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2021 Enrollment2021 Formulary

Advantage Dual SNP (HMO SNP) Medicare Advantage Dual Eligible Special Needs Plan

H5742_21RXFORM_C FirstCare Advantage Dual SNP (HMO SNP)

2021 Formulary

List of Covered Drugs

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

FirstCare Advantage Dual SNP is a Health plan with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in FirstCare Advantage Dual SNP (HMO SNP) depends on contract renewal.

Formulary File Submission ID 00021537, Version 14

This formulary was updated on September 1, 2021. For more recent information or other questions, please contact FirstCare Advantage Dual Special Needs Plan (SNP) Customer Experience Center at 1-866-229-4969 or, for TTY users, 711, October 1 – March 31, 8 a.m. to 8 p.m. Central Time (CT) daily; April 1 – September 30, 8 a.m. to 8 p.m. CT, Monday through Friday, or visit www.firstcare.com/dualsnp.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means FirstCare Health Plans. When it refers to “plan” or “our plan,” it means FirstCare Advantage Dual SNP. This document includes list of the drugs (formulary) for our plan which is current as of September 1, 2021 For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

H5742_RXFORMULARY_C

Updated date September 1, 2021 1 What is the FirstCare Advantage Dual SNP Formulary? A formulary is a list of covered drugs selected by FirstCare Advantage Dual SNP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. FirstCare Advantage Dual SNP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a FirstCare Advantage Dual SNP network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but FirstCare Advantage Dual SNP may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

 New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the FirstCare Advantage Dual SNP Formulary?”  Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.  Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the

Updated date September 1, 2021 2 change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the FirstCare Advantage Dual SNP Formulary?” Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs. The enclosed formulary is current as of September 1, 2021. To get updated information about the drugs covered by FirstCare Advantage Dual SNP, please contact us. Our contact information appears on the front and back cover pages. In the event of any CMS-approved, mid-year non-maintenance formulary changes, the formularies will be updated monthly and posted on our website.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents-Misc”. If you know what your drug is used for, look for the category name in the list that begins on page number 7. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 103. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? FirstCare Advantage Dual SNP covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Updated date September 1, 2021 3 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

 Prior Authorization: FirstCare Advantage Dual SNP requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from FirstCare Advantage Dual SNP before you fill your prescriptions. If you don’t get approval, FirstCare Advantage Dual SNP may not cover the drug.

 Quantity Limits: For certain drugs, FirstCare Advantage Dual SNP limits the amount of the drug that FirstCare Advantage Dual SNP will cover. For example, FirstCare Advantage Dual SNP provides 9 tablets per prescription for tablets. This may be in addition to a standard one-month or three-month supply.  Step Therapy: In some cases, FirstCare Advantage Dual SNP 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, FirstCare Advantage Dual SNP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FirstCare Advantage Dual SNP will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask FirstCare Advantage Dual SNP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the FirstCare Advantage Dual SNP formulary?” on page 5 for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that FirstCare Advantage Dual SNP does not cover your drug, you have two options:  You can ask Member Services for a list of similar drugs that are covered by FirstCare Advantage Dual SNP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FirstCare Advantage Dual SNP.  You can ask FirstCare Advantage Dual SNP to make an exception and cover your drug. See below for information about how to request an exception.

4 Updated date September 1, 2021 How do I request an exception to the FirstCare Advantage Dual SNP Formulary? You can ask FirstCare Advantage Dual SNP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.  You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.  You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, FirstCare Advantage Dual SNP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, FirstCare Advantage Dual SNP will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. FirstCare Advantage Dual SNP provides transition fills for members who have a level-of-care change from one treatment setting to another. Please visit our website for further details.

Updated date September 1, 2021 5 For more information For more detailed information about your FirstCare Advantage Dual SNP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about FirstCare Advantage Dual SNP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

FirstCare Advantage Dual SNP’s Formulary The formulary that begins below provides coverage information about the drugs covered by FirstCare Advantage Dual SNP. If you have trouble finding your drug in the list, turn to the Index that begins on page 103. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM and generic drugs are listed in lower-case italics (e.g., lidocaine). The information in the Requirements/Limits column tells you if FirstCare Advantage Dual SNP has any special requirements for coverage of your drug. Below are abbreviations you may find in this column:  LD next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the FDA. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs.  PA indicates that prior authorization may apply.  PA BvD indicates that prior authorization may apply for medications that could be eligible for payment under either Medicare Part B or Part D.  PA NSO indicates that prior authorization may apply on certain medications for new members.  QL indicates that quantities dispensed may be limited.  ST indicates that step therapy may apply.  ST NSO indicates that step therapy may apply on certain medications for new members.  NDS indicates the drug is limited to a 1-month supply.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1- 866-229-4969 (TTY: 711). Atención: Si usted habla español, puede obtener asistencia en su idioma sin costo alguno. Llame al 1-866-229-4969 (TTY:711).

Updated date September 1, 2021 6 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES amphetamine- 10mg ER cap 1 amphetamine-dextroamphetamine 10mg tab 1 amphetamine-dextroamphetamine 12.5mg tab 1 amphetamine-dextroamphetamine 15mg ER cap 1 amphetamine-dextroamphetamine 15mg tab 1 amphetamine-dextroamphetamine 20mg ER cap 1 amphetamine-dextroamphetamine 20mg tab 1 amphetamine-dextroamphetamine 25mg ER cap 1 amphetamine-dextroamphetamine 30mg ER cap 1 amphetamine-dextroamphetamine 30mg tab 1 amphetamine-dextroamphetamine 5mg ER cap 1 amphetamine-dextroamphetamine 5mg tab 1 amphetamine-dextroamphetamine 7.5mg tab 1 dextroamphetamine sulfate 10mg er cap 1 dextroamphetamine sulfate 10mg tab 1 dextroamphetamine sulfate 15mg er cap 1 dextroamphetamine sulfate 5mg er cap 1 dextroamphetamine sulfate 5mg tab 1 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine 100mg cap 1 QL=60 EA/30 Days atomoxetine 10mg cap 1 QL=60 EA/30 Days atomoxetine 18mg cap 1 QL=60 EA/30 Days atomoxetine 25mg cap 1 QL=60 EA/30 Days atomoxetine 40mg cap 1 QL=60 EA/30 Days atomoxetine 60mg cap 1 QL=60 EA/30 Days atomoxetine 80mg cap 1 QL=60 EA/30 Days clonidine 0.1mg er tab 1 guanfacine 1mg er tab 1 guanfacine 2mg er tab 1 guanfacine 3mg er tab 1 guanfacine 4mg er tab 1 DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS) SUNOSI 150MG TAB 1 PA QL=30 EA/30 Days SUNOSI 75MG TAB 1 PA QL=30 EA/30 Days HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS WAKIX 17.8MG TAB 1 NDS PA QL=60 EA/30 Days WAKIX 4.45MG TAB 1 NDS PA QL=60 EA/30 Days STIMULANTS - MISC. armodafinil 150mg tab 1 PA QL=30 EA/30 Days armodafinil 200mg tab 1 PA QL=30 EA/30 Days armodafinil 250mg tab 1 PA QL=30 EA/30 Days armodafinil 50mg tab 1 PA QL=30 EA/30 Days dexmethylphenidate 10mg er cap 1 dexmethylphenidate 10mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS dexmethylphenidate 15mg er cap 1 dexmethylphenidate 2.5mg tab 1 dexmethylphenidate 20mg er cap 1 dexmethylphenidate 25mg er cap 1 dexmethylphenidate 30mg er cap 1 dexmethylphenidate 35mg er cap 1 dexmethylphenidate 40mg er cap 1 dexmethylphenidate 5mg er cap 1 dexmethylphenidate 5mg tab 1 methylphenidate 10mg cr cap 1 methylphenidate 10mg er tab 1 methylphenidate 10mg la cap 1 methylphenidate 10mg tab 1 methylphenidate 18mg er tab 1 METHYLPHENIDATE 18MG ER TAB 1 methylphenidate 1mg/ml oral soln 1 methylphenidate 20mg cr cap 1 methylphenidate 20mg er tab 1 methylphenidate 20mg la cap 1 methylphenidate 20mg tab 1 methylphenidate 27mg sr tab 1 methylphenidate 2mg/ml oral soln 1 methylphenidate 30mg cr cap 1 methylphenidate 30mg la cap 1 methylphenidate 36mg sr tab 1 methylphenidate 40mg cr cap 1 methylphenidate 40mg la cap 1 methylphenidate 50mg cr cap 1 methylphenidate 54mg sr tab 1 methylphenidate 5mg tab 1 methylphenidate 60mg cr cap 1 modafinil 100mg tab 1 PA QL=60 EA/30 Days modafinil 200mg tab 1 PA QL=60 EA/30 Days AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin 250mg/ml inj 1 ARIKAYCE 590MG/8.4ML INH SUSP 1 NDS PA QL=252 ML/30 Days GENTAMICIN 0.8MG/ML INJ 1 gentamicin 1.2mg/ml inj 1 GENTAMICIN 1.6MG/ML INJ 1 GENTAMICIN 1MG/ML INJ 1 gentamicin 40mg/ml inj 1 neomycin sulfate 500mg tab 1 paromomycin 250mg cap 1 STREPTOMYCIN 1000MG INJ 1 TOBRAMYCIN 10MG/ML INJ 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS tobramycin 40mg/ml inj 1 tobramycin 60mg/ml inh soln 1 NDS PA QL=300 ML/30 Days ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC - ENZYME INHIBITORS OLUMIANT 1MG TAB 1 NDS PA OLUMIANT 2MG TAB 1 NDS PA RINVOQ 15MG ER TAB 1 NDS PA XELJANZ 10MG TAB 1 NDS PA XELJANZ 1MG/ML ORAL SOLN 1 NDS PA XELJANZ 5MG TAB 1 NDS PA XELJANZ XR 11MG TAB 1 NDS PA XELJANZ XR 22MG TAB 1 NDS PA ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA 10MG/0.1ML SYRINGE 1 NDS PA HUMIRA 20MG/0.2ML SYRINGE 1 NDS PA HUMIRA 40MG/0.4ML AUTO-INJECTOR 1 NDS PA HUMIRA 40MG/0.4ML SYRINGE 1 NDS PA HUMIRA 40MG/0.8ML AUTO-INJECTOR 1 NDS PA HUMIRA 40MG/0.8ML SYRINGE 1 NDS PA HUMIRA 80MG/0.8ML AUTO-INJECTOR 1 NDS PA HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 1 NDS PA 80MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER PACK 1 NDS PA SYRINGE (2) 40MG/0.4ML HUMIRA PEN - CROHN'S STARTER PACK 1 NDS PA 40MG/0.8ML INJ HUMIRA PEN - CROHN'S STARTER PACK 1 NDS PA 80MG/0.8ML INJ HUMIRA PEN - PEDIATRIC UC STARTER PACK 1 NDS PA 80MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER PACK 1 NDS PA 40MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER PACK 1 NDS PA 80MG/0.8ML INJ SIMPONI 100MG/ML AUTO-INJECTOR 1 NDS PA SIMPONI 100MG/ML SYRINGE 1 NDS PA SIMPONI 50MG/0.5ML AUTO-INJECTOR 1 NDS PA SIMPONI 50MG/0.5ML SYRINGE 1 NDS PA GOLD COMPOUNDS RIDAURA 3MG CAP 1 INTERLEUKIN-1 BLOCKERS ARCALYST 220MG INJ 1 NDS PA INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA 162MG/0.9ML AUTO-INJECTOR 1 NDS PA ACTEMRA 162MG/0.9ML SYRINGE 1 NDS PA KEVZARA 150MG/1.14ML AUTO-INJECTOR 1 NDS PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS KEVZARA 150MG/1.14ML SYRINGE 1 NDS PA KEVZARA 200MG/1.14ML AUTO-INJECTOR 1 NDS PA KEVZARA 200MG/1.14ML SYRINGE 1 NDS PA NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib 100mg cap 1 QL=60 EA/30 Days celecoxib 200mg cap 1 QL=60 EA/30 Days celecoxib 400mg cap 1 QL=60 EA/30 Days celecoxib 50mg cap 1 QL=60 EA/30 Days diclofenac potassium 50mg tab 1 diclofenac sodium 100mg er tab 1 diclofenac sodium 25mg dr tab 1 diclofenac sodium 50mg dr tab 1 diclofenac sodium 50mg/misoprostol 0.2mg dr tab 1 diclofenac sodium 75mg dr tab 1 diclofenac sodium 75mg/misoprostol 0.2mg dr tab 1 etodolac 200mg cap 1 etodolac 300mg cap 1 etodolac 400mg er tab 1 etodolac 400mg tab 1 etodolac 500mg er tab 1 etodolac 500mg tab 1 etodolac 600mg er tab 1 flurbiprofen 100mg tab 1 ibu 600mg tab 1 ibu 800mg tab 1 ibuprofen 20mg/ml susp 1 ibuprofen 400mg tab 1 ibuprofen 600mg tab 1 ibuprofen 800mg tab 1 INDOCIN 50MG RECTAL SUPP 1 indomethacin 25mg cap 1 indomethacin 50mg cap 1 indomethacin 75mg er cap 1 ketorolac tromethamine 10mg tab 1 QL=20 EA/5 Days meloxicam 15mg tab 1 meloxicam 7.5mg tab 1 nabumetone 500mg tab 1 nabumetone 750mg tab 1 naproxen 250mg tab 1 naproxen 375mg dr tab 1 naproxen 375mg tab 1 naproxen 500mg dr tab 1 naproxen 500mg tab 1 naproxen sodium 275mg tab 1 naproxen sodium 550mg tab 1 oxaprozin 600mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS piroxicam 10mg cap 1 piroxicam 20mg cap 1 sulindac 150mg tab 1 sulindac 200mg tab 1 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA 28-DAY STARTER PACK 1 NDS PA OTEZLA 30MG TAB 1 NDS PA PYRIMIDINE SYNTHESIS INHIBITORS leflunomide 10mg tab 1 leflunomide 20mg tab 1 SELECTIVE COSTIMULATION MODULATORS ORENCIA 125MG/ML AUTO-INJECTOR 1 NDS PA ORENCIA 125MG/ML SYRINGE 1 NDS PA ORENCIA 50MG/0.4ML SYRINGE 1 NDS PA ORENCIA 87.5MG/0.7ML SYRINGE 1 NDS PA SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL 25MG INJ 1 NDS PA ENBREL 25MG/0.5ML INJ 1 NDS PA ENBREL 25MG/0.5ML SYRINGE 1 NDS PA ENBREL 50MG/ML AUTO-INJECTOR 1 NDS PA ENBREL 50MG/ML CARTRIDGE 1 NDS PA ENBREL 50MG/ML SYRINGE 1 NDS PA ANALGESICS - NONNARCOTIC SALICYLATES diflunisal 500mg tab 1 ANALGESICS - OPIOID OPIOID AGONISTS CODEINE SULFATE 15MG TAB 1 QL=240 EA/30 Days codeine sulfate 30mg tab 1 QL=240 EA/30 Days codeine sulfate 60mg tab 1 QL=180 EA/30 Days fentanyl 0.012mg/hr patch 1 QL=10 EA/30 Days fentanyl 0.025mg/hr patch 1 QL=10 EA/30 Days fentanyl 0.05mg/hr patch 1 QL=10 EA/30 Days fentanyl 0.075mg/hr patch 1 QL=10 EA/30 Days FENTANYL 0.1MG BUCCAL TAB 1 PA QL=120 EA/30 Days fentanyl 0.1mg/hr patch 1 QL=10 EA/30 Days FENTANYL 0.2MG BUCCAL TAB 1 PA QL=120 EA/30 Days fentanyl 0.2mg lozenge 1 PA QL=120 EA/30 Days FENTANYL 0.4MG BUCCAL TAB 1 PA QL=120 EA/30 Days fentanyl 0.4mg lozenge 1 PA QL=120 EA/30 Days FENTANYL 0.6MG BUCCAL TAB 1 PA QL=120 EA/30 Days fentanyl 0.6mg lozenge 1 PA QL=120 EA/30 Days FENTANYL 0.8MG BUCCAL TAB 1 PA QL=120 EA/30 Days fentanyl 0.8mg lozenge 1 PA QL=120 EA/30 Days fentanyl 1.2mg lozenge 1 PA QL=120 EA/30 Days fentanyl 1.6mg lozenge 1 PA QL=120 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FENTORA 100MCG BUCCAL TAB 1 PA QL=120 EA/30 Days FENTORA 200MCG BUCCAL TAB 1 PA QL=120 EA/30 Days FENTORA 400MCG BUCCAL TAB 1 PA QL=120 EA/30 Days FENTORA 600MCG BUCCAL TAB 1 PA QL=120 EA/30 Days FENTORA 800MCG BUCCAL TAB 1 PA QL=120 EA/30 Days hydrocodone bitartrate 10mg er cap 1 QL=60 EA/30 Days hydrocodone bitartrate 15mg er cap 1 QL=60 EA/30 Days hydrocodone bitartrate 20mg er cap 1 QL=60 EA/30 Days hydrocodone bitartrate 30mg er cap 1 QL=60 EA/30 Days hydrocodone bitartrate 40mg er cap 1 QL=60 EA/30 Days hydrocodone bitartrate 50mg er cap 1 QL=60 EA/30 Days hydromorphone 10mg/ml (1ml) inj 1 hydromorphone 10mg/ml (5ml) inj 1 hydromorphone 1mg/ml oral soln 1 QL=2400 ML/30 Days hydromorphone 2mg tab 1 QL=450 EA/30 Days hydromorphone 4mg tab 1 QL=240 EA/30 Days hydromorphone 8mg tab 1 QL=120 EA/30 Days methadone 10mg tab 1 QL=360 EA/30 Days methadone 5mg tab 1 QL=360 EA/30 Days morphine sulfate 100mg er tab 1 QL=120 EA/30 Days morphine sulfate 15mg er tab 1 QL=120 EA/30 Days morphine sulfate 15mg tab 1 QL=180 EA/30 Days morphine sulfate 200mg er tab 1 QL=120 EA/30 Days morphine sulfate 20mg/ml oral soln 1 QL=180 ML/30 Days morphine sulfate 2mg/ml oral soln 1 QL=1800 ML/30 Days morphine sulfate 30mg er tab 1 QL=120 EA/30 Days morphine sulfate 30mg tab 1 QL=180 EA/30 Days morphine sulfate 4mg/ml oral soln 1 QL=900 ML/30 Days morphine sulfate 60mg er tab 1 QL=120 EA/30 Days NUCYNTA 100MG ER TAB 1 QL=60 EA/30 Days NUCYNTA 150MG ER TAB 1 QL=60 EA/30 Days NUCYNTA 200MG ER TAB 1 QL=60 EA/30 Days NUCYNTA 250MG ER TAB 1 QL=60 EA/30 Days NUCYNTA 50MG ER TAB 1 QL=60 EA/30 Days oxycodone 10mg tab 1 QL=180 EA/30 Days oxycodone 15mg tab 1 QL=180 EA/30 Days oxycodone 1mg/ml oral soln 1 QL=5400 ML/30 Days oxycodone 20mg tab 1 QL=180 EA/30 Days oxycodone 20mg/ml oral soln 1 QL=270 ML/30 Days oxycodone 30mg tab 1 QL=180 EA/30 Days oxycodone 5mg cap 1 QL=360 EA/30 Days oxycodone 5mg tab 1 QL=360 EA/30 Days oxymorphone 10mg tab 1 QL=360 EA/30 Days oxymorphone 5mg tab 1 QL=360 EA/30 Days tramadol 100mg er tab 1 QL=60 EA/30 Days tramadol 100mg er tab (matrix delivery) 1 QL=60 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS tramadol 200mg er tab 1 QL=60 EA/30 Days tramadol 200mg er tab (matrix delivery) 1 QL=60 EA/30 Days tramadol 300mg er tab 1 QL=60 EA/30 Days tramadol 300mg er tab (matrix delivery) 1 QL=60 EA/30 Days tramadol 50mg tab 1 QL=240 EA/30 Days XTAMPZA 13.5MG ER CAP 1 QL=120 EA/30 Days XTAMPZA 18MG ER CAP 1 QL=120 EA/30 Days XTAMPZA 27MG ER CAP 1 QL=120 EA/30 Days XTAMPZA 36MG ER CAP 1 QL=120 EA/30 Days XTAMPZA 9MG ER CAP 1 QL=120 EA/30 Days OPIOID COMBINATIONS acetaminophen 21.7mg/ml/hydrocodone bitartrate 1 QL=5400 ML/30 Days 0.5mg/ml oral soln acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml 1 QL=4980 ML/30 Days oral soln acetaminophen 300mg/codeine phosphate 15mg tab 1 QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 30mg tab 1 QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 60mg tab 1 QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 10mg 1 QL=390 EA/30 Days tab acetaminophen 300mg/hydrocodone bitartrate 5mg 1 QL=390 EA/30 Days tab acetaminophen 300mg/hydrocodone bitartrate 7.5mg 1 QL=390 EA/30 Days tab acetaminophen 325mg/hydrocodone bitartrate 10mg 1 QL=360 EA/30 Days tab acetaminophen 325mg/hydrocodone bitartrate 5mg 1 QL=360 EA/30 Days tab acetaminophen 325mg/hydrocodone bitartrate 7.5mg 1 QL=360 EA/30 Days tab acetaminophen 325mg/oxycodone 10mg tab 1 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 2.5mg tab 1 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 5mg tab 1 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 7.5mg tab 1 QL=360 EA/30 Days acetaminophen 325mg/tramadol 37.5mg tab 1 QL=360 EA/30 Days endocet 325-10mg tab 1 QL=360 EA/30 Days endocet 325-5mg tab 1 QL=360 EA/30 Days endocet 325-7.5mg tab 1 QL=360 EA/30 Days hydrocodone bitartrate 10mg/ibuprofen 200mg tab 1 QL=480 EA/30 Days hydrocodone bitartrate 5mg/ibuprofen 200mg tab 1 QL=480 EA/30 Days hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab 1 QL=480 EA/30 Days OPIOID PARTIAL AGONISTS buprenorphine 12mg/naloxone 3mg sublingual film 1 buprenorphine 2mg sl tab 1 buprenorphine 2mg/naloxone 0.5mg sl tab 1 buprenorphine 2mg/naloxone 0.5mg sublingual film 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS buprenorphine 4mg/naloxone 1mg sublingual film 1 buprenorphine 8mg sl tab 1 buprenorphine 8mg/naloxone 2mg sl tab 1 buprenorphine 8mg/naloxone 2mg sublingual film 1 butorphanol tartrate 1mg/act nasal inhaler 1 QL=10 ML/30 Days ZUBSOLV 1.4-0.36MG SL TAB 1 QL=90 EA/30 Days ZUBSOLV 11.4-2.9MG SL TAB 1 QL=60 EA/30 Days ZUBSOLV 2.9-0.71MG SL TAB 1 QL=90 EA/30 Days ZUBSOLV 5.7-1.4MG SL TAB 1 QL=90 EA/30 Days ZUBSOLV 8.6-2.1MG SL TAB 1 QL=60 EA/30 Days ANDROGENS-ANABOLIC ANABOLIC STEROIDS oxandrolone 10mg tab 1 oxandrolone 2.5mg tab 1 ANDROGENS ANDRODERM 2MG/24HR PATCH 1 PA QL=60 EA/30 Days ANDRODERM 4MG/24HR PATCH 1 PA QL=30 EA/30 Days danazol 100mg cap 1 danazol 200mg cap 1 danazol 50mg cap 1 testosterone 1% (25mg) gel packet 1 PA QL=300 GM/30 Days testosterone 1% (50mg) gel packet 1 PA QL=300 GM/30 Days testosterone 1.62% (1.25gm) gel packet 1 PA QL=75 GM/30 Days testosterone 1.62% (2.5gm) gel packet 1 PA QL=150 GM/30 Days TESTOSTERONE 12.5MG/ACT GEL PUMP 1 PA QL=300 GM/30 Days testosterone 20.25mg/act gel pump 1 PA QL=150 GM/30 Days testosterone 30mg/act topical soln 1 PA QL=180 ML/30 Days testosterone cypionate 100mg/ml inj 1 testosterone cypionate 200mg/ml (1ml) inj 1 testosterone cypionate 200mg/ml inj 1 TESTOSTERONE ENANTHATE 200MG/ML INJ 1 ANORECTAL AGENTS INTRARECTAL STEROIDS hydrocortisone 1.67mg/ml enema 1 UCERIS 2MG/ACT RECTAL FOAM 1 PA VASODILATING AGENTS RECTIV 0.4% RECTAL OINTMENT 1 QL=30 GM/30 Days ANORECTAL AND RELATED PRODUCTS RECTAL COMBINATIONS hydrocortisone/pramoxine 1-1% rectal cream 1 RECTAL STEROIDS procto-med 2.5% cream 1 procto-pak 1% rectal cream 1 proctosol 2.5% cream 1 proctozone hc 2.5% cream 1 ANTHELMINTICS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANTHELMINTICS 200mg tab 1 BENZNIDAZOLE 100MG TAB 1 PA BENZNIDAZOLE 12.5MG TAB 1 PA ivermectin 3mg tab 1 ANTIANGINAL AGENTS ANTIANGINALS-OTHER ranolazine 1000mg er tab 1 ranolazine 500mg er tab 1 NITRATES isosorbide dinitrate 10mg tab 1 isosorbide dinitrate 20mg tab 1 isosorbide dinitrate 30mg tab 1 isosorbide dinitrate 5mg tab 1 isosorbide mononitrate 10mg tab 1 isosorbide mononitrate 120mg er tab 1 isosorbide mononitrate 20mg tab 1 isosorbide mononitrate 30mg er tab 1 isosorbide mononitrate 60mg er tab 1 minitran 0.1mg/hr patch 1 minitran 0.2mg/hr patch 1 minitran 0.4mg/hr patch 1 minitran 0.6mg/hr patch 1 NITRO-BID 2% OINTMENT 1 NITRO-DUR 0.3MG/HR PATCH 1 NITRO-DUR 0.8MG/HR PATCH 1 nitroglycerin 0.1mg/hr patch 1 nitroglycerin 0.2mg/hr patch 1 nitroglycerin 0.3mg sl tab 1 nitroglycerin 0.4mg sl tab 1 nitroglycerin 0.4mg/act spray 1 nitroglycerin 0.4mg/hr patch 1 nitroglycerin 0.6mg sl tab 1 nitroglycerin 0.6mg/hr patch 1 ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone 10mg tab 1 buspirone 15mg tab 1 buspirone 30mg tab 1 buspirone 5mg tab 1 buspirone 7.5mg tab 1 hydroxyzine 10mg tab 1 hydroxyzine 25mg tab 1 hydroxyzine 2mg/ml oral soln 1 hydroxyzine 50mg tab 1 HYDROXYZINE PAMOATE 100MG CAP 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS hydroxyzine pamoate 25mg cap 1 hydroxyzine pamoate 50mg cap 1 BENZODIAZEPINES alprazolam 0.25mg odt 1 alprazolam 0.25mg tab 1 alprazolam 0.5mg er tab 1 alprazolam 0.5mg odt 1 alprazolam 0.5mg tab 1 alprazolam 1mg er tab 1 alprazolam 1mg odt 1 alprazolam 1mg tab 1 alprazolam 2mg er tab 1 alprazolam 2mg odt 1 alprazolam 2mg tab 1 alprazolam 3mg er tab 1 chlordiazepoxide 10mg cap 1 chlordiazepoxide 25mg cap 1 chlordiazepoxide 5mg cap 1 clorazepate dipotassium 15mg tab 1 clorazepate dipotassium 3.75mg tab 1 clorazepate dipotassium 7.5mg tab 1 diazepam 10mg tab 1 DIAZEPAM 1MG/ML ORAL SOLN 1 diazepam 2mg tab 1 diazepam 5mg tab 1 diazepam 5mg/ml oral soln 1 lorazepam 0.5mg tab 1 lorazepam 1mg tab 1 lorazepam 2mg tab 1 lorazepam 2mg/ml oral soln 1 OXAZEPAM 10MG CAP 1 OXAZEPAM 15MG CAP 1 OXAZEPAM 30MG CAP 1 ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide 100mg cap 1 disopyramide 150mg cap 1 NORPACE 100MG ER CAP 1 NORPACE 150MG ER CAP 1 quinidine gluconate 324mg er tab 1 QUINIDINE SULFATE 200MG TAB 1 QUINIDINE SULFATE 300MG TAB 1 ANTIARRHYTHMICS TYPE I-B mexiletine 150mg cap 1 mexiletine 200mg cap 1 mexiletine 250mg cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANTIARRHYTHMICS TYPE I-C flecainide acetate 100mg tab 1 flecainide acetate 150mg tab 1 flecainide acetate 50mg tab 1 propafenone 150mg tab 1 propafenone 225mg er cap 1 propafenone 225mg tab 1 propafenone 300mg tab 1 propafenone 325mg er cap 1 propafenone 425mg er cap 1 ANTIARRHYTHMICS TYPE III amiodarone 200mg tab 1 amiodarone 400mg tab 1 dofetilide 0.125mg cap 1 dofetilide 0.25mg cap 1 dofetilide 0.5mg cap 1 MULTAQ 400MG TAB 1 pacerone 200mg tab 1 pacerone 400mg tab 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES FASENRA 30MG/ML AUTO-INJECTOR 1 PA FASENRA 30MG/ML SYRINGE 1 PA NUCALA 100MG INJ 1 NDS PA NUCALA 100MG/ML AUTO-INJECTOR 1 NDS PA NUCALA 100MG/ML SYRINGE 1 NDS PA XOLAIR 150MG INJ 1 NDS PA XOLAIR 150MG/ML SYRINGE 1 NDS PA XOLAIR 75MG/0.5ML SYRINGE 1 NDS PA BRONCHODILATORS - ANTICHOLINERGICS ATROVENT 17MCG INH 1 INCRUSE 62.5MCG/INH INH 1 ipratropium bromide 0.2mg/ml inh soln 1 PA BvD LONHALA 25MCG/ML INH SOLN 1 ST SPIRIVA 1.25MCG INH 1 ST QL=4 GM/30 Days LEUKOTRIENE MODULATORS montelukast 10mg tab 1 montelukast 4mg chew tab 1 montelukast 4mg granules 1 montelukast 5mg chew tab 1 zafirlukast 10mg tab 1 zafirlukast 20mg tab 1 SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250MCG TAB 1 DALIRESP 500MCG TAB 1 STEROID INHALANTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ARNUITY 100MCG INH 1 QL=30 EA/30 Days ARNUITY 200MCG INH 1 QL=30 EA/30 Days ARNUITY 50MCG INH 1 QL=30 EA/30 Days ASMANEX 100MCG INH 1 QL=13 GM/30 Days ASMANEX 110MCG/INH INH 1 QL=1 EA/30 Days ASMANEX 200MCG INH 1 QL=13 GM/30 Days ASMANEX 220MCG (120ACT) INH 1 QL=1 EA/30 Days ASMANEX 220MCG (30ACT) INH 1 QL=1 EA/30 Days ASMANEX 220MCG (60ACT) INH 1 QL=1 EA/30 Days ASMANEX 50MCG HFA INH 1 QL=13 GM/30 Days budesonide 0.125mg/ml inh susp 1 PA BvD QL=120 ML/30 Days budesonide 0.25mg/ml inh susp 1 PA BvD QL=120 ML/30 Days budesonide 0.5mg/ml inh susp 1 PA BvD QL=120 ML/30 Days FLOVENT 100MCG/BLIST INH 1 QL=60 EA/30 Days FLOVENT 110MCG INH 1 QL=24 GM/30 Days FLOVENT 220MCG INH 1 QL=24 GM/30 Days FLOVENT 250MCG/BLIST INH 1 QL=60 EA/30 Days FLOVENT 44MCG INH 1 QL=21.20 GM/30 Days FLOVENT 50MCG/BLIST INH 1 QL=60 EA/30 Days SYMPATHOMIMETICS ADVAIR 0.045-0.021MG INH 1 QL=12 GM/30 Days ADVAIR 0.115-0.021MG INH 1 QL=12 GM/30 Days ADVAIR 0.23-0.021MG INH 1 QL=12 GM/30 Days albuterol 0.21mg/ml inh soln 1 PA BvD albuterol 0.417mg/ml inh soln 1 PA BvD albuterol 0.4mg/ml oral soln 1 albuterol 0.83mg/ml inh soln 1 PA BvD albuterol 2mg tab 1 albuterol 4mg tab 1 albuterol 5mg/ml inh soln 1 PA BvD ANORO 0.0625-0.025MG INH 1 QL=60 EA/30 Days BREO 0.1-0.025MG INH 1 QL=60 EA/30 Days BREO 0.2-0.025MG INH 1 QL=60 EA/30 Days BREZTRI AEROSPHERE 160-9-4.8MCG/ACT INH 1 QL=10.70 GM/30 Days COMBIVENT 0.1-0.02MG INH 1 DULERA 0.005-0.1MG INH 1 QL=13 GM/30 Days DULERA 0.005-0.2MG INH 1 QL=13 GM/30 Days DULERA INHALER 50-5MCG 1 QL=13 GM/30 Days propionate 0.1mg/salmeterol 0.05mg inh 1 QL=60 EA/30 Days 0.25mg/salmeterol 0.05mg inh 1 QL=60 EA/30 Days fluticasone propionate 0.5mg/salmeterol 0.05mg inh 1 QL=60 EA/30 Days FLUTICASONE PROPIONATE/SALMETEROL 1 QL=1 EA/30 Days XINAFOATE 113-14MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL 1 QL=1 EA/30 Days XINAFOATE 232-14MCG/ACT POWDER INH

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FLUTICASONE PROPIONATE/SALMETEROL 1 QL=1 EA/30 Days XINAFOATE 55-14MCG/ACT POWDER INH ipratropium/albuterol 0.5-2.5mg/3ml inh soln 1 PA BvD levalbuterol 0.103mg/ml inh soln 1 PA BvD levalbuterol 0.21mg/ml inh soln 1 PA BvD levalbuterol 0.417mg/ml inh soln 1 PA BvD levalbuterol 2.5mg/ml inh soln 1 PA BvD SEREVENT 50MCG/DOSE INH 1 STIOLTO 0.0025-0.0025MG INH 1 QL=4 GM/30 Days terbutaline sulfate 2.5mg tab 1 terbutaline sulfate 5mg tab 1 TRELEGY ELLIPTA 100- 62.5-25MCG INHALER 1 QL=60 EA/30 Days TRELEGY ELLIPTA 200-62.5-25 MCG/INH 1 QL=60 EA/30 Days VENTOLIN 108MCG INH 1 QL=36 GM/30 Days wixela 0.1-0.05mg inh 1 QL=60 EA/30 Days wixela 0.25-0.05mg inh 1 QL=60 EA/30 Days wixela 0.5-0.05mg inh 1 QL=60 EA/30 Days XANTHINES THEOPHYLLINE 300MG ER TAB 1 theophylline 400mg er tab 1 theophylline 5.33mg/ml oral soln 1 theophylline 600mg er tab 1 ANTICOAGULANTS COUMARIN ANTICOAGULANTS jantoven 10mg tab 1 jantoven 1mg tab 1 jantoven 2.5mg tab 1 jantoven 2mg tab 1 jantoven 3mg tab 1 jantoven 4mg tab 1 jantoven 5mg tab 1 jantoven 6mg tab 1 jantoven 7.5mg tab 1 warfarin sodium 10mg tab 1 warfarin sodium 1mg tab 1 warfarin sodium 2.5mg tab 1 warfarin sodium 2mg tab 1 warfarin sodium 3mg tab 1 warfarin sodium 4mg tab 1 warfarin sodium 5mg tab 1 warfarin sodium 6mg tab 1 warfarin sodium 7.5mg tab 1 DIRECT FACTOR XA INHIBITORS ELIQUIS 2.5MG TAB 1 ELIQUIS 30-DAY STARTER PACK 5MG 1 ELIQUIS 5MG TAB 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS XARELTO 10MG TAB 1 XARELTO 15MG TAB 1 XARELTO 2.5MG TAB 1 XARELTO 20MG TAB 1 XARELTO KIT PACK 1 HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium 100mg/ml (0.3ml) syringe 1 QL=18 ML/30 Days enoxaparin sodium 100mg/ml (0.4ml) syringe 1 QL=24 ML/30 Days enoxaparin sodium 100mg/ml (0.6ml) syringe 1 QL=36 ML/30 Days enoxaparin sodium 100mg/ml (0.8ml) syringe 1 QL=48 ML/30 Days enoxaparin sodium 100mg/ml (1ml) syringe 1 QL=60 ML/30 Days enoxaparin sodium 150mg/ml (0.8ml) syringe 1 QL=48 ML/30 Days enoxaparin sodium 150mg/ml (1ml) syringe 1 QL=60 ML/30 Days sodium 12.5mg/ml (0.4ml) syringe 1 fondaparinux sodium 12.5mg/ml (0.6ml) syringe 1 fondaparinux sodium 12.5mg/ml (0.8ml) syringe 1 fondaparinux sodium 5mg/ml syringe 1 FRAGMIN 10000UNIT/ML SYRINGE 1 FRAGMIN 12500UNIT/0.5ML SYRINGE 1 FRAGMIN 15000UNIT/0.6ML SYRINGE 1 FRAGMIN 18000UNT/0.72ML SYRINGE 1 FRAGMIN 2500UNIT/0.2ML SYRINGE 1 FRAGMIN 5000UNIT/0.2ML SYRINGE 1 FRAGMIN 7500UNIT/0.3ML SYRINGE 1 FRAGMIN 95000UNIT/3.8ML INJ 1 heparin sodium porcine 10000unit/ml inj 1 heparin sodium porcine 1000unit/ml inj 1 heparin sodium porcine 20000unit/ml inj 1 heparin sodium porcine 5000unit/ml inj 1 THROMBIN INHIBITORS PRADAXA 110MG CAP 1 PRADAXA 150MG CAP 1 PRADAXA 75MG CAP 1 ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS FYCOMPA 0.5MG/ML SUSP 1 PA NSO FYCOMPA 10MG TAB 1 PA NSO FYCOMPA 12MG TAB 1 PA NSO FYCOMPA 2MG TAB 1 PA NSO FYCOMPA 4MG TAB 1 PA NSO FYCOMPA 6MG TAB 1 PA NSO FYCOMPA 8MG TAB 1 PA NSO ANTICONVULSANTS - BENZODIAZEPINES clobazam 10mg tab 1 clobazam 2.5mg/ml susp 1 clobazam 20mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clonazepam 0.125mg odt 1 clonazepam 0.25mg odt 1 clonazepam 0.5mg odt 1 clonazepam 0.5mg tab 1 clonazepam 1mg odt 1 clonazepam 1mg tab 1 clonazepam 2mg odt 1 clonazepam 2mg tab 1 DIASTAT 10MG RECTAL GEL 1 DIASTAT 2.5MG RECTAL GEL 1 DIASTAT 20MG RECTAL GEL 1 DIAZEPAM 10MG/2ML RECTAL GEL 1 DIAZEPAM 2.5MG/0.5ML RECTAL GEL 1 DIAZEPAM 20MG/4ML RECTAL GEL 1 NAYZILAM 5MG/0.1ML NASAL SPRAY 1 SYMPAZAN 10MG ORAL FILM 1 ST_NSO SYMPAZAN 20MG ORAL FILM 1 ST_NSO SYMPAZAN 5MG ORAL FILM 1 ST_NSO VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK 1 VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK 1 VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK 1 VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK 1 ANTICONVULSANTS - MISC. APTIOM 200MG TAB 1 PA NSO APTIOM 400MG TAB 1 PA NSO APTIOM 600MG TAB 1 PA NSO APTIOM 800MG TAB 1 PA NSO BANZEL 40MG/ML SUSP 1 PA NSO BRIVIACT 100MG TAB 1 PA NSO QL=60 EA/30 Days BRIVIACT 10MG TAB 1 PA NSO QL=60 EA/30 Days BRIVIACT 10MG/ML ORAL SOLN 1 PA NSO BRIVIACT 25MG TAB 1 PA NSO QL=60 EA/30 Days BRIVIACT 50MG TAB 1 PA NSO QL=60 EA/30 Days BRIVIACT 75MG TAB 1 PA NSO QL=60 EA/30 Days carbamazepine 100mg chew tab 1 carbamazepine 100mg er cap 1 carbamazepine 100mg er tab 1 carbamazepine 200mg er cap 1 carbamazepine 200mg er tab 1 carbamazepine 200mg tab 1 carbamazepine 20mg/ml susp 1 carbamazepine 300mg er cap 1 carbamazepine 400mg er tab 1 DIACOMIT 250MG CAP 1 NDS PA NSO DIACOMIT 250MG POWDER FOR ORAL SUSP 1 NDS PA NSO DIACOMIT 500MG CAP 1 NDS PA NSO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS DIACOMIT 500MG POWDER FOR ORAL SUSP 1 NDS PA NSO EPIDIOLEX 100MG/ML ORAL SOLN 1 PA NSO epitol 200mg tab 1 FINTEPLA 2.2MG/ML ORAL SOLN 1 NDS PA NSO QL=360 ML/30 Days gabapentin 100mg cap 1 gabapentin 300mg cap 1 gabapentin 400mg cap 1 gabapentin 50mg/ml oral soln 1 gabapentin 600mg tab 1 gabapentin 800mg tab 1 LAMICTAL XR BLUE KIT 1 LAMICTAL XR GREEN KIT 1 LAMICTAL XR ORANGE KIT 1 100mg er tab 1 lamotrigine 100mg odt 1 lamotrigine 100mg tab 1 lamotrigine 150mg tab 1 lamotrigine 200mg er tab 1 lamotrigine 200mg odt 1 lamotrigine 200mg tab 1 lamotrigine 250mg er tab 1 lamotrigine 25mg chew tab 1 lamotrigine 25mg er tab 1 lamotrigine 25mg odt 1 lamotrigine 25mg pack 1 lamotrigine 25mg tab 1 lamotrigine 300mg er tab 1 lamotrigine 50mg er tab 1 lamotrigine 50mg odt 1 lamotrigine 5mg chew tab 1 lamotrigine ODT kit 1 lamotrigine tab 25mg (42)/100mg (7) starter pack 1 lamotrigine tab 25mg (84)/100mg (14) starter pack 1 levetiracetam 1000mg tab 1 levetiracetam 100mg/ml oral soln 1 levetiracetam 250mg tab 1 levetiracetam 500mg er tab 1 levetiracetam 500mg tab 1 levetiracetam 750mg er tab 1 levetiracetam 750mg tab 1 oxcarbazepine 150mg tab 1 oxcarbazepine 300mg tab 1 oxcarbazepine 600mg tab 1 oxcarbazepine 60mg/ml susp 1 OXTELLAR 150MG ER TAB 1 OXTELLAR 300MG ER TAB 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS OXTELLAR 600MG ER TAB 1 pregabalin 100mg cap 1 pregabalin 150mg cap 1 pregabalin 200mg cap 1 pregabalin 20mg/ml oral soln 1 pregabalin 225mg cap 1 pregabalin 25mg cap 1 pregabalin 300mg cap 1 pregabalin 50mg cap 1 pregabalin 75mg cap 1 primidone 250mg tab 1 primidone 50mg tab 1 QUDEXY 100MG ER CAP 1 PA NSO QUDEXY 150MG ER CAP 1 PA NSO QUDEXY 200MG ER CAP 1 PA NSO QUDEXY 25MG ER CAP 1 PA NSO QUDEXY 50MG ER CAP 1 PA NSO roweepra 500mg tab 1 rufinamide 200mg tab 1 PA NSO rufinamide 400mg tab 1 PA NSO rufinamide 40mg/ml susp 1 PA NSO SPRITAM 1000MG TAB FOR ORAL SUSP 1 PA NSO SPRITAM 250MG TAB FOR ORAL SUSP 1 PA NSO SPRITAM 500MG TAB FOR ORAL SUSP 1 PA NSO SPRITAM 750MG TAB FOR ORAL SUSP 1 PA NSO TOPIRAMATE 100MG ER CAP 1 PA NSO topiramate 100mg tab 1 TOPIRAMATE 150MG ER CAP 1 PA NSO topiramate 15mg cap 1 TOPIRAMATE 200MG ER CAP 1 PA NSO topiramate 200mg tab 1 topiramate 25mg cap 1 TOPIRAMATE 25MG ER CAP 1 PA NSO topiramate 25mg tab 1 TOPIRAMATE 50MG ER CAP 1 PA NSO topiramate 50mg tab 1 TROKENDI 100MG ER CAP 1 PA NSO TROKENDI 200MG ER CAP 1 PA NSO TROKENDI 25MG ER CAP 1 PA NSO TROKENDI 50MG ER CAP 1 PA NSO VIMPAT 100MG TAB 1 QL=60 EA/30 Days VIMPAT 10MG/ML ORAL SOLN 1 VIMPAT 150MG TAB 1 QL=60 EA/30 Days VIMPAT 200MG TAB 1 QL=60 EA/30 Days VIMPAT 50MG TAB 1 QL=60 EA/30 Days zonisamide 100mg cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS zonisamide 25mg cap 1 zonisamide 50mg cap 1 CARBAMATES felbamate 120mg/ml susp 1 felbamate 400mg tab 1 felbamate 600mg tab 1 XCOPRI 100MG TAB 1 XCOPRI 12.5/25MG TITRATION PACK 1 XCOPRI 150/200MG TITRATION PACK 1 XCOPRI 150MG TAB 1 XCOPRI 200MG TAB 1 XCOPRI 50/100MG TITRATION PACK 1 XCOPRI 50MG TAB 1 XCOPRI TAB 100/150MG MAINTENANCE PACK 1 XCOPRI TAB 150/200MG PACK 1 XCOPRI TAB 50/200MG PACK 1 GABA MODULATORS tiagabine 12mg tab 1 tiagabine 16mg tab 1 tiagabine 2mg tab 1 tiagabine 4mg tab 1 vigabatrin 500mg powder for oral soln 1 NDS PA NSO vigabatrin 500mg tab 1 NDS PA NSO vigadrone 500mg powder for oral soln 1 NDS PA NSO HYDANTOINS DILANTIN 30MG ER CAP 1 phenytoin 25mg/ml susp 1 phenytoin 50mg chew tab 1 phenytoin sodium 100mg er cap 1 phenytoin sodium 200mg er cap 1 phenytoin sodium 300mg er cap 1 SUCCINIMIDES CELONTIN 300MG CAP 1 ethosuximide 250mg cap 1 ethosuximide 50mg/ml oral soln 1 VALPROIC ACID divalproex sodium 125mg dr cap 1 divalproex sodium 125mg dr tab 1 divalproex sodium 250mg dr tab 1 divalproex sodium 250mg er tab 1 divalproex sodium 500mg dr tab 1 divalproex sodium 500mg er tab 1 valproic acid 250mg cap 1 valproic acid 50mg/ml oral soln 1 ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS mirtazapine 15mg odt 1 mirtazapine 15mg tab 1 mirtazapine 30mg odt 1 mirtazapine 30mg tab 1 mirtazapine 45mg odt 1 mirtazapine 45mg tab 1 mirtazapine 7.5mg tab 1 ANTIDEPRESSANTS - MISC. APLENZIN 174MG ER TAB 1 ST_NSO APLENZIN 348MG ER TAB 1 ST_NSO APLENZIN 522MG ER TAB 1 ST_NSO 100mg er tab 1 bupropion 100mg tab 1 bupropion 150mg sr (12 hr) tab 1 bupropion 150mg xl (24 hr) tab 1 bupropion 200mg er tab 1 bupropion 300mg er tab 1 bupropion 75mg tab 1 MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM 12MG/24HR PATCH 1 EMSAM 6MG/24HR PATCH 1 EMSAM 9MG/24HR PATCH 1 MARPLAN 10MG TAB 1 phenelzine 15mg tab 1 10mg tab 1 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram 10mg tab 1 citalopram 20mg tab 1 citalopram 2mg/ml oral soln 1 citalopram 40mg tab 1 escitalopram 10mg tab 1 escitalopram 1mg/ml oral soln 1 escitalopram 20mg tab 1 escitalopram 5mg tab 1 fluoxetine 10mg cap 1 fluoxetine 10mg tab 1 fluoxetine 20mg cap 1 fluoxetine 20mg tab 1 fluoxetine 40mg cap 1 fluoxetine 4mg/ml oral soln 1 fluvoxamine maleate 100mg er cap 1 ST_NSO fluvoxamine maleate 100mg tab 1 fluvoxamine maleate 150mg er cap 1 ST_NSO fluvoxamine maleate 25mg tab 1 fluvoxamine maleate 50mg tab 1 10mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS paroxetine 12.5mg er tab 1 paroxetine 20mg tab 1 paroxetine 25mg er tab 1 paroxetine 30mg tab 1 paroxetine 37.5mg er tab 1 paroxetine 40mg tab 1 PAXIL 10MG/5ML SUSP 1 PEXEVA 10MG TAB 1 PEXEVA 20MG TAB 1 PEXEVA 30MG TAB 1 PEXEVA 40MG TAB 1 sertraline 100mg tab 1 sertraline 20mg/ml oral soln 1 sertraline 25mg tab 1 sertraline 50mg tab 1 SEROTONIN MODULATORS NEFAZODONE 100MG TAB 1 NEFAZODONE 150MG TAB 1 NEFAZODONE 200MG TAB 1 NEFAZODONE 250MG TAB 1 NEFAZODONE 50MG TAB 1 trazodone 100mg tab 1 trazodone 150mg tab 1 trazodone 300mg tab 1 trazodone 50mg tab 1 TRINTELLIX 10MG TAB 1 ST_NSO QL=30 EA/30 Days TRINTELLIX 20MG TAB 1 ST_NSO QL=30 EA/30 Days TRINTELLIX 5MG TAB 1 ST_NSO QL=30 EA/30 Days VIIBRYD 10/20MG STARTER PACK 1 ST_NSO QL=30 EA/30 Days VIIBRYD 10MG TAB 1 ST_NSO QL=30 EA/30 Days VIIBRYD 20MG TAB 1 ST_NSO QL=30 EA/30 Days VIIBRYD 40MG TAB 1 ST_NSO QL=30 EA/30 Days SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine succinate 100mg er tab 1 desvenlafaxine succinate 25mg er tab 1 desvenlafaxine succinate 50mg er tab 1 DRIZALMA 20MG DR CAP 1 ST_NSO DRIZALMA 30MG DR CAP 1 ST_NSO DRIZALMA 40MG DR CAP 1 ST_NSO DRIZALMA 60MG DR CAP 1 ST_NSO duloxetine 20mg dr cap 1 duloxetine 30mg dr cap 1 duloxetine 40mg dr cap 1 ST_NSO QL=30 EA/30 Days duloxetine 60mg dr cap 1 FETZIMA 120MG ER CAP 1 ST_NSO QL=30 EA/30 Days FETZIMA 20MG ER CAP 1 ST_NSO QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FETZIMA 40MG ER CAP 1 ST_NSO QL=30 EA/30 Days FETZIMA 80MG ER CAP 1 ST_NSO QL=30 EA/30 Days FETZIMA PACK 1 ST_NSO QL=30 EA/30 Days venlafaxine 100mg tab 1 venlafaxine 150mg er cap 1 venlafaxine 25mg tab 1 venlafaxine 37.5mg er cap 1 venlafaxine 37.5mg tab 1 venlafaxine 50mg tab 1 venlafaxine 75mg er cap 1 venlafaxine 75mg tab 1 TRICYCLIC AGENTS amitriptyline 100mg tab 1 amitriptyline 10mg tab 1 amitriptyline 150mg tab 1 amitriptyline 25mg tab 1 amitriptyline 50mg tab 1 amitriptyline 75mg tab 1 AMOXAPINE 100MG TAB 1 AMOXAPINE 150MG TAB 1 AMOXAPINE 25MG TAB 1 AMOXAPINE 50MG TAB 1 clomipramine 25mg cap 1 clomipramine 50mg cap 1 clomipramine 75mg cap 1 desipramine 100mg tab 1 desipramine 10mg tab 1 desipramine 150mg tab 1 desipramine 25mg tab 1 desipramine 50mg tab 1 desipramine 75mg tab 1 doxepin 100mg cap 1 doxepin 10mg cap 1 doxepin 10mg/ml oral soln 1 doxepin 150mg cap 1 doxepin 25mg cap 1 doxepin 50mg cap 1 doxepin 75mg cap 1 imipramine 10mg tab 1 imipramine 25mg tab 1 imipramine 50mg tab 1 imipramine pamoate 100mg cap 1 imipramine pamoate 125mg cap 1 imipramine pamoate 150mg cap 1 imipramine pamoate 75mg cap 1 nortriptyline 10mg cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nortriptyline 25mg cap 1 NORTRIPTYLINE 2MG/ML ORAL SOLN 1 nortriptyline 50mg cap 1 nortriptyline 75mg cap 1 protriptyline 10mg tab 1 protriptyline 5mg tab 1 trimipramine 100mg cap 1 trimipramine 25mg cap 1 trimipramine 50mg cap 1 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose 100mg tab 1 acarbose 25mg tab 1 acarbose 50mg tab 1 miglitol 100mg tab 1 miglitol 25mg tab 1 miglitol 50mg tab 1 ANTIDIABETIC COMBINATIONS glipizide 2.5mg/metformin 250mg tab 1 glipizide 2.5mg/metformin 500mg tab 1 glipizide 5mg/metformin 500mg tab 1 glyburide 1.25mg/metformin 250mg tab 1 glyburide 2.5mg/metformin 500mg tab 1 glyburide 5mg/metformin 500mg tab 1 GLYXAMBI 10-5MG TAB 1 QL=30 EA/30 Days GLYXAMBI 25-5MG TAB 1 QL=30 EA/30 Days JANUMET 1000-100MG ER TAB 1 QL=30 EA/30 Days JANUMET 1000-50MG ER TAB 1 QL=60 EA/30 Days JANUMET 1000-50MG TAB 1 QL=60 EA/30 Days JANUMET 500-50MG ER TAB 1 QL=60 EA/30 Days JANUMET 500-50MG TAB 1 QL=60 EA/30 Days JENTADUETO 2.5-1000MG ER TAB 1 QL=30 EA/30 Days JENTADUETO 2.5-1000MG TAB 1 QL=60 EA/30 Days JENTADUETO 2.5-500MG TAB 1 QL=60 EA/30 Days JENTADUETO 2.5-850MG TAB 1 QL=60 EA/30 Days JENTADUETO 5-1000MG ER TAB 1 QL=30 EA/30 Days SOLIQUA 100UNIT-0.033MG/ML PEN INJ 1 PA QL=15 ML/25 Days SYNJARDY 10-1000MG ER TAB 1 QL=30 EA/30 Days SYNJARDY 12.5-1000MG ER TAB 1 QL=60 EA/30 Days SYNJARDY 12.5-1000MG TAB 1 QL=60 EA/30 Days SYNJARDY 12.5-500MG TAB 1 QL=60 EA/30 Days SYNJARDY 25-1000MG ER TAB 1 QL=30 EA/30 Days SYNJARDY 5-1000MG ER TAB 1 QL=60 EA/30 Days SYNJARDY 5-1000MG TAB 1 QL=60 EA/30 Days SYNJARDY 5-500MG TAB 1 QL=60 EA/30 Days TRIJARDY 10-5-1000MG ER TAB 1 QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS TRIJARDY 12.5-2.5-1000MG ER TAB 1 QL=60 EA/30 Days TRIJARDY 25-5-1000MG ER TAB 1 QL=30 EA/30 Days TRIJARDY 5-2.5-1000MG ER TAB 1 QL=60 EA/30 Days XIGDUO 10-1000MG ER TAB 1 QL=30 EA/30 Days XIGDUO 10-500MG ER TAB 1 QL=30 EA/30 Days XIGDUO 2.5-1000MG ER TAB 1 QL=60 EA/30 Days XIGDUO 5-1000MG ER TAB 1 QL=60 EA/30 Days XIGDUO 5-500MG ER TAB 1 QL=30 EA/30 Days XULTOPHY 100UNIT-3.6MG/ML PEN INJ 1 PA QL=15 ML/30 Days BIGUANIDES metformin 1000mg tab 1 metformin 500mg er tab 1 metformin 500mg tab 1 metformin 750mg er tab 1 metformin 850mg tab 1 DIABETIC OTHER BAQSIMI 3MG/DOSE NASAL POWDER 1 QL=2 EA/7 Days diazoxide 50mg/ml susp 1 GLUCAGEN 1MG INJ 1 QL=2 EA/7 Days GLUCAGON (RDNA) 1MG INJ 1 QL=2 EA/7 Days GVOKE 0.5MG/0.1ML AUTO-INJECTOR 1 QL=.20 ML/7 Days GVOKE 0.5MG/0.1ML SYRINGE 1 QL=.20 ML/7 Days GVOKE 1MG/0.2ML AUTO-INJECTOR 1 QL=.40 ML/7 Days GVOKE 1MG/0.2ML SYRINGE 1 QL=.40 ML/7 Days KORLYM 300MG TAB 1 NDS PA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 100MG TAB 1 QL=30 EA/30 Days JANUVIA 25MG TAB 1 QL=30 EA/30 Days JANUVIA 50MG TAB 1 QL=30 EA/30 Days TRADJENTA 5MG TAB 1 QL=30 EA/30 Days INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYDUREON 2MG/0.85ML AUTO-INJECTOR 1 QL=3.40 ML/28 Days OZEMPIC 2MG/1.5ML PEN INJ 1 QL=1.50 ML/28 Days OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) 1 QL=3 ML/28 Days OZEMPIC 4MG/3ML PEN INJ 1 QL=3 ML/28 Days RYBELSUS 14MG TAB 1 QL=30 EA/30 Days RYBELSUS 3MG TAB 1 QL=30 EA/30 Days RYBELSUS 7MG TAB 1 QL=30 EA/30 Days TRULICITY 0.75MG/0.5ML AUTO-INJECTOR 1 QL=2 ML/28 Days TRULICITY 1.5MG/0.5ML AUTO-INJECTOR 1 QL=2 ML/28 Days TRULICITY 3MG/0.5ML AUTO-INJECTOR 1 QL=2 ML/28 Days TRULICITY 4.5MG/0.5ML AUTO-INJECTOR 1 QL=2 ML/28 Days VICTOZA 18MG/3ML PEN INJ 1 QL=9 ML/30 Days INSULIN FIASP 100UNIT/ML CARTRIDGE 1 FIASP 100UNIT/ML INJ 1 PA BvD You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FIASP 100UNIT/ML PEN INJ 1 HUMULIN R 500UNIT/ML INJ 1 PA BvD HUMULIN R 500UNIT/ML PEN INJ 1 LANTUS 100UNIT/ML INJ 1 LANTUS 100UNIT/ML PEN INJ 1 LEVEMIR 100UNIT/ML INJ 1 LEVEMIR 100UNIT/ML PEN INJ 1 NOVOLIN MIX (70/30) 100UNIT/ML INJ 1 NOVOLIN MIX (70/30) FLEXPEN 100UNIT/ML 1 NOVOLIN N 100UNIT/ML INJ 1 NOVOLIN N 100UNIT/ML PEN INJ 1 NOVOLIN R 100UNIT/ML INJ 1 NOVOLIN R 100UNIT/ML PEN INJ 1 NOVOLOG 100UNIT/ML CARTRIDGE 1 NOVOLOG 100UNIT/ML INJ 1 PA BvD NOVOLOG 100UNIT/ML PEN INJ 1 NOVOLOG MIX (70/30) 100UNIT/ML FLEXPEN 1 NOVOLOG MIX (70/30) 100UNIT/ML INJ 1 TOUJEO 300UNIT/ML PEN INJ 1 TOUJEO MAX 300UNIT/ML PEN INJ (3ML) 1 TRESIBA 100UNIT/ML INJ 1 TRESIBA 100UNIT/ML PEN INJ 1 TRESIBA 200UNIT/ML PEN INJ 1 INSULIN SENSITIZING AGENTS pioglitazone 15mg tab 1 pioglitazone 30mg tab 1 pioglitazone 45mg tab 1 MEGLITINIDE ANALOGUES nateglinide 120mg tab 1 nateglinide 60mg tab 1 repaglinide 0.5mg tab 1 repaglinide 1mg tab 1 repaglinide 2mg tab 1 SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 10MG TAB 1 QL=30 EA/30 Days FARXIGA 5MG TAB 1 QL=30 EA/30 Days JARDIANCE 10MG TAB 1 QL=30 EA/30 Days JARDIANCE 25MG TAB 1 QL=30 EA/30 Days SULFONYLUREAS glimepiride 1mg tab 1 glimepiride 2mg tab 1 glimepiride 4mg tab 1 glipizide 10mg er tab 1 glipizide 10mg tab 1 glipizide 2.5mg er tab 1 glipizide 5mg er tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS glipizide 5mg tab 1 glyburide 1.25mg tab 1 glyburide 1.5mg tab 1 glyburide 2.5mg tab 1 glyburide 3mg tab 1 glyburide 5mg tab 1 glyburide 6mg tab 1 ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIPERISTALTIC AGENTS atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml 1 oral soln atropine sulfate 0.025mg/diphenoxylate 2.5mg tab 1 loperamide 2mg cap 1 ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS CHEMET 100MG CAP 1 deferasirox 125mg tab for oral susp 1 deferasirox 180mg granules 1 NDS deferasirox 180mg tab 1 deferasirox 250mg tab for oral susp 1 deferasirox 360mg granules 1 NDS deferasirox 360mg tab 1 deferasirox 500mg tab for oral susp 1 deferasirox 90mg granules 1 NDS deferasirox 90mg tab 1 deferiprone 500mg tab 1 NDS PA FERRIPROX 1000MG TAB 1 NDS PA FERRIPROX 100MG/ML ORAL SOLN 1 NDS PA FERRIPROX 500MG TAB 1 NDS PA OPIOID ANTAGONISTS NALOXONE 0.4MG/ML CARTRIDGE 1 QL=2 ML/2 Days naloxone 0.4mg/ml inj 1 QL=2 ML/2 Days naloxone 1mg/ml syringe 1 naltrexone 50mg tab 1 NARCAN 4MG/0.1ML NASAL SPRAY 1 VIVITROL 380MG INJ 1 NDS ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron 1mg tab 1 PA BvD QL=60 EA/30 Days 0.8mg/ml oral soln 1 PA BvD ONDANSETRON 24MG TAB 1 PA BvD ondansetron 4mg odt 1 PA BvD ondansetron 4mg tab 1 PA BvD ondansetron 8mg odt 1 PA BvD ondansetron 8mg tab 1 PA BvD ANTIEMETICS - ANTICHOLINERGIC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS meclizine 12.5mg tab 1 meclizine 25mg tab 1 scopolamine 0.0139mg/hr patch 1 trimethobenzamide 300mg cap 1 ANTIEMETICS - MISCELLANEOUS doxylamine succinate 10mg/pyridoxine 10mg dr tab 1 QL=120 EA/30 Days dronabinol 10mg cap 1 PA dronabinol 2.5mg cap 1 PA dronabinol 5mg cap 1 PA SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant 125mg cap 1 PA BvD QL=3 EA/2 Days aprepitant 125mg/aprepitant 80mg pack 1 PA BvD QL=6 EA/4 Days aprepitant 40mg cap 1 PA BvD QL=3 EA/2 Days aprepitant 80mg cap 1 PA BvD QL=6 EA/4 Days VARUBI 90MG TAB 1 PA BvD QL=4 EA/28 Days ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) caspofungin acetate 50mg inj 1 NDS caspofungin acetate 70mg inj 1 NDS ERAXIS 100MG INJ 1 ERAXIS 50MG INJ 1 micafungin sodium 100mg inj 1 micafungin sodium 50mg inj 1 ANTIFUNGALS ABELCET 5MG/ML INJ 1 PA BvD AMBISOME 50MG INJ 1 PA BvD AMPHOTERICIN B 50MG INJ 1 PA BvD flucytosine 250mg cap 1 flucytosine 500mg cap 1 griseofulvin 125mg tab 1 griseofulvin 250mg tab 1 griseofulvin 25mg/ml susp 1 griseofulvin 500mg tab 1 nystatin 500000unit tab 1 terbinafine 250mg tab 1 IMIDAZOLE-RELATED ANTIFUNGALS fluconazole 100mg tab 1 fluconazole 10mg/ml susp 1 fluconazole 150mg tab 1 fluconazole 200mg tab 1 fluconazole 2mg/ml (100ml) inj 1 fluconazole 2mg/ml (200ml) inj 1 fluconazole 40mg/ml susp 1 fluconazole 50mg tab 1 itraconazole 100mg cap 1 PA ketoconazole 200mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS NOXAFIL 40MG/ML SUSP 1 PA posaconazole 100mg dr tab 1 PA voriconazole 200mg inj 1 PA voriconazole 200mg tab 1 NDS PA voriconazole 40mg/ml susp 1 PA voriconazole 50mg tab 1 NDS PA ANTIHISTAMINES ANTIHISTAMINES - NON-SEDATING cetirizine 1mg/ml oral soln 1 desloratadine 5mg tab 1 levocetirizine 0.5mg/ml oral soln 1 levocetirizine 5mg tab 1 ANTIHISTAMINES - PHENOTHIAZINES promethazine 1.25mg/ml oral soln 1 promethazine 12.5mg rectal supp 1 promethazine 12.5mg tab 1 promethazine 25mg rectal supp 1 promethazine 25mg tab 1 promethazine 50mg tab 1 promethegan 25mg rectal supp 1 PROMETHEGAN 50MG RECTAL SUPP 1 ANTIHISTAMINES - PIPERIDINES cyproheptadine 0.4mg/ml oral soln 1 cyproheptadine 4mg tab 1 ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. omega-3 acid ethyl esters (usp) 1000mg cap 1 VASCEPA 0.5GM CAP 1 QL=120 EA/30 Days VASCEPA 1GM CAP 1 QL=120 EA/30 Days BILE ACID SEQUESTRANTS cholestyramine resin 4gm sf powder for oral susp 1 cholestyramine resin 4gm sf powder for oral susp 1 (sugar free) colesevelam 3750mg powder for oral susp 1 colesevelam 625mg tab 1 colestipol 1000mg tab 1 colestipol 5000mg granules for oral susp 1 prevalite 4gm powder for oral susp 1 FIBRIC ACID DERIVATIVES fenofibrate 134mg cap 1 fenofibrate 145mg tab 1 FENOFIBRATE 150MG CAP 1 fenofibrate 160mg tab 1 fenofibrate 200mg cap 1 fenofibrate 48mg tab 1 FENOFIBRATE 50MG CAP 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS fenofibrate 54mg tab 1 fenofibrate 67mg cap 1 fenofibric acid 135mg dr cap 1 fenofibric acid 45mg dr cap 1 gemfibrozil 600mg tab 1 HMG COA REDUCTASE INHIBITORS atorvastatin 10mg tab 1 atorvastatin 20mg tab 1 atorvastatin 40mg tab 1 atorvastatin 80mg tab 1 fluvastatin 20mg cap 1 fluvastatin 40mg cap 1 fluvastatin 80mg er tab 1 lovastatin 10mg tab 1 lovastatin 20mg tab 1 lovastatin 40mg tab 1 pravastatin sodium 10mg tab 1 pravastatin sodium 20mg tab 1 pravastatin sodium 40mg tab 1 pravastatin sodium 80mg tab 1 rosuvastatin 10mg tab 1 rosuvastatin calcium 20mg tab 1 rosuvastatin calcium 40mg tab 1 rosuvastatin calcium 5mg tab 1 simvastatin 10mg tab 1 simvastatin 20mg tab 1 simvastatin 40mg tab 1 simvastatin 5mg tab 1 simvastatin 80mg tab 1 INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 10mg tab 1 QL=30 EA/30 Days MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID 10MG CAP 1 NDS PA JUXTAPID 20MG CAP 1 NDS PA JUXTAPID 30MG CAP 1 NDS PA JUXTAPID 5MG CAP 1 NDS PA NICOTINIC ACID DERIVATIVES niacin 1000mg er tab 1 niacin 500mg er tab 1 niacin 750mg er tab 1 PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT 150MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 Days PRALUENT 75MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 Days REPATHA 140MG/ML AUTO-INJECTOR 1 PA QL=2 ML/28 Days REPATHA 140MG/ML SYRINGE 1 PA QL=2 ML/28 Days REPATHA 420MG/3.5ML CARTRIDGE 1 PA QL=3.50 ML/28 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANTIHYPERTENSIVES ACE INHIBITORS benazepril 10mg tab 1 benazepril 20mg tab 1 benazepril 40mg tab 1 benazepril 5mg tab 1 captopril 100mg tab 1 captopril 12.5mg tab 1 captopril 25mg tab 1 captopril 50mg tab 1 enalapril maleate 10mg tab 1 enalapril maleate 2.5mg tab 1 enalapril maleate 20mg tab 1 enalapril maleate 5mg tab 1 fosinopril sodium 10mg tab 1 fosinopril sodium 20mg tab 1 fosinopril sodium 40mg tab 1 lisinopril 10mg tab 1 lisinopril 2.5mg tab 1 lisinopril 20mg tab 1 lisinopril 30mg tab 1 lisinopril 40mg tab 1 lisinopril 5mg tab 1 moexipril 15mg tab 1 moexipril 7.5mg tab 1 perindopril erbumine 2mg tab 1 perindopril erbumine 4mg tab 1 perindopril erbumine 8mg tab 1 QBRELIS 1MG/ML ORAL SOLN 1 PA quinapril 10mg tab 1 quinapril 20mg tab 1 quinapril 40mg tab 1 quinapril 5mg tab 1 ramipril 1.25mg cap 1 ramipril 10mg cap 1 ramipril 2.5mg cap 1 ramipril 5mg cap 1 trandolapril 1mg tab 1 trandolapril 2mg tab 1 trandolapril 4mg tab 1 AGENTS FOR PHEOCHROMOCYTOMA DEMSER 250MG CAP 1 NDS metyrosine 250mg cap 1 NDS phenoxybenzamine 10mg cap 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 16mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS candesartan cilexetil 32mg tab 1 candesartan cilexetil 4mg tab 1 candesartan cilexetil 8mg tab 1 irbesartan 150mg tab 1 irbesartan 300mg tab 1 irbesartan 75mg tab 1 losartan potassium 100mg tab 1 losartan potassium 25mg tab 1 losartan potassium 50mg tab 1 olmesartan medoxomil 20mg tab 1 olmesartan medoxomil 40mg tab 1 olmesartan medoxomil 5mg tab 1 telmisartan 20mg tab 1 telmisartan 40mg tab 1 telmisartan 80mg tab 1 valsartan 160mg tab 1 valsartan 320mg tab 1 valsartan 40mg tab 1 valsartan 80mg tab 1 ANTIADRENERGIC ANTIHYPERTENSIVES clonidine 0.00417mg/hr weekly patch 1 clonidine 0.00833mg/hr weekly patch 1 clonidine 0.0125mg/hr weekly patch 1 clonidine 0.1mg tab 1 clonidine 0.2mg tab 1 clonidine 0.3mg tab 1 doxazosin 1mg tab 1 doxazosin 2mg tab 1 doxazosin 4mg tab 1 doxazosin 8mg tab 1 guanfacine 1mg tab 1 guanfacine 2mg tab 1 methyldopa 250mg tab 1 methyldopa 500mg tab 1 prazosin 1mg cap 1 prazosin 2mg cap 1 prazosin 5mg cap 1 terazosin 10mg cap 1 terazosin 1mg cap 1 terazosin 2mg cap 1 terazosin 5mg cap 1 ANTIHYPERTENSIVE COMBINATIONS amlodipine 10mg/benazepril 20mg cap 1 amlodipine 10mg/benazepril 40mg cap 1 amlodipine 10mg/hydrochlorothiazide 1 12.5mg/valsartan 160mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS amlodipine 10mg/hydrochlorothiazide 1 25mg/valsartan 160mg tab amlodipine 10mg/hydrochlorothiazide 1 25mg/valsartan 320mg tab amlodipine 10mg/olmesartan medoxomil 20mg tab 1 amlodipine 10mg/olmesartan medoxomil 40mg tab 1 amlodipine 10mg/valsartan 160mg tab 1 amlodipine 10mg/valsartan 320mg tab 1 amlodipine 2.5mg/benazepril 10mg cap 1 amlodipine 5mg/benazepril 10mg cap 1 amlodipine 5mg/benazepril 20mg cap 1 amlodipine 5mg/benazepril 40mg cap 1 amlodipine 5mg/hydrochlorothiazide 1 12.5mg/valsartan 160mg tab amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 1 160mg tab amlodipine 5mg/olmesartan medoxomil 20mg tab 1 amlodipine 5mg/olmesartan medoxomil 40mg tab 1 amlodipine 5mg/valsartan 160mg tab 1 amlodipine 5mg/valsartan 320mg tab 1 atenolol 100mg/chlorthalidone 25mg tab 1 atenolol 50mg/chlorthalidone 25mg tab 1 benazepril 10mg/hydrochlorothiazide 12.5mg tab 1 benazepril 20mg/hydrochlorothiazide 12.5mg tab 1 benazepril 20mg/hydrochlorothiazide 25mg tab 1 benazepril 5mg/hydrochlorothiazide 6.25mg tab 1 bisoprolol fumarate 10mg/hydrochlorothiazide 1 6.25mg tab bisoprolol fumarate 2.5mg/hydrochlorothiazide 1 6.25mg tab bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg 1 tab enalapril maleate 10mg/hydrochlorothiazide 25mg 1 tab enalapril maleate 5mg/hydrochlorothiazide 12.5mg 1 tab fosinopril sodium 10mg/hydrochlorothiazide 12.5mg 1 tab fosinopril sodium 20mg/hydrochlorothiazide 12.5mg 1 tab hydrochlorothiazide 12.5mg/irbesartan 150mg tab 1 hydrochlorothiazide 12.5mg/irbesartan 300mg tab 1 hydrochlorothiazide 12.5mg/lisinopril 10mg tab 1 hydrochlorothiazide 12.5mg/lisinopril 20mg tab 1 hydrochlorothiazide 12.5mg/losartan potassium 1 100mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS hydrochlorothiazide 12.5mg/losartan potassium 50mg 1 tab hydrochlorothiazide 12.5mg/olmesartan medoxomil 1 20mg tab hydrochlorothiazide 12.5mg/olmesartan medoxomil 1 40mg tab hydrochlorothiazide 12.5mg/quinapril 10mg tab 1 hydrochlorothiazide 12.5mg/quinapril 20mg tab 1 hydrochlorothiazide 12.5mg/valsartan 160mg tab 1 hydrochlorothiazide 12.5mg/valsartan 320mg tab 1 hydrochlorothiazide 12.5mg/valsartan 80mg tab 1 hydrochlorothiazide 25mg/lisinopril 20mg tab 1 hydrochlorothiazide 25mg/losartan potassium 100mg 1 tab hydrochlorothiazide 25mg/metoprolol tartrate 100mg 1 tab hydrochlorothiazide 25mg/metoprolol tartrate 50mg 1 tab hydrochlorothiazide 25mg/olmesartan medoxomil 1 40mg tab hydrochlorothiazide 25mg/quinapril 20mg tab 1 hydrochlorothiazide 25mg/valsartan 160mg tab 1 hydrochlorothiazide 25mg/valsartan 320mg tab 1 hydrochlorothiazide 50mg/metoprolol tartrate 100mg 1 tab TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB 1 trandolapril 2mg/verapamil 180mg er tab 1 trandolapril 2mg/verapamil 240mg er tab 1 trandolapril 4mg/verapamil 240mg er tab 1 DIRECT RENIN INHIBITORS aliskiren 150mg tab 1 aliskiren 300mg tab 1 SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone 25mg tab 1 eplerenone 50mg tab 1 VASODILATORS hydralazine 100mg tab 1 hydralazine 10mg tab 1 hydralazine 25mg tab 1 hydralazine 50mg tab 1 minoxidil 10mg tab 1 minoxidil 2.5mg tab 1 ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. IMPAVIDO 50MG CAP 1 NDS PA QL=84 EA/28 Days metronidazole 250mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS metronidazole 375mg cap 1 metronidazole 500mg tab 1 metronidazole 5mg/ml inj 1 pentamidine isethionate 300mg inj 1 pentamidine isethionate 50mg/ml inh soln 1 PA BvD tinidazole 250mg tab 1 tinidazole 500mg tab 1 trimethoprim 100mg tab 1 XIFAXAN 200MG TAB 1 QL=9 EA/3 Days XIFAXAN 550MG TAB 1 PA QL=60 EA/30 Days ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole 400mg/trimethoprim 80mg tab 1 sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp 1 sulfamethoxazole 800mg/trimethoprim 160mg tab 1 ANTIPROTOZOAL AGENTS ALINIA 100MG/5ML SUSP 1 PA QL=150 ML/3 Days ALINIA 500MG TAB 1 PA QL=6 EA/3 Days atovaquone 150mg/ml susp 1 LAMPIT 120MG TAB 1 PA LAMPIT 30MG TAB 1 PA nitazoxanide 500mg tab 1 PA QL=6 EA/3 Days CARBAPENEMS CILASTATIN 250MG/IMIPENEM 250MG INJ 1 cilastatin 500mg/imipenem 500mg inj 1 ertapenem 1000mg inj 1 meropenem 1000mg inj 1 meropenem 500mg inj 1 CYCLIC LIPOPEPTIDES daptomycin 500mg inj 1 NDS GLYCOPEPTIDES DALVANCE 500MG INJ 1 NDS FIRVANQ 25MG/ML ORAL SOLN 1 FIRVANQ 50MG/ML ORAL SOLN 1 vancomycin 1000mg inj 1 vancomycin 100mg/ml inj 1 vancomycin 125mg cap 1 QL=120 EA/30 Days vancomycin 250mg cap 1 QL=120 EA/30 Days VANCOMYCIN 250MG INJ 1 vancomycin 500mg inj 1 vancomycin 750mg inj 1 LEPROSTATICS dapsone 100mg tab 1 dapsone 25mg tab 1 LINCOSAMIDES clindamycin 12mg/ml inj 1 clindamycin 150mg cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clindamycin 150mg/ml (2ml) inj 1 clindamycin 150mg/ml (4ml) inj 1 clindamycin 150mg/ml (6ml) inj 1 clindamycin 15mg/ml oral soln 1 clindamycin 18mg/ml inj 1 clindamycin 300mg cap 1 clindamycin 6mg/ml inj 1 clindamycin 75mg cap 1 MONOBACTAMS aztreonam 1000mg inj 1 CAYSTON 75MG INH SOLN 1 NDS PA OXAZOLIDINONES linezolid 20mg/ml susp 1 linezolid 2mg/ml inj 1 linezolid 600mg tab 1 SIVEXTRO 200MG INJ 1 NDS PA QL=6 EA/6 Days SIVEXTRO 200MG TAB 1 NDS PA QL=6 EA/6 Days PLEUROMUTILINS XENLETA 600MG TAB 1 PA QL=14 EA/7 Days POLYMYXINS colistin 75mg/ml inj 1 polymyxin b 250000unit/ml inj 1 ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone 250mg/proguanil 100mg tab 1 atovaquone 62.5mg/proguanil 25mg tab 1 COARTEM 20-120MG TAB 1 ANTIMALARIALS CHLOROQUINE PHOSPHATE 250MG TAB 1 chloroquine phosphate 500mg tab 1 hydroxychloroquine sulfate 200mg tab 1 KRINTAFEL 150MG TAB 1 MEFLOQUINE 250MG TAB 1 PRIMAQUINE PHOSPHATE 26.3MG TAB 1 quinine sulfate 324mg cap 1 PA ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS pyridostigmine bromide 180mg er tab 1 pyridostigmine bromide 60mg tab 1 RUZURGI 10MG TAB 1 NDS PA ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS ethambutol 100mg tab 1 ethambutol 400mg tab 1 isoniazid 100mg tab 1 ISONIAZID 10MG/ML ORAL SOLN 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS isoniazid 300mg tab 1 PASER D/R 4GM GRANULES 1 PRETOMANID 200MG TAB 1 QL=30 EA/30 Days PRIFTIN 150MG TAB 1 pyrazinamide 500mg tab 1 rifabutin 150mg cap 1 rifampin 150mg cap 1 rifampin 300mg cap 1 rifampin 600mg inj 1 SIRTURO 100MG TAB 1 NDS PA SIRTURO 20MG TAB 1 NDS PA TRECATOR 250MG TAB 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS CYCLOPHOSPHAMIDE 25MG CAP 1 PA BvD CYCLOPHOSPHAMIDE 25MG TAB 1 CYCLOPHOSPHAMIDE 50MG CAP 1 PA BvD CYCLOPHOSPHAMIDE 50MG TAB 1 LEUKERAN 2MG TAB 1 ANTIMETABOLITES mercaptopurine 50mg tab 1 methotrexate 2.5mg tab 1 methotrexate 25mg/ml (2ml) inj 1 methotrexate 25mg/ml inj 1 ONUREG 200MG TAB 1 NDS PA NSO QL=14 EA/28 Days ONUREG 300MG TAB 1 NDS PA NSO QL=14 EA/28 Days PURIXAN 2000MG/100ML SUSP 1 TABLOID 40MG TAB 1 XATMEP 2.5MG/ML ORAL SOLN 1 PA ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA 100MG TAB 1 NDS PA NSO VENCLEXTA 10MG TAB 1 PA NSO VENCLEXTA 50MG TAB 1 PA NSO VENCLEXTA STARTING PACK 1 NDS PA NSO ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO 100MG TAB 1 NDS PA NSO DAURISMO 25MG TAB 1 NDS PA NSO ERIVEDGE 150MG CAP 1 NDS PA NSO ODOMZO 200MG CAP 1 NDS PA NSO ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate 250mg tab 1 QL=120 EA/30 Days anastrozole 1mg tab 1 bicalutamide 50mg tab 1 ELIGARD 22.5MG SYRINGE 1 ELIGARD 30MG SYRINGE 1 ELIGARD 45MG SYRINGE 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ELIGARD 7.5MG SYRINGE 1 EMCYT 140MG CAP 1 ERLEADA 60MG TAB 1 NDS PA NSO QL=120 EA/30 Days exemestane 25mg tab 1 FIRMAGON 120MG INJ 1 PA NSO FIRMAGON 80MG INJ 1 PA NSO flutamide 125mg cap 1 letrozole 2.5mg tab 1 leuprolide acetate 5mg/ml inj 1 LUPRON 11.25MG SYRINGE 1 LUPRON 22.5MG SYRINGE 1 LUPRON 3.75MG SYRINGE 1 LUPRON 30MG SYRINGE 1 LUPRON 45MG SYRINGE 1 LUPRON 7.5MG SYRINGE 1 LYSODREN 500MG TAB 1 megestrol acetate 20mg tab 1 PA NSO megestrol acetate 40mg tab 1 PA NSO megestrol acetate 40mg/ml susp 1 PA nilutamide 150mg tab 1 NDS NUBEQA 300MG TAB 1 NDS PA NSO QL=120 EA/30 Days ORGOVYX 120MG TAB 1 NDS PA NSO QL=32 EA/30 Days SOLTAMOX 10MG/5ML ORAL SOLN 1 PA NSO tamoxifen 10mg tab 1 tamoxifen 20mg tab 1 toremifene 60mg tab 1 TRELSTAR 11.25MG INJ 1 TRELSTAR 22.5MG INJ 1 TRELSTAR 3.75MG INJ 1 XTANDI 40MG CAP 1 NDS PA NSO QL=120 EA/30 Days ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST 1MG CAP 1 NDS PA NSO POMALYST 2MG CAP 1 NDS PA NSO POMALYST 3MG CAP 1 NDS PA NSO POMALYST 4MG CAP 1 NDS PA NSO ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO 100 MG ONCE WEEKLY 1 NDS PA NSO QL=32 EA/28 Days XPOVIO 100MG ONCE WEEKLY CARTON (8-PACK) 1 NDS PA NSO QL=8 EA/28 Days XPOVIO 40MG ONCE WEEKLY CARTON (4-PACK) 1 NDS PA NSO QL=4 EA/28 Days XPOVIO 40MG ONCE WEEKLY PACK 1 NDS PA NSO XPOVIO 40MG TWICE WEEKLY CARTON (8-PACK) 1 NDS PA NSO QL=8 EA/28 Days XPOVIO 40MG TWICE WEEKLY PACK 1 NDS PA NSO XPOVIO 60 MG ONCE WEEKLY 1 NDS PA NSO QL=32 EA/28 Days XPOVIO 60MG ONCE WEEKLY CARTON (4-PACK) 1 NDS PA NSO QL=4 EA/28 Days XPOVIO 60MG TWICE WEEKLY PACK 1 NDS PA NSO XPOVIO 80 MG ONCE WEEKLY 1 NDS PA NSO QL=32 EA/28 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS XPOVIO 80 MG TWICE WEEKLY 1 NDS PA NSO QL=32 EA/28 Days XPOVIO 80MG ONCE WEEKLY CARTON (8-PACK) 1 NDS PA NSO QL=8 EA/28 Days ANTINEOPLASTIC COMBINATIONS INQOVI 5 TABLET PACK 1 NDS PA NSO QL=5 EA/28 Days KISQALI FEMARA CO-PACK 200 PACK 1 NDS PA NSO QL=49 EA/28 Days KISQALI FEMARA CO-PACK 400 PACK 1 NDS PA NSO QL=70 EA/28 Days KISQALI FEMARA CO-PACK 600 PACK 1 NDS PA NSO QL=91 EA/28 Days LONSURF 6.14-15MG TAB 1 NDS PA NSO LONSURF 8.19-20MG TAB 1 NDS PA NSO ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR 10MG TAB 1 NDS PA NSO QL=30 EA/30 Days AFINITOR 2MG TAB FOR ORAL SUSP 1 NDS PA NSO AFINITOR 3MG TAB FOR ORAL SUSP 1 NDS PA NSO AFINITOR 5MG TAB FOR ORAL SUSP 1 NDS PA NSO ALECENSA 150MG CAP 1 NDS PA NSO QL=240 EA/30 Days ALUNBRIG 180MG TAB 1 NDS PA NSO QL=30 EA/30 Days ALUNBRIG 30MG TAB 1 NDS PA NSO QL=120 EA/30 Days ALUNBRIG 90MG TAB 1 NDS PA NSO QL=30 EA/30 Days ALUNBRIG INITIATION PACK 1 NDS PA NSO QL=30 EA/30 Days AYVAKIT 100MG TAB 1 NDS PA NSO QL=30 EA/30 Days AYVAKIT 200MG TAB 1 NDS PA NSO QL=30 EA/30 Days AYVAKIT 300MG TAB 1 NDS PA NSO QL=30 EA/30 Days BALVERSA 3MG TAB 1 NDS PA NSO QL=60 EA/30 Days BALVERSA 4MG TAB 1 NDS PA NSO QL=60 EA/30 Days BALVERSA 5MG TAB 1 NDS PA NSO QL=30 EA/30 Days BOSULIF 100MG TAB 1 NDS PA NSO BOSULIF 400MG TAB 1 NDS PA NSO BOSULIF 500MG TAB 1 NDS PA NSO BRAFTOVI 75MG CAP 1 NDS PA NSO QL=180 EA/30 Days BRUKINSA 80MG CAP 1 NDS PA NSO QL=120 EA/30 Days CABOMETYX 20MG TAB 1 NDS PA NSO CABOMETYX 40MG TAB 1 NDS PA NSO CABOMETYX 60MG TAB 1 NDS PA NSO CALQUENCE 100MG CAP 1 NDS PA NSO QL=60 EA/30 Days CAPRELSA 100MG TAB 1 NDS PA NSO QL=60 EA/30 Days CAPRELSA 300MG TAB 1 NDS PA NSO QL=30 EA/30 Days COMETRIQ 100MG DAILY DOSE CARTON PACK 1 NDS PA NSO COMETRIQ 140MG DAILY DOSE CARTON PACK 1 NDS PA NSO COMETRIQ 60MG DAILY DOSE CARTON PACK 1 NDS PA NSO COPIKTRA 15MG CAP 1 NDS PA NSO QL=60 EA/30 Days COPIKTRA 25MG CAP 1 NDS PA NSO QL=60 EA/30 Days COTELLIC 20MG TAB 1 NDS PA NSO QL=63 EA/28 Days erlotinib 100mg tab 1 PA NSO erlotinib 150mg tab 1 PA NSO erlotinib 25mg tab 1 PA NSO everolimus 2.5mg tab 1 PA NSO QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS everolimus 5mg tab 1 PA NSO QL=30 EA/30 Days everolimus 7.5mg tab 1 PA NSO QL=30 EA/30 Days FARYDAK 10MG CAP 1 NDS PA NSO FARYDAK 15MG CAP 1 NDS PA NSO FARYDAK 20MG CAP 1 NDS PA NSO FOTIVDA 0.89MG CAP 1 NDS PA NSO QL=21 EA/28 Days FOTIVDA 1.34MG CAP 1 NDS PA NSO QL=21 EA/28 Days GAVRETO 100MG CAP 1 NDS PA NSO QL=120 EA/30 Days GILOTRIF 20MG TAB 1 NDS PA NSO QL=30 EA/30 Days GILOTRIF 30MG TAB 1 NDS PA NSO QL=30 EA/30 Days GILOTRIF 40MG TAB 1 NDS PA NSO QL=30 EA/30 Days IBRANCE 100MG CAP 1 NDS PA NSO QL=21 EA/28 Days IBRANCE 100MG TAB 1 NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG CAP 1 NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG TAB 1 NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG CAP 1 NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG TAB 1 NDS PA NSO QL=21 EA/28 Days ICLUSIG 10MG TAB 1 NDS PA NSO QL=30 EA/30 Days ICLUSIG 15MG TAB 1 NDS PA NSO QL=60 EA/30 Days ICLUSIG 30MG TAB 1 NDS PA NSO QL=30 EA/30 Days ICLUSIG 45MG TAB 1 NDS PA NSO QL=30 EA/30 Days IDHIFA 100MG TAB 1 NDS PA NSO QL=30 EA/30 Days IDHIFA 50MG TAB 1 NDS PA NSO QL=30 EA/30 Days imatinib 100mg tab 1 imatinib 400mg tab 1 IMBRUVICA 140MG CAP 1 NDS PA NSO QL=90 EA/30 Days IMBRUVICA 140MG TAB 1 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 280MG TAB 1 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 420MG TAB 1 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 560MG TAB 1 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 70MG CAP 1 NDS PA NSO QL=30 EA/30 Days INLYTA 1MG TAB 1 NDS PA NSO INLYTA 5MG TAB 1 NDS PA NSO INREBIC 100MG CAP 1 NDS PA NSO QL=120 EA/30 Days IRESSA 250MG TAB 1 NDS PA NSO JAKAFI 10MG TAB 1 NDS PA NSO QL=60 EA/30 Days JAKAFI 15MG TAB 1 NDS PA NSO QL=60 EA/30 Days JAKAFI 20MG TAB 1 NDS PA NSO QL=60 EA/30 Days JAKAFI 25MG TAB 1 NDS PA NSO QL=60 EA/30 Days JAKAFI 5MG TAB 1 NDS PA NSO QL=60 EA/30 Days KISQALI 200MG DAILY DOSE PACK 1 NDS PA NSO QL=21 EA/28 Days KISQALI 400MG DAILY DOSE PACK 1 NDS PA NSO QL=42 EA/28 Days KISQALI 600MG DAILY DOSE PACK 1 NDS PA NSO QL=63 EA/28 Days KOSELUGO 10MG CAP 1 NDS PA NSO KOSELUGO 25MG CAP 1 NDS PA NSO 250mg tab 1 NDS PA NSO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS LENVIMA 10 10MG PACK 1 NDS PA NSO QL=30 EA/30 Days LENVIMA 12 4MG PACK 1 NDS PA NSO QL=90 EA/30 Days LENVIMA 14 PACK 1 NDS PA NSO QL=60 EA/30 Days LENVIMA 18 PACK 1 NDS PA NSO QL=90 EA/30 Days LENVIMA 20 10MG PACK 1 NDS PA NSO QL=60 EA/30 Days LENVIMA 24 PACK 1 NDS PA NSO QL=90 EA/30 Days LENVIMA 4 4MG PACK 1 NDS PA NSO QL=30 EA/30 Days LENVIMA 8 4MG PACK 1 NDS PA NSO QL=60 EA/30 Days LORBRENA 100MG TAB 1 NDS PA NSO QL=30 EA/30 Days LORBRENA 25MG TAB 1 NDS PA NSO QL=90 EA/30 Days LYNPARZA 100MG TAB 1 NDS PA NSO QL=120 EA/30 Days LYNPARZA 150MG TAB 1 NDS PA NSO QL=120 EA/30 Days MEKINIST 0.5MG TAB 1 NDS PA NSO QL=90 EA/30 Days MEKINIST 2MG TAB 1 NDS PA NSO QL=30 EA/30 Days MEKTOVI 15MG TAB 1 NDS PA NSO QL=180 EA/30 Days NERLYNX 40MG TAB 1 NDS PA NSO NEXAVAR 200MG TAB 1 NDS PA NSO NINLARO 2.3MG CAP 1 NDS PA NSO NINLARO 3MG CAP 1 NDS PA NSO NINLARO 4MG CAP 1 NDS PA NSO PEMAZYRE 13.5MG TAB 1 NDS PA NSO QL=14 EA/21 Days PEMAZYRE 4.5MG TAB 1 NDS PA NSO QL=14 EA/21 Days PEMAZYRE 9MG TAB 1 NDS PA NSO QL=14 EA/21 Days PIQRAY 200MG DAILY DOSE PACK 1 NDS PA NSO QL=30 EA/30 Days PIQRAY 250MG DAILY DOSE PACK 1 NDS PA NSO QL=60 EA/30 Days PIQRAY 300MG DAILY DOSE 150MG PACK 1 NDS PA NSO QL=60 EA/30 Days QINLOCK 50MG TAB 1 NDS PA NSO QL=90 EA/30 Days RETEVMO 40MG CAP 1 NDS PA NSO QL=180 EA/30 Days RETEVMO 80MG CAP 1 NDS PA NSO QL=120 EA/30 Days ROZLYTREK 100MG CAP 1 NDS PA NSO QL=30 EA/30 Days ROZLYTREK 200MG CAP 1 NDS PA NSO QL=90 EA/30 Days RUBRACA 200MG TAB 1 NDS PA NSO QL=120 EA/30 Days RUBRACA 250MG TAB 1 NDS PA NSO QL=120 EA/30 Days RUBRACA 300MG TAB 1 NDS PA NSO QL=120 EA/30 Days RYDAPT 25MG CAP 1 NDS PA NSO SPRYCEL 100MG TAB 1 NDS PA NSO SPRYCEL 140MG TAB 1 NDS PA NSO SPRYCEL 20MG TAB 1 NDS PA NSO SPRYCEL 50MG TAB 1 NDS PA NSO SPRYCEL 70MG TAB 1 NDS PA NSO SPRYCEL 80MG TAB 1 NDS PA NSO STIVARGA 40MG TAB 1 NDS PA NSO QL=84 EA/28 Days SUTENT 12.5MG CAP 1 NDS PA NSO SUTENT 25MG CAP 1 NDS PA NSO SUTENT 37.5MG CAP 1 NDS PA NSO SUTENT 50MG CAP 1 NDS PA NSO You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS TABRECTA 150MG TAB 1 NDS PA NSO QL=120 EA/30 Days TABRECTA 200MG TAB 1 NDS PA NSO QL=120 EA/30 Days TAFINLAR 50MG CAP 1 NDS PA NSO QL=120 EA/30 Days TAFINLAR 75MG CAP 1 NDS PA NSO QL=120 EA/30 Days TAGRISSO 40MG TAB 1 NDS PA NSO TAGRISSO 80MG TAB 1 NDS PA NSO TALZENNA 0.25MG CAP 1 NDS PA NSO QL=90 EA/30 Days TALZENNA 1MG CAP 1 NDS PA NSO QL=30 EA/30 Days TASIGNA 150MG CAP 1 NDS PA NSO TASIGNA 200MG CAP 1 NDS PA NSO TASIGNA 50MG CAP 1 NDS PA NSO TAZVERIK 200MG TAB 1 NDS PA NSO QL=240 EA/30 Days TEPMETKO 225MG TAB 1 NDS PA NSO QL=60 EA/30 Days TIBSOVO 250MG TAB 1 NDS PA NSO QL=60 EA/30 Days TUKYSA 150MG TAB 1 NDS PA NSO QL=120 EA/30 Days TUKYSA 50MG TAB 1 NDS PA NSO QL=120 EA/30 Days TURALIO 200MG CAP 1 NDS PA NSO QL=120 EA/30 Days UKONIQ 200MG TAB 1 NDS PA NSO QL=120 EA/30 Days VERZENIO 100MG TAB 1 NDS PA NSO QL=56 EA/28 Days VERZENIO 150MG TAB 1 NDS PA NSO QL=56 EA/28 Days VERZENIO 200MG TAB 1 NDS PA NSO QL=56 EA/28 Days VERZENIO 50MG TAB 1 NDS PA NSO QL=56 EA/28 Days VITRAKVI 100MG CAP 1 NDS PA NSO VITRAKVI 20MG/ML ORAL SOLN 1 NDS PA NSO VITRAKVI 25MG CAP 1 NDS PA NSO VIZIMPRO 15MG TAB 1 NDS PA NSO QL=30 EA/30 Days VIZIMPRO 30MG TAB 1 NDS PA NSO QL=30 EA/30 Days VIZIMPRO 45MG TAB 1 NDS PA NSO QL=30 EA/30 Days VOTRIENT 200MG TAB 1 NDS PA NSO XALKORI 200MG CAP 1 NDS PA NSO QL=60 EA/30 Days XALKORI 250MG CAP 1 NDS PA NSO QL=60 EA/30 Days XOSPATA 40MG TAB 1 NDS PA NSO ZEJULA 100MG CAP 1 NDS PA NSO QL=90 EA/30 Days ZELBORAF 240MG TAB 1 NDS PA NSO QL=240 EA/30 Days ZOLINZA 100MG CAP 1 NDS PA NSO ZYDELIG 100MG TAB 1 NDS PA NSO QL=60 EA/30 Days ZYDELIG 150MG TAB 1 NDS PA NSO QL=60 EA/30 Days ZYKADIA 150MG TAB 1 NDS PA NSO QL=90 EA/30 Days ANTINEOPLASTICS MISC. ACTIMMUNE 2000000UNIT/0.5ML INJ 1 NDS PA NSO bexarotene 75mg cap 1 PA NSO hydroxyurea 500mg cap 1 INTRON A 10MU INJ 1 INTRON A 10MU/ML INJ 1 INTRON A 18MU INJ 1 NDS INTRON A 50MU INJ 1 NDS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS INTRON A 6000000UNIT/ML INJ 1 MATULANE 50MG CAP 1 NDS SYNRIBO 3.5MG INJ 1 NDS tretinoin 10mg cap 1 CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN 10MG TAB 1 LEUCOVORIN 15MG TAB 1 leucovorin 25mg tab 1 leucovorin 5mg tab 1 MESNEX 400MG TAB 1 ANTIPARKINSON AGENTS ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate 2mg tab 1 trihexyphenidyl 2mg tab 1 trihexyphenidyl 5mg tab 1 ANTIPARKINSON DOPAMINERGICS amantadine 10mg/ml oral soln 1 bromocriptine 2.5mg tab 1 bromocriptine 5mg cap 1 carbidopa 10mg/levodopa 100mg odt 1 carbidopa 10mg/levodopa 100mg tab 1 carbidopa 25mg/levodopa 100mg er tab 1 carbidopa 25mg/levodopa 100mg odt 1 carbidopa 25mg/levodopa 100mg tab 1 carbidopa 25mg/levodopa 250mg odt 1 carbidopa 50mg/levodopa 200mg er tab 1 NEUPRO 1MG/24HR PATCH 1 NEUPRO 2MG/24HR PATCH 1 NEUPRO 3MG/24HR PATCH 1 NEUPRO 4MG/24HR PATCH 1 NEUPRO 6MG/24HR PATCH 1 NEUPRO 8MG/24HR PATCH 1 pramipexole 0.125mg tab 1 pramipexole 0.25mg tab 1 pramipexole 0.375mg er tab 1 pramipexole 0.5mg tab 1 pramipexole 0.75mg er tab 1 pramipexole 0.75mg tab 1 pramipexole 1.5mg er tab 1 pramipexole 1.5mg tab 1 pramipexole 1mg tab 1 pramipexole 2.25mg er tab 1 pramipexole 3.75mg er tab 1 pramipexole 3mg er tab 1 pramipexole 4.5mg er tab 1 0.25mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ropinirole 0.5mg tab 1 ropinirole 12mg er tab 1 ropinirole 2mg er tab 1 ropinirole 3mg tab 1 ropinirole 4mg er tab 1 ropinirole 4mg tab 1 ropinirole 5mg tab 1 ropinirole 6mg er tab 1 ropinirole 8mg er tab 1 ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUNCTIVE THERAPY carbidopa 25mg tab 1 NOURIANZ 40MG TAB 1 PA QL=30 EA/30 Days NOURIANZ TAB 20MG 1 PA QL=30 EA/30 Days ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate 0.5mg tab 1 benztropine mesylate 1mg tab 1 trihexyphenidyl 0.4mg/ml oral soln 1 ANTIPARKINSON COMT INHIBITORS entacapone 200mg tab 1 tolcapone 100mg tab 1 ANTIPARKINSON DOPAMINERGICS amantadine 100mg cap 1 amantadine 100mg tab 1 APOKYN 30MG/3ML CARTRIDGE 1 NDS CARBIDOPA 12.5MG/ENTACAPONE 1 200MG/LEVODOPA 50MG TAB CARBIDOPA 18.75MG/ENTACAPONE 1 200MG/LEVODOPA 75MG TAB CARBIDOPA 25MG/ENTACAPONE 1 200MG/LEVODOPA 100MG TAB carbidopa 25mg/levodopa 250mg tab 1 CARBIDOPA 31.25MG/ENTACAPONE 1 200MG/LEVODOPA 125MG TAB CARBIDOPA 37.5MG/ENTACAPONE 1 200MG/LEVODOPA 150MG TAB CARBIDOPA 50MG/ENTACAPONE 1 200MG/LEVODOPA 200MG TAB ropinirole 1mg tab 1 ropinirole 2mg tab 1 ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline 0.5mg tab 1 rasagiline 1mg tab 1 selegiline 5mg cap 1 SELEGILINE 5MG TAB 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANTIMANIC AGENTS lithium carbonate 150mg cap 1 lithium carbonate 300mg cap 1 lithium carbonate 300mg er tab 1 lithium carbonate 300mg tab 1 lithium carbonate 450mg er tab 1 lithium carbonate 600mg cap 1 lithium citrate 60mg/ml oral soln 1 ANTIPSYCHOTICS - MISC. CAPLYTA 42MG CAP 1 PA NSO QL=30 EA/30 Days EQUETRO 100MG ER CAP 1 EQUETRO 200MG ER CAP 1 EQUETRO 300MG ER CAP 1 LATUDA 120MG TAB 1 ST_NSO QL=30 EA/30 Days LATUDA 20MG TAB 1 ST_NSO QL=30 EA/30 Days LATUDA 40MG TAB 1 ST_NSO QL=30 EA/30 Days LATUDA 60MG TAB 1 ST_NSO QL=30 EA/30 Days LATUDA 80MG TAB 1 ST_NSO QL=30 EA/30 Days NUPLAZID 10MG TAB 1 PA NSO QL=30 EA/30 Days NUPLAZID 34MG CAP 1 PA NSO QL=30 EA/30 Days VRAYLAR 1.5/3MG MIXED PACK 1 PA NSO QL=30 EA/30 Days VRAYLAR 1.5MG CAP 1 PA NSO QL=30 EA/30 Days VRAYLAR 3MG CAP 1 PA NSO QL=30 EA/30 Days VRAYLAR 4.5MG CAP 1 PA NSO QL=30 EA/30 Days VRAYLAR 6MG CAP 1 PA NSO QL=30 EA/30 Days ziprasidone 20mg cap 1 ziprasidone 20mg inj 1 ziprasidone 40mg cap 1 ziprasidone 60mg cap 1 ziprasidone 80mg cap 1 BENZISOXAZOLES FANAPT 10MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 12MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 1MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 2MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 4MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 6MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT 8MG TAB 1 PA NSO QL=60 EA/30 Days FANAPT TITRATION PACK 1 PA NSO QL=60 EA/30 Days INVEGA 117MG/0.75ML SYRINGE 1 INVEGA 156MG/ML SYRINGE 1 INVEGA 234MG/1.5ML SYRINGE 1 INVEGA 273MG/0.875ML SYRINGE 1 INVEGA 39MG/0.25ML SYRINGE 1 INVEGA 410MG/1.315ML SYRINGE 1 INVEGA 546MG/1.75ML SYRINGE 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS INVEGA 78MG/0.5ML SYRINGE 1 INVEGA 819MG/2.625ML SYRINGE 1 paliperidone 1.5mg er tab 1 PA NSO QL=30 EA/30 Days paliperidone 3mg er tab 1 PA NSO QL=30 EA/30 Days paliperidone 6mg er tab 1 PA NSO QL=60 EA/30 Days paliperidone 9mg er tab 1 PA NSO QL=30 EA/30 Days PERSERIS 120MG SYRINGE 1 NDS PERSERIS 90MG SYRINGE 1 NDS RISPERDAL 12.5MG INJ 1 RISPERDAL 25MG INJ 1 RISPERDAL 37.5MG INJ 1 RISPERDAL 50MG INJ 1 risperidone 0.25mg odt 1 risperidone 0.25mg tab 1 risperidone 0.5mg odt 1 risperidone 0.5mg tab 1 risperidone 1mg odt 1 risperidone 1mg tab 1 risperidone 1mg/ml oral soln 1 risperidone 2mg odt 1 risperidone 2mg tab 1 risperidone 3mg odt 1 risperidone 3mg tab 1 risperidone 4mg odt 1 risperidone 4mg tab 1 BUTYROPHENONES haloperidol 0.5mg tab 1 haloperidol 10mg tab 1 haloperidol 1mg tab 1 haloperidol 20mg tab 1 haloperidol 2mg tab 1 haloperidol 2mg/ml oral soln 1 haloperidol 5mg tab 1 haloperidol 5mg/ml inj 1 haloperidol decanoate 100mg/ml (1ml) inj 1 haloperidol decanoate 100mg/ml inj 1 haloperidol decanoate 50mg/ml inj 1 DIBENZAPINES asenapine 10mg sl tab 1 PA NSO QL=60 EA/30 Days asenapine 2.5mg sl tab 1 PA NSO QL=60 EA/30 Days asenapine 5mg sl tab 1 PA NSO QL=60 EA/30 Days clozapine 100mg odt 1 clozapine 100mg tab 1 CLOZAPINE 12.5MG ODT 1 CLOZAPINE 150MG ODT 1 CLOZAPINE 200MG ODT 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS clozapine 200mg tab 1 clozapine 25mg odt 1 clozapine 25mg tab 1 clozapine 50mg tab 1 loxapine 10mg cap 1 loxapine 25mg cap 1 loxapine 50mg cap 1 loxapine 5mg cap 1 olanzapine 10mg inj 1 olanzapine 10mg odt 1 olanzapine 10mg tab 1 olanzapine 15mg odt 1 olanzapine 15mg tab 1 olanzapine 2.5mg tab 1 olanzapine 20mg odt 1 olanzapine 20mg tab 1 olanzapine 5mg odt 1 olanzapine 5mg tab 1 olanzapine 7.5mg tab 1 quetiapine 100mg tab 1 quetiapine 150mg er tab 1 quetiapine 200mg er tab 1 quetiapine 200mg tab 1 quetiapine 25mg tab 1 quetiapine 300mg er tab 1 quetiapine 300mg tab 1 quetiapine 400mg er tab 1 quetiapine 400mg tab 1 quetiapine 50mg er tab 1 quetiapine 50mg tab 1 SECUADO 3.8MG/24HR PATCH 1 PA NSO QL=30 EA/30 Days SECUADO 5.7MG/24HR PATCH 1 PA NSO QL=30 EA/30 Days SECUADO 7.6MG/24HR PATCH 1 PA NSO QL=30 EA/30 Days VERSACLOZ 50MG/ML SUSP 1 ZYPREXA RELPREVV 210MG INJ 1 DIHYDROINDOLONES MOLINDONE 10MG TAB 1 MOLINDONE 25MG TAB 1 MOLINDONE 5MG TAB 1 PHENOTHIAZINES chlorpromazine 100mg tab 1 chlorpromazine 10mg tab 1 chlorpromazine 200mg tab 1 chlorpromazine 25mg tab 1 chlorpromazine 50mg tab 1 compro 25mg rectal supp 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FLUPHENAZINE 0.5MG/ML ORAL SOLN 1 fluphenazine 10mg tab 1 fluphenazine 1mg tab 1 fluphenazine 2.5mg tab 1 FLUPHENAZINE 2.5MG/ML INJ 1 fluphenazine 5mg tab 1 FLUPHENAZINE 5MG/ML ORAL SOLN 1 fluphenazine decanoate 25mg/ml inj 1 perphenazine 16mg tab 1 perphenazine 2mg tab 1 perphenazine 4mg tab 1 perphenazine 8mg tab 1 prochlorperazine 10mg tab 1 prochlorperazine 25mg rectal supp 1 prochlorperazine 5mg tab 1 thioridazine 100mg tab 1 thioridazine 10mg tab 1 thioridazine 25mg tab 1 thioridazine 50mg tab 1 trifluoperazine 10mg tab 1 trifluoperazine 1mg tab 1 trifluoperazine 2mg tab 1 trifluoperazine 5mg tab 1 QUINOLINONE DERIVATIVES ABILIFY 300MG INJ 1 NDS ABILIFY 300MG SYRINGE 1 NDS ABILIFY 400MG INJ 1 NDS ABILIFY 400MG SYRINGE 1 NDS aripiprazole 10mg odt 1 QL=60 EA/30 Days aripiprazole 10mg tab 1 aripiprazole 15mg odt 1 QL=60 EA/30 Days aripiprazole 15mg tab 1 aripiprazole 1mg/ml oral soln 1 aripiprazole 20mg tab 1 aripiprazole 2mg tab 1 aripiprazole 30mg tab 1 aripiprazole 5mg tab 1 ARISTADA 1064MG/3.9ML SYRINGE 1 ARISTADA 441MG/1.6ML SYRINGE 1 NDS ARISTADA 662MG/2.4ML SYRINGE 1 NDS ARISTADA 675MG/2.4ML SYRINGE 1 NDS ARISTADA 882MG/3.2ML SYRINGE 1 REXULTI 0.25MG TAB 1 PA NSO QL=30 EA/30 Days REXULTI 0.5MG TAB 1 PA NSO QL=30 EA/30 Days REXULTI 1MG TAB 1 PA NSO QL=30 EA/30 Days REXULTI 2MG TAB 1 PA NSO QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS REXULTI 3MG TAB 1 PA NSO QL=30 EA/30 Days REXULTI 4MG TAB 1 PA NSO QL=30 EA/30 Days THIOXANTHENES thiothixene 10mg cap 1 thiothixene 1mg cap 1 thiothixene 2mg cap 1 thiothixene 5mg cap 1 ANTIVIRALS ANTIRETROVIRALS 20mg/ml oral soln 1 abacavir 300mg tab 1 abacavir 300mg/ 150mg/ 300mg 1 tab abacavir 600mg/lamivudine 300mg tab 1 NDS APTIVUS 250MG CAP 1 NDS atazanavir 150mg cap 1 atazanavir 200mg cap 1 atazanavir 300mg cap 1 BIKTARVY 50-200-25MG TAB 1 NDS CIMDUO 300-300MG TAB 1 NDS COMPLERA 200-25-300MG TAB 1 NDS DELSTRIGO 100-300-300MG TAB 1 NDS DESCOVY 200-25MG TAB 1 NDS DOVATO 50-300MG TAB 1 NDS EDURANT 25MG TAB 1 NDS efavirenz 200mg cap 1 efavirenz 50mg cap 1 efavirenz 600mg tab 1 efavirenz/emtricitabine/tenofovir disoproxil fumarate 1 600-200-300mg tab efavirenz/emtricitabine/tenofovir disoproxil fumarate 1 NDS 600-200-300mg tab efavirenz/lamivudine/tenofovir disoproxil fumarate 1 400-300-300mg tab emtricitabine 200mg cap 1 emtricitabine/tenofovir disoproxil fumarate 1 NDS 100-150mg tab emtricitabine/tenofovir disoproxil fumarate 1 NDS 133-200mg tab emtricitabine/tenofovir disoproxil fumarate 1 NDS 167-250mg tab emtricitabine/tenofovir disoproxil fumarate 1 NDS 200-300mg tab EMTRIVA 10MG/ML ORAL SOLN 1 EMTRIVA 200MG CAP 1 etravirine 100mg tab 1 NDS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS etravirine 200mg tab 1 NDS EVOTAZ 300-150MG TAB 1 NDS fosamprenavir 700mg tab 1 NDS FUZEON 90MG INJ 1 NDS GENVOYA 150-150-200-10MG TAB 1 NDS INTELENCE 25MG TAB 1 NDS INVIRASE 500MG TAB 1 NDS ISENTRESS 100MG CHEW TAB 1 NDS ISENTRESS 100MG GRANULES FOR ORAL SUSP 1 ISENTRESS 25MG CHEW TAB 1 ISENTRESS 400MG TAB 1 NDS ISENTRESS 600MG TAB 1 NDS JULUCA 50-25MG TAB 1 NDS lamivudine 10mg/ml oral soln 1 lamivudine 150mg tab 1 lamivudine 150mg/zidovudine 300mg tab 1 lamivudine 300mg tab 1 LEXIVA 50MG/ML SUSP 1 lopinavir 80mg/ml/ritonavir 20mg/ml oral solution 1 NDS lopinavir-ritonavir 100-25mg tab 1 lopinavir-ritonavir 200-50mg tab 1 NDS NEVIRAPINE 100MG ER TAB 1 nevirapine 10mg/ml susp 1 nevirapine 200mg tab 1 nevirapine 400mg er tab 1 NORVIR 100MG ORAL POWDER 1 NORVIR 80MG/ML ORAL SOLN 1 ODEFSEY 200-25-25MG TAB 1 NDS PIFELTRO 100MG TAB 1 NDS PREZCOBIX 150-800MG TAB 1 NDS PREZISTA 100MG/ML SUSP 1 PREZISTA 150MG TAB 1 PREZISTA 600MG TAB 1 NDS PREZISTA 75MG TAB 1 PREZISTA 800MG TAB 1 NDS REYATAZ 50MG ORAL POWDER 1 NDS ritonavir 100mg tab 1 RUKOBIA 600MG ER TAB 1 NDS SELZENTRY 150MG TAB 1 NDS SELZENTRY 20MG/ML ORAL SOLN 1 NDS SELZENTRY 25MG TAB 1 SELZENTRY 300MG TAB 1 NDS SELZENTRY 75MG TAB 1 NDS STRIBILD 150-150-200-300MG TAB 1 NDS SYMFI 400-300-300MG TAB 1 SYMFI 600-300-300MG TAB 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS SYMTUZA 800-150-200-10MG TAB 1 NDS TEMIXYS 300-300MG TAB 1 NDS tenofovir disoproxil fumarate 300mg tab 1 NDS TIVICAY 10MG TAB 1 TIVICAY 25MG TAB 1 TIVICAY 50MG TAB 1 NDS TIVICAY 5MG TAB FOR ORAL SUSP 1 TRIUMEQ 600-50-300MG TAB 1 NDS TYBOST 150MG TAB 1 VIRACEPT 250MG TAB 1 NDS VIRACEPT 625MG TAB 1 NDS VIREAD 150MG TAB 1 NDS VIREAD 200MG TAB 1 NDS VIREAD 250MG TAB 1 NDS VIREAD 40MG/GM ORAL POWDER 1 zidovudine 100mg cap 1 zidovudine 10mg/ml oral soln 1 zidovudine 300mg tab 1 CMV AGENTS PREVYMIS 240MG TAB 1 NDS PA QL=30 EA/30 Days PREVYMIS 480MG TAB 1 NDS PA QL=30 EA/30 Days valganciclovir 450mg tab 1 NDS valganciclovir 50mg/ml oral soln 1 NDS HEPATITIS AGENTS adefovir dipivoxil 10mg tab 1 entecavir 0.5mg tab 1 entecavir 1mg tab 1 EPIVIR HBV 5MG/ML ORAL SOLN 1 lamivudine 100mg tab 1 MAVYRET 100-40MG TAB 1 NDS PA QL=90 EA/30 Days PEGASYS 180MCG/0.5ML SYRINGE 1 NDS PEGASYS 180MCG/ML INJ 1 NDS ribavirin 200mg cap 1 ribavirin 200mg tab 1 SOFOSBUVIR 400MG/VELPATASVIR 100MG TAB 1 NDS PA QL=30 EA/30 Days VEMLIDY 25MG TAB 1 NDS VOSEVI 400-100-100MG TAB 1 NDS PA QL=30 EA/30 Days HERPES AGENTS acyclovir 200mg cap 1 acyclovir 400mg tab 1 acyclovir 40mg/ml susp 1 acyclovir 50mg/ml inj 1 PA BvD acyclovir 800mg tab 1 famciclovir 125mg tab 1 famciclovir 250mg tab 1 famciclovir 500mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS valacyclovir 1000mg tab 1 valacyclovir 500mg tab 1 INFLUENZA AGENTS oseltamivir 30mg cap 1 QL=84 EA/180 Days oseltamivir 45mg cap 1 QL=42 EA/180 Days oseltamivir 6mg/ml susp 1 QL=540 ML/180 Days oseltamivir 75mg cap 1 QL=42 EA/180 Days RELENZA 5MG/BLISTER INH 1 QL=120 EA/30 Days RIMANTADINE 100MG TAB 1 XOFLUZA 20MG THERAPY PACK 1 QL=2 EA/30 Days XOFLUZA 40MG THERAPY PACK 1 QL=2 EA/30 Days ASSORTED CLASSES IMMUNOSUPPRESSIVE AGENTS AZASAN 100MG TAB 1 PA BvD AZASAN 75MG TAB 1 PA BvD cyclosporine 100mg cap 1 PA BvD cyclosporine 25mg cap 1 PA BvD cyclosporine modified 100mg cap 1 PA BvD cyclosporine modified 25mg cap 1 PA BvD gengraf 100mg cap 1 PA BvD gengraf 100mg/ml oral soln 1 PA BvD gengraf 25mg cap 1 PA BvD mycophenolate mofetil 200mg/ml susp 1 PA BvD mycophenolate mofetil 250mg cap 1 PA BvD mycophenolate mofetil 500mg tab 1 PA BvD SANDIMMUNE 100MG/ML ORAL SOLN 1 PA BvD sirolimus 0.5mg tab 1 PA BvD sirolimus 1mg tab 1 PA BvD sirolimus 2mg tab 1 PA BvD tacrolimus 0.5mg cap 1 PA BvD tacrolimus 1mg cap 1 PA BvD tacrolimus 5mg cap 1 PA BvD BETA BLOCKERS ALPHA-BETA BLOCKERS 12.5mg tab 1 carvedilol 25mg tab 1 carvedilol 3.125mg tab 1 carvedilol 6.25mg tab 1 labetalol 100mg tab 1 labetalol 200mg tab 1 labetalol 300mg tab 1 BETA BLOCKERS CARDIO-SELECTIVE acebutolol 200mg cap 1 acebutolol 400mg cap 1 atenolol 100mg tab 1 atenolol 25mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS atenolol 50mg tab 1 betaxolol 10mg tab 1 betaxolol 20mg tab 1 bisoprolol fumarate 10mg tab 1 bisoprolol fumarate 5mg tab 1 BYSTOLIC 10MG TAB 1 BYSTOLIC 2.5MG TAB 1 BYSTOLIC 20MG TAB 1 BYSTOLIC 5MG TAB 1 metoprolol succinate 100mg er tab 1 metoprolol succinate 200mg er tab 1 metoprolol succinate 25mg er tab 1 metoprolol succinate 50mg er tab 1 metoprolol tartrate 100mg tab 1 metoprolol tartrate 25mg tab 1 metoprolol tartrate 50mg tab 1 BETA BLOCKERS NON-SELECTIVE INNOPRAN 120MG ER CAP 1 INNOPRAN 80MG ER CAP 1 nadolol 20mg tab 1 nadolol 40mg tab 1 nadolol 80mg tab 1 pindolol 10mg tab 1 pindolol 5mg tab 1 propranolol 10mg tab 1 propranolol 120mg er cap 1 propranolol 160mg er cap 1 propranolol 20mg tab 1 propranolol 40mg tab 1 PROPRANOLOL 4MG/ML ORAL SOLN 1 propranolol 60mg er cap 1 propranolol 60mg tab 1 propranolol 80mg er cap 1 propranolol 80mg tab 1 PROPRANOLOL 8MG/ML ORAL SOLN 1 sorine 120mg tab 1 sorine 160mg tab 1 sorine 240mg tab 1 sorine 80mg tab 1 sotalol 120mg tab 1 sotalol 160mg tab 1 sotalol 240mg tab 1 sotalol 80mg tab 1 sotalol af 120mg tab 1 sotalol AF 160mg tab 1 sotalol AF 80mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS timolol 10mg tab 1 timolol 20mg tab 1 timolol 5mg tab 1 CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS amlodipine 10mg tab 1 amlodipine 2.5mg tab 1 amlodipine 5mg tab 1 cartia 120mg er cap 1 cartia 180mg er cap 1 cartia 240mg er cap 1 cartia 300mg er cap 1 DILT 120MG ER CAP 1 DILT 180MG ER CAP 1 DILT 240MG ER CAP 1 diltiazem 120mg er (12 hr) cap 1 diltiazem 120mg er (24 hr) cap 1 diltiazem 120mg tab 1 diltiazem 180mg er cap 1 diltiazem 180mg er tab 1 diltiazem 240mg er cap 1 diltiazem 240mg er tab 1 diltiazem 300mg er cap 1 diltiazem 300mg er tab 1 diltiazem 30mg tab 1 diltiazem 360mg er cap 1 diltiazem 360mg er tab 1 diltiazem 420mg er cap 1 diltiazem 60mg er cap 1 diltiazem 60mg tab 1 diltiazem 90mg er cap 1 diltiazem 90mg tab 1 felodipine 10mg er tab 1 felodipine 2.5mg er tab 1 felodipine 5mg er tab 1 isradipine 2.5mg cap 1 isradipine 5mg cap 1 matzim 180mg er tab 1 matzim 240mg er tab 1 matzim 300mg er tab 1 matzim 360mg er tab 1 matzim 420mg er tab 1 nicardipine 20mg cap 1 nicardipine 30mg cap 1 nifedipine 30mg er tab 1 nifedipine 30mg osmotic er tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nifedipine 60mg er tab 1 nifedipine 60mg osmotic er tab 1 nifedipine 90mg er tab 1 nifedipine 90mg osmotic er tab 1 nimodipine 30mg cap 1 nisoldipine 17mg er tab 1 nisoldipine 20mg er tab 1 NISOLDIPINE 25.5MG ER TAB 1 nisoldipine 30mg er tab 1 nisoldipine 34mg er tab 1 nisoldipine 40mg er tab 1 nisoldipine 8.5mg er tab 1 taztia 120mg er cap 1 taztia 180mg er cap 1 taztia 240mg er cap 1 taztia 300mg er cap 1 taztia 360mg er cap 1 tiadylt 120mg er cap 1 tiadylt 180mg er cap 1 tiadylt 240mg er cap 1 tiadylt 300mg er cap 1 tiadylt 360mg er cap 1 tiadylt 420mg er cap 1 VERAPAMIL 100MG ER CAP 1 verapamil 120mg er cap 1 verapamil 120mg er tab 1 verapamil 120mg tab 1 verapamil 180mg er cap 1 verapamil 180mg er tab 1 VERAPAMIL 200MG ER CAP 1 verapamil 240mg er cap 1 verapamil 240mg er tab 1 VERAPAMIL 300MG ER CAP 1 VERAPAMIL 360MG ER CAP 1 verapamil 40mg tab 1 verapamil 80mg tab 1 CARDIOTONICS CARDIAC GLYCOSIDES digitek 0.125mg tab 1 digitek 0.25mg tab 1 digox 125mcg tab 1 digox 250mcg tab 1 0.05mg/ml oral soln 1 digoxin 0.125mg tab 1 digoxin 0.25mg tab 1 CARDIOVASCULAR AGENTS - MISC. You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine 10mg/atorvastatin 10mg tab 1 amlodipine 10mg/atorvastatin 20mg tab 1 amlodipine 10mg/atorvastatin 40mg tab 1 amlodipine 10mg/atorvastatin 80mg tab 1 amlodipine 2.5mg/atorvastatin 10mg tab 1 amlodipine 2.5mg/atorvastatin 20mg tab 1 amlodipine 2.5mg/atorvastatin 40mg tab 1 amlodipine 5mg/atorvastatin 10mg tab 1 amlodipine 5mg/atorvastatin 20mg tab 1 amlodipine 5mg/atorvastatin 40mg tab 1 amlodipine 5mg/atorvastatin 80mg tab 1 BIDIL 37.5-20MG TAB 1 ENTRESTO 24-26MG TAB 1 QL=60 EA/30 Days ENTRESTO 49-51MG TAB 1 QL=60 EA/30 Days ENTRESTO 97-103MG TAB 1 QL=60 EA/30 Days PROSTAGLANDIN VASODILATORS ORENITRAM 0.125MG ER TAB 1 PA ORENITRAM 0.25MG ER TAB 1 NDS PA ORENITRAM 1MG ER TAB 1 NDS PA ORENITRAM 2.5MG ER TAB 1 NDS PA ORENITRAM 5MG ER TAB 1 NDS PA VENTAVIS 10MCG/ML INH SOLN 1 NDS PA VENTAVIS 20MCG/ML INH SOLN 1 NDS PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan 10mg tab 1 PA QL=30 EA/30 Days ambrisentan 5mg tab 1 PA QL=30 EA/30 Days bosentan 125mg tab 1 PA QL=60 EA/30 Days bosentan 62.5mg tab 1 PA QL=60 EA/30 Days OPSUMIT 10MG TAB 1 NDS PA QL=30 EA/30 Days TRACLEER 32MG TAB FOR ORAL SUSP 1 NDS PA QL=120 EA/30 Days PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS alyq 20mg tab 1 PA sildenafil 20mg tab 1 PA tadalafil 20mg tab 1 PA PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI 1000MCG TAB 1 NDS PA UPTRAVI 1200MCG TAB 1 NDS PA UPTRAVI 1400MCG TAB 1 NDS PA UPTRAVI 1600MCG TAB 1 NDS PA UPTRAVI 200MCG TAB 1 NDS PA UPTRAVI 400MCG TAB 1 NDS PA UPTRAVI 600MCG TAB 1 NDS PA UPTRAVI 800MCG TAB 1 NDS PA UPTRAVI TITRATION PACK 1 NDS PA QL=200 EA/28 Days PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ADEMPAS 0.5MG TAB 1 NDS PA ADEMPAS 1.5MG TAB 1 NDS PA ADEMPAS 1MG TAB 1 NDS PA ADEMPAS 2.5MG TAB 1 NDS PA ADEMPAS 2MG TAB 1 NDS PA SINUS NODE INHIBITORS CORLANOR 5MG TAB 1 PA CORLANOR 5MG/5ML ORAL SOLN 1 PA CORLANOR 7.5MG TAB 1 PA TRANSTHYRETIN STABILIZERS VYNDAMAX 61MG CAP 1 NDS PA QL=30 EA/30 Days VYNDAQEL 20MG CAP 1 NDS PA QL=120 EA/30 Days VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) VERQUVO 10MG TAB 1 PA QL=30 EA/30 Days VERQUVO 2.5MG TAB 1 PA QL=30 EA/30 Days VERQUVO 5MG TAB 1 PA QL=30 EA/30 Days CEPHALOSPORINS CEPHALOSPORIN COMBINATIONS AVYCAZ 500-2000MG INJ 1 NDS ZERBAXA 1000-500MG INJ 1 NDS CEPHALOSPORINS - 1ST GENERATION cefadroxil 1000mg tab 1 cefadroxil 100mg/ml susp 1 cefadroxil 500mg cap 1 cefadroxil 50mg/ml susp 1 cefazolin 1000mg inj 1 cefazolin 200mg/ml inj 1 cefazolin 500mg inj 1 cephalexin 250mg cap 1 cephalexin 25mg/ml susp 1 cephalexin 500mg cap 1 cephalexin 50mg/ml susp 1 CEPHALOSPORINS - 2ND GENERATION cefaclor 250mg cap 1 cefaclor 500mg cap 1 cefotetan 1000mg inj 1 cefotetan 2000mg inj 1 cefoxitin 1000mg inj 1 cefoxitin 2000mg inj 1 cefoxitin 200mg/ml inj 1 cefprozil 250mg tab 1 cefprozil 25mg/ml susp 1 cefprozil 500mg tab 1 cefprozil 50mg/ml susp 1 1500mg inj 1 cefuroxime 250mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS cefuroxime 500mg tab 1 cefuroxime 750mg inj 1 cefuroxime 95mg/ml inj 1 CEPHALOSPORINS - 3RD GENERATION cefdinir 25mg/ml susp 1 cefdinir 300mg cap 1 cefdinir 50mg/ml susp 1 cefixime 20mg/ml susp 1 cefixime 400mg cap 1 cefixime 40mg/ml susp 1 cefpodoxime 100mg tab 1 cefpodoxime 10mg/ml susp 1 cefpodoxime 200mg tab 1 cefpodoxime 20mg/ml susp 1 ceftazidime 1000mg inj 1 ceftazidime 2000mg inj 1 ceftazidime 200mg/ml inj 1 ceftriaxone 1000mg inj 1 ceftriaxone 100mg/ml inj 1 ceftriaxone 2000mg inj 1 ceftriaxone 250mg inj 1 ceftriaxone 500mg inj 1 tazicef 1gm inj 1 tazicef 2gm inj 1 tazicef 6gm inj 1 CEPHALOSPORINS - 4TH GENERATION cefepime 1000mg inj 1 cefepime 2000mg inj 1 CEPHALOSPORINS - 5TH GENERATION TEFLARO 400MG INJ 1 NDS TEFLARO 600MG INJ 1 NDS CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL altavera 28 day pack 1 alyacen 1/35 28 day pack 1 amethia 91 day pack 1 apri 28 day pack 1 aranelle 28 pack 1 ashlyna 91 day pack 1 aubra 28 day pack 1 aviane 28 pack 1 balziva 28 day pack 1 blisovi 21 fe 1.5/30 28 day 1 blisovi 24 fe 1/20 28 day pack 1 briellyn 28 day pack 1 camreselo 91 day pack 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS caziant 28 day pack 1 cryselle 28 pack 1 cyclafem 1/35 28 day pack 1 cyclafem 7/7/7 28 day pack 1 cyred 28 day pack 1 desogestrel /ethinyl estradiol 0.15mg-30mcg tab 1 desogestrel/ethinyl estradiol pack 1 dolishale 28 day pack 1 drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg 1 pack drospirenone 3mg/ethinyl estradiol 0.03mg/inert 1 ingredients 1mg pack emoquette pack 1 enpresse 28 day pack 1 enskyce 28 day pack 1 estarylla 28 day pack 1 ethinyl estradiol 0.01mg/ethinyl estradiol 1 0.02mg/levonorgestrel 0.1mg 91 day pack ethinyl estradiol 0.01mg/ethinyl estradiol 1 0.03mg/levonorgestrel 0.15mg pack ethinyl estradiol 0.025mg/ferrous fumarate 1 75mg/norethindrone 0.8mg pack ethinyl estradiol 0.025mg/inert/norgestimate 1 0.18mg/0.215mg/0.25mg pack ethinyl estradiol 0.02mg/ferrous fumarate 1 75mg/norethindrone acetate 1mg 21 day pack ethinyl estradiol 0.02mg/inert ingredients 1 1mg/levonorgestrel 0.1mg pack ethinyl estradiol 0.02mg/norethindrone acetate 1mg 1 pack ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack 1 ethinyl estradiol 0.035mg/ferrous fumarate 1 75mg/norethindrone 0.4mg pack ethinyl estradiol 0.035mg/inert/norgestimate 1 0.18mg/0.215mg/0.25mg pack ethinyl estradiol 0.035mg/norgestimate 0.25mg pack 1 ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 1 0.05mg/ 0.075mg pack ethinyl estradiol 0.03mg/inert ingredients 1 1mg/levonorgestrel 0.15mg pack ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 1 day pack ethinyl estradiol 0.05mg/ethynodiol 1mg/inert 1 ingredients 1mg 28 day pack ethinyl estradiol/levonorgestrel 91 day pack 1 falmina 28 day pack 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS fayosim 91 day pack 1 femynor 28 day pack 1 hailey 24 fe 28 day pack 1 iclevia 91 day pack 1 introvale 91 day pack 1 isibloom 28 day pack 1 jasmiel 28 day pack 1 juleber 28 day pack 1 junel 1.5/30 21 day pack 1 junel 1/20 21 day pack 1 junel fe 1.5/30 28 day pack 1 junel fe 1/20 28 day pack 1 junel fe 24 1/20 28 day pack 1 kaitlib fe 28 day pack 1 kariva 28 day pack 1 kelnor 1/35 28 day pack 1 kelnor 1/50 28 day pack 1 kurvelo pack 1 larin 1.5/30 pack 1 larin 1/20 pack 1 larin fe 1.5/30 pack 1 larin fe 1/20 pack 1 larissia 28 day pack 1 layolis fe 28 pack 1 leena 28 day pack 1 lessina 28 day pack 1 levonest 28 day pack 1 levora 0.15/30 28 day pack 1 loryna 28 day pack 1 low-ogestrel 28 day pack 1 lutera 28 day pack 1 marlissa 28 day pack 1 microgestin 1.5/30 21 day pack 1 microgestin 1/20 21 day pack 1 microgestin fe 1.5/30 28 day pack 1 microgestin fe 1/20 28 day pack 1 mili 28 day pack 1 NATAZIA 28 DAY PACK 1 necon 0.5/35 28 day pack 1 nikki 28 day pack 1 nortrel 0.5/35 28 day pack 1 nortrel 1/35 21 day pack 1 nortrel 1/35 28 day pack 1 nortrel 7/7/7 28 day pack 1 nylia 7/7/7 28 day pack 1 nymyo 28 day pack 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ocella 28 day pack 1 orsythia 28 day pack 1 pimtrea pack 1 pirmella 1/35 28 day pack 1 portia 28 day pack 1 previfem 28 day pack 1 reclipsen 28 day pack 1 rivelsa 91 day pack 1 setlakin 91 day pack 1 sprintec 28 day pack 1 sronyx 28 day pack 1 syeda 28 day pack 1 tarina 24 fe 1/20 28 day pack 1 tarina fe 1/20 28 day pack 1 tilia fe pack 1 tri-estarylla 28 day pack 1 tri-legest 28 day pack 1 tri-lo-estarylla 28 day pack 1 tri-lo-sprintec 28 day pack 1 tri-mili 28 day pack 1 tri-nymyo 28 day pack 1 tri-previfem 28 day pack 1 tri-sprintec 28 day pack 1 tri-vylibra 28 day pack 1 tri-vylibra lo 28 day pack 1 trivora 28 day pack 1 velivet 28 day pack 1 vestura 3-0.02mg pack 1 vienva 28 day pack 1 vyfemla 28 day pack 1 vylibra 28 day pack 1 wymzya fe 28 day pack 1 zarah pack 1 zovia 1/35e 28 day pack 1 COMBINATION CONTRACEPTIVES - TRANSDERMAL XULANE 0.00146-0.00625MG/HR PATCH 1 zafemy 150-35mcg/24hr patch 1 COMBINATION CONTRACEPTIVES - VAGINAL eluryng 0.000625-0.005mg/hr vaginal system 1 etonogestrel-ethinyl estradiol 0.120-0.015mg/24hr 1 vaginal ring PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate 150mg/ml inj 1 medroxyprogesterone acetate 150mg/ml syringe 1 PROGESTIN CONTRACEPTIVES - ORAL camila 28 day 0.35mg pack 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS deblitane 28 day 0.35mg pack 1 errin 28 day 0.35mg pack 1 incassia 28 day 0.35mg pack 1 lyleq 28 day 0.35mg pack 1 lyza 0.35mg pack 1 nora-be 28 day 0.35mg pack 1 norethindrone 0.35mg pack 1 sharobel 28 day 0.35mg pack 1 SLYND TAB 4MG 1 CORTICOSTEROIDS GLUCOCORTICOSTEROIDS budesonide 3mg dr cap 1 budesonide 9mg er tab 1 PA QL=30 EA/30 Days dexamethasone 0.1mg/ml oral soln 1 dexamethasone 0.5mg tab 1 dexamethasone 0.75mg tab 1 dexamethasone 1.5mg tab 1 DEXAMETHASONE 1MG TAB 1 DEXAMETHASONE 2MG TAB 1 dexamethasone 4mg tab 1 dexamethasone 6mg tab 1 hydrocortisone 10mg tab 1 hydrocortisone 20mg tab 1 hydrocortisone 5mg tab 1 MEDROL 2MG TAB 1 PA BvD methylprednisolone 16mg tab 1 PA BvD methylprednisolone 32mg tab 1 PA BvD methylprednisolone 4mg pack 1 methylprednisolone 4mg tab 1 PA BvD methylprednisolone 8mg tab 1 PA BvD prednisolone 10mg odt 1 PA BvD prednisolone 15mg odt 1 PA BvD prednisolone 1mg/ml oral soln 1 PA BvD prednisolone 30mg odt 1 PA BvD PREDNISOLONE 3MG/ML ORAL SOLN 1 PA BvD prednisone 10mg tab 1 PA BvD prednisone 1mg tab 1 PA BvD PREDNISONE 1MG/ML ORAL SOLN 1 PA BvD prednisone 2.5mg tab 1 PA BvD prednisone 20mg tab 1 PA BvD prednisone 50mg tab 1 PA BvD prednisone 5mg tab 1 PA BvD PREDNISONE 5MG/ML ORAL SOLN 1 PA BvD MINERALOCORTICOIDS fludrocortisone 0.1mg tab 1 COUGH/COLD/ALLERGY You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS COUGH/COLD/ALLERGY COMBINATIONS CLARINEX-D 2.5-120MG ER TAB 1 PHENYLEPHRINE 1MG/ML/PROMETHAZINE 1 1.25MG/ML ORAL SOLN MUCOLYTICS acetylcysteine 100mg/ml inh soln 1 PA BvD acetylcysteine 200mg/ml inh soln 1 PA BvD DERMATOLOGICALS ACNE PRODUCTS accutane 20mg cap 1 accutane 30mg cap 1 accutane 40mg cap 1 adapalene 0.1% cream 1 PA adapalene 0.1% gel 1 PA adapalene 0.3% gel 1 PA adapalene/benzoyl peroxide 0.1-2.5% gel 1 PA amnesteem 10mg cap 1 amnesteem 20mg cap 1 amnesteem 40mg cap 1 avita 0.025% cream 1 PA avita 0.025% gel 1 PA claravis 10mg cap 1 claravis 20mg cap 1 claravis 30mg cap 1 claravis 40mg cap 1 clindacin 1% pad 1 QL=120 EA/30 Days clindamycin 1% gel 1 QL=180 GM/30 Days clindamycin 1% lotion 1 QL=180 ML/30 Days clindamycin 1% pad 1 QL=120 EA/30 Days clindamycin 1% topical soln 1 QL=300 ML/30 Days clindamycin/benzoyl peroxide 1-5% gel 1 QL=100 GM/30 Days EPIDUO 0.3-2.5% GEL 1 PA ERY 2% PAD 1 erythromycin 2% gel 1 erythromycin 2% topical soln 1 erythromycin/benzoyl peroxide 5-3% gel 1 isotretinoin 10mg cap 1 isotretinoin 20mg cap 1 isotretinoin 30mg cap 1 isotretinoin 40mg cap 1 myorisan 10mg cap 1 myorisan 20mg cap 1 myorisan 30mg cap 1 myorisan 40mg cap 1 sulfacetamide sodium 10% lotion 1 tretinoin 0.01% gel 1 PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS tretinoin 0.025% cream 1 PA tretinoin 0.025% gel 1 PA tretinoin 0.04% gel 1 PA tretinoin 0.05% cream 1 PA tretinoin 0.05% gel 1 PA tretinoin 0.1% cream 1 PA tretinoin 0.1% gel 1 PA zenatane 10mg cap 1 zenatane 20mg cap 1 zenatane 30mg cap 1 zenatane 40mg cap 1 ANTIBIOTICS - TOPICAL gentamicin 0.1% cream 1 QL=120 GM/30 Days gentamicin 0.1% ointment 1 QL=120 GM/30 Days mupirocin 2% ointment 1 QL=220 GM/30 Days ANTIFUNGALS - TOPICAL betamethasone/clotrimazole 1-0.05% cream 1 QL=270 GM/30 Days betamethasone/clotrimazole 1-0.05% lotion 1 QL=180 ML/30 Days ciclopirox 0.77% cream 1 QL=270 GM/30 Days ciclopirox 0.77% gel 1 QL=300 GM/30 Days ciclopirox 0.77% lotion 1 QL=240 ML/30 Days ciclopirox 1% shampoo 1 QL=240 ML/30 Days ciclopirox 8% topical soln 1 QL=13.20 ML/30 Days clotrimazole 1% cream 1 QL=180 GM/30 Days clotrimazole 1% topical soln 1 QL=240 ML/30 Days econazole nitrate 1% cream 1 QL=255 GM/30 Days ketoconazole 2% cream 1 QL=240 GM/30 Days ketoconazole 2% foam 1 QL=300 GM/30 Days ketoconazole 2% shampoo 1 QL=360 ML/30 Days ketodan 2% foam 1 QL=300 GM/30 Days naftifine 1% cream 1 QL=270 GM/30 Days naftifine 2% cream 1 QL=240 GM/30 Days nyamyc 100000unit/gm topical powder 1 QL=480 GM/30 Days nystatin 100000unit/ml cream 1 QL=240 GM/30 Days nystatin 100unit/mg ointment 1 QL=240 GM/30 Days nystatin 100unit/mg topical powder 1 QL=480 GM/30 Days nystop 100000unit/gm topical powder 1 QL=480 GM/30 Days ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac sodium 1% gel 1 QL=1000 GM/30 Days diclofenac sodium 1.5% topical soln 1 QL=450 ML/30 Days ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL diclofenac sodium 3% gel 1 PA QL=300 GM/30 Days FLUOROPLEX 1% CREAM 1 FLUOROURACIL 2% TOPICAL SOLN 1 fluorouracil 5% cream 1 FLUOROURACIL 5% TOPICAL SOLN 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PICATO 0.015% GEL 1 QL=3 EA/10 Days PICATO 0.05% GEL 1 QL=2 EA/10 Days TARGRETIN 1% GEL 1 NDS PA NSO VALCHLOR 0.016% GEL 1 NDS PA NSO QL=240 GM/30 Days ANTIPSORIATICS acitretin 10mg cap 1 acitretin 17.5mg cap 1 acitretin 25mg cap 1 calcipotriene 0.005% cream 1 PA QL=240 GM/30 Days calcipotriene 0.005% ointment 1 PA QL=240 GM/30 Days calcipotriene 0.005% topical soln 1 PA methoxsalen 10mg cap 1 SKYRIZI 150MG DOSE PACK 75MG/0.83ML 1 PA SKYRIZI 150MG/ML AUTO-INJECTOR 1 PA SKYRIZI 150MG/ML SYRINGE 1 PA STELARA 45MG/0.5ML INJ 1 PA STELARA 45MG/0.5ML SYRINGE 1 PA STELARA 90MG/ML SYRINGE 1 PA TALTZ 80MG/ML AUTO-INJECTOR 1 NDS PA TALTZ 80MG/ML SYRINGE 1 NDS PA tazarotene 0.1% cream 1 TAZORAC 0.05% CREAM 1 TAZORAC 0.05% GEL 1 TAZORAC 0.1% GEL 1 TREMFYA 100MG/ML AUTO-INJECTOR 1 NDS PA TREMFYA 100MG/ML SYRINGE 1 NDS PA ANTISEBORRHEIC PRODUCTS selenium sulfide 2.5% shampoo 1 ANTIVIRALS - TOPICAL acyclovir 5% ointment 1 QL=60 GM/30 Days DENAVIR 1% CREAM 1 QL=5 GM/7 Days BURN PRODUCTS silver sulfadiazine 1% cream 1 ssd 1% cream 1 SULFAMYLON 85MG/GM CREAM 1 CORTICOSTEROIDS - TOPICAL ala-cort 1% cream 1 ala-cort 2.5% cream 1 alclometasone dipropionate 0.05% cream 1 alclometasone dipropionate 0.05% ointment 1 betamethasone 0.05% aug cream 1 betamethasone 0.05% aug lotion 1 betamethasone 0.05% aug ointment 1 betamethasone 0.05% cream 1 BETAMETHASONE 0.05% GEL 1 betamethasone 0.05% lotion 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS betamethasone 0.05% ointment 1 betamethasone 0.1% cream 1 betamethasone 0.1% lotion 1 betamethasone 0.1% ointment 1 calcipotriene/betamethasone 0.005-0.064% ointment 1 PA QL=420 GM/30 Days clobetasol propionate 0.05% cream 1 clobetasol propionate 0.05% e cream 1 clobetasol propionate 0.05% foam 1 clobetasol propionate 0.05% gel 1 clobetasol propionate 0.05% lotion 1 clobetasol propionate 0.05% ointment 1 clobetasol propionate 0.05% shampoo 1 clobetasol propionate 0.05% spray 1 clobetasol propionate 0.05% topical soln 1 QL=450 ML/30 Days clodan 0.05% shampoo 1 desonide 0.05% ointment 1 desoximetasone 0.05% gel 1 QL=240 GM/30 Days desoximetasone 0.25% cream 1 QL=300 GM/30 Days desoximetasone 0.25% ointment 1 QL=300 GM/30 Days fluocinolone acetonide 0.01% cream 1 fluocinolone acetonide 0.01% topical soln 1 fluocinolone acetonide 0.025% cream 1 fluocinolone acetonide 0.025% ointment 1 fluocinolone acetonide 0.1mg/ml oil 1 fluocinonide 0.05% cream 1 fluocinonide 0.05% e cream 1 fluocinonide 0.05% gel 1 fluocinonide 0.05% ointment 1 fluocinonide 0.05% topical soln 1 fluocinonide 0.1% cream 1 fluticasone propionate 0.005% ointment 1 fluticasone propionate 0.05% cream 1 halobetasol propionate 0.05% cream 1 halobetasol propionate 0.05% ointment 1 hydrocortisone 1% cream 1 hydrocortisone 2.5% cream 1 hydrocortisone 2.5% lotion 1 hydrocortisone 2.5% ointment 1 mometasone furoate 0.1% cream 1 mometasone furoate 0.1% lotion 1 mometasone furoate 0.1% ointment 1 PREDNICARBATE 0.1% OINTMENT 1 triamcinolone acetonide 0.0147% spray 1 triamcinolone acetonide 0.025% cream 1 triamcinolone acetonide 0.025% lotion 1 triamcinolone acetonide 0.025% ointment 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS triamcinolone acetonide 0.1% cream 1 triamcinolone acetonide 0.1% lotion 1 triamcinolone acetonide 0.1% ointment 1 triamcinolone acetonide 0.5% cream 1 triamcinolone acetonide 0.5% ointment 1 triderm 0.1% cream 1 triderm 0.5% cream 1 ECZEMA AGENTS DUPIXENT 200MG/1.14ML SYRINGE 1 NDS PA DUPIXENT 300MG/2ML AUTO-INJECTOR 1 NDS PA DUPIXENT 300MG/2ML SYRINGE 1 NDS PA EMOLLIENTS ammonium lactate 12% cream 1 ammonium lactate 12% lotion 1 ENZYMES - TOPICAL SANTYL 250UNIT/GM OINTMENT 1 QL=90 GM/30 Days IMMUNOMODULATING AGENTS - TOPICAL imiquimod 5% cream 1 ZYCLARA 2.5% CREAM 1 IMMUNOSUPPRESSIVE AGENTS - TOPICAL pimecrolimus 1% cream 1 tacrolimus 0.03% ointment 1 QL=100 GM/30 Days tacrolimus 0.1% ointment 1 QL=100 GM/30 Days KERATOLYTIC/ANTIMITOTIC AGENTS podofilox 0.5% topical soln 1 LOCAL ANESTHETICS - TOPICAL lidocaine 4% topical soln 1 lidocaine 5% ointment 1 PA QL=107 GM/30 Days lidocaine 5% patch 1 PA QL=90 EA/30 Days lidocaine/prilocaine 2.5-2.5% cream 1 QL=60 GM/30 Days ROSACEA AGENTS azelaic acid 15% gel 1 FINACEA 15% FOAM 1 metronidazole 0.75% cream 1 metronidazole 0.75% gel 1 metronidazole 0.75% lotion 1 metronidazole 1% gel 1 SCABICIDES & PEDICULICIDES lindane 1% shampoo 1 malathion 0.5% lotion 1 permethrin 5% cream 1 WOUND CARE PRODUCTS REGRANEX 0.01% GEL 1 QL=30 GM/15 Days DIGESTIVE AIDS DIGESTIVE ENZYMES CREON 120000-76000-24000UNIT DR CAP 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CREON 15000-9500-3000UNIT DR CAP 1 CREON 30000-19000-6000UNIT DR CAP 1 CREON 36000-114000-180000UNIT DR CAP 1 CREON 60000-38000-12000UNIT DR CAP 1 SUCRAID 8500UNIT/ML ORAL SOLN 1 NDS PA ZENPEP 105000-79000-25000UNIT DR CAP 1 ST ZENPEP 14000-10000-3000UNIT DR CAP 1 ST ZENPEP 24000-17000-5000UNIT DR CAP 1 ST ZENPEP 40000-126000-168000UNIT DR CAP 1 ST ZENPEP 42000-32000-10000UNIT DR CAP 1 ST ZENPEP 63000-47000-15000UNIT DR CAP 1 ST ZENPEP 84000-63000-20000UNIT DR CAP 1 ST DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide 125mg tab 1 acetazolamide 250mg tab 1 acetazolamide 500mg er cap 1 methazolamide 25mg tab 1 methazolamide 50mg tab 1 DIURETIC COMBINATIONS amiloride 5mg/hydrochlorothiazide 50mg tab 1 hydrochlorothiazide 25mg/spironolactone 25mg tab 1 hydrochlorothiazide 25mg/triamterene 37.5mg cap 1 hydrochlorothiazide 25mg/triamterene 37.5mg tab 1 hydrochlorothiazide 50mg/triamterene 75mg tab 1 LOOP DIURETICS bumetanide 0.25mg/ml inj 1 bumetanide 0.5mg tab 1 bumetanide 1mg tab 1 bumetanide 2mg tab 1 ethacrynic acid 25mg tab 1 furosemide 10mg/ml inj 1 furosemide 10mg/ml oral soln 1 furosemide 10mg/ml syringe 1 furosemide 20mg tab 1 furosemide 40mg tab 1 furosemide 80mg tab 1 FUROSEMIDE 8MG/ML ORAL SOLN 1 torsemide 100mg tab 1 torsemide 10mg tab 1 torsemide 20mg tab 1 torsemide 5mg tab 1 POTASSIUM SPARING DIURETICS amiloride 5mg tab 1 spironolactone 100mg tab 1 spironolactone 25mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS spironolactone 50mg tab 1 triamterene 100mg cap 1 triamterene 50mg cap 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone 25mg tab 1 chlorthalidone 50mg tab 1 DIURIL 250MG/5ML SUSP 1 hydrochlorothiazide 12.5mg cap 1 hydrochlorothiazide 12.5mg tab 1 hydrochlorothiazide 25mg tab 1 hydrochlorothiazide 50mg tab 1 indapamide 1.25mg tab 1 indapamide 2.5mg tab 1 metolazone 10mg tab 1 metolazone 2.5mg tab 1 metolazone 5mg tab 1 ENDOCRINE AND METABOLIC AGENTS - MISC. ADRENAL STEROID INHIBITORS ISTURISA 10MG TAB 1 NDS PA QL=180 EA/30 Days ISTURISA 1MG TAB 1 NDS PA QL=240 EA/30 Days ISTURISA 5MG TAB 1 NDS PA QL=60 EA/30 Days BONE DENSITY REGULATORS 0.933MG/ML ORAL SOLN 1 alendronic acid 10mg tab 1 alendronic acid 35mg tab 1 alendronic acid 70mg tab 1 FORTEO 600MCG/2.4ML PEN INJ 1 NDS ibandronic acid 150mg tab 1 QL=1 EA/30 Days NATPARA 100MCG CARTRIDGE 1 NDS PA NATPARA 25MCG CARTRIDGE 1 NDS PA NATPARA 50MCG CARTRIDGE 1 NDS PA NATPARA 75MCG CARTRIDGE 1 NDS PA PROLIA 60MG/ML SYRINGE 1 PA risedronate sodium 150mg tab 1 risedronate sodium 30mg tab 1 risedronate sodium 35mg (12) pack 1 risedronate sodium 35mg (4) pack 1 risedronate sodium 35mg tab 1 risedronate sodium 5mg tab 1 salmon 200unit/act nasal spray 1 TYMLOS 3120MCG/1.56ML PEN INJ 1 NDS XGEVA 120MG/1.7ML INJ 1 NDS PA GNRH/LHRH ANTAGONISTS ORILISSA 150MG TAB 1 PA QL=30 EA/30 Days ORILISSA 200MG TAB 1 PA QL=60 EA/30 Days GROWTH HORMONE RECEPTOR ANTAGONISTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS SOMAVERT 10MG INJ 1 NDS PA SOMAVERT 15MG INJ 1 NDS PA SOMAVERT 20MG INJ 1 NDS PA SOMAVERT 25MG INJ 1 NDS PA SOMAVERT 30MG INJ 1 NDS PA GROWTH HORMONES GENOTROPIN 0.2MG SYRINGE 1 NDS PA GENOTROPIN 0.4MG SYRINGE 1 NDS PA GENOTROPIN 0.6MG SYRINGE 1 NDS PA GENOTROPIN 0.8MG SYRINGE 1 NDS PA GENOTROPIN 1.2MG SYRINGE 1 NDS PA GENOTROPIN 1.4MG SYRINGE 1 NDS PA GENOTROPIN 1.6MG SYRINGE 1 NDS PA GENOTROPIN 1.8MG SYRINGE 1 NDS PA GENOTROPIN 12MG CARTRIDGE 1 NDS PA GENOTROPIN 1MG SYRINGE 1 NDS PA GENOTROPIN 2MG SYRINGE 1 NDS PA GENOTROPIN 5MG CARTRIDGE 1 NDS PA HORMONE RECEPTOR MODULATORS OSPHENA 60MG TAB 1 PA raloxifene 60mg tab 1 INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX 40MG/4ML INJ 1 NDS PA LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPANETA PACK 1-MONTH PACK 1 NDS LUPANETA PACK 3-MONTH PACK 1 SYNAREL 2MG/ML NASAL INHALER 1 NDS METABOLIC MODIFIERS calcitriol 0.00025mg cap 1 calcitriol 0.0005mg cap 1 calcitriol 0.001mg/ml oral soln 1 CARBAGLU 200MG TAB FOR ORAL SUSP 1 PA cinacalcet 30mg tab 1 cinacalcet 60mg tab 1 cinacalcet 90mg tab 1 doxercalciferol 0.0005mg cap 1 doxercalciferol 0.001mg cap 1 doxercalciferol 0.0025mg cap 1 GALAFOLD 28 DAY WALLET 123MG PACK 1 NDS PA QL=15 EA/30 Days KUVAN 100MG POWDER FOR ORAL SOLN 1 NDS PA KUVAN 100MG TAB 1 NDS PA KUVAN 500MG POWDER FOR ORAL SOLN 1 NDS PA levocarnitine 100mg/ml oral soln 1 levocarnitine 330mg tab 1 nitisinone 10mg cap 1 NDS PA nitisinone 2mg cap 1 NDS PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS nitisinone 5mg cap 1 NDS PA ORFADIN 20MG CAP 1 NDS PA ORFADIN 4MG/ML SUSP 1 NDS PA PALYNZIQ 10MG/0.5ML SYRINGE 1 NDS PA PALYNZIQ 2.5MG/0.5ML SYRINGE 1 NDS PA PALYNZIQ 20MG/ML SYRINGE 1 NDS PA paricalcitol 0.001mg cap 1 paricalcitol 0.002mg cap 1 paricalcitol 0.004mg cap 1 RAVICTI 1.1GM/ML ORAL SOLN 1 NDS PA sapropterin 100mg powder for oral soln 1 NDS PA sapropterin 100mg tab 1 NDS PA sapropterin 500mg powder for oral soln 1 NDS PA sodium phenylbutyrate 0.94mg/mg oral powder 1 POSTERIOR PITUITARY HORMONES desmopressin acetate 0.01mg/act nasal spray 1 desmopressin acetate 0.1mg tab 1 desmopressin acetate 0.2mg tab 1 PROLACTIN INHIBITORS cabergoline 0.5mg tab 1 SOMATOSTATIC AGENTS octreotide 0.05mg/ml inj 1 octreotide 0.1mg/ml inj 1 octreotide 0.2mg/ml inj 1 octreotide 0.5mg/ml inj 1 octreotide 1mg/ml inj 1 SIGNIFOR 0.3MG/ML INJ 1 NDS PA QL=60 ML/30 Days SIGNIFOR 0.6MG/ML INJ 1 NDS PA QL=60 ML/30 Days SIGNIFOR 0.9MG/ML INJ 1 NDS PA QL=60 ML/30 Days VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE 15MG TAB 1 NDS PA QL=120 EA/30 Days JYNARQUE 30MG TAB 1 NDS PA QL=120 EA/30 Days JYNARQUE 45/15 THERAPY PACK 1 NDS PA QL=60 EA/30 Days JYNARQUE 60/30 THERAPY PACK 1 NDS PA QL=60 EA/30 Days JYNARQUE 90/30 THERAPY PACK 1 NDS PA QL=60 EA/30 Days JYNARQUE TAB 15/15MG THERAPY PACK 1 NDS PA QL=60 EA/30 Days JYNARQUE TAB 30/15MG THERAPY PACK 1 NDS PA QL=60 EA/30 Days ESTROGENS ESTROGEN COMBINATIONS amabelz 0.5/0.1mg 28 day pack 1 amabelz 1/0.5mg 28 day pack 1 COMBIPATCH 0.00208-0.00583MG/HR PATCH 1 COMBIPATCH 0.00208-0.0104MG/HR PATCH 1 estradiol 0.5mg/norethindrone acetate 0.1mg pack 1 estradiol 1mg/norethindrone acetate 0.5mg pack 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ethinyl estradiol 0.0025mg/norethindrone acetate 1 0.5mg pack ethinyl estradiol 0.005mg/norethindrone acetate 1mg 1 pack fyavolv 0.0025-0.5mg tab 1 fyavolv 0.005-1mg tab 1 jinteli 0.005-1mg tab 1 mimvey pack 1 ORIAHNN 28 DAY KIT PACK 1 PA QL=56 EA/28 Days PREMPHASE 28 DAY PACK 1 PREMPRO 0.3/1.5MG 28 DAY PACK 1 PREMPRO 0.45/1.5 28 DAY PACK 1 PREMPRO 0.625/2.5MG 28 DAY PACK 1 PREMPRO 0.625/5MG 28 DAY PACK 1 ESTROGENS dotti 0.025mg/24hr patch 1 dotti 0.0375mg/24hr patch 1 dotti 0.05mg/24hr patch 1 dotti 0.075mg/24hr patch 1 dotti 0.1mg/24hr patch 1 estradiol 0.00104mg/hr twice weekly patch 1 estradiol 0.00104mg/hr weekly patch 1 estradiol 0.00156mg/hr twice weekly patch 1 estradiol 0.00156mg/hr weekly patch 1 estradiol 0.00208mg/hr twice weekly patch 1 estradiol 0.00208mg/hr weekly patch 1 estradiol 0.0025mg/hr weekly patch 1 estradiol 0.00312mg/hr weekly patch 1 estradiol 0.00313mg/hr twice weekly patch 1 estradiol 0.00417mg/hr twice weekly patch 1 estradiol 0.00417mg/hr weekly patch 1 estradiol 0.5mg tab 1 estradiol 1mg tab 1 estradiol 2mg tab 1 estradiol valerate 20mg/ml inj 1 estradiol valerate 40mg/ml inj 1 lyllana 0.025mg/24hr patch 1 lyllana 0.0375mg/24hr patch 1 lyllana 0.05mg/24hr patch 1 lyllana 0.075mg/24hr patch 1 lyllana 0.1mg/24hr patch 1 PREMARIN 0.3MG TAB 1 PREMARIN 0.45MG TAB 1 PREMARIN 0.625MG TAB 1 PREMARIN 0.9MG TAB 1 PREMARIN 1.25MG TAB 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS FLUOROQUINOLONES FLUOROQUINOLONES BAXDELA 450MG TAB 1 PA QL=60 EA/30 Days ciprofloxacin 250mg tab 1 ciprofloxacin 2mg/ml inj 1 ciprofloxacin 500mg tab 1 ciprofloxacin 750mg tab 1 levofloxacin 250mg tab 1 levofloxacin 25mg/ml inj 1 levofloxacin 25mg/ml oral soln 1 levofloxacin 500mg tab 1 levofloxacin 5mg/ml (100ml) inj 1 levofloxacin 5mg/ml (150ml) inj 1 levofloxacin 750mg tab 1 moxifloxacin 1.6mg/ml inj 1 moxifloxacin 400mg tab 1 ofloxacin 400mg tab 1 GASTROINTESTINAL AGENTS - MISC. AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE 3MG TAB 1 PA BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM 250MG CAP 1 NDS PA CHOLBAM 50MG CAP 1 NDS PA FARNESOID X RECEPTOR (FXR) AGONISTS OCALIVA 10MG TAB 1 NDS PA QL=30 EA/30 Days OCALIVA 5MG TAB 1 NDS PA QL=30 EA/30 Days GALLSTONE SOLUBILIZING AGENTS CHENODAL 250MG TAB 1 NDS ursodiol 250mg tab 1 ursodiol 300mg cap 1 ursodiol 500mg tab 1 GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium 20mg/ml oral soln 1 GASTROINTESTINAL STIMULANTS metoclopramide 10mg tab 1 metoclopramide 1mg/ml oral soln 1 metoclopramide 5mg tab 1 INFLAMMATORY BOWEL AGENTS balsalazide disodium 750mg cap 1 CIMZIA 200MG INJ 1 NDS PA CIMZIA 200MG/ML SYRINGE 1 NDS PA DIPENTUM 250MG CAP 1 mesalamine 1000mg rectal supp 1 mesalamine 1200mg dr tab 1 mesalamine 375mg er cap 1 mesalamine 400mg dr cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS mesalamine 66.7mg/ml enema 1 mesalamine 800mg dr tab 1 sulfasalazine 500mg dr tab 1 sulfasalazine 500mg tab 1 INTESTINAL ACIDIFIERS enulose 10gm/15ml oral soln 1 generlac 10gm/15ml oral soln 1 IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron 0.5mg tab 1 alosetron 1mg tab 1 VIBERZI 100MG TAB 1 PA VIBERZI 75MG TAB 1 PA PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK 12.5MG TAB 1 PA MOVANTIK 25MG TAB 1 PA RELISTOR 12MG/0.6ML INJ 1 PA RELISTOR 12MG/0.6ML SYRINGE 1 PA RELISTOR 8MG/0.4ML SYRINGE 1 PA SYMPROIC 0.2MG TAB 1 PA PHOSPHATE BINDER AGENTS AURYXIA 210MG TAB 1 PA calcium acetate 667mg cap 1 calcium acetate 667mg tab 1 FOSRENOL 1000MG ORAL POWDER 1 FOSRENOL 750MG ORAL POWDER 1 lanthanum carbonate 1000mg chew tab 1 lanthanum carbonate 500mg chew tab 1 lanthanum carbonate 750mg chew tab 1 PHOSLYRA 667MG/5ML ORAL SOLN 1 sevelamer carbonate 2400mg powder for oral susp 1 sevelamer carbonate 800mg powder for oral susp 1 sevelamer carbonate 800mg tab 1 SHORT BOWEL SYNDROME (SBS) AGENTS GATTEX 5MG INJ 1 NDS PA GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS potassium citrate 10meq er tab 1 potassium citrate 15meq er tab 1 potassium citrate 5meq er tab 1 CYSTINOSIS AGENTS CYSTAGON 150MG CAP 1 CYSTAGON 50MG CAP 1 GENITOURINARY IRRIGANTS sodium chloride 0.154meq/ml soln 1 INTERSTITIAL CYSTITIS AGENTS ELMIRON 100MG CAP 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PROSTATIC HYPERTROPHY AGENTS alfuzosin 10mg er tab 1 0.5mg cap 1 dutasteride 0.5mg/tamsulosin 0.4mg cap 1 finasteride 5mg tab 1 silodosin 4mg cap 1 silodosin 8mg cap 1 tamsulosin 0.4mg cap 1 URINARY STONE AGENTS LITHOSTAT 250MG TAB 1 THIOLA 100MG DR TAB 1 THIOLA 300MG DR TAB 1 tiopronin 100mg tab 1 GOUT AGENTS GOUT AGENT COMBINATIONS colchicine 0.5mg/probenecid 500mg tab 1 GOUT AGENTS allopurinol 100mg tab 1 allopurinol 300mg tab 1 febuxostat 40mg tab 1 ST febuxostat 80mg tab 1 ST MITIGARE 0.6MG CAP 1 URICOSURICS probenecid 500mg tab 1 HEMATOLOGICAL AGENTS - MISC. BRADYKININ B2 RECEPTOR ANTAGONISTS icatibant 10mg/ml syringe 1 NDS PA COMPLEMENT INHIBITORS BERINERT 500UNIT INJ 1 NDS PA CINRYZE 500UNIT INJ 1 NDS PA HAEGARDA 2000UNIT INJ 1 NDS PA HAEGARDA 3000UNIT INJ 1 NDS PA RUCONEST 2100UNIT INJ 1 NDS PA HEMATAOLOGIC - TYROSINE KINASE INHIBITORS TAVALISSE 100MG TAB 1 NDS PA QL=60 EA/30 Days TAVALISSE 150MG TAB 1 NDS PA QL=60 EA/30 Days HEMATORHEOLOGIC AGENTS pentoxifylline 400mg er tab 1 PLASMA KALLIKREIN INHIBITORS TAKHZYRO 300MG/2ML INJ 1 NDS PA QL=4 ML/28 Days PLATELET AGGREGATION INHIBITORS anagrelide 0.5mg cap 1 anagrelide 1mg cap 1 aspirin 25mg/dipyridamole 200mg er cap 1 BRILINTA 60MG TAB 1 BRILINTA 90MG TAB 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CABLIVI 11MG INJ 1 NDS PA QL=30 EA/30 Days cilostazol 100mg tab 1 cilostazol 50mg tab 1 clopidogrel 75mg tab 1 dipyridamole 25mg tab 1 dipyridamole 50mg tab 1 dipyridamole 75mg tab 1 prasugrel 10mg tab 1 prasugrel 5mg tab 1 HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE CERDELGA 84MG CAP 1 NDS PA QL=60 EA/30 Days miglustat 100mg cap 1 NDS PA AGENTS FOR SICKLE CELL ANEMIA DROXIA 200MG CAP 1 DROXIA 300MG CAP 1 DROXIA 400MG CAP 1 ENDARI 5GM POWDER FOR ORAL SOLN 1 NDS PA QL=180 EA/30 Days OXBRYTA 500MG TAB 1 NDS PA QL=90 EA/30 Days HEMATOPOIETIC GROWTH FACTORS ARANESP 100MCG/0.5ML SYRINGE 1 PA BvD ST ARANESP 100MCG/ML INJ 1 PA BvD ST ARANESP 10MCG/0.4ML SYRINGE 1 PA BvD ST ARANESP 150MCG/0.3ML SYRINGE 1 PA BvD ST ARANESP 200MCG/0.4ML SYRINGE 1 PA BvD ST ARANESP 200MCG/ML INJ 1 PA BvD ST ARANESP 25MCG/0.42ML SYRINGE 1 PA BvD ST ARANESP 25MCG/ML INJ 1 PA BvD ST ARANESP 300MCG/0.6ML SYRINGE 1 PA BvD ST ARANESP 300MCG/ML INJ 1 PA BvD ST ARANESP 40MCG/0.4ML SYRINGE 1 PA BvD ST ARANESP 40MCG/ML INJ 1 PA BvD ST ARANESP 500MCG/ML SYRINGE 1 PA BvD ST ARANESP 60MCG/0.3ML SYRINGE 1 PA BvD ST ARANESP 60MCG/ML INJ 1 PA BvD ST DOPTELET 20MG TAB 1 NDS PA QL=60 EA/30 Days DOPTELET 40MG DAILY DOSE PACK 1 NDS PA QL=10 EA/5 Days DOPTELET 60MG DAILY DOSE PACK 1 NDS PA QL=15 EA/5 Days FULPHILA 6MG/0.6ML SYRINGE 1 NDS NIVESTYM 300MCG/0.5ML SYRINGE 1 NDS NIVESTYM 300MCG/ML INJ 1 NDS NIVESTYM 480MCG/0.8ML SYRINGE 1 NDS NIVESTYM 480MCG/1.6ML INJ 1 NDS PROMACTA 12.5MG POWDER FOR ORAL SUSP 1 NDS PA PROMACTA 12.5MG TAB 1 NDS PA PROMACTA 25MG POWDER FOR ORAL SUSP 1 NDS PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PROMACTA 25MG TAB 1 NDS PA PROMACTA 50MG TAB 1 NDS PA PROMACTA 75MG TAB 1 NDS PA RETACRIT 10000UNIT/ML INJ 1 PA BvD RETACRIT 20000UNIT/2ML INJ 1 PA BvD RETACRIT 20000UNIT/ML INJ 1 PA BvD RETACRIT 2000UNIT/ML INJ 1 PA BvD RETACRIT 3000UNIT/ML INJ 1 PA BvD RETACRIT 40000UNIT/ML INJ 1 PA BvD RETACRIT 4000UNIT/ML INJ 1 PA BvD ZARXIO 300MCG/0.5ML SYRINGE 1 NDS ZARXIO 480MCG/0.8ML SYRINGE 1 NDS ZIEXTENZO 6MG/0.6ML SYRINGE 1 NDS HEMOSTATICS HEMOSTATICS - SYSTEMIC tranexamic acid 650mg tab 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS BARBITURATE HYPNOTICS phenobarbital 100mg tab 1 phenobarbital 15mg tab 1 phenobarbital 16.2mg tab 1 phenobarbital 30mg tab 1 phenobarbital 32.4mg tab 1 phenobarbital 4mg/ml oral soln 1 phenobarbital 60mg tab 1 phenobarbital 64.8mg tab 1 phenobarbital 97.2mg tab 1 NON-BARBITURATE HYPNOTICS estazolam 1mg tab 1 estazolam 2mg tab 1 eszopiclone 1mg tab 1 QL=30 EA/30 Days eszopiclone 2mg tab 1 QL=30 EA/30 Days eszopiclone 3mg tab 1 QL=30 EA/30 Days FLURAZEPAM 15MG CAP 1 FLURAZEPAM 30MG CAP 1 temazepam 15mg cap 1 temazepam 22.5mg cap 1 temazepam 30mg cap 1 temazepam 7.5mg cap 1 triazolam 0.125mg tab 1 triazolam 0.25mg tab 1 zaleplon 10mg cap 1 QL=30 EA/30 Days zaleplon 5mg cap 1 QL=30 EA/30 Days zolpidem tartrate 10mg tab 1 QL=30 EA/30 Days zolpidem tartrate 5mg tab 1 QL=60 EA/30 Days SELECTIVE MELATONIN RECEPTOR AGONISTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS HETLIOZ 20MG CAP 1 NDS PA QL=30 EA/30 Days ramelteon 8mg tab 1 QL=30 EA/30 Days LAXATIVES LAXATIVE COMBINATIONS CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN 1 GAVILYTE-C ORAL SOLN 1 gavilyte-g powder for oral soln 1 gavilyte-n powder for oral soln 1 peg 3350/electrolyte oral soln 1 peg 3350/kcl/sodium bicarbonate/sodium chloride 1 powder for oral soln trilyte powder for oral soln 1 LAXATIVES - MISCELLANEOUS constulose 10gm/15ml oral soln 1 lactulose 667mg/ml oral soln 1 MACROLIDES AZITHROMYCIN azithromycin 20mg/ml susp 1 azithromycin 250mg pack 1 azithromycin 250mg tab 1 azithromycin 40mg/ml susp 1 azithromycin 500mg inj 1 azithromycin 500mg pack 1 azithromycin 500mg tab 1 azithromycin 600mg tab 1 CLARITHROMYCIN clarithromycin 250mg tab 1 CLARITHROMYCIN 25MG/ML SUSP 1 clarithromycin 500mg er tab 1 clarithromycin 500mg tab 1 CLARITHROMYCIN 50MG/ML SUSP 1 ERYTHROMYCINS ERYTHROCIN 500MG INJ 1 erythromycin 250mg dr cap 1 erythromycin 250mg tab 1 erythromycin 500mg tab 1 erythromycin ethylsuccinate 40mg/ml susp 1 erythromycin ethylsuccinate 80mg/ml susp 1 MEDICAL DEVICES PARENTERAL THERAPY SUPPLIES INSULIN SYRINGE (DISP) U-100 1/2ML 1 MEDICAL DEVICES AND SUPPLIES BANDAGES-DRESSINGS-TAPE GAUZE PADS & DRESSINGS - PADS 2 X 2 1 MISC. DEVICES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ISOPROPYL ALCOHOL 0.7ML/ML PAD 1 PARENTERAL THERAPY SUPPLIES INSULIN PEN NEEDLE 1 INSULIN SYRINGE (DISP) U-100 0.3ML 1 INSULIN SYRINGE (DISP) U-100 1ML 1 NEEDLES INSULIN DISP. SAFETY 1 MIGRAINE PRODUCTS CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG AIMOVIG 140MG/ML AUTO-INJECTOR 1 PA AIMOVIG 70MG/ML AUTO-INJECTOR 1 PA EMGALITY 100MG/ML SYRINGE 1 PA EMGALITY 120MG/ML AUTO-INJECTOR 1 PA EMGALITY 120MG/ML SYRINGE 1 PA NURTEC 75MG ODT 1 PA QL=16 EA/30 Days MIGRAINE PRODUCTS dihydroergotamine mesylate 0.5mg/act nasal inhaler 1 QL=16 ML/30 Days MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES UBRELVY 100MG TAB 1 PA QL=16 EA/30 Days UBRELVY 50MG TAB 1 PA QL=16 EA/30 Days SEROTONIN AGONISTS eletriptan 20mg tab 1 QL=18 EA/30 Days eletriptan 40mg tab 1 QL=18 EA/30 Days 1mg tab 1 QL=18 EA/30 Days naratriptan 2.5mg tab 1 QL=18 EA/30 Days REYVOW 100MG TAB 1 PA QL=8 EA/30 Days REYVOW 50MG TAB 1 PA QL=8 EA/30 Days rizatriptan 10mg odt 1 QL=36 EA/60 Days rizatriptan 10mg tab 1 QL=36 EA/60 Days rizatriptan 5mg odt 1 QL=36 EA/60 Days rizatriptan 5mg tab 1 QL=36 EA/60 Days sumatriptan 100mg tab 1 QL=18 EA/30 Days sumatriptan 12mg/ml auto-injector 1 QL=5 ML/30 Days sumatriptan 12mg/ml cartridge 1 QL=5 ML/30 Days sumatriptan 12mg/ml inj 1 QL=5 ML/30 Days sumatriptan 20mg/act nasal spray 1 QL=12 EA/30 Days sumatriptan 25mg tab 1 QL=18 EA/30 Days sumatriptan 50mg tab 1 QL=18 EA/30 Days sumatriptan 5mg/act nasal spray 1 QL=12 EA/30 Days sumatriptan 8mg/ml auto-injector 1 QL=5 ML/30 Days sumatriptan 8mg/ml cartridge 1 QL=5 ML/30 Days zolmitriptan 2.5mg odt 1 QL=18 EA/30 Days zolmitriptan 2.5mg tab 1 QL=18 EA/30 Days zolmitriptan 5mg odt 1 QL=18 EA/30 Days zolmitriptan 5mg tab 1 QL=18 EA/30 Days ZOMIG 2.5MG NASAL SPRAY 1 QL=16 EA/30 Days ZOMIG 5MG NASAL SPRAY 1 QL=12 EA/30 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS MINERALS & ELECTROLYTES ELECTROLYTE MIXTURES GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342 1 PA BvD MEQ/ML INJ GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769 1 PA BvD MEQ/ML INJ GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 1 MEQ/ML INJ glucose 50 mg/ml/potassium chloride 1 0.04meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.01 1 meq/ml/sodium chloride 0.0769 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 meq/ml inj 1 glucose 50mg/ml/potassium chloride 0.02 1 meq/ml/sodium chloride 0.0342 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 1 meq/ml/sodium chloride 0.154 meq/ml inj glucose 50mg/ml/potassium chloride 1 0.02meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.03 1 meq/ml/sodium chloride 0.0769 meq/ml inj GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 1 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj 1 glucose 50mg/ml/sodium chloride 4.5mg/ml inj 1 glucose 50mg/ml/sodium chloride 9mg/ml inj 1 ISOLYTE P INJ 1 ISOLYTE S INJ 1 KCL/D5W/LR INJ 0.15% 1 PLASMA-LYTE 148 INJ 1 PLASMALYTE A INJ 1 potassium chloride 0.02 meq/ml/sodium chloride 1 0.0769 meq/ml inj potassium chloride 0.02 meq/ml/sodium chloride 1 0.154 meq/ml inj POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM 1 CHLORIDE 0.154 MEQ/ML INJ MAGNESIUM magnesium sulfate 500mg/ml inj 1 magnesium sulfate 500mg/ml syringe 1 POTASSIUM K-TAB 8MEQ ER TAB 1 klor-con 10meq er tab 1 klor-con 10meq micro er tab 1 KLOR-CON 15MEQ MICRO ER TAB 1 klor-con 20meq micro er tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS klor-con 20meq powder for oral soln 1 klor-con 8meq er tab 1 POTASSIUM CHLORIDE 0.1MEQ/ML INJ 1 POTASSIUM CHLORIDE 0.2MEQ/ML INJ 1 POTASSIUM CHLORIDE 0.4MEQ/ML INJ 1 potassium chloride 1.33meq/ml oral soln 1 potassium chloride 10meq er cap 1 potassium chloride 10meq er tab 1 potassium chloride 10meq micro er tab 1 potassium chloride 2.67meq/ml oral soln 1 potassium chloride 20meq er tab 1 potassium chloride 20meq micro er tab 1 potassium chloride 20meq powder for oral soln 1 potassium chloride 2meq/ml (20ml) inj 1 potassium chloride 2meq/ml inj 1 potassium chloride 8meq er cap 1 potassium chloride 8meq er tab 1 SODIUM sodium chloride 30mg/ml inj 1 sodium chloride 4.5mg/ml inj 1 sodium chloride 50mg/ml inj 1 sodium chloride 9mg/ml inj 1 MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS clovique 250mg cap 1 PA penicillamine 250mg tab 1 trientine 250mg cap 1 PA IMMUNOMODULATORS REVLIMID 10MG CAP 1 NDS PA NSO QL=30 EA/30 Days REVLIMID 15MG CAP 1 NDS PA NSO QL=30 EA/30 Days REVLIMID 2.5MG CAP 1 NDS PA NSO QL=30 EA/30 Days REVLIMID 20MG CAP 1 NDS PA NSO QL=30 EA/30 Days REVLIMID 25MG CAP 1 NDS PA NSO QL=30 EA/30 Days REVLIMID 5MG CAP 1 NDS PA NSO QL=30 EA/30 Days THALOMID 100MG CAP 1 NDS PA NSO THALOMID 150MG CAP 1 NDS PA NSO THALOMID 200MG CAP 1 NDS PA NSO THALOMID 50MG CAP 1 NDS PA NSO IMMUNOSUPPRESSIVE AGENTS ASTAGRAF 0.5MG ER CAP 1 PA BvD ASTAGRAF 1MG ER CAP 1 PA BvD ASTAGRAF 5MG ER CAP 1 PA BvD azathioprine 50mg tab 1 PA BvD cyclosporine modified 100mg/ml oral soln 1 PA BvD cyclosporine modified 50mg cap 1 PA BvD ENSPRYNG 120MG/ML SYRINGE 1 NDS PA QL=1 ML/28 Days You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ENVARSUS 0.75MG ER TAB 1 PA BvD ENVARSUS 1MG ER TAB 1 PA BvD ENVARSUS 4MG ER TAB 1 PA BvD everolimus 0.25mg tab 1 PA BvD everolimus 0.5mg tab 1 PA BvD everolimus 0.75mg tab 1 PA BvD LUPKYNIS 7.9MG CAP 1 NDS PA QL=180 EA/30 Days mycophenolic acid 180mg dr tab 1 PA BvD mycophenolic acid 360mg dr tab 1 PA BvD PROGRAF 0.2MG GRANULES FOR ORAL SUSP 1 PA BvD PROGRAF 1MG GRANULES FOR ORAL SUSP 1 PA BvD sirolimus 1mg/ml oral soln 1 PA BvD POTASSIUM REMOVING AGENTS LOKELMA 10GM POWDER FOR ORAL SUSP 1 PA LOKELMA 5GM POWDER FOR ORAL SUSP 1 PA sodium polystyrene sulfonate 15000mg powder for 1 oral susp sps 15gm/60ml susp 1 VELTASSA 16.8GM POWDER FOR ORAL SUSP 1 PA VELTASSA 25.2GM POWDER FOR ORAL SUSP 1 PA VELTASSA 8.4GM POWDER FOR ORAL SUSP 1 PA SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA 200MG/ML AUTO-INJECTOR 1 NDS PA QL=4 ML/28 Days BENLYSTA 200MG/ML SYRINGE 1 NDS PA QL=4 ML/28 Days MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine 2% topical soln 1 ANTI-INFECTIVES - THROAT clotrimazole 10mg lozenge 1 nystatin 100000unit/ml susp 1 ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate 0.12% mouthwash 1 periogard 0.12% mouthwash 1 STEROIDS - MOUTH/THROAT/DENTAL triamcinolone acetonide 0.1% oral paste 1 THROAT PRODUCTS - MISC. cevimeline 30mg cap 1 pilocarpine 5mg tab 1 pilocarpine 7.5mg tab 1 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen 10mg tab 1 baclofen 20mg tab 1 carisoprodol 350mg tab 1 chlorzoxazone 500mg tab 1 cyclobenzaprine 10mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS cyclobenzaprine 5mg tab 1 METAXALONE 400MG TAB 1 metaxalone 800mg tab 1 methocarbamol 500mg tab 1 methocarbamol 750mg tab 1 orphenadrine citrate 100mg er tab 1 tizanidine 2mg cap 1 tizanidine 2mg tab 1 tizanidine 4mg cap 1 tizanidine 4mg tab 1 tizanidine 6mg cap 1 DIRECT MUSCLE RELAXANTS dantrolene sodium 100mg cap 1 dantrolene sodium 25mg cap 1 dantrolene sodium 50mg cap 1 NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTIALLERGY azelastine 0.137mg/act nasal inhaler 1 azelastine 0.206mg/act nasal inhaler 1 olopatadine 0.665mg/act nasal inhaler 1 NASAL ANTICHOLINERGICS ipratropium bromide 0.021mg/act nasal inhaler 1 ipratropium bromide 0.042mg/act nasal inhaler 1 NASAL STEROIDS FLUNISOLIDE 0.025MG/ACT NASAL INHALER 1 QL=50 ML/30 Days fluticasone propionate 0.05mg/act nasal inhaler 1 QL=32 GM/30 Days NEUROMUSCULAR AGENTS ALS AGENTS riluzole 50mg tab 1 SPINAL MUSCULAR ATROPHY AGENTS (SMA) EVRYSDI 0.75MG/ML ORAL SOLN 1 NDS PA QL=200 ML/30 Days NUTRIENTS CARBOHYDRATES glucose 100mg/ml inj 1 PA BvD glucose 50mg/ml inj 1 LIPIDS INTRALIPID 20GM/100ML INJ 1 PA BvD NUTRILIPID 20GM/100ML INJ 1 PA BvD PROTEINS AMINOSYN-PF 7% INJ 1 PA BvD CLINIMIX 4.25/10 INJ 1 PA BvD CLINIMIX 4.25/5 INJ 1 PA BvD CLINIMIX 5/15 INJ 1 PA BvD CLINIMIX 5/20 INJ 1 PA BvD CLINIMIX E 2.75/5 INJ 1 PA BvD CLINIMIX E 4.25/10 INJ 1 PA BvD You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CLINIMIX E 4.25/5 INJ 1 PA BvD CLINIMIX E 5/15 INJ 1 PA BvD CLINIMIX E 5/20 INJ 1 PA BvD clinisol 15% inj 1 PA BvD HEPATAMINE 8% INJ 1 PA BvD plenamine 15% inj 1 PA BvD PREMASOL 10% INJ 1 PA BvD PROCALAMINE 3% INJ 1 PA BvD PROSOL 20% INJ 1 PA BvD TRAVASOL 10% INJ 1 PA BvD TROPHAMINE 10% INJ 1 PA BvD OPHTHALMIC AGENTS BETA-BLOCKERS - OPHTHALMIC betaxolol 0.5% ophth soln 1 BETIMOL 0.25% OPHTH SOLN 1 BETIMOL 0.5% OPHTH SOLN 1 BETOPTIC S 0.25% OPHTH SUSP 1 CARTEOLOL 1% OPHTH SOLN 1 COMBIGAN 2-5MG/ML OPHTH SOLN 1 dorzolamide/timolol 22.3-6.8mg/ml ophth soln 1 dorzolamide/timolol 22.3-6.8mg/ml ophth soln 1 (preservative-free) LEVOBUNOLOL 0.5% OPHTH SOLN 1 timolol 0.25% ophth gel 1 timolol 0.25% ophth soln 1 timolol 0.5% ophth gel 1 timolol 0.5% ophth soln 1 timolol 5mg/ml ophth 24hr ophth soln 1 TIMOPTIC 0.25% OPHTH GEL 1 TIMOPTIC 0.5% OPHTH GEL 1 CYCLOPLEGIC MYDRIATICS ATROPINE SULFATE 1% OPHTH SOLN 1 MIOTICS pilocarpine 1% ophth soln 1 pilocarpine 2% ophth soln 1 pilocarpine 4% ophth soln 1 OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN 0.1% OPHTH SOLN 1 apraclonidine 0.5% ophth soln 1 brimonidine tartrate 0.15% ophth soln 1 brimonidine tartrate 0.2% ophth soln 1 IOPIDINE 1% OPHTH SOLN 1 SIMBRINZA 0.2-1% OPHTH SUSP 1 OPHTHALMIC ANTI-INFECTIVES AZASITE 1% OPHTH SOLN 1 BACITRACIN 0.5UNIT/MG OPHTH OINTMENT 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth 1 QL=7 GM/7 Days ointment ciprofloxacin 0.3% ophth soln 1 QL=60 ML/30 Days erythromycin 0.5% ophth ointment 1 QL=7 GM/7 Days gatifloxacin 0.5% ophth soln 1 QL=5 ML/7 Days GENTAK 0.3% OPHTH OINTMENT 1 QL=7 GM/7 Days gentamicin 0.3% ophth soln 1 QL=10 ML/7 Days GRAMICIDIN 0.025MG/ML/NEOMYCIN 1 QL=10 ML/7 Days 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN levofloxacin 0.5% ophth soln 1 QL=60 ML/30 Days moxifloxacin 0.5% ophth soln 1 QL=6 ML/7 Days NATACYN 5% OPHTH SUSP 1 QL=15 ML/7 Days neomycin/bacitracin/polymyxin ophth ointment 1 QL=7 GM/7 Days 5(3.5)mg-400unit-10000unit ofloxacin 0.3% ophth soln 1 QL=60 ML/30 Days polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth 1 QL=10 ML/7 Days soln SULFACETAMIDE SODIUM 10% OPHTH OINTMENT 1 QL=7 GM/7 Days sulfacetamide sodium 10% ophth soln 1 QL=15 ML/7 Days tobramycin 0.3% ophth soln 1 QL=60 ML/30 Days TRIFLURIDINE 1% OPHTH SOLN 1 QL=15 ML/7 Days ZIRGAN 0.15% OPHTH GEL 1 QL=10 GM/7 Days OPHTHALMIC IMMUNOMODULATORS RESTASIS 0.05% OPHTH SUSP 1 OPHTHALMIC KINASE INHIBITORS RHOPRESSA 0.02% OPHTH SOLN 1 QL=5 ML/30 Days ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN 1 QL=5 ML/30 Days OPHTHALMIC LOCAL ANESTHETICS proparacaine 0.5% ophth soln 1 OPHTHALMIC NERVE GROWTH FACTORS OXERVATE 0.002% OPHTH SOLN 1 NDS PA QL=112 ML/365 Days OPHTHALMIC STEROIDS ALREX 0.2% OPHTH SUSP 1 BLEPHAMIDE 0.2-10% OPHTH SUSP 1 DEXAMETHASONE PHOSPHATE 0.1% OPHTH 1 SOLN dexamethasone/neomycin/polymyxin b 0.1% ophth 1 ointment dexamethasone/neomycin/polymyxin b 0.1% ophth 1 susp dexamethasone/tobramycin 0.3-0.1% ophth susp 1 DUREZOL 0.05% OPHTH SUSP 1 fluorometholone 0.1% ophth susp 1 hydrocortisone 10mg/ml/neomycin 1 3.5mg/ml/polymyxin b 10000unit/ml ophth susp You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS LOTEMAX 0.5% OPHTH OINTMENT 1 loteprednol etabonate 0.5% ophth gel 1 loteprednol etabonate 0.5% ophth susp 1 MAXIDEX 0.1% OPHTH SUSP 1 neomycin/polymyxin/bacitracin/hydrocortisone ophth 1 ointmentment 1% PRED MILD 0.12% OPHTH SUSP 1 PRED-G 0.3-1% OPHTH SUSP 1 PREDNISOLONE 1% OPHTH SOLN 1 PREDNISOLONE ACETATE 1% OPHTH SUSP 1 PREDNISOLONE SODIUM PHOSPHATE 1 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN TOBRADEX 0.1-0.3% OPHTH OINTMENT 1 ZYLET 0.5-0.3% OPHTH SUSP 1 OPHTHALMICS - MISC. ALOCRIL 2% OPHTH SOLN 1 ALOMIDE 0.1% OPHTH SOLN 1 azelastine 0.05% ophth soln 1 AZOPT 1% OPHTH SUSP 1 bepotastine besilate 1.5% ophth soln 1 brinzolamide 1% ophth susp 1 bromfenac 0.09% ophth soln 1 cromolyn sodium 4% ophth soln 1 CYSTADROPS 0.37% OPHTH SOLN 1 NDS PA QL=20 ML/28 Days CYSTARAN 0.44% OPHTH SOLN 1 NDS PA QL=60 ML/30 Days diclofenac sodium 0.1% ophth soln 1 dorzolamide 2% ophth soln 1 epinastine 0.05% ophth soln 1 FLURBIPROFEN SODIUM 0.03% OPHTH SOLN 1 ILEVRO 0.3% OPHTH SUSP 1 ketorolac tromethamine 0.4% ophth soln 1 ketorolac tromethamine 0.5% ophth soln 1 NEVANAC 0.1% OPHTH SUSP 1 olopatadine 0.1% ophth soln 1 olopatadine 0.2% ophth soln 1 PROSTAGLANDINS - OPHTHALMIC bimatoprost 0.03% ophth soln 1 QL=5 ML/30 Days latanoprost 0.005% ophth soln 1 QL=5 ML/30 Days LUMIGAN 0.01% OPHTH SOLN 1 QL=5 ML/30 Days travoprost 0.004% ophth soln 1 QL=5 ML/30 Days OTIC AGENTS OTIC AGENTS - MISCELLANEOUS acetic acid 2% otic soln 1 OTIC ANTI-INFECTIVES CETRAXAL 0.2% OTIC SOLN 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CIPROFLOXACIN 0.2% OTIC SOLN 1 ofloxacin 0.3% otic soln 1 OTIC COMBINATIONS ciprofloxacin/dexamethasone 0.3-0.1% otic susp 1 hydrocortisone 10mg/ml/neomycin 1 3.5mg/ml/polymyxin b 10000unit/ml otic soln hydrocortisone 10mg/ml/neomycin 1 3.5mg/ml/polymyxin b 10000unit/ml otic susp OTIC STEROIDS acetic acid/hydrocortisone 1-2% otic soln 1 flac 0.01% otic soln 1 fluocinolone acetonide 0.01% otic soln 1 PASSIVE IMMUNIZING AND TREATMENT AGENTS IMMUNE SERUMS BIVIGAM 5GM/50ML INJ 1 NDS PA FLEBOGAMMA 5GM/50ML INJ 1 NDS PA GAMMAGARD 10GM INJ 1 NDS PA GAMMAGARD 2.5GM/25ML INJ 1 NDS PA GAMMAGARD 5GM INJ 1 NDS PA GAMMAKED 1GM/10ML INJ 1 NDS PA GAMMAPLEX 10GM/100ML INJ 1 NDS PA GAMMAPLEX 10GM/200ML INJ 1 NDS PA GAMMAPLEX 20GM/200ML INJ 1 NDS PA GAMMAPLEX 5GM/50ML INJ 1 NDS PA GAMUNEX 1GM/10ML INJ 1 NDS PA OCTAGAM 1GM/20ML INJ 1 NDS PA OCTAGAM 2GM/20ML INJ 1 NDS PA PANZYGA 10GM/100ML INJ 1 NDS PA PANZYGA 1GM/10ML INJ 1 NDS PA PANZYGA 2.5GM/25ML INJ 1 NDS PA PANZYGA 20GM/200ML INJ 1 NDS PA PANZYGA 30GM/300ML INJ 1 NDS PA PANZYGA 5GM/50ML INJ 1 NDS PA PRIVIGEN 20GM/200ML INJ 1 NDS PA VARIZIG 125UNIT/1.2ML INJ 1 NDS PENICILLINS AMINOPENICILLINS 125mg chew tab 1 amoxicillin 250mg cap 1 AMOXICILLIN 250MG CHEW TAB 1 amoxicillin 25mg/ml susp 1 amoxicillin 40mg/ml susp 1 amoxicillin 500mg cap 1 amoxicillin 500mg tab 1 amoxicillin 50mg/ml susp 1 amoxicillin 80mg/ml susp 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS amoxicillin 875mg tab 1 ampicillin 1000mg inj 1 ampicillin 100mg/ml inj 1 AMPICILLIN 125MG INJ 1 AMPICILLIN 500MG CAP 1 NATURAL PENICILLINS BICILLIN L-A 1200000UNIT/2ML SYRINGE 1 BICILLIN L-A 2400000UNIT/4ML SYRINGE 1 BICILLIN L-A 600000UNIT/ML SYRINGE 1 penicillin g potassium 1000000unit/ml inj 1 PENICILLIN G POTASSIUM 40000UNIT/ML INJ 1 PENICILLIN G POTASSIUM 60000UNIT/ML INJ 1 PENICILLIN G PROCAINE 600000UNIT/ML 1 SYRINGE PENICILLIN G SODIUM 100000UNIT/ML INJ 1 penicillin v potassium 250mg tab 1 PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN 1 penicillin v potassium 500mg tab 1 PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN 1 PENICILLIN COMBINATIONS AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER 1 TAB amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp 1 AMOXICILLIN 200MG/CLAVULANATE 28.5MG 1 CHEW TAB amoxicillin 250mg/clavulanate 125mg tab 1 AMOXICILLIN 400MG/CLAVULANATE 57MG 1 CHEW TAB amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp 1 amoxicillin 500mg/clavulanate 125mg tab 1 amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp 1 amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp 1 amoxicillin 875mg/clavulanate 125mg tab 1 ampicillin 1000mg/sulbactam 500mg inj 1 ampicillin 100mg/ml/sulbactam 50mg/ml inj 1 ampicillin 2000mg/sulbactam 1000mg inj 1 BICILLIN 300000-300000UNIT/ML SYRINGE 1 BICILLIN 450000-150000UNIT/ML SYRINGE 1 piperacillin 2000mg/tazobactam 250mg inj 1 piperacillin 200mg/ml/tazobactam 25mg/ml inj 1 piperacillin 3000mg/tazobactam 375mg inj 1 piperacillin 4000mg/tazobactam 500mg inj 1 ZOSYN 2000-250MG INJ 1 ZOSYN 3000-375MG INJ 1 PENICILLINASE-RESISTANT PENICILLINS dicloxacillin 250mg cap 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS dicloxacillin 500mg cap 1 nafcillin 1000mg inj 1 nafcillin 100mg/ml inj 1 nafcillin 2000mg inj 1 oxacillin 1000mg inj 1 oxacillin 100mg/ml inj 1 oxacillin 2000mg inj 1 OXACILLIN 20MG/ML INJ 1 OXACILLIN 40MG/ML INJ 1 PROGESTINS PROGESTINS medroxyprogesterone acetate 10mg tab 1 medroxyprogesterone acetate 2.5mg tab 1 medroxyprogesterone acetate 5mg tab 1 megestrol acetate 125mg/ml susp 1 PA norethindrone acetate 5mg tab 1 progesterone 100mg cap 1 progesterone 200mg cap 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium 333mg dr tab 1 disulfiram 250mg tab 1 disulfiram 500mg tab 1 ANTI-CATAPLECTIC AGENTS XYREM 500MG/ML ORAL SOLN 1 NDS PA QL=540 ML/30 Days ANTIDEMENTIA AGENTS donepezil 10mg odt 1 QL=30 EA/30 Days donepezil 10mg tab 1 donepezil 23mg tab 1 QL=30 EA/30 Days donepezil 5mg odt 1 QL=30 EA/30 Days donepezil 5mg tab 1 galantamine 12mg tab 1 galantamine 4mg tab 1 galantamine 8mg tab 1 galantamine hydrobromide 16mg er cap 1 galantamine hydrobromide 24mg er cap 1 GALANTAMINE HYDROBROMIDE 4MG/ML ORAL 1 SOLN galantamine hydrobromide 8mg er cap 1 memantine 10mg tab 1 memantine 10mg/memantine 5mg pack 1 memantine 14mg er cap 1 memantine 21mg er cap 1 memantine 28mg er cap 1 memantine 2mg/ml oral soln 1 memantine 5mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS memantine 7mg er cap 1 rivastigmine 0.192mg/hr patch 1 rivastigmine 0.396mg/hr patch 1 rivastigmine 0.554mg/hr patch 1 rivastigmine 1.5mg cap 1 rivastigmine 3mg cap 1 rivastigmine 4.5mg cap 1 rivastigmine 6mg cap 1 COMBINATION PSYCHOTHERAPEUTICS AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB 1 AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB 1 amitriptyline 12.5mg/chlordiazepoxide 5mg tab 1 amitriptyline 25mg/chlordiazepoxide 10mg tab 1 AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB 1 AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB 1 AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB 1 fluoxetine 25mg/olanzapine 12mg cap 1 fluoxetine 25mg/olanzapine 3mg cap 1 fluoxetine 25mg/olanzapine 6mg cap 1 fluoxetine 50mg/olanzapine 12mg cap 1 fluoxetine 50mg/olanzapine 6mg cap 1 FIBROMYALGIA AGENTS SAVELLA 100MG TAB 1 QL=60 EA/30 Days SAVELLA 12.5MG TAB 1 QL=60 EA/30 Days SAVELLA 25MG TAB 1 QL=60 EA/30 Days SAVELLA 4-WEEK TITRATION PACK 1 SAVELLA 50MG TAB 1 QL=60 EA/30 Days MOVEMENT DISORDER DRUG THERAPY AUSTEDO 12MG TAB 1 NDS PA AUSTEDO 6MG TAB 1 NDS PA AUSTEDO 9MG TAB 1 NDS PA INGREZZA 40MG CAP 1 NDS PA INGREZZA 80MG CAP 1 NDS PA tetrabenazine 12.5mg tab 1 PA tetrabenazine 25mg tab 1 PA MULTIPLE SCLEROSIS AGENTS AUBAGIO 14MG TAB 1 NDS AUBAGIO 7MG TAB 1 NDS AVONEX 30MCG/0.5ML AUTO-INJECTOR 1 NDS AVONEX 30MCG/0.5ML SYRINGE 1 NDS dalfampridine 10mg er tab 1 QL=60 EA/30 Days dimethyl fumarate 120mg dr cap 1 NDS dimethyl fumarate 120mg/dimethyl fumarate 240mg 1 NDS pack dimethyl fumarate 240mg dr cap 1 NDS EXTAVIA 0.3MG INJ 1 NDS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS GILENYA 0.5MG CAP 1 NDS glatiramer acetate 20mg/ml syringe 1 glatiramer acetate 40mg/ml syringe 1 glatopa 20mg/ml syringe 1 glatopa 40mg/ml syringe 1 KESIMPTA 20MG/0.4ML PEN INJ 1 NDS MAYZENT 0.25MG TAB 1 NDS MAYZENT 0.25MG TAB STARTER PACK 1 NDS MAYZENT 2MG TAB 1 NDS PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR 1 NDS PLEGRIDY 125MCG/0.5ML SYRINGE 1 NDS REBIF 22MCG/0.5ML AUTO-INJECTOR 1 NDS REBIF 22MCG/0.5ML SYRINGE 1 NDS REBIF 44MCG/0.5ML AUTO-INJECTOR 1 NDS REBIF 44MCG/0.5ML SYRINGE 1 NDS REBIF REBIDOSE PACK 1 NDS REBIF TITRATION PACK 1 NDS ZEPOSIA 0.92MG CAP 1 NDS ZEPOSIA 7-DAY STARTER PACK 1 NDS ZEPOSIA STARTER KIT PACK 1 NDS PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS FLUOXETINE 10MG TAB 1 FLUOXETINE 20MG TAB 1 PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA 20-10MG CAP 1 PA QL=60 EA/30 Days PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ERGOLOID MESYLATES USP 1MG TAB 1 PIMOZIDE 1MG TAB 1 PIMOZIDE 2MG TAB 1 SMOKING DETERRENTS bupropion 150mg sr tab 1 CHANTIX 0.5MG TAB 1 CHANTIX 1MG TAB 1 CHANTIX CONTINUING MONTHS OF THERAPY 1 1MG PACK CHANTIX FIRST MONTH OF THERAPY PACK 1 NICOTROL 10MG INH SOLN 1 NICOTROL 10MG/ML NASAL INHALER 1 TRANSTHYRETIN AMYLOIDOSIS AGENTS TEGSEDI 284MG/1.5ML SYRINGE 1 NDS PA QL=6 ML/28 Days RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN) ARALAST 1000MG INJ 1 NDS GLASSIA 1000MG/50ML INJ 1 NDS PROLASTIN 1000MG INJ 1 NDS ZEMAIRA 1000MG INJ 1 NDS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS CYSTIC FIBROSIS AGENTS KALYDECO 150MG TAB 1 NDS PA QL=60 EA/30 Days KALYDECO 25MG GRANULES 1 NDS PA QL=60 EA/30 Days KALYDECO 50MG GRANULES 1 NDS PA QL=60 EA/30 Days KALYDECO 75MG GRANULES 1 NDS PA QL=60 EA/30 Days ORKAMBI 125-100MG GRANULES 1 NDS PA QL=60 EA/30 Days ORKAMBI 125-100MG TAB 1 NDS PA QL=120 EA/30 Days ORKAMBI 125-200MG TAB 1 NDS PA QL=120 EA/30 Days ORKAMBI 188-150MG GRANULES 1 NDS PA QL=60 EA/30 Days PULMOZYME 1MG/ML INH SOLN 1 NDS PA BvD SYMDEKO 50-75MG/75MG PACK 1 NDS PA QL=60 EA/30 Days SYMDEKO TAB 4-WEEK PACK 1 NDS PA QL=60 EA/30 Days TRIKAFTA 100-50-75MG/150MG PACK 1 NDS PA QL=90 EA/30 Days PULMONARY FIBROSIS AGENTS ESBRIET 267MG CAP 1 NDS PA ESBRIET 267MG TAB 1 NDS PA ESBRIET 801MG TAB 1 NDS PA OFEV 100MG CAP 1 NDS PA OFEV 150MG CAP 1 NDS PA SULFONAMIDES SULFONAMIDES SULFADIAZINE 500MG TAB 1 TETRACYCLINES AMINOMETHYLCYCLINES NUZYRA 150MG TAB 1 NDS PA QL=30 EA/14 Days GLYCYLCYCLINES TIGECYCLINE 50MG INJ 1 NDS TETRACYCLINES demeclocycline 150mg tab 1 demeclocycline 300mg tab 1 doxy 100mg inj 1 doxycycline hyclate 100mg cap 1 doxycycline hyclate 100mg tab 1 doxycycline hyclate 20mg tab 1 doxycycline hyclate 50mg cap 1 doxycycline monohydrate 100mg cap 1 doxycycline monohydrate 100mg tab 1 doxycycline monohydrate 50mg cap 1 doxycycline monohydrate 50mg tab 1 doxycycline monohydrate 5mg/ml susp 1 minocycline 100mg cap 1 minocycline 100mg tab 1 minocycline 50mg cap 1 minocycline 50mg tab 1 minocycline 75mg cap 1 minocycline 75mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS mondoxyne 100mg cap 1 tetracycline 250mg cap 1 tetracycline 500mg cap 1 THYROID AGENTS ANTITHYROID AGENTS methimazole 10mg tab 1 methimazole 5mg tab 1 propylthiouracil 50mg tab 1 THYROID HORMONES euthyrox 100mcg tab 1 euthyrox 112mcg tab 1 euthyrox 125mcg tab 1 euthyrox 137mcg tab 1 euthyrox 150mcg tab 1 euthyrox 175mcg tab 1 euthyrox 200mcg tab 1 euthyrox 25mcg tab 1 euthyrox 50mcg tab 1 euthyrox 75mcg tab 1 euthyrox 88mcg tab 1 levo-t 100mcg tab 1 levo-t 112mcg tab 1 levo-t 125mcg tab 1 levo-t 137mcg tab 1 levo-t 150mcg tab 1 levo-t 175mcg tab 1 levo-t 200mcg tab 1 levo-t 25mcg tab 1 levo-t 300mcg tab 1 levo-t 50mcg tab 1 levo-t 75mcg tab 1 levo-t 88mcg tab 1 levothyroxine sodium 0.025mg tab 1 levothyroxine sodium 0.05mg tab 1 levothyroxine sodium 0.075mg tab 1 levothyroxine sodium 0.088mg tab 1 levothyroxine sodium 0.112mg tab 1 levothyroxine sodium 0.125mg tab 1 levothyroxine sodium 0.137mg tab 1 levothyroxine sodium 0.15mg tab 1 levothyroxine sodium 0.175mg tab 1 levothyroxine sodium 0.1mg tab 1 levothyroxine sodium 0.2mg tab 1 levothyroxine sodium 0.3mg tab 1 levoxyl 100mcg tab 1 levoxyl 112mcg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS levoxyl 125mcg tab 1 levoxyl 137mcg tab 1 levoxyl 150mcg tab 1 levoxyl 175mcg tab 1 levoxyl 200mcg tab 1 levoxyl 25mcg tab 1 levoxyl 50mcg tab 1 levoxyl 75mcg tab 1 levoxyl 88mcg tab 1 liothyronine sodium 0.005mg tab 1 liothyronine sodium 0.025mg tab 1 liothyronine sodium 0.05mg tab 1 SYNTHROID 100MCG TAB 1 SYNTHROID 112MCG TAB 1 SYNTHROID 125MCG TAB 1 SYNTHROID 137MCG TAB 1 SYNTHROID 150MCG TAB 1 SYNTHROID 175MCG TAB 1 SYNTHROID 200MCG TAB 1 SYNTHROID 25MCG TAB 1 SYNTHROID 300MCG TAB 1 SYNTHROID 50MCG TAB 1 SYNTHROID 75MCG TAB 1 SYNTHROID 88MCG TAB 1 unithroid 100mcg tab 1 unithroid 112mcg tab 1 unithroid 125mcg tab 1 unithroid 137mcg tab 1 unithroid 150mcg tab 1 unithroid 175mcg tab 1 unithroid 200mcg tab 1 unithroid 25mcg tab 1 unithroid 300mcg tab 1 unithroid 50mcg tab 1 unithroid 75mcg tab 1 unithroid 88mcg tab 1 TOXOIDS TOXOID COMBINATIONS ADACEL INJ 1 ADACEL SYRINGE 1 BOOSTRIX INJ 1 BOOSTRIX SYRINGE 1 DAPTACEL INJ 1 DIPHTHERIA/TETANUS TOXOID INJ 1 PA BvD INFANRIX SYRINGE 1 KINRIX INJ 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS KINRIX PF INJ 1 PEDIARIX INJ 1 QUADRACEL INJ 1 TDVAX 4-4UNIT/ML INJ 1 PA BvD TENIVAC 4-10UNIT/ML SYRINGE 1 PA BvD ULCER DRUGS ANTISPASMODICS dicyclomine 10mg cap 1 dicyclomine 20mg tab 1 glycopyrrolate 1mg tab 1 glycopyrrolate 2mg tab 1 H-2 ANTAGONISTS 200mg tab 1 cimetidine 300mg tab 1 cimetidine 400mg tab 1 cimetidine 800mg tab 1 famotidine 20mg tab 1 famotidine 8mg/ml susp 1 MISC. ANTI-ULCER sucralfate 1000mg tab 1 PROTON PUMP INHIBITORS esomeprazole 20mg dr cap 1 lansoprazole 15mg dr cap 1 lansoprazole 30mg dr cap 1 omeprazole 20mg dr cap 1 pantoprazole 20mg dr tab 1 rabeprazole sodium 20mg dr tab 1 ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS ANTISPASMODICS dicyclomine 2mg/ml oral soln 1 METHSCOPOLAMINE BROMIDE 2.5MG TAB 1 METHSCOPOLAMINE BROMIDE 5MG TAB 1 H-2 ANTAGONISTS CIMETIDINE 60MG/ML ORAL SOLN 1 famotidine 40mg tab 1 nizatidine 150mg cap 1 nizatidine 300mg cap 1 MISC. ANTI-ULCER sucralfate 100mg/ml susp 1 PROTON PUMP INHIBITORS esomeprazole 40mg dr cap 1 omeprazole 10mg dr cap 1 omeprazole 40mg dr cap 1 pantoprazole 40mg dr tab 1 ULCER DRUGS - PROSTAGLANDINS misoprostol 0.1mg tab 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS misoprostol 0.2mg tab 1 ULCER THERAPY COMBINATIONS amoxicillin 500mg/clarithromycin 1 500mg/lansoprazole 30mg pack PYLERA 140-125-125MG CAP 1 URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES methenamine hippurate 1000mg tab 1 nitrofurantoin macro 25mg/nitrofurantoin mono 75mg 1 cap nitrofurantoin macrocrystals 100mg cap 1 nitrofurantoin macrocrystals 50mg cap 1 URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) oxybutynin chloride 10mg er tab 1 oxybutynin chloride 15mg er tab 1 oxybutynin chloride 1mg/ml oral soln 1 oxybutynin chloride 5mg er tab 1 oxybutynin chloride 5mg tab 1 solifenacin succinate 10mg tab 1 solifenacin succinate 5mg tab 1 tolterodine tartrate 1mg tab 1 tolterodine tartrate 2mg er cap 1 tolterodine tartrate 2mg tab 1 tolterodine tartrate 4mg er cap 1 trospium chloride 20mg tab 1 trospium chloride 60mg er cap 1 URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ 25MG ER TAB 1 MYRBETRIQ 50MG ER TAB 1 URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride 10mg tab 1 bethanechol chloride 25mg tab 1 bethanechol chloride 50mg tab 1 bethanechol chloride 5mg tab 1 URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS flavoxate 100mg tab 1 VACCINES BACTERIAL VACCINES ACTHIB INJ 1 BCG LIVE TICE STRAIN 50MG INJ 1 BEXSERO SYRINGE 1 HIBERIX 10MCG INJ 1 MENACTRA INJ 1 MENQUADFI INJ 1 MENVEO INJ 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS PEDVAXHIB 7.5MCG/0.5ML INJ 1 TRUMENBA SYRINGE 1 TYPHIM VI 25MCG/0.5ML INJ 1 TYPHIM VI 25MCG/0.5ML SYRINGE 1 VIRAL VACCINES ENGERIX-B 10MCG/0.5ML SYRINGE 1 PA BvD ENGERIX-B 20MCG/ML SYRINGE 1 PA BvD GARDASIL 9 INJ 1 GARDASIL 9 SYRINGE 1 HAVRIX 1440ELU/ML SYRINGE 1 HAVRIX 720ELU/0.5ML SYRINGE 1 IMOVAX 2.5UNIT/ML INJ 1 PA BvD IPOL INJ 1 IXIARO 0.012MG/ML SYRINGE 1 M-M-R II INJ 1 PROQUAD INJ 1 RABAVERT 2.5UNIT/ML INJ 1 PA BvD RECOMBIVAX 10MCG/ML INJ 1 PA BvD RECOMBIVAX 10MCG/ML SYRINGE 1 PA BvD RECOMBIVAX 40MCG/ML INJ 1 PA BvD RECOMBIVAX 5MCG/0.5ML SYRINGE 1 PA BvD ROTARIX SUSP 1 ROTATEQ SUSP 1 SHINGRIX 50MCG/0.5ML INJ 1 TWINRIX 720UNIT SYRINGE 1 VAQTA 25UNIT/0.5ML INJ 1 VAQTA 25UNIT/0.5ML SYRINGE 1 VAQTA 50UNIT/ML INJ 1 VAQTA 50UNIT/ML SYRINGE 1 VARIVAX 1350PFU/0.5ML INJ 1 YF-VAX 4000UNIT/ML INJ 1 VAGINAL AND RELATED PRODUCTS VAGINAL ANTI-INFECTIVES clindamycin 2% vaginal cream 1 metronidazole 0.75% vaginal gel 1 terconazole 0.4% vaginal cream 1 TERCONAZOLE 0.8% VAGINAL CREAM 1 terconazole 80mg vaginal insert 1 vandazole 0.75% vaginal gel 1 VAGINAL ESTROGENS estradiol 0.01% vaginal cream 1 ESTRING 2MG VAGINAL SYSTEM 1 ST PREMARIN 0.625MG/GM VAGINAL CREAM 1 VAGINAL PROGESTINS CRINONE 4% VAGINAL GEL 1 PA CRINONE 8% VAGINAL GEL 1 PA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101 DRUG NAME DRUG TIER REQUIREMENTS/LIMITS VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS epinephrine 0.5mg/ml auto-injector 1 QL=2 EA/15 Days epinephrine 1mg/ml auto-injector 1 QL=2 EA/15 Days SYMJEPI 0.15MG/0.3ML SYRINGE 1 QL=2 EA/15 Days SYMJEPI 0.3MG/0.3ML SYRINGE 1 QL=2 EA/15 Days NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS droxidopa 100mg cap 1 PA droxidopa 200mg cap 1 PA droxidopa 300mg cap 1 PA VASOPRESSORS midodrine 10mg tab 1 midodrine 2.5mg tab 1 midodrine 5mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102 ALPHABETICAL LISTING OF DRUGS

A acetaminophen 13 acetylcysteine 100mg/ml 67 300mg/codeine inh soln abacavir 20mg/ml oral 53 phosphate 60mg tab acetylcysteine 200mg/ml 67 soln acetaminophen 13 inh soln abacavir 300mg tab 53 300mg/hydrocodone acitretin 10mg cap 69 abacavir 53 bitartrate 10mg tab acitretin 17.5mg cap 69 300mg/lamivudine acetaminophen 13 acitretin 25mg cap 69 150mg/zidovudine 300mg 300mg/hydrocodone ACTEMRA 9 tab bitartrate 5mg tab 162MG/0.9ML abacavir 53 acetaminophen 13 AUTO-INJECTOR 600mg/lamivudine 300mg 300mg/hydrocodone ACTEMRA 9 tab bitartrate 7.5mg tab 162MG/0.9ML SYRINGE ABELCET 5MG/ML INJ 32 acetaminophen 13 ACTHIB INJ 100 ABILIFY 300MG INJ 52 325mg/hydrocodone ACTIMMUNE 46 ABILIFY 300MG 52 bitartrate 10mg tab 2000000UNIT/0.5ML INJ SYRINGE acetaminophen 13 acyclovir 200mg cap 55 ABILIFY 400MG INJ 52 325mg/hydrocodone acyclovir 400mg tab 55 ABILIFY 400MG 52 bitartrate 5mg tab acyclovir 40mg/ml susp 55 SYRINGE acetaminophen 13 acyclovir 5% ointment 69 abiraterone acetate 41 325mg/hydrocodone acyclovir 50mg/ml inj 55 250mg tab bitartrate 7.5mg tab acyclovir 800mg tab 55 acamprosate calcium 93 acetaminophen 13 ADACEL INJ 98 333mg dr tab 325mg/oxycodone 10mg ADACEL SYRINGE 98 acarbose 100mg tab 28 tab adapalene 0.1% cream 67 acarbose 25mg tab 28 acetaminophen 13 adapalene 0.1% gel 67 acarbose 50mg tab 28 325mg/oxycodone 2.5mg adapalene 0.3% gel 67 accutane 20mg cap 67 tab adapalene/benzoyl 67 accutane 30mg cap 67 acetaminophen 13 peroxide 0.1-2.5% gel accutane 40mg cap 67 325mg/oxycodone 5mg adefovir dipivoxil 10mg 55 acebutolol 200mg cap 56 tab tab acebutolol 400mg cap 56 acetaminophen 13 ADEMPAS 0.5MG TAB 61 acetaminophen 13 325mg/oxycodone 7.5mg ADEMPAS 1.5MG TAB 61 21.7mg/ml/hydrocodone tab ADEMPAS 1MG TAB 61 bitartrate 0.5mg/ml oral acetaminophen 13 ADEMPAS 2.5MG TAB 61 soln 325mg/tramadol 37.5mg ADEMPAS 2MG TAB 61 acetaminophen 13 tab ADVAIR 0.045-0.021MG 18 24mg/ml/codeine acetazolamide 125mg tab 72 INH phosphate 2.4mg/ml oral acetazolamide 250mg tab 72 ADVAIR 0.115-0.021MG 18 soln acetazolamide 500mg er 72 INH acetaminophen 13 cap ADVAIR 0.23-0.021MG 18 300mg/codeine acetic acid 2% otic soln 90 INH phosphate 15mg tab acetic 91 AFINITOR 10MG TAB 43 acetaminophen 13 acid/hydrocortisone 1-2% AFINITOR 2MG TAB FOR 43 300mg/codeine otic soln ORAL SUSP phosphate 30mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103 ALPHABETICAL LISTING OF DRUGS

AFINITOR 3MG TAB FOR 43 ALOMIDE 0.1% OPHTH 90 AMINOSYN-PF 7% INJ 87 ORAL SUSP SOLN amiodarone 200mg tab 17 AFINITOR 5MG TAB FOR 43 alosetron 0.5mg tab 78 amiodarone 400mg tab 17 ORAL SUSP alosetron 1mg tab 78 amitriptyline 100mg tab 27 AIMOVIG 140MG/ML 83 ALPHAGAN 0.1% 88 amitriptyline 10mg tab 27 AUTO-INJECTOR OPHTH SOLN AMITRIPTYLINE 94 AIMOVIG 70MG/ML 83 alprazolam 0.25mg odt 16 10MG/PERPHENAZINE AUTO-INJECTOR alprazolam 0.25mg tab 16 2MG TAB ala-cort 1% cream 69 alprazolam 0.5mg er tab 16 AMITRIPTYLINE 94 ala-cort 2.5% cream 69 alprazolam 0.5mg odt 16 10MG/PERPHENAZINE albendazole 200mg tab 15 alprazolam 0.5mg tab 16 4MG TAB albuterol 0.21mg/ml inh 18 alprazolam 1mg er tab 16 amitriptyline 94 soln alprazolam 1mg odt 16 12.5mg/chlordiazepoxide albuterol 0.417mg/ml inh 18 alprazolam 1mg tab 16 5mg tab soln alprazolam 2mg er tab 16 amitriptyline 150mg tab 27 albuterol 0.4mg/ml oral 18 alprazolam 2mg odt 16 amitriptyline 25mg tab 27 soln alprazolam 2mg tab 16 amitriptyline 94 albuterol 0.83mg/ml inh 18 alprazolam 3mg er tab 16 25mg/chlordiazepoxide soln ALREX 0.2% OPHTH 89 10mg tab albuterol 2mg tab 18 SUSP AMITRIPTYLINE 94 albuterol 4mg tab 18 altavera 28 day pack 62 25MG/PERPHENAZINE albuterol 5mg/ml inh soln 18 ALUNBRIG 180MG TAB 43 2MG TAB alclometasone 69 ALUNBRIG 30MG TAB 43 AMITRIPTYLINE 94 dipropionate 0.05% ALUNBRIG 90MG TAB 43 25MG/PERPHENAZINE cream ALUNBRIG INITIATION 43 4MG TAB alclometasone 69 PACK amitriptyline 50mg tab 27 dipropionate 0.05% alyacen 1/35 28 day pack 62 AMITRIPTYLINE 94 ointment alyq 20mg tab 60 50MG/PERPHENAZINE ALECENSA 150MG CAP 43 amabelz 0.5/0.1mg 28 day 75 4MG TAB ALENDRONIC ACID 73 pack amitriptyline 75mg tab 27 0.933MG/ML ORAL amabelz 1/0.5mg 28 day 75 amlodipine 10mg tab 58 SOLN pack amlodipine 60 alendronic acid 10mg tab 73 amantadine 100mg cap 48 10mg/atorvastatin 10mg alendronic acid 35mg tab 73 amantadine 100mg tab 48 tab alendronic acid 70mg tab 73 amantadine 10mg/ml oral 47 amlodipine 60 alfuzosin 10mg er tab 79 soln 10mg/atorvastatin 20mg ALINIA 100MG/5ML 39 AMBISOME 50MG INJ 32 tab SUSP ambrisentan 10mg tab 60 amlodipine 60 ALINIA 500MG TAB 39 ambrisentan 5mg tab 60 10mg/atorvastatin 40mg aliskiren 150mg tab 38 amethia 91 day pack 62 tab aliskiren 300mg tab 38 amikacin 250mg/ml inj 8 amlodipine 60 allopurinol 100mg tab 79 amiloride 5mg tab 72 10mg/atorvastatin 80mg allopurinol 300mg tab 79 amiloride 72 tab ALOCRIL 2% OPHTH 90 5mg/hydrochlorothiazide SOLN 50mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104 ALPHABETICAL LISTING OF DRUGS amlodipine 36 amlodipine 60 AMOXAPINE 150MG 27 10mg/benazepril 20mg 5mg/atorvastatin 10mg TAB cap tab AMOXAPINE 25MG TAB 27 amlodipine 36 amlodipine 60 AMOXAPINE 50MG TAB 27 10mg/benazepril 40mg 5mg/atorvastatin 20mg AMOXICILLIN 92 cap tab 1000MG/CLAVULANAT amlodipine 36 amlodipine 60 E 62.5MG ER TAB 10mg/hydrochlorothiazid 5mg/atorvastatin 40mg amoxicillin 92 e 12.5mg/valsartan tab 120mg/ml/clavulanate 160mg tab amlodipine 60 8.58mg/ml susp amlodipine 37 5mg/atorvastatin 80mg amoxicillin 125mg chew 91 10mg/hydrochlorothiazid tab tab e 25mg/valsartan 160mg amlodipine 37 AMOXICILLIN 92 tab 5mg/benazepril 10mg cap 200MG/CLAVULANATE amlodipine 37 amlodipine 37 28.5MG CHEW TAB 10mg/hydrochlorothiazid 5mg/benazepril 20mg cap amoxicillin 250mg cap 91 e 25mg/valsartan 320mg amlodipine 37 AMOXICILLIN 250MG 91 tab 5mg/benazepril 40mg cap CHEW TAB amlodipine 37 amlodipine 37 amoxicillin 92 10mg/olmesartan 5mg/hydrochlorothiazide 250mg/clavulanate medoxomil 20mg tab 12.5mg/valsartan 160mg 125mg tab amlodipine 37 tab amoxicillin 25mg/ml susp 91 10mg/olmesartan amlodipine 37 AMOXICILLIN 92 medoxomil 40mg tab 5mg/hydrochlorothiazide 400MG/CLAVULANATE amlodipine 37 25mg/valsartan 160mg 57MG CHEW TAB 10mg/valsartan 160mg tab amoxicillin 40mg/ml susp 91 tab amlodipine 37 amoxicillin 92 amlodipine 37 5mg/olmesartan 40mg/ml/clavulanate 10mg/valsartan 320mg medoxomil 20mg tab 5.7mg/ml susp tab amlodipine 37 amoxicillin 500mg cap 91 amlodipine 2.5mg tab 58 5mg/olmesartan amoxicillin 500mg tab 91 amlodipine 60 medoxomil 40mg tab amoxicillin 100 2.5mg/atorvastatin 10mg amlodipine 37 500mg/clarithromycin tab 5mg/valsartan 160mg tab 500mg/lansoprazole amlodipine 60 amlodipine 37 30mg pack 2.5mg/atorvastatin 20mg 5mg/valsartan 320mg tab amoxicillin 92 tab ammonium lactate 12% 71 500mg/clavulanate amlodipine 60 cream 125mg tab 2.5mg/atorvastatin 40mg ammonium lactate 12% 71 amoxicillin 50mg/ml susp 91 tab lotion amoxicillin 92 amlodipine 37 amnesteem 10mg cap 67 50mg/ml/clavulanate 2.5mg/benazepril 10mg amnesteem 20mg cap 67 12.5mg/ml susp cap amnesteem 40mg cap 67 amoxicillin 80mg/ml susp 91 amlodipine 5mg tab 58 AMOXAPINE 100MG 27 TAB You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105 ALPHABETICAL LISTING OF DRUGS amoxicillin 92 ampicillin 92 ARANESP 80 80mg/ml/clavulanate 2000mg/sulbactam 150MCG/0.3ML 11.4mg/ml susp 1000mg inj SYRINGE amoxicillin 875mg tab 92 AMPICILLIN 500MG 92 ARANESP 80 amoxicillin 92 CAP 200MCG/0.4ML 875mg/clavulanate anagrelide 0.5mg cap 79 SYRINGE 125mg tab anagrelide 1mg cap 79 ARANESP 200MCG/ML 80 amphetamine-dextroamp 7 anastrozole 1mg tab 41 INJ hetamine 10mg ER cap ANDRODERM 14 ARANESP 80 amphetamine-dextroamp 7 2MG/24HR PATCH 25MCG/0.42ML hetamine 10mg tab ANDRODERM 14 SYRINGE amphetamine-dextroamp 7 4MG/24HR PATCH ARANESP 25MCG/ML 80 hetamine 12.5mg tab ANORO 0.0625-0.025MG 18 INJ amphetamine-dextroamp 7 INH ARANESP 80 hetamine 15mg ER cap APLENZIN 174MG ER 25 300MCG/0.6ML amphetamine-dextroamp 7 TAB SYRINGE hetamine 15mg tab APLENZIN 348MG ER 25 ARANESP 300MCG/ML 80 amphetamine-dextroamp 7 TAB INJ hetamine 20mg ER cap APLENZIN 522MG ER 25 ARANESP 80 amphetamine-dextroamp 7 TAB 40MCG/0.4ML SYRINGE hetamine 20mg tab APOKYN 30MG/3ML 48 ARANESP 40MCG/ML 80 amphetamine-dextroamp 7 CARTRIDGE INJ hetamine 25mg ER cap apraclonidine 0.5% ophth 88 ARANESP 500MCG/ML 80 amphetamine-dextroamp 7 soln SYRINGE hetamine 30mg ER cap aprepitant 125mg cap 32 ARANESP 80 amphetamine-dextroamp 7 aprepitant 32 60MCG/0.3ML SYRINGE hetamine 30mg tab 125mg/aprepitant 80mg ARANESP 60MCG/ML 80 amphetamine-dextroamp 7 pack INJ hetamine 5mg ER cap aprepitant 40mg cap 32 ARCALYST 220MG INJ 9 amphetamine-dextroamp 7 aprepitant 80mg cap 32 ARIKAYCE 8 hetamine 5mg tab apri 28 day pack 62 590MG/8.4ML INH SUSP amphetamine-dextroamp 7 APTIOM 200MG TAB 21 aripiprazole 10mg odt 52 hetamine 7.5mg tab APTIOM 400MG TAB 21 aripiprazole 10mg tab 52 AMPHOTERICIN B 32 APTIOM 600MG TAB 21 aripiprazole 15mg odt 52 50MG INJ APTIOM 800MG TAB 21 aripiprazole 15mg tab 52 ampicillin 1000mg inj 92 APTIVUS 250MG CAP 53 aripiprazole 1mg/ml oral 52 ampicillin 92 ARALAST 1000MG INJ 95 soln 1000mg/sulbactam aranelle 28 pack 62 aripiprazole 20mg tab 52 500mg inj ARANESP 80 aripiprazole 2mg tab 52 ampicillin 100mg/ml inj 92 100MCG/0.5ML aripiprazole 30mg tab 52 ampicillin 92 SYRINGE aripiprazole 5mg tab 52 100mg/ml/sulbactam ARANESP 100MCG/ML 80 ARISTADA 52 50mg/ml inj INJ 1064MG/3.9ML AMPICILLIN 125MG INJ 92 ARANESP 80 SYRINGE 10MCG/0.4ML SYRINGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106 ALPHABETICAL LISTING OF DRUGS

ARISTADA 52 atenolol 25mg tab 56 AVONEX 30MCG/0.5ML 94 441MG/1.6ML SYRINGE atenolol 50mg tab 57 SYRINGE ARISTADA 52 atenolol 37 AVYCAZ 500-2000MG 61 662MG/2.4ML SYRINGE 50mg/chlorthalidone INJ ARISTADA 52 25mg tab AYVAKIT 100MG TAB 43 675MG/2.4ML SYRINGE atomoxetine 100mg cap 7 AYVAKIT 200MG TAB 43 ARISTADA 52 atomoxetine 10mg cap 7 AYVAKIT 300MG TAB 43 882MG/3.2ML SYRINGE atomoxetine 18mg cap 7 AZASAN 100MG TAB 56 armodafinil 150mg tab 7 atomoxetine 25mg cap 7 AZASAN 75MG TAB 56 armodafinil 200mg tab 7 atomoxetine 40mg cap 7 AZASITE 1% OPHTH 88 armodafinil 250mg tab 7 atomoxetine 60mg cap 7 SOLN armodafinil 50mg tab 7 atomoxetine 80mg cap 7 azathioprine 50mg tab 85 ARNUITY 100MCG INH 18 atorvastatin 10mg tab 34 azelaic acid 15% gel 71 ARNUITY 200MCG INH 18 atorvastatin 20mg tab 34 azelastine 0.05% ophth 90 ARNUITY 50MCG INH 18 atorvastatin 40mg tab 34 soln asenapine 10mg sl tab 50 atorvastatin 80mg tab 34 azelastine 0.137mg/act 87 asenapine 2.5mg sl tab 50 atovaquone 150mg/ml 39 nasal inhaler asenapine 5mg sl tab 50 susp azelastine 0.206mg/act 87 ashlyna 91 day pack 62 atovaquone 40 nasal inhaler ASMANEX 100MCG INH 18 250mg/proguanil 100mg azithromycin 20mg/ml 82 ASMANEX 110MCG/INH 18 tab susp INH atovaquone 40 azithromycin 250mg pack 82 ASMANEX 200MCG INH 18 62.5mg/proguanil 25mg azithromycin 250mg tab 82 ASMANEX 220MCG 18 tab azithromycin 40mg/ml 82 (120ACT) INH atropine sulfate 31 susp ASMANEX 220MCG 18 0.005mg/ml/diphenoxylat azithromycin 500mg inj 82 (30ACT) INH e 0.5mg/ml oral soln azithromycin 500mg pack 82 ASMANEX 220MCG 18 atropine sulfate 31 azithromycin 500mg tab 82 (60ACT) INH 0.025mg/diphenoxylate azithromycin 600mg tab 82 ASMANEX 50MCG HFA 18 2.5mg tab AZOPT 1% OPHTH SUSP 90 INH ATROPINE SULFATE 1% 88 aztreonam 1000mg inj 40 aspirin 79 OPHTH SOLN B 25mg/dipyridamole ATROVENT 17MCG INH 17 BACITRACIN 88 200mg er cap AUBAGIO 14MG TAB 94 0.5UNIT/MG OPHTH ASTAGRAF 0.5MG ER 85 AUBAGIO 7MG TAB 94 OINTMENT CAP aubra 28 day pack 62 bacitracin 89 ASTAGRAF 1MG ER CAP 85 AURYXIA 210MG TAB 78 0.5unit/mg/polymyxin b ASTAGRAF 5MG ER CAP 85 AUSTEDO 12MG TAB 94 10unit/mg ophth ointment atazanavir 150mg cap 53 AUSTEDO 6MG TAB 94 baclofen 10mg tab 86 atazanavir 200mg cap 53 AUSTEDO 9MG TAB 94 baclofen 20mg tab 86 atazanavir 300mg cap 53 aviane 28 pack 62 balsalazide disodium 77 atenolol 100mg tab 56 avita 0.025% cream 67 750mg cap atenolol 37 avita 0.025% gel 67 BALVERSA 3MG TAB 43 100mg/chlorthalidone AVONEX 30MCG/0.5ML 94 BALVERSA 4MG TAB 43 25mg tab AUTO-INJECTOR You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107 ALPHABETICAL LISTING OF DRUGS

BALVERSA 5MG TAB 43 betamethasone 0.05% 69 BICILLIN 92 balziva 28 day pack 62 aug lotion 300000-300000UNIT/ML BANZEL 40MG/ML 21 betamethasone 0.05% 69 SYRINGE SUSP aug ointment BICILLIN 92 BAQSIMI 3MG/DOSE 29 betamethasone 0.05% 69 450000-150000UNIT/ML NASAL POWDER cream SYRINGE BAXDELA 450MG TAB 77 BETAMETHASONE 69 BICILLIN L-A 92 BCG LIVE TICE STRAIN 100 0.05% GEL 1200000UNIT/2ML 50MG INJ betamethasone 0.05% 69 SYRINGE benazepril 10mg tab 35 lotion BICILLIN L-A 92 benazepril 37 betamethasone 0.05% 70 2400000UNIT/4ML 10mg/hydrochlorothiazid ointment SYRINGE e 12.5mg tab betamethasone 0.1% 70 BICILLIN L-A 92 benazepril 20mg tab 35 cream 600000UNIT/ML benazepril 37 betamethasone 0.1% 70 SYRINGE 20mg/hydrochlorothiazid lotion BIDIL 37.5-20MG TAB 60 e 12.5mg tab betamethasone 0.1% 70 BIKTARVY 53 benazepril 37 ointment 50-200-25MG TAB 20mg/hydrochlorothiazid betamethasone/clotrimaz 68 bimatoprost 0.03% ophth 90 e 25mg tab ole 1-0.05% cream soln benazepril 40mg tab 35 betamethasone/clotrimaz 68 bisoprolol fumarate 10mg 57 benazepril 5mg tab 35 ole 1-0.05% lotion tab benazepril 37 betaxolol 0.5% ophth 88 bisoprolol fumarate 37 5mg/hydrochlorothiazide soln 10mg/hydrochlorothiazid 6.25mg tab betaxolol 10mg tab 57 e 6.25mg tab BENLYSTA 200MG/ML 86 betaxolol 20mg tab 57 bisoprolol fumarate 37 AUTO-INJECTOR bethanechol chloride 100 2.5mg/hydrochlorothiazid BENLYSTA 200MG/ML 86 10mg tab e 6.25mg tab SYRINGE bethanechol chloride 100 bisoprolol fumarate 5mg 57 BENZNIDAZOLE 100MG 15 25mg tab tab TAB bethanechol chloride 100 bisoprolol fumarate 37 BENZNIDAZOLE 15 50mg tab 5mg/hydrochlorothiazide 12.5MG TAB bethanechol chloride 5mg 100 6.25mg tab benztropine mesylate 48 tab BIVIGAM 5GM/50ML 91 0.5mg tab BETIMOL 0.25% OPHTH 88 INJ benztropine mesylate 1mg 48 SOLN BLEPHAMIDE 0.2-10% 89 tab BETIMOL 0.5% OPHTH 88 OPHTH SUSP benztropine mesylate 2mg 47 SOLN blisovi 21 fe 1.5/30 28 62 tab BETOPTIC S 0.25% 88 day bepotastine besilate 1.5% 90 OPHTH SUSP blisovi 24 fe 1/20 28 day 62 ophth soln bexarotene 75mg cap 46 pack BERINERT 500UNIT INJ 79 BEXSERO SYRINGE 100 BOOSTRIX INJ 98 betamethasone 0.05% 69 bicalutamide 50mg tab 41 BOOSTRIX SYRINGE 98 aug cream bosentan 125mg tab 60 bosentan 62.5mg tab 60 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108 ALPHABETICAL LISTING OF DRUGS

BOSULIF 100MG TAB 43 buprenorphine 13 CABOMETYX 40MG 43 BOSULIF 400MG TAB 43 2mg/naloxone 0.5mg sl TAB BOSULIF 500MG TAB 43 tab CABOMETYX 60MG 43 BRAFTOVI 75MG CAP 43 buprenorphine 13 TAB BREO 0.1-0.025MG INH 18 2mg/naloxone 0.5mg calcipotriene 0.005% 69 BREO 0.2-0.025MG INH 18 sublingual film cream BREZTRI AEROSPHERE 18 buprenorphine 14 calcipotriene 0.005% 69 160-9-4.8MCG/ACT INH 4mg/naloxone 1mg ointment briellyn 28 day pack 62 sublingual film calcipotriene 0.005% 69 BRILINTA 60MG TAB 79 buprenorphine 8mg sl tab 14 topical soln BRILINTA 90MG TAB 79 buprenorphine 14 calcipotriene/betamethas 70 brimonidine tartrate 88 8mg/naloxone 2mg sl tab one 0.005-0.064% 0.15% ophth soln buprenorphine 14 ointment brimonidine tartrate 88 8mg/naloxone 2mg calcitriol 0.00025mg cap 74 0.2% ophth soln sublingual film calcitriol 0.0005mg cap 74 brinzolamide 1% ophth 90 bupropion 100mg er tab 25 calcitriol 0.001mg/ml oral 74 susp bupropion 100mg tab 25 soln BRIVIACT 100MG TAB 21 bupropion 150mg sr (12 25 calcium acetate 667mg 78 BRIVIACT 10MG TAB 21 hr) tab cap BRIVIACT 10MG/ML 21 bupropion 150mg sr tab 95 calcium acetate 667mg 78 ORAL SOLN bupropion 150mg xl (24 25 tab BRIVIACT 25MG TAB 21 hr) tab CALQUENCE 100MG 43 BRIVIACT 50MG TAB 21 bupropion 200mg er tab 25 CAP BRIVIACT 75MG TAB 21 bupropion 300mg er tab 25 camila 28 day 0.35mg 65 bromfenac 0.09% ophth 90 bupropion 75mg tab 25 pack soln buspirone 10mg tab 15 camreselo 91 day pack 62 bromocriptine 2.5mg tab 47 buspirone 15mg tab 15 candesartan cilexetil 35 bromocriptine 5mg cap 47 buspirone 30mg tab 15 16mg tab BRUKINSA 80MG CAP 43 buspirone 5mg tab 15 candesartan cilexetil 36 budesonide 0.125mg/ml 18 buspirone 7.5mg tab 15 32mg tab inh susp butorphanol tartrate 14 candesartan cilexetil 4mg 36 budesonide 0.25mg/ml 18 1mg/act nasal inhaler tab inh susp BYDUREON 29 candesartan cilexetil 8mg 36 budesonide 0.5mg/ml inh 18 2MG/0.85ML tab susp AUTO-INJECTOR CAPLYTA 42MG CAP 49 budesonide 3mg dr cap 66 BYSTOLIC 10MG TAB 57 CAPRELSA 100MG TAB 43 budesonide 9mg er tab 66 BYSTOLIC 2.5MG TAB 57 CAPRELSA 300MG TAB 43 bumetanide 0.25mg/ml inj 72 BYSTOLIC 20MG TAB 57 captopril 100mg tab 35 bumetanide 0.5mg tab 72 BYSTOLIC 5MG TAB 57 captopril 12.5mg tab 35 bumetanide 1mg tab 72 C captopril 25mg tab 35 bumetanide 2mg tab 72 captopril 50mg tab 35 cabergoline 0.5mg tab 75 buprenorphine 13 CARBAGLU 200MG TAB 74 CABLIVI 11MG INJ 80 12mg/naloxone 3mg FOR ORAL SUSP CABOMETYX 20MG 43 sublingual film carbamazepine 100mg 21 TAB buprenorphine 2mg sl tab 13 chew tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109 ALPHABETICAL LISTING OF DRUGS carbamazepine 100mg er 21 carbidopa 47 cefazolin 1000mg inj 61 cap 25mg/levodopa 250mg cefazolin 200mg/ml inj 61 carbamazepine 100mg er 21 odt cefazolin 500mg inj 61 tab carbidopa 48 cefdinir 25mg/ml susp 62 carbamazepine 200mg er 21 25mg/levodopa 250mg cefdinir 300mg cap 62 cap tab cefdinir 50mg/ml susp 62 carbamazepine 200mg er 21 CARBIDOPA 48 cefepime 1000mg inj 62 tab 31.25MG/ENTACAPONE cefepime 2000mg inj 62 carbamazepine 200mg 21 200MG/LEVODOPA cefixime 20mg/ml susp 62 tab 125MG TAB cefixime 400mg cap 62 carbamazepine 20mg/ml 21 CARBIDOPA 48 cefixime 40mg/ml susp 62 susp 37.5MG/ENTACAPONE cefotetan 1000mg inj 61 carbamazepine 300mg er 21 200MG/LEVODOPA cefotetan 2000mg inj 61 cap 150MG TAB cefoxitin 1000mg inj 61 carbamazepine 400mg er 21 CARBIDOPA 48 cefoxitin 2000mg inj 61 tab 50MG/ENTACAPONE cefoxitin 200mg/ml inj 61 carbidopa 47 200MG/LEVODOPA cefpodoxime 100mg tab 62 10mg/levodopa 100mg 200MG TAB cefpodoxime 10mg/ml 62 odt carbidopa 47 susp carbidopa 47 50mg/levodopa 200mg er cefpodoxime 200mg tab 62 10mg/levodopa 100mg tab cefpodoxime 20mg/ml 62 tab carisoprodol 350mg tab 86 susp CARBIDOPA 48 CARTEOLOL 1% OPHTH 88 cefprozil 250mg tab 61 12.5MG/ENTACAPONE SOLN cefprozil 25mg/ml susp 61 200MG/LEVODOPA cartia 120mg er cap 58 cefprozil 500mg tab 61 50MG TAB cartia 180mg er cap 58 cefprozil 50mg/ml susp 61 CARBIDOPA 48 cartia 240mg er cap 58 ceftazidime 1000mg inj 62 18.75MG/ENTACAPONE cartia 300mg er cap 58 ceftazidime 2000mg inj 62 200MG/LEVODOPA carvedilol 12.5mg tab 56 ceftazidime 200mg/ml inj 62 75MG TAB carvedilol 25mg tab 56 ceftriaxone 1000mg inj 62 carbidopa 25mg tab 48 carvedilol 3.125mg tab 56 ceftriaxone 100mg/ml inj 62 CARBIDOPA 48 carvedilol 6.25mg tab 56 ceftriaxone 2000mg inj 62 25MG/ENTACAPONE caspofungin acetate 50mg 32 ceftriaxone 250mg inj 62 200MG/LEVODOPA inj ceftriaxone 500mg inj 62 100MG TAB caspofungin acetate 70mg 32 cefuroxime 1500mg inj 61 carbidopa 47 inj cefuroxime 250mg tab 61 25mg/levodopa 100mg er CAYSTON 75MG INH 40 cefuroxime 500mg tab 62 tab SOLN cefuroxime 750mg inj 62 carbidopa 47 caziant 28 day pack 63 cefuroxime 95mg/ml inj 62 25mg/levodopa 100mg cefaclor 250mg cap 61 celecoxib 100mg cap 10 odt cefaclor 500mg cap 61 celecoxib 200mg cap 10 carbidopa 47 cefadroxil 1000mg tab 61 celecoxib 400mg cap 10 25mg/levodopa 100mg cefadroxil 100mg/ml susp 61 celecoxib 50mg cap 10 tab cefadroxil 500mg cap 61 CELONTIN 300MG CAP 24 cefadroxil 50mg/ml susp 61 cephalexin 250mg cap 61 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110 ALPHABETICAL LISTING OF DRUGS cephalexin 25mg/ml susp 61 cholestyramine resin 4gm 33 citalopram 40mg tab 25 cephalexin 500mg cap 61 sf powder for oral susp claravis 10mg cap 67 cephalexin 50mg/ml susp 61 (sugar free) claravis 20mg cap 67 CERDELGA 84MG CAP 80 ciclopirox 0.77% cream 68 claravis 30mg cap 67 cetirizine 1mg/ml oral 33 ciclopirox 0.77% gel 68 claravis 40mg cap 67 soln ciclopirox 0.77% lotion 68 CLARINEX-D 67 CETRAXAL 0.2% OTIC 90 ciclopirox 1% shampoo 68 2.5-120MG ER TAB SOLN ciclopirox 8% topical soln 68 clarithromycin 250mg tab 82 cevimeline 30mg cap 86 CILASTATIN 39 CLARITHROMYCIN 82 CHANTIX 0.5MG TAB 95 250MG/IMIPENEM 25MG/ML SUSP CHANTIX 1MG TAB 95 250MG INJ clarithromycin 500mg er 82 CHANTIX CONTINUING 95 cilastatin 39 tab MONTHS OF THERAPY 500mg/imipenem 500mg clarithromycin 500mg tab 82 1MG PACK inj CLARITHROMYCIN 82 CHANTIX FIRST MONTH 95 cilostazol 100mg tab 80 50MG/ML SUSP OF THERAPY PACK cilostazol 50mg tab 80 CLENPIQ 82 CHEMET 100MG CAP 31 CIMDUO 300-300MG 53 75-21.9-0.0625MG/ML CHENODAL 250MG TAB 77 TAB ORAL SOLN chlordiazepoxide 10mg 16 cimetidine 200mg tab 99 clindacin 1% pad 67 cap cimetidine 300mg tab 99 clindamycin 1% gel 67 chlordiazepoxide 25mg 16 cimetidine 400mg tab 99 clindamycin 1% lotion 67 cap CIMETIDINE 60MG/ML 99 clindamycin 1% pad 67 chlordiazepoxide 5mg 16 ORAL SOLN clindamycin 1% topical 67 cap cimetidine 800mg tab 99 soln chlorhexidine gluconate 86 CIMZIA 200MG INJ 77 clindamycin 12mg/ml inj 39 0.12% mouthwash CIMZIA 200MG/ML 77 clindamycin 150mg cap 39 CHLOROQUINE 40 SYRINGE clindamycin 150mg/ml 40 PHOSPHATE 250MG cinacalcet 30mg tab 74 (2ml) inj TAB cinacalcet 60mg tab 74 clindamycin 150mg/ml 40 chloroquine phosphate 40 cinacalcet 90mg tab 74 (4ml) inj 500mg tab CINRYZE 500UNIT INJ 79 clindamycin 150mg/ml 40 chlorpromazine 100mg 51 CIPROFLOXACIN 0.2% 91 (6ml) inj tab OTIC SOLN clindamycin 15mg/ml oral 40 chlorpromazine 10mg tab 51 ciprofloxacin 0.3% ophth 89 soln chlorpromazine 200mg 51 soln clindamycin 18mg/ml inj 40 tab ciprofloxacin 250mg tab 77 clindamycin 2% vaginal 101 chlorpromazine 25mg tab 51 ciprofloxacin 2mg/ml inj 77 cream chlorpromazine 50mg tab 51 ciprofloxacin 500mg tab 77 clindamycin 300mg cap 40 chlorthalidone 25mg tab 73 ciprofloxacin 750mg tab 77 clindamycin 6mg/ml inj 40 chlorthalidone 50mg tab 73 ciprofloxacin/dexamethas 91 clindamycin 75mg cap 40 chlorzoxazone 500mg tab 86 one 0.3-0.1% otic susp clindamycin/benzoyl 67 CHOLBAM 250MG CAP 77 citalopram 10mg tab 25 peroxide 1-5% gel CHOLBAM 50MG CAP 77 citalopram 20mg tab 25 CLINIMIX 4.25/10 INJ 87 cholestyramine resin 4gm 33 citalopram 2mg/ml oral 25 CLINIMIX 4.25/5 INJ 87 sf powder for oral susp soln CLINIMIX 5/15 INJ 87 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111 ALPHABETICAL LISTING OF DRUGS

CLINIMIX 5/20 INJ 87 clonidine 0.0125mg/hr 36 colestipol 5000mg 33 CLINIMIX E 2.75/5 INJ 87 weekly patch granules for oral susp CLINIMIX E 4.25/10 INJ 87 clonidine 0.1mg er tab 7 colistin 75mg/ml inj 40 CLINIMIX E 4.25/5 INJ 88 clonidine 0.1mg tab 36 COMBIGAN 2-5MG/ML 88 CLINIMIX E 5/15 INJ 88 clonidine 0.2mg tab 36 OPHTH SOLN CLINIMIX E 5/20 INJ 88 clonidine 0.3mg tab 36 COMBIPATCH 75 clinisol 15% inj 88 clopidogrel 75mg tab 80 0.00208-0.00583MG/HR clobazam 10mg tab 20 clorazepate dipotassium 16 PATCH clobazam 2.5mg/ml susp 20 15mg tab COMBIPATCH 75 clobazam 20mg tab 20 clorazepate dipotassium 16 0.00208-0.0104MG/HR clobetasol propionate 70 3.75mg tab PATCH 0.05% cream clorazepate dipotassium 16 COMBIVENT 18 clobetasol propionate 70 7.5mg tab 0.1-0.02MG INH 0.05% e cream clotrimazole 1% cream 68 COMETRIQ 100MG 43 clobetasol propionate 70 clotrimazole 1% topical 68 DAILY DOSE CARTON 0.05% foam soln PACK clobetasol propionate 70 clotrimazole 10mg 86 COMETRIQ 140MG 43 0.05% gel lozenge DAILY DOSE CARTON clobetasol propionate 70 clovique 250mg cap 85 PACK 0.05% lotion clozapine 100mg odt 50 COMETRIQ 60MG 43 clobetasol propionate 70 clozapine 100mg tab 50 DAILY DOSE CARTON 0.05% ointment CLOZAPINE 12.5MG 50 PACK clobetasol propionate 70 ODT COMPLERA 53 0.05% shampoo CLOZAPINE 150MG 50 200-25-300MG TAB clobetasol propionate 70 ODT compro 25mg rectal supp 51 0.05% spray CLOZAPINE 200MG 50 constulose 10gm/15ml 82 clobetasol propionate 70 ODT oral soln 0.05% topical soln clozapine 200mg tab 51 COPIKTRA 15MG CAP 43 clodan 0.05% shampoo 70 clozapine 25mg odt 51 COPIKTRA 25MG CAP 43 clomipramine 25mg cap 27 clozapine 25mg tab 51 CORLANOR 5MG TAB 61 clomipramine 50mg cap 27 clozapine 50mg tab 51 CORLANOR 5MG/5ML 61 clomipramine 75mg cap 27 COARTEM 20-120MG 40 ORAL SOLN clonazepam 0.125mg odt 21 TAB CORLANOR 7.5MG TAB 61 clonazepam 0.25mg odt 21 CODEINE SULFATE 11 COTELLIC 20MG TAB 43 clonazepam 0.5mg odt 21 15MG TAB CREON 71 clonazepam 0.5mg tab 21 codeine sulfate 30mg tab 11 120000-76000-24000UNI clonazepam 1mg odt 21 codeine sulfate 60mg tab 11 T DR CAP clonazepam 1mg tab 21 colchicine 79 CREON 72 clonazepam 2mg odt 21 0.5mg/probenecid 500mg 15000-9500-3000UNIT clonazepam 2mg tab 21 tab DR CAP clonidine 0.00417mg/hr 36 colesevelam 3750mg 33 CREON 72 weekly patch powder for oral susp 30000-19000-6000UNIT clonidine 0.00833mg/hr 36 colesevelam 625mg tab 33 DR CAP weekly patch colestipol 1000mg tab 33

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112 ALPHABETICAL LISTING OF DRUGS

CREON 72 CYSTADROPS 0.37% 90 deferiprone 500mg tab 31 36000-114000-180000U OPHTH SOLN DELSTRIGO 53 NIT DR CAP CYSTAGON 150MG CAP 78 100-300-300MG TAB CREON 72 CYSTAGON 50MG CAP 78 demeclocycline 150mg 96 60000-38000-12000UNIT CYSTARAN 0.44% 90 tab DR CAP OPHTH SOLN demeclocycline 300mg 96 CRINONE 4% VAGINAL 101 D tab GEL DEMSER 250MG CAP 35 dalfampridine 10mg er 94 CRINONE 8% VAGINAL 101 DENAVIR 1% CREAM 69 tab GEL DESCOVY 200-25MG 53 DALIRESP 250MCG TAB 17 cromolyn sodium 77 TAB DALIRESP 500MCG TAB 17 20mg/ml oral soln desipramine 100mg tab 27 DALVANCE 500MG INJ 39 cromolyn sodium 4% 90 desipramine 10mg tab 27 danazol 100mg cap 14 ophth soln desipramine 150mg tab 27 danazol 200mg cap 14 cryselle 28 pack 63 desipramine 25mg tab 27 danazol 50mg cap 14 cyclafem 1/35 28 day 63 desipramine 50mg tab 27 dantrolene sodium 100mg 87 pack desipramine 75mg tab 27 cap cyclafem 7/7/7 28 day 63 desloratadine 5mg tab 33 dantrolene sodium 25mg 87 pack desmopressin acetate 75 cap cyclobenzaprine 10mg 86 0.01mg/act nasal spray dantrolene sodium 50mg 87 tab desmopressin acetate 75 cap cyclobenzaprine 5mg tab 87 0.1mg tab dapsone 100mg tab 39 CYCLOPHOSPHAMIDE 41 desmopressin acetate 75 dapsone 25mg tab 39 25MG CAP 0.2mg tab DAPTACEL INJ 98 CYCLOPHOSPHAMIDE 41 desogestrel /ethinyl 63 daptomycin 500mg inj 39 25MG TAB estradiol 0.15mg-30mcg DAURISMO 100MG TAB 41 CYCLOPHOSPHAMIDE 41 tab DAURISMO 25MG TAB 41 50MG CAP desogestrel/ethinyl 63 deblitane 28 day 0.35mg 66 CYCLOPHOSPHAMIDE 41 estradiol pack pack 50MG TAB desonide 0.05% ointment 70 deferasirox 125mg tab 31 cyclosporine 100mg cap 56 desoximetasone 0.05% 70 for oral susp cyclosporine 25mg cap 56 gel deferasirox 180mg 31 cyclosporine modified 56 desoximetasone 0.25% 70 granules 100mg cap cream deferasirox 180mg tab 31 cyclosporine modified 85 desoximetasone 0.25% 70 deferasirox 250mg tab 31 100mg/ml oral soln ointment for oral susp cyclosporine modified 56 desvenlafaxine succinate 26 deferasirox 360mg 31 25mg cap 100mg er tab granules cyclosporine modified 85 desvenlafaxine succinate 26 deferasirox 360mg tab 31 50mg cap 25mg er tab deferasirox 500mg tab 31 cyproheptadine 0.4mg/ml 33 desvenlafaxine succinate 26 for oral susp oral soln 50mg er tab deferasirox 90mg 31 cyproheptadine 4mg tab 33 dexamethasone 0.1mg/ml 66 granules cyred 28 day pack 63 oral soln deferasirox 90mg tab 31 dexamethasone 0.5mg tab 66 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113 ALPHABETICAL LISTING OF DRUGS dexamethasone 0.75mg 66 dextroamphetamine 7 diclofenac sodium 100mg 10 tab sulfate 10mg tab er tab dexamethasone 1.5mg tab 66 dextroamphetamine 7 diclofenac sodium 25mg 10 DEXAMETHASONE 1MG 66 sulfate 15mg er cap dr tab TAB dextroamphetamine 7 diclofenac sodium 3% gel 68 DEXAMETHASONE 2MG 66 sulfate 5mg er cap diclofenac sodium 50mg 10 TAB dextroamphetamine 7 dr tab dexamethasone 4mg tab 66 sulfate 5mg tab diclofenac sodium 10 dexamethasone 6mg tab 66 DIACOMIT 250MG CAP 21 50mg/misoprostol 0.2mg DEXAMETHASONE 89 DIACOMIT 250MG 21 dr tab PHOSPHATE 0.1% POWDER FOR ORAL diclofenac sodium 75mg 10 OPHTH SOLN SUSP dr tab dexamethasone/neomycin 89 DIACOMIT 500MG CAP 21 diclofenac sodium 10 /polymyxin b 0.1% ophth DIACOMIT 500MG 22 75mg/misoprostol 0.2mg ointment POWDER FOR ORAL dr tab dexamethasone/neomycin 89 SUSP dicloxacillin 250mg cap 92 /polymyxin b 0.1% ophth DIASTAT 10MG RECTAL 21 dicloxacillin 500mg cap 93 susp GEL dicyclomine 10mg cap 99 dexamethasone/tobramyc 89 DIASTAT 2.5MG RECTAL 21 dicyclomine 20mg tab 99 in 0.3-0.1% ophth susp GEL dicyclomine 2mg/ml oral 99 dexmethylphenidate 7 DIASTAT 20MG RECTAL 21 soln 10mg er cap GEL diflunisal 500mg tab 11 dexmethylphenidate 7 diazepam 10mg tab 16 digitek 0.125mg tab 59 10mg tab DIAZEPAM 10MG/2ML 21 digitek 0.25mg tab 59 dexmethylphenidate 8 RECTAL GEL digox 125mcg tab 59 15mg er cap DIAZEPAM 1MG/ML 16 digox 250mcg tab 59 dexmethylphenidate 8 ORAL SOLN digoxin 0.05mg/ml oral 59 2.5mg tab DIAZEPAM 21 soln dexmethylphenidate 8 2.5MG/0.5ML RECTAL digoxin 0.125mg tab 59 20mg er cap GEL digoxin 0.25mg tab 59 dexmethylphenidate 8 DIAZEPAM 20MG/4ML 21 dihydroergotamine 83 25mg er cap RECTAL GEL mesylate 0.5mg/act nasal dexmethylphenidate 8 diazepam 2mg tab 16 inhaler 30mg er cap diazepam 5mg tab 16 DILANTIN 30MG ER 24 dexmethylphenidate 8 diazepam 5mg/ml oral 16 CAP 35mg er cap soln DILT 120MG ER CAP 58 dexmethylphenidate 8 diazoxide 50mg/ml susp 29 DILT 180MG ER CAP 58 40mg er cap diclofenac potassium 10 DILT 240MG ER CAP 58 dexmethylphenidate 5mg 8 50mg tab diltiazem 120mg er (12 58 er cap diclofenac sodium 0.1% 90 hr) cap dexmethylphenidate 5mg 8 ophth soln diltiazem 120mg er (24 58 tab diclofenac sodium 1% gel 68 hr) cap dextroamphetamine 7 diclofenac sodium 1.5% 68 diltiazem 120mg tab 58 sulfate 10mg er cap topical soln diltiazem 180mg er cap 58 diltiazem 180mg er tab 58 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114 ALPHABETICAL LISTING OF DRUGS diltiazem 240mg er cap 58 dofetilide 0.5mg cap 17 doxycycline hyclate 96 diltiazem 240mg er tab 58 dolishale 28 day pack 63 100mg cap diltiazem 300mg er cap 58 donepezil 10mg odt 93 doxycycline hyclate 96 diltiazem 300mg er tab 58 donepezil 10mg tab 93 100mg tab diltiazem 30mg tab 58 donepezil 23mg tab 93 doxycycline hyclate 20mg 96 diltiazem 360mg er cap 58 donepezil 5mg odt 93 tab diltiazem 360mg er tab 58 donepezil 5mg tab 93 doxycycline hyclate 50mg 96 diltiazem 420mg er cap 58 DOPTELET 20MG TAB 80 cap diltiazem 60mg er cap 58 DOPTELET 40MG DAILY 80 doxycycline monohydrate 96 diltiazem 60mg tab 58 DOSE PACK 100mg cap diltiazem 90mg er cap 58 DOPTELET 60MG DAILY 80 doxycycline monohydrate 96 diltiazem 90mg tab 58 DOSE PACK 100mg tab dimethyl fumarate 120mg 94 dorzolamide 2% ophth 90 doxycycline monohydrate 96 dr cap soln 50mg cap dimethyl fumarate 94 dorzolamide/timolol 88 doxycycline monohydrate 96 120mg/dimethyl fumarate 22.3-6.8mg/ml ophth soln 50mg tab 240mg pack dorzolamide/timolol 88 doxycycline monohydrate 96 dimethyl fumarate 240mg 94 22.3-6.8mg/ml ophth soln 5mg/ml susp dr cap (preservative-free) doxylamine succinate 32 DIPENTUM 250MG CAP 77 dotti 0.025mg/24hr patch 76 10mg/pyridoxine 10mg dr DIPHTHERIA/TETANUS 98 dotti 0.0375mg/24hr 76 tab TOXOID INJ patch DRIZALMA 20MG DR 26 dipyridamole 25mg tab 80 dotti 0.05mg/24hr patch 76 CAP dipyridamole 50mg tab 80 dotti 0.075mg/24hr patch 76 DRIZALMA 30MG DR 26 dipyridamole 75mg tab 80 dotti 0.1mg/24hr patch 76 CAP disopyramide 100mg cap 16 DOVATO 50-300MG TAB 53 DRIZALMA 40MG DR 26 disopyramide 150mg cap 16 doxazosin 1mg tab 36 CAP disulfiram 250mg tab 93 doxazosin 2mg tab 36 DRIZALMA 60MG DR 26 disulfiram 500mg tab 93 doxazosin 4mg tab 36 CAP DIURIL 250MG/5ML 73 doxazosin 8mg tab 36 dronabinol 10mg cap 32 SUSP doxepin 100mg cap 27 dronabinol 2.5mg cap 32 divalproex sodium 125mg 24 doxepin 10mg cap 27 dronabinol 5mg cap 32 dr cap doxepin 10mg/ml oral 27 drospirenone 3mg/ethinyl 63 divalproex sodium 125mg 24 soln estradiol 0.02mg/inert 1 dr tab doxepin 150mg cap 27 mg pack divalproex sodium 250mg 24 doxepin 25mg cap 27 drospirenone 3mg/ethinyl 63 dr tab doxepin 50mg cap 27 estradiol 0.03mg/inert divalproex sodium 250mg 24 doxepin 75mg cap 27 ingredients 1mg pack er tab doxercalciferol 0.0005mg 74 DROXIA 200MG CAP 80 divalproex sodium 500mg 24 cap DROXIA 300MG CAP 80 dr tab doxercalciferol 0.001mg 74 DROXIA 400MG CAP 80 divalproex sodium 500mg 24 cap droxidopa 100mg cap 102 er tab doxercalciferol 0.0025mg 74 droxidopa 200mg cap 102 dofetilide 0.125mg cap 17 cap droxidopa 300mg cap 102 dofetilide 0.25mg cap 17 doxy 100mg inj 96 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115 ALPHABETICAL LISTING OF DRUGS

DULERA 0.005-0.1MG 18 ELIGARD 22.5MG 41 EMTRIVA 200MG CAP 53 INH SYRINGE enalapril maleate 10mg 35 DULERA 0.005-0.2MG 18 ELIGARD 30MG 41 tab INH SYRINGE enalapril maleate 37 DULERA INHALER 18 ELIGARD 45MG 41 10mg/hydrochlorothiazid 50-5MCG SYRINGE e 25mg tab duloxetine 20mg dr cap 26 ELIGARD 7.5MG 42 enalapril maleate 2.5mg 35 duloxetine 30mg dr cap 26 SYRINGE tab duloxetine 40mg dr cap 26 ELIQUIS 2.5MG TAB 19 enalapril maleate 20mg 35 duloxetine 60mg dr cap 26 ELIQUIS 30-DAY 19 tab DUPIXENT 71 STARTER PACK 5MG enalapril maleate 5mg 35 200MG/1.14ML ELIQUIS 5MG TAB 19 tab SYRINGE ELMIRON 100MG CAP 78 enalapril maleate 37 DUPIXENT 300MG/2ML 71 eluryng 65 5mg/hydrochlorothiazide AUTO-INJECTOR 0.000625-0.005mg/hr 12.5mg tab DUPIXENT 300MG/2ML 71 vaginal system ENBREL 25MG INJ 11 SYRINGE EMCYT 140MG CAP 42 ENBREL 25MG/0.5ML 11 DUREZOL 0.05% OPHTH 89 EMGALITY 100MG/ML 83 INJ SUSP SYRINGE ENBREL 25MG/0.5ML 11 dutasteride 0.5mg cap 79 EMGALITY 120MG/ML 83 SYRINGE dutasteride 79 AUTO-INJECTOR ENBREL 50MG/ML 11 0.5mg/tamsulosin 0.4mg EMGALITY 120MG/ML 83 AUTO-INJECTOR cap SYRINGE ENBREL 50MG/ML 11 E emoquette pack 63 CARTRIDGE EMSAM 12MG/24HR 25 ENBREL 50MG/ML 11 econazole nitrate 1% 68 PATCH SYRINGE cream EMSAM 6MG/24HR 25 ENDARI 5GM POWDER 80 EDURANT 25MG TAB 53 PATCH FOR ORAL SOLN efavirenz 200mg cap 53 EMSAM 9MG/24HR 25 endocet 325-10mg tab 13 efavirenz 50mg cap 53 PATCH endocet 325-5mg tab 13 efavirenz 600mg tab 53 emtricitabine 200mg cap 53 endocet 325-7.5mg tab 13 efavirenz/emtricitabine/te 53 emtricitabine/tenofovir 53 ENGERIX-B 101 nofovir disoproxil disoproxil fumarate 10MCG/0.5ML SYRINGE fumarate 600-200-300mg 100-150mg tab ENGERIX-B 20MCG/ML 101 tab emtricitabine/tenofovir 53 SYRINGE efavirenz/emtricitabine/te 53 disoproxil fumarate enoxaparin sodium 20 nofovir disoproxil 133-200mg tab 100mg/ml (0.3ml) syringe fumarate 600-200-300mg emtricitabine/tenofovir 53 enoxaparin sodium 20 tab disoproxil fumarate 100mg/ml (0.4ml) syringe efavirenz/lamivudine/ten 53 167-250mg tab enoxaparin sodium 20 ofovir disoproxil emtricitabine/tenofovir 53 100mg/ml (0.6ml) syringe fumarate 400-300-300mg disoproxil fumarate enoxaparin sodium 20 tab 200-300mg tab 100mg/ml (0.8ml) syringe eletriptan 20mg tab 83 EMTRIVA 10MG/ML 53 enoxaparin sodium 20 eletriptan 40mg tab 83 ORAL SOLN 100mg/ml (1ml) syringe You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116 ALPHABETICAL LISTING OF DRUGS enoxaparin sodium 20 ERGOLOID MESYLATES 95 estradiol 0.00104mg/hr 76 150mg/ml (0.8ml) syringe USP 1MG TAB twice weekly patch enoxaparin sodium 20 ERIVEDGE 150MG CAP 41 estradiol 0.00104mg/hr 76 150mg/ml (1ml) syringe ERLEADA 60MG TAB 42 weekly patch enpresse 28 day pack 63 erlotinib 100mg tab 43 estradiol 0.00156mg/hr 76 enskyce 28 day pack 63 erlotinib 150mg tab 43 twice weekly patch ENSPRYNG 120MG/ML 85 erlotinib 25mg tab 43 estradiol 0.00156mg/hr 76 SYRINGE errin 28 day 0.35mg pack 66 weekly patch entacapone 200mg tab 48 ertapenem 1000mg inj 39 estradiol 0.00208mg/hr 76 entecavir 0.5mg tab 55 ERY 2% PAD 67 twice weekly patch entecavir 1mg tab 55 ERYTHROCIN 500MG 82 estradiol 0.00208mg/hr 76 ENTRESTO 24-26MG 60 INJ weekly patch TAB erythromycin 0.5% ophth 89 estradiol 0.0025mg/hr 76 ENTRESTO 49-51MG 60 ointment weekly patch TAB erythromycin 2% gel 67 estradiol 0.00312mg/hr 76 ENTRESTO 97-103MG 60 erythromycin 2% topical 67 weekly patch TAB soln estradiol 0.00313mg/hr 76 enulose 10gm/15ml oral 78 erythromycin 250mg dr 82 twice weekly patch soln cap estradiol 0.00417mg/hr 76 ENVARSUS 0.75MG ER 86 erythromycin 250mg tab 82 twice weekly patch TAB erythromycin 500mg tab 82 estradiol 0.00417mg/hr 76 ENVARSUS 1MG ER TAB 86 erythromycin 82 weekly patch ENVARSUS 4MG ER TAB 86 ethylsuccinate 40mg/ml estradiol 0.01% vaginal 101 EPIDIOLEX 100MG/ML 22 susp cream ORAL SOLN erythromycin 82 estradiol 0.5mg tab 76 EPIDUO 0.3-2.5% GEL 67 ethylsuccinate 80mg/ml estradiol 75 epinastine 0.05% ophth 90 susp 0.5mg/norethindrone soln erythromycin/benzoyl 67 acetate 0.1mg pack epinephrine 0.5mg/ml 102 peroxide 5-3% gel estradiol 1mg tab 76 auto-injector ESBRIET 267MG CAP 96 estradiol 75 epinephrine 1mg/ml 102 ESBRIET 267MG TAB 96 1mg/norethindrone auto-injector ESBRIET 801MG TAB 96 acetate 0.5mg pack epitol 200mg tab 22 escitalopram 10mg tab 25 estradiol 2mg tab 76 EPIVIR HBV 5MG/ML 55 escitalopram 1mg/ml oral 25 estradiol valerate 76 ORAL SOLN soln 20mg/ml inj eplerenone 25mg tab 38 escitalopram 20mg tab 25 estradiol valerate 76 eplerenone 50mg tab 38 escitalopram 5mg tab 25 40mg/ml inj EQUETRO 100MG ER 49 esomeprazole 20mg dr 99 ESTRING 2MG VAGINAL 101 CAP cap SYSTEM EQUETRO 200MG ER 49 esomeprazole 40mg dr 99 eszopiclone 1mg tab 81 CAP cap eszopiclone 2mg tab 81 EQUETRO 300MG ER 49 estarylla 28 day pack 63 eszopiclone 3mg tab 81 CAP estazolam 1mg tab 81 ethacrynic acid 25mg tab 72 ERAXIS 100MG INJ 32 estazolam 2mg tab 81 ethambutol 100mg tab 40 ERAXIS 50MG INJ 32 ethambutol 400mg tab 40 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117 ALPHABETICAL LISTING OF DRUGS ethinyl estradiol 76 ethinyl estradiol 63 euthyrox 137mcg tab 97 0.0025mg/norethindrone 0.035mg/inert/norgestima euthyrox 150mcg tab 97 acetate 0.5mg pack te euthyrox 175mcg tab 97 ethinyl estradiol 76 0.18mg/0.215mg/0.25mg euthyrox 200mcg tab 97 0.005mg/norethindrone pack euthyrox 25mcg tab 97 acetate 1mg pack ethinyl estradiol 63 euthyrox 50mcg tab 97 ethinyl estradiol 63 0.035mg/norgestimate euthyrox 75mcg tab 97 0.01mg/ethinyl estradiol 0.25mg pack euthyrox 88mcg tab 97 0.02mg/levonorgestrel ethinyl estradiol 63 everolimus 0.25mg tab 86 0.1mg 91 day pack 0.03mg/0.04mg everolimus 0.5mg tab 86 ethinyl estradiol 63 /inert/levonorgestrel everolimus 0.75mg tab 86 0.01mg/ethinyl estradiol 0.05mg/ 0.075mg pack everolimus 2.5mg tab 43 0.03mg/levonorgestrel ethinyl estradiol 63 everolimus 5mg tab 44 0.15mg pack 0.03mg/inert ingredients everolimus 7.5mg tab 44 ethinyl estradiol 63 1mg/levonorgestrel EVOTAZ 300-150MG 54 0.025mg/ferrous 0.15mg pack TAB fumarate ethinyl estradiol 63 EVRYSDI 0.75MG/ML 87 75mg/norethindrone 0.03mg/levonorgestrel ORAL SOLN 0.8mg pack 0.15mg tab 28 day pack exemestane 25mg tab 42 ethinyl estradiol 63 ethinyl estradiol 63 EXTAVIA 0.3MG INJ 94 0.025mg/inert/norgestima 0.05mg/ethynodiol ezetimibe 10mg tab 34 te 1mg/inert ingredients F 0.18mg/0.215mg/0.25mg 1mg 28 day pack falmina 28 day pack 63 pack ethinyl 63 famciclovir 125mg tab 55 ethinyl estradiol 63 estradiol/levonorgestrel famciclovir 250mg tab 55 0.02mg/ferrous fumarate 91 day pack famciclovir 500mg tab 55 75mg/norethindrone ethosuximide 250mg cap 24 famotidine 20mg tab 99 acetate 1mg 21 day pack ethosuximide 50mg/ml 24 famotidine 40mg tab 99 ethinyl estradiol 63 oral soln famotidine 8mg/ml susp 99 0.02mg/inert ingredients etodolac 200mg cap 10 FANAPT 10MG TAB 49 1mg/levonorgestrel etodolac 300mg cap 10 FANAPT 12MG TAB 49 0.1mg pack etodolac 400mg er tab 10 FANAPT 1MG TAB 49 ethinyl estradiol 63 etodolac 400mg tab 10 FANAPT 2MG TAB 49 0.02mg/norethindrone etodolac 500mg er tab 10 FANAPT 4MG TAB 49 acetate 1mg pack etodolac 500mg tab 10 FANAPT 6MG TAB 49 ethinyl estradiol 63 etodolac 600mg er tab 10 FANAPT 8MG TAB 49 0.035mg/ethynodiol 1mg etonogestrel-ethinyl 65 FANAPT TITRATION 49 28 day pack estradiol PACK ethinyl estradiol 63 0.120-0.015mg/24hr FARXIGA 10MG TAB 30 0.035mg/ferrous vaginal ring FARXIGA 5MG TAB 30 fumarate etravirine 100mg tab 53 FARYDAK 10MG CAP 44 75mg/norethindrone etravirine 200mg tab 54 FARYDAK 15MG CAP 44 0.4mg pack euthyrox 100mcg tab 97 FARYDAK 20MG CAP 44 euthyrox 112mcg tab 97 euthyrox 125mcg tab 97 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118 ALPHABETICAL LISTING OF DRUGS

FASENRA 30MG/ML 17 FENTANYL 0.6MG 11 flavoxate 100mg tab 100 AUTO-INJECTOR BUCCAL TAB FLEBOGAMMA 91 FASENRA 30MG/ML 17 fentanyl 0.6mg lozenge 11 5GM/50ML INJ SYRINGE FENTANYL 0.8MG 11 flecainide acetate 100mg 17 fayosim 91 day pack 64 BUCCAL TAB tab febuxostat 40mg tab 79 fentanyl 0.8mg lozenge 11 flecainide acetate 150mg 17 febuxostat 80mg tab 79 fentanyl 1.2mg lozenge 11 tab felbamate 120mg/ml susp 24 fentanyl 1.6mg lozenge 11 flecainide acetate 50mg 17 felbamate 400mg tab 24 FENTORA 100MCG 12 tab felbamate 600mg tab 24 BUCCAL TAB FLOVENT 18 felodipine 10mg er tab 58 FENTORA 200MCG 12 100MCG/BLIST INH felodipine 2.5mg er tab 58 BUCCAL TAB FLOVENT 110MCG INH 18 felodipine 5mg er tab 58 FENTORA 400MCG 12 FLOVENT 220MCG INH 18 femynor 28 day pack 64 BUCCAL TAB FLOVENT 18 fenofibrate 134mg cap 33 FENTORA 600MCG 12 250MCG/BLIST INH fenofibrate 145mg tab 33 BUCCAL TAB FLOVENT 44MCG INH 18 FENOFIBRATE 150MG 33 FENTORA 800MCG 12 FLOVENT 50MCG/BLIST 18 CAP BUCCAL TAB INH fenofibrate 160mg tab 33 FERRIPROX 1000MG 31 fluconazole 100mg tab 32 fenofibrate 200mg cap 33 TAB fluconazole 10mg/ml susp 32 fenofibrate 48mg tab 33 FERRIPROX 100MG/ML 31 fluconazole 150mg tab 32 FENOFIBRATE 50MG 33 ORAL SOLN fluconazole 200mg tab 32 CAP FERRIPROX 500MG TAB 31 fluconazole 2mg/ml 32 fenofibrate 54mg tab 34 FETZIMA 120MG ER 26 (100ml) inj fenofibrate 67mg cap 34 CAP fluconazole 2mg/ml 32 fenofibric acid 135mg dr 34 FETZIMA 20MG ER CAP 26 (200ml) inj cap FETZIMA 40MG ER CAP 27 fluconazole 40mg/ml susp 32 fenofibric acid 45mg dr 34 FETZIMA 80MG ER CAP 27 fluconazole 50mg tab 32 cap FETZIMA PACK 27 flucytosine 250mg cap 32 fentanyl 0.012mg/hr 11 FIASP 100UNIT/ML 29 flucytosine 500mg cap 32 patch CARTRIDGE fludrocortisone 0.1mg tab 66 fentanyl 0.025mg/hr 11 FIASP 100UNIT/ML INJ 29 FLUNISOLIDE 87 patch FIASP 100UNIT/ML PEN 30 0.025MG/ACT NASAL fentanyl 0.05mg/hr patch 11 INJ INHALER fentanyl 0.075mg/hr 11 FINACEA 15% FOAM 71 fluocinolone acetonide 70 patch finasteride 5mg tab 79 0.01% cream FENTANYL 0.1MG 11 FINTEPLA 2.2MG/ML 22 fluocinolone acetonide 91 BUCCAL TAB ORAL SOLN 0.01% otic soln fentanyl 0.1mg/hr patch 11 FIRMAGON 120MG INJ 42 fluocinolone acetonide 70 FENTANYL 0.2MG 11 FIRMAGON 80MG INJ 42 0.01% topical soln BUCCAL TAB FIRVANQ 25MG/ML 39 fluocinolone acetonide 70 fentanyl 0.2mg lozenge 11 ORAL SOLN 0.025% cream FENTANYL 0.4MG 11 FIRVANQ 50MG/ML 39 fluocinolone acetonide 70 BUCCAL TAB ORAL SOLN 0.025% ointment fentanyl 0.4mg lozenge 11 flac 0.01% otic soln 91 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119 ALPHABETICAL LISTING OF DRUGS fluocinolone acetonide 70 FLUPHENAZINE 52 FLUTICASONE 18 0.1mg/ml oil 0.5MG/ML ORAL SOLN PROPIONATE/SALMETE fluocinonide 0.05% cream 70 fluphenazine 10mg tab 52 ROL XINAFOATE fluocinonide 0.05% e 70 fluphenazine 1mg tab 52 232-14MCG/ACT cream fluphenazine 2.5mg tab 52 POWDER INH fluocinonide 0.05% gel 70 FLUPHENAZINE 52 FLUTICASONE 19 fluocinonide 0.05% 70 2.5MG/ML INJ PROPIONATE/SALMETE ointment fluphenazine 5mg tab 52 ROL XINAFOATE fluocinonide 0.05% 70 FLUPHENAZINE 52 55-14MCG/ACT topical soln 5MG/ML ORAL SOLN POWDER INH fluocinonide 0.1% cream 70 fluphenazine decanoate 52 fluvastatin 20mg cap 34 fluorometholone 0.1% 89 25mg/ml inj fluvastatin 40mg cap 34 ophth susp FLURAZEPAM 15MG 81 fluvastatin 80mg er tab 34 FLUOROPLEX 1% 68 CAP fluvoxamine maleate 25 CREAM FLURAZEPAM 30MG 81 100mg er cap FLUOROURACIL 2% 68 CAP fluvoxamine maleate 25 TOPICAL SOLN flurbiprofen 100mg tab 10 100mg tab fluorouracil 5% cream 68 FLURBIPROFEN 90 fluvoxamine maleate 25 FLUOROURACIL 5% 68 SODIUM 0.03% OPHTH 150mg er cap TOPICAL SOLN SOLN fluvoxamine maleate 25 fluoxetine 10mg cap 25 flutamide 125mg cap 42 25mg tab fluoxetine 10mg tab 25 fluticasone propionate 70 fluvoxamine maleate 25 FLUOXETINE 10MG TAB 25 0.005% ointment 50mg tab fluoxetine 20mg cap 25 fluticasone propionate 70 fondaparinux sodium 20 fluoxetine 20mg tab 25 0.05% cream 12.5mg/ml (0.4ml) syringe FLUOXETINE 20MG TAB 25 fluticasone propionate 87 fondaparinux sodium 20 fluoxetine 94 0.05mg/act nasal inhaler 12.5mg/ml (0.6ml) syringe 25mg/olanzapine 12mg fluticasone propionate 18 fondaparinux sodium 20 cap 0.1mg/salmeterol 0.05mg 12.5mg/ml (0.8ml) syringe fluoxetine 94 inh fondaparinux sodium 20 25mg/olanzapine 3mg fluticasone propionate 18 5mg/ml syringe cap 0.25mg/salmeterol FORTEO 600MCG/2.4ML 73 fluoxetine 94 0.05mg inh PEN INJ 25mg/olanzapine 6mg fluticasone propionate 18 fosamprenavir 700mg tab 54 cap 0.5mg/salmeterol 0.05mg fosinopril sodium 10mg 35 fluoxetine 40mg cap 25 inh tab fluoxetine 4mg/ml oral 25 FLUTICASONE 18 fosinopril sodium 37 soln PROPIONATE/SALMETE 10mg/hydrochlorothiazid fluoxetine 94 ROL XINAFOATE e 12.5mg tab 50mg/olanzapine 12mg 113-14MCG/ACT fosinopril sodium 20mg 35 cap POWDER INH tab fluoxetine 94 fosinopril sodium 37 50mg/olanzapine 6mg 20mg/hydrochlorothiazid cap e 12.5mg tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120 ALPHABETICAL LISTING OF DRUGS fosinopril sodium 40mg 35 fyavolv 0.005-1mg tab 76 GAMMAPLEX 91 tab FYCOMPA 0.5MG/ML 20 20GM/200ML INJ FOSRENOL 1000MG 78 SUSP GAMMAPLEX 91 ORAL POWDER FYCOMPA 10MG TAB 20 5GM/50ML INJ FOSRENOL 750MG 78 FYCOMPA 12MG TAB 20 GAMUNEX 1GM/10ML 91 ORAL POWDER FYCOMPA 2MG TAB 20 INJ FOTIVDA 0.89MG CAP 44 FYCOMPA 4MG TAB 20 GARDASIL 9 INJ 101 FOTIVDA 1.34MG CAP 44 FYCOMPA 6MG TAB 20 GARDASIL 9 SYRINGE 101 FRAGMIN 20 FYCOMPA 8MG TAB 20 gatifloxacin 0.5% ophth 89 10000UNIT/ML G soln SYRINGE GATTEX 5MG INJ 78 gabapentin 100mg cap 22 FRAGMIN 20 GAUZE PADS & 82 gabapentin 300mg cap 22 12500UNIT/0.5ML DRESSINGS - PADS 2 X gabapentin 400mg cap 22 SYRINGE 2 gabapentin 50mg/ml oral 22 FRAGMIN 20 GAVILYTE-C ORAL 82 soln 15000UNIT/0.6ML SOLN gabapentin 600mg tab 22 SYRINGE gavilyte-g powder for 82 gabapentin 800mg tab 22 FRAGMIN 20 oral soln GALAFOLD 28 DAY 74 18000UNT/0.72ML gavilyte-n powder for 82 WALLET 123MG PACK SYRINGE oral soln galantamine 12mg tab 93 FRAGMIN 20 GAVRETO 100MG CAP 44 galantamine 4mg tab 93 2500UNIT/0.2ML gemfibrozil 600mg tab 34 galantamine 8mg tab 93 SYRINGE generlac 10gm/15ml oral 78 galantamine 93 FRAGMIN 20 soln hydrobromide 16mg er 5000UNIT/0.2ML gengraf 100mg cap 56 cap SYRINGE gengraf 100mg/ml oral 56 galantamine 93 FRAGMIN 20 soln hydrobromide 24mg er 7500UNIT/0.3ML gengraf 25mg cap 56 cap SYRINGE GENOTROPIN 0.2MG 74 GALANTAMINE 93 FRAGMIN 20 SYRINGE HYDROBROMIDE 95000UNIT/3.8ML INJ GENOTROPIN 0.4MG 74 4MG/ML ORAL SOLN FULPHILA 6MG/0.6ML 80 SYRINGE galantamine 93 SYRINGE GENOTROPIN 0.6MG 74 hydrobromide 8mg er cap furosemide 10mg/ml inj 72 SYRINGE GAMMAGARD 10GM 91 furosemide 10mg/ml oral 72 GENOTROPIN 0.8MG 74 INJ soln SYRINGE GAMMAGARD 91 furosemide 10mg/ml 72 GENOTROPIN 1.2MG 74 2.5GM/25ML INJ syringe SYRINGE GAMMAGARD 5GM INJ 91 furosemide 20mg tab 72 GENOTROPIN 1.4MG 74 GAMMAKED 91 furosemide 40mg tab 72 SYRINGE 1GM/10ML INJ furosemide 80mg tab 72 GENOTROPIN 1.6MG 74 GAMMAPLEX 91 FUROSEMIDE 8MG/ML 72 SYRINGE 10GM/100ML INJ ORAL SOLN GENOTROPIN 1.8MG 74 GAMMAPLEX 91 FUZEON 90MG INJ 54 SYRINGE 10GM/200ML INJ fyavolv 0.0025-0.5mg tab 76 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121 ALPHABETICAL LISTING OF DRUGS

GENOTROPIN 12MG 74 glipizide 28 glucose 84 CARTRIDGE 2.5mg/metformin 500mg 50mg/ml/potassium GENOTROPIN 1MG 74 tab chloride 0.02 SYRINGE glipizide 5mg er tab 30 meq/ml/sodium chloride GENOTROPIN 2MG 74 glipizide 5mg tab 31 0.154 meq/ml inj SYRINGE glipizide 5mg/metformin 28 glucose 84 GENOTROPIN 5MG 74 500mg tab 50mg/ml/potassium CARTRIDGE GLUCAGEN 1MG INJ 29 chloride GENTAK 0.3% OPHTH 89 GLUCAGON (RDNA) 29 0.02meq/ml/sodium OINTMENT 1MG INJ chloride 4.5mg/ml inj gentamicin 0.1% cream 68 glucose 100mg/ml inj 87 glucose 84 gentamicin 0.1% ointment 68 GLUCOSE 84 50mg/ml/potassium gentamicin 0.3% ophth 89 100MG/ML/SODIUM chloride 0.03 soln CHLORIDE 0.0342 meq/ml/sodium chloride GENTAMICIN 0.8MG/ML 8 MEQ/ML INJ 0.0769 meq/ml inj INJ GLUCOSE 84 GLUCOSE 84 gentamicin 1.2mg/ml inj 8 100MG/ML/SODIUM 50MG/ML/POTASSIUM GENTAMICIN 1.6MG/ML 8 CHLORIDE 0.0769 CHLORIDE 0.04 INJ MEQ/ML INJ MEQ/ML/SODIUM GENTAMICIN 1MG/ML 8 GLUCOSE 84 CHLORIDE 0.154 INJ 25MG/ML/SODIUM MEQ/ML INJ gentamicin 40mg/ml inj 8 CHLORIDE 0.0769 glucose 50mg/ml/sodium 84 GENVOYA 54 MEQ/ML INJ chloride 0.0342 meq/ml 150-150-200-10MG TAB glucose 50 84 inj GILENYA 0.5MG CAP 95 mg/ml/potassium chloride glucose 50mg/ml/sodium 84 GILOTRIF 20MG TAB 44 0.04meq/ml/sodium chloride 4.5mg/ml inj GILOTRIF 30MG TAB 44 chloride 4.5mg/ml inj glucose 50mg/ml/sodium 84 GILOTRIF 40MG TAB 44 glucose 50mg/ml inj 87 chloride 9mg/ml inj GLASSIA 1000MG/50ML 95 glucose 84 glyburide 1.25mg tab 31 INJ 50mg/ml/potassium glyburide 28 glatiramer acetate 95 chloride 0.01 1.25mg/metformin 250mg 20mg/ml syringe meq/ml/sodium chloride tab glatiramer acetate 95 0.0769 meq/ml inj glyburide 1.5mg tab 31 40mg/ml syringe glucose 84 glyburide 2.5mg tab 31 glatopa 20mg/ml syringe 95 50mg/ml/potassium glyburide 28 glatopa 40mg/ml syringe 95 chloride 0.02 meq/ml inj 2.5mg/metformin 500mg glimepiride 1mg tab 30 glucose 84 tab glimepiride 2mg tab 30 50mg/ml/potassium glyburide 3mg tab 31 glimepiride 4mg tab 30 chloride 0.02 glyburide 5mg tab 31 glipizide 10mg er tab 30 meq/ml/sodium chloride glyburide 5mg/metformin 28 glipizide 10mg tab 30 0.0342 meq/ml inj 500mg tab glipizide 2.5mg er tab 30 glyburide 6mg tab 31 glipizide 28 glycopyrrolate 1mg tab 99 2.5mg/metformin 250mg glycopyrrolate 2mg tab 99 tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122 ALPHABETICAL LISTING OF DRUGS

GLYXAMBI 10-5MG 28 haloperidol 2mg tab 50 HUMIRA PEDIATRIC 9 TAB haloperidol 2mg/ml oral 50 CROHN'S STARTER GLYXAMBI 25-5MG 28 soln PACK SYRINGE (2) TAB haloperidol 5mg tab 50 40MG/0.4ML GRAMICIDIN 89 haloperidol 5mg/ml inj 50 HUMIRA PEN - 9 0.025MG/ML/NEOMYCI haloperidol decanoate 50 CROHN'S STARTER N 100mg/ml (1ml) inj PACK 40MG/0.8ML INJ 1.75MG/ML/POLYMYXI haloperidol decanoate 50 HUMIRA PEN - 9 N B 10000UNIT/ML 100mg/ml inj CROHN'S STARTER OPHTH SOLN haloperidol decanoate 50 PACK 80MG/0.8ML INJ granisetron 1mg tab 31 50mg/ml inj HUMIRA PEN - 9 griseofulvin 125mg tab 32 HAVRIX 1440ELU/ML 101 PEDIATRIC UC STARTER griseofulvin 250mg tab 32 SYRINGE PACK 80MG/0.8ML INJ griseofulvin 25mg/ml 32 HAVRIX 720ELU/0.5ML 101 HUMIRA PEN - 9 susp SYRINGE PSORIASIS STARTER griseofulvin 500mg tab 32 heparin sodium porcine 20 PACK 40MG/0.8ML INJ guanfacine 1mg er tab 7 10000unit/ml inj HUMIRA PEN - 9 guanfacine 1mg tab 36 heparin sodium porcine 20 PSORIASIS STARTER guanfacine 2mg er tab 7 1000unit/ml inj PACK 80MG/0.8ML INJ guanfacine 2mg tab 36 heparin sodium porcine 20 HUMULIN R 30 guanfacine 3mg er tab 7 20000unit/ml inj 500UNIT/ML INJ guanfacine 4mg er tab 7 heparin sodium porcine 20 HUMULIN R 30 GVOKE 0.5MG/0.1ML 29 5000unit/ml inj 500UNIT/ML PEN INJ AUTO-INJECTOR HEPATAMINE 8% INJ 88 hydralazine 100mg tab 38 GVOKE 0.5MG/0.1ML 29 HETLIOZ 20MG CAP 82 hydralazine 10mg tab 38 SYRINGE HIBERIX 10MCG INJ 100 hydralazine 25mg tab 38 GVOKE 1MG/0.2ML 29 HUMIRA 10MG/0.1ML 9 hydralazine 50mg tab 38 AUTO-INJECTOR SYRINGE hydrochlorothiazide 73 GVOKE 1MG/0.2ML 29 HUMIRA 20MG/0.2ML 9 12.5mg cap SYRINGE SYRINGE hydrochlorothiazide 73 H HUMIRA 40MG/0.4ML 9 12.5mg tab AUTO-INJECTOR hydrochlorothiazide 37 HAEGARDA 2000UNIT 79 HUMIRA 40MG/0.4ML 9 12.5mg/irbesartan 150mg INJ SYRINGE tab HAEGARDA 3000UNIT 79 HUMIRA 40MG/0.8ML 9 hydrochlorothiazide 37 INJ AUTO-INJECTOR 12.5mg/irbesartan 300mg hailey 24 fe 28 day pack 64 HUMIRA 40MG/0.8ML 9 tab halobetasol propionate 70 SYRINGE hydrochlorothiazide 37 0.05% cream HUMIRA 80MG/0.8ML 9 12.5mg/lisinopril 10mg halobetasol propionate 70 AUTO-INJECTOR tab 0.05% ointment HUMIRA PEDIATRIC 9 hydrochlorothiazide 37 haloperidol 0.5mg tab 50 CROHN'S STARTER 12.5mg/lisinopril 20mg haloperidol 10mg tab 50 PACK (3) 80MG/0.8ML tab haloperidol 1mg tab 50 INJ haloperidol 20mg tab 50

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123 ALPHABETICAL LISTING OF DRUGS hydrochlorothiazide 37 hydrochlorothiazide 72 hydrocortisone 14 12.5mg/losartan 25mg/spironolactone 1.67mg/ml enema potassium 100mg tab 25mg tab hydrocortisone 10mg tab 66 hydrochlorothiazide 38 hydrochlorothiazide 72 hydrocortisone 89 12.5mg/losartan 25mg/triamterene 37.5mg 10mg/ml/neomycin potassium 50mg tab cap 3.5mg/ml/polymyxin b hydrochlorothiazide 38 hydrochlorothiazide 72 10000unit/ml ophth susp 12.5mg/olmesartan 25mg/triamterene 37.5mg hydrocortisone 91 medoxomil 20mg tab tab 10mg/ml/neomycin hydrochlorothiazide 38 hydrochlorothiazide 38 3.5mg/ml/polymyxin b 12.5mg/olmesartan 25mg/valsartan 160mg 10000unit/ml otic soln medoxomil 40mg tab tab hydrocortisone 91 hydrochlorothiazide 38 hydrochlorothiazide 38 10mg/ml/neomycin 12.5mg/quinapril 10mg 25mg/valsartan 320mg 3.5mg/ml/polymyxin b tab tab 10000unit/ml otic susp hydrochlorothiazide 38 hydrochlorothiazide 73 hydrocortisone 2.5% 70 12.5mg/quinapril 20mg 50mg tab cream tab hydrochlorothiazide 38 hydrocortisone 2.5% 70 hydrochlorothiazide 38 50mg/metoprolol tartrate lotion 12.5mg/valsartan 160mg 100mg tab hydrocortisone 2.5% 70 tab hydrochlorothiazide 72 ointment hydrochlorothiazide 38 50mg/triamterene 75mg hydrocortisone 20mg tab 66 12.5mg/valsartan 320mg tab hydrocortisone 5mg tab 66 tab hydrocodone bitartrate 12 hydrocortisone/pramoxin 14 hydrochlorothiazide 38 10mg er cap e 1-1% rectal cream 12.5mg/valsartan 80mg hydrocodone bitartrate 13 hydromorphone 10mg/ml 12 tab 10mg/ibuprofen 200mg (1ml) inj hydrochlorothiazide 73 tab hydromorphone 10mg/ml 12 25mg tab hydrocodone bitartrate 12 (5ml) inj hydrochlorothiazide 38 15mg er cap hydromorphone 1mg/ml 12 25mg/lisinopril 20mg tab hydrocodone bitartrate 12 oral soln hydrochlorothiazide 38 20mg er cap hydromorphone 2mg tab 12 25mg/losartan potassium hydrocodone bitartrate 12 hydromorphone 4mg tab 12 100mg tab 30mg er cap hydromorphone 8mg tab 12 hydrochlorothiazide 38 hydrocodone bitartrate 12 hydroxychloroquine 40 25mg/metoprolol tartrate 40mg er cap sulfate 200mg tab 100mg tab hydrocodone bitartrate 12 hydroxyurea 500mg cap 46 hydrochlorothiazide 38 50mg er cap hydroxyzine 10mg tab 15 25mg/metoprolol tartrate hydrocodone bitartrate 13 hydroxyzine 25mg tab 15 50mg tab 5mg/ibuprofen 200mg tab hydroxyzine 2mg/ml oral 15 hydrochlorothiazide 38 hydrocodone bitartrate 13 soln 25mg/olmesartan 7.5mg/ibuprofen 200mg hydroxyzine 50mg tab 15 medoxomil 40mg tab tab HYDROXYZINE 15 hydrochlorothiazide 38 hydrocortisone 1% cream 70 PAMOATE 100MG CAP 25mg/quinapril 20mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124 ALPHABETICAL LISTING OF DRUGS hydroxyzine pamoate 16 imipramine pamoate 27 INTRON A 10MU INJ 46 25mg cap 125mg cap INTRON A 10MU/ML INJ 46 hydroxyzine pamoate 16 imipramine pamoate 27 INTRON A 18MU INJ 46 50mg cap 150mg cap INTRON A 50MU INJ 46 I imipramine pamoate 27 INTRON A 47 75mg cap 6000000UNIT/ML INJ ibandronic acid 150mg 73 imiquimod 5% cream 71 introvale 91 day pack 64 tab IMOVAX 2.5UNIT/ML 101 INVEGA 117MG/0.75ML 49 IBRANCE 100MG CAP 44 INJ SYRINGE IBRANCE 100MG TAB 44 IMPAVIDO 50MG CAP 38 INVEGA 156MG/ML 49 IBRANCE 125MG CAP 44 incassia 28 day 0.35mg 66 SYRINGE IBRANCE 125MG TAB 44 pack INVEGA 234MG/1.5ML 49 IBRANCE 75MG CAP 44 INCRELEX 40MG/4ML 74 SYRINGE IBRANCE 75MG TAB 44 INJ INVEGA 49 ibu 600mg tab 10 INCRUSE 62.5MCG/INH 17 273MG/0.875ML ibu 800mg tab 10 INH SYRINGE ibuprofen 20mg/ml susp 10 indapamide 1.25mg tab 73 INVEGA 39MG/0.25ML 49 ibuprofen 400mg tab 10 indapamide 2.5mg tab 73 SYRINGE ibuprofen 600mg tab 10 INDOCIN 50MG RECTAL 10 INVEGA 49 ibuprofen 800mg tab 10 SUPP 410MG/1.315ML icatibant 10mg/ml syringe 79 indomethacin 25mg cap 10 SYRINGE iclevia 91 day pack 64 indomethacin 50mg cap 10 INVEGA 546MG/1.75ML 49 ICLUSIG 10MG TAB 44 indomethacin 75mg er 10 SYRINGE ICLUSIG 15MG TAB 44 cap INVEGA 78MG/0.5ML 50 ICLUSIG 30MG TAB 44 INFANRIX SYRINGE 98 SYRINGE ICLUSIG 45MG TAB 44 INGREZZA 40MG CAP 94 INVEGA 50 IDHIFA 100MG TAB 44 INGREZZA 80MG CAP 94 819MG/2.625ML IDHIFA 50MG TAB 44 INLYTA 1MG TAB 44 SYRINGE ILEVRO 0.3% OPHTH 90 INLYTA 5MG TAB 44 INVIRASE 500MG TAB 54 SUSP INNOPRAN 120MG ER 57 IOPIDINE 1% OPHTH 88 imatinib 100mg tab 44 CAP SOLN imatinib 400mg tab 44 INNOPRAN 80MG ER 57 IPOL INJ 101 IMBRUVICA 140MG 44 CAP ipratropium bromide 87 CAP INQOVI 5 TABLET PACK 43 0.021mg/act nasal IMBRUVICA 140MG TAB 44 INREBIC 100MG CAP 44 inhaler IMBRUVICA 280MG TAB 44 INSULIN PEN NEEDLE 83 ipratropium bromide 87 IMBRUVICA 420MG TAB 44 INSULIN SYRINGE 83 0.042mg/act nasal IMBRUVICA 560MG TAB 44 (DISP) U-100 0.3ML inhaler IMBRUVICA 70MG CAP 44 INSULIN SYRINGE 82 ipratropium bromide 17 imipramine 10mg tab 27 (DISP) U-100 1/2ML 0.2mg/ml inh soln imipramine 25mg tab 27 INSULIN SYRINGE 83 ipratropium/albuterol 19 imipramine 50mg tab 27 (DISP) U-100 1ML 0.5-2.5mg/3ml inh soln imipramine pamoate 27 INTELENCE 25MG TAB 54 irbesartan 150mg tab 36 100mg cap INTRALIPID 87 irbesartan 300mg tab 36 20GM/100ML INJ irbesartan 75mg tab 36 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125 ALPHABETICAL LISTING OF DRUGS

IRESSA 250MG TAB 44 ISTURISA 5MG TAB 73 JENTADUETO 28 ISENTRESS 100MG 54 itraconazole 100mg cap 32 5-1000MG ER TAB CHEW TAB ivermectin 3mg tab 15 jinteli 0.005-1mg tab 76 ISENTRESS 100MG 54 IXIARO 0.012MG/ML 101 juleber 28 day pack 64 GRANULES FOR ORAL SYRINGE JULUCA 50-25MG TAB 54 SUSP J junel 1.5/30 21 day pack 64 ISENTRESS 25MG 54 junel 1/20 21 day pack 64 JAKAFI 10MG TAB 44 CHEW TAB junel fe 1.5/30 28 day 64 JAKAFI 15MG TAB 44 ISENTRESS 400MG TAB 54 pack JAKAFI 20MG TAB 44 ISENTRESS 600MG TAB 54 junel fe 1/20 28 day pack 64 JAKAFI 25MG TAB 44 isibloom 28 day pack 64 junel fe 24 1/20 28 day 64 JAKAFI 5MG TAB 44 ISOLYTE P INJ 84 pack jantoven 10mg tab 19 ISOLYTE S INJ 84 JUXTAPID 10MG CAP 34 jantoven 1mg tab 19 isoniazid 100mg tab 40 JUXTAPID 20MG CAP 34 jantoven 2.5mg tab 19 ISONIAZID 10MG/ML 40 JUXTAPID 30MG CAP 34 jantoven 2mg tab 19 ORAL SOLN JUXTAPID 5MG CAP 34 jantoven 3mg tab 19 isoniazid 300mg tab 41 JYNARQUE 15MG TAB 75 jantoven 4mg tab 19 ISOPROPYL ALCOHOL 83 JYNARQUE 30MG TAB 75 jantoven 5mg tab 19 0.7ML/ML PAD JYNARQUE 45/15 75 jantoven 6mg tab 19 isosorbide dinitrate 10mg 15 THERAPY PACK jantoven 7.5mg tab 19 tab JYNARQUE 60/30 75 JANUMET 1000-100MG 28 isosorbide dinitrate 20mg 15 THERAPY PACK ER TAB tab JYNARQUE 90/30 75 JANUMET 1000-50MG 28 isosorbide dinitrate 30mg 15 THERAPY PACK ER TAB tab JYNARQUE TAB 75 JANUMET 1000-50MG 28 isosorbide dinitrate 5mg 15 15/15MG THERAPY TAB tab PACK JANUMET 500-50MG ER 28 isosorbide mononitrate 15 JYNARQUE TAB 75 TAB 10mg tab 30/15MG THERAPY JANUMET 500-50MG 28 isosorbide mononitrate 15 PACK TAB 120mg er tab JANUVIA 100MG TAB 29 K isosorbide mononitrate 15 JANUVIA 25MG TAB 29 kaitlib fe 28 day pack 64 20mg tab JANUVIA 50MG TAB 29 KALYDECO 150MG TAB 96 isosorbide mononitrate 15 JARDIANCE 10MG TAB 30 KALYDECO 25MG 96 30mg er tab JARDIANCE 25MG TAB 30 GRANULES isosorbide mononitrate 15 jasmiel 28 day pack 64 KALYDECO 50MG 96 60mg er tab JENTADUETO 28 GRANULES isotretinoin 10mg cap 67 2.5-1000MG ER TAB KALYDECO 75MG 96 isotretinoin 20mg cap 67 JENTADUETO 28 GRANULES isotretinoin 30mg cap 67 2.5-1000MG TAB kariva 28 day pack 64 isotretinoin 40mg cap 67 JENTADUETO 28 KCL/D5W/LR INJ 0.15% 84 isradipine 2.5mg cap 58 2.5-500MG TAB kelnor 1/35 28 day pack 64 isradipine 5mg cap 58 JENTADUETO 28 kelnor 1/50 28 day pack 64 ISTURISA 10MG TAB 73 2.5-850MG TAB ISTURISA 1MG TAB 73 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126 ALPHABETICAL LISTING OF DRUGS

KESIMPTA 20MG/0.4ML 95 klor-con 20meq micro er 84 lamotrigine 200mg tab 22 PEN INJ tab lamotrigine 250mg er tab 22 ketoconazole 2% cream 68 klor-con 20meq powder 85 lamotrigine 25mg chew 22 ketoconazole 2% foam 68 for oral soln tab ketoconazole 2% 68 klor-con 8meq er tab 85 lamotrigine 25mg er tab 22 shampoo KORLYM 300MG TAB 29 lamotrigine 25mg odt 22 ketoconazole 200mg tab 32 KOSELUGO 10MG CAP 44 lamotrigine 25mg pack 22 ketodan 2% foam 68 KOSELUGO 25MG CAP 44 lamotrigine 25mg tab 22 ketorolac tromethamine 90 KRINTAFEL 150MG TAB 40 lamotrigine 300mg er tab 22 0.4% ophth soln K-TAB 8MEQ ER TAB 84 lamotrigine 50mg er tab 22 ketorolac tromethamine 90 kurvelo pack 64 lamotrigine 50mg odt 22 0.5% ophth soln KUVAN 100MG 74 lamotrigine 5mg chew tab 22 ketorolac tromethamine 10 POWDER FOR ORAL lamotrigine ODT kit 22 10mg tab SOLN lamotrigine tab 25mg 22 KEVZARA 9 KUVAN 100MG TAB 74 (42)/100mg (7) starter 150MG/1.14ML KUVAN 500MG 74 pack AUTO-INJECTOR POWDER FOR ORAL lamotrigine tab 25mg 22 KEVZARA 10 SOLN (84)/100mg (14) starter 150MG/1.14ML L pack SYRINGE LAMPIT 120MG TAB 39 labetalol 100mg tab 56 KEVZARA 10 LAMPIT 30MG TAB 39 labetalol 200mg tab 56 200MG/1.14ML lansoprazole 15mg dr cap 99 labetalol 300mg tab 56 AUTO-INJECTOR lansoprazole 30mg dr cap 99 lactulose 667mg/ml oral 82 KEVZARA 10 lanthanum carbonate 78 soln 200MG/1.14ML 1000mg chew tab LAMICTAL XR BLUE 22 SYRINGE lanthanum carbonate 78 KIT KINRIX INJ 98 500mg chew tab LAMICTAL XR GREEN 22 KINRIX PF INJ 99 lanthanum carbonate 78 KIT KISQALI 200MG DAILY 44 750mg chew tab LAMICTAL XR ORANGE 22 DOSE PACK LANTUS 100UNIT/ML 30 KIT KISQALI 400MG DAILY 44 INJ lamivudine 100mg tab 55 DOSE PACK LANTUS 100UNIT/ML 30 lamivudine 10mg/ml oral 54 KISQALI 600MG DAILY 44 PEN INJ soln DOSE PACK lapatinib 250mg tab 44 lamivudine 150mg tab 54 KISQALI FEMARA 43 larin 1.5/30 pack 64 lamivudine 54 CO-PACK 200 PACK larin 1/20 pack 64 150mg/zidovudine 300mg KISQALI FEMARA 43 larin fe 1.5/30 pack 64 tab CO-PACK 400 PACK larin fe 1/20 pack 64 lamivudine 300mg tab 54 KISQALI FEMARA 43 larissia 28 day pack 64 lamotrigine 100mg er tab 22 CO-PACK 600 PACK latanoprost 0.005% 90 lamotrigine 100mg odt 22 klor-con 10meq er tab 84 ophth soln lamotrigine 100mg tab 22 klor-con 10meq micro er 84 LATUDA 120MG TAB 49 lamotrigine 150mg tab 22 tab LATUDA 20MG TAB 49 lamotrigine 200mg er tab 22 KLOR-CON 15MEQ 84 LATUDA 40MG TAB 49 lamotrigine 200mg odt 22 MICRO ER TAB LATUDA 60MG TAB 49 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127 ALPHABETICAL LISTING OF DRUGS

LATUDA 80MG TAB 49 levetiracetam 750mg er 22 levothyroxine sodium 97 layolis fe 28 pack 64 tab 0.088mg tab leena 28 day pack 64 levetiracetam 750mg tab 22 levothyroxine sodium 97 leflunomide 10mg tab 11 LEVOBUNOLOL 0.5% 88 0.112mg tab leflunomide 20mg tab 11 OPHTH SOLN levothyroxine sodium 97 LENVIMA 10 10MG 45 levocarnitine 100mg/ml 74 0.125mg tab PACK oral soln levothyroxine sodium 97 LENVIMA 12 4MG PACK 45 levocarnitine 330mg tab 74 0.137mg tab LENVIMA 14 PACK 45 levocetirizine 0.5mg/ml 33 levothyroxine sodium 97 LENVIMA 18 PACK 45 oral soln 0.15mg tab LENVIMA 20 10MG 45 levocetirizine 5mg tab 33 levothyroxine sodium 97 PACK levofloxacin 0.5% ophth 89 0.175mg tab LENVIMA 24 PACK 45 soln levothyroxine sodium 97 LENVIMA 4 4MG PACK 45 levofloxacin 250mg tab 77 0.1mg tab LENVIMA 8 4MG PACK 45 levofloxacin 25mg/ml inj 77 levothyroxine sodium 97 lessina 28 day pack 64 levofloxacin 25mg/ml 77 0.2mg tab letrozole 2.5mg tab 42 oral soln levothyroxine sodium 97 LEUCOVORIN 10MG 47 levofloxacin 500mg tab 77 0.3mg tab TAB levofloxacin 5mg/ml 77 levoxyl 100mcg tab 97 LEUCOVORIN 15MG 47 (100ml) inj levoxyl 112mcg tab 97 TAB levofloxacin 5mg/ml 77 levoxyl 125mcg tab 98 leucovorin 25mg tab 47 (150ml) inj levoxyl 137mcg tab 98 leucovorin 5mg tab 47 levofloxacin 750mg tab 77 levoxyl 150mcg tab 98 LEUKERAN 2MG TAB 41 levonest 28 day pack 64 levoxyl 175mcg tab 98 leuprolide acetate 5mg/ml 42 levora 0.15/30 28 day 64 levoxyl 200mcg tab 98 inj pack levoxyl 25mcg tab 98 levalbuterol 0.103mg/ml 19 levo-t 100mcg tab 97 levoxyl 50mcg tab 98 inh soln levo-t 112mcg tab 97 levoxyl 75mcg tab 98 levalbuterol 0.21mg/ml 19 levo-t 125mcg tab 97 levoxyl 88mcg tab 98 inh soln levo-t 137mcg tab 97 LEXIVA 50MG/ML SUSP 54 levalbuterol 0.417mg/ml 19 levo-t 150mcg tab 97 lidocaine 2% topical soln 86 inh soln levo-t 175mcg tab 97 lidocaine 4% topical soln 71 levalbuterol 2.5mg/ml inh 19 levo-t 200mcg tab 97 lidocaine 5% ointment 71 soln levo-t 25mcg tab 97 lidocaine 5% patch 71 LEVEMIR 100UNIT/ML 30 levo-t 300mcg tab 97 lidocaine/prilocaine 71 INJ levo-t 50mcg tab 97 2.5-2.5% cream LEVEMIR 100UNIT/ML 30 levo-t 75mcg tab 97 lindane 1% shampoo 71 PEN INJ levo-t 88mcg tab 97 linezolid 20mg/ml susp 40 levetiracetam 1000mg tab 22 levothyroxine sodium 97 linezolid 2mg/ml inj 40 levetiracetam 100mg/ml 22 0.025mg tab linezolid 600mg tab 40 oral soln levothyroxine sodium 97 liothyronine sodium 98 levetiracetam 250mg tab 22 0.05mg tab 0.005mg tab levetiracetam 500mg er 22 levothyroxine sodium 97 liothyronine sodium 98 tab 0.075mg tab 0.025mg tab levetiracetam 500mg tab 22 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128 ALPHABETICAL LISTING OF DRUGS liothyronine sodium 98 lorazepam 2mg tab 16 lutera 28 day pack 64 0.05mg tab lorazepam 2mg/ml oral 16 lyleq 28 day 0.35mg pack 66 lisinopril 10mg tab 35 soln lyllana 0.025mg/24hr 76 lisinopril 2.5mg tab 35 LORBRENA 100MG TAB 45 patch lisinopril 20mg tab 35 LORBRENA 25MG TAB 45 lyllana 0.0375mg/24hr 76 lisinopril 30mg tab 35 loryna 28 day pack 64 patch lisinopril 40mg tab 35 losartan potassium 36 lyllana 0.05mg/24hr 76 lisinopril 5mg tab 35 100mg tab patch lithium carbonate 150mg 49 losartan potassium 25mg 36 lyllana 0.075mg/24hr 76 cap tab patch lithium carbonate 300mg 49 losartan potassium 50mg 36 lyllana 0.1mg/24hr patch 76 cap tab LYNPARZA 100MG TAB 45 lithium carbonate 300mg 49 LOTEMAX 0.5% OPHTH 90 LYNPARZA 150MG TAB 45 er tab OINTMENT LYSODREN 500MG TAB 42 lithium carbonate 300mg 49 loteprednol etabonate 90 lyza 0.35mg pack 66 tab 0.5% ophth gel M lithium carbonate 450mg 49 loteprednol etabonate 90 magnesium sulfate 84 er tab 0.5% ophth susp 500mg/ml inj lithium carbonate 600mg 49 lovastatin 10mg tab 34 magnesium sulfate 84 cap lovastatin 20mg tab 34 500mg/ml syringe lithium citrate 60mg/ml 49 lovastatin 40mg tab 34 malathion 0.5% lotion 71 oral soln low-ogestrel 28 day pack 64 marlissa 28 day pack 64 LITHOSTAT 250MG TAB 79 loxapine 10mg cap 51 MARPLAN 10MG TAB 25 LOKELMA 10GM 86 loxapine 25mg cap 51 MATULANE 50MG CAP 47 POWDER FOR ORAL loxapine 50mg cap 51 matzim 180mg er tab 58 SUSP loxapine 5mg cap 51 matzim 240mg er tab 58 LOKELMA 5GM 86 LUMIGAN 0.01% OPHTH 90 matzim 300mg er tab 58 POWDER FOR ORAL SOLN matzim 360mg er tab 58 SUSP LUPANETA PACK 74 matzim 420mg er tab 58 LONHALA 25MCG/ML 17 1-MONTH PACK MAVYRET 100-40MG 55 INH SOLN LUPANETA PACK 74 TAB LONSURF 6.14-15MG 43 3-MONTH PACK MAXIDEX 0.1% OPHTH 90 TAB LUPKYNIS 7.9MG CAP 86 SUSP LONSURF 8.19-20MG 43 LUPRON 11.25MG 42 MAYZENT 0.25MG TAB 95 TAB SYRINGE MAYZENT 0.25MG TAB 95 loperamide 2mg cap 31 LUPRON 22.5MG 42 STARTER PACK lopinavir 54 SYRINGE MAYZENT 2MG TAB 95 80mg/ml/ritonavir LUPRON 3.75MG 42 meclizine 12.5mg tab 32 20mg/ml oral solution SYRINGE meclizine 25mg tab 32 lopinavir-ritonavir 54 LUPRON 30MG 42 MEDROL 2MG TAB 66 100-25mg tab SYRINGE medroxyprogesterone 93 lopinavir-ritonavir 54 LUPRON 45MG 42 acetate 10mg tab 200-50mg tab SYRINGE medroxyprogesterone 65 lorazepam 0.5mg tab 16 LUPRON 7.5MG 42 acetate 150mg/ml inj lorazepam 1mg tab 16 SYRINGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129 ALPHABETICAL LISTING OF DRUGS medroxyprogesterone 65 mesalamine 66.7mg/ml 78 METHYLPHENIDATE 8 acetate 150mg/ml syringe enema 18MG ER TAB medroxyprogesterone 93 mesalamine 800mg dr tab 78 methylphenidate 1mg/ml 8 acetate 2.5mg tab MESNEX 400MG TAB 47 oral soln medroxyprogesterone 93 METAXALONE 400MG 87 methylphenidate 20mg cr 8 acetate 5mg tab TAB cap MEFLOQUINE 250MG 40 metaxalone 800mg tab 87 methylphenidate 20mg er 8 TAB metformin 1000mg tab 29 tab megestrol acetate 93 metformin 500mg er tab 29 methylphenidate 20mg la 8 125mg/ml susp metformin 500mg tab 29 cap megestrol acetate 20mg 42 metformin 750mg er tab 29 methylphenidate 20mg 8 tab metformin 850mg tab 29 tab megestrol acetate 40mg 42 methadone 10mg tab 12 methylphenidate 27mg sr 8 tab methadone 5mg tab 12 tab megestrol acetate 42 methazolamide 25mg tab 72 methylphenidate 2mg/ml 8 40mg/ml susp methazolamide 50mg tab 72 oral soln MEKINIST 0.5MG TAB 45 methenamine hippurate 100 methylphenidate 30mg cr 8 MEKINIST 2MG TAB 45 1000mg tab cap MEKTOVI 15MG TAB 45 methimazole 10mg tab 97 methylphenidate 30mg la 8 meloxicam 15mg tab 10 methimazole 5mg tab 97 cap meloxicam 7.5mg tab 10 methocarbamol 500mg 87 methylphenidate 36mg sr 8 memantine 10mg tab 93 tab tab memantine 93 methocarbamol 750mg 87 methylphenidate 40mg cr 8 10mg/memantine 5mg tab cap pack methotrexate 2.5mg tab 41 methylphenidate 40mg la 8 memantine 14mg er cap 93 methotrexate 25mg/ml 41 cap memantine 21mg er cap 93 (2ml) inj methylphenidate 50mg cr 8 memantine 28mg er cap 93 methotrexate 25mg/ml inj 41 cap memantine 2mg/ml oral 93 methoxsalen 10mg cap 69 methylphenidate 54mg sr 8 soln METHSCOPOLAMINE 99 tab memantine 5mg tab 93 BROMIDE 2.5MG TAB methylphenidate 5mg tab 8 memantine 7mg er cap 94 METHSCOPOLAMINE 99 methylphenidate 60mg cr 8 MENACTRA INJ 100 BROMIDE 5MG TAB cap MENQUADFI INJ 100 methyldopa 250mg tab 36 methylprednisolone 16mg 66 MENVEO INJ 100 methyldopa 500mg tab 36 tab mercaptopurine 50mg tab 41 methylphenidate 10mg cr 8 methylprednisolone 32mg 66 meropenem 1000mg inj 39 cap tab meropenem 500mg inj 39 methylphenidate 10mg er 8 methylprednisolone 4mg 66 mesalamine 1000mg 77 tab pack rectal supp methylphenidate 10mg la 8 methylprednisolone 4mg 66 mesalamine 1200mg dr 77 cap tab tab methylphenidate 10mg 8 methylprednisolone 8mg 66 mesalamine 375mg er cap 77 tab tab mesalamine 400mg dr cap 77 methylphenidate 18mg er 8 metoclopramide 10mg tab 77 tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130 ALPHABETICAL LISTING OF DRUGS metoclopramide 1mg/ml 77 microgestin fe 1.5/30 28 64 mometasone furoate 0.1% 70 oral soln day pack lotion metoclopramide 5mg tab 77 microgestin fe 1/20 28 64 mometasone furoate 0.1% 70 metolazone 10mg tab 73 day pack ointment metolazone 2.5mg tab 73 midodrine 10mg tab 102 mondoxyne 100mg cap 97 metolazone 5mg tab 73 midodrine 2.5mg tab 102 montelukast 10mg tab 17 metoprolol succinate 57 midodrine 5mg tab 102 montelukast 4mg chew 17 100mg er tab miglitol 100mg tab 28 tab metoprolol succinate 57 miglitol 25mg tab 28 montelukast 4mg 17 200mg er tab miglitol 50mg tab 28 granules metoprolol succinate 57 miglustat 100mg cap 80 montelukast 5mg chew 17 25mg er tab mili 28 day pack 64 tab metoprolol succinate 57 mimvey pack 76 morphine sulfate 100mg 12 50mg er tab minitran 0.1mg/hr patch 15 er tab metoprolol tartrate 57 minitran 0.2mg/hr patch 15 morphine sulfate 15mg er 12 100mg tab minitran 0.4mg/hr patch 15 tab metoprolol tartrate 25mg 57 minitran 0.6mg/hr patch 15 morphine sulfate 15mg 12 tab minocycline 100mg cap 96 tab metoprolol tartrate 50mg 57 minocycline 100mg tab 96 morphine sulfate 200mg 12 tab minocycline 50mg cap 96 er tab metronidazole 0.75% 71 minocycline 50mg tab 96 morphine sulfate 20mg/ml 12 cream minocycline 75mg cap 96 oral soln metronidazole 0.75% gel 71 minocycline 75mg tab 96 morphine sulfate 2mg/ml 12 metronidazole 0.75% 71 minoxidil 10mg tab 38 oral soln lotion minoxidil 2.5mg tab 38 morphine sulfate 30mg er 12 metronidazole 0.75% 101 mirtazapine 15mg odt 25 tab vaginal gel mirtazapine 15mg tab 25 morphine sulfate 30mg 12 metronidazole 1% gel 71 mirtazapine 30mg odt 25 tab metronidazole 250mg tab 38 mirtazapine 30mg tab 25 morphine sulfate 4mg/ml 12 metronidazole 375mg cap 39 mirtazapine 45mg odt 25 oral soln metronidazole 500mg tab 39 mirtazapine 45mg tab 25 morphine sulfate 60mg er 12 metronidazole 5mg/ml inj 39 mirtazapine 7.5mg tab 25 tab metyrosine 250mg cap 35 misoprostol 0.1mg tab 99 MOVANTIK 12.5MG TAB 78 mexiletine 150mg cap 16 misoprostol 0.2mg tab 100 MOVANTIK 25MG TAB 78 mexiletine 200mg cap 16 MITIGARE 0.6MG CAP 79 moxifloxacin 0.5% ophth 89 mexiletine 250mg cap 16 M-M-R II INJ 101 soln micafungin sodium 32 modafinil 100mg tab 8 moxifloxacin 1.6mg/ml inj 77 100mg inj modafinil 200mg tab 8 moxifloxacin 400mg tab 77 micafungin sodium 50mg 32 moexipril 15mg tab 35 MULTAQ 400MG TAB 17 inj moexipril 7.5mg tab 35 mupirocin 2% ointment 68 microgestin 1.5/30 21 day 64 MOLINDONE 10MG TAB 51 mycophenolate mofetil 56 pack MOLINDONE 25MG TAB 51 200mg/ml susp microgestin 1/20 21 day 64 MOLINDONE 5MG TAB 51 mycophenolate mofetil 56 pack mometasone furoate 0.1% 70 250mg cap cream You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131 ALPHABETICAL LISTING OF DRUGS mycophenolate mofetil 56 NATACYN 5% OPHTH 89 NEUPRO 4MG/24HR 47 500mg tab SUSP PATCH mycophenolic acid 180mg 86 NATAZIA 28 DAY PACK 64 NEUPRO 6MG/24HR 47 dr tab nateglinide 120mg tab 30 PATCH mycophenolic acid 360mg 86 nateglinide 60mg tab 30 NEUPRO 8MG/24HR 47 dr tab NATPARA 100MCG 73 PATCH myorisan 10mg cap 67 CARTRIDGE NEVANAC 0.1% OPHTH 90 myorisan 20mg cap 67 NATPARA 25MCG 73 SUSP myorisan 30mg cap 67 CARTRIDGE NEVIRAPINE 100MG ER 54 myorisan 40mg cap 67 NATPARA 50MCG 73 TAB MYRBETRIQ 25MG ER 100 CARTRIDGE nevirapine 10mg/ml susp 54 TAB NATPARA 75MCG 73 nevirapine 200mg tab 54 MYRBETRIQ 50MG ER 100 CARTRIDGE nevirapine 400mg er tab 54 TAB NAYZILAM 5MG/0.1ML 21 NEXAVAR 200MG TAB 45 N NASAL SPRAY niacin 1000mg er tab 34 necon 0.5/35 28 day pack 64 niacin 500mg er tab 34 nabumetone 500mg tab 10 NEEDLES INSULIN 83 niacin 750mg er tab 34 nabumetone 750mg tab 10 DISP. SAFETY nicardipine 20mg cap 58 nadolol 20mg tab 57 NEFAZODONE 100MG 26 nicardipine 30mg cap 58 nadolol 40mg tab 57 TAB NICOTROL 10MG INH 95 nadolol 80mg tab 57 NEFAZODONE 150MG 26 SOLN nafcillin 1000mg inj 93 TAB NICOTROL 10MG/ML 95 nafcillin 100mg/ml inj 93 NEFAZODONE 200MG 26 NASAL INHALER nafcillin 2000mg inj 93 TAB nifedipine 30mg er tab 58 naftifine 1% cream 68 NEFAZODONE 250MG 26 nifedipine 30mg osmotic 58 naftifine 2% cream 68 TAB er tab NALOXONE 0.4MG/ML 31 NEFAZODONE 50MG 26 nifedipine 60mg er tab 59 CARTRIDGE TAB nifedipine 60mg osmotic 59 naloxone 0.4mg/ml inj 31 neomycin sulfate 500mg 8 er tab naloxone 1mg/ml syringe 31 tab nifedipine 90mg er tab 59 naltrexone 50mg tab 31 neomycin/bacitracin/poly 89 nifedipine 90mg osmotic 59 naproxen 250mg tab 10 myxin ophth ointment er tab naproxen 375mg dr tab 10 5(3.5)mg-400unit-10000u nikki 28 day pack 64 naproxen 375mg tab 10 nit nilutamide 150mg tab 42 naproxen 500mg dr tab 10 neomycin/polymyxin/bacit 90 nimodipine 30mg cap 59 naproxen 500mg tab 10 racin/hydrocortisone NINLARO 2.3MG CAP 45 naproxen sodium 275mg 10 ophth ointmentment 1% NINLARO 3MG CAP 45 tab NERLYNX 40MG TAB 45 NINLARO 4MG CAP 45 naproxen sodium 550mg 10 NEUPRO 1MG/24HR 47 nisoldipine 17mg er tab 59 tab PATCH nisoldipine 20mg er tab 59 naratriptan 1mg tab 83 NEUPRO 2MG/24HR 47 NISOLDIPINE 25.5MG 59 naratriptan 2.5mg tab 83 PATCH ER TAB NARCAN 4MG/0.1ML 31 NEUPRO 3MG/24HR 47 nisoldipine 30mg er tab 59 NASAL SPRAY PATCH nisoldipine 34mg er tab 59 nisoldipine 40mg er tab 59 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132 ALPHABETICAL LISTING OF DRUGS nisoldipine 8.5mg er tab 59 norethindrone 0.35mg 66 NOVOLOG MIX (70/30) 30 nitazoxanide 500mg tab 39 pack 100UNIT/ML INJ nitisinone 10mg cap 74 norethindrone acetate 93 NOXAFIL 40MG/ML 33 nitisinone 2mg cap 74 5mg tab SUSP nitisinone 5mg cap 75 NORPACE 100MG ER 16 NUBEQA 300MG TAB 42 NITRO-BID 2% 15 CAP NUCALA 100MG INJ 17 OINTMENT NORPACE 150MG ER 16 NUCALA 100MG/ML 17 NITRO-DUR 0.3MG/HR 15 CAP AUTO-INJECTOR PATCH nortrel 0.5/35 28 day 64 NUCALA 100MG/ML 17 NITRO-DUR 0.8MG/HR 15 pack SYRINGE PATCH nortrel 1/35 21 day pack 64 NUCYNTA 100MG ER 12 nitrofurantoin macro 100 nortrel 1/35 28 day pack 64 TAB 25mg/nitrofurantoin nortrel 7/7/7 28 day pack 64 NUCYNTA 150MG ER 12 mono 75mg cap nortriptyline 10mg cap 27 TAB nitrofurantoin 100 nortriptyline 25mg cap 28 NUCYNTA 200MG ER 12 macrocrystals 100mg cap NORTRIPTYLINE 28 TAB nitrofurantoin 100 2MG/ML ORAL SOLN NUCYNTA 250MG ER 12 macrocrystals 50mg cap nortriptyline 50mg cap 28 TAB nitroglycerin 0.1mg/hr 15 nortriptyline 75mg cap 28 NUCYNTA 50MG ER 12 patch NORVIR 100MG ORAL 54 TAB nitroglycerin 0.2mg/hr 15 POWDER NUEDEXTA 20-10MG 95 patch NORVIR 80MG/ML 54 CAP nitroglycerin 0.3mg sl tab 15 ORAL SOLN NUPLAZID 10MG TAB 49 nitroglycerin 0.4mg sl tab 15 NOURIANZ 40MG TAB 48 NUPLAZID 34MG CAP 49 nitroglycerin 0.4mg/act 15 NOURIANZ TAB 20MG 48 NURTEC 75MG ODT 83 spray NOVOLIN MIX (70/30) 30 NUTRILIPID 87 nitroglycerin 0.4mg/hr 15 100UNIT/ML INJ 20GM/100ML INJ patch NOVOLIN MIX (70/30) 30 NUZYRA 150MG TAB 96 nitroglycerin 0.6mg sl tab 15 FLEXPEN 100UNIT/ML nyamyc 100000unit/gm 68 nitroglycerin 0.6mg/hr 15 NOVOLIN N 30 topical powder patch 100UNIT/ML INJ nylia 7/7/7 28 day pack 64 NIVESTYM 80 NOVOLIN N 30 nymyo 28 day pack 64 300MCG/0.5ML 100UNIT/ML PEN INJ nystatin 100000unit/ml 68 SYRINGE NOVOLIN R 30 cream NIVESTYM 300MCG/ML 80 100UNIT/ML INJ nystatin 100000unit/ml 86 INJ NOVOLIN R 30 susp NIVESTYM 80 100UNIT/ML PEN INJ nystatin 100unit/mg 68 480MCG/0.8ML NOVOLOG 100UNIT/ML 30 ointment SYRINGE CARTRIDGE nystatin 100unit/mg 68 NIVESTYM 80 NOVOLOG 100UNIT/ML 30 topical powder 480MCG/1.6ML INJ INJ nystatin 500000unit tab 32 nizatidine 150mg cap 99 NOVOLOG 100UNIT/ML 30 nystop 100000unit/gm 68 nizatidine 300mg cap 99 PEN INJ topical powder nora-be 28 day 0.35mg 66 NOVOLOG MIX (70/30) 30 O pack 100UNIT/ML FLEXPEN You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133 ALPHABETICAL LISTING OF DRUGS

OCALIVA 10MG TAB 77 omega-3 acid ethyl esters 33 ORKAMBI 125-100MG 96 OCALIVA 5MG TAB 77 (usp) 1000mg cap TAB ocella 28 day pack 65 omeprazole 10mg dr cap 99 ORKAMBI 125-200MG 96 OCTAGAM 1GM/20ML 91 omeprazole 20mg dr cap 99 TAB INJ omeprazole 40mg dr cap 99 ORKAMBI 188-150MG 96 OCTAGAM 2GM/20ML 91 ondansetron 0.8mg/ml 31 GRANULES INJ oral soln orphenadrine citrate 87 octreotide 0.05mg/ml inj 75 ONDANSETRON 24MG 31 100mg er tab octreotide 0.1mg/ml inj 75 TAB orsythia 28 day pack 65 octreotide 0.2mg/ml inj 75 ondansetron 4mg odt 31 oseltamivir 30mg cap 56 octreotide 0.5mg/ml inj 75 ondansetron 4mg tab 31 oseltamivir 45mg cap 56 octreotide 1mg/ml inj 75 ondansetron 8mg odt 31 oseltamivir 6mg/ml susp 56 ODEFSEY 200-25-25MG 54 ondansetron 8mg tab 31 oseltamivir 75mg cap 56 TAB ONUREG 200MG TAB 41 OSPHENA 60MG TAB 74 ODOMZO 200MG CAP 41 ONUREG 300MG TAB 41 OTEZLA 28-DAY 11 OFEV 100MG CAP 96 OPSUMIT 10MG TAB 60 STARTER PACK OFEV 150MG CAP 96 ORENCIA 125MG/ML 11 OTEZLA 30MG TAB 11 ofloxacin 0.3% ophth soln 89 AUTO-INJECTOR oxacillin 1000mg inj 93 ofloxacin 0.3% otic soln 91 ORENCIA 125MG/ML 11 oxacillin 100mg/ml inj 93 ofloxacin 400mg tab 77 SYRINGE oxacillin 2000mg inj 93 olanzapine 10mg inj 51 ORENCIA 50MG/0.4ML 11 OXACILLIN 20MG/ML 93 olanzapine 10mg odt 51 SYRINGE INJ olanzapine 10mg tab 51 ORENCIA 11 OXACILLIN 40MG/ML 93 olanzapine 15mg odt 51 87.5MG/0.7ML SYRINGE INJ olanzapine 15mg tab 51 ORENITRAM 0.125MG 60 oxandrolone 10mg tab 14 olanzapine 2.5mg tab 51 ER TAB oxandrolone 2.5mg tab 14 olanzapine 20mg odt 51 ORENITRAM 0.25MG ER 60 oxaprozin 600mg tab 10 olanzapine 20mg tab 51 TAB OXAZEPAM 10MG CAP 16 olanzapine 5mg odt 51 ORENITRAM 1MG ER 60 OXAZEPAM 15MG CAP 16 olanzapine 5mg tab 51 TAB OXAZEPAM 30MG CAP 16 olanzapine 7.5mg tab 51 ORENITRAM 2.5MG ER 60 OXBRYTA 500MG TAB 80 olmesartan medoxomil 36 TAB oxcarbazepine 150mg tab 22 20mg tab ORENITRAM 5MG ER 60 oxcarbazepine 300mg tab 22 olmesartan medoxomil 36 TAB oxcarbazepine 600mg tab 22 40mg tab ORFADIN 20MG CAP 75 oxcarbazepine 60mg/ml 22 olmesartan medoxomil 36 ORFADIN 4MG/ML 75 susp 5mg tab SUSP OXERVATE 0.002% 89 olopatadine 0.1% ophth 90 ORGOVYX 120MG TAB 42 OPHTH SOLN soln ORIAHNN 28 DAY KIT 76 OXTELLAR 150MG ER 22 olopatadine 0.2% ophth 90 PACK TAB soln ORILISSA 150MG TAB 73 OXTELLAR 300MG ER 22 olopatadine 0.665mg/act 87 ORILISSA 200MG TAB 73 TAB nasal inhaler ORKAMBI 125-100MG 96 OXTELLAR 600MG ER 23 OLUMIANT 1MG TAB 9 GRANULES TAB OLUMIANT 2MG TAB 9 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134 ALPHABETICAL LISTING OF DRUGS oxybutynin chloride 10mg 100 PANZYGA 10GM/100ML 91 penicillin g potassium 92 er tab INJ 1000000unit/ml inj oxybutynin chloride 15mg 100 PANZYGA 1GM/10ML 91 PENICILLIN G 92 er tab INJ POTASSIUM oxybutynin chloride 100 PANZYGA 2.5GM/25ML 91 40000UNIT/ML INJ 1mg/ml oral soln INJ PENICILLIN G 92 oxybutynin chloride 5mg 100 PANZYGA 20GM/200ML 91 POTASSIUM er tab INJ 60000UNIT/ML INJ oxybutynin chloride 5mg 100 PANZYGA 30GM/300ML 91 PENICILLIN G 92 tab INJ PROCAINE oxycodone 10mg tab 12 PANZYGA 5GM/50ML 91 600000UNIT/ML oxycodone 15mg tab 12 INJ SYRINGE oxycodone 1mg/ml oral 12 paricalcitol 0.001mg cap 75 PENICILLIN G SODIUM 92 soln paricalcitol 0.002mg cap 75 100000UNIT/ML INJ oxycodone 20mg tab 12 paricalcitol 0.004mg cap 75 penicillin v potassium 92 oxycodone 20mg/ml oral 12 paromomycin 250mg cap 8 250mg tab soln paroxetine 10mg tab 25 PENICILLIN V 92 oxycodone 30mg tab 12 paroxetine 12.5mg er tab 26 POTASSIUM 25MG/ML oxycodone 5mg cap 12 paroxetine 20mg tab 26 ORAL SOLN oxycodone 5mg tab 12 paroxetine 25mg er tab 26 penicillin v potassium 92 oxymorphone 10mg tab 12 paroxetine 30mg tab 26 500mg tab oxymorphone 5mg tab 12 paroxetine 37.5mg er tab 26 PENICILLIN V 92 OZEMPIC 2MG/1.5ML 29 paroxetine 40mg tab 26 POTASSIUM 50MG/ML PEN INJ PASER D/R 4GM 41 ORAL SOLN OZEMPIC 2MG/1.5ML 29 GRANULES pentamidine isethionate 39 PEN INJ (1MG DOSE) PAXIL 10MG/5ML SUSP 26 300mg inj OZEMPIC 4MG/3ML 29 PEDIARIX INJ 99 pentamidine isethionate 39 PEN INJ PEDVAXHIB 101 50mg/ml inh soln P 7.5MCG/0.5ML INJ pentoxifylline 400mg er 79 peg 3350/electrolyte oral 82 tab pacerone 200mg tab 17 soln perindopril erbumine 35 pacerone 400mg tab 17 peg 3350/kcl/sodium 82 2mg tab paliperidone 1.5mg er tab 50 bicarbonate/sodium perindopril erbumine 35 paliperidone 3mg er tab 50 chloride powder for oral 4mg tab paliperidone 6mg er tab 50 soln perindopril erbumine 35 paliperidone 9mg er tab 50 PEGASYS 55 8mg tab PALYNZIQ 10MG/0.5ML 75 180MCG/0.5ML periogard 0.12% 86 SYRINGE SYRINGE mouthwash PALYNZIQ 75 PEGASYS 180MCG/ML 55 permethrin 5% cream 71 2.5MG/0.5ML SYRINGE INJ perphenazine 16mg tab 52 PALYNZIQ 20MG/ML 75 PEMAZYRE 13.5MG TAB 45 perphenazine 2mg tab 52 SYRINGE PEMAZYRE 4.5MG TAB 45 perphenazine 4mg tab 52 pantoprazole 20mg dr tab 99 PEMAZYRE 9MG TAB 45 perphenazine 8mg tab 52 pantoprazole 40mg dr tab 99 penicillamine 250mg tab 85 PERSERIS 120MG 50 SYRINGE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135 ALPHABETICAL LISTING OF DRUGS

PERSERIS 90MG 50 PIMOZIDE 1MG TAB 95 POMALYST 1MG CAP 42 SYRINGE PIMOZIDE 2MG TAB 95 POMALYST 2MG CAP 42 PEXEVA 10MG TAB 26 pimtrea pack 65 POMALYST 3MG CAP 42 PEXEVA 20MG TAB 26 pindolol 10mg tab 57 POMALYST 4MG CAP 42 PEXEVA 30MG TAB 26 pindolol 5mg tab 57 portia 28 day pack 65 PEXEVA 40MG TAB 26 pioglitazone 15mg tab 30 posaconazole 100mg dr 33 phenelzine 15mg tab 25 pioglitazone 30mg tab 30 tab phenobarbital 100mg tab 81 pioglitazone 45mg tab 30 potassium chloride 0.02 84 phenobarbital 15mg tab 81 piperacillin 92 meq/ml/sodium chloride phenobarbital 16.2mg tab 81 2000mg/tazobactam 0.0769 meq/ml inj phenobarbital 30mg tab 81 250mg inj potassium chloride 0.02 84 phenobarbital 32.4mg tab 81 piperacillin 92 meq/ml/sodium chloride phenobarbital 4mg/ml 81 200mg/ml/tazobactam 0.154 meq/ml inj oral soln 25mg/ml inj POTASSIUM CHLORIDE 84 phenobarbital 60mg tab 81 piperacillin 92 0.04 MEQ/ML/SODIUM phenobarbital 64.8mg tab 81 3000mg/tazobactam CHLORIDE 0.154 phenobarbital 97.2mg tab 81 375mg inj MEQ/ML INJ phenoxybenzamine 10mg 35 piperacillin 92 POTASSIUM CHLORIDE 85 cap 4000mg/tazobactam 0.1MEQ/ML INJ PHENYLEPHRINE 67 500mg inj POTASSIUM CHLORIDE 85 1MG/ML/PROMETHAZI PIQRAY 200MG DAILY 45 0.2MEQ/ML INJ NE 1.25MG/ML ORAL DOSE PACK POTASSIUM CHLORIDE 85 SOLN PIQRAY 250MG DAILY 45 0.4MEQ/ML INJ phenytoin 25mg/ml susp 24 DOSE PACK potassium chloride 85 phenytoin 50mg chew tab 24 PIQRAY 300MG DAILY 45 1.33meq/ml oral soln phenytoin sodium 100mg 24 DOSE 150MG PACK potassium chloride 85 er cap pirmella 1/35 28 day pack 65 10meq er cap phenytoin sodium 200mg 24 piroxicam 10mg cap 11 potassium chloride 85 er cap piroxicam 20mg cap 11 10meq er tab phenytoin sodium 300mg 24 PLASMA-LYTE 148 INJ 84 potassium chloride 85 er cap PLASMALYTE A INJ 84 10meq micro er tab PHOSLYRA 667MG/5ML 78 PLEGRIDY 95 potassium chloride 85 ORAL SOLN 125MCG/0.5ML 2.67meq/ml oral soln PICATO 0.015% GEL 69 AUTO-INJECTOR potassium chloride 85 PICATO 0.05% GEL 69 PLEGRIDY 95 20meq er tab PIFELTRO 100MG TAB 54 125MCG/0.5ML potassium chloride 85 pilocarpine 1% ophth 88 SYRINGE 20meq micro er tab soln plenamine 15% inj 88 potassium chloride 85 pilocarpine 2% ophth 88 podofilox 0.5% topical 71 20meq powder for oral soln soln soln pilocarpine 4% ophth 88 polymyxin b 89 potassium chloride 85 soln 10000unit/ml/trimethopri 2meq/ml (20ml) inj pilocarpine 5mg tab 86 m 1mg/ml ophth soln potassium chloride 85 pilocarpine 7.5mg tab 86 polymyxin b 40 2meq/ml inj pimecrolimus 1% cream 71 250000unit/ml inj You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136 ALPHABETICAL LISTING OF DRUGS potassium chloride 8meq 85 prazosin 2mg cap 36 pregabalin 75mg cap 23 er cap prazosin 5mg cap 36 PREMARIN 0.3MG TAB 76 potassium chloride 8meq 85 PRED MILD 0.12% 90 PREMARIN 0.45MG TAB 76 er tab OPHTH SUSP PREMARIN 0.625MG 76 potassium citrate 10meq 78 PRED-G 0.3-1% OPHTH 90 TAB er tab SUSP PREMARIN 101 potassium citrate 15meq 78 PREDNICARBATE 0.1% 70 0.625MG/GM VAGINAL er tab OINTMENT CREAM potassium citrate 5meq er 78 PREDNISOLONE 1% 90 PREMARIN 0.9MG TAB 76 tab OPHTH SOLN PREMARIN 1.25MG TAB 76 PRADAXA 110MG CAP 20 prednisolone 10mg odt 66 PREMASOL 10% INJ 88 PRADAXA 150MG CAP 20 prednisolone 15mg odt 66 PREMPHASE 28 DAY 76 PRADAXA 75MG CAP 20 prednisolone 1mg/ml oral 66 PACK PRALUENT 150MG/ML 34 soln PREMPRO 0.3/1.5MG 28 76 AUTO-INJECTOR prednisolone 30mg odt 66 DAY PACK PRALUENT 75MG/ML 34 PREDNISOLONE 66 PREMPRO 0.45/1.5 28 76 AUTO-INJECTOR 3MG/ML ORAL SOLN DAY PACK pramipexole 0.125mg tab 47 PREDNISOLONE 90 PREMPRO 0.625/2.5MG 76 pramipexole 0.25mg tab 47 ACETATE 1% OPHTH 28 DAY PACK pramipexole 0.375mg er 47 SUSP PREMPRO 0.625/5MG 76 tab PREDNISOLONE 90 28 DAY PACK pramipexole 0.5mg tab 47 SODIUM PHOSPHATE PRETOMANID 200MG 41 pramipexole 0.75mg er 47 2.5MG/ML/SULFACETA TAB tab MIDE SODIUM prevalite 4gm powder for 33 pramipexole 0.75mg tab 47 100MG/ML OPHTH oral susp pramipexole 1.5mg er tab 47 SOLN previfem 28 day pack 65 pramipexole 1.5mg tab 47 prednisone 10mg tab 66 PREVYMIS 240MG TAB 55 pramipexole 1mg tab 47 prednisone 1mg tab 66 PREVYMIS 480MG TAB 55 pramipexole 2.25mg er 47 PREDNISONE 1MG/ML 66 PREZCOBIX 150-800MG 54 tab ORAL SOLN TAB pramipexole 3.75mg er 47 prednisone 2.5mg tab 66 PREZISTA 100MG/ML 54 tab prednisone 20mg tab 66 SUSP pramipexole 3mg er tab 47 prednisone 50mg tab 66 PREZISTA 150MG TAB 54 pramipexole 4.5mg er tab 47 prednisone 5mg tab 66 PREZISTA 600MG TAB 54 prasugrel 10mg tab 80 PREDNISONE 5MG/ML 66 PREZISTA 75MG TAB 54 prasugrel 5mg tab 80 ORAL SOLN PREZISTA 800MG TAB 54 pravastatin sodium 10mg 34 pregabalin 100mg cap 23 PRIFTIN 150MG TAB 41 tab pregabalin 150mg cap 23 PRIMAQUINE 40 pravastatin sodium 20mg 34 pregabalin 200mg cap 23 PHOSPHATE 26.3MG tab pregabalin 20mg/ml oral 23 TAB pravastatin sodium 40mg 34 soln primidone 250mg tab 23 tab pregabalin 225mg cap 23 primidone 50mg tab 23 pravastatin sodium 80mg 34 pregabalin 25mg cap 23 PRIVIGEN 20GM/200ML 91 tab pregabalin 300mg cap 23 INJ prazosin 1mg cap 36 pregabalin 50mg cap 23 probenecid 500mg tab 79 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137 ALPHABETICAL LISTING OF DRUGS

PROCALAMINE 3% INJ 88 PROMETHEGAN 50MG 33 Q prochlorperazine 10mg 52 RECTAL SUPP QBRELIS 1MG/ML 35 tab propafenone 150mg tab 17 ORAL SOLN prochlorperazine 25mg 52 propafenone 225mg er 17 QINLOCK 50MG TAB 45 rectal supp cap QUADRACEL INJ 99 prochlorperazine 5mg tab 52 propafenone 225mg tab 17 QUDEXY 100MG ER 23 procto-med 2.5% cream 14 propafenone 300mg tab 17 CAP procto-pak 1% rectal 14 propafenone 325mg er 17 QUDEXY 150MG ER 23 cream cap CAP proctosol 2.5% cream 14 propafenone 425mg er 17 QUDEXY 200MG ER 23 proctozone hc 2.5% 14 cap CAP cream proparacaine 0.5% ophth 89 QUDEXY 25MG ER CAP 23 progesterone 100mg cap 93 soln QUDEXY 50MG ER CAP 23 progesterone 200mg cap 93 propranolol 10mg tab 57 quetiapine 100mg tab 51 PROGRAF 0.2MG 86 propranolol 120mg er 57 quetiapine 150mg er tab 51 GRANULES FOR ORAL cap quetiapine 200mg er tab 51 SUSP propranolol 160mg er 57 quetiapine 200mg tab 51 PROGRAF 1MG 86 cap quetiapine 25mg tab 51 GRANULES FOR ORAL propranolol 20mg tab 57 quetiapine 300mg er tab 51 SUSP propranolol 40mg tab 57 quetiapine 300mg tab 51 PROLASTIN 1000MG INJ 95 PROPRANOLOL 57 quetiapine 400mg er tab 51 PROLIA 60MG/ML 73 4MG/ML ORAL SOLN quetiapine 400mg tab 51 SYRINGE propranolol 60mg er cap 57 quetiapine 50mg er tab 51 PROMACTA 12.5MG 80 propranolol 60mg tab 57 quetiapine 50mg tab 51 POWDER FOR ORAL propranolol 80mg er cap 57 quinapril 10mg tab 35 SUSP propranolol 80mg tab 57 quinapril 20mg tab 35 PROMACTA 12.5MG 80 PROPRANOLOL 57 quinapril 40mg tab 35 TAB 8MG/ML ORAL SOLN quinapril 5mg tab 35 PROMACTA 25MG 80 propylthiouracil 50mg 97 quinidine gluconate 16 POWDER FOR ORAL tab 324mg er tab SUSP PROQUAD INJ 101 QUINIDINE SULFATE 16 PROMACTA 25MG TAB 81 PROSOL 20% INJ 88 200MG TAB PROMACTA 50MG TAB 81 protriptyline 10mg tab 28 QUINIDINE SULFATE 16 PROMACTA 75MG TAB 81 protriptyline 5mg tab 28 300MG TAB promethazine 1.25mg/ml 33 PULMOZYME 1MG/ML 96 quinine sulfate 324mg 40 oral soln INH SOLN cap promethazine 12.5mg 33 PURIXAN 41 R rectal supp 2000MG/100ML SUSP RABAVERT 2.5UNIT/ML 101 promethazine 12.5mg tab 33 PYLERA 100 INJ promethazine 25mg rectal 33 140-125-125MG CAP rabeprazole sodium 20mg 99 supp pyrazinamide 500mg tab 41 dr tab promethazine 25mg tab 33 pyridostigmine bromide 40 raloxifene 60mg tab 74 promethazine 50mg tab 33 180mg er tab ramelteon 8mg tab 82 promethegan 25mg rectal 33 pyridostigmine bromide 40 ramipril 1.25mg cap 35 supp 60mg tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138 ALPHABETICAL LISTING OF DRUGS ramipril 10mg cap 35 REPATHA 140MG/ML 34 rifampin 300mg cap 41 ramipril 2.5mg cap 35 SYRINGE rifampin 600mg inj 41 ramipril 5mg cap 35 REPATHA 420MG/3.5ML 34 riluzole 50mg tab 87 ranolazine 1000mg er tab 15 CARTRIDGE RIMANTADINE 100MG 56 ranolazine 500mg er tab 15 RESTASIS 0.05% OPHTH 89 TAB rasagiline 0.5mg tab 48 SUSP RINVOQ 15MG ER TAB 9 rasagiline 1mg tab 48 RETACRIT 81 risedronate sodium 73 RAVICTI 1.1GM/ML 75 10000UNIT/ML INJ 150mg tab ORAL SOLN RETACRIT 81 risedronate sodium 30mg 73 REBIF 22MCG/0.5ML 95 20000UNIT/2ML INJ tab AUTO-INJECTOR RETACRIT 81 risedronate sodium 35mg 73 REBIF 22MCG/0.5ML 95 20000UNIT/ML INJ (12) pack SYRINGE RETACRIT 2000UNIT/ML 81 risedronate sodium 35mg 73 REBIF 44MCG/0.5ML 95 INJ (4) pack AUTO-INJECTOR RETACRIT 3000UNIT/ML 81 risedronate sodium 35mg 73 REBIF 44MCG/0.5ML 95 INJ tab SYRINGE RETACRIT 81 risedronate sodium 5mg 73 REBIF REBIDOSE PACK 95 40000UNIT/ML INJ tab REBIF TITRATION PACK 95 RETACRIT 4000UNIT/ML 81 RISPERDAL 12.5MG INJ 50 reclipsen 28 day pack 65 INJ RISPERDAL 25MG INJ 50 RECOMBIVAX 101 RETEVMO 40MG CAP 45 RISPERDAL 37.5MG INJ 50 10MCG/ML INJ RETEVMO 80MG CAP 45 RISPERDAL 50MG INJ 50 RECOMBIVAX 101 REVLIMID 10MG CAP 85 risperidone 0.25mg odt 50 10MCG/ML SYRINGE REVLIMID 15MG CAP 85 risperidone 0.25mg tab 50 RECOMBIVAX 101 REVLIMID 2.5MG CAP 85 risperidone 0.5mg odt 50 40MCG/ML INJ REVLIMID 20MG CAP 85 risperidone 0.5mg tab 50 RECOMBIVAX 101 REVLIMID 25MG CAP 85 risperidone 1mg odt 50 5MCG/0.5ML SYRINGE REVLIMID 5MG CAP 85 risperidone 1mg tab 50 RECTIV 0.4% RECTAL 14 REXULTI 0.25MG TAB 52 risperidone 1mg/ml oral 50 OINTMENT REXULTI 0.5MG TAB 52 soln REGRANEX 0.01% GEL 71 REXULTI 1MG TAB 52 risperidone 2mg odt 50 RELENZA 5MG/BLISTER 56 REXULTI 2MG TAB 52 risperidone 2mg tab 50 INH REXULTI 3MG TAB 53 risperidone 3mg odt 50 RELISTOR 12MG/0.6ML 78 REXULTI 4MG TAB 53 risperidone 3mg tab 50 INJ REYATAZ 50MG ORAL 54 risperidone 4mg odt 50 RELISTOR 12MG/0.6ML 78 POWDER risperidone 4mg tab 50 SYRINGE REYVOW 100MG TAB 83 ritonavir 100mg tab 54 RELISTOR 8MG/0.4ML 78 REYVOW 50MG TAB 83 rivastigmine 0.192mg/hr 94 SYRINGE RHOPRESSA 0.02% 89 patch repaglinide 0.5mg tab 30 OPHTH SOLN rivastigmine 0.396mg/hr 94 repaglinide 1mg tab 30 ribavirin 200mg cap 55 patch repaglinide 2mg tab 30 ribavirin 200mg tab 55 rivastigmine 0.554mg/hr 94 REPATHA 140MG/ML 34 RIDAURA 3MG CAP 9 patch AUTO-INJECTOR rifabutin 150mg cap 41 rivastigmine 1.5mg cap 94 rifampin 150mg cap 41 rivastigmine 3mg cap 94 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139 ALPHABETICAL LISTING OF DRUGS rivastigmine 4.5mg cap 94 RUKOBIA 600MG ER 54 SEREVENT 19 rivastigmine 6mg cap 94 TAB 50MCG/DOSE INH rivelsa 91 day pack 65 RUZURGI 10MG TAB 40 sertraline 100mg tab 26 rizatriptan 10mg odt 83 RYBELSUS 14MG TAB 29 sertraline 20mg/ml oral 26 rizatriptan 10mg tab 83 RYBELSUS 3MG TAB 29 soln rizatriptan 5mg odt 83 RYBELSUS 7MG TAB 29 sertraline 25mg tab 26 rizatriptan 5mg tab 83 RYDAPT 25MG CAP 45 sertraline 50mg tab 26 ROCKLATAN 89 S setlakin 91 day pack 65 0.05-0.2MG/ML OPHTH sevelamer carbonate 78 salmon calcitonin 73 SOLN 2400mg powder for oral 200unit/act nasal spray ropinirole 0.25mg tab 47 susp SANDIMMUNE 56 ropinirole 0.5mg tab 48 sevelamer carbonate 78 100MG/ML ORAL SOLN ropinirole 12mg er tab 48 800mg powder for oral SANTYL 250UNIT/GM 71 ropinirole 1mg tab 48 susp OINTMENT ropinirole 2mg er tab 48 sevelamer carbonate 78 sapropterin 100mg 75 ropinirole 2mg tab 48 800mg tab powder for oral soln ropinirole 3mg tab 48 sharobel 28 day 0.35mg 66 sapropterin 100mg tab 75 ropinirole 4mg er tab 48 pack sapropterin 500mg 75 ropinirole 4mg tab 48 SHINGRIX 101 powder for oral soln ropinirole 5mg tab 48 50MCG/0.5ML INJ SAVELLA 100MG TAB 94 ropinirole 6mg er tab 48 SIGNIFOR 0.3MG/ML 75 SAVELLA 12.5MG TAB 94 ropinirole 8mg er tab 48 INJ SAVELLA 25MG TAB 94 rosuvastatin calcium 34 SIGNIFOR 0.6MG/ML 75 SAVELLA 4-WEEK 94 10mg tab INJ TITRATION PACK rosuvastatin calcium 34 SIGNIFOR 0.9MG/ML 75 SAVELLA 50MG TAB 94 20mg tab INJ scopolamine 0.0139mg/hr 32 rosuvastatin calcium 34 sildenafil 20mg tab 60 patch 40mg tab silodosin 4mg cap 79 SECUADO 3.8MG/24HR 51 rosuvastatin calcium 5mg 34 silodosin 8mg cap 79 PATCH tab silver sulfadiazine 1% 69 SECUADO 5.7MG/24HR 51 ROTARIX SUSP 101 cream PATCH ROTATEQ SUSP 101 SIMBRINZA 0.2-1% 88 SECUADO 7.6MG/24HR 51 roweepra 500mg tab 23 OPHTH SUSP PATCH ROZLYTREK 100MG 45 SIMPONI 100MG/ML 9 selegiline 5mg cap 48 CAP AUTO-INJECTOR SELEGILINE 5MG TAB 48 ROZLYTREK 200MG 45 SIMPONI 100MG/ML 9 selenium sulfide 2.5% 69 CAP SYRINGE shampoo RUBRACA 200MG TAB 45 SIMPONI 50MG/0.5ML 9 SELZENTRY 150MG TAB 54 RUBRACA 250MG TAB 45 AUTO-INJECTOR SELZENTRY 20MG/ML 54 RUBRACA 300MG TAB 45 SIMPONI 50MG/0.5ML 9 ORAL SOLN RUCONEST 2100UNIT 79 SYRINGE SELZENTRY 25MG TAB 54 INJ simvastatin 10mg tab 34 SELZENTRY 300MG TAB 54 rufinamide 200mg tab 23 simvastatin 20mg tab 34 SELZENTRY 75MG TAB 54 rufinamide 400mg tab 23 simvastatin 40mg tab 34 rufinamide 40mg/ml susp 23 simvastatin 5mg tab 34 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140 ALPHABETICAL LISTING OF DRUGS simvastatin 80mg tab 34 SOMAVERT 15MG INJ 74 STIOLTO 19 sirolimus 0.5mg tab 56 SOMAVERT 20MG INJ 74 0.0025-0.0025MG INH sirolimus 1mg tab 56 SOMAVERT 25MG INJ 74 STIVARGA 40MG TAB 45 sirolimus 1mg/ml oral 86 SOMAVERT 30MG INJ 74 STREPTOMYCIN 8 soln sorine 120mg tab 57 1000MG INJ sirolimus 2mg tab 56 sorine 160mg tab 57 STRIBILD 54 SIRTURO 100MG TAB 41 sorine 240mg tab 57 150-150-200-300MG SIRTURO 20MG TAB 41 sorine 80mg tab 57 TAB SIVEXTRO 200MG INJ 40 sotalol 120mg tab 57 SUCRAID 8500UNIT/ML 72 SIVEXTRO 200MG TAB 40 sotalol 160mg tab 57 ORAL SOLN SKYRIZI 150MG DOSE 69 sotalol 240mg tab 57 sucralfate 1000mg tab 99 PACK 75MG/0.83ML sotalol 80mg tab 57 sucralfate 100mg/ml susp 99 SKYRIZI 150MG/ML 69 sotalol af 120mg tab 57 sulfacetamide sodium 67 AUTO-INJECTOR sotalol AF 160mg tab 57 10% lotion SKYRIZI 150MG/ML 69 sotalol AF 80mg tab 57 SULFACETAMIDE 89 SYRINGE SPIRIVA 1.25MCG INH 17 SODIUM 10% OPHTH SLYND TAB 4MG 66 spironolactone 100mg 72 OINTMENT sodium chloride 78 tab sulfacetamide sodium 89 0.154meq/ml soln spironolactone 25mg tab 72 10% ophth soln sodium chloride 30mg/ml 85 spironolactone 50mg tab 73 SULFADIAZINE 500MG 96 inj sprintec 28 day pack 65 TAB sodium chloride 4.5mg/ml 85 SPRITAM 1000MG TAB 23 sulfamethoxazole 39 inj FOR ORAL SUSP 400mg/trimethoprim sodium chloride 50mg/ml 85 SPRITAM 250MG TAB 23 80mg tab inj FOR ORAL SUSP sulfamethoxazole 39 sodium chloride 9mg/ml 85 SPRITAM 500MG TAB 23 40mg/ml/trimethoprim inj FOR ORAL SUSP 8mg/ml susp sodium phenylbutyrate 75 SPRITAM 750MG TAB 23 sulfamethoxazole 39 0.94mg/mg oral powder FOR ORAL SUSP 800mg/trimethoprim sodium polystyrene 86 SPRYCEL 100MG TAB 45 160mg tab sulfonate 15000mg SPRYCEL 140MG TAB 45 SULFAMYLON 69 powder for oral susp SPRYCEL 20MG TAB 45 85MG/GM CREAM SOFOSBUVIR 55 SPRYCEL 50MG TAB 45 sulfasalazine 500mg dr 78 400MG/VELPATASVIR SPRYCEL 70MG TAB 45 tab 100MG TAB SPRYCEL 80MG TAB 45 sulfasalazine 500mg tab 78 solifenacin succinate 100 sps 15gm/60ml susp 86 sulindac 150mg tab 11 10mg tab sronyx 28 day pack 65 sulindac 200mg tab 11 solifenacin succinate 5mg 100 ssd 1% cream 69 sumatriptan 100mg tab 83 tab STELARA 45MG/0.5ML 69 sumatriptan 12mg/ml 83 SOLIQUA 28 INJ auto-injector 100UNIT-0.033MG/ML STELARA 45MG/0.5ML 69 sumatriptan 12mg/ml 83 PEN INJ SYRINGE cartridge SOLTAMOX 10MG/5ML 42 STELARA 90MG/ML 69 sumatriptan 12mg/ml inj 83 ORAL SOLN SYRINGE sumatriptan 20mg/act 83 SOMAVERT 10MG INJ 74 nasal spray You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 141 ALPHABETICAL LISTING OF DRUGS sumatriptan 25mg tab 83 SYNJARDY 12.5-500MG 28 tacrolimus 5mg cap 56 sumatriptan 50mg tab 83 TAB tadalafil 20mg tab 60 sumatriptan 5mg/act 83 SYNJARDY 25-1000MG 28 TAFINLAR 50MG CAP 46 nasal spray ER TAB TAFINLAR 75MG CAP 46 sumatriptan 8mg/ml 83 SYNJARDY 5-1000MG 28 TAGRISSO 40MG TAB 46 auto-injector ER TAB TAGRISSO 80MG TAB 46 sumatriptan 8mg/ml 83 SYNJARDY 5-1000MG 28 TAKHZYRO 300MG/2ML 79 cartridge TAB INJ SUNOSI 150MG TAB 7 SYNJARDY 5-500MG 28 TALTZ 80MG/ML 69 SUNOSI 75MG TAB 7 TAB AUTO-INJECTOR SUTENT 12.5MG CAP 45 SYNRIBO 3.5MG INJ 47 TALTZ 80MG/ML 69 SUTENT 25MG CAP 45 SYNTHROID 100MCG 98 SYRINGE SUTENT 37.5MG CAP 45 TAB TALZENNA 0.25MG CAP 46 SUTENT 50MG CAP 45 SYNTHROID 112MCG 98 TALZENNA 1MG CAP 46 syeda 28 day pack 65 TAB tamoxifen 10mg tab 42 SYMDEKO 96 SYNTHROID 125MCG 98 tamoxifen 20mg tab 42 50-75MG/75MG PACK TAB tamsulosin 0.4mg cap 79 SYMDEKO TAB 4-WEEK 96 SYNTHROID 137MCG 98 TARGRETIN 1% GEL 69 PACK TAB tarina 24 fe 1/20 28 day 65 SYMFI 400-300-300MG 54 SYNTHROID 150MCG 98 pack TAB TAB tarina fe 1/20 28 day 65 SYMFI 600-300-300MG 54 SYNTHROID 175MCG 98 pack TAB TAB TASIGNA 150MG CAP 46 SYMJEPI 0.15MG/0.3ML 102 SYNTHROID 200MCG 98 TASIGNA 200MG CAP 46 SYRINGE TAB TASIGNA 50MG CAP 46 SYMJEPI 0.3MG/0.3ML 102 SYNTHROID 25MCG 98 TAVALISSE 100MG TAB 79 SYRINGE TAB TAVALISSE 150MG TAB 79 SYMPAZAN 10MG 21 SYNTHROID 300MCG 98 tazarotene 0.1% cream 69 ORAL FILM TAB tazicef 1gm inj 62 SYMPAZAN 20MG 21 SYNTHROID 50MCG 98 tazicef 2gm inj 62 ORAL FILM TAB tazicef 6gm inj 62 SYMPAZAN 5MG ORAL 21 SYNTHROID 75MCG 98 TAZORAC 0.05% 69 FILM TAB CREAM SYMPROIC 0.2MG TAB 78 SYNTHROID 88MCG 98 TAZORAC 0.05% GEL 69 SYMTUZA 55 TAB TAZORAC 0.1% GEL 69 800-150-200-10MG TAB T taztia 120mg er cap 59 SYNAREL 2MG/ML 74 taztia 180mg er cap 59 TABLOID 40MG TAB 41 NASAL INHALER taztia 240mg er cap 59 TABRECTA 150MG TAB 46 SYNJARDY 10-1000MG 28 taztia 300mg er cap 59 TABRECTA 200MG TAB 46 ER TAB taztia 360mg er cap 59 tacrolimus 0.03% 71 SYNJARDY 28 TAZVERIK 200MG TAB 46 ointment 12.5-1000MG ER TAB TDVAX 4-4UNIT/ML INJ 99 tacrolimus 0.1% ointment 71 SYNJARDY 28 TEFLARO 400MG INJ 62 tacrolimus 0.5mg cap 56 12.5-1000MG TAB TEFLARO 600MG INJ 62 tacrolimus 1mg cap 56

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142 ALPHABETICAL LISTING OF DRUGS

TEGSEDI 284MG/1.5ML 95 testosterone cypionate 14 TIBSOVO 250MG TAB 46 SYRINGE 100mg/ml inj TIGECYCLINE 50MG INJ 96 telmisartan 20mg tab 36 testosterone cypionate 14 tilia fe pack 65 telmisartan 40mg tab 36 200mg/ml (1ml) inj timolol 0.25% ophth gel 88 telmisartan 80mg tab 36 testosterone cypionate 14 timolol 0.25% ophth soln 88 temazepam 15mg cap 81 200mg/ml inj timolol 0.5% ophth gel 88 temazepam 22.5mg cap 81 TESTOSTERONE 14 timolol 0.5% ophth soln 88 temazepam 30mg cap 81 ENANTHATE 200MG/ML timolol 10mg tab 58 temazepam 7.5mg cap 81 INJ timolol 20mg tab 58 TEMIXYS 300-300MG 55 tetrabenazine 12.5mg tab 94 timolol 5mg tab 58 TAB tetrabenazine 25mg tab 94 timolol 5mg/ml ophth 88 TENIVAC 4-10UNIT/ML 99 tetracycline 250mg cap 97 24hr ophth soln SYRINGE tetracycline 500mg cap 97 TIMOPTIC 0.25% OPHTH 88 tenofovir disoproxil 55 THALOMID 100MG CAP 85 GEL fumarate 300mg tab THALOMID 150MG CAP 85 TIMOPTIC 0.5% OPHTH 88 TEPMETKO 225MG TAB 46 THALOMID 200MG CAP 85 GEL terazosin 10mg cap 36 THALOMID 50MG CAP 85 tinidazole 250mg tab 39 terazosin 1mg cap 36 THEOPHYLLINE 300MG 19 tinidazole 500mg tab 39 terazosin 2mg cap 36 ER TAB tiopronin 100mg tab 79 terazosin 5mg cap 36 theophylline 400mg er 19 TIVICAY 10MG TAB 55 terbinafine 250mg tab 32 tab TIVICAY 25MG TAB 55 terbutaline sulfate 2.5mg 19 theophylline 5.33mg/ml 19 TIVICAY 50MG TAB 55 tab oral soln TIVICAY 5MG TAB FOR 55 terbutaline sulfate 5mg 19 theophylline 600mg er 19 ORAL SUSP tab tab tizanidine 2mg cap 87 terconazole 0.4% vaginal 101 THIOLA 100MG DR TAB 79 tizanidine 2mg tab 87 cream THIOLA 300MG DR TAB 79 tizanidine 4mg cap 87 TERCONAZOLE 0.8% 101 thioridazine 100mg tab 52 tizanidine 4mg tab 87 VAGINAL CREAM thioridazine 10mg tab 52 tizanidine 6mg cap 87 terconazole 80mg vaginal 101 thioridazine 25mg tab 52 TOBRADEX 0.1-0.3% 90 insert thioridazine 50mg tab 52 OPHTH OINTMENT testosterone 1% (25mg) 14 thiothixene 10mg cap 53 tobramycin 0.3% ophth 89 gel packet thiothixene 1mg cap 53 soln testosterone 1% (50mg) 14 thiothixene 2mg cap 53 TOBRAMYCIN 8 gel packet thiothixene 5mg cap 53 10MG/ML INJ testosterone 1.62% 14 tiadylt 120mg er cap 59 tobramycin 40mg/ml inj 9 (1.25gm) gel packet tiadylt 180mg er cap 59 tobramycin 60mg/ml inh 9 testosterone 1.62% 14 tiadylt 240mg er cap 59 soln (2.5gm) gel packet tiadylt 300mg er cap 59 tolcapone 100mg tab 48 TESTOSTERONE 14 tiadylt 360mg er cap 59 tolterodine tartrate 1mg 100 12.5MG/ACT GEL PUMP tiadylt 420mg er cap 59 tab testosterone 20.25mg/act 14 tiagabine 12mg tab 24 tolterodine tartrate 2mg 100 gel pump tiagabine 16mg tab 24 er cap testosterone 30mg/act 14 tiagabine 2mg tab 24 tolterodine tartrate 2mg 100 topical soln tiagabine 4mg tab 24 tab You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 143 ALPHABETICAL LISTING OF DRUGS tolterodine tartrate 4mg 100 trandolapril 2mg tab 35 tretinoin 0.05% gel 68 er cap trandolapril 38 tretinoin 0.1% cream 68 TOPIRAMATE 100MG 23 2mg/verapamil 180mg er tretinoin 0.1% gel 68 ER CAP tab tretinoin 10mg cap 47 topiramate 100mg tab 23 trandolapril 38 triamcinolone acetonide 70 TOPIRAMATE 150MG 23 2mg/verapamil 240mg er 0.0147% spray ER CAP tab triamcinolone acetonide 70 topiramate 15mg cap 23 trandolapril 4mg tab 35 0.025% cream TOPIRAMATE 200MG 23 trandolapril 38 triamcinolone acetonide 70 ER CAP 4mg/verapamil 240mg er 0.025% lotion topiramate 200mg tab 23 tab triamcinolone acetonide 70 topiramate 25mg cap 23 tranexamic acid 650mg 81 0.025% ointment TOPIRAMATE 25MG ER 23 tab triamcinolone acetonide 71 CAP tranylcypromine 10mg 25 0.1% cream topiramate 25mg tab 23 tab triamcinolone acetonide 71 TOPIRAMATE 50MG ER 23 TRAVASOL 10% INJ 88 0.1% lotion CAP travoprost 0.004% ophth 90 triamcinolone acetonide 71 topiramate 50mg tab 23 soln 0.1% ointment toremifene 60mg tab 42 trazodone 100mg tab 26 triamcinolone acetonide 86 torsemide 100mg tab 72 trazodone 150mg tab 26 0.1% oral paste torsemide 10mg tab 72 trazodone 300mg tab 26 triamcinolone acetonide 71 torsemide 20mg tab 72 trazodone 50mg tab 26 0.5% cream torsemide 5mg tab 72 TRECATOR 250MG TAB 41 triamcinolone acetonide 71 TOUJEO 300UNIT/ML 30 TRELEGY ELLIPTA 100- 19 0.5% ointment PEN INJ 62.5-25MCG INHALER triamterene 100mg cap 73 TOUJEO MAX 30 TRELEGY ELLIPTA 19 triamterene 50mg cap 73 300UNIT/ML PEN INJ 200-62.5-25 MCG/INH triazolam 0.125mg tab 81 (3ML) TRELSTAR 11.25MG INJ 42 triazolam 0.25mg tab 81 TRACLEER 32MG TAB 60 TRELSTAR 22.5MG INJ 42 triderm 0.1% cream 71 FOR ORAL SUSP TRELSTAR 3.75MG INJ 42 triderm 0.5% cream 71 TRADJENTA 5MG TAB 29 TREMFYA 100MG/ML 69 trientine 250mg cap 85 tramadol 100mg er tab 12 AUTO-INJECTOR tri-estarylla 28 day pack 65 tramadol 100mg er tab 12 TREMFYA 100MG/ML 69 trifluoperazine 10mg tab 52 (matrix delivery) SYRINGE trifluoperazine 1mg tab 52 tramadol 200mg er tab 13 TRESIBA 100UNIT/ML 30 trifluoperazine 2mg tab 52 tramadol 200mg er tab 13 INJ trifluoperazine 5mg tab 52 (matrix delivery) TRESIBA 100UNIT/ML 30 TRIFLURIDINE 1% 89 tramadol 300mg er tab 13 PEN INJ OPHTH SOLN tramadol 300mg er tab 13 TRESIBA 200UNIT/ML 30 trihexyphenidyl 0.4mg/ml 48 (matrix delivery) PEN INJ oral soln tramadol 50mg tab 13 tretinoin 0.01% gel 67 trihexyphenidyl 2mg tab 47 trandolapril 1mg tab 35 tretinoin 0.025% cream 68 trihexyphenidyl 5mg tab 47 TRANDOLAPRIL 38 tretinoin 0.025% gel 68 TRIJARDY 10-5-1000MG 28 1MG/VERAPAMIL tretinoin 0.04% gel 68 ER TAB 240MG ER TAB tretinoin 0.05% cream 68 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144 ALPHABETICAL LISTING OF DRUGS

TRIJARDY 29 trospium chloride 20mg 100 unithroid 300mcg tab 98 12.5-2.5-1000MG ER tab unithroid 50mcg tab 98 TAB trospium chloride 60mg 100 unithroid 75mcg tab 98 TRIJARDY 25-5-1000MG 29 er cap unithroid 88mcg tab 98 ER TAB TRULANCE 3MG TAB 77 UPTRAVI 1000MCG TAB 60 TRIJARDY 29 TRULICITY 29 UPTRAVI 1200MCG TAB 60 5-2.5-1000MG ER TAB 0.75MG/0.5ML UPTRAVI 1400MCG TAB 60 TRIKAFTA 96 AUTO-INJECTOR UPTRAVI 1600MCG TAB 60 100-50-75MG/150MG TRULICITY 29 UPTRAVI 200MCG TAB 60 PACK 1.5MG/0.5ML UPTRAVI 400MCG TAB 60 tri-legest 28 day pack 65 AUTO-INJECTOR UPTRAVI 600MCG TAB 60 tri-lo-estarylla 28 day 65 TRULICITY 3MG/0.5ML 29 UPTRAVI 800MCG TAB 60 pack AUTO-INJECTOR UPTRAVI TITRATION 60 tri-lo-sprintec 28 day 65 TRULICITY 29 PACK pack 4.5MG/0.5ML ursodiol 250mg tab 77 trilyte powder for oral 82 AUTO-INJECTOR ursodiol 300mg cap 77 soln TRUMENBA SYRINGE 101 ursodiol 500mg tab 77 trimethobenzamide 32 TUKYSA 150MG TAB 46 V 300mg cap TUKYSA 50MG TAB 46 valacyclovir 1000mg tab 56 trimethoprim 100mg tab 39 TURALIO 200MG CAP 46 valacyclovir 500mg tab 56 tri-mili 28 day pack 65 TWINRIX 720UNIT 101 VALCHLOR 0.016% GEL 69 trimipramine 100mg cap 28 SYRINGE valganciclovir 450mg tab 55 trimipramine 25mg cap 28 TYBOST 150MG TAB 55 valganciclovir 50mg/ml 55 trimipramine 50mg cap 28 TYMLOS 73 oral soln TRINTELLIX 10MG TAB 26 3120MCG/1.56ML PEN valproic acid 250mg cap 24 TRINTELLIX 20MG TAB 26 INJ valproic acid 50mg/ml 24 TRINTELLIX 5MG TAB 26 TYPHIM VI 101 oral soln tri-nymyo 28 day pack 65 25MCG/0.5ML INJ valsartan 160mg tab 36 tri-previfem 28 day pack 65 TYPHIM VI 101 valsartan 320mg tab 36 tri-sprintec 28 day pack 65 25MCG/0.5ML SYRINGE valsartan 40mg tab 36 TRIUMEQ 55 U valsartan 80mg tab 36 600-50-300MG TAB UBRELVY 100MG TAB 83 VALTOCO 10MG DOSE 21 trivora 28 day pack 65 UBRELVY 50MG TAB 83 KIT 10MG/0.1ML PACK tri-vylibra 28 day pack 65 UCERIS 2MG/ACT 14 VALTOCO 15MG DOSE 21 tri-vylibra lo 28 day pack 65 RECTAL FOAM KIT 7.5MG/0.1ML PACK TROKENDI 100MG ER 23 UKONIQ 200MG TAB 46 VALTOCO 20MG DOSE 21 CAP unithroid 100mcg tab 98 KIT 10MG/0.1ML PACK TROKENDI 200MG ER 23 unithroid 112mcg tab 98 VALTOCO 5MG DOSE 21 CAP unithroid 125mcg tab 98 KIT 5MG/0.1ML PACK TROKENDI 25MG ER 23 unithroid 137mcg tab 98 vancomycin 1000mg inj 39 CAP unithroid 150mcg tab 98 vancomycin 100mg/ml inj 39 TROKENDI 50MG ER 23 unithroid 175mcg tab 98 vancomycin 125mg cap 39 CAP unithroid 200mcg tab 98 vancomycin 250mg cap 39 TROPHAMINE 10% INJ 88 unithroid 25mcg tab 98

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 145 ALPHABETICAL LISTING OF DRUGS

VANCOMYCIN 250MG 39 venlafaxine 75mg tab 27 VIIBRYD 10MG TAB 26 INJ VENTAVIS 10MCG/ML 60 VIIBRYD 20MG TAB 26 vancomycin 500mg inj 39 INH SOLN VIIBRYD 40MG TAB 26 vancomycin 750mg inj 39 VENTAVIS 20MCG/ML 60 VIMPAT 100MG TAB 23 vandazole 0.75% vaginal 101 INH SOLN VIMPAT 10MG/ML 23 gel VENTOLIN 108MCG INH 19 ORAL SOLN VAQTA 25UNIT/0.5ML 101 VERAPAMIL 100MG ER 59 VIMPAT 150MG TAB 23 INJ CAP VIMPAT 200MG TAB 23 VAQTA 25UNIT/0.5ML 101 verapamil 120mg er cap 59 VIMPAT 50MG TAB 23 SYRINGE verapamil 120mg er tab 59 VIRACEPT 250MG TAB 55 VAQTA 50UNIT/ML INJ 101 verapamil 120mg tab 59 VIRACEPT 625MG TAB 55 VAQTA 50UNIT/ML 101 verapamil 180mg er cap 59 VIREAD 150MG TAB 55 SYRINGE verapamil 180mg er tab 59 VIREAD 200MG TAB 55 VARIVAX 101 VERAPAMIL 200MG ER 59 VIREAD 250MG TAB 55 1350PFU/0.5ML INJ CAP VIREAD 40MG/GM 55 VARIZIG 91 verapamil 240mg er cap 59 ORAL POWDER 125UNIT/1.2ML INJ verapamil 240mg er tab 59 VITRAKVI 100MG CAP 46 VARUBI 90MG TAB 32 VERAPAMIL 300MG ER 59 VITRAKVI 20MG/ML 46 VASCEPA 0.5GM CAP 33 CAP ORAL SOLN VASCEPA 1GM CAP 33 VERAPAMIL 360MG ER 59 VITRAKVI 25MG CAP 46 velivet 28 day pack 65 CAP VIVITROL 380MG INJ 31 VELTASSA 16.8GM 86 verapamil 40mg tab 59 VIZIMPRO 15MG TAB 46 POWDER FOR ORAL verapamil 80mg tab 59 VIZIMPRO 30MG TAB 46 SUSP VERQUVO 10MG TAB 61 VIZIMPRO 45MG TAB 46 VELTASSA 25.2GM 86 VERQUVO 2.5MG TAB 61 voriconazole 200mg inj 33 POWDER FOR ORAL VERQUVO 5MG TAB 61 voriconazole 200mg tab 33 SUSP VERSACLOZ 50MG/ML 51 voriconazole 40mg/ml 33 VELTASSA 8.4GM 86 SUSP susp POWDER FOR ORAL VERZENIO 100MG TAB 46 voriconazole 50mg tab 33 SUSP VERZENIO 150MG TAB 46 VOSEVI 400-100-100MG 55 VEMLIDY 25MG TAB 55 VERZENIO 200MG TAB 46 TAB VENCLEXTA 100MG 41 VERZENIO 50MG TAB 46 VOTRIENT 200MG TAB 46 TAB vestura 3-0.02mg pack 65 VRAYLAR 1.5/3MG 49 VENCLEXTA 10MG TAB 41 VIBERZI 100MG TAB 78 MIXED PACK VENCLEXTA 50MG TAB 41 VIBERZI 75MG TAB 78 VRAYLAR 1.5MG CAP 49 VENCLEXTA STARTING 41 VICTOZA 18MG/3ML 29 VRAYLAR 3MG CAP 49 PACK PEN INJ VRAYLAR 4.5MG CAP 49 venlafaxine 100mg tab 27 vienva 28 day pack 65 VRAYLAR 6MG CAP 49 venlafaxine 150mg er cap 27 vigabatrin 500mg powder 24 vyfemla 28 day pack 65 venlafaxine 25mg tab 27 for oral soln vylibra 28 day pack 65 venlafaxine 37.5mg er 27 vigabatrin 500mg tab 24 VYNDAMAX 61MG CAP 61 cap vigadrone 500mg powder 24 VYNDAQEL 20MG CAP 61 venlafaxine 37.5mg tab 27 for oral soln W venlafaxine 50mg tab 27 VIIBRYD 10/20MG 26 WAKIX 17.8MG TAB 7 venlafaxine 75mg er cap 27 STARTER PACK You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146 ALPHABETICAL LISTING OF DRUGS

WAKIX 4.45MG TAB 7 XELJANZ 10MG TAB 9 XPOVIO 40MG TWICE 42 warfarin sodium 10mg 19 XELJANZ 1MG/ML 9 WEEKLY PACK tab ORAL SOLN XPOVIO 60 MG ONCE 42 warfarin sodium 1mg tab 19 XELJANZ 5MG TAB 9 WEEKLY warfarin sodium 2.5mg 19 XELJANZ XR 11MG TAB 9 XPOVIO 60MG ONCE 42 tab XELJANZ XR 22MG TAB 9 WEEKLY CARTON warfarin sodium 2mg tab 19 XENLETA 600MG TAB 40 (4-PACK) warfarin sodium 3mg tab 19 XGEVA 120MG/1.7ML 73 XPOVIO 60MG TWICE 42 warfarin sodium 4mg tab 19 INJ WEEKLY PACK warfarin sodium 5mg tab 19 XIFAXAN 200MG TAB 39 XPOVIO 80 MG ONCE 42 warfarin sodium 6mg tab 19 XIFAXAN 550MG TAB 39 WEEKLY warfarin sodium 7.5mg 19 XIGDUO 10-1000MG ER 29 XPOVIO 80 MG TWICE 43 tab TAB WEEKLY wixela 0.1-0.05mg inh 19 XIGDUO 10-500MG ER 29 XPOVIO 80MG ONCE 43 wixela 0.25-0.05mg inh 19 TAB WEEKLY CARTON wixela 0.5-0.05mg inh 19 XIGDUO 2.5-1000MG ER 29 (8-PACK) wymzya fe 28 day pack 65 TAB XTAMPZA 13.5MG ER 13 X XIGDUO 5-1000MG ER 29 CAP TAB XTAMPZA 18MG ER 13 XALKORI 200MG CAP 46 XIGDUO 5-500MG ER 29 CAP XALKORI 250MG CAP 46 TAB XTAMPZA 27MG ER 13 XARELTO 10MG TAB 20 XOFLUZA 20MG 56 CAP XARELTO 15MG TAB 20 THERAPY PACK XTAMPZA 36MG ER 13 XARELTO 2.5MG TAB 20 XOFLUZA 40MG 56 CAP XARELTO 20MG TAB 20 THERAPY PACK XTAMPZA 9MG ER CAP 13 XARELTO KIT PACK 20 XOLAIR 150MG INJ 17 XTANDI 40MG CAP 42 XATMEP 2.5MG/ML 41 XOLAIR 150MG/ML 17 XULANE 65 ORAL SOLN SYRINGE 0.00146-0.00625MG/HR XCOPRI 100MG TAB 24 XOLAIR 75MG/0.5ML 17 PATCH XCOPRI 12.5/25MG 24 SYRINGE XULTOPHY 29 TITRATION PACK XOSPATA 40MG TAB 46 100UNIT-3.6MG/ML XCOPRI 150/200MG 24 XPOVIO 100 MG ONCE 42 PEN INJ TITRATION PACK WEEKLY XYREM 500MG/ML 93 XCOPRI 150MG TAB 24 XPOVIO 100MG ONCE 42 ORAL SOLN XCOPRI 200MG TAB 24 WEEKLY CARTON XCOPRI 50/100MG 24 Y (8-PACK) TITRATION PACK YF-VAX 4000UNIT/ML 101 XPOVIO 40MG ONCE 42 XCOPRI 50MG TAB 24 INJ WEEKLY CARTON XCOPRI TAB 24 (4-PACK) Z 100/150MG XPOVIO 40MG ONCE 42 zafemy 150-35mcg/24hr 65 MAINTENANCE PACK WEEKLY PACK patch XCOPRI TAB 24 XPOVIO 40MG TWICE 42 zafirlukast 10mg tab 17 150/200MG PACK WEEKLY CARTON zafirlukast 20mg tab 17 XCOPRI TAB 50/200MG 24 (8-PACK) zaleplon 10mg cap 81 PACK zaleplon 5mg cap 81 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 147 ALPHABETICAL LISTING OF DRUGS zarah pack 65 ZIEXTENZO 6MG/0.6ML 81 ZARXIO 300MCG/0.5ML 81 SYRINGE SYRINGE ziprasidone 20mg cap 49 ZARXIO 480MCG/0.8ML 81 ziprasidone 20mg inj 49 SYRINGE ziprasidone 40mg cap 49 ZEJULA 100MG CAP 46 ziprasidone 60mg cap 49 ZELBORAF 240MG TAB 46 ziprasidone 80mg cap 49 ZEMAIRA 1000MG INJ 95 ZIRGAN 0.15% OPHTH 89 zenatane 10mg cap 68 GEL zenatane 20mg cap 68 ZOLINZA 100MG CAP 46 zenatane 30mg cap 68 zolmitriptan 2.5mg odt 83 zenatane 40mg cap 68 zolmitriptan 2.5mg tab 83 ZENPEP 72 zolmitriptan 5mg odt 83 105000-79000-25000UNI zolmitriptan 5mg tab 83 T DR CAP zolpidem tartrate 10mg 81 ZENPEP 72 tab 14000-10000-3000UNIT zolpidem tartrate 5mg tab 81 DR CAP ZOMIG 2.5MG NASAL 83 ZENPEP 72 SPRAY 24000-17000-5000UNIT ZOMIG 5MG NASAL 83 DR CAP SPRAY ZENPEP 72 zonisamide 100mg cap 23 40000-126000-168000U zonisamide 25mg cap 24 NIT DR CAP zonisamide 50mg cap 24 ZENPEP 72 ZOSYN 2000-250MG INJ 92 42000-32000-10000UNIT ZOSYN 3000-375MG INJ 92 DR CAP zovia 1/35e 28 day pack 65 ZENPEP 72 ZUBSOLV 1.4-0.36MG 14 63000-47000-15000UNIT SL TAB DR CAP ZUBSOLV 11.4-2.9MG 14 ZENPEP 72 SL TAB 84000-63000-20000UNIT ZUBSOLV 2.9-0.71MG 14 DR CAP SL TAB ZEPOSIA 0.92MG CAP 95 ZUBSOLV 5.7-1.4MG SL 14 ZEPOSIA 7-DAY 95 TAB STARTER PACK ZUBSOLV 8.6-2.1MG SL 14 ZEPOSIA STARTER KIT 95 TAB PACK ZYCLARA 2.5% CREAM 71 ZERBAXA 1000-500MG 61 ZYDELIG 100MG TAB 46 INJ ZYDELIG 150MG TAB 46 zidovudine 100mg cap 55 ZYKADIA 150MG TAB 46 zidovudine 10mg/ml oral 55 ZYLET 0.5-0.3% OPHTH 90 soln SUSP zidovudine 300mg tab 55 ZYPREXA RELPREVV 51 210MG INJ You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148 This formulary was updated on September 1, 2021. For more recent information or other questions, please contact FirstCare Advantage Dual Special Needs Plan (SNP) Customer Experience Center at 1-866-229-4969 or, for TTY users, 711, October 1 – March 31, 8 a.m. to 8 p.m. Central Time (CT) daily; April 1 – September 30, 8 a.m. to 8 p.m. CT, Monday through Friday, or visit www.firstcare.com/dualsnp.

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Last Updated September 1, 2021 Our mission as part of the Baylor Scott & White Health family

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