTASE ACIDIFIER - INHIBITORS PHOSPHATES finasteride oral tablet 5 1 K-PHOS NO 2 1 mg K-PHOS ORIGINAL 1 PROSCAR 3 K-PHOS-NEUTRAL 3 PROSTATIC PHOSPHA 250 1 HYPERTROPHY NEUTRAL AGENT- PHOSPHOROUS 1 SEL.CGMP PHOSPHO-TRIN 250 PHOSPHODIEST 1 NEUTRAL ERASE TYPE5 VIRT-PHOS 250 INHIBITOR 1 NEUTRAL CIALIS ORAL TABLET 2.5 MG, 5 3 URINARY MG ALKALINIZER - tadalafil oral tablet 2.5 CITRATES 2 PA mg, 5 mg CYTRA-2 3 PROSTATIC CYTRA-3 3 HYPERTROPHY cytra-k 3 AGENT-TYPE I ORACIT 1 AND II 5-ALPHA pot,sodium citrate-citric 1 REDUCTASE acid INHIBITORS potassium citrate 3 AVODART 3 potassium citrate-citric 1 dutasteride 1 acid oral solution dutasteride (bulk) 3 SHOHL'S MODIFIED 1 sodium citrate URINARY 1 ACIDIFIER - dihydrate(bulk) granules sodium citrate-citric BACTERIAL 1 UREASE acid INHIBITOR TRICITRATES 1 LITHOSTAT 2 PA UROCIT-K 10 3 UROCIT-K 15 3 UROCIT-K 5 3 VIRTRATE-2 3 VIRTRATE-3 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 206 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VIRTRATE-K 3 URINARY ANTI- URINARY INFECTIVE ANALGESICS METHENAMINE- phenazopyridine oral ANTISPAS- 1 tablet 100 mg, 200 mg ANALG PYRIDIUM 3 COMBINATIONS URINARY HYOPHEN 3 ANTIBACTERIAL PHOSPHASAL 1 - METHENAMINE URELLE 3 AND SALTS URETRON D-S ORAL HIPREX 3 TABLET 81.6-10.8- 1 40.8 MG methenamine hippurate 1 URIBEL 3 methenamine mandelate 3 URIMAR-T 3 methenamine mandelate 3 (bulk) URIN DS 1 UROQID-ACID NO.2 3 URO-MP 3 URINARY USTELL 3 ANTIBACTERIAL UTIRA-C 3 - NITROFURAN URINARY ANTI- DERIVATIVES INFECTIVE FURADANTIN 1 METHENAMINE- MACROBID 3 ANTISPASMODIC COMBINATIONS MACRODANTIN 3 methen-sod phos-meth nitrofurantoin 1 3 blue-hyos nitrofurantoin 1 UROGESIC-BLUE 3 macrocrystal URYL 3 nitrofurantoin 1 monohyd/m-cryst URINARY URINARY ANTISPASMODIC ANTIBACTERIAL - ANTICHOL., - QUINOLONES M(3) MUSCARINIC CIPRO XR 3 SELECTIVE URINARY (BLADDER) ANTIBACTERIAL darifenacin 2 PA S OTHER solifenacin 3 MONUROL 1 VESICARE 3 ZEMDRI 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 207 Drug Name Drug Tier Limits Drug Name Drug Tier Limits URINARY GELNIQUE ANTISPASMODIC TRANSDERMAL GEL 3 - IN PACKET ANTICHOLINER oxybutynin chloride 1 GICS, NON- OXYTROL 3 SELECTIVE tolterodine 3 ANASPAZ 3 TOVIAZ 3 ED-SPAZ 1 trospium 3 hyoscyamine sulfate 3 URINARY PH (bulk) MODIFIERS hyoscyamine sulfate aminobenzoic acid 1 3 oral (bulk) hyoscyamine sulfate 1 URINARY sublingual RETENTION HYOSYNE 1 THERAPY - LEVBID 3 PARASYMPATH LEVSIN ORAL 3 OMIMETIC LEVSIN/SL 3 AGENTS NULEV 1 bethanechol chloride 1 OSCIMIN ORAL bethanechol chloride 1 3 TABLET (bulk) OSCIMIN SL 1 GOUT AND OSCIMIN SR 1 HYPERURICEM SYMAX DUOTAB 3 IA THERAPY SYMAX FASTABS 1 GOUT ACUTE SYMAX-SL 1 THERAPY - SYMAX-SR 1 ANTIMITOTICS URINARY colchicine (bulk) 3 ANTISPASMODIC colchicine oral capsule 1 - SMOOTH colchicine oral tablet 3 MUSCLE COLCRYS 3 RELAXANTS GLOPERBA 3 PA DETROL 3 PA MITIGARE 3 DETROL LA 3 PA DITROPAN XL ORAL TABLET EXTENDED 3 RELEASE 24HR 10 MG, 5 MG flavoxate 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 208 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GOUT AND ANTICOAGULAN HYPERURICEMI TS - CITRATE- A - BASED ANTIMITOTIC- ACD SOLUTION A 3 URICOSURIC anticoag citrate phos 1 COMBINATIONS dextrose probenecid-colchicine 1 sodium citrate (bulk) 3 HYPERURICEMI sodium citrate in 0.9 % 4 A THERAPY - nacl URATE-OXIDASE sodium citrate intra- ENZYME-TYPE catheter syringe 4 % (3 4 ml), 4 % (5 ml) ELITEK 4 KRYSTEXXA 4 PA ANTICOAGULAN TS - COUMARIN HYPERURICEMI A THERAPY - JANTOVEN 1 URICOSURICS warfarin 1 probenecid 1 BLOOD CELL AND PLATELET HYPERURICEMI DISORDER TX- A THERAPY - SPLEEN XANTHINE TYROSINE OXIDASE KINASE INHIBITORS INHIBITORS allopurinol 1 TAVALISSE 2 PA ALOPRIM 4 C1 ESTERASE febuxostat 3 INHIBITOR ULORIC 3 ST AGENTS ZYLOPRIM 3 BERINERT 4 PA HEMATOLOGIC INTRAVENOUS KIT AL AGENTS CINRYZE 4 PA AGENTS TO HAEGARDA 2 PA TREAT ATTP- RUCONEST 4 PA ANTI VON CXCR4 WILLEBRAND CHEMOKINE FACTOR (VWF) RECEPTOR A1 DOMAIN ANTAGONISTS CABLIVI INJECTION 4 PA MOZOBIL 3 KIT DIRECT FACTOR CABLIVI INJECTION 3 PA RECON SOLN XA INHIBITORS ELIQUIS 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 209 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ELIQUIS DVT-PE ZIEXTENZO 4 1 TREAT 30D START GRANULOCYTE- SAVAYSA 3 MACROPHAGE XARELTO DVT-PE QL (51 EA per 1 COLONY- TREAT 30D START 23 days) STIMULATING XARELTO ORAL QL (30 EA per FACTOR (GM- TABLET 10 MG, 15 1 23 days) CSF) MG, 20 MG LEUKINE INJECTION XARELTO ORAL 3 1 RECON SOLN TABLET 2.5 MG HEMATORHEOL ERYTHROPOIET OGIC AGENTS INS pentoxifylline 1 ARANESP (IN POLYSORBATE) HEMOSTATIC 4 PA INJECTION SYSTEMIC - SOLUTION ANTIFIBRINOLY ARANESP (IN TIC AGENTS POLYSORBATE) 2 PA AMICAR 1 INJECTION SYRINGE aminocaproic acid 4 EPOGEN INJECTION intravenous SOLUTION 10,000 aminocaproic acid oral UNIT/ML, 2,000 1 UNIT/ML, 20,000 tablet 4 PA UNIT/2 ML, 20,000 CYKLOKAPRON 4 UNIT/ML, 3,000 LYSTEDA 3 UNIT/ML, 4,000 tranexamic acid (bulk) UNIT/ML 3 powder MIRCERA 3 PA tranexamic acid in 4 PROCRIT 3 PA nacl,iso-os RETACRIT 3 PA tranexamic acid 4 GRANULOCYTE intravenous COLONY- tranexamic acid oral 1 STIMULATING HEMOSTATIC FACTOR (G-CSF) TOPICAL FULPHILA 3 PA AGENTS GRANIX 2 PA ferric chloride (bulk) 3 NEULASTA 3 PA powder NEUPOGEN 4 PA GEL-FLOW 3 NIVESTYM GEL-FLOW NT 4 3 INJECTION MONSEL'S 1 UDENYCA 3 PA ZARXIO 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 210 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SURGIFOAM heparin (porcine) in 5 % TOPICAL SPONGE 3 dex intravenous 100 parenteral solution 20,000 unit/500 ml (40 HEPARIN FLUSH 2 PA unit/ml), 25,000 FORMULATIONS unit/250 ml(100 HEP FLUSH-10 (PF) 4 unit/ml), 25,000 heparin (porcine) in nacl unit/500 ml (50 unit/ml) 2 PA (pf) heparin (porcine) in nacl 2 PA heparin flush(porcine)- (pf) 4 0.9nacl heparin (porcine) 2 PA HEPARIN LOCK 4 injection cartridge heparin lock flush heparin (porcine) (porcine) intravenous 2 PA injection solution 1,000 1 solution unit/ml, 5,000 unit/ml heparin lock flush heparin (porcine) injection solution (porcine) intravenous 4 2 PA syringe 10 unit/ml 10,000 unit/ml, 20,000 unit/ml heparin lock flush heparin flush(porcine)- (porcine) intravenous 2 PA 4 syringe 100 unit/ml 0.9nacl HEPARIN LOCK HEPARIN LOCK 4 FLUSH heparin lock flush 4 INTRAVENOUS (porcine) intravenous 2 PA SOLUTION solution HEPARIN LOCK heparin lock flush FLUSH (porcine) intravenous 4 2 PA INTRAVENOUS syringe 10 unit/ml SYRINGE heparin lock flush HEPARIN (porcine) intravenous 2 PA LOCKFLUSH(PORCIN 4 syringe 100 unit/ml E)(PF) HEPARIN LOCK heparin, porcine (pf) FLUSH 4 intravenous solution 100 4 INTRAVENOUS unit/ml (1 ml) SOLUTION heparin, porcine (pf) HEPARIN LOCK 2 PA intravenous syringe FLUSH 2 PA HEPARINS INTRAVENOUS SYRINGE HEP FLUSH-10 (PF) 4 HEPARIN heparin (porcine) in LOCKFLUSH(PORCIN 4 0.9% nacl intravenous 1 E)(PF) parenteral solution 30,000 unit/1,000 ml

You can find information on what the symbols and abbreviationson this table mean on page 4. 211 Drug Name Drug Tier Limits Drug Name Drug Tier Limits heparin(porcine) in PLASBUMIN 5 % 4 0.45% nacl intravenous HUMAN parenteral solution 2 PA 12,500 unit/250 ml, MONOCLONAL 25,000 unit/250 ml, ANTIBODY 25,000 unit/500 ml COMPLEMENT heparin, porcine (pf) (C5) INHIBITORS 2 PA injection solution SOLIRIS 4 heparin, porcine (pf) ULTOMIRIS 4 PA injection syringe 5,000 2 PA unit/0.5 ml INDIRECT FACTOR XA heparin, porcine (pf) injection syringe 5,000 1 INHIBITORS unit/ml ARIXTRA 3 heparin, porcine (pf) fondaparinux 3 intravenous solution 100 4 LOW unit/ml (1 ml) MOLECULAR heparin, porcine (pf) 2 PA WEIGHT intravenous syringe HEPARINS heparin, porcine (pf) 2 PA QL (20 ML per subcutaneous enoxaparin 1 10 days) HUMAN FRAGMIN ALBUMIN SUBCUTANEOUS 3 ALBUKED-25 4 SOLUTION ALBUKED-5 4 FRAGMIN albumin, human 25 % 4 SUBCUTANEOUS 3 SYRINGE albumin, human 5 % 4 QL (20 ML per LOVENOX 3 ALBUMINAR 25 % 4 10 days) ALBUMINAR 5 % 4 PLASMA ALBUMINEX 4 EXPANDERS ALBURX (HUMAN) 4 HESPAN 6 % IN NS 4 25 % hetastarch 6 % in 0.9 % ALBURX (HUMAN) 5 4 4 nacl % HEXTEND 4 ALBUTEIN 25 % 4 LMD 10 % IN 0.9 % 4 ALBUTEIN 5 % 4 SODIUM CHLOR BUMINATE 25 % 4 LMD 10 % IN 5 % 4 BUMINATE 5 % 4 DEXTROSE FLEXBUMIN 25 % 4 PLASMA FLEXBUMIN 5 % 4 FRACTIONS PLASBUMIN 25 % 4 OCTAPLAS (BLOOD 4 GROUP A) You can find information on what the symbols and abbreviationson this table mean on page 4. 212 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OCTAPLAS (BLOOD 4 PLATELET GROUP AB) AGGREGATION OCTAPLAS (BLOOD 4 INHIBITORS - GROUP B) PHOSPHODIEST OCTAPLAS (BLOOD 4 ERASE III GROUP O) INHIBITORS PLASMANATE 4 cilostazol 1 PLASMA PLATELET PROTEINS AGGREGATION WHICH INHIBITORS - FACILITATE QUINAZOLINE ANTICOAGULAT AGENTS ION AGRYLIN 3 THROMBATE III 4 anagrelide 1 PLATELET PLATELET AGGREGATION AGGREGATION INHIB - INHIBITORS - CYCLOPENTYL- SALICYLATES TRIAZOLO- PYRIMIDINES DURLAZA 3 (CPTPS) PLATELET BRILINTA 1 ST AGGREGATION INHIBITORS - KENGREAL 3 THIENOPYRIDIN PLATELET E AGENTS AGGREGATION clopidogrel 1 INHIBITOR COMBINATIONS EFFIENT 3 ST PLAVIX ORAL AGGRENOX 3 3 TABLET 75 MG aspirin-dipyridamole 1 prasugrel 3 PA PLATELET PLATELET AGGREGATION AGGREGATION INHIBITORS - INHIB- GLYCOPROTEIN PDESTERASE IIB/IIIA AND ADENOSINE RECEPTOR DEAMINASE INHIB INHIBITR AGGRASTAT IN 4 dipyridamole SODIUM CHLORIDE 4 intravenous INTEGRILIN 4 dipyridamole oral 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 213 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PLATELET THROMBIN AGGREGATION INHIBITOR - INHIB- SELECTIVE PROTEASE- DIRECT AND ACTIV.RECEPTO REVERSIBLE - R-1(PAR-1) HIRUDIN TYPE ANTAGONIST bivalirudin intravenous 4 ZONTIVITY 3 recon soln bivalirudin-0.9 % PROTEIN C 4 PREPARATIONS sodium chlor CEPROTIN (BLUE THROMBIN 4 BAR) INHIBITOR - CEPROTIN (GREEN SELECTIVE 4 BAR) DIRECT AND SICKLE CELL REVERSIBLE ANEMIA argatroban 4 argatroban in 0.9 % sod AGENTS, 4 OTHERS chlor argatroban in nacl (iso- DROXIA 1 4 os) ENDARI 3 PRADAXA 1 L-GLUTAMINE 3 THROMBOLYTI SIKLOS ORAL 1 TABLET 1,000 MG C - NUCLEOTIDE TYPE SIKLOS ORAL 2 TABLET 100 MG DEFITELIO 4 SICKLE CELL THROMBOLYTI ANEMIA C - TISSUE AGENTS PLASMINOGEN DROXIA 1 ACTIVATORS ENDARI 3 ACTIVASE 4 L-GLUTAMINE 3 CATHFLO ACTIVASE 1 SIKLOS ORAL RETAVASE 1 TABLET 1,000 MG INTRAVENOUS 4 PA RECON SOLN SIKLOS ORAL 2 TABLET 100 MG TNKASE INTRAVENOUS 4 RECON SOLN

You can find information on what the symbols and abbreviationson this table mean on page 4. 214 Drug Name Drug Tier Limits Drug Name Drug Tier Limits THROMBOPOIET HISTAMINE IN RECEPTOR PREPARATIONS AGONISTS FOR DOPTELET (10 TAB 2 DESENSITIZATI PACK) ON DOPTELET (15 TAB 2 PACK) HISTAMINE PREPARATIONS MULPLETA 3 PA FOR NPLATE 4 DESENSITIZATI PROMACTA ORAL ON POWDER IN PACKET 2 PA histamine phosphate 12.5 MG 1 (bulk) crystals PROMACTA ORAL 2 HISTATROL TABLET 4 PERCUTANEOUS HEPATOBILIAR IMMUNOSUPPR Y SYSTEM ESSIVE AGENTS TREATMENT AGENTS IMMUNOSUPPRE SSIVE - AHP AGENTS - INTERFERON ALAS1 GAMMA DEGRADATION, INHIBITOR, SMALL MONOCLONAL INTERFERING ANTIBODY RNA (SIRNA) BASED GAMIFANT 4 GIVLAARI 4 IMMUNOSUPPRE SSIVE - FARNESOID X CALCINEURIN RECEPTOR INHIBITORS (FXR) AGONIST, BILE ACID ASTAGRAF XL 3 ANALOG cyclosporine (bulk) 3 cyclosporine OCALIVA 3 4 intravenous cyclosporine modified oral capsule 100 mg, 25 1 mg cyclosporine modified 3 PA oral capsule 50 mg cyclosporine modified 1 oral solution

You can find information on what the symbols and abbreviationson this table mean on page 4. 215 Drug Name Drug Tier Limits Drug Name Drug Tier Limits cyclosporine oral mycophenolate sodium 1 capsule oral tablet,delayed 3 PA ENVARSUS XR 3 release (dr/ec) 180 mg GENGRAF ORAL mycophenolate sodium CAPSULE 100 MG, 25 1 oral tablet,delayed 3 MG release (dr/ec) 360 mg GENGRAF ORAL MYFORTIC 3 1 SOLUTION IMMUNOSUPPRE NEORAL 3 SSIVE - PROGRAF MAMMALIAN 4 INTRAVENOUS TARGET OF PROGRAF ORAL RAPAMYCIN 3 PA CAPSULE (MTOR) PROGRAF ORAL INHIBITORS GRANULES IN 3 RAPAMUNE 3 PACKET sirolimus oral solution 3 SANDIMMUNE 4 sirolimus oral tablet 2 PA INTRAVENOUS ZORTRESS 3 SANDIMMUNE ORAL 3 CAPSULE IMMUNOSUPPRE SANDIMMUNE ORAL SSIVE - 3 PA SOLUTION MONOCLONAL tacrolimus oral capsule ANTIBODIES 1 0.5 mg, 1 mg SIMULECT 4 tacrolimus oral capsule 4 IMMUNOSUPPRE 5 mg SSIVE - IMMUNOSUPPRE MONOCLONAL SSIVE - INOSINE ANTIBODY MONOPHOSPHA INHIB. T TE LYMPHOCYTE DEHYDROGENA FUNCTION SE INHIBITORS SIMULECT 4 CELLCEPT 4 IMMUNOSUPPRE INTRAVENOUS SSIVE - PURINE CELLCEPT ORAL 3 ANALOGS CAPSULE AZASAN 3 CELLCEPT ORAL SUSPENSION FOR 4 azathioprine 1 RECONSTITUTION azathioprine sodium 4 mycophenolate mofetil 1 IMURAN 3 mycophenolate mofetil 4 (hcl)

You can find information on what the symbols and abbreviationson this table mean on page 4. 216 Drug Name Drug Tier Limits Drug Name Drug Tier Limits IMMUNOSUPPRE neostigmine methylsulfate SSIVE - 2 PA SELECTIVE T- intravenous syringe 3 mg/3 ml (1 mg/ml) CELL COSTIMULATIO neostigmine methylsulfate 4 N BLOCKER intravenous syringe 5 NULOJIX 4 mg/5 ml (1 mg/ml) pyridostigmine bromide LOCOMOTOR 3 SYSTEM (bulk) pyridostigmine bromide 2 PA AGENTS TO oral syrup TREAT pyridostigmine bromide 1 PERIODIC oral tablet PARALYSIS - pyridostigmine bromide CARBONIC oral tablet extended 1 ANHYDRASE release INHIBITORS REGONOL 2 PA KEVEYIS 3 ANTIMYASTHEN ALS AGENTS - IC AGENTS BENZATHIAZOL OTHER ES guanidine 3 PA RILUTEK 3 MUSCULOSKELE riluzole 1 TAL THERAPY TIGLUTIK 3 PA AGENT - ANTIMYASTHEN VISCOSUPPLEM IC AGENT - ENTS REVERSIBLE DUROLANE 4 PA CHOLINESTERA EUFLEXXA 4 PA SE INHIBITORS GEL-ONE 4 PA BLOXIVERZ 2 PA GELSYN-3 4 PA MESTINON ORAL 2 PA GENVISC 850 4 PA SYRUP HYALGAN 4 PA MESTINON ORAL 3 PA TABLET HYMOVIS 4 PA MESTINON MONOVISC 4 PA 3 PA TIMESPAN ORTHOVISC 4 PA neostigmine SUPARTZ FX 4 PA methylsulfate 2 PA SYNVISC 4 PA intravenous solution SYNVISC-ONE 4 PA TRIVISC 4 VISCO-3 4 PA You can find information on what the symbols and abbreviationson this table mean on page 4. 217 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MUSCULOSKELE SELECTIVE TAL TX AGENT- RELAXANT JOINT BINDING AGENT CONTRACTURE - MODIFIED THERAPY, GAMMA- COLLAGENASE CYCLODEXTRIN ENZYME BRIDION 4 XIAFLEX 4 SKELETAL NEUROMUSCUL MUSCLE AR BLOCKER - RELAXANT - DEPOLARIZING ANALGESIC AGENTS SALICYLATE succinylcholine-sod COMBINATIONS 4 cl,iso(pf) carisoprodol-aspirin 3 NEUROMUSCUL NORGESIC FORTE 3 AR BLOCKER - SKELETAL NEUROTOXINS MUSCLE BOTOX 4 PA RELAXANT - DYSPORT 4 PA CENTRAL MYOBLOC 4 PA MUSCLE NEUROMUSCUL RELAXANTS AR BLOCKER - AMRIX 3 NONDEPOLARIZ baclofen (bulk) 3 ING AGENTS baclofen intrathecal 4 PA atracurium 4 baclofen oral tablet 10 1 cisatracurium mg, 20 mg 4 intravenous solution baclofen oral tablet 5 3 PA NIMBEX 4 mg pancuronium carisoprodol (bulk) 3 intravenous solution 1 4 carisoprodol oral tablet 3 mg/ml 250 mg rocuronium intravenous carisoprodol oral tablet 4 3 PA solution 350 mg rocuronium intravenous chlorzoxazone 3 syringe 100 mg/10 ml 4 cyclobenzaprine (bulk) 3 (10 mg/ml), 75 mg/7.5 ml (10 mg/ml) cyclobenzaprine oral capsule,extended release 3 PA vecuronium bromide 4 24hr cyclobenzaprine oral 1 tablet FEXMID 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 218 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LIORESAL DANTRIUM ORAL INTRATHECAL CAPSULE 25 MG, 50 1 SOLUTION 2,000 4 PA MG MCG/ML, 500 dantrolene (bulk) 3 MCG/ML dantrolene oral 3 PA LIORESAL INTRATHECAL REVONTO 4 4 SOLUTION 50 RYANODEX 4 MCG/ML SKELETAL LORZONE 3 MUSCLE METAXALL 3 RELAXANT - metaxalone oral tablet OPIOID 3 400 mg ANALGESIC metaxalone oral tablet COMBINATIONS 3 PA 800 mg carisoprodol-aspirin- 3 PA methocarbamol codeine 4 PA injection SKELETAL methocarbamol oral 1 MUSCLE orphenadrine citrate 4 PA RELAXANT, injection SALICYLATE, orphenadrine citrate oral 3 AND OPIOID ROBAXIN INJECTION 4 ANALGESIC ROBAXIN-750 3 COMB. carisoprodol-aspirin- SKELAXIN 3 3 PA codeine SOMA 3 tizanidine oral capsule 3 PA MEDICAL tizanidine oral tablet 1 SUPPLIES AND ZANAFLEX ORAL DURABLE CAPSULE 2 MG, 4 3 PA MEDICAL MG EQUIPMENT ZANAFLEX ORAL (DME) 3 CAPSULE 6 MG MEDICAL ZANAFLEX ORAL 3 SUPPLIES AND TABLET DME - SKELETAL APPLICATORS MUSCLE AND COTTON RELAXANT - SUPPLIES DIRECT MUSCLE COSMETIC BALLS 4 RELAXANTS COSMETIC PUFFS 4 DANTRIUM 4 INTRAVENOUS

You can find information on what the symbols and abbreviationson this table mean on page 4. 219 Drug Name Drug Tier Limits Drug Name Drug Tier Limits WIDE-SEAL MEDICAL 4 SUPPLIES AND DIAPHRAGM 70 WIDE-SEAL DME - BLOOD 4 COLLECTION DIAPHRAGM 75 WIDE-SEAL NEEDLES 4 DIAPHRAGM 80 MONOJECT BLOOD COLLECTION WIDE-SEAL 4 4 NEEDLE 20 GAUGE X DIAPHRAGM 85 1" MEDICAL MEDICAL SUPPLIES AND SUPPLIES AND DME - GAUZE DME - CERVICAL PADS AND CAPS DRESSINGS FEMCAP 1 RESTORE TOPICAL 4 MEDICAL BANDAGE 2 X 2 " SUPPLIES AND XEROFORM 4 DME - XEROFORM COMPRESSION PETROLATUM STOCKINGS DRESSING TOPICAL 4 BANDAGE 2 X 2 ", 4 T.E.D. ANTI- X 3 "-YARD, 4 X 4 " EMBOLISM 4 XEROFORM STOCKING PETROLATUM 4 T.E.D. KNEE OVERWRAP LENGTH-S- 4 REGULAR MEDICAL SUPPLIES AND MEDICAL DME - GLUCOSE SUPPLIES AND MONITORING DME - DENTAL TEST SUPPLIES SUPPLIES DEXCOM G4 PA; QL (1 EA OTHER 2 RECEIVER per 365 days) Q-CARE RX Q4 3 DEXCOM G4 MEDICAL RECEIVER 2 PA SUPPLIES AND PEDIATRIC DME - DEXCOM G4 DIAPHRAGMS RECEIVER-SHARE 2 PA (PED) CAYA CONTOURED 4 DEXCOM G4 WIDE-SEAL 4 RECEIVER-SHARE 2 PA DIAPHRAGM 60 KIT WIDE-SEAL 4 DEXCOM G4 DIAPHRAGM 65 2 PA TRANSMITTER

You can find information on what the symbols and abbreviationson this table mean on page 4. 220 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DEXCOM G5 WELL BEGINNINGS 2 PA 4 RECEIVER SLEEP PANTS DEXCOM G5 2 PA MEDICAL TRANSMITTER SUPPLIES AND DEXCOM G5-G4 2 PA DME - INFANT SENSOR DIAPERS DEXCOM G6 COMFORT-STRETCH 2 PA 4 RECEIVER DIAPERS DEXCOM G6 SENSOR 2 PA COMFORT-STRETCH 4 DEXCOM G6 TRAINING PANTS 2 PA TRANSMITTER CUTIEPANTS 4 DEXCOM RECEIVER 2 PA TRAINING PANTS ENLITE SYSTEM 3 CUTIES BABY 4 EVERSENSE DIAPERS 3 SENSOR-HOLDER diaper,brief,infant- 4 EVERSENSE SMART todd,disp 3 TRANSMITTER DIAPERS 4 FREESTYLE LIBRE DIAPERS, UNISEX 2 PA 4 14 DAY READER SIZE 3 FREESTYLE LIBRE DIAPERS, UNISEX 2 PA 4 14 DAY SENSOR SIZE 4 GUARDIAN DIAPERS, UNISEX 4 CONNECT 4 SIZE 5 TRANSMITTER DIAPERS, UNISEX 4 GUARDIAN REAL- QL (1 EA per SIZE 6 3 TIME GLU MONITOR 390 days) DIAPERS-DISP- MEDICAL POLYETHYLENE 4 SUPPLIES AND BACK GOODNITES DME - 1 INCONTINENCE UNDERPANTS L-XL HUGGIES LITTLE SUPPLIES 4 MOVERS PREVAIL BRIEF 4 YOUTH HUGGIES PULL-UPS 4 HUGGIES PULL-UPS SLEEP COMFORTS 4 4 2T-3T SLEEP OVERS PANTS 4 HUGGIES PULL-UPS SLEEP PANTS 4 4 3T-4T TUGABOOS 4 HUGGIES PULL-UPS OVERNIGHTS 4 4T-5T UNDERJAMS L-XL 4 HUGGIES SLIP-ON 4 UNDERJAMS 4 HUGGIES SNUG AND SMALL-MEDIUM 4 DRY STEP 5

You can find information on what the symbols and abbreviationson this table mean on page 4. 221 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HUGGIES SNUG AND PAMPERS PREEMIE 4 4 DRY STEP 6 SWAD SIZE P-S LUVS NEWBORN 4 PAMPERS PREMIE 4 LUVS SIZE 1 4 PAMPERS LUVS SIZE 2 4 SWADDLERS SENS. 4 SIZE 1 LUVS SIZE 3 4 PAMPERS 4 LUVS SIZE 4 4 SWADDLERS SIZE 1 LUVS SIZE 5 4 PAMPERS 4 LUVS SIZE 6 4 SWADDLERS SIZE 2 PAMPERS BABY- PAMPERS 4 4 DRY SIZE 1 SWADDLERS SIZE 3 PAMPERS BABY- PAMPERS 4 4 DRY SIZE 2 SWADDLERS SIZE N PAMPERS BABY- PAMPERS UNISEX 4 4 DRY SIZE 3 BABY-DRY PAMPERS BABY- PREMIUM BABY 4 4 DRY SIZE 4 DIAPERS PAMPERS BABY- PREMIUM 4 4 DRY SIZE 5 COMFORT-STRETCH PAMPERS BABY- PREMIUM TRAINING 4 4 DRY SIZE 6 PANTS PAMPERS BABY- SELECT KIDS BRIEFS 4 4 DRY SIZE N SLEEP PANTS 4 PAMPERS CRUISERS 4 SUPREME DIAPERS 4 PAMPERS CRUISERS SIZE 1 4 SIZE 3 SUPREME DIAPERS 4 PAMPERS CRUISERS SIZE 2 4 SIZE 5 SUPREME DIAPERS 4 PAMPERS CRUISERS SIZE 3 4 SIZE 6 SUPREME DIAPERS 4 PAMPERS CRUISERS SIZE 4 4 SIZE 7 SUPREME DIAPERS 4 PAMPERS EASY UPS 4 SIZE 5 PAMPERS EXTRA SUPREME DIAPERS 4 4 PROTECTION SZ 3 SIZE 6 PAMPERS EXTRA TRAINING PANTS 4 4 PROTECTION SZ 4 2T-3T PAMPERS EXTRA TRAINING PANTS 4 4 PROTECTION SZ 5 3T-4T PAMPERS EXTRA TRAINING PANTS 4 4 PROTECTION SZ 6 4T-5T

You can find information on what the symbols and abbreviationson this table mean on page 4. 222 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TUGABOOS 4 MEDICAL TRAINING PANTS SUPPLIES AND WELL BEGINNINGS 4 DME - SLEEP PANTS MISCELLANEOU WONDERPANTS 4 S OTHER MEDICAL adapter cap for bottle 4 SUPPLIES AND BOSTON ROUND 4 DME - INSULIN NATURAL NEEDLES- BOTTLE 4 SYRINGES AND BOTTLETOP ADMIN DISPENSER 4 SUPPLIES ADAPTER BD INSULIN DISPOSERX 3 1 SYRINGE U-500 OMNIPOD INSULIN 2 MAGELLAN INSULIN REFILL SAFETY SYRNG PRO COMFORT TENS 1 4 SYRINGE 1 ML 29 ELECTRODE GAUGE X 1/2" PRO COMFORT TENS 4 MAGELLAN UNIT SYRINGE SYRINGE 1 0.5 ML 30 GAUGE X SUPPOSISTRIP 4 5/16" suppository molds 4 MONOJECT INSULIN SUPPOSITORY 4 SAFETY SYRING SHELL, MEDIUM SYRINGE 0.3 ML 30 SUPPOSITORY 4 GAUGE X 5/16", 0.5 1 SHELL, SMALL ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X T.E.D. ANTI- 5/16" EMBOLISM 4 STOCKING NOVOPEN ECHO 1 T:SLIM 3 OMNIPOD DASH 2 PA PDM KIT T:SLIM G4 3 SNAP INSULIN PUMP UNGUATOR LID 4 4 CONTROLLER MEDICAL MEDICAL SUPPLIES AND SUPPLIES AND DME - DME - IV SETS- NEBULIZERS TUBING AIRS DISPOSABLE 4 COMFORT INFUSION NEBULIZER 4 SET 31" DEVILBISS DISPOSABLE 4 NEBULIZER FLYP NEBULIZER 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 223 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INNOSPIRE GO MONOJECT 4 NEBULIZER HYPODERMIC NEEDLES NEEDLE 25 LC PLUS 4 1 GAUGE X 1 1/2", 25 LC PLUS GAUGE X 1", 30 NEBULIZER-PED 4 GAUGE X 3/4" MASK MONOJECT SAFETY MICROAIR MESH SYRINGES SYRINGE 4 1 NEBULIZER 3 ML 22 GAUGE X 1 PRODIGY MINI-MIST 1/2" 4 NEBULIZER MONOJECT SYRINGE 1 SIDESTREAM 4 SYRINGE 3 ML SIDESTREAM MONOJECT TB LUER 4 1 NEBULIZER LOK MEDICAL NORM-JECT SUPPLIES AND SYRINGE 10 ML, 20 3 DME - NEEDLES ML AND SYRINGES SURGUARD2 SAFETY NEEDLE 18 4 ALLERGIST TRAY GAUGE X 1" 1/2 ML 27GX3/8" 4 SYRINGE syringe (reusable) 1 ALLERGIST TRAY TUBERCULIN INTRADERMAL BEV SYRINGE SYRINGE 1 4 SYRINGE 1 ML 26 4 ML 25 GAUGE X 1" GAUGE X 3/8", 1 ML ULTICARE SYRINGE 27 GAUGE X 3/8" 1 ML 25 GAUGE X 3 BD ALLERGIST 5/8" TRAY REG BEVEL 1 MEDICAL SYRINGE SUPPLIES AND BD ALLERGIST DME - OSTOMY TRAY REG BEVEL 1 SUPPLIES TRAY 1/2 ML 27 X 1/2" FRESHNET 4 BD FILTER NEEDLE- HEX-ON LIGHT 1 4 5 MICRON ODOR BD SAFETYGLIDE karaya gum (bulk) 3 ALLERGIST TRAY ODOR ELIMINATOR 1 4 SYRINGE 1 ML 27 X DROPS 1/2" blunt needle, disposable 3 needle 18 x 1 1/2 " MONOJECT CONTROL SYRINGE 1 LUER

You can find information on what the symbols and abbreviationson this table mean on page 4. 224 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MEDICAL AEROCHAMBER SUPPLIES AND PLUS FLOW-VU,L 1 DME - MSK PARENTERAL AEROCHAMBER THERAPY PLUS FLOW-VU,M 1 MSK SUPPLIES AEROCHAMBER ACCU-CHEK SPIRIT 3 PLUS FLOW-VU,S 1 ADAPTER MSK EMPTY STERILIZED AEROCHAMBER 4 1 VIAL WITH FLOWSIGNAL empty vial 4 AEROTRACH PLUS 1 INTERLINK LEVER 4 COMP-AIR LOCK CANNULA NEBULIZER 4 PARADIGM COMPRESSOR SILHOUETTE INFUS 4 DEVILBISS SET COMPACT 4 PHASEAL COMPRESSOR PROTECTOR DEVICE 4 DEVILBISS PULMO- 4 20 MM AIDE COMPRESSR SURE-T INFUSION 4 DEVILBISS SET PULMOMATE 4 TOPI-CLICK FILLING COMPRESSOR 4 NOZZLE DEVILBISS UNIVERSAL SLEEVE 4 TRAVELER 4 MEDICAL COMPRESSOR EASIVENT HOLDING SUPPLIES AND 1 DME - PEAK CHAMBER EASIVENT MASK FLOW METERS 1 LARGE ASTHMAPACK 1 EASIVENT MASK CHILDREN'S 1 MEDIUM MEDICAL EASIVENT MASK 1 SUPPLIES AND SMALL DME - INNOSPIRE 4 RESPIRATORY ELEGANCE THERAPY INNOSPIRE ESSENCE 4 SUPPLIES LITE TOUCH- ACE AEROSOL 1 4 MEDIUM MASK CLOUD ENHANCER LITEAIRE MDI 1 AEROCHAMBER MV 1 CHAMBER AEROCHAMBER LITETOUCH-LARGE 1 1 PLUS FLOW-VU MASK

You can find information on what the symbols and abbreviationson this table mean on page 4. 225 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LITETOUCH-SMALL REUSABLE 1 4 MASK NEBULIZER KIT MICROCHAMBER 1 SAMI THE SEAL 4 MICROSPACER 1 SAMI THE SEAL 4 OPTICHAMBER MASK ADULT MASK- 1 SILICONE MASK - 4 LARGE INFANT OPTICHAMBER 1 MEDICAL DIAMOND LG MASK SUPPLIES AND OPTICHAMBER 1 DME - SCAR DIAMOND VHC TREATMENTS OPTICHAMBER 1 CELACYN 3 DIAMOND-MED MSK CICATRACE PAD 3 OPTICHAMBER DIAMOND-SML 1 DERM-SILK 3 MASK KELOTOP 3 PARI BABY CONV NUVAKAAN 3 4 KIT - SIZE 1 SCARCARE 3 PFLEX SCARCINPAD 3 INSPIRATORY 4 TRAINER SILIVEX 3 PILLOW MASK SILTREX 3 4 CHILD MEDICAL POCKET CHAMBER 1 SUPPLIES AND PRIMEAIRE 3 DME - PRO COMFORT SUBCUTANEOUS SPACER-ADULT 3 ADMINISTRATIO MASK N SUPPLY PRO COMFORT INSUFLON 1 SPACER-CHILD 3 NERIA MASK SUBCUTANEOUS 4 PROCARE INFUSION SET 8 X COMPRESSOR 4 110 MM-CM NEBULIZER SOFT-GLIDE SAF-Q 3 PROCHAMBER 1 MEDICAL PRONEB ULTRA II 4 SUPPLIES AND FILTER ASSEM DME - PULMO-AIDE 4 SUBCUTANEOUS COMPRESSOR INSULIN PULMONEB LT DELIVERY COMPRESSOR 4 DEVICES NEBUL V-GO 20 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 226 Drug Name Drug Tier Limits Drug Name Drug Tier Limits V-GO 30 4 MEDICAL V-GO 40 4 SUPPLIES AND MEDICAL DME-GLUCOSE SUPPLIES AND MONITORING DME - AND INSULIN SUBCUTANEOUS ADMIN INSULIN PUMP SUPPLIES OMNIPOD INSULIN ACCU-CHEK COMBO 1 3 MANAGEMENT SYSTEM ONETOUCH PING AUTOSOFT XC 4 4 INSULIN PUMP INFUSION SET 23" CLEO 90 INFUSION REVEL 4 PROGRAMMABLE 4 SET 24" PUMP CLEO 90 INFUSION 4 T:FLEX INSULIN SET 31" 4 DELIVERY PUMP COMFORT INFUSION 4 T:SLIM X2 BASAL-IQ SET 31" 3 INSULIN PMP COMFORT INFUSION 4 MEDICAL SET 43" COMFORT SHORT SUPPLIES AND 4 DME - TISSUE INSULIN PUMP 23" CONTACT DETACH BULKING 4 IMPLANTS NON- INFUS SET 23" CONTACT DETACH COSMETIC 4 INFUS SET 32" SOLESTA 4 CONTACT DETACH 4 MEDICAL INFUS SET 43" SUPPLIES AND MINIMED INFUSION 4 DME - TISSUE SET-MMT 390 BULKING MIO INFUSION SET 3 IMPLANTS QUICK-SET 4 SOLESTA 4 PARADIGM MEDICAL SNAP INSULIN 4 SUPPLIES AND PUMP-INFUSION SET DME - URINARY SURE-T PARADIGM 4 CATHETERS T:30 INFUSION SET 4 AND RELATED T:90 INFUSION SET 3 DEVICES 23" LOFRIC 14-16 FR-" 4 SILASTIC FOLEY 4 CATHETER TOUCH-TROL 4 You can find information on what the symbols and abbreviationson this table mean on page 4. 227 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TISSUE ALLERGIST TRAY BULKING INTRADERMAL BEV IMPLANTS - SYRINGE 1 ML 26 4 GAUGE X 3/8", 1 ML ANORECTAL 27 GAUGE X 3/8" SOLESTA 4 ALLEVYN TOPICAL 1 MEDICAL BANDAGE 8 X 8 " ASTHMAPACK SUPPLY, FDB 1 SUPERSET CHILDREN'S AUTOSOFT XC 4 MEDICAL INFUSION SET 23" SUPPLY, FDB BD ALLERGIST SUPERSET TRAY REG BEVEL 1 ACCU-CHEK COMBO 3 SYRINGE SYSTEM BD ALLERGIST ACCU-CHEK SPIRIT TRAY REG BEVEL 3 1 ADAPTER TRAY 1/2 ML 27 X ACE AEROSOL 1/2" 4 CLOUD ENHANCER BD FILTER NEEDLE- 1 adapter cap for bottle 4 5 MICRON BD INSULIN AEROCHAMBER MV 1 1 SYRINGE U-500 AEROCHAMBER 1 PLUS FLOW-VU BD SAFETYGLIDE ALLERGIST TRAY 1 AEROCHAMBER SYRINGE 1 ML 27 X PLUS FLOW-VU,L 1 1/2" MSK blunt needle, disposable 3 AEROCHAMBER needle 18 x 1 1/2 " PLUS FLOW-VU,M 1 BOSTON ROUND MSK 4 NATURAL AEROCHAMBER PLUS FLOW-VU,S 1 BOTTLE 4 MSK BOTTLETOP AEROCHAMBER DISPENSER 4 1 WITH FLOWSIGNAL ADAPTER AEROTRACH PLUS 1 CAYA CONTOURED 4 AIRS DISPOSABLE CICATRACE PAD 3 4 NEBULIZER CLEO 90 INFUSION 4 ALLERGIST TRAY SET 24" 1/2 ML 27GX3/8" 4 CLEO 90 INFUSION 4 SYRINGE SET 31" COMFORT INFUSION 4 SET 31" COMFORT INFUSION 4 SET 43" You can find information on what the symbols and abbreviationson this table mean on page 4. 228 Drug Name Drug Tier Limits Drug Name Drug Tier Limits COMFORT SHORT DEXCOM G4 4 INSULIN PUMP 23" RECEIVER-SHARE 2 PA COMFORT-STRETCH (PED) 4 DIAPERS DEXCOM G4 COMFORT-STRETCH RECEIVER-SHARE 2 PA 4 TRAINING PANTS KIT DEXCOM G4 COMP-AIR 2 PA NEBULIZER 4 TRANSMITTER COMPRESSOR DEXCOM G5 2 PA CONTACT DETACH RECEIVER 4 INFUS SET 23" DEXCOM G5 2 PA CONTACT DETACH TRANSMITTER 4 INFUS SET 32" DEXCOM G5-G4 2 PA CONTACT DETACH SENSOR 4 INFUS SET 43" DEXCOM G6 2 PA COSMETIC BALLS 4 RECEIVER COSMETIC PUFFS 4 DEXCOM G6 SENSOR 2 PA CUTIEPANTS DEXCOM G6 4 2 PA TRAINING PANTS TRANSMITTER CUTIES BABY DEXCOM RECEIVER 2 PA 4 DIAPERS diaper,brief,infant- 4 DERM-SILK 3 todd,disp DEVILBISS DIAPERS 4 COMPACT 4 DIAPERS, UNISEX 4 COMPRESSOR SIZE 3 DEVILBISS DIAPERS, UNISEX 4 DISPOSABLE 4 SIZE 4 NEBULIZER DIAPERS, UNISEX 4 DEVILBISS PULMO- SIZE 5 4 AIDE COMPRESSR DIAPERS, UNISEX 4 DEVILBISS SIZE 6 PULMOMATE 4 DIAPERS-DISP- COMPRESSOR POLYETHYLENE 4 DEVILBISS BACK TRAVELER 4 DISPOSERX 3 COMPRESSOR EASIVENT HOLDING DEXCOM G4 PA; QL (1 EA 1 2 CHAMBER RECEIVER per 365 days) EASIVENT MASK 1 DEXCOM G4 LARGE RECEIVER 2 PA EASIVENT MASK PEDIATRIC 1 MEDIUM EASIVENT MASK 1 SMALL You can find information on what the symbols and abbreviationson this table mean on page 4. 229 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EMPTY STERILIZED INTERLINK LEVER 4 4 VIAL LOCK CANNULA empty vial 4 KELOTOP 3 ENLITE SYSTEM 3 LC PLUS 4 EVERSENSE LC PLUS 3 SENSOR-HOLDER NEBULIZER-PED 4 EVERSENSE SMART MASK 3 TRANSMITTER LITE TOUCH- 1 FEMCAP 1 MEDIUM MASK LITEAIRE MDI FLYP NEBULIZER 4 1 CHAMBER FREESTYLE LIBRE 2 PA LITETOUCH-LARGE 14 DAY READER 1 MASK FREESTYLE LIBRE 2 PA LITETOUCH-SMALL 14 DAY SENSOR 1 MASK GOODNITES 1 UNDERPANTS L-XL LOFRIC 14-16 FR-" 4 GUARDIAN LUVS NEWBORN 4 CONNECT 4 LUVS SIZE 1 4 TRANSMITTER LUVS SIZE 2 4 GUARDIAN REAL- QL (1 EA per 3 LUVS SIZE 3 4 TIME GLU MONITOR 390 days) LUVS SIZE 4 4 HUGGIES LITTLE 4 MOVERS LUVS SIZE 5 4 HUGGIES PULL-UPS 4 LUVS SIZE 6 4 HUGGIES PULL-UPS MAGELLAN INSULIN 4 SAFETY SYRNG 2T-3T 1 SYRINGE 1 ML 29 HUGGIES PULL-UPS 4 GAUGE X 1/2" 3T-4T MAGELLAN HUGGIES PULL-UPS SYRINGE SYRINGE 4 1 4T-5T 0.5 ML 30 GAUGE X HUGGIES SLIP-ON 4 5/16" HUGGIES SNUG AND MICROAIR MESH 4 4 DRY STEP 5 NEBULIZER HUGGIES SNUG AND MICROCHAMBER 1 4 DRY STEP 6 MICROSPACER 1 INNOSPIRE MINIMED INFUSION 4 4 ELEGANCE SET-MMT 390 INNOSPIRE ESSENCE 4 MIO INFUSION SET 3 INNOSPIRE GO 4 MONOJECT BLOOD NEBULIZER COLLECTION 4 INSUFLON 1 NEEDLE 20 GAUGE X 1"

You can find information on what the symbols and abbreviationson this table mean on page 4. 230 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MONOJECT OPTICHAMBER 1 CONTROL SYRINGE 1 DIAMOND VHC LUER OPTICHAMBER 1 MONOJECT DIAMOND-MED MSK HYPODERMIC OPTICHAMBER NEEDLES NEEDLE 25 1 DIAMOND-SML 1 GAUGE X 1 1/2", 25 MASK GAUGE X 1", 30 PAMPERS BABY- GAUGE X 3/4" 4 DRY SIZE 1 MONOJECT INSULIN PAMPERS BABY- SAFETY SYRING 4 SYRINGE 0.3 ML 30 DRY SIZE 2 GAUGE X 5/16", 0.5 1 PAMPERS BABY- 4 ML 29 GAUGE X 1/2", DRY SIZE 3 0.5 ML 30 GAUGE X PAMPERS BABY- 4 5/16" DRY SIZE 4 MONOJECT SAFETY PAMPERS BABY- SYRINGES SYRINGE 4 1 DRY SIZE 5 3 ML 22 GAUGE X 1 PAMPERS BABY- 1/2" 4 DRY SIZE 6 MONOJECT SYRINGE 1 PAMPERS BABY- SYRINGE 3 ML 4 DRY SIZE N MONOJECT TB LUER 1 LOK PAMPERS CRUISERS 4 PAMPERS CRUISERS NERIA 4 SUBCUTANEOUS SIZE 3 4 INFUSION SET 8 X PAMPERS CRUISERS 4 110 MM-CM SIZE 5 NORM-JECT PAMPERS CRUISERS 4 SYRINGE 10 ML, 20 3 SIZE 6 ML PAMPERS CRUISERS 4 NOVOPEN ECHO 1 SIZE 7 OMNIPOD DASH PAMPERS EASY UPS 4 2 PA PDM KIT PAMPERS EXTRA 4 OMNIPOD INSULIN PROTECTION SZ 3 1 MANAGEMENT PAMPERS EXTRA 4 OMNIPOD INSULIN PROTECTION SZ 4 2 REFILL PAMPERS EXTRA 4 ONETOUCH PING PROTECTION SZ 5 4 INSULIN PUMP PAMPERS EXTRA 4 OPTICHAMBER PROTECTION SZ 6 ADULT MASK- 1 PAMPERS PREEMIE 4 LARGE SWAD SIZE P-S OPTICHAMBER 1 PAMPERS PREMIE 4 DIAMOND LG MASK You can find information on what the symbols and abbreviationson this table mean on page 4. 231 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PAMPERS PRO COMFORT TENS 4 SWADDLERS SENS. 4 ELECTRODE SIZE 1 PRO COMFORT TENS 4 PAMPERS UNIT 4 SWADDLERS SIZE 1 PROCARE PAMPERS COMPRESSOR 4 4 SWADDLERS SIZE 2 NEBULIZER PAMPERS PROCHAMBER 1 4 SWADDLERS SIZE 3 PRODIGY MINI-MIST 4 PAMPERS NEBULIZER 4 SWADDLERS SIZE N PRONEB ULTRA II 4 PAMPERS UNISEX FILTER ASSEM 4 BABY-DRY PULMO-AIDE 4 PARADIGM COMPRESSOR SILHOUETTE INFUS 4 PULMONEB LT SET COMPRESSOR 4 PARI BABY CONV NEBUL 4 KIT - SIZE 1 QUICK-SET 4 PFLEX PARADIGM INSPIRATORY 4 RESTORE TOPICAL 4 TRAINER BANDAGE 2 X 2 " PHASEAL REUSABLE 4 PROTECTOR DEVICE 4 NEBULIZER KIT 20 MM REVEL PILLOW MASK 4 PROGRAMMABLE 4 CHILD PUMP POCKET CHAMBER 1 SAMI THE SEAL 4 PREMIUM BABY SAMI THE SEAL 4 4 DIAPERS MASK PREMIUM 4 SCARCINPAD 3 COMFORT-STRETCH SELECT KIDS BRIEFS 4 PREMIUM TRAINING 4 PANTS SIDESTREAM 4 PREVAIL BRIEF SIDESTREAM 4 4 YOUTH NEBULIZER SILASTIC FOLEY PRIMEAIRE 3 4 CATHETER PRO COMFORT SILICONE MASK - SPACER-ADULT 3 4 MASK INFANT PRO COMFORT SILIVEX 3 SPACER-CHILD 3 SILTREX 3 MASK SLEEP COMFORTS 4 SLEEP OVERS PANTS 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 232 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SLEEP PANTS 4 T:FLEX INSULIN 4 SNAP INSULIN PUMP DELIVERY PUMP 4 CONTROLLER T:SLIM 3 SNAP INSULIN T:SLIM G4 3 4 PUMP-INFUSION SET T:SLIM X2 BASAL-IQ 3 SOFT-GLIDE SAF-Q 3 INSULIN PMP SPECTRAGEL 4 TOPI-CLICK FILLING 4 SUPPOSISTRIP 4 NOZZLE suppository molds 4 TOUCH-TROL 4 SUPPOSITORY TRAINING PANTS 4 4 SHELL, MEDIUM 2T-3T SUPPOSITORY TRAINING PANTS 4 4 SHELL, SMALL 3T-4T SUPREME DIAPERS TRAINING PANTS 4 4 SIZE 1 4T-5T SUPREME DIAPERS TUBERCULIN 4 SIZE 2 SYRINGE SYRINGE 1 4 ML 25 GAUGE X 1" SUPREME DIAPERS 4 TUGABOOS SIZE 3 4 OVERNIGHTS SUPREME DIAPERS 4 TUGABOOS SIZE 4 4 TRAINING PANTS SUPREME DIAPERS 4 SIZE 5 ULTICARE SYRINGE 1 ML 25 GAUGE X 3 SUPREME DIAPERS 4 5/8" SIZE 6 UNDERJAMS L-XL 4 SURE-T INFUSION 4 UNDERJAMS SET 4 SMALL-MEDIUM SURE-T PARADIGM 4 UNGUATOR LID 4 SURGUARD2 SAFETY NEEDLE 18 4 UNIVERSAL SLEEVE 4 GAUGE X 1" VAPRO PLUS INTERMITT syringe (reusable) 1 4 CATHETER COMBO T.E.D. ANTI- PACK 14 FR- 16" EMBOLISM 4 STOCKING V-GO 20 4 T.E.D. KNEE V-GO 30 4 LENGTH-S- 4 V-GO 40 4 REGULAR WELL BEGINNINGS 4 T:30 INFUSION SET 4 SLEEP PANTS T:90 INFUSION SET WIDE-SEAL 3 4 23" DIAPHRAGM 60

You can find information on what the symbols and abbreviationson this table mean on page 4. 233 Drug Name Drug Tier Limits Drug Name Drug Tier Limits WIDE-SEAL ELELYSO 4 4 DIAPHRAGM 65 VPRIV 4 WIDE-SEAL 4 METABOLIC DIAPHRAGM 70 DISEASE WIDE-SEAL 4 ENZYME DIAPHRAGM 75 REPLACEMENT, WIDE-SEAL 4 HYPOPHOSPHAT DIAPHRAGM 80 ASIA WIDE-SEAL 4 DIAPHRAGM 85 STRENSIQ SUBCUTANEOUS 2 PA WONDERPANTS 4 SOLUTION 18 XEROFORM 4 MG/0.45 ML XEROFORM STRENSIQ PETROLATUM SUBCUTANEOUS DRESSING TOPICAL 4 SOLUTION 40 4 BANDAGE 2 X 2 ", 4 MG/ML, 80 MG/0.8 X 3 "-YARD, 4 X 4 " ML XEROFORM METABOLIC PETROLATUM 4 DISEASE OVERWRAP ENZYME METABOLIC REPLACEMENT, DISEASE LYSOSOMAL ENZYME ACID LIPASE REPLACEMENT DEFICIENCY AGENTS KANUMA 4 METABOLIC METABOLIC DISEASE DISEASE ENZYME ENZYME REPLACEMENT, REPLACEMENT, FABRY'S MUCOPOLYSAC DISEASE CHARIDOSIS FABRAZYME 4 ALDURAZYME 4 METABOLIC ELAPRASE 4 DISEASE MEPSEVII 4 ENZYME NAGLAZYME 4 REPLACEMENT, VIMIZIM 4 GAUCHER'S DISEASE CEREZYME INTRAVENOUS 4 RECON SOLN 400 UNIT

You can find information on what the symbols and abbreviationson this table mean on page 4. 234 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CARNITOR METABOLIC 4 DISEASE INTRAVENOUS ENZYME CARNITOR ORAL 3 REPLACEMENT, L-CARNITINE 3 POMPE DISEASE levocarnitine (with 1 LUMIZYME 4 sugar) METABOLIC METABOLIC MODIFIERS MODIFIER - GAUCHER'S HYPERPARATHY DISEASE, TYPE- ROID 1, SUBSTRATE TREATMENT REDUCTION TX AGENTS - VITAMIN D CERDELGA 3 ANALOG-TYPE miglustat 2 PA calcitriol intravenous ZAVESCA 2 PA 4 solution 1 mcg/ml METABOLIC calcitriol oral capsule 1 MODIFIER - calcitriol oral solution 3 HEREDITARY doxercalciferol OROTIC 4 intravenous ACIDURIA doxercalciferol oral 3 PA TREATMENT AGENTS HECTOROL 4 INTRAVENOUS XURIDEN 3 paricalcitol METABOLIC hemodialysis port 4 MODIFIER - injection HEREDITARY paricalcitol oral 3 PA TYROSINEMIA ROCALTROL 3 TREATMENT ZEMPLAR AGENTS 4 INTRAVENOUS NITYR ORAL 2 PA ZEMPLAR ORAL TABLET 10 MG CAPSULE 1 MCG, 2 3 ORFADIN 2 PA MCG METABOLIC METABOLIC MODIFIER - MODIFIER - HOMOCYSTINUR CARNITINE IA TREATMENT REPLENISHER AGENTS AGENTS CYSTADANE 3 CARNITOR (SUGAR- 3 FREE)

You can find information on what the symbols and abbreviationson this table mean on page 4. 235 Drug Name Drug Tier Limits Drug Name Drug Tier Limits METABOLIC PHENYLKETON MODIFIER - URIA(PKU) TX UREA CYCLE AGENTS - DISORDER COFACTOR OF AGENTS- PHENYLALANIN CONJUGATING E AGENTS HYDROXYLASE AMMONUL 4 KUVAN ORAL BUPHENYL 3 POWDER IN PACKET 3 500 MG RAVICTI 3 KUVAN ORAL 2 sodium phenylbutyrate 2 PA TABLET,SOLUBLE METABOLIC MOUTH- MODIFIER- THROAT- CARBAMOYL DENTAL - PHOSPHATE SYNTHETASE 1 PREPARATIONS (CPS 1) DENTAL ACTIVATOR PRODUCT - CARBAGLU 2 FLUORIDE PREPARATIONS PHARMACOENH ANCER - FLORIVA (FLUORIDE- 3 CYTOCHROME VITAMIN D3) P450 INHIBITORS fluoride (sodium) dental 3 TYBOST 1 gel PHARMACOLOG fluoride (sodium) oral 3 ICAL drops CHAPERONE TX fluoride (sodium) oral 3 - ALPHA- tablet,chewable GALACTOSIDAS FLUORIDEX E A ENZYME SENSITIVITY RELIEF 3 STABILIZER DENTAL PASTE FLUORITAB ORAL GALAFOLD 2 PA 3 TABLET,CHEWABLE FLURA-DROPS 3 LUDENT FLUORIDE 3 sodium fluoride (bulk) 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 236 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DENTAL MOUTH AND PRODUCT - THROAT - LOCAL ARTIFICIAL ANESTHETICS SALIVA CARBOCAINE BOCASAL 3 INJECTION 4 MUCOSITISRX 3 CARTRIDGE SALIVAMAX 3 MARCAINE- EPINEPHRINE XEROSTOMIA 4 3 INJECTION RELIEF CARTRIDGE MOUTH AND SCANDONEST PLAIN 4 THROAT - VIVACAINE 3 GLUCOCORTICO MOUTH AND IDS THROAT - ORALONE 3 triamcinolone acetonide ANTIFUNGALS 1 dental clotrimazole mucous 1 membrane MOUTH AND nystatin oral suspension 1 THROAT - MOUTH AND LOCAL THROAT - ANTI- ANESTHETIC INFECTIVE AMIDES lidocaine hcl mucous QL (2 ML per MIXTURES 2 membrane jelly 23 days) DEBACTEROL lidocaine hcl mucous MUCOUS QL (2 ML per 3 membrane solution 4 % 3 MEMBRANE 23 days) SOLUTION (40 mg/ml) LIDOCAINE QL (2 ML per DEBACTEROL 2 MUCOUS 1 VISCOUS 23 days) MEMBRANE SWAB MOUTH AND MOUTH AND THROAT - THROAT - MUCOSITIS- ANTISEPTICS STOMATITIS chlorhexidine gluconate AGENTS 1 (bulk) EPISIL 3 chlorhexidine gluconate GELCLAIR 3 1 mucous membrane GELX 3 PAROEX ORAL 1 MUGARD 3 RINSE ORAMAGICRX 3 PERIDEX 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 237 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MOUTH AND MULTIPLE THROAT - SCLEROSIS PROTECTANTS AGENTS GELX 3 LEUKOCYTE MUGARD 3 ADHESION ORAFATE 3 INHIBITORS, PROTHELIAL 3 ALPHA4- MOUTH AND MEDIATED, THROAT - IGG4K MC SALIVA ANTIBODY STIMULANTS TYSABRI 4 PA cevimeline 2 PA MULTIPLE EVOXAC 3 SCLEROSIS pilocarpine hcl (bulk) 3 AGENT - CD20 SPECIFIC pilocarpine hcl oral 1 MONOCLONAL SALAGEN 3 ANTIBODY (PILOCARPINE) OCREVUS 4 PA XYLIMELTS 3 MULTIPLE PERIODONTAL SCLEROSIS PRODUCT - AGENT - CD52 TETRACYCLINE- SPECIFIC TYPE, MONOCLONAL COLLAGENASE ANTIBODY INHIBITORS LEMTRADA 4 PA doxycycline hyclate oral 1 tablet 20 mg MULTIPLE THERAPY FOR SCLEROSIS DROOLING- AGENT - PRIMARY OR INTERFERONS SECONDARY AVONEX SIALORRHEA- INTRAMUSCULAR 2 PA ANTICHOLINER PEN INJECTOR KIT AVONEX GIC PA; QL (1 EA INTRAMUSCULAR 2 per 23 days) CUVPOSA 3 SYRINGE KIT BETASERON PA; QL (14 EA 2 SUBCUTANEOUS KIT per 23 days) BETASERON SUBCUTANEOUS 2 PA RECON SOLN EXTAVIA 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 238 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PLEGRIDY 3 MAVENCLAD (5 3 PA REBIF (WITH TABLET PACK) 2 PA ALBUMIN) MAVENCLAD (6 3 PA REBIF REBIDOSE 2 PA TABLET PACK) REBIF TITRATION MAVENCLAD (7 1 3 PA PACK TABLET PACK) MAVENCLAD (8 MULTIPLE 3 PA TABLET PACK) SCLEROSIS MAVENCLAD (9 AGENT - 3 PA TABLET PACK) OTHERS MULTIPLE COPAXONE SUBCUTANEOUS 2 PA SCLEROSIS SYRINGE 20 MG/ML AGENT - COPAXONE PYRIMIDINE SUBCUTANEOUS 1 SYNTHESIS SYRINGE 40 MG/ML INHIBITORS glatiramer 3 AUBAGIO 3 GLATOPA 3 MULTIPLE TECFIDERA 2 PA SCLEROSIS VUMERITY 3 PA AGENT - MULTIPLE SPHINGOSINE 1- SCLEROSIS PHOSPHATE AGENT - RECEPTOR POTASSIUM MODULATOR GILENYA ORAL CHANNEL 3 BLOCKER CAPSULE 0.25 MG GILENYA ORAL AMPYRA 3 1 CAPSULE 0.5 MG dalfampridine 3 PA MAYZENT 3 dalfampridine (bulk) 3 MAYZENT STARTER 3 FIRDAPSE 3 PA PACK RUZURGI 3 PA OPHTHALMIC MULTIPLE AGENTS SCLEROSIS ARTIFICIAL AGENT - PURINE TEARS AND NUCLEOSIDE LUBRICANT ANALOGS SINGLE AGENTS MAVENCLAD (10 3 PA KLARITY TABLET PACK) 3 (CHONDROITIN) (PF) MAVENCLAD (4 3 PA LACRISERT 1 TABLET PACK)

You can find information on what the symbols and abbreviationson this table mean on page 4. 239 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MIOTICS - OPHTHALMIC - CHOLINESTERA ADRENERGIC- SE INHIBITORS CARBONIC PHOSPHOLINE ANHYDRASE 3 IODIDE INHIBITOR MIOTICS - COMBINATIONS DIRECT ACTING SIMBRINZA 1 acetylcholine chloride OPHTHALMIC - 3 (bulk) AGENTS FOR ISOPTO CARPINE 3 CORNEAL MIOCHOL-E 3 COLLAGEN MIOSTAT 3 CROSS-LINKING PHOTREXA CROSS- pilocarpine hcl (bulk) 3 4 LINKING KIT pilocarpine hcl ophthalmic (eye) drops 3 OPHTHALMIC - 1 %, 2 %, 4 % ANTIBACTERIAL MYDRIATIC AND - CYCLOPLEGIC GLUCOCORTICO COMBINATIONS ID COMBINATIONS CYCLOMYDRIL 1 BLEPHAMIDE 3 lidocaine-phenylephrn 4 in water BLEPHAMIDE S.O.P. 3 dexameth-moxiflox(pf)- PAREMYD 3 3 nacl,iso racepineph-lidocaine- 4 bss 7(pf) MAXITROL 3 neomycin-bacitracin- OPHTH - BETA 3 BLOCKER- poly-hc neomycin-polymyxin b- ADRENERG- 1 CARBONIC dexameth neomycin-polymyxin-hc ANHYD INHIB- 3 PROSTAGLADIN ophthalmic (eye) ANALOG NEO-POLYCIN HC 3 timol-brimon-dorzo- PRED-G 3 3 latanop(pf) PRED-G S.O.P. 3 prednisolone acet- 3 gatifloxacin prednisolone- 3 moxifloxacin hcl sulfacetamide- 1 prednisolone

You can find information on what the symbols and abbreviationson this table mean on page 4. 240 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TOBRADEX OPHTHALMIC - OPHTHALMIC (EYE) 1 ANTIHISTAMINE OINTMENT S TOBRADEX ST 3 azelastine ophthalmic tobramycin- 3 1 (eye) dexamethasone BEPREVE 3 triamcinolon-moxiflox- 4 epinastine 3 PA watr(pf) LASTACAFT 3 ZYLET 3 olopatadine ophthalmic 3 OPHTHALMIC - (eye) drops 0.1 % ANTIBACTERIAL PAZEO 3 - GLUCOCORTICO OPHTHALMIC - ID-NSAID ANTI- COMBINATIONS INFLAMMATOR Y, dexamet-moxifl-ketoro- 3 nacl(pf) GLUCOCORTICO IDS prednisol ace-gatiflox- 3 bromfen ALREX 3 prednisoln sp-gatiflox- dexamethasone sodium 3 bromfen phosphate ophthalmic 1 (eye) prednisolone-moxiflo- 3 nepafenac DEXTENZA 4 OPHTHALMIC - DEXYCU (PF) 4 ANTICHOLINER DUREZOL 1 GICS FLAREX 3 atropine ophthalmic fluorometholone 1 1 (eye) drops FML FORTE 3 atropine ophthalmic 1 FML LIQUIFILM 3 (eye) ointment FML S.O.P. 3 CYCLOGYL 3 ILUVIEN 4 cyclopentolate 1 INVELTYS 3 PA HOMATROPAIRE 1 LOTEMAX 3 ISOPTO ATROPINE 1 LOTEMAX SM 3 MYDRIACYL 3 loteprednol etabonate 3 PA tropicamide 1 MAXIDEX 3 OPHTHALMIC - OZURDEX 4 ANTIFIBROTIC AGENTS PRED FORTE 3 PRED MILD 3 MITOSOL 3 prednisolone acetate 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 241 Drug Name Drug Tier Limits Drug Name Drug Tier Limits prednisolone acetate NEVANAC 3 3 (pf) PROLENSA 3 prednisolone sodium OPHTHALMIC - phosphate ophthalmic 3 (eye) BETA BLOCKER- ADRENERGIC- RETISERT 4 CARBONIC TRIESENCE (PF) 4 ANHYDRASE YUTIQ 4 INHIBITOR OPHTHALMIC - COMB ANTI- timolol-brimonidi- 3 INFLAMMATOR dorzolam(pf) Y, OPHTHALMIC - IMMUNOMODUL BETA BLOCKER- ATORS CARBONIC CEQUA 3 PA ANHYDRASE RESTASIS 1 INHIB- RESTASIS PROSTAGLADIN 3 MULTIDOSE ANALOG XIIDRA 3 timolol-dorzolamid- 3 OPHTHALMIC - latanop(pf) ANTI- OPHTHALMIC - INFLAMMATOR BETA Y, LFA-1 BLOCKERS- ANTAGONISTS ADRENERGIC XIIDRA 3 COMBINATIONS OPHTHALMIC - COMBIGAN 1 ANTI- OPHTHALMIC - INFLAMMATOR BETA Y, NSAIDS BLOCKERS- ACULAR 3 CARBONIC ANHYDRASE ACULAR LS 3 INHIBITOR ACUVAIL (PF) 3 COMBINATIONS bromfenac 3 COSOPT 3 BROMSITE 3 COSOPT (PF) 3 PA diclofenac sodium 1 dorzolamide-timolol 1 ophthalmic (eye) dorzolamide-timolol flurbiprofen sodium 1 (pf) ophthalmic (eye) 1 ILEVRO 1 dropperette ketorolac ophthalmic 1 (eye)

You can find information on what the symbols and abbreviationson this table mean on page 4. 242 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dorzolamide-timolol OPHTHALMIC - (pf) ophthalmic (eye) 3 GLUCOCORTICO drops ID-NSAID OPHTHALMIC - COMBINATIONS BETA prednisolone acetate- 3 BLOCKERS- nepafenac PROSTAGLANDI prednisolone sod ph- 3 N ANALOG bromfenac COMBINATIONS OPHTHALMIC - timolol-latanoprost(pf) 3 HUMAN NERVE OPHTHALMIC - GROWTH CARBONIC FACTOR (HNGF) ANHYDRASE OXERVATE 3 INHIBITORS OPHTHALMIC - AZOPT 1 INTRAOCULAR dorzolamide 1 PRESSURE dorzolamide (pf) 3 REDUCING TRUSOPT 3 AGENTS, BETA- OPHTHALMIC - BLOCKERS betaxolol ophthalmic CYSTINE 3 DEPLETING (eye) AGENTS BETIMOL 3 CYSTARAN 2 PA BETOPTIC S 3 OPHTHALMIC - carteolol 3 DECONGESTANT ISTALOL 3 levobunolol ophthalmic S 1 (eye) drops 0.5 % phenylephrine hcl 1 ophthalmic (eye) metipranolol 3 timolol maleate OPHTHALMIC - 1 DIAGNOSTIC ophthalmic (eye) TIMOPTIC OCUDOSE AGENTS 3 (PF) AK-FLUOR 4 TIMOPTIC fluorescein- 1 OPHTHALMIC (EYE) 3 proparacaine DROPS 0.25 % FLUORESCITE 4 TIMOPTIC-XE 1 GLOSTRIPS OPHTHALMIC - OPHTHALMIC (EYE) 3 STRIP 1 MG LOCAL ANESTHETIC COMBINATIONS ALTAFLUOR BENOX 3 You can find information on what the symbols and abbreviationson this table mean on page 4. 243 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC - OPHTHALMIC - LOCAL MYDRIATIC- ANESTHETIC NSAID ESTERS COMBINATIONS ALTACAINE 3 MYDRIATIC4(TROP- 3 proparacaine 1 PROP-PE-KTRLC) tetracaine hcl 1 OMIDRIA 3 tetracaine hcl (pf) OPHTHALMIC - 1 ophthalmic (eye) PHOTODYNAMI OPHTHALMIC - C THERAPY LOCAL AGENTS ANESTHETIC, VISUDYNE 4 AMIDES OPHTHALMIC - AKTEN (PF) 3 RHO KINASE OPHTHALMIC - INHIBITOR AND MACULAR PROSTAGLANDI DEGENERATION, N ANALOG AGE-RELATED, COMBINATION THERAPY ROCKLATAN 3 AGENTS OPHTHALMIC - bevacizumab intravitreal SURGICAL AID 4 syringe 2.5 mg/0.1 ml COMBINATIONS EYLEA VISCOAT 1 INTRAVITREAL 4 SOLUTION OPHTHALMIC - SURGICAL AIDS LUCENTIS INTRAVITREAL 4 PA OTHER SOLUTION SILIKON 3 LUCENTIS OPHTHALMIC - INTRAVITREAL 4 PA VISCOELASTIC SYRINGE 0.3 MG/0.05 AGENTS ML AMVISC 1 OPHTHALMIC - MAST CELL AMVISC PLUS 1 STABILIZERS BIOLON 4 ALOCRIL 3 PA HEALON ENDOCOAT 4 ALOMIDE 3 PA HEALON GV 4 cromolyn ophthalmic HEALON PRO 4 1 (eye) HEALON5 4 HEALON5 PRO 4 VISCOAT 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 244 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC gatifloxacin 3 ANTIBACTERIAL levofloxacin ophthalmic 3 MIXTURES (eye) bacitracin-polymyxin b MOXEZA 1 3 ophthalmic (eye) moxifloxacin 3 neomycin-bacitracin- ophthalmic (eye) drops 3 polymyxin moxifloxacin neomycin-polymyxin- ophthalmic (eye) drops, 1 3 gramicidin viscous NEO-POLYCIN 3 moxifloxacin-sod chlor,iso(pf) intraocular 3 POLYCIN 3 solution 5 mg/ml polymyxin b sulf- 1 moxifloxacin-sod trimethoprim chlor,iso(pf) intraocular 4 POLYTRIM 3 syringe OPHTHALMIC OCUFLOX 3 ANTIBIOTIC - ofloxacin ophthalmic 1 AMINOGLYCOSI (eye) DES VIGAMOX 1 GENTAK ZYMAXID 3 OPHTHALMIC (EYE) 3 OINTMENT OPHTHALMIC ANTIBIOTIC - gentamicin ophthalmic 1 (eye) MACROLIDES tobramycin ophthalmic AZASITE 3 1 (eye) erythromycin 1 TOBREX 3 ophthalmic (eye) OPHTHALMIC OPHTHALMIC ANTIBIOTIC - ANTIBIOTIC - DEHYDROPEPTI SULFONAMIDES DASE BLEPH-10 3 INHIBITORS sulfacetamide sodium 1 bacitracin ophthalmic ophthalmic (eye) 3 (eye) OPHTHALMIC OPHTHALMIC ANTIFUNGALS - ANTIBIOTIC - TETRAENE FLUOROQUINOL POLYENE-TYPE ONES NATACYN 1 BESIVANCE 3 OPHTHALMIC CILOXAN 3 ANTIFUNGALS ciprofloxacin hcl NATACYN 1 1 ophthalmic (eye) You can find information on what the symbols and abbreviationson this table mean on page 4. 245 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC OPHTHALMIC- ANTISEPTICS INTRAOCULAR BETADINE PRESSURE 3 OPHTHALMIC PREP REDUCING OPHTHALMIC AGENTS, RHO ANTIVIRALS KINASE INHIBITORS trifluridine 1 RHOPRESSA 3 ZIRGAN 3 OPHTHALMIC- VASCULAR INTRAOCULAR ENDOTHELIAL PRESS. GROWTH REDUCING, SEL. FACTOR (VEGF- ALPHA A) RECEPTOR ADRENERGIC ANTAGONISTS bevacizumab intravitreal AGONISTS 4 syringe 2.5 mg/0.1 ml ALPHAGAN P 1 LUCENTIS apraclonidine 3 INTRAVITREAL 4 PA brimonidine 1 SOLUTION IOPIDINE LUCENTIS OPHTHALMIC (EYE) 3 INTRAVITREAL 4 PA DROPPERETTE SYRINGE 0.3 MG/0.05 OPHTHALMIC- ML INTRAOCULAR VASCULAR PRESSURE ENDOTHELIAL REDUCING GROWTH AGENTS, FACTOR(VEGF-A PROSTAGLANDI AND N ANALOGS PLGF)RECEPTO bimatoprost ophthalmic R INHIBITORS 3 (eye) EYLEA latanoprost 1 INTRAVITREAL 4 SOLUTION latanoprost (pf) 3 LUMIGAN OTIC (EAR) OPHTHALMIC (EYE) 3 OTIC (EAR) - DROPS 0.01 % ANTI- TRAVATAN Z 1 INFECTIVE- VYZULTA 3 GLUCOCORTICO XALATAN 3 PA ID XELPROS 3 PA COMBINATIONS ZIOPTAN (PF) 3 CIPRO HC 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 246 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CIPRODEX 1 RESPIRATORY neomycin-polymyxin-hc 1 THERAPY otic (ear) AGENTS OTOVEL 3 1ST OTIC (EAR) - GENERATION ANTI- ANTIHISTAMINE INFECTIVES - OTHER DECONGESTANT acetic acid otic (ear) 1 COMBINATIONS OTIC (EAR) - CENTERGY 3 FLUOROQUINOL PROMETHAZINE VC 1 ONES 2ND CETRAXAL 3 GENERATION ciprofloxacin hcl otic 3 ANTIHISTAMINE (ear) - ofloxacin otic (ear) 1 DECONGESTANT OTIPRIO 3 COMBINATIONS CLARINEX-D 12 OTIC (EAR) - 3 GLUCOCORTICO HOUR IDS SEMPREX-D 3 DERMOTIC OIL 3 ANTIHISTAMINE FLAC OTIC OIL 3 - 1ST fluocinolone acetonide GENERATION - 1 oil ALKYLAMINES hydrocortisone-acetic brompheniramine 1 3 acid maleate (bulk) OTIC (EAR) - RYCLORA 3 PINNA ANTIHISTAMINE COMBINATIONS - 1ST CORTANE-B GENERATION - 3 TOPICAL ETHANOLAMINE S carbinoxamine maleate 2 PA oral liquid carbinoxamine maleate 2 PA oral tablet 4 mg carbinoxamine maleate 3 oral tablet 6 mg clemastine oral tablet 2 PA 2.68 mg

You can find information on what the symbols and abbreviationson this table mean on page 4. 247 Drug Name Drug Tier Limits Drug Name Drug Tier Limits diphenhydramine (bulk) 3 carbinoxamine maleate 3 diphenhydramine hcl oral tablet 6 mg injection solution 50 4 clemastine oral tablet 2 PA mg/ml 2.68 mg diphenhydramine hcl cyproheptadine 1 4 injection syringe diphenhydramine hcl KARBINAL ER 3 injection solution 50 4 ANTIHISTAMINE mg/ml diphenhydramine hcl - 1ST 4 GENERATION - injection syringe PHENOTHIAZIN KARBINAL ER 3 ES PHENERGAN INJECTION 3 PHENERGAN SOLUTION 25 MG/ML INJECTION 3 SOLUTION 25 MG/ML PHENERGAN INJECTION 1 PHENERGAN SOLUTION 50 MG/ML INJECTION 1 SOLUTION 50 MG/ML promethazine (bulk) 3 promethazine injection promethazine injection 3 3 solution 25 mg/ml solution 25 mg/ml promethazine injection promethazine injection 1 1 solution 50 mg/ml solution 50 mg/ml promethazine oral tablet 1 promethazine oral tablet 1 promethazine rectal promethazine rectal suppository 12.5 mg, 25 1 suppository 12.5 mg, 25 1 mg mg promethazine rectal promethazine rectal 3 3 suppository 50 mg suppository 50 mg PROMETHEGAN 1 PROMETHEGAN 1 pyrilamine maleate ANTIHISTAMINE 3 - 1ST (bulk) GENERATION - RYCLORA 3 PIPERIDINES ANTIHISTAMINE cyproheptadine 1 S - 2ND GENERATION - ANTIHISTAMINE PIPERAZINES S - 1ST levocetirizine oral GENERATION 3 solution carbinoxamine maleate 2 PA oral liquid QUZYTTIR 4 carbinoxamine maleate 2 PA oral tablet 4 mg

You can find information on what the symbols and abbreviationson this table mean on page 4. 248 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHISTAMINE ASTHMA S - 2ND THERAPY - GENERATION - ALPHA/BETA PIPERIDINES ADRENERGIC CLARINEX ORAL AGENTS 3 TABLET ADRENALIN QL (3 ML per INJECTION 3 desloratadine oral tablet 1 21 days) SOLUTION 1 MG/ML desloratadine oral 3 tablet,disintegrating epinephrine (bulk) 3 epinephrine injection QL (3 ML per ANTIHISTAMINE 2 S - 2ND solution 1 mg/ml 21 days) epinephrine injection QL (3 ML per GENERATION 2 syringe 0.1 mg/ml 21 days) CLARINEX ORAL 3 TABLET ASTHMA desloratadine oral tablet 1 THERAPY - INHALED desloratadine oral 3 tablet,disintegrating CORTICOSTERO IDS levocetirizine oral 3 solution (GLUCOCORTIC OIDS) QUZYTTIR 4 ALVESCO 3 ANTITUSSIVES - NON-OPIOID ARMONAIR RESPICLICK dextromethorphan hbr 3 INHALATION (bulk) AEROSOL POWDR 3 PA AROMATIC BREATH ANTITUSSIVE ACTIVATED 232 MCG/ACTUATION DEMULCENTS ARMONAIR menthol (bulk) 1 RESPICLICK ASTHMA INHALATION THERAPY - 5- AEROSOL POWDR 3 LIPOXYGENASE BREATH ACTIVATED 55 INHIBITORS MCG/ACTUATION zileuton 3 ARNUITY ELLIPTA 3 ZYFLO 3 ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 3 MCG/ACTUATION, 200 MCG/ACTUATION

You can find information on what the symbols and abbreviationson this table mean on page 4. 249 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ASMANEX ASTHMA TWISTHALER THERAPY - INHALATION INTERLEUKIN-5 AEROSOL POWDR BREATH (IL-5) RECEPTOR ACTIVATED 110 ALPHA MCG/ ACTUATION ANTAGONISTS, 3 (30), 220 MCG/ MAB ACTUATION (120), FASENRA 2 PA 220 MCG/ ACTUATION (14), 220 FASENRA PEN 2 PA MCG/ ACTUATION ASTHMA (30), 220 MCG/ THERAPY - ACTUATION (60) LEUKOTRIENE beclomethasone diprop 3 RECEPTOR (bulk) ANTAGONISTS budesonide inhalation 1 ACCOLATE 3 FLOVENT DISKUS 1 montelukast oral 1 PA FLOVENT HFA 1 granules in packet flunisolide (bulk) 3 montelukast oral tablet 1 PULMICORT 3 montelukast oral 1 PULMICORT tablet,chewable 1 FLEXHALER SINGULAIR ORAL QVAR REDIHALER 3 GRANULES IN 1 ASTHMA PACKET SINGULAIR ORAL THERAPY - 3 INTERLEUKIN-4 TABLET SINGULAIR ORAL (IL-4) RECEPTOR 3 ALPHA TABLET,CHEWABLE ANTAGONISTS, zafirlukast 2 PA MAB ASTHMA DUPIXENT SYRINGE THERAPY - SUBCUTANEOUS MAST CELL 3 PA SYRINGE 200 STABILIZERS MG/1.14 ML cromolyn (bulk) 1 DUPIXENT SYRINGE cromolyn inhalation 1 SUBCUTANEOUS 3 SYRINGE 300 MG/2 ASTHMA ML THERAPY - MONOCLONAL ANTIBODIES TO IMMUNOGLOBU LIN E (IGE) XOLAIR 2 PA You can find information on what the symbols and abbreviationson this table mean on page 4. 250 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ASTHMA NUCALA THERAPY - SUBCUTANEOUS 3 PA XANTHINES RECON SOLN NUCALA aminophylline (bulk) 3 SUBCUTANEOUS 3 PA aminophylline 4 SYRINGE 100 MG/ML intravenous ASTHMA/COPD - ELIXOPHYLLIN PHOSPHODIEST ORAL ELIXIR 80 3 MG/15 ML ERASE-4 (PDE4) INHIBITORS THEO-24 3 DALIRESP 2 THEOCHRON 1 theophylline (bulk) 3 ASTHMA/COPD - ANTICHOLINER theophylline in dextrose 5 % intravenous GIC AGENTS, parenteral solution 200 INHALED LONG 4 mg/100 ml, 200 mg/50 ACTING ml, 400 mg/250 ml, 800 INCRUSE ELLIPTA 3 mg/250 ml LONHALA MAGNAIR theophylline oral 3 1 REFILL solution LONHALA MAGNAIR 3 theophylline oral tablet STARTER extended release 12 hr 1 300 mg, 450 mg SEEBRI NEOHALER 3 theophylline oral tablet SPIRIVA RESPIMAT 3 1 extended release 24 hr SPIRIVA WITH 1 ASTHMA HANDIHALER THERAPY- TUDORZA PRESSAIR 3 MONOCLONAL YUPELRI 3 PA ANTIBODY - ASTHMA/COPD - INTERLEUKIN-5 ANTICHOLINER (IL-5) GIC AGENTS, ANTAGONISTS INHALED SHORT NUCALA 100 MG/ML ACTING AUTO-INJECTOR 2 PA ATROVENT HFA 1 LATEX-FREE, P/F, ipratropium bromide SUV 1 (bulk) NUCALA 100 MG/ML 2 PA ipratropium bromide SYRINGE 1 inhalation NUCALA SUBCUTANEOUS 3 PA AUTO-INJECTOR 100 MG/ML

You can find information on what the symbols and abbreviationson this table mean on page 4. 251 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ASTHMA/COPD - VENTOLIN HFA 3 BETA 2- XOPENEX 3 ADRENERGIC XOPENEX 3 AGENTS, CONCENTRATE INHALED, XOPENEX HFA 3 ULTRA-LONG ASTHMA/COPD ACTING THERAPY - BETA ARCAPTA 3 ADRENERGIC NEOHALER AGENTS STRIVERDI 3 albuterol sulfate oral 1 RESPIMAT metaproterenol oral 3 PA ASTHMA/COPD syrup THERAPY - BETA terbutaline 3 2-ADRENERGIC AGENTS, ASTHMA/COPD INHALED, LONG THERAPY - BETA ACTING ADRENERGIC- ANTICHOLINER BROVANA 3 GIC PERFOROMIST 3 COMBINATIONS QL (56 EA per SEREVENT DISKUS 1 ANORO ELLIPTA 3 23 days) BEVESPI 3 ASTHMA/COPD AEROSPHERE THERAPY - BETA COMBIVENT 1 2-ADRENERGIC RESPIMAT AGENTS, ipratropium-albuterol 1 INHALED, SHORT ACTING STIOLTO RESPIMAT 1 UTIBRON albuterol sulfate (bulk) 3 3 NEOHALER albuterol sulfate inhalation hfa aerosol 3 ASTHMA/COPD inhaler THERAPY - BETA albuterol sulfate ADRENERGIC- inhalation solution for 1 GLUCOCORTICO nebulization ID levalbuterol hcl 3 COMBINATIONS levalbuterol tartrate 3 ADVAIR DISKUS 1 QL (2 inhalers ADVAIR HFA 1 PROAIR HFA 2 Max Qty Per AIRDUO RESPICLICK 3 PA Fill Retail) BREO ELLIPTA 3 PA PROAIR RESPICLICK 3 budesonide-formoterol 1 PROVENTIL HFA 1

You can find information on what the symbols and abbreviationson this table mean on page 4. 252 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DULERA TOBI PODHALER INHALATION HFA INHALATION AEROSOL INHALER CAPSULE, 2 PA 100-5 1 W/INHALATION MCG/ACTUATION, DEVICE 200-5 PA; QL (280 tobramycin in 0.225 % MCG/ACTUATION 2 ML per 23 nacl fluticasone propion- days) salmeterol inhalation 3 PA CYSTIC aerosol powdr breath activated FIBROSIS - INHALED fluticasone propion- salmeterol inhalation 1 MONOBACTAMS blister with device CAYSTON 2 PA; ST SYMBICORT 1 CYSTIC WIXELA INHUB 3 PA FIBROSIS- ASTHMA/COPD TRANSMEMBRA TX - BETA- NE ADRENERGIC- CONDUCTANCE ANTICHOLINER REGULATOR GIC- (CFTR) GLUCOCORTICO POTENTIATOR ID COMB, KALYDECO ORAL GRANULES IN 2 PA TRELEGY ELLIPTA PACKET 25 MG INHALATION BLISTER WITH 3 PA KALYDECO ORAL GRANULES IN DEVICE 100-62.5-25 2 MCG PACKET 50 MG, 75 MG CORTICOSTERO KALYDECO ORAL ID IMPLANT FOR 2 TABLET MAINTAINING SINUS PATENCY CYSTIC FIB- TRANSMEMB SINUVA 4 CONDUCT. CYSTIC REG.(CFTR) FIBROSIS - POTENTIATOR INHALED AND AMINOGLYCOSI CORRECTOR DES CMB BETHKIS 2 PA ORKAMBI ORAL 2 KITABIS PAK 2 PA TABLET 200-125 MG TOBI 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 253 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SYMDEKO ORAL ipratropium bromide QL (30 ML per TABLETS, nasal spray,non-aerosol 1 2 PA 23 days) SEQUENTIAL 100-150 0.03 % MG (D)/ 150 MG (N) ipratropium bromide QL (15 ML per SYMDEKO ORAL nasal spray,non-aerosol 1 23 days) TABLETS, 42 mcg (0.06 %) 3 SEQUENTIAL 50-75 NASAL MG (D)/ 75 MG (N) ANTIHISTAMINE TRIKAFTA 3 AND ANTI- ELASTASE INFLAMMATOR INHIBITORS Y STEROID ARALAST NP 4 COMBINATIONS GLASSIA 4 PA DYMISTA 3 PROLASTIN-C 4 NASAL ZEMAIRA 4 ANTIHISTAMINE EXPECTORANTS S azelastine nasal QL (60 ML per - SINGLE 2 AGENTS, aerosol,spray 23 days) azelastine nasal GENERAL 2 PA spray,non-aerosol guaifenesin (bulk) 3 olopatadine nasal 3 LUNG SURFACTANTS PATANASE 3 CUROSURF 3 NASAL CORTICOSTERO INFASURF 3 IDS SURFAXIN 3 beclomethasone diprop 3 SURVANTA 3 (bulk) MUCOLYTICS BECONASE AQ 2 PA acetylcysteine 1 flunisolide (bulk) 3 PULMOZYME 2 PA flunisolide nasal QL (50 ML per spray,non-aerosol 25 2 NASAL 23 days) ANESTHETICS mcg (0.025 %) QL (17 GM per cocaine nasal 4 mometasone nasal 1 23 days) GOPRELTO 4 QL (17 GM per NASONEX 3 NASAL 23 days) ANTICHOLINER OMNARIS 1 GICS QNASL 3 ipratropium bromide 1 TICANASE 3 (bulk) ZETONNA 3

You can find information on what the symbols and abbreviationson this table mean on page 4. 254 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NASAL POST- phenylephrine hcl (bulk) 3 SURGICAL pseudoephedrine hcl 3 AGENTS (bulk) SINUVA 4 VAGINAL NASAL PRODUCTS SYMPATHOMIM VAGINAL ETIC ANTIBACTERIAL DECONGESTANT - LINCOSAMIDES S (INTRANASAL) CLEOCIN VAGINAL 3 ADRENALIN NASAL 3 CREAM TYZINE NASAL CLEOCIN VAGINAL 3 1 DROPS 0.1 % SUPPOSITORY TYZINE NASAL clindamycin phosphate 1 SPRAY,NON- 3 vaginal AEROSOL CLINDESSE 3 PLEURAL VAGINAL SCLEROSING ANTIFUNGAL - AGENTS IMIDAZOLES STERITALC 4 GYNAZOLE-1 3 PULMONARY MICONAZOLE-3 QL (3 EA per FIBROSIS VAGINAL 2 23 days) TREATMENT SUPPOSITORY AGENTS - VAGINAL ANTIFIBROTIC ANTIFUNGAL - THERAPY TRIAZOLES ESBRIET 2 PA terconazole vaginal QL (180 GM 2 PULMONARY cream 0.4 % per 23 days) terconazole vaginal QL (80 GM per FIBROSIS 2 TREATMENT cream 0.8 % 23 days) terconazole vaginal QL (12 EA per AGENTS - 3 MULTIKINASE suppository 23 days) INHIBITORS VAGINAL OFEV 2 PA ANTIPROTOZOA L- SYSTEMIC ANTIBACTERIAL SYMPATHOMIM - NITROIMIDAZO ETIC LE DECONGESTANT DERIVATIVES S METROGEL ephedrine hcl (bulk) 3 3 VAGINAL ephedrine sulfate (bulk) 3 metronidazole vaginal 1 You can find information on what the symbols and abbreviationson this table mean on page 4. 255 Drug Name Drug Tier Limits NUVESSA 3 VANDAZOLE 1 VAGINAL ANTISEPTIC MIXTURES FEM PH 3 RELAGARD 3 TRIMO-SAN JELLY 3 VAGINAL ESTROGENS ESTRACE VAGINAL 1 estradiol vaginal tablet 1 ESTRING 1 FEMRING 3 PREMARIN 1 VAGINAL VAGIFEM 1 YUVAFEM 1 VAGINAL PRODUCTS MISCELLANEOU S CLEANSING WASH 3 TOPICAL SOLUTION SUMMER'S EVE 3 FEMININE WASH VAGINAL PROGESTINS CRINONE VAGINAL 3 GEL 4 %

You can find information on what the symbols and abbreviationson this table mean on page 4. 256 You can find information on what the symbols and abbreviationson this table mean on page 4. 257 Medical Benefit Drug Name Drug Tier Limits amikacin injection solution 1,000 mg/4 ml, 4 PA 500 mg/2 ml aztreonam injection 4 PA recon soln 1 gram CINQAIR 4 ganciclovir intravenous 4 gentamicin injection 4 PA solution 40 mg/ml gentamicin sulfate (ped) 4 (pf) hydroxyprogest(pf)(preg 4 PA presv) hydroxyprogesterone 4 PA cap(ppres) hydroxyprogesterone 4 caproate MAKENA 4 PA MAKENA (PF) 4 penicillin g potassium injection recon soln 5 2 PA million unit PFIZERPEN-G 4 polymyxin b sulfate 4

You can find information on what the symbols and abbreviationson this table mean on page 4. 258 You can find information on what the symbols and abbreviationson this table mean on page 4. 259 Index (d)-limonene flavor (bulk) 105, 115 ACIDOPHILUS EX STR (L. adenosine...... 69 5-AMINOSALICYLIC ACID..105 SPOROG)...... 202 adenosine (bulk)...... 69, 105, 143 5-hydroxy-l-tryptophan (bulk) ACIDOPHILUS PROBIOTIC adenosine (diagnostic)...... 143 ...... 105, 148 BLEND...... 202 ADHANSIA XR...... 94 7-KETO DHEA, acidophilus-pectin, citrus...... 202 ADLYXIN...... 182 MICRONIZED...... 12, 105 ACIPHEX...... 197 ADMELOG SOLOSTAR U- A THRU Z ADVANCED ACIPHEX SPRINKLE...... 197 100 INSULIN...... 190 FORMULA...... 164 acitretin...... 130 ADMELOG U-100 INSULIN A THRU Z SELECT...... 160 ACTEMRA...... 23 LISPRO...... 190 abacavir...... 37 ACTEMRA ACTPEN...... 23 ADRENALIN...... 75, 76, 249, 255 abacavir-lamivudine...... 38 ACTHAR...... 179 ADREVIEW...... 144 abacavir-lamivudine-zidovudine 38 ACTHIB (PF)...... 64 ADRIAMYCIN...... 58 ABATRON...... 155 ACTHREL...... 143 ADRUCIL...... 51 ABELCET...... 34 ACTICAL...... 160 ADULT MULTIVITAMIN ABILIFY...... 93, 97 ACTICLATE...... 47 GUMMIES...... 160 ABILIFY MAINTENA...... 93 ACTICOAT 7 DRESSING...... 141 ADULT ONE DAILY ABILIFY MYCITE...... 93, 97 ACTIGALL...... 197 GUMMIES...... 160 abiraterone...... 48, 50 ACTIMMUNE...... 35 ADVAIR DISKUS...... 252 ABLYSINOL...... 79 ACTIQ...... 14 ADVAIR HFA...... 252 ABRAXANE...... 57 ACTIVASE...... 214 ADVANCED ALLERGY ABSORICA...... 123 activated charcoal...... 198 COLLECT KIT...... 133 acacia (bulk)...... 105 ACTIVE FE...... 155 ADVANCED CALCIUM...... 151 acamprosate...... 105 ACTIVELLA...... 185 ADVANTAGE WITH IRON... 149 ACANYA...... 124 ACTIVE-PAC...... 84, 103 ADZENYS ER...... 94, 98 acarbose...... 181 ACTIVITE...... 146 ADZENYS XR-ODT...... 94, 98 ACCOLATE...... 250 ACTONEL...... 184 AEMCOLO...... 47 ACCU-CHEK COMBO ACTOPLUS MET...... 182 AEROCHAMBER MV.... 225, 228 SYSTEM...... 227, 228 ACTOS...... 190 AEROCHAMBER PLUS ACCU-CHEK SPIRIT ACUICYN...... 133 FLOW-VU...... 225, 228 ADAPTER...... 225, 228 ACULAR...... 242 AEROCHAMBER PLUS ACCUPRIL...... 66 ACULAR LS...... 242 FLOW-VU,L MSK...... 225, 228 ACCURETIC...... 66 ACUVAIL (PF)...... 242 AEROCHAMBER PLUS ACD SOLUTION A...... 209 acyclovir...... 43, 131 FLOW-VU,M MSK...... 225, 228 ACE AEROSOL CLOUD acyclovir (bulk)...... 43, 105 AEROCHAMBER PLUS ENHANCER...... 225, 228 acyclovir sodium...... 43 FLOW-VU,S MSK...... 225, 228 acebutolol...... 72 ACZONE...... 124 AEROCHAMBER WITH acebutolol (bulk)...... 73, 105 ADACEL(TDAP FLOWSIGNAL...... 225, 228 ACETADOTE...... 30 ADOLESN/ADULT)(PF)...... 64 AEROTRACH PLUS...... 225, 228 acetaminophen (bulk)...... 20, 105 ADALAT CC...... 74 AFINITOR...... 55 acetaminophen-caff-dihydrocod. 17 adapalene...... 126 AFINITOR DISPERZ...... 55 acetaminophen-codeine...... 17 adapter cap for bottle...... 223, 228 AFIRMELLE...... 120 acetazolamide...... 78 ADASUVE...... 92 AFREZZA...... 189 acetazolamide (bulk)...... 78, 105 ADCETRIS...... 50, 59 AGGRASTAT IN SODIUM acetazolamide sodium...... 78 ADCIRCA...... 81 CHLORIDE...... 213 acetic acid...... 204, 247 ADDAMEL N...... 160 AGGRENOX...... 213 acetone...... 113 ADDERALL...... 94, 98, 102 AGRYLIN...... 213 acetylcarnitine...... 145 ADDERALL XR...... 94, 98 A-HYDROCORT...... 186 acetylcholine chloride (bulk) ADDYI...... 99 AIMOVIG AUTOINJECTOR ...... 105, 240 adefovir...... 43 ...... 99, 100 acetylcysteine...... 30, 254 ADEMPAS...... 81 AIRDUO RESPICLICK...... 252 ADENOSCAN...... 143

260 AIRS DISPOSABLE alkyl (c12-15) benzoate (bulk) AMERGE...... 100 NEBULIZER...... 223, 228 ...... 105, 118 AMERIPHOR...... 131 AIRSHIELD...... 160 ALLERGIST TRAY 1/2 ML AMERISTORE...... 132 AIRSHIELD IMMUNE...... 13 27GX3/8"...... 224, 228 AMETHIA...... 119 AJOVY SYRINGE...... 99, 100 ALLERGIST TRAY AMETHIA LO...... 119 AK-FLUOR...... 243 INTRADERMAL BEV.... 224, 228 AMETHYST (28)...... 120 AKOVAZ...... 76 ALLEVYN...... 141, 228 AMICAR...... 210 AKTEN (PF)...... 244 allopurinol...... 209 AMIDATE...... 27 AKYNZEO ALLZITAL...... 20 amikacin...... 258 (FOSNETUPITANT)...... 196 almotriptan malate...... 100 amiloride...... 78 AKYNZEO (NETUPITANT)...196 ALOCRIL...... 244 amiloride-hydrochlorothiazide....78 ALA-CORT...... 133 ALOE GRANDE...... 131 aminobenzoic acid (bulk)..106, 208 ALBA-LYBE...... 146 aloe vera (bulk)...... 13, 106 aminocaproic acid...... 210 albendazole...... 33 alogliptin...... 181 aminophylline...... 251 ALBENZA...... 33 alogliptin-metformin...... 183 aminophylline (bulk)...... 106, 251 ALBUKED-25...... 212 alogliptin-pioglitazone...... 183 AMINOPROTECT...... 166 ALBUKED-5...... 212 ALOMIDE...... 244 aminosalicylic acid (bulk)...38, 106 albumin, human 25 %...... 212 ALOPRIM...... 209 AMINOSALICYLIC ACID-5..106 albumin, human 5 %...... 212 ALORA...... 185 AMINOSYN 10 %...... 168 ALBUMINAR 25 %...... 212 alosetron...... 200, 202 AMINOSYN 3.5 %...... 168 ALBUMINAR 5 %...... 212 ALOXI...... 195 AMINOSYN 7 %...... 168 ALBUMINEX...... 212 ALPHABATH...... 131 AMINOSYN 7 % WITH ALBURX (HUMAN) 25 %...... 212 ALPHAGAN P...... 246 ELECTROLYTES...... 167 ALBURX (HUMAN) 5 %...... 212 alprazolam...... 82, 95 AMINOSYN 8.5 %...... 168 ALBUTEIN 25 %...... 212 ALPRAZOLAM INTENSOL AMINOSYN 8.5 %- ALBUTEIN 5 %...... 212 ...... 82, 95 ELECTROLYTES...... 167 albuterol sulfate...... 252 alprostadil...... 80 AMINOSYN II 10 %...... 168 albuterol sulfate (bulk)...... 105, 252 ALREX...... 241 AMINOSYN II 15 %...... 168 alclometasone...... 133 ALSUMA...... 100 AMINOSYN II 7 %...... 168 ALCOHOL, DENATURED.....113 ALTABAX...... 127 AMINOSYN II 8.5 %...... 168 ALDACTAZIDE...... 78 ALTACAINE...... 244 AMINOSYN II 8.5 %- ALDACTONE...... 66, 77 ALTACE...... 66 ELECTROLYTES...... 167 ALDARA...... 136 ALTAFLUOR BENOX...... 243 AMINOSYN M 3.5 %...... 167, 168 ALDURAZYME...... 234 ALTAVERA (28)...... 120 AMINOSYN-HBC 7%...... 168 ALECENSA...... 50 ALTOPREV...... 70 AMINOSYN-PF 10 %...... 168 alendronate...... 184 ALTRENO...... 126 AMINOSYN-PF 7 % alfentanil...... 14 aluminum, (acetato-o)dih(bulk) 106 (SULFITE-FREE)...... 168 ALFERON N...... 136 ALUNBRIG...... 50 AMINOSYN-RF 5.2 %...... 168 alfuzosin...... 205 ALVESCO...... 249 amiodarone...... 69 ALGAL OMEGA-3 DHA...... 72 ALYACEN 1/35 (28)...... 120 amiodarone in dextrose 5 %...... 69 ALGAL-900 DHA...... 72 ALYACEN 7/7/7 (28)...... 122 AMITIZA...... 200, 202 alginic acid (bulk)...... 105, 118 ALYQ...... 81 amitriptyline...... 89 ALIMTA...... 50 AMABELZ...... 185 amitriptyline (bulk)...... 89, 106 ALINIA...... 35, 36 amantadine hcl...... 90 amitriptyline-chlordiazepoxide ALIQOPA...... 55, 56 amantadine hcl (bulk)...... 90, 106 ...... 88, 95 aliskiren...... 81 AMARYL...... 182 AMLACTIN...... 131 ALIVE ONCE DAILY AMBIEN...... 103 amlodipine...... 74 WOMEN 50 PLUS...... 160 AMBIEN CR...... 103 amlodipine-atorvastatin...... 72 ALIVE PRENATAL...... 174 AMBISOME...... 34 amlodipine-benazepril...... 66 ALIVE WOMEN'S ENERGY..160 ambrisentan...... 81 amlodipine-olmesartan...... 67 ALKERAN...... 49 amcinonide...... 133 amlodipine-valsartan...... 67 ALKERAN (AS HCL)...... 49 AMELUZ...... 138 amlodipine-valsartan-hcthiazid...67

261 ammonium chloride...... 78, 206 ANIMI-3 WITH VITAMIN D. 164 argatroban in 0.9 % sod chlor... 214 ammonium sulfate (bulk)...... 106 anise flavor extract (bulk).106, 115 argatroban in nacl (iso-os)...... 214 AMMONUL...... 236 ANNOVERA...... 123 arginine (l-arginine)...... 145 AMNESTEEM...... 123 ANORO ELLIPTA...... 252 arginine hcl (l-arginine)...... 146 amoxapine...... 89 ANTABUSE...... 105 arginine-lysine in 0.9 % nacl.... 166 amoxicil-clarithromy-lansopraz 204 ANTARA...... 70 ARICEPT...... 118 amoxicillin...... 33 anthralin (bulk)...... 106, 130 ARIKAYCE...... 32 amoxicillin-pot clavulanate...... 32 ANTI MONKEY BUTT...... 139 ARIMIDEX...... 51 AMPHADASE...... 193 anticoag citrate phos dextrose...209 aripiprazole...... 93, 97 amphetamine...... 94, 98 ANTIVERT...... 194 ARISTADA...... 93 amphetamine sulfate..... 94, 98, 102 APADAZ...... 18 ARISTADA INITIO...... 93 amphotericin b...... 34 APATATE...... 175 ARISTOSPAN INTRA- ampicillin...... 33 APETEX...... 146 ARTICULAR...... 186 ampicillin sodium...... 33 APETIGEN...... 146 ARISTOSPAN ampicillin-sulbactam...... 32, 33 APETIGEN PLUS...... 147, 155 INTRALESIONAL...... 186 AMPYRA...... 239 APIDRA SOLOSTAR U-100 ARIXTRA...... 212 AMRIX...... 218 INSULIN...... 190 ARKALIOX...... 176 AMVISC...... 244 APIDRA U-100 INSULIN...... 190 armodafinil...... 102 AMVISC PLUS...... 244 APLENZIN...... 89 ARMONAIR RESPICLICK.....249 AMYTAL...... 103 APOKYN...... 90 ARMOUR THYROID...... 193 AMYVID...... 143 apple flavor (bulk)...... 106, 115 ARNUITY ELLIPTA...... 249 ANADROL-50...... 179 APPLE-ADE FLAVOR....106, 115 AROMASIN...... 51 ANAFRANIL...... 89 apraclonidine...... 246 ARRANON...... 50 anagrelide...... 213 aprepitant...... 195 arsenic trioxide...... 51 ANA-LEX KIT...... 29 APRI...... 120 arsenic trioxide (bulk)...... 51, 106 ANALPRAM-HC...... 29, 135 apricot flavor (bulk)...... 106, 115 ARTHROTEC 50...... 24 ANALPRAM-HC SINGLES...... 29 APRISO...... 200 ARTHROTEC 75...... 24 ANAPROX DS...... 25 APRIZIO PAK...... 137 ARYMO ER...... 14 ANASCORP...... 62 APTENSIO XR...... 94 ARZERRA...... 52 ANASPAZ...... 199, 208 APTIOM...... 85 ASACOL HD...... 200 anastrozole...... 51 APTIVUS...... 46 ASCLERA...... 82 ANAVIP...... 62 APTIVUS (WITH VITAMIN ASCOMP WITH CODEINE...... 17 ANCOBON...... 34, 35 E)...... 46 ASCOR...... 177 ANDEXXA...... 30 AQUA CARE...... 132 ascorbic acid (vitamin c)...... 177 ANDRODERM...... 180 AQUA CARE SODIUM ASHLYNA...... 119 ANDROGEL...... 180 CHLORIDE...... 151 ASMANEX HFA...... 249 ANDROID...... 180 AQUA CARE STERILE ASMANEX TWISTHALER.... 250 ANESTHESIA S/I-40 WATER...... 151 aspirin-dipyridamole...... 213 (PROPOFOL)...... 27 AQUA GLYCOLIC HC...... 135 ASTAGRAF XL...... 215 ANESTHESIA S/I-40A AQUADEKS...... 160 ASTHMAPACK CHILDREN'S (PROPOFOL)...... 27 AQUADEKS PEDIATRIC...... 169 ...... 225, 228 ANESTHESIA S/I-40H AQUANIL SKIN CLEANSER 132 ASTRAMORPH-PF...... 14 (PROPOFOL)...... 27 AQUASOL A...... 175 ATACAND...... 67 ANESTHESIA S/I-40S ARAKODA...... 35 ATACAND HCT...... 67 (PROPOFOL)...... 27 ARALAST NP...... 254 atazanavir...... 46 ANESTHESIA S/I-60 ARANELLE (28)...... 122 ATELVIA...... 184 (PROPOFOL)...... 27 ARANESP (IN atenolol...... 73 ANGELIQ...... 184 POLYSORBATE)...... 210 atenolol-chlorthalidone...... 75 ANIMAL CHEWS...... 170 ARAVA...... 24 ATGAM...... 63 ANIMAL SHAPE VITAMINS 170 ARCALYST...... 21 ATIVAN...... 82, 95, 103 ANIMAL SHAPES ARCAPTA NEOHALER...... 252 atomoxetine...... 95 COMPLETE...... 169, 170 argatroban...... 214 ATOPADERM...... 131

262 ATOPICLAIR...... 131 AYUNA...... 120 BALANCED B-100 atorvastatin...... 70 AYVAKIT...... 56 COMPLEX...... 146 atovaquone...... 35 AZ...... 106, 114 BALANCED B-50...... 147 atovaquone-proguanil...... 35 azacitidine...... 51 BAL-CARE DHA...... 171 atracurium...... 218 AZACTAM...... 45 BAL-CARE DHA ESSENTIAL ATRALIN...... 126 AZASAN...... 23, 216 ...... 171 ATRAPRO CP...... 131 AZASITE...... 245 BALCOLTRA...... 120 ATRAPRO HYDROGEL...... 132 azathioprine...... 23, 216 BALNEOL...... 132 ATREVIS HYDROGEL...106, 114 azathioprine sodium...... 23, 216 balsalazide...... 200 ATRIPLA...... 38 azelaic acid...... 124, 139 balsam peru-castor oil...... 141 ATROPEN...... 79 azelastine...... 241, 254 BALVERSA...... 53 atropine...... 79, 199, 241 AZELEX...... 124, 139 BALZIVA (28)...... 120 atropine (bulk)...... 79, 106, 199 AZESCO...... 174 BANANA CONCENTRATE ATROVENT HFA...... 251 AZILECT...... 90 ...... 106, 115 AUBAGIO...... 239 azithromycin...... 44 BANANA CREAM FLAVOR AUBRA...... 120 AZO CRANBERRY + ...... 106, 115 AUBRA EQ...... 120 PROBIOTIC...... 13 banana creme flavor (bulk) AUGMENTIN...... 33 AZOPT...... 243 ...... 106, 115 AUGMENTIN ES-600...... 33 AZOR...... 67 banana flavor (bulk)...... 106, 115 AUGMENTIN XR...... 33 aztreonam...... 45, 258 BANATROL PLUS...... 194 AUROVELA 1.5/30 (21)...... 120 AZULFIDINE...... 23, 200 BANZEL...... 86 AUROVELA 1/20 (21)...... 120 AZULFIDINE EN-TABS...23, 200 BARACLUDE...... 43 AUROVELA 24 FE...... 120 AZURETTE (28)...... 120 barium sulfate (bulk)...... 106, 142 AUROVELA FE 1.5/30 (28)....120 B COMPLEX...... 147 BASAGLAR KWIKPEN U-100 AUROVELA FE 1-20 (28)...... 120 B COMPLEX 100...... 146, 147 INSULIN...... 189 AURYXIA...... 156, 205 B COMPLEX PLUS VITAMIN BASE B,POLYETHYLENE AUSTEDO...... 101 C...... 146 GLYCOL3350...... 106, 114 AUTOSOFT XC INFUSION B COMPLEX W-VIT C...... 175 BASE W301...... 106, 114 SET 23"...... 227, 228 b complex-vitamin c-folic acid.146 BASE X...... 106, 118 AUVI-Q...... 75 B-100 COMPLEX...... 146 BASE, PCCA POLYPEG.106, 114 AVALIDE...... 67 B12...... 176 BASE, PCCA VANPEN.. 106, 114 AVANDIA...... 190 B-12 DOTS...... 176 BAXDELA...... 42 AVAPRO...... 67 BABY DDROPS...... 177 bcg vaccine, live (pf)...... 63, 64 AVAR...... 124 BABY VITAMIN D3...... 177 B-COMPLEX PLUS VIT C AVAR LS...... 124 BABY WASH...... 140 (CALCIUM)...... 146 AVAR-E GREEN...... 127 BABY'S SUPER DAILY D3....177 B-COMPLEX WITH B-12...... 175 AVAR-E LS...... 124 BACID...... 202 b-complex with vitamin c...... 146 AVASTIN...... 48 bacitracin...... 46, 245 B-COMPLEX WITH AVEED...... 180 bacitracin (bulk)...... 46, 106 VITAMIN C...... 146 AVELOX IN NACL (ISO- bacitracin, micronized (bulk) BD ALLERGIST TRAY REG OSMOTIC)...... 42 ...... 46, 106 BEVEL...... 224, 228 AVIANE...... 120 bacitracin-polymyxin b...... 245 BD FILTER NEEDLE-5 AVIDOXY...... 47 baclofen...... 218 MICRON...... 224, 228 AVIDOXY DK...... 47 baclofen (bulk)...... 106, 218 BD INSULIN SYRINGE U-500 AVITA...... 126 BACMIN...... 160 ...... 223, 228 AVO CREAM...... 132 BACTERIOSTATIC BD PRE-FILLED NORMAL AVODART...... 206 WATER(PARABENS)...... 117 SALINE...... 174 AVONEX...... 238 BACTRIM...... 33 BD SAFETYGLIDE AVOSIL...... 132 BACTRIM DS...... 33 ALLERGIST TRAY...... 224, 228 AVYCAZ...... 40 BAL IN OIL...... 31 BEANO...... 198 AXUMIN...... 144 BALANCED B-100...... 146 AYGESTIN...... 192

263 beclomethasone diprop (bulk) betamethasone valerate...... 133 bitter mask flavoring (bulk) ...... 106, 133, 186, 250, 254 betamethasone valerate (bulk) ...... 106, 115 BECONASE AQ...... 254 ...... 106, 186 BITTERNESS MASK BEELITH...... 157 betamethasone, augmented...... 133 FLAVOR...... 106, 115 BEKYREE (28)...... 120 BETAMIDE...... 132 bivalirudin...... 214 BELBUCA...... 19 BETAPACE...... 69, 73 bivalirudin-0.9 % sodium chlor 214 BELEODAQ...... 53 BETAPACE AF...... 69, 73 BIVIGAM...... 62 belladonna alkaloids-opium...... 200 BETASERON...... 238 blackberry flavor (bulk)....106, 115 belladonna tincture (bulk).106, 199 betaxolol...... 73, 243 BLADDER 2.2...... 160 BELRAPZO...... 49 bethanechol chloride...... 208 bleomycin...... 58 BELSOMRA...... 103 bethanechol chloride (bulk) BLEPH-10...... 245 benazepril...... 66 ...... 106, 208 BLEPHAMIDE...... 240 benazepril-hydrochlorothiazide.. 66 BETHKIS...... 253 BLEPHAMIDE S.O.P...... 240 BENDEKA...... 49 BETIMOL...... 243 BLINCYTO...... 59 BENEFIBER HEALTHY BETOPTIC S...... 243 BLISOVI 24 FE...... 120 SHAPE...... 203 bevacizumab...... 244, 246 BLISOVI FE 1.5/30 (28)...... 120 BENICAR...... 67 BEVESPI AEROSPHERE...... 252 BLISOVI FE 1/20 (28)...... 120 BENICAR HCT...... 67 bexarotene...... 57 BLOXIVERZ...... 217 BENLYSTA...... 24 BEXSERO...... 64 BLUEBERRY FLAVOR..106, 115 BENSAL HP...... 136 BEYAZ...... 120 blunt needle, disposable....224, 228 BENTYL...... 199 BIAFINE EMULSION...... 132 BOCASAL...... 237 BENZACLIN...... 124 bicalutamide...... 50 BODY, HAIR, SKIN AND BENZACLIN PUMP...... 124 BICILLIN C-R...... 46 NAILS...... 160 BENZAMYCIN...... 124 BICILLIN L-A...... 45 BONE DENSITY CALCIUM + BENZEPRO...... 125 BICNU...... 49 D...... 151 BENZEPRO BIDIL...... 82 BONE ESSENTIALS...... 151 (MICROSPHERES)...... 125 BIJUVA...... 185 BONIVA...... 184 benzhydrocodone- BIKTARVY...... 38 BONJESTA...... 194 acetaminophen...... 18 BILTRICIDE...... 33 BOOSTRIX TDAP...... 64 BENZODOX 30...... 47 bimatoprost...... 246 bortezomib...... 56 BENZODOX 60...... 47 BINOSTO...... 184 bosentan...... 81 benzoic acid (bulk)...... 35, 106, 118 BIO-35, GLUTEN FREE...... 160 BOSTON ROUND NATURAL benzoin compound (bulk). 106, 139 BIOCAL...... 151 ...... 223, 228 benzoyl peroxide...... 125 bioflavonoids, citrus (bulk) BOSULIF...... 56 benzoyl peroxide (bulk)...... 106 ...... 106, 177 BOTOX...... 218 benztropine...... 90 BIOGAIA PROTECTIS WITH BOTTLE...... 223, 228 BEPREVE...... 241 VIT D3...... 202 BOTTLETOP DISPENSER BERINERT...... 209 BIOLON...... 244 ADAPTER...... 223, 228 BEROCCA (FA-GUARANA- BIONECT...... 139 BP 10-1...... 124 CAFF)...... 160 BIORPHEN...... 76 BPCO...... 141 BESER...... 133 BIOTECT PLUS...... 160 BRAFTOVI...... 52 BESER KIT...... 135 BIOTHRAX...... 65 BRAINSTRONG PRENATAL 171 BESIVANCE...... 245 biotin...... 177 BREO ELLIPTA...... 252 beta carotene...... 175 biotin (bulk)...... 106, 177 BREVIBLOC...... 69, 73 BETADINE OPHTHALMIC BIOTIN PLUS-CALCIUM BREVIBLOC IN NACL (ISO- PREP...... 246 AND VIT D3...... 160 OSM)...... 69, 73 betamethasone acet,sod phos.... 186 BIOVOL...... 160 BRIDION...... 218 betamethasone dipropionate..... 133 bismuth citrate (bulk)...... 106, 194 BRIELLYN...... 120 betamethasone sod phos (bulk) bismuth subnitrate (bulk)...... 106 BRIGHT BEGINNINGS SOY. 148 ...... 106, 186 bisoprolol fumarate...... 73 BRILINTA...... 213 betamethasone sod phosph- bisoprolol-hydrochlorothiazide...75 brimonidine...... 246 water...... 186 bitter almond oil (bulk).....106, 115 BRISDELLE...... 191

264 BRIVIACT...... 86 BUTTERSCOTCH calcium chloride...... 154 bromfenac...... 242 FLAVORING...... 107, 115 calcium citrate...... 154 bromocriptine...... 90 BYDUREON...... 182 CALCIUM CITRATE + D...... 153 brompheniramine maleate BYDUREON BCISE...... 182 calcium citrate malate-vit d3.....153 (bulk)...... 106, 247 BYETTA...... 182 CALCIUM CITRATE PLUS BROMSITE...... 242 BYSTOLIC...... 73 (VIT B6)...... 161 BROVANA...... 252 cabergoline...... 192 calcium citrate-vitamin d3...... 153 BRUKINSA...... 52, 56 CABLIVI...... 209 CALCIUM DISODIUM BRYHALI...... 130, 133 CABOMETYX...... 55 VERSENATE...... 31 B-STRESS...... 146 ca-d3-mag ox-zinc-cop-mang- CALCIUM FOR WOMEN...... 152 BUBBLE GUM bor...... 151 calcium gluc in nacl, iso-osm... 154 CONCENTRATE...... 107, 115 ca-d3-mag-zinc-cop-mang-bor. 151 calcium glucon monohyd (bulk) bubblegum flavor (bulk)... 107, 115 CADEAU DHA...... 171 ...... 107 budesonide...... 201, 250 CA-DTPA...... 31 calcium gluconate...... 154 budesonide, micronized (bulk) CADUET...... 72 calcium gluconate in 0.9% nacl 154 ...... 107, 186 CAFCIT...... 98 calcium gluconate in water...... 154 budesonide-formoterol...... 252 CAFERGOT...... 100 CALCIUM MAGNESIUM...... 152 bumetanide...... 78 caffeine (bulk)...... 98, 107 CALCIUM MAGNESIUM + D BUMINATE 25 %...... 212 caffeine citrate...... 98, 99 ...... 152 BUMINATE 5 %...... 212 caffeine citrate (bulk)...... 98, 107 calcium phos, tribasic (bulk) BUNAVAIL...... 104 caffeine-sodium benzoate..... 98, 99 ...... 107, 154 BUPAP...... 20 CAL MAG ZINC PLUS D3..... 151 calcium phosphate (bulk)...... 107 BUPHENYL...... 236 CALAN SR...... 75 calcium phosphate-vitamin d3..153 bupivacaine...... 28 CALCET PETITES...... 152 CALCIUM PNV...... 164, 171 bupivacaine (bulk)...... 28, 107 CALCILO XD...... 149 CALCIUM SOFT CHEW...... 152 bupivacaine (pf)...... 28 CALCI-MAX...... 151 CALCIUM WITH BORON...... 152 bupivacaine in nacl(pf)...... 28 calcipotriene...... 130 CALCIUM WITH VITAMIN D bupivacaine-epinephrine...... 29 calcipotriene-betamethasone.....126 ...... 153 bupivacaine-epinephrine (pf)...... 29 calcitonin (salmon)...... 184 CALCIUM-FOLIC ACID- bupivacaine-ketorolac-ketamine.29 CAL-CITRATE...... 152 VITAMIN D...... 152 BUPRENEX...... 19 calcitriol...... 130, 177, 235 calcium-magnesium-copper- buprenorphine...... 20 CALCIUM 500...... 154 zinc...... 157 buprenorphine hcl...... 19, 104 CALCIUM 500 + D...... 152 calcium-magnesium-zinc...... 152 buprenorphine hcl (bulk).... 19, 107 CALCIUM 500 WITH D...... 152 calcium-vitamin d3-vitamin k...152 buprenorphine-naloxone...... 104 CALCIUM 600 + D(3)...... 153 CALDOLOR...... 25 bupropion hcl...... 89, 105 CALCIUM 600 + MINERALS 151 CAL-MAG...... 152 bupropion hcl (bulk)...... 89, 107 CALCIUM 600 WITH CALMAG THINS...... 152 bupropion hcl (smoking deter)..105 VITAMIN D3...... 153 CALPHRON...... 154, 205 buspirone...... 83 calcium acetate...... 154, 205 CALQUENCE...... 52, 56 BUSULFEX...... 49 calcium acetate(phosphat bind) CAL-QUICK...... 153 butalbital (bulk)...... 83, 103, 107 ...... 154, 205 CALTRATE + D3 PLUS BUTALBITAL COMPOUND calcium amino acid chelate...... 154 MINERALS...... 152 W/CODEINE...... 17 calcium carb and citrate-vitd3...153 CALTRATE 600 PLUS D...... 153 butalbital-acetaminop-caf-cod.... 17 calcium carb-d3-mag cmb11- CALTRATE 600-D PLUS butalbital-acetaminophen...... 20 zinc...... 152 MINERALS...... 152 butalbital-acetaminophen-caff.... 20 calcium carb-mag oxide-zinc ox CALTRATE GUMMY BITES.153 butalbital-aspirin-caffeine...... 26 ...... 152 CALTRATE WITH VITAMIN butorphanol...... 20 calcium carb-mag ox-zinc gluc.152 D3...... 153 BUTRANS...... 20 calcium carb-mag ox-zinc sulf..152 CAMBIA...... 25, 26, 100 butter flavor (bulk)...... 107, 115 calcium carbonate...... 154 CAMILA...... 122 butter rum flavor (bulk).... 107, 115 calcium carbonate-vit d3-min... 152 CAMPATH...... 52 butterscotch flavor (bulk)..107, 115 calcium carbonate-vitamin d3...153 CAMPTOSAR...... 57

265 CAMRESE...... 120 CAPSULE CONI-SNAP #2 CATHFLO ACTIVASE...... 214 CAMRESE LO...... 120 (GELATIN)...... 116 CAVERJECT...... 145 CANASA...... 200 CAPSULE CONI-SNAP #3 CAVERJECT IMPULSE...... 144 CANCIDAS...... 34 (GELATIN)...... 116 CAYA CONTOURED..... 220, 228 candesartan...... 67 CAPSULE CONI-SNAP CAYSTON...... 253 candesartan-hydrochlorothiazid..67 #3(HYPROMEL)...... 117 CAZIANT (28)...... 122 CANDIN...... 61 CAPSULE CONI-SNAP #4 cefaclor...... 40 cantharidin in acetone...... 136 (GELATIN)...... 116 cefadroxil...... 40 CAPASTAT...... 38 captopril...... 66 cefazolin...... 40 capecitabine...... 51 captopril-hydrochlorothiazide.....66 cefazolin in 0.9% sod chloride....40 CAPEX...... 133 CARAC...... 129 cefazolin in dextrose (iso-os)...... 40 CAPLYTA...... 92 CARAFATE...... 203 cefdinir...... 40 CAPRELSA...... 56 caramel flavor (bulk)...... 107, 115 cefditoren pivoxil...... 40 CAPSFENAC PAK...... 138 CARBAGLU...... 236 cefepime...... 41 CAPSULE #0...... 116 carbamazepine...... 85, 96 cefepime in dextrose 5 %...... 41 CAPSULE #0 (CELLULOSE). 114 CARBATROL...... 85, 96 cefepime in dextrose,iso-osm..... 41 CAPSULE #0 carbidopa...... 90 cefixime...... 40 (HYPROMELLOSE)...... 116 carbidopa (bulk)...... 90, 107 CEFOTAN...... 40 CAPSULE #0 DRCAPS...... 116 carbidopa-levodopa...... 89 cefotaxime...... 40 CAPSULE #00...... 116 carbidopa-levodopa-entacapone. 89 cefotetan...... 40 CAPSULE #00 (CELLULOSE) carbinoxamine maleate..... 247, 248 cefotetan in dextrose, iso-osm.... 40 ...... 114 CARBOCAINE...... 28, 237 cefoxitin...... 40 CAPSULE #00 carboplatin...... 56 cefoxitin in dextrose, iso-osm.....40 (HYPROMELLOSE)...... 116 carboxymethylcellul.sod.(bulk) 107 cefpodoxime...... 40 CAPSULE #000...... 116 CARDENE IV...... 74 cefprozil...... 40 CAPSULE #1...... 116 CARDENE IV IN DEXTROSE. 74 ceftazidime...... 40 CAPSULE #1 (CELLULOSE). 114 CARDENE IV IN SODIUM ceftazidime in d5w...... 40 CAPSULE #1 CHLORIDE...... 74 ceftriaxone...... 41 (HYPROMELLOSE)...... 116 CARDIZEM...... 74 ceftriaxone in dextrose,iso-os..... 41 CAPSULE #1 DRCAPS...... 116 CARDIZEM CD...... 73 cefuroxime axetil...... 40 CAPSULE #10...... 116 CARDIZEM LA...... 74 cefuroxime sodium...... 40 CAPSULE #13...... 116 CARDURA...... 80 CELACYN...... 132, 226 CAPSULE #2...... 116 CARDURA XL...... 80 CELEBREX...... 25 CAPSULE #3...... 116 carica papaya...... 193 celecoxib...... 25 CAPSULE #3 (CELLULOSE). 114 carisoprodol...... 218 celecoxib (bulk)...... 25, 107 CAPSULE #3 carisoprodol (bulk)...... 107, 218 CELESTONE SOLUSPAN...... 186 (HYPROMELLOSE)...... 116 carisoprodol-aspirin...... 218 CELEXA...... 87 CAPSULE #4...... 116 carisoprodol-aspirin-codeine.... 219 CELLCEPT...... 23, 216 CAPSULE #5...... 116 carmustine...... 49 CELLCEPT INTRAVENOUS CAPSULE #7...... 116 CARNITOR...... 235 ...... 23, 216 CAPSULE CONI-SNAP #0 CARNITOR (SUGAR-FREE)..235 CELONTIN...... 86 (GELATIN)...... 116 carteolol...... 243 CEM-UREA...... 136 CAPSULE CONI-SNAP CARTIA XT...... 74 CENTANY...... 127 #0(HYPROMEL)...... 116 carvedilol...... 66 CENTANY AT...... 127 CAPSULE CONI-SNAP #00 carvedilol phosphate...... 66 CENTERGY...... 247 (GELATIN...... 116 CASODEX...... 50 CENTRAL-VITE WOMEN'S CAPSULE CONI-SNAP #000. 116 caspofungin...... 34 MATURE...... 161 CAPSULE CONI-SNAP #1 castor oil...... 113, 203 CENTRATEX...... 155 (GELATIN)...... 116 CATAPRES...... 77 CENTRAVITES...... 161 CAPSULE CONI-SNAP CATAPRES-TTS-1...... 77 CENTRUM...... 161 #1(HYPROMEL)...... 117 CATAPRES-TTS-2...... 77 CENTRUM CHEWABLES..... 161 CATAPRES-TTS-3...... 77 CENTRUM COMPLETE...... 164

266 CENTRUM MEN...... 161 CHILD CHEWABLE CHOLEXTRA T-F...... 166 CENTRUM SILVER...... 161 VITAMN COMPLETE...... 169 choline,magnesium salicylate..... 26 CENTRUM SILVER ULTRA CHILD COMPLETE chorionic gonadotropin, human 189 MEN'S...... 161 MULTIVITAMIN...... 169 CHROMAGEN(SUMALATE- CENTRUM SILVER WOMEN161 CHILD MULTIVITAMINS.....170 QUATREFOLI)...... 155 CENTRUM SPECIALIST CHILDREN MULTIVITAMIN170 chromium chloride...... 160 ENERGY...... 161 CHILDREN'S CHEW chromium picolinate...... 160 CENTRUM ULTRA MEN'S....161 MULTIVIT-IRON...... 169 CIALIS...... 145, 206 CENTURY ULTIMATE CHILDREN'S CHEWABLE CICATRACE PAD...... 226, 228 MEN'S...... 161 COMPLETE...... 169 CICLODAN...... 128 cephalexin...... 40 CHILDREN'S CHEWABLE ciclopirox...... 128 CEPROTIN (BLUE BAR)...... 214 VITAMIN...... 170 ciclopirox olamine (bulk)..107, 128 CEPROTIN (GREEN BAR).....214 CHILDREN'S CHEWABLES..170 ciclopirox-ure-camph-menth- CEQUA...... 242 CHILDREN'S CHEWABLES euc...... 128 CERACADE...... 132 EXTRA C...... 170 CIDAFLEX...... 12 CERALYTE 50 POTASSIUM CHILDREN'S IRON...... 156 cidofovir...... 41 FREE...... 158 CHILDREN'S MIGRELIEF...... 13 CIFEREX...... 175, 177 CERALYTE 90...... 158 CHILDREN'S MULTI-VIT cilostazol...... 213 CERALYTE-70...... 158 GUMMIES...... 170 CILOXAN...... 245 CERAMAX...... 132 CHILDREN'S CIMDUO...... 37 CERASPORT...... 158 MULTIVITAMIN...... 169, 170 cimetidine...... 197 CERAVE...... 131 CHILD'S CHEWABLE cimetidine hcl...... 197 CERDELGA...... 235 VITAMINS/IRON...... 169 CIMZIA...... 21, 201 CEREBYX...... 84 CHILDS/IRON...... 169 CIMZIA POWDER FOR CEREFOLIN...... 164 CHIRHOSTIM...... 143 RECONST...... 21, 201 CEREFOLIN NAC (ALGAL chloramphenicol (bulk)...... 41, 107 CIMZIA STARTER KIT....21, 201 OIL)...... 175 chloramphenicol sod succinate... 41 cinacalcet...... 184 CERETEC...... 143 chlordiazepoxide hcl...... 82, 95 CINQAIR...... 258 CEREZYME...... 234 chlordiazepoxide-clidinium CINRYZE...... 209 CEROVITE JR...... 169 ...... 95, 199, 200 CINVANTI...... 195 CERTA PLUS...... 161 chlorhexidine (bulk)...... 107, 115 CIPRO...... 42 CERVIDIL...... 179 chlorhexidine gluconate...... 237 CIPRO HC...... 246 CESAMET...... 98, 194 chlorhexidine gluconate (bulk) CIPRO XR...... 42, 207 CETACAINE ANESTHETIC.. 137 ...... 61, 107, 237 CIPRODEX...... 247 CETA-KLENZ GENTLE...... 140 chlorobutanol (bulk). 107, 118, 140 ciprofloxacin...... 42 CETAPHIL...... 140 chloroquine phosphate...... 35 ciprofloxacin hcl...... 42, 245, 247 CETRAXAL...... 247 chloroquine phosphate (bulk) ciprofloxacin in 5 % dextrose..... 42 CETROTIDE...... 191 ...... 35, 107 cisatracurium...... 218 cevimeline...... 238 chlorothiazide...... 79 cisplatin...... 56 CHANTIX...... 105 chlorothiazide sodium...... 79 citalopram...... 87 CHANTIX CONTINUING chlorpromazine...... 92 CITRACAL + D MAXIMUM..153 MONTH BOX...... 105 chlorthalidone...... 79 CITRACAL PLUS BONE CHANTIX STARTING chlorzoxazone...... 218 DENSITY...... 152 MONTH BOX...... 105 chocolate flavor (bulk)...... 107, 115 CITRACAL REGULAR...... 153 CHATEAL (28)...... 120 chocolate hazelnut flav (bulk) CITRACAL-D3 GUMMIES.... 153 CHATEAL EQ (28)...... 120 ...... 107, 115 CITRACAL-D3 PETITES...... 153 cheesecake flavor (bulk)... 107, 115 CHOLBAM...... 196 CITRACAL-D3 PLUS HEART CHEMET...... 31 cholecalciferol (vitamin d3)...... 177 HEALTH...... 152 CHENODAL...... 197 cholestyramine (bulk)...... 69, 107 CITRACAL-D3 PLUS cherry flavor (bulk)...... 107, 117 cholestyramine (with sugar)...... 69 MAGNESIUM...... 152 CHEW Q...... 13 CHOLESTYRAMINE LIGHT...69 CITRACAL-D3 SLOW CHEWABLE IRON...... 155 CHOLETEC...... 144 RELEASE...... 153

267 CITRANATAL B-CALM (FE CLINIMIX E 2.75%/D5W codeine sulfate...... 14 GLUC)...... 171 SULF FREE...... 168 codeine-butalbital-asa-caff...... 17 citrulline (bulk)...... 107, 167 CLINIMIX E 4.25%/D10W coenzyme q10...... 13 cladribine...... 51 SUL FREE...... 168 coenzyme q10 (bulk).. 13, 107, 149 CLAFORAN...... 41 CLINIMIX E 4.25%/D5W coenzyme q10-vitamin e...... 13 CLARAVIS...... 123 SULF FREE...... 168 coffee flavor (bulk)...... 107, 115 CLARINEX...... 249 CLINIMIX E 5%/D15W COGENTIN...... 90 CLARINEX-D 12 HOUR...... 247 SULFIT FREE...... 168, 169 cola (syrup)...... 194 clarithromycin...... 44 CLINIMIX E 5%/D20W cola flavor (bulk)...... 107, 115 CLASSIC PRENATAL...... 171 SULFIT FREE...... 168, 169 COLAZAL...... 201 CLEANSING WASH CLINISOL SF 15 %...... 168 colchicine...... 208 ...... 124, 139, 256 clioquinol (bulk)...... 35, 107 colchicine (bulk)...... 107, 208 clemastine...... 247, 248 clobazam...... 83, 95 COLCRYS...... 208 CLENPIQ...... 203 clobetasol...... 133 colesevelam...... 69 CLEO 90 INFUSION SET 24" clobetasol-emollient...... 133 COLESTID...... 70 ...... 227, 228 CLOBEX...... 133 COLESTID FLAVORED...... 70 CLEO 90 INFUSION SET 31" clocortolone pivalate...... 133 colestipol...... 70 ...... 227, 228 CLODAN...... 133 colistin (colistimethate na)...... 46 CLEOCIN...... 44, 255 CLODERM...... 133 colistin sulfate (bulk)...... 46, 107 CLEOCIN HCL...... 44 clofarabine...... 51 COLLATYL...... 141 CLEOCIN PEDIATRIC...... 44 CLOLAR...... 51 collodion (bulk)...... 107 CLEOCIN T...... 124 clomiphene citrate (bulk)..107, 186 COLOX...... 203 CLEVIPREX...... 74 clomipramine...... 89 COLY-MYCIN M CLIMARA...... 185 clonazepam...... 82, 83, 95 PARENTERAL...... 46 CLIMARA PRO...... 185 clonidine...... 77 COMBIGAN...... 242 CLINDACIN ETZ...... 124 clonidine (pf)...... 14 COMBIPATCH...... 185 CLINDACIN P...... 124 clonidine hcl...... 77, 94 COMBIVENT RESPIMAT...... 252 CLINDACIN PAC...... 124 clopidogrel...... 213 COMBIVIR...... 38 CLINDAGEL...... 124 clorazepate dipotassium...... 82, 95 COMETRIQ...... 55 clindamycin hcl...... 44 CLOROTEKAL...... 29 COMFORT INFUSION SET clindamycin hcl (bulk)...... 44, 107 CLORPRES...... 77 31"...... 223, 227, 228 clindamycin in 5 % dextrose...... 44 clotrimazole...... 237 COMFORT INFUSION SET clindamycin palmitate hcl...... 44 clotrimazole (bulk)...... 34, 107 43"...... 227, 228 CLINDAMYCIN PEDIATRIC.. 44 clotrimazole-betamethasone..... 129 COMFORT SHORT INSULIN clindamycin phosphate44, 124, 255 CLOVIQUE...... 31 PUMP 23"...... 227, 229 clindamycin phosphate (bulk) clozapine...... 92 COMFORT-STRETCH ...... 44, 107 CLOZARIL...... 92 DIAPERS...... 221, 229 clindamycin-benzoyl peroxide..124 C-NATE DHA...... 171 COMFORT-STRETCH CLINDESSE...... 255 CO Q-10...... 13 TRAINING PANTS...... 221, 229 CLINIMIX 5%/D15W CO Q-10 (WITH VIT E)...... 13 COMP-AIR NEBULIZER SULFITE FREE...... 167 coal tar...... 137 COMPRESSOR...... 225, 229 CLINIMIX 5%/D25W coal tar (crude) (bulk)...... 107, 137 COMPAZINE...... 92, 195 SULFITE-FREE...... 167 COARTEM...... 35 COMPLERA...... 38 CLINIMIX 4.25%/D10W cocaine...... 254 COMPLETE AMINO ACID SULF FREE...... 167 cocoa butter...... 114 MIX...... 145 CLINIMIX 4.25%/D5W cocoa butter (bulk)...... 107, 114 COMPLETE MULTI...... 161 SULFIT FREE...... 167 COCOA BUTTER CREAM.....132 COMPLETE MULTIVITAMIN CLINIMIX 4.25%-D25W coconut flavor (bulk)...... 107, 115 ...... 161 SULF-FREE...... 167 cod liver oil...... 164 COMPLETE CLINIMIX 5%- COD LIVER OIL...... 175 MULTIVITAMIN-MINERAL.161 D20W(SULFITE-FREE)...... 167 cod liver oil (bulk)...... 107, 175 COMPLETE MV ADULT 50 codeine phosphate (bulk)....14, 107 PLUS...... 161

268 COMPLETE NATAL DHA..... 171 CORVITE FE...... 155 CYCLAFEM 1/35 (28)...... 120 COMPLETE PREMIUM CORVITE FREE...... 161 CYCLAFEM 7/7/7 (28)...... 122 VITAMIN...... 161 COSENTYX...... 127 cyclobenzaprine...... 218 COMPLETENATE...... 171 COSENTYX (2 SYRINGES)...127 cyclobenzaprine (bulk)..... 108, 218 COMPLEX B-100...... 146, 147 COSENTYX PEN...... 127 CYCLOGYL...... 241 COMPLEX B-50...... 146 COSENTYX PEN (2 PENS).... 127 CYCLOMYDRIL...... 240 COMPLEX ESSENTIAL...... 166 COSMEGEN...... 58 cyclopentolate...... 241 COMPLEX MSUD AMINO COSMETIC BALLS...... 219, 229 cyclophosphamide...... 23, 49 ACID BLEND...... 166 COSMETIC PUFFS...... 219, 229 cycloserine...... 38 COMPRO...... 195 COSOPT...... 242 CYCLOSET...... 181 COMTAN...... 90 COSOPT (PF)...... 242 cyclosporine...... 23, 215, 216 CONCEPT DHA...... 161, 171 cosyntropin...... 143 cyclosporine (bulk)...... 108, 215 CONCEPT OB...... 161, 171 COTELLIC...... 55 cyclosporine modified...... 23, 215 CONCERTA...... 94 COTEMPLA XR-ODT...... 94 CYKLOKAPRON...... 210 CONDYLOX...... 136 cotton candy flavor (bulk).107, 115 CYMBALTA...... 88, 99 CONRAY-30...... 142 COVARYX...... 184 cyproheptadine...... 248 CONRAY-43...... 142 COVARYX H.S...... 184 CYRAMZA...... 58 CONSTULOSE...... 203 COZAAR...... 67 CYRED...... 120 CONTACT DETACH INFUS cranberry extract-vitamin c...... 13 CYRED EQ...... 120 SET 23"...... 227, 229 cranberry fruit...... 13 CYSTADANE...... 235 CONTACT DETACH INFUS CRANBERRY URINARY CYSTAGON...... 204 SET 32"...... 227, 229 COMFORT...... 13, 164 CYSTARAN...... 243 CONTACT DETACH INFUS CRANBERRY-PROBIOTIC... 149 cytarabine...... 51 SET 43"...... 227, 229 cran-raspberry flavor (bulk) cytarabine (pf)...... 51 CONTI CASTILE SOAP...... 140 ...... 107, 115 CYTO B7...... 177 CONZIP...... 14 cream base no.64 (bulk)....107, 114 CYTOGAM...... 62 COPAXONE...... 239 cream de menthe (bulk).... 107, 115 CYTOMEL...... 193 COPIKTRA...... 56 CREON...... 196 CYTOTEC...... 198 COPPER CHLORIDE...... 160 CRESEMBA...... 34 CYTOTINE...... 149 CORAL CALCIUM...... 152 CRESTOR...... 70 CYTOVENE...... 41 CORDRAN...... 133 CRINONE...... 186, 256 CYTRA-2...... 206 COREG...... 66 CRIXIVAN...... 46 CYTRA-3...... 206 COREG CR...... 66 CROFAB...... 62 cytra-k...... 206 COREMINO...... 47, 123 cromolyn...... 55, 244, 250 D.H.E.45...... 100 CORGARD...... 73 cromolyn (bulk)...... 55, 108, 250 d10 %-0.45 % sodium chloride.148 CORLANOR...... 79 CROTAN...... 141 d2.5 %-0.45 % sodium chloride148 CORLOPAM...... 79 CRYSELLE (28)...... 120 D3 + K2 DOTS...... 177 corn starch (bulk)...... 107, 117 CUBICIN...... 42 D3-2000...... 177 CORTANE-B...... 247 CULTURELLE WOMEN d5 % and 0.9 % sodium CORTEF...... 186 HEALTH BALANC...... 202 chloride...... 148 CORTENEMA...... 201 CUPRIMINE...... 23, 31 d5 %-0.45 % sodium chloride...148 corticotropin (bulk)...... 107, 179 CUROSURF...... 254 dacarbazine...... 50 CORTIFOAM...... 201 CUTAQUIG...... 62 DACOGEN...... 51 cortisone...... 186 CUTIEPANTS TRAINING DAILY AMINO...... 145 cortisone (bulk)...... 107, 186 PANTS...... 221, 229 DAILY GUMMIES...... 161 CORTISPORIN...... 128 CUTIES BABY DIAPERS DAILY MULTIPLE...... 161 CORTROSYN...... 143 ...... 221, 229 DAILY MULTIPLE FOR CORVERT...... 69 CUTIVATE...... 133 WOMEN...... 164 CORVITA...... 161 CUVITRU...... 63 DAILY MULTIVITAMIN...... 161 CORVITA 150...... 155 CUVPOSA...... 238 DAILY MULTIVITAMIN CORVITE...... 161 cyanocobalamin (vitamin b-12) 176 WITH IRON...... 164 CORVITE 150...... 155 CYANOKIT...... 30

269 DAILY MULTIVITAMIN- DELESTROGEN...... 185 DETROL...... 208 MINERALS...... 151, 161 DELSTRIGO...... 38 DETROL LA...... 208 DAILY PRENATAL...... 171 DELUO...... 61, 141 DEVILBISS COMPACT DAILY PROBIOTIC (10 DELZICOL...... 201 COMPRESSOR...... 225, 229 STRAINS)...... 202 demeclocycline...... 47 DEVILBISS DISPOSABLE DAILY VALUE...... 164 DEMEROL...... 14 NEBULIZER...... 223, 229 DAIRY AID...... 196 DEMEROL (PF)...... 14 DEVILBISS PULMO-AIDE DAIRY DIGESTIVE...... 196 DEMSER...... 80 COMPRESSR...... 225, 229 DAIRY DIGESTIVE DENAVIR...... 131 DEVILBISS PULMOMATE SUPPLEMENT...... 196 DENOVO...... 178 COMPRESSOR...... 225, 229 DAIRY RELIEF...... 196 DEPAKOTE...... 83, 96 DEVILBISS TRAVELER dalfampridine...... 239 DEPAKOTE ER...... 83, 96, 100 COMPRESSOR...... 225, 229 dalfampridine (bulk)...... 108, 239 DEPAKOTE SPRINKLES...83, 96 DEX4 GLUCOSE BITS...... 179 DALIRESP...... 251 DEPEN TITRATABS...... 23, 31 DEX4 GLUCOSE POUCH DALVANCE...... 44 DEPLIN (ALGAL OIL)...... 178 PACK...... 179 danazol...... 188 DEPO-ESTRADIOL...... 185 DEX4 GLUCOSE QUICK DANTRIUM...... 219 DEPO-MEDROL...... 186 DISSOLVE...... 179 dantrolene...... 219 DEPO-PROVERA...... 56, 119 dexamethasone...... 186, 187 dantrolene (bulk)...... 108, 219 DEPO-SUBQ PROVERA 104. 119 dexamethasone ac, micro (bulk) dapsone...... 35 DEPO-TESTOSTERONE...... 180 ...... 108, 186 DAPTACEL (DTAP DERMACERIN...... 132 dexamethasone acetate (bulk) PEDIATRIC) (PF)...... 64 DERMACINRX LEXITRAL...138 ...... 108, 186 daptomycin...... 42 DERMACINRX PUREFOLIX DEXAMETHASONE DARAPRIM...... 35 ...... 175, 177 INTENSOL...... 186 darifenacin...... 207 DERMACINRX SILAPAK...... 135 dexamethasone sod phos (bulk) DARZALEX...... 52 DERMACLOUD...... 132 ...... 108, 187 DASETTA 1/35 (28)...... 120 DERMA-SMOOTHE/FS dexamethasone sodium phos DASETTA 7/7/7 (28)...... 122 BODY OIL...... 133 (pf)...... 187 DATSCAN...... 144 DERMA-SMOOTHE/FS dexamethasone sodium daunorubicin...... 58 SCALP OIL...... 133 phosphate...... 187, 241 DAURISMO...... 53 DERMAWERX SDS...... 135 dexamethasone,micronized(bulk DAYPRO...... 25 DERMOTIC OIL...... 247 )...... 108, 187 DAYSEE...... 120 DERM-SILK...... 226, 229 dexameth-moxiflox(pf)-nacl,iso240 DAYTRANA...... 94 DERMULCERA...... 141 dexamet-moxifl-ketoro-nacl(pf)241 DDAVP...... 180 DESCOVY...... 37 DEXCOM G4 RECEIVER DDROPS...... 177 desflurane...... 27 ...... 220, 229 DEBACTEROL...... 237 desipramine...... 89 DEXCOM G4 RECEIVER DEBLITANE...... 122 desloratadine...... 249 PEDIATRIC...... 220, 229 DECADRON...... 186 desmopressin...... 180 DEXCOM G4 RECEIVER- DECARA...... 177 desmopressin acetate (bulk) SHARE (PED)...... 220, 229 decitabine...... 51 ...... 108, 180 DEXCOM G4 RECEIVER- DECUBI VITE...... 164 desog-e.estradiol/e.estradiol...... 120 SHARE KIT...... 220, 229 deferasirox...... 31 desogestrel-ethinyl estradiol..... 120 DEXCOM G4 TRANSMITTER deferoxamine...... 31 DESONATE...... 133 ...... 220, 229 DEFINITY...... 142 desonide...... 133 DEXCOM G5 RECEIVER DEFITELIO...... 214 DESOWEN...... 133 ...... 221, 229 DEHYDROEPIANDROSTER desoximetasone...... 133, 134 DEXCOM G5 TRANSMITTER ONE (MICRO)...... 12, 108 desoximetasone, micro (bulk) ...... 221, 229 DEKAS BARIATRIC...... 161 ...... 108, 186 DEXCOM G5-G4 SENSOR DEKAS ESSENTIAL...... 164 DESOXYN...... 94, 98 ...... 221, 229 DEKAS PLUS (FOLIC ACID) 161 desvenlafaxine...... 88 DEKAS PLUS LIQUID...... 170 desvenlafaxine succinate...... 88

270 DEXCOM G6 RECEIVER DIALYVITE 800 WITH ZINC DILANTIN...... 84 ...... 221, 229 50...... 146 DILANTIN EXTENDED...... 84 DEXCOM G6 SENSOR...221, 229 DIALYVITE 800-ULTRA D... 146 DILANTIN INFATABS...... 84 DEXCOM G6 TRANSMITTER DIALYVITE SUPREME D...... 146 DILANTIN-125...... 84 ...... 221, 229 DIALYVITE VITAMIN D3 DILATRATE-SR...... 68 DEXCOM RECEIVER.... 221, 229 MAX...... 177 DILAUDID...... 14 DEXEDRINE SPANSULE diaper,brief,infant-todd,disp diltiazem hcl...... 69, 74 ...... 94, 98, 102 ...... 221, 229 diltiazem hcl (bulk)...... 108 DEXIFOL...... 146 DIAPERS...... 221, 229 diltiazem hcl in 0.9% nacl...... 74 DEXILANT...... 197 DIAPERS, UNISEX SIZE 3 DILT-XR...... 74 dexmedetomidine...... 104 ...... 221, 229 DILUENT FOR dexmedetomidine in 0.9 % nacl104 DIAPERS, UNISEX SIZE 4 EPOPROSTENOL/FLOLA...... 117 dexmedetomidine in dextrose ...... 221, 229 DILUENT FOR HIBERIX...... 150 5%...... 104 DIAPERS, UNISEX SIZE 5 DILUENT FOR IXEMPRA (15 dexmethylphenidate...... 94 ...... 221, 229 MG)...... 117 dexrazoxane hcl...... 60 DIAPERS, UNISEX SIZE 6 DILUENT FOR IXEMPRA (45 DEXTENZA...... 241 ...... 221, 229 MG)...... 117 dextroamphetamine...... 94, 98, 102 DIAPERS-DISP- DILUENT FOR RABAVERT..151 dextroamphetamine- POLYETHYLENE BACK diluent for treprostinil (gly)...... 117 amphetamine...... 94, 98, 102 ...... 221, 229 dimenhydrinate...... 194 dextromethorphan hbr (bulk) DIASTAT...... 83, 95 dimethyl sulfoxide (bulk). 108, 113 ...... 108, 249 DIASTAT ACUDIAL...... 83, 95 dinitrochlorobenzen(2,4)(bulk) dextrose 10 % and 0.2 % nacl...148 diazepam...... 82, 83, 95 ...... 108, 139 dextrose 10 % in water (d10w).148 DIAZEPAM INTENSOL..... 82, 95 DINO-LIFE WITH IRON- dextrose 20 % in water (d20w).148 DIBENZYLINE...... 80 ZINC...... 169, 170 dextrose 25 % in water (d25w).148 dibucaine hcl (bulk).... 27, 108, 140 DIOVAN...... 67 dextrose 30 % in water (d30w).148 DICLEGIS...... 194 DIOVAN HCT...... 67 dextrose 40 % in water (d40w).148 diclofenac epolamine...... 138 DIPENTUM...... 201 dextrose 5 % in ringer's...... 154 diclofenac potassium...... 25 diphencyprone (bulk)...... 108, 136 dextrose 5 % in water (d5w).....148 diclofenac sodium diphenhydramine (bulk)....108, 248 dextrose 5 %-lactated ringers....148 ...... 25, 129, 138, 242 diphenhydramine hcl...... 248 dextrose 5%-0.2 % sod chloride148 diclofenac-misoprostol...... 24 diphenoxylate-atropine...... 194 dextrose 5%-0.3 % sod.chloride148 DICLOFEX DC...... 138 DIPRIVAN...... 28 dextrose 50 % in water (d50w).148 DICLOFONO...... 138 DIPROLENE...... 134 dextrose 70 % in water (d70w).148 DICLOPAK...... 138 dipyridamole...... 143, 213 DEXYCU (PF)...... 241 DICLOTRAL...... 138 DISALCID...... 26 DHA ALGAL-900...... 72 DICLOVIX...... 138 DISKETS...... 14 DHEA...... 12 dicloxacillin...... 45 disopyramide phosphate...... 68 DIABETES HEALTH...... 161 dicyclomine...... 199 DISPOSERX...... 223, 229 DIABETES HEALTH didanosine...... 37 disulfiram...... 105 FORMULA...... 161 diethylstilbestrol (bulk)...... 53, 108 DITROPAN XL...... 208 DIACOMIT...... 86 DIFFERIN...... 126 DIURIL...... 79 DIAFOODS THICK-IT...... 117 DIFICID...... 44 DIURIL IV...... 79 DIAFOODS THICK-IT #2...... 117 diflorasone...... 134 divalproex...... 83, 96, 100 DIALYVITE...... 146, 147 DIFLUCAN...... 34 DIVIGEL...... 185 DIALYVITE 3000...... 146 diflunisal...... 26 DMSA...... 144 DIALYVITE 5000...... 161 DIGIFAB...... 30 DMSA (BULK)...... 31, 108 DIALYVITE 800...... 146 DIGITEK...... 77 dobutamine...... 76 DIALYVITE 800 WITH IRON164 DIGOX...... 77 dobutamine in d5w...... 76 DIALYVITE 800 WITH ZINC digoxin...... 77 DOCEFREZ...... 57 15...... 146 digoxin, micronized (bulk). 77, 108 docetaxel...... 57 dihydroergotamine...... 100 dofetilide...... 69

271 DOLOPHINE...... 14 DUOPA...... 89 EGRIFTA SV...... 188 donepezil...... 118, 119 DUPIXENT SYRINGE.... 127, 250 ELAPRASE...... 234 DONNATAL...... 200 DURACHOL...... 175, 177 ELDEPRYL...... 90 dopamine...... 76 DURAGESIC...... 14 ELDERTONIC...... 151 dopamine in 5 % dextrose...... 76 DURAMORPH (PF)...... 14 electrolyte-48 in d5w...... 154 DOPRAM...... 98, 99 DUREZOL...... 241 electrolytes-dextrose...... 158 DOPTELET (10 TAB PACK)..215 DURLAZA...... 26, 213 ELELYSO...... 234 DOPTELET (15 TAB PACK)..215 DUROLANE...... 217 ELESTRIN...... 185 DORAL...... 95, 103 dutasteride...... 206 ELETONE...... 132 DORYX...... 47 dutasteride (bulk)...... 108, 206 eletriptan...... 100 DORYX MPC...... 47 dutasteride-tamsulosin...... 204 ELFOLATE...... 178 dorzolamide...... 243 DUTOPROL...... 75 ELIDEL...... 131 dorzolamide (pf)...... 243 DVORAH...... 17, 18 ELIGARD...... 54 dorzolamide-timolol...... 242 DXEVO...... 187 ELIGARD (3 MONTH)...... 54 dorzolamide-timolol (pf)...242, 243 DYANAVEL XR...... 94, 98 ELIGARD (4 MONTH)...... 54 DOTAREM...... 142 DYAZIDE...... 78 ELIGARD (6 MONTH)...... 54 DOTTI...... 185 DYMISTA...... 254 ELIMITE...... 141 DOVATO...... 36 DYRENIUM...... 78 ELINEST...... 120 DOVONEX...... 130 DYSPORT...... 218 ELIQUIS...... 209 doxapram...... 98, 99 E.E.S. 400...... 44 ELIQUIS DVT-PE TREAT doxazosin...... 80 E.E.S. GRANULES...... 44 30D START...... 210 doxepin...... 89, 104, 141 EAR CARE...... 148 ELITEK...... 209 doxercalciferol...... 235 EAR HEALTH FORMULA.....148 ELIXOPHYLLIN...... 251 DOXIL...... 58 EASIVENT HOLDING ELLA...... 123 doxorubicin...... 58 CHAMBER...... 225, 229 ELLENCE...... 58 doxorubicin, peg-liposomal...... 58 EASIVENT MASK LARGE ELMIRON...... 205 DOXY-100...... 47 ...... 225, 229 ELON...... 131 doxycycline hyclate...... 47, 238 EASIVENT MASK MEDIUM ELON MATRIX 5000 doxycycline hyclate (bulk)..47, 108 ...... 225, 229 COMPLETE...... 161 doxycycline monohydrate EASIVENT MASK SMALL ELURYNG...... 123 ...... 47, 48, 139 ...... 225, 229 ELZONRIS...... 59 doxylamine-pyridoxine (vit b6) 194 EASY FIBER...... 203 EMCYT...... 53 D-PENAMINE...... 23, 31 echinacea...... 13 EMEND...... 195 DRAXIMAGE DTPA...... 144 EC-NAPROSYN...... 25 EMEND (FOSAPREPITANT).195 DRITHOCREME HP...... 130 EC-NAPROXEN...... 25 EMERGEN-C...... 175 DRIZALMA SPRINKLE..... 88, 99 econazole...... 128 EMERGEN-C KIDZ...... 169 dronabinol...... 98, 145, 194 econazole nitrate (bulk)...... 34, 108 EMFLAZA...... 187 droperidol...... 28 ECOZA...... 128 EMGALITY PEN...... 99, 100 drospirenone-e.estradiol-lm.fa..120 EDARBI...... 68 EMGALITY SYRINGE82, 99, 100 drospirenone-ethinyl estradiol.. 120 EDARBYCLOR...... 67 emollient...... 132 DROXIA...... 214 EDECRIN...... 78 EMPLICITI...... 51 DSUVIA...... 14 EDEX...... 145 EMPTY STERILIZED VIAL DUAVEE...... 184 EDLUAR...... 103 ...... 225, 230 DUET DHA BALANCED...... 171 ED-SPAZ...... 199, 208 empty vial...... 225, 230 DUET DHA WITH OMEGA-3171 EDURANT...... 37 EMSAM...... 87 DUETACT...... 182 EEMT...... 184 EMTRIVA...... 37 DUEXIS...... 24 EEMT HS...... 184 EMULSION SB...... 132 DULERA...... 253 efavirenz...... 37 EMVERM...... 33 duloxetine...... 88, 99 EFFER-K...... 159 enalapril maleate...... 66 DUOBRII...... 126 EFFEXOR XR...... 88 enalaprilat...... 66 DUODOTE...... 30 EFFIENT...... 213 enalapril-hydrochlorothiazide.....66 DUOFER...... 155 EFUDEX...... 129 ENBRACE HR...... 164, 172

272 ENBREL...... 21 EPIDIOLEX...... 83 ESGIC...... 20 ENBREL MINI...... 21 EPIDUO...... 126 ESKATA...... 130 ENBREL SURECLICK...... 21 EPIDUO FORTE...... 125 esmolol...... 69, 73 ENDARI...... 146, 166, 204, 214 EPIFOAM...... 135 esmolol in nacl (iso-osm)...... 69, 73 ENDOCET...... 19 epinastine...... 241 ESOMEP-EZS...... 197 ENDUR-ACIN...... 176 epinephrine...... 75, 76, 249 esomeprazole magnesium...... 197 ENDUR-AMIDE...... 176 epinephrine (bulk)...... 75, 108, 249 esomeprazole sodium...... 197 ENFAGROW TODDLR epinephrine hcl in 5% dextrose...76 ESSENTIAL AMINO ACID TRANSITION SOY...... 149 epinephrine in sod chlor,iso...... 76 MIX...... 167 ENFAMIL ENFALYTE...... 158 EPINEPHRINESNAP-EMS...... 75 ESSENTIAL BALANCE ENFAMIL GENTLEASE...... 149 EPIPEN 2-PAK...... 75 WITH LUTEIN...... 161, 164 ENFAMIL GLUCOSE...... 165 EPIPEN JR 2-PAK...... 75 ESSENTIAL MAN...... 161 ENFAMIL INFANT...... 149 epirubicin...... 58 ESSENTIAL WOMAN 50+.....161 ENFAMIL NEURO EPISIL...... 237 ESTARYLLA...... 120 ENFACARE NON-GMO...... 149 EPITOL...... 85, 96 estazolam...... 95, 103 ENFAMIL NEURO EPIVIR...... 37 ESTRACE...... 185, 256 GENTLEASE NONGMO...... 149 EPIVIR HBV...... 43 estradiol...... 185, 256 ENFAMIL NEUROPRO NON- eplerenone...... 66, 77 estradiol cypionate (bulk). 108, 185 GMO...... 149 EPOGEN...... 210 estradiol hemihydrate (bulk) ENFAMIL NEWBORN...... 149 epoprostenol (glycine)...... 81 ...... 108, 185 ENFAMIL PROSOBEE...... 149 eprosartan...... 68 estradiol valerate (bulk).... 108, 185 ENFAMIL PROSOBEE LIPIL 149 EPZICOM...... 38 estradiol-norethindrone acet..... 185 ENGERIX-B (PF)...... 62 EQUETRO...... 85, 96 ESTRING...... 256 ENGERIX-B PEDIATRIC (PF).62 ERAXIS(WATER DILUENT)...34 estriol (bulk)...... 108, 185 ENGLISH TOFFEE FLAVOR ERBITUX...... 60 estriol micronized (bulk)...108, 185 ...... 108, 115 ergocalciferol (vit d2) (bulk) ESTROGEL...... 185 ENLITE SYSTEM...... 221, 230 ...... 108, 177 estrogens-methyltestosterone....184 ENLYTE...... 178 ergocalciferol (vitamin d2)...... 177 estrone (bulk)...... 108, 185 enoxaparin...... 212 ergoloid...... 119 ESTROSTEP FE-28...... 122 ENPRESSE...... 122 ERGOMAR...... 100 eszopiclone...... 103 ENSKYCE...... 120 ergotamine tartrate (bulk). 100, 108 ethacrynate sodium...... 78 ENSTILAR...... 126 ERIVEDGE...... 53 ethacrynic acid...... 78 ENSURE CLEAR...... 149 ERLEADA...... 50 ethambutol...... 39 ENSURE ORIGINAL...... 149 erlotinib...... 49 ETHAMOLIN...... 82 entacapone...... 90 ERRIN...... 122 ethinyl estradiol (bulk)...... 108, 185 entecavir...... 43 ERTACZO...... 128 ethosuximide...... 86 ENTEREG...... 31 ertapenem...... 39 ethyl chloride...... 137 ENTOCORT EC...... 201 ERWINAZE...... 51 ethynodiol diac-eth estradiol.....120 ENTRESTO...... 67 ERY PADS...... 124 etidronate disodium...... 184 ENTTY...... 132 ERYGEL...... 124 etodolac...... 26 ENTYVIO...... 201 ERYPED 200...... 44 etomidate...... 27 ENULOSE...... 196 ERYPED 400...... 44 etonogestrel-ethinyl estradiol....123 ENVARSUS XR...... 216 ERY-TAB...... 44 ETOPOPHOS...... 53 EOVIST...... 142 ERYTHROCIN...... 44 etoposide...... 53 EPANED...... 66 ERYTHROCIN (AS EUCERIN...... 132 ephedrine hcl (bulk)....76, 108, 255 STEARATE)...... 44 EUFLEXXA...... 217 ephedrine sulfate...... 76 erythromycin...... 44, 245 EURAX...... 141 ephedrine sulfate (bulk) erythromycin ethylsuccinate...... 44 EUTHYROX...... 193 ...... 76, 108, 255 erythromycin with ethanol...... 124 EVAMIST...... 185 ephedrine sulfate-0.9%nacl(pf)...76 erythromycin-benzoyl peroxide 124 EVEKEO...... 94, 98, 102 EPICERAM...... 132 ESBRIET...... 255 EVEKEO ODT...... 94, 98 EPICYN...... 141 escitalopram oxalate...... 87 evening primrose oil...... 13

273 EVENITY...... 183 febuxostat...... 209 FETROJA...... 41 everolimus (antineoplastic)...... 55 felbamate...... 83 FETZIMA...... 88 EVERSENSE SENSOR- FELBATOL...... 83 FEXMID...... 218 HOLDER...... 221, 230 FELDENE...... 25 FIASP FLEXTOUCH U-100 EVERSENSE SMART felodipine...... 74 INSULIN...... 190 TRANSMITTER...... 221, 230 FEM PH...... 256 FIASP U-100 INSULIN...... 190 EVISTA...... 192 FEMARA...... 51 FIBER (DEXTRIN)...... 203 EVIVO...... 202 FEM-CAL CITRATE...... 152 FIBRICOR...... 70 EVIVO STARTER KIT...... 202 FEMCAP...... 220, 230 FINACEA...... 124, 139 EVIVO WITH MCT OIL...... 202 FEMHRT LOW DOSE...... 185 finasteride...... 206 EVOCLIN...... 124 FEMRING...... 256 FINTEPLA...... 86 EVOMELA...... 49 fenofibrate...... 70 FIORINAL...... 26 EVOTAZ...... 37, 46 fenofibrate micronized...... 70 FIORINAL-CODEINE #3...... 17 EVOXAC...... 238 fenofibrate nanocrystallized...... 70 FIRAZYR...... 73 EXALGO ER...... 14 fenofibric acid...... 70 FIRDAPSE...... 239 EXELDERM...... 128 fenofibric acid (choline)...... 70 FIRMAGON KIT W DILUENT EXELON...... 119 FENOGLIDE...... 70 SYRINGE...... 55 exemestane...... 51 fenoprofen...... 26 FIRVANQ...... 42 EXFORGE...... 67 fentanyl...... 15 FISH OIL...... 71, 72 EXFORGE HCT...... 67 fentanyl citrate...... 14 FISH OIL EXTRA EXJADE...... 31 fentanyl citrate (bulk)...... 14, 108 STRENGTH...... 71 EXODERM...... 128 fentanyl citrate (pf)...... 14, 28 fish oil-dha-epa...... 71, 72 EXPECTA PRENATAL...... 172 fentanyl citrate (pf)-0.9%nacl.....14 FIXED OIL SUSPENSION EXTAVIA...... 238 fentanyl-ropivacaine-nacl (pf).... 18 ...... 108, 118 EXTINA...... 128 FENTORA...... 15 FLAC OTIC OIL...... 247 EXTRA-VIRT PLUS DHA...... 172 FEOSOL...... 156 FLAGYL...... 36 EYLEA...... 244, 246 FEOSOL BIFERA...... 155 FLAREX...... 241 EZALLOR SPRINKLE...... 70 FERAHEME...... 156 FLAVOR BLEND 2 IN 1...... 117 ezetimibe...... 71 FERGON...... 156 FLAVOR PLUS...... 117 ezetimibe-simvastatin...... 72 FERIDEX IV...... 142 FLAVOR SWEET...... 117 EZFE 200...... 156 FER-IN-SOL...... 156 FLAVOR SWEET-SF...... 117 FA-8...... 178 FEROCON...... 155 FLAVORX...... 108, 115 FABB...... 175, 178 FEROSUL...... 156 flavoxate...... 208 FABIOR...... 126 FERRACTIV...... 155 flaxseed oil...... 13 FABRAZYME...... 234 FERRETTS IPS...... 156 FLEBOGAMMA DIF...... 63 FALMINA (28)...... 120 FERREX 150 FORTE...... 155 flecainide...... 69 famciclovir...... 43 FERREX 150 FORTE PLUS....155 FLECTOR...... 138 famotidine...... 197 FERREX 150 PLUS...... 155 FLEXBUMIN 25 %...... 212 famotidine (pf)...... 197 FERREX 28...... 155 FLEXBUMIN 5 %...... 212 famotidine (pf)-nacl (iso-os)....197 ferric chloride (bulk).108, 131, 210 FLEXIPAK...... 24 FANAPT...... 91 FERRIMIN 150...... 156 FLINTSTONES COMPLETE..170 FARESTON...... 57 FERRIPROX...... 31 FLINTSTONES COMPLETE FARXIGA...... 181 FERRLECIT...... 156 (IRON)...... 169 FARYDAK...... 53 FERROCITE PLUS...... 155 FLINTSTONES GUMMIES.... 170 FASENRA...... 250 FERRO-SEQUELS (IRON-VIT FLINTSTONES GUMMIES FASENRA PEN...... 250 C)...... 155 OMEGA-3...... 170 FASLODEX...... 53 FERRO-TIME...... 156 FLINTSTONES MULTI-VIT FATIGUE RELIEF COMPLEX ferrous fumarate...... 156 GUMMIES...... 169, 170 ...... 146 ferrous fumarate (bulk)..... 108, 156 FLINTSTONES FATTYBLEND...... 108, 118 ferrous gluconate...... 156 MULTIVITAMIN...... 170 FE C...... 155 ferrous gluconate (bulk)....108, 156 FLINTSTONES PLUS FE C PLUS...... 156 ferrous sulfate...... 156 CALCIUM...... 169

274 FLINTSTONES SOUR flurandrenolide...... 134 FREAMINE III 10 %...... 168 GUMMIES...... 170 flurazepam...... 95, 103 FREEDAVITE...... 161 FLINTSTONES TAB CHEW.. 169 flurbiprofen...... 26 FREESTYLE LIBRE 14 DAY FLINTSTONES WITH IRON..169 flurbiprofen sodium...... 242 READER...... 221, 230 FLINTSTONES/EXTRA C...... 170 flutamide...... 50 FREESTYLE LIBRE 14 DAY FLOLAN...... 81 fluticasone propionate...... 134 SENSOR...... 221, 230 FLOMAX...... 205 fluticasone propion-salmeterol. 253 FRESHNET...... 224 FLORAJEN3...... 202 fluvastatin...... 70 FROTEK...... 138 FLORAJEN4KIDS...... 202 fluvoxamine...... 87 FROVA...... 100 FLORICAL...... 157 FLUZONE QUAD 2020-2021... 65 frovatriptan...... 100 FLORIVA...... 169 FLYP NEBULIZER...... 223, 230 FULL SPECTRUM B- FLORIVA (FLUORIDE- FML FORTE...... 241 VITAMIN C...... 147 VITAMIN D3)...... 169, 236 FML LIQUIFILM...... 241 FULPHILA...... 210 FLORIVA PLUS...... 169 FML S.O.P...... 241 fulvestrant...... 53 FLOVENT DISKUS...... 250 FOCALIN...... 94 FURADANTIN...... 33, 207 FLOVENT HFA...... 250 FOCALIN XR...... 94 furosemide...... 78 floxuridine...... 51 FOLBEE...... 175, 178 furosemide in 0.9 % nacl...... 78 FLUAD QUAD 2020-21(65Y FOLBEE AR...... 147 FUSILEV...... 60 UP)(PF)...... 65 FOLBEE PLUS...... 147 FUSION...... 155 fluconazole...... 34 FOLBIC...... 175, 178 FUSION PLUS...... 155 fluconazole in nacl (iso-osm)...... 34 folic acid...... 178 FUSION SPRINKLES...... 155 flucytosine...... 34, 35 folic acid-vit b6-vit b12...... 175 FUZEON...... 36 fludarabine...... 51 FOLINIC-PLUS...... 175 FYAVOLV...... 185 fludeoxyglucose f-18...... 144 FOLITAB...... 155 FYCOMPA...... 83 fludrocortisone...... 191 FOLIVANE-F...... 155 gabapentin...... 84 FLUMADINE...... 43 FOLIVANE-OB...... 161, 172 GABITRIL...... 84 flumazenil...... 31 FOLIVANE-PLUS...... 155 GADAVIST...... 142 flunisolide...... 254 FOLOTYN...... 50 GALAFOLD...... 236 flunisolide (bulk)...... 108, 250, 254 FOLPLEX 2.2...... 175, 178 galantamine...... 119 fluocinolone...... 134 FOLTABS 800...... 175 GALZIN...... 31 fluocinolone acetonide (bulk) FOLTANX...... 175 GAMASTAN S/D...... 63 ...... 108, 187 FOLTRATE...... 176 GAMIFANT...... 215 fluocinolone acetonide oil...... 247 FOLTX...... 175 GAMMAGARD LIQUID...... 63 fluocinolone and shower cap.... 134 FOLVITE-D...... 175 GAMMAGARD S-D (IGA < 1 fluocinonide...... 134 fomepizole...... 30 MCG/ML)...... 63 fluocinonide, micronized(bulk) fondaparinux...... 212 GAMMAKED...... 63 ...... 108, 187 FORFIVO XL...... 89 GAMMAPLEX (WITH FLUOCINONIDE-E...... 134 FORTAMET...... 190 SORBITOL)...... 63 fluorescein-proparacaine...... 243 FORTAVIT...... 164 GAMUNEX-C...... 63 FLUORESCITE...... 243 FORTEO...... 183 ganciclovir...... 258 fluoride (sodium)...... 236 FORTESTA...... 180 ganciclovir sodium...... 41 FLUORIDEX SENSITIVITY FOSAMAX...... 184 ganirelix...... 191 RELIEF...... 236 FOSAMAX PLUS D...... 183 GARDASIL 9 (PF)...... 65 FLUORITAB...... 236 fosamprenavir...... 46 garlic...... 13 fluorometholone...... 241 fosaprepitant...... 195 GASTROCROM...... 55 FLUOROPLEX...... 129 FOSCAVIR...... 41 gatifloxacin...... 245 fluorouracil...... 51, 129 FOSFREE...... 161 GATTEX 30-VIAL...... 204 fluorouracil (bulk)...... 51, 108 fosinopril...... 66 GATTEX ONE-VIAL...... 204 fluoxetine...... 87 fosinopril-hydrochlorothiazide... 66 GAVILYTE-C...... 203 fluphenazine decanoate...... 92 fosphenytoin...... 84 GAVILYTE-G...... 203 fluphenazine hcl...... 92 FOSRENOL...... 205 GAVILYTE-N...... 203 FLURA-DROPS...... 236 FRAGMIN...... 212 GAZYVA...... 52

275 gelatin...... 13 GLIADEL WAFER...... 49 GLYSET...... 181 gelatin (bulk)...... 118 glimepiride...... 182 GLYTACTIN GELCLAIR...... 237 glipizide...... 182 15PECOMPLETE-TAURINE..166 GEL-FLOW...... 210 glipizide (bulk)...... 108, 182 GLYXAMBI...... 181 GEL-FLOW NT...... 210 glipizide-metformin...... 182 GOCOVRI...... 90 GELNIQUE...... 208 GLOPERBA...... 208 GOLYTELY...... 203 GEL-ONE...... 217 GLOSTRIPS...... 243 GOODNITES UNDERPANTS GELSYN-3...... 217 GLUCAGEN DIAGNOSTIC L-XL...... 221, 230 GELX...... 237, 238 KIT...... 143 GOPRELTO...... 254 gemcitabine...... 51 GLUCAGEN HYPOKIT...... 179 GORDONS-VITE E...... 132 gemfibrozil...... 70 GLUCAGON (HCL) GORMEL...... 132 GENERESS FE...... 120 EMERGENCY KIT...... 179 G-PREPROTEIN...... 167 GENERLAC...... 196 GLUCAGON EMERGENCY GRALISE...... 103 GENGRAF...... 23, 216 KIT (HUMAN)...... 179 granisetron (pf)...... 195 GENICIN VITA-D...... 175 glucagon hcl...... 143, 179 granisetron hcl...... 195 GENICIN VITA-Q...... 178 GLUCOLESS...... 13 GRANIX...... 210 GENICIN VITA-S...... 147 GLUCOPHAGE...... 190 grape flavor (bulk)...... 108, 115 GENOTROPIN...... 188 GLUCOPHAGE XR...... 190 GRAPEFRUIT...... 108, 115 GENOTROPIN MINIQUICK.. 188 glucosam-chon-msm1-c-mang- GRASTEK...... 61 GENTAK...... 245 bosw...... 12 green soap...... 139 gentamicin...... 32, 127, 245, 258 GLUCOSAMINE COMPLEX- griseofulvin (bulk)...... 35, 109 gentamicin (bulk)...... 32, 108 MSM...... 12 griseofulvin microsize...... 35 gentamicin in nacl (iso-osm)...... 32 GLUCOSAMINE RELIEF...... 12 griseofulvin ultramicrosize...... 35 gentamicin sulfate (ped) (pf).....258 glucosamine su 2kcl-chondroit... 12 guaifenesin (bulk)...... 109, 254 gentamicin sulfate (pf)...... 32 glucosamine sulfate...... 12 guanethidine sulfate (bulk). 81, 109 gentamicin-sodium citrate...... 39 GLUCOSAMINE SULF- guanfacine...... 77, 94 GENTLE SKIN CLEANSER...140 CHONDROITIN...... 12 guanidine...... 217 GENVISC 850...... 217 glucosamine-chondroitin...... 12 GUARDIAN CONNECT GENVOYA...... 38 GLUCOSAMINE- TRANSMITTER...... 221, 230 GEODON...... 91, 97 CHONDROITIN COMPLX...... 12 GUARDIAN REAL-TIME GERBER GENTLE GLUCOSAMINE- GLU MONITOR...... 221, 230 PROBIOTIC...... 202 CHONDROITIN DS...... 12 guava flavor (bulk)...... 109, 115 GERBER GOOD START glucosamine-chondroit-vit c-mn.12 GUMMI BEAR GENTLE...... 149 GLUCOTROL...... 182 MULTIVITAMIN...... 170 GERBER GOOD START SOY149 GLUCOTROL XL...... 182 GUMMIES CHILDREN GERBER SOOTHE VIT D- GLUMETZA...... 190 MULTIVITAMIN...... 170 PROBIOTIC...... 202 GLUTARADE JUNIOR...... 165 GUMMY DINOS...... 170 GERITOL COMPLETE...... 161 GLUTOL GEL...... 143 GVOKE PFS 1-PACK GERITOL TONIC WITH GLUTOSE-45...... 179 SYRINGE...... 179 FERREX 18...... 151 glyburide...... 182 GYNAZOLE-1...... 255 GIANVI (28)...... 120 glyburide micronized...... 182 HAEGARDA...... 209 GIAPREZA...... 192 glyburide-metformin...... 182 HAILEY...... 120 GILENYA...... 239 glycerol formal (bulk)...... 108, 113 HAILEY 24 FE...... 120 GILOTRIF...... 49 glycine...... 146 HAIR FORMULA...... 161 ginseng...... 13 glycolic acid (bulk)...... 108, 113 HAIR, SKIN AND NAILS- GIVLAARI...... 215 GLYCOPHOS...... 158 ARGAN OIL...... 161 GLASSIA...... 254 glycopyrrolate...... 199 HAIR,SKIN AND NAILS...... 161 glatiramer...... 239 glycopyrrolate (bulk)...... 79, 108 HAIR,SKIN AND NAILS(FA- GLATOPA...... 239 glycopyrrolate (pf) in water...... 199 BIOTIN)...... 162 GLEEVEC...... 57 GLYDO...... 140 HAIR-SKIN-NAILS (MV-FA- GLEOLAN...... 144 GLYNASE...... 182 BIOTIN)...... 164 GLEOSTINE...... 49 GLYRX-PF...... 199 HAIR-SKIN-NAILS (PABA)...162

276 HALAVEN...... 53 HESPAN 6 % IN NS...... 212 HUMALOG MIX 75-25 HALCION...... 95, 103 hetastarch 6 % in 0.9 % nacl.....212 KWIKPEN...... 189 HALDOL...... 92 HETLIOZ...... 99 HUMALOG MIX 75-25(U- HALDOL DECANOATE...... 92 HEX-ON LIGHT ODOR...... 224 100)INSULN...... 189 halobetasol propionate...... 130, 134 HEXTEND...... 212 HUMALOG U-100 INSULIN..190 HALOG...... 134 HIBERIX (PF)...... 64 HUMATROPE...... 188 haloperidol...... 92 HI-CAL PLUS VIT D...... 153 HUMIRA...... 21, 22, 201 haloperidol decanoate...... 92 HIDEX...... 187 HUMIRA PEN...... 21, 22, 201 haloperidol lactate...... 92 HIGH POTENCY IRON...... 156 HUMIRA PEN CROHNS-UC- HAVRIX (PF)...... 62 HIGH POTENCY PROBIOTIC HS START...... 21, 22, 201 HEALON ENDOCOAT...... 244 ...... 202 HUMIRA PEN PSOR- HEALON GV...... 244 HIPREX...... 45, 207 UVEITS-ADOL HS...... 21, 22, 201 HEALON PRO...... 244 histamine phosphate (bulk) HUMIRA(CF)...... 21, 22, 201 HEALON5...... 244 ...... 109, 215 HUMIRA(CF) PEDI CROHNS HEALON5 PRO...... 244 HISTATROL...... 215 STARTER...... 21, 22, 201 HEALTHY EYES LUTEIN- HIZENTRA...... 63 HUMIRA(CF) PEN...... 21, 22, 202 ZEAXANTHIN...... 12 HOMATROPAIRE...... 241 HUMULIN R U-500 (CONC) HEARTBURN AND ACID homatropine methylbrom (bulk) INSULIN...... 189 REFLUX-ALOE...... 162 ...... 109, 199 HUMULIN R U-500 (CONC) HEATHER...... 122 HOMOCYSTEINE FORMULA KWIKPEN...... 189 HECTOROL...... 235 ...... 175 HYALGAN...... 217 HEMANGEOL...... 73 HONEY BEARS WITH IRON- HYCAMTIN...... 57 HEMATINIC PLUS ZINC...... 169, 170 HYCET...... 18 VIT/MINERALS...... 155 honey flavor (bulk)...... 109, 115 HYCLODEX...... 61, 141 HEMATINIC/FOLIC ACID.....155 HORIZANT...... 101 hydralazine...... 77 HEMATOGEN...... 155 HPR...... 132 HYDREA...... 51 HEMATOGEN FA...... 155 HPR PLUS...... 132 HYDRO 35...... 136 HEMATOGEN FORTE...... 155 HPR PLUS HYDROGEL...... 131 HYDRO 40...... 136 HEMAX...... 155 HPR PLUS-MB HYDROGEL. 131 HYDROCERIN...... 132 HEMETAB...... 155 HUGGIES LITTLE MOVERS hydrochlorothiazide...... 79 HEMOCYTE...... 156 ...... 221, 230 hydrochlorothiazide (bulk). 79, 109 HEMOCYTE-F...... 155 HUGGIES PULL-UPS..... 221, 230 hydrocodone-acetaminophen...... 18 HEMOCYTE-PLUS...... 155 HUGGIES PULL-UPS 2T-3T hydrocodone-ibuprofen...... 18 HEP FLUSH-10 (PF)...... 211 ...... 221, 230 hydrocortisone.... 29, 134, 187, 201 HEPAGAM B...... 63 HUGGIES PULL-UPS 3T-4T hydrocortisone (bulk)...... 109, 187 heparin (porcine)...... 211 ...... 221, 230 hydrocortisone acetate (bulk) heparin (porcine) in 0.9% nacl..211 HUGGIES PULL-UPS 4T-5T ...... 109, 187 heparin (porcine) in 5 % dex.....211 ...... 221, 230 hydrocortisone butyrate...... 134 heparin (porcine) in nacl (pf)....211 HUGGIES SLIP-ON...... 221, 230 hydrocortisone butyr-emollient.134 heparin flush(porcine)-0.9nacl..211 HUGGIES SNUG AND DRY hydrocortisone valerate...... 134 HEPARIN LOCK...... 211 STEP 5...... 221, 230 hydrocortisone-acetic acid...... 247 HEPARIN LOCK FLUSH...... 211 HUGGIES SNUG AND DRY hydrocortisone-iodoquinol...... 129 heparin lock flush (porcine)...... 211 STEP 6...... 222, 230 hydrocortisone-pramoxine...... 29 HEPARIN HUMALOG JUNIOR hydromorphone...... 15 LOCKFLUSH(PORCINE)(PF) 211 KWIKPEN U-100...... 190 hydromorphone (bulk)...... 15, 109 heparin(porcine) in 0.45% nacl.212 HUMALOG KWIKPEN hydromorphone (pf)...... 15 heparin, porcine (pf)...... 211, 212 INSULIN...... 190 hydromorphone (pf) in water...... 15 HEPATAMINE 8%...... 168 HUMALOG MIX 50-50 hydromorphone (pf)-0.9 % nacl..15 HEPLISAV-B (PF)...... 62 INSULN U-100...... 189 hydrophilic...... 114 HEPSERA...... 43 HUMALOG MIX 50-50 HYDROPHILIC OINTMENT HERCEPTIN...... 60 KWIKPEN...... 189 BASE(FAG)...... 109, 114 HERCEPTIN HYLECTA...... 60

277 HYDROPHILIC ICAPS MV...... 162 INFASURF...... 254 PETROLATUM...... 114 ICAR...... 156 INFED...... 156 HYDROUS EMULSIFIED ICAR-C...... 155 INFLAMMA-K...... 138 BASE...... 109, 114 ICAR-C PLUS...... 156 INFLECTRA...... 21, 22, 202 hydroxocobalamin...... 176 icatibant...... 73 INFUGEM...... 51 hydroxychloroquine...... 22, 35 ICLUSIG...... 55 INFUMORPH P/F...... 15 hydroxychloroquine sulf (bulk) IDAMYCIN PFS...... 58 INFUVITE ADULT...... 164 ...... 22, 35, 109 idarubicin...... 58 INFUVITE PEDIATRIC...... 171 hydroxyprogest(pf)(preg presv) 258 IDHIFA...... 55 INGREZZA...... 101, 102 hydroxyprogesterone cap(ppres) IFE-BIMIX 30/1...... 145 INGREZZA INITIATION ...... 258 IFE-PG20...... 145 PACK...... 101, 102 hydroxyprogesterone capr(bulk) IFEREX 150 FORTE...... 155 INJECTAFER...... 156 ...... 109, 192 IFEX...... 49 INLYTA...... 57 hydroxyprogesterone caproate..258 ifosfamide...... 49 INNOPRAN XL...... 73 hydroxyurea...... 51 ILARIS (PF)...... 20 INNOSPIRE ELEGANCE225, 230 hydroxyzine hcl...... 82 ILEVRO...... 242 INNOSPIRE ESSENCE... 225, 230 hydroxyzine pamoate...... 82 ILUVIEN...... 241 INNOSPIRE GO NEBULIZER HYLATOPIC...... 132 imatinib...... 57 ...... 224, 230 HYLATOPICPLUS...... 132 IMBRUVICA...... 52, 57 inositol...... 72 HYLAVITE...... 147 imipenem-cilastatin...... 39 INOSITOL HYLENEX...... 193 imipramine hcl...... 89 HEXANICOTINATE...... 109, 176 HYMOVIS...... 217 imipramine pamoate...... 89 INOVA...... 125 HYOPHEN...... 45, 207 imiquimod...... 136 INOVA 4-1...... 125 hyoscyamine sulfate...... 199, 208 IMITREX...... 101 INOVA 8-2...... 125 hyoscyamine sulfate (bulk) IMITREX STATDOSE PEN....101 INREBIC...... 54 ...... 109, 199, 208 IMITREX STATDOSE INSPRA...... 66, 77 HYOSYNE...... 199, 208 REFILL...... 101 INSUFLON...... 226, 230 HYPER-HEAL...... 132 IMLYGIC...... 54, 63 insulin lispro...... 190 HYPERHEP B S/D...... 63 IMOGAM RABIES-HT (PF)..... 63 insulin lispro protamin-lispro... 189 HYPERHEP B S-D IMOVAX RABIES VACCINE INTEGRA...... 155 NEONATAL...... 63 (PF)...... 65 INTEGRA F...... 155 HYPERLYTE CR...... 158 IMPAVIDO...... 35 INTEGRA PLUS...... 155 HYPERRAB (PF)...... 63 IMPOYZ...... 130, 134 INTEGRILIN...... 213 HYPERRAB S/D (PF)...... 63 IMURAN...... 23, 216 INTELENCE...... 37 HYPERTET S/D (PF)...... 63 IMVEXXY MAINTENANCE INTERLINK LEVER LOCK HYPOCYN...... 133 PACK...... 191 CANNULA...... 225, 230 HYPROST...... 149 IMVEXXY STARTER PACK. 191 INTERMEZZO...... 103 HYQVIA...... 63 INBRIJA...... 90 INTRALIPID...... 168 HYQVIA HY COMPONENT..193 INCASSIA...... 122 INTROVALE...... 120 HYQVIA IG COMPONENT...... 63 INCRELEX...... 191 INTUNIV ER...... 94 HYSINGLA ER...... 15 INCRUSE ELLIPTA...... 251 INVANZ...... 39 HYZAAR...... 67 indapamide...... 79 INVEGA...... 91 I.L.X. B-12...... 155 INDERAL LA...... 73 INVEGA SUSTENNA...... 91 ibandronate...... 184 INDERAL XL...... 73 INVEGA TRINZA...... 91 IBRANCE...... 53 indium in-111 oxyquinoline..... 144 INVELTYS...... 241 IBUDONE...... 18 INDOCIN...... 26 INVIRASE...... 46 ibuprofen...... 26 indocyanine green...... 142 INVOKAMET...... 181 ibuprofen (bulk)...... 26, 109 indomethacin...... 26 INVOKANA...... 181 ibuprofen-oxycodone...... 19 indomethacin (bulk)...... 26, 109 iodine (bulk)...... 61, 109 ibutilide fumarate...... 69 indomethacin sodium...... 80 IODOFLEX...... 61 IC GREEN...... 142 INFANRIX (DTAP) (PF)...... 64 IODOPEN...... 154 ICAPS...... 162 infant formula with iron...... 149 iodoquinol (bulk)...... 32, 109

278 IODOSORB...... 61 ISOVUE-370...... 142 karaya gum (bulk).....109, 203, 224 IONOSOL-B IN D5W...... 154 ISOVUE-M 300...... 142 KARBINAL ER...... 248 IONOSOL-MB IN D5W...... 154 isoxsuprine...... 80 KARIVA (28)...... 120 iopanoic acid (bulk)...... 109, 142 isradipine...... 74 KAZANO...... 183 IOPIDINE...... 246 ISTALOL...... 243 KEDRAB (PF)...... 63 IPOL...... 65 ISTODAX...... 54 KEFLEX...... 40 ipratropium bromide...... 251, 254 itraconazole...... 34 KELARX...... 138 ipratropium bromide (bulk) ivermectin...... 33 KELNOR 1/35 (28)...... 121 ...... 109, 251, 254 ivermectin (bulk)...... 33, 109 KELNOR 1-50...... 121 ipratropium-albuterol...... 252 IXEMPRA...... 53 KELOTOP...... 226, 230 irbesartan...... 68 IXIARO (PF)...... 65 KENALOG...... 134, 187 irbesartan-hydrochlorothiazide... 67 JADENU...... 31 KENALOG-80...... 187 IRESSA...... 49 JADENU SPRINKLE...... 31 KENGREAL...... 213 irinotecan...... 58 JAKAFI...... 54 KEPIVANCE...... 203 iron...... 156 JALYN...... 204 KEPPRA...... 86 IRON...... 156 JANTOVEN...... 209 KEPPRA XR...... 86 IRON (DRIED)...... 156 JANUMET...... 183 KERAFOAM...... 136 IRON 100 PLUS...... 156 JANUMET XR...... 183 KERALAC...... 136 IRON CHEWS...... 156 JANUVIA...... 181 KERALYT RX...... 136 iron,carbonyl-vitamin c...... 155 JARDIANCE...... 181 KERALYT SCALP IRONUP...... 156 JASMIEL (28)...... 120 COMPLETE...... 136 IRO-PLEX (IRON JENCYCLA...... 122 KERYDIN...... 129 CARBONYL)...... 155 JENTADUETO...... 183 ketamine...... 27 IRO-PLEX (IRON JENTADUETO XR...... 183 ketamine (bulk)...... 27, 109 POLYSACCHARIDE)...... 155 JEVTANA...... 57 ketamine in 0.9 % sod chloride...27 IROSPAN 24/6...... 155 JINTELI...... 185 ketamine in nacl, iso-osmotic..... 27 ISENTRESS...... 36 JOLESSA...... 120 ketamine in sterile water...... 27 ISENTRESS HD...... 36 JORNAY PM...... 94 KETOCAL 2.5:1...... 165 ISOCHRON...... 68 JUBLIA...... 129 ketoconazole...... 34, 128 ISOLEUCINE AMINO ACID JULEBER...... 120 ketoconazole (bulk)...... 34, 109 SUPPLMNT...... 146, 166 JULUCA...... 36 ketoprofen...... 26 ISOLYTE S PH 7.4...... 158 JUNEL 1.5/30 (21)...... 121 KETOQ10 5.5:1...... 165 ISOLYTE-P IN 5 % JUNEL 1/20 (21)...... 121 ketorolac...... 25, 242 DEXTROSE...... 154 JUNEL FE 1.5/30 (28)...... 121 KEVEYIS...... 217 ISOLYTE-S...... 158 JUNEL FE 1/20 (28)...... 121 KEVZARA...... 23 isometh-dichloral-acetaminophn 99 JUNEL FE 24...... 121 KEYTRUDA...... 59 ISOMIL ADVANCE...... 149 JUXTAPID...... 72 KHAPZORY...... 60 ISOMIL DF...... 149 JYNARQUE...... 78, 193, 205 KIDS COD LIVER OIL AND ISOMIL/IRON...... 149 K2 PLUS D3...... 177 VIT D...... 171 isoniazid...... 39 KABIVEN...... 168 KIDS FIRST VITAMIN D3.....178 isoproterenol hcl...... 75 KADCYLA...... 50, 59 KIDS' GUMMY...... 171 isoproterenol hcl (bulk)...... 75, 109 KADIAN...... 15 KIDS MULTIVITAMIN- ISOPTO ATROPINE...... 241 kahlua flavor (bulk)...... 109, 115 MINERALS...... 171 ISOPTO CARPINE...... 240 KAITLIB FE...... 121 KIDS VITAMIN D3...... 178 ISORDIL...... 68 KALBITOR...... 80 KINERET...... 23 ISORDIL TITRADOSE...... 68 KALETRA...... 38 KINEVAC...... 143 isosorbide dinitrate...... 68 KALLIGA...... 121 KINRIX (PF)...... 64 isosorbide mononitrate...... 68 KALYDECO...... 253 KISQALI...... 53 isotretinoin...... 123 KAMDOY...... 137 KISQALI FEMARA CO-PACK 54 ISOVUE-200...... 142 KANUMA...... 234 KITABIS PAK...... 253 ISOVUE-250...... 142 KAPSPARGO SPRINKLE...... 73 KLARITY (CHONDROITIN) ISOVUE-300...... 142 KAPVAY...... 94 (PF)...... 239

279 KLARON...... 124 LAMICTAL ODT STARTER leflunomide...... 24 KLONOPIN...... 82, 83, 95 (BLUE)...... 85, 96 lemon flavor extract (bulk)...... 115 KLOR-CON...... 159 LAMICTAL ODT STARTER lemonade flavor oil (bulk) 109, 115 KLOR-CON 10...... 159 (GREEN)...... 85, 96 LEMTRADA...... 238 KLOR-CON 8...... 159 LAMICTAL ODT STARTER LENVIMA...... 57 KLOR-CON M10...... 159 (ORANGE)...... 85, 96 LESCOL...... 70 KLOR-CON M15...... 159 LAMICTAL STARTER LESCOL XL...... 70 KLOR-CON M20...... 159 (BLUE) KIT...... 85, 97 LESSINA...... 121 KLOR-CON/EF...... 159 LAMICTAL STARTER LETAIRIS...... 81 KOBEE...... 147 (GREEN) KIT...... 85, 97 letrozole...... 51 KOMBIGLYZE XR...... 183 LAMICTAL STARTER leucine...... 146 KORLYM...... 181 (ORANGE) KIT...... 85, 97 leucovorin calcium...... 60, 61 K-PAX...... 162 LAMICTAL XR...... 85 leucovorin calcium (bulk)...... 109 K-PAX IMMUNE SUPPORT..162 LAMICTAL XR STARTER LEUKERAN...... 49 K-PHOS NO 2...... 206 (BLUE)...... 85 LEUKINE...... 210 K-PHOS ORIGINAL...... 206 LAMICTAL XR STARTER leuprolide...... 54 K-PHOS-NEUTRAL...... 158, 206 (GREEN)...... 85 levalbuterol hcl...... 252 KPN...... 172 LAMICTAL XR STARTER levalbuterol tartrate...... 252 krill-om-3-dha-epa-phospho-ast. 71 (ORANGE)...... 85 levamisole (bulk)...... 55, 109 KRINTAFEL...... 35 lamivudine...... 37, 43 LEVBID...... 199, 208 KRISTALOSE...... 203 lamivudine-zidovudine...... 38 LEVEMIR FLEXTOUCH U- KRYSTEXXA...... 209 lamotrigine...... 85, 86, 97 100 INSULN...... 190 K-TAB...... 159 LANOXIN...... 77 LEVEMIR U-100 INSULIN.... 190 KURVELO (28)...... 121 LANOXIN PEDIATRIC...... 77 levetiracetam...... 86 KUVAN...... 236 lansoprazole...... 197 levetiracetam in nacl (iso-os)...... 86 KYLEENA...... 119 lansoprazole (bulk)...... 109, 197 LEVITRA...... 145 KYNMOBI...... 90 lanthanum...... 205 levobunolol...... 243 KYPROLIS...... 56 LANTUS SOLOSTAR U-100 levocarnitine (with sugar)...... 235 l norgest/e.estradiol-e.estrad..... 120 INSULIN...... 189 levocetirizine...... 248, 249 l.acidoph,saliva-b.bif-s.therm... 202 LANTUS U-100 INSULIN...... 189 levofloxacin...... 42, 245 L.E.T. (LIDO-EPINEPH- LARIN 1.5/30 (21)...... 121 levofloxacin in d5w...... 42 TETRA)...... 140 LARIN 1/20 (21)...... 121 levoleucovorin calcium...... 60, 61 labetalol...... 67 LARIN 24 FE...... 121 LEVONEST (28)...... 122 LAC-HYDRIN FIVE...... 132 LARIN FE 1.5/30 (28)...... 121 levonorgestrel-ethinyl estrad.....121 LACRISERT...... 239 LARIN FE 1/20 (28)...... 121 levonorg-eth estrad triphasic.....122 lactase...... 196 LASIX...... 78 LEVOPHED (BITARTRATE)...76 LACTASE FAST ACTING..... 196 LASTACAFT...... 241 LEVORA-28...... 121 lactated ringers...... 151, 174 latanoprost...... 246 levorphanol tartrate...... 15 lactic acid (bulk)...... 109, 113 latanoprost (pf)...... 246 levorphanol tartrate (bulk).. 15, 109 LACTINEX...... 202 LATUDA...... 91 LEVO-T...... 193 lactobacill.acidophilus (bulk) LAYOLIS FE...... 121 levothyroxine...... 193 ...... 109, 202 LAZANDA...... 15 levothyroxine (bulk)...... 109, 193 lactobacillus acidophilus...... 202 LC PLUS...... 224, 230 LEVOXYL...... 193 lactobacillus acidoph-l.bulgar...202 LC PLUS NEBULIZER-PED LEVSIN...... 199, 208 lactose (bulk)...... 109, 118 MASK...... 224, 230 LEVSIN/SL...... 199, 208 LACTOSE FAST ACTING L-CARNITINE...... 109, 235 LEVULAN...... 138 RELIEF...... 196 l-cystine...... 146 LEXAPRO...... 87 lactulose...... 196, 203 lecithin...... 72 LEXETTE...... 130, 134 L-ALANINE...... 109, 167 lecithin (bulk)...... 109 LEXISCAN...... 143 LAMICTAL...... 85 lecithin, soy...... 72 LEXIVA...... 46 LAMICTAL ODT...... 85, 96 LECITHIN-KELP-B6...... 13 L-GLUTAMINE...... 109, 167, 214 LEENA 28...... 122 LIALDA...... 201

280 LIBRAX (WITH CLIDINIUM) LIQUID CALCIUM WITH LOPROX...... 128 ...... 95, 199, 200 VITAMIN D...... 153 lorazepam...... 82, 95, 96, 103 LIBTAYO...... 59 LIQUIVIDA HYDRATION LORAZEPAM INTENSOL. 82, 95 LICE BEDDING SPRAY...... 141 KIT...... 174 LORBRENA...... 50 licorice flavor (bulk)...... 109, 115 lisinopril...... 66 LORCET HD...... 18 lidocaine...... 28, 140 lisinopril-hydrochlorothiazide.... 66 LORID...... 147 lidocaine (pf)...... 28, 68 L-ISOLEUCINE...... 109, 167 LORTAB ELIXIR...... 18, 19 lidocaine hcl...... 28, 140, 237 LITE TOUCH-MEDIUM LORYNA (28)...... 121 lidocaine hcl-hydrocortison ac MASK...... 225, 230 LORZONE...... 219 ...... 29, 30, 135 LITEAIRE MDI CHAMBER losartan...... 68 lidocaine in 5 % dextrose (pf).....68 ...... 225, 230 losartan-hydrochlorothiazide...... 67 LIDOCAINE VISCOUS...... 237 LITETOUCH-LARGE MASK LOSEASONIQUE...... 120 lidocaine-epinephrine...... 29 ...... 225, 230 LOTEMAX...... 241 lidocaine-epineph-sodium chlor. 29 LITETOUCH-SMALL MASK LOTEMAX SM...... 241 lidocaine-hydrocortisone-aloe.... 30 ...... 226, 230 LOTENSIN...... 66 lidocaine-phenylephrn in water 240 lithium carbonate...... 98 LOTENSIN HCT...... 66 lidocaine-prilocaine...... 137 lithium citrate...... 98 loteprednol etabonate...... 241 lidocaine-tetracaine...... 140 LITHOBID...... 98 LOTREL...... 66 LIDODERM...... 140 LITHOSTAT...... 206 LOTRONEX...... 200, 203 LIDO-K...... 140 LITTLE ANIMALS-IRON...... 171 LOUTREX...... 130, 132 LIDOPIN...... 140 LIVALO...... 70 lovastatin...... 70 LIDORX...... 140 LIVIXIL PAK...... 137 LOVENOX...... 212 LIDOTREX...... 140 L-LYSINE...... 146 LOW-OGESTREL (28)...... 121 LIDOVEX...... 140 LMD 10 % IN 0.9 % SODIUM loxapine succinate...... 92 LIDOZION...... 140 CHLOR...... 212 LO-ZUMANDIMINE (28)...... 121 LILETTA...... 119 LMD 10 % IN 5 % LTA PRE-ATTACHED...... 28 LIME FLAVOR...... 109, 115 DEXTROSE...... 212 LUCEMYRA...... 104 LINCOCIN...... 44 LO LOESTRIN FE...... 120 LUCENTIS...... 244, 246 lincomycin...... 44 LOCALNESIUM...... 152 LUDENT FLUORIDE...... 236 lindane...... 141 LOCALNESIUM-C...... 152 LUGOLS...... 154 linezolid...... 45 LOCOID...... 134 luliconazole...... 128 linezolid in dextrose 5%...... 45 LOCOID LIPOCREAM...... 134 LUMIGAN...... 246 linezolid-0.9% sodium chloride..45 LODOSYN...... 90 LUMITENE...... 175 LINZESS...... 196, 200, 203 LOESTRIN 1.5/30 (21)...... 121 LUMIZYME...... 235 LIORESAL...... 219 LOESTRIN 1/20 (21)...... 121 LUMOXITI...... 52, 54 liothyronine...... 193 LOESTRIN FE 1.5/30 (28- LUMOXITI IV SOLN liothyronine (bulk)...... 109, 193 DAY)...... 121 STABILIZER...... 118 LIP BALM BASE (BULK) LOESTRIN FE 1/20 (28-DAY)121 LUNESTA...... 103 ...... 109, 113, 118 LOFRIC...... 227, 230 LUPANETA PACK (1 LIPIODOL...... 142 LOKELMA...... 151 MONTH)...... 191 LIPITOR...... 70 LOMOTIL...... 194 LUPANETA PACK (3 LIPOBASE REGULAR... 109, 114 LONHALA MAGNAIR MONTH)...... 191 LIPOCHOL PLUS...... 71 REFILL...... 251 LUPRON DEPOT...... 55, 191 LIPOFEN...... 70 LONHALA MAGNAIR LUPRON DEPOT (3 MONTH) LIPOIC ACID...... 12, 109 STARTER...... 251 ...... 54, 191 LIPOSYN II...... 168 LONSURF...... 51 LUPRON DEPOT (4 MONTH). 54 LIPOSYN III...... 168 loperamide (bulk)...... 109, 194 LUPRON DEPOT (6 MONTH). 54 LIPOTRIAD (WITH LUTEIN) 162 LOPID...... 70 LUPRON DEPOT-PED...... 191 LIPOVAN CREAM BASE lopinavir-ritonavir...... 38 LUPRON DEPOT-PED (3 ...... 109, 114 LOPREEZA...... 185 MONTH)...... 191 LIQUID B-12...... 176 LOPRESSOR...... 73 lutein...... 12 LOPRESSOR HCT...... 75 LUTERA (28)...... 121

281 LUVS NEWBORN...... 222, 230 magnesium, potassium aspartate MCT OIL...... 166 LUVS SIZE 1...... 222, 230 ...... 157 meclofenamate...... 25 LUVS SIZE 2...... 222, 230 MAGNEVIST...... 142 mecobalamin (bulk)...... 110, 176 LUVS SIZE 3...... 222, 230 MAKENA...... 258 MEDI-LYTE...... 157 LUVS SIZE 4...... 222, 230 MAKENA (PF)...... 258 MEDIUM CREAM...... 110, 114 LUVS SIZE 5...... 222, 230 MALARONE...... 35 MEDROL...... 187 LUVS SIZE 6...... 222, 230 MALARONE PEDIATRIC...... 35 MEDROL (PAK)...... 187 LUXAMEND...... 132 malathion...... 141 medroxyprogesterone...... 119, 192 LUXIQ...... 134 manganese chloride...... 157 MEDTYCHOLL-B LUZU...... 129 manganese sulfate...... 157 COMPLEX-LIVER...... 147 LYDIA PINKHAM HERBAL mannitol 10 %...... 78 mefenamic acid...... 25 ...... 13, 155 mannitol 20 %...... 78 mefenamic acid (bulk)...... 25, 110 LYMPHOSEEK...... 144 mannitol 25 %...... 78 mefloquine...... 35 LYNPARZA...... 56 mannitol 5 %...... 78 MEFOXIN IN DEXTROSE LYRICA...... 84, 99 MANNXTRA...... 13 (ISO-OSM)...... 40 LYRICA CR...... 99, 102, 103 maple flavor (bulk)...... 110, 115 MEGA BIOTIN...... 177 lysine...... 146 MAPO BATH...... 132 MEGA lysine hcl...... 146 maprotiline...... 89 MULTIPLE/CHELATED LYSIPLEX PLUS...... 169 MARCAINE-EPINEPHRINE..237 MINERAL...... 162 LYSODREN...... 50 MARLISSA (28)...... 121 MEGA MULTIVITAMIN FOR LYSTEDA...... 210 MARNATAL-F...... 172 MEN...... 162 LYZA...... 122 MARPLAN...... 87 MEGA MULTIVITAMIN M.V.I. ADULT...... 164 MARQIBO...... 58 WITH MINERAL...... 162 M.V.I. PEDIATRIC...... 171 marshmallow flavor (bulk)110, 115 megestrol...... 56, 145 M.V.I.-12 (WITHOUT MAS CARE-PAK (PF)...... 187 MEKINIST...... 55 VITAMIN K)...... 164 MATULANE...... 49 MEKTOVI...... 55 MACRILEN...... 143 MAVENCLAD (10 TABLET melatonin-lemon balm leaf extr..99 MACROBID...... 33, 207 PACK)...... 239 MELODETTA 24 FE...... 121 MACRODANTIN...... 33, 207 MAVENCLAD (4 TABLET meloxicam...... 25 mag oxide-d3-turmeric rt xt...... 13 PACK)...... 239 meloxicam (bulk)...... 25, 110 MAGELLAN INSULIN MAVENCLAD (5 TABLET melphalan hcl...... 49 SAFETY SYRNG...... 223, 230 PACK)...... 239 memantine...... 119 MAGELLAN SYRINGE..223, 230 MAVENCLAD (6 TABLET MENACTRA (PF)...... 64 MAGNASWEET 110...... 109, 115 PACK)...... 239 MENEST...... 185 MAGNEBIND 300...... 205 MAVENCLAD (7 TABLET MENOSTAR...... 185 MAGNEBIND 400...... 205 PACK)...... 239 MEN'S 50 PLUS magnesium...... 157 MAVENCLAD (8 TABLET MULTIVITAMIN...... 162 magnesium amino acid chelate.157 PACK)...... 239 MEN'S DAILY...... 162 magnesium carbonate (bulk).....109 MAVENCLAD (9 TABLET MEN'S DAILY GUMMIES..... 162 magnesium chloride...... 157 PACK)...... 239 MEN'S DAILY MULTIVIT- magnesium gluconate (bulk) MAXALT...... 101 MINERAL...... 162 ...... 109, 157 MAXALT-MLT...... 101 MEN'S MULTIVITAMIN magnesium glycinate (bulk) MAXIDEX...... 241 GUMMIES...... 162 ...... 109, 157 MAXIMIN PACK...... 162 MEN'S ONE DAILY...... 162 magnesium hydroxide (bulk)....109 MAXITROL...... 240 MEN'S PACK...... 162 magnesium l-lactate...... 157 MAXZIDE...... 78 MENS POTENT FORMULA.... 13 magnesium oxide...... 157 MAXZIDE-25MG...... 78 MENTAX...... 128 magnesium sulfate...... 157 MAYZENT...... 239 menthol (bulk)...... 110, 141, 249 magnesium sulfate in d5w...... 157 MAYZENT STARTER PACK 239 MENVEO A-C-Y-W-135-DIP magnesium sulfate in water...... 157 MB HYDROGEL...... 131 (PF)...... 64 MB HYDROGEL meperidine...... 15 (CYCLOMETHICONE)...... 131 meperidine (pf)...... 15

282 MEPHYTON...... 178 methoxsalen (bulk) MICROAIR MESH meprobamate...... 83 ...... 56, 110, 130, 138 NEBULIZER...... 224, 230 MEPRON...... 35 methscopolamine...... 199 MICROCHAMBER...... 226, 230 MEPSEVII...... 234 methylcellulose 1500cps (bulk) MICROGESTIN 1.5/30 (21).... 121 mercaptopurine...... 51 ...... 110, 118 MICROGESTIN 1/20 (21)...... 121 MERIBIN...... 177 methylcellulose 4000cps (bulk) MICROGESTIN FE 1.5/30 (28) meropenem...... 39 ...... 110, 118 ...... 121 meropenem-0.9% sodium methyldopa...... 77 MICROGESTIN FE 1/20 (28)..121 chloride...... 39 methyldopa- MICROLIPID...... 165, 166 MERREM...... 39 hydrochlorothiazide...... 77 MICROSPACER...... 226, 230 mesalamine...... 201 methyldopate...... 77 midazolam...... 27, 96, 103 mesalamine (bulk)...... 110 methylene blue (antidote)...... 31 midazolam (pf)...... 27, 96 mesalamine with cleansing wipe methylergonovine...... 191 midazolam (pf) in 0.9 % nacl27, 96 ...... 201 METHYLIN...... 94, 102 midazolam in 0.9 % sod chlorid mesna...... 61 methylphenidate hcl...... 94, 95, 102 ...... 27, 96 MESNEX...... 61 methylprednisolon ac,mic(bulk) midodrine...... 76 MESTINON...... 217 ...... 110, 187 MIFEPREX...... 179 MESTINON TIMESPAN...... 217 methylprednisolone...... 187 mifepristone...... 179 METADATE ER...... 94 methylprednisolone acetate...... 187 MIGERGOT...... 100 METAFOLBIC...... 164 methylprednisolone sodium miglitol...... 181 METAMUCIL FREE...... 203 succ...... 187 miglustat...... 235 METAMUCIL PLUS methylprednisolone, mic (bulk) MIGRANAL...... 100 CALCIUM...... 203 ...... 110, 187 MIGRANOW...... 101 METANX (ALGAL OIL)...... 176 methylsulfonylmethane...... 12 MILI...... 121 metaproterenol...... 252 methyltestosterone...... 180 milk thistle...... 13 METAXALL...... 219 methyltestosterone (bulk). 110, 180 milk thistle seed extract...... 13 metaxalone...... 219 methyltestosterone,micro(bulk) MILLIPRED...... 187 metformin...... 190 ...... 110, 180 MILLIPRED DP...... 187 methacholine chloride (bulk) metipranolol...... 243 milrinone...... 75 ...... 110, 143 metoclopramide (bulk)...... 110 milrinone in 5 % dextrose...... 75 methadone...... 15 metoclopramide hcl...... 198 MIMVEY...... 185 methadone (bulk)...... 15, 110 metolazone...... 79 MINASTRIN 24 FE...... 121 METHADONE INTENSOL...... 15 METOPIRONE...... 143 mineral oil...... 110, 113 METHADOSE...... 16 metoprolol succinate...... 73 MINI PRENATAL...... 172 methamphetamine...... 94, 98 metoprolol ta-hydrochlorothiaz.. 75 MINIMED INFUSION SET- METHAVER...... 176 metoprolol tartrate...... 73 MMT 390...... 227, 230 methazolamide...... 78 METRO I.V...... 36 MINIPRESS...... 80 methenamine hippurate...... 45, 207 METROCREAM...... 124, 139 MINITRAN...... 68 methenamine mandelate..... 45, 207 METROGEL...... 139 MINIVELLE...... 185, 186 methenamine mandelate (bulk) METROGEL VAGINAL...... 255 MINOCIN...... 48 ...... 110, 207 METROLOTION...... 124, 139 minocycline...... 24, 48, 123 methen-sod phos-meth blue- metronidazole...... 36, 124, 139, 255 MINOLIRA ER...... 48, 123 hyos...... 45, 207 metronidazole in nacl (iso-os).....36 minoxidil...... 77 METHERGINE...... 191 mexiletine...... 68 minoxidil (bulk)...... 77, 110, 141 methimazole...... 183 MG-PLUS-PROTEIN...... 13 mint chocolate chip flv (bulk) METHITEST...... 180 MIACALCIN...... 184 ...... 110, 115 methocarbamol...... 219 MIADERM...... 132 MIO INFUSION SET...... 227, 230 METHOCEL E 4 M...... 118 MIBELAS 24 FE...... 121 MIOCHOL-E...... 240 methotrexate sodium...... 22, 50 MICARDIS...... 68 MIOSTAT...... 240 methotrexate sodium (pf)...... 50 MICARDIS HCT...... 67 MIRAPEX...... 91 methoxsalen...... 130 miconazole nitrate-zinc ox-pet..129 MIRAPEX ER...... 91 MICONAZOLE-3...... 255 MIRCERA...... 210

283 MIRCETTE (28)...... 120 morphine concentrate...... 16 MULTIVITAMINS WITH MIRENA...... 119 morphine in 0.9 % sodium chlor.16 FLUORIDE...... 170 mirtazapine...... 86, 87 MOTEGRITY...... 198 MULTI-VITE...... 162 MIRVASO...... 139 MOTOFEN...... 194 mupirocin...... 127 misoprostol...... 198 MOVANTIK...... 31 mupirocin calcium...... 127 MITIGARE...... 208 MOVIPREP...... 203 MUSE...... 145 mitomycin...... 58 MOXATAG...... 33 MVC-FLUORIDE...... 170 MITOSOL...... 241 MOXEZA...... 245 mv-min-folic acid-lutein...... 162 mitoxantrone...... 58 moxifloxacin...... 42, 245 MVW COMPLETE FORMUL MKO (MIDAZOLAM- moxifloxacin-sod chlor,iso(pf). 245 MULTIVIT...... 171 KETAMINE-ONDAN)...... 27, 104 moxifloxacin-sod.ace,sul-water..42 MVW COMPLETE FORMUL M-M-R II (PF)...... 63, 65 moxifloxacin-sod.chloride(iso)...42 PEDIATRIC...... 171 M-NATAL PLUS...... 172 MOZOBIL...... 209 MVW COMPLETE MOBIC...... 25 MS CONTIN...... 16 FORMULATION D3000...... 171 modafinil...... 102 MSUD ANALOG...... 149, 166 MVW COMPLETE moexipril...... 66 MUCOSITISRX...... 237 FORMULATION D5000...... 171 molindone...... 92 MUGARD...... 237, 238 MYAMBUTOL...... 39 mometasone...... 134, 254 MULPLETA...... 215 MYCAMINE...... 34 MONDOXYNE NL...... 48 MULTAQ...... 69 MYCOBUTIN...... 39, 47 MONOCAL...... 157 MULTI FOR HER...... 162 mycophenolate mofetil...... 23, 216 MONOCAPS...... 162 MULTI VITAMIN...... 162 mycophenolate mofetil (hcl) MONODOX...... 48 MULTIBASE...... 110, 114 ...... 23, 216 MONOJECT 0.9% SODIUM MULTI-DAY PLUS mycophenolate sodium...... 216 CHLORIDE...... 174 MINERALS...... 162 MYDAYIS...... 95, 98 MONOJECT BLOOD MULTI-DELYN WITH IRON.162 MYDRIACYL...... 241 COLLECTION...... 220, 230 MULTIGEN FOLIC...... 155 MYDRIATIC4(TROP-PROP- MONOJECT CONTROL MULTIGEN PLUS...... 155 PE-KTRLC)...... 244 SYRINGE LUER...... 224, 231 MULTIHANCE...... 142 MYFERON 150 FORTE...... 155 MONOJECT HYPODERMIC MULTIHANCE MULTIPACK142 MYFORTIC...... 216 NEEDLES...... 224, 231 MULTIPLE VITAMIN, MYLERAN...... 49 MONOJECT INSULIN WOMENS...... 162 MYNATAL...... 172 SAFETY SYRING...... 223, 231 MULTITRACE-4...... 160 MYNATAL PLUS...... 172 MONOJECT PREFILL MULTITRACE-4 MYNATAL-Z...... 172 ADVANCED NS...... 174 CONCENTRATE...... 160 MYNEPHROCAPS...... 147 MONOJECT SAFETY MULTITRACE-4 NEONATAL MYOBLOC...... 218 SYRINGES...... 224, 231 ...... 160 MYORISAN...... 123 MONOJECT SYRINGE...224, 231 MULTITRACE-4 PEDIATRIC160 MYOVIEW KIT...... 144 MONOJECT TB LUER LOK MULTITRACE-5...... 160 MYRBETRIQ...... 205 ...... 224, 231 MULTITRACE-5 MYSOLINE...... 83 MONO-LINYAH...... 121 CONCENTRATE...... 160 NABI-HB...... 63 MONOVISC...... 217 MULTIUSE BASE...... 110, 114 nabumetone...... 25 MONSEL'S...... 210 MULTI-VIT WITH N-ACETYL-ALPHA-D- montelukast...... 250 FLUORIDE-IRON...... 169, 170 GLUCOSAMINE...... 12, 110 MONUROL...... 34, 207 multivitamin...... 164 nadolol...... 73 MOOD SUPPORT MULTI-VITAMIN nadolol-bendroflumethiazide...... 79 PROBIOTIC...... 202 HP/MINERALS...... 162 nafcillin...... 45 MORGIDOX...... 48 MULTIVITAMIN WITH nafcillin in dextrose iso-osm...... 45 MORGIDOX 2X100...... 48 FLUORIDE...... 170 naftifine...... 128 morphine...... 16 MULTI-VITAMIN WITH NAFTIN...... 128 morphine (bulk)...... 16, 110 FLUORIDE...... 170 NAGLAZYME...... 234 morphine (pf)...... 16 MULTIVITAMIN WOMEN 50 nalbuphine...... 20 morphine (pf) in 0.9 % sod chl... 16 PLUS...... 162 NALFON...... 26

284 NALOCET...... 19 neomycin-polymyxin-hc...240, 247 niacinamide (bulk)...... 110, 176 naloxone...... 32 NEO-POLYCIN...... 245 NIACOR...... 71 naloxone (bulk)...... 32, 110 NEO-POLYCIN HC...... 240 NIASPAN EXTENDED- naltrexone...... 32 NEOPROFEN (IBUPROFEN RELEASE...... 71 naltrexone hcl (bulk)...... 32, 110 LYSN)(PF)...... 80 nicardipine...... 74 NAMENDA...... 119 NEORAL...... 23, 216 nicardipine in 0.9 % sod chlor.... 74 NAMENDA TITRATION PAK NEOSALUS...... 132 NICOMIDE (SELENIUM- ...... 119 neostigmine methylsulfate...... 217 CHROMIUM)...... 162 NAMENDA XR...... 119 NEO-SYNALAR...... 128 NICOTROL...... 105 NAMZARIC...... 119 NEO-SYNALAR KIT...... 128 NICOTROL NS...... 105 NANO VM 1-3...... 171 NEPHPLEX RX...... 147 nifedipine...... 74 NANO VM 4-8...... 171 NEPHRAMINE 5.4 %...... 168 nifedipine (bulk)...... 74, 110 NANOVM 9-18...... 169 NEPHRONEX...... 147 nifedipine, micronized (bulk) NANOVM T-F...... 169 NEPHRONEX-SL...... 147 ...... 74, 110 NAPRELAN CR...... 26 NEPHRO-VITE...... 147 NIKKI (28)...... 121 NAPROSYN...... 26 NEPHRO-VITE RX...... 147 NILANDRON...... 50 naproxen...... 26 NERIA...... 226, 231 nilutamide...... 50 naproxen (bulk)...... 26, 110 NERLYNX...... 49 NIMBEX...... 218 naproxen sodium...... 26 NESINA...... 181 nimodipine...... 74 naproxen sodium (bulk)...... 26, 110 NESTABS...... 172 NINLARO...... 56 naratriptan...... 101 NESTABS ABC...... 172 NIPENT...... 51 NARCAN...... 32 NESTABS DHA...... 172 NIPRIDE RTU...... 77 NARDIL...... 87 NEUAC...... 124 nisoldipine...... 74 NAROPIN (PF)...... 28 NEULASTA...... 210 NITHIODOTE...... 30 NASONEX...... 254 NEUPOGEN...... 210 NITRO-BID...... 68 NATACHEW (FE BIS- NEUPRO...... 91 NITRO-DUR...... 68 GLYCINATE)...... 172 NEURAPTINE...... 138 nitrofurantoin...... 33, 207 NATACYN...... 245 NEURCAINE...... 140 nitrofurantoin (bulk)...... 33, 110 NATAZIA...... 122 NEURIN-SL...... 176 nitrofurantoin macrocrystal.33, 207 nateglinide...... 181 NEUROLITE...... 143 nitrofurantoin monohyd/m-cryst NATESTO...... 180 NEURONTIN...... 84 ...... 33, 207 NATPARA...... 192 NEUTROGENA...... 139 nitroglycerin...... 68 NATROBA...... 141 NEUTROGENA ACNE nitroglycerin in 5 % dextrose...... 68 NATURAL B-100 COMPLEX 147 CLEANSING SOAP...... 140 NITROLINGUAL...... 68 NAVELBINE...... 58 NEUTROGENA FACIAL NITROMIST...... 68 NAYZILAM...... 83, 96 SOAP...... 140 NITROPRESS...... 77 NEBUPENT...... 45 NEVANAC...... 242 NITROSTAT...... 68 NEBUSAL...... 117 nevirapine...... 37 NITRO-TIME...... 68 NECON 0.5/35 (28)...... 121 NEWGEN...... 172 NITYR...... 235 NEEVODHA (WITH ALGAL NEXAVAR...... 55 NIVA-FOL...... 176, 178 OIL)...... 164, 172 NEXAVIR...... 137 NIVA-PLUS...... 162, 172 nefazodone...... 88 NEXIUM...... 197 NIVATOPIC PLUS...... 132 NEMBUTAL SODIUM...... 103 NEXIUM IV...... 197 NIVESTYM...... 210 neomycin...... 32 NEXIUM PACKET...... 197 nizatidine...... 197 neomycin-bacitracin-poly-hc....240 NEXLETOL...... 69 NOCDURNA (MEN)...... 180 neomycin-bacitracin-polymyxin NEXPLANON...... 119 NOCDURNA (WOMEN)...... 180 ...... 245 NEXTERONE...... 69 NOCTIVA...... 180 neomycin-polymyxin b gu...... 204 niacin...... 71, 176 NOLIX...... 134 neomycin-polymyxin b- niacin (inositol niacinate)...... 176 NORA-BE...... 122 dexameth...... 240 NIACIN FLUSH FREE...... 176 NORCO...... 18, 19 neomycin-polymyxin- NIACIN NO FLUSH...... 176 NORDITROPIN FLEXPRO.... 188 gramicidin...... 245 niacinamide...... 176, 177 norepinephrine bitartrate...... 76

285 norepinephrine bitartrate-d5w.....76 NOXIFOL-D3...... 175, 178 O-CAL PRENATAL...... 172 norepinephrine bitartrate-nacl.....76 NOXIPAK...... 135 OCALIVA...... 215 noreth-ethinyl estradiol-iron..... 121 NP THYROID...... 193 OCELLA...... 121 norethindrone (contraceptive)...122 NPLATE...... 215 OCREVUS...... 238 norethindrone acetate...... 192 NUBEQA...... 50 OCTAGAM...... 63 norethindrone ac-eth estradiol NUCALA...... 251 OCTAPLAS (BLOOD GROUP ...... 121, 185 NUCYNTA...... 16 A)...... 212 norethindrone-e.estradiol-iron.. 121 NUCYNTA ER...... 16 OCTAPLAS (BLOOD GROUP NORGESIC FORTE...... 218 NUDROXIPAK...... 25 AB)...... 213 norgestimate-ethinyl estradiol NUDROXIPAK DSDR-50...... 24 OCTAPLAS (BLOOD GROUP ...... 121, 122 NUDROXIPAK DSDR-75...... 24 B)...... 213 NORITATE...... 124, 139 NUDROXIPAK E-400...... 24 OCTAPLAS (BLOOD GROUP NORMAL SALINE FLUSH NUDROXIPAK I-800...... 24 O)...... 213 ...... 174, 175 NUDROXIPAK N-500...... 24 OCTREOSCAN...... 144 NORM-JECT...... 224, 231 NUEDEXTA...... 103 octreotide acetate...... 192, 204 NORMOSOL-M IN 5 % NUFERA...... 155 OCUFLOX...... 245 DEXTROSE...... 154 NU-IRON...... 156 OCUTABS...... 162 NORMOSOL-R...... 158 NULEV...... 199, 208 OCUVITE EYE PLUS MULTI162 NORMOSOL-R IN 5 % NULOJIX...... 217 ODACTRA...... 62 DEXTROSE...... 154 NULYTELY LEMON-LIME...203 ODEFSEY...... 38 NORMOSOL-R PH 7.4...... 158 NULYTELY WITH FLAVOR ODOMZO...... 53 NORPACE...... 68 PACKS...... 203 ODOR ELIMINATOR DROPS224 NORPACE CR...... 68 NUPLAZID...... 93 ODORLESS GARLIC...... 13 NORPRAMIN...... 89 NURETIN...... 149 OFEV...... 57, 255 NORTHERA...... 76 NUTRA PRO HIGH PROTEIN OFIRMEV...... 20 NORTREL 0.5/35 (28)...... 121 ...... 149 ofloxacin...... 42, 245, 247 NORTREL 1/35 (21)...... 121 NUTRAMIGEN DHA-ARA.... 149 olanzapine...... 93, 97 NORTREL 7/7/7 (28)...... 122 NUTRAMIGEN TODDLER olanzapine-fluoxetine...... 88, 93, 97 nortriptyline...... 89 ENFLORA-LGG...... 149 olive oil...... 113 NORVASC...... 74 NUTRILIPID...... 168 olmesartan...... 68 NORVIR...... 46 NUTRILYTE...... 158 olmesartan-amlodipin-hcthiazid. 67 NORWEGIAN COD LIVER NUTRISURE PLUS...... 149 olopatadine...... 241, 254 OIL...... 164, 175 NUTRIVIT...... 147 OLUMIANT...... 23 NOVACORT...... 135 NUTROPIN AQ NUSPIN...... 188 OLUX...... 134 NOVAFERRUM...... 156 NUVAKAAN...... 137, 226 OLUX-E...... 134 NOVAFERRUM 125...... 156 NUVARING...... 123 OMECLAMOX-PAK...... 204 NOVAFERRUM 50...... 156 NUVESSA...... 256 OMEGA-3 (WITH DPA)...... 71 NOVAFERRUM PEDIATRIC 169 NUVIGIL...... 102 OMEGA-3 2100...... 71 NOVAMV...... 171 NUZYRA...... 32, 48 omega-3 acid ethyl esters...... 71, 72 NOVAREL...... 189 NYAMYC...... 128 omega-3 fatty acids-fish oil...... 71 NOVOLOG FLEXPEN U-100 nylidrin (bulk)...... 80, 110 OMEGA-3 FISH OIL...... 71 INSULIN...... 190 nystatin...... 34, 128, 237 omega-3s-dha-epa-fish oil...... 71 NOVOLOG MIX 70-30 U-100 nystatin (bulk)...... 34, 110 OMEGAVEN...... 168 INSULN...... 189 nystatin-triamcinolone...... 129 omeprazole...... 197 NOVOLOG MIX 70- NYSTOP...... 128 omeprazole (bulk)...... 110, 197 30FLEXPEN U-100...... 189 OB COMPLETE...... 155, 162, 172 omeprazole-sodium bicarbonate NOVOLOG PENFILL U-100 OB COMPLETE ONE...... 172 ...... 198 INSULIN...... 190 OB COMPLETE PETITE...... 172 OMIDRIA...... 244 NOVOLOG U-100 INSULIN OB COMPLETE PREMIER OMNARIS...... 254 ASPART...... 190 ...... 155, 172 OMNIPAQUE...... 142 NOVOPEN ECHO...... 223, 231 OB COMPLETE WITH DHA..172 OMNIPAQUE 140...... 142 NOXAFIL...... 34 O-CAL F.A...... 162 OMNIPAQUE 240...... 142

286 OMNIPAQUE 300...... 142 ONE-A-DAY TRUBIOTICS... 202 ORACEA...... 48, 139 OMNIPAQUE 350...... 142 ONE-A-DAY VITACRAVES..163 ORACIT...... 206 OMNIPOD DASH PDM KIT ONE-A-DAY VITACRAVES ORAFATE...... 238 ...... 223, 231 IMMUNITY...... 163 ORAL MIX...... 117 OMNIPOD INSULIN ONE-A-DAY VITACRAVES ORAL MIX SF...... 117 MANAGEMENT...... 227, 231 OMEGA-3...... 163 ORAL SUSPEND...... 117 OMNIPOD INSULIN REFILL ONE-A-DAY ORAL SYRUP...... 117 ...... 223, 231 WEIGHTSMART...... 163 ORAL SYRUP SF...... 117 OMNISCAN...... 142 ONE-A-DAY WOMEN ORALAIR...... 62 OMNITROPE...... 188 VITACRAVES...... 163 ORALONE...... 237 OMNIVEX...... 164 ONE-A-DAY WOMEN'S ORALYTE...... 158 ONCASPAR...... 52 ACTIVE...... 163 ORAMAGICRX...... 237 ONCOVITE...... 164 ONE-A-DAY WOMENS ORANGE CONCENTRATE ondansetron...... 195 FORMULA...... 163, 165 ...... 110, 115 ondansetron hcl...... 195 ONE-A-DAY WOMEN'S orange cream flavor (bulk)110, 115 ondansetron hcl (pf)...... 195 HEALTHY SKIN...... 163 orange flavor (bulk)...... 110, 117 ONE A DAY WOMEN'S ONE-A-DAY WOMEN'S ORA-PLUS...... 117 PRENATAL DHA...... 172 PETITES...... 165 ORAPRED ODT...... 187 ONE DAILY ESSENTIAL...... 164 ONE-A-DAY WOMEN'S ORA-SWEET...... 117 ONE DAILY FOR MEN...... 162 PRENATAL 1...... 172 ORA-SWEET SF...... 117 ONE DAILY FOR WOMEN... 162 ONETOUCH PING INSULIN ORAVIG...... 34 ONE DAILY HEALTHY PUMP...... 227, 231 ORAZINC...... 160 WEIGHT...... 162 ONEXTON...... 124 ORENCIA...... 22 ONE DAILY MEN'S 50 PLUS ONFI...... 83, 96 ORENCIA (WITH MALTOSE).22 MEMORY...... 164 ONGLYZA...... 181 ORENCIA CLICKJECT...... 22 ONE DAILY MEN'S 50 PLUS ONIVYDE...... 58 ORENITRAM...... 81 W-D3...... 162 ONPATTRO...... 179 ORFADIN...... 235 ONE DAILY MULTI-VIT W- ONZETRA XSAIL...... 101 ORILISSA...... 191 MINERAL...... 162 OPDIVO...... 59 ORKAMBI...... 253 ONE DAILY opium tincture...... 194 orphenadrine citrate...... 219 MULTIVITAMIN...... 164, 165 OPSUMIT...... 81 ORSYTHIA...... 121 ONE DAILY OPTICHAMBER ADULT ORTHO MICRONOR...... 122 MULTIVITAMIN-IRON...... 162 MASK-LARGE...... 226, 231 ORTHO TRI-CYCLEN (28).... 122 ONE DAILY PRENATAL...... 172 OPTICHAMBER DIAMOND ORTHODIET...... 13 ONE DAILY WOMEN'S...... 165 LG MASK...... 226, 231 ORTHO-NOVUM 7/7/7 (28)... 122 ONE DAILY WOMENS 50 OPTICHAMBER DIAMOND ORTHO-TABS...... 152 PLUS...... 162 VHC...... 226, 231 ORTHOVISC...... 217 ONE DAILY WOMEN'S OPTICHAMBER DIAMOND- OS-CAL 500 + D3...... 153, 154 HEALTH...... 165 MED MSK...... 226, 231 OSCIMIN...... 199, 208 ONE-A-DAY CHOLESTEROL OPTICHAMBER DIAMOND- OSCIMIN SL...... 199, 208 PLUS...... 163 SML MASK...... 226, 231 OSCIMIN SR...... 199, 208 ONE-A-DAY ENERGY...... 165 OPTIMAL D3...... 178 oseltamivir...... 43 ONE-A-DAY KID'S...... 171 OPTIMAL D3 M...... 178 oseltamivir phosphate (bulk) ONE-A-DAY MEN OPTIRAY 240...... 142 ...... 43, 110 VITACRAVES...... 163 OPTIRAY 300...... 142 OSENI...... 183 ONE-A-DAY MENOPAUSE OPTIRAY 320...... 142 OSMITROL 10 %...... 78 FORMULA...... 163 OPTIRAY 350...... 142 OSMITROL 15 %...... 78 ONE-A-DAY MEN'S 50 PLUS163 OPTISON...... 142 OSMITROL 20 %...... 78 ONE-A-DAY MEN'S OPTISOURCE...... 163 OSMITROL 5 %...... 78 MULTIVITAMIN...... 163 OPURITY MULTIVITAMIN.. 163 OSMOLEX ER...... 91 ONE-A-DAY TEEN HIM ORA-BLEND...... 117 OSMOPREP...... 203 VITACRAVES...... 171 ORA-BLEND SF...... 117 OSTEO BI-FLEX...... 12

287 OTEZLA...... 24, 130 PALFORZIA (LEVEL 3)...... 64 PAMPERS SWADDLERS OTEZLA STARTER...... 24, 130 PALFORZIA (LEVEL 4)...... 64 SENS. SIZE 1...... 222, 232 OTIPRIO...... 247 PALFORZIA (LEVEL 5)...... 64 PAMPERS SWADDLERS OTOVEL...... 247 PALFORZIA (LEVEL 6)...... 64 SIZE 1...... 222, 232 OTREXUP (PF)...... 22 PALFORZIA (LEVEL 7)...... 64 PAMPERS SWADDLERS OVACE...... 130 PALFORZIA (LEVEL 8)...... 64 SIZE 2...... 222, 232 OVACE PLUS...... 130 PALFORZIA (LEVEL 9)...... 64 PAMPERS SWADDLERS OVACE PLUS SHAMPOO..... 130 PALFORZIA (LEVEL 10)...... 64 SIZE 3...... 222, 232 OVACE PLUS WASH...... 130 PALFORZIA (LEVEL 11 UP- PAMPERS SWADDLERS OVIDE...... 141 DOSE)...... 64 SIZE N...... 222, 232 OVIDREL...... 189 PALFORZIA INITIAL DOSE... 64 PAMPERS UNISEX BABY- oxacillin...... 45 PALFORZIA LEVEL 11 DRY...... 222, 232 oxacillin in dextrose(iso-osm).... 45 MAINTENANCE...... 64 PANCREAZE...... 196 oxalic acid (bulk)...... 110, 113 paliperidone...... 91 pancuronium...... 218 oxaliplatin...... 56 palonosetron...... 195 PANDEL...... 134 OXANDRIN...... 179 PAMELOR...... 89 PANRETIN...... 129 oxandrolone...... 179 pamidronate...... 184 pantoprazole...... 197, 198 oxaprozin...... 26 PAMPERS BABY-DRY SIZE pantothenic acid (vit b5)...... 177 OXAYDO...... 16 1...... 222, 231 PANZYGA...... 63 oxazepam...... 82, 96 PAMPERS BABY-DRY SIZE papaverine...... 80 oxcarbazepine...... 85 2...... 222, 231 papaverine (bulk)...... 80, 110 OXERVATE...... 243 PAMPERS BABY-DRY SIZE PARADIGM SILHOUETTE oxiconazole...... 129 3...... 222, 231 INFUS SET...... 225, 232 OXISTAT...... 129 PAMPERS BABY-DRY SIZE PARAGARD T 380A...... 119 OXSORALEN ULTRA...... 130 4...... 222, 231 PAREMYD...... 240 OXTELLAR XR...... 85 PAMPERS BABY-DRY SIZE PARI BABY CONV KIT - oxybutynin chloride...... 208 5...... 222, 231 SIZE 1...... 226, 232 oxybutynin chloride (bulk)...... 110 PAMPERS BABY-DRY SIZE paricalcitol...... 235 oxycodone...... 16, 17 6...... 222, 231 PARLODEL...... 90 oxycodone (bulk)...... 16, 110 PAMPERS BABY-DRY SIZE PARNATE...... 87 oxycodone-acetaminophen...... 19 N...... 222, 231 PAROEX ORAL RINSE...... 237 oxycodone-aspirin...... 19 PAMPERS CRUISERS.... 222, 231 paromomycin...... 32 OXYCONTIN...... 17 PAMPERS CRUISERS SIZE 3 paroxetine hcl...... 87 oxymorphone...... 17 ...... 222, 231 PARVA-CAL 250...... 154 oxytetracycline (bulk)...... 48, 110 PAMPERS CRUISERS SIZE 5 PARVA-CAL 500...... 154 oxytocin...... 192 ...... 222, 231 PARVLEX...... 155 oxytocin (bulk)...... 110, 191 PAMPERS CRUISERS SIZE 6 PASER...... 38 oxytocin in 0.9 % sod chloride. 192 ...... 222, 231 PATANASE...... 254 OXYTROL...... 208 PAMPERS CRUISERS SIZE 7 PAXIL...... 87 OYSCO 500/D...... 154 ...... 222, 231 PAXIL CR...... 87 OYSTER SHELL CALCIUM..154 PAMPERS EASY UPS.... 222, 231 PAZEO...... 241 OYSTER SHELL CALCIUM PAMPERS EXTRA PCCA NATACREAM...... 110, 114 500...... 154 PROTECTION SZ 3...... 222, 231 PCCA T4 SODIUM OYSTER SHELL CALCIUM- PAMPERS EXTRA DILUTION...... 110, 193 VIT D3...... 154 PROTECTION SZ 4...... 222, 231 peach flavor (bulk)...... 110, 115 OZEMPIC...... 182 PAMPERS EXTRA PEANUT BUTTER FLAVOR OZURDEX...... 241 PROTECTION SZ 5...... 222, 231 ...... 110, 115 PACERONE...... 69 PAMPERS EXTRA peanut butter flavor (bulk) 110, 115 paclitaxel...... 57 PROTECTION SZ 6...... 222, 231 pectin (bulk)...... 110 PACNEX...... 125 PAMPERS PREEMIE SWAD PEDIA D-VITE...... 178 PALFORZIA (LEVEL 1)...... 63 SIZE P-S...... 222, 231 PEDIA IRON...... 156 PALFORZIA (LEVEL 2)...... 63 PAMPERS PREMIE...... 222, 231 PEDIA POLY-VITE...... 169, 171

288 PEDIA POLY-VITE WITH PERIFLEX LQ PKU...... 166 phenytoin sodium...... 69, 85 IRON...... 169 PERIFRESH...... 140 phenytoin sodium (bulk) PEDIA TRI-VITE...... 171 PERIKABIVEN...... 168 ...... 68, 85, 111 PEDIALYTE...... 158 perindopril erbumine...... 66 phenytoin sodium extended...... 85 PEDIALYTE ADVANCED PERJETA...... 60 PHILITH...... 121 CARE...... 158 permethrin...... 141 PHILLIPS...... 157 PEDIALYTE FREEZER POPS158 perphenazine...... 92 PHILLIPS' COLON HEALTH.202 PEDIALYTE SINGLES...... 158 perphenazine-amitriptyline...... 88 PHLEXY-VITS...... 149 PEDIARIX (PF)...... 62, 64 PERRY PRENATAL...... 172 PHOSLYRA...... 205 PEDIASURE HARVEST...... 149 PERSERIS...... 91 PHOS-NAK...... 158 PEDIASURE SIDEKICKS...... 149 PERTZYE...... 196 PHOSPHA 250 NEUTRAL PEDIATRIC ELECTROLYTE 158 PETROLATUM...... 114, 132 ...... 158, 206 PEDIATRIC FREEZER POPS.158 petrolatum, yellow (bulk)...... 114 PHOSPHASAL...... 45, 207 PEDITRACE...... 160 PEXEVA...... 87 PHOSPHOLINE IODIDE...... 240 PEDVAX HIB (PF)...... 64 PFIZERPEN-G...... 258 PHOSPHOROUS...... 158, 206 peg 3350-electrolytes...... 203 PFLEX INSPIRATORY PHOSPHO-TRIN 250 PEG OINTMENT BASE TRAINER...... 226, 232 NEUTRAL...... 158, 206 (BULK)...... 110, 113, 118 PHARMABASE...... 111, 114 PHOTOFRIN...... 56 PEG-3350 WITH FLAVOR PHARMABASE COSMETIC PHOTREXA CROSS- PACKS...... 203 ...... 111, 132 LINKING KIT...... 240 PEGANONE...... 84 PHARMABASE HEAVY 111, 114 PHYSIOLYTE...... 151 PEGBLEND...... 111, 114 PHARMABASE LIGHT.. 111, 114 PHYSIOSOL IRRIGATION.... 151 peg-electrolyte soln...... 203 PHARMABASE NATURAL phytonadione (vitamin k1)...... 178 PEG-PREP...... 203 ...... 111, 114 PICATO...... 129 penicillamine...... 24, 31 PHARMABASE VAGINAL PIFELTRO...... 37 penicillamine (bulk)...... 24, 31, 111 ...... 111, 114 PILLOW MASK CHILD..226, 232 PENICILLAMINE(D-).24, 31, 111 PHASEAL PROTECTOR 225, 232 pilocarpine hcl...... 238, 240 penicillin g pot in dextrose...... 45 phenazopyridine...... 207 pilocarpine hcl (bulk) 111, 238, 240 penicillin g potassium...... 45, 258 phenelzine...... 87 pimecrolimus...... 131 penicillin g procaine...... 45 PHENERGAN...... 195, 248 pimozide...... 92 penicillin g sodium...... 45 phenobarbital...... 83, 103 PIMTREA (28)...... 120 penicillin v potassium...... 45 phenobarbital (bulk)....83, 103, 111 pindolol...... 73 PENLEN...... 132 phenobarbital sodium...... 83, 103 pineapple flavor (bulk)...... 111, 116 PENNSAID...... 138 PHENOHYTRO...... 200 pioglitazone...... 190 PENSOMAL...... 111, 114 phenol...... 61 pioglitazone-glimepiride...... 182 PENTACEL (PF)...... 65 phenol (bulk)...... 61, 111 pioglitazone-metformin...... 182 PENTAM...... 45 phenoxybenzamine...... 80 piperacillin-tazobactam...... 46 pentamidine...... 45 phentolamine...... 80 PIQRAY...... 56 PENTASA...... 201 PHENYLADE 40...... 166 PIRMELLA...... 121, 122 pentazocine-naloxone...... 20 PHENYLADE GMP MIX-IN.. 166 piroxicam...... 25 pentetate calcium trisodium...... 31 PHENYLADE GMP READY..166 PLAQUENIL...... 22, 35 pentoxifylline...... 210 PHENYLADE MTE AMINO PLASBUMIN 25 %...... 212 PEPCID...... 197 ACIDS...... 166 PLASBUMIN 5 %...... 212 PEPPERMINT FLAVORING phenylbutazone (bulk)...... 26, 111 PLASMA-LYTE 148...... 158 ...... 111, 116 phenylephrine hcl...... 76, 243 PLASMA-LYTE A...... 158 PERCOCET...... 19 phenylephrine hcl (bulk) PLASMANATE...... 213 PERFECT IRON...... 156 ...... 30, 76, 111, 255 PLAVIX...... 213 PERFOROMIST...... 252 phenylephrine hcl in 0.9% nacl...76 PLEGRIDY...... 239 PERIANAL CLEANSING...... 140 PHENYL-FREE 1...... 166 PLENAMINE...... 168 PERIDEX...... 237 PHENYTEK...... 84 PLENVU...... 203 PERIDIN-C...... 148 phenytoin...... 84 PLEXION...... 124 PERIFLEX INFANT...... 166 phenytoin (bulk)...... 84, 111

289 PLEXION CLEANSING potassium chloride in water...... 159 prednisoln sp-gatiflox-bromfen 241 CLOTHS...... 125 potassium chloride-0.45 % nacl 159 prednisolone...... 187 PNEUMOVAX-23...... 64 potassium chloride-d5-0.2%nacl prednisolone (bulk)...... 111, 187 PNV 29-1...... 172 ...... 159 prednisolone ac, micro (bulk) PNV-DHA...... 165, 172 potassium chloride-d5-0.3%nacl ...... 111, 187 PNV-FERROUS FUMARATE- ...... 159 prednisolone acetate...... 241 DOCU-FA...... 172 potassium chloride-d5-0.9%nacl prednisolone acetate (pf)...... 242 PNV-OMEGA...... 163, 172 ...... 159 prednisolone acetate-nepafenac 243 PNV-SELECT...... 172 potassium citrate...... 206 prednisolone acet-gatifloxacin..240 POCKET CHAMBER...... 226, 232 potassium citrate-citric acid...... 206 prednisolone sod ph-bromfenac 243 POD-CARE 100C...... 186 potassium gluconate...... 159 prednisolone sod phos (bulk) POD-CARE 100CG...... 186 potassium iodide (bulk).... 111, 154 ...... 111, 187 POD-CARE 100K...... 187 potassium phos in 0.9 % nacl... 158 prednisolone sodium phosphate POD-CARE 100KG...... 187 potassium phosph, mono (bulk) ...... 187, 188, 242 PODIAPN...... 147 ...... 111, 158 prednisolone, micro (bulk)111, 188 PODOCON...... 136 potassium phosphate m-/d-basic prednisolone-moxiflo-nepafenac podofilox...... 136 ...... 158 ...... 241 POLIVY...... 50, 59 potassium sorbate (bulk)...... 111 prednisolone-moxifloxacin hcl. 240 POLYCIN...... 245 potassium, sodium phosphates..158 prednisone...... 188 polyethylene glycol 1000(bulk) POTELIGEO...... 52 prednisone (bulk)...... 111, 188 ...... 111, 114 PR BENZOYL PEROXIDE..... 125 PREDNISONE INTENSOL.....188 polyethylene glycol 1450(bulk) PR NATAL 400...... 172 prednisone micronized (bulk) ...... 111, 118 PR NATAL 400 EC...... 172 ...... 111, 188 polyethylene glycol 3350(bulk) PR NATAL 430...... 172 PREFEST...... 185 ...... 111, 114 PR NATAL 430 EC...... 172 pregabalin...... 84, 99 POLY-IRON...... 156 PRADAXA...... 214 PREGESTIMIL...... 149 POLY-IRON 150 FORTE...... 155 pralines and cream flavr(bulk) PREGNYL...... 189 polymyxin b sulf,micron.(bulk) ...... 111, 116 PREMARIN...... 186, 256 ...... 46, 111 PRALUENT PEN...... 72 PREMASOL 10 %...... 168 polymyxin b sulfate...... 258 pramipexole...... 91 PREMIUM BABY DIAPERS polymyxin b sulf-trimethoprim.245 PRAMOSONE...... 135 ...... 222, 232 polysorbate 80...... 118 pramoxine hcl (bulk)...... 111 PREMIUM COMFORT- POLYTRIM...... 245 PRANDIN...... 181 STRETCH...... 222, 232 POLY-VI-FLOR...... 170 prasterone (dhea), micro(bulk) PREMIUM INFANT POLY-VI-FLOR WITH IRON.170 ...... 12, 111 FORMULA...... 150 POLY-VI-SOL...... 171 prasugrel...... 213 PREMIUM TRAINING POLY-VI-SOL WITH IRON... 169 PRAVACHOL...... 70 PANTS...... 222, 232 POLY-VITAMINS...... 171 pravastatin...... 70 PREMPHASE...... 185 POMALYST...... 57 PRAXBIND...... 30 PREMPRO...... 185 PORTIA 28...... 121 praziquantel...... 33 PRENA1 CHEW...... 172 PORTRAZZA...... 60 prazosin...... 80 PRENA1 PEARL...... 172 pot,sodium citrate-citric acid.... 206 PRE PROTEIN...... 145 PRENA1 TRUE...... 172 POTABA...... 179 PRECEDEX...... 104 PRENATA...... 172 potassium acetate...... 158 PRECEDEX IN 0.9 % PRENATABS FA...... 172 potassium bicarbonate (bulk)....111 SODIUM CHLOR...... 104 PRENATABS RX...... 172 potassium chlorid-d5-0.45%nacl PRECOSE...... 181 PRENATAL...... 173, 174 ...... 159 PRED FORTE...... 241 PRENATAL + DHA...... 172 potassium chloride...... 159 PRED MILD...... 241 PRENATAL 19...... 172 potassium chloride (bulk). 111, 160 PRED-G...... 240 PRENATAL COMPLETE...... 172 potassium chloride in 0.9%nacl 159 PRED-G S.O.P...... 240 PRENATAL DAILY DUO...... 163 potassium chloride in 5 % dex..159 prednicarbate...... 134 PRENATAL FORMULA...... 172 potassium chloride in lr-d5...... 159 prednisol ace-gatiflox-bromfen.241 PRENATAL GUMMY...... 172

290 PRENATAL LOW IRON...... 172 PRIFTIN...... 39, 47 PROCRIT...... 210 PRENATAL MULTI...... 172 PRIKAAN...... 137 PROCTOCORT...... 29, 134 PRENATAL MULTI-DHA PRIKAAN LITE...... 137 PROCTOFOAM HC...... 30 (ALGAL OIL)...... 172 prilocaine (bulk)...... 28, 111 PROCTO-MED HC...... 29, 134 PRENATAL PRILOSEC...... 198 PROCTO-PAK...... 29, 134 MULTIVITAMINS...... 173 PRILOVIX LITE...... 137 PROCTOSOL HC...... 29, 134 PRENATAL ONE DAILY...... 173 PRILOVIX PLUS...... 137 PROCTOZONE-HC...... 29, 134 PRENATAL PLUS...... 173 primaquine...... 35 PROCYSBI...... 204 PRENATAL PLUS PRIMAXIN IV...... 39 PRODIGEN...... 202 (CALCIUM CARB)...... 173 PRIMEAIRE...... 226, 232 PRODIGY MINI-MIST PRENATAL TABLET...... 173 primidone...... 83 NEBULIZER...... 224, 232 PRENATAL VITAMIN...... 173 PRIMLEV...... 19 PROFERRIN ES...... 156 PRENATAL VITAMIN PLUS PRIMSOL...... 33 PROFERRIN-FORTE...... 155 LOW IRON...... 173 PRINIVIL...... 66 progesterone...... 192 PRENATAL VITAMIN WITH PRISTIQ...... 88 progesterone micronized...... 192 MINERALS...... 173 PRIVIGEN...... 63 PROGLYCEM...... 179 prenatal vit-iron fum-folic ac....173 PRO COMFORT SPACER- PROGRAF...... 216 prenatal vits96-iron fum-folic...173 ADULT MASK...... 226, 232 PROHANCE...... 142 PRENATAL-U...... 165, 173 PRO COMFORT SPACER- PROLASTIN-C...... 254 PRENATE AM...... 165, 173 CHILD MASK...... 226, 232 PROLENSA...... 242 PRENATE CHEWABLE. 165, 173 PRO COMFORT TENS PROLEUKIN...... 54 PRENATE DHA (FERR ASP ELECTRODE...... 223, 232 PROLIA...... 192 GLYCIN)...... 173 PRO COMFORT TENS UNIT PROMACTA...... 215 PRENATE ELITE (IRON ASP ...... 223, 232 promethazine...... 195, 248 GLYC)...... 173 PRO FE...... 156 promethazine (bulk)..111, 195, 248 PRENATE ENHANCE...... 173 PROAIR HFA...... 252 PROMETHAZINE VC...... 247 PRENATE PROAIR RESPICLICK...... 252 PROMETHEGAN...... 195, 248 ESSENTIAL(IRON-ASP-GL) probenecid...... 209 PROMETRIUM...... 192 ...... 165, 173 probenecid-colchicine...... 209 PROMISEB...... 131, 132 PRENATE MINI (FERR ASP PROBIOTIC COMPLEX PROMOD PROTEIN...... 167 GLYCIN)...... 173 (WITH FOS)...... 202 PRONEB ULTRA II FILTER PRENATE PIXIE...... 173 PROBIOTIC-10 (WITH ASSEM...... 226, 232 PRENATE RESTORE...... 173 INULIN)...... 202 PRONOURISH...... 166 PRENATE STAR...... 173 PROBUPHINE...... 104 propafenone...... 69 PREPIDIL...... 179 procainamide...... 68 propantheline...... 199 PREPLUS...... 173 procaine (bulk)...... 111 proparacaine...... 244 PREPOPIK...... 203 PRO-CAL...... 152 propofol...... 28 PRE-PROTEIN...... 167 PROCALAMINE 3%...... 167, 168 propranolol...... 73 PRESERA...... 132 PROCARDIA...... 74 propranolol-hydrochlorothiazid..79 PRESTALIA...... 66 PROCARDIA XL...... 74 propylthiouracil...... 183 PRETAB...... 173 PROCARE COMPRESSOR PROQUAD (PF)...... 63, 65 pretomanid...... 39 NEBULIZER...... 226, 232 PRORENAL...... 147 PREVACID...... 198 PROCEL...... 167 PRORENAL QD...... 163 PREVACID SOLUTAB...... 198 PROCEL 100...... 167 PROSCAR...... 206 PREVAIL BRIEF YOUTH PROCEL SINGLES...... 167 PROSHIELD FOAM/SPRAY ...... 221, 232 PROCENTRA...... 98 CLEANSER...... 140 PREVALITE...... 70 PROCERV HP...... 163 PROSIGHT...... 12 PREVIFEM...... 121 PROCHAMBER...... 226, 232 PROSOL 20 %...... 168 PREVNAR 13 (PF)...... 64 prochlorperazine...... 195 PROSOURCE...... 167 PREVYMIS...... 42 prochlorperazine edisylate...... 195 PROSOURCE NO CARB...... 167 PREZCOBIX...... 38, 46 prochlorperazine maleate....92, 195 PRO-STAT RENAL CARE..... 167 PREZISTA...... 46 PROCORT...... 30 PRO-STAT SUGAR FREE...... 167

291 PROSTATE CONTROL...... 13 pyridostigmine bromide (bulk) RANEXA...... 68 PROSTEON...... 154 ...... 111, 217 ranitidine hcl...... 197 PROSTIN E2...... 179 pyridoxine (bulk)...... 111, 177 ranolazine...... 68 PROSTIN VR PEDIATRIC...... 80 pyridoxine (vitamin b6)...... 177 RAPAFLO...... 205 PROSYNMINIC...... 167 pyrilamine maleate (bulk).111, 248 RAPAMUNE...... 216 protamine...... 32 pyrimethamine (bulk)...... 35, 111 RAPIVAB (PF)...... 43 PROTECT CARDIO AF...... 163 QBRELIS...... 66 rasagiline...... 90 PROTECT IRON...... 163 Q-CARE RX Q4...... 220 raspberry flavor (bulk)...... 112, 116 PROTECT PLUS SO...... 163 Q-GEL MEGA...... 13 RASUVO (PF)...... 22 protein...... 167 QINLOCK...... 57 RAVICTI...... 236 PROTEINEX...... 167 QNASL...... 254 RAYOS...... 188 PROTEINEX-18...... 167 QTERN...... 181 RAZADYNE ER...... 119 PROTHELIAL...... 238 QUADRACEL (PF)...... 64 RCF SOY PROTEIN PROTONIX...... 198 QUALAQUIN...... 35 FORMULA BASE...... 150 PROTOPIC...... 131 QUARTETTE...... 122 REBIF (WITH ALBUMIN)..... 239 protriptyline...... 89 quazepam...... 96, 103 REBIF REBIDOSE...... 239 PROTYL AG...... 141 QUDEXY XR...... 85 REBIF TITRATION PACK..... 239 PROVAD...... 202 QUESTRAN...... 70 RECLAST...... 184 PROVELLA...... 202 QUESTRAN LIGHT...... 70 RECLIPSEN (28)...... 121 PROVENGE...... 54 quetiapine...... 93, 97 RECOMBIVAX HB (PF)...... 62 PROVENTIL HFA...... 252 QUFLORA...... 170 RECTIV...... 29 PROVERA...... 192 QUFLORA FE (FERROUS REFEX...... 13 PROVIDA OB...... 173 SULFATE)...... 170 REFISSA...... 139 PROVIGIL...... 102 QUFLORA PEDIATRIC...... 170 REGLAN...... 198 PROVOCHOLINE...... 143 QUFLORA PEDIATRIC REGONOL...... 217 PROZAC...... 87 DROPS...... 170 REGRANEX...... 141 PRUCLAIR...... 132 QUICK-SET PARADIGM RELADOR PAK...... 137 PRUDOXIN...... 141 ...... 227, 232 RELADOR PAK PLUS...... 137 PRUMYX...... 132 QUILLICHEW ER...... 95 RELAGARD...... 256 pseudoephedrine hcl (bulk) QUILLIVANT XR...... 95 RELENZA DISKHALER...... 43 ...... 111, 255 QUIN B STRONG...... 147 RELEXXII...... 95 PSORCON...... 134 quinacrine (bulk)...... 35, 111 RELISTOR...... 31, 32 PULMICORT...... 250 quinapril...... 66 RELPAX...... 101 PULMICORT FLEXHALER...250 quinapril-hydrochlorothiazide.... 66 REMEDY PHYTOPLEX PULMO-AIDE quinidine gluconate...... 68 MOISTURIZER...... 132 COMPRESSOR...... 226, 232 quinidine sulfate...... 68 REMERON...... 87 PULMONEB LT quinidine sulfate (bulk)...... 68, 112 REMERON SOLTAB...... 87 COMPRESSOR NEBUL..226, 232 quinine sulfate...... 35 REMICADE...... 21, 22, 202 PULMOSAL...... 117 QUINTABS...... 165 REMODULIN...... 81 PULMOZYME...... 254 QUINTABS-M...... 163 RENACIDIN...... 204 PUMPKIN FLAVOR...... 111, 116 QUTENZA...... 141 RENAGEL...... 205 PURAMINO JR...... 166 QUZYTTIR...... 248, 249 RENAL CAPS...... 147 PURE L-CITRULLINE...... 146 QVAR REDIHALER...... 250 RENAL VITAMIN...... 147 PUREFE OB PLUS...... 163, 173 RABAVERT (PF)...... 65 RENAPLEX...... 147 PUREFE PLUS...... 163, 173 rabeprazole...... 198 RENAPLEX-D...... 147 PUREVIT DUALFE PLUS...... 165 racepineph-lidocaine-bss 7(pf). 240 RENA-VITE...... 147 PURIXAN...... 51 RADIAGEL...... 132 RENA-VITE RX...... 147 PYLERA...... 204 RADIOGARDASE...... 31 RENFLEXIS...... 21, 22, 202 pyrazinamide...... 39 RAGWITEK...... 62 RENO CAPS...... 147 PYRIDIUM...... 207 raloxifene...... 192 RENVELA...... 205 pyridostigmine bromide...... 217 ramelteon...... 99 repaglinide...... 181 ramipril...... 66 repaglinide-metformin...... 181

292 REPATHA PUSHTRONEX...... 72 RISPERDAL CONSTA...... 91 SALAGEN (PILOCARPINE).. 238 REPATHA SURECLICK...... 72 risperidone...... 92, 97 SALEX...... 136 REPATHA SYRINGE...... 72 RITALIN...... 95, 102 salicylic acid...... 136, 137 REPLESTA NX...... 178 RITALIN LA...... 95 salicylic acid (bulk)...... 112, 136 REPREXAIN...... 18, 19 RITUXAN...... 22, 52 salicylic acid-ceramides no.1....137 REQUIP...... 91 RITUXAN HYCELA...... 52 SALIVAMAX...... 237 REQUIP XL...... 91 rivastigmine...... 119 SALKERA...... 136 resorcinol (bulk)...... 112 rivastigmine tartrate...... 119 salsalate...... 26 RESTASIS...... 242 rizatriptan...... 101 SALTSTABLE LO CREAM RESTASIS MULTIDOSE...... 242 R-NATAL OB...... 173 BASE...... 112, 114 RESTORA RX...... 178, 202 ROBAXIN...... 219 SALTSTABLE LS...... 112, 114 RESTORE...... 141, 220, 232 ROBAXIN-750...... 219 SALVAX...... 137 RESTORE FOAM DRESSING ROCALTROL...... 178, 235 SALVAX DUO PLUS...... 136 SILVER...... 141 ROCKLATAN...... 244 SAMI THE SEAL...... 226, 232 RESTORIL...... 96, 103 rocuronium...... 218 SAMI THE SEAL MASK 226, 232 RETACRIT...... 210 romidepsin...... 54 SAMSCA...... 78, 194, 205 RETAVASE...... 214 root beer flavor (bulk)...... 112, 116 SANADERMRX...... 135 RETIN-A...... 126 ropinirole...... 91 SANCUSO...... 195 RETIN-A MICRO...... 126 ropivacaine (pf)...... 28 SANDIMMUNE...... 23, 216 RETIN-A MICRO PUMP...... 126 ropivacaine (pf)-nacl,iso-osm..... 28 SANDOSTATIN...... 192, 204 RETINOIC ACID...... 112 ropivacaine(pf)-0.9 % sodchlor SANDOSTATIN LAR DEPOT RETISERT...... 242 ...... 28, 29 ...... 192, 204 RETROVIR...... 37 ROSADAN...... 124, 139 SANTYL...... 133 REUSABLE NEBULIZER KIT ROSANIL...... 125 SAPHRIS...... 91, 97 ...... 226, 232 ROSULA...... 125 SARAFEM...... 88 REVATIO...... 81 ROSULA CLEANSING SAVAYSA...... 210 REVEL PROGRAMMABLE CLOTHS...... 125 SAVELLA...... 88, 99 PUMP...... 227, 232 rosuvastatin...... 71 saw palmetto...... 13 REVESTA...... 175, 178 ROTARIX...... 63, 65 SAW PALMETTO EXTRACT REVIA...... 32 ROTATEQ VACCINE...... 63, 65 (W-ZINC)...... 13 REVLIMID...... 57 ROWASA...... 201 saw palmetto-pumpkin seed oil.. 13 REVONTO...... 219 ROWEEPRA...... 86 saw palmto frt xtr-zinc picoli...... 13 REXULTI...... 93 ROWEEPRA XR...... 86 SCALACORT...... 134 REYATAZ...... 46 ROXICODONE...... 17 SCALACORT DK...... 134 R-GENE 10...... 143 ROZEREM...... 99 SCANDONEST PLAIN..... 29, 237 RHOPRESSA...... 246 ROZLYTREK...... 57 SCARCARE...... 139, 226 RIDAURA...... 22 RUBRACA...... 56 SCARCIN GEL...... 138 rifabutin...... 39, 47 RUCONEST...... 209 SCARCIN ROLL-ON...... 138 RIFADIN...... 39, 47 RUZURGI...... 239 SCARCINPAD...... 226, 232 RIFAMATE...... 39 RYANODEX...... 219 SCARSILK GEL...... 139 rifampin...... 39, 47 RYCLORA...... 247, 248 SCOOBY-DOO ONE A DAY. 169 rifampin (bulk)...... 47, 112 RYDAPT...... 57 SCOOBY-DOO ONE A DAY RIFATER...... 39 RYNODERM...... 136 KIDS...... 171 RILUTEK...... 217 RYTARY...... 89 SEASONIQUE...... 120 riluzole...... 217 RYTHMOL SR...... 69 SECONAL SODIUM...... 103 rimantadine...... 43 SABRIL...... 84 SECUADO...... 91 ringer's...... 151, 174 saccharin...... 150 SEEBRI NEOHALER...... 251 RIOMET...... 190 SAF-CLENS AF DERMAL SEGLUROMET...... 181 RISA-BID...... 202 WOUND...... 140 SELECT KIDS BRIEFS...222, 232 RISACAL-D...... 154 SAFYRAL...... 121 SELECT-OB...... 173 risedronate...... 184 SAIZEN...... 188, 204 SELECT-OB + DHA...... 173 RISPERDAL...... 91, 97 SAIZEN SAIZENPREP...... 189 selegiline hcl...... 90

293 selenium...... 160 SIMILAC ADVANCE SNAP INSULIN PUMP- selenium sulfide...... 131 LAMEHADRIN...... 150 INFUSION SET...... 227, 233 SELRX...... 131 SIMILAC ADVANCE WITH sodium acetate...... 151 SELZENTRY...... 36 IRON...... 150 sodium benzoate (bulk).....112, 118 SEMPREX-D...... 247 SIMILAC EXPERT CARE...... 150 sodium bicarbonate...... 151 SE-NATAL 19 CHEWABLE...173 SIMILAC EXPERT CARE sodium bicarbonate in d5w...... 151 SE-NATAL-19...... 173 NEOSURE...... 150 sodium bisulfite (bulk)...... 113 SENIOR PROBIOTIC...... 202 SIMILAC FOR SPIT-UP...... 150 sodium chlor 0.9% bacteriostat SENNA...... 203 SIMILAC HUMAN MILK ...... 150, 174 SENSIPAR...... 184 FORTIFIER...... 150 sodium chloride 117, 151, 174, 175 SEREVENT DISKUS...... 252 SIMILAC LAMEHADRIN...... 149 sodium chloride 0.45 %...... 175 SERNIVO...... 134 SIMILAC LOW-IRON...... 150 sodium chloride 0.9 % SEROQUEL...... 93, 97 SIMILAC NEOSURE...... 150 ...... 150, 174, 175 SEROQUEL XR...... 93, 97 SIMILAC PM...... 150 sodium chloride 0.9 % (flush) SEROSTIM...... 189 SIMILAC PRENATAL...... 173 ...... 150, 174, 175 sertraline...... 88 SIMILAC PRO-TOTAL CMFT sodium chloride 3 %...... 174, 175 SE-TAN PLUS...... 165 NON-GMO...... 150 sodium chloride 5 %...... 174, 175 SETLAKIN...... 121 SIMILAC SENSITIVE sodium citrate...... 209 sevelamer carbonate...... 205 ISOMIL SOY...... 150 sodium citrate (bulk)...... 112, 209 sevelamer hcl...... 205 SIMILAC SOY ISOMIL...... 150 sodium citrate dihydrate(bulk) SEYSARA...... 48, 123 SIMILAC SPECIAL CARE 24 150 ...... 112, 206 SFROWASA...... 201 SIMILAC TOTAL COMFORT150 sodium citrate in 0.9 % nacl...... 209 SHAROBEL...... 122 SIMILAC TOTAL COMFORT sodium citrate-citric acid...... 206 SHINGRIX (PF)...... 65 NON-GMO...... 150 SODIUM EDECRIN...... 78 SHOHL'S MODIFIED...... 206 SIMLIYA (28)...... 120 sodium ferric gluconat-sucrose.157 SIDEROL...... 156 SIMPESSE...... 120 sodium fluoride (bulk)...... 112, 236 SIDESTREAM...... 224, 232 simple syrup...... 117 sodium nitrite...... 30 SIDESTREAM NEBULIZER SIMPLYTHICK...... 117 sodium nitroprusside...... 77 ...... 224, 232 SIMPONI...... 21, 22, 202 sodium phenylbutyrate...... 236 SIGNIFOR...... 192 SIMPONI ARIA...... 21, 22 sodium phosphate...... 158 SIKLOS...... 214 SIMULECT...... 216 sodium polystyrene sulfonate... 151 SILASTIC FOLEY simvastatin...... 71 sodium saccharin (bulk)....112, 150 CATHETER...... 227, 232 SINEMET...... 89 sodium succinate...... 113 SILAZONE-II...... 135 SINGULAIR...... 250 sodium thiosulfate...... 30 sildenafil (pulm.hypertension)....81 SINOGRAFIN...... 142 sodium thiosulfate (bulk)....30, 112 SILENOR...... 104 SINUVA...... 253, 255 SOFT-GLIDE SAF-Q...... 226, 233 silicon,colloidal (bulk)...... 112 sirolimus...... 216 SOLARAZE...... 129 SILICONE MASK - INFANT SIRTURO...... 39 SOLESTA...... 227, 228 ...... 226, 232 SITAVIG...... 43 solifenacin...... 207 SILIKON...... 244 SIVEXTRO...... 45 SOLIQUA 100/33...... 183 SILIPAC...... 139 SKELAXIN...... 219 SOLIRIS...... 212 SILIQ...... 127 SKIN CLEANSER...... 140 SOLO...... 163 SILIVEX...... 226, 232 SKLICE...... 141 SOLODYN...... 48, 123 silodosin...... 205 SKYLA...... 119 SOLOSEC...... 36 SILTREX...... 226, 232 SKYRIZI...... 126 SOLOX GEL...... 127 SILVADENE...... 131 SLEEP COMFORTS...... 221, 232 SOLTAMOX...... 57 silver nitrate...... 127 SLEEP OVERS PANTS...221, 232 SOLU-CORTEF...... 188 silver nitrate applicators...... 136 SLEEP PANTS...... 221, 222, 233 SOLU-CORTEF ACT-O-VIAL silver protein mild (bulk).... 61, 112 SLOW RELEASE IRON...... 157 (PF)...... 188 silver sulfadiazine...... 131 SLYND...... 122 SOLU-MEDROL...... 188 SIMBRINZA...... 240 SNAP INSULIN PUMP SOLU-MEDROL (PF)...... 188 SIMILAC ADVANCE...... 150 CONTROLLER...... 223, 233 SOMA...... 219

294 SOMATULINE DEPOT...... 192 STALEVO 75...... 89 sufentanil citrate...... 28 SOMAVERT...... 188 STARLIX...... 181 SUGARUP...... 179 SONAFINE...... 132 stavudine...... 37 SULAR...... 74 SOOLANTRA...... 139 STAXYN...... 145 sulfacetamide (bulk)...... 47, 112 SOOTHE AND COOL SKIN stearyl alcohol...... 118 sulfacetamide sod, mono (bulk) CREAM...... 132 STEGLATRO...... 181 ...... 47, 112 sorbitol...... 204 STEGLUJAN...... 181 sulfacetamide sodium...... 131, 245 sorbitol-mannitol...... 204 STELARA...... 126, 200 sulfacetamide sodium (acne).... 124 SORBOLENE...... 132 STENDRA...... 145 sulfacetamide sodium (bulk) SORIATANE...... 130 STERITALC...... 255 ...... 47, 112 SORILUX...... 130 STEVIA...... 112, 150 sulfacetamide sodium-sulfur SORINE...... 69, 73 STIOLTO RESPIMAT...... 252 ...... 125, 127 sotalol...... 69, 73 STIVARGA...... 55 sulfacetamide sod-sulfur-urea SOTALOL AF...... 69, 73 STRATTERA...... 95 ...... 125, 139 SOTRADECOL...... 82 strawberry flavor (bulk)....112, 116 sulfacetamide-prednisolone...... 240 SOTYLIZE...... 69, 73 STRENSIQ...... 234 sulfacetamide-sulfur-cleansr23.125 SOY FORMULA...... 152 streptomycin...... 32 SULFACLEANSE 8-4...... 125 spearmint oil...... 116 STRESS B PLUS ZINC...... 147 sulfadiazine...... 47 SPECTRACEF...... 41 STRESS B WITH ZINC...... 147 sulfadiazine (bulk)...... 47, 112 SPECTRAGEL...... 141, 233 STRESS B-COMPLEX...... 163 sulfadiazine sodium (bulk)..47, 112 SPECTRAVITE ULTRA MEN STRESS FORMULA...... 147, 156 sulfamethoxazole (bulk)..... 47, 112 50+...... 163 STRESS FORMULA 600 C.....147 sulfamethoxazole-trimethoprim..33 SPECTRAVITE ULTRA STRESS FORMULA WITH SULFAMYLON...... 131 MEN'S SR...... 163 IRON...... 147 sulfanilamide (bulk)...... 47, 112 spinosad...... 141 STRESS FORMULA WITH sulfasalazine...... 24, 201 SPIRIVA RESPIMAT...... 251 IRON(SULF)...... 147 SULFATRIM...... 33 SPIRIVA WITH STRESS FORMULA WITH sulfisoxazole (bulk)...... 47, 112 HANDIHALER...... 251 ZINC...... 147 sulindac...... 25 spironolactone...... 66, 77 STRIBILD...... 38 SUMADAN...... 125 spironolacton-hydrochlorothiaz..78 STRIVERDI RESPIMAT...... 252 SUMADAN XLT...... 125, 139 SPORANOX...... 34 STROMECTOL...... 33 sumatriptan...... 101 SPORANOX PULSEPAK...... 34 STRONG IODINE...... 61, 155 sumatriptan succinate...... 101 SPRAVATO...... 87 strontium-89 chloride...... 57 sumatriptan-naproxen...... 101 SPRINTEC (28)...... 121 STROVITE FORTE...... 163 SUMAXIN...... 125 SPRITAM...... 86 STROVITE ONE...... 163 SUMAXIN CP...... 125 SPRIX...... 25 STUART ONE...... 173 SUMAXIN TS...... 125 SPRYCEL...... 57 SUBLOCADE...... 104 SUMMER'S EVE FEMININE SPS (WITH SORBITOL)...... 151 SUBOXONE...... 104 WASH...... 256 squaric acid (bulk)...... 112, 138 SUBSOLV RDT...... 112, 118 SUNOSI...... 102 squaric acid dibutylest.(bulk) SUBSYS...... 17 SUNVITE...... 163 ...... 112, 138 SUBVENITE...... 86 SUPARTZ FX...... 217 SQUARIC ACID IN SUBVENITE STARTER SUPER B COMPLEX- BUTANOL...... 61, 112 (BLUE) KIT...... 86, 97 VITAMIN C...... 147 SRONYX...... 121 SUBVENITE STARTER SUPER B/C...... 147 SSD...... 131 (GREEN) KIT...... 86, 97 SUPER DAILY D3...... 178 SSKI...... 154 SUBVENITE STARTER SUPER GINSENG SSS 10-5...... 125, 127 (ORANGE) KIT...... 86, 97 MULTIVITAMIN...... 163 STALEVO 100...... 89 succinylcholine-sod cl,iso(pf)...218 SUPER MULTIPLE...... 163 STALEVO 125...... 89 SUCRAID...... 196 SUPER MULTIPLE - LOW STALEVO 150...... 89 sucralfate...... 203 IRON...... 163 STALEVO 200...... 89 sucralfate (bulk)...... 112, 203 SUPER QUINTS...... 147 STALEVO 50...... 89 sucrose (bulk)...... 112, 150 SUPER QUINTS B-50...... 148

295 SUPERSOFT...... 132 SYMFI...... 38 TALTZ AUTOINJECTOR...... 127 SUPERVITE...... 147 SYMFI LO...... 38 TALTZ AUTOINJECTOR (2 SUPPORT-500...... 147 SYMJEPI...... 75 PACK)...... 127 SUPPOSISTRIP...... 223, 233 SYMLINPEN 120...... 182 TALTZ AUTOINJECTOR (3 suppository molds...... 223, 233 SYMLINPEN 60...... 182 PACK)...... 127 SUPPOSITORY SHELL, SYMPAZAN...... 83, 96 TALTZ SYRINGE...... 127 MEDIUM...... 223, 233 SYMPROIC...... 32 TALZENNA...... 56 SUPPOSITORY SHELL, SYMTUZA...... 38 TAMIFLU...... 43 SMALL...... 223, 233 SYNAGIS...... 62 tamoxifen...... 57 SUPPRELIN LA...... 191 SYNALAR...... 135 tamoxifen (bulk)...... 57, 112 SUPRAX...... 41 SYNALAR CREAM KIT...... 135 tamsulosin...... 205 SUPREME DIAPERS SIZE 1 SYNALAR OINTMENT KIT..135 TANDEM DUAL ACTION..... 157 ...... 222, 233 SYNALAR TS...... 135 TANDEM PLUS...... 165 SUPREME DIAPERS SIZE 2 SYNAREL...... 191 tangerine oil (bulk)....112, 113, 116 ...... 222, 233 SYNDROS...... 98, 145, 194 TANGERINE OIL, NATURAL SUPREME DIAPERS SIZE 3 SYNERA...... 140 ...... 112, 113, 116 ...... 222, 233 SYNERCID...... 47 TAPAZOLE...... 183 SUPREME DIAPERS SIZE 4 SYNJARDY...... 181 TAPERDEX...... 188 ...... 222, 233 SYNJARDY XR...... 181 TARCEVA...... 49 SUPREME DIAPERS SIZE 5 SYNRIBO...... 58 TARGRETIN...... 57, 130 ...... 222, 233 SYNTHAMIN 17 WITHOUT TARINA 24 FE...... 121 SUPREME DIAPERS SIZE 6 ELYTE...... 168 TARINA FE 1/20 (28)...... 121 ...... 222, 233 SYNTHROID...... 193 TARINA FE 1-20 EQ (28)...... 121 SUPREP BOWEL PREP KIT.. 203 SYNVISC...... 217 TARKA...... 66 SURE RESULT DSS SYNVISC-ONE...... 217 TARON FORTE...... 156 PREMIUM PACK...... 138 SYPRINE...... 31 TARON-C DHA...... 163, 173 SURE RESULT TAC PAK...... 135 syringe (reusable)...... 224, 233 TART CHERRY...... 149 SURE-T INFUSION SET.225, 233 SYRPALTA VEHICLE...... 117 TASIGNA...... 57 SURE-T PARADIGM...... 227, 233 SYRSPEND SF ALKA...... 117 TASMAR...... 90 SURFAXIN...... 254 SYRSPEND SF LIQUID...... 117 TAVALISSE...... 209 SURGIFOAM...... 211 T.E.D. ANTI-EMBOLISM TAXOTERE...... 57 SURGUARD2 SAFETY.. 224, 233 STOCKING...... 220, 223, 233 tazarotene...... 130, 139 SURVANTA...... 254 T.E.D. KNEE LENGTH-S- TAZICEF...... 41 SUSPENDOL-S...... 118 REGULAR...... 220, 233 TAZORAC...... 130 SUSTIVA...... 37 T:30 INFUSION SET...... 227, 233 TDVAX...... 64 SUSTOL...... 195 T:90 INFUSION SET 23" 227, 233 teaberry oil flavor (bulk)...112, 116 SUTENT...... 57 T:FLEX INSULIN DELIVERY TEARS AGAIN HYDRATE...... 14 SUVICORT...... 140 PUMP...... 227, 233 TECARTUS...... 52 SWABFLUSH...... 150, 174, 175 T:SLIM...... 223, 233 TECENTRIQ...... 59 SWEEN CREAM...... 132 T:SLIM G4...... 223, 233 TECFIDERA...... 239 SWEET OIL...... 112, 113, 116 T:SLIM X2 BASAL-IQ TECNU...... 140 SWEETNESS ENHANCER INSULIN PMP...... 227, 233 TEFLARO...... 41 FLAVOR...... 112, 116 TABLOID...... 51 TEGRETOL...... 85, 97 SYEDA...... 121 TACLONEX...... 126 TEGRETOL XR...... 85, 97 SYLVANT...... 54 tacrolimus...... 131, 216 TEGSEDI...... 179 SYMAX DUOTAB...... 199, 208 tadalafil...... 81, 145, 206 TEKTURNA...... 81 SYMAX FASTABS...... 199, 208 tadalafil (pulm. hypertension).....81 TEKTURNA HCT...... 81 SYMAX-SL...... 199, 208 TAFINLAR...... 52 telmisartan...... 68 SYMAX-SR...... 199, 208 TAGRISSO...... 49 telmisartan-amlodipine...... 67 SYMBICORT...... 253 TAKHZYRO...... 80 telmisartan-hydrochlorothiazid...67 SYMBYAX...... 89, 93, 97 talc (bulk)...... 112, 139 temazepam...... 96, 103 SYMDEKO...... 254 TALIVA...... 149 TEMODAR...... 50

296 TEMOVATE...... 135 THERAGRAN-M PREMIER TIS-U-SOL PENTALYTE...... 151 temozolomide...... 50 50 PLUS...... 163 TIVICAY...... 36 TENCON...... 20 THERANATAL...... 163, 173 TIVORBEX...... 26 TENDERA-OB...... 173 THERANATAL COMPLETE. 173 tizanidine...... 219 teniposide...... 53 THERANATAL ONE...... 173 TNKASE...... 214 TENIVAC (PF)...... 64 THERANATAL OVAVITE.....173 TOBAKIENT...... 165 tenofovir disoproxil fumarate..... 37 THERANATAL PLUS...... 173 TOBI...... 253 TENORETIC 100...... 75 THERAPEUTIC-M TOBI PODHALER...... 253 TENORETIC 50...... 75 VITAMIN/MINERALS...... 163 TOBRADEX...... 241 TENORMIN...... 73 thiabendazole (bulk)...... 33, 112 TOBRADEX ST...... 241 TEPADINA...... 49 thiamine hcl (vitamin b1)...... 176 tobramycin...... 245 terazosin...... 80 THICK NOW...... 117 tobramycin (bulk)...... 32, 112 terbinafine (bulk)...... 34, 112 THICK-IT #2...... 117 tobramycin in 0.225 % nacl...... 253 terbinafine hcl...... 34 THIOLA...... 205 tobramycin in 0.9 % nacl...... 32 terbutaline...... 252 THIOLA EC...... 205 tobramycin sulfate...... 32 terbutaline sulfate (bulk)...... 112 thioridazine...... 93 tobramycin sulfate (bulk)....32, 112 terconazole...... 255 thiotepa...... 49 tobramycin-dexamethasone...... 241 teriparatide...... 183 thiothixene...... 93 TOBREX...... 245 TERSI FOAM...... 131 THRIVITE RX...... 173 TOLAK...... 129 TESTIM...... 180 THROMBATE III...... 213 tolcapone...... 90 TESTONE CIK...... 180 THYMOGLOBULIN...... 63 tolmetin...... 25 TESTOPEL...... 180 thymus gland,calf (bulk).....14, 112 TOLSURA...... 35 testosterone...... 180 THYROGEN...... 143 tolterodine...... 208 testosterone (bulk)...... 112, 180 thyroid, pork (bulk)...... 112, 193 TOPAMAX...... 85 testosterone cypionate...... 180 THYROLAR-1...... 192 TOPI-CLICK FILLING testosterone cypionate (bulk) THYROLAR-1/2...... 192 NOZZLE...... 225, 233 ...... 112, 180 THYROLAR-1/4...... 192 TOPICORT...... 135 testosterone enanthate...... 180 THYROLAR-2...... 192 topiramate...... 85 testosterone propionate (bulk) THYROLAR-3...... 192 TOPOSAR...... 53 ...... 112, 180 TIADYLT ER...... 74 topotecan...... 58 TESTRED...... 180 tiagabine...... 84 TOPROL XL...... 73 tetanus,diphtheria tox ped(pf).....64 TIAZAC...... 74 TOPROPHAN...... 13, 99 tetrabenazine...... 101 TIBSOVO...... 55 toremifene...... 57 tetracaine hcl...... 244 TICANASE...... 254 TORISEL...... 55 tetracaine hcl (pf)...... 244 TICE BCG...... 55, 63 torsemide...... 78 tetracycline...... 48 TIGAN...... 194 TOUCH-TROL...... 227, 233 tetracycline hcl (bulk)...... 48, 112 tigecycline...... 42, 48 TOUJEO MAX U-300 tetrahydrocurcumin (bulk).. 12, 112 TIGLUTIK...... 217 SOLOSTAR...... 190 TEXACORT...... 135 TIKOSYN...... 69 TOUJEO SOLOSTAR U-300 thallous chloride tl-201...... 144 TILIA FE...... 122 INSULIN...... 190 THALOMID...... 35, 57 timol-brimon-dorzo-latanop(pf)240 TOVIAZ...... 208 THAM...... 151 timolol maleate...... 73, 243 TPN ELECTROLYTES...... 158 THEO-24...... 251 timolol-brimonidi-dorzolam(pf)242 TPN ELECTROLYTES II...... 158 THEOCHRON...... 251 timolol-dorzolamid-latanop(pf) 242 TRACE ELEMENTS theophylline...... 251 timolol-latanoprost(pf)...... 243 4/PEDIATRIC...... 160 theophylline (bulk)...... 112, 251 TIMOPTIC...... 243 TRACLEER...... 81 theophylline in dextrose 5 %.... 251 TIMOPTIC OCUDOSE (PF)... 243 TRADJENTA...... 181 THERA BATH...... 132 TIMOPTIC-XE...... 243 tragacanth...... 118 THERACAL D2000...... 154 tinidazole...... 36 TRAINING PANTS 2T-3T THERACAL D4000...... 154 tinidazole (bulk)...... 36, 112 ...... 222, 233 THERA-D...... 178 TIROSINT...... 193 THERA-D 4000...... 178 TIROSINT-SOL...... 193

297 TRAINING PANTS 3T-4T triazolam...... 96, 103 TRIZIVIR...... 38 ...... 222, 233 TRIBENZOR...... 67 TROCHIBASE...... 113, 118 TRAINING PANTS 4T-5T TRICARE...... 173 TROCHIBASE S CLASSIC ...... 222, 233 TRICITRATES...... 206 ...... 113, 118 tramadol...... 17 TRICON...... 156 TROGARZO...... 36 tramadol-acetaminophen...... 20 TRICOR...... 70 TROKENDI XR...... 85 trandolapril...... 66 TRIDERM...... 135 TROMBONEX...... 148 trandolapril-verapamil...... 66 trientine...... 31 TRONVITE...... 147 tranexamic acid...... 210 TRIESENCE (PF)...... 242 TROPHAMINE 10 %...... 168 tranexamic acid (bulk)...... 113, 210 TRI-ESTARYLLA...... 122 tropical punch flavor (bulk) tranexamic acid in nacl,iso-os...210 trifluoperazine...... 92 ...... 113, 116 TRANSDERM-SCOP...... 194 trifluridine...... 246 tropicamide...... 241 TRANXENE T-TAB...... 82, 96 TRIGELS-F FORTE...... 156 trospium...... 208 tranylcypromine...... 87 trihexyphenidyl...... 90 TRUEPLUS DIABETIC TRAVASOL 10 %...... 168 TRIKAFTA...... 254 MULTIVITAMIN...... 163 TRAVATAN Z...... 246 TRI-LEGEST FE...... 122 TRULANCE...... 196, 200 trazodone...... 88 TRILEPTAL...... 85 TRULICITY...... 182 TREANDA...... 50 TRI-LINYAH...... 122 TRUMENBA...... 64 TRECATOR...... 39 TRILIPIX...... 70 TRUSOPT...... 243 TRELEGY ELLIPTA...... 253 TRI-LO-ESTARYLLA...... 122 TRUVADA...... 37 TREMFYA...... 126 TRI-LO-MARZIA...... 122 tryptophan...... 13 treprostinil sodium...... 81 TRI-LO-MILI...... 122 TUBERCULIN SYRINGE TRESIBA FLEXTOUCH U- TRI-LO-SPRINTEC...... 122 ...... 224, 233 100...... 190 TRILYTE WITH FLAVOR TUDORZA PRESSAIR...... 251 TRESIBA FLEXTOUCH U- PACKETS...... 203 TUGABOOS OVERNIGHTS 200...... 190 trimethobenzamide...... 194 ...... 221, 233 TRESIBA U-100 INSULIN...... 190 trimethoprim...... 33 TUGABOOS TRAINING tretinoin...... 126 trimethoprim (bulk)...... 33, 113 PANTS...... 223, 233 tretinoin (antineoplastic)...... 57 trimethoprim, micro (bulk). 33, 113 TULANA...... 122 tretinoin (bulk)...... 113 TRI-MILI...... 122 TURALIO...... 57 tretinoin (emollient)...... 139 trimipramine...... 89 TURKEY-SWEET tretinoin microspheres...... 126 TRIMO-SAN JELLY...... 256 POTATOES-PEACHES...... 149 TRETIN-X...... 126 TRINATAL RX 1...... 173 turmeric...... 14 TRETIN-X CREAM KIT...... 126 TRINATE...... 173 turmeric-turmeric ext-pepper...... 14 TREXALL...... 22, 50 TRINTELLIX...... 88 tutti-frutti flavor (bulk)..... 113, 116 TREXIMET...... 101 TRIOSTAT...... 193 TWINRIX (PF)...... 62 TREZIX...... 17, 18 TRIPHROCAPS...... 147 TWYNSTA...... 67 triacetin...... 129 TRI-PREVIFEM (28)...... 122 TYBOST...... 236 TRIADVANCE...... 173 TRIPTODUR...... 191 TYDEMY...... 122 triamcin diacet, micro (bulk).... 113 TRISENOX...... 51 TYGACIL...... 43, 48 triamcinol ace-bupiv-0.9% nacl 186 TRI-SPRINTEC (28)...... 122 TYKERB...... 48 triamcinolone (bulk)...... 113, 188 TRISTART DHA...... 173 TYMLOS...... 183 triamcinolone acetonide TRIUMEQ...... 38 TYR LOPHLEX GMP MIX-IN167 ...... 135, 188, 237 TRIVEEN-DUO DHA...... 173 tyrosine...... 145 triamcinolone acetonide (bulk) TRI-VI-FLOR...... 170 TYSABRI...... 238 ...... 113, 188 TRIVISC...... 217 TYVASO...... 81 triamcinolone diacetate (bulk) TRI-VITAMIN WITH TYVASO INSTITUTIONAL ...... 113, 188 FLUORIDE...... 170 START KIT...... 81 triamcinolon-moxiflox-watr(pf)241 TRI-VITE WITH FLUORIDE. 170 TYVASO REFILL KIT...... 81 triamterene (bulk)...... 78, 113 TRIVORA (28)...... 122 TYVASO STARTER KIT...... 81 triamterene-hydrochlorothiazid.. 78 TRI-VYLIBRA...... 122 TYZINE...... 255 TRIANEX...... 135 TRI-VYLIBRA LO...... 122 U-BASE...... 113, 114

298 UBRELVY...... 100 UROCIT-K 5...... 206 vanilla butternut flavor(bulk) UCERIS...... 201 UROGESIC-BLUE...... 45, 207 ...... 113, 116 UDAMIN SP...... 163 URO-MP...... 45, 207 vanilla extract flavor (bulk) UDENYCA...... 210 UROQID-ACID NO.2...... 45, 207 ...... 113, 116 ULESFIA...... 141 UROXATRAL...... 206 VANIQA...... 138 ULORIC...... 209 URSO 250...... 197 VANISHING CREAM.....113, 133 ULTICARE...... 224, 233 URSO FORTE...... 197 VANISH-PEN CREAM BASE ULTIMATE FLORA ursodiol...... 197 ...... 113, 114 PROBIOTIC...... 202 ursodiol (bulk)...... 113, 197 VANOS...... 135 ULTIMATE MEN'S URYL...... 45, 207 VANOXIDE-HC...... 125 COMPLETE 50+...... 163 USTELL...... 45, 207 VANTAS...... 55 ULTIMATE WOMEN'S UTIBRON NEOHALER...... 252 VAPRISOL IN 5 % COMPLETE 50+...... 163 UTIRA-C...... 45, 207 DEXTROSE...... 77 ULTIVA...... 28 UTOPIC...... 137 VAPRO PLUS INTERMITT ULTOMIRIS...... 212 UVADEX...... 56 CATHETER...... 233 ULTRA DAIRY DIGESTIVE..196 VABOMERE...... 39 VAQTA (PF)...... 62 ULTRA FREEDA...... 163 VAGIFEM...... 256 vardenafil...... 145 ULTRA MIDE 25...... 132 VAGISIL...... 138 VARITHENA...... 82 ULTRACET...... 20 valacyclovir...... 43 VARIVAX (PF)...... 63, 65 ULTRAM...... 17 VALCHLOR...... 129 VARUBI...... 195 ULTRAM ER...... 17 VALCYTE...... 41 VASCEPA...... 71, 72 ULTRASAL-ER...... 137 valganciclovir...... 41 VASERETIC...... 66 ULTRAVATE...... 130, 135 VALINE AMINO ACID VASHE WOUND THERAPY. 141 UMECTA...... 137 SUPPLEMENT...... 146 VASOFLEX FORTE...... 148 UNASYN...... 33 VALINEX...... 14 vasopressin in 0.9 % sod chlor..180 UNDERJAMS L-XL...... 221, 233 VALIUM...... 83, 96 VASOSTRICT...... 180 UNDERJAMS SMALL- valproate sodium...... 83 VASOTEC...... 66 MEDIUM...... 221, 233 valproic acid...... 83, 97 VB7 MAX...... 177 UNGUATOR LID...... 223, 233 valproic acid (as sodium salt) V-C FORTE...... 163 UNITHROID...... 193 ...... 83, 84, 97 VECAMYL...... 79 UNITUXIN...... 50 valrubicin...... 58 VECTIBIX...... 60 UNIVERSAL SLEEVE....225, 233 valsartan...... 68 VECTICAL...... 130 UNSCENTED COLD CREAM132 valsartan-hydrochlorothiazide.... 67 vecuronium bromide...... 218 UPCAL D...... 154 VALSTAR...... 58 VELCADE...... 56 UPTRAVI...... 79 VALTOCO...... 83, 96 VELETRI...... 81 URAMAXIN...... 137 VALTREX...... 43 VELIVET TRIPHASIC URAMAXIN GT...... 136, 137 VANATOL LQ...... 20 REGIMEN (28)...... 122 urea...... 132, 137 VANCOCIN...... 42 VELPHORO...... 205 urea (bulk)...... 113, 137 vancomycin...... 42 VELTASSA...... 151 UREA NAIL STICK...... 137 vancomycin hcl in water...... 42 VELTIN...... 125 UREACIN-10...... 132 vancomycin in 0.9 % sodium VEMLIDY...... 43 UREACIN-20...... 132 chl...... 42 VENCLEXTA...... 52 UREDEB...... 132 vancomycin in dextrose 5 %...... 42 VENCLEXTA STARTING URE-K...... 137 vancomycin-water inject (peg)... 42 PACK...... 52 URELLE...... 45, 207 VANDAZOLE...... 256 VENELEX...... 141 URETRON D-S...... 45, 207 VANIBASE...... 113, 132 venlafaxine...... 88 UREVAZ...... 137 VANIBASE TRADITIONAL VENOFER...... 157 URIBEL...... 45, 207 FORMULA...... 113, 114 VENTAVIS...... 81 URIMAR-T...... 45, 207 VANILLA BUTTERNUT VENTOLIN HFA...... 252 URIN DS...... 45, 207 FLAVOR...... 113, 116 verapamil...... 69, 75 UROCIT-K 10...... 206 verapamil (bulk)...... 75, 113 UROCIT-K 15...... 206 VERDESO...... 135

299 VERDROCET...... 18, 19 VIRT-CAPS...... 147 VITAMINS A-D-E VEREGEN...... 136 VIRT-GARD...... 176, 178 SELENIUM...... 164 VERELAN...... 75 VIRT-NATE DHA...... 173 VITAMINS B COMPLEX VERELAN PM...... 75 VIRT-PHOS 250 NEUTRAL ...... 147, 148 VERIPRED 20...... 188 ...... 158, 206 VITAMINS FOR HAIR... 147, 165 VERSA FREE...... 117 VIRT-PN DHA...... 165, 173 VITAMN E BEAUTY WITH VERSA PLUS...... 117 VIRT-PN PLUS...... 164, 174 SAFFLOWER...... 132 VERSACLOZ...... 92 VIRTRATE-2...... 206 VITAPEARL...... 174 VERSATILE...... 113, 114 VIRTRATE-3...... 206 VITA-RAY...... 132 VERZENIO...... 53 VIRTRATE-K...... 207 VITA-RESPA...... 176, 178 VESICARE...... 207 VIRT-VITE...... 176, 178 VITASURE...... 147 VFEND...... 35 VIRT-VITE PLUS...... 147 VITATRUE...... 174 VFEND IV...... 35 VISCO-3...... 217 VITRAKVI...... 58 V-GO 20...... 226, 233 VISCOAT...... 244 VITRASE...... 193 V-GO 30...... 227, 233 VISIPAQUE...... 142 VITRON-C...... 156 V-GO 40...... 227, 233 VISTARIL...... 82 VITRUM SENIOR...... 164 VIACTIV...... 152 VISTOGARD...... 60 VIVA DHA...... 174 VIAGRA...... 145 VISUDYNE...... 244 VIVACAINE...... 237 VIBATIV...... 44 VIT 3...... 165 VIVELLE-DOT...... 186 VIBERZI...... 200, 203 vit a and d3 in cod liver oil...... 175 VIVITROL...... 105 VIBRAMYCIN...... 48 VITABEX PLUS...... 164 VIVLODEX...... 25 VIC-FORTE...... 164 VITAFOL...... 156 VIZIMPRO...... 49 VICODIN HP...... 18, 19 VITAFOL GUMMIES...... 174 VOGELXO...... 180 VICTOZA 2-PAK...... 182 VITAFOL NANO...... 174 VOLTAREN...... 138 VICTOZA 3-PAK...... 182 VITAFOL ULTRA...... 174 VOLTAREN-XR...... 25 VIDAZA...... 51 VITAFOL-OB...... 174 VORAXAZE...... 60, 61 VIENVA...... 122 VITAFOL-OB+DHA...... 174 voriconazole...... 35 vigabatrin...... 84 VITAFOL-ONE...... 174 VOTRIENT...... 57 VIGADRONE...... 84 VITAL-D RX...... 164, 178 VP-CH PLUS...... 174 VIGAMOX...... 245 VITALETS...... 169 VP-CH-PNV...... 174 VIIBRYD...... 88 VITAMED MD ONE RX...... 174 VP-PNV-DHA...... 174 VIMIZIM...... 234 VITAMEDMD REDICHEW VPRIV...... 234 VIMOVO...... 24 RX...... 174 VP-VITE RX...... 147 VIMPAT...... 84 vitamin a...... 175 VRAYLAR...... 94, 97 VINACAL B...... 173 VITAMIN B-1...... 176 VSL#3 DS...... 202 VINATE CARE...... 165, 173 VITAMIN B-1 VUMERITY...... 239 VINATE DHA RF...... 165, 173 (MONONITRATE)...... 176 VUSION...... 129 VINATE II...... 173 VITAMIN B-12...... 176 VYFEMLA (28)...... 122 VINATE M...... 173 VITAMIN B-2...... 176 VYLIBRA...... 122 VINATE ONE...... 173 VITAMIN B-6...... 177 VYNDAQEL...... 179 VINATE ULTRA...... 173 VITAMIN C FIZZY DRINK... 175 VYTORIN 10-10...... 72 vinblastine...... 58 VITAMIN D3...... 178 VYTORIN 10-20...... 72 vincristine...... 58 VITAMIN D-3 WITH ALOE...164 VYTORIN 10-40...... 72 vinorelbine...... 58 vitamin e...... 71, 178 VYTORIN 10-80...... 72 VIOKACE...... 196 vitamin e-safflower oil...... 132 VYVANSE...... 95 VIORELE (28)...... 120 VITAMIN K...... 178 VYZULTA...... 246 VIRACEPT...... 47 VITAMIN K1...... 178 WAKIX...... 102 VIRAMUNE...... 37 vitamin k2...... 178 warfarin...... 209 VIRAMUNE XR...... 37 vitamins a and d...... 165 water for inject, bacteriostat...... 150 VIRASAL...... 137 VITAMINS A,C,D AND water for injection, sterile. 150, 175 VIREAD...... 37 FLUORIDE...... 170 water for irrigation, sterile...... 151 VIRT-C DHA...... 164, 173 watermelon flavor (bulk).. 113, 116

300 WEE CARE...... 157 XATMEP...... 22, 50 XYLOCAINE WITH WELCHOL...... 70 XCLAIR...... 132 EPINEPHRINE...... 29 WELL BEGINNINGS SLEEP XCOPRI...... 86 XYLOCAINE-MPF...... 29 PANTS...... 221, 223, 233 XCOPRI TITRATION PACK....86 XYLON 10...... 18, 19 WELLBUTRIN SR...... 89 XELITRAL...... 138 XYOSTED...... 180 WELLBUTRIN XL...... 89 XELJANZ...... 23, 201 XYREM...... 102 WERA (28)...... 122 XELJANZ XR...... 23, 201 XYZBAC...... 165 WESTAB ONE...... 176, 178 XELODA...... 51 YASMIN (28)...... 122 WESTHROID...... 193 XELPROS...... 246 YAZ (28)...... 122 white petrolatum (bulk).... 113, 114 XENAZINE...... 101 YERVOY...... 53 WHYTEDERM TDPAK...... 135 XEPI...... 127 YONDELIS...... 59 WHYTEDERM TRILASIL XERAVA...... 42, 48 YONSA...... 48, 50 PAK...... 135 XERESE...... 131 YUPELRI...... 251 WIDE-SEAL DIAPHRAGM 60 XEROFORM...... 220, 234 YUTIQ...... 242 ...... 220, 233 XEROFORM PETROLATUM YUVAFEM...... 256 WIDE-SEAL DIAPHRAGM 65 DRESSING...... 220, 234 zafirlukast...... 250 ...... 220, 234 XEROFORM PETROLATUM zaleplon...... 103 WIDE-SEAL DIAPHRAGM 70 OVERWRAP...... 220, 234 ZALTRAP...... 59 ...... 220, 234 XEROSTOMIA RELIEF...... 237 ZANAFLEX...... 219 WIDE-SEAL DIAPHRAGM 75 XGEVA...... 192 ZANOSAR...... 58 ...... 220, 234 XIAFLEX...... 218 ZARAH...... 122 WIDE-SEAL DIAPHRAGM 80 XIFAXAN...... 47 ZARONTIN...... 86 ...... 220, 234 XIGDUO XR...... 181 ZARXIO...... 210 WIDE-SEAL DIAPHRAGM 85 XIIDRA...... 242 ZATEAN-PN DHA...... 165, 174 ...... 220, 234 XLEU ANALOG...... 150, 165 ZATEAN-PN PLUS...... 164, 174 wild cherry flavor (bulk)...113, 116 XLYS- XTRP ANALOG..150, 165 ZAVARA...... 175, 178 WINRHO SDF...... 63 XMET ANALOG...... 150, 166 ZAVESCA...... 235 WINTERGREEN OIL...... 141 XMTVI ANALOG...... 150, 166 ZEBUTAL...... 20 WIXELA INHUB...... 253 XOFIGO...... 57 ZEGERID...... 198 WOMEN'S 50 PLUS XOFLUZA...... 43 ZEJULA...... 56 MULTIVITAMIN...... 164 XOLAIR...... 250 ZELAC...... 202 WOMEN'S DAILY CAPLET.. 164 XOLEGEL...... 129 ZELAPAR...... 90 WOMEN'S DAILY XOPENEX...... 252 ZELBORAF...... 52 FORMULA...... 165 XOPENEX CONCENTRATE. 252 ZEMAIRA...... 254 WOMENS DAILY GUMMIES164 XOPENEX HFA...... 252 ZEMBRACE SYMTOUCH..... 101 WOMEN'S DAILY PACK...... 164 XOSPATA...... 53 ZEMDRI...... 32, 207 WOMEN'S MULTIVITAMIN.164 XPHE MAXAMUM...... 166 ZEMPLAR...... 235 WOMEN'S MULTIVITAMIN XPHE, XTYR ANALOG. 150, 167 ZENATANE...... 123 GUMMIES...... 164 XPTM ANALOG...... 150, 167 ZENPEP...... 196 WOMEN'S ONE DAILY...... 165 XRYLIX (DICLOFENAC- ZENZEDI...... 95, 98, 102 WONDERPANTS...... 223, 234 KINES TAPE)...... 138 ZERBAXA...... 40 WPR PLUS...... 137 XTAMPZA ER...... 17 ZERIT...... 37 WYMZYA FE...... 122 XTANDI...... 50 ZESTORETIC...... 66 XADAGO...... 90 XULANE...... 123 ZESTRIL...... 66 XALATAN...... 246 XULTOPHY 100/3.6...... 183 ZETIA...... 71 XALKORI...... 50 XURIDEN...... 235 ZETONNA...... 254 XANAX...... 83, 96 XVITE...... 147 ZEVALIN (Y-90)...... 55 XANAX XR...... 83, 96 XYLIMELTS...... 238 ZIAC...... 75 XAQUIL XR...... 178 XYLOCAINE...... 29 ZIAGEN...... 37 XARELTO...... 210 XYLOCAINE (CARDIAC) ZIANA...... 125 XARELTO DVT-PE TREAT (PF)...... 69 zidovudine...... 37 30D START...... 210 ZIEXTENZO...... 210

301 zileuton...... 249 ZUMANDIMINE (28)...... 122 ZILRETTA...... 188 ZUPLENZ...... 195 zinc chloride...... 160 ZYCLARA...... 136 zinc gluconate...... 160 ZYDELIG...... 56 zinc oxide...... 139 ZYFLO...... 249 zinc sulfate...... 160 ZYKADIA...... 50 ZINC-15...... 160 ZYLET...... 241 ZINGIBER...... 174, 176 ZYLOPRIM...... 209 ZINGO...... 29 ZYMAXID...... 245 ZIOPTAN (PF)...... 246 ZYPITAMAG...... 71 ziprasidone hcl...... 91, 97 ZYPREXA...... 93, 97, 98 ziprasidone mesylate...... 91, 97 ZYPREXA RELPREVV...... 93 ZIPSOR...... 25 ZYPREXA ZYDIS...... 93, 98 ZIRABEV...... 48 ZYTIGA...... 48, 50 ZIRGAN...... 246 ZYVOX...... 45 ZITHRANOL...... 130 ZITHROMAX...... 44 ZITHROMAX TRI-PAK...... 44 ZITHROMAX Z-PAK...... 44 ZN-DTPA...... 31 ZOCOR...... 71 ZOFRAN...... 195 ZOHYDRO ER...... 17 ZOLADEX...... 55 zoledronic acid...... 184 zoledronic acid-mannitol-water 184 zoledronic ac-mannitol-0.9nacl 184 ZOLINZA...... 54 zolmitriptan...... 101 ZOLOFT...... 88 zolpidem...... 103 ZOLPIMIST...... 103 ZOMACTON...... 189 ZOMIG...... 101 ZOMIG ZMT...... 101 ZONALON...... 141 ZONEGRAN...... 86 zonisamide...... 86 ZONTIVITY...... 214 ZOO CHEWS...... 171 ZOO FRIENDS...... 171 ZORBTIVE...... 189, 204 ZORTRESS...... 216 ZORVOLEX...... 25 ZOSTAVAX (PF)...... 63, 65 ZOSYN IN DEXTROSE (ISO- OSM)...... 46 ZOVIA 1/35E (28)...... 122 ZOVIRAX...... 43, 131 ZTLIDO...... 140 ZUBSOLV...... 104 ZULRESSO...... 87

302