2020 LIST OF COVERED DRUGS (FORMULARY)

Prescription drug list information

UnitedHealthcare® Senior Care Options (HMO D-SNP) UnitedHealthcare® Senior Care Options NHC (HMO D-SNP)

Important Notes: This document has information about the drugs covered by this plan. For more recent information or if you have questions, please call Customer Service at: Toll-free 1-888-867-5511, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Formulary ID Number 00020047, Version 21 H2226_190701_012345_C v01.12 UHCSCO 190701_012345 Last updated December 1, 2020 UnitedHealthcare® Senior Care Options (HMO D-SNP) UnitedHealthcare® Senior Care Options NHC (HMO D-SNP) 2020 List of Covered Drugs (Formulary)

Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs are covered by UnitedHealthcare Senior Care Options. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UnitedHealthcare Senior Care Options. Key terms and their definitions appear in the last chapter of the Evidence of Coverage.

Our contact information, along with the date we last updated the Drug List, appears on the front and back cover pages.

Table of Contents

A. Disclaimers...... 4 B. Frequently Asked Questions (FAQ)...... 5 B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)...... 5 B2. Does the Drug List ever change?...... 5 B3. What happens when there is a change to the Drug List?...... 6 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?...... 7 B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug?...... 7 B6. What happens if we change our rules about how we cover some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...... 8 B7. How can you find a drug on the Drug List?...... 8 B8. What if the drug you want to take is not on the Drug List?...... 8 B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find your drug on the Drug List or have a problem getting your drug?...... 8 B10. Can you ask for an exception to cover your drug?...... 9 B11. How can you ask for an exception?...... 10 B12. How long does it take to get an exception?...... 10 B13. What are generic drugs?...... 10

This section is continued on the next page. B14. What are over-the-counter (OTC) drugs?...... 10 B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products?...... 10 B16. Can you get a long-term supply of drugs?...... 10 B17. What is your copay?...... 11 C. Overview of the List of Covered Drugs...... 12 C1. List of Drugs by Medical Condition...... 12 C2. Covered drugs with a quantity limit (QL)...... 91 C3. Over-the-counter (OTC) Drug List...... 120 D. Index of Covered Drugs...... 190

If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more information, visit www.UHCCommunityPlan.com. 4

A. Disclaimers This is a list of drugs that members can get in UnitedHealthcare Senior Care Options. v UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. v The Drug List (formulary) may change on January 1 of each year, and from time to time during the plan year. You will receive notice when necessary. v You can always check UnitedHealthcare Senior Care Options’ up-to-date List of Covered Drugs online at www.UHCCommunityPlan.com or by calling Customer Service toll-free at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. v ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. v ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame a Servicio al Cliente de UnitedHealthcare Senior Care Options al 1-888-867-5511, TTY 711, de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. v You can call Customer Service and ask us to make a note in our system that you would like materials in Spanish, large print, braille or audio now and in the future. 5

B. Frequently Asked Questions (FAQ) Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the Drug List that starts on page 12 are the drugs covered by UnitedHealthcare Senior Care Options. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” · UnitedHealthcare Senior Care Options will cover all medically necessary drugs on the Drug List if: o Your doctor or other prescriber says you need them to get better or stay healthy, o The plan agrees that the drug is medically necessary for you, and o You fill the prescription at a UnitedHealthcare Senior Care Options network pharmacy. · UnitedHealthcare Senior Care Options may have additional steps to access certain drugs. See question B4 for more information. You can also see an up-to-date list of drugs we cover on our website at www.UHCCommunityPlan.com or call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

B2. Does the Drug List ever change? Yes. UnitedHealthcare Senior Care Options may add or remove drugs on the Drug List during the year. We must follow Medicare rules in making these changes. We may also change our rules about drugs. For example we could: · Decide to require or not require prior authorization (approval) for a drug. (Prior authorization (approval) is permission from UnitedHealthcare Senior Care Options before you can get a drug.) · Add or change the amount of a drug you can get (called quantity limits). · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more information, visit www.UHCCommunityPlan.com. 6 · A new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or · We learn that a drug is not safe, or · A drug is removed from the market. Questions B3 and B6 have more information on what happens when the Drug List changes. · You can always check UnitedHealthcare Senior Care Options’ current Drug List online at www.UHCCommunityPlan.com. · You can also call Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week to check the current Drug List.

B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: · A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits. o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens. o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see questions B10 - B12 for more information on exceptions.

· A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Contact your doctor or other prescriber and ask about your other options. We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

· The FDA provides new guidance or there are new clinical guidelines about a drug. · We add a generic drug that is new to the market and · Replace a brand name drug currently on the Drug List or · Change the coverage rules or limits for the brand name drug. When these changes happen, we will:

· Tell you at least 30 days before we make the change to the Drug List or · Let you know and give you a 30-day supply of the drug after you ask for a refill. This section is continued on the next page. 7 This will give you time to talk to your doctor or other prescriber. He or she can help you decide:

· If there is a similar drug on the Drug List you can take instead or · Whether to ask for an exception from these changes. To learn more about exceptions, see questions B10 - B12 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes. Some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

· Prior authorization (approval): For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).

· Quantity limits: Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.

· Step therapy: Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 14 - 90. You can also get more information by visiting our website at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception to these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 - B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on pages 14 - 90 has a column labeled “Necessary actions, restrictions, or limits on use.”

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more information, visit www.UHCCommunityPlan.com. 8

B6. What happens if we change our rules about how we cover some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List? There are two ways to find a drug:

· You can search alphabetically (if you know how to spell the drug), or

· You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section that begins on page 190. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information.

To search by medical condition, find the section labeled “List of Drugs by Medical Condition” on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Customer Service at 1-888-867-5511, TTY 711 and ask about it. If you learn that UnitedHealthcare Senior Care Options will not cover the drug, you can do one of these things:

· Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

· You can ask the health plan to make an exception to cover your drug. Please see questions B10 - B12 for more information about exceptions.

B9. What if you are a new UnitedHealthcare Senior Care Options member and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Senior Care Options. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to ask for an exception.

This section is continued on the next page. 9 If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication.

We will cover a temporary 30-day supply of your drug if:

· You are taking a drug that is not on our Drug List, or · Health plan rules do not let you get the amount ordered by your prescriber, or · The drug requires prior authorization (approval) by UnitedHealthcare Senior Care Options, or

· You are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

· We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Senior Care Options member.

· This is in addition to the temporary supply during the first 90 days you are a member of UnitedHealthcare Senior Care Options. If you are going through a change in your level of care, such as being transferred from a hospital to a long-term care facility, any time during the year, we may cover a temporary 31-day supply of the drug you need. This will give you time to talk to your doctor or other prescriber about other treatment options or to try to get an exception. Please see questions B10 - B12 for more information about exceptions. We will not pay for more of your drug after you get a temporary supply unless you receive authorization from the plan.

B10. Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Senior Care Options to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.

· For example, UnitedHealthcare Senior Care Options may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

· Other examples: You can ask us to drop step therapy restrictions or prior authorization (approval) requirements.

This section is continued on the next page.

If you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more information, visit www.UHCCommunityPlan.com. 10

B11. How can you ask for an exception? To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 8 of the Evidence of Coverage to learn more about exceptions.

B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Senior Care Options covers both brand name drugs and generic drugs.

B14. What are over-the-counter (OTC) drugs? OTC stands for “over-the-counter.” UnitedHealthcare Senior Care Options covers some OTC drugs when they are written as prescriptions by your provider. These OTC drugs are listed in this Drug List starting on page 120. B15. Does UnitedHealthcare Senior Care Options cover non-drug OTC products? Yes. UnitedHealthcare Senior Care Options covers some non-drug OTC products when they are written as prescriptions by your provider. These non-drug OTC products are listed in the Drug List.

B16. Can you get a long-term supply of drugs? Yes. UnitedHealthcare Senior Care Options offers two ways to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) · Retail pharmacy. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. · Mail-order. For certain kinds of drugs, you can use the plan’s network mail-order services. Our plan’s mail-order service allows you to get up to a 90-day supply. To get order forms and information about filling your prescriptions by mail, please reference your Pharmacy Directory to find the mail service pharmacies in our network. This section is continued on the next page. 11 For more information about getting a long-term supply of drugs, call Customer Service at 1-888-867-5511, TTY 711.

B17. What is your copay? UnitedHealthcare Senior Care Options members have no copays for prescription and over-the- counter (OTC) drugs and non-drug products as long as the member follows the plan’s rules. See questions B14 and B15 for more information about OTC drugs and non-drug products. Tiers are groups of drugs on our Drug List. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier.

· Tier 1 Generic drugs have $0 copay. · Tier 1 Brand name drugs have $0 copay. OTCs have $0 copay. I f you have questions, call Customer Service at 1-888-867-5511, TTY 711.

I f you have questions, please call UnitedHealthcare Senior Care Options Customer Service at 1-888-867-5511, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. The call is free. For more information, visit www.UHCCommunityPlan.com. 12 tRACK tRACK 1 C. Overview of the List of Covered Drugs The List of Covered Drugs gives you information about the drugs covered by UnitedHealthcare Senior Care Options. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 190. The index alphabetically lists all drugs covered by UnitedHealthcare Senior Care Options.

C1. List of Drugs by Medical Condition The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the “Antimigraine Agents” category. That is where you will find drugs that treat migraines.

The first column of the table lists the name of the drug. Generic drugs are listed in plain type (e.g., Simvastatin) and brand name drugs are in bold type (e.g., Humalog).

The second column lists the Medicare Part D drug tier. Your plan has 1 tier named “Covered Drugs.” All covered drugs are in this tier. As a member of this plan, you have no copays for covered, prescribed drugs when obtained from network pharmacies.

The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Senior Care Options has any rules for covering your drug.

Coverage Rules and Limits

PA – Prior authorization (approval) For some drugs, you, your doctor or other prescriber must get authorization (approval) from UnitedHealthcare Senior Care Options before you fill your prescription. Prior authorization is different from a referral. UnitedHealthcare Senior Care Options may not cover the drug if you don’t get authorization (approval).

QL – Quantity limits Sometimes UnitedHealthcare Senior Care Options limits the amount of a drug you can get.

ST – Step therapy Sometimes UnitedHealthcare Senior Care Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn’t work for you, then we will cover the second.

This section is continued on the next page. tRACK 13 2 Other Special Coverage Rules

B/D – Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

LA – Limited access Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

MME – Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than 1 opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.

7D – 7-Day limit An opioid drug used for the treatment of acute pain may be limited to a 7-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.

DL – Dispensing limit Dispensing limits apply to this drug. This drug is limited to a 1 month supply per prescription. 14 tRACK tRACK 3 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

A1 C1 Ibu Analgesics Ibu (600MG Oral B1 Analgesics Tablet, 800MG Oral 1

C1 Butalbital- Acetaminophen- Caffeine Tablet)

C1 Butalbital- Ibuprofen Ibuprofen (Oral Acetaminophen- 1 QL 1 Suspension)

Caffeine (Oral Tablet) C1 Ibuprofen

C1 Butalbital-Aspirin- Caffeine Butalbital-Aspirin- Ibuprofen (400MG Oral 1 QL Caffeine (Oral Capsule) Tablet, 600MG Oral

B1 1 Tablet, 800MG Oral Nonsteroidal Anti-inflammatory Drugs

C1 Celecoxib Tablet)

C1 Celecoxib (Oral Indomethacin 1 QL Indomethacin (25MG Capsule)

C1 Diclofenac Epolamine Oral Capsule Diclofenac Epolamine Immediate Release, 1 (1.3% Transdermal 1 PA; QL 50MG Oral Capsule Patch)

C1 Immediate Release) Diclofenac Potassium C1 Diclofenac Potassium Ketoprofen 1 Ketoprofen (Oral (Oral Tablet)

C1 Capsule Immediate 1 Diclofenac Sodium ER Diclofenac Sodium ER Release)

C1 Meloxicam (Oral Tablet Extended 1 Meloxicam (Oral Release 24 Hour) 1

C1 Tablet) Diclofenac Sodium

C1 Nabumetone Diclofenac Sodium Nabumetone (Oral 1 (Oral Tablet Delayed 1 Tablet)

C1 Release) Naproxen DR

C1 Diclofenac Sodium Naproxen DR (Oral Diclofenac Sodium 1 Tablet Delayed (1% Transdermal Gel) 1

C1 Release) (Generic EC- Diflunisal Diflunisal (Oral Tablet) 1 Naprosyn)

C1 C1 Naproxen Etodolac ER Naproxen (Oral Etodolac ER (Oral 1 Tablet Extended 1 Suspension) C1 Naproxen Release 24 Hour) Naproxen (Oral Tablet C1 Etodolac 1 Etodolac (Oral Immediate Release) C1 1 Piroxicam Capsule) Piroxicam (Oral C1 Etodolac 1 Etodolac (Oral Tablet Capsule) C1 1 Sulindac Immediate Release) Sulindac (Oral Tablet) 1 C1 Flector

B1 Flector (1.3% Opioid Analgesics, Long-acting

1 PA; QL C1 Transdermal Patch) Buprenorphine

C1 Flurbiprofen Buprenorphine Flurbiprofen (100MG 1 (Transdermal Patch 1 7D; DL; QL Oral Tablet) Weekly)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 15 4 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Fentanyl Nucynta ER Fentanyl (100MCG/HR Nucynta ER (Oral 7D; MME; Transdermal Patch 72 Tablet Extended 1 DL; QL Hour, 12MCG/HR Release 12 Hour)

C1 Tramadol HCl ER Transdermal Patch 72 Tramadol HCl ER Hour, 25MCG/HR 7D; MME; (Biphasic) (Oral Tablet 7D; MME; Transdermal Patch 72 1 1 DL; QL Extended Release 24 DL; QL Hour, 50MCG/HR Hour)

C1 Transdermal Patch 72 Tramadol HCl ER Hour, 75MCG/HR Tramadol HCl ER (Oral 7D; MME; Transdermal Patch 72 Tablet Extended 1 Release 24 Hour) DL; QL

C1 Hour) Xtampza ER

C1 Hydromorphone HCl ER Xtampza ER (Oral Hydromorphone HCl 7D; MME; ER (Oral Tablet 7D; MME; Capsule ER 12 Hour 1 1 DL; QL Extended Release 24 DL; QL Abuse-Deterrent) B1 Hour) Opioid Analgesics, Short-acting C1 Hysingla ER C1 Acetaminophen- Hysingla ER (Oral Codeine 7D; MME; Acetaminophen- 7D; MME; Tablet ER 24 Hour 1 Codeine (120-12MG/ 1 DL; QL DL; QL Abuse-Deterrent) 5ML Oral Solution)

C1 C1 Acetaminophen- Levorphanol Codeine Tartrate Levorphanol Tartrate 7D; MME; Acetaminophen- 1 (Oral Tablet) DL; QL Codeine (300-15MG

C1 Methadone HCl 7D; MME; Methadone HCl (Oral 7D; MME; Oral Tablet, 300-30MG 1 1 Oral Tablet, 300-60MG DL; QL Solution) DL; QL

C1 Methadone HCl Oral Tablet)

C1 Butorphanol Methadone HCl (Oral 7D; MME; Tartrate 1 Butorphanol Tartrate 7D; MME; Tablet) DL; QL 1

C1 Morphine Sulfate ER (Nasal Solution) DL; QL

C1 Morphine Sulfate ER Codeine Sulfate Codeine Sulfate 7D; MME; (100MG Oral Tablet 1 (15MG Oral Tablet) DL; QL

C1 Extended Release, Codeine Sulfate Codeine Sulfate 15MG Oral Tablet 7D; MME; Extended Release, 7D; MME; (30MG Oral Tablet, 1 1 DL; QL 30MG Oral Tablet DL; QL 60MG Oral Tablet) C1 Endocet Extended Release, Endocet (10-325MG 60MG Oral Tablet Oral Tablet, 5-325MG 7D; MME; 1 Extended Release) Oral Tablet, 7.5-325MG DL; QL (Generic MS Contin) Oral Tablet) C1 Morphine Sulfate C1 ER Fentanyl Citrate Morphine Sulfate ER Fentanyl Citrate (200MG Oral Tablet 7D; MME; 1 (Buccal Lozenge On A 1 PA; DL; QL Extended Release) DL; QL Handle) (Generic MS Contin)

Bold type = Brand name drug Plain type = Generic drug 16 tRACK 5 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Hydrocodone- Oxycodone HCl Acetaminophen Hydrocodone- Oxycodone HCl (10MG Acetaminophen 7D; MME; Oral Tablet Immediate 1 (7.5-325MG/15ML Oral DL; QL Release, 15MG Oral Solution) Tablet Immediate

C1 Hydrocodone- Acetaminophen Hydrocodone- Release, 20MG Oral 7D; MME; Tablet Immediate 1 Acetaminophen DL; QL (10-325MG Oral 7D; MME; Release, 30MG Oral 1 Tablet, 5-325MG Oral DL; QL Tablet Immediate Tablet, 7.5-325MG Oral Release, 5MG Oral Tablet) Tablet Immediate

C1 Hydrocodone- Ibuprofen Release)

C1 Oxycodone- Hydrocodone- 7D; MME; Acetaminophen Ibuprofen (7.5-200MG 1 Oxycodone- Oral Tablet) DL; QL Acetaminophen

C1 Hydromorphone HCl (10-325MG Oral Hydromorphone HCl 7D; MME; 7D; MME; 1 Tablet, 2.5-325MG Oral 1 (1MG/ML Oral Liquid) DL; QL DL; QL

C1 Hydromorphone HCl Tablet, 5-325MG Oral Hydromorphone HCl Tablet, 7.5-325MG Oral (2MG Oral Tablet Tablet)

C1 Oxycodone-Aspirin Immediate Release, 7D; MME; Oxycodone-Aspirin 7D; MME; 4MG Oral Tablet 1 1 DL; QL (Oral Tablet) DL; QL

C1 Immediate Release, Tramadol HCl 8MG Oral Tablet Tramadol HCl (50MG 7D; MME; Immediate Release) Oral Tablet Immediate 1 C1 DL; QL Hydromorphone HCl Preservative Free Release)

C1 Tramadol- Hydromorphone HCl Acetaminophen Preservative Free Tramadol- 7D; MME; (10MG/ML Injection 1 DL Acetaminophen (Oral 1 Tablet) DL; QL

Solution, 50MG/5ML C1 Trezix Injection Solution) 7D; MME;

C1 Morphine Sulfate Trezix (Oral Capsule) 1 Morphine Sulfate (Oral 7D; MME; DL; QL 1 A1 Solution) DL; QL Anesthetics

C1 B1 Morphine Sulfate Morphine Sulfate Local Anesthetics

C1 7D; MME; Lidocaine (Oral Tablet 1 Lidocaine (5% External DL; QL 1 QL Immediate Release) Ointment)

C1 Oxycodone HCl C1 Lidocaine Oxycodone HCl Lidocaine (5% External 7D; MME; 1 PA; QL (100MG/5ML Oral 1 Patch)

C1 DL; QL Lidocaine HCl Concentrate) C1 Oxycodone HCl Lidocaine HCl (4% 1 Oxycodone HCl (5MG/ 7D; MME; External Solution)

C1 1 Lidocaine HCl 5ML Oral Solution) DL; QL Lidocaine HCl 1 (External Gel)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 17 6 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Lidocaine Viscous Naloxone HCl Lidocaine Viscous (2% Naloxone HCl Mouth/Throat 1 (Injection Solution 1 Solution) Prefilled Syringe)

C1 C1 Lidocaine-Prilocaine Narcan Lidocaine-Prilocaine Narcan (Nasal Liquid) 1 1 B1 (External Cream) A1 Smoking Cessation Agents

C1 Bupropion HCl SR Anti-Addiction/Substance Abuse Treatment Bupropion HCl SR Agents B1 (150MG Oral Tablet Alcohol Deterrents/Anti-craving Extended Release 12 1

C1 Acamprosate Calcium Acamprosate Calcium Hour Smoking- Deterrent)

(Oral Tablet Delayed 1 C1 Chantix Continuing Release) Month Pak Chantix Continuing

C1 Disulfiram Disulfiram (Oral Tablet) 1 Month Pak (Oral 1

C1 Naltrexone HCl Tablet)

C1 Naltrexone HCl (Oral Chantix 1 Tablet) Chantix (Oral Tablet) 1

C1 C1 Chantix Starting Vivitrol Month Pak Vivitrol (Intramuscular Chantix Starting

Suspension 1 Month Pak (Oral 1 Reconstituted) Tablet)

C1 B1 Nicotrol Opioid Dependence Treatments Nicotrol (Inhalation

C1 Buprenorphine HCl 1 Buprenorphine HCl Inhaler) C1 1 QL Nicotrol NS (Tablet Sublingual) Nicotrol NS (Nasal

C1 Buprenorphine HCl- Naloxone HCl 1 Buprenorphine HCl- Solution) A1 Naloxone HCl 1 QL Antibacterials (Sublingual Film) B1

C1 Buprenorphine HCl- Aminoglycosides Naloxone HCl

C1 Buprenorphine HCl- Amikacin Sulfate Amikacin Sulfate Naloxone HCl (Tablet 1 QL (500MG/2ML Injection 1 Sublingual)

C1 Suboxone Solution)

C1 Suboxone (Sublingual Gentak 1 QL Gentak (Ophthalmic Film) 1

B1 Ointment)

C1 Gentamicin Sulfate-0.9% Opioid Reversal Agents Sodium Chloride

C1 Gentamicin Naloxone HCl Naloxone HCl (0.4MG/ Sulfate-0.9% Sodium 1 1 ML Injection Solution) Chloride (Intravenous

C1 Naloxone HCl Naloxone HCl Solution) C1 Gentamicin Sulfate (Injection Solution 1 Gentamicin Sulfate 1 Cartridge) (External Cream)

C1 Gentamicin Sulfate Gentamicin Sulfate 1 (External Ointment)

Bold type = Brand name drug Plain type = Generic drug 18 tRACK 7 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Gentamicin Sulfate Clindamycin Phosphate Gentamicin Sulfate Clindamycin (40MG/ML Injection 1 Phosphate (Vaginal 1 Solution) Cream)

C1 C1 Gentamicin Sulfate Colistimethate Gentamicin Sulfate Sodium Colistimethate Sodium 1 (Ophthalmic Solution) (CBA) (Injection

C1 Neomycin Sulfate 1 Neomycin Sulfate (Oral Solution 1 Reconstituted)

Tablet) C1 Dalvance

C1 Paromomycin Sulfate Paromomycin Sulfate Dalvance (Intravenous 1 (Oral Capsule) Solution 1 PA

C1 Streptomycin Sulfate Reconstituted)

C1 Streptomycin Sulfate Daptomycin Daptomycin (350MG (Intramuscular Solution 1 Reconstituted) Intravenous Solution 1

C1 Tobramycin Tobramycin Reconstituted) C1 1 Daptomycin (Ophthalmic Solution) Daptomycin (500MG C1 Tobramycin Sulfate Tobramycin Sulfate Intravenous Solution 1 (10MG/ML Injection Reconstituted) C1 1 Linezolid Solution, 80MG/2ML Linezolid (Intravenous 1 Injection Solution) Solution) C1 Tobrex C1 Tobrex (Ophthalmic Linezolid 1 Linezolid (Oral Ointment) Suspension 1 B1 Reconstituted)

Antibacterials, Other C1 Linezolid C1 Bacitracin Bacitracin (Ophthalmic Linezolid (Oral Tablet) 1 QL C1 Methenamine 1 Hippurate Ointment) Methenamine C1 Clindamycin HCl 1 Clindamycin HCl (Oral Hippurate (Oral Tablet) C1 1 Metronidazole Capsule) Metronidazole (0.75% C1 Clindamycin Palmitate HCl 1 Clindamycin Palmitate External Cream) C1 Metronidazole HCl (Oral Solution 1 Metronidazole (0.75% Reconstituted) External Gel, 1% 1 C1 Clindamycin Phosphate in D5W Clindamycin External Gel) C1 Metronidazole Phosphate in D5W 1 Metronidazole (0.75% 1 (Intravenous Solution) External Lotion) C1 Clindamycin Phosphate C1 Metronidazole in Clindamycin NaCl 0.79% Metronidazole in NaCl Phosphate (300MG/ 0.79% (Intravenous 1 2ML Injection Solution, Solution)

C1 1 Metronidazole 600MG/4ML Injection Metronidazole (250MG Solution, 900MG/6ML Oral Tablet, 500MG 1 Injection Solution) Oral Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 19 8 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Metronidazole Vancomycin HCl Metronidazole (0.75% Vancomycin HCl 1 Vaginal Gel) (250MG Intravenous C1 Mupirocin Calcium 1 Mupirocin Calcium Solution 1 (External Cream) Reconstituted)

C1 C1 Mupirocin Vancomycin HCl Mupirocin (External Vancomycin HCl (Oral 1 1 QL Ointment) Capsule)

C1 C1 Nitrofurantoin Vandazole Macrocrystal Nitrofurantoin Vandazole (Vaginal 1 Macrocrystal (100MG Gel)

B1 Oral Capsule, 50MG 1 Beta-lactam, Cephalosporins

C1 Oral Capsule) (Generic Cefaclor Cefaclor (Oral Macrodantin) 1 C1 Nitrofurantoin Monohydrate Capsule)

C1 Nitrofurantoin Cefadroxil Cefadroxil (Oral Monohydrate (Generic 1 1 Capsule)

C1 Macrobid) Cefadroxil

C1 Nitrofurantoin Nitrofurantoin (Oral Cefadroxil (Oral 1 Suspension) Suspension 1

C1 Polymyxin B Sulfate Reconstituted)

C1 Polymyxin B Sulfate Cefazolin Sodium (Injection Solution 1 Cefazolin Sodium Reconstituted) (10GM Injection

C1 Sulfamylon Solution Sulfamylon (External 1 Reconstituted, 1GM Cream) 1

C1 Injection Solution Tigecycline Tigecycline Reconstituted, 500MG (Intravenous Solution 1 Injection Solution Reconstituted) Reconstituted)

C1 C1 Tinidazole Cefdinir Tinidazole (Oral Tablet) 1 Cefdinir (Oral Capsule) 1

C1 C1 Trimethoprim Cefdinir Trimethoprim (Oral Cefdinir (Oral 1 Tablet) Suspension 1

C1 Vancomycin HCl Reconstituted)

Vancomycin HCl C1 Cefepime HCl (10GM Intravenous Cefepime HCl Solution (Injection Solution 1 Reconstituted, 1GM Reconstituted)

C1 Cefixime Intravenous Solution Cefixime (Oral 1 1 Reconstituted, 500MG Capsule)

C1 Intravenous Solution Cefixime Cefixime (Oral Reconstituted, 750MG Suspension 1 Intravenous Solution Reconstituted) Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 20 tRACK 9 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Cefotetan Disodium Cefuroxime Sodium Cefotetan Disodium Cefuroxime Sodium (Injection Solution 1 (Injection Solution 1 Reconstituted) Reconstituted)

C1 C1 Cefoxitin Sodium Cefuroxime Sodium Cefoxitin Sodium Cefuroxime Sodium (Injection Solution 1 (Intravenous Solution 1 Reconstituted) Reconstituted)

C1 C1 Cefoxitin Sodium Cephalexin Cefoxitin Sodium Cephalexin (Oral 1 (Intravenous Solution 1 Capsule)

C1 Reconstituted) Cephalexin

C1 Cephalexin (Oral Cefpodoxime Proxetil Cefpodoxime Proxetil Suspension 1 (Oral Suspension 1 Reconstituted)

C1 Reconstituted) Suprax

C1 Suprax (Oral Capsule) Cefpodoxime 1 Proxetil

C1 Cefpodoxime Proxetil Suprax 1 Suprax (500MG/5ML (Oral Tablet)

C1 Cefprozil Oral Suspension 1 Cefprozil (Oral Reconstituted) C1 Suspension 1 Suprax Suprax (Oral Tablet Reconstituted) 1

C1 Cefprozil Chewable) C1 Cefprozil (Oral Tablet) 1 Tazicef

C1 Ceftazidime Tazicef (Injection Ceftazidime (Injection Solution 1 Solution 1 Reconstituted)

C1 Reconstituted) Zerbaxa

C1 Ceftriaxone Sodium Zerbaxa (Intravenous Ceftriaxone Sodium Solution 1 PA (1GM Injection Reconstituted) Solution B1 Beta-lactam, Other

C1 Reconstituted, 250MG Aztreonam Injection Solution Aztreonam (1GM 1 Reconstituted, 2GM Injection Solution 1 Injection Solution Reconstituted) C1 Reconstituted, 500MG Ertapenem Sodium Ertapenem Sodium Injection Solution (Injection Solution 1 Reconstituted) Reconstituted) C1 Ceftriaxone Sodium C1 Ceftriaxone Sodium Imipenem-Cilastatin Imipenem-Cilastatin (10GM Intravenous 1 (Intravenous Solution 1 Solution Reconstituted)

C1 Reconstituted) Meropenem

C1 Cefuroxime Axetil Meropenem Cefuroxime Axetil (Oral 1 (Intravenous Solution 1 Tablet) Reconstituted)

B1 Beta-lactam, Penicillins

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 21 10 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Amoxicillin Ampicillin- Sulbactam Sodium Amoxicillin (Oral Ampicillin-Sulbactam 1 Capsule) Sodium (Injection

C1 Amoxicillin 1 Amoxicillin (Oral Solution Reconstituted)

Suspension 1 C1 Ampicillin- Reconstituted) Sulbactam Sodium Ampicillin-Sulbactam

C1 Amoxicillin Amoxicillin (Oral Tablet Sodium (15 (10-5)GM 1 1 Immediate Release) Intravenous Solution

C1 Amoxicillin Reconstituted)

C1 Amoxicillin (Oral Tablet Bicillin C-R 900/300 1 Chewable) Bicillin C-R 900/300

C1 Amoxicillin- Potassium Clavulanate ER Amoxicillin-Potassium (Intramuscular 1 Suspension) C1 Clavulanate ER (Oral Bicillin C-R 1 Bicillin C-R Tablet Extended Release 12 Hour) (Intramuscular 1

C1 Amoxicillin- Potassium Clavulanate Amoxicillin-Potassium Suspension) C1 Bicillin L-A Clavulanate (Oral Bicillin L-A 1 Suspension (Intramuscular 1 Reconstituted)

C1 Suspension) Amoxicillin- Potassium Clavulanate C1 Dicloxacillin Sodium Amoxicillin-Potassium Dicloxacillin Sodium Clavulanate (Oral 1 1 (Oral Capsule) C1 Tablet Immediate Nafcillin Sodium Release) Nafcillin Sodium (1GM

C1 Amoxicillin- Potassium Clavulanate Injection Solution Amoxicillin-Potassium Reconstituted, 2GM 1 Clavulanate (Oral 1 Injection Solution Tablet Chewable)

C1 Ampicillin Reconstituted)

C1 Ampicillin (Oral Nafcillin Sodium 1 Nafcillin Sodium Capsule) C1 (10GM Intravenous Ampicillin Sodium 1 Ampicillin Sodium Solution (125MG Injection Reconstituted)

C1 Oxacillin Sodium in Solution Dextrose Oxacillin Sodium in 1 Reconstituted, 1GM Dextrose (Intravenous 1 Injection Solution Solution)

C1 Reconstituted) Oxacillin Sodium

C1 Ampicillin Sodium Oxacillin Sodium Ampicillin Sodium (Injection Solution 1 (10GM Intravenous 1 Reconstituted)

C1 Solution Oxacillin Sodium Reconstituted) Oxacillin Sodium (Intravenous Solution 1 Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 22 tRACK 11 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Penicillin G Clarithromycin Potassium Penicillin G Potassium Clarithromycin (Oral (20000000UNIT Tablet Immediate 1 1 Injection Solution Release)

C1 Reconstituted) Dificid C1 Dificid (Oral Tablet) Penicillin G 1 Procaine

C1 E.E.S. Granules Penicillin G Procaine E.E.S. Granules (Oral

(Intramuscular 1 Suspension 1 Suspension)

C1 Penicillin G Sodium Reconstituted)

C1 Erythrocin Penicillin G Sodium Lactobionate (Injection Solution 1 Erythrocin Lactobionate Reconstituted) 1

C1 Penicillin V Potassium (Intravenous Solution Penicillin V Potassium Reconstituted) C1 (Oral Solution 1 Erythromycin Base Reconstituted) Erythromycin Base

C1 Penicillin V Potassium (Oral Capsule Delayed 1 Penicillin V Potassium 1 Release Particles) C1 (Oral Tablet) Erythromycin Base

C1 Piperacillin- Tazobactam Erythromycin Base Piperacillin- (Oral Tablet Immediate 1 Tazobactam 1 Release) C1 (Intravenous Solution Erythromycin Base Reconstituted) Erythromycin Base B1 (Oral Tablet Delayed 1 Macrolides C1 Release) Azasite

C1 Erythromycin Azasite (Ophthalmic Ethylsuccinate 1 Erythromycin Solution) Ethylsuccinate C1 Azithromycin Azithromycin (200MG/5ML Oral 1 (Intravenous Solution 1 Suspension Reconstituted) Reconstituted)

C1 C1 Erythromycin Azithromycin Ethylsuccinate Azithromycin (Oral Erythromycin Suspension 1 Ethylsuccinate (Oral 1 Reconstituted) Tablet)

C1 C1 Erythromycin Azithromycin Azithromycin (Oral Erythromycin 1 1 Tablet) (Ophthalmic Ointment)

C1 B1 Clarithromycin ER Clarithromycin ER Quinolones

C1 Besivance (Oral Tablet Extended 1 Besivance Release 24 Hour) C1 (Ophthalmic 1 Clarithromycin Clarithromycin (Oral Suspension)

C1 Ciloxan Suspension 1 Ciloxan (Ophthalmic Reconstituted) 1 Ointment)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 23 12 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Ciprofloxacin HCl Moxifloxacin HCl Ciprofloxacin HCl Moxifloxacin HCl 1 (Ophthalmic Solution) (Ophthalmic Solution) 1

C1 Ciprofloxacin HCl (Generic Vigamox)

Ciprofloxacin HCl C1 Moxifloxacin HCl (100MG Oral Tablet 1 Moxifloxacin HCl (Oral 1 Immediate Release) Tablet)

C1 C1 Ciprofloxacin HCl Ofloxacin Ciprofloxacin HCl Ofloxacin (Ophthalmic 1 (250MG Oral Tablet Solution)

C1 Ofloxacin Immediate Release, Ofloxacin (Oral Tablet) 1

C1 500MG Oral Tablet 1 Ofloxacin Ofloxacin (Otic Immediate Release, 1 Solution) 750MG Oral Tablet B1 Immediate Release) Sulfonamides C1 Silver Sulfadiazine C1 Ciprofloxacin in D5W Silver Sulfadiazine Ciprofloxacin in D5W 1 (200MG/100ML 1 (External Cream) C1 SSD Intravenous Solution) SSD (External Cream) 1 C1 Gatifloxacin C1 Sulfacetamide Gatifloxacin Sodium 1 Sulfacetamide Sodium (Ophthalmic Solution) 1

C1 (Ophthalmic Ointment) Levofloxacin in D5W C1 Sulfacetamide Levofloxacin in D5W Sodium Sulfacetamide Sodium 1 (500MG/100ML (Ophthalmic Solution) C1 Intravenous Solution, 1 Sulfadiazine Sulfadiazine (Oral 750MG/150ML 1 Tablet)

C1 Sulfamethoxazole- Intravenous Solution) Trimethoprim

C1 Levofloxacin Sulfamethoxazole- Levofloxacin (25MG/ Trimethoprim (Oral 1 ML Intravenous 1 Suspension)

C1 Sulfamethoxazole- Solution) Trimethoprim

C1 Levofloxacin Sulfamethoxazole- Levofloxacin (0.5% 1 Trimethoprim (Oral 1 Ophthalmic Solution)

C1 Levofloxacin Tablet) Levofloxacin (25MG/ B1 1 Tetracyclines

C1 Demeclocycline ML Oral Solution) HCl

C1 Levofloxacin Demeclocycline HCl Levofloxacin (250MG 1 (Oral Tablet)

C1 Oral Tablet, 500MG Doxy 100 1 Oral Tablet, 750MG Doxy 100 (Intravenous Oral Tablet) Solution 1

C1 Moxifloxacin HCl in NaCl Reconstituted)

C1 Moxifloxacin HCl in Doxycycline Hyclate Doxycycline Hyclate NaCl (Intravenous 1 1 Solution) (Oral Capsule)

Bold type = Brand name drug Plain type = Generic drug 24 tRACK 13 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Doxycycline Hyclate Levetiracetam ER Doxycycline Hyclate Levetiracetam ER (Oral (100MG Oral Tablet Tablet Extended 1 Immediate Release, 1 Release 24 Hour)

C1 Levetiracetam 20MG Oral Tablet Levetiracetam (Oral Immediate Release) 1

C1 Solution) Doxycycline Monohydrate C1 Levetiracetam Doxycycline Levetiracetam (Oral Monohydrate (100MG 1 Tablet Immediate 1 Oral Capsule, 50MG Release)

C1 Oral Capsule) Nayzilam

C1 Doxycycline Monohydrate Nayzilam (Nasal 1 Doxycycline Solution)

C1 Monohydrate (Oral Roweepra 1 Roweepra (Oral Tablet Suspension 1 Immediate Release)

C1 Reconstituted) Roweepra XR

C1 Doxycycline Monohydrate Doxycycline Roweepra XR (Oral Monohydrate (100MG Tablet Extended 1 Release 24 Hour)

C1 Oral Tablet, 50MG Oral 1 Spritam ODT Spritam ODT (Oral Tablet, 75MG Oral Tablet) Tablet Disintegrating 1

C1 Minocycline HCl Soluble) Minocycline HCl (Oral C1 1 Xcopri Capsule) Xcopri (250MG Daily

C1 Minocycline HCl Dose) (Oral Tablet 1 PA; QL Minocycline HCl (Oral Tablet Immediate 1 Therapy Pack)

C1 Xcopri Release) Xcopri (350MG Daily C1 Tetracycline HCl Tetracycline HCl (Oral Dose) (Oral Tablet 1 1 PA; QL Capsule) Therapy Pack) C1 Vibramycin C1 Vibramycin (50MG/ Xcopri 1 Xcopri (100MG Oral 5ML Oral Syrup) Tablet, 150MG Oral A1 1 PA; QL Anticonvulsants Tablet, 50MG Oral

B1 Anticonvulsants, Other Tablet) C1 Xcopri C1 BRIVIACT BRIVIACT (Oral Xcopri (200MG Oral 1 PA; QL 1 PA; QL Solution) Tablet) C1 Xcopri C1 BRIVIACT BRIVIACT (Oral Xcopri (14x12.5MG & 1 PA; QL Tablet) 14x25MG Oral Tablet 1 PA; QL

C1 Epidiolex Epidiolex (Oral Therapy Pack) 1 PA Solution)

C1 Fintepla Fintepla (Oral 1 PA; QL Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 25 14 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Xcopri Gabapentin Xcopri (14x150MG & Gabapentin (Oral 1 14x200MG Oral Tablet) C1 Phenobarbital Tablet Therapy Pack, Phenobarbital (Oral 1 PA; QL 1 14x50MG & Elixir)

C1 Phenobarbital 14x100MG Oral Phenobarbital (Oral 1 Tablet Therapy Pack) Tablet)

B1 C1 Primidone Calcium Channel Modifying Agents Primidone (Oral Tablet) 1 C1 Celontin C1 Sympazan Celontin (Oral Sympazan (Oral Film) 1 PA; QL

1 C1 Capsule) Tiagabine HCl

C1 Ethosuximide Tiagabine HCl (Oral 1 Ethosuximide (Oral Tablet)

C1 1 Valproic Acid Capsule)

C1 Ethosuximide Valproic Acid (Oral 1 Ethosuximide (Oral Capsule)

C1 1 Valproic Acid Solution)

C1 Zonisamide Valproic Acid (Oral 1 Zonisamide (Oral Solution)

C1 1 Valtoco 10 MG Capsule) Dose B1 Valtoco 10 MG Dose 1 QL Gamma-aminobutyric Acid (GABA) (Nasal Liquid)

C1 Valtoco 15 MG Augmenting Agents Dose

C1 Clobazam Valtoco 15 MG Dose Clobazam (2.5MG/ML 1 PA; QL (Nasal Liquid Therapy 1 QL Oral Suspension)

C1 Clobazam Pack)

C1 Valtoco 20 MG Clobazam (10MG Oral Dose 1 PA; QL Valtoco 20 MG Dose Tablet)

C1 Clobazam (Nasal Liquid Therapy 1 QL Clobazam (20MG Oral 1 PA; QL Pack) C1 Tablet) Valtoco 5 MG Dose

C1 Diastat AcuDial Valtoco 5 MG Dose Diastat AcuDial 1 QL 1 (Nasal Liquid) C1 (Rectal Gel) Vigabatrin

C1 Diastat Pediatric Vigabatrin (Oral 1 PA; LA; QL Diastat Pediatric Packet)

1 C1 (Rectal Gel) Vigabatrin

C1 Diazepam Vigabatrin (Oral Tablet) 1 PA; LA; QL

C1 Diazepam (10MG Vigadrone Vigadrone (Oral Rectal Gel, 2.5MG 1 PA; LA; QL 1 Packet) Rectal Gel, 20MG B1 Rectal Gel) Glutamate Reducing Agents C1 Felbamate C1 Gabapentin Gabapentin (Oral Felbamate (Oral 1 1 Capsule) Suspension) C1 Felbamate C1 Gabapentin Gabapentin (250MG/ Felbamate (Oral 1 1 5ML Oral Solution) Tablet)

Bold type = Brand name drug Plain type = Generic drug 26 tRACK 15 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Fycompa Carbamazepine Fycompa (Oral Carbamazepine (Oral 1 Suspension) Tablet Immediate 1

C1 Fycompa Release)

C1 Fycompa (Oral Tablet) 1 Carbamazepine

C1 Lamotrigine Carbamazepine (Oral Lamotrigine (100MG 1 Tablet Chewable)

C1 Oral Tablet Immediate Dilantin INFATABS Dilantin INFATABS Release, 150MG Oral 1 Tablet Immediate (Oral Tablet Chewable) C1 Dilantin Release, 200MG Oral 1 Dilantin (Oral Capsule) 1

C1 Tablet Immediate Epitol Epitol (Oral Tablet) 1

C1 Release, 25MG Oral Oxcarbazepine Tablet Immediate Oxcarbazepine Release) (300MG/5ML Oral 1

C1 Lamotrigine Suspension)

C1 Lamotrigine (25MG Oxcarbazepine Oral Tablet Chewable, Oxcarbazepine 1 (150MG Oral Tablet, 5MG Oral Tablet 1 Chewable) 300MG Oral Tablet,

C1 Topiramate 600MG Oral Tablet)

C1 Topiramate (Oral Peganone Peganone (Oral Capsule Sprinkle 1 1 Immediate Release) Tablet) C1 Phenytek C1 Topiramate Topiramate (Oral Phenytek (Oral 1 1 Tablet) Capsule) C1 B1 Phenytoin Sodium Channel Agents Phenytoin (125MG/

C1 Aptiom 1 5ML Oral Suspension)

C1 Aptiom (Oral Tablet) 1 QL Phenytoin

C1 Banzel Phenytoin (Oral Tablet Banzel (Oral 1 1 Chewable)

C1 Phenytoin Sodium Suspension) Extended

C1 Banzel Phenytoin Sodium Banzel (Oral Tablet) 1

C1 Extended (Oral 1 Carbamazepine ER Carbamazepine ER Capsule)

C1 (Oral Capsule Vimpat 1 Vimpat (Oral Solution) 1 QL C1 Extended Release 12 Vimpat Hour) Vimpat (Oral Tablet) 1 QL A1

C1 Carbamazepine ER Antidementia Agents Carbamazepine ER B1 (Oral Tablet Extended 1 Cholinesterase Inhibitors

C1 Release 12 Hour) Donepezil HCl

C1 Donepezil HCl (Oral Carbamazepine 1 QL Carbamazepine (Oral Tablet)

C1 1 Donepezil HCl ODT Suspension) Donepezil HCl ODT (Oral Tablet 1 QL Dispersible)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 27 16 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Galantamine Bupropion HCl XL Hydrobromide ER Galantamine Bupropion HCl XL Hydrobromide ER (150MG Oral Tablet (Oral Capsule 1 QL Extended Release 24 1 Extended Release 24 Hour, 300MG Oral Hour) Tablet Extended

C1 Galantamine Hydrobromide Release 24 Hour)

Galantamine C1 Bupropion HCl Hydrobromide (Oral 1 QL Bupropion HCl (Oral Solution) Tablet Immediate 1

C1 Galantamine Hydrobromide Release)

Galantamine C1 Mirtazapine Hydrobromide (Oral 1 QL Mirtazapine (Oral 1 Tablet) Tablet)

C1 C1 Rivastigmine Mirtazapine ODT Tartrate Rivastigmine Tartrate Mirtazapine ODT (Oral 1 QL 1 (Oral Capsule) Tablet Dispersible)

C1 B1 Rivastigmine Rivastigmine Monoamine Oxidase Inhibitors

C1 Emsam (Transdermal Patch 24 1 ST; QL Emsam (Transdermal Hour) 1 QL B1 Patch 24 Hour)

C1 Marplan N-methyl-D-aspartate (NMDA) Receptor Marplan (Oral Tablet) 1

C1 Antagonist Phenelzine Sulfate

C1 Memantine HCl ER Phenelzine Sulfate 1 Memantine HCl ER (Oral Tablet)

C1 Tranylcypromine (Oral Capsule Sulfate 1 PA; QL Tranylcypromine Extended Release 24 1 Sulfate (Oral Tablet) Hour) B1

C1 Memantine HCl Memantine HCl (2MG/ SSRI/SNRI (Selective Serotonin Reuptake 1 PA; QL ML Oral Solution) Inhibitors/Serotonin and Norepinephrine

C1 Memantine HCl Reuptake Inhibitors)

C1 Citalopram Memantine HCl (10MG Hydrobromide Oral Tablet, 5MG Oral 1 PA; QL Citalopram Tablet) Hydrobromide (Oral 1

C1 Memantine HCl Titration Pak Solution)

C1 Citalopram Memantine HCl Hydrobromide Titration Pak (Oral 1 PA Citalopram Tablet) Hydrobromide (Oral 1 A1 Tablet)

C1 Desvenlafaxine Antidepressants Succinate ER B1 Desvenlafaxine Antidepressants, Other

C1 Bupropion HCl SR Succinate ER (Oral Bupropion HCl SR Tablet Extended 1 QL (Oral Tablet Extended 1 Release 24 Hour) Release 12 Hour) (Generic Pristiq)

C1 Escitalopram Oxalate Escitalopram Oxalate 1 (Oral Solution)

Bold type = Brand name drug Plain type = Generic drug 28 tRACK 17 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Escitalopram Trazodone HCl Oxalate Escitalopram Oxalate Trazodone HCl 1 (Oral Tablet) (100MG Oral Tablet,

C1 Fetzima 1 Fetzima (Oral Capsule 150MG Oral Tablet, 50MG Oral Tablet)

C1 Extended Release 24 1 ST; QL Trazodone HCl Hour) Trazodone HCl

C1 Fetzima Titration 1 (300MG Oral Tablet)

C1 Fetzima Titration Trintellix (Oral Capsule ER 24 1 ST Trintellix (Oral Tablet) 1 QL C1 Venlafaxine HCl ER Hour Therapy Pack) Venlafaxine HCl ER

C1 Fluoxetine HCl (Oral Capsule Fluoxetine HCl (10MG 1 Oral Capsule Extended Release 24 Hour)

Immediate Release, C1 Venlafaxine HCl 20MG Oral Capsule 1 Venlafaxine HCl (Oral Immediate Release, Tablet Immediate 1 40MG Oral Capsule Release)

C1 Immediate Release) Viibryd

C1 Viibryd (Oral Tablet) Fluoxetine HCl 1 QL

C1 Viibryd Starter Pack Fluoxetine HCl (90MG Viibryd Starter Pack 1 QL Oral Capsule Delayed 1 (Oral Kit) Release) B1

C1 Fluoxetine HCl Tricyclics

C1 Fluoxetine HCl (20MG/ Amitriptyline HCl 1 Amitriptyline HCl (Oral 5ML Oral Solution) 1 C1 Fluvoxamine Maleate Tablet)

C1 Fluvoxamine Maleate Amoxapine 1 Amoxapine (Oral (Oral Tablet) 1 C1 Maprotiline HCl Tablet)

C1 Maprotiline HCl (Oral Clomipramine HCl 1 Clomipramine HCl Tablet) 1 C1 Nefazodone HCl (Oral Capsule)

C1 Nefazodone HCl (Oral Desipramine HCl 1 Desipramine HCl (Oral Tablet) 1 C1 Paroxetine HCl Tablet)

C1 Paroxetine HCl (Oral Doxepin HCl Doxepin HCl (Oral Tablet Immediate 1 1 Capsule) Release) C1 Doxepin HCl

C1 Paxil Doxepin HCl (Oral Paxil (Oral 1 1 Concentrate)

C1 Suspension) Imipramine HCl

C1 Sertraline HCl Imipramine HCl (Oral Sertraline HCl (Oral 1 1 Tablet)

C1 Imipramine Concentrate) Pamoate

C1 Sertraline HCl Imipramine Pamoate Sertraline HCl (Oral 1 1 (Oral Capsule)

C1 Tablet) Nortriptyline HCl Nortriptyline HCl (Oral 1 Capsule)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 29 18 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Nortriptyline HCl Dronabinol Nortriptyline HCl (Oral Dronabinol (Oral 1 1 PA Solution) Capsule)

C1 C1 Protriptyline HCl Granisetron HCl Protriptyline HCl (Oral Granisetron HCl (Oral 1 1 B/D, PA; QL Tablet) Tablet)

C1 C1 Trimipramine Ondansetron HCl Maleate Trimipramine Maleate Ondansetron HCl (Oral 1 1 B/D, PA (Oral Capsule) Solution)

A1 C1 Ondansetron HCl Antiemetics Ondansetron HCl (Oral B1 1 B/D, PA Tablet)

Antiemetics, Other C1 Ondansetron ODT

C1 Compro Compro (Rectal Ondansetron ODT 1 Suppository) (Oral Tablet 1 B/D, PA

C1 Hydroxyzine Pamoate Dispersible)

C1 Hydroxyzine Pamoate Sancuso 1 (Oral Capsule) Sancuso C1 1 Meclizine HCl (Transdermal Patch) Meclizine HCl (Oral A1 1 Tablet) Antifungals B1

C1 Metoclopramide HCl Metoclopramide HCl Antifungals C1 Abelcet (10MG/10ML Oral 1 Abelcet (Intravenous 1 B/D, PA Solution) Suspension) C1 Metoclopramide HCl C1 Metoclopramide HCl AmBisome 1 AmBisome (Oral Tablet)

C1 (Intravenous Perphenazine Perphenazine (Oral 1 B/D, PA 1 Suspension Tablet) Reconstituted) C1 Prochlorperazine Maleate C1 Prochlorperazine Amphotericin B 1 Amphotericin B Maleate (Oral Tablet) (Intravenous Solution 1 B/D, PA C1 Prochlorperazine Prochlorperazine Reconstituted)

C1 1 Ciclopirox (Rectal Suppository) Ciclopirox (External C1 Scopolamine 1 Scopolamine Gel)

C1 Ciclopirox (Transdermal Patch 72 1 Ciclopirox (External 1 Hour) Shampoo) C1 Transderm-Scop C1 Ciclopirox Transderm-Scop Ciclopirox (External 1 (1.5MG) (Transdermal 1 Solution)

C1 Patch 72 Hour) Ciclopirox Olamine B1 Ciclopirox Olamine 1 Emetogenic Therapy Adjuncts (External Cream)

C1 C1 Aprepitant Ciclopirox Olamine Aprepitant (Oral Ciclopirox Olamine 1 Therapy Pack, Oral 1 PA (External Suspension)

C1 Clotrimazole Capsule) Clotrimazole (External 1 Cream)

Bold type = Brand name drug Plain type = Generic drug 30 tRACK 19 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Clotrimazole Ketoconazole Clotrimazole (External Ketoconazole (External 1 1 Solution) Shampoo)

C1 C1 Clotrimazole Ketoconazole Clotrimazole (Mouth/ Ketoconazole (Oral 1 1 Throat Troche) Tablet)

C1 C1 Econazole Nitrate Mentax Econazole Nitrate Mentax (External 1 QL 1 (External Cream) Cream)

C1 Eraxis C1 Eraxis (100MG Micafungin Sodium Micafungin Sodium Intravenous Solution 1 (Intravenous Solution 1 Reconstituted) Reconstituted)

C1 C1 Miconazole 3 Eraxis Eraxis (50MG Miconazole 3 (Vaginal 1 Intravenous Solution 1 Suppository) C1 Mycamine Reconstituted) Mycamine

C1 Fluconazole in Sodium Chloride (Intravenous Solution 1 Fluconazole in Sodium Chloride (Intravenous 1 Reconstituted) C1 Naftifine HCl Solution) Naftifine HCl (External C1 Fluconazole 1 Fluconazole (Oral Cream) C1 Naftin Suspension 1 Naftin (External Gel) 1

C1 Reconstituted) Natacyn

C1 Fluconazole Natacyn (Ophthalmic Fluconazole (Oral 1 1 Suspension) C1 Tablet) Noxafil

C1 Flucytosine Noxafil (Oral Flucytosine (Oral 1 QL 1 Suspension)

C1 Capsule) Noxafil

C1 Griseofulvin Microsize Noxafil (Oral Tablet Griseofulvin Microsize 1 PA; QL 1 Delayed Release)

C1 (Oral Suspension) Nyamyc

C1 Griseofulvin Microsize Nyamyc (External Griseofulvin Microsize 1 1 Powder)

C1 (Oral Tablet) Nystatin

C1 Griseofulvin Ultramicrosize Nystatin (External Griseofulvin 1 Cream)

C1 Ultramicrosize (Oral 1 Nystatin Tablet) Nystatin (External C1 1 Itraconazole Ointment)

C1 Itraconazole (Oral Nystatin 1 PA; QL Capsule) Nystatin (External

C1 1 Itraconazole Powder)

C1 Itraconazole (Oral Nystatin 1 PA Solution) Nystatin (Mouth/Throat

C1 Jublia 1 Suspension)

C1 Jublia (External Nystatin 1 Solution) Nystatin (Oral Tablet) 1 C1 Nystop C1 Ketoconazole Ketoconazole (External Nystop (External 1 QL 1 Cream) Powder)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 31 20 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Posaconazole Dihydroergotamine Mesylate Posaconazole (Oral Dihydroergotamine Tablet Delayed 1 PA; QL Mesylate (Nasal 1 Release) Solution)

C1 C1 Terbinafine HCl Ergotamine- Terbinafine HCl (Oral Caffeine Ergotamine-Caffeine 1 1 Tablet) (Oral Tablet)

C1 C1 Terconazole Migergot Terconazole (Vaginal Migergot (Rectal 1 1 Cream) Suppository)

C1 B1 Terconazole Terconazole (Vaginal Prophylactic

C1 1 Aimovig Suppository)

C1 Aimovig Voriconazole Voriconazole (Subcutaneous 1 PA; QL (Intravenous Solution 1 Solution Auto- Reconstituted)

C1 Injector) Voriconazole

C1 Emgality Voriconazole (Oral Emgality (300MG Suspension 1 Dose) (100MG/ML Reconstituted)

C1 Voriconazole Subcutaneous 1 PA; QL Voriconazole (Oral 1 Solution Prefilled Tablet) A1 Syringe)

C1 Antigout Agents Emgality B1 Emgality Antigout Agents (Subcutaneous C1 Allopurinol 1 PA; QL Allopurinol (Oral 1 Solution Auto- Tablet) Injector) C1 Colchicine C1 Emgality Colchicine (0.6MG Emgality (120MG/ML Oral Capsule) (Brand 1 QL Subcutaneous 1 PA; QL Equivalent Mitigare) Solution Prefilled C1 Colchicine Colchicine (0.6MG Syringe)

C1 Timolol Maleate Oral Tablet) (Generic 1 QL Timolol Maleate (Oral Colcrys) 1

C1 Tablet) Colcrys

B1 Colcrys (Oral Tablet) 1 QL Serotonin (5-HT) 1b/1d Receptor Agonists C1 Febuxostat C1 Naratriptan HCl Febuxostat (Oral Naratriptan HCl (Oral 1 ST 1 QL Tablet) Tablet) C1 Probenecid C1 Rizatriptan Probenecid (Oral Benzoate Rizatriptan Benzoate 1 1 QL Tablet) (Oral Tablet) C1 Probenecid- Colchicine C1 Rizatriptan Probenecid-Colchicine Benzoate ODT 1 Rizatriptan Benzoate (Oral Tablet) ODT (Oral Tablet 1 QL A1 Antimigraine Agents Dispersible)

B1 Ergot Alkaloids

Bold type = Brand name drug Plain type = Generic drug 32 tRACK 21 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Sumatriptan Pyridostigmine Bromide ER Sumatriptan (Nasal Pyridostigmine 1 QL Solution) Bromide ER (Oral

C1 Sumatriptan Succinate 1 Sumatriptan Succinate Tablet Extended Release)

(100MG Oral Tablet, C1 Pyridostigmine 1 QL Bromide 25MG Oral Tablet, Pyridostigmine 50MG Oral Tablet) Bromide (Oral 1

C1 Sumatriptan Succinate Refill Solution)

Sumatriptan C1 Pyridostigmine Bromide Succinate Refill Pyridostigmine 1 QL Bromide (60MG Oral (Subcutaneous 1 Solution Cartridge) Tablet Immediate

C1 Sumatriptan Succinate Release) Sumatriptan Succinate A1 Antimycobacterials

(6MG/0.5ML B1 1 QL Subcutaneous Antimycobacterials, Other

C1 Solution) Dapsone

C1 Dapsone (Oral Tablet) 1 Sumatriptan Succinate

C1 Rifabutin Sumatriptan Succinate Rifabutin (Oral 1 (4MG/0.5ML Capsule) Subcutaneous Solution B1 1 QL Antituberculars

C1 Auto-Injector, 6MG/ Ethambutol HCl Ethambutol HCl (Oral 0.5ML Subcutaneous 1 Solution Auto-Injector) Tablet) C1 Isoniazid C1 Sumatriptan Succinate Sumatriptan Isoniazid (Oral Syrup) 1

C1 Isoniazid Succinate (6MG/ Isoniazid (Oral Tablet) 1

C1 0.5ML Subcutaneous Paser 1 QL Paser (Oral Packet) 1

C1 Solution Auto- Priftin Priftin (Oral Tablet) 1

C1 Injector) (Generic Pyrazinamide Imitrex STATdose) Pyrazinamide (Oral

C1 Sumatriptan 1 Succinate Tablet)

C1 Sumatriptan Succinate Rifampin (6MG/0.5ML Rifampin (600MG 1 QL Subcutaneous Solution Intravenous Solution 1 Prefilled Syringe) Reconstituted) C1 Rifampin A1 Antimyasthenic Agents Rifampin (150MG Oral

B1 Parasympathomimetics Capsule, 300MG Oral 1

C1 Guanidine HCl Capsule)

C1 Guanidine HCl (Oral Sirturo 1 Sirturo (Oral Tablet) 1 PA; LA

C1 Tablet) Trecator Trecator (Oral Tablet) 1

A1 Antineoplastics

B1 Alkylating Agents

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 33 22 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Cyclophosphamide Emcyt Cyclophosphamide Emcyt (Oral Capsule) 1

C1 1 B/D, PA Soltamox (Oral Capsule) C1 Gleostine Soltamox (Oral 1 Gleostine (100MG Solution)

C1 1 Tamoxifen Citrate Oral Capsule)

C1 Gleostine Tamoxifen Citrate (Oral 1 Gleostine (10MG Oral Tablet)

C1 Toremifene Citrate Capsule, 40MG Oral 1 Toremifene Citrate 1 Capsule) (Oral Tablet) C1 Leukeran B1 Leukeran (Oral Antimetabolites

C1 1 Droxia Tablet)

C1 Matulane Droxia (Oral Capsule) 1

C1 Matulane (Oral Hydroxyurea 1 LA Hydroxyurea (Oral Capsule) 1

C1 Valchlor Capsule)

C1 Valchlor (External Mercaptopurine 1 PA; LA Mercaptopurine (Oral Gel) 1

B1 Tablet)

C1 Antiandrogens Purixan

C1 Purixan (Oral Abiraterone Acetate 1 PA Abiraterone Acetate Suspension)

C1 1 PA; QL Tabloid (Oral Tablet)

C1 Bicalutamide Tabloid (Oral Tablet) 1 PA Bicalutamide (Oral B1 1 Antineoplastics

C1 Tablet) Xpovio

C1 Erleada Xpovio (100MG Once Erleada (Oral Tablet) 1 PA; QL

C1 Flutamide Weekly) (Oral Tablet 1 PA; QL Flutamide (Oral 1 Therapy Pack) C1 Capsule) Xpovio

C1 Nilutamide Xpovio (40MG Once Nilutamide (Oral 1 Weekly) (Oral Tablet 1 PA; QL Tablet)

C1 Nubeqa Therapy Pack)

C1 Nubeqa (Oral Tablet) 1 PA; QL Xpovio

C1 Xtandi Xpovio (40MG Twice Xtandi (Oral Capsule) 1 PA; LA; QL Weekly) (Oral Tablet 1 PA; QL B1 Antiangiogenic Agents Therapy Pack) C1 C1 Xpovio Pomalyst Pomalyst (Oral Xpovio (60MG Once 1 PA; QL Capsule) Weekly) (Oral Tablet 1 PA; QL

C1 Revlimid Revlimid (Oral Therapy Pack) C1 1 PA; LA; QL Xpovio Capsule) Xpovio (60MG Twice

C1 Tabrecta Tabrecta (Oral Tablet) 1 PA; QL Weekly) (Oral Tablet 1 PA; QL

C1 Thalomid Therapy Pack)

C1 Thalomid (Oral Xpovio 1 PA; QL Capsule) Xpovio (80MG Once B1 Weekly) (Oral Tablet 1 PA; QL Antiestrogens/Modifiers Therapy Pack)

Bold type = Brand name drug Plain type = Generic drug 34 tRACK 23 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Xpovio Piqray Xpovio (80MG Twice Piqray (200MG Daily Weekly) (Oral Tablet 1 PA; QL Dose) (Oral Tablet 1 PA; QL Therapy Pack) Therapy Pack)

B1 C1 Piqray Antineoplastics, Other Piqray (250MG Daily

C1 Copiktra Copiktra (Oral Dose) (Oral Tablet 1 PA; QL 1 PA; QL Capsule) Therapy Pack) C1 Piqray C1 Inrebic Inrebic (Oral Capsule) 1 PA; QL Piqray (300MG Daily

C1 Kisqali Kisqali (200MG Dose) Dose) (Oral Tablet 1 PA; QL 1 PA; QL Therapy Pack)

C1 (Oral Tablet) Qinlock

C1 Kisqali Qinlock (Oral Tablet) 1 PA; QL

C1 Kisqali (400MG Dose) Retevmo 1 PA; QL (Oral Tablet) Retevmo (Oral

C1 Kisqali 1 PA; QL Capsule)

C1 Kisqali (600MG Dose) Rozlytrek 1 PA; QL (Oral Tablet) Rozlytrek (Oral

C1 Kisqali Femara 1 PA; QL Capsule)

C1 Kisqali Femara Synribo (400MG Dose) (Oral 1 PA; QL Synribo Tablet Therapy Pack) (Subcutaneous

C1 Kisqali Femara 1 PA Kisqali Femara Solution Reconstituted)

(600MG Dose) (Oral C1 1 PA; QL Tazverik Tablet Therapy Pack) Tazverik (Oral Tablet) 1 PA; QL

C1 C1 Kisqali Femara Tukysa Kisqali Femara Tukysa (Oral Tablet) 1 PA; QL

C1 Verzenio (200MG Dose) (Oral 1 PA; QL Verzenio (Oral Tablet) 1 PA; LA; QL

C1 Tablet Therapy Pack) Zolinza

C1 Leucovorin Calcium Zolinza (Oral Capsule) 1 PA Leucovorin Calcium B1 Aromatase Inhibitors, 3rd Generation

C1 (10MG Oral Tablet, Anastrozole 1 Anastrozole (Oral 15MG Oral Tablet, 1 5MG Oral Tablet) Tablet) C1 Exemestane C1 Leucovorin Calcium Leucovorin Calcium Exemestane (Oral 1 1 (25MG Oral Tablet) Tablet) C1 Letrozole C1 Lonsurf Lonsurf (Oral Tablet) 1 PA; LA; QL Letrozole (Oral Tablet) 1 B1 C1 Lorbrena Lorbrena (Oral Tablet) 1 PA; QL Enzyme Inhibitors C1 Balversa

C1 Ninlaro Ninlaro (Oral Capsule) 1 PA; QL Balversa (Oral Tablet) 1 PA; QL C1 Rubraca

C1 Pemazyre Pemazyre (Oral Rubraca (Oral Tablet) 1 PA; LA; QL C1 1 PA; QL Talzenna Tablet) Talzenna (Oral 1 PA; LA; QL Capsule)

C1 Zejula Zejula (Oral Capsule) 1 PA; LA; QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 35 24 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

B1 C1 Everolimus Molecular Target Inhibitors Everolimus (2.5MG

C1 Afinitor Disperz Afinitor Disperz (Oral Oral Tablet, 5MG Oral 1 PA 1 PA Tablet Soluble) Tablet, 7.5MG Oral

C1 Afinitor Tablet)

C1 Afinitor (Oral Tablet) 1 PA Farydak

C1 Alecensa Farydak (Oral Alecensa (Oral 1 PA 1 PA; LA; QL Capsule) C1 Capsule) Gavreto

C1 Alunbrig Gavreto (Oral Alunbrig (Oral Tablet) 1 PA; LA; QL 1 PA; QL

C1 Capsule) Alunbrig

C1 Alunbrig (Oral Tablet Gilotrif 1 PA; LA; QL Gilotrif (Oral Tablet) 1 PA; LA C1 Therapy Pack) Ibrance

C1 Ayvakit Ibrance (Oral Ayvakit (Oral Tablet) 1 PA; LA; QL 1 PA; LA; QL

C1 Capsule) Bosulif

C1 Ibrance Bosulif (Oral Tablet) 1 PA; QL Ibrance (Oral Tablet) 1 PA; LA; QL C1 Braftovi

C1 Braftovi (Oral Iclusig 1 PA Iclusig (Oral Tablet) 1 PA; LA; QL C1 Capsule) IDHIFA

C1 Brukinsa IDHIFA (Oral Tablet) 1 PA; LA; QL

C1 Brukinsa (Oral Imatinib Mesylate 1 PA; LA; QL Imatinib Mesylate (Oral Capsule) 1 PA; QL

C1 Cabometyx Tablet)

C1 Cabometyx (Oral Imbruvica 1 PA; LA; QL Imbruvica (Oral Tablet) 1 PA; LA; QL

C1 Calquence Capsule)

C1 Calquence (Oral Imbruvica 1 PA; QL Imbruvica (Oral Capsule) 1 PA; QL

C1 Caprelsa Tablet)

C1 Caprelsa (Oral Tablet) 1 PA; LA Inlyta

C1 Cometriq Inlyta (Oral Tablet) 1 PA; LA; QL

C1 Cometriq (100MG Inqovi 1 PA; LA Inqovi (Oral Tablet) 1 PA; QL

C1 Daily Dose) (Oral Kit) Iressa

C1 Cometriq Iressa (Oral Tablet) 1 PA; LA; QL

Cometriq (140MG C1 1 PA; LA Jakafi Daily Dose) (Oral Kit) Jakafi (Oral Tablet) 1 PA; LA; QL

C1 C1 Cometriq Koselugo Cometriq (60MG Daily Koselugo (Oral 1 PA; LA 1 PA; QL Dose) (Oral Kit) Capsule)

C1 C1 Cotellic Lenvima 10MG Daily Dose Cotellic (Oral Tablet) 1 PA; LA; QL Lenvima 10MG Daily

C1 Daurismo Daurismo (Oral Dose (Oral Capsule 1 PA; LA 1 PA; LA; QL Therapy Pack)

Tablet) C1 Lenvima 12MG Daily Dose C1 Erivedge Erivedge (Oral Lenvima 12MG Daily 1 PA; LA; QL Capsule) Dose (Oral Capsule 1 PA; LA

C1 Erlotinib HCl Therapy Pack) Erlotinib HCl (Oral 1 PA; QL Tablet)

Bold type = Brand name drug Plain type = Generic drug 36 tRACK 25 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Lenvima 14MG Tibsovo Daily Dose Lenvima 14MG Daily Tibsovo (Oral Tablet) 1 PA; QL

C1 Turalio Dose (Oral Capsule 1 PA; LA Turalio (Oral Capsule) 1 PA; LA; QL

C1 Therapy Pack) Tykerb

C1 Lenvima 18MG Daily Dose Tykerb (Oral Tablet) 1 PA; LA

C1 Lenvima 18MG Daily Venclexta Dose (Oral Capsule 1 PA; LA Venclexta (100MG Therapy Pack) Oral Tablet, 50MG 1 PA; LA; QL

C1 Lenvima 20MG Daily Dose Oral Tablet)

C1 Lenvima 20MG Daily Venclexta Venclexta (10MG Oral Dose (Oral Capsule 1 PA; LA 1 PA; LA; QL Tablet)

C1 Venclexta Starting Therapy Pack) Pack

C1 Lenvima 24MG Daily Dose Lenvima 24MG Daily Venclexta Starting Dose (Oral Capsule 1 PA; LA Pack (Oral Tablet 1 PA; LA Therapy Pack)

C1 Therapy Pack) Vitrakvi

C1 Lenvima 4MG Daily Dose Vitrakvi (Oral Lenvima 4MG Daily 1 PA; LA; QL Capsule)

C1 Dose (Oral Capsule 1 PA; LA Vitrakvi Therapy Pack) Vitrakvi (Oral

C1 1 PA; LA; QL Lenvima 8MG Daily Dose Solution)

C1 Lenvima 8MG Daily Vizimpro Dose (Oral Capsule 1 PA; LA Vizimpro (Oral Tablet) 1 PA; LA; QL C1 Votrient Therapy Pack) Votrient (Oral Tablet) 1 PA; LA; QL

C1 Lynparza C1 Xalkori Lynparza (Oral Tablet) 1 PA; LA; QL Xalkori (Oral Capsule) 1 PA; LA

C1 Mekinist C1 Xospata Mekinist (Oral Tablet) 1 PA; LA Xospata (Oral Tablet) 1 PA; QL

C1 Mektovi C1 Zelboraf Mektovi (Oral Tablet) 1 PA Zelboraf (Oral Tablet) 1 PA; LA; QL

C1 Nerlynx C1 Zydelig Nerlynx (Oral Tablet) 1 PA; LA; QL Zydelig (Oral Tablet) 1 PA; LA; QL

C1 Nexavar C1 Zykadia Nexavar (Oral Tablet) 1 PA; LA Zykadia (Oral Tablet) 1 PA; QL

C1 Odomzo B1 Odomzo (Oral Retinoids

C1 1 PA; LA; QL Bexarotene Capsule)

C1 Bexarotene (Oral Rydapt 1 PA Rydapt (Oral Capsule) 1 PA; QL Capsule)

C1 C1 Panretin Sprycel Sprycel (Oral Tablet) 1 PA; QL Panretin (External

C1 Stivarga 1 Gel)

C1 Stivarga (Oral Tablet) 1 PA; LA; QL Targretin

C1 Sutent Targretin (External Sutent (Oral Capsule) 1 PA; QL 1 PA

C1 Tafinlar Gel)

C1 Tafinlar (Oral Tretinoin 1 PA; LA Tretinoin (Oral Capsule) 1

C1 Tagrisso Capsule) Tagrisso (Oral Tablet) 1 PA; LA; QL B1

C1 Tasigna Treatment Adjuncts

C1 Tasigna (Oral Mesnex 1 PA; QL Mesnex (Oral Tablet) 1 Capsule)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 37 26 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

A1 C1 Pentamidine Isethionate Antiparasitics Pentamidine

B1 Anthelmintics Isethionate (Inhalation

C1 1 B/D, PA; QL Albendazole Solution Albendazole (Oral 1 QL Reconstituted)

C1 Pentamidine Tablet) Isethionate

C1 Ivermectin Pentamidine Ivermectin (Oral 1 Isethionate (Injection Tablet) 1

C1 Praziquantel Solution Praziquantel (Oral Reconstituted)

1 C1 Primaquine Tablet) Phosphate B1 Primaquine Phosphate Antiprotozoals 1

C1 (Oral Tablet) Alinia

C1 Pyrimethamine Alinia (Oral Pyrimethamine (Oral 1 Suspension 1 Tablet)

C1 Reconstituted) Quinine Sulfate

C1 Alinia Quinine Sulfate (Oral 1 PA Alinia (Oral Tablet) 1 Capsule)

B1 C1 Atovaquone Atovaquone (Oral Pediculicides/Scabicides

C1 1 Lindane Suspension) Lindane (External C1 Atovaquone- Proguanil HCl 1 Atovaquone-Proguanil Shampoo)

C1 1 Malathion HCl (Oral Tablet) Malathion (External C1 Benznidazole 1 Benznidazole (Oral Lotion)

C1 1 Permethrin Tablet) Permethrin (External C1 Chloroquine Phosphate 1 Chloroquine Cream) A1 Phosphate (Oral 1 Antiparkinson Agents Tablet) B1

C1 Coartem Anticholinergics

C1 Benztropine Coartem (Oral Tablet) 1 Mesylate C1 Benztropine Mesylate DARAPRIM 1 DARAPRIM (Oral (Oral Tablet)

C1 1 Trihexyphenidyl HCl Tablet) Trihexyphenidyl HCl C1 Hydroxychloroquin e Sulfate 1 Hydroxychloroquine (Oral Solution) C1 1 Trihexyphenidyl HCl Sulfate (Oral Tablet) Trihexyphenidyl HCl C1 Mefloquine HCl 1 Mefloquine HCl (Oral (Oral Tablet) 1 B1 Tablet) Antiparkinson Agents, Other C1 Nebupent C1 Amantadine HCl Nebupent (Inhalation Amantadine HCl (Oral 1 Solution 1 B/D, PA; QL Capsule)

C1 Reconstituted) Amantadine HCl C1 Amantadine HCl (Oral PENTAM 300 1 PENTAM 300 Syrup)

C1 Amantadine HCl (Injection Solution 1 Amantadine HCl (Oral 1 Reconstituted) Tablet)

Bold type = Brand name drug Plain type = Generic drug 38 tRACK 27 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Entacapone Carbidopa- Levodopa- Entacapone (Oral Entacapone Carbidopa-Levodopa- 1 Tablet) Entacapone (Oral 1

C1 Tolcapone Tablet)

Tolcapone (Oral C1 1 QL Rytary Tablet) Rytary (Oral Capsule B1 1 ST Dopamine Agonists Extended Release) B1

C1 Apokyn Apokyn Monoamine Oxidase B (MAO-B) Inhibitors C1 Rasagiline Mesylate (Subcutaneous 1 PA; LA; QL Rasagiline Mesylate 1 Solution Cartridge) (Oral Tablet)

C1 C1 Selegiline HCl Bromocriptine Mesylate Selegiline HCl (Oral Bromocriptine 1 Mesylate (Oral 1 Capsule) C1 Selegiline HCl Capsule) Selegiline HCl (Oral C1 Bromocriptine Mesylate 1 Bromocriptine Tablet) C1 1 Zelapar ODT Mesylate (Oral Tablet) Zelapar ODT (Oral C1 Neupro 1 Neupro (Transdermal Tablet Dispersible) 1 A1 Patch 24 Hour) Antipsychotics C1 Pramipexole Dihydrochloride B1 Pramipexole 1st Generation/Typical

C1 Chlorpromazine HCl Dihydrochloride (Oral Chlorpromazine HCl 1 1 Tablet Immediate (Oral Tablet)

C1 Fluphenazine Release) Decanoate

C1 Ropinirole HCl Fluphenazine Ropinirole HCl (Oral Decanoate (Injection 1 Tablet Immediate 1 Solution)

C1 Release) Fluphenazine HCl B1 Fluphenazine HCl Dopamine Precursors/L-Amino Acid (2.5MG/ML Injection 1 Decarboxylase Inhibitors

C1 Carbidopa Solution)

C1 Carbidopa (Oral Fluphenazine HCl 1 Fluphenazine HCl Tablet)

C1 Carbidopa- (5MG/ML Oral 1 Levodopa ER Carbidopa-Levodopa Concentrate)

C1 Fluphenazine HCl ER (Oral Tablet 1 Fluphenazine HCl Extended Release)

C1 Carbidopa- (2.5MG/5ML Oral 1 Levodopa Carbidopa-Levodopa Elixir)

C1 Fluphenazine HCl (Oral Tablet Immediate 1 Fluphenazine HCl Release)

C1 Carbidopa- (10MG Oral Tablet, Levodopa ODT Carbidopa-Levodopa 1MG Oral Tablet, 1 ODT (Oral Tablet 1 2.5MG Oral Tablet, Dispersible) 5MG Oral Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 39 28 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Haloperidol Aripiprazole ODT Decanoate Haloperidol Decanoate Aripiprazole ODT (Intramuscular 1 (10MG Oral Tablet 1 QL Solution) Dispersible, 15MG Oral

C1 Haloperidol Lactate Tablet Dispersible) Haloperidol Lactate C1 1 Aristada Initio (Injection Solution) Aristada Initio

C1 Haloperidol Lactate Haloperidol Lactate (Intramuscular 1 1 (Oral Concentrate) Prefilled Syringe)

C1 C1 Aristada Haloperidol Haloperidol (Oral Aristada 1 Tablet) (Intramuscular 1

C1 Loxapine Succinate Loxapine Succinate Prefilled Syringe) C1 1 Caplyta (Oral Capsule) Caplyta (Oral C1 Molindone HCl 1 ST; QL Molindone HCl (Oral Capsule)

C1 1 Fanapt Tablet) Fanapt (10MG Oral C1 Pimozide Pimozide (Oral Tablet) 1 Tablet, 12MG Oral

C1 Thioridazine HCl Thioridazine HCl (Oral Tablet, 4MG Oral 1 1 ST; QL Tablet) Tablet, 6MG Oral

C1 Thiothixene Thiothixene (Oral Tablet, 8MG Oral 1 Capsule) Tablet) C1 Fanapt C1 Trifluoperazine HCl Trifluoperazine HCl Fanapt (1MG Oral 1 (Oral Tablet) Tablet, 2MG Oral 1 ST; QL B1 Tablet)

2nd Generation/Atypical C1 Fanapt Titration Pack C1 Abilify Maintena Fanapt Titration Pack Abilify Maintena 1 ST (Oral Tablet)

(Intramuscular 1 C1 Geodon Prefilled Syringe) Geodon

C1 Abilify Maintena (Intramuscular Abilify Maintena 1 (Intramuscular Solution 1 Suspension Reconstituted) Reconstituted ER)

C1 Aripiprazole Aripiprazole (1MG/ML 1 QL Oral Solution)

C1 Aripiprazole Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral 1 QL Tablet, 30MG Oral Tablet, 5MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 40 tRACK 29 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Invega Sustenna Olanzapine Invega Sustenna Olanzapine (10MG (117MG/0.75ML Oral Tablet, 15MG Oral Intramuscular Tablet, 2.5MG Oral Suspension Prefilled Tablet, 20MG Oral 1 QL Syringe, 156MG/ML Tablet, 5MG Oral Intramuscular Tablet, 7.5MG Oral Tablet)

C1 Suspension Prefilled Olanzapine ODT 1 Syringe, 234MG/ Olanzapine ODT (10MG Oral Tablet 1.5ML Intramuscular Dispersible, 15MG Oral Suspension Prefilled Tablet Dispersible, 1 QL Syringe, 78MG/0.5ML 20MG Oral Tablet Intramuscular Dispersible, 5MG Oral Suspension Prefilled Tablet Dispersible)

C1 Syringe) Paliperidone ER

C1 Invega Sustenna Paliperidone ER (Oral Invega Sustenna Tablet Extended 1 QL (39MG/0.25ML Release 24 Hour)

C1 Perseris Intramuscular 1 Perseris

Suspension Prefilled (Subcutaneous 1 Syringe) Prefilled Syringe) C1 Invega Trinza C1 Quetiapine Invega Trinza Fumarate ER Quetiapine Fumarate (Intramuscular ER (Oral Tablet 1 1 QL Suspension Prefilled Extended Release 24 Syringe) Hour) C1 Quetiapine C1 Latuda Fumarate Latuda (Oral Tablet) 1 QL Quetiapine Fumarate

C1 Nuplazid (Oral Tablet Immediate 1 QL Nuplazid (Oral 1 PA; QL Release)

C1 Capsule) Rexulti

C1 Nuplazid Rexulti (Oral Tablet) 1 QL

C1 Nuplazid (10MG Oral Risperdal Consta 1 PA; QL Tablet) Risperdal Consta

C1 Olanzapine (12.5MG Olanzapine (10MG Intramuscular Solution 1 Intramuscular Suspension Reconstituted) 1 Reconstituted ER, 25MG Intramuscular Suspension Reconstituted ER)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 41 30 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Risperdal Consta Vraylar Risperdal Consta Vraylar (Oral Capsule 1 ST (37.5MG Therapy Pack)

C1 Ziprasidone HCl Intramuscular Ziprasidone HCl (Oral 1 QL Suspension Capsule)

C1 Ziprasidone 1 Mesylate Reconstituted ER, Ziprasidone Mesylate 50MG Intramuscular (Intramuscular Solution 1 Suspension Reconstituted)

C1 Zyprexa Relprevv Reconstituted ER) Zyprexa Relprevv C1 Risperidone Risperidone (1MG/ML (210MG 1 Oral Solution) Intramuscular 1 C1 Risperidone Risperidone (0.25MG Suspension Oral Tablet, 0.5MG Reconstituted)

B1 Oral Tablet, 1MG Oral Treatment-Resistant C1 Tablet, 2MG Oral 1 Clozapine Tablet, 3MG Oral Clozapine (100MG Tablet, 4MG Oral Oral Tablet, 200MG Tablet) Oral Tablet, 25MG Oral 1

C1 Risperidone ODT Tablet, 50MG Oral Risperidone ODT Tablet)

C1 (0.25MG Oral Tablet Clozapine ODT Dispersible, 0.5MG Clozapine ODT Oral Tablet (100MG Oral Tablet Dispersible, 12.5MG Dispersible, 1MG Oral Tablet Dispersible, 1 Oral Tablet Dispersible, 150MG 2MG Oral Tablet 1 QL Dispersible, 3MG Oral Oral Tablet Tablet Dispersible, Dispersible, 200MG 4MG Oral Tablet Oral Tablet Dispersible) Dispersible, 25MG Oral

C1 Saphris Tablet Dispersible)

C1 Saphris (Tablet Versacloz 1 QL Versacloz (Oral Sublingual) 1

C1 Secuado Suspension) Secuado A1 Antivirals (Transdermal Patch 1 PA; QL B1 Anti-cytomegalovirus (CMV) Agents

C1 24 Hour) Valganciclovir HCl

C1 Vraylar Vraylar (1.5MG Oral Valganciclovir HCl Capsule, 3MG Oral (Oral Solution 1 QL Reconstituted)

C1 Capsule, 4.5MG Oral 1 ST; QL Valganciclovir HCl Valganciclovir HCl Capsule, 6MG Oral 1 QL (Oral Tablet) Capsule)

Bold type = Brand name drug Plain type = Generic drug 42 tRACK 31 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Zirgan Sovaldi Zirgan (Ophthalmic Sovaldi (400MG Oral 1 1 PA; QL Gel) Tablet)

B1 C1 Vosevi Anti-hepatitis B (HBV) Agents Vosevi (Oral Tablet) 1 PA; QL

C1 Adefovir Dipivoxil B1 Adefovir Dipivoxil (Oral Antiherpetic Agents

C1 1 Acyclovir Tablet)

C1 Baraclude Acyclovir (External 1 QL Baraclude (Oral Ointment)

C1 1 Acyclovir Solution) C1 Acyclovir (Oral Entecavir 1 Entecavir (Oral Tablet) 1 Capsule)

C1 C1 Acyclovir Epivir HBV Epivir HBV (Oral Acyclovir (Oral 1 1 Solution) Suspension) C1 Acyclovir C1 Lamivudine Lamivudine (100MG Acyclovir (Oral Tablet) 1 C1 1 Acyclovir Sodium Oral Tablet) Acyclovir Sodium C1 Vemlidy 1 B/D, PA Vemlidy (Oral Tablet) 1 QL (Intravenous Solution) C1 Denavir B1 Anti-hepatitis C (HCV) Agents, Other Denavir (External

C1 Intron A 1 QL Cream)

C1 Intron A (Injection Famciclovir 1 PA; LA Solution) Famciclovir (Oral

C1 Intron A 1 QL Tablet)

C1 Intron A (Injection Trifluridine Trifluridine Solution 1 PA; LA 1 (Ophthalmic Solution)

C1 Reconstituted) Valacyclovir HCl

C1 Pegasys ProClick Valacyclovir HCl (Oral Pegasys ProClick 1 QL Tablet) (Subcutaneous 1 PA B1 Anti-HIV Agents, Integrase Inhibitors (INSTI)

Solution) C1 Dovato

C1 Pegasys Pegasys Dovato (Oral Tablet) 1 QL C1 Genvoya (Subcutaneous 1 PA Genvoya (Oral Tablet) 1 QL

C1 Solution) Isentress HD

C1 Isentress HD (Oral Ribavirin 1 QL Ribavirin (Oral Tablet) 1 Tablet)

B1 C1 Isentress Anti-hepatitis C (HCV) Direct Acting Agents Isentress (Oral

C1 Epclusa 1 QL Epclusa (400-100MG Packet) C1 1 PA; QL Isentress Oral Tablet) Isentress (Oral Tablet) 1 QL

C1 Mavyret C1 Isentress Mavyret (Oral Tablet) 1 PA; QL Isentress (100MG

C1 Sofosbuvir- Velpatasvir 1 QL Sofosbuvir-Velpatasvir Oral Tablet Chewable) C1 1 PA; QL Isentress (Oral Tablet) Isentress (25MG Oral

C1 Sovaldi 1 QL Sovaldi (Oral Packet) 1 PA; QL Tablet Chewable) C1 Stribild Stribild (Oral Tablet) 1 QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 43 32 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Tivicay Symfi Lo Tivicay (10MG Oral Symfi Lo (Oral Tablet) 1 QL

C1 1 QL Symfi Tablet)

C1 Tivicay Symfi (Oral Tablet) 1 QL

B1 Tivicay (25MG Oral Anti-HIV Agents, Nucleoside and Nucleotide Tablet, 50MG Oral 1 QL Reverse Transcriptase Inhibitors (NRTI)

C1 Tablet) Abacavir Sulfate

C1 Tivicay PD Abacavir Sulfate (Oral 1 QL Tivicay PD (Oral Solution)

1 QL C1 Tablet Soluble) Abacavir Sulfate

C1 Triumeq Abacavir Sulfate (Oral 1 QL Triumeq (Oral Tablet) 1 QL Tablet) C1 Tybost C1 Abacavir Sulfate- Tybost (Oral Tablet) 1 QL Lamivudine Abacavir Sulfate-

B1 Anti-HIV Agents, Non-nucleoside Reverse Lamivudine (Oral 1 QL Tablet)

C1 Transcriptase Inhibitors (NNRTI) Abacavir- Lamivudine- Zidovudine C1 Atripla Atripla (Oral Tablet) 1 QL Abacavir-Lamivudine-

C1 Complera Zidovudine (Oral 1 QL Complera (Oral Tablet)

1 QL C1 Tablet) Biktarvy

C1 Delstrigo Biktarvy (Oral Tablet) 1 QL

C1 Delstrigo (Oral Tablet) 1 QL Cimduo

C1 Edurant Cimduo (Oral Tablet) 1 QL

C1 Edurant (Oral Tablet) 1 QL Descovy

C1 Efavirenz Descovy (Oral Tablet) 1 QL

C1 Efavirenz (Oral Didanosine 1 QL Capsule) Didanosine (250MG

C1 Efavirenz Oral Capsule Delayed Efavirenz (Oral Tablet) 1 QL Release, 400MG Oral 1 QL C1 Intelence Intelence (100MG Capsule Delayed Oral Tablet, 200MG 1 QL Release) C1 Emtricitabine Oral Tablet) Emtricitabine (Oral

C1 Intelence 1 QL Capsule)

Intelence (25MG Oral C1 1 QL Emtriva Tablet) Emtriva (Oral

C1 Juluca 1 QL Capsule)

Juluca (Oral Tablet) C1 1 QL Emtriva

C1 Nevirapine ER Emtriva (Oral Nevirapine ER (Oral 1 QL Solution)

Tablet Extended 1 QL C1 Lamivudine Release 24 Hour) Lamivudine (10MG/ML

C1 Nevirapine 1 QL Oral Solution)

Nevirapine (Oral C1 1 QL Lamivudine Suspension) Lamivudine (150MG

C1 Nevirapine Nevirapine (Oral Tablet Oral Tablet, 300MG 1 QL 1 QL Oral Tablet)

Immediate Release) C1 Lamivudine- Zidovudine C1 Odefsey Lamivudine-Zidovudine Odefsey (Oral Tablet) 1 QL 1 QL C1 Pifeltro (Oral Tablet) Pifeltro (Oral Tablet) 1 QL

Bold type = Brand name drug Plain type = Generic drug 44 tRACK 33 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Stavudine Aptivus Stavudine (Oral Aptivus (Oral 1 QL 1 QL Capsule) Solution) C1 Tenofovir Disoproxil C1 Fumarate Atazanavir Sulfate Tenofovir Disoproxil Atazanavir Sulfate 1 QL 1 QL Fumarate (Oral Tablet) (Oral Capsule) C1 Truvada C1 Crixivan Truvada (Oral Tablet) 1 QL Crixivan (Oral

C1 Viread 1 QL Viread (Oral Powder) Capsule) 1 QL C1 Evotaz

C1 Viread Viread (150MG Oral Evotaz (Oral Tablet) 1 QL C1 Fosamprenavir Tablet, 200MG Oral Calcium Fosamprenavir 1 QL 1 QL Tablet, 250MG Oral Calcium (Oral Tablet) C1 Invirase Tablet) Invirase (Oral Tablet) 1 QL C1 Zidovudine C1 Zidovudine (Oral Kaletra 1 QL Kaletra (100-25MG Capsule) 1 QL

C1 Oral Tablet) Zidovudine

C1 Zidovudine (Oral Kaletra 1 QL Kaletra (200-50MG Syrup) 1 QL

C1 Zidovudine Oral Tablet)

C1 Zidovudine (Oral Lexiva 1 QL Lexiva (Oral Tablet) 1 QL B1 Suspension)

C1 Anti-HIV Agents, Other Lopinavir-Ritonavir

C1 Fuzeon Lopinavir-Ritonavir 1 QL Fuzeon (Oral Solution)

C1 (Subcutaneous Norvir 1 QL Norvir (Oral Packet) 1 QL C1 Solution Norvir Norvir (Oral Solution) 1 QL

C1 Reconstituted) Prezcobix

C1 Rukobia Prezcobix (Oral Rukobia (Oral Tablet 1 QL Tablet)

C1 Extended Release 12 1 QL Prezista Hour) Prezista (Oral

C1 Selzentry 1 QL Suspension)

C1 Selzentry (Oral Prezista 1 QL Solution) Prezista (150MG Oral

C1 Selzentry Selzentry (150MG Tablet, 75MG Oral 1 QL Tablet)

C1 Oral Tablet, 300MG Prezista 1 QL Oral Tablet, 75MG Prezista (600MG Oral Oral Tablet) Tablet, 800MG Oral 1 QL

C1 Selzentry Tablet)

C1 Selzentry (25MG Oral Reyataz 1 QL Tablet) Reyataz (Oral Packet) 1 QL C1 B1 Ritonavir Anti-HIV Agents, Protease Inhibitors Ritonavir (Oral Tablet) 1 QL

C1 C1 Aptivus Symtuza Aptivus (Oral Symtuza (Oral Tablet) 1 QL

C1 1 QL Viracept Capsule) Viracept (Oral Tablet) 1 QL

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 45 34 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

B1 C1 Clonazepam ODT Anti-influenza Agents Clonazepam ODT

C1 Oseltamivir Phosphate Oseltamivir Phosphate (0.125MG Oral Tablet 1 QL (Oral Capsule) Dispersible, 0.25MG

C1 Oseltamivir Phosphate Oral Tablet Oseltamivir Phosphate Dispersible, 0.5MG (Oral Suspension 1 QL 1 QL Oral Tablet Reconstituted)

C1 Relenza Diskhaler Dispersible, 1MG Oral Relenza Diskhaler Tablet Dispersible, (Inhalation Aerosol 1 QL 2MG Oral Tablet Powder Breath Dispersible)

C1 Clorazepate Activated) Dipotassium Clorazepate C1 Rimantadine HCl Rimantadine HCl (Oral Dipotassium (Oral 1 QL 1 Tablet) Tablet)

C1 C1 Xofluza Diazepam Intensol Xofluza (40 MG Dose) Diazepam Intensol (Oral Tablet Therapy 1 QL (5MG/ML Oral 1 QL Pack) Concentrate) C1 Diazepam C1 Xofluza Diazepam (5MG/5ML Xofluza (80 MG Dose) 1 Oral Solution)

(Oral Tablet Therapy C1 1 QL Diazepam Pack) Diazepam (10MG Oral A1 Tablet, 2MG Oral Anxiolytics 1 QL B1 Tablet, 5MG Oral Anxiolytics, Other

C1 Buspirone HCl Tablet)

C1 Buspirone HCl (Oral Lorazepam 1 Lorazepam (2MG/ML Tablet) 1 QL

C1 Hydroxyzine HCl Oral Concentrate)

C1 Hydroxyzine HCl (Oral Lorazepam 1 Lorazepam (0.5MG Syrup)

C1 Hydroxyzine HCl Oral Tablet, 1MG Oral Hydroxyzine HCl (Oral 1 QL 1 Tablet, 2MG Oral Tablet) Tablet) B1 A1 Benzodiazepines Bipolar Agents C1 Alprazolam B1 Alprazolam (Oral Mood Stabilizers

C1 Divalproex Sodium Tablet Immediate 1 QL ER Divalproex Sodium ER Release)

C1 Chlordiazepoxide (Oral Tablet Extended 1 HCl Chlordiazepoxide HCl Release 24 Hour)

C1 1 Divalproex Sodium (Oral Capsule)

C1 Clonazepam Divalproex Sodium Clonazepam (0.5MG (Oral Capsule Delayed 1 Oral Tablet, 1MG Oral 1 QL Release Sprinkle) Tablet, 2MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 46 tRACK 35 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Divalproex Sodium Glipizide-Metformin HCl Divalproex Sodium Glipizide-Metformin 1 QL (Oral Tablet Delayed 1 HCl (Oral Tablet)

C1 Release) Glyxambi

C1 Glyxambi (Oral Lithium Carbonate ER 1 QL Lithium Carbonate ER Tablet)

C1 Invokamet (Oral Tablet Extended 1 Invokamet (Oral Release)

C1 Lithium Carbonate Tablet Immediate 1 QL Lithium Carbonate Release)

1 C1 (Oral Capsule) Invokamet XR

C1 Lithium Carbonate Invokamet XR (Oral Lithium Carbonate Tablet Extended 1 QL (Oral Tablet Immediate 1 Release 24 Hour)

C1 Release) Invokana

C1 Lithium Invokana (Oral Tablet) 1 QL

C1 Lithium (Oral Janumet 1 Solution) Janumet (Oral Tablet

A1 1 QL Immediate Release)

C1 Blood Glucose Regulators Janumet XR

B1 Antidiabetic Agents Janumet XR (Oral

C1 Acarbose Tablet Extended 1 QL Acarbose (Oral Tablet) 1 QL

C1 Bydureon BCise Release 24 Hour)

C1 Bydureon BCise Januvia Januvia (Oral Tablet) 1 QL

C1 (Subcutaneous Auto- 1 QL Jardiance Jardiance (Oral Injector) 1 QL C1 Bydureon Tablet)

C1 Bydureon Jentadueto (Subcutaneous Pen- 1 QL Jentadueto (Oral Injector) Tablet Immediate 1 QL

C1 Byetta 10MCG Pen Release)

C1 Byetta 10MCG Pen Jentadueto XR (Subcutaneous 1 QL Jentadueto XR (Oral Solution Pen-Injector) Tablet Extended 1 QL

C1 Byetta 5MCG Pen Release 24 Hour)

C1 Byetta 5MCG Pen Metformin HCl ER (Subcutaneous 1 QL Metformin HCl ER (Oral Tablet Extended Solution Pen-Injector)

C1 Cycloset Release 24 Hour) 1 QL Cycloset (Oral Tablet) 1 PA; QL (Generic Glucophage C1 Glimepiride Glimepiride (Oral XR) C1 1 QL Metformin HCl Tablet) Metformin HCl C1 Glipizide ER Glipizide ER (Oral (500MG/5ML Oral 1 QL Tablet Extended 1 QL Solution) Release 24 Hour)

C1 Glipizide Glipizide (Oral Tablet 1 QL Immediate Release)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 47 36 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Metformin HCl Soliqua Metformin HCl Soliqua (1000MG Oral Tablet (Subcutaneous 1 QL Immediate Release, Solution Pen-Injector)

C1 SymlinPen 120 500MG Oral Tablet 1 QL SymlinPen 120 Immediate Release, (Subcutaneous 1 PA 850MG Oral Tablet Solution Pen-Injector)

C1 Immediate Release) SymlinPen 60

C1 Miglitol SymlinPen 60 Miglitol (Oral Tablet) 1 QL

C1 Nateglinide (Subcutaneous 1 PA Nateglinide (Oral 1 QL Solution Pen-Injector)

C1 Tablet) Synjardy

C1 Ozempic Synjardy (Oral Tablet Ozempic (0.25MG/ 1 QL Immediate Release)

C1 DOSE or 0.5MG/ Synjardy XR DOSE) 1 QL Synjardy XR (Oral (Subcutaneous Tablet Extended 1 QL Release 24 Hour)

C1 Solution Pen-Injector) Tradjenta

C1 Ozempic Tradjenta (Oral Ozempic (1MG/ 1 QL Tablet)

C1 DOSE) Trijardy XR 1 QL (Subcutaneous Trijardy XR (Oral Solution Pen-Injector) Tablet Extended 1 QL

C1 Pioglitazone HCl Release 24 Hour)

C1 Pioglitazone HCl (Oral Trulicity 1 QL Tablet) Trulicity

C1 Pioglitazone HCl- Glimepiride Pioglitazone HCl- (Subcutaneous 1 QL Solution Pen-Injector)

Glimepiride (Oral 1 QL C1 Victoza Tablet) Victoza

C1 Pioglitazone HCl- Metformin HCl Pioglitazone HCl- (Subcutaneous 1 QL Metformin HCl (Oral 1 QL Solution Pen-Injector)

B1 Tablet) Glycemic Agents C1 Repaglinide C1 Repaglinide (Oral Baqsimi Two Pack 1 QL Baqsimi Two Pack Tablet) 1

C1 (Nasal Powder) Riomet ER

C1 Diazoxide Riomet ER (Oral Diazoxide (Oral 1 Suspension 1 QL Suspension)

C1 Reconstituted ER) GlucaGen HypoKit

C1 Riomet GlucaGen HypoKit

Riomet (Oral Solution) 1 QL (Injection Solution 1 C1 Rybelsus Rybelsus (Oral Tablet) 1 QL Reconstituted) C1 Glucagon Glucagon (Injection 1 Kit) (Lilly)

Bold type = Brand name drug Plain type = Generic drug 48 tRACK 37 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Gvoke HypoPen 2- Humalog Pack Gvoke HypoPen 2- Humalog

Pack (Subcutaneous (Subcutaneous 1 1 Solution Auto- Solution)

C1 Humalog Injector) Humalog C1 Gvoke PFS Gvoke PFS (Subcutaneous 1 (Subcutaneous Solution Cartridge)

C1 Humulin 70/30 1 KwikPen Solution Prefilled Humulin 70/30 Syringe) KwikPen C1 Proglycem Proglycem (Oral (Subcutaneous 1 1 Suspension) Suspension Pen-

B1 Insulins Injector) C1 Humulin 70/30 C1 Humalog Junior KwikPen Humulin 70/30 Humalog Junior KwikPen (Subcutaneous 1 1 (Subcutaneous Suspension) C1 Humulin N KwikPen Solution Pen-Injector) Humulin N KwikPen

C1 Humalog KwikPen Humalog KwikPen (Subcutaneous 1 (Subcutaneous 1 Suspension Pen- Solution Pen-Injector) Injector) C1 Humulin N C1 Humalog Mix 50/50 KwikPen Humulin N Humalog Mix 50/50 KwikPen (Subcutaneous 1

(Subcutaneous 1 Suspension) C1 Humulin R Suspension Pen- Humulin R (Injection 1 Injector) Solution)

C1 C1 Humalog Mix 50/50 Humulin R U-500 Humalog Mix 50/50 Humulin R U-500

(Subcutaneous 1 (Concentrated) 1 Suspension) (Subcutaneous

C1 Humalog Mix 75/25 KwikPen Humalog Mix 75/25 Solution) C1 Humulin R U-500 KwikPen KwikPen Humulin R U-500

(Subcutaneous 1 KwikPen 1 Suspension Pen- (Subcutaneous Injector) Solution Pen-Injector)

C1 C1 Humalog Mix 75/25 Insulin Lispro Humalog Mix 75/25 Insulin Lispro (1 Unit

(Subcutaneous 1 Dial) (Subcutaneous

Suspension) Solution Pen-Injector) 1 (Brand Equivalent Humalog)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 49 38 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Insulin Lispro Junior Toujeo SoloStar KwikPen Insulin Lispro Junior Toujeo SoloStar

KwikPen (Subcutaneous 1 (Subcutaneous Solution Pen-Injector)

C1 1 Tresiba FlexTouch Solution Pen-Injector) Tresiba FlexTouch

(Brand Equivalent (Subcutaneous 1 Humalog) Solution Pen-Injector) C1 Insulin Lispro Prot & Lispro C1 Tresiba Insulin Lispro Prot & Tresiba Lispro (Subcutaneous (Subcutaneous 1 Suspension Pen- 1 Solution)

A1 Injector) (Brand Blood Products/Modifiers/Volume Expanders Equivalent Humalog) B1

C1 Insulin Lispro Anticoagulants

C1 Eliquis DVT/PE Insulin Lispro Starter Pack Eliquis DVT/PE (Subcutaneous 1 Starter Pack (Oral 1 QL Solution) (Brand Tablet Therapy Pack)

C1 Equivalent Humalog) Eliquis

C1 Lantus SoloStar Eliquis (Oral Tablet) 1 QL

C1 Lantus SoloStar Enoxaparin Sodium

(Subcutaneous 1 Enoxaparin Sodium Solution Pen-Injector) (Subcutaneous 1 QL

C1 Lantus Solution)

C1 Fondaparinux Lantus Sodium Fondaparinux Sodium (Subcutaneous 1 (10MG/0.8ML Solution)

C1 Levemir FlexTouch Subcutaneous Levemir FlexTouch Solution, 5MG/0.4ML 1 (Subcutaneous 1 Subcutaneous Solution Pen-Injector) Solution, 7.5MG/

C1 Levemir Levemir 0.6ML Subcutaneous Solution)

C1 (Subcutaneous Fondaparinux 1 Sodium Solution) Fondaparinux Sodium

C1 Lyumjev (2.5MG/0.5ML Lyumjev (Injection 1 1 Subcutaneous Solution)

C1 Lyumjev KwikPen Solution)

C1 Lyumjev KwikPen Heparin Sodium Heparin Sodium (Subcutaneous 1 (10000UNIT/ML Solution Pen-Injector)

C1 Injection Solution, Toujeo Max SoloStar Toujeo Max SoloStar 20000UNIT/ML 1

(Subcutaneous 1 Injection Solution, Solution Pen-Injector) 5000UNIT/ML Injection Solution)

Bold type = Brand name drug Plain type = Generic drug 50 tRACK 39 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Heparin Sodium Aranesp Heparin Sodium Aranesp (Albumin (1000UNIT/ML 1 B/D, PA Free) (100MCG/ Injection Solution) 0.5ML Injection C1 Jantoven Jantoven (Oral Tablet) 1 Solution Prefilled

C1 Warfarin Sodium Warfarin Sodium (Oral Syringe, 150MCG/ 1 Tablet) 0.3ML Injection

C1 Xarelto Xarelto (Oral Tablet) 1 QL Solution Prefilled

C1 Xarelto Starter Pack Syringe, 200MCG/ Xarelto Starter Pack 0.4ML Injection (Oral Tablet Therapy 1 QL Solution Prefilled 1 PA Pack) B1 Syringe, 300MCG/ Blood Formation Modifiers

C1 Anagrelide HCl 0.6ML Injection Anagrelide HCl (Oral 1 Solution Prefilled Capsule)

C1 Syringe, 500MCG/ML Aranesp Aranesp (Albumin Injection Solution Free) (100MCG/ML Prefilled Syringe, Injection Solution, 60MCG/0.3ML 200MCG/ML Injection Solution Injection Solution, 1 PA Prefilled Syringe)

C1 Aranesp 300MCG/ML Aranesp (Albumin Injection Solution, Free) (10MCG/0.4ML 60MCG/ML Injection Injection Solution Solution)

C1 Prefilled Syringe, Aranesp Aranesp (Albumin 25MCG/0.42ML 1 PA Free) (25MCG/ML Injection Solution Injection Solution, 1 PA Prefilled Syringe, 40MCG/ML Injection 40MCG/0.4ML Solution) Injection Solution Prefilled Syringe)

C1 Granix Granix (Subcutaneous 1 ST Solution)

C1 Granix Granix (Subcutaneous Solution Prefilled 1 ST Syringe)

C1 Leukine Leukine (Injection Solution 1 PA Reconstituted)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 51 40 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Neulasta Udenyca Neulasta Udenyca (Subcutaneous (Subcutaneous 1 PA 1 PA Solution Prefilled Solution Prefilled Syringe) Syringe)

C1 C1 Neupogen Zarxio Neupogen (Injection Zarxio (Injection 1 ST Solution) Solution Prefilled 1

C1 Neupogen Neupogen (Injection Syringe) B1 Solution Prefilled 1 ST Hemostasis Agents

C1 Tranexamic Acid Syringe) Tranexamic Acid (Oral C1 Procrit 1 Procrit (10000UNIT/ Tablet)

B1 ML Injection Solution, Platelet Modifying Agents

C1 Aspirin- 2000UNIT/ML Dipyridamole ER Aspirin-Dipyridamole Injection Solution, ER (Oral Capsule 1 PA 1 QL 3000UNIT/ML Extended Release 12 Injection Solution, Hour)

C1 Brilinta 4000UNIT/ML Brilinta (Oral Tablet) 1 QL

C1 Injection Solution) Cablivi

C1 Procrit Cablivi (Injection Kit) 1 PA; QL

C1 Procrit (20000UNIT/ Cilostazol Cilostazol (Oral Tablet) 1

C1 Clopidogrel ML Injection Solution, Bisulfate 1 PA Clopidogrel Bisulfate 40000UNIT/ML 1 QL (75MG Oral Tablet)

C1 Injection Solution) Prasugrel HCl

C1 Promacta Prasugrel HCl (Oral Promacta (Oral 1 QL 1 PA; LA; QL Tablet) Packet) A1

C1 Promacta Cardiovascular Agents Promacta (Oral B1 1 PA; LA; QL Alpha-adrenergic Agonists

C1 Tablet) Clonidine HCl

C1 Retacrit Retacrit (10000UNIT/ Clonidine HCl (Oral ML Injection Solution, Tablet Immediate 1 Release)

C1 2000UNIT/ML Clonidine Injection Solution, Clonidine 1 PA 3000UNIT/ML (Transdermal Patch 1 Weekly)

C1 Injection Solution, Methyldopa Methyldopa (Oral 4000UNIT/ML 1 Tablet)

C1 Injection Solution) Midodrine HCl

C1 Retacrit Midodrine HCl (Oral Retacrit (40000UNIT/ 1 1 PA Tablet)

C1 ML Injection Solution) Northera Northera (Oral 1 PA; LA; QL Capsule)

Bold type = Brand name drug Plain type = Generic drug 52 tRACK 41 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

B1 C1 Ramipril Alpha-adrenergic Blocking Agents Ramipril (Oral Capsule) 1 QL

C1 Doxazosin Mesylate C1 Trandolapril Doxazosin Mesylate Trandolapril (Oral 1 1 QL (Oral Tablet) Tablet) C1 Phenoxybenzamine B1 HCl Phenoxybenzamine Antiarrhythmics

C1 1 Amiodarone HCl HCl (Oral Capsule)

C1 Prazosin HCl Amiodarone HCl 1 Prazosin HCl (Oral (200MG Oral Tablet)

C1 1 Dofetilide Capsule) B1 Dofetilide (Oral 1 Angiotensin II Receptor Antagonists Capsule) C1 Candesartan C1 Cilexetil Flecainide Acetate Candesartan Cilexetil Flecainide Acetate 1 QL 1 (Oral Tablet) (Oral Tablet) C1 Edarbi C1 Mexiletine HCl Edarbi (Oral Tablet) 1 QL Mexiletine HCl (Oral

C1 Irbesartan 1 Capsule)

C1 Irbesartan (Oral Tablet) 1 QL Multaq

C1 Losartan Potassium Multaq (Oral Tablet) 1 QL

Losartan Potassium C1 1 QL Pacerone (Oral Tablet) Pacerone (200MG Oral

C1 Olmesartan Medoxomil 1 Tablet)

Olmesartan Medoxomil C1 Propafenone HCl 1 QL ER (Oral Tablet) Propafenone HCl ER

C1 Telmisartan Telmisartan (Oral (Oral Capsule 1 QL 1 Tablet) Extended Release 12

C1 Valsartan Hour)

C1 Valsartan (Oral Tablet) 1 QL Propafenone HCl B1 Propafenone HCl (Oral 1 Angiotensin-converting Enzyme (ACE) Tablet)

C1 Quinidine Inhibitors Gluconate ER

C1 Benazepril HCl Quinidine Gluconate Benazepril HCl (Oral 1 QL ER (Oral Tablet 1 Tablet) C1 Extended Release) Captopril

C1 Quinidine Sulfate Captopril (Oral Tablet) 1 QL Quinidine Sulfate (Oral C1 Enalapril Maleate 1 Enalapril Maleate (Oral Tablet) C1 1 QL Sotalol HCl AF Tablet) Sotalol HCl AF (Oral C1 Fosinopril Sodium 1 Fosinopril Sodium Tablet)

C1 1 QL Sotalol HCl (Oral Tablet) Sotalol HCl (Oral C1 Lisinopril 1 Lisinopril (Oral Tablet) 1 QL Tablet) B1

C1 Moexipril HCl Moexipril HCl (Oral Beta-adrenergic Blocking Agents C1 1 QL Acebutolol HCl Tablet) Acebutolol HCl (Oral

C1 Perindopril Erbumine 1 Perindopril Erbumine Capsule) C1 1 QL Atenolol (Oral Tablet) Atenolol (Oral Tablet) 1 C1 Quinapril HCl C1 Betaxolol HCl Quinapril HCl (Oral Betaxolol HCl (Oral 1 QL 1 Tablet) Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 53 42 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Bisoprolol Diltiazem HCl ER Fumarate Coated Beads Bisoprolol Fumarate Diltiazem HCl ER 1 (Oral Tablet) Coated Beads (120MG

C1 Bystolic Bystolic (Oral Tablet) 1 QL Oral Capsule Extended

C1 Carvedilol Release 24 Hour, Carvedilol (Oral Tablet) 1

C1 180MG Oral Capsule Labetalol HCl Labetalol HCl (Oral Extended Release 24 1 1 Tablet) Hour, 240MG Oral

C1 Metoprolol Succinate ER Metoprolol Succinate Capsule Extended ER (Oral Tablet Release 24 Hour, 1 Extended Release 24 300MG Oral Capsule Hour) Extended Release 24

C1 Metoprolol Tartrate Hour)

C1 Metoprolol Tartrate Diltiazem HCl ER (100MG Oral Tablet, Diltiazem HCl ER (Oral 1 25MG Oral Tablet, Capsule Extended 1 Release 12 Hour)

50MG Oral Tablet) C1 Diltiazem HCl C1 Nadolol Nadolol (Oral Tablet) 1 Diltiazem HCl (Oral

C1 Pindolol Tablet Immediate 1 Pindolol (Oral Tablet) 1

C1 Release) Propranolol HCl ER

C1 Dilt-XR Propranolol HCl ER Dilt-XR (Oral Capsule (Oral Capsule 1 Extended Release 24 1 Extended Release 24 Hour)

C1 Hour) Felodipine ER

C1 Propranolol HCl Felodipine ER (Oral Propranolol HCl (Oral 1 Tablet Extended 1 Solution) C1 Release 24 Hour) Propranolol HCl

C1 Propranolol HCl (Oral Matzim LA 1 Matzim LA (Oral Tablet Tablet) B1 Extended Release 24 1 Calcium Channel Blocking Agents Hour)

C1 Amlodipine C1 Besylate Nicardipine HCl Amlodipine Besylate Nicardipine HCl (Oral 1 1 (Oral Tablet) Capsule)

C1 Cartia XT C1 Nifedipine ER Cartia XT (Oral Nifedipine ER (Oral Capsule Extended 1 Tablet Extended 1 QL Release 24 Hour) Release 24 Hour)

C1 C1 Diltiazem HCl ER Nifedipine ER Beads Diltiazem HCl ER Osmotic Release Nifedipine ER Osmotic Beads (360MG Oral Release (Oral Tablet 1 QL Capsule Extended Extended Release 24 Release 24 Hour, 1 Hour)

C1 Nimodipine 420MG Oral Capsule Nimodipine (Oral 1 Extended Release 24 Capsule) Hour)

Bold type = Brand name drug Plain type = Generic drug 54 tRACK 43 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Nymalize Amiloride- Hydrochlorothiazid Nymalize (6MG/ML e Amiloride- 1 Oral Solution) Hydrochlorothiazide 1

C1 Taztia XT (Oral Tablet)

C1 Taztia XT (Oral Amlodipine- Atorvastatin Capsule Extended 1 Amlodipine- Release 24 Hour) Atorvastatin (Oral 1 QL

C1 Tiadylt ER Tablet)

C1 Tiadylt ER (Oral Amlodipine- Benazepril Amlodipine-Benazepril Capsule Extended 1 1 QL Release 24 Hour) (Oral Capsule) C1 C1 Amlodipine- Verapamil HCl ER Olmesartan Verapamil HCl ER Amlodipine- (100MG Oral Capsule Olmesartan (Oral 1 QL Extended Release 24 Tablet) C1 Amlodipine- Hour, 120MG Oral Valsartan Amlodipine-Valsartan 1 QL Capsule Extended (Oral Tablet)

C1 Amlodipine- Release 24 Hour, Valsartan-HCTZ Amlodipine-Valsartan- 1 QL 180MG Oral Capsule HCTZ (Oral Tablet)

C1 Atenolol- Extended Release 24 Chlorthalidone 1 Hour, 200MG Oral Atenolol- Capsule Extended Chlorthalidone (Oral 1 Tablet)

C1 Release 24 Hour, Benazepril- Hydrochlorothiazid 240MG Oral Capsule e Benazepril- Extended Release 24 Hydrochlorothiazide 1 QL Hour, 300MG Oral (Oral Tablet) C1 BiDil Capsule Extended BiDil (Oral Tablet) 1 QL

C1 Bisoprolol- Hydrochlorothiazid Release 24 Hour) e

C1 Verapamil HCl ER Bisoprolol- Verapamil HCl ER Hydrochlorothiazide 1 QL (360MG Oral Capsule (Oral Tablet)

C1 1 Candesartan Extended Release 24 Cilexetil-HCTZ Candesartan Cilexetil- Hour) 1 QL

C1 HCTZ (Oral Tablet) Verapamil HCl ER

C1 Captopril- Hydrochlorothiazid e Verapamil HCl ER Captopril- (Oral Tablet Extended 1 Hydrochlorothiazide 1 QL Release)

C1 (Oral Tablet) Verapamil HCl

C1 Corlanor Verapamil HCl (Oral Corlanor (Oral 1 PA; QL Tablet Immediate 1 Solution)

C1 Release) Corlanor B1 Corlanor (Oral Tablet) 1 PA; QL

C1 Cardiovascular Agents, Other Demser

C1 Aliskiren Fumarate Demser (Oral Aliskiren Fumarate 1 1 QL Capsule)

C1 (Oral Tablet) Digitek Digitek (Oral Tablet) 1

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 55 44 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Digox Propranolol-HCTZ Digox (Oral Tablet) 1 Propranolol-HCTZ

C1 Digoxin 1 (Oral Tablet) C1 Digoxin (Oral Quinapril- Hydrochlorothiazid 1 e Solution) Quinapril-

C1 Digoxin Hydrochlorothiazide 1 QL Digoxin (Oral Tablet) 1

C1 Edarbyclor (Oral Tablet)

C1 Edarbyclor (Oral Ranolazine ER 1 QL Ranolazine ER (Oral Tablet)

C1 Enalapril- Tablet Extended 1 QL Hydrochlorothiazid e Enalapril- Release 12 Hour)

C1 Spironolactone- Hydrochlorothiazide 1 QL HCTZ Spironolactone-HCTZ (Oral Tablet) 1

C1 Entresto (Oral Tablet)

C1 Telmisartan- Entresto (Oral Tablet) 1 QL Amlodipine

C1 Telmisartan- Fosinopril Sodium- HCTZ Fosinopril Sodium- Amlodipine (Oral 1 QL 1 QL HCTZ (Oral Tablet) Tablet)

C1 C1 Irbesartan- Telmisartan-HCTZ Hydrochlorothiazid e Irbesartan- Telmisartan-HCTZ 1 QL Hydrochlorothiazide 1 QL (Oral Tablet)

C1 (Oral Tablet) Triamterene-HCTZ C1 Triamterene-HCTZ Lanoxin 1 Lanoxin (Oral Tablet) 1 (Oral Capsule) C1 C1 Triamterene-HCTZ Lisinopril- Hydrochlorothiazid e Triamterene-HCTZ Lisinopril- 1 Hydrochlorothiazide 1 QL (Oral Tablet) C1 Valsartan- Hydrochlorothiazid (Oral Tablet) e Valsartan- C1 Losartan Potassium-HCTZ Losartan Potassium- Hydrochlorothiazide 1 QL 1 QL HCTZ (Oral Tablet) (Oral Tablet) C1 Vyndamax C1 Methyldopa- Hydrochlorothiazid e Vyndamax (Oral Methyldopa- 1 PA; QL Hydrochlorothiazide 1 Capsule)

C1 Vyndaqel (Oral Tablet) Vyndaqel (Oral C1 Metoprolol- Hydrochlorothiazid e 1 PA; QL Metoprolol- Capsule) B1 Hydrochlorothiazide 1 Diuretics, Carbonic Anhydrase Inhibitors

C1 (Oral Tablet) Acetazolamide ER

C1 Olmesartan Medoxomil-HCTZ Acetazolamide ER Olmesartan (Oral Capsule 1 Medoxomil-HCTZ (Oral 1 QL Extended Release 12 Tablet)

C1 Hour) Olmesartan- Amlodipine-HCTZ C1 Acetazolamide Olmesartan- Acetazolamide (Oral 1 Amlodipine-HCTZ (Oral 1 QL Tablet)

C1 Tablet) Methazolamide

C1 Pentoxifylline ER Methazolamide (Oral 1 Pentoxifylline ER (Oral Tablet) Tablet Extended 1 B1 Release) Diuretics, Loop

Bold type = Brand name drug Plain type = Generic drug 56 tRACK 45 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 B1 Bumetanide Bumetanide (Injection Dyslipidemics, Fibric Acid Derivatives

C1 Fenofibrate 1 Micronized Solution)

C1 Fenofibrate Micronized Bumetanide Bumetanide (Oral (134MG Oral Capsule, 1 1 Tablet) 200MG Oral Capsule,

C1 Ethacrynic Acid 67MG Oral Capsule) Ethacrynic Acid (Oral C1 1 Fenofibrate Tablet) Fenofibrate (145MG

C1 Furosemide Furosemide (Injection Oral Tablet, 48MG Oral 1 1 B/D, PA Tablet)

Solution) C1 Fenofibrate

C1 Furosemide Furosemide (Oral Fenofibrate (160MG 1 Solution) Oral Tablet, 54MG Oral 1

C1 Furosemide Tablet)

C1 Furosemide (Oral Fenofibric Acid 1 Tablet) Fenofibric Acid (Oral C1 Torsemide Capsule Delayed 1 Torsemide (Oral 1 Release)

C1 Tablet) Gemfibrozil B1 Gemfibrozil (Oral Diuretics, Potassium-sparing 1

C1 Amiloride HCl Tablet) Amiloride HCl (Oral B1 1 Dyslipidemics, HMG CoA Reductase Tablet)

C1 Eplerenone Inhibitors

C1 Atorvastatin Eplerenone (Oral Calcium 1 Atorvastatin Calcium Tablet) 1 QL C1 Spironolactone (Oral Tablet)

C1 Spironolactone (Oral Fluvastatin Sodium 1 Fluvastatin Sodium Tablet) 1 QL C1 Triamterene (Oral Capsule)

C1 Triamterene (Oral Livalo 1 Livalo (Oral Tablet) 1 QL

C1 Capsule) Lovastatin

B1 Diuretics, Thiazide Lovastatin (Oral Tablet) 1 QL C1 Pravastatin Sodium C1 Chlorthalidone Chlorthalidone (Oral Pravastatin Sodium 1 1 QL Tablet) (Oral Tablet) C1 Rosuvastatin C1 Calcium Diuril Rosuvastatin Calcium Diuril (Oral 1 QL 1 (Oral Tablet)

Suspension) C1 Simvastatin

C1 Hydrochlorothiazid e Simvastatin (Oral Hydrochlorothiazide 1 QL 1 Tablet)

(Oral Capsule) B1

C1 Hydrochlorothiazid e Dyslipidemics, Other Hydrochlorothiazide C1 Cholestyramine 1 Light (Oral Tablet) Cholestyramine Light

C1 Indapamide 1 (Oral Powder) Indapamide (Oral C1 1 Cholestyramine Tablet) Cholestyramine (Oral

C1 Metolazone 1 Metolazone (Oral Packet) 1 Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 57 46 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Colesevelam HCl Repatha Colesevelam HCl (Oral Repatha 1 Packet) (Subcutaneous C1 Colesevelam HCl 1 PA; QL Colesevelam HCl (Oral Solution Prefilled 1 Tablet) Syringe)

C1 C1 Colestipol HCl Repatha SureClick Colestipol HCl (Oral Repatha SureClick 1 Packet) (Subcutaneous C1 Colestipol HCl 1 PA; QL Colestipol HCl (Oral Solution Auto- 1 Tablet) Injector)

C1 Ezetimibe C1 Vascepa Ezetimibe (Oral Tablet) 1 QL Vascepa (Oral

C1 Ezetimibe- Simvastatin 1 Capsule)

Ezetimibe-Simvastatin B1 1 QL (Oral Tablet) Vasodilators, Direct-acting Arterial

C1 C1 Juxtapid Hydralazine HCl Juxtapid (10MG Oral Hydralazine HCl (Oral 1 Capsule, 20MG Oral Tablet)

C1 Minoxidil Capsule, 30MG Oral 1 PA; LA Minoxidil (Oral Tablet) 1

B1 Capsule, 5MG Oral Vasodilators, Direct-acting Arterial/Venous

C1 Capsule) Isosorbide Dinitrate

C1 Niacin ER Isosorbide Dinitrate Niacin ER (10MG Oral Tablet (Antihyperlipidemic) 1 Immediate Release, (Oral Tablet Extended 20MG Oral Tablet Release)

C1 Immediate Release, 1 Niacor Niacor (Oral Tablet) 1 30MG Oral Tablet

C1 Omega-3-Acid Ethyl Esters Omega-3-Acid Ethyl Immediate Release, Esters (Oral Capsule) 1 QL 5MG Oral Tablet Immediate Release)

C1 (Generic Lovaza) Isosorbide Mononitrate ER

C1 Praluent Praluent Isosorbide Mononitrate ER (Oral Tablet (Subcutaneous 1 1 PA; LA; QL Extended Release 24 Solution Auto- Hour)

C1 Isosorbide Injector) Mononitrate

C1 Prevalite Isosorbide Mononitrate Prevalite (Oral Packet) 1

C1 (Oral Tablet Immediate 1 Repatha Pushtronex System Repatha Pushtronex Release)

C1 Minitran System Minitran (Transdermal 1 PA; QL 1 (Subcutaneous Patch 24 Hour)

C1 Nitro-Bid Solution Cartridge) Nitro-Bid (Transdermal 1 Ointment)

C1 Nitroglycerin Nitroglycerin (Tablet 1 Sublingual)

Bold type = Brand name drug Plain type = Generic drug 58 tRACK 47 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Nitroglycerin Dexmethylphenidat e HCl ER Nitroglycerin Dexmethylphenidate (Transdermal Patch 24 1 HCl ER (Oral Capsule 1 Hour) Extended Release 24

C1 Nitroglycerin Hour) Nitroglycerin C1 Dexmethylphenidat 1 e HCl (Translingual Solution) Dexmethylphenidate

C1 Nitrostat 1 QL HCl (Oral Tablet) Nitrostat (Tablet C1 1 Guanfacine HCl ER Sublingual) Guanfacine HCl ER

C1 Rectiv Rectiv (Rectal (Oral Tablet Extended 1 1 Release 24 Hour)

C1 Methylphenidate Ointment) HCl ER

A1 Central Nervous System Agents Methylphenidate HCl B1 ER (10MG Oral Tablet Attention Deficit Hyperactivity Disorder Extended Release, 1 QL Agents, Amphetamines

C1 20MG Oral Tablet Amphetamine- Dextroamphetamin e ER Amphetamine- Extended Release)

C1 Methylphenidate Dextroamphetamine HCl Methylphenidate HCl 1 QL ER (Oral Capsule 1 QL (Oral Solution)

C1 Methylphenidate Extended Release 24 HCl Methylphenidate HCl Hour)

C1 Amphetamine- Dextroamphetamin e (Oral Tablet Immediate 1 QL Amphetamine- Release) (Generic Dextroamphetamine 1 QL Ritalin) (Oral Tablet) B1

C1 Dextroamphetamin e Sulfate ER Central Nervous System, Other

C1 Dextroamphetamine Austedo Austedo (Oral Tablet) 1 PA; LA; QL

C1 Sulfate ER (Oral Ingrezza 1 QL Ingrezza (Oral Capsule Extended 1 PA; QL Release 24 Hour) Capsule)

C1 C1 Ingrezza Dextroamphetamin e Sulfate Dextroamphetamine Ingrezza (Oral 1 QL Sulfate (Oral Tablet) Capsule Therapy 1 PA; QL

C1 Vyvanse Vyvanse (Oral Pack) C1 1 Namzaric Capsule) Namzaric (Oral

C1 Vyvanse Vyvanse (Oral Tablet Capsule ER 24 Hour 1 PA; QL 1 Chewable) Therapy Pack) C1 Namzaric B1 Attention Deficit Hyperactivity Disorder Namzaric (Oral Agents, Non-amphetamines Capsule Extended 1 PA; QL

C1 Atomoxetine HCl Release 24 Hour)

Atomoxetine HCl (Oral C1 1 QL Nuedexta Capsule) Nuedexta (Oral

C1 Clonidine HCl ER 1 PA Clonidine HCl ER (Oral Capsule) C1 Riluzole Tablet Extended 1 PA Riluzole (Oral Tablet) 1 Release 12 Hour)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 59 48 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Tetrabenazine Dalfampridine ER Tetrabenazine (Oral Dalfampridine ER (Oral 1 PA; LA; QL Tablet) Tablet Extended 1 QL B1 Release 12 Hour)

Fibromyalgia Agents C1 Dimethyl Fumarate

C1 Drizalma Sprinkle Drizalma Sprinkle Dimethyl Fumarate (Oral Capsule (120MG Oral Capsule 1 ST; QL Delayed Release Delayed Release, 1 QL 240MG Oral Capsule Sprinkle)

C1 Duloxetine HCl Delayed Release)

C1 Duloxetine HCl (20MG Gilenya Gilenya (0.5MG Oral Oral Capsule Delayed 1 QL Capsule)

C1 Release Particles, Glatiramer Acetate 30MG Oral Capsule Glatiramer Acetate 1 QL (Subcutaneous Delayed Release 1 QL Particles, 60MG Oral Solution Prefilled Capsule Delayed Syringe) C1 Glatopa Release Particles) Glatopa

C1 Pregabalin Pregabalin (Oral (Subcutaneous 1 QL 1 QL Capsule) Solution Prefilled

C1 Pregabalin Syringe)

C1 Pregabalin (Oral Mayzent 1 QL Solution) Mayzent (Oral Tablet) 1 QL C1 C1 Rebif Rebidose Savella Savella (Oral Tablet) 1 Rebif Rebidose

C1 Savella Titration Pack Savella Titration Pack (Subcutaneous 1 1 QL (Oral Tablet) Solution Auto- B1 Injector)

C1 Rebif Rebidose Multiple Sclerosis Agents Titration Pack

C1 Ampyra Rebif Rebidose Ampyra (Oral Tablet Titration Pack Extended Release 12 1 QL (Subcutaneous 1 QL Hour)

C1 Aubagio Solution Auto- Aubagio (Oral Tablet) 1 LA; QL

C1 Avonex Pen Injector)

C1 Rebif Avonex Pen Rebif (Subcutaneous (Intramuscular Auto- 1 QL Solution Prefilled 1 QL Injector Kit)

C1 Syringe) Avonex Prefilled

C1 Rebif Titration Pack Avonex Prefilled Rebif Titration Pack (Intramuscular 1 QL (Subcutaneous Prefilled Syringe Kit) 1 QL

C1 Solution Prefilled Betaseron Betaseron Syringe)

C1 Tecfidera Starter 1 QL Pack (Subcutaneous Kit) Tecfidera Starter 1 LA Pack (Oral)

Bold type = Brand name drug Plain type = Generic drug 60 tRACK 49 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Tecfidera Calcitriol Tecfidera (Oral Calcitriol (External 1 Capsule Delayed 1 LA; QL Ointment)

C1 Carac Release) Carac (External A1 1 PA Dental and Oral Agents Cream)

B1 C1 Claravis Dental and Oral Agents Claravis (Oral Capsule) 1 PA

C1 Chlorhexidine C1 Gluconate Clindamycin Chlorhexidine Phosphate Clindamycin Gluconate (Mouth 1 Phosphate (External 1 Solution) Gel) C1 Pilocarpine HCl C1 Clindamycin Pilocarpine HCl (Oral Phosphate 1 Clindamycin Tablet) Phosphate (External 1 C1 Triamcinolone Acetonide Triamcinolone Lotion) C1 Clindamycin Phosphate Acetonide (Dental 1 Clindamycin Paste) Phosphate (External 1 A1 Dermatological Agents Solution) C1 Clindamycin B1 Phosphate Dermatological Agents Clindamycin

C1 Acitretin Acitretin (Oral Capsule) 1 Phosphate (External 1

C1 Adapalene Swab)

C1 Clindamycin Phosphate-Benzoyl Adapalene (External Peroxide 1 Clindamycin Cream)

C1 Adapalene Phosphate-Benzoyl Adapalene (0.1% 1 1 Peroxide (1-5% External Gel)

C1 External Gel) Ammonium Lactate

C1 Clotrimazole- Ammonium Lactate Betamethasone 1 Clotrimazole- (External Cream)

C1 Betamethasone 1 Ammonium Lactate Ammonium Lactate (External Cream)

C1 Clotrimazole- 1 Betamethasone (External Lotion)

C1 Clotrimazole- Azelaic Acid Azelaic Acid (External Betamethasone 1 1 Gel) (External Lotion)

C1 C1 Benzoyl Peroxide- Cortisporin Erythromycin Benzoyl Peroxide- Cortisporin (External 1 Erythromycin (External 1 Cream)

C1 Gel) Cortisporin

C1 Calcipotriene Cortisporin (External 1 Calcipotriene (External Ointment)

C1 1 Cosentyx Cream)

C1 Calcipotriene Cosentyx (300 MG Calcipotriene (External 1 Dose) (Subcutaneous Ointment) 1 PA; LA

C1 Calcipotriene Solution Prefilled Calcipotriene (External 1 Syringe) Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 61 50 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Cosentyx Pimecrolimus Sensoready Cosentyx Sensoready Pimecrolimus (External 1 ST (300 MG) Cream) C1 Podofilox (Subcutaneous 1 PA; LA Podofilox (External 1 Solution Auto- Solution)

C1 Regranex Injector) Regranex (External C1 Diclofenac Sodium 1 PA Diclofenac Sodium Gel)

C1 1 PA Santyl (3% Transdermal Gel) Santyl (External C1 Doxepin HCl 1 Doxepin HCl (External Ointment)

C1 1 PA; QL Selenium Sulfide Cream) C1 Ery Selenium Sulfide 1 Ery (External Pad) 1 (External Lotion)

C1 C1 Erythromycin Stelara Erythromycin (External Stelara 1 Gel) (Subcutaneous 1 PA

C1 Erythromycin Erythromycin (External Solution) C1 1 Stelara Solution) Stelara C1 Finacea Finacea (External (Subcutaneous 1 1 PA Foam) Solution Prefilled

C1 Fluorouracil Fluorouracil (0.5% Syringe) C1 1 Tacrolimus External Cream) Tacrolimus (External

C1 Fluorouracil 1 ST Fluorouracil (5% Ointment) C1 1 Tazarotene External Cream) Tazarotene (External

C1 Fluorouracil 1 PA Fluorouracil (External Cream) C1 1 Tazorac Solution) Tazorac (0.05%

C1 Imiquimod 1 PA Imiquimod (5% External Cream) C1 1 Tazorac External Cream) Tazorac (0.05% C1 Imiquimod Pump 1 PA Imiquimod Pump External Gel)

C1 Tazorac (3.75% External 1 PA Tazorac (0.1% Cream) 1 PA

C1 Isotretinoin External Gel)

C1 Isotretinoin (Oral Tolak 1 PA Tolak (External Capsule) 1

C1 Methoxsalen Rapid Cream)

C1 Methoxsalen Rapid Tretinoin 1 Tretinoin (External (Oral Capsule) 1 PA

C1 Mirvaso Cream)

C1 Mirvaso (External Gel) 1 Tretinoin

C1 Oxsoralen Ultra Tretinoin (0.01% Oxsoralen Ultra (Oral External Gel, 0.025% 1 PA 1 Capsule) External Gel)

C1 C1 Picato Tretinoin Microsphere Tretinoin Microsphere Picato (External Gel) 1 1 PA (External Gel)

Bold type = Brand name drug Plain type = Generic drug 62 tRACK 51 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Zyclara Pump KCl in Dextrose- Zyclara Pump NaCl KCl in Dextrose-NaCl 1 PA 1 (External Cream) (Intravenous Solution)

A1 C1 KCl-Lactated Electrolytes/Minerals/Metals/Vitamins Ringers-D5W KCl-Lactated Ringers- B1 Electrolyte/Mineral Replacement D5W (Intravenous 1

C1 Aminosyn II Solution)

Aminosyn II C1 1 B/D, PA Klor-Con 10 (Intravenous Solution) Klor-Con 10 (Oral

C1 Aminosyn-PF Aminosyn-PF (7% Tablet Extended 1 1 B/D, PA Release)

C1 Intravenous Solution) Klor-Con M10

C1 Carbaglu Carbaglu (Oral Tablet) 1 LA Klor-Con M10 (Oral

C1 Dextrose Tablet Extended 1 Dextrose (10% Release)

1 C1 Intravenous Solution) Klor-Con M15

C1 Dextrose Klor-Con M15 (Oral Dextrose (5% 1 B/D, PA Tablet Extended 1 Intravenous Solution)

C1 Release) Dextrose-NaCl C1 Dextrose-NaCl Klor-Con M20 Klor-Con M20 (Oral (10-0.2% Intravenous Tablet Extended 1 Solution, 10-0.45% Release)

C1 Intravenous Solution, Klor-Con Klor-Con (Oral Packet) 1 C1 2.5-0.45% 1 Klor-Con 8 Klor-Con 8 (Oral Intravenous Solution, Tablet Extended 1 5-0.2% Intravenous Release)

C1 Solution, 5-0.45% Levocarnitine Levocarnitine (1GM/ Intravenous Solution) 1

C1 Dextrose-NaCl 10ML Oral Solution)

C1 Dextrose-NaCl Levocarnitine Levocarnitine (330MG (5-0.9% Intravenous 1 B/D, PA 1 Oral Tablet)

C1 Solution) Magnesium Sulfate

C1 FreAmine HBC Magnesium Sulfate FreAmine HBC 1 B/D, PA (50% Injection 1 (Intravenous Solution)

C1 HepatAmine Solution)

C1 HepatAmine Magnesium Sulfate 1 B/D, PA Magnesium Sulfate (Intravenous Solution)

C1 Intralipid (50% (10ML Syringe) 1 Intralipid (Intravenous Injection Solution)

C1 1 B/D, PA NephrAmine Emulsion)

C1 Isolyte-P in D5W NephrAmine 1 B/D, PA Isolyte-P in D5W (Intravenous Solution)

C1 1 Normosol-M in (Intravenous Solution) D5W

C1 Isolyte-S Normosol-M in D5W Isolyte-S (Intravenous 1 1 (Intravenous Solution) Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 63 52 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Nutrilipid Potassium Chloride Nutrilipid Potassium Chloride (Intravenous 1 B/D, PA (2MEQ/ML Intravenous Emulsion) Solution, 2MEQ/ML 1 B/D, PA

C1 Plasma-Lyte 148 Plasma-Lyte 148 (20ML) Intravenous 1 Solution)

C1 (Intravenous Solution) Potassium Chloride

C1 Plasma-Lyte A Potassium Chloride Plasma-Lyte A 1 1 (Oral Packet)

C1 (Intravenous Solution) Potassium Chloride

C1 Plenamine Potassium Chloride Plenamine 1 1 B/D, PA (Oral Solution) C1 Potassium Citrate (Intravenous Solution) ER

C1 Potassium Chloride CR Potassium Citrate ER Potassium Chloride CR (Oral Tablet Extended 1 (Oral Tablet Extended 1 Release)

C1 Release) Premasol

C1 Potassium Chloride ER Premasol (Intravenous 1 B/D, PA Potassium Chloride ER Solution)

C1 (Oral Capsule 1 Procalamine Procalamine Extended Release) 1 B/D, PA C1 Potassium Chloride in Dextrose (Intravenous Solution)

C1 Potassium Chloride in Prosol Prosol (Intravenous Dextrose (Intravenous 1 B/D, PA 1 B/D, PA Solution)

C1 Solution) Sodium Chloride

C1 Potassium Chloride in NaCl Sodium Chloride Potassium Chloride in NaCl (20-0.45MEQ/L-% 1 B/D, PA (0.45% Intravenous 1 Intravenous Solution) Solution) C1 Sodium Chloride C1 Potassium Chloride in NaCl Sodium Chloride (0.9% Potassium Chloride in 1 B/D, PA Intravenous Solution)

NaCl (20-0.9MEQ/L-% C1 Sodium Chloride Intravenous Solution, 1 B/D, PA Sodium Chloride (3% Intravenous Solution, 40-0.9MEQ/L-% 1 B/D, PA Intravenous Solution) 5% Intravenous

C1 Potassium Chloride Solution)

Potassium Chloride C1 Sodium Chloride Sodium Chloride (10MEQ/100ML 1 Intravenous Solution, (Irrigation Solution) C1 Sodium Fluoride 20MEQ/100ML 1 B/D, PA Sodium Fluoride (Oral 1 Intravenous Solution, Tablet)

C1 TPN Electrolytes 40MEQ/100ML TPN Electrolytes

Intravenous Solution) (Intravenous 1 Concentrate)

C1 Travasol Travasol (Intravenous 1 B/D, PA Solution)

Bold type = Brand name drug Plain type = Generic drug 64 tRACK 53 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 TrophAmine Veltassa TrophAmine (10% Veltassa (Oral Packet) 1 QL 1 B/D, PA B1 Intravenous Solution)

B1 Phosphate Binders

C1 Electrolyte/Mineral/Metal Modifiers Auryxia

C1 Chemet Auryxia (Oral Tablet) 1 PA

C1 Chemet (Oral Calcium Acetate 1 Calcium Acetate Capsule)

C1 (Phosphate Binder) 1 Clovique Clovique (Oral (Oral Capsule)

C1 1 PA; QL Calcium Acetate Capsule)

C1 Calcium Acetate Deferasirox Granules Deferasirox Granules 1 PA (Phosphate Binder) 1 (Oral Packet) (Oral Tablet)

C1 C1 Deferasirox Lanthanum Deferasirox (Oral Carbonate Lanthanum Carbonate 1 Tablet) (Generic 1 PA (Oral Tablet Chewable)

C1 Jadenu) Phoslyra

C1 Phoslyra (Oral Deferasirox 1 Deferasirox (Oral Solution)

C1 Sevelamer Tablet Soluble) 1 PA Carbonate Sevelamer Carbonate (Generic Exjade) 1

C1 Deferiprone (Oral Packet)

C1 Sevelamer Deferiprone (Oral Carbonate 1 PA Sevelamer Carbonate Tablet)

C1 Ferriprox (Oral Tablet) (Generic 1 Ferriprox (Oral Renvela)

C1 1 PA Velphoro Solution)

C1 Velphoro (Oral Tablet Ferriprox 1 Ferriprox (Oral Tablet) 1 PA Chewable)

C1 B1 Jadenu Jadenu (Oral Tablet) 1 PA Vitamins

C1 C1 VP-PNV-DHA Jadenu Sprinkle Jadenu Sprinkle (Oral VP-PNV-DHA (Oral 1 PA 1 Packet) Capsule) A1

C1 Kionex Kionex (Oral Gastrointestinal Agents 1 B1 Suspension) Antispasmodics, Gastrointestinal C1 Lokelma C1 Cuvposa Lokelma (Oral Packet) 1 QL Cuvposa (Oral

C1 Sodium Polystyrene Sulfonate 1 PA Sodium Polystyrene Solution) C1 Dicyclomine HCl Sulfonate (Oral 1 Dicyclomine HCl (Oral 1 Powder) Capsule)

C1 Sodium Polystyrene C1 Sulfonate Dicyclomine HCl Sodium Polystyrene Dicyclomine HCl (Oral 1 Sulfonate (Oral 1 Solution)

C1 Suspension) Dicyclomine HCl C1 Dicyclomine HCl (Oral SPS 1 SPS (Oral Suspension) 1 Tablet)

C1 C1 Methscopolamine Trientine HCl Bromide Trientine HCl (Oral Methscopolamine 1 PA; QL 1 Capsule) Bromide (Oral Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 65 54 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

B1 C1 Cimetidine Gastrointestinal Agents, Other Cimetidine (Oral

C1 Chenodal 1 Tablet)

C1 Chenodal (Oral Tablet) 1 Famotidine

C1 Cromolyn Sodium Cromolyn Sodium Famotidine (Oral 1 (Oral Concentrate) Suspension 1

C1 Diphenoxylate- Atropine Reconstituted)

C1 Diphenoxylate-Atropine Famotidine 1 (Oral Liquid) Famotidine (20MG

C1 Diphenoxylate- Atropine Oral Tablet, 40MG Oral 1 Diphenoxylate-Atropine 1 Tablet) (Oral Tablet) B1

C1 Gattex Irritable Bowel Syndrome Agents

C1 Gattex (Subcutaneous Alosetron HCl 1 PA; LA Alosetron HCl (Oral Kit) 1 PA

C1 Loperamide HCl Tablet)

C1 Loperamide HCl (Oral Amitiza 1 Amitiza (Oral Capsule) 1 QL C1 Myalept Capsule)

C1 Myalept Linzess Linzess (Oral (Subcutaneous 1 QL 1 PA; LA Capsule)

C1 Solution Xifaxan Reconstituted) Xifaxan (Oral Tablet) 1 PA B1

C1 Relistor Relistor (Oral Tablet) Laxatives 1 PA; QL C1 Clenpiq

C1 Relistor Clenpiq (Oral Relistor 1 Solution)

(Subcutaneous 1 PA C1 Constulose Solution) Constulose (Oral

C1 Serostim 1 Solution)

C1 Serostim Enulose (Subcutaneous Enulose (Oral Solution) 1 C1 1 PA; LA GaviLyte-C Solution GaviLyte-C (Oral Reconstituted) Solution 1

C1 Ursodiol Reconstituted) Ursodiol (Oral C1 1 GaviLyte-G Capsule) GaviLyte-G (Oral

C1 Ursodiol Ursodiol (Oral Tablet) 1 Solution 1

C1 Zorbtive Reconstituted)

C1 GaviLyte-N with Zorbtive Flavor Pack GaviLyte-N with Flavor (Subcutaneous 1 PA; LA Pack (Oral Solution 1 Solution Reconstituted)

C1 Reconstituted) Generlac B1 Generlac (Oral Histamine2 (H2) Receptor Antagonists 1

C1 Cimetidine HCl Solution)

C1 Lactulose Cimetidine HCl (Oral Lactulose (10GM/ 1 1 Solution) 15ML Oral Solution)

Bold type = Brand name drug Plain type = Generic drug 66 tRACK 55 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 PEG-3350-NaCl-Na Omeprazole Bicarbonate-KCl PEG-3350-NaCl-Na Omeprazole (20MG Bicarbonate-KCl (Oral Oral Capsule Delayed 1 Solution) (Generic Release, 40MG Oral 1 NuLYTELY) Capsule Delayed

C1 PEG-3350- Electrolytes Release)

PEG-3350-Electrolytes C1 Pantoprazole Sodium (Oral Solution) 1 Pantoprazole Sodium (Generic GoLYTELY) (Oral Tablet Delayed 1 QL

C1 Suprep Bowel Prep Kit Release) Suprep Bowel Prep C1 1 Prilosec Kit (Oral Solution) Prilosec (Oral Packet) 1 PA

C1 C1 TriLyte Rabeprazole TriLyte (Oral Solution Sodium Rabeprazole Sodium 1 Reconstituted) (Oral Tablet Delayed 1 B1 Release)

Protectants A1

C1 Carafate Carafate (Oral Genetic or Enzyme Disorder: Replacement, 1 Suspension) Modifiers, Treatment B1

C1 Misoprostol Misoprostol (Oral Genetic or Enzyme Disorder: Replacement, 1 Tablet) Modifiers, Treatment C1 Aralast NP C1 Sucralfate Sucralfate (Oral Aralast NP (1000MG 1 Suspension) Intravenous Solution 1 PA; LA

C1 Sucralfate Reconstituted)

Sucralfate (Oral Tablet) 1 C1 Cholbam

B1 Proton Pump Inhibitors Cholbam (Oral

C1 1 PA Dexilant Capsule)

C1 Dexilant (Oral Creon Creon (Oral Capsule Capsule Delayed 1 QL Release) Delayed Release 1

C1 Esomeprazole Magnesium Particles)

C1 Esomeprazole Cystadane Cystadane (Oral Magnesium (Oral 1 Capsule Delayed 1 QL Powder) C1 Cystagon Release) (Generic Cystagon (Oral 1 LA Nexium) Capsule) C1 Lansoprazole C1 Glassia Lansoprazole (Oral Glassia (Intravenous 1 PA; LA Capsule Delayed 1 QL Solution)

C1 Release) Kuvan

C1 Omeprazole Kuvan (Oral Packet) 1 LA

C1 Omeprazole (10MG Kuvan Kuvan (Oral Tablet Oral Capsule Delayed 1 QL 1 LA Soluble)

Release) C1 Miglustat Miglustat (Oral 1 PA; LA Capsule)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 67 56 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Nitisinone Oxybutynin Chloride ER Nitisinone (Oral Oxybutynin Chloride 1 Capsule) ER (Oral Tablet

C1 Ocaliva 1 QL Ocaliva (Oral Tablet) 1 PA; QL Extended Release 24

C1 Orfadin Hour)

C1 Oxybutynin Orfadin (Oral Chloride 1 LA Oxybutynin Chloride Capsule) 1

C1 Orfadin (Oral Syrup)

C1 Oxybutynin Orfadin (Oral Chloride 1 LA Oxybutynin Chloride Suspension)

C1 Procysbi (Oral Tablet Immediate 1 Procysbi (Oral Release)

C1 1 LA Solifenacin Packet) Succinate

C1 Prolastin-C Solifenacin Succinate 1 QL Prolastin-C (Oral Tablet)

B1 (Intravenous Solution 1 PA; LA Benign Prostatic Hypertrophy Agents

C1 Reconstituted) Alfuzosin HCl ER

C1 RAVICTI Alfuzosin HCl ER (Oral RAVICTI (Oral Liquid) 1 LA; QL Tablet Extended 1 C1 Sodium Phenylbutyrate Sodium Phenylbutyrate Release 24 Hour) C1 1 Dutasteride (Oral Powder) Dutasteride (Oral C1 Sodium Phenylbutyrate 1 QL Sodium Phenylbutyrate Capsule) C1 1 Finasteride (Oral Tablet) Finasteride (5MG Oral

C1 Sucraid Sucraid (Oral Tablet) (Generic 1 1 LA Proscar)

Solution) C1 Silodosin

C1 Tegsedi Silodosin (Oral Tegsedi 1 QL Capsule)

C1 (Subcutaneous Tamsulosin HCl 1 PA; LA Tamsulosin HCl (Oral Solution Prefilled 1 Capsule)

Syringe) C1 Terazosin HCl

C1 Zemaira Terazosin HCl (Oral Zemaira (Intravenous 1 Capsule) Solution 1 PA; LA B1 Reconstituted) Genitourinary Agents, Other C1 Bethanechol Chloride C1 Zenpep Bethanechol Chloride Zenpep (Oral Capsule 1 (Oral Tablet)

Delayed Release C1 1 Depen Titratabs Particles) Depen Titratabs (Oral A1 1 Tablet)

C1 Genitourinary Agents Elmiron

B1 Antispasmodics, Urinary Elmiron (Oral

C1 1 Myrbetriq Capsule)

C1 Myrbetriq (Oral Tablet Lithostat

Extended Release 24 1 Lithostat (Oral Tablet) 1 C1 Penicillamine Hour) Penicillamine (250MG 1 PA Oral Capsule)

Bold type = Brand name drug Plain type = Generic drug 68 tRACK 57 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Penicillamine Betamethasone Valerate Penicillamine (250MG Betamethasone 1 Oral Tablet) Valerate (External 1 A1 Cream)

Hormonal Agents, Stimulant/Replacement/ C1 Betamethasone Valerate Modifying (Adrenal) Betamethasone

B1 Hormonal Agents, Stimulant/Replacement/ Valerate (External 1 Lotion)

C1 Betamethasone Modifying (Adrenal) Valerate

C1 Ala-Cort Ala-Cort (1% External Betamethasone 1 Cream) Valerate (External 1

C1 Alclometasone Dipropionate Ointment)

C1 Clobetasol Propionate Alclometasone Emollient Base Dipropionate (External 1 Clobetasol Propionate Cream) Emollient Base 1

C1 Alclometasone Dipropionate (External Cream)

C1 Clobetasol Alclometasone Propionate Clobetasol Propionate Dipropionate (External 1 1 (External Cream)

C1 Clobetasol Ointment) Propionate

C1 Betamethasone Dipropionate Aug Clobetasol Propionate Betamethasone 1 (External Gel)

C1 Clobetasol Dipropionate Aug 1 Propionate (External Cream) Clobetasol Propionate

C1 Betamethasone 1 Dipropionate Aug (External Ointment)

C1 Clobetasol Betamethasone Propionate Clobetasol Propionate Dipropionate Aug 1 1 (External Gel) (External Shampoo) C1 Clobetasol C1 Propionate Betamethasone Dipropionate Aug Clobetasol Propionate Betamethasone 1 Dipropionate Aug 1 (External Solution) C1 Cordran (External Lotion) Cordran (External

C1 Betamethasone Dipropionate Aug 1 Betamethasone Tape) C1 Cortisone Acetate Dipropionate Aug 1 Cortisone Acetate 1 (External Ointment) (Oral Tablet) C1 Betamethasone Dipropionate C1 Desonide Betamethasone Desonide (External 1 Dipropionate (External 1 Ointment)

C1 Cream) Desoximetasone

C1 Betamethasone Dipropionate Desoximetasone 1 Betamethasone (External Cream)

C1 Dexamethasone Dipropionate (External 1 Dexamethasone (Oral Lotion) 1

C1 Betamethasone Dipropionate Elixir)

C1 Dexamethasone Betamethasone Dexamethasone (Oral 1 Dipropionate (External 1 Tablet)

C1 Fludrocortisone Ointment) Acetate Fludrocortisone 1 Acetate (Oral Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 69 58 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Fluocinolone Hydrocortisone Acetonide Fluocinolone Hydrocortisone (2.5% 1 Acetonide (External 1 External Lotion)

C1 Cream) Hydrocortisone

C1 Hydrocortisone (1% Fluocinolone Acetonide Fluocinolone External Ointment, 1 Acetonide (External 1 2.5% External Ointment) Ointment)

C1 C1 Fluocinolone Hydrocortisone Acetonide Fluocinolone Hydrocortisone (Oral 1 Acetonide (External 1 Tablet)

C1 Hydrocortisone Solution) Valerate

C1 Hydrocortisone Fluocinolone Acetonide Scalp Fluocinolone Valerate (External 1 Acetonide Scalp 1 Cream)

C1 Hydrocortisone (External Oil) Valerate

C1 Hydrocortisone Fluocinonide Emulsified Base Fluocinonide Valerate (External 1 Emulsified Base 1 Ointment)

C1 (External Cream) Methylprednisolone C1 Methylprednisolone Fluocinonide 1 Fluocinonide (External (Oral Tablet)

C1 1 Methylprednisolone Gel)

C1 Methylprednisolone Fluocinonide Fluocinonide (External (Oral Tablet Therapy 1 1 Ointment) Pack)

C1 C1 Fluocinonide Mometasone Fluocinonide (External Furoate Mometasone Furoate 1 1 Solution) (External Cream)

C1 C1 Fluticasone Mometasone Propionate Fluticasone Propionate Furoate Mometasone Furoate 1 1 (External Cream) (External Ointment)

C1 C1 Fluticasone Mometasone Propionate Fluticasone Propionate Furoate Mometasone Furoate 1 1 (External Ointment) (External Solution)

C1 C1 Halobetasol Prednicarbate Propionate Halobetasol Prednicarbate 1 Propionate (External 1 (External Cream)

C1 Cream) Prednicarbate C1 Prednicarbate Halobetasol Propionate 1 Halobetasol (External Ointment)

C1 Prednisolone Propionate (External 1 Prednisolone (Oral Ointment) 1

C1 Solution) Hydrocortisone Butyrate C1 Prednisolone Sodium Phosphate Hydrocortisone Prednisolone Sodium Butyrate (External 1 Phosphate (25MG/ Ointment)

C1 5ML Oral Solution, 1 Hydrocortisone Hydrocortisone (1% 6.7MG/5ML Oral External Cream, 2.5% 1 Solution) External Cream)

Bold type = Brand name drug Plain type = Generic drug 70 tRACK 59 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Prednisone Intensol Desmopressin Acetate Prednisone Intensol Desmopressin Acetate 1 1 (Oral Concentrate) (Oral Tablet)

C1 C1 Prednisone Desmopressin Prednisone (5MG/5ML Acetate Spray Desmopressin Acetate 1 1 Oral Solution) Spray (Nasal Solution)

C1 C1 Prednisone Genotropin Prednisone (10MG MiniQuick Genotropin MiniQuick Oral Tablet, 1MG Oral (Subcutaneous 1 PA Tablet, 2.5MG Oral Solution Tablet, 20MG Oral 1 Reconstituted)

C1 Tablet, 50MG Oral Genotropin Genotropin Tablet, 5MG Oral (Subcutaneous Tablet) 1 PA C1 Prednisone Solution Prednisone (10MG (21) Reconstituted)

C1 Oral Tablet Therapy Humatrope Pack, 10MG (48) Oral Humatrope (Injection Tablet Therapy Pack, Solution 1 5MG (21) Oral Tablet Renconstituted), 1 PA Therapy Pack, 5MG Humatrope Combo (48) Oral Tablet Pack (Injection)

C1 Therapy Pack) Increlex

C1 Triamcinolone Acetonide Increlex Triamcinolone (Subcutaneous 1 PA; LA Acetonide (External 1 Solution)

C1 Cream) Norditropin FlexPro

C1 Triamcinolone Acetonide Norditropin FlexPro Triamcinolone (Subcutaneous 1 PA Acetonide (External 1 Solution Pen-Injector)

C1 Nutropin AQ Lotion) NuSpin 10

C1 Triamcinolone Acetonide Nutropin AQ NuSpin Triamcinolone Acetonide (0.025% 10 (Subcutaneous 1 PA Solution Pen-Injector) C1 External Ointment, Nutropin AQ 1 NuSpin 20 0.1% External Nutropin AQ NuSpin Ointment, 0.5% 20 (Subcutaneous 1 PA External Ointment) Solution Pen-Injector) C1 Triderm C1 Nutropin AQ Triderm (External NuSpin 5 1 Nutropin AQ NuSpin 5 Cream) (Subcutaneous A1 1 PA Hormonal Agents, Stimulant/Replacement/ Solution Pen-Injector)

C1 Saizen Modifying (Pituitary) Saizen (Injection B1 Hormonal Agents, Stimulant/Replacement/ Solution 1 PA; LA Modifying (Pituitary) Reconstituted)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 71 60 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Saizenprep Testosterone Saizenprep (Injection Testosterone Solution 1 PA; LA (20.25MG/1.25GM Reconstituted) 1.62% Transdermal A1 Gel, 40.5MG/2.5GM Hormonal Agents, Stimulant/Replacement/ 1 1.62% Transdermal Modifying (Prostaglandins) B1 Gel), Testosterone Hormonal Agents, Stimulant/Replacement/ Pump (1.62% Modifying (Prostaglandins) Transdermal Gel) C1 Korlym B1 Korlym (Oral Tablet) 1 PA; LA; QL Estrogens

A1 C1 Altavera Hormonal Agents, Stimulant/Replacement/ Altavera (Oral Tablet) 1

C1 Modifying (Sex Hormones/Modifiers) Alyacen 1/35 B1 Alyacen 1/35 (Oral 1 Androgens Tablet)

C1 C1 Anadrol-50 Amethia Lo Anadrol-50 (Oral Amethia Lo (Oral 1 PA 1 Tablet) Tablet)

C1 C1 Amethia Androderm Androderm Amethia (Oral Tablet) 1

C1 Apri (Transdermal Patch 1 QL Apri (Oral Tablet) 1

C1 24 Hour) Aranelle

C1 Danazol Aranelle (Oral Tablet) 1 C1 Danazol (Oral Capsule) 1 Ashlyna

C1 Oxandrolone Ashlyna (Oral Tablet) 1

C1 Oxandrolone (10MG Aubra 1 PA; QL Aubra (Oral Tablet) 1

Oral Tablet) C1 Aviane

C1 Oxandrolone Oxandrolone (2.5MG Aviane (Oral Tablet) 1 C1 1 PA; QL Balziva Oral Tablet) Balziva (Oral Tablet) 1 C1 Testosterone Cypionate C1 Blisovi 24 Fe Testosterone Blisovi 24 Fe (Oral 1 Cypionate Tablet) 1 C1 Blisovi Fe 1.5/30 (Intramuscular Blisovi Fe 1.5/30 (Oral Solution) 1

C1 Testosterone Enanthate Tablet)

C1 Testosterone Briellyn Briellyn (Oral Tablet) 1

C1 Enanthate Camrese Lo 1 Camrese Lo (Oral (Intramuscular 1 Solution) Tablet) C1 Caziant C1 Testosterone Testosterone (25MG/ Caziant (Oral Tablet) 1 C1 Climara Pro 2.5GM 1% Climara Pro

Transdermal Gel, (Transdermal Patch 1 50MG/5GM 1% 1 Weekly)

C1 Transdermal Gel), Cryselle-28 Cryselle-28 (Oral Testosterone Pump 1 (1% Transdermal Gel) Tablet)

Bold type = Brand name drug Plain type = Generic drug 72 tRACK 61 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Cyclafem 1/35 Ethynodiol Diacetate-Ethinyl Cyclafem 1/35 (Oral Estradiol Ethynodiol Diacetate- 1 Tablet) Ethinyl Estradiol (Oral 1

C1 Cyclafem 7/7/7 Tablet) Cyclafem 7/7/7 (Oral C1 Etonogestrel-Ethinyl 1 Estradiol Tablet) Etonogestrel-Ethinyl

C1 Cyred Cyred (Oral Tablet) 1 Estradiol (Vaginal 1

C1 Depo-Estradiol Ring)

C1 Depo-Estradiol Falmina 1 Falmina (Oral Tablet) 1

(Intramuscular Oil) C1 Fayosim

C1 Desogestrel-Ethinyl Estradiol Desogestrel-Ethinyl Fayosim (Oral Tablet) 1 C1 Femring Estradiol Femring (Vaginal 1 1 (0.15-0.02/0.01MG Ring)

C1 (21/5) Oral Tablet) Femynor

C1 Drospirenone- Ethinyl Estradiol Femynor (Oral Tablet) 1

C1 Drospirenone-Ethinyl Fyavolv 1 Fyavolv (Oral Tablet) 1

C1 Estradiol (Oral Tablet) Gianvi

C1 Duavee Gianvi (Oral Tablet) 1

Duavee (Oral Tablet) 1 C1 Hailey 24 Fe

C1 Elestrin Hailey 24 Fe (Oral Elestrin (Transdermal 1 1 Tablet)

C1 Imvexxy Gel) Maintenance Pack

C1 EluRyng Imvexxy Maintenance EluRyng (Vaginal Ring) 1 1 PA; QL

C1 Emoquette Pack (Vaginal Insert)

C1 Imvexxy Starter Emoquette (Oral Pack 1 Imvexxy Starter Pack Tablet) 1 PA; QL C1 Enpresse-28 (Vaginal Insert)

C1 Enpresse-28 (Oral Introvale 1 Introvale (Oral Tablet) 1

Tablet) C1 Isibloom C1 Enskyce Enskyce (Oral Tablet) 1 Isibloom (Oral Tablet) 1 C1 Jasmiel C1 Estarylla Estarylla (Oral Tablet) 1 Jasmiel (Oral Tablet) 1 C1 Jinteli C1 Estradiol Estradiol (Oral Tablet) 1 Jinteli (Oral Tablet) 1 C1 Juleber C1 Estradiol Estradiol (Transdermal Juleber (Oral Tablet) 1 C1 1 QL Junel 1.5/30 Patch Weekly) Junel 1.5/30 (Oral C1 Estradiol 1 Estradiol (Vaginal Tablet) C1 1 Junel 1/20 Cream) Junel 1/20 (Oral C1 Estradiol 1 Estradiol (Vaginal Tablet) C1 1 QL Junel Fe 1.5/30 Tablet) Junel Fe 1.5/30 (Oral C1 Estradiol Valerate 1 Estradiol Valerate Tablet) C1 1 Junel Fe 1/20 (Intramuscular Oil) Junel Fe 1/20 (Oral C1 Estring 1 Estring (Vaginal Ring) 1 Tablet) C1 Junel Fe 24 Junel Fe 24 (Oral 1 Tablet)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 73 62 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Kaitlib Fe Lutera Kaitlib Fe (Oral Tablet Lutera (Oral Tablet) 1

C1 1 Marlissa Chewable)

C1 Kariva Marlissa (Oral Tablet) 1

C1 Kariva (Oral Tablet) 1 Melodetta 24 Fe

C1 Kelnor 1/35 Melodetta 24 Fe (Oral 1 Kelnor 1/35 (Oral Tablet Chewable)

C1 1 Menest Tablet)

C1 Kelnor 1/50 Menest (Oral Tablet) 1

C1 Kelnor 1/50 (Oral Mibelas 24 Fe 1 Mibelas 24 Fe (Oral Tablet) 1

C1 Kurvelo Tablet Chewable)

C1 Kurvelo (Oral Tablet) 1 Microgestin 1.5/30

C1 LARIN 1.5/30 Microgestin 1.5/30 1 LARIN 1.5/30 (Oral (Oral Tablet)

C1 1 Microgestin 1/20 Tablet)

C1 LARIN 1/20 Microgestin 1/20 (Oral 1 LARIN 1/20 (Oral Tablet)

C1 1 Microgestin Fe Tablet) 1.5/30

C1 LARIN Fe 1.5/30 Microgestin Fe 1.5/30 1 LARIN Fe 1.5/30 (Oral (Oral Tablet)

C1 1 Microgestin Fe 1/20 Tablet)

C1 LARIN Fe 1/20 Microgestin Fe 1/20 1 LARIN Fe 1/20 (Oral (Oral Tablet)

C1 1 Mili Tablet)

C1 Larissia Mili (Oral Tablet) 1

C1 Larissia (Oral Tablet) 1 Necon 0.5/35

C1 Layolis Fe Necon 0.5/35 (28) 1 Layolis Fe (Oral (Oral Tablet)

C1 1 Nikki Tablet Chewable)

C1 Leena Nikki (Oral Tablet) 1

C1 Norethindrone Acetate-Ethinyl Leena (Oral Tablet) 1 Estradiol

C1 Norethindrone Acetate- Lessina Lessina (Oral Tablet) 1 Ethinyl Estradiol

C1 Levonest Levonest (Oral Tablet) 1 (0.5-2.5MG-MCG Oral 1

C1 Levonorgestrel- Ethinyl Estradiol & Ethinyl Estradiol Tablet, 1-5MG-MCG Levonorgestrel-Ethinyl Oral Tablet) C1 Norethindrone Acetate-Ethinyl Estradiol & Ethinyl 1 Estradiol Estradiol (Oral Tablet) Norethindrone Acetate-

C1 Levonorgestrel- Ethinyl Estradiol 91- Day Ethinyl Estradiol 1 Levonorgestrel-Ethinyl (1-20MG-MCG Oral Estradiol 91-Day (Oral 1 Tablet)

C1 Norethindrone Acetate-Ethinyl Tablet) Estradiol-Fe

C1 Levonorgestrel- Ethinyl Estradiol Norethindrone Acetate- Levonorgestrel-Ethinyl 1 Ethinyl Estradiol-Fe Estradiol (Oral Tablet) C1 (0.4-35MG-MCG Oral Levora 0.15/30 Levora 0.15/30 (28) Tablet Chewable, 1 1 (Oral Tablet) 0.8-25MG-MCG Oral

C1 Loryna Loryna (Oral Tablet) 1 Tablet Chewable,

C1 Low-Ogestrel 1-20MG-MCG(24) Oral Low-Ogestrel (Oral 1 Tablet Chewable) Tablet)

Bold type = Brand name drug Plain type = Generic drug 74 tRACK 63 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Norgestimate- Tarina 24 Fe Ethinyl Estradiol Norgestimate-Ethinyl Tarina 24 Fe (Oral 1 1 Estradiol (Oral Tablet) Tablet)

C1 C1 Norgestimate- Tarina Fe 1/20 Ethinyl Estradiol Triphasic Norgestimate-Ethinyl Tarina Fe 1/20 (Oral 1 Estradiol Triphasic 1 Tablet)

C1 (Oral Tablet) Tri-Estarylla C1 Tri-Estarylla (Oral Nortrel 0.5/35 1 Nortrel 0.5/35 (28) Tablet)

C1 1 Tri-Legest Fe (Oral Tablet) C1 Tri-Legest Fe (Oral Nortrel 1/35 1 Nortrel 1/35 (21) (Oral Tablet)

C1 1 Tri-Lo-Estarylla Tablet) C1 Tri-Lo-Estarylla (Oral Nortrel 1/35 1 Nortrel 1/35 (28) (Oral Tablet)

C1 1 Tri-Lo-Sprintec Tablet) C1 Tri-Lo-Sprintec (Oral Nortrel 7/7/7 1 Nortrel 7/7/7 (Oral Tablet)

C1 1 Tri-Mili Tablet)

C1 Ocella Tri-Mili (Oral Tablet) 1

C1 Tri-Previfem Ocella (Oral Tablet) 1 C1 Tri-Previfem (Oral Orsythia 1 Orsythia (Oral Tablet) 1 Tablet)

C1 C1 Tri-Sprintec Pimtrea Pimtrea (Oral Tablet) 1 Tri-Sprintec (Oral

C1 1 Pirmella 1/35 Tablet)

C1 Pirmella 1/35 (Oral Trivora 1 Tablet) Trivora (28) (Oral

C1 1 Portia-28 Tablet)

C1 Portia-28 (Oral Tablet) 1 Tri-VyLibra Lo

C1 Premarin Tri-VyLibra Lo (Oral Premarin (Oral Tablet) 1 QL 1

C1 Tablet) Premarin

C1 Tri-VyLibra Premarin (Vaginal Tri-VyLibra (Oral 1 1 Cream) Tablet) C1 Premphase C1 Velivet Premphase (Oral Velivet (Oral Tablet) 1

1 QL C1 Tablet) Vienva

C1 Prempro Vienva (Oral Tablet) 1

C1 Prempro (Oral Tablet) 1 QL Vyfemla

C1 Previfem Vyfemla (Oral Tablet) 1 C1 Previfem (Oral Tablet) 1 VyLibra

C1 Reclipsen VyLibra (Oral Tablet) 1 C1 Reclipsen (Oral Tablet) 1 WYMZYA Fe

C1 Rivelsa WYMZYA Fe (Oral 1 Rivelsa (Oral Tablet) 1 Tablet Chewable) C1 Setlakin C1 Xulane Setlakin (Oral Tablet) 1 Xulane (Transdermal

C1 Sprintec 28 1 Patch Weekly) Sprintec 28 (Oral C1 1 Yuvafem Tablet) Yuvafem (Vaginal

C1 Sronyx 1 QL Tablet)

C1 Sronyx (Oral Tablet) 1 Zarah

C1 Syeda Syeda (Oral Tablet) 1 Zarah (Oral Tablet) 1

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 75 64 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Zovia 1/35E Norethindrone Acetate Zovia 1/35E (28) (Oral Norethindrone Acetate 1 1 Tablet) (5MG Oral Tablet)

B1 C1 Norethindrone Progestins Norethindrone

C1 Camila 1 (0.35MG Oral Tablet)

Camila (Oral Tablet) 1 C1 Progesterone Micronized

C1 Crinone Crinone (Vaginal Gel) 1 PA Progesterone

C1 Deblitane Micronized (Oral 1 Deblitane (Oral Tablet) 1 Capsule) C1 Depo-Provera C1 Sharobel Depo-Provera Sharobel (Oral Tablet) 1 (400MG/ML B1 1 Selective Estrogen Receptor Modifying Intramuscular Agents

C1 Suspension) Osphena

C1 Errin Osphena (Oral Tablet) 1 PA; QL

C1 Errin (Oral Tablet) 1 Raloxifene HCl

C1 Incassia Raloxifene HCl (Oral Incassia (Oral Tablet) 1 1 QL

C1 Tablet) Lyza A1 Lyza (Oral Tablet) 1 Hormonal Agents, Stimulant/Replacement/ C1 Medroxyprogestero ne Acetate Medroxyprogesterone Modifying (Thyroid) Acetate (150MG/ML B1 1 Hormonal Agents, Stimulant/Replacement/ Intramuscular Modifying (Thyroid)

C1 Suspension) Euthyrox

C1 Medroxyprogestero ne Acetate Euthyrox (Oral Tablet) 1

C1 Medroxyprogesterone Levo-T Levo-T (Oral Tablet) 1

Acetate (150MG/ML C1 Levothyroxine Sodium Intramuscular 1 Levothyroxine Sodium 1 Suspension Prefilled (Oral Tablet)

C1 Syringe) Levoxyl

C1 Medroxyprogestero Levoxyl (Oral Tablet) 1 ne Acetate

C1 Liothyronine Medroxyprogesterone Sodium Liothyronine Sodium 1 Acetate (10MG Oral (Oral Tablet)

C1 Tablet, 2.5MG Oral 1 Synthroid Synthroid (Oral Tablet, 5MG Oral 1 Tablet) Tablet)

C1 Megestrol Acetate Megestrol Acetate (40MG/ML Oral 1 Suspension)

C1 Megestrol Acetate Megestrol Acetate (625MG/5ML Oral 1 Suspension)

C1 Megestrol Acetate Megestrol Acetate 1 (Oral Tablet)

C1 Nora-BE Nora-BE (Oral Tablet) 1

Bold type = Brand name drug Plain type = Generic drug 76 tRACK 65 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Unithroid Lupaneta Pack Unithroid (100MCG Lupaneta Pack 1 PA Oral Tablet, 112MCG (Combination Kit)

C1 Lupron Depot Oral Tablet, 125MCG Lupron Depot (1- Oral Tablet, 150MCG Month) 1 PA Oral Tablet, 175MCG (Intramuscular Kit)

C1 Oral Tablet, 200MCG Lupron Depot 1 Lupron Depot (3- Oral Tablet, 25MCG Month) 1 PA Oral Tablet, 300MCG (Intramuscular Kit)

C1 Oral Tablet, 50MCG Lupron Depot Lupron Depot (4- Oral Tablet, 75MCG Month) 1 PA Oral Tablet, 88MCG (Intramuscular Kit)

C1 Oral Tablet) Lupron Depot A1 Lupron Depot (6- Hormonal Agents, Suppressant (Adrenal) B1 Month) 1 PA Hormonal Agents, Suppressant (Adrenal)

C1 Lysodren (Intramuscular Kit)

C1 Lysodren (Oral Octreotide Acetate 1 Octreotide Acetate Tablet)

A1 (1000MCG/ML Hormonal Agents, Suppressant (Pituitary) Injection Solution, 1 PA

B1 Hormonal Agents, Suppressant (Pituitary) 500MCG/ML Injection

C1 Cabergoline Solution)

C1 Cabergoline (Oral Octreotide Acetate 1 Tablet) Octreotide Acetate

C1 Egrifta SV (100MCG/ML Injection Egrifta SV (2MG Solution, 200MCG/ML Subcutaneous 1 PA 1 PA; LA Injection Solution, Solution 50MCG/ML Injection Reconstituted) Solution) C1 Firmagon C1 Signifor Firmagon (240MG Signifor Dose) (120MG/Vial (Subcutaneous 1 PA; LA Subcutaneous 1 PA Solution)

C1 Somatuline Depot Solution Somatuline Depot Reconstituted)

C1 Firmagon (Subcutaneous 1 Firmagon (80MG Solution)

C1 Subcutaneous Somavert 1 PA Somavert Solution (Subcutaneous Reconstituted) 1 PA; LA; QL

C1 Leuprolide Acetate Solution Leuprolide Acetate Reconstituted)

1 PA C1 Synarel (Injection Kit) Synarel (Nasal 1 Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 77 66 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Trelstar Mixject Cimzia Trelstar Mixject Cimzia 1 PA (Intramuscular (Subcutaneous Kit)

C1 Cyclosporine 1 PA Modified Suspension Cyclosporine Modified 1 B/D, PA Reconstituted) (Oral Capsule)

A1 C1 Cyclosporine Hormonal Agents, Suppressant (Thyroid) Modified Cyclosporine Modified B1 1 B/D, PA Antithyroid Agents (Oral Solution) C1 Cyclosporine C1 Methimazole Methimazole (Oral Cyclosporine (Oral 1 1 B/D, PA Tablet) Capsule) C1 Enbrel Mini C1 Propylthiouracil Propylthiouracil (Oral Enbrel Mini 1 Tablet) (Subcutaneous 1 PA A1 Solution Cartridge)

Immunological Agents C1 Enbrel

B1 Angioedema Agents Enbrel

C1 Berinert Berinert (Intravenous (Subcutaneous 1 PA 1 PA; LA Solution)

C1 Kit) Enbrel

C1 Cinryze Cinryze (Intravenous Enbrel (Subcutaneous Solution 1 PA; LA 1 PA Reconstituted) Solution Prefilled

C1 Firazyr Syringe)

C1 Firazyr Enbrel (Subcutaneous 1 PA; QL Enbrel (Subcutaneous Solution) 1 PA C1 Haegarda Solution Haegarda Reconstituted)

C1 (Subcutaneous Enbrel SureClick 1 PA; LA Solution Enbrel SureClick (Subcutaneous Reconstituted) 1 PA C1 Icatibant Acetate Solution Auto- Icatibant Acetate Injector)

C1 (Subcutaneous 1 PA; QL Envarsus XR Solution) Envarsus XR (Oral

C1 Ruconest Ruconest Tablet Extended 1 B/D, PA Release 24 Hour)

C1 (Intravenous Solution 1 PA; LA Everolimus Reconstituted) Everolimus (0.25MG B1 Oral Tablet, 0.5MG Immune Suppressants 1 B/D, PA

C1 Azathioprine Oral Tablet, 0.75MG Azathioprine (Oral Oral Tablet)

1 B/D, PA C1 Tablet) Gengraf

C1 Cimzia Prefilled Gengraf (Oral Capsule) 1 B/D, PA

C1 Cimzia Prefilled Gengraf 1 PA (Subcutaneous Kit) Gengraf (Oral Solution) 1 B/D, PA

Bold type = Brand name drug Plain type = Generic drug 78 tRACK 67 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Humira Pediatric Mycophenolate Crohns Start Mofetil Humira Pediatric Mycophenolate Mofetil 1 B/D, PA Crohns Start (Oral Tablet) C1 Mycophenolate 1 PA Sodium (Subcutaneous Mycophenolate Prefilled Syringe Kit) Sodium (Oral Tablet 1 B/D, PA

C1 Humira Pen Delayed Release)

Humira Pen C1 Orencia ClickJect (Subcutaneous Pen- 1 PA Orencia ClickJect Injector Kit) (Subcutaneous

C1 Humira Pen Crohns Disease Starter 1 PA Humira Pen Crohns Solution Auto- Injector)

Disease Starter C1 1 PA Orencia (Subcutaneous Pen- Orencia Injector Kit) (Subcutaneous

C1 Humira Pen Psoriasis Starter 1 PA Humira Pen Psoriasis Solution Prefilled Syringe)

Starter C1 1 PA Prograf (Subcutaneous Pen- Prograf (Oral Packet) 1 B/D, PA

C1 Rasuvo Injector Kit) Rasuvo C1 Humira Humira (Subcutaneous 1 PA (Subcutaneous 1 PA Solution Auto- Prefilled Syringe Kit) Injector)

C1 C1 Kineret Sandimmune Kineret Sandimmune (Oral 1 B/D, PA (Subcutaneous Solution)

C1 1 PA Simponi Solution Prefilled Simponi Syringe) (Subcutaneous C1 Methotrexate 1 PA Methotrexate (Oral Solution Auto- 1 Tablet) Injector) C1 Methotrexate C1 Sodium Simponi Methotrexate Sodium Simponi (50MG/2ML Injection (Subcutaneous 1 1 PA Solution Prefilled Solution Prefilled Syringe)

C1 Methotrexate Syringe) Sodium

C1 Sirolimus Methotrexate Sodium Sirolimus (Oral 1 B/D, PA (50MG/2ML Injection 1 Solution)

C1 Solution) Sirolimus

C1 Mycophenolate Mofetil Sirolimus (Oral Tablet) 1 B/D, PA

C1 Mycophenolate Mofetil Tacrolimus 1 B/D, PA Tacrolimus (Oral (Oral Capsule) 1 B/D, PA C1 Mycophenolate Mofetil Capsule)

C1 Mycophenolate Mofetil Trexall (Oral Suspension 1 B/D, PA Trexall (Oral Tablet) 1 C1 Xatmep Reconstituted) Xatmep (Oral 1 PA Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 79 68 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Xeljanz Octagam Xeljanz (Oral Tablet Octagam (1GM/20ML 1 PA; QL Immediate Release) Intravenous Solution,

C1 Xeljanz XR 1 PA Xeljanz XR (Oral 2GM/20ML Tablet Extended 1 PA; QL Intravenous Solution) C1 Panzyga Release 24 Hour) Panzyga (Intravenous

C1 Zortress 1 PA Zortress (Oral Tablet) 1 B/D, PA Solution) C1 Privigen

B1 Immunizing Agents, Passive Privigen (20GM/

C1 BIVIGAM BIVIGAM (Intravenous 200ML Intravenous 1 PA 1 PA Solution)

C1 Solution) Varizig

C1 Flebogamma DIF Varizig (Intramuscular Flebogamma DIF 1 Solution) (5GM/50ML 1 PA B1 Immunomodulators

Intravenous Solution) C1 Actemra ACTPen

C1 Gammagard Gammagard (2.5GM/ Actemra ACTPen (Subcutaneous 25ML Injection 1 PA 1 PA Solution) Solution Auto-

C1 Gammagard S/D Less IgA Injector)

C1 Gammagard S/D Less Actemra IgA (Intravenous Actemra 1 PA (Subcutaneous Solution 1 PA Reconstituted) Solution Prefilled

C1 Gammaked Syringe)

C1 Gammaked (1GM/ Actimmune 10ML Injection 1 PA Actimmune Solution) (Subcutaneous 1 LA

C1 Gammaplex Solution)

C1 Gammaplex (10GM/ Arcalyst 100ML Intravenous Arcalyst (Subcutaneous Solution, 10GM/ 1 PA; LA 200ML Intravenous Solution 1 PA Reconstituted)

Solution, 20GM/ C1 Benlysta 200ML Intravenous Benlysta (Subcutaneous Solution, 5GM/50ML 1 PA Intravenous Solution) Solution Auto-

C1 Gamunex-C Injector)

Gamunex-C (1GM/ C1 Benlysta 10ML Injection 1 PA Benlysta (Subcutaneous Solution) 1 PA Solution Prefilled Syringe)

Bold type = Brand name drug Plain type = Generic drug 80 tRACK 69 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Leflunomide Diphtheria-Tetanus Toxoids DT Leflunomide (Oral Diphtheria-Tetanus 1 Tablet) Toxoids DT C1 Otezla 1 Otezla (Oral Tablet) 1 PA; LA (Intramuscular

C1 Otezla Suspension)

C1 Otezla (Oral Tablet Engerix-B 1 PA; LA Therapy Pack) Engerix-B (Injection

C1 Ridaura 1 B/D, PA Suspension)

C1 Ridaura (Oral Gardasil 9 1 Capsule) Gardasil 9

C1 Xolair Xolair (Subcutaneous (Intramuscular 1 Suspension)

C1 Solution Prefilled 1 PA; LA Gardasil 9 Syringe) Gardasil 9

C1 Xolair (Intramuscular Xolair (Subcutaneous 1 Solution 1 PA; LA Suspension Prefilled Syringe)

C1 Reconstituted) Havrix B1 Havrix (Intramuscular Vaccines 1 PA C1 ActHIB Suspension)

C1 ActHIB Hiberix (Intramuscular Hiberix (Injection 1 Solution Solution 1 Reconstituted)

C1 Reconstituted) Imovax Rabies

C1 Adacel Adacel (Intramuscular Imovax Rabies 1 Suspension) (Intramuscular 1 B/D, PA

C1 BCG Vaccine Injectable)

C1 BCG Vaccine Infanrix 1 Infanrix (Injection) C1 Bexsero (Intramuscular 1 Bexsero Suspension)

C1 (Intramuscular IPOL 1 Suspension Prefilled IPOL (Injection) 1 C1 Ixiaro Syringe) Ixiaro (Intramuscular

C1 Boostrix 1 Boostrix (5-2.5-18.5 Suspension) C1 Kinrix Intramuscular Kinrix (Intramuscular 1 Suspension, Suspension)

C1 Menactra 5-2.5-18.5 (0.5ML 1 Menactra

Syringe) (Intramuscular 1 Intramuscular Injectable)

C1 Suspension) MenQuadfi

C1 MenQuadfi Daptacel Daptacel (Intramuscular 1 (Intramuscular 1 Injectable) Suspension)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 81 70 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Menveo TDVAX Menveo TDVAX

(Intramuscular (Intramuscular 1 1 Solution Suspension)

C1 Tenivac Reconstituted) Tenivac C1 M-M-R II M-M-R II (Injection (Intramuscular 1

Solution 1 Injectable)

C1 Trumenba Reconstituted) Trumenba C1 Pediarix Pediarix (Intramuscular 1 (Intramuscular 1 Suspension Prefilled Suspension) Syringe)

C1 C1 Pedvax HIB Twinrix Pedvax HIB Twinrix

(Intramuscular 1 (Intramuscular 1 Suspension) Suspension Prefilled

C1 ProQuad ProQuad Syringe) C1 Typhim Vi (Subcutaneous Typhim Vi 1 Suspension (Intramuscular 1 Reconstituted) Solution)

C1 C1 Quadracel VAQTA Quadracel VAQTA

(Intramuscular 1 (Intramuscular 1 PA Suspension) Suspension)

C1 C1 RabAvert Varivax RabAvert Varivax

(Intramuscular (Subcutaneous 1 1 B/D, PA Suspension Injectable)

C1 YF-Vax Reconstituted) YF-Vax C1 Recombivax HB Recombivax HB (Subcutaneous 1 (Injection 1 B/D, PA Injectable)

A1 Suspension) Inflammatory Bowel Disease Agents C1 Rotarix B1 Rotarix (Oral Aminosalicylates

C1 Apriso Suspension 1 Apriso (Oral Capsule Reconstituted)

C1 RotaTeq Extended Release 24 1 QL RotaTeq (Oral Hour)

C1 1 Balsalazide Solution) Disodium C1 Shingrix Balsalazide Disodium 1 Shingrix (Oral Capsule)

C1 Canasa (Intramuscular Canasa (Rectal 1 PA 1 Suspension Suppository) Reconstituted)

Bold type = Brand name drug Plain type = Generic drug 82 tRACK 71 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Dipentum Sulfasalazine Dipentum (Oral Sulfasalazine (Oral 1 Capsule) Tablet Immediate 1

C1 Mesalamine ER Release)

C1 Mesalamine ER Sulfasalazine (0.375MG Oral Sulfasalazine (Oral Capsule Extended 1 QL Tablet Delayed 1 Release 24 Hour) Release) A1 (Generic Apriso) Metabolic Bone Disease Agents C1 Mesalamine B1 Mesalamine (1.2GM Metabolic Bone Disease Agents

C1 Alendronate Oral Tablet Delayed Sodium Alendronate Sodium 1 QL 1 Release) (Generic (Oral Solution)

C1 Alendronate Lialda) Sodium

C1 Mesalamine Alendronate Sodium Mesalamine (Rectal 1 QL (10MG Oral Tablet, Enema) 1 QL

C1 Mesalamine 35MG Oral Tablet, Mesalamine (Rectal 70MG Oral Tablet)

C1 1 Binosto Suppository)

C1 Pentasa Binosto (Oral Tablet 1 QL Pentasa (Oral Effervescent)

C1 Calcitonin Salmon Capsule Extended 1 QL Calcitonin Salmon Release) 1 QL B1 (Nasal Solution)

C1 Glucocorticoids Calcitriol

C1 Budesonide ER Calcitriol (Oral 1 B/D, PA Budesonide ER (Oral Capsule)

C1 Calcitriol Tablet Extended 1 ST Calcitriol (Oral Release 24 Hour) 1 B/D, PA

C1 Budesonide Solution)

C1 Cinacalcet HCl Budesonide (Oral Cinacalcet HCl (30MG 1 B/D, PA; QL Capsule Delayed 1 Oral Tablet)

C1 Release Particles) Cinacalcet HCl

C1 Hydrocortisone Cinacalcet HCl (60MG Hydrocortisone (Rectal 1 Oral Tablet, 90MG Oral 1 B/D, PA; QL Enema)

C1 Procto-Med HC Tablet)

C1 Procto-Med HC Doxercalciferol 1 Doxercalciferol (Oral (External Cream) 1 B/D, PA; QL

C1 Procto-Pak Capsule)

C1 Procto-Pak (External Forteo 1 Forteo (Subcutaneous Cream) 1 PA; QL

C1 Proctosol HC Solution Pen-Injector)

C1 Ibandronate Proctosol HC (2.5% Sodium 1 Ibandronate Sodium External Cream) 1 QL

C1 Proctozone-HC (Oral Tablet)

C1 Proctozone-HC Natpara 1 Natpara (External Cream) B1 (Subcutaneous 1 PA; LA Sulfonamides Cartridge)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 83 72 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Paricalcitol Neomycin- Polymyxin- Bacitracin- Paricalcitol (Oral Hydrocortisone Neomycin-Polymyxin- 1 B/D, PA Capsule) Bacitracin-

C1 Prolia 1 Prolia (Subcutaneous Hydrocortisone (Ophthalmic Ointment)

C1 Solution Prefilled 1 QL Blephamide Syringe) Blephamide

C1 Rayaldee Rayaldee (Oral (Ophthalmic 1 Suspension)

C1 Capsule Extended 1 QL Blephamide S.O.P. Release) Blephamide S.O.P.

C1 Risedronate 1 Sodium (Ophthalmic Ointment)

C1 Risedronate Sodium Cystaran Cystaran (Ophthalmic (Oral Tablet Immediate 1 QL 1 LA Release) Solution) C1 C1 Lacrisert Teriparatide Teriparatide Lacrisert (Ophthalmic 1 (Recombinant) Insert) C1 1 PA; QL Lastacaft (Subcutaneous Lastacaft (Ophthalmic 1 Solution Pen-Injector) Solution)

C1 Tymlos C1 Neomycin- Bacitracin- Tymlos Polymyxin Neomycin-Bacitracin- (Subcutaneous 1 PA; QL Polymyxin 1 Solution Pen-Injector) (5-400-10000

C1 Xgeva Ophthalmic Ointment)

C1 Xgeva (Subcutaneous Neomycin- Polymyxin- 1 PA Dexamethasone Solution) Neomycin-Polymyxin- A1 Miscellaneous Therapeutic Agents Dexamethasone 1 B1 (Ophthalmic Ointment)

C1 Neomycin- Polymyxin- Miscellaneous Therapeutic Agents Dexamethasone

C1 Alcohol Prep Pads Neomycin-Polymyxin- Alcohol Prep Pads 1 Dexamethasone C1 Gauze Gauze (Non-medicated (3.5-10000-0.1 1 1 2X2 Pad) Ophthalmic

C1 Insulin Syringes, Needles Suspension) C1 Insulin Syringes, Neomycin- Polymyxin- 1 Gramicidin Needles Neomycin-Polymyxin- A1 Ophthalmic Agents Gramicidin 1 B1 (Ophthalmic Solution)

C1 Neomycin- Ophthalmic Agents, Other Polymyxin-HC

C1 Atropine Sulfate Neomycin-Polymyxin- Atropine Sulfate (1% 1 HC (Ophthalmic 1 Ophthalmic Solution)

C1 Bacitracin- Suspension) Polymyxin B

C1 Polymyxin B- Bacitracin-Polymyxin B Trimethoprim 1 Polymyxin B- (Ophthalmic Ointment) Trimethoprim 1 (Ophthalmic Solution)

Bold type = Brand name drug Plain type = Generic drug 84 tRACK 73 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Pred-G Cromolyn Sodium Pred-G (Ophthalmic Cromolyn Sodium 1 1 Suspension) (Ophthalmic Solution) C1 C1 Epinastine HCl Pred-G S.O.P. Pred-G S.O.P. Epinastine HCl 1 (Ophthalmic 1 (Ophthalmic Solution) C1 Olopatadine HCl Ointment) Olopatadine HCl

C1 Proparacaine HCl 1 (Ophthalmic Solution) Proparacaine HCl C1 1 Pazeo (Ophthalmic Solution) Pazeo (Ophthalmic

C1 Restasis Single-Use Vials 1 Restasis Single-Use Solution) B1 Vials (Ophthalmic 1 QL Ophthalmic Antiglaucoma Agents

C1 Alphagan P Emulsion) Alphagan P (0.1% C1 Rhopressa 1 Rhopressa Ophthalmic Solution)

C1 1 ST Apraclonidine HCl (Ophthalmic Solution) Apraclonidine HCl C1 Sulfacetamide- Prednisolone 1 Sulfacetamide- (Ophthalmic Solution) C1 Azopt Prednisolone 1 Azopt (Ophthalmic 1 (Ophthalmic Solution) Suspension) C1 TobraDex C1 Betaxolol HCl TobraDex Betaxolol HCl 1 (Ophthalmic 1 (Ophthalmic Solution)

C1 Ointment) Betimol

C1 Betimol (Ophthalmic TobraDex ST 1 TobraDex ST Solution)

C1 Brimonidine (Ophthalmic 1 Tartrate Brimonidine Tartrate Suspension)

C1 (0.15% Ophthalmic Tobramycin- 1 Dexamethasone Tobramycin- Solution)

C1 Brimonidine Dexamethasone Tartrate 1 Brimonidine Tartrate (Ophthalmic (0.2% Ophthalmic 1 Suspension)

C1 Xiidra Solution)

C1 Xiidra (Ophthalmic Carteolol HCl 1 QL Carteolol HCl Solution) 1

B1 (Ophthalmic Solution)

C1 Ophthalmic Anti-allergy Agents Combigan

C1 Combigan Alocril 1 Alocril (Ophthalmic (Ophthalmic Solution)

C1 1 Cosopt PF Solution)

C1 Cosopt PF Alomide 1 Alomide (Ophthalmic (Ophthalmic Solution)

C1 1 Dorzolamide HCl Solution) C1 Dorzolamide HCl Azelastine HCl 1 Azelastine HCl (Ophthalmic Solution)

C1 Dorzolamide HCl- 1 Timolol Maleate (Ophthalmic Solution)

C1 Bepreve Dorzolamide HCl- Bepreve (Ophthalmic Timolol Maleate 1 1 Solution) (Ophthalmic Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 85 74 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Dorzolamide HCl- Fluorometholone Timolol Maleate Preservative Free Dorzolamide HCl- Fluorometholone Timolol Maleate (Ophthalmic 1 1 Preservative Free Suspension)

C1 Flurbiprofen (Ophthalmic Solution) Sodium C1 Flurbiprofen Sodium Levobunolol HCl 1 Levobunolol HCl (Ophthalmic Solution)

C1 1 FML Forte (Ophthalmic Solution)

C1 FML Forte Phospholine Iodide Phospholine Iodide (Ophthalmic 1 (Ophthalmic Solution 1 Suspension)

C1 FML Reconstituted) C1 FML (Ophthalmic Pilocarpine HCl 1 Pilocarpine HCl Ointment)

C1 1 Ilevro (Ophthalmic Solution)

C1 Rocklatan Ilevro (Ophthalmic 1 Rocklatan Suspension)

C1 1 ST Ketorolac (Ophthalmic Solution) Tromethamine

C1 Simbrinza Ketorolac Simbrinza Tromethamine 1 (Ophthalmic 1 (Ophthalmic Solution)

C1 Lotemax Suspension) Lotemax (Ophthalmic C1 Timolol Maleate Ophthalmic Gel Forming 1 Timolol Maleate Gel)

C1 Lotemax Ophthalmic Gel Lotemax (Ophthalmic 1 Forming (Ophthalmic 1 Ointment)

C1 Solution) (Generic Lotemax Lotemax (Ophthalmic Timoptic-XE) 1 C1 Timolol Maleate Suspension)

C1 Timolol Maleate Lotemax SM Lotemax SM (0.25% Ophthalmic 1 Solution, 0.5% 1 (Ophthalmic Gel) C1 Loteprednol Etabonate Ophthalmic Solution) Loteprednol Etabonate (Generic Timoptic) (Ophthalmic 1 B1 Suspension)

Ophthalmic Anti-inflammatories C1 Pred Mild C1 Dexamethasone Sodium Phosphate Pred Mild Dexamethasone Sodium Phosphate 1 (Ophthalmic 1 (Ophthalmic Solution) Suspension)

C1 C1 Prednisolone Diclofenac Sodium Acetate Diclofenac Sodium Prednisolone Acetate 1 (Ophthalmic Solution) (Ophthalmic 1

C1 Durezol Suspension)

Durezol (Ophthalmic C1 Prednisolone 1 Sodium Phosphate Emulsion) Prednisolone Sodium

C1 Flarex Flarex (Ophthalmic Phosphate (1% 1 1 Ophthalmic Solution) Suspension)

Bold type = Brand name drug Plain type = Generic drug 86 tRACK 75 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 B1 Prolensa Prolensa (Ophthalmic Antihistamines

C1 1 Azelastine HCl Solution) Azelastine HCl (0.1% B1 Ophthalmic Prostaglandin and Prostamide Nasal Solution, 0.15% 1 Analogs Nasal Solution) C1 Cetirizine HCl C1 Latanoprost Latanoprost Cetirizine HCl (1MG/ 1 1 (Ophthalmic Solution) ML Oral Solution) C1 Cyproheptadine C1 HCl Lumigan Cyproheptadine HCl Lumigan (Ophthalmic 1 1 (Oral Syrup)

Solution) C1 Cyproheptadine HCl C1 Travoprost Cyproheptadine HCl Travoprost (BAK Free) 1 1 (Oral Tablet)

(Ophthalmic Solution) C1 Levocetirizine Dihydrochloride C1 Vyzulta Vyzulta (Ophthalmic Levocetirizine 1 Solution) Dihydrochloride (Oral 1 QL

C1 Zioptan Tablet)

C1 Zioptan (Ophthalmic Promethazine HCl 1 Promethazine HCl Solution) 1 A1 (Oral Syrup)

C1 Otic Agents Promethazine HCl B1 Promethazine HCl Otic Agents 1

C1 (Oral Tablet) Acetic Acid

C1 Acetic Acid (Otic Promethazine HCl 1 Promethazine HCl Solution) 1

C1 (Rectal Suppository) Cipro HC

C1 Promethegan Cipro HC (Otic Promethegan (25MG 1 1 Suspension) Rectal Suppository) C1 Ciprodex B1 Ciprodex (Otic Anti-inflammatories, Inhaled Corticosteroids

C1 1 Arnuity Ellipta Suspension)

C1 Ciprofloxacin- Arnuity Ellipta Dexamethasone Ciprofloxacin- (Inhalation Aerosol 1 QL Dexamethasone (Otic 1 Powder Breath Suspension)

C1 Flac Activated)

C1 Budesonide Flac (Otic Oil) 1

C1 Budesonide (Inhalation Fluocinolone Acetonide 1 B/D, PA Fluocinolone Suspension)

C1 1 Flovent Diskus Acetonide (Otic Oil)

C1 Flovent Diskus Hydrocortisone- Acetic Acid Hydrocortisone-Acetic (Inhalation Aerosol 1 1 QL Acid (Otic Solution) Powder Breath C1 Neomycin- Polymyxin-HC Neomycin-Polymyxin- Activated)

C1 1 Flovent HFA HC (1% Otic Solution)

C1 Flovent HFA Neomycin- Polymyxin-HC 1 QL Neomycin-Polymyxin- (Inhalation Aerosol)

C1 1 Flunisolide HC (Otic Suspension) A1 Flunisolide (Nasal 1 Respiratory Tract/Pulmonary Agents Solution)

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 87 76 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Fluticasone Spiriva Respimat Propionate Fluticasone Propionate Spiriva Respimat 1 (Nasal Suspension) (Inhalation Aerosol 1 QL C1 Mometasone Furoate Mometasone Furoate Solution) 1 B1 (Nasal Suspension) Bronchodilators, Sympathomimetic B1

C1 Albuterol Sulfate Antileukotrienes HFA Albuterol Sulfate HFA C1 Montelukast Sodium Montelukast Sodium (108 (90 Base)MCG/ 1 QL (Oral Packet) ACT Inhalation Aerosol

C1 Montelukast Sodium Montelukast Sodium Solution (Generic 1 QL (Oral Tablet) Proair), 108 (90 1

C1 Montelukast Sodium Base)MCG/ACT Montelukast Sodium 1 QL Inhalation Aerosol (Oral Tablet Chewable)

C1 Zafirlukast Solution) (Generic Zafirlukast (Oral Proventil)

C1 1 QL Albuterol Sulfate Tablet)

C1 Zileuton ER Albuterol Sulfate Zileuton ER (Oral (Inhalation 1 B/D, PA Tablet Extended 1 ST Nebulization Solution)

C1 Release 12 Hour) Albuterol Sulfate

C1 Zyflo Albuterol Sulfate (Oral 1 Zyflo (Oral Tablet Syrup)

C1 1 ST Albuterol Sulfate Immediate Release) B1 Albuterol Sulfate (Oral Bronchodilators, Anticholinergic Tablet Immediate 1 C1 Atrovent HFA Atrovent HFA Release) C1 Epinephrine (Inhalation Aerosol 1 Epinephrine (Injection 1 QL Solution) Solution Auto-Injector) C1 C1 EpiPen 2-Pak Incruse Ellipta Incruse Ellipta EpiPen 2-Pak (Inhalation Aerosol (Injection Solution 1 QL 1 QL Powder Breath Auto-Injector) C1 EpiPen Jr 2-Pak Activated) EpiPen Jr 2-Pak

C1 Ipratropium Bromide Ipratropium Bromide (Injection Solution 1 QL 1 B/D, PA (Inhalation Solution) Auto-Injector)

C1 C1 Ipratropium Levalbuterol HCl Bromide Ipratropium Bromide Levalbuterol HCl 1 (Nasal Solution) (Inhalation 1 B/D, PA

C1 Lonhala Magnair Nebulization Solution)

Lonhala Magnair C1 Metaproterenol 1 QL Sulfate (Inhalation Solution) Metaproterenol Sulfate

C1 Spiriva HandiHaler 1 (Oral Syrup)

C1 Spiriva HandiHaler Perforomist 1 QL (Inhalation Capsule) Perforomist (Inhalation 1 B/D, PA; QL Nebulization Solution)

Bold type = Brand name drug Plain type = Generic drug 88 tRACK 77 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 ProAir HFA Theophylline ER ProAir HFA Theophylline ER (Oral

(Inhalation Aerosol 1 Tablet Extended 1 Solution) Release 24 Hour) C1 Theophylline C1 ProAir RespiClick Theophylline (Oral ProAir RespiClick 1 Solution) (Inhalation Aerosol B1 1 Powder Breath Pulmonary Antihypertensives C1 Adempas Activated) Adempas (Oral

C1 Serevent Diskus 1 PA; LA Serevent Diskus Tablet) C1 Alyq (Inhalation Aerosol Alyq (Oral Tablet) 1 PA; QL

C1 1 QL Ambrisentan Powder Breath Ambrisentan (Oral Activated) 1 PA; LA; QL

B1 Tablet)

C1 Cystic Fibrosis Agents Bosentan

C1 Bosentan (Oral Tablet) 1 PA; LA; QL Bethkis

C1 Bethkis (Inhalation Opsumit 1 B/D, PA; QL Opsumit (Oral Tablet) 1 PA; LA C1 Nebulization Solution) Orenitram

C1 Cayston Orenitram (0.125MG Cayston (Inhalation Oral Tablet Extended 1 PA; LA Solution 1 PA; LA Release)

C1 Reconstituted) Orenitram

C1 Orkambi Orenitram (0.25MG Orkambi (Oral Packet) 1 PA; LA; QL

C1 Orkambi Oral Tablet Extended Orkambi (Oral Tablet) 1 PA; LA; QL Release, 1MG Oral

C1 TOBI Podhaler TOBI Podhaler Tablet Extended 1 PA; QL (Inhalation Capsule) Release, 2.5MG Oral 1 PA; LA

C1 Tobramycin Tobramycin (300MG/ Tablet Extended 5ML Inhalation 1 B/D, PA; QL Release, 5MG Oral Nebulization Solution) Tablet Extended B1 Release)

Mast Cell Stabilizers C1 Sildenafil Citrate C1 Cromolyn Sodium Cromolyn Sodium Sildenafil Citrate (Inhalation 1 B/D, PA (20MG Oral Tablet) 1 PA; QL (Generic Revatio)

Nebulization Solution) C1 Tadalafil B1 Tadalafil (PAH) (20MG Phosphodiesterase Inhibitors, Airways 1 PA; QL Oral Tablet)

C1 Disease Tracleer

C1 Daliresp Tracleer (Oral Tablet Daliresp (Oral Tablet) 1 PA; QL 1 PA; LA; QL C1 Theophylline ER Soluble)

C1 Theophylline ER Ventavis Ventavis (Inhalation (300MG Oral Tablet 1 PA; LA; QL 1 Solution)

Extended Release 12 B1 Hour) Pulmonary Fibrosis Agents

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. tRACK 89 78 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Esbriet Fasenra Esbriet (Oral Capsule) 1 PA; LA; QL Fasenra

C1 Esbriet (Subcutaneous Esbriet (Oral Tablet) 1 PA; LA; QL 1 PA; LA C1 Ofev Solution Prefilled Ofev (Oral Capsule) 1 PA; LA; QL B1 Syringe)

C1 Fluticasone- Respiratory Tract Agents, Other Salmeterol

C1 Acetylcysteine Fluticasone-Salmeterol Acetylcysteine (Inhalation Aerosol 1 B/D, PA 1 QL (Inhalation Solution) Powder Breath C1 Advair Diskus Advair Diskus Activated)

C1 Ipratropium- (Inhalation Aerosol Albuterol Ipratropium-Albuterol 1 QL 1 B/D, PA Powder Breath (Inhalation Solution)

C1 Kalydeco Activated) Kalydeco (Oral C1 Advair HFA 1 PA; LA; QL Advair HFA Packet)

C1 1 QL Kalydeco (Inhalation Aerosol) Kalydeco (Oral C1 Anoro Ellipta 1 PA; LA; QL Anoro Ellipta Tablet)

C1 (Inhalation Aerosol Nucala 1 QL Nucala Powder Breath (Subcutaneous 1 PA; LA; QL Activated) Solution Auto- C1 Azelastine- Fluticasone Azelastine-Fluticasone Injector)

C1 1 Nucala (Nasal Suspension)

C1 Nucala Bevespi Aerosphere Bevespi Aerosphere (Subcutaneous 1 QL 1 PA; LA; QL (Inhalation Aerosol) Solution Prefilled C1 Breo Ellipta Breo Ellipta Syringe)

C1 Nucala (Inhalation Aerosol Nucala 1 QL Powder Breath (Subcutaneous 1 PA; LA; QL Activated) Solution

C1 Combivent Respimat Combivent Respimat Reconstituted)

C1 Pulmozyme (Inhalation Aerosol 1 QL Pulmozyme 1 B/D, PA; QL Solution) (Inhalation Solution)

C1 Dulera C1 Stiolto Respimat Dulera (Inhalation Stiolto Respimat 1 QL Aerosol) (Inhalation Aerosol 1 QL C1 Dymista Dymista (Nasal Solution)

C1 1 Symbicort Suspension) Symbicort (Inhalation C1 Fasenra Pen 1 QL Fasenra Pen Aerosol) (Subcutaneous 1 PA; LA Solution Auto- Injector)

Bold type = Brand name drug Plain type = Generic drug 90 tRACK 79 Necessary Necessary Drug actions, Drug actions, Drug Name Drug Name Tier restriction, Tier restriction, or limits on or limits on use use

C1 C1 Trelegy Ellipta Tizanidine HCl Trelegy Ellipta Tizanidine HCl (Oral 1 (100-62.5-25MCG/ Tablet) A1 INH Inhalation 1 QL Sleep Disorder Agents

B1 Aerosol Powder GABA Receptor Modulators

C1 Breath Activated) Temazepam

C1 Wixela Inhub Temazepam (15MG Wixela Inhub Oral Capsule, 30MG 1 QL (Inhalation Aerosol Oral Capsule)

C1 Zaleplon Powder Breath 1 QL Zaleplon (Oral 1 QL Activated) (Generic Capsule)

C1 Advair) Zolpidem Tartrate A1 Zolpidem Tartrate Skeletal Muscle Relaxants B1 (Oral Tablet Immediate 1 QL Skeletal Muscle Relaxants Release) C1 Baclofen B1 Baclofen (Oral Tablet) 1 Sleep Disorders, Other

C1 C1 Chlorzoxazone Belsomra Chlorzoxazone Belsomra (Oral 1 1 QL (500MG Oral Tablet) Tablet) C1 Cyclobenzaprine C1 HCl Hetlioz Cyclobenzaprine HCl Hetlioz (Oral Capsule) 1 PA; LA; QL C1 (10MG Oral Tablet, 1 Modafinil Modafinil (Oral Tablet) 1 PA; QL

C1 5MG Oral Tablet) Ramelteon

C1 Cyclobenzaprine HCl Ramelteon (Oral Cyclobenzaprine HCl 1 QL 1 Tablet)

C1 (7.5MG Oral Tablet) Xyrem

C1 Dantrolene Sodium Dantrolene Sodium Xyrem (Oral Solution) 1 PA; LA; QL 1 (Oral Capsule)

tRACK

You can find information on what the symbols and abbreviations in this table mean by going to pages 12 and 13. 91

C2. Covered drugs with a quantity limit (QL) This list shows drugs that have a quantity limit. Some drugs come in several strengths. Each strength may have a different quantity limit. If quantity limits for a drug vary by strength, the different strengths are listed on separate lines. These limits may be in place to ensure your safety.

Your plan will cover only a certain amount of these drugs or will only cover these drugs for a certain number of days. For more information about quantity limits, talk with your doctor or pharmacist. You can also call Customer Service. Our contact information is on the cover.

Drugs are listed in alphabetical order in the tables below.

Drug Name Quantity Limit Abacavir Sulfate (Oral Solution) Maximum of 32 ml per day Abacavir Sulfate (Oral Tablet) Maximum of 2 tablets per day Abacavir Sulfate-Lamivudine (Oral Tablet) Maximum of 1 tablet per day Abacavir-Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Abiraterone Acetate (Oral Tablet) Maximum of 4 tablets per day Acarbose (100MG Oral Tablet) Maximum of 3 tablets per day Acarbose (25MG Oral Tablet) Maximum of 12 tablets per day Acarbose (50MG Oral Tablet) Maximum of 6 tablets per day Acetaminophen-Codeine (120-12MG/5ML Oral Maximum of 150 ml per day Solution) Acetaminophen-Codeine (300-15MG Oral Tablet, 300-30MG Oral Tablet, 300-60MG Oral Maximum of 13 tablets per day Tablet) Acyclovir (External Ointment) Maximum of 1 tube (30 grams) per 30 days Advair Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Advair HFA (Inhalation Aerosol) Maximum of 1 inhaler (12 grams) per 30 days Aimovig (140MG/ML Subcutaneous Solution Maximum of 1 pen (1 ml) per 30 days Auto-Injector) Aimovig (70MG/ML Subcutaneous Solution Maximum of 2 pens (2 ml) per 30 days Auto-Injector) Albendazole (Oral Tablet) Maximum of 16 tablets per day Alecensa (Oral Capsule) Maximum of 8 capsules per day Alendronate Sodium (10MG Oral Tablet) Maximum of 1 tablet per day Alendronate Sodium (35MG Oral Tablet) Maximum of 8 tablets per 28 days Alendronate Sodium (70MG Oral Tablet) Maximum of 4 tablets per 28 days Aliskiren Fumarate (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 92 Drug Name Quantity Limit Alprazolam (0.25MG Oral Tablet Immediate Release, 0.5MG Oral Tablet Immediate Maximum of 4 tablets per day Release, 1MG Oral Tablet Immediate Release) Alprazolam (2MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Alunbrig (180MG Oral Tablet, 90MG Oral Maximum of 1 tablet per day Tablet) Alunbrig (30MG Oral Tablet) Maximum of 4 tablets per day Alunbrig (Oral Tablet Therapy Pack) Maximum of 1 pack (30 tablets) per 30 days Alyq (Oral Tablet) Maximum of 2 tablets per day Ambrisentan (Oral Tablet) Maximum of 1 tablet per day Amitiza (Oral Capsule) Maximum of 2 capsules per day Amlodipine-Atorvastatin (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Benazepril (Oral Capsule) Maximum of 1 capsule per day Amlodipine-Olmesartan (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Valsartan (Oral Tablet) Maximum of 1 tablet per day Amlodipine-Valsartan-HCTZ (Oral Tablet) Maximum of 1 tablet per day Amphetamine-Dextroamphetamine ER (Oral Maximum of 2 capsules per day Capsule Extended Release 24 Hour) Amphetamine-Dextroamphetamine (10MG Oral Tablet, 12.5MG Oral Tablet, 15MG Oral Tablet, Maximum of 2 tablets per day 30MG Oral Tablet, 5MG Oral Tablet, 7.5MG Oral Tablet) Amphetamine-Dextroamphetamine (20MG Oral Maximum of 3 tablets per day Tablet) Ampyra (Oral Tablet Extended Release 12 Maximum of 2 tablets per day Hour) Androderm (Transdermal Patch 24 Hour) Maximum of 1 patch per day Anoro Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Apokyn (Subcutaneous Solution Cartridge) Maximum of 3 ml per day Apriso (Oral Capsule Extended Release 24 Maximum of 4 capsules per day Hour) Aptiom (200MG Oral Tablet, 400MG Oral Maximum of 1 tablet per day Tablet) Aptiom (600MG Oral Tablet, 800MG Oral Maximum of 2 tablets per day Tablet) Aptivus (Oral Capsule) Maximum of 4 capsules per day Aptivus (Oral Solution) Maximum of 4 bottles (380 ml) per 30 days Aripiprazole (1MG/ML Oral Solution) Maximum of 25 ml per day

Bold type = Brand name drug Plain type = Generic drug 93 Drug Name Quantity Limit Aripiprazole (10MG Oral Tablet, 15MG Oral Tablet, 20MG Oral Tablet, 2MG Oral Tablet, Maximum of 1 tablet per day 30MG Oral Tablet, 5MG Oral Tablet) Aripiprazole ODT (10MG Oral Tablet Maximum of 3 tablets per day Dispersible) Aripiprazole ODT (15MG Oral Tablet Maximum of 2 tablets per day Dispersible) Arnuity Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Aspirin-Dipyridamole ER (Oral Capsule Maximum of 2 capsules per day Extended Release 12 Hour) Atazanavir Sulfate (150MG Oral Capsule, Maximum of 1 capsule per day 300MG Oral Capsule) Atazanavir Sulfate (200MG Oral Capsule) Maximum of 2 capsules per day Atomoxetine HCl (100MG Oral Capsule, 60MG Maximum of 1 capsule per day Oral Capsule, 80MG Oral Capsule) Atomoxetine HCl (10MG Oral Capsule, 18MG Oral Capsule, 25MG Oral Capsule, 40MG Oral Maximum of 2 capsules per day Capsule) Atorvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Atripla (Oral Tablet) Maximum of 1 tablet per day Aubagio (Oral Tablet) Maximum of 1 tablet per day Austedo (Oral Tablet) Maximum of 4 tablets per day Avonex Pen (Intramuscular Auto-Injector Kit) Maximum of 1 kit per 28 days Avonex Prefilled (Intramuscular Prefilled Maximum of 1 kit per 28 days Syringe Kit) Ayvakit (Oral Tablet) Maximum of 1 tablet per day Balversa (3MG Oral Tablet) Maximum of 3 tablets per day Balversa (4MG Oral Tablet) Maximum of 2 tablets per day Balversa (5MG Oral Tablet) Maximum of 1 tablet per day Belsomra (Oral Tablet) Maximum of 1 tablet per day Benazepril HCl (Oral Tablet) Maximum of 2 tablets per day Benazepril-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Betaseron (Subcutaneous Kit) Maximum of 1 kit (15 vials) per 30 days Bethkis (Inhalation Nebulization Solution) Maximum of 2 ampules (8 ml) per day Bevespi Aerosphere (Inhalation Aerosol) Maximum of 1 inhaler (10.7 grams) per 30 days BiDil (Oral Tablet) Maximum of 6 tablets per day Biktarvy (Oral Tablet) Maximum of 1 tablet per day Binosto (Oral Tablet Effervescent) Maximum of 4 tablets per 28 days

Bold type = Brand name drug Plain type = Generic drug 94 Drug Name Quantity Limit Bisoprolol-Hydrochlorothiazide (Oral Tablet) Maximum of 2 tablets per day Bosentan (Oral Tablet) Maximum of 2 tablets per day Bosulif (100MG Oral Tablet) Maximum of 6 tablets per day Bosulif (400MG Oral Tablet, 500MG Oral Maximum of 1 tablet per day Tablet) Breo Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) Brilinta (Oral Tablet) Maximum of 2 tablets per day BRIVIACT (10MG/ML Oral Solution) Maximum of 20 ml per day BRIVIACT (100MG Oral Tablet, 10MG Oral Tablet, 25MG Oral Tablet, 50MG Oral Tablet, Maximum of 2 tablets per day 75MG Oral Tablet) Brukinsa (Oral Capsule) Maximum of 4 capsules per day Buprenorphine HCl (Tablet Sublingual) Maximum of 3 tablets per day Buprenorphine HCl-Naloxone HCl (12-3MG Maximum of 2 films per day Sublingual Film, 4-1MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (2-0.5MG Maximum of 3 films per day Sublingual Film, 8-2MG Sublingual Film) Buprenorphine HCl-Naloxone HCl (Tablet Maximum of 3 tablets per day Sublingual) Buprenorphine (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Butalbital-Acetaminophen-Caffeine (Oral Maximum of 6 tablets per day Tablet) Butalbital-Aspirin-Caffeine (Oral Capsule) Maximum of 6 capsules per day Butorphanol Tartrate (Nasal Solution) Maximum of 2 bottles (5 ml) per 30 days Bydureon BCise (Subcutaneous Auto- Maximum of 4 pens (3.4 ml) per 28 days Injector) Bydureon (Subcutaneous Pen-Injector) Maximum of 4 pens per 28 days Byetta 10MCG Pen (Subcutaneous Solution Maximum of 1 pen (2.4 ml) per 30 days Pen-Injector) Byetta 5MCG Pen (Subcutaneous Solution Maximum of 1 pen (1.2 ml) per 30 days Pen-Injector) Bystolic (10MG Oral Tablet, 2.5MG Oral Maximum of 1 tablet per day Tablet, 5MG Oral Tablet) Bystolic (20MG Oral Tablet) Maximum of 2 tablets per day Cablivi (Injection Kit) Maximum of 1 kit per day Cabometyx (20MG Oral Tablet, 60MG Oral Maximum of 1 tablet per day Tablet) Cabometyx (40MG Oral Tablet) Maximum of 2 tablets per day Calcitonin Salmon (Nasal Solution) Maximum of 1 bottle per 28 days

Bold type = Brand name drug Plain type = Generic drug 95 Drug Name Quantity Limit Calquence (Oral Capsule) Maximum of 2 capsules per day Candesartan Cilexetil (16MG Oral Tablet, Maximum of 1 tablet per day 32MG Oral Tablet, 4MG Oral Tablet) Candesartan Cilexetil (8MG Oral Tablet) Maximum of 3 tablets per day Candesartan Cilexetil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Caplyta (Oral Capsule) Maximum of 1 capsule per day Captopril (100MG Oral Tablet) Maximum of 4 tablets per day Captopril (12.5MG Oral Tablet, 25MG Oral Maximum of 3 tablets per day Tablet) Captopril (50MG Oral Tablet) Maximum of 9 tablets per day Captopril-Hydrochlorothiazide (25-15MG Oral Maximum of 3 tablets per day Tablet, 50-15MG Oral Tablet) Captopril-Hydrochlorothiazide (25-25MG Oral Maximum of 2 tablets per day Tablet, 50-25MG Oral Tablet) Celecoxib (Oral Capsule) Maximum of 2 capsules per day Cimduo (Oral Tablet) Maximum of 1 tablet per day Cinacalcet HCl (30MG Oral Tablet, 60MG Oral Maximum of 2 tablets per day Tablet) Cinacalcet HCl (90MG Oral Tablet) Maximum of 4 tablets per day Clobazam (2.5MG/ML Oral Suspension) Maximum of 16 ml per day Clobazam (10MG Oral Tablet, 20MG Oral Maximum of 2 tablets per day Tablet) Clonazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Clonazepam (2MG Oral Tablet) Maximum of 10 tablets per day Clonazepam ODT (0.125MG Oral Tablet Dispersible, 0.25MG Oral Tablet Dispersible, Maximum of 4 tablets per day 0.5MG Oral Tablet Dispersible, 1MG Oral Tablet Dispersible) Clonazepam ODT (2MG Oral Tablet Maximum of 10 tablets per day Dispersible) Clopidogrel Bisulfate (75MG Oral Tablet) Maximum of 4 tablets per day Clorazepate Dipotassium (15MG Oral Tablet) Maximum of 6 tablets per day Clorazepate Dipotassium (3.75MG Oral Tablet) Maximum of 24 tablets per day Clorazepate Dipotassium (7.5MG Oral Tablet) Maximum of 12 tablets per day Clovique (Oral Capsule) Maximum of 8 capsules per day Clozapine ODT (100MG Oral Tablet Maximum of 9 tablets per day Dispersible) Clozapine ODT (12.5MG Oral Tablet Maximum of 2 tablets per day Dispersible)

Bold type = Brand name drug Plain type = Generic drug 96 Drug Name Quantity Limit Clozapine ODT (150MG Oral Tablet Maximum of 6 tablets per day Dispersible) Clozapine ODT (200MG Oral Tablet Maximum of 4 tablets per day Dispersible) Clozapine ODT (25MG Oral Tablet Dispersible) Maximum of 3 tablets per day Codeine Sulfate (15MG Oral Tablet) Maximum of 6 tablets per day Codeine Sulfate (30MG Oral Tablet, 60MG Oral Maximum of 6 tablets per day Tablet) Colchicine (0.6MG Oral Capsule) (Brand Maximum of 4 capsules per day Equivalent Mitigare) Colchicine (0.6MG Oral Tablet) (Generic Maximum of 4 tablets per day Colcrys) Colcrys (Oral Tablet) Maximum of 4 tablets per day Combivent Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 20 days Solution) Complera (Oral Tablet) Maximum of 1 tablet per day Copiktra (Oral Capsule) Maximum of 2 capsules per day Corlanor (Oral Solution) Maximum of 15 ml per day Corlanor (Oral Tablet) Maximum of 2 tablets per day Cotellic (Oral Tablet) Maximum of 3 tablets per day Crixivan (200MG Oral Capsule) Maximum of 9 capsules per day Crixivan (400MG Oral Capsule) Maximum of 6 capsules per day Cycloset (Oral Tablet) Maximum of 6 tablets per day Dalfampridine ER (Oral Tablet Extended Maximum of 2 tablets per day Release 12 Hour) Daliresp (Oral Tablet) Maximum of 1 tablet per day Daurismo (100MG Oral Tablet) Maximum of 1 tablet per day Daurismo (25MG Oral Tablet) Maximum of 2 tablets per day Delstrigo (Oral Tablet) Maximum of 1 tablet per day Denavir (External Cream) Maximum of 1 tube (5 grams) per 30 days Descovy (Oral Tablet) Maximum of 1 tablet per day Desvenlafaxine Succinate ER (100MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 4 tablets per day Pristiq) Desvenlafaxine Succinate ER (25MG Oral Tablet Extended Release 24 Hour, 50MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) (Generic Pristiq) Dexilant (Oral Capsule Delayed Release) Maximum of 1 capsule per day

Bold type = Brand name drug Plain type = Generic drug 97 Drug Name Quantity Limit Dexmethylphenidate HCl (Oral Tablet) Maximum of 2 tablets per day Dextroamphetamine Sulfate ER (10MG Oral Maximum of 6 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (15MG Oral Maximum of 4 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate ER (5MG Oral Maximum of 3 capsules per day Capsule Extended Release 24 Hour) Dextroamphetamine Sulfate (Oral Tablet) Maximum of 6 tablets per day Diazepam Intensol (5MG/ML Oral Concentrate) Maximum of 8 ml per day Diazepam (10MG Oral Tablet, 2MG Oral Tablet, Maximum of 4 tablets per day 5MG Oral Tablet) Diclofenac Epolamine (1.3% Transdermal Maximum of 2 patches per day Patch) Didanosine (250MG Oral Capsule Delayed Release, 400MG Oral Capsule Delayed Maximum of 1 capsule per day Release) Dimethyl Fumarate (120MG Oral Capsule Delayed Release, 240MG Oral Capsule Maximum of 2 capsules per day Delayed Release) Donepezil HCl (10MG Oral Tablet) Maximum of 2 tablets per day Donepezil HCl (23MG Oral Tablet, 5MG Oral Maximum of 1 tablet per day Tablet) Donepezil HCl ODT (10MG Oral Tablet Maximum of 2 tablets per day Dispersible) Donepezil HCl ODT (5MG Oral Tablet Maximum of 1 tablet per day Dispersible) Dovato (Oral Tablet) Maximum of 1 tablet per day Doxepin HCl (External Cream) Maximum of 90 grams per 30 days Doxercalciferol (0.5MCG Oral Capsule) Maximum of 3 capsules per day Doxercalciferol (1MCG Oral Capsule, 2.5MCG Maximum of 4 capsules per day Oral Capsule) Drizalma Sprinkle (20MG Oral Capsule Delayed Release Sprinkle, 30MG Oral Maximum of 2 capsules per day Capsule Delayed Release Sprinkle, 60MG Oral Capsule Delayed Release Sprinkle) Drizalma Sprinkle (40MG Oral Capsule Maximum of 3 capsules per day Delayed Release Sprinkle) Dulera (120 Inhalation Aerosol) Maximum of 1 inhaler (13 grams) per 30 days

Bold type = Brand name drug Plain type = Generic drug 98 Drug Name Quantity Limit Duloxetine HCl (20MG Oral Capsule Delayed Release Particles, 30MG Oral Capsule Delayed Maximum of 2 capsules per day Release Particles, 60MG Oral Capsule Delayed Release Particles) Dutasteride (Oral Capsule) Maximum of 1 capsule per day Econazole Nitrate (External Cream) Maximum of 90 grams per 30 days Edarbi (Oral Tablet) Maximum of 1 tablet per day Edarbyclor (Oral Tablet) Maximum of 1 tablet per day Edurant (Oral Tablet) Maximum of 1 tablet per day Efavirenz (Oral Capsule) Maximum of 3 capsules per day Efavirenz (Oral Tablet) Maximum of 1 tablet per day Eliquis DVT/PE Starter Pack (5MG Oral Maximum of 1 pack (74 tablets) per 30 days Tablet) Eliquis (Oral Tablet) Maximum of 2 tablets per day Emgality (300MG Dose) (100MG/ML Maximum of 3 syringes or pens (3 ml) per 30 Subcutaneous Solution Prefilled Syringe) days Emgality (Subcutaneous Solution Auto- Maximum of 2 syringes or pens (2 ml) per 30 Injector) days Emgality (120MG/ML Subcutaneous Maximum of 2 syringes or pens (2 ml) per 30 Solution Prefilled Syringe) days Emsam (Transdermal Patch 24 Hour) Maximum of 1 patch per day Emtricitabine (Oral Capsule) Maximum of 1 capsule per day Emtriva (Oral Capsule) Maximum of 1 capsule per day Emtriva (Oral Solution) Maximum of 5 bottles (850 ml) per 30 days Enalapril Maleate (Oral Tablet) Maximum of 2 tablets per day Enalapril-Hydrochlorothiazide (10-25MG Oral Maximum of 2 tablets per day Tablet) Enalapril-Hydrochlorothiazide (5-12.5MG Oral Maximum of 1 tablet per day Tablet) Endocet (10-325MG Oral Tablet, 5-325MG Oral Maximum of 12 tablets per day Tablet, 7.5-325MG Oral Tablet) Enoxaparin Sodium (100MG/ML Subcutaneous Solution, 150MG/ML Maximum of 2 syringes (2 ml) per day Subcutaneous Solution) Enoxaparin Sodium (120MG/0.8ML Subcutaneous Solution, 80MG/0.8ML Maximum of 2 syringes (1.6 ml) per day Subcutaneous Solution) Enoxaparin Sodium (30MG/0.3ML Maximum of 2 syringes (0.6 ml) per day Subcutaneous Solution)

Bold type = Brand name drug Plain type = Generic drug 99 Drug Name Quantity Limit Enoxaparin Sodium (40MG/0.4ML Maximum of 2 syringes (0.8 ml) per day Subcutaneous Solution) Enoxaparin Sodium (60MG/0.6ML Maximum of 2 syringes (1.2 ml) per day Subcutaneous Solution) Entresto (Oral Tablet) Maximum of 2 tablets per day Epclusa (400-100MG Oral Tablet) Maximum of 1 tablet per day Epinephrine (Injection Solution Auto-Injector) Maximum of 4 pens (2 boxes) per 30 days EpiPen 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) EpiPen Jr 2-Pak (Injection Solution Auto- Maximum of 4 pens (2 boxes) per 30 days Injector) Erivedge (Oral Capsule) Maximum of 1 capsule per day Erleada (Oral Tablet) Maximum of 4 tablets per day Erlotinib HCl (100MG Oral Tablet, 150MG Oral Maximum of 1 tablet per day Tablet) Erlotinib HCl (25MG Oral Tablet) Maximum of 3 tablets per day Esbriet (Oral Capsule) Maximum of 9 capsules per day Esbriet (267MG Oral Tablet) Maximum of 9 tablets per day Esbriet (801MG Oral Tablet) Maximum of 3 tablets per day Esomeprazole Magnesium (20MG Oral Maximum of 3 capsules per day Capsule Delayed Release) (Generic Nexium) Esomeprazole Magnesium (40MG Oral Maximum of 2 capsules per day Capsule Delayed Release) (Generic Nexium) Estradiol (Transdermal Patch Weekly) Maximum of 4 patches per 28 days Estradiol (Vaginal Tablet) Maximum of 1 tablet per day Evotaz (Oral Tablet) Maximum of 1 tablet per day Ezetimibe (Oral Tablet) Maximum of 1 tablet per day Ezetimibe-Simvastatin (Oral Tablet) Maximum of 1 tablet per day Famciclovir (125MG Oral Tablet, 250MG Oral Maximum of 2 tablets per day Tablet) Famciclovir (500MG Oral Tablet) Maximum of 3 tablets per day Fanapt (10MG Oral Tablet, 12MG Oral Tablet, 1MG Oral Tablet, 2MG Oral Tablet, Maximum of 2 tablets per day 4MG Oral Tablet, 6MG Oral Tablet, 8MG Oral Tablet) Fentanyl Citrate (Buccal Lozenge On A Handle) Maximum of 4 lozenges per day

Bold type = Brand name drug Plain type = Generic drug 100 Drug Name Quantity Limit Fentanyl (100MCG/HR Transdermal Patch 72 Hour, 12MCG/HR Transdermal Patch 72 Hour, 25MCG/HR Transdermal Patch 72 Hour, Maximum of 15 patches per 30 days 50MCG/HR Transdermal Patch 72 Hour, 75MCG/HR Transdermal Patch 72 Hour) Fetzima (Oral Capsule Extended Release 24 Maximum of 1 capsule per day Hour) Fintepla (Oral Solution) Maximum of 12 ml per day Firazyr (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day Flector (1.3% Transdermal Patch) Maximum of 2 patches per day Flovent Diskus (Inhalation Aerosol Powder Maximum of 2 inhalers (120 blisters) per 30 Breath Activated) days Flovent HFA (110MCG/ACT Inhalation Maximum of 1 inhaler (12 grams) per 30 days Aerosol) Flovent HFA (220MCG/ACT Inhalation Maximum of 2 inhalers (24 grams) per 30 days Aerosol) Flovent HFA (44MCG/ACT Inhalation Maximum of 1 inhaler (10.6 grams) per 30 days Aerosol) Fluticasone-Salmeterol (100-50MCG/DOSE Inhalation Aerosol Powder Breath Activated, 250-50MCG/DOSE Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated, 500-50MCG/DOSE Inhalation Aerosol Powder Breath Activated) (Generic Advair) Fluticasone-Salmeterol (113-14MCG/ACT Inhalation Aerosol Powder Breath Activated, 232-14MCG/ACT Inhalation Aerosol Powder Maximum of 1 inhaler per 30 days Breath Activated, 55-14MCG/ACT Inhalation Aerosol Powder Breath Activated) (Brand Equivalent AirDuo) Fluvastatin Sodium (20MG Oral Capsule) Maximum of 1 capsule per day Fluvastatin Sodium (40MG Oral Capsule) Maximum of 2 capsules per day Forteo (Subcutaneous Solution Pen-Injector) Maximum of 1 pen (2.4 ml) per 28 days Fosamprenavir Calcium (Oral Tablet) Maximum of 4 tablets per day Fosinopril Sodium (Oral Tablet) Maximum of 2 tablets per day Fosinopril Sodium-HCTZ (Oral Tablet) Maximum of 4 tablets per day Fuzeon (Subcutaneous Solution Maximum of 2 vials per day Reconstituted) Galantamine Hydrobromide ER (Oral Capsule Maximum of 1 capsule per day Extended Release 24 Hour) Galantamine Hydrobromide (Oral Solution) Maximum of 2 bottles (200 ml) per 30 days

Bold type = Brand name drug Plain type = Generic drug 101 Drug Name Quantity Limit Galantamine Hydrobromide (Oral Tablet) Maximum of 2 tablets per day Gavreto (Oral Capsule) Maximum of 4 capsules per day Genvoya (Oral Tablet) Maximum of 1 tablet per day Gilenya (0.5MG Oral Capsule) Maximum of 1 pack (30 capsules) per 30 days Glatiramer Acetate (20MG/ML Subcutaneous Maximum of 1 syringe (1 ml) per day Solution Prefilled Syringe) Glatiramer Acetate (40MG/ML Subcutaneous Maximum of 12 syringes (12 ml) per 28 days Solution Prefilled Syringe) Glatopa (20MG/ML Subcutaneous Solution Maximum of 1 syringe (1 ml) per day Prefilled Syringe) Glatopa (40MG/ML Subcutaneous Solution Maximum of 12 syringes (12 ml) per 28 days Prefilled Syringe) Glimepiride (1MG Oral Tablet) Maximum of 8 tablets per day Glimepiride (2MG Oral Tablet) Maximum of 4 tablets per day Glimepiride (4MG Oral Tablet) Maximum of 2 tablets per day Glipizide ER (10MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Glipizide ER (2.5MG Oral Tablet Extended Maximum of 8 tablets per day Release 24 Hour) Glipizide ER (5MG Oral Tablet Extended Maximum of 4 tablets per day Release 24 Hour) Glipizide (10MG Oral Tablet Immediate Maximum of 4 tablets per day Release) Glipizide (5MG Oral Tablet Immediate Release) Maximum of 8 tablets per day Glipizide-Metformin HCl (2.5-250MG Oral Maximum of 8 tablets per day Tablet) Glipizide-Metformin HCl (2.5-500MG Oral Maximum of 4 tablets per day Tablet, 5-500MG Oral Tablet) Glyxambi (Oral Tablet) Maximum of 1 tablet per day Granisetron HCl (Oral Tablet) Maximum of 2 tablets per day Hetlioz (Oral Capsule) Maximum of 1 capsule per day Hydrocodone-Acetaminophen (7.5-325MG/ Maximum of 180 ml per day 15ML Oral Solution) Hydrocodone-Acetaminophen (10-325MG Oral Tablet, 5-325MG Oral Tablet, 7.5-325MG Oral Maximum of 12 tablets per day Tablet) Hydrocodone-Ibuprofen (7.5-200MG Oral Maximum of 5 tablets per day Tablet) Hydromorphone HCl ER (Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 102 Drug Name Quantity Limit Hydromorphone HCl (1MG/ML Oral Liquid) Maximum of 50 ml per day Hydromorphone HCl (2MG Oral Tablet Immediate Release, 4MG Oral Tablet Maximum of 8 tablets per day Immediate Release) Hydromorphone HCl (8MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Hysingla ER (Oral Tablet ER 24 Hour Abuse- Maximum of 1 tablet per day Deterrent) Ibandronate Sodium (Oral Tablet) Maximum of 1 tablet per 28 days Ibrance (Oral Capsule) Maximum of 1 capsule per day Ibrance (Oral Tablet) Maximum of 1 tablet per day Icatibant Acetate (Subcutaneous Solution) Maximum of 3 syringes (9 ml) per day Iclusig (15MG Oral Tablet) Maximum of 2 tablets per day Iclusig (45MG Oral Tablet) Maximum of 1 tablet per day IDHIFA (Oral Tablet) Maximum of 1 tablet per day Imatinib Mesylate (Oral Tablet) Maximum of 3 tablets per day Imbruvica (140MG Oral Capsule) Maximum of 4 capsules per day Imbruvica (70MG Oral Capsule) Maximum of 1 capsule per day Imbruvica (Oral Tablet) Maximum of 1 tablet per day Imvexxy Maintenance Pack (Vaginal Insert) Maximum of 1 vaginal insert per day Imvexxy Starter Pack (Vaginal Insert) Maximum of 1 vaginal insert per day Incruse Ellipta (Inhalation Aerosol Powder Maximum of 1 inhaler (30 blisters) per 30 days Breath Activated) Ingrezza (Oral Capsule) Maximum of 1 capsule per day Ingrezza (Oral Capsule Therapy Pack) Maximum of 1 pack (28 capsules) per 28 days Inlyta (Oral Tablet) Maximum of 4 tablets per day Inqovi (Oral Tablet) Maximum of 1 pack (5 tablets) per 28 days Inrebic (Oral Capsule) Maximum of 4 capsules per day Intelence (100MG Oral Tablet, 200MG Oral Maximum of 2 tablets per day Tablet) Intelence (25MG Oral Tablet) Maximum of 4 tablets per day Invirase (Oral Tablet) Maximum of 4 tablets per day Invokamet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Invokamet XR (Oral Tablet Extended Release Maximum of 2 tablets per day 24 Hour) Invokana (Oral Tablet) Maximum of 1 tablet per day Irbesartan (150MG Oral Tablet, 300MG Oral Maximum of 1 tablet per day Tablet) Irbesartan (75MG Oral Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug 103 Drug Name Quantity Limit Irbesartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Iressa (Oral Tablet) Maximum of 2 tablets per day Isentress HD (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Packet) Maximum of 2 packets per day Isentress (Oral Tablet) Maximum of 2 tablets per day Isentress (Oral Tablet Chewable) Maximum of 6 tablets per day Itraconazole (Oral Capsule) Maximum of 4 capsules per day Jakafi (Oral Tablet) Maximum of 2 tablets per day Janumet (Oral Tablet Immediate Release) Maximum of 2 tablets per day Janumet XR (100-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Janumet XR (50-1000MG Oral Tablet Extended Release 24 Hour, 50-500MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Januvia (Oral Tablet) Maximum of 1 tablet per day Jardiance (Oral Tablet) Maximum of 1 tablet per day Jentadueto (Oral Tablet Immediate Release) Maximum of 2 tablets per day Jentadueto XR (2.5-1000MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Jentadueto XR (5-1000MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Juluca (Oral Tablet) Maximum of 1 tablet per day Kaletra (100-25MG Oral Tablet) Maximum of 8 tablets per day Kaletra (200-50MG Oral Tablet) Maximum of 4 tablets per day Kalydeco (Oral Packet) Maximum of 2 packets per day Kalydeco (Oral Tablet) Maximum of 2 tablets per day Ketoconazole (External Cream) Maximum of 90 grams per 30 days Kisqali (200MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali (400MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali (600MG Dose) (Oral Tablet) Maximum of 3 tablets per day Kisqali Femara (400MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Kisqali Femara (600MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Kisqali Femara (200MG Dose) (Oral Tablet Maximum of 1 pack (91 tablets) per 28 days Therapy Pack) Korlym (Oral Tablet) Maximum of 4 tablets per day Koselugo (10MG Oral Capsule) Maximum of 8 capsules per day Koselugo (25MG Oral Capsule) Maximum of 4 capsules per day

Bold type = Brand name drug Plain type = Generic drug 104 Drug Name Quantity Limit Lamivudine (10MG/ML Oral Solution) Maximum of 32 ml per day Lamivudine (150MG Oral Tablet) Maximum of 2 tablets per day Lamivudine (300MG Oral Tablet) Maximum of 1 tablet per day Lamivudine-Zidovudine (Oral Tablet) Maximum of 2 tablets per day Lansoprazole (Oral Capsule Delayed Release) Maximum of 2 capsules per day Latuda (120MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet, 40MG Oral Tablet, 60MG Oral Tablet) Latuda (80MG Oral Tablet) Maximum of 2 tablets per day Levocetirizine Dihydrochloride (Oral Tablet) Maximum of 1 tablet per day Levorphanol Tartrate (Oral Tablet) Maximum of 6 tablets per day Lexiva (Oral Suspension) Maximum of 60 ml per day Lidocaine (5% External Ointment) Maximum of 152 grams per 30 days Lidocaine (5% External Patch) Maximum of 3 patches per day Linezolid (Oral Tablet) Maximum of 2 tablets per day Linzess (Oral Capsule) Maximum of 1 capsule per day Lisinopril (Oral Tablet) Maximum of 2 tablets per day Lisinopril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet) Lisinopril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 4 tablets per day Tablet) Lisinopril-Hydrochlorothiazide (20-25MG Oral Maximum of 2 tablets per day Tablet) Livalo (Oral Tablet) Maximum of 1 tablet per day Lokelma (Oral Packet) Maximum of 90 packets per 30 days Lonhala Magnair (Inhalation Solution) Maximum of 2 vials (2 ml) per day Lonsurf (15-6.14MG Oral Tablet) Maximum of 10 tablets per day Lonsurf (20-8.19MG Oral Tablet) Maximum of 8 tablets per day Lopinavir-Ritonavir (Oral Solution) Maximum of 2 bottles (320 ml) per 30 days Lorazepam (2MG/ML Oral Concentrate) Maximum of 5 ml per day Lorazepam (0.5MG Oral Tablet, 1MG Oral Maximum of 4 tablets per day Tablet) Lorazepam (2MG Oral Tablet) Maximum of 5 tablets per day Lorbrena (100MG Oral Tablet) Maximum of 1 tablet per day Lorbrena (25MG Oral Tablet) Maximum of 3 tablets per day Losartan Potassium (100MG Oral Tablet) Maximum of 1 tablet per day Losartan Potassium (25MG Oral Tablet, 50MG Maximum of 2 tablets per day Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 105 Drug Name Quantity Limit Losartan Potassium-HCTZ (100-12.5MG Oral Maximum of 1 tablet per day Tablet, 100-25MG Oral Tablet) Losartan Potassium-HCTZ (50-12.5MG Oral Maximum of 2 tablets per day Tablet) Lovastatin (10MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet) Lovastatin (40MG Oral Tablet) Maximum of 2 tablets per day Lynparza (Oral Tablet) Maximum of 4 tablets per day Mavyret (Oral Tablet) Maximum of 3 tablets per day Mayzent (0.25MG Oral Tablet) Maximum of 8 tablets per day Mayzent (2MG Oral Tablet) Maximum of 1 tablet per day Memantine HCl ER (Oral Capsule Extended Maximum of 1 capsule per day Release 24 Hour) Memantine HCl (2MG/ML Oral Solution) Maximum of 10 ml per day Memantine HCl (10MG Oral Tablet) Maximum of 2 tablets per day Memantine HCl (5MG Oral Tablet) Maximum of 3 tablets per day Mesalamine ER (0.375MG Oral Capsule Maximum of 4 capsules per day Extended Release 24 Hour) (Generic Apriso) Mesalamine (1.2GM Oral Tablet Delayed Maximum of 4 tablets per day Release) (Generic Lialda) Mesalamine (Rectal Enema) Maximum of 1 bottle (60 ml) per day Metformin HCl ER (500MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 4 tablets per day Glucophage XR) Metformin HCl ER (750MG Oral Tablet Extended Release 24 Hour) (Generic Maximum of 2 tablets per day Glucophage XR) Metformin HCl (500MG/5ML Oral Solution) Maximum of 25.5 ml per day Metformin HCl (1000MG Oral Tablet Immediate Maximum of 2.5 tablets per day Release) Metformin HCl (500MG Oral Tablet Immediate Maximum of 5 tablets per day Release) Metformin HCl (850MG Oral Tablet Immediate Maximum of 3 tablets per day Release) Methadone HCl (10MG/5ML Oral Solution) Maximum of 60 ml per day Methadone HCl (5MG/5ML Oral Solution) Maximum of 120 ml per day Methadone HCl (10MG Oral Tablet) Maximum of 12 tablets per day Methadone HCl (5MG Oral Tablet) Maximum of 8 tablets per day Methylphenidate HCl ER (10MG Oral Tablet Maximum of 4 tablets per day Extended Release)

Bold type = Brand name drug Plain type = Generic drug 106 Drug Name Quantity Limit Methylphenidate HCl ER (20MG Oral Tablet Maximum of 3 tablets per day Extended Release) Methylphenidate HCl (10MG/5ML Oral Maximum of 30 ml per day Solution) Methylphenidate HCl (5MG/5ML Oral Solution) Maximum of 60 ml per day Methylphenidate HCl (Oral Tablet Immediate Maximum of 3 tablets per day Release) (Generic Ritalin) Miglitol (100MG Oral Tablet) Maximum of 3 tablets per day Miglitol (25MG Oral Tablet) Maximum of 12 tablets per day Miglitol (50MG Oral Tablet) Maximum of 6 tablets per day Modafinil (100MG Oral Tablet) Maximum of 1 tablet per day Modafinil (200MG Oral Tablet) Maximum of 2 tablets per day Moexipril HCl (Oral Tablet) Maximum of 2 tablets per day Montelukast Sodium (Oral Packet) Maximum of 1 packet per day Montelukast Sodium (Oral Tablet) Maximum of 1 tablet per day Montelukast Sodium (Oral Tablet Chewable) Maximum of 1 tablet per day Morphine Sulfate (100MG/5ML Oral Solution) Maximum of 10 ml per day Morphine Sulfate ER (100MG Oral Tablet Extended Release, 15MG Oral Tablet Extended Maximum of 3 tablets per day Release) (Generic MS Contin) Morphine Sulfate ER (200MG Oral Tablet Maximum of 2 tablets per day Extended Release) (Generic MS Contin) Morphine Sulfate ER (30MG Oral Tablet Extended Release, 60MG Oral Tablet Extended Maximum of 4 tablets per day Release) (Generic MS Contin) Morphine Sulfate (10MG/5ML Oral Solution) Maximum of 100 ml per day Morphine Sulfate (20MG/5ML Oral Solution) Maximum of 50 ml per day Morphine Sulfate (15MG Oral Tablet Maximum of 8 tablets per day Immediate Release) Morphine Sulfate (30MG Oral Tablet Maximum of 6 tablets per day Immediate Release) Multaq (Oral Tablet) Maximum of 2 tablets per day Namzaric (Oral Capsule ER 24 Hour Therapy Maximum of 1 capsule per day Pack) Namzaric (Oral Capsule Extended Release Maximum of 1 capsule per day 24 Hour) Naratriptan HCl (Oral Tablet) Maximum of 12 tablets per 30 days Nateglinide (120MG Oral Tablet) Maximum of 3 tablets per day Nateglinide (60MG Oral Tablet) Maximum of 6 tablets per day

Bold type = Brand name drug Plain type = Generic drug 107 Drug Name Quantity Limit Nebupent (Inhalation Solution Reconstituted) Maximum of 1 vial (300 mg) per 28 days Nerlynx (Oral Tablet) Maximum of 6 tablets per day Nevirapine ER (100MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Nevirapine ER (400MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Nevirapine (Oral Suspension) Maximum of 40 ml per day Nevirapine (Oral Tablet Immediate Release) Maximum of 2 tablets per day Nifedipine ER (Oral Tablet Extended Release Maximum of 2 tablets per day 24 Hour) Nifedipine ER Osmotic Release (Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Ninlaro (Oral Capsule) Maximum of 3 capsules per 28 days Northera (100MG Oral Capsule) Maximum of 3 capsules per day Northera (200MG Oral Capsule, 300MG Oral Maximum of 6 capsules per day Capsule) Norvir (Oral Packet) Maximum of 12 packets per day Norvir (Oral Solution) Maximum of 16 ml per day Noxafil (Oral Suspension) Maximum of 20 ml per day Noxafil (Oral Tablet Delayed Release) Maximum of 6 tablets per day Nubeqa (Oral Tablet) Maximum of 4 tablets per day Nucala (Subcutaneous Solution Auto- Maximum of 3 ml per 28 days Injector) Nucala (Subcutaneous Solution Prefilled Maximum of 3 ml per 28 days Syringe) Nucala (Subcutaneous Solution Maximum of 3 vials per 28 days Reconstituted) Nucynta ER (Oral Tablet Extended Release Maximum of 2 tablets per day 12 Hour) Nuplazid (Oral Capsule) Maximum of 1 capsule per day Nuplazid (10MG Oral Tablet) Maximum of 1 tablet per day Ocaliva (Oral Tablet) Maximum of 1 tablet per day Odefsey (Oral Tablet) Maximum of 1 tablet per day Odomzo (Oral Capsule) Maximum of 1 capsule per day Ofev (Oral Capsule) Maximum of 2 capsules per day Olanzapine (10MG Oral Tablet, 15MG Oral Tablet, 2.5MG Oral Tablet, 20MG Oral Tablet, Maximum of 1 tablet per day 5MG Oral Tablet, 7.5MG Oral Tablet)

Bold type = Brand name drug Plain type = Generic drug 108 Drug Name Quantity Limit Olanzapine ODT (10MG Oral Tablet Dispersible, 15MG Oral Tablet Dispersible, Maximum of 1 tablet per day 20MG Oral Tablet Dispersible, 5MG Oral Tablet Dispersible) Olmesartan Medoxomil (20MG Oral Tablet, Maximum of 1 tablet per day 40MG Oral Tablet) Olmesartan Medoxomil (5MG Oral Tablet) Maximum of 2 tablets per day Olmesartan Medoxomil-HCTZ (Oral Tablet) Maximum of 1 tablet per day Olmesartan-Amlodipine-HCTZ (Oral Tablet) Maximum of 1 tablet per day Omega-3-Acid Ethyl Esters (Oral Capsule) Maximum of 4 capsules per day (Generic Lovaza) Omeprazole (10MG Oral Capsule Delayed Maximum of 3 capsules per day Release) Orkambi (Oral Packet) Maximum of 56 packets per 28 days Orkambi (Oral Tablet) Maximum of 112 tablets per 28 days Oseltamivir Phosphate (Oral Capsule) Maximum of 2 capsules per day Oseltamivir Phosphate (Oral Suspension Maximum of 26 ml per day Reconstituted) Osphena (Oral Tablet) Maximum of 1 tablet per day Oxandrolone (10MG Oral Tablet) Maximum of 2 tablets per day Oxandrolone (2.5MG Oral Tablet) Maximum of 4 tablets per day Oxybutynin Chloride ER (10MG Oral Tablet Maximum of 3 tablets per day Extended Release 24 Hour) Oxybutynin Chloride ER (15MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour) Oxybutynin Chloride ER (5MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Oxycodone HCl (100MG/5ML Oral Maximum of 6 ml per day Concentrate) Oxycodone HCl (5MG/5ML Oral Solution) Maximum of 130 ml per day Oxycodone HCl (10MG Oral Tablet Immediate Maximum of 12 tablets per day Release, 5MG Oral Tablet Immediate Release) Oxycodone HCl (15MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Oxycodone HCl (20MG Oral Tablet Immediate Maximum of 6 tablets per day Release, 30MG Oral Tablet Immediate Release) Oxycodone-Acetaminophen (10-325MG Oral Tablet, 2.5-325MG Oral Tablet, 5-325MG Oral Maximum of 12 tablets per day Tablet, 7.5-325MG Oral Tablet) Oxycodone-Aspirin (Oral Tablet) Maximum of 12 tablets per day

Bold type = Brand name drug Plain type = Generic drug 109 Drug Name Quantity Limit Ozempic (0.25MG/DOSE or 0.5MG/DOSE) Maximum of 1 pen (1.5 ml) per 28 days (Subcutaneous Solution Pen-Injector) Ozempic (1MG/DOSE) (Subcutaneous Maximum of 2 pens (3 ml) per 28 days Solution Pen-Injector) Paliperidone ER (1.5MG Oral Tablet Extended Release 24 Hour, 3MG Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour, 9MG Oral Tablet Extended Release 24 Hour) Paliperidone ER (6MG Oral Tablet Extended Maximum of 2 tablets per day Release 24 Hour) Pantoprazole Sodium (20MG Oral Tablet Maximum of 3 tablets per day Delayed Release) Pantoprazole Sodium (40MG Oral Tablet Maximum of 2 tablets per day Delayed Release) Pemazyre (Oral Tablet) Maximum of 1 tablet per day Pentamidine Isethionate (Inhalation Solution Maximum of 1 vial (300 mg) per 28 days Reconstituted) Pentasa (250MG Oral Capsule Extended Maximum of 12 capsules per day Release) Pentasa (500MG Oral Capsule Extended Maximum of 8 capsules per day Release) Perforomist (Inhalation Nebulization Maximum of 2 vials (4 ml) per day Solution) Perindopril Erbumine (Oral Tablet) Maximum of 2 tablets per day Pifeltro (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl (15MG Oral Tablet) Maximum of 3 tablets per day Pioglitazone HCl (30MG Oral Tablet, 45MG Maximum of 1 tablet per day Oral Tablet) Pioglitazone HCl-Glimepiride (Oral Tablet) Maximum of 1 tablet per day Pioglitazone HCl-Metformin HCl (Oral Tablet) Maximum of 3 tablets per day Piqray (200MG Daily Dose) (Oral Tablet Maximum of 1 tablet per day Therapy Pack) Piqray (250MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Piqray (300MG Daily Dose) (Oral Tablet Maximum of 2 tablets per day Therapy Pack) Pomalyst (Oral Capsule) Maximum of 1 capsule per day Posaconazole (Oral Tablet Delayed Release) Maximum of 6 tablets per day Praluent (Subcutaneous Solution Auto- Maximum of 2 pens (2 ml) per 28 days Injector)

Bold type = Brand name drug Plain type = Generic drug 110 Drug Name Quantity Limit Prasugrel HCl (Oral Tablet) Maximum of 1 tablet per day Pravastatin Sodium (Oral Tablet) Maximum of 1 tablet per day Pregabalin (100MG Oral Capsule, 150MG Oral Capsule, 200MG Oral Capsule, 25MG Oral Maximum of 3 capsules per day Capsule, 50MG Oral Capsule, 75MG Oral Capsule) Pregabalin (225MG Oral Capsule, 300MG Oral Maximum of 2 capsules per day Capsule) Pregabalin (Oral Solution) Maximum of 30 ml per day Premarin (Oral Tablet) Maximum of 1 tablet per day Premphase (Oral Tablet) Maximum of 1 tablet per day Prempro (Oral Tablet) Maximum of 1 tablet per day Prezcobix (Oral Tablet) Maximum of 1 tablet per day Prezista (Oral Suspension) Maximum of 2 bottles (400 ml) per 30 days Prezista (150MG Oral Tablet) Maximum of 6 tablets per day Prezista (600MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Prezista (800MG Oral Tablet) Maximum of 1 tablet per day Prolia (Subcutaneous Solution Prefilled Maximum of 1 syringe per 180 days Syringe) Promacta (Oral Packet) Maximum of 6 packets per day Promacta (12.5MG Oral Tablet, 25MG Oral Maximum of 1 tablet per day Tablet) Promacta (50MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Pulmozyme (Inhalation Solution) Maximum of 2 ampules (5 ml) per day Qinlock (Oral Tablet) Maximum of 3 tablets per day Quetiapine Fumarate ER (150MG Oral Tablet Extended Release 24 Hour, 200MG Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Quetiapine Fumarate ER (300MG Oral Tablet Extended Release 24 Hour, 400MG Oral Tablet Maximum of 2 tablets per day Extended Release 24 Hour, 50MG Oral Tablet Extended Release 24 Hour) Quetiapine Fumarate (100MG Oral Tablet Immediate Release, 200MG Oral Tablet Maximum of 3 tablets per day Immediate Release, 50MG Oral Tablet Immediate Release) Quetiapine Fumarate (25MG Oral Tablet Maximum of 4 tablets per day Immediate Release)

Bold type = Brand name drug Plain type = Generic drug 111 Drug Name Quantity Limit Quetiapine Fumarate (300MG Oral Tablet Immediate Release, 400MG Oral Tablet Maximum of 2 tablets per day Immediate Release) Quinapril HCl (Oral Tablet) Maximum of 2 tablets per day Quinapril-Hydrochlorothiazide (10-12.5MG Oral Maximum of 1 tablet per day Tablet) Quinapril-Hydrochlorothiazide (20-12.5MG Oral Maximum of 2 tablets per day Tablet, 20-25MG Oral Tablet) Raloxifene HCl (Oral Tablet) Maximum of 1 tablet per day Ramelteon (Oral Tablet) Maximum of 1 tablet per day Ramipril (Oral Capsule) Maximum of 2 capsules per day Ranolazine ER (Oral Tablet Extended Release Maximum of 2 tablets per day 12 Hour) RAVICTI (Oral Liquid) Maximum of 17.5 ml per day Rayaldee (Oral Capsule Extended Release) Maximum of 2 capsules per day Rebif Rebidose (Subcutaneous Solution Maximum of 12 pens (6 ml) per 28 days Auto-Injector) Rebif Rebidose Titration Pack Maximum of 1 pack (4.2 ml) per 28 days (Subcutaneous Solution Auto-Injector) Rebif (Subcutaneous Solution Prefilled Maximum of 12 syringes (6 ml) per 28 days Syringe) Rebif Titration Pack (Subcutaneous Solution Maximum of 1 pack (4.2 ml) per 28 days Prefilled Syringe) Relenza Diskhaler (Inhalation Aerosol Maximum of 3 inhalers (60 blisters) per 30 days Powder Breath Activated) Relistor (Oral Tablet) Maximum of 3 tablets per day Repaglinide (0.5MG Oral Tablet) Maximum of 32 tablets per day Repaglinide (1MG Oral Tablet) Maximum of 16 tablets per day Repaglinide (2MG Oral Tablet) Maximum of 8 tablets per day Repatha Pushtronex System (Subcutaneous Maximum of 1 cartridge (3.5 ml) per 28 days Solution Cartridge) Repatha (Subcutaneous Solution Prefilled Maximum of 3 syringes (3 ml) per 28 days Syringe) Repatha SureClick (Subcutaneous Solution Maximum of 3 pens (3 ml) per 28 days Auto-Injector) Restasis Single-Use Vials (Ophthalmic Maximum of 2 vials per day Emulsion) Retevmo (40MG Oral Capsule) Maximum of 6 capsules per day Retevmo (80MG Oral Capsule) Maximum of 4 capsules per day Revlimid (Oral Capsule) Maximum of 1 capsule per day

Bold type = Brand name drug Plain type = Generic drug 112 Drug Name Quantity Limit Rexulti (Oral Tablet) Maximum of 1 tablet per day Reyataz (Oral Packet) Maximum of 6 packets per day Riomet ER (Oral Suspension Reconstituted Maximum of 20 ml per day ER) Riomet (Oral Solution) Maximum of 25.5 ml per day Risedronate Sodium (150MG Oral Tablet Maximum of 1 tablet per 30 days Immediate Release) Risedronate Sodium (30MG Oral Tablet Immediate Release, 5MG Oral Tablet Maximum of 1 tablet per day Immediate Release) Risedronate Sodium (35MG Oral Tablet Immediate Release, 35MG (12 PACK) Oral Maximum of 4 tablets per 28 days Tablet Immediate Release, 35MG (4 PACK) Oral Tablet Immediate Release) Ritonavir (Oral Tablet) Maximum of 12 tablets per day Rivastigmine Tartrate (Oral Capsule) Maximum of 2 capsules per day Rivastigmine (Transdermal Patch 24 Hour) Maximum of 1 patch per day Rizatriptan Benzoate (Oral Tablet) Maximum of 12 tablets per 30 days Rizatriptan Benzoate ODT (Oral Tablet Maximum of 12 tablets per 30 days Dispersible) Rosuvastatin Calcium (Oral Tablet) Maximum of 1 tablet per day Rozlytrek (100MG Oral Capsule) Maximum of 5 capsules per day Rozlytrek (200MG Oral Capsule) Maximum of 3 capsules per day Rubraca (Oral Tablet) Maximum of 4 tablets per day Rukobia (Oral Tablet Extended Release 12 Maximum of 2 tablets per day Hour) Rybelsus (Oral Tablet) Maximum of 1 tablet per day Rydapt (Oral Capsule) Maximum of 8 capsules per day Saphris (Tablet Sublingual) Maximum of 2 tablets per day Secuado (Transdermal Patch 24 Hour) Maximum of 1 patch per day Selzentry (Oral Solution) Maximum of 8 bottles (1840 ml) per 30 days Selzentry (150MG Oral Tablet, 75MG Oral Maximum of 2 tablets per day Tablet) Selzentry (25MG Oral Tablet, 300MG Oral Maximum of 4 tablets per day Tablet) Serevent Diskus (Inhalation Aerosol Powder Maximum of 1 inhaler (60 inhalations) per 30 Breath Activated) (60 Inhalations) days Sildenafil Citrate (20MG Oral Tablet) (Generic Maximum of 3 tablets per day Revatio)

Bold type = Brand name drug Plain type = Generic drug 113 Drug Name Quantity Limit Silodosin (Oral Capsule) Maximum of 1 capsule per day Simvastatin (Oral Tablet) Maximum of 1 tablet per day Sofosbuvir-Velpatasvir (Oral Tablet) Maximum of 1 tablet per day Solifenacin Succinate (Oral Tablet) Maximum of 1 tablet per day Soliqua (Subcutaneous Solution Pen- Maximum of 6 pens (18 ml) per 30 days Injector) Somavert (Subcutaneous Solution Maximum of 1 vial per day Reconstituted) Sovaldi (150MG Oral Packet) Maximum of 1 carton (28 packets) per 28 days Sovaldi (200MG Oral Packet) Maximum of 2 cartons (56 packets) per 28 days Sovaldi (400MG Oral Tablet) Maximum of 1 tablet per day Spiriva HandiHaler (Inhalation Capsule) Maximum of 1 capsule per day Spiriva Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 30 days Solution) Sprycel (100MG Oral Tablet, 140MG Oral Maximum of 1 tablet per day Tablet, 70MG Oral Tablet) Sprycel (20MG Oral Tablet, 50MG Oral Maximum of 3 tablets per day Tablet) Sprycel (80MG Oral Tablet) Maximum of 2 tablets per day Stavudine (Oral Capsule) Maximum of 2 capsules per day Stiolto Respimat (Inhalation Aerosol Maximum of 1 inhaler (4 grams) per 30 days Solution) Stivarga (Oral Tablet) Maximum of 4 tablets per day Stribild (Oral Tablet) Maximum of 1 tablet per day Suboxone (12-3MG Sublingual Film, 4-1MG Maximum of 2 films per day Sublingual Film) Suboxone (2-0.5MG Sublingual Film, 8-2MG Maximum of 3 films per day Sublingual Film) Sumatriptan (Nasal Solution) Maximum of 12 devices per 30 days Sumatriptan Succinate (100MG Oral Tablet, Maximum of 12 tablets per 30 days 25MG Oral Tablet, 50MG Oral Tablet) Sumatriptan Succinate Refill (Subcutaneous Maximum of 12 injections (6 ml) per 30 days Solution Cartridge) Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution) Sumatriptan Succinate (4MG/0.5ML Subcutaneous Solution Auto-Injector, 6MG/ Maximum of 12 injections (6 ml) per 30 days 0.5ML Subcutaneous Solution Auto-Injector)

Bold type = Brand name drug Plain type = Generic drug 114 Drug Name Quantity Limit Sumatriptan Succinate (6MG/0.5ML Subcutaneous Solution Auto-Injector) Maximum of 12 injections (6 ml) per 30 days (Generic Imitrex STATdose) Sumatriptan Succinate (6MG/0.5ML Maximum of 12 injections (6 ml) per 30 days Subcutaneous Solution Prefilled Syringe) Sutent (12.5MG Oral Capsule, 25MG Oral Maximum of 1 capsule per day Capsule, 50MG Oral Capsule) Sutent (37.5MG Oral Capsule) Maximum of 2 capsules per day Symbicort (120 Inhalation Aerosol) Maximum of 1 inhaler (10.2 grams) per 30 days Symfi Lo (Oral Tablet) Maximum of 1 tablet per day Symfi (Oral Tablet) Maximum of 1 tablet per day Sympazan (Oral Film) Maximum of 2 films per day Symtuza (Oral Tablet) Maximum of 1 tablet per day Synjardy (Oral Tablet Immediate Release) Maximum of 2 tablets per day Synjardy XR (10-1000MG Oral Tablet Extended Release 24 Hour, 25-1000MG Oral Maximum of 1 tablet per day Tablet Extended Release 24 Hour) Synjardy XR (12.5-1000MG Oral Tablet Extended Release 24 Hour, 5-1000MG Oral Maximum of 2 tablets per day Tablet Extended Release 24 Hour) Tabrecta (Oral Tablet) Maximum of 4 tablets per day Tadalafil (PAH) (20MG Oral Tablet) Maximum of 2 tablets per day Tagrisso (Oral Tablet) Maximum of 1 tablet per day Talzenna (0.25MG Oral Capsule) Maximum of 3 capsules per day Talzenna (1MG Oral Capsule) Maximum of 1 capsule per day Tasigna (150MG Oral Capsule) Maximum of 5 capsules per day Tasigna (200MG Oral Capsule) Maximum of 4 capsules per day Tasigna (50MG Oral Capsule) Maximum of 14 capsules per day Tazverik (Oral Tablet) Maximum of 8 tablets per day Tecfidera (Oral Capsule Delayed Release) Maximum of 2 capsules per day Telmisartan (Oral Tablet) Maximum of 1 tablet per day Telmisartan-Amlodipine (Oral Tablet) Maximum of 1 tablet per day Telmisartan-HCTZ (40-12.5MG Oral Tablet, Maximum of 1 tablet per day 80-25MG Oral Tablet) Telmisartan-HCTZ (80-12.5MG Oral Tablet) Maximum of 2 tablets per day Temazepam (15MG Oral Capsule, 30MG Oral Maximum of 1 capsule per day Capsule) Tenofovir Disoproxil Fumarate (Oral Tablet) Maximum of 1 tablet per day

Bold type = Brand name drug Plain type = Generic drug 115 Drug Name Quantity Limit Teriparatide (Recombinant) (Subcutaneous Maximum of 1 pen (2.48 ml) per 28 days Solution Pen-Injector) Tetrabenazine (12.5MG Oral Tablet) Maximum of 3 tablets per day Tetrabenazine (25MG Oral Tablet) Maximum of 4 tablets per day Thalomid (100MG Oral Capsule, 50MG Oral Maximum of 1 capsule per day Capsule) Thalomid (150MG Oral Capsule, 200MG Oral Maximum of 2 capsules per day Capsule) Tibsovo (Oral Tablet) Maximum of 2 tablets per day Tivicay (10MG Oral Tablet, 25MG Oral Maximum of 1 tablet per day Tablet) Tivicay (50MG Oral Tablet) Maximum of 2 tablets per day Tivicay PD (Oral Tablet Soluble) Maximum of 6 tablets per day TOBI Podhaler (Inhalation Capsule) Maximum of 8 capsules per day Tobramycin (300MG/5ML Inhalation Maximum of 2 ampules (10 ml) per day Nebulization Solution) Tolcapone (Oral Tablet) Maximum of 6 tablets per day Tracleer (Oral Tablet Soluble) Maximum of 8 tablets per day Tradjenta (Oral Tablet) Maximum of 1 tablet per day Tramadol HCl ER (Biphasic) (Oral Tablet Maximum of 1 tablet per day Extended Release 24 Hour) Tramadol HCl ER (Oral Tablet Extended Maximum of 1 tablet per day Release 24 Hour) Tramadol HCl (50MG Oral Tablet Immediate Maximum of 8 tablets per day Release) Tramadol-Acetaminophen (Oral Tablet) Maximum of 8 tablets per day Trandolapril (1MG Oral Tablet, 2MG Oral Maximum of 1 tablet per day Tablet) Trandolapril (4MG Oral Tablet) Maximum of 2 tablets per day Trelegy Ellipta (100-62.5-25MCG/INH Inhalation Aerosol Powder Breath Activated) Maximum of 1 inhaler (60 blisters) per 30 days (60 Blisters) Trezix (Oral Capsule) Maximum of 10 capsules per day Trientine HCl (Oral Capsule) Maximum of 8 capsules per day Trijardy XR (10-5-1000MG Oral Tablet Extended Release 24 Hour, 25-5-1000MG Maximum of 1 tablet per day Oral Tablet Extended Release 24 Hour) Trijardy XR (12.5-2.5-1000MG Oral Tablet Extended Release 24 Hour, 5-2.5-1000MG Maximum of 2 tablets per day Oral Tablet Extended Release 24 Hour)

Bold type = Brand name drug Plain type = Generic drug 116 Drug Name Quantity Limit Trintellix (Oral Tablet) Maximum of 1 tablet per day Triumeq (Oral Tablet) Maximum of 1 tablet per day Trulicity (Subcutaneous Solution Pen- Maximum of 4 pens (2 ml) per 28 days Injector) Truvada (Oral Tablet) Maximum of 1 tablet per day Tukysa (150MG Oral Tablet) Maximum of 4 tablets per day Tukysa (50MG Oral Tablet) Maximum of 12 tablets per day Turalio (Oral Capsule) Maximum of 4 capsules per day Tybost (Oral Tablet) Maximum of 1 tablet per day Tymlos (Subcutaneous Solution Pen-Injector) Maximum of 1.56 ml per 30 days Valacyclovir HCl (1GM Oral Tablet) Maximum of 4 tablets per day Valacyclovir HCl (500MG Oral Tablet) Maximum of 2 tablets per day Valganciclovir HCl (50MG/ML Oral Solution Maximum of 36 ml per day Reconstituted) Valganciclovir HCl (450MG Oral Tablet) Maximum of 4 tablets per day Valsartan (160MG Oral Tablet, 40MG Oral Maximum of 2 tablets per day Tablet, 80MG Oral Tablet) Valsartan (320MG Oral Tablet) Maximum of 1 tablet per day Valsartan-Hydrochlorothiazide (Oral Tablet) Maximum of 1 tablet per day Maximum of 10 blister packs (10 spray devices) Valtoco 10 MG Dose (Nasal Liquid) per 30 days Valtoco 15 MG Dose (Nasal Liquid Therapy Maximum of 10 blister packs (20 spray devices) Pack) per 30 days Valtoco 20 MG Dose (Nasal Liquid Therapy Maximum of 10 blister packs (20 spray devices) Pack) per 30 days Maximum of 10 blister packs (10 spray devices) Valtoco 5 MG Dose (Nasal Liquid) per 30 days Vancomycin HCl (125MG Oral Capsule) Maximum of 4 capsules per day Vancomycin HCl (250MG Oral Capsule) Maximum of 8 capsules per day Veltassa (Oral Packet) Maximum of 1 packet per day Vemlidy (Oral Tablet) Maximum of 1 tablet per day Venclexta (100MG Oral Tablet) Maximum of 6 tablets per day Venclexta (10MG Oral Tablet) Maximum of 2 tablets per day Venclexta (50MG Oral Tablet) Maximum of 1 tablet per day Ventavis (10MCG/ML Inhalation Solution) Maximum of 7 ml per day Ventavis (20MCG/ML Inhalation Solution) Maximum of 3 ml per day Verzenio (Oral Tablet) Maximum of 2 tablets per day Victoza (Subcutaneous Solution Pen-Injector) Maximum of 3 pens (9 ml) per 30 days

Bold type = Brand name drug Plain type = Generic drug 117 Drug Name Quantity Limit Vigabatrin (Oral Packet) Maximum of 6 packets per day Vigabatrin (Oral Tablet) Maximum of 6 tablets per day Vigadrone (Oral Packet) Maximum of 6 packets per day Viibryd (Oral Tablet) Maximum of 1 tablet per day Viibryd Starter Pack (Oral Kit) Maximum of 1 pack (30 tablets) per 30 days Vimpat (Oral Solution) Maximum of 40 ml per day Vimpat (Oral Tablet) Maximum of 2 tablets per day Viracept (250MG Oral Tablet) Maximum of 10 tablets per day Viracept (625MG Oral Tablet) Maximum of 4 tablets per day Viread (Oral Powder) Maximum of 4 bottles (240 grams) per 30 days Viread (150MG Oral Tablet, 200MG Oral Maximum of 1 tablet per day Tablet, 250MG Oral Tablet) Vitrakvi (100MG Oral Capsule) Maximum of 4 capsules per day Vitrakvi (25MG Oral Capsule) Maximum of 6 capsules per day Vitrakvi (Oral Solution) Maximum of 20 ml per day Vizimpro (Oral Tablet) Maximum of 1 tablet per day Vosevi (Oral Tablet) Maximum of 1 tablet per day Votrient (Oral Tablet) Maximum of 4 tablets per day Vraylar (1.5MG Oral Capsule, 3MG Oral Capsule, 4.5MG Oral Capsule, 6MG Oral Maximum of 1 capsule per day Capsule) Vyndamax (Oral Capsule) Maximum of 1 capsule per day Vyndaqel (Oral Capsule) Maximum of 4 capsules per day Wixela Inhub (Inhalation Aerosol Powder Maximum of 1 inhaler (60 blisters) per 30 days Breath Activated) (Generic Advair) Xarelto (10MG Oral Tablet, 20MG Oral Maximum of 1 tablet per day Tablet) Xarelto (15MG Oral Tablet, 2.5MG Oral Maximum of 2 tablets per day Tablet) Xarelto Starter Pack (Oral Tablet Therapy Maximum of 1 pack (51 tablets) per 30 days Pack) Xcopri (250MG Daily Dose) (Oral Tablet Maximum of 1 pack (56 tablets) per 28 days Therapy Pack) Xcopri (350MG Daily Dose) (Oral Tablet Maximum of 1 pack (56 tablets) per 28 days Therapy Pack) Xcopri (100MG Oral Tablet, 50MG Oral Maximum of 1 tablet per day Tablet) Xcopri (150MG Oral Tablet, 200MG Oral Maximum of 2 tablets per day Tablet)

Bold type = Brand name drug Plain type = Generic drug 118 Drug Name Quantity Limit Xcopri (Oral Tablet Titration Therapy Pack) Maximum of 1 pack (28 tablets) per 28 days Xeljanz (Oral Tablet Immediate Release) Maximum of 2 tablets per day Xeljanz XR (Oral Tablet Extended Release 24 Maximum of 1 tablet per day Hour) Xiidra (Ophthalmic Solution) Maximum of 2 vials per day Xofluza (40 MG Dose) (Oral Tablet Therapy Maximum of 2 tablets per 30 days Pack) Xofluza (80 MG Dose) (Oral Tablet Therapy Maximum of 2 tablets per 30 days Pack) Xospata (Oral Tablet) Maximum of 3 tablets per day Xpovio (100MG Once Weekly) (Oral Tablet Maximum of 20 tablets per 28 days Therapy Pack) Xpovio (40MG Once Weekly) (Oral Tablet Maximum of 8 tablets per 28 days Therapy Pack) Xpovio (40MG Twice Weekly) (Oral Tablet Maximum of 16 tablets per 28 days Therapy Pack) Xpovio (60MG Once Weekly) (Oral Tablet Maximum of 12 tablets per 28 days Therapy Pack) Xpovio (60MG Twice Weekly) (Oral Tablet Maximum of 24 tablets per 28 days Therapy Pack) Xpovio (80MG Once Weekly) (Oral Tablet Maximum of 16 tablets per 28 days Therapy Pack) Xpovio (80MG Twice Weekly) (Oral Tablet Maximum of 32 tablets per 28 days Therapy Pack) Xtampza ER (13.5MG Oral Capsule ER 12 Hour Abuse-Deterrent, 18MG Oral Capsule Maximum of 3 capsules per day ER 12 Hour Abuse-Deterrent, 9MG Oral Capsule ER 12 Hour Abuse-Deterrent) Xtampza ER (27MG Oral Capsule ER 12 Hour Abuse-Deterrent, 36MG Oral Capsule ER 12 Maximum of 6 capsules per day Hour Abuse-Deterrent) Xtandi (Oral Capsule) Maximum of 4 capsules per day Xyrem (Oral Solution) Maximum of 18 ml per day Yuvafem (Vaginal Tablet) Maximum of 1 tablet per day Zafirlukast (Oral Tablet) Maximum of 2 tablets per day Zaleplon (10MG Oral Capsule) Maximum of 2 capsules per day Zaleplon (5MG Oral Capsule) Maximum of 1 capsule per day Zejula (Oral Capsule) Maximum of 3 capsules per day Zelboraf (Oral Tablet) Maximum of 8 tablets per day Zidovudine (Oral Capsule) Maximum of 6 capsules per day

Bold type = Brand name drug Plain type = Generic drug 119 Drug Name Quantity Limit Zidovudine (Oral Syrup) Maximum of 64 ml per day Zidovudine (Oral Tablet) Maximum of 2 tablets per day Ziprasidone HCl (Oral Capsule) Maximum of 2 capsules per day Zolpidem Tartrate (Oral Tablet Immediate Maximum of 1 tablet per day Release) Zydelig (Oral Tablet) Maximum of 2 tablets per day Zykadia (Oral Tablet) Maximum of 3 tablets per day

Bold type = Brand name drug Plain type = Generic drug 120

C3. Over-the-counter (OTC) Drug List UnitedHealthcare Senior Care Options covers some prescription OTC drugs that aren’t normally covered under our Medicare Part D benefit.

You need a prescription from your doctor to have drugs on this list covered. If your prescription is for a brand name drug, you will get the generic version of the drug if it’s available. Your doctor should write “no substitution” on the prescription to get the brand name drug.

Some of these drugs may need prior authorization. Please check with your doctor and the plan. If the drug requires a prior authorization, you or your doctor will need to get approval from the plan before the drug may be covered.

The list below shows the prescription OTC drugs covered by the plan.

tRACK OTC Drug Name OTC Drug Name

A1 C1 Analgesics Acetaminophen/Extra Strength (Tablet)

B1 C1 Analgesics Aminofen (Tablet) C1

C1 8 Hour Arthritis Pain Reliever (Tablet Apap (Elixir) Extended-Release) C1 C1 Apra (Elixir) 8 Hour Pain Relief (Tablet Extended- C1 Arthritis Pain (Tablet Extended-Release) Release) C1

C1 8 Hour Pain Reliever (Tablet Extended- Arthritis Pain Relief (Tablet Extended- Release) Release) C1

C1 8 Hr Arthritis Pain Relief (Tablet Extended- Arthritis Pain Reliever (Tablet Extended- Release) Release) C1 C1 Betatemp Children's (Suspension)

8Hr Muscle Aches & Pain (Tablet C1 Extended-Release) Chewable Acetaminophen Children's C1 (Tablet Chewable)

Acephen (Suppository) C1 C1 Children's Acetaminophen (Suspension)

Acetaminophen (160mg/5ml Liquid, C1 160mg/5ml Solution, 120mg Suppository, Children's Apap (Tablet Chewable)

C1 650mg Suppository, 325mg Tablet) Children's Chewable Acetaminophen C1 Acetaminophen Children's (Suspension) (Tablet Chewable)

C1 C1 Acetaminophen ER (Tablet Extended- Children's Medi-Tabs (Tablet Chewable) Release) C1

C1 Children's Pain Reliever (Tablet Chewable)

C1 Acetaminophen Extra Strength (Tablet) Children's Pain Reliever (Tablet C1 Acetaminophen Infants (Suspension) Disintegrating)

C1 C1 Acetaminophen Junior Strength (Tablet Children's Silapap (Liquid) Disintegrating) C1

C1 Children's Tactinal (Tablet Chewable)

C1 Acetaminophen Rapid Tabs Children's Chloraseptic Sore Throat (Liquid) (Tablet Disintegrating)

Bold type = Brand name drug Plain type = Generic drug 121 OTC Drug Name OTC Drug Name

C1 C1 CVS 8Hr Arthritis Pain Relief (Tablet EQ Arthritis Pain (Tablet Extended- Extended-Release) Release)

C1 C1 CVS 8Hr Muscle Aches & Pain (Tablet EQ Children's Pain Reliever (Tablet Extended-Release) Chewable)

C1 C1 CVS Acetaminophen (Liquid) EQ Pain & Fever Children's (Suspension)

C1 C1 CVS Acetaminophen Extra Strength EQ Pain & Fever Children's (Tablet (Tablet) Chewable)

C1 C1 CVS Arthritis Pain Relief (Tablet Extended- EQ Pain & Fever Infants (Suspension) Release) C1 C1 EQ Pain Relief Adult/Rapid Burst (Liquid) CVS Children's Pain Relief (Suspension) C1

C1 EQ Pain Reliever (Tablet)

C1 CVS Fever Reducing Children's EQ Pain Reliever Junior (Tablet Chewable) (Suppository) C1 C1 EQL Acetaminophen (Tablet CVS Infants Pain Relief (Suspension) C1 Disintegrating) CVS Pain & Fever Children's (Suspension) C1

C1 EQL Acetaminophen (Tablet) CVS Pain & Fever Infants (Suspension) C1

C1 EQL Acetaminophen Children's CVS Pain Relief 8 Hour (Tablet Extended- (Suspension) Release) C1

C1 EQL Acetaminophen Extra Strength CVS Pain Relief Adult/Rapid Burst (Liquid) (Tablet)

C1 C1 CVS Pain Relief Children's (Suspension) EQL Acetaminophen Infants (Suspension)

C1 C1 CVS Pain Relief Children's (Tablet EQL Acetaminophen Rapid Tabs (Tablet Chewable) Disintegrating)

C1 C1 CVS Pain Relief Extra Strength (Tablet) EQL Arthritis Pain Relief (Tablet Extended- C1 Release)

CVS Pain Relief Regular Strength C1 (Capsule) Extra Strength Pain Relief (Tablet)

C1 C1 CVS Pain Relief Regular Strength (Tablet) Fever Reducer Children's (Suppository)

C1 C1 ED-Apap (Liquid) Feverall Adults (Suppository)

C1 C1 EQ 8Hr Arthritis Pain Relief (Tablet Feverall Children's (Suppository) Extended-Release) C1

C1 Feverall Infants (Suppository) EQ Acetaminophen (Tablet) C1

C1 Feverall Junior Strength (Suppository)

C1 EQ Acetaminophen Children's GNP 8 Hour Pain Reliever (Tablet (Suspension) C1 Extended-Release)

C1 EQ Acetaminophen Children's (Tablet GNP Acetaminophen (Tablet) Disintegrating) C1 C1 GNP Acetaminophen Extra Strength EQ Acetaminophen Extra Strength (Tablet) C1 (Capsule)

C1 EQ Acetaminophen Junior (Tablet GNP All Day Pain Relief (Tablet) Disintegrating) C1 GNP Arthritis Pain Relief (Tablet Extended- Release)

Bold type = Brand name drug Plain type = Generic drug 122 OTC Drug Name OTC Drug Name

C1 C1 GNP Children's Easy-Melts (Tablet Little Remedies Fever/Pain Reliever Disintegrating) Children's (Liquid)

C1 C1 GNP Children's Pain Relief (Suspension) Little Remedies For Fevers Fever/Pain C1 Reliever Children's (Liquid) GNP Infants Pain Relief (Suspension) C1

C1 GNP Infants Pain/Fever (Suspension) Little Remedies For Fevers Fever/Pain C1 Reliever Infant (Liquid) GNP Pain & Fever Children's (Suspension) C1 C1 Mapap (500mg Capsule, 80mg Tablet GNP Pain Relief (160mg Tablet Chewable, Chewable, 160mg/5ml Liquid, 325mg 325mg Tablet) C1 Tablet, 500mg Tablet)

C1 GNP Pain Relief Extra Strength (167mg/ Mapap Acetaminophen Extra Strength 5ml Liquid, 500mg Tablet) C1 (Liquid)

C1 GNP Pain Reliever Extra Strength (Tablet) Mapap Arthritis Pain (Tablet Extended- C1 Goodsense Arthritis Pain (Tablet Extended- Release) Release) C1

C1 Mapap Children's (Suspension)

C1 Goodsense Pain & Fever Children's Mapap Children's (Tablet Chewable) (Suspension) C1 C1 Mapap Children's (Tablet) Goodsense Pain & Fever Infants C1 Mapap Extra Strength (Tablet)

(Suspension) C1

C1 Goodsense Pain Relief (Tablet Extended- Maxapap Maximum Strength (Tablet) C1 Release) Maxapap Regular Strength (Tablet)

C1 C1 Goodsense Pain Relief Extra Strength Medi-Tabs Children's (Elixir) (Tablet) C1 C1 Medi-Tabs Extra Strength (Tablet) Healthy Mama Shake That Ache (Tablet) C1 C1 Medi-Tabs Junor Strength (Tablet HM Acetaminophen Children's (Tablet Chewable) Chewable) C1 C1 Midol (Tablet Extended-Release) HM Arthritis Pain Relief (Tablet Extended- C1 Non-Aspirin Children's (Suspension) Release) C1 C1 Nortemp (Suspension) HM Pain & Fever Children's (Suspension) C1 C1 Nortemp Infants (Suspension) HM Pain & Fever Infants (Suspension) C1 C1 Pain & Fever (Tablet) HM Pain Relief (Tablet Extended-Release) C1 C1 Pain & Fever Children's (Solution) HM Pain Relief Extra Strength (Tablet) C1 C1 Pain & Fever Children's (Suspension) HM Pain Reliever (Tablet) C1 C1 Pain & Fever Children's (Tablet Chewable) HM Rapid Melts Junior (Tablet) C1 C1 Pain & Fever Children's Dye-Free Infants Pain & Fever (Suspension) C1 (Suspension) KLS Acetaminophen Extra Strength C1 Pain & Fever Children's/Dye-Free (Tablet) C1 (Suspension) KLS Rapid Release Pain Reliever (Tablet) C1 C1 Pain & Fever Extra Strength (Tablet) Liquid Pain Relief (Liquid)

Bold type = Brand name drug Plain type = Generic drug 123 OTC Drug Name OTC Drug Name

C1 C1 Pain & Fever Infants (Suspension) RA Acetaminophen Children's (Tablet C1 Chewable) Pain Relief (325mg Tablet, 500mg Tablet) C1

C1 Pain Relief 8 Hour (Tablet Extended- RA Acetaminophen ER (Tablet Extended- Release) Release) C1 C1 RA Acetaminophen Extra Strength (Tablet)

Pain Relief Children's (Suspension) C1

C1 Pain Relief Extra Strength (Tablet) RA Acetaminophen Rapid Melts Children's C1 (Tablet Disintegrating) Pain Relief Regular Strength (Tablet) C1 C1 RA Acetaminophen Rapid Melts Junior Pain Reliever (Liquid) (Tablet Disintegrating) C1

C1 Pain Reliever (Tablet) RA Arthritis Pain Relief (Tablet Extended- C1 Pain Reliever Extra Strength (Tablet) Release) C1

C1 Pain Reliever/Fever Reducer Children's RA Arthritis Pain Relief Acetaminophen (Suppository) (Tablet Extended-Release) C1

C1 Pediacare Children (Suspension) RA Fever Reducer & Pain Reliever Infants C1 (Suspension) Pediacare Fever Reducer/Pain Reliever/ C1 Infant (Suspension) RA Fever Reducer/Pain Reliever Children's C1 (Suspension) Pediacare Infants (Suspension) C1 C1 RA Fever Reducer/Pain Reliever Infants Pharbetol (Tablet) C1 (Suspension) Pharbetol Extra Strength (Tablet) C1

C1 RA Pain Relief Acetaminophen (Tablet)

C1 PX Arthritis Pain Relief (Tablet Extended- RA Pain Reliever Extra Strength Adult Release) C1 (Liquid) PX Children's Pain Relief (Suspension) C1

C1 SB Arthritis Pain Relief (Tablet Extended- PX Pain Relief Extra Strength (Tablet) Release)

C1 C1 QC Acetaminophen 8 Hours (Tablet SB Pain Reliever Children's (Suspension) Extended-Release) C1 C1 SB Pain Reliever Extra Strength (Tablet)

C1 QC Arthritis Pain Relief (Tablet Extended- SM 8 Hour Pain Relief (Tablet Extended- Release) C1 Release) QC Non-Aspirin Children's (Suspension) C1

C1 SM Arthritis Pain Relief (Tablet Extended- QC Non-Aspirin Extra Strength (Tablet) Release)

C1 C1 QC Non-Aspirin Jr Strength (Tablet) SM Arthritis Pain Reliever (Tablet C1 Extended-Release)

QC Pain Relief (Tablet) C1 C1 SM Pain & Fever Children's (Suspension)

QC Pain Relief Children's (Suspension) C1 C1 SM Pain & Fever Infants (Suspension)

QC Pain Relief Extra Strength (Tablet) C1 C1 SM Pain Relief Extra Strength (Tablet)

QC Pain Relief Infants (Suspension) C1

C1 RA 8 Hour Pain Relief (Tablet Extended- SM Pain Reliever (Tablet) Release)

C1 RA Acetaminophen (Tablet)

Bold type = Brand name drug Plain type = Generic drug 124 OTC Drug Name OTC Drug Name

C1 C1 SM Pain Reliever Extra Strength (500mg GNP Capsaicin (0.15% Liquid)

C1 Capsule, 500mg Tablet, 650mg Tablet RA Capsicum Hot Patch (Pad) Extended-Release) C1 C1 Sure Result Sr Relief (Cream) SM Rapid Melts Junior (Tablet) C1 C1 Zostrix High Potency (Cream) Tactinal (Tablet) C1 C1 Zostrix High Potency Footpain Relief Tactinal Extra Strength (Tablet)

C1 (Cream)

C1 TGT Acetaminophen Children's Zostrix Natural Pain Relief (Cream) (Suspension) C1 C1 Zostrix-HP TGT Acetaminophen Extra Strength B1 (Tablet) Non-Steroidal Anti Inflammatory Drugs C1 (NSAIDs) TGT Acetaminophen Extra Strength Quick C1 Adult Aspirin Regimen (Tablet)

Release (Tablet) C1

C1 TGT Acetaminophen Melts Children's Addaprin (Tablet) C1 (Tablet Disintegrating) Adult Aspirin EC Low Strength (Tablet

C1 TGT Arthritis Pain Relief (Tablet Extended- Delayed-Release) C1 Release) Advil Junior Strength (Tablet)

C1 C1 TGT Children's Acetaminophen All Day Pain Relief (Tablet) (Suspension) C1 C1 All Day Relief (Tablet)

C1 TGT Pain Reliever Jr Strength Melts Aspirin (120mg Suppository, 200mg (Tablet Disintegrating) B1 Suppository, 300mg Suppository, 600mg Analgesics, Topical

C1 Suppository, 325mg Tablet, 325mg Tablet Arthritis Pain Relieving (Cream) Delayed-Release, 81mg Tablet Delayed-

C1 Aspercreme Warming Pain Relief Patch Release) C1 (Pad) Aspirin (81mg Tablet Chewable)

C1 C1 Capsagel (Gel) Aspirin 81 (Tablet Delayed-Release)

C1 C1 Capsagel Extra Strength (Gel) Aspirin 81 Low Dose (Tablet Chewable)

C1 C1 Capsagel Maximum Strength (Gel) Aspirin Adult (Tablet)

C1 C1 Capsaicin (Cream) Aspirin Adult Low Dose (81mg Tablet

C1 Capsaicin Hot Patch (Pad) Chewable, 81mg Tablet Delayed-Release) C1

C1 Capsaicin HP (Cream) Aspirin Adult Low Strength (Tablet C1 Chewable) Capzasin-HP (Cream) C1 C1 Aspirin Children's (Tablet Chewable) Capzasin-P (Cream) C1 C1 Aspirin DR (Tablet Delayed-Release) Castiva Warming (Lotion) C1 C1 Aspirin EC (Tablet Delayed-Release) CVS Capsaicin HP (Cream) C1 C1 Aspirin EC Low Dose (Tablet Delayed- CVS Medicated Heat Patch (Pad)

C1 Release)

C1 GNP Capsaicin (0.1% Cream) Aspirin Enteric Coated Adult Low Strength (Tablet Delayed-Release)

Bold type = Brand name drug Plain type = Generic drug 125 OTC Drug Name OTC Drug Name

C1 C1 Aspirin Low Dose (Tablet Chewable) CVS Aspirin Low Dose (Tablet Delayed- C1 Release) Aspirin Low Dose (Tablet Delayed-Release) C1

C1 Aspirin Low Strength (Tablet Chewable) CVS Aspirin Low Strength (Tablet Delayed- C1 Release) Aspirin Regimen Low Dose/Adult (Tablet C1 CVS Childs Non-Aspirin (Tablet Chewable) Delayed-Release) C1 C1 CVS Ibuprofen (Capsule)

Aspirin Regular Strength (Tablet Delayed- C1 Release) CVS Ibuprofen (Tablet)

C1 C1 Aspir-Low (Tablet Delayed-Release) CVS Ibuprofen IB (Tablet)

C1 C1 Aspirtab (Tablet Delayed-Release) CVS Ibuprofen Infants (Suspension)

C1 C1 Aspirtab Maximum Strength (Tablet) CVS Ibuprofen Junior Strength (Tablet C1 Chewable)

Bayer Advanced Aspirin Extra Strength C1 (Tablet) CVS Ibuprofen Liquid Filled (Capsule)

C1 C1 Bayer Advanced Aspirin Regular Strength CVS Naproxen Sodium (Capsule) (Tablet) C1 C1 CVS Naproxen Sodium (Tablet) Bayer Aspirin (Tablet Delayed-Release) C1

C1 CVS Non-Aspirin Children's (Tablet Bayer Aspirin (Tablet) Chewable)

C1 C1 Bayer Aspirin EC Low Dose (Tablet CVS Non-Aspirin Extra Strength (Tablet) Delayed-Release) C1 C1 Dyspel (Tablet) Bayer Aspirin Extra Strength (Tablet) C1

C1 EC-81 Aspirin (Tablet Delayed-Release) Bayer Low Dose (Tablet Delayed-Release) C1

C1 Ecotrin (Tablet Delayed-Release) Bayer Plus (Tablet) C1

C1 Ecotrin Low Strength (Tablet Delayed- Careall Aspirin (Tablet Chewable) Release)

C1 C1 Children's Aspirin (Tablet Chewable) Ecotrin Maximum Strength (Tablet C1 Delayed-Release) Children's Aspirin Free (Elixir) C1 C1 Ecpirin (Tablet Delayed-Release)

Children's Aspirin Low Strength (Tablet C1 Chewable) Enovarx-Ibuprofen (Cream)

C1 C1 Children's Non-Aspirin (Suspension) Enteric Coated Aspirin (Tablet Delayed- C1 Release) Children's Non-Aspirin (Tablet Chewable) C1

C1 CVS All Day Pain Relief (Tablet) EQ Adult Aspirin Low Strength (Tablet C1 Delayed-Release) CVS Aspirin (Tablet Delayed-Release) C1 C1 EQ All Day Pain Relief (Tablet) CVS Aspirin (Tablet) C1 C1 EQ Aspirin (Tablet Delayed-Release) CVS Aspirin Adult Low Dose (Tablet C1 EQ Aspirin Adult Low Dose (Tablet Chewable) C1 Delayed-Release) CVS Aspirin Adult Low Strength (Tablet C1 EQ Aspirin EC (Tablet Delayed-Release) Delayed-Release) C1

C1 CVS Aspirin Ec (Tablet Delayed-Release) EQ Aspirin Low Dose (Tablet Chewable)

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C1 C1 EQ Aspirin Low Dose (Tablet Delayed- GNP Naproxen Sodium (220mg Capsule, Release) 220mg Tablet)

C1 C1 EQ Children's Aspirin (Tablet Chewable) Goodsense Aspirin (81mg Tablet C1 Chewable, 325mg Tablet) EQ Ibuprofen (Capsule) C1

C1 EQ Ibuprofen (Tablet) Goodsense Aspirin Adult Low Strength C1 (Tablet Chewable) EQ Ibuprofen Infants (Suspension) C1 C1 Goodsense Aspirin Low Dose (Tablet EQ Ibuprofen Junior Strength (Tablet Delayed-Release) Chewable) C1 C1 Goodsense Ibuprofen (Tablet) EQ Naproxen Sodium (Capsule) C1 C1 Goodsense Ibuprofen Infants (Suspension) EQ Naproxen Sodium (Tablet) C1 C1 Goodsense Ibuprofen Junior Strength EQL Aspirin (Tablet) (Tablet Chewable) C1

C1 EQL Aspirin EC (Tablet Delayed-Release) Goodsense Naproxen Sodium (Tablet) C1

C1 EQL Aspirin Low Dose (Tablet Chewable) H-E-B Aspirin (Tablet Delayed-Release) C1

C1 EQL Aspirin Low Dose (Tablet Delayed- HM Aspirin (81mg Tablet Chewable, Release) 325mg Tablet) C1

C1 EQL Ibuprofen (Capsule) HM Aspirin EC (Tablet Delayed-Release) C1

C1 EQL Ibuprofen (Tablet) HM Aspirin EC Low Dose (Tablet Delayed- C1 EQL Ibuprofen Infants (Suspension) Release) C1

C1 EQL Ibuprofen Junior Strength (Tablet HM Ibuprofen (Capsule)

C1 Chewable) HM Ibuprofen (Tablet Chewable) C1

C1 EQL Naproxen Sodium (Capsule) HM Ibuprofen (Tablet) C1

C1 EQL Naproxen Sodium (Tablet) HM Ibuprofen IB (Tablet) C1

C1 Flanax Pain Relief (Tablet) HM Ibuprofen IB/Junior Strength (Tablet C1 Genpril (Tablet) Chewable) C1

C1 GNP Adult Aspirin Low Strength (Tablet HM Ibuprofen Infants (Suspension)

C1 Chewable) HM Naproxen Sodium (220mg Capsule, C1 GNP Aspirin (325mg Tablet, 81mg Tablet 220mg Tablet)

C1 Delayed-Release, 325mg Delayed-Release) Hy-Vee All Day Relief (Tablet) C1

C1 GNP Aspirin Low Dose (Tablet Delayed- Ibu-200 (Tablet) Release) C1 C1 Ibu-Drops Infants (Suspension) GNP Ibuprofen (200mg Capsule, 200mg C1 Ibuprofen (200mg Capsule, 200mg Tablet) Tablet) C1

C1 GNP Ibuprofen Infants (Suspension) Ibuprofen 100 Junior Strength (Tablet C1 Chewable) GNP Ibuprofen Junior Strength (Tablet C1 Ibuprofen 200 (Tablet) Chewable) C1

C1 GNP Naproxen (Tablet) Ibuprofen Infants (Suspension)

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C1 C1 Ibuprofen Infants Drops (Suspension) Non-Aspirin Junior Strength (Tablet C1 Chewable)

Ibuprofen Junior Strength (Tablet C1 Chewable) Non-Aspirin Pain Relief (Tablet)

C1 C1 Ibuprofen Lysine (Solution) Non-Aspirin Pain Relief Extra Strength C1 (Tablet) Infants Ibuprofen (Suspension) C1 C1 Norwich Aspirin (Tablet)

I-Prin (Tablet) C1

C1 KLS Aspirin EC (Tablet Delayed-Release) Pamprin All Day Maximum Strength C1 (Tablet) KLS Aspirin Low Dose (Tablet Delayed- C1 Provil (Tablet) Release) C1 C1 PX All Day Relief (Tablet)

KLS Ibuprofen (Tablet) C1 C1 PX Aspirin (Tablet Chewable)

KLS Naproxen Sodium (Tablet) C1 C1 PX Aspirin (Tablet)

KP Aspirin (Tablet Delayed-Release) C1

C1 KS Ibuprofen (Capsule) PX Enteric Aspirin (Tablet Delayed- C1 Release) Medi-Profen (Capsule) C1 C1 PX Ibuprofen (Tablet) Medi-Profen (Suspension) C1 C1 PX Ibuprofen Junior Strength (Tablet Medi-Profen (Tablet) Chewable) C1

C1 Mediproxen (Tablet) PX Infants Profen IB (Suspension) C1

C1 Medique Aspirin (Tablet) QC Aspirin (Tablet) C1

C1 Meijer Aspirin EC (Tablet Delayed-Release) QC Aspirin Low Dose (Tablet Delayed- C1 Meijer Aspirin Free (Tablet) Release) C1

C1 Meijer Ibuprofen (Tablet) QC Chewable Aspirin Low Dose (Tablet C1 Chewable) Meijer Jr Strength Aspirin Free (Tablet C1 Chewable) QC Children's Aspirin (Tablet Chewable) C1

C1 Miniprin Low Dose (Tablet Delayed- QC Enteric Aspirin (Tablet Delayed- Release) Release) C1

C1 MM Aspirin (Tablet) QC Ibuprofen (Tablet) C1

C1 Motrin IB (Capsule) QC Ibuprofen IB (Tablet) C1

C1 Naproxen Sodium (Capsule) QC Ibuprofen Infants (Suspension) C1

C1 Naproxen Sodium (Tablet) QC Naproxen Sodium (Tablet) C1

C1 Naproxen Sodium CR (Tablet Extended- QC Non-Aspirin 8 Hour (Tablet Extended- Release) Release) C1

C1 Naproxen Sodium ER (Tablet Extended- RA Aspirin (Tablet)

C1 Release) RA Aspirin Adult Low Dose (Tablet C1 Non-Aspirin (Tablet) Chewable) C1

C1 Non-Aspirin Extra Strength (Tablet) RA Aspirin Adult Low Strength (Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 128 OTC Drug Name OTC Drug Name

C1 C1 RA Aspirin Children's (Tablet Chewable) SM Aspirin EC Low Strength (Tablet C1 Delayed-Release) RA Aspirin EC (Tablet Delayed-Release) C1

C1 RA Aspirin EC Adult Low Strength (Tablet SM Aspirin Enteric Coated (Tablet Delayed-Release) Delayed-Release) C1 C1 SM Aspirin Low Dose (Tablet Chewable)

RA Children's Aspirin (Tablet Chewable) C1 C1 SM Children's Aspirin (Tablet Chewable)

RA Children's Non-Aspirin (Suspension) C1

C1 RA Ibuprofen (Capsule) SM Ibuprofen (200mg Capsule, 200mg C1 Tablet) RA Ibuprofen (Tablet) C1 C1 SM Ibuprofen IB (100mg Tablet Chewable, RA Ibuprofen Infants (Suspension) 200mg Tablet) C1

C1 RA Ibuprofen Junior Strength (Tablet SM Ibuprofen Jr (Tablet) Chewable) C1 C1 SM Infants Ibuprofen (Suspension) RA Naproxen Sodium (Capsule) C1 C1 SM Naproxen Sodium (Tablet) RA Naproxen Sodium (Tablet) C1 C1 St Joseph Aspirin (Tablet Delayed-Release) RA Pain Relief Aspirin (Tablet) C1 C1 St Joseph Low Dose Aspirin (Tablet RA Pain Relief Ibuprofen (Tablet) Chewable) C1

C1 SB Aspirin (Tablet) TGT Aspirin (Tablet Chewable) C1

C1 SB Aspirin Adult Low Strength (Tablet TGT Aspirin (Tablet Delayed-Release) Delayed-Release) C1 C1 TGT Aspirin (Tablet) SB Aspirin EC (Tablet Delayed-Release) C1 C1 TGT Aspirin Low Dose (Tablet Delayed- SB Children's Aspirin (Tablet Chewable) Release) C1

C1 SB Children's Non-Aspirin (Tablet TGT Children's Aspirin (Tablet Chewable) Disintegrating) C1 C1 TGT Enteric-Coated Aspirin (Tablet SB Ibuprofen (Tablet) Delayed-Release) C1

C1 SB Infants Ibuprofen (Suspension) TGT Ibuprofen (Capsule) C1

C1 SB Low Dose ASA EC (Tablet Delayed- TGT Ibuprofen (Tablet) Release) C1 C1 TGT Ibuprofen Junior Strength (Tablet SB Naproxen Sodium (Tablet) Chewable) C1

C1 SB Non-Aspirin (Tablet Chewable) TGT Infants Ibuprofen (Suspension) C1

C1 SB Non-Aspirin (Tablet) TGT Naproxen Sodium (Capsule) C1

C1 SB Non-Aspirin Extra Strength (Tablet) TGT Naproxen Sodium (Tablet) C1

C1 SB Non-Aspirin Jr Strength (Tablet Wal-Profen (Capsule) Disintegrating) C1 C1 Wal-Profen (Tablet) SM Aspirin (Tablet) A1 C1 Anti-Addiction/Substance Abuse Treatment SM Aspirin Adult Low Strength (81mg Agents Tablet Chewable, 81mg Tablet Delayed- B1 Smoking Cessation Agents Release)

Bold type = Brand name drug Plain type = Generic drug 129 OTC Drug Name OTC Drug Name

C1 C1 CVS Nicotine (Gum) HM Nicotine Transdermal System (Patch)

C1 C1 CVS Nicotine Lozenge (Lozenge) HM Nicotine Transdermal System Step 1 C1 (Patch) CVS Nicotine Polacrilex (Gum) C1

C1 CVS Nicotine Polacrilex (Lozenge) HM Nicotine Transdermal System Step 2 C1 (Patch) CVS Nicotine Polacrilex Starter (Gum) C1 C1 HM Nicotine Transdermal System Step 3 CVS Nicotine Transdermal System (Patch) (Patch) C1

C1 CVS Nicotine Transdermal System Step 1 KLS Quit2 (Gum) (Patch) C1 C1 KLS Quit2 (Lozenge) CVS Nicotine Transdermal System Step 2 C1 KLS Quit4 (Gum) (Patch) C1 C1 KLS Quit4 (Lozenge)

CVS Nicotine Transdermal System/Step 3 C1 (Patch) Nicorelief (Gum)

C1 C1 EQ Nicotine (Lozenge) Nicotine (Gum)

C1 C1 EQ Nicotine (Patch) Nicotine (Lozenge)

C1 C1 EQ Nicotine Gum Refill (Gum) Nicotine (Patch)

C1 C1 EQ Nicotine Gum Starter (Gum) Nicotine Mini Lozenge (Lozenge)

C1 C1 EQ Nicotine Lozenges (Lozenge) Nicotine Polacrilex (Gum)

C1 C1 EQ Nicotine Polacrilex (Gum) Nicotine Polacrilex (Lozenge)

C1 C1 EQ Nicotine Polacrilex (Lozenge) Nicotine Polacrilex Refill (Gum)

C1 C1 EQ Nicotine Step 3 (Patch) Nicotine Polacrilex Starter Kit (Gum)

C1 C1 EQL Nicotine Polacrilex (Gum) Nicotine Step 1 (Patch)

C1 C1 EQL Nicotine Polacrilex (Lozenge) Nicotine Step 2 (Patch)

C1 C1 GNP Nicotine Gum (Gum) Nicotine Step 3 (Patch)

C1 C1 GNP Nicotine Mini Lozenge (Lozenge) Nicotine Transdermal System (Patch)

C1 C1 GNP Nicotine Polacrilex (Gum) Nicotine Transdermal System Step 1 C1 (Patch) GNP Nicotine Polacrilex (Lozenge) C1

C1 GNP Nicotine Polacrilex Mini (Lozenge) Nicotine Transdermal System Step 2 C1 (Patch) GNP Nicotine Transdermal System (Patch) C1 C1 Nicotine Transdermal System Step 3 GNP Nicotine Transdermal System Step 2 (Patch) (Patch) C1 C1 PX Stop Smoking Aid (Gum) Goodsense Nicotine (Lozenge) C1 C1 PX Stop Smoking Aid (Lozenge) Goodsense Nicotine Gum (Gum) C1 C1 RA Mini Nicotine (Lozenge) Goodsense Nicotine Polacrilex (Lozenge) C1 C1 RA Nicotine (Gum) HM Nicotine Polacrilex (Gum) C1 C1 RA Nicotine (Patch) HM Nicotine Polacrilex (Lozenge)

Bold type = Brand name drug Plain type = Generic drug 130 OTC Drug Name OTC Drug Name

C1 C1 RA Nicotine Gum (Gum) Aplicare Povidone-Iodine Scrub (Solution)

C1 C1 RA Nicotine Polacrilex (Gum) Athletes Foot Antifungal Powder Spray C1 (Aerosol Powder) RA Nicotine Polacrilex (Lozenge) C1 C1 Athletes Foot Powder (Powder)

RA Nicotine Transdermal System (Patch) C1

C1 RA Nicotine Transdermal System Step 3 Athletes Foot Powder Spray (Aerosol Powder) (Patch) C1 C1 Athletes Foot Spray (Aerosol)

SM Nicotine (Gum) C1 C1 Bacitracin (Ointment)

SM Nicotine (Lozenge) C1 C1 Bacitracin Zinc (Ointment)

SM Nicotine Polacrilex (Gum) C1

C1 SM Nicotine Polacrilex (Lozenge) Bacitracin/Neomycin/Polymyxin C1 (Ointment) SM Nicotine Transdermal System (Patch) C1 C1 Bacitracin/Polymyxin (Ointment) SM Nicotine Transdermal System/Step 1/ C1 Bacitraycin Plus (Ointment) Clear (Patch) C1 C1 Band-Aid Plus Antibiotic (Pad)

SM Nicotine Transdermal System/Step 2/ C1 Clear (Patch) Band-Aid Plus Antibiotic/Extra Large C1 (Pad)

SM Nicotine Transdermal System/Step 3/ C1 Clear (Patch) Baza Antifungal (Cream)

C1 C1 Sr Nicotine Gum (Gum) Betadine (Solution)

C1 C1 TGT Nicotine Gum (Gum) Betadine Surgical Scrub (Solution)

C1 C1 TGT Nicotine Polacrilex (Gum) Betadine Swabsticks (Swab)

C1 C1 TGT Nicotine Polacrilex (Lozenge) Betasept Surgical Scrub (Liquid)

C1 C1 TGT Nicotine Step One (Patch) Biopatch Antimicrobial Dressing/1" C1 Disk/4Mm Hole

TGT Nicotine Step Three (Patch) C1

C1 TGT Nicotine Step Two (Patch) Biopatch Antimicrobial Dressing/1" C1 Disk/7Mm Hole Thrive (Gum) C1 A1 Biopatch Antimicrobial Dressing/3/4" Antimicrobial Agents

B1 Disk/1.5Mm Hole Antimicrobials, Topical C1 C1 Biopatch Protective Disk With Chg/ Alevazol (Ointment) 1"Disk/4Mm Hole

C1 C1 Aloe Vesta Clear Antifungal (Ointment) Blis-To-Sol (Solution)

C1 C1 Antibiotic + Pain Relief Maximum Strength Carrington Antifungal (Cream) (Cream) C1 C1 Cavilon (Cream)

C1 Antifungal (1% Aerosol, 1% Cream, 2% Chlorhexidine Gluconate (2% Liquid, Cream) C1 20% Solution) Anti-Fungal Powder (Powder) C1

C1 Chlorhexidine Gluconate Cloth (Pad) Antiseptic Skin Cleanser (Solution) C1 C1 Clorox Nasal Antiseptic Swabs (Swabs) Aplicare Povidone/Iodine (Solution)

Bold type = Brand name drug Plain type = Generic drug 131 OTC Drug Name OTC Drug Name

C1 C1 Clotrimazole-7 (Cream) Ear Dry (Liquid)

C1 C1 Critic-Aid Clear AF (Ointment) EQ Antibiotic + Pain Relief Maximum C1 Strength (Cream)

Cruex Prescription Strength (Aerosol C1 Powder) EQ Athletes Foot (Aerosol Powder)

C1 C1 Curad Triple Antibiotic (Ointment) EQ Athletes Foot (Cream)

C1 C1 CVS 3-Day Vaginal Cream (Cream) EQ Athletes Foot Powder Spray (Aerosol C1 Powder) CVS Af Spray Powder (Aerosol Powder) C1 C1 EQ Bacitracin Zinc (Ointment)

CVS Antibiotic (Ointment) C1 C1 EQ First Aid Antiseptic (Solution)

CVS Antibiotic Plus (Cream) C1 C1 EQ Hydrogen Peroxide (Solution)

CVS Antifungal (Cream) C1 C1 EQ Povidone-Iodine (Solution)

CVS Anti-Fungal Powder (Powder) C1 C1 EQ Tolnaftate (Aerosol)

CVS Antiseptic Skin Cleanser (Solution) C1 C1 EQ Triple Antibiotic (Ointment)

CVS Athletes Foot Powder Spray (Aerosol C1 Powder) EQL Antibiotic + Pain Relief Maximum C1 Strength (Cream) CVS Bacitracin (Ointment) C1 C1 EQL Antifungal (Cream)

CVS Clotrimazole 3 (Cream) C1 C1 EQL Bacitracin Zinc (Ointment)

CVS Foot & Sneaker Powder Spray C1 (Aerosol Powder) EQL First Aid Antibiotic (Ointment)

C1 C1 CVS Hand Wash Advanced Antibacterial EQL Hydrogen Peroxide (Solution) (Solution) C1 C1 First Aid Antibiotic (Ointment) CVS Hydrogen Peroxide (Solution) C1

C1 Foot Repair Serum (Solution)

C1 CVS Peroxide Sore Mouth Cleanser Fungal Nail Eraser (Solution) (Solution) C1 C1 Fungi-Guard (Cream) CVS Poly Bacitracin (Ointment) C1 C1 Fungoid Tincture (2% Kit, 2% Solution) CVS Povidone-Iodine (Solution) C1 C1 Fungoid-D (Cream) CVS Triple Antibiotic (Ointment) C1 C1 GNP Antibiotic Plus Pramoxine (Cream) Dermafungal (Ointment) C1 C1 GNP Antiseptic Skin Cleanser (Solution) Desenex (Powder) C1 C1 GNP Athlete's Foot Relief (Aerosol Powder) Desenex Jock Itch Spray Powder (Aerosol C1 Powder) GNP Bacitracin Zinc (Ointment) C1

C1 Desenex Shake Powder (Powder) GNP Hydrogen Peroxide (Solution) C1

C1 Double Antibiotic (Ointment) GNP Hydrogen Peroxide Wipes C1

C1 Dr G's Clear Nail (Solution) GNP Iodides Tincture (Tincture) C1

C1 Dyna-Hex 2 (Solution) GNP Iodine Tincture (Tincture) C1

C1 Dyna-Hex 4 (Solution) GNP Miconazole Nitrate (Aerosol Powder)

Bold type = Brand name drug Plain type = Generic drug 132 OTC Drug Name OTC Drug Name

C1 C1 GNP Miconazorb AF (Powder) Lanabiotic (Ointment)

C1 C1 GNP Povidone-Iodine (Solution) Lotrimin AF (Aerosol)

C1 C1 GNP Tolnaftate (Cream) Lotrimin AF Deodorant Powder (Aerosol C1 Powder) GNP Triple Antibiotic (Ointment) C1

C1 Goodsense Hydrogen Peroxide (Solution) Lotrimin AF Jock Itch Powder (Aerosol C1 Powder) HM Antiseptic Skin Cleanser (Solution) C1 C1 Lotrimin AF Powder (Aerosol Powder) HM Bacitracin (Ointment) C1 C1 Lugols Strong Iodine (Tincture) HM Double Antibiotic (Ointment) C1 C1 Medicated Anti-Fungal (Solution) HM Hydrogen Peroxide (Solution) C1 C1 Medi-First Triple Antibiotic (Ointment) HM Iodides Tincture (Tincture) C1 C1 Meijer Hydrogen Peroxide (Solution) HM Iodine Tincture (Tincture) C1 C1 Meijer Triple Antibiotic (Ointment) HM Povidone-Iodine (Solution) C1 C1 Micaderm (Cream) HM Triple Antibiotic (Ointment) C1 C1 Miconazole (Cream) Hydrogen Peroxide (Solution) C1 C1 Miconazole Antifungal (Cream) Hydrogen Peroxide Spray (Solution) C1 C1 Miconazole Nitrate (Cream) Hylamend First Aid Antiseptic (Gel) C1 C1 Micro Guard (Powder) Instaclean (Liquid) C1 C1 Multi Antibiotic Plus (Cream) Iodex (Ointment) C1 C1 Mycocide Clinical NS Antifungal Treatment Iodides Tincture (Tincture) (Solution) C1

C1 Iodine Tincture (Tincture) Odor Control Foot & Sneaker Spray C1 Iodine Tincture Mild (Tincture) (Aerosol Powder) C1

C1 Iodine Tincture Strong (Tincture) Odor Eaters Antifungal (Powder) C1

C1 Iodine Tincture Strong Decolorized Odor Eaters Foot & Sneaker Spray (Tincture) (Aerosol Powder) C1

C1 Iso-Blu (Liquid) Operand Chlorhexidine Gluconate (Liquid) C1

C1 Isopropyl Alcohol Spray Perox-A-Mint (Solution) C1

C1 Jock Itch Spray (Aerosol Powder) Peroxyl Oral Spot Treatment (Gel) C1

C1 Jock Itch Spray Powder (Aerosol Powder) Podactin (Cream) C1

C1 Kelp (Tablet) Podactin Powder (Powder) C1

C1 KP Bacitracin Zinc (Ointment) Poly Bacitracin (Ointment) C1

C1 KP Double Antibiotic (Ointment) Polysporin (Ointment) C1

C1 KP Miconazole Nitrate (Cream) Povidone Iodine (Solution) C1

C1 KP Tolnaftate (Cream) Povidone/Iodine Swabsticks (Swabs)

C1 Lamisil AF Defense (Aerosol Powder)

Bold type = Brand name drug Plain type = Generic drug 133 OTC Drug Name OTC Drug Name

C1 C1 Povidone-Iodine (10% Ointment, 10% RA Povidone Iodine (Ointment) Solution) C1 C1 RA Triple Antibiotic (Ointment) Povidone-Iodine Antiseptic (Swabs) C1

C1 RA Triple Antibiotic Spray (Aerosol)

C1 Povidone-Iodine Antiseptic Swabsticks Remedy Antifungal (Cream) (Swabs) C1 C1 Remedy Antifungal Clear/Phytoplex Povidone-Iodine Paint Sponge Swabstick (Ointment) (Swabs) C1 C1 Remedy Phytoplex Antifungal (Powder) PVP Prep (Solution) C1 C1 SB Anti-Fungal (Cream) PX Hydrogen Peroxide (Solution) C1 C1 SB Bacitracin (Ointment) PX Triple Ointment (Ointment) C1 C1 SB Povidone-Iodine (Solution) QC Bacitracin (Ointment) C1 C1 SB Triple Antibiotic (Ointment) QC Hydrogen Peroxide (Solution) C1 C1 Secura Antifungal (Cream) QC Iodides Tincture (Tincture) C1 C1 Secura Antifungal Extra Thick (Cream) QC Iodine Tincture (Tincture) C1 C1 SM Antibiotic (Ointment) QC Povidone Iodine (Solution) C1 C1 SM Antibiotic Plus Pain Relief Maximum QC Tolnaftate (Cream) C1 Strength (Cream) RA Antibiotic Plus (Cream) C1

C1 SM Antifungal Miconazole (Cream) RA Antifungal (Cream) C1

C1 SM Antifungal Tolnaftate (Cream) RA Antifungal Spray (Aerosol) C1

C1 SM Double Antibiotic (Ointment) RA Antiseptic (Solution) C1

C1 SM Hydrogen Peroxide (Solution) RA Antiseptic Skin Cleanser (Solution) C1

C1 SM Iodides Tincture (Tincture) RA Athletes Foot (Cream) C1

C1 SM Iodine Tincture (Tincture)

C1 RA Athletes Foot Powder Spray (Aerosol SM Povidone-Iodine (Solution) Powder) C1 C1 SM Swimmers Ear Drops (Otic Solution) RA Bacitracin (Ointment) C1 C1 SM Triple Antibiotic (Ointment) RA Bacitracin Zinc First Aid (Ointment) C1 C1 SM Triple Antibiotic Original Strength RA Clotrimazole 3 (Cream) C1 (Ointment) RA Clotrimazole 7 (Cream) C1

C1 Soothe & Cool Inzo Antifungal Cream RA Double Antibiotic (Ointment) (Cream)

C1 C1 RA First Aid Iodine (Tincture) Soothe (Tablet Chewable)

C1 C1 RA Foot Care Antifungal (Cream) Swim Ear (Liquid)

C1 C1 RA Hydrogen Peroxide (Solution) Swimmers Ear Drops (Otic Solution)

C1 C1 Ra Hydrogen Peroxide Wipes Swimmers Instant Ear Dry (Otic Solution)

C1 C1 RA Jock Itch Maximum Strength Powder Tegaderm Chg Dressing/2-3/4"X3-3/8"

C1 (Aerosol Powder) Tegaderm Chg Dressing/3-1/2"X4-1/2"

Bold type = Brand name drug Plain type = Generic drug 134 OTC Drug Name OTC Drug Name

C1 C1 Tegaderm Chg Dressing/4"X4-3/4" Bedding Spray Lice Treatment Step 3 C1 (Aerosol) Tegaderm Chg Dressing/4"X6-1/8" C1

C1 Tetterine (Ointment) CVS Bedding Spray Lice Treatment C1 (Aerosol) TGT Antifungal (Cream) C1 C1 CVS Lice Killing (Shampoo) TGT Antifungal Spray Powder (Aerosol C1 CVS Lice Treatment (Rinse) Powder) C1

C1 TGT First Aid Antibiotic Maximum Strength EQ Lice Killing Maximum Strength (Shampoo) (Cream) C1

C1 TGT Hydrogen Peroxide (Solution) EQL Lice Killing Maximum Strength C1 (Shampoo) The Treatment Formula 3 (Solution) C1 C1 GNP Lice Bedding (Aerosol) Tinaspore (Solution) C1 C1 GNP Lice Treatment (1% Rinse, 0.33-4% Tineacide (Cream) Shampoo) C1

C1 Tolnaftate (1% Cream, 1% Powder) HM Lice Killing Maximum Strength C1 Triple Antibiotic (Ointment) (Shampoo) C1

C1 Triple Antibiotic First Aid (Ointment) HM Lice Treatment (Rinse) C1

C1 Triple Paste AF (Ointment) Lice Killing Maximum Strength (Shampoo) C1

C1 Wal-Sporin (Ointment) Lice Killing Shampoo (Shampoo) C1

C1 Zeasorb-AF (Powder) Lice Treatment (Lotion) C1

B1 Antimicrobials, Vaginal Lice Treatment Creme Rinse (Liquid)

C1 C1 3 Day Vaginal (Cream) LiceMD Complete Kit (Gel)

C1 C1 Clotrimazole (Cream) Licide (Aerosol)

C1 C1 Clotrimazole 3 (Cream) Licide Maximum Strength (Liquid)

C1 C1 GNP Clotrimazole 3 (Cream) RA Lice Bedding (Aerosol)

C1 C1 SM 3-Day Vaginal (Cream) RA Lice Maximum Strength (Shampoo)

C1 C1 SM Clotrimazole Vaginal (Cream) RA Lice Treatment (Lotion)

C1 A1 Antiparasitics Rid Lice Killing Shampoo (Shampoo)

B1 C1 Anthelmintic Agents SB Lice Killing Maximum Strength

C1 CVS Pinworm Treatment (Suspension) (Shampoo) C1

C1 Pinworm Medicine (Suspension) SB Lice Treatment (Liquid) C1

C1 Reeses Pinworm Medicine (144mg/ml SB Lice Treatment (Rinse) C1 Suspension) SM Bedding Lice Treatment (Aerosol) C1

C1 Reeses Pinworm Medicine (180mg SM Lice Killing (Liquid) Tablet) C1 B1 SM Lice Killing Maximum Strength Pediculicides/Scabicides

C1 (Shampoo)

C1 Bedding Spray Lice Treat Ment (Aerosol) SM Lice Treatment (Lotion)

Bold type = Brand name drug Plain type = Generic drug 135 OTC Drug Name OTC Drug Name

C1 C1 Stop Lice (Aerosol) Benzepro Short Contact (Foam)

C1 C1 Stop Lice Maximum Strength (Liquid) Benziq (Gel)

C1 C1 Stop Lice Step 3 (Aerosol) Benziq LS (Gel)

C1 C1 TGT Lice Killing Maximum Strength Benziq Wash (Liquid) (Shampoo) C1 C1 Benzoyl Peroxide (5% Gel) Vanalice (Gel) C1

A1 Benzoyl Peroxide (5.3% Foam, 9.8% Foam, Dermatological Agents 10% Gel, 2.5% Gel, 6.5% Gel) B1 C1 Dermatologic Agents, Topical Benzoyl Peroxide Cleanser (3% Lotion, C1 Acne Maximum Strength (Cream) 9% Lotion) C1

C1 Acne Foaming Wash (Liquid) Benzoyl Peroxide Cleanser (Liquid) C1

C1 Acne Medication 10 (Gel) Benzoyl Peroxide Wash (10% Liquid, 5% C1 Liquid) Acne Medication 10 (Lotion) C1 C1 Beta HC (Lotion) Acne Medication 5 (Gel) C1 C1 Boudreauxs Butt Paste Maximum Strength Acne Medication 5 (Lotion) C1 (Ointment) Acne Treatment Cleansing Bar Maximum C1 BP Foam (5.3% Foam, 9.8% Foam) Strength C1 C1 BP Foaming Wash (Liquid) Acne Treatment Gel (Gel) C1 C1 BP Gel (Gel) Acne-Clear (Gel) C1 C1 BP Wash (2.5% Liquid, 7% Liquid) Acnefree 24 Hour Acne Clearing System C1 C1 BPO (4% Gel, 8% Gel) Acnefree Severe 24 Hour Clearing C1 System BPO 6% Foaming Cloths C1

C1 Advanced Acne Wash (Liquid) BPO Creamy Wash Complete Pack C1 (Cream) Anti-Dandruff Shampoo (Lotion) C1 C1 BPO Foaming Cloths Anti-Itch Intensive Healing (Lotion) C1 C1 Calamine (Lotion) Aquanil HC (Lotion) C1 C1 Clean & Clear Continuous Control Acne Baby Diaper Rash Cream (Cream) C1 Cleanser (Cream) Baby Ease (Ointment) C1

C1 Clearasil Daily Clear Vanishing Acne Baby Vitamin A & D (Ointment) Treatment (Cream)

C1 C1 Baza Clear (Ointment) Clearskin (Cream)

C1 C1 Benzefoam (Foam) Corticool (Gel)

C1 C1 Benzefoam Ultra (Foam) Cortizone-10 (Gel)

C1 C1 Benzefoamultra (Foam) Cortizone-10 Diabetics Skin (Lotion)

C1 C1 Benzepro (Foam) Cortizone-10 Eczema (Lotion)

C1 C1 Benzepro Creamy Wash (Liquid) Cortizone-10 Hydratensivehealing (Lotion)

C1 Benzepro Foaming Cloths (Cloth)

Bold type = Brand name drug Plain type = Generic drug 136 OTC Drug Name OTC Drug Name

C1 C1 Cortizone-10 Hydratensivesoothing Desitin (Cream) (Lotion) C1 C1 Desitin Rapid Relief (Cream) Cottontails Diaper Rash (Ointment) C1

C1 Diaper Rash (Ointment)

C1 Cottontails Diaper Rash Creamy W/Vitamin Diaper Rash Paste (Paste) E (Ointment) C1 C1 Dickinsons Witch Hazel (Liquid) Curad Vitamin A & D (Ointment) C1 C1 Effaclar Duo (Solution) CVS Acne (Cream) C1 C1 EQ Diaper Rash (Ointment) CVS Acne Cleansing Bar C1 C1 EQ Hemorrhoidal Pads (Pad) CVS Acne Control Cleanser (Cream) C1 C1 EQ Hygienic Cleansing Wipes (Pad) CVS Acne Foaming Face Wash (Liquid) C1 C1 EQ Petroleum Jelly (Gel) CVS Acne Treatment/Maximum Strength C1 (Gel) EQ Vitamins A & D (Ointment) C1

C1 CVS Advanced 3-In-1 Exfoliating Cleanser EQL Baby Basics Diaper Rash (Ointment) C1 (Liquid) EQL Medicated Dandruff (Lotion) C1

C1 CVS Anti-Dandruff (Lotion) EQL Witch Hazel (Solution) C1

C1 CVS Cortisone Maximum Strength (Gel) Eucerin Eczema Relief (Cream) C1

C1 CVS Creamy Acne Face Wash (Liquid) GNP Acne Treatment Maximum Strength

C1 CVS Diaper Rash (Ointment) (Cream) C1

C1 CVS Eczema Relief (Cream) GNP Diaper Rash (Cream) C1

C1 CVS Foaming Acne Face Wash (Liquid) GNP Diaper Rash Creamy (Ointment) C1

C1 CVS Hydrocortisone Anti-Itch (Cream) GNP Hydrocortisone (Cream) C1

C1 CVS Medicated Pads (Pad) GNP Hydro-Lotion (Lotion) C1

C1 CVS Medicated Wipes (Pad) GNP Hygienic Cleansing (Pad) C1

C1 CVS Petroleum Jelly (Gel) GNP Hygienic Cleansing Pads (Pad) C1

C1 CVS Quick Relief Diaper Rash Cream GNP Medicated Wipes (Pad) C1 (Cream) GNP Petroleum Jelly (Gel) C1

C1 CVS Targeted Acne Spot Treatment GNP Soothing Bath Treatment (Packet) (Cream) C1 C1 GNP Zinc Oxide (Ointment) CVS Vitamin A&D Ointment (Ointment) C1 C1 Goodsense Petroleum Jelly (Gel) CVS Witch Hazel (Liquid) C1 C1 Gynecort 10 (Cream) CVS Zinc Oxide (Ointment) C1 C1 Hemorrhoidal (Pad) Daily Care Skin Protectant (Ointment) C1 C1 Hemorrhoidal Hygiene Pads (Pad) Dandruff Shampoo (Lotion) C1 C1 HM Medicated Cooling Pads (Pad) Delbase Compounding (Ointment) C1 C1 HM Petroleum Jelly (Gel) Dermarest Eczema (Lotion) C1 HM Witch Hazel (Liquid)

Bold type = Brand name drug Plain type = Generic drug 137 OTC Drug Name OTC Drug Name

C1 C1 Hydrocortisone (0.5% Cream, 0.5% Pinxav (Ointment) Ointment) C1 C1 PR Benzoyl Peroxide Wash (Liquid) Hydrocortisone Acetate (Cream) C1

C1 Pre-Moistened Witch Hazel (Pad) Hydrophilic (Ointment) C1

C1 Preparation H (Pad) Hydroskin (Lotion) C1

C1 Preparation H For Women (Pad) Instacort 5 (Cream) C1

C1 Preparation H Totables (Pad) Invisible Acne Treatment (Cream) C1

C1 QC Calamine (Lotion) KP Benzoyl Peroxide (Gel) C1

C1 QC Medicated Pads Pre-Moistened (Pad) KP Benzoyl Peroxide Wash (Liquid) C1

C1 QC Witch Hazel (Liquid) Lanacort 10 (Cream) C1

C1 RA Acne Treatment (Cream) Lanolin Hydrous-GRX (Ointment) C1

C1 RA Baby Care Vitamins A&D to Go Lan-O-Soothe (Cream) (Ointment)

C1 C1 Medicated Cleansing Pads (Pad) RA Dandruff Shampoo (Lotion)

C1 C1 Medicated Wipes Pre-Moistened (Pad) RA Daylogic Acne Foaming Wash C1 Maximum Strength (Foam) Medi-First Hydrocortisone (Cream) C1 C1 RA Diaper Rash (Ointment)

Medi-Pads (Pad) C1 C1 RA First Aid Anti-Itch Spray (Solution)

Meijer Calamine (Lotion) C1

C1 Meijer Zinc Oxide (Ointment) RA Hemorrhoid Relief Medicated Wipes C1 Maximum Strength (Pad) MG217 Psoriasis Anti-Itch (Gel) C1 C1 RA Medicated Wipes Pre-Moistened (Pad) Natural Oatmeal Bath Treatment (Packet) C1 C1 RA Petroleum Jelly (Gel) Neutrogena Clear Pore Cleanser/Mask C1 C1 RA Renewal Dandruff Shampoo (Lotion) Neutrogena On-The-Spot Acne C1 RA Renewal Dandruff Shampoo Clinical Treatment (Cream) C1 (Lotion) Noble Formula HC (Solution) C1 C1 RA Renewal Eczema Moisturizing Cream OC8 (Gel) (Cream) C1

C1 Occluvan (Ointment) RA Renewal Soothing Bath Treatment C1 Panoxyl (Liquid) (Packet) C1

C1 Panoxyl Creamy Wash (Liquid) RA Tugaboos Creamy Petroleum Jelly/ C1 Shea Butter (Gel) Panoxyl Foaming Wash (Liquid) C1 C1 RA Tugaboos Petroleum Jelly (Gel) Panoxyl Wash (Liquid) C1 C1 RA Vanishing Acne Treatment/Maximum Panoxyl-4 Creamy Wash (Liquid) C1 Strength (Cream) Petrolatum (Ointment) C1

C1 RA Vitamin A & D (Ointment) Petrolatum White (Gel) C1 C1 RA Vitamins A & D (Ointment)

C1 Petroleum Jelly (Gel) RA Witch Hazel (Solution)

Bold type = Brand name drug Plain type = Generic drug 138 OTC Drug Name OTC Drug Name

C1 C1 RA Zinc Oxide (Ointment) Witch Hazel (Solution)

C1 C1 Riax (5.5% Foam, 9.5% Foam) Zaclir Cleansing (Lotion)

C1 C1 Sarnol-HC (Lotion) Zinc Oxide (Ointment)

C1 A1 Scalp Relief Maximum Strength (Solution) Gastrointestinal Agents

B1 C1 Scalpicin Maximum Strength (Solution) Antacids C1

C1 Secura Protective (Cream) Acid Controller (Tablet) C1

C1 Selenium Sulfide (Shampoo) Acid Controller Original Strength (Tablet) C1

C1 Selenium Sulfide Shampoo (Shampoo) Acid Reducer (10mg Tablet, 75mg Tablet) C1

C1 Skin Protectant Moisture Barrier (Cream) Acidophilus (Capsule) C1

C1 SM Calamine (Lotion) Acidophilus (Tablet Chewable) C1

C1 SM Hydrocortisone (Cream) Acidophilus (Tablet) C1

C1 SM Hydrocortisone (Ointment) Acidophilus (Wafer) C1

C1 SM Medicated Wipes (Pad) Acidophilus Extra Strength (Capsule) C1

C1 SM Oatmeal Bath (Packet) Acidophilus Lactobacilli (Capsule) C1

C1 SM Petroleum Jelly (Gel) Acidophilus Probiotic (Capsule) C1

C1 SM Witch Hazel (Liquid) Acidophilus Probiotic (Tablet) C1

C1 SM Witch Hazel (Solution) Acidophilus Probiotic Formula (Tablet) C1

C1 Spot Acne Treatment (Cream) Acidophilus With Bifidus (Tablet C1 Chewable) TGT Medicated Hemorrhoidal Pads (Pad) C1 C1 Acidophilus/Bifidus (Wafer) TGT Medicated Wipe/Witch Hazel/Aloe C1 (Pad) Acidophilus/L-Sporogenes Extra Strength C1 (Tablet) Tippy Toes Diaper Rash (Ointment) C1 C1 Acidophilus/Pectin (Capsule) TN Dickinsons Witch Hazel (Liquid) C1 C1 Align (Capsule) TN Dickinsons Witch Hazel Cleansing C1 Aluminum Hydroxide

Pads (Pad) C1

C1 TN Dickinsons Witch Hazel Hemorrhoidal Antacid (Tablet Chewable) C1 (Pad) Antacid Calcium Extra Strength (Tablet

C1 Vagisil (Cream) Chewable) C1

C1 Vaseline (Gel) Antacid Calcium Regular Strength (Tablet C1 Chewable) Vaseline Pure Ultra White Petroleum Jelly C1 Antacid Extra Strength (Tablet Chewable)

(Gel) C1

C1 Vitamin A (Tablet) Antacid Flavor Chews (Tablet Chewable) C1

C1 White Petrolatum (Gel) Antacid Maximum (Tablet Chewable) C1

C1 White Petrolatum (Ointment) Antacid Ultra Strength (Tablet Chewable) C1

C1 White Petroleum Jelly (Gel) Calcium Antacid (Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 139 OTC Drug Name OTC Drug Name

C1 C1 Calcium Antacid Extra Strength (Tablet EQ Antacid Extra Strength (Tablet Chewable) Chewable)

C1 C1 Calcium Antacid Ultra Maximum Strength EQ Antacid Ultra Strength (Tablet (Tablet Chewable) Chewable)

C1 C1 Calcium Antacid Ultra Strength (Tablet EQL Acid Reducer (Tablet) Chewable) C1 C1 EQL Antacid (Tablet Chewable) Calcium Carbonate (Suspension) C1

C1 EQL Antacid Extra Strength (Tablet Calcium Carbonate (Tablet Chewable) Chewable)

C1 C1 Calcium Carbonate (Tablet) EQL Antacid Ultra Strength (Tablet C1 Chewable)

Calcium Carbonate Extra Strength (Tablet C1 Chewable) Famotidine (Tablet)

C1 C1 Cal-Gest Antacid (Tablet Chewable) Florajen Acidophilus (Capsule)

C1 C1 Children's Pepto (Tablet Chewable) Freeze Dried Acidophilus (Capsule)

C1 C1 Children's Soothe (Tablet Chewable) Geri-Lanta Supreme (Suspension)

C1 C1 CVS Acid Controller (Tablet) GNP Acid Reducer (10mg Tablet, 75mg C1 Tablet) CVS Acid Reducer (Tablet) C1

C1 CVS Acidophilus (Capsule) GNP Antacid & Anti-Gas Maximum C1 Strength (Tablet Chewable) CVS Acidophilus Probioticformula (Tablet) C1 C1 GNP Antacid (Tablet Chewable) CVS Antacid & Anti-Gas Fast Relief (Tablet C1 GNP Antacid Extra Strength (Tablet Chewable) C1 Chewable) CVS Antacid Extra (Tablet Chewable) C1 C1 GNP Antacid Ultra Strength (Tablet CVS Antacid Extra Strength (Tablet Chewable) Chewable) C1 C1 GNP Heartburn Relief (Tablet) CVS Antacid Kids (Tablet Chewable) C1 C1 Goodsense Acid Reducer (Tablet) CVS Antacid Maximum Strength (Tablet C1 Healthy Mama Tame The Flame (Tablet Chewable) C1 Chewable) CVS Antacid Supreme (Suspension) C1 C1 Heartburn Relief (10mg Tablet, 75mg CVS Antacid Ultra Strength (Tablet Tablet, 200mg Tablet) Chewable) C1 C1 HM Acid Reducer (Tablet) CVS Chewy Not Chalky Flavor Chews C1 HM Acidophilus Probiotic Formula (Tablet) (Tablet Chewable) C1 C1 HM Calcium Antacid (Tablet Chewable)

CVS Probiotic Acidophilus (Capsule) C1

C1 CVS Smooth Antacid Extra Strength HM Calcium Antacid Extra Strength (Tablet Chewable) (Tablet Chewable) C1

C1 EQ Acid Reducer (Tablet) HM Calcium Antacid Smooth Dissolve C1 (Tablet Chewable) EQ Antacid (Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 140 OTC Drug Name OTC Drug Name

C1 C1 HM Calcium Antacid Smooth Dissolve RA Senna (Tablet) Extra Strength (Tablet Chewable) C1

C1 RA Smooth Antacid Extra Strength (Tablet HM Calcium Antacid Ultra Strength (Tablet Chewable) Chewable) C1 C1 RA Stomach Relief Kids (Tablet Chewable) HM Famotidine (Tablet) C1

C1 Ranitidine 75 (Tablet) KLS Acid Reducer (Tablet) C1

C1 Ranitidine Acid Reducer (Tablet) Long Lasting Antacid (Tablet Chewable) C1

C1 Rolaids (Tablet Chewable) Maalox Children's (Tablet Chewable) C1

C1 SB Acid Controller (Tablet) Mi-Acid (Tablet Chewable) C1

C1 SB Acid Reducer (Tablet) More-Dophilus Acidophilus (Powder) C1

C1 SB Acid Reducer Ranitidine 75 (Tablet) Probiotic Acidophilus (Capsule) C1

C1 SB Antacid (Tablet Chewable)

C1 Probiotic Acidophilus Super Strength SB Antacid Extra Strength (Tablet (Tablet) C1 Chewable) PX Acid Reducer (Tablet) C1

C1 SM Acid Reducer (10mg Tablet, 75mg PX Antacid Extra Strength (Tablet Tablet, 200mg Tablet) Chewable) C1 C1 SM Acidophilus (Capsule)

C1 PX Antacid Maximum Strength (Tablet SM Calcium Antacid (Tablet Chewable) Chewable) C1 C1 SM Calcium Antacid Extra Strength (Tablet PX Calcium Antacid Regular Strength Chewable) (Tablet Chewable) C1 C1 SM Calcium Antacid Ultra Strength (Tablet QC Acid Controller (Tablet) C1 Chewable) QC Antacid (Tablet Chewable) C1

C1 SM Smooth Antacid Extra Strength (Tablet QC Antacid Extra Strength (Tablet Chewable) Chewable) C1

C1 Sodium Bicarbonate (325mg Tablet, RA Acid Reducer (Tablet) 650mg Tablet)

C1 C1 RA Acidophilus (Capsule) Sodium Bicarbonate (Powder)

C1 C1 RA Antacid (Tablet Chewable) TGT Acid Reducer (Tablet)

C1 C1 RA Antacid Extra Strength (Tablet TGT Antacid (Tablet Chewable) Chewable) C1

C1 TGT Antacid Extra Strength (Tablet RA Antacid Ultra Strength (Tablet Chewable) Chewable) C1 C1 Titralac (Tablet Chewable) RA Multihealth Fiber Supplement (Powder) C1

C1 Tums Freshers (Tablet Chewable) RA Probiotic Digestive Care (Capsule) C1

C1 Tums Gas Relief Chewy Bites (Tablet RA Probiotic Gummies (Tablet Chewable) Chewable)

C1 C1 RA Saline Enema (Enema) Zantac 75 (Tablet)

C1 B1 RA Senna (Capsule) Gastrointestinal Agents, Other

Bold type = Brand name drug Plain type = Generic drug 141 OTC Drug Name OTC Drug Name

C1 C1 Align (Tablet Chewable) EQ Pink-Bismuth (Tablet Chewable)

C1 C1 Align Extra Strength (Capsule) EQ Stomach Relief (Tablet Chewable)

C1 C1 Align Jr For Kids (Tablet Chewable) EQL Dairy Digest Fast Acting (Tablet)

C1 C1 Anti-Diarrheal (1mg/7.5ml Liquid, 2mg EQL Stomach Relief (Tablet Chewable) Tablet) C1 C1 Fast Acting Dairy Aid (Tablet)

C1 Bismatrol (262mg/15ml Suspension, Florastor (Capsule) 262mg Tablet Chewable) C1 C1 Florastor Kids (Packet) Bismatrol Maximum Strength (Suspension) C1 C1 Florastormax (Packet) Bismuth (Tablet Chewable) C1 C1 Gas Relief (40mg/0.6ml Suspension, 80mg Bismuth Subsalicylate (Tablet Chewable) C1 Tablet Chewable) Culturelle (Capsule) C1

C1 Gas Relief Extra Strength (Capsule)

C1 Culturelle Immunity Support Formula Gas Relief Maximum Strength (Tablet (Capsule) C1 Chewable) Culturelle Kids (Packet) C1

C1 Gas Relief Ultra Strength (Capsule) Culturelle Kids (Tablet Chewable) C1

C1 Gas-X Extra Strength (Capsule) Culturelle Kids Regularity (Packet) C1

C1 Gas-X Ultra Strength (Capsule) Culturelle Probiotics Kids (Packet) C1

C1 GNP Anti-Diarrheal (Tablet) CVS Bismuth (Tablet Chewable) C1

C1 GNP Anti-Gas (Capsule) CVS Dairy Relief (Chewable Tablet) C1

C1 GNP Dairy Relief (Tablet) CVS Dairy Relief Fast Acting (Tablet) C1

C1 GNP Fast Acting Dairy Relief (Chewable CVS Easy Fiber/Calcium (Tablet Tablet) Chewable) C1 C1 GNP Gas Relief (Tablet Chewable) CVS Lactase (Tablet) C1

C1 GNP Gas Relief Extra Strength (125mg CVS Lactase Enzyme Ultra Strength Capsule, 125mg Tablet Chewable) (Tablet) C1 C1 GNP Infants Gas Relief (Suspension) CVS Stomach Relief (Tablet Chewable) C1

C1 GNP Loperamide HCL (Liquid) Dairy Digest Ultra (Tablet) C1

C1 GNP Pink Bismuth (262mg Tablet Dairy Digestive Supplement Fast Acting Chewable, 262mg Tablet) (Tablet) C1 C1 GNP Stomach Relief (Suspension) Dairy Digestive Ultra (Tablet) C1

C1 GNP Stomach Relief Maximum Strength Dairy Relief (Tablet) (Suspension)

C1 C1 Dairy-Digestive (Chewable Tablet) Goodsense Stomach Relief (Tablet C1 Chewable)

EQ Dairy Digestive Supplement Fast Acting C1 (Chewable Tablet) HM Anti-Diarrheal (Tablet)

C1 C1 EQ Dairy Digestive Supplement Fast Acting HM Gas Relief (80mg Tablet Chewable, (Tablet) 125mg Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 142 OTC Drug Name OTC Drug Name

C1 C1 HM Gas Relief Extra Strength (Capsule) Medi-Lax (Tablet)

C1 C1 HM Gas Relief Infants (Suspension) Medi-Mucil (Capsule)

C1 C1 HM Loperamide HCL (Liquid) Medi-Natural (Tablet)

C1 C1 HM Stomach Relief (262mg Tablet Meijer Anti-Diarrheal (Tablet) Chewable, 262mg/15ml Suspension) C1 C1 Meta Biotic/Bio-Active 12 (Capsule)

C1 HM Stomach Relief Maximum Strength Metamucil (Powder) (Suspension) C1 C1 Metamucil Smooth Texture (Powder) Infants Gas Relief (Suspension) C1 C1 Metamucil Smooth Texture Sugar Free Infants Simethicone (Suspension) C1 (Powder) Kao-Tin (Suspension) C1

C1 Mi-Acid Gas Relief (Tablet Chewable) KLS Fast Acting Lactase (Tablet) C1

C1 Mineral Oil (Enema) Lac-Dose (Tablet) C1

C1 Mineral Oil (Oil) Lactase (Tablet) C1

C1 Mineral Oil Heavy (Oil) Lactase Enzyme (Tablet) C1

C1 MM Anti-Diarrheal (Tablet) Lactase Fast Acting (Tablet) C1

C1 MM Stool Softener (Capsule) Lactinex (Tablet Chewable) C1

C1 Mommys Bliss Gas Relief Drops Lactobacillus (Packet) (Suspension)

C1 C1 Lactobacillus (Tablet) Motion Sickness Relief (Tablet Chewable)

C1 C1 Lactobacillus Extra Strength (Capsule) Motion-Time (Tablet Chewable)

C1 C1 Lacto-Key-100 (Capsule) Mytab Gas (Tablet Chewable)

C1 C1 Lacto-Key-600 (Capsule) Natural Psyllium Seed Indian Husks C1 (Powder)

Lactose Fast Acting Relief (Chewable C1 Tablet) Natural Vegetable Fiber (Powder)

C1 C1 Lactose Fast Acting Relief (Tablet) Pediacare Gas Relief Drops Infants C1 (Suspension)

Little Remedies For Tummys Gas Relief C1 (Suspension) Pediatric Enema (Enema)

C1 C1 Little Tummys Gas Relief (Suspension) Peptic Relief (Suspension)

C1 C1 Loperamide A-D (Tablet) Peptic Relief (Tablet Chewable)

C1 C1 Loperamide HCL (1mg/5ml Liquid, 1mg/ Pepto-Bismol (Tablet Chewable) 7.5ml Liquid) C1

C1 Pepto-Bismol Instacool (Tablet Loperamide Hydrochloride (Tablet) Chewable)

C1 C1 Meclizine (Tablet Chewable) Pepto-Bismol To-Go (Tablet Chewable)

C1 C1 Meclizine HCL (Tablet Chewable) Phazyme (Tablet Chewable)

C1 C1 Meclizine Hydrochloride (Tablet Chewable) Phillips Stool Softener (Capsule)

C1 C1 Medi-Bismuth (Tablet Chewable) Pink Bismuth (Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 143 OTC Drug Name OTC Drug Name

C1 C1 Pink Bismuth Maximum Strength QC Pink Bismuth (Tablet Chewable) (Suspension) C1 C1 QC Senna (Tablet) Primadophilus (Capsule) C1

C1 RA Anti-Diarrheal (Liquid) Probiotic (Capsule) C1

C1 RA Anti-Diarrheal (Tablet)

C1 Probiotic Chewable Children's (Tablet RA Col-Rite (Capsule) Chewable) C1 C1 RA Dairy Aid (Tablet) Probiotic Choclate Bears Children's (Tablet C1 Chewable) RA Dairy Relief Fast Acting (Chewable C1 Tablet) Probiotic Gold Extra Strength (Capsule) C1 C1 RA Dairy Relief Fast Acting (Tablet) Probiotic Packets Children's (Packet) C1 C1 RA Digestive Health (Capsule) Probiotic-10 Chewable (Tablet Chewable) C1 C1 RA Enema (Enema) Promolaxin (Tablet) C1 C1 RA Fiber (Capsule) Psyldex (Powder) C1 C1 RA Fiber (Powder) Psyllium Fiber (Capsule) C1 C1 RA Fiber Supplement (Powder) Psyllium Husk (Powder) C1 C1 RA Fiber Therapy (Capsule) Pure & Gentle Enema (Enema) C1 C1 RA Gas Relief (Capsule) PX Anti-Diarrheal (Tablet) C1 C1 RA Gas Relief (Suspension) PX Dairy Digestive (Tablet) C1 C1 RA Gas Relief (Tablet Chewable) PX Docusate Sodium (Capsule) C1 C1 RA Gas Relief Extra Strength (Capsule) PX Fiber (Capsule) C1 C1 RA Gas Relief Extra Strength (Tablet PX Gas Relief Extra Strength (Capsule) C1 Chewable) PX Gas Relief Infants (Suspension) C1

C1 RA Gas Relief Maximum Strength (Tablet PX Gas Relief Ultra Strength (Capsule) Chewable)

C1 C1 PX Ranitidine (Tablet) RA Gas Relief Ultra Strength (Capsule)

C1 C1 PX Stomach Relief (Tablet Chewable) RA Gas Relief/Infants (Suspension)

C1 C1 PX Stomach Relief Maximum Strength RA K-Pec (Suspension) (Suspension) C1 C1 RA Loperamide HCl (Liquid) QC Anti-Diarrheal (Tablet) C1

C1 RA Mineral Oil (Oil) QC Anti-Gas Ultra Strength (Capsule) C1

C1 RA Motion Sickness Relief (Tablet QC Diarrhea Relief (Suspension) Chewable)

C1 C1 QC Gas Relief (Capsule) RA Pink Bismuth (Tablet Chewable)

C1 C1 QC Gas Relief (Tablet Chewable) RA Soluble Fiber (Tablet)

C1 C1 QC Gas Relief Extra Strength (Tablet RA Stomach Relief (Tablet Chewable) Chewable) C1

C1 RA Stomach Relief Maximum Strength QC Natural Vegetable (Powder) (Suspension)

Bold type = Brand name drug Plain type = Generic drug 144 OTC Drug Name OTC Drug Name

C1 C1 RA Stool Softener (Capsule) SM Mineral Oil (Enema)

C1 C1 Ranitidine HCl (Tablet) SM Mineral Oil (Oil)

C1 C1 Reliable-1 Psyllium (Capsule) SM Probiotic (Capsule)

C1 C1 SB Anti-Diarrhea (Tablet) SM Stomach Relief (262mg/15ml

C1 SB Anti-Gas (Capsule) Suspension, 262mg Tablet Chewable, C1 262mg Tablet) SB Bismuth (Tablet) C1 C1 SM Stomach Relief Liquid (Suspension) SB Docusate Sodium (Capsule) C1 C1 SM Stomach Relief Maximum Strength SB Fib Lax Orange (Powder)

C1 (Suspension) SB Gas Relief (Suspension) C1

C1 SM Ultra Dairy Digestive (Tablet)

C1 SB Gas Relief (Tablet Chewable) Smarty Pants Kids Probiotic Complete C1 SB Gentle Lax-Women (Tablet Delayed- (Tablet Chewable) Release) C1

C1 Sodium Bicarbonate Partial Fill (Solution) SB Senna-Lax (Tablet) C1

C1 Soluble Fiber/Probiotics (Tablet Chewable) Senna Lax (Tablet) C1

C1 Soothe Maximum Strength (Suspension) Senna Regular Strength (Tablet) C1

C1 Sorbulax (Powder) Senna Smooth (Tablet) C1

C1 SR Anti-Diarrheal (Tablet) Sennacon (Tablet) C1

C1 Stablegi (Capsule)

C1 Senna-GRX (Syrup) Stomach Relief (262mg/15ml Suspension, C1 Sennazon (Syrup) 262mg Tablet Chewable)

C1 C1 Sennosides (Senna) (Tablet) Stomach Relief Maximum Strength C1 (Suspension) Sennosides (Tablet) C1 C1 Stomach Relief Plus (Suspension) Simeped (Suspension) C1 C1 Surelac (Tablet)

Simethicone (180mg Capsule, 40mg/0.6ml C1 Suspension) TGT Anti-Diarrheal (Tablet)

C1 C1 Simethicone Extra Strength (Capsule) TGT Dairy Digestive Aid (Tablet)

C1 C1 SM Anti-Diarrheal (Tablet) TGT Fiber Therapy (Powder)

C1 C1 SM Fiber Powder (Powder) TGT Gas Relief Extra Strength (Capsule)

C1 C1 SM Gas Relief (80mg Tablet Chewable, TGT Gas Relief Extra Strength (Tablet 125mg Tablet Chewable) Chewable)

C1 C1 SM Gas Relief Antiflatuent (Capsule) TGT Gas Relief Infants Drops (Liquid)

C1 C1 SM Gas Relief Drops Infants (Suspension) TGT Psyllium Fiber (Capsule)

C1 C1 SM Gas Relief Extra Strength (Capsule) TGT Senna (Tablet)

C1 C1 SM Gas Relief Infants Drops (Suspension) TGT Stomach Relief (Tablet)

C1 C1 SM Loperamide HCL (Liquid) The Magic Bullet (Suppository)

C1 Travel Sickness (Tablet Chewable)

Bold type = Brand name drug Plain type = Generic drug 145 OTC Drug Name OTC Drug Name

C1 C1 Trunature Probiotic For Kids (Tablet CVS Advanced Probiotic Gummies (Tablet Chewable) Chewable)

C1 C1 Ultimate Probiotic Formula (Capsule) CVS Anti-Diarrheal (Suspension)

C1 C1 Veracolate (Tablet Delayed-Release) CVS Anti-Diarrheal (Tablet)

C1 C1 Wal-Mucil (Capsule) CVS Bisacodyl (Suppository)

C1 C1 Wal-Mucil (Powder) CVS Bisacodyl (Tablet Delayed-Release)

C1 C1 Wal-Mucil Plus Calcium (Capsule) CVS Bismuth Maximum Strength C1 (Suspension) Wal-Zan 75 (Tablet) C1

B1 Laxatives CVS Chocolate Laxative Pieces (Tablet C1 Chewable) Abatinex (Capsule) C1 C1 CVS C-Lax Laxative (Tablet Delayed- Alophen (Tablet Delayed-Release)

C1 Release)

C1 AZO Complete Feminine Balance CVS Daily Fiber (Capsule) (Capsule) C1 C1 CVS Digestive Probiotic (Capsule) Benefiber On The Go (Powder) C1 C1 CVS Easy Fiber (Powder) Biohm Children's Probiotic Supplement C1 CVS Enema Disposable (Enema)

(Tablet Chewable) C1

C1 Biotinex (Capsule) CVS Enema Ready-To-Use (Enema) C1

C1 Bisac-Evac (Suppository) CVS Fiber (Capsule) C1

C1 Bisacodyl (Suppository) CVS Gas Relief (Capsule) C1

C1 Bisacodyl EC (Tablet Delayed-Release) CVS Gas Relief (Tablet Chewable) C1

C1 Bisacodyl Laxative (Suppository) CVS Gas Relief Drops Extra Strength C1 (Liquid) Biscolax (Suppository) C1 C1 CVS Gas Relief Extra Strength (Capsule) Bonine (Tablet Chewable) C1 C1 CVS Gas Relief Extra Strength (Tablet Carters Little Pills (Tablet Delayed-Release)

C1 Chewable) Children's Probiotic (Tablet Chewable) C1

C1 CVS Gas Relief Infants (Suspension) Chocolated Laxative (Tablet Chewable) C1

C1 CVS Gas Relief Ultra Strength (Capsule) Citrucel (Tablet) C1

C1 CVS Gentle Laxative (Suppository)

C1 Citrucel Fiber Laxative (Powder) CVS Gentle Laxative (Tablet Delayed- C1 Clear Soluble Fiber (Powder) Release)

C1 C1 Clearlax (Powder) CVS Gentle Laxative Womens (Tablet C1 Delayed-Release) Colace (Capsule) C1 C1 CVS Glycerin Adult (Suppository) Colace Clear (Capsule) C1 C1 CVS Glycerin Child (Suppository) Correct (Tablet Delayed-Release) C1 C1 CVS Infants Gas Relief (Suspension) Correctol (Tablet Delayed-Release) C1

C1 Correctol Extra Gentle (Capsule) CVS Laxative Pills (Tablet)

Bold type = Brand name drug Plain type = Generic drug 146 OTC Drug Name OTC Drug Name

C1 C1 CVS Loperamide HCl (Liquid) Docusate Sodium Extra Strength (Capsule)

C1 C1 CVS Loperamide Hydrochloride (Liquid) Docusil (Capsule)

C1 C1 CVS Mineral Oil (Oil) Docusol Kids (Enema)

C1 C1 CVS Mineral Oil Enema (Enema) Docusol Mini (Enema)

C1 C1 CVS Mini Enema Kids (Enema) Dofus (Capsule)

C1 C1 CVS Motion Sickness Relief (Tablet DOK (100mg Capsule, 250mg Capsule, Chewable) 100mg Tablet)

C1 C1 CVS Natural Daily Fiber (Powder) Dr Edwards Olive Laxative (Tablet)

C1 C1 CVS Natural Fiber Supplement (Powder) DRx Choice Gas Relief (Tablet Chewable)

C1 C1 CVS Probiotic (Capsule) DSS (Capsule)

C1 C1 CVS Probiotic (Tablet Chewable) Ducodyl (Tablet Delayed-Release)

C1 C1 CVS Probiotic Children's (Tablet Dulcolax Pink Stool Softener (Capsule) Chewable) C1 C1 Dulcolax Stool Softener (Capsule) CVS Ranitidine (Tablet) C1

C1 Easy Fiber (Powder) CVS Senna (Tablet) C1

C1 Easy-Lax (Capsule) CVS Senna-Extra (Tablet) C1

C1 Enema (Enema) CVS Soluble Fiber Therapy (Tablet) C1

C1 Enema Disposable (Enema)

C1 CVS Stomach Relief Maximum Strength Enema Mineral Oil (Enema) (Suspension) C1 C1 Enema Mineral Oil Ready-To-Use (Enema) CVS Stool Softener (Capsule) C1 C1 Enema Ready-To-Use (Enema) Dialyvite Chewable Probiotic (Tablet C1 Chewable) Enemeez Mini (Enema) C1

C1 Diamode (Tablet) EQ Anti-Diarrheal (Liquid) C1

C1 Diarrhea (Suspension) EQ Anti-Diarrheal (Tablet) C1

C1 Digestive Advantage Probiotic Gummies EQ Daily Fiber (Capsule) C1 (Tablet Chewable) EQ Enema (Enema) C1

C1 Digestive Health Probiotic (Capsule) EQ Fiber Powder (Powder) C1

C1 Diocto (Liquid) EQ Fiber Therapy (Capsule) C1

C1 Diocto (Syrup) EQ Fiber Therapy (Powder) C1

C1 Docqlace (Capsule) EQ Fiber Therapy (Tablet) C1

C1 Docu (Liquid) EQ Gas Relief (Capsule) C1

C1 Docu Soft (Capsule) EQ Gas Relief (Tablet Chewable) C1

C1 Docuprene (Tablet) EQ Gas Relief Extra Strength (Tablet

C1 Docusate Sodium (100mg Capsule, Chewable) 150mg/15ml Liquid)

Bold type = Brand name drug Plain type = Generic drug 147 OTC Drug Name OTC Drug Name

C1 C1 EQ Gentle Laxative (Tablet Delayed- EQL Laxative Maximum Strength (Tablet) Release) C1 C1 EQL Loperamide HCl (Liquid) EQ Infants Gas Relief (Suspension) C1

C1 EQL Natural Fiber (Powder) EQ Laxative (Tablet Chewable) C1

C1 EQL Ready-To-Use Enema (Enema) EQ Laxative Maximum Strength (Tablet) C1

C1 EQL Senna Laxative (Tablet) EQ Loperamide HCl (Liquid) C1

C1 EQL Stomach Relief Maximum Strength EQ Mineral Oil (Oil) (Suspension)

C1 C1 EQ Natural Fiber Laxative (Powder) EQL Stool Softener (Capsule)

C1 C1 EQ Natural Laxative (Tablet) Evac-U-Gen (Tablet)

C1 C1 EQ Natural Vegetable Laxative (Tablet) Ex-Lax (15mg Tablet Chewable, 15mg C1 Tablet)

EQ Probiotic Digestive System Support C1 (Capsule) Ex-Lax Ultra (Tablet Delayed-Release)

C1 C1 EQ Ranitidine (Tablet) Feenamint (Tablet Delayed-Release)

C1 C1 EQ Stool Softener (Capsule) Fiber Laxative (Capsule)

C1 C1 EQ Vegetable Laxative (Tablet) Fiber Powder (Powder)

C1 C1 EQ Womans Laxative (Tablet Delayed- Fiber Therapy (Powder) Release) C1 C1 Fiber Therapy (Tablet)

C1 EQ Womens Laxative (Tablet Delayed- Fleet Bisacodyl (Enema) Release) C1 C1 Fleet Enema (Enema) EQL Anti-Diarrheal (Tablet) C1 C1 Fleet Liquid Glycerin Suppositories EQL Digestive Probiotic (Capsule)

C1 (Enema) EQL Fiber Supplement (Powder) C1

C1 Fleet Oil (Enema) EQL Fiber Therapy (Powder) C1

C1 Fleet Pediatric (Enema) EQL Fiber Therapy (Tablet) C1

C1 Flora Assist (Packet)

C1 EQL Gas Gone Extra Strength (Tablet Floranex (Packet) Chewable) C1 C1 Floranex (Tablet) EQL Gas Relief (Capsule) C1 C1 Gas Relief Drops Infants (Suspension) EQL Gas Relief Extra Strength (Capsule) C1 C1 Gas Relief Infants (Liquid) EQL Gas Relief Ultra Strength (Capsule) C1 C1 Gas Relief Infants (Suspension) EQL Gentle Laxative (Tablet Delayed- C1 Release) Gas-X Infant Drops (Liquid) C1

C1 EQL Heartburn Prevention (Tablet) Gavilax (Powder) C1

C1 EQL Infants Gas Relief (Suspension) Gentle Laxative (Suppository) C1

C1 EQL Laxative (Tablet Delayed-Release) Gentle Laxative (Tablet Delayed-Release) C1

C1 EQL Laxative EQL Laxative (Tablet Gentle Laxative For Women (Tablet Chewable) Delayed-Release)

Bold type = Brand name drug Plain type = Generic drug 148 OTC Drug Name OTC Drug Name

C1 C1 Gentle Laxative Overnight Relief (Tablet GNP Stool Softener (100mg Capsule, Delayed-Release) 250mg Capsule, 150mg/15ml Liquid,

C1 60mg/15ml Syrup)

Geri-Kot (Tablet) C1

C1 Geri-Mucil (Powder) GNP Stool Softener Extra Strength C1 (Capsule) Geri-Pectate (Suspension) C1 C1 GNP Womens Gentle Laxative (Tablet Glycerin Adult (2gm Suppository, 2.1gm Delayed-Release) Suppository) C1 C1 GNP Womens Laxative (Tablet Delayed- Glycerin Adult (Suppository)

C1 Release) Glycerin Children (Suppository) C1

C1 Goodsense Best Fiber (Powder)

C1 Glycerin Children's (Suppository) Goodsense Bisacodyl Ec (Tablet Delayed- C1 Glycerin Infants & Children (Suppository) Release)

C1 C1 Glycerin Pediatric (Suppository) Goodsense Clearlax (Powder)

C1 C1 Glycolax (Powder) Goodsense Fiber (Tablet)

C1 C1 GNP Best Fiber (Powder) Goodsense Gas Relief Extra Strength C1 (Tablet Chewable) GNP Bisa-Lax (Tablet Delayed-Release) C1 C1 Goodsense Laxative Pills (Tablet) GNP Clearlax (Packet) C1 C1 Goodsense Mineral Oil Lubricant Laxative GNP Clearlax (Powder) C1 (Oil) GNP Enema (Enema) C1 C1 Goodsense Natural Fiber (Powder) GNP Enema Mineral Oil Laxative (Enema) C1 C1 Goodsense Psyllium Fiber (Powder) GNP Fiber Therapy (Tablet) C1 C1 Goodsense Senna Laxative (Tablet) GNP Gas Relief Maximum Strength (Tablet C1 Healthy Mama Move It Along (Tablet) Chewable) C1 C1 Healthylax (Packet) GNP Gentle Laxative (Suppository) C1 C1 HM Clear Fiber (Powder) GNP Glycerin Adult (Suppository) C1 C1 HM Clearlax (Packet) GNP Glycerin Child (Suppository) C1 C1 HM Clearlax (Powder) GNP Glycerin Infant (Suppository) C1 C1 HM Enema (Enema) GNP K-Pec (Suspension) C1 C1 HM Enema Mineral Oil (Enema) GNP Laxative (Tablet Delayed-Release) C1 C1 HM Enema Ready-To-Use (Enema) GNP Laxative Pills (Tablet) C1 C1 HM Enema Saline Laxative (Enema) GNP Loperamide Hydrochloride (Liquid) C1 C1 HM Fiber (0.52gm Capsule, 500mg Tablet, GNP Mineral Oil (Oil) C1 28.3% Powder, 30.9% Powder, 48.57% GNP Mineral Oil Heavy (Oil)

C1 Powder, 58.6% Powder)

C1 GNP Natural Fiber (Powder) HM Fiber Powder (Powder) C1

C1 GNP Senna-Lax (Tablet) HM Gas Relief Infants Drops (Suspension)

Bold type = Brand name drug Plain type = Generic drug 149 OTC Drug Name OTC Drug Name

C1 C1 HM Laxative (Tablet Delayed-Release) Laxative Pills Regular Strength (Tablet)

C1 C1 HM Mineral Oil (Oil) Laxative With Senna (Tablet)

C1 C1 HM Probiotic Digestive Health (Capsule) Natural Fiber (Powder)

C1 C1 HM Senna (Tablet) Natural Fiber Laxative (48.57% Powder, C1 58.6% Powder) HM Stomach Relief Ultra (Suspension) C1

C1 HM Stool Softener (100mg Capsule, Natural Fiber Therapy (28.3% Powder, 48.57% Powder) 100mg Tablet) C1 C1 Natural Senna Laxative (Tablet)

HM Stool Softener Maximum Strength C1 (Capsule) Oral Saline Laxative (Solution)

C1 C1 Intestinex (Capsule) Pedia-Lax (1gm Suppository, 2.8gm C1 Suppository) Kaopectate (Suspension) C1 C1 Peg 3350 (Packet)

Kaopectate (Tablet) C1 C1 Peg 3350 (Powder)

Kaopectate Extra Strength (Suspension) C1 C1 Perdiem Overnight Relief (Tablet)

KLS Anti-Diarrheal (Tablet) C1 C1 Polyethylene Glycol 3350 (Packet)

KLS Natural Psyllium Fiber (Powder) C1 C1 Polyethylene Glycol 3350 (Powder)

KLS Stool Softener (Capsule) C1 C1 PX Glycerin (Suppository)

Kondremul (Oil) C1 C1 PX Laxative (Tablet Delayed-Release)

Konsyl (Capsule) C1 C1 PX Vegetable Laxative (Tablet)

Konsyl (Powder) C1 C1 QC Enema (Enema)

Konsyl Daily Fiber (100% Powder) C1 C1 QC Fiber Laxative (Capsule)

Konsyl Daily Fiber (28.3% Powder, 28.3% C1 Powder Packet, 100% Powder Packet) QC Gentle Laxative (Suppository)

C1 C1 Konsyl Original Formula Daily Fiber QC Laxative (Tablet) (Powder) C1

C1 QC Mineral Oil Heavy (Oil) Konsyl-D (Powder) C1

C1 QC Natural Vegetable Laxative (Tablet) KP Bisacodyl (Tablet Delayed-Release) C1

C1 QC Natura-Lax (Powder) KP Senna (Tablet) C1

C1 QC Stool Softener (Capsule) KS Stool Softener (Capsule) C1

C1 RA Fast Relief Laxative (Suppository) Laxa Basic (Capsule) C1

C1 RA Fiber Laxative (Powder)

C1 Laxative (10mg Suppository, 5mg Tablet RA Glycerin Adult (Suppository) Delayed-Release, 25mg Tablet) C1 C1 RA Glycerin Child (Suppository) Laxative Feminine (Tablet Delayed- C1 Release) RA Laxative (Tablet Chewable) C1

C1 Laxative Maximum Strength (Tablet) RA Laxative (Tablet Delayed-Release) C1

C1 Laxative Pills Maximum Strength (Tablet) RA Laxative (Tablet)

Bold type = Brand name drug Plain type = Generic drug 150 OTC Drug Name OTC Drug Name

C1 C1 RA Laxative Extra Strength (Tablet) SM Glycerin Pediatric (Suppository)

C1 C1 RA Laxative Maximum Strength (Tablet) SM Laxative (Suppository)

C1 C1 RA Stimulant Laxative (Suppository) SM Laxative Maximum Strength (Tablet)

C1 C1 RA Womens Laxative (Tablet Delayed- SM Senna Laxative (Tablet) Release) C1

C1 SM Senna Laxative Maximum Strength Reguloid (28.3% Powder, 48.57% Powder, (Tablet) 58.6% Powder) C1 C1 SM Stool Softener (Capsule)

C1 SB Bisacodyl Laxative EC (Tablet Delayed- SM Womans Laxative (Tablet Delayed- Release) C1 Release) SB Fiber Laxative (Powder) C1

C1 Soluble Fiber (Powder)

C1 SB Gentle Laxative Womens (Tablet Stimulant Laxative (Tablet Delayed- Delayed-Release) C1 Release) SB Glycerin Adult (Suppository) C1

C1 Stool Softener (Capsule) SB Glycerin Pediatric (Suppository) C1

C1 Stool Softener Extra Strength (Capsule) SB Laxative (Suppository) C1

C1 Stool Softener Laxative (Capsule) SB Natural Fiber Laxative (Powder) C1

C1 Stool Softener Laxative Extra Strength Senexon (Tablet) (Capsule)

C1 C1 Senna (Tablet) TGT Gentle Laxative (Tablet Delayed- C1 Release) Senna Laxative (Tablet) C1

C1 Senna-Lax (Tablet) TGT Laxative Pills Maximum Strength C1 (Tablet) Senna-Tabs (Tablet) C1 C1 TGT Natural Laxative Pills Maximum Senna-Time (Tablet) Strength (Tablet) C1

C1 Senno (Tablet) TGT Saline Laxative (Enema) C1

C1 Senokot (Tablet) TGT Senna Laxative (Tablet) C1

C1 Senokot Extra Strength (Tablet) TGT Womens Laxative (Tablet Delayed- C1 Silace (150mg/15ml Liquid, 60mg/15ml Release)

C1 Syrup) Total Fiber (Powder) C1

C1 SM Clearlax (Powder) Womans Laxative (Tablet Delayed-Release) C1

C1 SM Enema (Enema) Womens Laxative (Tablet Delayed- C1 SM Fiber (28.3% Powder, 48.57% Powder, Release)

A1 58.6% Powder) Hormonal Agents, Stimulant/Replacement/ C1 SM Fiber Laxative (Tablet) Modifying (Sex Hormones/Modifiers) B1

C1 SM Gentle Laxative (Tablet Delayed- Contraceptives, Oral C1 Release) Aftera (Tablet)

C1 C1 SM Glycerin Laxative Pediatric Econtra EZ (Tablet)

C1 (Suppository) Econtra One-Step (Tablet)

Bold type = Brand name drug Plain type = Generic drug 151 OTC Drug Name OTC Drug Name

C1 C1 Levonorgestrel (Tablet) Aerochamber Plus Flow-Vu/Small Mask C1 (Device) My Choice (Tablet) C1 C1 Aerochamber Plus/Small Mask (Device)

My Way (Tablet) C1

C1 New Day (Tablet) Aerochamber Z-Stat Plus Valved Holding C1 Chamber W/Flow Vu (Device) Next Choice One Dose (Tablet) C1 C1 Aerochamber Z-Stat Plus/Flowsignal Opcicon One-Step (Tablet) (Device) C1

C1 Option 2 (Tablet) Aerochamber Z-Stat Plus/Large Mask

C1 Preventeza (Tablet) (Device) C1

C1 React (Tablet) Aerochamber Z-Stat Plus/Medium Mask C1 (Device) Take Action (Tablet) C1 B1 Aerochamber Z-Stat Plus/Small Mask Contraceptives, Topical C1 (Device) Encare (Suppository) C1 C1 Aerochamber/Flowsignal (Device) Options Conceptrol Vaginal C1 Aerovent Plus Holding Chamber/ Contraceptive (Gel) C1 Collapsible (Device) Options Gynol II Vaginal Contraceptive C1 Arial Chamber (Device) (Gel) C1 C1 Breathe Ease/Large Mask (Device) Shur-Seal (Gel) C1 C1 Breathe Ease/Medium Mask (Device) Today Sponge C1 C1 Breathe Ease/Small Mask (Device) VCF Vaginal Contraceptive Film C1 C1 Breatherite (Device) VCF Vaginal Contraceptive Foam (Foam) C1 C1 Breatherite Collapsible Adult Spacer W/ VCF Vaginal Contraceptive Gel (Gel) A1 Mask (Device) Miscellaneous Therapeutic Agents C1 B1 Breatherite Collapsible Child Spacer W/ Devices / Other Therapeutic Agents C1 Mask (Device)

C1 Aerochamber Mini Aerosol Chamber Breatherite Collapsible Infant Spacer W/ (Device) C1 Mask (Device) Aerochamber MV (Device) C1

C1 Breatherite Collapsible Small Child Aerochamber Plus (Device) Spacer W/Mask (Device)

C1 C1 Aerochamber Plus Flow Vu (Device) Breatherite Collapsible Spacer W/ C1 Neonate Mask (Device) Aerochamber Plus Flow-Vu (Device) C1

C1 Aerochamber Plus Flow-Vu/Large Mask Breatherite Rigid Spacer W/Mask (Device) (Device) C1 C1 Breatherite W/Large Mask (Device)

Aerochamber Plus Flow-Vu/Mask C1 (Device) Breatherite W/Medium Mask (Device)

C1 C1 Aerochamber Plus Flow-Vu/Medium Breatherite W/Small Mask (Device)

C1 Mask (Device) Clever Choice Anti-Staticvalved Holding Chamber/Adult Large (Device)

Bold type = Brand name drug Plain type = Generic drug 152 OTC Drug Name OTC Drug Name

C1 C1 Clever Choice Anti-Staticvalved Holding Mask Vortex/Toddler/Lady Bug (Mask) Chamber/Medium (Device) C1 C1 Microchamber (Device)

C1 Clever Choice Anti-Staticvalved Holding Microspacer (Device) Chamber/Small (Device) C1 C1 Nebusal (3% Solution) Compact Space Chamber/Anti-Static C1 (Device) Nebusal (6% Solution) C1

C1 Compact Space Chamber/Anti-Static/ Optichamber Advantage/Large Mask Large Mask (Device) (Device) C1

C1 Compact Space Chamber/Anti-Static/ Optichamber Advantage/Medium Face Medium Mask (Device) Mask (Device) C1

C1 Compact Space Chamber/Anti-Static/ Optichamber Advantage/Small Face Small Mask (Device) Mask (Device) C1

C1 Easivent (Device) Optichamber Diamond (Device) C1

C1 Easivent/Mask-Large (Device) Optichamber Diamond/Largeface Mask C1 (Device) Easivent/Mask-Medium (Device) C1 C1 Optichamber Diamond/Medium Face Easivent/Mask-Small (Device) C1 Mask (Device) Flexichamber (Device) C1

C1 Optichamber Diamond/Smallface Mask Flexichamber Adult Mask/Small (Mask) (Device)

C1 C1 Flexichamber Child Mask/Large (Mask) Optichamber Face Mask/Large (Device)

C1 C1 Flexichamber Child Mask/Small (Mask) Optichamber Face Mask/Medium C1 (Device) Hyper-Sal (3.5% Solution, 7% Solution) C1 C1 Optichamber Face Mask/Small (Device)

Inspirachamber/Anti-Static Valved/ C1 Mouthpiece (Device) Optihaler (Device)

C1 C1 Inspirachamber/Large (Device) Optihaler MDI Drug Delivery System C1 (Device)

Inspirachamber/Soothermask/ C1 Inspiramask/Medium (Device) Panda Mask Large (Mask)

C1 C1 Inspirachamber/Soothermask/ Panda Mask Medium (Mask) Inspiramask/Small (Device) C1

C1 Panda Mask Small (Mask)

C1 Inspirease Drug Delivery System Pediatric Panda Mask (Mask) (Device) C1 C1 Pocket Chamber (Device) Inspirease Reservoir Bags (Aerosol) C1 C1 Pocket Spacer (Device) Liteaire (Device) C1 C1 Pro Comfort Inhaler Spacer Chamber Lma Mad Nasal (Device)

C1 Adult (Device) Mask Vortex/Baby Whirl Duckling (Mask) C1

C1 Pro Comfort Inhaler Spacer Chamber Mask Vortex/Child/Frog (Mask) Child (Device)

C1 C1 Mask Vortex/Spinner The Duck (Mask) Riteflo (Device)

Bold type = Brand name drug Plain type = Generic drug 153 OTC Drug Name OTC Drug Name

C1 C1 Valved Holding Chamber (Device) HM Eye Itch Relief (Ophthalmic Solution)

C1 C1 Vortex Valved Holding Chamber (Device) Ketotifen Fumarate (Ophthalmic Solution)

C1 C1 Watchhaler (Device) Ketotifen Fumarate (Solution)

B1 C1 Saliva Replacement Agents KP Ketotifen Fumarate (Solution)

C1 C1 Act Dry Mouth (Lozenge) Naphcon-A (Ophthalmic Solution)

C1 C1 Biotene Dry Mouth (Lozenge) Opcon-A (Ophthalmic Solution)

C1 C1 Oral Relief For Dry Mouth (Lozenge) RA Antihistamine Eye Drops (Ophthalmic

C1 Solution)

Oral Relief For Dry Mouth& Discomfort (Kit) C1

C1 Oral Relief For Dry Mouth& Discomfort RA Eye Allergy Relief (Ophthalmic Solution)

(Lozenge) C1 C1 RA Eye Itch Relief (Ophthalmic Solution)

Salese/Xylitol (Lozenge) C1 C1 SM Eye Itch Relief (Ophthalmic Solution)

Salivasure (Lozenge) C1

C1 Therabreath Dry Mouth (Lozenge) TGT Eye Allergy Relief (Ophthalmic A1 Solution) Ophthalmic Agents C1 B1 Theratears Allergy Eye Itch Relief Allergy Agents, Ophthalmic C1 (Ophthalmic Solution) Alaway (Ophthalmic Solution) C1 C1 Visine-A (Ophthalmic Solution) Alaway (Ophthalmic Solution) C1 C1 Zaditor (Ophthalmic Solution) Alaway Children's Allergy Eye Itch Relief B1 Ophthalmic Agents, Other (Ophthalmic Solution) C1 C1 Akwa Tears (Ointment) Allergy Eye Drops (Ophthalmic Solution) C1 C1 Artificial Tears (Ophthalmic Solution) Clear Eyes Pure Relief For Dry Eyes C1 (Solution) CVS Artificial Tears (Ophthalmic Solution) C1 C1 Computer Eye Drops (Solution) EQ Artificial Tears (Ophthalmic Solution) C1 C1 CVS Allergy Eye Drops (Ophthalmic Genteal Tears Liquid Drops Moderate Solution) (Solution) C1

C1 CVS Eye Allergy Relief (Ophthalmic RA Artificial Tears Eye Care (Ophthalmic Solution) Solution) C1

C1 CVS Eye Itch Relief (Ophthalmic Solution) RA Lubricant Eye Drops (Ophthalmic C1 Solution) EQ Eye Allergy Relief (Ophthalmic C1 Solution) TGT Lubricant Eye Drops/Mild To C1 Moderate (Ophthalmic Solution) Eye Allergy Relief (Ophthalmic Solution) A1 C1 Otic Agents Eye Itch Relief (Ophthalmic Solution) B1 C1 Otic Agents GNP Eye Itch Relief (Ophthalmic Solution) C1 C1 Auraphene-B (Otic Solution) GNP Itchy Eye (Ophthalmic Solution) C1 C1 Clearcanal Earwax Softener (Otic Solution) Goodsense Itchy Eye (Ophthalmic C1 Solution) CVS Ear Drops (Otic Solution)

Bold type = Brand name drug Plain type = Generic drug 154 OTC Drug Name OTC Drug Name

C1 C1 CVS Ear Wax Removal Kit (Otic Solution) RA Ear Wax Cleansing System (Otic C1 Solution) CVS Earwax Removal Kit (Otic Solution) C1 C1 RA Earwax Removal Kit (Otic Solution)

CVS Earwax Removal System (Otic C1 Solution) SB Ear Wax Remover (Otic Solution)

C1 C1 Ear Drops (Solution) SM Ear Drops (Solution)

C1 A1 Ear Drops Earwax Removal Aid (Otic Respiratory Tract/Pulmonary Agents

B1 Solution) Antihistamines / Decongestants C1

C1 Ear Wax Cleansing (Otic Solution) 12 Hour Decongestant (Tablet Extended-

C1 Ear Wax Cleansing Kit (Solution) Release) C1

C1 Ear Wax Drops (Otic Solution) 12 Hour Allergy-D (Tablet Extended- C1 Release) Ear Wax Removal Drops (Otic Solution) C1 C1 12 Hour Nasal Decongestant/Maximum Ear Wax Removal Kit (Otic Solution) C1 Strength (Tablet Extended-Release) Ear Wax Removal System (Otic Solution) C1

C1 Alavert (Tablet Disintegrating) Earwax Removal (Otic Solution) C1

C1 Aler-Cap (Capsule) Earwax Removal Aid (Otic Solution) C1

C1 Aler-Dryl (Tablet) Earwax Removal Kit (Solution) C1

C1 Alertab (Tablet) Earwax Treatment Drops (Solution) C1

C1 Alka-Seltzer Plus Allergy Fast Relief EQ Ear Wax Removal Aid (Otic Solution) Formula (Tablet)

C1 C1 GNP Ear Drops (Otic Solution) All Day Allergy (Tablet)

C1 C1 GNP Ear Systems (Solution) All Day Allergy D-12 (Tablet Extended- C1 Release)

GNP Earwax Removal Drops (Otic C1 Solution) All Day Allergy-D (Tablet Extended- C1 Release) GNP Earwax Removal Kit (Otic Solution) C1 C1 Aller-Chlor (Tablet)

Goodsense Ear Wax Removal (Otic C1 Solution) Allergy & Congestion Relief (Tablet C1 Extended-Release) HM Earwax Removal Aid (Solution) C1

C1 HM Earwax Removal Kit (Solution) Allergy (12mg Tablet Extended-Release, C1 4mg Tablet, 10mg Tablet) Murine Ear (Otic Solution) C1 C1 Allergy 24 Hour Indoor/Outdoor (Tablet) Murine For Ear Wax Removal System (Otic C1 Allergy Children's (Syrup) Solution) C1 C1 Allergy D-12 (Tablet Extended-Release)

Otix (Otic Solution) C1 C1 Allergy Medication (Capsule)

QC Ear Wax Removal Drops (Otic Solution) C1 C1 Allergy Medication (Tablet)

QC Earwax Removal (Otic Solution) C1 C1 Allergy Medication Children's (Liquid)

RA Ear Drops (Otic Solution) C1 Allergy Non-Drowsy (Tablet)

Bold type = Brand name drug Plain type = Generic drug 155 OTC Drug Name OTC Drug Name

C1 C1 Allergy Relief (4mg Tablet, 25mg Tablet, Claritin Allergy Children's (Syrup) 10mg Tablet Disintegrating, 10mg Tablet) C1 C1 Complete Allergy Medication (Tablet) Allergy Relief Child (Syrup) C1

C1 Complete Allergy Medicine (Capsule)

C1 Allergy Relief Children's (12.5mg/5ml Complete Allergy Medicine (Tablet) Liquid, 12.5mg Tablet Disintegrating) C1 C1 Complete Allergy Relief (Tablet) Allergy Relief D (Tablet Extended-Release) C1 C1 Cough Daytime/Nighttime (Liquid) Allergy Relief D-24 (Tablet Extended- C1 Release) CVS 12 Hour Nasal Decongestant (Tablet C1 Extended-Release) Allergy Relief Loratadine (Tablet) C1 C1 CVS Allergy (Capsule) Allergy Relief Nasal Decongestant (Tablet C1 Extended-Release) CVS Allergy (Tablet) C1

C1 Allergy Relief Nighttime (Tablet) CVS Allergy Relief (Tablet Extended- C1 Release) Allergy Relief/Indoor/Outdoor (Tablet) C1 C1 CVS Allergy Relief Adult Maximum Allergy Relief/Nasal Decongestant (Tablet Strength (Liquid) Extended-Release) C1 C1 CVS Allergy Relief Children's (Tablet) Allergy Relief-D (Tablet Extended-Release) C1 C1 CVS Allergy Relief Nighttime (Tablet) Allergy Tablets (Tablet) C1 C1 CVS Allergy Relief-D (Tablet Extended- Allergy-Relief-D (Tablet Extended-Release) C1 Release) Allergy-Time (Tablet) C1

C1 CVS Allergy Relief-D12 (Tablet Extended- Anti-Hist Allergy (Tablet) Release)

C1 C1 Banophen (Liquid) CVS Children's Allergy (Liquid)

C1 C1 Banophen (Tablet) CVS Children's Allergy Relief (Liquid)

C1 C1 Cetirizine HCL (10mg Tablet Chewable, CVS Daytime/Nighttime Cough Relief 5mg Tablet Chewable, 5mg Tablet) (Liquid)

C1 C1 Cetirizine HCL Children's (10mg Tablet CVS Dye-Free Allergy (Tablet) Chewable, 5mg Tablet Chewable) C1 C1 CVS Indoor/Outdoor Allergy Relief (Tablet)

C1 Cetirizine HCL/Pseudoephedrine HCL ER CVS Indoor/Outdoor Allergy Relief (Tablet Extended-Release) C1 Children's (Tablet Chewable) Cetirizine Hydrochloride (Tablet) C1

C1 CVS Loratadine (Tablet) Children's Allergy (Liquid) C1

C1 CVS Nasal Decongestant (Tablet) Children's Loratadine (Syrup) C1

C1 CVS Nighttime Cough (Liquid) Children's Silfedrine (Liquid) C1

C1 CVS Nighttime Tussin DM (Liquid) Chlorhist (Tablet) C1

C1 CVS Sleep-Aid Nighttime (Tablet) Chlorphen SR (Tablet Extended-Release) C1

C1 CVS Ultra Sleep (Tablet)

C1 Chlorpheniramine Maleate (Tablet Decongestant (Tablet) Extended-Release)

Bold type = Brand name drug Plain type = Generic drug 156 OTC Drug Name OTC Drug Name

C1 C1 Decongestant 12Hour Maximum Strength EQL Allergy Relief (Tablet) (Tablet Extended-Release) C1 C1 EQL Allergy Relief Children's (Tablet) Diabetic Tussin Allergy (Syrup) C1

C1 EQL Allergy/Congestion Relief (Tablet Diphen (Tablet) Extended-Release)

C1 C1 Diphenhist (12.5mg/5ml Liquid, 25mg EQL Children's Allergy (Liquid) Tablet) C1 C1 EQL Nasal Decongestant (Tablet) Diphenhydramine HCL (Tablet) C1

C1 EQL Nasal Decongestant Maximum Diphenhydramine Hydrochloride (Liquid) Strength (Tablet)

C1 C1 Diphenhydramine Hydrochloride Children's EQL Nighttime Cough Relief (Liquid) Dye Free (Liquid) C1 C1 EQL Nighttime Sleep Aid (Tablet) Dye-Free Allergy Relief Children's (Liquid) C1

C1 Genahist (Capsule) ED Chlorped Jr (Syrup) C1

C1 Genaphed (Tablet)

C1 EQ Allergy & Congestion Relief (Tablet Geri-Dryl (Capsule) Extended-Release) C1 C1 Geri-Dryl (Liquid) EQ Allergy (Capsule) C1 C1 Geri-Dryl Allergy Relief (Tablet) EQ Allergy Children's (Syrup) C1 C1 GNP All Day Allergy (Tablet) EQ Allergy Relief (Capsule) C1 C1 GNP All Day Allergy-D (Tablet Extended- EQ Allergy Relief (Tablet) C1 Release) EQ Allergy Relief Children's (Tablet) C1

C1 GNP Allergy & Congestion Relief (Tablet EQ Allergy Relief D 24 Hour (Tablet Extended-Release) Extended-Release) C1 C1 GNP Allergy (4mg Tablet, 25mg Tablet)

C1 EQ Cetirizine Hydrochloride Children's GNP Allergy AntihistamineChildren's (Tablet Chewable) C1 (Liquid) EQ Children's Loratadine (Syrup) C1

C1 GNP Allergy Relief (12.5mg Tablet EQ Chlortabs (Tablet) Chewable, 10mg Tablet)

C1 C1 EQ Loratadine (Tablet Disintegrating) GNP Allergy Relief For Kids (Tablet)

C1 C1 EQ Loratadine (Tablet) GNP Children's Allergy (Liquid)

C1 C1 EQ Loratadine Children's (Tablet GNP Loratadine (5mg/5ml Syrup, 10mg Chewable) Tablet)

C1 C1 EQ Night Time Cough (Liquid) GNP Loratadine Children's (Syrup)

C1 C1 EQ Suphedrine (Tablet) GNP Loratadine-D 12Hr (Tablet Extended- C1 Release) EQL All Day Allergy (Tablet) C1

C1 EQL All Day Allergy-D (Tablet Extended- GNP Loratadine-D 24 Hour (Tablet Extended-Release) Release) C1

C1 EQL Allergy (Tablet) GNP Nasal Decongestant (Tablet)

C1 EQL Allergy Relief (Capsule)

Bold type = Brand name drug Plain type = Generic drug 157 OTC Drug Name OTC Drug Name

C1 C1 GNP Nasal Decongestant/Maximum KLS Allerclear D-12Hr (Tablet Extended- Strength (Tablet) Release)

C1 C1 GNP Night Time Cough (Liquid) KLS Allerclear D-24Hr (Tablet Extended- C1 Release)

GNP Pseudoephedrine HCL 12 Hour C1 (Tablet Extended-Release) KLS Allerclear-D 24Hr (Tablet Extended- C1 Release)

GNP Pseudoephedrine HCL ER (Tablet C1 Extended-Release) KLS Allergy Medicine (Tablet)

C1 C1 GNP Sleep Aid (Tablet) KLS Aller-Tec (Tablet)

C1 C1 GNP Suphedrin (Liquid) KLS Aller-Tec D (Tablet Extended-Release)

C1 C1 GNP Tussin DM Max (Liquid) KP Cetirizine HCl (Tablet)

C1 C1 Goodsense All Day Allergy (Tablet) KP Cetirizine Hydrochloride (Tablet)

C1 C1 Goodsense Allergy Relief (Tablet) KP Diphenhydramine HCl (Capsule)

C1 C1 HM All Day Allergy (Tablet) KP Loratadine (Tablet)

C1 C1 HM Allergy & Congestion (Tablet KP Pseudoephedrine HCl (Tablet) Extended-Release) C1 C1 Loradamed (Tablet) HM Allergy (Tablet) C1

C1 Loratadine (Tablet) HM Allergy Children's (Liquid) C1

C1 Loratadine Children's (5mg/ml Syrup, 5mg HM Allergy Complete-D (Tablet Extended- Tablet Chewable) Release) C1 C1 Loratadine Hives Relief (Syrup)

C1 HM Allergy Relief & Nasal Decongestant Loratadine/Pseudoephedrine (Tablet (Tablet Extended-Release) C1 Extended-Release)

C1 HM Allergy Relief (4mg Tablet, 25mg Loratadine-D 12Hr (Tablet Extended- Tablet) C1 Release) HM Allergy Relief Children's (Liquid) C1

C1 Loratadine-D 24Hr (Tablet Extended- HM Allgery Multi Symptom (Capsule) Release)

C1 C1 HM Cetirizine Hydrochloride (Tablet) Medi-Phedryl (Capsule)

C1 C1 HM Loratadine (Tablet) Meijer Allergy Relief (Tablet Disintegrating)

C1 C1 HM Loratadine Children's (Syrup) Meijer Allergy Relief (Tablet)

C1 C1 HM Nasal Decongestant (Tablet) Meijer Allergy Relief-D (Tablet Extended- C1 Release)

HM Nasal Decongestant 12 Hour (Tablet C1 Extended-Release) Meijer Allergy/Congestion Relief (Tablet C1 Extended-Release) HM Sleep Aid (Tablet) C1 C1 Meijer Antihistamine Allergy (Capsule)

KLS Allerclear (Tablet) C1 C1 Meijer Loratadine (Syrup)

KLS Allerclear D-12 Hr (Tablet Extended- C1 Release) Meijer Nasal Decongestant (Tablet)

C1 MM Cetirizine Hydrochloride (Tablet)

Bold type = Brand name drug Plain type = Generic drug 158 OTC Drug Name OTC Drug Name

C1 C1 MM Loratadine-D 24 Hour (Tablet QC Complete Allergy Medicine (Tablet) Extended-Release) C1 C1 QC Loratadine Allergy Relief (Tablet) Naramin (Liquid) C1

C1 QC Loratadine-D (Tablet Extended- Nasal Decongestant (30mg/5ml Liquid, Release) 30mg/5ml Syrup, 30mg Tablet) C1 C1 QC Nighttime Cough (Liquid)

C1 Nasal Decongestant 12 Hour Sinus (Tablet QC Suphedrine (Tablet) Extended-Release) C1 C1 QC Suphedrine Maximum Strength (Tablet Nasal Decongestant Maximum Strength Extended-Release) (Tablet) C1 C1 RA Allergy (Liquid) Nighttime Cough (Liquid) C1 C1 RA Allergy (Tablet) Nite Time Cough (Liquid) C1 C1 RA Allergy Medication (Capsule) Pediacare Children's Allergy (Liquid) C1 C1 RA Allergy Medication (Tablet) Pediaclear Cough Children's (Liquid) C1 C1 RA Allergy Medication Children's (Liquid) Pharbechlor (Tablet) C1 C1 RA Allergy Relief (Capsule) Pharbedryl (Capsule) C1 C1 RA Allergy Relief (Tablet Disintegrating) Pseudoephedrine (Syrup) C1 C1 RA Allergy Relief (Tablet) Pseudoephedrine HCL (Tablet) C1 C1 RA Allergy Relief 24 Hour (Tablet) Pseudoephedrine HCL ER (Tablet C1 Extended-Release) RA Allergy Relief Children's (Tablet) C1

C1 Pseudoephedrine Hydrochloride (Tablet) RA Allergy/Congestion Relief (Tablet C1 Extended-Release) PX Allergy (Capsule) C1 C1 RA Cetiri-D (Tablet Extended-Release) PX Allergy (Liquid) C1 C1 RA Cetirizine (Tablet) PX Allergy (Tablet) C1 C1 RA Cetirizine Children's (Tablet Chewable) PX Allergy Relief (Tablet Disintegrating) C1 C1 RA Chlorpheniramine Maleate (Tablet) PX Allergy Relief (Tablet) C1 C1 RA Complete Allergy (Tablet) PX Allergy Relief D (Tablet Extended- C1 Release) RA Diphedryl Allergy (Liquid) C1

C1 PX Nasal Decongestant (Tablet Extended- RA Lorata-D (Tablet Extended-Release) C1 Release) RA Loratadine (Syrup) C1

C1 PX Nasal Decongestant (Tablet) RA Loratadine (Tablet Disintegrating) C1

C1 PX Nitetime Cough (Liquid) RA Loratadine (Tablet) C1

C1 QC All Day Allergy (Tablet) RA Loratadine Children's (Syrup) C1

C1 QC Allergy Relief (Tablet Disintegrating) RA Night Sleep Aid (Tablet) C1

C1 QC Allergy Relief (Tablet) RA Nighttime Cough Relief (Liquid) C1

C1 QC Allergy Relief Children's (Syrup) RA Nite Time Cough (Liquid) C1 QC Chlor-Pheniramine (Tablet)

Bold type = Brand name drug Plain type = Generic drug 159 OTC Drug Name OTC Drug Name

C1 C1 RA Sleep Aid (Tablet) SM Allergy Children's (Syrup)

C1 C1 RA Suphedrine (Tablet Extended-Release) SM Allergy Relief (12.5mg/ml Liquid, 25mg C1 Tablet) RA Suphedrine (Tablet) C1 C1 SM Allergy Relief Children's (Liquid)

RA Tussin Nighttime Cough DM/Maximum C1 Strength/Adult (Liquid) SM Children's Loratadine (Syrup)

C1 C1 Robitussin Nightime Cough DM Maximum SM Loratadine (Syrup) Strength (Liquid) C1 C1 SM Loratadine (Tablet) Robitussin Nighttime Cough DM (Liquid) C1

C1 SM Loratadine Allergy Relief (Tablet Safe Tussin PM (Liquid) Disintegrating)

C1 C1 SB Allergy (Capsule) SM Lorata-Dine D (Tablet Extended- C1 Release) SB Allergy (Tablet) C1

C1 SB Allergy Medicine (Liquid) SM Loratadine D 12Hr (Tablet Extended- C1 Release) SB Allergy Medicine (Tablet) C1 C1 SM Nasal Decongestant Maximum SB Allergy Relief (Tablet Disintegrating) Strength (Tablet) C1

C1 SB Allergy Relief/Nasal Decongestant SM Sleep Aid (Tablet) (Tablet Extended-Release) C1 C1 Sudafed 12 Hour (Tablet Extended- SB Chlorpheniramine (Tablet) Release) C1

C1 SB Loratadine (Syrup) Sudafed Sinus Congestion 12 Hour (Tablet C1 SB Loratadine (Tablet) Extended-Release) C1

C1 SB Loratadine Allergy Relief (Tablet) Sudogest (30mg Tablet, 60mg Tablet) C1

C1 SB Nighttime Cough (Liquid) Sudogest 12 Hour (Tablet Extended- C1 Release) Shopko Allergy Relief-D (Tablet Extended- C1 Release) Sudogest Maximum Strength (Tablet) C1

C1 Shopko Nasal Decongestant (Tablet SW Allergy Relief-D (Tablet Extended- Extended-Release) Release) C1

C1 Shopko Nasal Decongestant Maximum TGT All Day Allergy Relief (Tablet)

C1 Strength (Tablet) TGT All Day Allergy-D (Tablet Extended- C1 Siladryl Allergy (Liquid) Release) C1

C1 Silphen Cough (Syrup) TGT Allergy & Congestion Relief (Tablet C1 Extended-Release) Sleep Aid (Tablet) C1 C1 TGT Allergy Melts Children's (Tablet) SM 12 Hour Sinus Decongestant (Tablet C1 Extended-Release) TGT Allergy Relief (Capsule) C1

C1 SM All Day Allergy (Tablet) TGT Allergy Relief (Tablet Disintegrating) C1

C1 SM All Day Allergy-D (Tablet Extended- TGT Allergy Relief (Tablet)

C1 Release) TGT Allergy Relief Children's (Liquid) C1 SM Allergy 4 Hour (Tablet)

Bold type = Brand name drug Plain type = Generic drug 160 OTC Drug Name OTC Drug Name

C1 C1 TGT Allergy Relief Children's Dye Free Wal-Zyr (Tablet) (Liquid) C1 C1 Wal-Zyr Children's (Tablet Chewable)

C1 TGT Allergy+ Congestion Relief-D (Tablet Wal-Zyr D (Tablet Extended-Release) Extended-Release) C1 C1 Zephrex-D (Tablet) TGT Loratadine Children's (Syrup) B1 C1 Intranasal Sprays TGT Sinus 12 Hour (Tablet Extended- C1 Allergy Nasal Spray 24 Hour (Suspension)

Release) C1 C1 Budesonide Nasal Spray (Suspension)

Total Allergy (Tablet) C1

C1 Total Allergy Medicine (Liquid) CVS Budesonide Nasal Spray C1 (Suspension) Triaminic Allerchews (Tablet C1 CVS Nasal Allergy Spray (Suspension)

Disintegrating) C1 C1 EQ Budesonide Nasal Spray (Suspension)

Vicks Dayquil/Nyquil Cough (Liquid) C1 C1 EQ Nasal Allergy Spray (Suspension)

Wal-Dryl Allergy (Capsule) C1

C1 Wal-Dryl Allergy (Liquid) GNP 24 Hour Nasal Allergy Spray C1 (Suspension) Wal-Dryl Allergy (Tablet) C1 C1 GNP Budesonide Nasal Spray Wal-Dryl Allergy Children's (Liquid)

C1 (Suspension)

C1 Wal-Dryl Allergy Dye-FreeChildren's Goodsense Nasal Allergy Spray (Liquid)

C1 (Suspension)

C1 Wal-Dryl Allergy Relief Children's (Tablet) Nasacort Allergy 24Hr (Suspension) C1

C1 Wal-Finate (Tablet) Nasacort Allergy 24Hr Children's C1 Wal-Itin (Syrup) (Suspension)

C1 C1 Wal-Itin (Tablet Disintegrating) Nasal Allergy 24 Hour (Suspension)

C1 C1 Wal-Itin (Tablet) Nasal Allergy 24 Hour Multi-Symptom C1 (Suspension) Wal-Itin Allergy Relief Reditabs (Tablet C1 Disintegrating) RA Budesonide Nasal Spray (Suspension) C1 C1 Wal-Itin Aller-Melts (Tablet Disintegrating) RA Nasal Allergy Spray (Suspension)

C1 C1 Wal-Itin Children's (Syrup) Rhinocort Allergy (Suspension)

B1 C1 Wal-Itin D (Tablet Extended-Release) Respiratory Agents C1

C1 Wal-Itin D 24 Hour (Tablet Extended- Nasal Mist (Solution) C1 Release) Pulmosal (Solution) C1

C1 Wal-Phed (Tablet) Simply Saline Baby (Solution) C1

C1 Wal-Phed 12 Hour (Tablet Extended- Sodium Chloride (0.9% Solution, 10%, Release) Solution, 3% Solution, 7% Solution) C1

C1 Wal-Phed D (Tablet Extended-Release) Triamcinolone Acetonide (Suspension) C1

A1 Wal-Som (Tablet) Therapeutic Nutrients/Minerals/Electrolytes

C1 B1 Wal-Vert (Tablet Disintegrating) Vitamins / Nutrients / Supplements

Bold type = Brand name drug Plain type = Generic drug 161 OTC Drug Name OTC Drug Name

C1 C1 600+D3 Plus Minerals (Tablet Chewable) Airborne (Tablet Chewable)

C1 C1 50+ Adult Eye Health (Capsule) Airborne (Tablet)

C1 C1 A Thru Z Advanced (Tablet) Airborne Gummies (Tablet Chewable)

C1 C1 A Thru Z Advanced Adult Formula (Tablet) Airborne Immune System (Tablet C1 Chewable) A Thru Z High Potency (Tablet) C1

C1 A Thru Z Select (Tablet Chewable) Alive Gummies For Children (Tablet C1 Chewable) A Thru Z Select (Tablet) C1 C1 Alive Multi-Vitamin Children's Chewable A Thru Z Select 50+ Advanced Formula (Tablet Chewable) (Tablet) C1 C1 Alph-E (Capsule) A Thru Z Select 50+ Mens (Tablet) C1 C1 Alph-E-Mixed (200unit Capsule, 400unit A Thru Z Select Advanced (Tablet) Capsule) C1

C1 A Thru Z Select Ultimate Womens (Tablet) Alph-E-Mixed 1000 (Capsule) C1

C1 A Thru Z Ultimate Mens (Tablet) Amoryn Mood Booster (Capsule) C1

C1 A-10000 (Capsule) Animal Chews (Tablet Chewable) C1

C1 A-25 (Capsule) Animal Shapes (Tablet Chewable) C1

C1 ABC Plus (Tablet) Animal Shapes/Iron (Tablet Chewable) C1

C1 ABC Plus Senior (Tablet) Antioxidant (Capsule) C1

C1 ABC Plus Senior Adults 50+ (Tablet) Anti-Oxidant (Tablet) C1

C1 Abdek (Tablet Chewable) Anti-Oxidant Formula (Capsule) C1

C1 Abdek Pediatric (Drops) Antioxidant Formula/Minerals (Capsule) C1

C1 Acerola C-500 (Tablet Chewable) Antioxidant Protection Formula (Tablet) C1

C1 Act Anticavity Fluoride Rinse (Rinse) Antioxidant Vitamins (Tablet) C1

C1 Act Anticavity Fluoride Rinse Kids (Rinse) Antioxin 4000 (Capsule) C1

C1 Act Restoring Fluoride Rinse (Rinse) Aqueous Vitamin D Infants (Liquid) C1

C1 Act Total Care (Rinse) Aqueous Vitamin E (Solution) C1

C1 Act Total Care Dry Mouth (Rinse) Ascocid-Iso-Ph (Powder) C1

C1 Actical (Capsule) Ascorbic Acid (250mg Tablet Chewable, C1 ADC/Fluoride (Solution) 250mg Tablet, 500mg Tablet, 1000mg C1 Tablet) Adult Gummy (Tablet Chewable) C1 C1 Asco-Tabs-1000 (Tablet) Advanced Calcium Formula (Tablet) C1 C1 Avoria Cal+D (Packet) Advanced Eye Health (Capsule) C1 C1 B Complex (Capsule) Advanced Multi EA (Tablet Chewable) C1 C1 B-1 (100mg, 250mg Tablet)

Advantage Care Oral Electrolyte Pediatric C1 (Oral Solution) B-1 (Tablet)

Bold type = Brand name drug Plain type = Generic drug 162 OTC Drug Name OTC Drug Name

C1 C1 B-1 High Potency (Tablet) Body/Hair/Skin/Nails (Capsule)

C1 C1 B-1 Natural (Tablet) Bone Density (Tablet)

C1 C1 B-12 (Capsule) Bone Meal (Tablet)

C1 C1 B-12 (Lozenge) Bounty Bears/C (Tablet Chewable)

C1 C1 B-12 (Tablet Extended-Release) BP Multinatal Plus (Tablet Chewable)

C1 C1 B-12 (Tablet) BP Multinatal Plus (Tablet)

C1 C1 B-12 Fast Dissolve (Tablet) B-Plex Plus (Tablet)

C1 C1 B-12 Super Strength (Liquid) BProtected Multi-Vite (Liquid)

C1 C1 B-12 TR (Tablet Extended-Release) Bprotected Pedia D-Vite (Liquid)

C1 C1 B-12-Sl (Tablet) Bprotected Pedia Iron (Solution)

C1 C1 B-2 (Tablet) Bprotected Pedia Poly-Vite (Solution)

C1 C1 B-6 (Tablet) Bprotected Pedia Poly-Vite/Iron (Drops)

C1 C1 B-6 Natural (Tablet) Bprotected Pedia Tri-Vite (Drops)

C1 C1 Baby Super Daily D3 (Drops) Bprotected Vitamin C/Rosehips (Liquid)

C1 C1 Baby Vitamin D3 Drops (Drops) B-Redi/Red Hearts/Red Roosters (Tablet)

C1 C1 B-Complex (Capsule) Brewers Yeast (Tablet)

C1 C1 B-Complex 50 (Tablet) Buffered Vitamin C (Capsule)

C1 C1 B-Complex 50 TR (Tablet Extended- C 1000 (Tablet) Release) C1 C1 C 250 (Tablet Chewable)

C1 B-Complex High Potency (Tablet C 250 (Tablet) Extended-Release) C1 C1 C 500 (Tablet Chewable) B-Complex Plus Vitamin C (Tablet) C1 C1 C 500 (Tablet) B-Complex With B-12 (Tablet) C1 C1 C 500/Rose Hips (Tablet) B-Complex/B-12 (Liquid) C1 C1 C-1000 (Tablet) B-Complex/B-12 (Tablet) C1 C1 C-1000 Prolonged Release (Tablet BD Posiflush (Solution) C1 Extended-Release) Berocca (Tablet) C1

C1 C-1000 SR (Tablet Extended-Release) Biocel (Tablet) C1

C1 C-1000/Rose Hips (Tablet) Bio-D-Mulsion (Drops) C1

C1 C-1000/Rose Hips SR (Tablet Extended- Bio-D-Mulsion Forte (Drops) Release)

C1 C1 Biosupp (Liquid) C-1500/Rose Hips SR (Tablet Extended- C1 Release) Biotin Plus/Calcium/Vit D3 (Tablet) C1 C1 C-250 (Tablet Chewable)

Bite-A-Mins (Tablet Chewable) C1

C1 Bite-A-Mins/Iron (Tablet Chewable) C-250 (Tablet)

Bold type = Brand name drug Plain type = Generic drug 163 OTC Drug Name OTC Drug Name

C1 C1 C-500 (Tablet Chewable) Calcium 500/D (Tablet Chewable)

C1 C1 C-500 (Tablet) Calcium 500/D (Tablet)

C1 C1 C-500 Non-Acid (Tablet) Calcium 500/Vitamin D (Tablet)

C1 C1 C-500 Prolonged Release (Tablet Calcium 500/Vitamin D3 (Tablet) Extended-Release) C1 C1 Calcium 500+D (Tablet) C-500 SR (Capsule) C1

C1 Calcium 500+D High Potency (Tablet) C-500 SR (Tablet Extended-Release) C1

C1 Calcium 500+D3 (Tablet) C-500/Rose Hips (Tablet) C1

C1 Calcium 600 (Tablet) Cal/Mag (Tablet) C1

C1 Calcium 600 + D (Tablet) Cal/Mag Citrate (Tablet) C1

C1 Calcium 600 + Minerals (Tablet) Cal-Carb Forte (Tablet) C1

C1 Calcium 600 High Potency (Tablet) Calcet Creamy Bites (Tablet Chewable) C1

C1 Calcium 600 With Vitamin D (Tablet Calcet Petites (Tablet) Chewable)

C1 C1 Calcidol (Solution) Calcium 600 With Vitamin D (Tablet)

C1 C1 Calciferol (Solution) Calcium 600/Magnesium 300/Vitamin D C1 (Capsule) Calcifol (Wafer) C1 C1 Calcium 600/Vitamin D (Tablet)

Calci-Max (Capsule) C1 C1 Calcium 600/Vitamin D3 (Tablet)

Calcitrate (Tablet) C1 C1 Calcium 600+D (Tablet)

Calcitrate Plus D (Tablet) C1 C1 Calcium 600+D High Potency (Tablet)

Cal-Citrate Plus Vitamin D (Tablet) C1

C1 Calcium & Magnesium + Zinc (Tablet) Calcium 600+D Plus Minerals (Tablet C1 Chewable) Calcium (Capsule) C1 C1 Calcium 600+D Plus Minerals (Tablet) Calcium (Tablet Chewable) C1 C1 Calcium 600+D3 (Tablet) Calcium (Tablet) C1 C1 Calcium 600+D3 Plus Minerals (Tablet Calcium + D (Tablet Chewable) Chewable) C1

C1 Calcium + D + K (Tablet) Calcium 600+D3 Plus Minerals (Tablet) C1

C1 Calcium + D3 (Tablet) Calcium 600-D (Tablet) C1

C1 Calcium 1000 + D (Tablet) Calcium Acetate (Tablet) C1

C1 Calcium 1200 (Tablet Chewable) Calcium Ascorbate (Tablet) C1

C1 Calcium 500 (Tablet) Calcium Aspartate (Tablet) C1

C1 Calcium 500 + D (Tablet) Calcium Carbonate (Tablet) C1

C1 Calcium 500 + D3 (Tablet Chewable) Calcium Carbonate (Wafer) C1

C1 Calcium 500 +D (Tablet) Calcium Carbonate/D3 (Tablet) C1

C1 Calcium 500 +D3 (Tablet) Calcium Carbonate/Vitamin D (Tablet)

Bold type = Brand name drug Plain type = Generic drug 164 OTC Drug Name OTC Drug Name

C1 C1 Calcium Chews (Tablet Chewable) Calcium Magnesium & Zinc (Tablet)

C1 C1 Calcium Citrate (Oral Granules) Calcium Magnesium 750 (Tablet)

C1 C1 Calcium Citrate (Tablet) Calcium Oyster Shell (Tablet)

C1 C1 Calcium Citrate + (Tablet) Calcium Plus D3 Absorbable (Capsule)

C1 C1 Calcium Citrate + D (Tablet) Calcium Plus Vitamin D (Capsule)

C1 C1 Calcium Citrate + D3 (Tablet) Calcium Plus Vitamin D3 (Capsule)

C1 C1 Calcium Citrate + D3 Maximum (Tablet) Calcium Plus Vitamin D3 (Tablet)

C1 C1 Calcium Citrate +D (Tablet) Calcium Soft Chews (Tablet Chewable)

C1 C1 Calcium Citrate Chewy Bite (Tablet Calcium Soft Chews (Tablet Chewable) Chewable) C1 C1 Calcium/C/D (Tablet Chewable) Calcium Citrate Malate/Vitamin D (Tablet) C1

C1 Calcium/D (Wafer) Calcium Citrate Petite/Vitamin D (Tablet) C1

C1 Calcium/D3 Adult Gummies (Tablet Calcium Citrate W/D (Tablet) Chewable)

C1 C1 Calcium Citrate W/Vitamin D (Tablet) Calcium/Magnesium (Tablet)

C1 C1 Calcium Citrate/D3 (Tablet) Calcium/Magnesium (Tablet)

C1 C1 Calcium Citrate/Magnesium/Vitamin D Calcium/Magnesium Citrate (Tablet) Chewable Wafers (Wafer) C1 C1 Calcium/Magnesium/Vitamind (Tablet) Calcium Citrate/Vitamin D (Tablet) C1

C1 Calcium/Magnesium/Zinc (Tablet) Calcium Citrate/Vitamin D3 (Liquid) C1

C1 Calcium/Vitamin D (Capsule) Calcium Citrate/Vitamin D3 (Tablet) C1

C1 Calcium/Vitamin D (Tablet) Calcium Citrate+D (Tablet) C1

C1 Calcium/Vitamin D/Minerals (Tablet Calcium Citrate+D3 (Tablet) Chewable)

C1 C1 Calcium Citrate+D3 Petites (Tablet) Calcium/Vitamin D3 (Capsule)

C1 C1 Calcium Creamies (Tablet Chewable) Calcium/Vitamin D-3 (Tablet Chewable)

C1 C1 Calcium Extra D3 (Tablet) Calcium/Vitamin D3 (Tablet)

C1 C1 Calcium For Women (Tablet Chewable) Calcium/Vitamin D3 Gummies (Tablet C1 Chewable) Calcium Gluconate (Tablet) C1

C1 Calcium Gluconate/Dextrose (Solution) Calcium/Vitamin D3 Gummies (Tablet C1 Chewable) Calcium Gluconate/Sodium Chloride C1 Calcium/Vitamin D3/Adult Gummy (Tablet (Solution) C1 Chewable) Calcium Gummies (Tablet Chewable) C1 C1 Calcium+D3 (Tablet) Calcium High Potency (Tablet) C1 C1 Calcium+D3 Gradual Release (Tablet Calcium High Potency + Vitamin D (Tablet) Extended-Release) C1

C1 Calcium Lactate (Tablet) Calcium+Menaq7 (Tablet)

Bold type = Brand name drug Plain type = Generic drug 165 OTC Drug Name OTC Drug Name

C1 C1 Calcium-Folic Acid Plus D (Wafer) Ceralyte 70 (Oral Solution)

C1 C1 Calciumvitamin D3 Plus Minerals (Tablet Cerovite Advanced Formula (Tablet) Chewable) C1 C1 Cerovite Jr (Tablet Chewable) Cal-Mag (Tablet) C1

C1 Cerovite Senior (Tablet) Cal-Mag Aspartate (Tablet) C1

C1 Certa Plus (Tablet) Cal-Mag Chela-Max (Capsule) C1

C1 Certagen (Tablet) Cal-Mag Complex (Tablet) C1

C1 Certavite/Antioxidants (Tablet) Calmag Thins (Tablet) C1

C1 Chelated Calcium (Tablet) Cal-Quick (Liquid) C1

C1 Chelated Magnesium (Tablet) Caltrate 600 (Tablet) C1

C1 Chelated Potassium (Tablet)

C1 Caltrate 600+D Plus Minerals (Tablet Chewable Calcium (Tablet Chewable) Chewable) C1 C1 Chewable Vitamin C (Tablet Chewable) Caltrate 600+D Plus Minerals (Tablet) C1 C1 Chewable Vitamins Children's (Tablet Caltrate 600+D3 (Tablet) C1 Chewable)

C1 Caltrate 600+D3 Soft Chews (Tablet Chewable Vite Children's (Tablet Chewable) C1 Chewable) Caltrate Gummy Bites (Tablet Chewable) C1

C1 Chewable Vite With Iron/Children's (Tablet Caltrate Minis Plus Minerals (Tablet) Chewable)

C1 C1 Carravite (Tablet) Chew-C (Tablet Chewable)

C1 C1 C-Chewable (Tablet Chewable) Children's Animal Shapes Complete C1 (Tablet Chewable)

Celebrate Calcium Citrate (Tablet C1 Chewable) Children's Chewable Multivitamin (Tablet C1 Chewable)

Celebrate Calcium Plus 500 (Tablet C1 Chewable) Children's Chewable Multivitamin With Iron C1 (Tablet Chewable) Cemill (Tablet Extended-Release) C1

C1 Cemill SR (Tablet Extended-Release) Children's Chewable Vitamin (Tablet C1 Chewable) Centamin (Liquid) C1 C1 Children's Chewable Vitamins (Tablet Centavite (Liquid) Chewable) C1

C1 Centavite A-Z Complete Multivitamin/ Children's Chewable Vitamins/Iron (Tablet Minerals (Tablet) Chewable) C1

C1 Centravites (Tablet) Children's Gummies (Tablet Chewable) C1

C1 Centravites 50 Plus (Tablet) Children's Multivitamin (Tablet Chewable) C1

C1 Centrum Kids Complete (Tablet Chewable) Chlorocaps (Capsule) C1

C1 Century (Tablet) Citracal + D3 Maximum (Tablet) C1 Century Mature (Tablet)

Bold type = Brand name drug Plain type = Generic drug 166 OTC Drug Name OTC Drug Name

C1 C1 Citracal Calcium Gummies (Tablet Coq-10 (Capsule) Chewable) C1 C1 Coq-10 Fast Dissolve (Tablet)

C1 Citracal Calcium+D Slow Release (Tablet Coq10 Gummies Adult (Tablet Chewable) Extended-Release) C1 C1 Coq10 Maximum Strength (Capsule) Citracal Maximum (Tablet) C1 C1 Coral Calcium (Capsule) Citracal Petites/Vitamin D (Tablet) C1 C1 Coral Calcium (Capsule) Citracal+D3 (Tablet Chewable) C1 C1 Coral Calcium Plus (Capsule) Citrate Of Magnesia (Solution) C1 C1 Coral Calcium Plus (Capsule) Citroma (Solution) C1 C1 Corvite Free (Tablet) Citrus Calcium +D (Tablet) C1 C1 Crest Complete (Paste) Citrus Calcium/Vitamin D (Tablet) C1 C1 Crest Pro-Health Complete (Rinse) Classic Prenatal (Tablet) C1 C1 Crush Vitamin C Drops (Lozenge) Co Q-10 (Capsule) C1 C1 C-Time SR (Capsule) Co Q-10 Maximum Strength (Capsule) C1 C1 CVS Airshield (Tablet) Cod Liver Oil (Capsule) C1 C1 CVS B-1 (Tablet) Cod Liver Oil W/Vitamins A&D (Capsule) C1 C1 CVS B-12 (Liquid) Cod Liver Oil/Low Vitamin A (Capsule) C1 C1 CVS B-12 (Tablet Chewable) Cod Liver Oil/Vitamins A & D (Capsule) C1 C1 CVS B-12 (Tablet) Co-Enzyme Q-10 (Capsule) C1 C1 CVS B-12 Gummies (Tablet Chewable) Coenzyme Q10 (Liquid) C1 C1 CVS B-6 (Tablet) Co-Enzyme Q-10 (Tablet) C1 C1 CVS Balanced B100 (Tablet Extended- Coenzyme Q-10 High Potency (Capsule) C1 Release) Companion (Tablet) C1

C1 CVS Calcium (Tablet Chewable) Compete (Tablet) C1

C1 CVS Calcium (Tablet) Complere (Tablet) C1

C1 CVS Calcium 600 & Vitamind3 (Tablet) Complete (Tablet) C1

C1 CVS Calcium 600 + D Plus Minerals (Tablet Complete Daily With Lutein (Tablet) Chewable)

C1 C1 Complete Energy (Tablet) CVS Calcium 600 + D Plus Minerals C1 (Tablet)

Complete Multi-Vitamin Gummies (Tablet C1 Chewable) CVS Calcium 600+D (Tablet)

C1 C1 Complete Multivitamin/Multimineral CVS Calcium Carbonate (Tablet) Supplement (Liquid) C1 C1 CVS Calcium Citrate + D (Tablet)

C1 Complete PMS Support Complex CVS Calcium Citrate +D3 Miniatures (Capsule) C1 (Tablet) Complete Womens (Tablet)

Bold type = Brand name drug Plain type = Generic drug 167 OTC Drug Name OTC Drug Name

C1 C1 CVS Calcium Soft Chews (Tablet CVS Magnesium Citrate (Capsule) Chewable) C1 C1 CVS Melatonin (Capsule) CVS Calcium/Magnesium/Zinc (Tablet) C1

C1 CVS Melatonin (Liquid)

C1 CVS Chewable Children's Vitamin (Tablet CVS Melatonin (Tablet) Chewable) C1 C1 CVS Melatonin Extra Strength (Liquid) CVS Children's Chewable Complete C1 (Tablet Chewable) CVS Melatonin Gummies (Tablet C1 Chewable) CVS Citrate Of Magnesia (Solution) C1 C1 CVS Melatonin Instant Dissolving (Tablet) CVS Cod Liver Oil (Capsule) C1 C1 CVS Melatonin Quick Dissolve (Tablet) CVS Coenzyme Q-10 (Capsule) C1 C1 CVS Melatonin TR (Tablet Extended- CVS Coq-10 (Capsule) C1 Release) CVS D3 (Capsule) C1

C1 CVS Mens Daily Gummies (Tablet CVS D3 (Tablet Chewable) Chewable)

C1 C1 CVS Daily Gummies (Tablet Chewable) CVS One Daily Essential (Tablet)

C1 C1 CVS Daily Multiple (Tablet) CVS One Daily Womens Formula (Tablet)

C1 C1 CVS Daily Multiple For Men (Tablet) CVS Oyster Shell Calcium +Vitamin D C1 (Tablet) CVS Daily Multiple For Women (Tablet) C1 C1 CVS Pediatric Electrolyte (Oral Solution)

CVS Daily Multiple For Women 50+ C1 (Tablet) CVS Pediatric Electrolyte Freezer Pops C1 (Oral Solution)

CVS Daily Multiple Plus Iron/Calcium/Zinc C1 (Tablet) CVS Prenatal (Tablet)

C1 C1 CVS Diabetes Health Support (Pack) CVS Prenatal Gummies (Tablet Chewable)

C1 C1 CVS E (Capsule) CVS Prenatal Gummy/DHA/Folic Acid C1 (Tablet Chewable) CVS Electrolyte Solution (Oral Solution) C1 C1 CVS Prenatal Multi+DHA (Capsule)

CVS Eye Health & Lutein (Tablet) C1 C1 CVS Quality Sleep (Capsule)

CVS Folic Acid (Tablet) C1

C1 CVS Glucose (Gel) CVS Slow Release Iron (Tablet Extended- C1 Release) CVS Glucose Liquid Shot (Liquid) C1 C1 CVS Spectravite Adult 50+ (Tablet) CVS Glucose Shot (Liquid) C1 C1 CVS Spectravite Advanced Formula CVS Gummy Dinos (Tablet Chewable) (Tablet) C1

C1 CVS Gummy Dinos Children's (Tablet CVS Spectravite Senior (Tablet) Chewable) C1 C1 CVS Spectravite Ultra Health Mens (Tablet) CVS Gummy Multivitamin Kids (Tablet C1 CVS Spectravite Ultra Men50+ (Tablet) Chewable) C1

C1 CVS Iron (Tablet) CVS Spectravite Ultra Mens Health Senior C1 (Tablet) CVS Magnesium (Tablet)

Bold type = Brand name drug Plain type = Generic drug 168 OTC Drug Name OTC Drug Name

C1 C1 CVS Spectravite Ultra Women (Tablet) D 5000 (Tablet)

C1 C1 CVS Spectravite Ultra Womens Health D-1000 Extra Strength (Tablet) Senior (Tablet) C1 C1 D-2000 Maximum Strength (Tablet) CVS Vision Formula (Tablet) C1

C1 D2000 Ultra Strength (Capsule) CVS Vitamin A (Capsule) C1

C1 D3 (Capsule)

C1 CVS Vitamin B-12 (Tablet Extended- D3 (Tablet Chewable) Release) C1 C1 D3 (Tablet) CVS Vitamin B12 (Tablet) C1 C1 D3 2000 (Tablet) CVS Vitamin B-12 (Tablet) C1 C1 D3 Adult (Tablet Chewable) CVS Vitamin B-12 TR (Tablet Extended- C1 Release) D3 Adult Gummy (Tablet Chewable) C1

C1 CVS Vitamin B-2 (Tablet) D3 High Potency (Capsule) C1

C1 CVS Vitamin C (Tablet) D3 High Potency (Tablet) C1

C1 CVS Vitamin C/Rose Hips (Tablet) D3 Kids (Tablet Chewable) C1

C1 CVS Vitamin D Children's Gummies (Tablet D3 Maximum Strength (Capsule) C1 Chewable) D3 Maximum Strength (Drops) C1

C1 CVS Vitamin D3 (Capsule) D3 Super Strength (Capsule) C1

C1 CVS Vitamin D3 (Tablet Chewable) D3 Ultra Strength (Capsule) C1

C1 CVS Vitamin D3 Drops/Infants (Drops) D3 Vitamin (Liquid) C1

C1 CVS Vitamin E (Capsule) D3-1000 (Capsule) C1

C1 CVS Womens Active Daily (Tablet) D3-1000 (Tablet) C1

C1 CVS Womens Daily Gummies (Tablet D-3-5 (Capsule) Chewable) C1 C1 D3-50 (Capsule) CVS Womens Prenatal+DHA (Capsule) C1 C1 D-400 (Tablet) CVS Yogurt+Calcium Gummies (Tablet C1 D-5000 (Tablet) Chewable) C1 C1 Daily Betic (Tablet)

Cyanocobalamin (Injection) C1 C1 Daily Combo Multi Vitamin (Tablet)

D 1000 (Capsule) C1 C1 Daily Heart Health Support (Pack)

D 1000 (Tablet Chewable) C1 C1 Daily Mens Health Formula (Tablet)

D 1000 (Tablet) C1 C1 Daily Multi (Tablet)

D 10000 (Capsule) C1 C1 Daily Multi 50+ (Tablet)

D 2000 (Tablet) C1 C1 Daily Multiple Vitamins (Tablet)

D 400 (Tablet Chewable) C1 C1 Daily Multiple Vitamins/Minerals (Tablet)

D 400 (Tablet) C1 C1 Daily Multivitamin (Capsule)

D 5000 (Capsule) C1 Daily Value Multivitamin (Tablet)

Bold type = Brand name drug Plain type = Generic drug 169 OTC Drug Name OTC Drug Name

C1 C1 Daily Vitamin Plus (Capsule) Endur-Acin (Tablet Extended-Release)

C1 C1 Daily Vitamins (Tablet) Endur-Amide (Tablet Extended-Release)

C1 C1 Daily Womens Health Formula (Tablet) Endur-C/Rose Hips (Tablet Extended- C1 Release) Daily-Vitamin (Tablet) C1 C1 Enviro-Stress (Tablet)

Daily-Vitamin Maximum Formula (Tablet) C1 C1 E-Oil (Oil)

Daily-Vite (Tablet) C1 C1 E-Pherol (Tablet)

Decara (Capsule) C1 C1 EQ Calcium 500+D (Tablet)

Dekas Plus (Liquid) C1 C1 EQ Calcium 600+D (Tablet)

Delta D3 (Tablet) C1 C1 EQ Calcium 600+D+Minerals (Tablet)

Diabetes Health Formula (Tablet) C1 C1 EQ Calcium Citrate+D (Tablet)

Dialyvite 800/Ultra D (Tablet) C1 C1 EQ Calcium Citrate+D3 (Tablet)

Dialyvite Vitamin D 5000 (Capsule) C1 C1 EQ Calcium Citrate+D3/Petites (Tablet)

Dialyvite Vitamin D3 Max (Tablet) C1

C1 Dino-Life (Tablet Chewable) EQ Complete Chewable Multivitamin C1 Children's (Tablet Chewable) Dino-Life W Extra C (Tablet Chewable) C1 C1 EQ Complete Multivitamin Adults 50+ Disney Calcium + Vitamin D3 Gummies (Tablet) (Tablet Chewable) C1 C1 EQ Complete Multivitamin Adults Under 50 Disney Cars Gummies (Tablet Chewable) (Tablet) C1

C1 Disney Princess Gummies (Tablet EQ Magnesium Citrate (Solution) Chewable) C1 C1 EQ Multivitamin Gummies Children's Doctors Choice Multivitamins Men (Tablet) (Tablet Chewable) C1

C1 Dolomite (Tablet) EQ Multivitamins Children's Gummy C1 Dry Eye Formula (Capsule) (Tablet Chewable) C1

C1 E-1000 (Capsule) EQ One Daily Womens Health (Tablet) C1

C1 E-200 (Capsule) EQ One Daily Womens Pro-Active (Tablet) C1

C1 E-400 (Capsule) EQ Slow-Release Iron (Tablet Extended- C1 Release) E-400-Clear (Capsule) C1 C1 EQ Vision Formula 50+ (Capsule) E-400-Mixed (Capsule) C1 C1 EQL Air Protector (Tablet) E600 (Capsule) C1 C1 EQL Anticavity Fluoride Rinse Kids (Rinse) Electrolyte Solution (Oral Solution) C1 C1 EQL Anticavity Mouthwash/Multiple Elite Ca/Mg (Tablet) C1 Benefit (Rinse) Elite Calcium (Tablet) C1

C1 EQL B-12 (Tablet) Elite Magnesium (Tablet) C1 C1 EQL B-6 (Tablet)

C1 E-Max-1000 (Capsule) EQL Calcium 600mg/Vitamin D3 (Tablet)

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C1 C1 EQL Calcium Citrate W/Vitamin D (Tablet) EQL Vitamin C Gummies (Tablet C1 Chewable) EQL Calcium Citrate/ Vitamin D3 (Tablet) C1 C1 EQL Vitamin C/Rose Hips (Tablet)

EQL Calcium Gummies (Tablet Chewable) C1 C1 EQL Vitamin D3 (Capsule)

EQL Calcium Soft Chews (Tablet C1 Chewable) EQL Vitamin D3 Gummies (Tablet C1 Chewable) EQL Calcium/Vitamin D (Capsule) C1 C1 EQL Vitamin E (Capsule)

EQL Calcium/Vitamin D (Tablet) C1 C1 Equalyte (Oral Solution)

EQL Century (Tablet) C1 C1 Ergocalciferol (Solution)

EQL Century Mature (Tablet) C1 C1 Essentia (Tablet)

EQL Century Mature Men 50+ (Tablet) C1 C1 Essential Balance (Tablet)

EQL Century Mature Women 50+ (Tablet) C1 C1 Essential One Daily Multivitamin (Tablet)

EQL Children's Multivitamins/Minerals C1 (Tablet Chewable) Ester-E (Capsule)

C1 C1 EQL Coq10 (Capsule) Eye Vitamins (Capsule)

C1 C1 EQL Dental Travel Pack (Paste) Eyeprotect (Tablet)

C1 C1 EQL Gummies Children's (Tablet Eye-Vites (Tablet) Chewable) C1 C1 Fa-8 (Capsule) EQL Iron Supplement Therapy (Tablet) C1

C1 Fa-8 (Tablet) EQL Magnesium Citrate (Solution) C1

C1 Fe Gluconate (Tablet) EQL Melatonin/Vitamin B-6 (Tablet) C1

C1 Fe Tabs (Tablet)

C1 EQL One Daily Mens 50+ Advanced Ferate (Tablet) (Tablet) C1 C1 Fergon (Tablet) EQL One Daily Mens Health Formula C1 (Tablet) Ferosul (Elixir) C1

C1 EQL One Daily Womens (Tablet) Ferosul (Tablet) C1

C1 EQL One Daily Womens 50+ Advanced Ferretts (Tablet) C1 (Tablet) Ferro-Bob (Tablet) C1

C1 EQL Prenatal Formula (Tablet) Ferrocite (Tablet) C1

C1 EQL Slow Release Iron (Tablet Extended- Ferrotabs (Tablet) Release) C1 C1 Ferrous Fumarate (Tablet) EQL Vision Formula (Tablet) C1 C1 Ferrous Fumarate 324 (Tablet) EQL Vitamin B-12 (Tablet) C1 C1 Ferrous Gluconate (Tablet) EQL Vitamin B-12 TR (Tablet Extended- C1 Ferrous Sulfate (Elixir) Release) C1 C1 Ferrous Sulfate (Liquid) EQL Vitamin C (Tablet) C1 Ferrous Sulfate (Solution)

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C1 C1 Ferrous Sulfate (Tablet Extended-Release) GNP Animal Shapes Plus Extra C (Tablet C1 Chewable) Ferrous Sulfate (Tablet) C1

C1 Ferrous Sulfate Iron (Tablet) GNP Animal Shapes Plus Iron (Tablet C1 Chewable) Ferrousul (Tablet) C1 C1 GNP B-12 (Tablet) Flintstones Complete (Tablet Chewable) C1 C1 GNP B-Complex Plus Vitamin C (Tablet) Flintstones Gummies Plus Bone Building C1 GNP Calcium (Tablet) Support (Tablet Chewable) C1 C1 GNP Calcium 1200 (Tablet Chewable)

Flintstones Gummies Plus Omega-3 DHA C1 (Tablet Chewable) GNP Calcium 500 +D3 (Tablet)

C1 C1 Flintstones Plus Calcium (Tablet GNP Calcium 500/D (Tablet) Chewable) C1 C1 GNP Calcium 600 +D/Minerals (Tablet) Flintstones Plus Extra C (Tablet Chewable) C1

C1 GNP Calcium 600 +D3 (Tablet) Flintstones Plus Iron (Tablet Chewable) C1

C1 GNP Calcium 600 +D3/Minerals (Tablet Flintstones/My First (Tablet Chewable) Chewable)

C1 C1 Fluoride Mouth Rinse (Rinse) GNP Calcium 600 Plus D/Minerals (Tablet)

C1 C1 Folic Acid (Capsule) GNP Calcium 600/D (Tablet)

C1 C1 Folic Acid (Tablet) GNP Calcium Citrate +D3 (Tablet)

C1 C1 Formula E 400 (Capsule) GNP Calcium Citrate+D Maximum (Tablet)

C1 C1 Fruit C 500 (Tablet Chewable) GNP Calcium Citrate+D3 Maximum C1 (Tablet) Fruit C-100 (Tablet Chewable) C1 C1 GNP Calcium Plus 600 +D (Tablet)

Fruity C (Tablet Chewable) C1 C1 GNP Calcium/Magnesium/Zinc (Tablet)

Fruity Chewables Multivitamin (Tablet C1 Chewable) GNP Calcuim/Vitamin D/Minerals (Tablet C1 Chewable) Fruity Chews (Tablet Chewable) C1 C1 GNP Century (Tablet)

Fruity Chews/Iron (Tablet Chewable) C1 C1 GNP Century Adult Formula (Tablet)

Gerivite Complete (Tablet) C1 C1 GNP Century Adults 50+ Senior (Tablet)

Gluco Burst (Gel) C1

C1 Glucose (Gel) GNP Century Cardio Healthformula C1 (Tablet) Glucose Liquid (Liquid) C1 C1 GNP Century Mature (Tablet) Glucoten (Capsule) C1 C1 GNP Century Mature Formula/Women'S Glutose 15 (Gel) 50+ (Tablet) C1

C1 Glutose 45 (Gel) GNP Century Ultimate Mens Complete C1 Glutose 5 (Gel) (Tablet) C1

C1 GNP Animal Shapes (Tablet Chewable) GNP Century Ultimate Mens Senior Formula (Tablet)

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C1 C1 GNP Century Ultimate Womens Complete GNP Melatonin Maximum Strength (Tablet) (Tablet) C1 C1 GNP Niacin (Tablet)

C1 GNP Century Ultimate Womens Senior GNP Niacin TR (Tablet Extended-Release) Formula (Tablet) C1 C1 GNP Norwegian Cod Liver Oil (Capsule) GNP Children's Chewables W/Extra C C1 (Tablet Chewable) GNP One Daily Maximum (Tablet) C1

C1 GNP Children's Chewables/Extra C (Tablet GNP One Daily Mens 50+ Advanced Chewable) (Tablet) C1

C1 GNP Children's Chewables/Iron (Tablet GNP One Daily Mens Health 50+ (Tablet) C1 Chewable) GNP One Daily Mens Health/Lycopene

C1 GNP Children's Complete Chewables (Tablet) C1 (Tablet Chewable) GNP One Daily Womens 50+ Advanced

C1 GNP Co Q10 (Capsule) (Tablet) C1

C1 GNP Cod Liver Oil (Capsule) GNP One Daily Womens Health (Tablet) C1

C1 GNP Coenzyme Q-10 (Capsule) GNP One Daily Womens Health 50+ C1 (Tablet) GNP D 1000 (Capsule) C1 C1 GNP One Daily Womens Metabolism GNP D 2000 (Tablet Chewable) C1 Support (Tablet) GNP Daily Prenatal (Capsule) C1

C1 GNP Opti-Vitamins (Tablet) GNP Diabetic Support Formula (Tablet) C1

C1 GNP Pediatric Electrolyte (Oral Solution) GNP Essential One Daily (Tablet) C1

C1 GNP Potassium (Tablet) GNP Folic Acid (Tablet) C1

C1 GNP Prenatal (Tablet) GNP Hair/Skin/Nails (Tablet) C1

C1 GNP Slow Release Iron (Tablet Extended- GNP Healthy Eyes (Tablet) Release)

C1 C1 GNP Healthy Eyes Supervision (Capsule) GNP Therapeutic-M (Tablet)

C1 C1 GNP Healthy Eyes Supervision 2 (Capsule) GNP Vitamin A & D (Ointment)

C1 C1 GNP Immune Support (Tablet) GNP Vitamin A (Capsule)

C1 C1 GNP Iron (Tablet Extended-Release) GNP Vitamin B1 (Tablet)

C1 C1 GNP Iron (Tablet) GNP Vitamin B-1 (Tablet)

C1 C1 GNP Little Ones Children's (Tablet GNP Vitamin B-12 (Tablet) Chewable) C1

C1 GNP Vitamin B-12 Prolonged Release GNP Magnesium (Tablet) (Tablet Extended-Release)

C1 C1 GNP Magnesium Citrate (Solution) GNP Vitamin B-12 TR (Tablet Extended- C1 Release) GNP Maximum One Daily (Tablet) C1 C1 GNP Vitamin B-6 (Tablet)

GNP Mega Multi For Men (Tablet) C1 C1 GNP Vitamin C (Tablet Chewable)

GNP Mega Multi For Women (Tablet) C1

C1 GNP Melatonin (Tablet) GNP Vitamin C (Tablet)

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C1 C1 GNP Vitamin C Drops (Lozenge) Healthy Eyes/Lutein (Tablet)

C1 C1 GNP Vitamin C PR (Tablet Extended- Healthy Hair Skin & Nails (Tablet) Release) C1 C1 Healthy Kids Gummies (Tablet Chewable)

C1 GNP Vitamin C TR (Tablet Extended- Healthy Kids Overall Health Multivitamins Release) C1 (Tablet Chewable) GNP Vitamin C W/Rose Hips (Tablet) C1

C1 Healthy Kids Vitamin D3 (Tablet Chewable)

C1 GNP Vitamin C W/Rose Hips TR (Tablet H-E-B Oral Electrolyte Solution (Oral Extended-Release) C1 Solution) GNP Vitamin C/Rose Hips (Tablet) C1

C1 Hemenatal OB + DHA (Capsule) GNP Vitamin D (Tablet Chewable) C1

C1 High Potency Calcium (Tablet) GNP Vitamin D (Tablet) C1

C1 High Potency Iron (Tablet) GNP Vitamin D Maximum Strength (Tablet) C1

C1 Hi-Kovite 2-Part Formula (Tablet) GNP Vitamin D Super Strength (Tablet) C1

C1 Hi-Potency Multi-Vitamin/Mineral GNP Vitamin D3 Extra Strength (Tablet) Supplement (Tablet)

C1 C1 GNP Vitamin D-400 (Tablet) HM Animal Shapes (Tablet Chewable)

C1 C1 GNP Vitamin E (Capsule) HM Antioxidant Vitamins (Tablet)

C1 C1 GNP Vitamin E Water Dispersible HM Calcium 600 & Vitamin D3 (Tablet) (Capsule) C1

C1 HM Calcium 600 + D Plus Minerals (Tablet GNP Womens One Daily (Tablet) Chewable)

C1 C1 GNP Zoochews Gummies (Tablet HM Calcium 600 + Vitamin D3 (Tablet) Chewable) C1 C1 HM Calcium Citrate + Vitamin D (Tablet) Goodsense Iron (Tablet) C1

C1 HM Calcium Citrate+D3 Petite (Tablet) Goodsense Magnesium Citrate (Solution) C1

C1 HM Calcium Magnesium & Zinc (Tablet) Goodsense Prenatal Vitamins (Tablet) C1

C1 HM Calcium/Vitamin D (Tablet)

C1 Gummi Bear Multivitamin/Mineral (Tablet HM Calcium/Vitamin D/Minerals (Tablet) Chewable) C1 C1 HM Complete (Tablet) H2Q (Capsule) C1 C1 HM Complete 50+ (Tablet) Hair Formula Extra Strength (Tablet) C1 C1 HM Complete 50+ Mens Ultimate (Tablet) Hair Skin And Nails Formula (Tablet) C1 C1 HM Complete 50+ Womens Ultimate Hair Vitamins (Tablet) C1 (Tablet) Hair/Skin/Nails (Capsule) C1

C1 HM Complete Women (Tablet) Hair/Skin/Nails (Tablet) C1

C1 HM Coq10 (Capsule) Hair/Skin/Nails/Biotin (Tablet) C1

C1 HM E Vitamin (Capsule) Halls Defense Vitamin C Drops (Lozenge) C1

C1 HM Folic Acid (Tablet)

C1 Healthy Eyes (Tablet) HM Hair/Skin/Nails (Tablet)

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C1 C1 HM Iron (Tablet) HM Vitamin E (Capsule)

C1 C1 HM Iron Slow Release (Tablet Extended- HM Vita-Mini Multi Complete (Tablet) Release) C1

C1 HM Womens 50+ Advanced One Daily HM Magnesium Citrate (Solution) (Tablet)

C1 C1 HM Melatonin (Tablet) Icaps (Capsule)

C1 C1 HM Melatonin Quick Dissolve (Tablet) Icaps Areds 2 (Capsule)

C1 C1 HM Mens 50+ Advanced One Daily Icaps Lutein & Omega-3 (Capsule) (Tablet) C1 C1 Icaps MV (Tablet)

C1 HM Multivitamin Adult Gummy (Tablet Iron (Tablet Extended-Release) Chewable) C1 C1 Iron (Tablet) HM Niacin (Tablet Extended-Release) C1 C1 Iron 27 (Tablet) HM Niacin TR (Tablet Extended-Release) C1 C1 Iron ER (Tablet Extended-Release) HM One Daily Essential (Tablet) C1 C1 Iron High-Potency (Tablet Extended- HM One Daily Mens (Tablet) C1 Release) HM One Daily Prenatal Combo (Capsule) C1

C1 Iron High-Potency (Tablet) HM One Daily Womens (Tablet) C1

C1 Iron Slow Release (Tablet Extended- HM Pediatric Electrolyte (Oral Solution) Release)

C1 C1 HM Prenatal (Tablet) Iron Supplement (Elixir)

C1 C1 HM Slow Release Iron (Tablet Extended- Iron Supplement Children's (Solution) Release) C1 C1 I-Vite (Tablet) HM Super Vitamin B12 (Tablet Chewable) C1

C1 I-Vite Protect (Tablet) HM Vitamin B1 (Tablet) C1

C1 Kids First Vitamin D3 Gummies (Tablet HM Vitamin B12 (Tablet Extended-Release) Chewable)

C1 C1 HM Vitamin B12 (Tablet) Kosher Prenatal Plus Iron (Tablet)

C1 C1 HM Vitamin B12 TR (Tablet Extended- KP Adults 50+ Daily Formula (Tablet) Release) C1 C1 KP Adults Daily Formula (Tablet) HM Vitamin B12 Ultra Strength (Tablet) C1

C1 KP Calcium 600+D (Capsule) HM Vitamin B6 (Tablet) C1

C1 KP Calcium 600+D (Tablet) HM Vitamin C (Tablet Chewable) C1

C1 KP Calcium 600+D3 (Capsule) HM Vitamin C (Tablet) C1

C1 KP Calcium Citrate+D (Tablet)

C1 HM Vitamin C TR (Tablet Extended- KP Calcium/Magnesium/Zinc (Tablet) Release) C1 C1 KP Ferrous Gluconate (Tablet) HM Vitamin C/Rose Hips (Tablet) C1 C1 KP Ferrous Sulfate (Tablet) HM Vitamin D (Tablet) C1 C1 KP Folic Acid (Tablet) HM Vitamin D3 (Capsule) C1 KP Mag-Oxide Magnesium (Tablet)

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C1 C1 KP Melatonin (Tablet) Listerine Total Care (Rinse)

C1 C1 KP Mens 50+ Daily Formula (Tablet) Listerine Total Care Pluswhitening C1 (Rinse) KP Mens Daily Formula (Tablet) C1 C1 Listerine Total Care Zero (Rinse)

KP Niacin (Tablet) C1 C1 Listerine Whitening/Restoring (Rinse)

KP Prenatal Multivitamins (Tablet) C1 C1 Little Animals (Tablet Chewable)

KP Vision Formula (Tablet) C1 C1 Little Animals Plus Iron (Tablet Chewable)

KP Vision Formula W/Lutein (Tablet) C1 C1 Localnesium (Tablet)

KP Vitamin B-12 (Tablet) C1 C1 Localnesium-C (Tablet)

KP Vitamin B-6 (Tablet) C1 C1 Lysiplex Plus (Tablet)

KP Vitamin D (Capsule) C1 C1 M2 Magnesium (Capsule)

KP Vitamin D (Tablet Chewable) C1 C1 Macular Health Formula (Capsule)

KP Vitamin D3 (Capsule) C1 C1 Macuvite (Tablet)

KP Vitamin E (Capsule) C1 C1 Macuvite Eye Care (Tablet)

KP Womens 50+ Daily Formula (Tablet) C1 C1 Macuvite/Lutein (Tablet)

KP Womens Daily Formula (Tablet) C1 C1 Magdelay (Tablet)

KPN Prenatal (Tablet) C1 C1 Mag-G (Tablet)

Land Before Time Multivitamin/Iron (Tablet C1 Chewable) Magnacaps (Capsule)

C1 C1 Land Before Time Multivitamin/Vitamin C Magnebind 300 (Tablet) (Tablet Chewable) C1 C1 Magnesium (Capsule) Liquid B12 (Liquid) C1

C1 Magnesium (Tablet)

C1 Liquid Calcium With D3 Maximum Magnesium 27 (Tablet) Strength (Capsule) C1 C1 Magnesium Carbonate (Powder) Liquid Calcium/D3 (Capsule) C1 C1 Magnesium Chloride (Injection) Liquid Calcium/Magnesium Citrate Plus C1 Vitamin D3 (Liquid) Magnesium Citrate (Capsule) C1

C1 Liquid Calcium/Vitamin D (Capsule) Magnesium Citrate (Solution) C1

C1 Liquid Calcium/Vitamins A & D (Capsule) Magnesium Citrate (Tablet) C1

C1 Listerine Healthy White Gentle (Rinse) Magnesium Elemental (Capsule) C1

C1 Listerine Healthy White Vibrant (Rinse) Magnesium Elemental (Tablet) C1

C1 Listerine Naturals With Fluoride (Rinse) Magnesium Gluconate (Tablet) C1

C1 Listerine Nightly Reset (Rinse) Magnesium L-Lactate Dihyrate (Tablet C1 Extended-Release) Listerine Restoring (Rinse) C1 C1 Magnesium Oxide (Capsule) Listerine Smart Rinse (Rinse) C1 C1 Magnesium Oxide (Powder) Listerine Smart Rinse Anticavity (Rinse)

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C1 C1 Magnesium Oxide (Tablet) Melatonin CR (Tablet Extended-Release)

C1 C1 Magnesium Oxide 400 (Powder) Melatonin Extra Strength (Liquid)

C1 C1 Magnesium Oxide 400 (Tablet) Melatonin Fast Dissolve (Tablet)

C1 C1 Magnesium-Oxide (Tablet) Melatonin Fast Meltz (Tablet)

C1 C1 Magnum-75 (Tablet) Melatonin Gummies (Tablet Chewable)

C1 C1 Mag-Oxide (Tablet) Melatonin Maximum Strength (Capsule)

C1 C1 Maximum Blue Label (Tablet) Melatonin Maximum Strength (Tablet)

C1 C1 Maximum Daily Green (Tablet) Melatonin Quick Dissolve (Tablet)

C1 C1 Maximum Green Label (Tablet) Melatonin TR (Tablet Extended-Release)

C1 C1 Maximum Red Label (Tablet) Melatonin TR/Vitamin B6 (Tablet C1 Extended-Release) Mediplex Plus (Tablet) C1

C1 Mega Coq10 (Capsule) Melatonin TR/Vitamin B-6 (Tablet C1 Extended-Release) Mega Coq-10 (Capsule) C1 C1 Melatonin/Vitamin B-6 Extra Strength Mega VM-80 (Tablet) (Tablet) C1

C1 Mega-Marathon 100 TR (Tablet Extended- Mens Daily Formula/Lycopene (Capsule) Release) C1 C1 Mens Hair Formula Ultra Man (Tablet) Megavite Golden Years 55+ (Tablet) C1 C1 Mens Life Pack (Tablet) Meijer Advanced Formula (Tablet) C1 C1 MGO (Tablet) Meijer Advanced Formula For Adults 50+ C1 MH Macular Health (Pack) (Tablet) C1

C1 Meijer C (Tablet) Milltrium Advanced Formula With Beta C1 Carotene (Tablet) Meijer Ferrous Sulfate (Tablet) C1 C1 Milltrium Cardio (Tablet) Meladox (Tablet Extended-Release) C1 C1 Milltrium Senior (Tablet) Melatin (Tablet) C1 C1 MM Melatonin TR (Tablet Extended- Melatonex (Tablet Extended-Release) Release) C1

C1 Melatonin (Capsule) Monoject Pharma Grade Flush Syringe C1 Melatonin (Liquid) (Solution) C1

C1 Melatonin (Lozenge) Monoject Sodium Chloride Flush (Solution) C1

C1 Melatonin (Tablet Chewable) Multi + Omega-3 Adult Gummies (Tablet C1 Chewable) Melatonin (Tablet Extended-Release) C1 C1 Multi Adult Gummies (Tablet Chewable) Melatonin (Tablet) C1 C1 Multi Complete (Capsule) Melatonin Adult Gummies (Tablet C1 Chewable) Multi Complete/Iron (Tablet) C1

C1 Melatonin Adult Gummy (Tablet Chewable) Multi For Her (Capsule) C1 Multi For Her (Tablet)

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C1 C1 Multi For Her 50+ (Capsule) Multiple Vitamins/Fluoride (Tablet C1 Chewable) Multi For Her 50+ (Tablet) C1 C1 Multiple Vitamins/Iron (Tablet Chewable)

Multi For Him (Capsule) C1 C1 Multiple Vitamins/Womens (Tablet)

Multi For Him (Tablet) C1 C1 Multi-Vit/Fluoride (Solution)

Multi For Him 50+ (Tablet) C1 C1 Multi-Vit/Iron/Fluoride (Drops)

Multi Prenatal (Tablet) C1 C1 Multivitamin & Mineral (Liquid)

Multi Vit/Fl (Tablet Chewable) C1 C1 Multivitamin (Liquid)

Multi Vita-Bets/Fluoride (Tablet Chewable) C1 C1 Multi-Vitamin (Tablet)

Multi Vitamin (Tablet) C1 C1 Multivitamin Adults (Tablet)

Multi Vitamin And Minerals (Tablet) C1 C1 Multivitamin Adults 50+ (Tablet)

Multi Vitamin Daily (Tablet) C1 C1 Multivitamin Children's (Tablet Chewable)

Multi Vitamin Mens (Tablet) C1 C1 Multi-Vitamin Daily (Tablet)

Multi Vitamin/D-3 (Tablet) C1

C1 Multi Vitamin/Minerals Full Spectrum Multivitamin Drops/Iron Infant & Toddler (Drops) (Tablet) C1 C1 Multi-Vitamin Gummies (Tablet Chewable)

Multi-Day (Tablet) C1

C1 Multi-Day Plus Minerals (Tablet) Multivitamin Gummies Adult (Tablet C1 Chewable) Multi-Day Vitamins (Tablet) C1 C1 Multivitamin Gummies Children's (Tablet Multi-Day W/Calcium And Extra Iron Chewable) (Tablet) C1 C1 Multivitamin Gummies Mens (Tablet Multi-Day Weight Trim (Tablet) Chewable) C1

C1 Multi-Delyn (Liquid) Multivitamin Gummies Womens (Tablet C1 Multi-Delyn/Iron (Liquid) Chewable) C1

C1 Multi-Lean (Tablet) Multivitamin Infant & Toddler (Drops) C1

C1 Multilex (Tablet) Multivitamin Iron-Free (Tablet) C1

C1 Multilex-T&M (Tablet) Multivitamin Men 50+ (Tablet) C1

C1 Multimineral Plus (Tablet) Multivitamin Mens (Tablet) C1

C1 Multi-Minerals (Tablet) Multi-Vitamin Monocaps (Tablet) C1

C1 Multiple Vitamin (Tablet) Multivitamin Plus Iron Children's (Tablet C1 Chewable) Multiple Vitamin/Folic Acid (Tablet) C1 C1 Multivitamin With Fluoride (Solution) Multiple Vitamin/Minerals/No Iron (Tablet) C1 C1 Multivitamin With Fluoride (Tablet Multiple Vitamins (Tablet) C1 Chewable) Multiple Vitamins Essential (Tablet) C1 C1 Multivitamin With Fluoride (Tablet)

C1 Multiple Vitamins Plain (Tablet) Multivitamin Women (Tablet)

Bold type = Brand name drug Plain type = Generic drug 178 OTC Drug Name OTC Drug Name

C1 C1 Multivitamin Women 50+ (Tablet) Nat-Rul Oyster Calcium + D (Tablet)

C1 C1 Multivitamin Womens (Tablet) Nat-Rul Vitamin D (Tablet)

C1 C1 Multivitamin/Extra Vitamin D3 Adult (Tablet Natural C/Rose Hips (Tablet) Chewable) C1 C1 Natural Coenzyme Q10 (Capsule) Multivitamin/Fluoride (Solution) C1

C1 Natural Vitamin A (Capsule) Multivitamin/Fluoride (Tablet Chewable) C1

C1 Natural Vitamin D-3 (Tablet) Multi-Vitamin/Fluoride Drops (Solution) C1

C1 Natural Vitamin E (Capsule) Multivitamin/Fluoride/Iron (Drops) C1

C1 Natural Vitamin E (Tablet) Multi-Vitamin/Fluoride/Iron (Drops) C1

C1 Naturalyte (Oral Solution)

C1 Multi-Vitamin/Menopausal Formula Neuro-K-250 Vitamin B6 (Tablet) (Tablet) C1 C1 Neuro-K-50 (Tablet) Multi-Vitamin/Multi-Mineral Adult/High C1 Potency (Liquid) Neuro-K-500 (Tablet) C1

C1 Multivitamins (Capsule) Niacin (Tablet) C1

C1 Multi-Vitamins (Tablet) Niacin ER (Capsule Extended-Release) C1

C1 Multivitamins/Fluoride (Tablet Chewable) Niacin ER (Tablet Extended-Release) C1

C1 Mult-Vitamin/Fluoride (Tablet Chewable) Niacin PR (Tablet Extended-Release) C1

C1 MVC-Fluoride (Tablet Chewable) Niacin SR (Capsule) C1

C1 MV-One (Capsule) Niacin TD (Capsule Extended-Release) C1

C1 MVW Complete Formulation (Tablet Niacin TD (Tablet Extended-Release) C1 Chewable) Niacin Time Release (Tablet Extended-

C1 MVW Complete Formulation D3000 (Tablet Release) C1 Chewable) Niacin Timed Release (Tablet Extended-

C1 MVW Complete Formulation D5000 (Tablet Release) C1 Chewable) Niacin TR (Capsule Extended-Release) C1

C1 Myamulti (Tablet) Niacin TR (Tablet Extended-Release) C1

C1 My-Vitalife (Capsule) Niacin-50 (Tablet) C1

C1 Nanovm 1-3 Years (Powder) Niacinamide (Tablet) C1

C1 Nanovm 4-8 Years (Powder) Niacinamide Prolonged Release (Tablet

C1 Nanovm 9-18 Years (Powder) Extended-Release) C1

C1 Nanovm T/F (Liquid) Normal Saline Flush (Solution) C1

C1 Nanovm T/F (Powder) Normal Saline Flush For Flushing Vascular C1 Access Devices (Solution) Nat-Rul Coenzyme Q-10 (Capsule) C1 C1 Normal Saline I.V. Flush (Solution) Nat-Rul Iron (Tablet) C1 C1 Norwegian Cod Liver Oil (Capsule) Natrul Magnesium (Tablet) C1 Novaferrum Pediatric Multivitamin (Liquid)

Bold type = Brand name drug Plain type = Generic drug 179 OTC Drug Name OTC Drug Name

C1 C1 Novaferrum Pediatric Multi-Vitamin/Iron One Daily Multivitamin Men (Tablet) (Drops) C1

C1 One Daily Multivitamin Mens 50+/ Nutr-E-Sol (Liquid) Lycopene (Tablet)

C1 C1 Nutricion Porvida (Tablet) One Daily Multivitamin Women (Tablet)

C1 C1 Nutrifac ZX (Tablet) One Daily Multivitamin/Iron-Free (Tablet)

C1 C1 Ocutabs (Tablet) One Daily Plus Iron (Tablet)

C1 C1 Ocutabs Vision Formula (Tablet) One Daily Plus Minerals (Tablet)

C1 C1 Ocutabs/Lutein (Tablet) One Daily Womens (Tablet)

C1 C1 Ocuvite Extra (Tablet) One Daily Womens 50 Plus (Tablet)

C1 C1 Ocuvite Eye + Multi (Tablet) One Daily Womens 50+ (Tablet)

C1 C1 Ocuvite Eye Health Formula (Capsule) One Daily/Iron/Calcium (Tablet)

C1 C1 Ocuvite Eye Health Gummies (Tablet One Daily/Minerals (Tablet) Chewable) C1

C1 One-A-Day Teen Advantage For Her Ocuvite/Lutein (Tablet) (Tablet)

C1 C1 Omnicap (Tablet) One-Daily Multi Vitamins (Tablet)

C1 C1 Once Daily (Tablet) Optic-Vites (Tablet)

C1 C1 One Daily (Tablet) Optic-Vites With Lutein (Tablet)

C1 C1 One Daily 50 Plus (Tablet) Optimal-D (Capsule)

C1 C1 One Daily Adults 50+ (Tablet) Optimal-D Pack (Capsule)

C1 C1 One Daily Complete (Tablet) Optimum Airvites (Tablet Chewable)

C1 C1 One Daily Complete For Men (Tablet) Optimum Pms (Tablet)

C1 C1 One Daily Essential (Tablet) Opurity Calcium Citrate Plus (Tablet C1 Chewable) One Daily For Men 50+ Advanced (Tablet) C1 C1 Opurity Vitamin D (Tablet Chewable)

One Daily For Men/Lycopene (Tablet) C1

C1 One Daily For Women (Tablet) Oral Electrolyte Solutionfreezer Pops C1 Pediatric (Oral Solution) One Daily For Women 50+A Dvanced C1 Oralyte (Oral Solution) (Tablet) C1 C1 Oralyte Freezer Pops (Oral Solution)

One Daily Healthy Weight (Tablet) C1 C1 Os-Cal (Tablet Chewable)

One Daily Healthy Weight Advanced C1 (Tablet) Os-Cal (Tablet Chewable)

C1 C1 One Daily Maximum (Tablet) Oscal 500/200 D-3 (Tablet)

C1 C1 One Daily Mens (Tablet) Os-Cal Calcium + D3 (Tablet)

C1 C1 One Daily Mens 50+ Multivitamin (Tablet) Os-Cal Extra D3 (Tablet)

C1 C1 One Daily Mens Health/Lycopene (Tablet) Os-Cal Ultra (Tablet)

C1 C1 One Daily Multivitamin Adult (Tablet) Osteo-Poretical (Tablet)

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C1 C1 Osteoprime Ultra (Tablet) PA Calcium 600/Vitamin D (Tablet)

C1 C1 Ostigen PA Coenzyme Q-10 (Capsule)

C1 C1 Oysco 500 (Tablet) PA Melatonin (Tablet)

C1 C1 Oysco 500+D (Tablet Chewable) PA Oyster Shell Calcium (Tablet)

C1 C1 Oysco 500+D (Tablet) PA Prenatal Formula (Tablet)

C1 C1 Oyst-Cal-D 500 (Tablet) PA Vitamin B-12 TR (Tablet Extended- C1 Release) Oyster Calcium (Tablet) C1 C1 PA Vitamin D-3 (Capsule)

Oyster Calcium/D3 (Tablet) C1 C1 PA Vitamin D-3 (Tablet)

Oyster Calcium/Vitamin D (Tablet) C1 C1 PA Vitamin D-3 Gummy (Tablet Chewable)

Oyster Shell (Tablet) C1 C1 PA Vitamin E (Capsule)

Oyster Shell Calcium (Tablet) C1 C1 Parva-Cal (Tablet)

Oyster Shell Calcium + D (Tablet) C1 C1 Parva-Cal 250 (Tablet)

Oyster Shell Calcium + D3 (Tablet) C1 C1 PC Pediatric Electrolyte (Oral Solution)

Oyster Shell Calcium + Vitamin D (Tablet) C1 C1 Pedia Vance (Oral Solution)

Oyster Shell Calcium 250+D (Tablet) C1 C1 Pediatric Electrolyte (Oral Solution)

Oyster Shell Calcium 500 (Tablet) C1

C1 Oyster Shell Calcium 500 + D (Tablet) Pediatric Electrolyte Freeze Pops (Oral C1 Solution) Oyster Shell Calcium 500/D (Tablet) C1 C1 Pediatric Electrolyte Freezer Pops (Oral Oyster Shell Calcium 500+D (Tablet Solution) Chewable) C1 C1 Pediatric Electrolyte/With Zinc (Oral Oyster Shell Calcium Plus Vitamin D Solution) (Tablet) C1 C1 Pediatric Electrolyte/Zinc (Oral Solution) Oyster Shell Calcium Plusvitamin D C1 Pediavit (Liquid) (Tablet) C1 C1 Phos-Nak Powder Concentrate (Powder)

Oyster Shell Calcium/D (Tablet) C1 C1 Phosphorus Supplement (Powder)

Oyster Shell Calcium/D3 (Tablet) C1 C1 Plain Niacin (Tablet)

Oyster Shell Calcium/Magnesium (Tablet) C1 C1 Pnv-Total (Capsule)

Oyster Shell Calcium/Vitamin D (Powder) C1 C1 Poly Vitamin (Tablet Chewable)

Oyster Shell Calcium/Vitamin D (Tablet) C1 C1 Polyvitamin (Solution)

Oyster Shell Calcium+D (Tablet) C1 C1 Poly-Vitamin/Fluoride (Solution)

Oyster Shell/Vitamin D (Tablet) C1 C1 Poly-Vitamin/Fluoride (Tablet Chewable)

Oystercal (Tablet) C1 C1 Polyvitamin/Iron (Tablet Chewable)

Oystercal-D (Tablet) C1 C1 Poly-Vitamin/Iron Drops (Drops)

PA B-Complex With B-12 (Tablet) C1 Posture (Tablet)

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C1 C1 Posture-D Calcium/Magnesium (Tablet) Prosight (Tablet)

C1 C1 Potassimin (Tablet) Prosight W/Lutein (Capsule)

C1 C1 Potassium (Tablet) Pure C 500 (Capsule)

C1 C1 Prenatal (Tablet) Pureway-C (Tablet)

C1 C1 Prenatal + Complete Multi/DHA/Choline/ PX Advanced Formula Multivitamins/ Folate (Capsule) Lycopene (Tablet)

C1 C1 Prenatal + Complete Multi/DHA/Choline/ PX Calcium & D (Tablet) Folate (Tablet Chewable) C1 C1 PX Children's Vitamin (Tablet Chewable)

C1 Prenatal Adult Gummy/DHA/Folic Acid PX Complete Senior Multivitamins (Tablet) (Tablet Chewable) C1 C1 PX Folic Acid (Tablet) Prenatal And Iron (Tablet) C1 C1 PX Iron (Tablet) Prenatal Complete (Tablet) C1 C1 PX Mens Multivitamins (Tablet) Prenatal Formula (Capsule) C1 C1 PX Niacin (Tablet) Pre-Natal Formula (Tablet) C1 C1 PX Prenatal Multivitamins (Tablet) Prenatal Formula A-Free (Tablet) C1 C1 PX Vitamin A (Capsule) Prenatal Forte (Tablet) C1 C1 PX Vitamin C (Tablet) Prenatal Gummies/DHA & Folic Acid C1 (Tablet Chewable) PX Vitamin E (Capsule) C1

C1 Prenatal Low Iron (Tablet) Pyri 500 (Tablet) C1

C1 Prenatal Multi + DHA (Capsule) Pyridoxine HCl (Tablet) C1

C1 Prenatal Multivitamin (Tablet) Pyridoxine Hydrochloride (Tablet) C1

C1 Prenatal Multivitamin Plus DHA (Capsule) QC B-Complex + Vitamin C (Tablet) C1

C1 Prenatal One Daily (Tablet) QC C With Rose Hips (Tablet) C1

C1 Prenatal Tablets (Tablet) QC Calcium 600 +D3 Plus Minerals (Tablet C1 Chewable) Prenatal Vitamin & Mineral (Tablet) C1 C1 QC Calcium Fast Dissolution (Tablet) Prenatal Vitamin (Tablet) C1 C1 QC Calcium Magnesium & Zinc +D3 Prenatal Vitamin/Iron (Tablet) C1 (Tablet) Prenatal Vitamins (Tablet) C1

C1 QC Calcium/Minerals/Vitamin D (Tablet)

C1 Prenatal/Omega-3/Folic Acid/Iron QC Children's Chewable Complete (Tablet (Capsule) C1 Chewable) Prenatal+DHA (Capsule) C1

C1 QC Children's Chewable Vitamins/Extra C Prevent (Capsule) (Tablet Chewable)

C1 C1 Pronutrients Calcium+D3 (Tablet) QC Children's Chewable Vitamins/Iron C1 (Tablet Chewable) Pronutrients Coq10 (Capsule) C1

C1 Pronutrients Vitamin D3 (Capsule) QC Co Q-10 (Capsule)

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C1 C1 QC Cod Liver Oil (Capsule) RA B-Complex (Tablet)

C1 C1 QC Essentials (Tablet) RA B-Complex With B-12 (Tablet)

C1 C1 QC Ferrous Sulfate (Tablet) RA Calcium (Tablet)

C1 C1 QC Folic Acid (Tablet) RA Calcium 600 (Tablet)

C1 C1 QC Hair Skin & Nails (Tablet) RA Calcium 600 Plus Vitamin D-3 & C1 Minerals (Tablet Chewable) QC Magnesium Citrate (Solution) C1 C1 RA Calcium 600 Plus Vitamin D-3 (Tablet)

QC Maximum Daily Multivitamin/ C1 Multimineral (Tablet) RA Calcium 600/Vit D/Minerals (Tablet)

C1 C1 QC Melatonin Maximum Strength (Tablet) RA Calcium Citrate Plus Vitamin D (Tablet)

C1 C1 QC Mens Daily Multivitamin (Tablet) RA Calcium Citrate Plus Vitamin D-3 C1 (Tablet) QC Multi-Vite (Tablet) C1

C1 QC Multi-Vite 50 & Over (Tablet) RA Calcium Citrate/Vitamin D-3 Petites C1 (Tablet) QC Multi-Vite Plus (Tablet) C1 C1 RA Calcium Hi-Cal (Tablet) QC Niacin (Tablet) C1 C1 RA Calcium Hi-Cal/Vitamind (Tablet) QC Prenatal (Tablet) C1 C1 RA Calcium High Potency (Tablet) QC Therin-M (Tablet) C1 C1 RA Calcium Plus Vitamin D (Tablet) QC Vitamin B1 (Tablet) C1 C1 RA Calcium Soft Chews (Tablet Chewable) QC Vitamin B12 (Tablet Extended-Release) C1 C1 RA Calcium/Boron (Tablet) QC Vitamin B12 (Tablet) C1 C1 RA Calcium/Magnesium/Zinc (Tablet) QC Vitamin B6 (Tablet) C1 C1 RA Calcium/Magnesium/Zinc/Copper QC Vitamin C (Tablet Chewable) (Tablet) C1

C1 QC Vitamin C (Tablet) RA Calcium/Minerals/Vitamin D (Tablet) C1

C1 QC Vitamin D3 (Tablet) RA Central-Vite (Tablet) C1

C1 QC Vitamin E (Capsule) RA Central-Vite Energy (Tablet) C1

C1 QC Womens Daily Multivitamin (Tablet) RA Central-Vite Mens Mature (Tablet) C1

C1 Q-Gel Forte (Capsule) RA Central-Vite Select (Tablet) C1

C1 Q-Gel Mega (Capsule) RA Central-Vite Select Mature (Tablet) C1

C1 Q-Gel Ultra (Capsule) RA Central-Vite Senior (Tablet) C1

C1 Q-Sorb (Capsule) RA Central-Vite Womens Mature (Tablet) C1

C1 Q-Sorb Co Q-10 (Capsule) RA Central-Vite/Antioxidants (Tablet) C1

C1 Quin B Strong (Tablet) RA Chewable Vitamins Complete C1 Quintabs (Tablet) Children's (Tablet Chewable) C1

C1 Quintabs-M (Tablet) RA Children's Chewable Vitamins/Iron C1 (Tablet Chewable) RA Anticavity Fluoride Rinse (Rinse)

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C1 C1 RA Coenzyme Q-10 (Capsule) RA Oyster Shell Calcium/Vitamin D C1 (Tablet) RA Coral Calcium (Capsule) C1 C1 RA Pediatric Electrolyte (Oral Solution)

RA Folic Acid (Tablet) C1

C1 RA Glucose (Gel) RA Pediatric Electrolyte Freezer Pops (Oral C1 Solution) RA Gummy Vitamins & Minerals Children's C1 RA Prenatal (Tablet) (Tablet Chewable) C1 C1 RA Prenatal Formula/Folicacid (Tablet)

RA Hair/Skin/Nails (Tablet) C1

C1 RA Hi Cal (Tablet) RA Slow Release Iron (Tablet Extended- C1 Release) RA Hi-Cal (Tablet) C1 C1 RA Stress Formula Advanced (Tablet) RA Hi-Cal Plus Vitamin D (Tablet) C1 C1 RA Stress Formula Energy (Tablet) RA High Potency Iron (Tablet) C1 C1 RA Therapeutic M Plus Beta Carotene RA Iron (Tablet) (Tablet) C1

C1 RA Magnesium (Capsule) RA Tooth Shield (Rinse) C1

C1 RA Magnesium Citrate (Solution) RA Vision Vite Plus Zinc (Tablet) C1

C1 RA Mature Womens Dietary Supplement RA Vitamin A (Capsule) (Tablet) C1 C1 RA Vitamin B-1 (Tablet) RA Melatonin (Tablet) C1 C1 RA Vitamin B-12 (Liquid) RA Natural Magnesium (Tablet) C1 C1 RA Vitamin B12 (Tablet Extended-Release) RA Natural Vitamin E (Capsule) C1 C1 RA Vitamin B-12 (Tablet) RA Niacin (Tablet) C1 C1 RA Vitamin B-12 TR (Tablet Extended- RA No Flush Niacin 500 (Tablet) Release) C1

C1 RA One Daily (Capsule) RA Vitamin B-6 (Tablet) C1

C1 RA One Daily Energy Formula (Tablet) RA Vitamin B-6 TR (Tablet Extended- C1 RA One Daily Essential (Tablet) Release) C1

C1 RA One Daily Gummy Vites (Tablet RA Vitamin C (Tablet Chewable)

C1 Chewable) RA Vitamin C (Tablet) C1

C1 RA One Daily Maximum (Tablet) RA Vitamin C Drops (Lozenge) C1

C1 RA One Daily Mens 50+ With Vitamin D-3 RA Vitamin C TR (Tablet Extended- (Tablet) Release) C1

C1 RA One Daily Mens Multi (Tablet) RA Vitamin C/Acerola (Tablet Chewable) C1

C1 RA One Daily Mens/Vitamin D-3 (Tablet) RA Vitamin C/Rose Hips (Tablet) C1

C1 RA One Daily Multi-Vitamin (Tablet) RA Vitamin C/Rose Hips TR (Tablet C1 RA One Daily Womens/Vitamin D-3 Extended-Release)

C1 (Tablet) RA Vitamin D-3 (Capsule) C1

C1 RA Oyster Shell Calcium (Tablet) RA Vitamin D-3 (Tablet)

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C1 C1 RA Vitamin E (Capsule) Signacal (Tablet)

C1 C1 RA Vitamin E Blend (Capsule) Sigtab (Tablet)

C1 C1 RA Vitamin E Natural (Capsule) Slo-Niacin (Tablet Extended-Release)

C1 C1 RA Whole Source Complete Formula For Slow Fe (Tablet Extended-Release) Men (Tablet) C1 C1 Slow Iron (Tablet Extended-Release) RA Whole Source Dietary (Tablet) C1

C1 Slow Release Iron (Tablet Extended- RA Whole Source Dietary For Men (Tablet) Release)

C1 C1 RA Whole Source Dietary Mature (Tablet) SM Animal Shapes Complete (Tablet C1 Chewable) RA Whole Source Womens (Tablet) C1

C1 Rehydralyte (Oral Solution) SM Animal Shapes Kids First (Tablet C1 Chewable) Relion Glucose (Gel) C1 C1 SM Anticavity Fluoride Rinse (Rinse) Relion Glucose Drink (Liquid) C1 C1 SM Antioxidant Vitamins (Tablet) Renal Multivitamin Formula/Zinc (Tablet) C1 C1 SM Calcium /Vitamin D (Tablet) Renaplex (Tablet) C1 C1 SM Calcium 500/Vitamin D3 (Tablet) Revital Freezer Pops (Oral Solution) C1 C1 SM Calcium 600 + D Plus Minerals (Tablet Revital Jell Cups (Oral Solution) Chewable) C1

C1 Revital Liquid Squeezers (Oral Solution) SM Calcium 600/Vitamin D (Tablet) C1

C1 Riboflavin (Tablet) SM Calcium 600+D3 (Tablet) C1

C1 Risacal-D (Tablet) SM Calcium Citrate + D (Tablet) C1

C1 Saline Flush (Solution) SM Calcium Citrate W/Vitamin D3 (Tablet) C1

C1 Saline Flush ZR/Sterile Field (Solution) SM Calcium Citrate/Vitamin D3 Petite C1 Savision (Tablet) (Tablet) C1

C1 SB Calcium + D (Tablet) SM Calcium Citrate+ W/Vitamin D (Tablet) C1

C1 SB Magnesium Citrate (Solution) SM Calcium Soft Chews (Tablet Chewable) C1

C1 SB Oyster Shell Calcium (Tablet) SM Calcium/Magnesium/Zinc (Tablet) C1

C1 SB Pediatric Electrolyte (Oral Solution) SM Calcium/Vitamin D (Tablet) C1

C1 SB Vitamin C (Tablet) SM Calcium/Vitamin D3 (Tablet) C1

C1 Sclerex (Tablet) SM Chewable Vitamin C (Tablet Chewable) C1

C1 Sea Buddies Daily Multiple (Tablet SM Co Q-10 (Capsule)

C1 Chewable) SM Cod Liver Oil (Capsule) C1

C1 Senior Tabs (Tablet) SM Coenzyme Q-10 (Capsule) C1

C1 Sentry (Tablet) SM Complete (Tablet) C1

C1 Sentry Adults Under 50 (Tablet) SM Complete 50+ (Tablet) C1

C1 Sentry Senior (Tablet) SM Complete 50+ Ultimate Mens (Tablet)

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C1 C1 SM Complete 50+ Ultimate Womens SM Vitamin C (Tablet Chewable) (Tablet) C1 C1 SM Vitamin C (Tablet) SM Complete Advanced Formula (Tablet) C1

C1 SM Vitamin C TR (Tablet Extended- SM Complete Senior Formula (Tablet) Release)

C1 C1 SM Coq-10 (Capsule) SM Vitamin C/Rose Hips (Tablet)

C1 C1 SM Daily Diet Support (Tablet) SM Vitamin D (Tablet)

C1 C1 SM Folic Acid (Tablet) SM Vitamin D3 (Capsule)

C1 C1 SM Hair/Skin/Nails (Tablet) SM Vitamin D3 (Tablet)

C1 C1 SM Iron (Tablet) SM Vitamin D3 Maximum Strength C1 (Capsule)

SM Iron Slow Release (Tablet Extended- C1 Release) SM Vitamin E (Capsule)

C1 C1 SM Magnesium (Tablet) SM Vitamin E Blended (Capsule)

C1 C1 SM Magnesium Citrate (Solution) Smarty Pants Kids Complete And Fiber C1 (Tablet Chewable) SM Melatonin (Tablet) C1 C1 Sodium Chloride (Tablet)

SM Multiple Vitamins Essential (Tablet) C1 C1 Sodium Chloride Flush (Solution)

SM Niacin CR (Tablet Extended-Release) C1 C1 Soluvita E (Solution)

SM One Daily Essential (Tablet) C1

C1 SM One Daily Mens (Tablet) Spider-Man Complete Multivitamin C1 Gummies (Tablet Chewable) SM One Daily Prenatal (Capsule) C1 C1 Spongebob Squarepants Gummies (Tablet SM One Daily Womens (Tablet) Chewable) C1

C1 SM Opti-Vitamins (Tablet) Stress B-Complex/C/Zinc (Tablet) C1

C1 SM Oyster Shell Calcium/Vitamin D Stress Formula (Tablet) (Tablet) C1 C1 Stress Formula/Iron (Tablet) SM Oyster Shell Calcium/Vitamin D3 C1 Stress Formula/Zinc (Tablet) (Tablet) C1 C1 Stresstabs Advanced (Tablet)

SM Pediatric Electrolyte (Oral Solution) C1 C1 Stresstabs Energy (Tablet)

SM Prenatal Vitamins (Tablet) C1 C1 Sunkist Vitamin C (Tablet Chewable)

SM Slow Release Iron (Tablet Extended- C1 Release) Sunvite Active Adult 50+ (Tablet)

C1 C1 SM Vit C/Rose Hips (Tablet) Sunvite Advanced (Tablet)

C1 C1 SM Vitamin B1 (Tablet) Super 28 Formula (Tablet)

C1 C1 SM Vitamin B-12 (Tablet) Super Antioxidant/A/C/E/Selenium C1 (Tablet)

SM Vitamin B12 TR (Tablet Extended- C1 Release) Super Antioxidants Protector (Capsule)

C1 C1 SM Vitamin B-6 (Tablet) Super Aytinal 50 Plus (Tablet)

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C1 C1 Super Aytinal For Active Adults (Tablet) Thera Vital-M (Tablet)

C1 C1 Super Cal/Mag (Tablet) Therabasic-M (Tablet)

C1 C1 Super Calcium (Tablet) Thera-D 2000 (Tablet)

C1 C1 Super Calcium 600 + D3 (Tablet) Thera-D Rapid Repletion (Tablet)

C1 C1 Super Calcium 600+D 400 (Tablet) Theradex "M" (Tablet)

C1 C1 Super Calcium 600+D3 400 (Tablet) Theradex "M"/Beta Carotene (Tablet)

C1 C1 Super Cal-Mag-D (Tablet) Thera-M (Tablet)

C1 C1 Super Multiple (Capsule) Thera-Mill (Tablet)

C1 C1 Super Multiple (Tablet) Thera-Mill M (Tablet)

C1 C1 Super Natrul-100 (Tablet Extended- Theramill Plus (Capsule) Release) C1 C1 Therapeutic (Tablet) Super Nu-Thera (Tablet) C1

C1 Therapeutic Formula/Hematinics (Tablet) Super Thera Vite M (Tablet) C1

C1 Therapeutic M (Tablet) Super Vikaps (Tablet) C1

C1 Therapeutic Multi Vitaminmineral (Tablet) Super Vita-Mins (Tablet) C1

C1 Therapeutic-M (Tablet) Superior 35 (Tablet Extended-Release) C1

C1 Therapeutic-M/Lutein (Tablet) Support (Liquid) C1

C1 Thera-Tabs (Tablet) SV Melatonin (Tablet) C1

C1 Thera-Tabs M (Tablet)

C1 SV Vitamin B12 TR (Tablet Extended- Theratrum Complete (Tablet) Release) C1 C1 Theratrum Complete 50 Plus (Tablet) Swabflush Saline Flush (Solution) C1 C1 Theravim -M (Tablet) Tab-A-Vite (Tablet) C1 C1 Therems (Tablet) Tab-A-Vite W/Beta Carotene (Tablet) C1 C1 Therems-H (Tablet) TGT Calcium + Vitamin D3 (Tablet) C1 C1 Therems-M (Tablet) TGT Calcium Dietary Supplement (Tablet C1 Chewable) Thiamine HCL (Tablet) C1

C1 TGT Daily Multivitamin Womens (Tablet) Thrive For Life Womens (Tablet) C1

C1 TGT Multivitamin/Multimineral Adults/ Total Formula (Tablet) C1 Lycopene (Tablet) Total Formula 2 (Tablet) C1

C1 TGT Multivitamin/Multimineral/Adult Total Formula 3 (Tablet) (Tablet) C1 C1 Totalday Multiple (Tablet Extended- TGT Vitamin C Drops (Lozenge) Release) C1

C1 Thera (Tablet) Tri-Vit/Fluoride (Solution) C1

C1 Thera M Plus (Tablet) Tri-Vit/Fluoride/Iron (Drops) C1

C1 Thera Vital M (Tablet) Tri-Vitamin/Fluoride (Solution)

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C1 C1 Tri-Vite/Fluoride (Solution) Vita-Calcium (Wafer)

C1 C1 Tropical Liquid Nutrition (Liquid) Vitacel (Tablet)

C1 C1 Trueplus Diabetic Multivitamin (Tablet) Vitachew Multiple Vitamin Children's C1 (Tablet Chewable) Ultra Antioxidant Formula (Tablet) C1

C1 Ultra Choice Multivitamin Kids (Tablet Vitachew Vitamin C Citrusburst Gummies (Tablet Chewable) Chewable) C1

C1 Ultra Freeda (Tablet) Vitajoy Daily D Gummies (Tablet C1 Chewable) Ultra Freeda/Iron (Tablet) C1 C1 Vitajoy Gummies (Tablet Chewable) Ultra Multi Formula/Iron (Capsule) C1 C1 Vitalee (Tablet) Ultra Vita-Time (Tablet) C1 C1 Vitaline Coq10 (Tablet) Ultrachoice Advanced Formula (Tablet) C1 C1 Vitamelts Energy Vitamin B-12 (Tablet) Ultrachoice Advanced Formula Mature C1 Vita-Min (Capsule) (Tablet) C1 C1 Vitamin A & D (Ointment)

Ultra-Mega (Tablet Extended-Release) C1 C1 Vitamin A (Capsule)

Unicomplex-M (Tablet) C1 C1 Vitamin A Palmitate (Tablet)

Upcal D (Powder) C1 C1 Vitamin B 12 (Lozenge)

UpSpring Baby Multivitamin/Iron (Liquid) C1 C1 Vitamin B 6 (Tablet)

Value Plus Glucose (Gel) C1 C1 Vitamin B Complex (Tablet)

Viactiv (Tablet Chewable) C1 C1 Vitamin B-1 (Tablet)

Vicap Forte (Capsule) C1 C1 Vitamin B12 (Liquid)

Vic-Forte (Capsule) C1 C1 Vitamin B-12 (Lozenge)

Vinate II (Tablet) C1 C1 Vitamin B-12 (Tablet Extended-Release)

Vinate M (Tablet) C1 C1 Vitamin B-12 (Tablet)

Vision Formula 2 (Tablet) C1

C1 Vision Formula Eye Health (Capsule) Vitamin B-12 CR (Tablet Extended- C1 Release) Vision Formula/Lutein (Tablet) C1 C1 Vitamin B-12 ER (Tablet Extended-Release) Vision Plus (Capsule) C1 C1 Vitamin B-12 LA (Tablet Extended-Release) Vision Vitamins (Tablet) C1 C1 Vitamin B-12 Natural (Tablet) Visivites (Tablet) C1 C1 Vitamin B12 TR (Tablet Extended-Release) Visivites/Lutein (Tablet) C1 C1 Vitamin B-12 TR (Tablet Extended-Release) Vita Hair (Tablet) C1 C1 Vitamin B-2 (Tablet) Vita S Forte (Tablet) C1 C1 Vitamin B-6 (Tablet Extended-Release) Vitabasic Complete (Tablet) C1 C1 Vitamin B-6 (Tablet) Vitabasic Senior (Tablet) C1 Vitamin B-6 Repack (Tablet)

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C1 C1 Vitamin B-6 TR (Tablet Extended-Release) Vitamin D 400 (Tablet Chewable)

C1 C1 Vitamin B-Complex (Tablet) Vitamin D High Potency (Capsule)

C1 C1 Vitamin B-Complex 100 (Injection) Vitamin D Infant (Liquid)

C1 C1 Vitamin C (Liquid) Vitamin D-1000 (Tablet)

C1 C1 Vitamin C (Powder) Vitamin D-1000 Maximum Strength (Tablet)

C1 C1 Vitamin C (Tablet Chewable) Vitamin D2 (Tablet)

C1 C1 Vitamin C (Tablet Extended-Release) Vitamin D-3 (Capsule)

C1 C1 Vitamin C (Tablet) Vitamin D3 (Drops)

C1 C1 Vitamin C Adult Gummies (Tablet Vitamin D3 (Liquid) Chewable) C1 C1 Vitamin D3 (Tablet Chewable) Vitamin C CR (Capsule) C1

C1 Vitamin D3 (Tablet) Vitamin C Drops (Lozenge) C1

C1 Vitamin D-3 (Tablet) Vitamin C Gummie (Tablet Chewable) C1

C1 Vitamin D3 400 (Capsule) Vitamin C Gummies (Tablet Chewable) C1

C1 Vitamin D3 Adult Gummies (Tablet Vitamin C Immune Health (Tablet Chewable) Chewable) C1 C1 Vitamin D3 Gummies (Tablet Chewable)

C1 Vitamin C Plus Bioflavonoids/Wild Rose Vitamin D3 High Potency (Capsule) Hips (Tablet) C1 C1 Vitamin D3 Maximum Strength (Capsule) Vitamin C Plus Wild Rose Hips (Tablet C1 Chewable) Vitamin D3 Super Strength (Capsule) C1

C1 Vitamin C SR (Capsule) Vitamin D3 Super Strength (Tablet) C1

C1 Vitamin C TR (Capsule) Vitamin D3 Ultra Potency (Tablet) C1

C1 Vitamin C TR (Tablet Extended-Release) Vitamin D3 Ultra Strength (Capsule) C1

C1 Vitamin C TR/Rose Hips (Tablet Extended- Vitamin D-400 (Tablet) C1 Release) Vitamin E (Capsule) C1

C1 Vitamin C/Acerola (Tablet Chewable) Vitamin E (Oil) C1

C1 Vitamin C/Acerola (Tablet) Vitamin E (Solution) C1

C1 Vitamin C/Rose Hips (Tablet Chewable) Vitamin E (Tablet) C1

C1 Vitamin C/Rose Hips (Tablet) Vitamin E Blend (Capsule) C1

C1 Vitamin C/Rose Hips TR (Tablet Extended- Vitamin E Complex (Capsule) Release) C1 C1 Vitamin E Complex Natural (Capsule) Vitamin C-500 Timed Release (Capsule C1 Vitamin E High Potency (Capsule) Extended-Release) C1 C1 Vitamin E Water Dispersible (Capsule) Vitamin D (Capsule) C1 C1 Vitamin E Water Solubilized (Capsule) Vitamin D (Liquid) C1

C1 Vitamin D (Tablet) Vitamin E Water Soluble (Capsule)

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C1 C1 Vitamin E/D-Alpha (Capsule) VP-Heme OB + DHA (Tablet)

C1 C1 Vitamin E/D-Alpha Natural (Capsule) Wegmans Complete Prenatal+DHA C1 (Capsule) Vitamin E/Dl-Alpha (Capsule) C1 C1 Womens 50+ Advanced (Capsule)

Vitamin E/Folic Acid/B-6/B-12 (Capsule) C1 C1 Womens Daily Formula (Tablet)

Vitamin E/Vitamin C/Beta Carotene C1 (Tablet) Womens Daily Formula/Folic Acid/ C1 Calcium/Iron (Tablet) Vitamin E-200 (Capsule) C1 C1 Womens Life Pack (Tablet)

Vitamin E-400 (Capsule) C1 C1 Womens Multi (Capsule)

Vitamin Supplement E-1000 (Capsule) C1 C1 Womens Multivitamin (Tablet)

Vitamin Supplement E-400 (Capsule) C1 C1 Womens One Daily (Tablet)

Vitamin-D3 (Tablet) C1 C1 Yl Coenzyme Q10 (Capsule)

Vitamins A/C/D/Fluoride (Solution) C1 C1 Yl Folic Acid (Tablet)

Vitamins A/D/C/Fluoride (Solution) C1 C1 Yl Vitamin B-6 (Tablet)

Vitamins A-D-E/Selenium (Tablet) C1 C1 Yl Vitamin C (Tablet)

Vita-Plus E (Capsule) C1 C1 Yl Vitamin C/Rose Hips (Tablet)

Vitatrum (Tablet Chewable) C1 C1 Yl Vitamin E (Capsule)

Vitatrum (Tablet) C1 C1 Your Life Multi Mens 50+ (Tablet)

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Bold type = Brand name drug Plain type = Generic drug 190 Trackedtrack

D. Index of Covered Drugs In this section, you can find a drug by searching for its name alphabetically. This will tell you the page number where you can find additional coverage information for your drug.

A Afinitor...... 35 Amikacin Sulfate...... 17 Abacavir Sulfate...... 43 Afinitor Disperz...... 35 Amiloride HCl...... 56 Abacavir Sulfate-Lamivudine Aimovig...... 31 Amiloride-Hydrochlorothiazide ...... 43 Ala-Cort...... 68 ...... 54 Abacavir-Lamivudine- Albendazole...... 37 Aminosyn II...... 62 Zidovudine...... 43 Albuterol Sulfate...... 87 Aminosyn-PF...... 62 Abelcet...... 29 Albuterol Sulfate HFA...... 87 Amiodarone HCl...... 52 Abilify Maintena...... 39 Alclometasone Dipropionate Amitiza...... 65 Abiraterone Acetate...... 33 ...... 68 Amitriptyline HCl...... 28 Acamprosate Calcium...... 17 Alcohol Prep Pads...... 83 Amlodipine Besylate...... 53 Acarbose...... 46 Alecensa...... 35 Amlodipine-Atorvastatin...... 54 Acebutolol HCl...... 52 Alendronate Sodium...... 82 Amlodipine-Benazepril...... 54 Acetaminophen-Codeine...... 15 Alfuzosin HCl ER...... 67 Amlodipine-Olmesartan...... 54 Acetazolamide...... 55 Alinia...... 37 Amlodipine-Valsartan...... 54 Acetazolamide ER...... 55 Aliskiren Fumarate...... 54 Amlodipine-Valsartan-HCTZ...54 Acetic Acid...... 86 Allopurinol...... 31 Ammonium Lactate...... 60 Acetylcysteine...... 89 Alocril...... 84 Amoxapine...... 28 Acitretin...... 60 Alomide...... 84 Amoxicillin...... 21 Actemra...... 79 Alosetron HCl...... 65 Amoxicillin-Potassium Actemra ACTPen...... 79 Alphagan P...... 84 Clavulanate...... 21 ActHIB...... 80 Alprazolam...... 45 Amoxicillin-Potassium Clavulanate ER...... 21 Actimmune...... 79 Altavera...... 71 Amphetamine- Acyclovir...... 42 Alunbrig...... 35 Dextroamphetamine...... 58 Acyclovir Sodium...... 42 Alyacen 1/35...... 71 Amphetamine- Adacel...... 80 Alyq...... 88 Dextroamphetamine ER...... 58 Adapalene...... 60 Amantadine HCl...... 37 Amphotericin B...... 29 Adefovir Dipivoxil...... 42 AmBisome...... 29 Ampicillin...... 21 Adempas...... 88 Ambrisentan...... 88 Ampicillin Sodium...... 21 Advair Diskus...... 89 Amethia...... 71 Ampicillin-Sulbactam Sodium Advair HFA...... 89 Amethia Lo...... 71 ...... 21 191 Tracked

Ampyra...... 59 Aubagio...... 59 Benzoyl Peroxide-Erythromycin Anadrol-50...... 71 Aubra...... 71 ...... 60 Anagrelide HCl...... 50 Auryxia...... 64 Benztropine Mesylate...... 37 Anastrozole...... 34 Austedo...... 58 Bepreve...... 84 Androderm...... 71 Aviane...... 71 Berinert...... 77 Anoro Ellipta...... 89 Avonex Pen...... 59 Besivance...... 22 Apokyn...... 38 Avonex Prefilled...... 59 Betamethasone Dipropionate ...... 68 Apraclonidine HCl...... 84 Ayvakit...... 35 Betamethasone Dipropionate Aprepitant...... 29 Azasite...... 22 Aug...... 68 Apri...... 71 Azathioprine...... 77 Betamethasone Valerate...... 68 Apriso...... 81 Azelaic Acid...... 60 Betaseron...... 59 Aptiom...... 26 Azelastine HCl...... 84, 86 Betaxolol HCl...... 52, 84 Aptivus...... 44 Azelastine-Fluticasone...... 89 Bethanechol Chloride...... 67 Aralast NP...... 66 Azithromycin...... 22 Bethkis...... 88 Aranelle...... 71 Azopt...... 84 Betimol...... 84 Aranesp...... 50 Aztreonam...... 20 Bevespi Aerosphere...... 89 Arcalyst...... 79 B Bexarotene...... 36 Aripiprazole...... 39 Bacitracin...... 18 Bexsero...... 80 Aripiprazole ODT...... 39 Bacitracin-Polymyxin B...... 83 Bicalutamide...... 33 Aristada...... 39 Baclofen...... 90 Bicillin C-R...... 21 Aristada Initio...... 39 Balsalazide Disodium...... 81 Bicillin C-R 900/300...... 21 Arnuity Ellipta...... 86 Balversa...... 34 Bicillin L-A...... 21 Ashlyna...... 71 Balziva...... 71 BiDil...... 54 Aspirin-Dipyridamole ER...... 51 Banzel...... 26 Biktarvy...... 43 Atazanavir Sulfate...... 44 Baqsimi Two Pack...... 47 Binosto...... 82 Atenolol...... 52 Baraclude...... 42 Bisoprolol Fumarate...... 53 Atenolol-Chlorthalidone...... 54 BCG Vaccine...... 80 Bisoprolol-Hydrochlorothiazide Atomoxetine HCl...... 58 Belsomra...... 90 ...... 54 Atorvastatin Calcium...... 56 Benazepril HCl...... 52 BIVIGAM...... 79 Atovaquone...... 37 Benazepril-Hydrochlorothiazide Blephamide...... 83 ...... 54 Atovaquone-Proguanil HCl.....37 Blephamide S.O.P...... 83 Atripla...... 43 Benlysta...... 79 Blisovi 24 Fe...... 71 Benznidazole...... 37 Atropine Sulfate...... 83 Blisovi Fe 1.5/30...... 71 Atrovent HFA...... 87 Boostrix...... 80 192 Tracked

Bosentan...... 88 Calcipotriene...... 60 Cefdinir...... 19 Bosulif...... 35 Calcitonin Salmon...... 82 Cefepime HCl...... 19 Braftovi...... 35 Calcitriol...... 60, 82 Cefixime...... 19 Breo Ellipta...... 89 Calcium Acetate...... 64 Cefotetan Disodium...... 20 Briellyn...... 71 Calquence...... 35 Cefoxitin Sodium...... 20 Brilinta...... 51 Camila...... 75 Cefpodoxime Proxetil...... 20 Brimonidine Tartrate...... 84 Camrese Lo...... 71 Cefprozil...... 20 BRIVIACT...... 24 Canasa...... 81 Ceftazidime...... 20 Bromocriptine Mesylate...... 38 Candesartan Cilexetil...... 52 Ceftriaxone Sodium...... 20 Brukinsa...... 35 Candesartan Cilexetil-HCTZ Cefuroxime Axetil...... 20 Budesonide...... 82, 86 ...... 54 Cefuroxime Sodium...... 20 Budesonide ER...... 82 Caplyta...... 39 Celecoxib...... 14 Bumetanide...... 56 Caprelsa...... 35 Celontin...... 25 Buprenorphine...... 14 Captopril...... 52 Cephalexin...... 20 Buprenorphine HCl...... 17 Captopril-Hydrochlorothiazide Cetirizine HCl...... 86 ...... 54 Buprenorphine HCl-Naloxone Chantix...... 17 Carac...... 60 HCl...... 17 Chantix Continuing Month Pak Bupropion HCl...... 27 Carafate...... 66 ...... 17 Bupropion HCl SR...... 17, 27 Carbaglu...... 62 Chantix Starting Month Pak... 17 Bupropion HCl XL...... 27 Carbamazepine...... 26 Chemet...... 64 Buspirone HCl...... 45 Carbamazepine ER...... 26 Chenodal...... 65 Butalbital-Acetaminophen- Carbidopa...... 38 Chlordiazepoxide HCl...... 45 Caffeine...... 14 Carbidopa-Levodopa...... 38 Chlorhexidine Gluconate...... 60 Butalbital-Aspirin-Caffeine...... 14 Carbidopa-Levodopa ER...... 38 Chloroquine Phosphate...... 37 Butorphanol Tartrate...... 15 Carbidopa-Levodopa ODT..... 38 Chlorpromazine HCl...... 38 Bydureon...... 46 Carbidopa-Levodopa- Chlorthalidone...... 56 Entacapone...... 38 Bydureon BCise...... 46 Chlorzoxazone...... 90 Carteolol HCl...... 84 Byetta 10MCG Pen...... 46 Cholbam...... 66 Cartia XT...... 53 Byetta 5MCG Pen...... 46 Cholestyramine...... 56 Carvedilol...... 53 Bystolic...... 53 Cholestyramine Light...... 56 Cayston...... 88 C Ciclopirox...... 29 Caziant...... 71 Cabergoline...... 76 Ciclopirox Olamine...... 29 Cefaclor...... 19 Cablivi...... 51 Cilostazol...... 51 Cefadroxil...... 19 Cabometyx...... 35 Ciloxan...... 22 Cefazolin Sodium...... 19 193 Tracked

Cimduo...... 43 Clonidine HCl ER...... 58 Cromolyn Sodium...... 65, 84, 88 Cimetidine...... 65 Clopidogrel Bisulfate...... 51 Cryselle-28...... 71 Cimetidine HCl...... 65 Clorazepate Dipotassium...... 45 Cuvposa...... 64 Cimzia...... 77 Clotrimazole...... 29, 30 Cyclafem 1/35...... 72 Cimzia Prefilled...... 77 Clotrimazole-Betamethasone Cyclafem 7/7/7...... 72 Cinacalcet HCl...... 82 ...... 60 Cyclobenzaprine HCl...... 90 Cinryze...... 77 Clovique...... 64 Cyclophosphamide...... 33 Cipro HC...... 86 Clozapine...... 41 Cycloset...... 46 Ciprodex...... 86 Clozapine ODT...... 41 Cyclosporine...... 77 Ciprofloxacin HCl...... 23 Coartem...... 37 Cyclosporine Modified...... 77 Ciprofloxacin in D5W...... 23 Codeine Sulfate...... 15 Cyproheptadine HCl...... 86 Ciprofloxacin-Dexamethasone Colchicine...... 31 Cyred...... 72 ...... 86 Colcrys...... 31 Cystadane...... 66 Citalopram Hydrobromide..... 27 Colesevelam HCl...... 57 Cystagon...... 66 Claravis...... 60 Colestipol HCl...... 57 Cystaran...... 83 Clarithromycin...... 22 Colistimethate Sodium...... 18 D Clarithromycin ER...... 22 Combigan...... 84 Dalfampridine ER...... 59 Clenpiq...... 65 Combivent Respimat...... 89 Daliresp...... 88 Climara Pro...... 71 Cometriq...... 35 Dalvance...... 18 Clindamycin HCl...... 18 Complera...... 43 Danazol...... 71 Clindamycin Palmitate HCl.... 18 Compro...... 29 Dantrolene Sodium...... 90 Clindamycin Phosphate... 18, 60 Constulose...... 65 Dapsone...... 32 Clindamycin Phosphate in D5W Copiktra...... 34 Daptacel...... 80 ...... 18 Cordran...... 68 Daptomycin...... 18 Clindamycin Phosphate- Corlanor...... 54 DARAPRIM...... 37 Benzoyl Peroxide...... 60 Cortisone Acetate...... 68 Daurismo...... 35 Clobazam...... 25 Cortisporin...... 60 Clobetasol Propionate...... 68 Deblitane...... 75 Cosentyx...... 60 Deferasirox...... 64 Clobetasol Propionate Cosentyx Sensoready...... 61 Emollient Base...... 68 Deferasirox Granules...... 64 Cosopt PF...... 84 Clomipramine HCl...... 28 Deferiprone...... 64 Cotellic...... 35 Clonazepam...... 45 Delstrigo...... 43 Creon...... 66 Clonazepam ODT...... 45 Demeclocycline HCl...... 23 Crinone...... 75 Clonidine...... 51 Demser...... 54 Crixivan...... 44 Clonidine HCl...... 51 Denavir...... 42 194 Tracked

Depen Titratabs...... 67 Dicloxacillin Sodium...... 21 Dovato...... 42 Depo-Estradiol...... 72 Dicyclomine HCl...... 64 Doxazosin Mesylate...... 52 Depo-Provera...... 75 Didanosine...... 43 Doxepin HCl...... 28, 61 Descovy...... 43 Dificid...... 22 Doxercalciferol...... 82 Desipramine HCl...... 28 Diflunisal...... 14 Doxy 100...... 23 Desmopressin Acetate...... 70 Digitek...... 54 Doxycycline Hyclate...... 23, 24 Desmopressin Acetate Spray Digox...... 55 Doxycycline Monohydrate...... 24 ...... 70 Digoxin...... 55 Drizalma Sprinkle...... 59 Desogestrel-Ethinyl Estradiol Dihydroergotamine Mesylate Dronabinol...... 29 ...... 72 ...... 31 Drospirenone-Ethinyl Estradiol Desonide...... 68 Dilantin...... 26 ...... 72 Desoximetasone...... 68 Dilantin INFATABS...... 26 Droxia...... 33 Desvenlafaxine Succinate ER Dilt-XR...... 53 Duavee...... 72 ...... 27 Diltiazem HCl...... 53 Dulera...... 89 Dexamethasone...... 68 Diltiazem HCl ER...... 53 Duloxetine HCl...... 59 Dexamethasone Sodium Diltiazem HCl ER Beads...... 53 Durezol...... 85 Phosphate...... 85 Diltiazem HCl ER Coated Beads Dutasteride...... 67 Dexilant...... 66 ...... 53 Dymista...... 89 Dexmethylphenidate HCl...... 58 Dimethyl Fumarate...... 59 E Dexmethylphenidate HCl ER Dipentum...... 82 ...... 58 E.E.S. Granules...... 22 Diphenoxylate-Atropine...... 65 Dextroamphetamine Sulfate Econazole Nitrate...... 30 ...... 58 Diphtheria-Tetanus Toxoids DT Edarbi...... 52 ...... 80 Dextroamphetamine Sulfate ER Edarbyclor...... 55 ...... 58 Disulfiram...... 17 Edurant...... 43 Dextrose...... 62 Diuril...... 56 Efavirenz...... 43 Dextrose-NaCl...... 62 Divalproex Sodium...... 45, 46 Egrifta SV...... 76 Diastat AcuDial...... 25 Divalproex Sodium ER...... 45 Elestrin...... 72 Diastat Pediatric...... 25 Dofetilide...... 52 Eliquis...... 49 Diazepam...... 25, 45 Donepezil HCl...... 26 Eliquis DVT/PE Starter Pack Diazepam Intensol...... 45 Donepezil HCl ODT...... 26 ...... 49 Diazoxide...... 47 Dorzolamide HCl...... 84 Elmiron...... 67 Diclofenac Epolamine...... 14 Dorzolamide HCl-Timolol EluRyng...... 72 Maleate...... 84 Diclofenac Potassium...... 14 Emcyt...... 33 Dorzolamide HCl-Timolol Diclofenac Sodium.....14, 61, 85 Emgality...... 31 Maleate Preservative Free... 85 Diclofenac Sodium ER...... 14 195 Tracked

Emoquette...... 72 Errin...... 75 Fanapt Titration Pack...... 39 Emsam...... 27 Ertapenem Sodium...... 20 Farydak...... 35 Emtricitabine...... 43 Ery...... 61 Fasenra...... 89 Emtriva...... 43 Erythrocin Lactobionate...... 22 Fasenra Pen...... 89 Enalapril Maleate...... 52 Erythromycin...... 22, 61 Fayosim...... 72 Enalapril-Hydrochlorothiazide Erythromycin Base...... 22 Febuxostat...... 31 ...... 55 Erythromycin Ethylsuccinate Felbamate...... 25 Enbrel...... 77 ...... 22 Felodipine ER...... 53 Enbrel Mini...... 77 Esbriet...... 89 Femring...... 72 Enbrel SureClick...... 77 Escitalopram Oxalate...... 27, 28 Femynor...... 72 Endocet...... 15 Esomeprazole Magnesium.... 66 Fenofibrate...... 56 Engerix-B...... 80 Estarylla...... 72 Fenofibrate Micronized...... 56 Enoxaparin Sodium...... 49 Estradiol...... 72 Fenofibric Acid...... 56 Enpresse-28...... 72 Estradiol Valerate...... 72 Fentanyl...... 15 Enskyce...... 72 Estring...... 72 Fentanyl Citrate...... 15 Entacapone...... 38 Ethacrynic Acid...... 56 Ferriprox...... 64 Entecavir...... 42 Ethambutol HCl...... 32 Fetzima...... 28 Entresto...... 55 Ethosuximide...... 25 Fetzima Titration...... 28 Enulose...... 65 Ethynodiol Diacetate-Ethinyl Finacea...... 61 Estradiol...... 72 Envarsus XR...... 77 Finasteride...... 67 Etodolac...... 14 Epclusa...... 42 Fintepla...... 24 Etodolac ER...... 14 Epidiolex...... 24 Firazyr...... 77 Etonogestrel-Ethinyl Estradiol Epinastine HCl...... 84 Firmagon...... 76 ...... 72 Epinephrine...... 87 Flac...... 86 Euthyrox...... 75 EpiPen 2-Pak...... 87 Flarex...... 85 Everolimus...... 35, 77 EpiPen Jr 2-Pak...... 87 Flebogamma DIF...... 79 Evotaz...... 44 Epitol...... 26 Flecainide Acetate...... 52 Exemestane...... 34 Epivir HBV...... 42 Flector...... 14 Ezetimibe...... 57 Eplerenone...... 56 Flovent Diskus...... 86 Ezetimibe-Simvastatin...... 57 Eraxis...... 30 F Flovent HFA...... 86 Ergotamine-Caffeine...... 31 Fluconazole...... 30 Falmina...... 72 Erivedge...... 35 Fluconazole in Sodium Chloride Famciclovir...... 42 Erleada...... 33 ...... 30 Famotidine...... 65 Erlotinib HCl...... 35 Flucytosine...... 30 Fanapt...... 39 196 Tracked

Fludrocortisone Acetate...... 68 Galantamine Hydrobromide Gleostine...... 33 Flunisolide...... 86 ...... 27 Glimepiride...... 46 Fluocinolone Acetonide... 69, 86 Galantamine Hydrobromide ER Glipizide...... 46 ...... 27 Fluocinolone Acetonide Scalp Glipizide ER...... 46 Gammagard...... 79 ...... 69 Glipizide-Metformin HCl...... 46 Gammagard S/D Less IgA..... 79 Fluocinonide...... 69 GlucaGen HypoKit...... 47 Gammaked...... 79 Fluocinonide Emulsified Base Glucagon...... 47 ...... 69 Gammaplex...... 79 Glyxambi...... 46 Fluorometholone...... 85 Gamunex-C...... 79 Granisetron HCl...... 29 Fluorouracil...... 61 Gardasil 9...... 80 Granix...... 50 Fluoxetine HCl...... 28 Gatifloxacin...... 23 Griseofulvin Microsize...... 30 Fluphenazine Decanoate...... 38 Gattex...... 65 Griseofulvin Ultramicrosize.... 30 Fluphenazine HCl...... 38 Gauze...... 83 Guanfacine HCl ER...... 58 Flurbiprofen...... 14 GaviLyte-C...... 65 Guanidine HCl...... 32 Flurbiprofen Sodium...... 85 GaviLyte-G...... 65 Gvoke HypoPen 2-Pack...... 48 Flutamide...... 33 GaviLyte-N with Flavor Pack Gvoke PFS...... 48 Fluticasone Propionate.... 69, 87 ...... 65 H Fluticasone-Salmeterol...... 89 Gavreto...... 35 Haegarda...... 77 Fluvastatin Sodium...... 56 Gemfibrozil...... 56 Hailey 24 Fe...... 72 Fluvoxamine Maleate...... 28 Generlac...... 65 Halobetasol Propionate...... 69 FML...... 85 Gengraf...... 77 Haloperidol...... 39 FML Forte...... 85 Genotropin...... 70 Haloperidol Decanoate...... 39 Fondaparinux Sodium...... 49 Genotropin MiniQuick...... 70 Haloperidol Lactate...... 39 Forteo...... 82 Gentak...... 17 Havrix...... 80 Fosamprenavir Calcium...... 44 Gentamicin Sulfate...... 17, 18 Heparin Sodium...... 49, 50 Fosinopril Sodium...... 52 Gentamicin Sulfate-0.9% Sodium Chloride...... 17 HepatAmine...... 62 Fosinopril Sodium-HCTZ...... 55 Genvoya...... 42 Hetlioz...... 90 FreAmine HBC...... 62 Geodon...... 39 Hiberix...... 80 Furosemide...... 56 Gianvi...... 72 Humalog...... 48 Fuzeon...... 44 Gilenya...... 59 Humalog Junior KwikPen...... 48 Fyavolv...... 72 Gilotrif...... 35 Humalog KwikPen...... 48 Fycompa...... 26 Glassia...... 66 Humalog Mix 50/50...... 48 G Glatiramer Acetate...... 59 Humalog Mix 50/50 KwikPen Gabapentin...... 25 ...... 48 Glatopa...... 59 197 Tracked

Humalog Mix 75/25...... 48 Hydroxyzine Pamoate...... 29 Insulin Lispro Prot & Lispro....49 Humalog Mix 75/25 KwikPen Hysingla ER...... 15 Insulin Syringes, Needles...... 83 ...... 48 I Intelence...... 43 Humatrope...... 70 Ibandronate Sodium...... 82 Intralipid...... 62 Humira...... 78 Ibrance...... 35 Intron A...... 42 Humira Pediatric Crohns Start Ibu...... 14 Introvale...... 72 ...... 78 Ibuprofen...... 14 Invega Sustenna...... 40 Humira Pen...... 78 Icatibant Acetate...... 77 Invega Trinza...... 40 Humira Pen Crohns Disease Iclusig...... 35 Invirase...... 44 Starter...... 78 IDHIFA...... 35 Invokamet...... 46 Humira Pen Psoriasis Starter ...... 78 Ilevro...... 85 Invokamet XR...... 46 Humulin 70/30...... 48 Imatinib Mesylate...... 35 Invokana...... 46 Humulin 70/30 KwikPen...... 48 Imbruvica...... 35 IPOL...... 80 Humulin N...... 48 Imipenem-Cilastatin...... 20 Ipratropium Bromide...... 87 Humulin N KwikPen...... 48 Imipramine HCl...... 28 Ipratropium-Albuterol...... 89 Humulin R...... 48 Imipramine Pamoate...... 28 Irbesartan...... 52 Humulin R U-500...... 48 Imiquimod...... 61 Irbesartan-Hydrochlorothiazide ...... 55 Humulin R U-500 KwikPen..... 48 Imiquimod Pump...... 61 Iressa...... 35 Hydralazine HCl...... 57 Imovax Rabies...... 80 Isentress...... 42 Hydrochlorothiazide...... 56 Imvexxy Maintenance Pack... 72 Isentress HD...... 42 Hydrocodone-Acetaminophen Imvexxy Starter Pack...... 72 ...... 16 Incassia...... 75 Isibloom...... 72 Hydrocodone-Ibuprofen...... 16 Increlex...... 70 Isolyte-P in D5W...... 62 Hydrocortisone...... 69, 82 Incruse Ellipta...... 87 Isolyte-S...... 62 Hydrocortisone Butyrate...... 69 Indapamide...... 56 Isoniazid...... 32 Hydrocortisone Valerate...... 69 Indomethacin...... 14 Isosorbide Dinitrate...... 57 Hydrocortisone-Acetic Acid... 86 Infanrix...... 80 Isosorbide Mononitrate...... 57 Hydromorphone HCl...... 16 Ingrezza...... 58 Isosorbide Mononitrate ER.... 57 Hydromorphone HCl ER...... 15 Inlyta...... 35 Isotretinoin...... 61 Hydromorphone HCl Inqovi...... 35 Itraconazole...... 30 Preservative Free...... 16 Inrebic...... 34 Ivermectin...... 37 Hydroxychloroquine Sulfate Insulin Lispro...... 48, 49 Ixiaro...... 80 ...... 37 Insulin Lispro Junior KwikPen J Hydroxyurea...... 33 ...... 49 Jadenu...... 64 Hydroxyzine HCl...... 45 198 Tracked

Jadenu Sprinkle...... 64 Kionex...... 64 Leena...... 73 Jakafi...... 35 Kisqali...... 34 Leflunomide...... 80 Jantoven...... 50 Kisqali Femara...... 34 Lenvima 10MG Daily Dose.....35 Janumet...... 46 Klor-Con...... 62 Lenvima 12MG Daily Dose.....35 Janumet XR...... 46 Klor-Con 10...... 62 Lenvima 14MG Daily Dose.....36 Januvia...... 46 Klor-Con 8...... 62 Lenvima 18MG Daily Dose.....36 Jardiance...... 46 Klor-Con M10...... 62 Lenvima 20MG Daily Dose.....36 Jasmiel...... 72 Klor-Con M15...... 62 Lenvima 24MG Daily Dose.....36 Jentadueto...... 46 Klor-Con M20...... 62 Lenvima 4MG Daily Dose...... 36 Jentadueto XR...... 46 Korlym...... 71 Lenvima 8MG Daily Dose...... 36 Jinteli...... 72 Koselugo...... 35 Lessina...... 73 Jublia...... 30 Kurvelo...... 73 Letrozole...... 34 Juleber...... 72 Kuvan...... 66 Leucovorin Calcium...... 34 Juluca...... 43 L Leukeran...... 33 Junel 1.5/30...... 72 Labetalol HCl...... 53 Leukine...... 50 Junel 1/20...... 72 Lacrisert...... 83 Leuprolide Acetate...... 76 Junel Fe 1.5/30...... 72 Lactulose...... 65 Levalbuterol HCl...... 87 Junel Fe 1/20...... 72 Lamivudine...... 42, 43 Levemir...... 49 Junel Fe 24...... 72 Lamivudine-Zidovudine...... 43 Levemir FlexTouch...... 49 Juxtapid...... 57 Lamotrigine...... 26 Levetiracetam...... 24 K Lanoxin...... 55 Levetiracetam ER...... 24 Kaitlib Fe...... 73 Lansoprazole...... 66 Levo-T...... 75 Kaletra...... 44 Lanthanum Carbonate...... 64 Levobunolol HCl...... 85 Kalydeco...... 89 Lantus...... 49 Levocarnitine...... 62 Kariva...... 73 Lantus SoloStar...... 49 Levocetirizine Dihydrochloride KCl in Dextrose-NaCl...... 62 LARIN 1.5/30...... 73 ...... 86 KCl-Lactated Ringers-D5W.... 62 LARIN 1/20...... 73 Levofloxacin...... 23 Kelnor 1/35...... 73 LARIN Fe 1.5/30...... 73 Levofloxacin in D5W...... 23 Kelnor 1/50...... 73 LARIN Fe 1/20...... 73 Levonest...... 73 Ketoconazole...... 30 Larissia...... 73 Levonorgestrel-Ethinyl Estradiol ...... 73 Ketoprofen...... 14 Lastacaft...... 83 Levonorgestrel-Ethinyl Estradiol Ketorolac Tromethamine...... 85 Latanoprost...... 86 & Ethinyl Estradiol...... 73 Kineret...... 78 Latuda...... 40 Levonorgestrel-Ethinyl Estradiol Kinrix...... 80 Layolis Fe...... 73 91-Day...... 73 199 Tracked

Levora 0.15/30...... 73 Lovastatin...... 56 Memantine HCl Titration Pak Levorphanol Tartrate...... 15 Low-Ogestrel...... 73 ...... 27 Levothyroxine Sodium...... 75 Loxapine Succinate...... 39 Menactra...... 80 Levoxyl...... 75 Lumigan...... 86 Menest...... 73 Lexiva...... 44 Lupaneta Pack...... 76 MenQuadfi...... 80 Lidocaine...... 16 Lupron Depot...... 76 Mentax...... 30 Lidocaine HCl...... 16 Lutera...... 73 Menveo...... 81 Lidocaine Viscous...... 17 Lynparza...... 36 Mercaptopurine...... 33 Lidocaine-Prilocaine...... 17 Lysodren...... 76 Meropenem...... 20 Lindane...... 37 Lyumjev...... 49 Mesalamine...... 82 Linezolid...... 18 Lyumjev KwikPen...... 49 Mesalamine ER...... 82 Linzess...... 65 Lyza...... 75 Mesnex...... 36 Liothyronine Sodium...... 75 M Metaproterenol Sulfate...... 87 Lisinopril...... 52 M-M-R II...... 81 Metformin HCl...... 46, 47 Lisinopril-Hydrochlorothiazide Magnesium Sulfate...... 62 Metformin HCl ER...... 46 ...... 55 Malathion...... 37 Methadone HCl...... 15 Lithium...... 46 Maprotiline HCl...... 28 Methazolamide...... 55 Lithium Carbonate...... 46 Marlissa...... 73 Methenamine Hippurate...... 18 Lithium Carbonate ER...... 46 Marplan...... 27 Methimazole...... 77 Lithostat...... 67 Matulane...... 33 Methotrexate...... 78 Livalo...... 56 Matzim LA...... 53 Methotrexate Sodium...... 78 Lokelma...... 64 Mavyret...... 42 Methoxsalen Rapid...... 61 Lonhala Magnair...... 87 Mayzent...... 59 Methscopolamine Bromide....64 Lonsurf...... 34 Meclizine HCl...... 29 Methyldopa...... 51 Loperamide HCl...... 65 Medroxyprogesterone Acetate Methyldopa- Lopinavir-Ritonavir...... 44 ...... 75 Hydrochlorothiazide...... 55 Lorazepam...... 45 Mefloquine HCl...... 37 Methylphenidate HCl...... 58 Lorbrena...... 34 Megestrol Acetate...... 75 Methylphenidate HCl ER...... 58 Loryna...... 73 Mekinist...... 36 Methylprednisolone...... 69 Losartan Potassium...... 52 Mektovi...... 36 Metoclopramide HCl...... 29 Losartan Potassium-HCTZ..... 55 Melodetta 24 Fe...... 73 Metolazone...... 56 Lotemax...... 85 Meloxicam...... 14 Metoprolol Succinate ER...... 53 Lotemax SM...... 85 Memantine HCl...... 27 Metoprolol Tartrate...... 53 Loteprednol Etabonate...... 85 Memantine HCl ER...... 27 Metoprolol-Hydrochlorothiazide ...... 55 200 Tracked

Metronidazole...... 18, 19 Mupirocin Calcium...... 19 Neomycin-Polymyxin-HC...... 83, Metronidazole in NaCl 0.79% Myalept...... 65 86 ...... 18 Mycamine...... 30 NephrAmine...... 62 Mexiletine HCl...... 52 Mycophenolate Mofetil...... 78 Nerlynx...... 36 Mibelas 24 Fe...... 73 Mycophenolate Sodium...... 78 Neulasta...... 51 Micafungin Sodium...... 30 Myrbetriq...... 67 Neupogen...... 51 Miconazole 3...... 30 N Neupro...... 38 Microgestin 1.5/30...... 73 Nabumetone...... 14 Nevirapine...... 43 Microgestin 1/20...... 73 Nadolol...... 53 Nevirapine ER...... 43 Microgestin Fe 1.5/30...... 73 Nafcillin Sodium...... 21 Nexavar...... 36 Microgestin Fe 1/20...... 73 Naftifine HCl...... 30 Niacin ER...... 57 Midodrine HCl...... 51 Naftin...... 30 Niacor...... 57 Migergot...... 31 Naloxone HCl...... 17 Nicardipine HCl...... 53 Miglitol...... 47 Naltrexone HCl...... 17 Nicotrol...... 17 Miglustat...... 66 Namzaric...... 58 Nicotrol NS...... 17 Mili...... 73 Naproxen...... 14 Nifedipine ER...... 53 Minitran...... 57 Naproxen DR...... 14 Nifedipine ER Osmotic Release ...... 53 Minocycline HCl...... 24 Naratriptan HCl...... 31 Nikki...... 73 Minoxidil...... 57 Narcan...... 17 Nilutamide...... 33 Mirtazapine...... 27 Natacyn...... 30 Nimodipine...... 53 Mirtazapine ODT...... 27 Nateglinide...... 47 Ninlaro...... 34 Mirvaso...... 61 Natpara...... 82 Nitisinone...... 67 Misoprostol...... 66 Nayzilam...... 24 Nitro-Bid...... 57 Modafinil...... 90 Nebupent...... 37 Nitrofurantoin...... 19 Moexipril HCl...... 52 Necon 0.5/35...... 73 Nitrofurantoin Macrocrystal... 19 Molindone HCl...... 39 Nefazodone HCl...... 28 Nitrofurantoin Monohydrate...19 Mometasone Furoate...... 69, 87 Neomycin Sulfate...... 18 Nitroglycerin...... 57, 58 Montelukast Sodium...... 87 Neomycin-Bacitracin-Polymyxin Morphine Sulfate...... 16 ...... 83 Nitrostat...... 58 Morphine Sulfate ER...... 15 Neomycin-Polymyxin-Bacitracin- Nora-BE...... 75 Moxifloxacin HCl...... 23 Hydrocortisone...... 83 Norditropin FlexPro...... 70 Moxifloxacin HCl in NaCl...... 23 Neomycin-Polymyxin- Norethindrone...... 75 Dexamethasone...... 83 Multaq...... 52 Norethindrone Acetate...... 75 Neomycin-Polymyxin- Mupirocin...... 19 Norethindrone Acetate-Ethinyl Gramicidin...... 83 Estradiol...... 73 201 Tracked

Norethindrone Acetate-Ethinyl Ofloxacin...... 23 Ozempic...... 47 Estradiol-Fe...... 73 Olanzapine...... 40 P Norgestimate-Ethinyl Estradiol Olanzapine ODT...... 40 Pacerone...... 52 ...... 74 Olmesartan Medoxomil...... 52 Paliperidone ER...... 40 Norgestimate-Ethinyl Estradiol Olmesartan Medoxomil-HCTZ Panretin...... 36 Triphasic...... 74 ...... 55 Pantoprazole Sodium...... 66 Normosol-M in D5W...... 62 Olmesartan-Amlodipine-HCTZ Panzyga...... 79 Northera...... 51 ...... 55 Paricalcitol...... 83 Nortrel 0.5/35...... 74 Olopatadine HCl...... 84 Paromomycin Sulfate...... 18 Nortrel 1/35...... 74 Omega-3-Acid Ethyl Esters.....57 Paroxetine HCl...... 28 Nortrel 7/7/7...... 74 Omeprazole...... 66 Paser...... 32 Nortriptyline HCl...... 28, 29 Ondansetron HCl...... 29 Paxil...... 28 Norvir...... 44 Ondansetron ODT...... 29 Pazeo...... 84 Noxafil...... 30 Opsumit...... 88 Pediarix...... 81 Nubeqa...... 33 Orencia...... 78 Pedvax HIB...... 81 Nucala...... 89 Orencia ClickJect...... 78 PEG-3350-Electrolytes...... 66 Nucynta ER...... 15 Orenitram...... 88 Nuedexta...... 58 PEG-3350-NaCl-Na Orfadin...... 67 Bicarbonate-KCl...... 66 Nuplazid...... 40 Orkambi...... 88 Peganone...... 26 Nutrilipid...... 63 Orsythia...... 74 Pegasys...... 42 Nutropin AQ NuSpin 10...... 70 Oseltamivir Phosphate...... 45 Pegasys ProClick...... 42 Nutropin AQ NuSpin 20...... 70 Osphena...... 75 Pemazyre...... 34 Nutropin AQ NuSpin 5...... 70 Otezla...... 80 Penicillamine...... 67, 68 Nyamyc...... 30 Oxacillin Sodium...... 21 Penicillin G Potassium...... 22 Nymalize...... 54 Oxacillin Sodium in Dextrose Penicillin G Procaine...... 22 Nystatin...... 30 ...... 21 Penicillin G Sodium...... 22 Nystop...... 30 Oxandrolone...... 71 Penicillin V Potassium...... 22 O Oxcarbazepine...... 26 PENTAM 300...... 37 Ocaliva...... 67 Oxsoralen Ultra...... 61 Pentamidine Isethionate...... 37 Ocella...... 74 Oxybutynin Chloride...... 67 Pentasa...... 82 Octagam...... 79 Oxybutynin Chloride ER...... 67 Pentoxifylline ER...... 55 Octreotide Acetate...... 76 Oxycodone HCl...... 16 Perforomist...... 87 Odefsey...... 43 Oxycodone-Acetaminophen Perindopril Erbumine...... 52 Odomzo...... 36 ...... 16 Permethrin...... 37 Ofev...... 89 Oxycodone-Aspirin...... 16 202 Tracked

Perphenazine...... 29 Posaconazole...... 31 Prilosec...... 66 Perseris...... 40 Potassium Chloride...... 63 Primaquine Phosphate...... 37 Phenelzine Sulfate...... 27 Potassium Chloride CR...... 63 Primidone...... 25 Phenobarbital...... 25 Potassium Chloride ER...... 63 Privigen...... 79 Phenoxybenzamine HCl...... 52 Potassium Chloride in Dextrose ProAir HFA...... 88 Phenytek...... 26 ...... 63 ProAir RespiClick...... 88 Phenytoin...... 26 Potassium Chloride in NaCl... 63 Probenecid...... 31 Phenytoin Sodium Extended Potassium Citrate ER...... 63 Probenecid-Colchicine...... 31 ...... 26 Praluent...... 57 Procalamine...... 63 Phoslyra...... 64 Pramipexole Dihydrochloride Prochlorperazine...... 29 ...... 38 Phospholine Iodide...... 85 Prochlorperazine Maleate...... 29 Prasugrel HCl...... 51 Picato...... 61 Procrit...... 51 Pravastatin Sodium...... 56 Pifeltro...... 43 Procto-Med HC...... 82 Praziquantel...... 37 Pilocarpine HCl...... 60, 85 Procto-Pak...... 82 Prazosin HCl...... 52 Pimecrolimus...... 61 Proctosol HC...... 82 Pred Mild...... 85 Pimozide...... 39 Proctozone-HC...... 82 Pred-G...... 84 Pimtrea...... 74 Procysbi...... 67 Pred-G S.O.P...... 84 Pindolol...... 53 Progesterone Micronized...... 75 Prednicarbate...... 69 Pioglitazone HCl...... 47 Proglycem...... 48 Prednisolone...... 69 Pioglitazone HCl-Glimepiride Prograf...... 78 ...... 47 Prednisolone Acetate...... 85 Prolastin-C...... 67 Pioglitazone HCl-Metformin HCl Prednisolone Sodium Prolensa...... 86 ...... 47 Phosphate...... 69, 85 Prolia...... 83 Piperacillin-Tazobactam...... 22 Prednisone...... 70 Promacta...... 51 Piqray...... 34 Prednisone Intensol...... 70 Promethazine HCl...... 86 Pirmella 1/35...... 74 Pregabalin...... 59 Promethegan...... 86 Piroxicam...... 14 Premarin...... 74 Propafenone HCl...... 52 Plasma-Lyte 148...... 63 Premasol...... 63 Propafenone HCl ER...... 52 Plasma-Lyte A...... 63 Premphase...... 74 Proparacaine HCl...... 84 Plenamine...... 63 Prempro...... 74 Propranolol HCl...... 53 Podofilox...... 61 Prevalite...... 57 Propranolol HCl ER...... 53 Polymyxin B Sulfate...... 19 Previfem...... 74 Propranolol-HCTZ...... 55 Polymyxin B-Trimethoprim.....83 Prezcobix...... 44 Propylthiouracil...... 77 Pomalyst...... 33 Prezista...... 44 ProQuad...... 81 Portia-28...... 74 Priftin...... 32 203 Tracked

Prosol...... 63 Rebif Titration Pack...... 59 Rivelsa...... 74 Protriptyline HCl...... 29 Reclipsen...... 74 Rizatriptan Benzoate...... 31 Pulmozyme...... 89 Recombivax HB...... 81 Rizatriptan Benzoate ODT..... 31 Purixan...... 33 Rectiv...... 58 Rocklatan...... 85 Pyrazinamide...... 32 Regranex...... 61 Ropinirole HCl...... 38 Pyridostigmine Bromide...... 32 Relenza Diskhaler...... 45 Rosuvastatin Calcium...... 56 Pyridostigmine Bromide ER...32 Relistor...... 65 Rotarix...... 81 Pyrimethamine...... 37 Repaglinide...... 47 RotaTeq...... 81 Q Repatha...... 57 Roweepra...... 24 Qinlock...... 34 Repatha Pushtronex System Roweepra XR...... 24 Quadracel...... 81 ...... 57 Rozlytrek...... 34 Quetiapine Fumarate...... 40 Repatha SureClick...... 57 Rubraca...... 34 Quetiapine Fumarate ER...... 40 Restasis Single-Use Vials...... 84 Ruconest...... 77 Quinapril HCl...... 52 Retacrit...... 51 Rukobia...... 44 Quinapril-Hydrochlorothiazide Retevmo...... 34 Rybelsus...... 47 ...... 55 Revlimid...... 33 Rydapt...... 36 Quinidine Gluconate ER...... 52 Rexulti...... 40 Rytary...... 38 Quinidine Sulfate...... 52 Reyataz...... 44 S Quinine Sulfate...... 37 Rhopressa...... 84 Saizen...... 70 R Ribavirin...... 42 Saizenprep...... 71 RabAvert...... 81 Ridaura...... 80 Sancuso...... 29 Rabeprazole Sodium...... 66 Rifabutin...... 32 Sandimmune...... 78 Raloxifene HCl...... 75 Rifampin...... 32 Santyl...... 61 Ramelteon...... 90 Riluzole...... 58 Saphris...... 41 Ramipril...... 52 Rimantadine HCl...... 45 Savella...... 59 Ranolazine ER...... 55 Riomet...... 47 Savella Titration Pack...... 59 Rasagiline Mesylate...... 38 Riomet ER...... 47 Scopolamine...... 29 Rasuvo...... 78 Risedronate Sodium...... 83 Secuado...... 41 RAVICTI...... 67 Risperdal Consta...... 40, 41 Selegiline HCl...... 38 Rayaldee...... 83 Risperidone...... 41 Selenium Sulfide...... 61 Rebif...... 59 Risperidone ODT...... 41 Selzentry...... 44 Rebif Rebidose...... 59 Ritonavir...... 44 Serevent Diskus...... 88 Rebif Rebidose Titration Pack Rivastigmine...... 27 Serostim...... 65 ...... 59 Rivastigmine Tartrate...... 27 Sertraline HCl...... 28 204 Tracked

Setlakin...... 74 SPS...... 64 Symtuza...... 44 Sevelamer Carbonate...... 64 Sronyx...... 74 Synarel...... 76 Sharobel...... 75 SSD...... 23 Synjardy...... 47 Shingrix...... 81 Stavudine...... 44 Synjardy XR...... 47 Signifor...... 76 Stelara...... 61 Synribo...... 34 Sildenafil Citrate...... 88 Stiolto Respimat...... 89 Synthroid...... 75 Silodosin...... 67 Stivarga...... 36 T Silver Sulfadiazine...... 23 Streptomycin Sulfate...... 18 Tabloid...... 33 Simbrinza...... 85 Stribild...... 42 Tabrecta...... 33 Simponi...... 78 Suboxone...... 17 Tacrolimus...... 61, 78 Simvastatin...... 56 Sucraid...... 67 Tadalafil...... 88 Sirolimus...... 78 Sucralfate...... 66 Tafinlar...... 36 Sirturo...... 32 Sulfacetamide Sodium...... 23 Tagrisso...... 36 Sodium Chloride...... 63 Sulfacetamide-Prednisolone Talzenna...... 34 Sodium Fluoride...... 63 ...... 84 Tamoxifen Citrate...... 33 Sodium Phenylbutyrate...... 67 Sulfadiazine...... 23 Tamsulosin HCl...... 67 Sodium Polystyrene Sulfonate Sulfamethoxazole-Trimethoprim Targretin...... 36 ...... 23 ...... 64 Tarina 24 Fe...... 74 Sulfamylon...... 19 Sofosbuvir-Velpatasvir...... 42 Tarina Fe 1/20...... 74 Sulfasalazine...... 82 Solifenacin Succinate...... 67 Tasigna...... 36 Sulindac...... 14 Soliqua...... 47 Tazarotene...... 61 Sumatriptan...... 32 Soltamox...... 33 Tazicef...... 20 Sumatriptan Succinate...... 32 Somatuline Depot...... 76 Tazorac...... 61 Sumatriptan Succinate Refill Somavert...... 76 Taztia XT...... 54 ...... 32 Sotalol HCl...... 52 Tazverik...... 34 Suprax...... 20 Sotalol HCl AF...... 52 TDVAX...... 81 Suprep Bowel Prep Kit...... 66 Sovaldi...... 42 Sutent...... 36 Tecfidera...... 60 Spiriva HandiHaler...... 87 Tecfidera Starter Pack...... 59 Syeda...... 74 Spiriva Respimat...... 87 Tegsedi...... 67 Symbicort...... 89 Spironolactone...... 56 Telmisartan...... 52 Symfi...... 43 Spironolactone-HCTZ...... 55 Telmisartan-Amlodipine...... 55 Symfi Lo...... 43 Sprintec 28...... 74 SymlinPen 120...... 47 Telmisartan-HCTZ...... 55 Spritam ODT...... 24 Temazepam...... 90 SymlinPen 60...... 47 Sprycel...... 36 Tenivac...... 81 Sympazan...... 25 205 Tracked

Tenofovir Disoproxil Fumarate Tolak...... 61 Tri-Previfem...... 74 ...... 44 Tolcapone...... 38 Tri-Sprintec...... 74 Terazosin HCl...... 67 Topiramate...... 26 Tri-VyLibra...... 74 Terbinafine HCl...... 31 Toremifene Citrate...... 33 Tri-VyLibra Lo...... 74 Terconazole...... 31 Torsemide...... 56 Triamcinolone Acetonide...... 60, Teriparatide...... 83 Toujeo Max SoloStar...... 49 70 Testosterone...... 71 Toujeo SoloStar...... 49 Triamterene...... 56 Testosterone Cypionate...... 71 TPN Electrolytes...... 63 Triamterene-HCTZ...... 55 Testosterone Enanthate...... 71 Tracleer...... 88 Triderm...... 70 Tetrabenazine...... 59 Tradjenta...... 47 Trientine HCl...... 64 Tetracycline HCl...... 24 Tramadol HCl...... 16 Trifluoperazine HCl...... 39 Thalomid...... 33 Tramadol HCl ER...... 15 Trifluridine...... 42 Theophylline...... 88 Tramadol-Acetaminophen..... 16 Trihexyphenidyl HCl...... 37 Theophylline ER...... 88 Trandolapril...... 52 Trijardy XR...... 47 Thioridazine HCl...... 39 Tranexamic Acid...... 51 TriLyte...... 66 Thiothixene...... 39 Transderm-Scop...... 29 Trimethoprim...... 19 Tiadylt ER...... 54 Tranylcypromine Sulfate...... 27 Trimipramine Maleate...... 29 Tiagabine HCl...... 25 Travasol...... 63 Trintellix...... 28 Tibsovo...... 36 Travoprost...... 86 Triumeq...... 43 Tigecycline...... 19 Trazodone HCl...... 28 Trivora...... 74 Timolol Maleate...... 31, 85 Trecator...... 32 TrophAmine...... 64 Timolol Maleate Ophthalmic Trelegy Ellipta...... 90 Trulicity...... 47 Gel Forming...... 85 Trelstar Mixject...... 77 Trumenba...... 81 Tinidazole...... 19 Tresiba...... 49 Truvada...... 44 Tivicay...... 43 Tresiba FlexTouch...... 49 Tukysa...... 34 Tivicay PD...... 43 Tretinoin...... 36, 61 Turalio...... 36 Tizanidine HCl...... 90 Tretinoin Microsphere...... 61 Twinrix...... 81 TOBI Podhaler...... 88 Trexall...... 78 Tybost...... 43 TobraDex...... 84 Trezix...... 16 Tykerb...... 36 TobraDex ST...... 84 Tri-Estarylla...... 74 Tymlos...... 83 Tobramycin...... 18, 88 Tri-Legest Fe...... 74 Typhim Vi...... 81 Tobramycin Sulfate...... 18 Tri-Lo-Estarylla...... 74 U Tobramycin-Dexamethasone Tri-Lo-Sprintec...... 74 Udenyca...... 51 ...... 84 Tri-Mili...... 74 Unithroid...... 76 Tobrex...... 18 206 Tracked

Ursodiol...... 65 Vienva...... 74 Xgeva...... 83 V Vigabatrin...... 25 Xifaxan...... 65 Valacyclovir HCl...... 42 Vigadrone...... 25 Xiidra...... 84 Valchlor...... 33 Viibryd...... 28 Xofluza...... 45 Valganciclovir HCl...... 41 Viibryd Starter Pack...... 28 Xolair...... 80 Valproic Acid...... 25 Vimpat...... 26 Xospata...... 36 Valsartan...... 52 Viracept...... 44 Xpovio...... 33, 34 Valsartan-Hydrochlorothiazide Viread...... 44 Xtampza ER...... 15 ...... 55 Vitrakvi...... 36 Xtandi...... 33 Valtoco 10 MG Dose...... 25 Vivitrol...... 17 Xulane...... 74 Valtoco 15 MG Dose...... 25 Vizimpro...... 36 Xyrem...... 90 Valtoco 20 MG Dose...... 25 Voriconazole...... 31 Y Valtoco 5 MG Dose...... 25 Vosevi...... 42 YF-Vax...... 81 Vancomycin HCl...... 19 Votrient...... 36 Yuvafem...... 74 Vandazole...... 19 VP-PNV-DHA...... 64 Z VAQTA...... 81 Vraylar...... 41 Zafirlukast...... 87 Varivax...... 81 Vyfemla...... 74 Zaleplon...... 90 Varizig...... 79 VyLibra...... 74 Zarah...... 74 Vascepa...... 57 Vyndamax...... 55 Zarxio...... 51 Velivet...... 74 Vyndaqel...... 55 Zejula...... 34 Velphoro...... 64 Vyvanse...... 58 Zelapar ODT...... 38 Veltassa...... 64 Vyzulta...... 86 Zelboraf...... 36 Vemlidy...... 42 W Zemaira...... 67 Venclexta...... 36 Warfarin Sodium...... 50 Zenpep...... 67 Venclexta Starting Pack...... 36 Wixela Inhub...... 90 Zerbaxa...... 20 Venlafaxine HCl...... 28 WYMZYA Fe...... 74 Zidovudine...... 44 Venlafaxine HCl ER...... 28 X Zileuton ER...... 87 Ventavis...... 88 Xalkori...... 36 Zioptan...... 86 Verapamil HCl...... 54 Xarelto...... 50 Ziprasidone HCl...... 41 Verapamil HCl ER...... 54 Xarelto Starter Pack...... 50 Ziprasidone Mesylate...... 41 Versacloz...... 41 Xatmep...... 78 Zirgan...... 42 Verzenio...... 34 Xcopri...... 24, 25 Zolinza...... 34 Vibramycin...... 24 Xeljanz...... 79 Zolpidem Tartrate...... 90 Victoza...... 47 Xeljanz XR...... 79 Zonisamide...... 25 207 Tracked

Zorbtive...... 65 Zyclara Pump...... 62 Zykadia...... 36 Zortress...... 79 Zydelig...... 36 Zyprexa Relprevv...... 41 Zovia 1/35E...... 75 Zyflo...... 87 For more recent information or if you have questions, please call Customer Service at:

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UHMA20HM4535866_013 Last updated December 1, 2020