Medicaid) Enhanced Care Plus (HARP) 2021 Drug Formulary Emblemhealth Enhanced Care and Enhanced Care Plus Formulary 2021 Formulary (List of Covered Drugs

Enhanced Care (Medicaid) Enhanced Care Plus (HARP) 2021 Drug Formulary EmblemHealth Enhanced Care and Enhanced Care Plus Formulary 2021 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT some of the drugs covered by your plan.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means EmblemHealth. When it refers to “plan” or “our plan,” it means EmblemHealth Enhanced Care (Medicaid) or Enhanced Care Plus (HARP).

This document includes a list of the drugs (formulary) for our plan which is current as of 10/1/2021. For a complete updated formulary, please call Customer Service at 888-447-7364 (TTY: 711). Our hours are 8 am to 6 pm, Monday through Friday and 10 am to 1 pm, Saturday and Sunday. A representative will be happy to help. You can also check our website at emblemhealth.com.

You must use network pharmacies to use your prescription drug benefit.

The formulary and pharmacy network may change.

Effective Oct. 1, 2021, New York State Medicaid will implement a single statewide Medication Assisted Treatment (MAT) formulary for opioid dependence agents and opioid antagonists.

i EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY

What is the EmblemHealth Enhanced Care and Enhanced Care Plus Formulary? A formulary is a list of covered drugs selected by our plan with help from a team of health care professionals. It represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Member Handbook.

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

Medical Condition The formulary begins on page 3. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular-Hypertensive/Lipids. If you know what conditions your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID and generic drugs are listed in lower-case italics (e.g., levothyroxine).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

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

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

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Our plan requires your doctor get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug. • Quantity Limits: For certain drugs our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per prescription for Januvia. This may be in addition to a standard one-month or three-month supply. • Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any other requirements or limits by looking in the formulary that begins on page 3.

ii EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY

You can ask us to make an exception (change a ruling) to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I ask for an exception to the EmblemHealth Enhanced Care/Enhanced Care Plus formulary?” on this page for information about how to ask for an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary you should first call Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. • You can ask our plan to make an exception and cover your drug. See below for information about how to ask for an exception. How do I ask for an exception (change a ruling) to the EmblemHealth Enhanced Care/ Enhanced Care Plus Formulary? You can ask us to make an exception to our coverage rules for the following:

• You can ask us to cover a drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit, and cover a greater amount.

Generally, we will only approve your request for an exception if the other drug is:

• Included on the plan’s formulary, • The lower cost-sharing drug (you and your insurance company share the costs of some of the drugs that your plan covers based on the drug’s level), or • Prior authorization, quantity limit or step therapy would not be as effective in treating your condition and/or would cause you to have a negative effects.

You should contact us to ask for an initial coverage decision for a formulary or utilization restriction exception. When you ask for a formulary or prior authorization, quantity limit, or step therapy exception, you should submit a statement from your prescriber or doctor supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision within 24 hours after we get a supporting statement from your doctor or other prescriber, but no later than 72 hours from receipt of the request.

What do I do before I can talk to my doctor about changing my drugs or asking for an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or ask for a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

iii EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we may cover a 30-day supply of your drug in certain cases during the first 90 days you are a member of our plan.

List of abbreviations Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column. They tell you if there are any special requirements for coverage of your drug.

Brand: Brand Drug

Generic: Generic Drug

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs the plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

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Table of Contents

ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ...... 9 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...... 14 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 28 DERMATOLOGICALS/TOPICAL THERAPY ...... 34 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 43 EAR, NOSE / THROAT MEDICATIONS ...... 46 ENDOCRINE/DIABETES ...... 49 GASTROENTEROLOGY ...... 52 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...... 64 MUSCULOSKELETAL / RHEUMATOLOGY ...... 65 OBSTETRICS / GYNECOLOGY ...... 66 OPHTHALMOLOGY ...... 73 RESPIRATORY AND ALLERGY ...... 77 UROLOGICALS ...... 93 VITAMINS, HEMATINICS / ELECTROLYTES ...... 94 Index ...... 120

List of Abbreviations

Brand: Brand Generic: Generic NC: NC NF: NF OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Drug Name Drug Tier Requirements / Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS clotrimazole mucous membrane Generic CRESEMBA ORAL Brand PA fluconazole oral suspension for reconstitution Generic fluconazole oral tablet 100 mg, 200 mg, 50 mg Generic fluconazole oral tablet 150 mg Generic QL flucytosine Generic griseofulvin microsize oral suspension Generic itraconazole oral capsule Generic QL itraconazole oral solution Generic ketoconazole oral Generic NOXAFIL ORAL SUSPENSION Brand PA nystatin oral Generic posaconazole oral tablet,delayed release (dr/ec) Generic PA terbinafine hcl oral Generic TOLSURA Brand PA; QL voriconazole oral Generic PA ANTIVIRALS abacavir Generic QL abacavir-lamivudine Generic QL abacavir-lamivudine-zidovudine Generic QL acyclovir oral capsule Generic acyclovir oral suspension 200 mg/5 ml Generic acyclovir oral tablet Generic adefovir Generic amantadine hcl Generic APTIVUS Brand QL atazanavir Generic QL ATRIPLA Brand QL BARACLUDE ORAL SOLUTION Brand BIKTARVY Brand QL cidofovir Generic CIMDUO Brand QL

Drug Name Drug Tier Requirements / Limits COMBIVIR Brand QL COMPLERA Brand QL DELSTRIGO Brand QL DESCOVY Brand QL didanosine oral capsule,delayed release(dr/ec) Generic QL 250 mg, 400 mg DOVATO Brand QL EDURANT Brand QL efavirenz Generic QL efavirenz-emtricitabin-tenofov Generic QL efavirenz-lamivu-tenofov disop Generic QL emtricitabine Generic QL emtricitabine-tenofovir (tdf) Generic QL entecavir Generic EPIVIR Brand QL EPIVIR HBV ORAL SOLUTION Brand EPZICOM Brand QL EVOTAZ Brand QL famciclovir Generic QL fosamprenavir Generic QL FUZEON SUBCUTANEOUS RECON SOLN Brand QL ganciclovir sodium intravenous recon soln Generic GENVOYA Brand QL INTELENCE Brand QL INVIRASE ORAL TABLET Brand QL ISENTRESS Brand QL ISENTRESS HD Brand QL JULUCA Brand QL KALETRA Brand QL lamivudine oral solution Generic QL lamivudine oral tablet 100 mg Generic lamivudine oral tablet 150 mg, 300 mg Generic QL lamivudine-zidovudine Generic QL LEXIVA Brand QL lopinavir-ritonavir oral solution Generic QL

Drug Name Drug Tier Requirements / Limits MAVYRET Brand QL nevirapine Generic QL NORVIR ORAL POWDER IN PACKET Brand QL NORVIR ORAL SOLUTION Brand QL NORVIR ORAL TABLET Brand QL ODEFSEY Brand QL oseltamivir Generic QL PIFELTRO Brand QL PREVYMIS ORAL Brand PA; QL PREZCOBIX Brand QL PREZISTA ORAL SUSPENSION Brand QL PREZISTA ORAL TABLET 150 MG, 600 MG, Brand QL 75 MG, 800 MG RELENZA DISKHALER Brand RETROVIR ORAL CAPSULE Brand QL RETROVIR ORAL SYRUP Brand QL REYATAZ ORAL CAPSULE 150 MG, 200 MG, Brand QL 300 MG REYATAZ ORAL POWDER IN PACKET Brand QL ribavirin oral capsule Generic PA ribavirin oral tablet 200 mg Generic PA rimantadine Generic ritonavir Generic QL RUKOBIA Brand QL SELZENTRY Brand QL SOFOSBUVIR-VELPATASVIR Brand QL stavudine oral capsule Generic QL STRIBILD Brand QL SUSTIVA ORAL CAPSULE Brand QL SYMTUZA Brand QL SYNAGIS Brand PA TEMIXYS Brand QL tenofovir disoproxil fumarate Generic QL TIVICAY Brand QL TIVICAY PD Brand QL

Drug Name Drug Tier Requirements / Limits TRIUMEQ Brand QL TRIZIVIR Brand QL TRUVADA Brand QL valacyclovir Generic QL valganciclovir Generic VEMLIDY Brand PA VIRACEPT ORAL TABLET Brand QL VIREAD ORAL POWDER Brand QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 Brand QL MG VOSEVI Brand PA XOFLUZA Brand QL zidovudine Generic QL CEPHALOSPORINS cefaclor oral capsule Generic cefaclor oral suspension for reconstitution 125 Generic mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr Generic cefadroxil oral capsule Generic cefadroxil oral suspension for reconstitution 250 Generic mg/5 ml, 500 mg/5 ml cefadroxil oral tablet Generic cefdinir Generic cefditoren pivoxil Generic cefprozil Generic cefuroxime axetil oral tablet Generic cephalexin Generic ERYTHROMYCINS / OTHER MACROLIDES azithromycin oral packet Generic QL azithromycin oral suspension for reconstitution Generic azithromycin oral tablet Generic clarithromycin Generic e.e.s. 400 oral tablet Generic ery-tab oral tablet,delayed release (dr/ec) 250 mg, Generic 333 mg

Drug Name Drug Tier Requirements / Limits erythrocin (as stearate) oral tablet 250 mg Generic erythromycin ethylsuccinate oral suspension for Generic reconstitution erythromycin ethylsuccinate oral tablet Generic erythromycin oral Generic MISCELLANEOUS ANTIINFECTIVES AEMCOLO Brand PA; QL albendazole Generic QL ALINIA Brand PA; QL ARIKAYCE Brand PA; QL atovaquone Generic atovaquone-proguanil Generic QL CAYSTON Brand QL chloroquine phosphate Generic clindamycin hcl Generic clindamycin pediatric Generic COARTEM Brand QL colistin (colistimethate na) Generic dapsone oral Generic EMVERM Brand QL ethambutol Generic hydroxychloroquine oral tablet 200 mg Generic isoniazid oral Generic ivermectin oral Generic QL KITABIS PAK Brand QL linezolid Generic PA mefloquine Generic QL metronidazole oral tablet Generic neomycin Generic nitazoxanide Generic PA; QL paromomycin Generic praziquantel Generic PRETOMANID Brand PA PRIFTIN Brand pyrazinamide Generic

Drug Name Drug Tier Requirements / Limits pyrimethamine Generic PA quinine sulfate Generic QL rifabutin Generic rifampin oral Generic SIRTURO Brand PA tinidazole Generic QL tobramycin in 0.225 % nacl Generic QL XIFAXAN Brand PA; QL PENICILLINS amoxicillin oral capsule Generic amoxicillin oral suspension for reconstitution Generic amoxicillin oral tablet Generic amoxicillin oral tablet,chewable 125 mg, 250 mg Generic amoxicillin-pot clavulanate Generic ampicillin oral capsule Generic AUGMENTIN ORAL SUSPENSION FOR Brand RECONSTITUTION 125-31.25 MG/5 ML dicloxacillin Generic penicillin v potassium Generic QUINOLONES BAXDELA ORAL Brand PA; QL ciprofloxacin Generic ciprofloxacin hcl oral Generic levofloxacin oral Generic moxifloxacin oral Generic ofloxacin oral tablet 300 mg, 400 mg Generic SULFA'S / RELATED AGENTS sulfadiazine Generic sulfamethoxazole-trimethoprim oral Generic sulfatrim Generic TETRACYCLINES avidoxy Generic demeclocycline Generic doxycycline hyclate oral capsule Generic

Drug Name Drug Tier Requirements / Limits doxycycline hyclate oral tablet 100 mg, 20 mg Generic doxycycline monohydrate oral capsule Generic doxycycline monohydrate oral tablet Generic minocycline oral capsule Generic minocycline oral tablet Generic mondoxyne nl oral capsule 100 mg, 75 mg Generic morgidox oral capsule 100 mg Generic tetracycline Generic URINARY TRACT AGENTS methenamine hippurate Generic methenamine mandelate Generic nitrofurantoin macrocrystal Generic nitrofurantoin monohyd/m-cryst Generic trimethoprim Generic VANCOMYCIN vancomycin oral capsule Generic QL ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium injection recon soln Generic leucovorin calcium oral Generic MESNEX ORAL Brand VISTOGARD Brand ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS abiraterone Generic PA AFINITOR DISPERZ Brand PA AFINITOR ORAL TABLET 10 MG Brand PA ALECENSA Brand PA anastrozole Generic QL AYVAKIT Brand PA; QL azacitidine Generic PA AZASAN Brand azathioprine Generic BALVERSA Brand PA bexarotene Generic PA

Drug Name Drug Tier Requirements / Limits bicalutamide Generic PA; QL bleomycin Generic BOSULIF Brand PA BRAFTOVI Brand PA; QL BRUKINSA Brand PA; QL CALQUENCE Brand PA; QL capecitabine Generic CAPRELSA Brand PA; QL carboplatin intravenous solution Generic carmustine Generic cisplatin intravenous solution Generic cladribine Generic COPIKTRA Brand PA; QL COTELLIC Brand PA; QL cyclophosphamide intravenous recon soln Generic cyclophosphamide oral capsule Generic cyclosporine modified Generic cyclosporine oral capsule Generic cytarabine Generic cytarabine (pf) Generic dacarbazine Generic DAURISMO Brand PA; QL docetaxel intravenous solution 20 mg/ml (1 ml), 80 Generic mg/4 ml (20 mg/ml) doxorubicin intravenous recon soln 50 mg Generic doxorubicin intravenous solution Generic doxorubicin, peg-liposomal Generic PA DROXIA Brand EMCYT Brand ERIVEDGE Brand PA; QL ERLEADA Brand PA; QL erlotinib Generic PA ETOPOPHOS Brand etoposide Generic everolimus (antineoplastic) Generic PA

Drug Name Drug Tier Requirements / Limits everolimus (immunosuppressive) Generic exemestane Generic QL fludarabine Generic fluorouracil intravenous Generic flutamide Generic QL GAVRETO Brand PA; QL gemcitabine intravenous recon soln Generic gemcitabine intravenous solution 1 gram/26.3 ml Generic (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gengraf Generic GILOTRIF Brand PA; QL HYCAMTIN ORAL Brand PA hydroxyurea Generic IBRANCE Brand PA; QL ICLUSIG Brand PA IDHIFA Brand PA ifosfamide intravenous recon soln 1 gram Generic imatinib Generic PA IMBRUVICA Brand PA INLYTA Brand PA; QL INQOVI Brand PA; QL INREBIC Brand PA; QL IRESSA Brand PA; QL irinotecan intravenous solution 100 mg/5 ml, 40 Generic mg/2 ml JAKAFI Brand PA; QL KOSELUGO Brand PA lapatinib Generic PA LENVIMA Brand PA; QL letrozole Generic PA; QL LEUKERAN Brand leuprolide subcutaneous kit Generic PA LONSURF Brand PA; QL LORBRENA Brand PA

Drug Name Drug Tier Requirements / Limits LUPRON DEPOT Brand LUPRON DEPOT (3 MONTH) Brand QL LUPRON DEPOT (4 MONTH) Brand LUPRON DEPOT (6 MONTH) Brand LUPRON DEPOT-PED Brand LUPRON DEPOT-PED (3 MONTH) Brand QL LYNPARZA Brand PA LYSODREN Brand QL MATULANE Brand megestrol oral suspension 400 mg/10 ml (40 Generic QL mg/ml) megestrol oral tablet Generic QL MEKINIST Brand PA; QL MEKTOVI Brand PA; QL melphalan Generic mercaptopurine Generic methotrexate sodium Generic methotrexate sodium (pf) Generic mitomycin intravenous Generic mitoxantrone Generic mycophenolate mofetil Generic mycophenolate sodium Generic MYLERAN Brand NERLYNX Brand PA NEXAVAR Brand PA nilutamide Generic PA; QL NINLARO Brand PA; QL NUBEQA Brand PA; QL octreotide acetate Generic PA ONCASPAR Brand paclitaxel Generic PEMAZYRE Brand PA; QL PIQRAY Brand PA; QL POMALYST Brand PA; QL PROGRAF INTRAVENOUS Brand

Drug Name Drug Tier Requirements / Limits PURIXAN Brand QINLOCK Brand PA; QL RETEVMO Brand PA; QL REVLIMID Brand PA; QL RITUXAN Brand PA ROZLYTREK Brand PA; QL RUBRACA Brand PA; QL RYDAPT Brand PA; QL SANDIMMUNE ORAL SOLUTION Brand SANDOSTATIN LAR DEPOT Brand PA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR Brand PA sirolimus Generic SPRYCEL Brand PA STIVARGA Brand PA; QL SUTENT Brand PA TABLOID Brand TABRECTA Brand PA; QL tacrolimus oral Generic TAFINLAR Brand PA TAGRISSO Brand PA TALZENNA Brand PA; QL tamoxifen Generic PA; QL TASIGNA Brand PA TAZVERIK Brand PA; QL temozolomide Generic PA THALOMID Brand PA; QL TIBSOVO Brand PA; QL toposar Generic toremifene Generic QL tretinoin (antineoplastic) Generic TREXALL Brand TUKYSA Brand PA; QL TURALIO Brand PA; QL

Drug Name Drug Tier Requirements / Limits TYKERB Brand PA VENCLEXTA Brand PA; QL VENCLEXTA STARTING PACK Brand PA; QL VERZENIO Brand PA; QL vinblastine Generic vincasar pfs intravenous solution 1 mg/ml Generic vincristine Generic vinorelbine Generic VITRAKVI Brand PA; QL VIZIMPRO Brand PA; QL VOTRIENT Brand PA XALKORI Brand PA; QL XERMELO Brand PA XPOVIO ORAL TABLET 100 MG/WEEK (50 Brand PA MG X 2), 40 MG/WEEK (40 MG X 1), 40MG TWICE WEEK (40 MG X 2), 60 MG/WEEK (60 MG X 1), 60MG TWICE WEEK (120 MG/WEEK), 80 MG/WEEK (40 MG X 2), 80MG TWICE WEEK (160 MG/WEEK) XTANDI Brand PA ZEJULA Brand PA; QL ZELBORAF Brand PA ZOLADEX SUBCUTANEOUS IMPLANT 3.6 Brand MG ZOLINZA Brand PA ZORTRESS ORAL TABLET 1 MG Brand ZYDELIG Brand PA; QL ZYKADIA ORAL TABLET Brand PA ZYTIGA ORAL TABLET 500 MG Brand PA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS carbamazepine oral capsule, er multiphase 12 hr Generic carbamazepine oral suspension 100 mg/5 ml Generic carbamazepine oral tablet Generic carbamazepine oral tablet extended release 12 hr Generic carbamazepine oral tablet,chewable Generic

Drug Name Drug Tier Requirements / Limits clonazepam Generic DIACOMIT Brand PA; QL diazepam rectal Generic DILANTIN Brand divalproex Generic epitol Generic ethosuximide Generic felbamate Generic FINTEPLA Brand PA gabapentin oral capsule Generic QL gabapentin oral solution 250 mg/5 ml Generic QL gabapentin oral tablet 600 mg, 800 mg Generic QL lamotrigine oral tablet Generic lamotrigine oral tablet disintegrating, dose pk Generic lamotrigine oral tablet extended release 24hr Generic lamotrigine oral tablet, chewable dispersible Generic lamotrigine oral tablet,disintegrating Generic levetiracetam oral Generic NAYZILAM Brand PA; QL oxcarbazepine Generic phenobarbital Generic phenytoin oral suspension 125 mg/5 ml Generic phenytoin oral tablet,chewable Generic phenytoin sodium extended Generic pregabalin oral capsule Generic QL pregabalin oral solution Generic QL primidone Generic roweepra Generic rufinamide oral suspension Generic tiagabine Generic topiramate oral capsule, sprinkle Generic topiramate oral tablet Generic valproate sodium Generic valproic acid Generic

Drug Name Drug Tier Requirements / Limits valproic acid (as sodium salt) oral solution 250 Generic mg/5 ml VALTOCO Brand PA vigabatrin Generic PA VIMPAT ORAL SOLUTION Brand PA VIMPAT ORAL TABLET Brand PA zonisamide Generic ANTIPARKINSONISM AGENTS APOKYN Brand benztropine oral Generic bromocriptine Generic PA carbidopa Generic carbidopa-levodopa Generic carbidopa-levodopa-entacapone Generic entacapone Generic INBRIJA INHALATION CAPSULE, Brand PA; QL W/INHALATION DEVICE pramipexole Generic rasagiline Generic ropinirole Generic selegiline hcl Generic tolcapone Generic trihexyphenidyl Generic MIGRAINE / CLUSTER HEADACHE THERAPY AIMOVIG AUTOINJECTOR Brand PA; QL AJOVY AUTOINJECTOR Brand PA; QL AJOVY SYRINGE Brand PA; QL EMGALITY PEN Brand PA; QL EMGALITY SYRINGE Brand PA; QL ergotamine-caffeine Generic migergot Generic naratriptan Generic QL rizatriptan Generic QL sumatriptan Generic QL sumatriptan succinate oral Generic QL

Drug Name Drug Tier Requirements / Limits sumatriptan succinate subcutaneous cartridge Generic QL sumatriptan succinate subcutaneous pen injector Generic QL sumatriptan succinate subcutaneous solution Generic QL sumatriptan succinate subcutaneous syringe 6 Generic QL mg/0.5 ml zolmitriptan oral Generic QL MISCELLANEOUS NEUROLOGICAL THERAPY dalfampridine Generic PA donepezil Generic galantamine Generic GILENYA ORAL CAPSULE 0.5 MG Brand PA glatopa Generic PA; QL INGREZZA Brand PA INGREZZA INITIATION PACK Brand PA MAVENCLAD (4 TABLET PACK) Brand PA MAYZENT Brand PA; QL MAYZENT STARTER PACK Brand PA memantine oral solution Generic memantine oral tablet Generic NUEDEXTA Brand PA; QL rivastigmine Generic rivastigmine tartrate Generic TEGSEDI Brand PA tetrabenazine Generic PA VUMERITY Brand PA; QL MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral Generic chlorzoxazone oral tablet 500 mg Generic cyclobenzaprine oral tablet 10 mg, 5 mg Generic dantrolene oral Generic LIORESAL Brand QL methocarbamol oral Generic orphenadrine citrate oral Generic pyridostigmine bromide oral syrup Generic pyridostigmine bromide oral tablet 60 mg Generic

Drug Name Drug Tier Requirements / Limits pyridostigmine bromide oral tablet extended Generic release tizanidine oral tablet Generic NARCOTIC ANALGESICS acetaminophen-caff-dihydrocod oral capsule Generic PA acetaminophen-codeine oral solution 120-12 mg/5 Generic PA ml acetaminophen-codeine oral tablet Generic PA ascomp with codeine Generic PA buprenorphine hcl sublingual Generic QL butalbital compound w/codeine Generic PA butalbital-acetaminop-caf-cod Generic PA butalbital-acetaminophen oral tablet 50-325 mg Generic butalbital-acetaminophen-caff oral capsule 50- Generic 325-40 mg butalbital-acetaminophen-caff oral tablet Generic butalbital-aspirin-caffeine Generic codeine sulfate Generic PA codeine-butalbital-asa-caff Generic PA diskets Generic PA endocet Generic PA fentanyl Generic PA; QL fentanyl citrate buccal lozenge on a handle Generic PA; QL hydrocodone-acetaminophen Generic PA hydromorphone oral liquid Generic PA hydromorphone oral tablet Generic PA hydromorphone rectal Generic PA methadone oral concentrate Generic PA methadone oral solution Generic PA methadone oral tablet Generic PA methadone oral tablet,soluble Generic PA methadose oral concentrate Generic PA methadose oral tablet,soluble Generic PA morphine concentrate oral solution Generic PA morphine oral solution Generic PA

Drug Name Drug Tier Requirements / Limits morphine oral tablet Generic PA morphine oral tablet extended release Generic PA; QL morphine rectal Generic PA oxycodone oral capsule Generic PA oxycodone oral concentrate Generic PA oxycodone oral solution Generic PA oxycodone oral tablet Generic PA oxycodone-acetaminophen oral tablet 10-325 mg, Generic PA 2.5-325 mg, 5-325 mg, 7.5-325 mg SUBLOCADE Brand tencon Generic zebutal Generic NON-NARCOTIC ANALGESICS 8 hour pain reliever Generic OTC acetadryl Generic OTC acetaminophen oral elixir Generic OTC acetaminophen oral liquid 500 mg/15 ml Generic OTC acetaminophen oral solution 325 mg/10.15 ml Generic OTC acetaminophen oral suspension 160 mg/5 ml Generic OTC acetaminophen oral tablet Generic OTC acetaminophen oral tablet extended release Generic OTC acetaminophen oral tablet,chewable 160 mg Generic OTC acetaminophen oral tablet,disintegrating 80 mg Generic OTC acetaminophen pm extra str Generic OTC acetaminophen rectal Generic OTC added strength headache relief Generic OTC advil junior strength Generic OTC ADVIL LIQUI-GEL Brand OTC ADVIL MIGRAINE Brand OTC ADVIL ORAL TABLET 200 MG Brand OTC ADVIL PM Brand OTC ALEVE Brand OTC alka-seltzer original Generic OTC all day pain relief Generic OTC all day relief Generic OTC

Drug Name Drug Tier Requirements / Limits arthritis pain relief (acetam) Generic OTC aspirin childrens Generic OTC aspirin low dose Generic OTC aspirin oral Generic OTC aspirin rectal suppository 300 mg Generic OTC aspirin,buffd-calcium carb-mag Generic OTC aspir-trin Generic OTC athenol Generic OTC back and body pain reliever Generic OTC backache relief extra strength Generic OTC bayer advanced Generic OTC BAYER CHEWABLE ASPIRIN Brand OTC bayer plus extra strength Generic OTC betatemp Generic OTC bufferin Generic OTC buprenorphine-naloxone sublingual tablet Generic QL butorphanol nasal Generic PA; QL celecoxib Generic ST child fever reducer-pain relvr Generic OTC child pain rel-fever reducer Generic OTC children's acetaminophen oral liquid Generic OTC children's acetaminophen oral tablet,chewable Generic OTC children's acetaminophen oral Generic OTC tablet,disintegrating children's advil Generic OTC children's easy-melts Generic OTC children's ibuprofen Generic OTC children's mapap oral tablet,chewable Generic OTC CHILDREN'S MOTRIN Brand OTC children's non-aspirin Generic OTC children's pain relief oral suspension Generic OTC children's pain-fever relief oral suspension Generic OTC children's pain-fever relief oral tablet,chewable Generic OTC 160 mg children's profen ib Generic OTC

Drug Name Drug Tier Requirements / Limits CHILDREN'S TYLENOL ORAL SUSPENSION Brand OTC choline,magnesium salicylate Generic cidatrine Generic OTC diclofenac potassium Generic diclofenac sodium oral Generic diclofenac sodium topical drops Generic QL diclofenac sodium topical gel 1 % Generic ST; QL diclofenac-misoprostol Generic diflunisal Generic dona oral tablet Generic OTC eazzze the pain Generic OTC ECOTRIN Brand OTC ecotrin low strength Generic OTC ed-apap Generic OTC efferves pain relief antacid Generic OTC effervescent pain relief Generic OTC etodolac oral capsule Generic etodolac oral tablet Generic EXCEDRIN EXTRA STRENGTH Brand OTC EXCEDRIN MIGRAINE Brand OTC EXCEDRIN TENSION HEADACHE Brand OTC EXTRA STRENGTH BAYER Brand OTC extraprin Generic OTC fenoprofen oral tablet Generic ST feverall rectal suppository 120 mg, 325 mg, 650 Generic OTC mg FEVERALL RECTAL SUPPOSITORY 80 MG Brand OTC flanax (naproxen) Generic OTC flurbiprofen oral tablet 100 mg Generic genicin Generic OTC glucosamine relief oral capsule Generic OTC glucosamine sulfate oral capsule 500 mg Generic OTC glucosamine sulfate oral tablet 500 mg, 750 mg Generic OTC headache pm Generic OTC headache relief (asa-acet-caf) Generic OTC

Drug Name Drug Tier Requirements / Limits headache relief pm Generic OTC ibu Generic ibuprofen ib Generic OTC ibuprofen jr strength Generic OTC ibuprofen oral capsule Generic OTC ibuprofen oral drops,suspension Generic OTC ibuprofen oral suspension Generic OTC ibuprofen oral tablet 100 mg, 200 mg Generic OTC ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic ibuprofen pm oral tablet Generic OTC indomethacin oral Generic infant fever reducer-pain relf Generic OTC infant pain reliever Generic OTC infant's advil Generic OTC infant's ibuprofen Generic OTC infant's motrin Generic OTC infants' pain and fever Generic OTC infants' pain relief Generic OTC infants profenib Generic OTC jr. acetaminophen Generic OTC jr. str non-aspirin pain Generic OTC jr. strength pain reliever Generic OTC ketoprofen oral capsule 50 mg, 75 mg Generic ketoprofen oral capsule,ext rel. pellets 24 hr 200 Generic ST mg ketorolac injection cartridge Generic ketorolac injection solution Generic ketorolac injection syringe 30 mg/ml Generic ketorolac intramuscular solution Generic ketorolac oral Generic QL little remedies fever and pain Generic OTC LUCEMYRA Brand PA; QL mapap (acetaminophen) oral capsule Generic OTC mapap (acetaminophen) oral liquid 500 mg/15 ml Generic OTC mapap (acetaminophen) oral tablet Generic OTC

Drug Name Drug Tier Requirements / Limits mapap arthritis pain Generic OTC masophen Generic OTC meclofenamate Generic mediproxen Generic OTC medi-seltzer Generic OTC meloxicam oral tablet 15 mg Generic meloxicam oral tablet 7.5 mg Generic QL MENSTRUAL RELIEF Brand OTC midol pm Generic OTC migraine formula Generic OTC migraine relief Generic OTC MOTRIN IB ORAL TABLET Brand OTC motrin pm Generic OTC nabumetone Generic naloxone injection solution Generic naloxone injection syringe Generic naltrexone Generic naproxen oral suspension Generic ST naproxen oral tablet Generic naproxen oral tablet,delayed release (dr/ec) Generic naproxen sodium oral capsule Generic OTC naproxen sodium oral tablet 220 mg Generic OTC NARCAN Brand QL night time pain medicine Generic OTC non-aspirin extra strength oral tablet Generic OTC non-aspirin oral tablet Generic OTC non-aspirin oral tablet,chewable Generic OTC non-aspirin pain relief Generic OTC non-aspirin pm Generic OTC nortemp Generic OTC pain relief (acetaminophen) Generic OTC pain relief adult Generic OTC pain relief pm Generic OTC pain relief pm rapid release Generic OTC

Drug Name Drug Tier Requirements / Limits pain relief regular strength Generic OTC pain reliever (acetam-aspirin) Generic OTC pain reliever (acetaminophen) oral tablet 325 mg Generic OTC pain reliever extra strength Generic OTC pain reliever plus Generic OTC pain-off Generic OTC pediacare fever reducer Generic OTC percogesic Generic OTC percogesic extra strength Generic OTC pharbetol Generic OTC piroxicam Generic pre-menstrual relief Generic OTC salsalate Generic severe allergy Generic OTC shake that ache Generic OTC silapap Generic OTC SUBOXONE Brand QL sulindac Generic synovacin Generic OTC tactinal Generic OTC TENSION HEADACHE Brand OTC TENSION HEADACHE PAIN RELIEVER Brand OTC tolmetin oral capsule Generic ST tolmetin oral tablet 200 mg Generic tolmetin oral tablet 600 mg Generic ST tramadol oral tablet 50 mg Generic PA; QL tramadol oral tablet extended release 24 hr Generic PA; QL tramadol oral tablet, er multiphase 24 hr Generic PA; QL tramadol-acetaminophen Generic PA; QL tri-buffered aspirin Generic OTC TYLENOL ARTHRITIS PAIN Brand OTC TYLENOL EXTRA STRENGTH ORAL Brand OTC TABLET TYLENOL ORAL TABLET Brand OTC TYLENOL PM EXTRA STRENGTH Brand OTC

Drug Name Drug Tier Requirements / Limits tylophen Generic OTC VIVITROL Brand wal-profen Generic OTC wal-proxen Generic OTC PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA Brand PA alprazolam Generic alprazolam intensol Generic amitriptyline Generic amitriptyline-chlordiazepoxide Generic amoxapine Generic aripiprazole Generic ARISTADA Brand ARISTADA INITIO Brand armodafinil Generic PA; QL atomoxetine Generic QL bupropion hcl oral tablet Generic bupropion hcl oral tablet extended release 24 hr Generic 150 mg, 300 mg bupropion hcl oral tablet sustained-release 12 hr Generic buspirone Generic CAPLYTA Brand PA; QL chlordiazepoxide hcl Generic chlorpromazine oral tablet Generic citalopram Generic clomipramine Generic clorazepate dipotassium Generic clozapine Generic desipramine Generic desvenlafaxine succinate Generic dexmethylphenidate Generic QL dextroamphetamine oral solution Generic QL dextroamphetamine-amphetamine Generic QL diazepam intensol Generic diazepam oral solution 5 mg/5 ml (1 mg/ml) Generic

Drug Name Drug Tier Requirements / Limits diazepam oral tablet Generic doxepin oral capsule Generic doxepin oral concentrate Generic duloxetine Generic ergoloid Generic escitalopram oxalate Generic estazolam Generic fluoxetine Generic fluphenazine decanoate Generic fluphenazine hcl oral Generic flurazepam Generic fluvoxamine Generic guanfacine oral tablet extended release 24 hr Generic QL haloperidol Generic haloperidol decanoate Generic haloperidol lactate oral Generic HETLIOZ Brand PA; QL HETLIOZ LQ Brand PA imipramine hcl Generic imipramine pamoate Generic lithium carbonate Generic lorazepam injection solution Generic lorazepam intensol Generic lorazepam oral concentrate Generic lorazepam oral tablet Generic loxapine succinate Generic maprotiline Generic metadate er Generic QL methamphetamine Generic QL methylphenidate hcl oral capsule, er biphasic 30- Generic QL 70 methylphenidate hcl oral capsule,er biphasic 50- Generic QL 50 methylphenidate hcl oral solution Generic QL methylphenidate hcl oral tablet Generic QL

Drug Name Drug Tier Requirements / Limits methylphenidate hcl oral tablet extended release Generic QL methylphenidate hcl oral tablet extended release Generic QL 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable Generic QL midazolam oral syrup 2 mg/ml Generic mirtazapine Generic modafinil Generic PA; QL molindone Generic nortriptyline Generic olanzapine oral Generic olanzapine-fluoxetine Generic oxazepam Generic paliperidone Generic paroxetine hcl oral tablet Generic paroxetine hcl oral tablet extended release 24 hr Generic perphenazine Generic perphenazine-amitriptyline Generic phenelzine Generic pimozide Generic procentra Generic QL protriptyline Generic quetiapine Generic ramelteon Generic PA; QL RISPERDAL CONSTA Brand PA risperidone oral solution Generic risperidone oral tablet Generic risperidone oral tablet,disintegrating Generic seconal sodium Generic QL SECUADO Brand PA; QL sertraline Generic temazepam oral capsule 15 mg, 30 mg Generic thioridazine Generic thiothixene Generic tranylcypromine Generic trazodone Generic

Drug Name Drug Tier Requirements / Limits trifluoperazine Generic trimipramine Generic venlafaxine oral capsule,extended release 24hr Generic venlafaxine oral tablet Generic venlafaxine oral tablet extended release 24hr 225 Generic mg VYVANSE Brand ST; QL XYREM Brand PA zaleplon Generic QL zenzedi oral tablet 10 mg, 5 mg Generic QL ziprasidone hcl Generic zolpidem oral tablet Generic QL CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral Generic dofetilide Generic flecainide Generic mexiletine Generic pacerone oral tablet 100 mg, 200 mg, 400 mg Generic propafenone Generic quinidine gluconate oral Generic quinidine sulfate oral tablet Generic sorine Generic sotalol af Generic sotalol oral Generic SOTYLIZE Brand ANTIHYPERTENSIVE THERAPY acebutolol Generic amiloride Generic amiloride-hydrochlorothiazide Generic amlodipine Generic amlodipine-benazepril Generic amlodipine-valsartan Generic amlodipine-valsartan-hcthiazid Generic

Drug Name Drug Tier Requirements / Limits atenolol Generic atenolol-chlorthalidone Generic benazepril Generic benazepril-hydrochlorothiazide Generic betaxolol oral Generic bisoprolol fumarate Generic bisoprolol-hydrochlorothiazide Generic bumetanide oral Generic captopril-hydrochlorothiazide Generic cartia xt Generic carvedilol Generic chlorthalidone oral tablet 25 mg, 50 mg Generic clonidine Generic QL clonidine hcl oral tablet Generic diltiazem hcl oral Generic dilt-xr Generic doxazosin Generic QL enalapril maleate oral tablet Generic enalapril-hydrochlorothiazide Generic epoprostenol (glycine) Generic PA ethacrynic acid Generic felodipine Generic fosinopril-hydrochlorothiazide Generic furosemide injection solution Generic furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 Generic mg/ml) furosemide oral tablet Generic guanfacine oral tablet Generic hydralazine oral Generic hydrochlorothiazide Generic indapamide Generic irbesartan Generic irbesartan-hydrochlorothiazide Generic isradipine Generic labetalol oral Generic

Drug Name Drug Tier Requirements / Limits lisinopril Generic lisinopril-hydrochlorothiazide Generic losartan Generic losartan-hydrochlorothiazide Generic matzim la Generic methyldopa Generic methyldopa-hydrochlorothiazide Generic metolazone Generic metoprolol succinate Generic metoprolol tartrate oral Generic metyrosine Generic PA minoxidil oral Generic moexipril Generic nadolol Generic nadolol-bendroflumethiazide oral tablet 80-5 mg Generic nifedipine oral tablet extended release Generic nifedipine oral tablet extended release 24hr Generic olmesartan-amlodipin-hcthiazid Generic perindopril erbumine Generic phenoxybenzamine Generic PA pindolol Generic prazosin Generic propranolol oral Generic propranolol-hydrochlorothiazid Generic quinapril Generic quinapril-hydrochlorothiazide Generic ramipril Generic REMODULIN Brand PA spironolactone Generic spironolacton-hydrochlorothiaz Generic taztia xt Generic terazosin Generic QL tiadylt er Generic timolol maleate oral Generic

Drug Name Drug Tier Requirements / Limits torsemide oral Generic trandolapril Generic trandolapril-verapamil Generic triamterene-hydrochlorothiazid oral capsule 37.5- Generic 25 mg triamterene-hydrochlorothiazid oral tablet Generic UPTRAVI ORAL Brand PA valsartan Generic valsartan-hydrochlorothiazide Generic veletri Generic PA verapamil oral Generic CARDIAC GLYCOSIDES digitek Generic digox Generic digoxin oral Generic COAGULATION THERAPY ADVATE Brand PA ADYNOVATE Brand PA ALPHANATE Brand PA ALPROLIX Brand PA aminocaproic acid oral Generic BENEFIX Brand PA BRILINTA Brand cilostazol Generic clopidogrel Generic CORIFACT Brand PA dipyridamole oral Generic ELIQUIS Brand ELIQUIS DVT-PE TREAT 30D START Brand ELOCTATE Brand PA enoxaparin Generic FEIBA NF Brand PA fondaparinux Generic heparin (porcine) injection solution Generic HUMATE-P Brand PA

Drug Name Drug Tier Requirements / Limits IXINITY Brand PA jantoven Generic MONONINE Brand PA MULPLETA Brand PA; QL NOVOSEVEN RT Brand PA pentoxifylline Generic PHYTONADIONE (VITAMIN K1) ORAL Brand OTC TABLET 100 MCG phytonadione (vitamin k1) oral tablet 5 mg Generic PROFILNINE Brand PA PROMACTA Brand PA RECOMBINATE Brand PA RIASTAP Brand PA TRETTEN Brand PA VONVENDI Brand PA warfarin Generic XARELTO Brand XARELTO DVT-PE TREAT 30D START Brand XYNTHA Brand PA XYNTHA SOLOFUSE Brand PA LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin Generic QL atorvastatin Generic QL cholestyramine (with sugar) Generic cholestyramine light Generic colestipol Generic endur-acin Generic OTC ezetimibe Generic QL fenofibrate micronized Generic fenofibrate nanocrystallized oral tablet 145 mg, 48 Generic mg fenofibrate oral tablet 160 mg, 54 mg Generic fenofibric acid Generic fenofibric acid (choline) Generic gemfibrozil Generic

Drug Name Drug Tier Requirements / Limits JUXTAPID Brand PA lovastatin Generic QL maxepa Generic OTC NEXLETOL Brand PA; QL niacin (inositol niacinate) oral capsule 500 mg Generic OTC niacin (niacinamide) Generic OTC niacin oral capsule, extended release Generic OTC niacin oral tablet Generic OTC NIACIN ORAL TABLET EXTENDED Brand OTC RELEASE 1,000 MG niacin oral tablet extended release 24 hr Generic niacin oral tablet extended release 250 mg, 500 Generic OTC mg, 750 mg niacinamide oral tablet Generic OTC omega-3 acid ethyl esters Generic PA PRALUENT PEN Brand PA pravastatin Generic QL prevalite Generic REPATHA PUSHTRONEX Brand PA REPATHA SURECLICK Brand PA REPATHA SYRINGE Brand PA rosuvastatin Generic QL simvastatin oral tablet Generic QL SLO-NIACIN ORAL TABLET EXTENDED Brand OTC RELEASE 250 MG, 750 MG slo-niacin oral tablet extended release 500 mg Generic OTC MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR Brand PA ENTRESTO Brand VYNDAMAX Brand PA; QL VYNDAQEL Brand PA; QL NITRATES isosorbide dinitrate oral tablet Generic isosorbide mononitrate Generic nitro-bid Generic

Drug Name Drug Tier Requirements / Limits nitroglycerin oral capsule, extended release 6.5 Generic mg, 9 mg nitroglycerin sublingual Generic nitroglycerin transdermal patch 24 hour Generic nitro-time Generic DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin Generic calcipotriene scalp Generic QL calcipotriene topical cream Generic QL calcipotriene topical ointment Generic QL SKYRIZI SUBCUTANEOUS SYRINGE KIT Brand PA; QL BURN THERAPY silver sulfadiazine Generic ssd Generic KERATOLYTICS sulfo-lo Generic OTC MISCELLANEOUS DERMATOLOGICALS 4-n-1 no rinse wash topical cream Generic OTC advanced healing (petrolatum) Generic OTC ALOE VESTA PROTECTANT OINTMENT Brand OTC amerigel Generic OTC antiseptic skin clnsr(chlorhe) Generic OTC aqua care Generic OTC aqua glycolic face Generic OTC aqua glycolic topical shampoo Generic OTC AQUA LUBE Brand OTC AQUANIL SKIN CLEANSER Brand OTC AQUAPHOR HEALING Brand OTC AQUAPHOR ORIGINAL Brand OTC astringent Generic OTC AVEENO DAILY MOISTURIZING Brand OTC baby wash Generic OTC benzoin Generic OTC

Drug Name Drug Tier Requirements / Limits benzoin compound topical tincture 10-2-8-4 % Generic OTC BETAMIDE Brand OTC betasept surgical scrub Generic OTC boro-packs Generic OTC BOUDREAUXS BUTT PASTE TOPICAL Brand OTC OINTMENT calamine phenolated Generic OTC calamine-zinc oxide topical lotion 8-8 % Generic OTC calamine-zinc oxide-phenol Generic OTC calmoseptine topical ointment Generic OTC CAVILON DURABLE BARRIER Brand OTC CERAVE FOAMING FACIAL Brand OTC CERAVE TOPICAL CLEANSER Brand OTC cetaphil gentle cleanser Generic OTC CETAPHIL TOPICAL BAR Brand OTC CETAPHIL TOPICAL CLEANSER Brand OTC chlorhexidine gluconate topical liquid Generic OTC clear anti-itch Generic OTC conti castile soap Generic OTC cool bottoms Generic OTC CUTEMOL Brand OTC dermabase Generic OTC dermamed (aluminum hydroxide) Generic OTC DERMAPHOR TOPICAL OINTMENT 44 % Brand OTC DESITIN Brand OTC DESITIN MULTI-PURPOSE Brand OTC DESITIN RAPID RELIEF Brand OTC diaper rash topical ointment Generic OTC DIAPER RASH TOPICAL PASTE Brand OTC DOMEBORO Brand OTC doxepin topical Generic PA; QL DR. SMITH'S DIAPER Brand OTC DUPIXENT PEN SUBCUTANEOUS PEN Brand PA INJECTOR 300 MG/2 ML DUPIXENT SYRINGE Brand PA

Drug Name Drug Tier Requirements / Limits emollient Generic OTC finger cream Generic OTC fluorouracil topical cream 5 % Generic fluorouracil topical solution Generic gentle skin cleanser Generic OTC gormel Generic OTC gormel ten Generic OTC green soap Generic OTC hand wash Generic OTC hibiclens Generic OTC HYDROPHOR Brand OTC imiquimod topical cream in packet 5 % Generic iodine-sodium iodide topical tincture 2 % Generic methoxsalen Generic moisture barrier ointment Generic OTC MONSEL'S Brand neutraphor Generic OTC NEUTROGENA ACNE CLEANSING SOAP Brand OTC NEUTROGENA FACIAL SOAP Brand OTC NEUTROGENA TOPICAL SHAMPOO Brand OTC ocusoft hand soap Generic OTC pediatric oint (cod liver oil) Generic OTC PEDI-BORO SOAK Brand OTC PERIANAL CLEANSING Brand OTC PERIFRESH Brand OTC petrolatum, yellow (bulk) Generic OTC podofilox Generic PRETTY FEET HANDS Brand OTC PROSHIELD FOAM/SPRAY CLEANSER Brand OTC prudoxin Generic PA; QL REGRANEX Brand PA; QL remedy cleansing body Generic OTC REMEDY NUTRASHIELD SKIN PROTEC Brand OTC risamine Generic OTC

Drug Name Drug Tier Requirements / Limits SAF-CLENS AF DERMAL WOUND Brand SECURA EXTRA PROTECTIVE Brand OTC skin cleanser Generic OTC sorbidon hydrate Generic OTC SWEEN 24 Brand OTC tacrolimus topical Generic ST; QL theraseal Generic OTC TRIAD WOUND DRESSING Brand OTC ultra mide 25 Generic OTC vanicream Generic OTC vitamin a and d diaper rash Generic OTC walgreens dry skin treatment Generic OTC WHITE PETROLATUM TOPICAL GEL Brand OTC white petroleum jelly Generic OTC witch hazel topical liquid Generic OTC zinc oxide topical ointment Generic OTC THERAPY FOR ACNE amnesteem Generic avita topical cream Generic PA claravis Generic clindacin p Generic clindamycin phosphate topical solution Generic QL clindamycin phosphate topical swab Generic ery pads Generic erythromycin with ethanol topical solution Generic metronidazole topical Generic myorisan Generic rosadan topical cream Generic rosadan topical gel Generic rosula cleansing cloths Generic tazarotene topical cream Generic PA TAZORAC TOPICAL CREAM 0.05 % Brand PA TAZORAC TOPICAL GEL Brand PA tretinoin Generic PA

Drug Name Drug Tier Requirements / Limits zenatane Generic TOPICAL ANESTHETICS ASPERCREME (LIDOCAINE) TOPICAL Brand PA; OTC ADHESIVE PATCH,MEDICATED glydo Generic QL lidocaine hcl laryngotracheal Generic lidocaine hcl mucous membrane jelly Generic QL lidocaine hcl mucous membrane jelly in applicator Generic QL lidocaine hcl mucous membrane solution 4 % (40 Generic mg/ml) lidocaine hcl-hydrocortison ac topical Generic LIDOCAINE PAIN RELIEF TOPICAL Brand PA; OTC ADHESIVE PATCH,MEDICATED lidocaine topical adhesive patch,medicated 5 % Generic PA lidocaine viscous Generic lidocaine-prilocaine topical cream Generic QL lidocaine-prilocaine topical kit Generic LIDOCARE Brand PA; OTC lta pre-attached Generic TOPICAL ANTIBACTERIALS antibiotic (bacitracin zinc) Generic OTC antibiotic (neomy-bacit-polym) Generic OTC ANTIBIOTIC PLUS (PRAMOXINE) Brand OTC antibiotic-pain relief (bacit) Generic OTC antiseptic Generic OTC bacitracin topical Generic OTC bacitracin zinc topical ointment Generic OTC BACITRACIN ZINC TOPICAL OINTMENT IN Brand OTC PACKET bacitraycin plus topical ointment 500 unit/gram Generic OTC BETADINE SURGICAL SCRUB Brand OTC BETADINE SWABSTICKS Brand OTC BETADINE TOPICAL SOLUTION Brand OTC BETADINE TOPICAL SPRAY,NON-AEROSOL Brand OTC DOUBLE ANTIBIOTIC (B.TRACN ZN) Brand OTC TOPICAL OINTMENT

Drug Name Drug Tier Requirements / Limits first aid antibiotic-pain rlf Generic OTC first aid antiseptic(povidone) topical solution Generic OTC gentamicin topical Generic mafenide acetate Generic multi antibiotic plus Generic OTC mupirocin Generic QL NEOSPORIN (NEO-BAC-POLYM) TOPICAL Brand OTC OINTMENT NEOSPORIN PLUS PAIN RELIEF Brand OTC POLY BACITRACIN (ZINC) Brand OTC POLYSPORIN (BACITRACIN ZINC) Brand OTC povidone-iodine topical liquid in packet Generic OTC povidone-iodine topical ointment Generic OTC povidone-iodine topical solution Generic OTC povidone-iodine topical spray,non-aerosol Generic OTC povidone-iodine topical swab Generic OTC SILVASORB Brand OTC SILVERMED TOPICAL GEL,EXTENDED Brand OTC RELEASE strong iodine topical Generic SULFAMYLON TOPICAL CREAM Brand triple antibiotic plus Generic OTC triple antibiotic topical ointment Generic OTC TRIPLE ANTIBIOTIC TOPICAL OINTMENT Brand OTC IN PACKET triple antibiotic-pain relief Generic OTC wal-sporin Generic OTC TOPICAL ANTIFUNGALS ALOE VESTA ANTIFUNGAL (MICON) Brand OTC anti-fungal Generic OTC antifungal (clotrimazole) Generic OTC antifungal (tolnaftate) topical aerosol,spray Generic OTC antifungal (tolnaftate) topical cream Generic OTC ANTIFUNGAL CREAM (MICONAZOLE) Brand OTC antifungal spray Generic OTC

Drug Name Drug Tier Requirements / Limits athlete's foot (clotrimazole) Generic OTC ATHLETE'S FOOT (TERBINAFINE) Brand OTC athlete's foot (tolnaftate) Generic OTC athlete's foot topical aerosol powder Generic OTC athlete's foot topical powder Generic OTC athletic foot cream Generic OTC azolen tincture Generic OTC baza antifungal Generic OTC blis-to-sol (tolnaftate) Generic OTC ciclodan topical cream Generic QL ciclodan topical solution Generic ciclopirox topical cream Generic QL ciclopirox topical gel Generic QL ciclopirox topical solution Generic clotrimazole topical cream Generic QL clotrimazole-betamethasone topical cream Generic QL critic-aid clear af(miconazol) Generic OTC desenex Generic OTC foot and sneaker Generic OTC formula 3 Generic OTC fungoid tincture topical tincture Generic OTC fungoid-d Generic OTC inzo antifungal Generic OTC itch relief (clotrimazole) Generic OTC jock itch Generic OTC jock itch (clotrimazole) Generic OTC jock itch (terbinafine) Generic OTC ketoconazole topical cream Generic QL ketoconazole topical shampoo Generic QL ketodan Generic QL lamisil af Generic OTC lamisil at Generic OTC LOTRIMIN AF Brand OTC LOTRIMIN AF (CLOTRIMAZOLE) TOPICAL Brand OTC CREAM

Drug Name Drug Tier Requirements / Limits lotrimin af powder Generic OTC LOTRIMIN ULTRA Brand OTC micatin Generic OTC miconazole nitrate topical Generic OTC miconazorb af Generic OTC micro-guard Generic OTC NIZORAL A-D Brand OTC nyamyc Generic QL nystatin topical Generic QL nystop Generic QL odor control foot-sneaker Generic OTC remedy antifungal Generic OTC remedy phytoplex antifungal topical powder Generic OTC secura antifungal Generic OTC sween prep Generic OTC terbinafine hcl topical Generic OTC tinactin topical aerosol powder Generic OTC TINACTIN TOPICAL AEROSOL,SPRAY Brand OTC TINACTIN TOPICAL CREAM Brand OTC tolnaftate Generic OTC TOPICAL ANTIVIRALS ABREVA Brand OTC TOPICAL CORTICOSTEROIDS ala-cort topical cream 1 % Generic anti-itch (hc) topical cream Generic OTC anti-itch (hc) topical ointment Generic OTC ANTI-ITCH PLUS Brand OTC AQUANIL HC Brand OTC beta-hc Generic OTC betamethasone dipropionate Generic betamethasone valerate topical cream Generic betamethasone valerate topical lotion Generic betamethasone valerate topical ointment Generic betamethasone, augmented topical cream Generic

Drug Name Drug Tier Requirements / Limits clobetasol scalp Generic QL cortisone (hydrocortisone) topical cream Generic OTC cortisone with aloe Generic OTC cortizone-10 topical cream Generic OTC cortizone-10 topical gel Generic OTC cortizone-10 topical ointment Generic OTC dermarest eczema (hydrocort) Generic OTC fluocinolone topical cream 0.025 % Generic fluocinolone topical ointment Generic fluocinonide topical cream 0.05 % Generic QL fluocinonide topical solution Generic QL fluticasone propionate topical cream Generic fluticasone propionate topical ointment Generic hydrocortisone acetate topical cream Generic OTC hydrocortisone acetate topical ointment Generic OTC hydrocortisone plus Generic OTC hydrocortisone topical cream 0.5 % Generic OTC hydrocortisone topical cream 1 %, 2.5 % Generic hydrocortisone topical lotion 1 % Generic OTC hydrocortisone topical lotion 2.5 % Generic hydrocortisone topical ointment 0.5 % Generic OTC hydrocortisone topical ointment 1 %, 2.5 % Generic hydrocortisone-aloe vera Generic OTC hydrocream Generic OTC mometasone topical Generic noble formula hc topical cream Generic OTC prednicarbate Generic PREPARATION H HYDROCORTISONE Brand OTC scalacort Generic scalpicin anti-itch Generic OTC soothing care (hydrocortisone) Generic OTC triamcinolone acetonide topical cream Generic triamcinolone acetonide topical lotion Generic triamcinolone acetonide topical ointment 0.025 %, Generic 0.1 %, 0.5 %

Drug Name Drug Tier Requirements / Limits triderm topical cream 0.1 % Generic triderm topical cream 0.5 % Generic ST TOPICAL ENZYMES SANTYL Brand QL TOPICAL SCABICIDES / PEDICULICIDES complete lice treatment Generic OTC lice bedding spray Generic OTC lice complete kit 1-2-3 Generic OTC lice killing Generic OTC lice killing (permethrin) Generic OTC lice pyrinyl shampoo Generic OTC lice solution Generic OTC lice treatment Generic OTC NIX CREME RINSE Brand OTC noble formula topical bar Generic OTC permethrin Generic RID COMPLETE LICE ELIM KIT Brand OTC rid complete lice elim kit topical Generic OTC RID LICE KILLING Brand OTC DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS acamprosate Generic ACD-A SOLUTION 2.45-2.2 GRAM- 730 Brand MG/100 ML anagrelide Generic ANASEPT SKIN-WOUND CLEANSER Brand OTC ANASEPT TOPICAL Brand OTC ANTICOAG CITRATE PHOS DEXTROSE Brand ARALAST NP Brand PA caffeine citrate oral Generic CARBAGLU Brand cevimeline Generic CHEMET Brand corn starch Generic OTC

Drug Name Drug Tier Requirements / Limits cryoserv Generic DAKIN'S SOLUTION SOLUTION 0.125 %, 0.25 Brand OTC % dakin's solution solution 0.5 % Generic OTC deferasirox Generic PA deferiprone Generic deferoxamine Generic dex4 glucose bits Generic OTC dex4 glucose oral gel Generic OTC dex4 glucose oral tablet,chewable Generic OTC DI-DAK-SOL Brand OTC diluent for epoprostenol/flola Generic disulfiram Generic ENDARI Brand PA; QL ENFAMIL GLUCOSE Brand OTC enfamil water Generic OTC etidronate disodium oral tablet 200 mg Generic FERRIPROX Brand PA forane Generic gerber good start water Generic OTC gluco burst Generic OTC GLUCOSAMINE HCL ORAL TABLET 1,500 Brand OTC MG glucose Generic OTC glucose bits Generic OTC glucose gel Generic OTC GLUTOSE-15 Brand OTC h-chlor 12 Generic OTC H-CHLOR 6 Brand OTC hydrogen peroxide Generic OTC hysept Generic OTC INCRELEX Brand PA isoflurane Generic l-carnitine oral Generic OTC levocarnitine (with sugar) Generic

Drug Name Drug Tier Requirements / Limits levocarnitine oral tablet Generic midodrine Generic mineral oil Generic OTC MINERAL OIL HEAVY Brand OTC MURI-LUBE Brand nitisinone Generic PA ORFADIN ORAL CAPSULE 20 MG Brand PA ORFADIN ORAL SUSPENSION Brand PA OXBRYTA Brand PA; QL pilocarpine hcl oral Generic RAVICTI Brand riluzole Generic PA risedronate oral tablet 30 mg Generic QL safe wash Generic OTC saline wound wash Generic OTC sevelamer carbonate Generic sevoflurane Generic similac sterilized water Generic OTC sodium ferric gluconat-sucrose Generic sodium phenylbutyrate Generic sodium polystyrene sulfonate oral powder Generic soothe and cool body powder Generic OTC sps (with sorbitol) Generic terrell Generic THYROGEN Brand PA VELTASSA Brand PA XURIDEN Brand PA ZEMAIRA Brand PA MISCELLANEOUS DEVICES dy-o-derm Generic OTC INSTACLEAN Brand OTC NEUTRACEUTICALS arnica Generic OTC complete premium vitamin Generic OTC

Drug Name Drug Tier Requirements / Limits flaxseed oil Generic OTC garlic oral capsule 1,000 mg, 1,500 mg, 500 mg Generic OTC ODORLESS GARLIC ORAL CAPSULE Brand OTC omega-3 flaxseed oil Generic OTC SMOKING DETERRENTS bupropion hcl (smoking deter) Generic NICODERM CQ Brand OTC NICORETTE Brand OTC nicotine Generic OTC nicotine (polacrilex) buccal gum Generic OTC NICOTINE (POLACRILEX) BUCCAL Brand OTC LOZENGE NICOTINE (POLACRILEX) BUCCAL MINI Brand OTC LOZENGE 2 MG nicotine (polacrilex) buccal mini lozenge 4 mg Generic OTC NICOTROL Brand NICOTROL NS Brand quit 2 Generic OTC quit 4 Generic OTC stop smoking aid Generic OTC EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS 12 hour nasal spray Generic OTC 4 way Generic OTC AFRIN (OXYMETAZOLINE) NASAL MIST Brand OTC afrin no drip(oxymetazolin) Generic OTC AFRIN SINUS (OXYMETAZOLINE) Brand OTC altamist Generic OTC anefrin Generic OTC anti-itch medicated Generic OTC ayr saline nasal aerosol,spray Generic OTC ayr saline nasal drops Generic OTC ayr saline nasal neti rinse Generic OTC AYR SINUS RINSE Brand OTC AYR SINUS RINSE REFILL Brand OTC

Drug Name Drug Tier Requirements / Limits azelastine nasal Generic QL baby ayr saline Generic OTC children's saline nasal spray Generic OTC chlorhexidine gluconate mucous membrane Generic decongestant inhaler Generic OTC deep sea nasal Generic OTC denta 5000 plus Generic dentagel Generic dristan long lasting Generic OTC ephrine Generic OTC FAST ACTING NASAL Brand OTC fluoride (sodium) dental cream Generic fluoride (sodium) dental gel Generic fluoride (sodium) dental solution Generic GOLD BOND MEDICATED ANTI-ITCH Brand OTC ipratropium bromide nasal Generic QL LITTLE NOSES Brand OTC little remedies Generic OTC mucinex sinus-max Generic OTC nasadock plus kit Generic OTC nasaflo porcelain kit Generic OTC nasal decongestant (oxymetazl) Generic OTC nasal four Generic OTC nasal mist Generic OTC nasal moisturizing Generic OTC nasal relief sinus wash w/neti Generic OTC nasal relief sinus wash-bottle Generic OTC nasal spray (oxymetazoline) Generic OTC nasal spray (sodium chloride) Generic OTC nasal spray 12hr(oxymetazoline nasal mist Generic OTC nasal spray long acting Generic OTC neilmed nasaflo Generic OTC neilmed pediat sinus rinse ref Generic OTC neilmed sinus rinse complete Generic OTC

Drug Name Drug Tier Requirements / Limits neilmed sinus rinse refill Generic OTC NEO-SYNEPHRINE (PHENYLEPHRINE) Brand OTC no drip Generic OTC nose drops Generic OTC ocean nasal Generic OTC olopatadine nasal Generic QL oralone Generic original nasal spray Generic OTC oxymetazoline Generic OTC periogard Generic saline mist Generic OTC saline nasal Generic OTC sf Generic sf 5000 plus Generic sinugator nasal wash kit Generic OTC sinus nasal spray Generic OTC sinus relief (oxymetazoline) Generic OTC sinus rinse pediatric Generic OTC sinus rinse pediatric starter Generic OTC sinus wash sinus irrigation packet Generic OTC SINUS WASH SINUS IRRIGATION PACKET Brand OTC 700-2,300 MG triamcinolone acetonide dental Generic vicks qlearquil(oxymetazoline) Generic OTC vicks sinex 12-hour Generic OTC vicks sinex ultra fine mist 12 Generic OTC wal-four Generic OTC MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) Generic ciprofloxacin hcl otic (ear) Generic fluocinolone acetonide oil Generic ofloxacin otic (ear) Generic OTIC STEROID / ANTIBIOTIC neomycin-polymyxin-hc otic (ear) Generic

Drug Name Drug Tier Requirements / Limits ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR Brand PA dexamethasone intensol Generic dexamethasone oral elixir Generic dexamethasone oral solution Generic dexamethasone oral tablet Generic dexamethasone sodium phos (pf) injection solution Generic dexamethasone sodium phosphate injection Generic EMFLAZA Brand PA fludrocortisone Generic hydrocortisone oral Generic methylprednisolone Generic methylprednisolone acetate Generic millipred dp Generic prednisolone oral solution Generic prednisolone sodium phosphate oral solution 10 Generic mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone Generic prednisone intensol Generic veripred 20 Generic ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg Generic propylthiouracil Generic DIABETES THERAPY acarbose Generic ACD-A SOLUTION Brand ADMELOG SOLOSTAR U-100 INSULIN Brand ADMELOG U-100 INSULIN LISPRO Brand BASAGLAR KWIKPEN U-100 INSULIN Brand BYDUREON BCISE Brand PA; QL CAYA CONTOURED Brand QL diazoxide Generic

Drug Name Drug Tier Requirements / Limits FEMCAP VAGINAL DEVICE 22 MM Brand QL glimepiride Generic glipizide Generic glipizide-metformin Generic GLUCAGEN HYPOKIT Brand GLUCAGON (HCL) EMERGENCY KIT Brand GLUCAGON EMERGENCY KIT (HUMAN) Brand glyburide Generic glyburide micronized Generic glyburide-metformin Generic GLYXAMBI Brand ST; QL HUMALOG MIX 50-50 INSULN U-100 Brand HUMALOG MIX 50-50 KWIKPEN Brand HUMALOG MIX 75-25 KWIKPEN Brand HUMALOG MIX 75-25(U-100)INSULN Brand HUMULIN 70/30 U-100 INSULIN Brand HUMULIN 70/30 U-100 KWIKPEN Brand HUMULIN N NPH INSULIN KWIKPEN Brand HUMULIN N NPH U-100 INSULIN Brand HUMULIN R REGULAR U-100 INSULN Brand HUMULIN R U-500 (CONC) INSULIN Brand HUMULIN R U-500 (CONC) KWIKPEN Brand JANUMET Brand ST; QL JANUMET XR Brand ST; QL JANUVIA Brand ST; QL JARDIANCE Brand ST; QL metformin oral tablet Generic metformin oral tablet extended release 24 hr Generic QL miglitol Generic nateglinide Generic pioglitazone Generic QL pioglitazone-glimepiride Generic QL pioglitazone-metformin Generic QL repaglinide Generic

Drug Name Drug Tier Requirements / Limits repaglinide-metformin Generic QL SEGLUROMET Brand ST; QL STEGLATRO Brand ST; QL SYMLINPEN 120 Brand PA; QL SYMLINPEN 60 Brand PA; QL SYNJARDY Brand ST; QL SYNJARDY XR Brand ST; QL MISCELLANEOUS HORMONES cabergoline Generic QL calcitonin (salmon) nasal Generic calcitriol oral Generic CERDELGA Brand cinacalcet Generic PA clomiphene citrate Generic PA danazol Generic desmopressin injection Generic desmopressin oral Generic doxercalciferol oral Generic ELAPRASE Brand PA GALAFOLD Brand PA; QL JYNARQUE ORAL TABLET Brand PA; QL JYNARQUE ORAL TABLETS, SEQUENTIAL Brand PA METHITEST Brand PA methyltestosterone oral capsule Generic PA miglustat Generic MYALEPT Brand NATPARA Brand PA ORILISSA Brand PA; QL oxandrolone Generic PA pamidronate Generic SAMSCA ORAL TABLET 15 MG Brand PA; QL sapropterin Generic PA serophene Generic PA SOMAVERT Brand

Drug Name Drug Tier Requirements / Limits STRENSIQ Brand PA testosterone cypionate intramuscular oil 100 Generic PA mg/ml, 200 mg/ml testosterone enanthate Generic PA testosterone transdermal gel in metered-dose Generic PA pump 10 mg/0.5 gram /actuation, 20.25 mg/1.25 gram (1.62 %) testosterone transdermal gel in metered-dose Generic PA; QL pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 Generic PA; QL mg/2.5gram), 1 % (50 mg/5 gram) testosterone transdermal gel in packet 1.62 % Generic PA (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram) tolvaptan oral tablet 30 mg Generic PA; QL VPRIV Brand PA zoledronic acid intravenous solution Generic PA THYROID HORMONES ARMOUR THYROID Brand euthyrox Generic levo-t Generic levothyroxine oral tablet Generic levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, Generic 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral Generic np thyroid Generic THYROLAR-1 Brand THYROLAR-1/2 Brand THYROLAR-1/4 Brand THYROLAR-2 Brand THYROLAR-3 Brand unithroid Generic westhroid Generic GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS acidophilus-pectin oral capsule Generic OTC

Drug Name Drug Tier Requirements / Limits ACIDOPHILUS-PECTIN, CITRUS ORAL Brand OTC TABLET anaspaz Generic anti-diarrheal Generic OTC anti-diarrheal (loperamide) Generic OTC BACID Brand OTC belladonna alkaloids-opium Generic PA bismatrol oral tablet,chewable Generic OTC bismuth oral tablet,chewable Generic OTC diamode Generic OTC diarrhea relief (bismuth subs) Generic OTC dicyclomine oral capsule Generic dicyclomine oral solution Generic dicyclomine oral tablet Generic DIGESTIVE PROBIOTIC ORAL CAPSULE 10 Brand OTC BILLION CELL digestive relief oral tablet Generic OTC diotame Generic OTC diphenoxylate-atropine Generic ed-spaz Generic florastor Generic OTC geri-pectate Generic OTC glycopyrrolate injection Generic glycopyrrolate oral tablet 1 mg, 2 mg Generic hyoscyamine sulfate oral Generic hyoscyamine sulfate sublingual Generic hyosyne Generic IMODIUM A-D ORAL LIQUID Brand OTC IMODIUM A-D ORAL TABLET Brand OTC IMODIUM MULTI-SYMPTOM RELIEF Brand OTC kaopectate (bismuth subsalicy) oral suspension Generic OTC kaopectate ex str (bismuth ss) Generic OTC k-pec antidiarrheal (bism sub) Generic OTC l.acidophilus-bifido.longum oral capsule,delayed Generic OTC release(dr/ec) 16 mg

Drug Name Drug Tier Requirements / Limits loperamide oral capsule Generic loperamide oral liquid 1 mg/7.5 ml Generic OTC loperamide oral tablet Generic OTC ONE-A-DAY TRUBIOTICS Brand OTC oscimin oral tablet Generic oscimin sl Generic oscimin sr Generic peptic relief Generic OTC PEPTO-BISMOL MAX ST Brand OTC PEPTO-BISMOL ORAL SUSPENSION Brand OTC PEPTO-BISMOL ORAL TABLET Brand OTC pepto-bismol to-go Generic OTC PHILLIPS' COLON HEALTH Brand OTC pink bismuth Generic OTC pink bismuth maximum strength Generic OTC probiotic colon care Generic OTC probiotic oral capsule 20 billion cell, 3 billion cell Generic OTC probiotic oral capsule, sprinkle 20 billion cell Generic OTC RISA-BID Brand OTC risaquad Generic OTC risaquad-2 Generic OTC soothe (bismuth subsalicylate) Generic OTC soothe regular strength Generic OTC stomach relief Generic OTC super probiotic Generic OTC symax fastabs Generic symax-sl Generic symax-sr Generic MISCELLANEOUS GASTROINTESTINAL AGENTS acid gone antacid Generic OTC acid gone antacid e.strength Generic OTC advanced antacid-antigas Generic OTC almacone-2 Generic OTC alophen (bisacodyl) Generic OTC

Drug Name Drug Tier Requirements / Limits alosetron Generic aluminum hydroxide gel oral suspension 320 mg/5 Generic OTC ml antacid (calcium carb-mag hyd) oral Generic OTC tablet,chewable 550-110 mg ANTACID ANTI-GAS (CA CARB-SIM) Brand OTC antacid anti-gas oral suspension 400-400-40 mg/5 Generic OTC ml antacid exst (mag carb-al hyd) Generic OTC antacid m Generic OTC antacid maximum strength Generic OTC antacid plus anti-gas Generic OTC antacid regular strength Generic OTC antacid supreme Generic OTC antacid ultra strength oral tablet,chewable 470 mg Generic OTC calcium (1,177 mg) antacid-antigas oral suspension 200-200-20 mg/5 Generic OTC ml antacid-simethicone Generic OTC anti-nausea Generic OTC aprepitant Generic QL BEANO ORAL TABLET Brand OTC BENEFIBER SUGAR FREE (DEXTRIN) ORAL Brand OTC POWDER best fiber Generic OTC bisacodyl rectal Generic OTC bisa-lax (bisacodyl) Generic OTC budesonide oral capsule,delayed,extend.release Generic castor oil Generic OTC CHENODAL Brand PA children's pepto Generic OTC children's soothe Generic OTC chocolate laxative Generic OTC CHOLBAM ORAL CAPSULE 250 MG Brand PA CHOLBAM ORAL CAPSULE 50 MG Brand PA; QL citrate of magnesia Generic OTC

Drug Name Drug Tier Requirements / Limits citroma Generic OTC citrucel Generic OTC CITRUCEL (SUCROSE) Brand OTC CITRUCEL SUGAR FREE Brand OTC clearlax oral powder Generic OTC COLACE Brand OTC col-rite Generic OTC comfort gel Generic OTC comfort gel extra strength Generic OTC compro Generic constulose Generic CORRECTOL Brand OTC CORTIFOAM Brand CREON Brand cromolyn oral Generic CYSTADANE Brand dimenhydrinate oral Generic OTC diocto Generic OTC docu Generic OTC docuprene Generic OTC DOCUSATE CALCIUM Brand OTC docusate sodium oral capsule Generic OTC docusate sodium oral liquid Generic OTC docusate sodium oral tablet Generic OTC DOCUSOL Brand OTC dok oral capsule 100 mg Generic OTC dok oral tablet Generic OTC dramamine less drowsy Generic OTC dramamine oral tablet Generic OTC driminate Generic OTC dss Generic OTC dulcoease Generic OTC DULCOLAX (BISACODYL) Brand OTC EMEND ORAL SUSPENSION FOR Brand QL RECONSTITUTION

Drug Name Drug Tier Requirements / Limits EMETROL Brand OTC enema Generic OTC enema disposable Generic OTC ENEMEEZ Brand OTC ENEMEEZ PLUS Brand OTC enulose Generic epsom salt (laxative) Generic OTC evac-u-gen (sennosides) Generic OTC EX-LAX (SENNOSIDES) Brand OTC EX-LAX MAXIMUM STRENGTH Brand OTC fiber (calcium polycarbophil) Generic OTC fiber (dextrin) Generic OTC fiber (psyllium husk) oral capsule 0.52 gram Generic OTC fiber (psyllium husk-sugar) oral powder 3.4 Generic OTC gram/12 gram, 3.4 gram/7 gram fiber (with aspartame) oral powder 3.4 gram/5.8 Generic OTC gram fiber laxative (ca polycarbo) Generic OTC fiber laxative (methylcellulo) Generic OTC fiber laxative (psyllium husk) Generic OTC fiber supplement (inulin) Generic OTC fiber therapy (ca polycarboph) Generic OTC fiber therapy (m-cell/sugar) Generic OTC fiber therapy (m-cellulose) Generic OTC fiber therapy laxative (husk) Generic OTC FIBERCON Brand OTC fiber-tabs Generic OTC fleet enema Generic OTC fleet glycerin (adult) Generic OTC FLEET GLYCERIN (CHILD) Brand OTC fleet laxative (bisacodyl) Generic OTC FLEET MINERAL OIL Brand OTC FLEET PEDIATRIC Brand OTC foaming antacid Generic OTC gavilax oral powder Generic OTC

Drug Name Drug Tier Requirements / Limits gavilyte-c Generic gavilyte-g Generic gavilyte-n Generic GAVISCON Brand OTC GAVISCON EXTRA STRENGTH Brand OTC GELUSIL ANTACID AND ANTI-GAS Brand OTC generlac Generic gentle laxative (bisacodyl) Generic OTC gentlelax Generic OTC geri-kot Generic OTC geri-lanta Generic OTC geri-mox antacid-antigas Generic OTC GERI-MUCIL (ASPARTAME) Brand OTC glycerin (adult) Generic OTC glycerin (child) Generic OTC granisetron (pf) intravenous solution 1 mg/ml (1 Generic ml) granisetron hcl intravenous Generic granisetron hcl oral Generic QL heartburn antacid Generic OTC heartburn relief oral tablet,chewable Generic OTC hemmorex-hc rectal suppository 30 mg Generic HYDROCIL Brand OTC HYDROCIL INSTANT Brand OTC hydrocortisone rectal Generic hydrocortisone topical cream with perineal Generic applicator hydrocortisone-pramoxine rectal cream 1-1 % Generic ipecac Generic OTC KAOPECTATE (DOCUSATE CALCIUM) Brand OTC konsyl (sugar) Generic OTC konsyl sugar-free oral powder in packet Generic OTC lactulose oral solution 10 gram/15 ml Generic laxacin Generic OTC laxaclear Generic OTC

Drug Name Drug Tier Requirements / Limits laxative (bisacodyl) Generic OTC laxative (glycerin-pediatric) Generic OTC laxative (sennosides) oral tablet 15 mg Generic OTC laxative peg 3350 Generic OTC laxative pills Generic OTC laxative pills regular Generic OTC laxative plus stool softener Generic OTC lidocaine hcl-hydrocortison ac rectal cream Generic lidocaine hcl-hydrocortison ac rectal kit Generic lidocaine-hydrocortisone-aloe Generic MAALOX ADVANCED Brand OTC maalox maximum strength Generic OTC MAG-AL Brand OTC magnesium citrate oral solution Generic OTC magnesium oral tablet 250 mg Generic OTC meclizine oral tablet 12.5 mg, 25 mg Generic meclizine oral tablet,chewable Generic OTC medi-meclizine Generic OTC mesalamine oral capsule,extended release 24hr Generic mesalamine rectal enema Generic mesalamine rectal suppository Generic QL METAMUCIL (WITH SUGAR) ORAL Brand OTC POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM METAMUCIL (WITH SUGAR) ORAL Brand OTC POWDER IN PACKET METAMUCIL FIBER SINGLES Brand OTC METAMUCIL FIBER THIN Brand OTC METAMUCIL FREE Brand OTC METAMUCIL MULTIHEALTH FIBER Brand OTC METAMUCIL ORAL CAPSULE Brand OTC METAMUCIL SUGAR-FREE (ASPART) Brand OTC METAMUCIL SUNRISE Brand OTC metoclopramide hcl oral Generic milk of magnesia Generic OTC

Drug Name Drug Tier Requirements / Limits milk of magnesia concentrated Generic OTC mineral oil extra heavy Generic OTC MINERAL OIL HEAVY ORAL Brand OTC MINERAL OIL ORAL Brand OTC MINERAL OIL RECTAL Brand OTC mintox Generic OTC mintox maximum strength Generic OTC mintox plus Generic OTC MIRALAX Brand OTC motion sickness Generic OTC motion sickness (meclizine) Generic OTC motion sickness relief Generic OTC motion sickness relief(mecliz) Generic OTC motion-time Generic OTC MOVANTIK Brand move it along Generic OTC natural fiber laxative Generic OTC natural fiber laxative (sugar) oral powder 3.4 Generic OTC gram/7 gram natural fiber laxative(aspart) oral powder Generic OTC natural veg laxative(sennosid) Generic OTC natural vegetable Generic OTC natural vegetable (psyllium) Generic OTC natural vegetable powder Generic OTC natura-lax Generic OTC nausea control Generic OTC nausea relief Generic OTC OCALIVA Brand PA; QL ondansetron Generic QL ondansetron hcl (pf) injection solution Generic ondansetron hcl intravenous Generic ondansetron hcl oral Generic QL oral saline laxative oral liquid Generic OTC p-col rite Generic OTC PEDIA-LAX ORAL Brand OTC

Drug Name Drug Tier Requirements / Limits PEDIA-LAX STOOL SOFTENER Brand OTC pediatric enema Generic OTC peg 3350-electrolytes oral recon soln 236-22.74- Generic 6.74 -5.86 gram peg-electrolyte soln Generic peg-prep Generic perdiem overnight relief Generic OTC PHILLIPS' LIQUI-GELS Brand OTC PHILLIPS MILK OF MAGNESIA ORAL Brand OTC SUSPENSION phosphate laxative Generic OTC polyethylene glycol 3350 oral powder Generic OTC powderlax oral powder Generic OTC prochlorperazine Generic prochlorperazine edisylate injection solution 10 Generic mg/2 ml (5 mg/ml) prochlorperazine maleate Generic procto-med hc Generic procto-pak Generic proctosol hc topical Generic proctozone-hc Generic promolaxin Generic OTC psyllium husk oral capsule 0.52 gram Generic OTC purelax Generic OTC READY-TO-USE ENEMA (MIN OIL) Brand OTC RECTIV Brand senexon-s Generic OTC senna laxative Generic OTC senna oral syrup 8.8 mg/5 ml Generic OTC senna oral tablet Generic OTC senna plus oral tablet Generic OTC senna with docusate sodium Generic OTC senna-s Generic OTC senna-time s Generic OTC sennosides-docusate sodium Generic OTC

Drug Name Drug Tier Requirements / Limits SENOKOT Brand OTC SENOKOT EXTRA STRENGTH Brand OTC SENOKOT-S Brand OTC sen-o-tab Generic OTC silace Generic OTC smoothlax Generic OTC sodium bicarbonate oral Generic OTC sof-lax Generic OTC stimulant laxative plus Generic OTC stool softener (docusate cal) Generic OTC stool softener oral capsule 100 mg, 250 mg Generic OTC STOOL SOFTENER ORAL CAPSULE 50 MG Brand OTC stool softener oral liquid Generic OTC stool softener oral syrup Generic OTC stool softener oral tablet Generic OTC stool softener-laxative Generic OTC stool softener-stimulant laxat oral tablet Generic OTC SUCRAID Brand PA sulfasalazine Generic surfak Generic OTC the magic bullet Generic OTC travel sickness Generic OTC trilyte with flavor packets Generic trimethobenzamide oral Generic TRULANCE Brand tums ultra oral tablet,chewable 470 mg calcium Generic OTC (1,177 mg) UNIFIBER Brand OTC ursodiol oral capsule 300 mg Generic ursodiol oral tablet Generic VARUBI ORAL Brand QL vegetable laxative Generic OTC VIBERZI Brand VIOKACE Brand wal-dram Generic OTC

Drug Name Drug Tier Requirements / Limits wal-mucil fiber Generic OTC wal-mucil fiber (aspartame) Generic OTC wal-mucil fiber (sugar) Generic OTC wal-mucil natural fiber lax Generic OTC woman's laxative (bisacodyl) oral tablet Generic OTC women's gentle laxative(bisac) Generic OTC women's laxative (bisacodyl) Generic OTC ULCER THERAPY acid controller Generic OTC acid reducer (cimetidine) Generic OTC acid reducer (famotidine) Generic OTC amoxicil-clarithromy-lansopraz Generic QL cimetidine hcl oral Generic cimetidine oral tablet 200 mg Generic OTC cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic famotidine (pf) Generic famotidine oral suspension Generic famotidine oral tablet 10 mg Generic OTC famotidine oral tablet 20 mg, 40 mg Generic heartburn prevention Generic OTC heartburn relief (cimetidine) Generic OTC heartburn relief (famotidine) Generic OTC lansoprazole oral capsule,delayed release(dr/ec) Generic QL 15 mg lansoprazole oral capsule,delayed release(dr/ec) Generic 30 mg misoprostol Generic NEXIUM 24HR Brand ST; OTC nizatidine Generic omeprazole magnesium oral capsule,delayed Generic OTC release(dr/ec) omeprazole magnesium oral tablet,delayed release Generic ST; OTC (dr/ec) omeprazole oral capsule,delayed release(dr/ec) 10 Generic QL mg

Drug Name Drug Tier Requirements / Limits omeprazole oral capsule,delayed release(dr/ec) 20 Generic mg, 40 mg omeprazole oral tablet,delayed release (dr/ec) Generic OTC pantoprazole oral tablet,delayed release (dr/ec) 20 Generic QL mg pantoprazole oral tablet,delayed release (dr/ec) 40 Generic mg PEPCID AC MAXIMUM STRENGTH Brand OTC PEPCID AC ORAL TABLET 10 MG Brand OTC pepcid ac oral tablet 20 mg Generic OTC PREVACID 24HR Brand ST; OTC PRILOSEC OTC Brand ST; OTC rabeprazole oral tablet,delayed release (dr/ec) Generic sucralfate oral tablet Generic tagamet hb Generic OTC ZEGERID OTC Brand ST; OTC IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE Brand PA ARCALYST Brand PA AVONEX INTRAMUSCULAR PEN INJECTOR Brand PA; QL KIT AVONEX INTRAMUSCULAR SYRINGE Brand PA; QL AVONEX INTRAMUSCULAR SYRINGE KIT Brand PA; QL EGRIFTA SV Brand PA EXTAVIA Brand PA; QL GRANIX SUBCUTANEOUS SYRINGE Brand PA INTRON A INJECTION RECON SOLN Brand PA LEUKINE INJECTION RECON SOLN Brand PA NEULASTA Brand PA; QL NEUPOGEN Brand PA NORDITROPIN FLEXPRO Brand PA OMNITROPE Brand PA PEGASYS Brand PA; QL PLEGRIDY Brand PA; QL

Drug Name Drug Tier Requirements / Limits PROCRIT Brand PA PROLEUKIN Brand PA REBIF (WITH ALBUMIN) Brand PA; QL REBIF REBIDOSE Brand PA; QL REBIF TITRATION PACK Brand PA; QL ZARXIO Brand PA VACCINES / MISCELLANEOUS IMMUNOLOGICALS AFLURIA QUAD 2021-2022(6MO UP) Brand BEXSERO Brand FLUAD QUAD 2021-22(65Y UP)(PF) Brand FLUARIX QUAD 2021-2022 (PF) Brand FLUBLOK QUAD 2021-2022 (PF) Brand FLUCELVAX QUAD 2021-2022 Brand FLUCELVAX QUAD 2021-2022 (PF) Brand FLULAVAL QUAD 2021-2022 (PF) Brand FLUZONE QUAD 2021-2022 Brand FLUZONE QUAD 2021-2022 (PF) Brand GAMMAGARD LIQUID Brand PA GAMMAGARD S-D (IGA < 1 MCG/ML) Brand PA GAMUNEX-C Brand PA HIZENTRA SUBCUTANEOUS SOLUTION Brand PA JANSSEN COVID-19 VACCINE (EUA) Brand MENACTRA (PF) INTRAMUSCULAR Brand SOLUTION MENQUADFI (PF) Brand MODERNA COVID-19 VACCINE (EUA) Brand PFIZER COVID-19 VACCINE (EUA) Brand PNEUMOVAX-23 Brand PREVNAR 13 (PF) Brand PRIVIGEN Brand PA SHINGRIX (PF) Brand TRUMENBA Brand ZOSTAVAX (PF) Brand MUSCULOSKELETAL / RHEUMATOLOGY

Drug Name Drug Tier Requirements / Limits GOUT THERAPY allopurinol Generic COLCHICINE ORAL CAPSULE Brand febuxostat Generic ST probenecid Generic probenecid-colchicine Generic OSTEOPOROSIS THERAPY alendronate oral solution Generic QL alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Generic QL ibandronate oral Generic QL raloxifene Generic PA risedronate oral tablet 5 mg Generic QL TYMLOS Brand PA; QL OTHER RHEUMATOLOGICALS BENLYSTA SUBCUTANEOUS Brand PA ENBREL Brand PA; QL ENBREL MINI Brand PA; QL ENBREL SURECLICK Brand PA; QL HUMIRA PEN Brand PA; QL HUMIRA SUBCUTANEOUS SYRINGE KIT 40 Brand PA; QL MG/0.8 ML HUMIRA(CF) Brand PA; QL HUMIRA(CF) PEDI CROHNS STARTER Brand PA; QL HUMIRA(CF) PEN Brand PA; QL HUMIRA(CF) PEN PEDIATRIC UC Brand PA; QL HUMIRA(CF) PEN PSOR-UV-ADOL HS Brand PA; QL leflunomide Generic QL OTEZLA Brand PA OTEZLA STARTER Brand PA penicillamine oral tablet Generic PA RIDAURA Brand SAVELLA Brand ST OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS

Drug Name Drug Tier Requirements / Limits amabelz Generic camila Generic covaryx Generic PA covaryx h.s. Generic PA CRINONE VAGINAL GEL 4 % Brand deblitane Generic DEPO-SUBQ PROVERA 104 Brand QL errin Generic estradiol oral Generic estradiol transdermal Generic QL estradiol vaginal Generic estradiol valerate intramuscular oil 20 mg/ml, 40 Generic mg/ml estradiol-norethindrone acet Generic fyavolv Generic heather Generic jencycla Generic jinteli Generic lyza Generic medroxyprogesterone intramuscular Generic QL medroxyprogesterone oral Generic MENEST Brand mimvey Generic nora-be Generic norethindrone (contraceptive) Generic norethindrone acetate Generic PA norethindrone ac-eth estradiol oral tablet 0.5-2.5 Generic mg-mcg, 1-5 mg-mcg norlyda Generic progesterone micronized Generic PA sharobel Generic yuvafem Generic MISCELLANEOUS OB/GYN 1-DAY Brand OTC 3 day vaginal Generic OTC

Drug Name Drug Tier Requirements / Limits 3-day vaginal Generic OTC clindamycin phosphate vaginal Generic clotrimazole vaginal Generic OTC clotrimazole-3 Generic OTC eluryng Generic QL etonogestrel-ethinyl estradiol Generic QL fem ph Generic GYNE-LOTRIMIN Brand OTC GYNE-LOTRIMIN 7 Brand OTC gynol ii Generic OTC isoxsuprine Generic LUPANETA PACK (1 MONTH) Brand QL LUPANETA PACK (3 MONTH) Brand QL metronidazole vaginal Generic miconazole nitrate vaginal comb pack,prefill appl, Generic OTC; QL cream miconazole nitrate vaginal cream Generic OTC; QL MICONAZOLE NITRATE VAGINAL KIT Brand OTC; QL miconazole-3 vaginal kit Generic OTC; QL miconazole-3 vaginal suppository Generic QL miconazole-7 Generic OTC; QL MONISTAT 1 COMBO PACK Brand OTC; QL MONISTAT 3 VAGINAL CREAM Brand OTC MONISTAT 3 VAGINAL KIT Brand OTC; QL MONISTAT 7 VAGINAL CREAM Brand OTC; QL ORIAHNN Brand PA terconazole Generic QL tioconazole-1 Generic OTC tranexamic acid oral Generic TRIMO-SAN JELLY Brand vandazole Generic xulane Generic ORAL CONTRACEPTIVES / RELATED AGENTS afirmelle Generic altavera (28) Generic

Drug Name Drug Tier Requirements / Limits alyacen 1/35 (28) Generic alyacen 7/7/7 (28) Generic amethia Generic amethyst (28) Generic apri Generic aranelle (28) Generic ashlyna Generic aubra Generic aubra eq Generic aurovela 1.5/30 (21) Generic aurovela 1/20 (21) Generic aurovela 24 fe Generic aurovela fe 1.5/30 (28) Generic aurovela fe 1-20 (28) Generic aviane Generic ayuna Generic azurette (28) Generic balziva (28) Generic blisovi 24 fe Generic blisovi fe 1.5/30 (28) Generic blisovi fe 1/20 (28) Generic briellyn Generic camrese Generic camrese lo Generic caziant (28) Generic chateal (28) Generic chateal eq (28) Generic cryselle (28) Generic cyclafem 1/35 (28) Generic cyclafem 7/7/7 (28) Generic cyred Generic cyred eq Generic dasetta 1/35 (28) Generic dasetta 7/7/7 (28) Generic

Drug Name Drug Tier Requirements / Limits daysee Generic desog-e.estradiol/e.estradiol Generic desogestrel-ethinyl estradiol Generic drospirenone-ethinyl estradiol Generic econtra ez Generic OTC elinest Generic ELLA Brand emoquette Generic enpresse Generic enskyce Generic estarylla Generic ethynodiol diac-eth estradiol Generic falmina (28) Generic femynor Generic hailey Generic hailey 24 fe Generic hailey fe 1.5/30 (28) Generic hailey fe 1/20 (28) Generic isibloom Generic jaimiess Generic jasmiel (28) Generic jolessa Generic juleber Generic junel 1.5/30 (21) Generic junel 1/20 (21) Generic junel fe 1.5/30 (28) Generic junel fe 1/20 (28) Generic junel fe 24 Generic kaitlib fe Generic kariva (28) Generic kelnor 1/35 (28) Generic kelnor 1-50 (28) Generic kurvelo (28) Generic l norgest/e.estradiol-e.estrad Generic

Drug Name Drug Tier Requirements / Limits larin 1.5/30 (21) Generic larin 1/20 (21) Generic larin 24 fe Generic larin fe 1.5/30 (28) Generic larin fe 1/20 (28) Generic larissia Generic layolis fe Generic leena 28 Generic lessina Generic levonest (28) Generic levonorgestrel Generic OTC levonorgestrel-ethinyl estrad Generic levonorg-eth estrad triphasic Generic levora-28 Generic lillow (28) Generic lojaimiess Generic loryna (28) Generic low-ogestrel (28) Generic lo-zumandimine (28) Generic lutera (28) Generic marlissa (28) Generic microgestin 1.5/30 (21) Generic microgestin 1/20 (21) Generic microgestin fe 1.5/30 (28) Generic microgestin fe 1/20 (28) Generic mili Generic mono-linyah Generic my way Generic OTC necon 0.5/35 (28) Generic nikki (28) Generic noreth-ethinyl estradiol-iron Generic norethindrone ac-eth estradiol oral tablet 1-20 Generic mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 Generic mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

Drug Name Drug Tier Requirements / Limits norgestimate-ethinyl estradiol Generic nortrel 0.5/35 (28) Generic nortrel 1/35 (21) Generic nortrel 1/35 (28) Generic nortrel 7/7/7 (28) Generic ocella Generic opcicon one-step Generic OTC option-2 Generic OTC orsythia Generic philith Generic pimtrea (28) Generic pirmella Generic PLAN B ONE-STEP Brand OTC portia 28 Generic previfem Generic reclipsen (28) Generic rivelsa Generic setlakin Generic simliya (28) Generic simpesse Generic sprintec (28) Generic sronyx Generic syeda Generic tarina 24 fe Generic tarina fe 1/20 (28) Generic tilia fe Generic tri femynor Generic tri-estarylla Generic tri-legest fe Generic tri-linyah Generic tri-lo-estarylla Generic tri-lo-marzia Generic tri-lo-mili Generic tri-lo-sprintec Generic

Drug Name Drug Tier Requirements / Limits tri-mili Generic tri-previfem (28) Generic tri-sprintec (28) Generic trivora (28) Generic tri-vylibra Generic tri-vylibra lo Generic velivet triphasic regimen (28) Generic vestura (28) Generic vienva Generic viorele (28) Generic volnea (28) Generic vyfemla (28) Generic wera (28) Generic wymzya fe Generic zarah Generic zovia 1/35e (28) Generic zumandimine (28) Generic OXYTOCICS methergine Generic methylergonovine oral Generic OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac Generic bacitracin ophthalmic (eye) Generic bacitracin-polymyxin b ophthalmic (eye) Generic ciprofloxacin hcl ophthalmic (eye) Generic erythromycin ophthalmic (eye) Generic gentak ophthalmic (eye) ointment Generic gentamicin ophthalmic (eye) drops Generic levofloxacin ophthalmic (eye) Generic NATACYN Brand neomycin-bacitracin-polymyxin Generic neomycin-polymyxin-gramicidin Generic neo-polycin Generic

Drug Name Drug Tier Requirements / Limits ofloxacin ophthalmic (eye) Generic polycin Generic polymyxin b sulf-trimethoprim Generic tobramycin ophthalmic (eye) Generic ANTIVIRALS trifluridine Generic BETA-BLOCKERS betaxolol ophthalmic (eye) Generic carteolol Generic levobunolol ophthalmic (eye) drops 0.5 % Generic metipranolol Generic timolol maleate ophthalmic (eye) drops Generic timolol maleate ophthalmic (eye) gel forming Generic solution CYCLOPLEGIC MYDRIATICS atropine ophthalmic (eye) drops Generic atropine ophthalmic (eye) ointment Generic cyclopentolate Generic homatropaire Generic tropicamide Generic DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, Generic 4 % MISCELLANEOUS OPHTHALMOLOGICS advanced eye relief Generic OTC altacaine Generic artificial tears (petro/min) Generic OTC artificial tears (pf) ophthalmic (eye) dropperette Generic OTC ARTIFICIAL TEARS (PF) OPHTHALMIC Brand OTC (EYE) DROPPERETTE 0.1-0.3 % artificial tears (polyvin alc) Generic OTC artificial tears(dext70-hypro) Generic OTC artificial tears(glycerin-peg) Generic OTC artificial tears(pg-hypm-glyc) Generic OTC artificial tears(pvalch-povid) Generic OTC

Drug Name Drug Tier Requirements / Limits azelastine ophthalmic (eye) Generic bion tears (pf) Generic OTC bss Generic cromolyn ophthalmic (eye) Generic CYSTARAN Brand dry eye relief Generic OTC epinastine Generic fluorescein-proparacaine Generic for sty relief Generic OTC gonak Generic OTC goniotaire Generic OTC goniovisc Generic OTC ISOPTO TEARS Brand OTC lubricant (p-glycol-glycerin) Generic OTC LUBRICANT EYE (PG-PEG 400) Brand OTC lubricant eye drops ophthalmic (eye) dropperette Generic OTC LUBRICANT EYE DROPS OPHTHALMIC Brand OTC (EYE) DROPS LUBRICANT EYE OPHTHALMIC (EYE) Brand OTC OINTMENT 57.3-42.5 %, 57.7-31.9 % lubricating plus Generic OTC lubrifresh pm Generic OTC moisture drops Generic OTC natural tears (pf) Generic OTC olopatadine ophthalmic (eye) Generic OXERVATE Brand PA; QL polyvinyl alcohol Generic OTC proparacaine Generic pure and gentle eye Generic OTC REFRESH CELLUVISC Brand OTC REFRESH CONTACTS Brand OTC REFRESH LACRI-LUBE Brand OTC REFRESH LIQUIGEL Brand OTC REFRESH PLUS Brand OTC REFRESH TEARS Brand OTC

Drug Name Drug Tier Requirements / Limits RETAINE PM Brand OTC SOOTHE NIGHT TIME LUBRICANT Brand OTC SYSTANE (PROPYLENE GLYCOL) Brand OTC SYSTANE NIGHTTIME Brand OTC SYSTANE ULTRA Brand OTC tetracaine hcl Generic THERATEARS Brand OTC ultra fresh Generic OTC ULTRA FRESH PM Brand OTC ULTRA LUBRICANT EYE Brand OTC VISINE TIRED EYE RELIEF Brand OTC XIIDRA Brand QL NON-STEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac sodium ophthalmic (eye) Generic flurbiprofen sodium Generic ketorolac ophthalmic (eye) Generic ORAL DRUGS FOR GLAUCOMA acetazolamide Generic OTHER GLAUCOMA DRUGS dorzolamide Generic dorzolamide-timolol Generic latanoprost Generic STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc Generic neomycin-polymyxin b-dexameth Generic neomycin-polymyxin-hc ophthalmic (eye) Generic neo-polycin hc Generic tobramycin-dexamethasone Generic STEROIDS dexamethasone sodium phosphate ophthalmic Generic (eye) fluorometholone Generic PRED MILD Brand prednisolone acetate Generic

Drug Name Drug Tier Requirements / Limits prednisolone sodium phosphate ophthalmic (eye) Generic STEROID-SULFONAMIDE COMBINATIONS sulfacetamide-prednisolone Generic SULFONAMIDES sulfacetamide sodium ophthalmic (eye) Generic SYMPATHOMIMETICS brimonidine ophthalmic (eye) drops 0.2 % Generic VASOCONSTRICTOR DECONGESTANTS phenylephrine hcl ophthalmic (eye) Generic RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 12 hour decongestant Generic OTC 24hour allergy Generic OTC; QL abanatuss ped oral liquid Generic OTC acticon (dexbromph-pse) oral tablet Generic OTC actidom dmx Generic OTC adult robitussin peak cold m-s Generic OTC adult tussin chest congestion Generic OTC adult tussin cough congest dm Generic OTC adult tussin dm Generic OTC adult tussin multi-symp cold Generic OTC adult wal-tussin Generic OTC adult wal-tussin dm max Generic OTC ADVIL COLD AND SINUS ORAL CAPSULE Brand OTC advil cold and sinus oral tablet Generic OTC ala-hist ir Generic OTC alavert Generic OTC; QL alavert d-12 allergy-sinus Generic OTC; QL aler-cap Generic OTC ALEVE COLD AND SINUS Brand OTC ALEVE SINUS AND HEADACHE Brand OTC ALEVE-D SINUS AND COLD Brand OTC ALEVE-D SINUS AND HEADACHE Brand OTC alka-seltzer plus allergy Generic OTC

Drug Name Drug Tier Requirements / Limits ALKA-SELTZER PLUS COLD/COUGHFM Brand OTC ALKA-SELTZER PLUS DAY Brand OTC alka-seltzer plus mucus-conges Generic OTC ALKA-SELTZER PLUS SINUS-COUGH Brand OTC all day allergy (cetirizine) oral capsule Generic OTC; QL all day allergy (cetirizine) oral solution Generic OTC all day allergy (cetirizine) oral tablet Generic OTC; QL all day allergy-d Generic OTC; QL ALLEGRA ALLERGY Brand OTC; QL ALLEGRA-D 12 HOUR Brand OTC; QL ALLEGRA-D 24 HOUR Brand OTC; QL aller-chlor Generic OTC allerclear Generic OTC; QL allerclear d-12hr Generic OTC; QL allerclear d-24hr Generic OTC; QL aller-ease Generic OTC; QL aller-fex Generic OTC; QL aller-g-time Generic OTC allergy (chlorpheniramine) Generic OTC allergy (diphenhydramine) oral capsule Generic OTC allergy (diphenhydramine) oral tablet Generic OTC allergy 4-hour Generic OTC allergy and congestion relief Generic OTC; QL allergy complete-d Generic OTC; QL allergy medication Generic OTC allergy medicine Generic OTC allergy multi-symptom Generic OTC allergy plus severe sinus ha Generic OTC allergy relief (cetirizine) oral capsule Generic OTC; QL allergy relief (cetirizine) oral solution Generic OTC allergy relief (cetirizine) oral tablet Generic OTC; QL allergy relief (fexofenadine) Generic OTC; QL allergy relief (loratadine) oral solution Generic OTC allergy relief (loratadine) oral tablet Generic OTC; QL

Drug Name Drug Tier Requirements / Limits allergy relief (loratadine) oral Generic OTC; QL tablet,disintegrating allergy relief d-24hr Generic OTC; QL allergy relief multi-symptom Generic OTC allergy relief(chlorpheniramn) oral tablet Generic OTC allergy relief(diphenhydramin) Generic OTC allergy relief,nasal decongest Generic OTC; QL allergy relief-d (cetirizine) Generic OTC; QL allergy relief-d (loratadine) Generic OTC; QL allergy relief-d(fexofenadine) Generic OTC; QL allergy sinus pe Generic OTC allergy sinus-d Generic OTC allergy-congestion relief-d Generic OTC; QL allergy-time Generic OTC aller-tec Generic OTC; QL aller-tec d Generic OTC; QL ALL-NITE COLD-FLU Brand OTC antitussive dm Generic OTC ap-hist dm Generic OTC aprodine Generic OTC banophen oral capsule Generic OTC banophen oral tablet Generic OTC BENADRYL ALLERGY Brand OTC BENADRYL ORAL Brand OTC benzonatate Generic biocotron Generic OTC bionel Generic OTC brohist d Generic OTC brompheniramine-pseudoeph-dm Generic broncotron ped oral liquid Generic OTC BRONKIDS Brand OTC brotapp dm Generic OTC carbinoxamine maleate oral liquid Generic carbinoxamine maleate oral tablet 4 mg Generic cetiri-d Generic OTC; QL

Drug Name Drug Tier Requirements / Limits cetirizine oral solution 1 mg/ml Generic cetirizine oral tablet Generic OTC; QL cetirizine oral tablet,chewable 5 mg Generic OTC; QL cetirizine-pseudoephedrine Generic OTC; QL chest congestion relief dm oral tablet Generic OTC chest congestion relief oral tablet Generic OTC chest congestion relief pe Generic OTC chest congestion-cough relief Generic OTC chest-sinus congestion relief Generic OTC child allergy relf(cetirizine) Generic OTC child allergy relief (diphen) Generic OTC child benadryl plus congestion Generic OTC child chest congestion-cough Generic OTC CHILD MUCINEX COUGH MINI-MELTS Brand OTC child mucus relief cough Generic OTC child mucus relief expectorant Generic OTC CHILD MULTI-SYMPTOM COLD/COUGH Brand OTC child triaminic cold-allergy Generic OTC child wal-tap cold-allergy Generic OTC children's allegra allergy oral suspension Generic OTC children's allegra allergy oral tablet,disintegrating Generic OTC; QL children's allergy (diphenhyd) oral liquid Generic OTC children's allergy relief(lor) oral solution Generic OTC children's benadryl allergy Generic OTC children's cetirizine oral solution Generic OTC children's cetirizine oral tablet,chewable Generic OTC; QL children's chest congestion Generic OTC CHILDREN'S CLARITIN ORAL SOLUTION Brand OTC CHILDREN'S CLARITIN ORAL Brand OTC; QL TABLET,CHEWABLE children's cold and cough (pe) Generic OTC children's cold-allergy (pe) Generic OTC CHILDREN'S COLD-COUGH-SORE Brand OTC children's cough Generic OTC CHILDREN'S COUGH DM ER Brand OTC

Drug Name Drug Tier Requirements / Limits CHILDREN'S DELSYM COUGH Brand OTC children's dibromm cold-allerg Generic OTC children's dibromm dm cold-cou Generic OTC children's flu relief Generic OTC CHILDREN'S MUCINEX COLD-FEVER Brand OTC children's mucinex cough Generic OTC CHILDREN'S MUCINEX MULTI-SYMP Brand OTC childrens plus cold Generic OTC children's plus flu Generic OTC CHILDRENS PLUS MULTI-SYMP COLD Brand OTC children's silfedrine Generic OTC CHILDREN'S SUDAFED Brand OTC children's sudafed pe cough Generic OTC CHILDREN'S SUDAFED PE NASAL Brand OTC children's wal-dryl allergy Generic OTC children's wal-zyr oral solution Generic OTC CHILDREN'S WAL-ZYR ORAL Brand OTC; QL TABLET,CHEWABLE child's all day allergy(cetir) Generic OTC childs triacting cold-cough Generic OTC chlorhist Generic OTC chlorpheniramine maleate oral tablet Generic OTC chlorpheniramine maleate oral tablet extended Generic OTC release chlortabs Generic OTC CHLOR-TRIMETON Brand OTC CLARITIN LIQUI-GEL Brand OTC; QL CLARITIN ORAL SOLUTION Brand OTC CLARITIN ORAL TABLET Brand OTC; QL CLARITIN REDITABS ORAL Brand OTC; QL TABLET,DISINTEGRATING 10 MG CLARITIN REDITABS ORAL Brand OTC TABLET,DISINTEGRATING 5 MG CLARITIN-D 12 HOUR Brand OTC; QL CLARITIN-D 24 HOUR Brand OTC; QL clemastine oral syrup Generic

Drug Name Drug Tier Requirements / Limits clemastine oral tablet 2.68 mg Generic cold and allergy Generic OTC cold and allergy (bromphen-pe) Generic OTC cold and allergy pe Generic OTC cold and cough dm Generic OTC cold and cough elixir Generic OTC COLD AND FLU SEVERE Brand OTC cold and sinus pain relief Generic OTC COLD HEAD CONGESTION DAY/NITE Brand OTC COLD HEAD CONGESTION DAYTIME Brand OTC cold head congestion nighttime Generic OTC COLD HEAD CONGESTION SEVER DAY Brand OTC COLD MULTI-SYMPTOM Brand OTC COLD MULTI-SYMPTOM (CHLORPHEN) Brand OTC COLD MULTI-SYMPTOM DAY/NIGHT Brand OTC COLD MULTI-SYMPTOM NIGHTTIME Brand OTC COLD RELIEF Brand OTC cold relief m/s day/night Generic OTC cold relief plus Generic OTC cold-flu relief oral liquid 12.5-30-1,000 mg/30 ml Generic OTC cold-sinus relief Generic OTC complete allergy medicine Generic OTC conex oral tablet Generic OTC CONTAC COLD-FLU NIGHT Brand OTC CORICIDIN HBP CHEST CONG-COUGH Brand OTC CORICIDIN HBP COLD-MULTI SYMPT Brand OTC CORICIDIN HBP COUGH AND COLD Brand OTC COUGH AND COLD (CHLORPHEN-DM) Brand OTC COUGH AND COLD MUCUS RELIEF CF Brand OTC COUGH DM ER Brand OTC cough formula dm Generic OTC cough relief Generic OTC cough syrup Generic OTC cough syrup dm Generic OTC

Drug Name Drug Tier Requirements / Limits cough-sore throat night Generic OTC cyproheptadine oral tablet Generic DAY TIME PE Brand OTC dayhist allergy Generic OTC DAYTIME Brand OTC DAYTIME AND NIGHTTIME COLD Brand OTC DAYTIME COLD-FLU Brand OTC DAYTIME COLD-FLU RELIEF (PE) Brand OTC day-time cough Generic OTC DECONEX DMX ORAL TABLET 10-17.5-400 Brand OTC MG DECONEX IR Brand OTC DELSYM 12 HOUR Brand OTC delsym cough-chest congest dm Generic OTC desgen dm oral liquid 5-10-100 mg/5 ml Generic OTC desloratadine Generic QL despec dm-g Generic OTC despec eda cough-cold drops Generic OTC despec-dm (phenyleph-dm-guaif) Generic OTC DESPEC-DM (PSEUDOEPH-DM-GUAIF) Brand OTC dextromethorphan polistirex Generic OTC dextromethorphan-guaifenesin oral syrup Generic OTC dextromethorphan-guaifenesin oral tablet Generic OTC diabetic siltussin-dm max str Generic OTC diabetic tussin dm Generic OTC diabetic tussin ex Generic OTC dimaphen dm Generic OTC DIMETAPP COLD-ALLERGY (PE) Brand OTC dimetapp cold-congestion Generic OTC dimetapp dm cold-cough (pe) Generic OTC diphedryl allergy Generic OTC diphen oral tablet Generic OTC diphenhist oral capsule Generic OTC diphenhydramine hcl injection solution 50 mg/ml Generic diphenhydramine hcl injection syringe Generic

Drug Name Drug Tier Requirements / Limits diphenhydramine hcl oral capsule 25 mg Generic OTC diphenhydramine hcl oral capsule 50 mg Generic diphenhydramine hcl oral elixir Generic OTC diphenhydramine hcl oral liquid Generic OTC diphenhydramine hcl oral tablet Generic OTC dm max Generic OTC dometuss-dmx Generic OTC dristan cold Generic OTC DURAFLU Brand OTC ed a-hist Generic OTC ed a-hist dm oral liquid Generic OTC ed bron gp Generic OTC ed chlorped jr Generic OTC endacof - dm Generic OTC ENTEX T Brand OTC epinephrine injection auto-injector 0.15 mg/0.3 ml, Generic QL 0.3 mg/0.3 ml expectorant oral liquid Generic OTC fenesin dm ir oral tablet 20-400 mg Generic OTC fenesin ir Generic OTC fenesin pe ir Generic OTC fexofenadine oral tablet Generic OTC; QL fexofenadine-pseudoephedrine Generic OTC; QL flu relief therapy daytime Generic OTC flu relief therapy nighttime Generic OTC flu severe cold-night(diph-pe) Generic OTC FLU-SEVERE COLD-COUGH DAYTIME Brand OTC geri-dryl oral tablet Generic OTC geri-tussin Generic OTC glenmax peb dm Generic OTC g-tron ped oral drops Generic OTC G-TUSICOF Brand OTC guaiasorb dm Generic OTC guaifenesin oral liquid Generic OTC guaifenesin oral tablet Generic OTC

Drug Name Drug Tier Requirements / Limits G-ZYNCOF Brand OTC hydroxyzine hcl oral Generic hydroxyzine pamoate Generic ibuprofen cold-sinus(with pse) Generic OTC levocetirizine oral solution Generic levocetirizine oral tablet Generic QL liquibid d-r Generic OTC LIQUIBID PD-R Brand OTC lohist - d Generic OTC lohist-dm Generic OTC lorata-d Generic OTC; QL loratadine oral solution Generic OTC loratadine oral tablet Generic OTC; QL loratadine oral tablet,disintegrating Generic OTC; QL loratadine-d Generic OTC; QL mapap cold formula Generic OTC m-clear wc Generic mucinex d Generic OTC mucinex d maximum strength Generic OTC mucinex dm oral tablet extended release 12 hr 30- Generic OTC 600 mg MUCINEX DM ORAL TABLET EXTENDED Brand OTC RELEASE 12 HR 60-1,200 MG mucinex fast-max cold-flu-thrt oral tablet Generic OTC MUCINEX FAST-MAX COLD-SINUS Brand OTC MUCINEX FAST-MAX CONGEST-COUGH Brand OTC ORAL LIQUID mucinex fast-max dm max Generic OTC MUCINEX ORAL TABLET EXTENDED Brand OTC RELEASE 12HR 1,200 MG mucinex oral tablet extended release 12hr 600 mg Generic OTC MUCINEX SINUS-MAX SEV CONGESTN Brand OTC ORAL TABLET mucosa Generic OTC mucosa dm Generic OTC MUCUS RELIEF COLD AND SINUS Brand OTC

Drug Name Drug Tier Requirements / Limits MUCUS RELIEF COLD-FLU-SORE THR Brand OTC MUCUS RELIEF CONGESTION-COUGH Brand OTC mucus relief cough Generic OTC mucus relief d (pseudoephed) oral tablet Generic OTC mucus relief dm Generic OTC mucus relief dm max Generic OTC mucus relief er oral tablet extended release 12hr Generic OTC 600 mg mucus relief oral tablet 400 mg Generic OTC mucus relief pe Generic OTC MUCUS RELIEF SEV CONGEST-COLD Brand OTC mucus relief sinus Generic OTC MULTI-SYMPTOM COLD (PE) Brand OTC nasal decongestant (pe) Generic OTC nasal decongestant (pseudoeph) oral tablet Generic OTC nasal decongestant (pseudoeph) oral tablet Generic OTC extended release neo-tuss Generic OTC NEOTUSS PLUS Brand OTC NEOTUSS-D (IMPROVED FORMULA) Brand OTC night time Generic OTC night time cold and flu relief Generic OTC night time cold-flu Generic OTC nightime sleep Generic OTC nighttime allergy relief Generic OTC nighttime cold-flu Generic OTC NIGHTTIME COLD-FLU RELIEF Brand OTC nighttime cough Generic OTC nighttime sleep aid (diphen) oral capsule 50 mg Generic OTC nighttime sleep aid (diphen) oral tablet Generic OTC NITE TIME COLD-FLU RELIEF ORAL LIQUID Brand OTC nite time-d cold-flu relief Generic OTC nitetime multi-symptom Generic OTC nohist-dm Generic OTC nohist-lq Generic OTC

Drug Name Drug Tier Requirements / Limits non-aspirin flu Generic OTC NOREL AD Brand OTC pain relief allergy sinus Generic OTC PECGEN DMX ORAL LIQUID 10-187 MG/5 Brand OTC ML pedia relief infant nasal Generic OTC pediacare multi-symptom cold Generic OTC pediatric cough and cold Generic OTC pharbechlor Generic OTC pharbedryl Generic OTC PHENAGIL Brand OTC pres gen Generic OTC PRES GEN PEDIATRIC Brand OTC PRESGEN B Brand OTC promethazine injection solution Generic promethazine oral Generic promethazine rectal Generic promethazine vc Generic promethegan Generic pseudoephedrine hcl oral tablet Generic OTC refenesen Generic OTC refenesen dm Generic OTC refenesen pe Generic OTC RESCON-DM Brand OTC rescon-gg Generic OTC robafen Generic OTC robafen cf (phenylephrine) Generic OTC robafen dm cough Generic OTC robafen dm cough-chest congest Generic OTC robitussin cough and cold cf Generic OTC robitussin cough-chest cong dm oral capsule Generic OTC robitussin cough-chest cong dm oral liquid 5-100 Generic OTC mg/5 ml ROBITUSSIN LONG-ACTING Brand OTC RU-HIST D Brand OTC

Drug Name Drug Tier Requirements / Limits rydex Generic rynex dm Generic OTC rynex pe Generic OTC rynex pse Generic OTC SAFE TUSSIN DM Brand OTC SCOT-TUSSIN DIABETES CF Brand OTC scot-tussin dm Generic OTC scot-tussin expectorant Generic OTC SCOT-TUSSIN SENIOR Brand OTC SEVERE ALLERGY-SINUS HEADACHE Brand OTC severe cold Generic OTC SEVERE COLD AND FLU-DAY (DM) Brand OTC SEVERE COLD MULTI-SYMPTOM Brand OTC siladryl sa Generic OTC siltussin dm das Generic OTC siltussin sa Generic OTC siltussin-dm Generic OTC simply sleep Generic OTC sinus 12 hour Generic OTC sinus and allergy pe Generic OTC SINUS CONGESTION AND PAIN Brand OTC sinus congestion-pain(chlorph) Generic OTC SINUS CONGESTION-PAIN(GUAIF) Brand OTC SINUS CONGEST-PAIN DAY-NIGHT Brand OTC sinus decongestant (pe) Generic OTC sinus headache pe Generic OTC sinus pain relief Generic OTC sinus pe decongestant Generic OTC sinus relief (non-drowsy) Generic OTC sinus-allergy (phenylephrine) Generic OTC sleep aid (diphenhydramine) oral capsule 50 mg Generic OTC SLEEP AID (DIPHENHYDRAMINE) ORAL Brand OTC LIQUID sleep aid (diphenhydramine) oral tablet Generic OTC sleep ii Generic OTC

Drug Name Drug Tier Requirements / Limits SLEEP TIME ORAL LIQUID Brand OTC sleep-tabs Generic OTC sorbugen nr Generic OTC SUDAFED Brand OTC SUDAFED 12 HOUR Brand OTC SUDAFED 24 HOUR Brand OTC sudogest Generic OTC sudogest 12-hour Generic OTC sudogest cold and allergy Generic OTC sudogest sinus and allergy Generic OTC suphedrin Generic OTC suphedrine Generic OTC suphedrine 12 hour Generic OTC suphedrine pe Generic OTC suphedrine pe cold and allergy Generic OTC SUPHEDRINE PE SINUS HEADACHE Brand OTC supress dx Generic OTC THERAFLU EXPRESSMAX COLD DAY Brand OTC THERAFLU FLU-SORE THROAT Brand OTC total allergy medicine Generic OTC TRIAMINIC COLD AND COUGH (PE) Brand OTC TUSICOF ORAL LIQUID Brand OTC tusnel diabetic Generic OTC TUSNEL NEW FORMULA ORAL TABLET Brand OTC tusnel pediatric oral drops Generic OTC tussi pres-b oral liquid 4-10-20 mg/5 ml Generic OTC TUSSI PRES-B ORAL LIQUID 4-10-30 MG/5 Brand OTC ML tussin cf (pe-dm-guaif) Generic OTC TUSSIN CF MAX Brand OTC tussin chest congestion Generic OTC tussin cough (dm only) Generic OTC tussin cough-chest congestion Generic OTC tussin dm Generic OTC tussin dm clear Generic OTC

Drug Name Drug Tier Requirements / Limits tussin dm cough and chest Generic OTC tussin dm max Generic OTC tussin expectorant Generic OTC tussin honey Generic OTC tussin long-acting Generic OTC tussin maximum strength cough Generic OTC tussin oral tablet Generic OTC tussi-pres oral liquid Generic OTC TUSSI-PRES PEDIATRIC Brand OTC unisom sleepgels Generic OTC valu-tapp Generic OTC VANACOF Brand OTC VICKS DAYQUIL COLD-FLU RELIEF ORAL Brand OTC CAPSULE vicks dayquil cold-flu relief oral liquid Generic OTC vicks dayquil cough Generic OTC VICKS DAYQUIL SEVERE COLD-FLU Brand OTC vicks nyquil cold/flu liquicap Generic OTC VICKS NYQUIL SEVERE COLD-FLU ORAL Brand OTC LIQUID wal-act d cold and allergy Generic OTC wal-dryl allergy Generic OTC wal-dryl severe allergy-sinus Generic OTC wal-dryl-d allergy and sinus Generic OTC wal-fex allergy Generic OTC; QL wal-fex d 12 hour Generic OTC; QL wal-fex d 24 hour Generic OTC; QL wal-finate Generic OTC wal-finate-d Generic OTC wal-flu night severe cold Generic OTC WAL-FLU NIGHT TIME Brand OTC WAL-FLU SEVERE COLD-COUGH Brand OTC wal-itin d Generic OTC; QL wal-itin d 12 hour Generic OTC; QL wal-itin oral solution Generic OTC

Drug Name Drug Tier Requirements / Limits wal-itin oral tablet Generic OTC; QL wal-phed Generic OTC wal-phed 12 hour Generic OTC wal-phed pe Generic OTC wal-phed pe nighttime cold Generic OTC wal-phed pe sinus and allergy Generic OTC wal-profen cold-sinus Generic OTC wal-profen d cold and sinus Generic OTC WAL-SLEEP Z ORAL LIQUID Brand OTC wal-som (diphenhydramine) Generic OTC wal-tap dm Generic OTC wal-tussin cough Generic OTC wal-tussin cough and cold cf Generic OTC wal-tussin dm Generic OTC wal-tussin max strength cough Generic OTC wal-zyr (cetirizine) oral capsule Generic OTC; QL wal-zyr (cetirizine) oral solution Generic OTC wal-zyr (cetirizine) oral tablet Generic OTC; QL wal-zyr d Generic OTC; QL ZYNCOF ORAL LIQUID Brand OTC zyncof oral tablet Generic OTC ZYRTEC ORAL CAPSULE Brand OTC; QL ZYRTEC ORAL TABLET Brand OTC; QL ZYRTEC-D Brand OTC; QL ZZZQUIL ORAL LIQUID Brand OTC PULMONARY AGENTS albuterol sulfate inhalation hfa aerosol inhaler Generic QL albuterol sulfate inhalation solution for Generic nebulization albuterol sulfate oral Generic aller-flo Generic OTC; QL ambrisentan Generic PA ANORO ELLIPTA Brand QL ARNUITY ELLIPTA Brand QL ATROVENT HFA Brand QL

Drug Name Drug Tier Requirements / Limits BEVESPI AEROSPHERE Brand QL bosentan Generic PA budesonide inhalation Generic QL budesonide nasal Generic OTC; QL CINRYZE Brand PA COMBIVENT RESPIMAT Brand QL cromolyn inhalation Generic cromolyn nasal Generic OTC ESBRIET ORAL CAPSULE Brand PA; QL ESBRIET ORAL TABLET Brand PA FLOVENT DISKUS Brand QL FLOVENT HFA Brand QL flunisolide Generic QL fluticasone propionate nasal Generic OTC; QL icatibant Generic PA INCRUSE ELLIPTA Brand QL ipratropium bromide inhalation Generic ipratropium-albuterol Generic QL KALYDECO Brand PA; QL metaproterenol oral syrup Generic montelukast Generic nasal allergy Generic OTC; QL nasal allergy symptom control Generic OTC NASALCROM Brand OTC nebusal inhalation solution for nebulization 3 % Generic OFEV Brand PA; QL OPSUMIT Brand PA ORKAMBI ORAL TABLET Brand PA; QL PERFOROMIST Brand QL PROAIR RESPICLICK Brand QL pulmosal Generic PULMOZYME Brand sildenafil (pulm.hypertension) oral tablet Generic PA; QL sodium chloride inhalation Generic

Drug Name Drug Tier Requirements / Limits STRIVERDI RESPIMAT Brand QL SYMDEKO Brand PA; QL terbutaline Generic theophylline oral elixir Generic theophylline oral solution Generic theophylline oral tablet extended release 12 hr 300 Generic mg, 450 mg theophylline oral tablet extended release 24 hr Generic TRACLEER ORAL TABLET FOR Brand PA SUSPENSION triamcinolone acetonide nasal Generic OTC; QL TRIKAFTA Brand PA; QL TYVASO Brand PA TYVASO REFILL KIT Brand PA TYVASO STARTER KIT Brand PA VENTAVIS Brand PA wixela inhub Generic QL zafirlukast Generic UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS darifenacin Generic flavoxate Generic oxybutynin chloride oral syrup Generic oxybutynin chloride oral tablet Generic oxybutynin chloride oral tablet extended release Generic 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release Generic QL 24hr 5 mg BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin Generic dutasteride Generic ST dutasteride-tamsulosin Generic ST finasteride oral tablet 5 mg Generic PA tamsulosin Generic CHOLINERGIC STIMULANTS

Drug Name Drug Tier Requirements / Limits bethanechol chloride Generic MISCELLANEOUS UROLOGICALS CYSTAGON Brand cytra-2 Generic OTC cytra-3 Generic OTC cytra-k Generic OTC ELMIRON Brand glycine urologic Generic glycine urologic solution Generic hyophen Generic K-PHOS NO 2 Brand K-PHOS ORIGINAL Brand methen-sod phos-meth blue-hyos Generic phosphasal Generic pot,sodium citrate-citric acid Generic OTC potassium citrate-citric acid Generic OTC RENACIDIN Brand sodium citrate-citric acid Generic OTC tricitrates Generic OTC uretron d-s Generic urimar-t Generic uro-458 Generic urogesic-blue Generic uro-mp Generic uryl Generic ustell Generic utira-c Generic virtrate-2 Generic OTC virtrate-3 Generic OTC virtrate-k Generic OTC URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg Generic VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

Drug Name Drug Tier Requirements / Limits alcalak Generic OTC antacid (calcium carbonate) Generic OTC antacid ext str (calcium carb) Generic OTC antacid extra-strength oral tablet,chewable Generic OTC antacid ultra strength oral tablet,chewable 400 mg Generic OTC calcium (1,000 mg), 430 mg calcium (1,000 mg) calcium 500 + d oral tablet 500 mg(1,250mg) -200 Generic OTC unit calcium 500 with d Generic OTC calcium 600 + d(3) oral capsule Generic OTC calcium 600 + d(3) oral tablet 600 mg(1,500mg) - Generic OTC 400 unit CALCIUM 600 WITH VITAMIN D3 ORAL Brand OTC CAPSULE calcium 600 with vitamin d3 oral tablet,chewable Generic OTC calcium acetate(phosphat bind) Generic calcium antacid oral tablet,chewable 200 mg Generic OTC calcium (500 mg), 300 mg (750 mg), 320 mg calcium (750 mg), 430 mg calcium (1,000 mg) calcium carb and citrate-vitd3 Generic OTC calcium carbonate oral suspension Generic OTC calcium carbonate oral tablet 260 mg calcium Generic OTC (648 mg), 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg) calcium carbonate oral tablet,chewable 200 mg Generic OTC calcium (500 mg), 300 mg (750 mg), 400 mg calcium (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CARBONATE-VITAMIN D3 ORAL Brand OTC CAPSULE 600 MG (1,500 MG)-2,500 UNIT, 600MG (1,500MG) -1,000 UNIT calcium carbonate-vitamin d3 oral capsule 600 Generic OTC mg(1,500mg) -400 unit CALCIUM CARBONATE-VITAMIN D3 ORAL Brand OTC TABLET 1,000 MG(2,500 MG)-800 UNIT, 500MG (1,250MG) -600 UNIT, 600 MG(1,500MG) -800 UNIT calcium carbonate-vitamin d3 oral tablet 250-125 Generic OTC mg-unit, 500 mg(1,250mg) -125 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

Drug Name Drug Tier Requirements / Limits calcium carbonate-vitamin d3 oral Generic OTC tablet,chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE-VITAMIN D3 ORAL Brand OTC TABLET,CHEWABLE 500-100 MG-UNIT calcium citrate + d Generic OTC calcium citrate oral tablet Generic OTC calcium citrate plus (vit b6) Generic OTC calcium citrate-vitamin d3 oral tablet 200 mg- Generic OTC 3.125 mcg (125 unit), 250 mg-5 mcg (200 unit), 315 mg-5 mcg (200 unit) CALCIUM CITRATE-VITAMIN D3 ORAL Brand OTC TABLET 200 MG-6.25 MCG (250 UNIT), 315 MG-6.25 MCG (250 UNIT) CALCIUM GLUCONATE ORAL TABLET 50 Brand OTC MG CALCIUM calcium gluconate oral tablet 60 mg calcium (650 Generic OTC mg) calcium magnesium Generic OTC calcium-magnesium-zinc oral tablet 333-133-5 Generic OTC mg, 333-133-8.3 mg cal-gest antacid Generic OTC CALPHRON Brand OTC CALTRATE 600 PLUS D Brand OTC CALTRATE WITH VITAMIN D3 Brand OTC CITRACAL + D MAXIMUM Brand OTC CITRACAL REGULAR Brand OTC CITRACAL-D3 PETITES Brand OTC CITRACAL-D3 SLOW RELEASE Brand OTC citrus calcium-vitamin d3 oral tablet 200 mg-6.25 Generic OTC mcg (250 unit) effer-k oral tablet, effervescent 25 meq Generic ENFAMIL ENFALYTE Brand OTC flavor chews antacid Generic OTC hi-cal plus vit d Generic OTC klor-con Generic klor-con 10 Generic klor-con 8 Generic

Drug Name Drug Tier Requirements / Limits klor-con m10 Generic klor-con m15 Generic klor-con m20 Generic klor-con/ef Generic k-phos-neutral Generic OTC k-tab oral tablet extended release 8 meq Generic LIQUID CALCIUM WITH VITAMIN D Brand OTC lugols oral Generic mag-g Generic OTC magnesium gluconate oral tablet 27 mg Generic OTC magnesium (500 mg), 27.5 mg magnesium (500 mg) MAGNESIUM GLUCONATE ORAL TABLET Brand OTC 30 MG (550 MG) magnesium oral tablet 200 mg Generic OTC magnesium oxide oral capsule 500 mg Generic OTC magnesium oxide oral tablet Generic OTC MAGOX Brand OTC mgo Generic OTC MG-PLUS-PROTEIN Brand OTC oralyte Generic OTC OS-CAL 500 + D3 Brand OTC oysco 500/d Generic OTC oyster shell calcium 500 Generic OTC oyster shell calcium-vit d3 oral tablet 500 Generic OTC mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit oystercal-d Generic OTC PEDIALYTE ADVANCED CARE Brand OTC pedialyte oral solution Generic OTC pedialyte singles Generic OTC pediatric electrolyte oral solution Generic OTC pediatric freezer pops Generic OTC PHILLIPS Brand OTC phos-nak Generic OTC phospha 250 neutral Generic OTC

Drug Name Drug Tier Requirements / Limits phospho-trin 250 neutral Generic OTC potassium chloride oral Generic potassium gluconate oral tablet 2.5 meq, 500 mg Generic OTC (83 mg), 550 mg (90 mg), 595 mg (99 mg) PROVIMIN Brand OTC smooth antacid Generic OTC strong iodine oral Generic super calcium Generic OTC thermotabs Generic OTC TUMS Brand OTC TUMS E-X Brand OTC TUMS EXTRA STRENGTH SMOOTHIES Brand OTC tums ultra oral tablet,chewable 400 mg calcium Generic OTC (1,000 mg) URO-MAG Brand OTC virt-phos 250 neutral Generic OTC zinc Generic OTC zinc gluconate oral tablet Generic OTC MISCELLANEOUS NUTRITION PRODUCTS ACERFLEX Brand OTC acidophilus oral capsule Generic OTC ADVANTAGE WITH IRON Brand OTC ALFAMINO JUNIOR Brand OTC arginine (l-arginine) oral tablet Generic OTC ARGININE HCL (L-ARGININE) ORAL Brand OTC TABLET BCAD 1 Brand OTC biotect plus Generic OTC CALCILO XD Brand OTC complete amino acid mix Generic OTC CYCLINEX-1 Brand OTC CYCLINEX-2 Brand OTC DIABETISOURCE AC Brand OTC DOJOLVI Brand PA EAA SUPPLEMENT Brand OTC

Drug Name Drug Tier Requirements / Limits ear care Generic OTC ear health formula Generic OTC ELECARE INFANT FORMULA Brand OTC ELECARE JR Brand OTC ENFAGROW TODDLR TRANSITION SOY Brand OTC enfamil a.r. oral powder Generic OTC ENFAMIL ENFACARE ORAL POWDER Brand OTC ENFAMIL GENTLEASE ORAL LIQUID Brand OTC ENFAMIL GENTLEASE ORAL POWDER Brand OTC ENFAMIL INFANT Brand OTC ENFAMIL NEWBORN NON-GMO Brand OTC ENFAMIL NEWBORN ORAL LIQUID Brand OTC ENFAMIL PROSOBEE LIPIL Brand OTC ENFAPORT Brand OTC ENSURE CLEAR THERAPEUTIC Brand OTC EO28 SPLASH ORAL LIQUID 0.025-1 GRAM- Brand OTC KCAL/ML essential amino acid mix Generic OTC FISH OIL ORAL CAPSULE,DELAYED Brand OTC RELEASE(DR/EC) 300-108-162-600 MG, 900- 1,400 MG FISH,BORA,FLAX OILS-OM3,6,9NO1 Brand OTC FLORANEX ORAL GRANULES IN PACKET Brand OTC floranex oral tablet Generic OTC GA GEL Brand OTC GA POWDER Brand OTC GERBER GOOD START GENTLE NOGMO Brand OTC GERBER GOOD START GENTLE ORAL Brand OTC LIQUID GERBER GOOD START SOY ORAL LIQUID Brand OTC GERBER GOOD START SOY ORAL POWDER Brand OTC GLUCERNA ADVANCE Brand OTC GLUCERNA HUNGER SMART Brand OTC GLUCERNA ORAL BAR Brand OTC GLUCERNA THERAPEUTIC NUTRITION Brand OTC GLUTARADE JUNIOR Brand OTC

Drug Name Drug Tier Requirements / Limits GLUTAREX-1 Brand OTC GLUTAREX-2 Brand OTC GLYCOSADE Brand OTC GLYTACTIN 15 PE COMPLETE Brand OTC GLYTACTIN 20PE BETTERMILK LITE Brand OTC GLYTROL Brand OTC HCU COOLER Brand OTC hcu express powder Generic OTC HCU GEL POWDER Brand OTC HCU LOPHLEX Brand OTC HCY 1 POWDER Brand OTC HCY 2 Brand OTC HOMINEX-1 Brand OTC HOMINEX-2 Brand OTC immulife Generic OTC IMPACT 1 CAL Brand OTC IMPACT ADVANCED RECOVERY ORAL Brand OTC LIQUID 0.1 GRAM-1.12 KCAL/ML IMPACT PEPTIDE 1.5 CAL Brand OTC inositol oral tablet 650 mg Generic OTC ISOLEUCINE Brand OTC ISOMIL ADVANCE Brand OTC ISOMIL DF Brand OTC ISOMIL/IRON Brand OTC I-VALEX-1 Brand OTC I-VALEX-2 Brand OTC JUVEN Brand OTC KETONEX-1 Brand OTC KETONEX-2 Brand OTC KETOVOLVE Brand OTC LACTINEX Brand OTC lactobacillus acidophilus oral capsule 100 million Generic OTC cell lactobacillus acidophilus oral tablet 0.5 mg (100 Generic OTC million cell), 1 billion cell

100

Drug Name Drug Tier Requirements / Limits LACTOBACILLUS ACIDOPHILUS ORAL Brand OTC TABLET 2 BILLION CELL, 500 MILLION CELL LANAFLEX Brand OTC lecithin oral capsule 1,200 mg Generic OTC LEU-FREE COOLER Brand OTC lipistart Generic OTC LIPO-FLAVONOID PLUS Brand OTC l-lysine Generic OTC LMD POWDER Brand OTC LOPHLEX Brand OTC l-phenylalanine Generic OTC lysine Generic OTC lysine hcl oral tablet 1,000 mg Generic OTC LYSINE HCL ORAL TABLET 500 MG Brand OTC mct pro-cal Generic OTC metafolbic plus Generic OTC METHIONAID Brand OTC MMA-PA COOLER15 Brand OTC MMA-PA EXPRESS15 Brand OTC MMA-PA GEL Brand OTC MSUD AID Brand OTC MSUD ANALOG Brand OTC MSUD COOLER Brand OTC MSUD EXPRESS COOLER Brand OTC MSUD GEL POWDER Brand OTC MSUD LOPHLEX Brand OTC MSUD MAXAMAID Brand OTC MSUD MAXAMUM Brand OTC NEOCATE INFANT DHA-ARA Brand OTC NEOCATE JUNIOR Brand OTC NEOCATE JUNIOR WITH PREBIOTICS Brand OTC NEOCATE NUTRA Brand OTC NEOCATE SPLASH Brand OTC NEPRO CARB STEADY Brand OTC

101

Drug Name Drug Tier Requirements / Limits niacin (inositol niacinate) oral capsule 400 mg Generic OTC niacin (500 mg) niacin flush free oral capsule 400 mg niacin (500 Generic OTC mg) NIACIN FLUSH FREE ORAL CAPSULE 750 Brand OTC MG NIACIN NO FLUSH Brand OTC novasource renal 2 cal Generic OTC NUTRAMIGEN DHA-ARA Brand OTC NUTRAMIGEN TODDLER ENFLORA-LGG Brand OTC NUTRAMIGEN WITH ENFLORA LGG Brand OTC NUTREN PULMONARY Brand OTC NUTRIHEP Brand OTC OA 1 POWDER Brand OTC OA2 POWDER Brand OTC OMEGA 3-DHA-EPA-FISH OIL ORAL Brand OTC CAPSULE 100-150-750 MG, 356 MG (100 MG- 256 MG)-554 MG OMEGA-3 FATTY ACIDS-FISH OIL ORAL Brand OTC CAPSULE 440-880 MG OXEPA Brand OTC PEPTAMEN Brand OTC PEPTAMEN 1.5 Brand OTC PEPTAMEN JUNIOR 1.5 Brand OTC PERATIVE Brand OTC PERIFLEX ADVANCE Brand OTC PERIFLEX INFANT Brand OTC PERIFLEX JUNIOR Brand OTC PFD 2 Brand OTC PFD TODDLER Brand OTC PHENEX-1 Brand OTC PHENEX-2 Brand OTC PHENYLADE 60 Brand OTC PHENYLADE ESSENTIAL Brand OTC PHENYL-FREE 1 Brand OTC PHENYL-FREE 2 PKU Brand OTC

102

Drug Name Drug Tier Requirements / Limits PHLEXY-10 DRINK MIX POWDER Brand OTC pivot 1.5 cal Generic OTC PKU COOLER 10 Brand OTC PKU COOLER 15 Brand OTC PKU COOLER 20 Brand OTC PKU LOPHLEX Brand OTC PREGESTIMIL Brand OTC PREMIUM INFANT FORMULA Brand OTC probiotic oral capsule 10 billion cell Generic OTC PRODUCT 3232A Brand OTC PRO-PHREE Brand OTC PROPIMEX-1 Brand OTC PROPIMEX-2 Brand OTC PULMOCARE Brand OTC PURAMINO TODDLER Brand OTC RCF SOY PROTEIN FORMULA BASE Brand OTC RENA START Brand OTC SIMILAC ADVANCE Brand OTC SIMILAC ADVANCE ORGANIC ORAL Brand OTC LIQUID similac advance organic oral powder Generic OTC SIMILAC ADVANCE WITH IRON Brand OTC similac alimentum Generic OTC SIMILAC EXPERT CARE ALIMENTUM Brand OTC SIMILAC EXPERT CARE NEOSURE Brand OTC SIMILAC EXPERT CARE ORAL LIQUID Brand OTC SIMILAC FOR SPIT-UP Brand OTC SIMILAC HUMAN MILK FORTIFIER ORAL Brand OTC POWDER IN PACKET SIMILAC LOW-IRON Brand OTC SIMILAC NEOSURE ORAL LIQUID Brand OTC SIMILAC PM Brand OTC SIMILAC PRO-ADVANCE NON-GMO ORAL Brand OTC LIQUID SIMILAC PRO-SENSITIVE NON-GMO ORAL Brand OTC LIQUID

103

Drug Name Drug Tier Requirements / Limits SIMILAC SENSITIVE Brand OTC similac sensitive fuss and gas oral concentrate Generic OTC SIMILAC SENSITIVE FUSS AND GAS ORAL Brand OTC LIQUID SIMILAC SENSITIVE FUSS AND GAS ORAL Brand OTC POWDER SIMILAC SENSITIVE FUSS-GAS Brand OTC SIMILAC SENSITIVE ISOMIL SOY Brand OTC SIMILAC SOY ISOMIL Brand OTC SIMILAC SPECIAL CARE 24 Brand OTC SIMILAC SPECIAL CARE 30 Brand OTC SIMILAC SUPPLEMENTATION Brand OTC SIMILAC TOTAL COMFORT Brand OTC SIMILAC TOTAL COMFORT NON-GMO Brand OTC SOOTHE XP Brand OTC SUPLENA CARB STEADY Brand OTC TOLEREX Brand OTC triple omega 3-6-9 Generic OTC tyr cooler oral liquid Generic OTC TYR EXPRESS20 Brand OTC TYR GEL POWDER Brand OTC TYREX-1 Brand OTC TYREX-2 Brand OTC TYROS 1 Brand OTC TYROS 2 Brand OTC UCD ANAMIX JUNIOR Brand OTC ultra omega-3 Generic OTC VITAL 1.0 CAL Brand OTC VITAL 1.5 CAL Brand OTC VITAL AF 1.2 CAL Brand OTC VITAL HIGH PROTEIN Brand OTC VIVONEX PEDIATRIC Brand OTC VIVONEX PLUS Brand OTC vivonex rtf Generic OTC VIVONEX T.E.N. Brand OTC

104

Drug Name Drug Tier Requirements / Limits WND 2 Brand OTC XLEU ANALOG Brand OTC XLEU MAXAMAID Brand OTC XLYS- XTRP ANALOG Brand OTC XLYS, XTRP MAXAMAID Brand OTC XLYS, XTRP MAXAMUM Brand OTC XMET ANALOG Brand OTC XMET MAXAMUM Brand OTC XMTVI ANALOG Brand OTC xmtvi maxamaid Generic OTC xmtvi maxamum Generic OTC XPHE MAXAMAID Brand OTC XPHE, XTRP MAXAMAID Brand OTC XPHE, XTYR ANALOG Brand OTC XPTM ANALOG Brand OTC XTRACAL PLUS Brand OTC VITAMINS / HEMATINICS a thru z Generic OTC a thru z advanced formula Generic OTC a thru z high potency Generic OTC A THRU Z MEN'S ULTIMATE Brand OTC a thru z select 50plus formula Generic OTC a thru z select oral tablet , 500-300-250 mcg Generic OTC a thru z select women's Generic OTC abc plus Generic OTC acerola c-500 Generic OTC actical Generic OTC adults 50 plus Generic OTC ALGAL OMEGA-3 DHA Brand OTC ALGAL-900 DHA ORAL CAPSULE 450 MG Brand OTC animal chews Generic OTC ANTIOXIDANT VITAMINS Brand OTC apatate forte Generic OTC APETEX Brand OTC

105

Drug Name Drug Tier Requirements / Limits APETIGEN Brand OTC apetigen plus oral liquid Generic OTC ascorbate calcium (vitamin c) Generic OTC ascorbic acid (vitamin c) oral syrup Generic OTC ascorbic acid (vitamin c) oral tablet 500 mg Generic OTC ascorbic acid (vitamin c) oral tablet extended Generic OTC release 1,500 mg b complex 1 (with folic acid) Generic OTC b complex-vitamin b12 Generic OTC b complex-vitamin c-folic acid oral tablet Generic OTC B COMPLEX-VITAMIN C-FOLIC ACID ORAL Brand OTC TABLET EXTENDED RELEASE b-12 dots Generic OTC balanced b-100 complex Generic OTC balanced b-100 oral tablet Generic OTC balanced b-50 Generic OTC bal-care dha Generic b-complex with vitamin c oral capsule Generic OTC b-complex with vitamin c oral tablet Generic OTC b-complex with vitamin c oral tablet extended Generic OTC release biotin oral capsule 2,500 mcg, 5 mg Generic OTC biotin oral tablet 1 mg, 800 mcg Generic OTC BIOTIN ORAL TABLET 10 MG, 5 MG Brand OTC BLADDER 2.2 Brand OTC c complex Generic OTC c-1000 oral tablet Generic OTC c-1000 with rose hips Generic OTC c-500 oral tablet Generic OTC c-500 oral tablet,chewable Generic OTC ca-d3-mag ox-zinc-cop-mang-bor Generic OTC calcidol Generic OTC calcium 600 + minerals Generic OTC calcium 600-d3 plus (mag-zinc) Generic OTC calcium carbonate-vit d3-min oral tablet Generic OTC

106

Drug Name Drug Tier Requirements / Limits calcium for women Generic OTC calcium soft chew Generic OTC calcium-folic acid-vitamin d Generic OTC calcium-magnesium-copper-zinc Generic OTC CALCIUM-VITAMIN D3-VITAMIN K ORAL Brand OTC TABLET,CHEWABLE 500 MG-1,000 UNIT-40 MCG calcium-vitamin d3-vitamin k oral tablet,chewable Generic OTC 500-200-40 mg-unit-mcg, 500-500-40 mg-unit- mcg CALTRATE 600-D PLUS MINERALS ORAL Brand OTC TABLET centamin Generic OTC centratex Generic OTC centravites Generic OTC centravites 50 plus oral tablet Generic OTC CENTRUM COMPLETE Brand OTC CENTRUM MEN Brand OTC CENTRUM ORAL LIQUID 9 MG IRON/15 ML Brand OTC CENTRUM SILVER Brand OTC CENTRUM SILVER ULTRA MEN'S Brand OTC CENTRUM SPECIALIST HEART Brand OTC CENTRUM ULTRA MEN'S Brand OTC centrum women Generic OTC century Generic OTC century adults 50 plus Generic OTC century cardio Generic OTC century mature oral tablet 0.4-300-250 mg-mcg- Generic OTC mcg CENTURY ULTIMATE MEN'S ORAL TABLET Brand OTC 8 MG IRON- 200 MCG-600 MCG century ultimate women's oral tablet 18-400 mg- Generic OTC mcg cerovite jr Generic OTC cerovite senior Generic OTC certa plus Generic OTC certavite senior Generic OTC

107

Drug Name Drug Tier Requirements / Limits certavite-antioxidant Generic OTC children's chewable vitamin Generic OTC children's iron Generic OTC childs/iron Generic OTC CHOLECALCIFEROL (VITAMIN D3) ORAL Brand OTC CAPSULE 1,250 MCG (50,000 UNIT) cholecalciferol (vitamin d3) oral capsule 125 mcg Generic OTC (5,000 unit), 25 mcg (1,000 unit), 250 mcg (10,000 unit), 50 mcg (2,000 unit) cholecalciferol (vitamin d3) oral drops 10 mcg/ml Generic OTC (400 unit/ml), 125 mcg/ml (5,000 unit/ml) cholecalciferol (vitamin d3) oral tablet 125 mcg Generic OTC (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit) cholecalciferol (vitamin d3) oral tablet,chewable Generic OTC 25 mcg (1,000 unit) CHOLECALCIFEROL (VITAMIN D3) ORAL Brand OTC TABLET,CHEWABLE 50 MCG (2,000 UNIT) classic prenatal Generic OTC c-nate dha Generic cod liver oil oral capsule , 1,250-135 unit Generic OTC cod liver oil oral oil Generic OTC complete 50 plus Generic OTC complete multivitamin-mineral oral tablet Generic OTC complete mv adult 50 plus Generic OTC complete natal dha Generic complete oral tablet Generic OTC complete senior Generic OTC completenate Generic OTC complex b-100 oral tablet extended release Generic OTC corvita Generic OTC corvita 150 Generic OTC cyanocobalamin (vitamin b-12) injection Generic CYANOCOBALAMIN (VITAMIN B-12) ORAL Brand OTC LOZENGE cyanocobalamin (vitamin b-12) oral tablet 1,000 Generic OTC mcg

108

Drug Name Drug Tier Requirements / Limits cyanocobalamin (vitamin b-12) oral tablet Generic OTC extended release 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet Generic OTC 1,000 mcg, 2,500 mcg CYANOCOBALAMIN (VITAMIN B-12) Brand OTC SUBLINGUAL TABLET 3,000 MCG, 500 MCG d3-2000 Generic OTC DAILY MULTIPLE FOR WOMEN Brand OTC daily multivitamin-minerals Generic OTC daily value Generic OTC daily vitamin formula Generic OTC daily vitamin formula-iron Generic OTC daily vites/iron Generic OTC daily-vite Generic OTC DECARA ORAL CAPSULE 1,250 MCG (50,000 Brand OTC UNIT), 625 MCG (25,000 UNIT) delta d3 Generic OTC dialyvite Generic OTC dialyvite 800 oral tablet Generic OTC dialyvite vitamin d Generic OTC dino-life extra c multivitamin Generic OTC dino-life multivitamin Generic OTC dino-life with iron-zinc Generic OTC d-vi-sol Generic OTC eldertonic oral elixir Generic OTC elfolate oral tablet 7.5 mg Generic OTC ergocalciferol (vitamin d2) oral capsule 1,250 mcg Generic (50,000 unit) ergocalciferol (vitamin d2) oral drops Generic OTC ergocalciferol (vitamin d2) oral tablet 10 mcg Generic OTC (400 unit) ERGOCALCIFEROL (VITAMIN D2) ORAL Brand OTC TABLET 50 MCG (2,000 UNIT) essentia Generic OTC ESTER-C WITH BIOFLAVONOIDS Brand OTC EXPECTA PRENATAL Brand OTC

109

Drug Name Drug Tier Requirements / Limits eye health plus lutein Generic OTC ezfe 200 Generic OTC fabb Generic OTC fe c Generic OTC fe c plus Generic OTC FEOSOL BIFERA Brand OTC feosol oral tablet 325 mg (65 mg iron) Generic OTC FEOSOL ORAL TABLET 45 MG Brand OTC ferate Generic OTC FERGON ORAL TABLET 240 MG (27 MG Brand OTC IRON) FER-IN-SOL Brand OTC ferocon Generic OTC ferosul oral tablet Generic OTC ferretts Generic OTC ferrex 150 Generic OTC ferrex 150 forte Generic OTC ferrex 150 forte plus Generic OTC ferrex 150 plus Generic OTC ferrex 28 Generic OTC ferric x-150 Generic OTC FERRIMIN 150 Brand OTC ferrocite Generic OTC ferro-time Generic OTC ferrous fumarate oral tablet 324 mg (106 mg iron) Generic OTC ferrous gluconate Generic OTC ferrous sulfate oral drops Generic OTC ferrous sulfate oral elixir Generic OTC ferrous sulfate oral liquid Generic OTC ferrous sulfate oral solution Generic OTC ferrous sulfate oral tablet Generic OTC ferrous sulfate oral tablet,delayed release (dr/ec) Generic OTC fish oil-dha-epa Generic OTC FLINTSTONES COMPLETE (IRON) ORAL Brand OTC TABLET,CHEWABLE

110

Drug Name Drug Tier Requirements / Limits FLINTSTONES MULTIVITAMIN ORAL Brand OTC TABLET,CHEWABLE FLINTSTONES/EXTRA C ORAL Brand OTC TABLET,CHEWABLE fluoride (sodium) oral drops Generic OTC fluoride (sodium) oral tablet,chewable Generic OTC folbee Generic OTC folbee plus Generic OTC folbic Generic OTC folic acid oral tablet Generic OTC folitab Generic OTC folivane-f Generic OTC folivane-ob Generic folivane-plus Generic OTC folplex 2.2 Generic OTC foltabs 800 Generic OTC foltanx Generic OTC fosfree Generic OTC fruit c Generic OTC fruit c-500 Generic OTC full spectrum b-vitamin c Generic OTC GERITOL COMPLETE Brand OTC GERITOL TONIC WITH FERREX 18 Brand OTC gummi bear multivitamin Generic OTC hair vitamins Generic OTC hair,skin and nails oral tablet Generic OTC halls defense Generic OTC HEALTHY EYES Brand OTC healthy eyes supervision Generic OTC hematinic plus vit/minerals Generic OTC hematinic/folic acid Generic OTC hematogen fa Generic OTC hematogen forte Generic OTC HEMOCYTE Brand OTC high potency iron oral tablet 134 mg (27 mg iron) Generic OTC

111

Drug Name Drug Tier Requirements / Limits honey bears multivitamin Generic OTC icaps areds oral capsule Generic OTC ICAR Brand OTC ICAR-C Brand OTC iferex 150 Generic OTC iferex 150 forte Generic OTC infed Generic iron (dried) Generic OTC iron 100 plus Generic OTC iron chews Generic OTC iron oral tablet 325 mg (65 mg iron) Generic OTC iron oral tablet extended release Generic OTC iron, carbonyl Generic OTC iron,carbonyl-vitamin c Generic OTC i-vite Generic OTC KIDS MULTIVITAMIN-MINERALS Brand OTC kids vitamin d3 Generic OTC kobee Generic OTC kpn oral tablet Generic OTC KPN ORAL TABLET 9 MG IRON- 267 MCG Brand OTC LIQUID B-12 Brand OTC little animals Generic OTC little animals-iron oral tablet,chewable Generic OTC ludent fluoride Generic OTC lysiplex plus oral liquid Generic OTC macuvite eye care Generic OTC MAXIMUM D3 Brand OTC maximum daily multivitamin Generic OTC mega multiple/chelated mineral Generic OTC men's daily multivit-mineral Generic OTC men's one daily oral tablet Generic OTC MERIBIN Brand OTC metafolbic Generic OTC milltrium senior Generic OTC

112

Drug Name Drug Tier Requirements / Limits multi complete with iron Generic OTC multi for her oral tablet Generic OTC multi-day with iron Generic OTC multi-delyn with iron Generic OTC multigen Generic OTC multigen folic Generic OTC multigen plus Generic OTC multiple vitamin-minerals Generic OTC multiple vitamins Generic OTC multi-vit with fluoride-iron Generic OTC multivitamin 50 plus Generic OTC multivitamin oral tablet Generic OTC multivitamin with fluoride Generic OTC multi-vitamin with fluoride oral drops Generic OTC multivitamin with iron Generic OTC multivitamin with minerals oral liquid Generic OTC multivitamins with fluoride Generic OTC mvc-fluoride Generic OTC myferon 150 Generic OTC myferon 150 forte Generic OTC mynatal Generic mynatal plus Generic mynatal-z Generic mynephrocaps Generic OTC mynephron Generic OTC my-vitalife Generic OTC natural b-100 complex Generic OTC nephplex rx Generic OTC nephronex Generic OTC NEPHRO-VITE Brand OTC nephro-vite rx Generic OTC newgen Generic norwegian cod liver oil Generic OTC NOVAFERRUM ORAL DROPS Brand OTC

113

Drug Name Drug Tier Requirements / Limits NU-IRON Brand OTC ocutabs Generic OTC OCUVITE WITH LUTEIN Brand OTC omnicap Generic OTC ONCOVITE Brand OTC one daily Generic OTC one daily calcium/iron Generic OTC one daily complete Generic OTC one daily energy oral tablet Generic OTC one daily essential oral tablet , 0.4 mg Generic OTC one daily for men Generic OTC one daily for men 50+ advanced Generic OTC one daily for women Generic OTC one daily maximum Generic OTC one daily men's 50 plus memory Generic OTC one daily multi-vit w-mineral oral tablet Generic OTC one daily multivitamin oral tablet Generic OTC one daily multivit-iron(folic) Generic OTC one daily plus iron Generic OTC one daily plus minerals Generic OTC ONE DAILY PRENATAL ORAL COMBO Brand OTC PACK 28-800-440 MG-MCG-MG ONE DAILY WOMEN 50 PLUS Brand OTC one daily womens 50 plus Generic OTC one daily women's health Generic OTC one daily women's oral tablet 18 mg iron-400 Generic OTC mcg-450 mg ca, 27-0.4 mg one-a-day essential Generic OTC one-a-day maximum formula Generic OTC ONE-A-DAY MEN'S 50PLUS(GINKGO) Brand OTC one-a-day teen advantage Generic OTC ONE-A-DAY WOMENS FORMULA ORAL Brand OTC TABLET 18 MG IRON-400 MCG-500 MG CA opti-vitamins Generic OTC perry prenatal Generic OTC

114

Drug Name Drug Tier Requirements / Limits pnv 29-1 Generic pnv-dha Generic pnv-omega Generic pnv-select Generic poly-iron 150 forte Generic OTC polysaccharide iron complex Generic OTC pr natal 400 Generic pr natal 400 ec Generic pr natal 430 Generic pr natal 430 ec Generic prena1 chew Generic prena1 pearl Generic prena1 true Generic prenatabs fa Generic prenatabs rx Generic prenatal + dha oral combo pack 28 mg iron- 975 Generic OTC mcg-200 mg PRENATAL + DHA ORAL COMBO PACK 28 Brand OTC MG IRON-800 MCG-200 MG prenatal 19 Generic OTC prenatal complete Generic OTC PRENATAL FORMULA ORAL TABLET 9 MG Brand OTC IRON- 267 MCG prenatal low iron Generic PRENATAL MULTI-DHA (ALGAL OIL) Brand OTC PRENATAL MULTI-DHA(WITH VIT K) Brand OTC prenatal multivitamins Generic OTC prenatal one daily Generic OTC prenatal oral tablet 28 mg iron- 800 mcg Generic OTC prenatal plus Generic prenatal tablet Generic OTC prenatal vitamin oral tablet 27 mg iron- 0.8 mg Generic OTC prenatal vitamin plus low iron Generic prenatal vits96-iron fum-folic Generic OTC prenatal-u Generic

115

Drug Name Drug Tier Requirements / Limits preplus Generic PRESERVISION AREDS Brand OTC pretab Generic PRO FE Brand OTC PROFERRIN-FORTE Brand OTC purevit dualfe plus Generic OTC pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, Generic OTC 250 mg, 50 mg quintabs-m iron free Generic OTC renal caps Generic OTC rena-vite Generic OTC rena-vite rx Generic OTC reno caps Generic OTC replesta Generic OTC REPLESTA NX Brand OTC riboflavin (vitamin b2) oral tablet 100 mg, 50 mg Generic OTC risacal-d Generic OTC SAVISION Brand OTC SCOOBY-DOO ONE A DAY Brand OTC se-natal 19 chewable Generic se-natal-19 Generic senior tabs Generic OTC sentry Generic OTC sentry senior Generic OTC se-tan plus Generic OTC SLOW FE Brand OTC SLOW RELEASE IRON ORAL TABLET Brand OTC EXTENDED RELEASE 140 MG (45 MG IRON), 142 MG (45 MG IRON), 143 MG (45 MG IRON), 144 MG (45 MG IRON), 168 MG (50 MG IRON) slow release iron oral tablet extended release 160 Generic OTC mg (50 mg iron), 250 mg (50 mg iron) soothing pureway-c Generic OTC spectravite adult 50 plus Generic OTC spectravite advanced formula Generic OTC spectravite men's Generic OTC

116

Drug Name Drug Tier Requirements / Limits stress b with zinc Generic OTC stress formula Generic OTC stress formula with iron Generic OTC stress formula with iron(sulf) Generic OTC stress formula with zinc Generic OTC sunvite Generic OTC super b complex-vitamin c Generic OTC super b maxi complex Generic OTC super b/c Generic OTC super multiple oral tablet Generic OTC super multivitamin Generic OTC super quints Generic OTC super quints b-50 Generic OTC super thera vite m Generic OTC support Generic OTC tab-a-vite Generic OTC tab-a-vite multivitamin w-iron oral tablet 15 mg Generic OTC iron- 400 mcg taron forte Generic OTC taron-c dha Generic thera-d Generic OTC theralogix companion Generic OTC thera-m oral tablet 27-0.4 mg, 9 mg iron-400 mcg Generic OTC therapeutic liquid Generic OTC therapeutic-m oral tablet 9 mg iron-400 mcg Generic OTC thera-tabs Generic OTC thera-tabs m Generic OTC theratrum complete 50 plus/lut Generic OTC theratrum complete 50 plus-lyc Generic OTC theratrum complete with lutein Generic OTC therems-m Generic OTC thiamine hcl (vitamin b1) oral tablet 100 mg, 250 Generic OTC mg thiamine mononitrate (vit b1) Generic OTC tricon Generic OTC

117

Drug Name Drug Tier Requirements / Limits trigels-f forte Generic OTC trinatal rx 1 Generic trinate Generic triphrocaps Generic OTC triveen-duo dha Generic tri-vitamin with fluoride Generic OTC v-c forte Generic OTC VENOFER Brand vic-forte Generic OTC virt-c dha Generic virt-gard Generic OTC virt-nate dha Generic virt-pn dha Generic virt-pn plus Generic VISION FORMULA (WITH LUTEIN) Brand OTC VISION PLUS LUTEIN Brand OTC vit 3 Generic OTC vita-c Generic OTC vitacel (with lutein) Generic OTC VITAFOL-OB Brand vitajoy daily d Generic OTC vitalee Generic OTC vitalets Generic OTC vitamin b complex Generic OTC vitamin b complex-folic acid oral tablet Generic OTC vitamin b-1 Generic OTC VITAMIN B-12 ORAL LOZENGE 50 MCG Brand OTC vitamin b-12 oral lozenge 500 mcg Generic OTC vitamin b-12 oral tablet 100 mcg, 250 mcg, 50 Generic OTC mcg, 500 mcg vitamin b-12 oral tablet extended release 2,000 Generic OTC mcg VITAMIN B-12 SUBLINGUAL TABLET 5,000 Brand OTC MCG vitamin b-2 Generic OTC

118

Drug Name Drug Tier Requirements / Limits vitamin b-6 oral tablet 25 mg, 250 mg, 50 mg Generic OTC vitamin c drops Generic OTC vitamin c oral capsule, extended release Generic OTC vitamin c oral powder Generic OTC vitamin c oral tablet Generic OTC vitamin c oral tablet extended release Generic OTC vitamin c oral tablet,chewable 250 mg, 500 mg Generic OTC vitamin c with rose hips oral tablet 500 mg Generic OTC vitamin c with rose hips oral tablet extended Generic OTC release vitamin d3 oral capsule 10 mcg (400 unit) Generic OTC vitamin d3 oral tablet 10 mcg (400 unit) Generic OTC vitamin d3 oral tablet,chewable Generic OTC vitamins a and d Generic OTC vitamins a,c,d and fluoride Generic OTC vitamins b complex oral capsule Generic OTC vitamins for hair Generic OTC vitatrum Generic OTC vitrum senior oral tablet Generic OTC VITRUM SENIOR ORAL TABLET 500-300-250 Brand OTC MCG vp-vite rx Generic OTC wee care Generic OTC WOMEN'S DAILY FORMULA ORAL TABLET Brand OTC 18 MG IRON-400 MCG-500 MG CA women's daily formula oral tablet 27-0.4 mg Generic OTC WOMEN'S ONE DAILY Brand OTC women's prenatal plus dha Generic OTC yelets Generic OTC zatean-pn dha Generic zatean-pn plus Generic zingiber Generic

119

Index

1 acid gone antacid ...... 54 AFINITOR ...... 9 12 hour decongestant ...... 76 acid gone antacid e.strength . 54 AFINITOR DISPERZ ...... 9 12 hour nasal spray ...... 46 acid reducer (cimetidine) ...... 62 afirmelle ...... 68 1-DAY ...... 67 acid reducer (famotidine) ..... 62 AFLURIA QUAD 2021- 2 acidophilus ...... 97 2022(6MO UP) ...... 64 24hour allergy ...... 76 acidophilus-pectin ...... 52 AFRIN (OXYMETAZOLINE) 3 ACIDOPHILUS-PECTIN, ...... 46 3 day vaginal ...... 67 CITRUS ...... 52 afrin no drip(oxymetazolin) .. 46 3-day vaginal ...... 67 acitretin ...... 34 AFRIN SINUS 4 ACTHAR ...... 48 (OXYMETAZOLINE) ..... 46 4 way ...... 46 actical ...... 104 AIMOVIG AUTOINJECTOR 4-n-1 no rinse wash ...... 34 acticon (dexbromph-pse) ...... 76 ...... 16 8 actidom dmx ...... 76 AJOVY AUTOINJECTOR .. 16 8 hour pain reliever ...... 19 ACTIMMUNE ...... 63 AJOVY SYRINGE ...... 16 A acyclovir ...... 3 ak-poly-bac ...... 72 a thru z ...... 104 added strength headache relief ala-cort ...... 41 a thru z advanced formula .. 104 ...... 19 ala-hist ir ...... 76 a thru z high potency ...... 104 adefovir ...... 3 alavert ...... 76 A THRU Z MEN'S ADMELOG SOLOSTAR U- alavert d-12 allergy-sinus ..... 76 ULTIMATE ...... 104 100 INSULIN ...... 49 albendazole ...... 7 a thru z select ...... 104 ADMELOG U-100 INSULIN albuterol sulfate ...... 90 a thru z select 50plus formula LISPRO ...... 49 alcalak ...... 94 ...... 104 adult robitussin peak cold m-s ALECENSA ...... 9 a thru z select women's ...... 104 ...... 76 alendronate ...... 65 abacavir ...... 3 adult tussin chest congestion 76 aler-cap ...... 76 abacavir-lamivudine ...... 3 adult tussin cough congest dm ALEVE ...... 19 abacavir-lamivudine- ...... 76 ALEVE COLD AND SINUS zidovudine ...... 3 adult tussin dm...... 76 ...... 76 abanatuss ped...... 76 adult tussin multi-symp cold 76 ALEVE SINUS AND abc plus ...... 104 adult wal-tussin ...... 76 HEADACHE ...... 77 ABILIFY MAINTENA ...... 25 adult wal-tussin dm max ...... 76 ALEVE-D SINUS AND abiraterone ...... 9 adults 50 plus ...... 104 COLD ...... 77 ABREVA ...... 41 advanced antacid-antigas ...... 54 ALEVE-D SINUS AND acamprosate ...... 43 advanced eye relief ...... 73 HEADACHE ...... 77 acarbose ...... 49 advanced healing (petrolatum) ALFAMINO JUNIOR ...... 97 ACD-A ...... 43, 49 ...... 34 alfuzosin ...... 92 acebutolol ...... 28 ADVANTAGE WITH IRON ALGAL OMEGA-3 DHA .. 104 ACERFLEX ...... 97 ...... 97 ALGAL-900 DHA ...... 104 acerola c-500 ...... 104 ADVATE ...... 31 ALINIA ...... 7 acetadryl ...... 19 ADVIL ...... 19 alka-seltzer original ...... 19 acetaminophen ...... 19 advil cold and sinus ...... 76 alka-seltzer plus allergy ...... 77 acetaminophen pm extra str.. 19 ADVIL COLD AND SINUS 76 ALKA-SELTZER PLUS acetaminophen-caff- advil junior strength ...... 19 COLD/COUGHFM ...... 77 dihydrocod ...... 18 ADVIL LIQUI-GEL ...... 19 ALKA-SELTZER PLUS DAY acetaminophen-codeine ...... 18 ADVIL MIGRAINE ...... 19 ...... 77 acetazolamide ...... 75 ADVIL PM ...... 19 alka-seltzer plus mucus-conges acetic acid ...... 48 ADYNOVATE ...... 31 ...... 77 acid controller ...... 62 AEMCOLO ...... 7

120

ALKA-SELTZER PLUS ALOE VESTA antacid (calcium carb-mag SINUS-COUGH ...... 77 PROTECTANT hyd) ...... 54 all day allergy (cetirizine) .... 77 OINTMENT ...... 34 antacid (calcium carbonate) .. 94 all day allergy-d ...... 77 alophen (bisacodyl) ...... 54 antacid anti-gas ...... 54 all day pain relief ...... 19 alosetron ...... 54 ANTACID ANTI-GAS (CA all day relief ...... 19 ALPHANATE ...... 31 CARB-SIM) ...... 54 ALLEGRA ALLERGY...... 77 alprazolam ...... 25 antacid exst (mag carb-al hyd) ALLEGRA-D 12 HOUR ...... 77 alprazolam intensol ...... 25 ...... 54 ALLEGRA-D 24 HOUR ...... 77 ALPROLIX ...... 31 antacid ext str (calcium carb) 94 aller-chlor ...... 77 altacaine ...... 73 antacid extra-strength ...... 94 allerclear ...... 77 altamist ...... 46 antacid m ...... 54 allerclear d-12hr ...... 77 altavera (28) ...... 68 antacid maximum strength ... 54 allerclear d-24hr ...... 77 aluminum hydroxide gel ...... 54 antacid plus anti-gas ...... 54 aller-ease...... 77 alyacen 1/35 (28) ...... 68 antacid regular strength ...... 54 aller-fex ...... 77 alyacen 7/7/7 (28) ...... 68 antacid supreme ...... 54 aller-flo ...... 90 amabelz ...... 66 antacid ultra strength ...... 54, 94 aller-g-time ...... 77 amantadine hcl ...... 3 antacid-antigas ...... 54 allergy (chlorpheniramine) ... 77 ambrisentan ...... 90 antacid-simethicone ...... 54 allergy (diphenhydramine) ... 77 amerigel ...... 34 antibiotic (bacitracin zinc) .... 38 allergy 4-hour ...... 77 amethia ...... 68 antibiotic (neomy-bacit-polym) allergy and congestion relief 77 amethyst (28) ...... 68 ...... 38 allergy complete-d ...... 77 amiloride ...... 28 ANTIBIOTIC PLUS allergy medication ...... 77 amiloride-hydrochlorothiazide (PRAMOXINE) ...... 38 allergy medicine ...... 77 ...... 28 antibiotic-pain relief (bacit) .. 38 allergy multi-symptom ...... 77 aminocaproic acid ...... 31 ANTICOAG CITRATE PHOS allergy plus severe sinus ha .. 77 amiodarone ...... 28 DEXTROSE ...... 43 allergy relief (cetirizine) ...... 77 amitriptyline ...... 25 anti-diarrheal ...... 52 allergy relief (fexofenadine) . 78 amitriptyline-chlordiazepoxide anti-diarrheal (loperamide) ... 52 allergy relief (loratadine) ...... 78 ...... 25 anti-fungal ...... 39 allergy relief d-24hr ...... 78 amlodipine ...... 28 antifungal (clotrimazole) ...... 39 allergy relief multi-symptom 78 amlodipine-atorvastatin ...... 32 antifungal (tolnaftate) ...... 39 allergy relief(chlorpheniramn) amlodipine-benazepril ...... 28 ANTIFUNGAL CREAM ...... 78 amlodipine-valsartan ...... 28 (MICONAZOLE) ...... 39 allergy relief(diphenhydramin) amlodipine-valsartan-hcthiazid antifungal spray ...... 39 ...... 78 ...... 28 anti-itch (hc) ...... 41 allergy relief,nasal decongest78 amnesteem ...... 37 anti-itch medicated ...... 46 allergy relief-d (cetirizine) ... 78 amoxapine ...... 25 ANTI-ITCH PLUS ...... 41 allergy relief-d (loratadine) .. 78 amoxicil-clarithromy-lansopraz anti-nausea ...... 54 allergy relief-d(fexofenadine) ...... 62 ANTIOXIDANT VITAMINS ...... 78 amoxicillin ...... 8 ...... 104 allergy sinus pe ...... 78 amoxicillin-pot clavulanate .... 8 antiseptic ...... 38 allergy sinus-d ...... 78 ampicillin ...... 8 antiseptic skin clnsr(chlorhe) 34 allergy-congestion relief-d ... 78 anagrelide ...... 43 antitussive dm ...... 78 allergy-time ...... 78 ANASEPT ...... 43 apatate forte ...... 104 aller-tec ...... 78 ANASEPT SKIN-WOUND APETEX ...... 104 aller-tec d ...... 78 CLEANSER ...... 43 APETIGEN ...... 104 ALL-NITE COLD-FLU ...... 78 anaspaz ...... 52 apetigen plus ...... 104 allopurinol ...... 65 anastrozole ...... 9 ap-hist dm ...... 78 almacone-2 ...... 54 anefrin ...... 46 APOKYN ...... 16 ALOE VESTA animal chews ...... 104 aprepitant ...... 54 ANTIFUNGAL (MICON)39 ANORO ELLIPTA ...... 90 apri ...... 68

121 aprodine ...... 78 atenolol-chlorthalidone ...... 28 b-12 dots ...... 105 APTIVUS ...... 3 athenol ...... 20 baby ayr saline ...... 46 aqua care ...... 34 athlete's foot ...... 39 baby wash ...... 34 aqua glycolic ...... 34 athlete's foot (clotrimazole) .. 39 BACID ...... 52 aqua glycolic face ...... 34 ATHLETE'S FOOT bacitracin ...... 38, 72 AQUA LUBE ...... 34 (TERBINAFINE) ...... 39 bacitracin zinc ...... 38 AQUANIL HC ...... 41 athlete's foot (tolnaftate) ...... 39 BACITRACIN ZINC ...... 38 AQUANIL SKIN CLEANSER athletic foot cream ...... 39 bacitracin-polymyxin b ...... 72 ...... 34 atomoxetine ...... 25 bacitraycin plus ...... 38 AQUAPHOR HEALING ..... 34 atorvastatin ...... 32 back and body pain reliever .. 20 AQUAPHOR ORIGINAL ... 34 atovaquone ...... 7 backache relief extra strength ARALAST NP ...... 43 atovaquone-proguanil ...... 7 ...... 20 aranelle (28)...... 68 ATRIPLA ...... 3 baclofen ...... 17 ARCALYST ...... 63 atropine ...... 73 balanced b-100 ...... 105 arginine (l-arginine)...... 97 ATROVENT HFA ...... 91 balanced b-100 complex ..... 105 ARGININE HCL (L- aubra ...... 68 balanced b-50 ...... 105 ARGININE) ...... 97 aubra eq ...... 68 bal-care dha ...... 105 ARIKAYCE ...... 7 AUGMENTIN ...... 8 BALVERSA ...... 9 aripiprazole ...... 25 aurovela 1.5/30 (21) ...... 68 balziva (28) ...... 68 ARISTADA ...... 25 aurovela 1/20 (21) ...... 68 banophen ...... 78 ARISTADA INITIO ...... 25 aurovela 24 fe ...... 68 BARACLUDE ...... 3 armodafinil ...... 25 aurovela fe 1.5/30 (28) ...... 68 BASAGLAR KWIKPEN U- ARMOUR THYROID ...... 51 aurovela fe 1-20 (28) ...... 68 100 INSULIN ...... 49 arnica ...... 45 AVEENO DAILY BAXDELA ...... 8 ARNUITY ELLIPTA ...... 91 MOISTURIZING ...... 34 bayer advanced ...... 20 arthritis pain relief (acetam) . 19 aviane ...... 68 BAYER CHEWABLE artificial tears (petro/min)..... 73 avidoxy ...... 8 ASPIRIN ...... 20 artificial tears (pf) ...... 73 avita ...... 37 bayer plus extra strength ...... 20 ARTIFICIAL TEARS (PF) .. 73 AVONEX ...... 63 baza antifungal ...... 39 artificial tears (polyvin alc) .. 74 ayr saline ...... 46 BCAD 1 ...... 97 artificial tears(dext70-hypro) 74 ayr saline nasal neti rinse ...... 46 b-complex with vitamin c ... 105 artificial tears(glycerin-peg) . 74 AYR SINUS RINSE ...... 46 BEANO ...... 55 artificial tears(pg-hypm-glyc) AYR SINUS RINSE REFILL belladonna alkaloids-opium .. 52 ...... 74 ...... 46 BENADRYL ...... 78 artificial tears(pvalch-povid) 74 ayuna ...... 68 BENADRYL ALLERGY ..... 78 ascomp with codeine ...... 18 AYVAKIT ...... 9 benazepril ...... 28 ascorbate calcium (vitamin c) azacitidine ...... 9 benazepril-hydrochlorothiazide ...... 104 AZASAN ...... 9 ...... 28 ascorbic acid (vitamin c) .... 105 azathioprine ...... 9 BENEFIBER SUGAR FREE ashlyna ...... 68 azelastine ...... 46, 74 (DEXTRIN) ...... 55 ASPERCREME azithromycin ...... 6 BENEFIX ...... 31 (LIDOCAINE) ...... 37 azolen tincture ...... 39 BENLYSTA ...... 65 aspirin ...... 20 azurette (28) ...... 68 benzoin ...... 34 aspirin childrens ...... 19 B benzoin compound ...... 34 aspirin low dose ...... 19 b complex 1 (with folic acid) benzonatate ...... 78 aspirin,buffd-calcium carb-mag ...... 105 benztropine ...... 16 ...... 20 b complex-vitamin b12 ...... 105 best fiber ...... 55 aspir-trin ...... 20 b complex-vitamin c-folic acid BETADINE ...... 38 astringent ...... 34 ...... 105 BETADINE SURGICAL atazanavir ...... 3 B COMPLEX-VITAMIN C- SCRUB ...... 38 atenolol ...... 28 FOLIC ACID ...... 105 BETADINE SWABSTICKS 38

122 beta-hc ...... 41 budesonide ...... 55, 91 calcium carbonate-vit d3-min betamethasone dipropionate . 41 bufferin ...... 20 ...... 105 betamethasone valerate ...... 41 bumetanide ...... 29 calcium carbonate-vitamin d3 betamethasone, augmented... 41 buprenorphine hcl ...... 18 ...... 94, 95 BETAMIDE ...... 34 buprenorphine-naloxone ...... 20 CALCIUM CARBONATE- betasept surgical scrub ...... 34 bupropion hcl ...... 25 VITAMIN D3 ...... 94, 95 betatemp ...... 20 bupropion hcl (smoking deter) calcium citrate ...... 95 betaxolol ...... 28, 73 ...... 45 calcium citrate + d ...... 95 bethanechol chloride ...... 93 buspirone ...... 25 calcium citrate plus (vit b6) .. 95 BEVESPI AEROSPHERE ... 91 butalbital compound w/codeine calcium citrate-vitamin d3 .... 95 bexarotene ...... 9 ...... 18 CALCIUM CITRATE- BEXSERO ...... 64 butalbital-acetaminop-caf-cod VITAMIN D3 ...... 95 bicalutamide ...... 9 ...... 18 calcium for women ...... 105 BIKTARVY ...... 3 butalbital-acetaminophen ..... 18 calcium gluconate ...... 95 biocotron...... 78 butalbital-acetaminophen-caff CALCIUM GLUCONATE .. 95 bion tears (pf) ...... 74 ...... 18 calcium magnesium ...... 95 bionel ...... 78 butalbital-aspirin-caffeine .... 18 calcium soft chew ...... 105 biotect plus ...... 97 butorphanol ...... 20 calcium-folic acid-vitamin d biotin ...... 105 BYDUREON BCISE ...... 49 ...... 105 BIOTIN ...... 105 C calcium-magnesium-copper- bisacodyl...... 55 c complex ...... 105 zinc ...... 105 bisa-lax (bisacodyl) ...... 55 c-1000 ...... 105 calcium-magnesium-zinc ...... 95 bismatrol ...... 52 c-1000 with rose hips ...... 105 calcium-vitamin d3-vitamin k bismuth ...... 52 c-500 ...... 105 ...... 106 bisoprolol fumarate ...... 29 cabergoline ...... 50 CALCIUM-VITAMIN D3- bisoprolol-hydrochlorothiazide ca-d3-mag ox-zinc-cop-mang- VITAMIN K ...... 106 ...... 29 bor ...... 105 cal-gest antacid ...... 95 BLADDER 2.2 ...... 105 caffeine citrate ...... 43 calmoseptine ...... 35 bleomycin ...... 9 calamine phenolated ...... 34 CALPHRON ...... 95 blisovi 24 fe ...... 68 calamine-zinc oxide ...... 34 CALQUENCE ...... 10 blisovi fe 1.5/30 (28) ...... 68 calamine-zinc oxide-phenol . 35 CALTRATE 600 PLUS D .... 95 blisovi fe 1/20 (28) ...... 68 calcidol ...... 105 CALTRATE 600-D PLUS blis-to-sol (tolnaftate) ...... 39 CALCILO XD ...... 97 MINERALS ...... 106 boro-packs ...... 34 calcipotriene ...... 34 CALTRATE WITH VITAMIN bosentan ...... 91 calcitonin (salmon) ...... 50 D3 ...... 95 BOSULIF ...... 10 calcitriol ...... 50 camila ...... 66 BOUDREAUXS BUTT calcium 500 + d ...... 94 camrese ...... 68 PASTE ...... 34 calcium 500 with d ...... 94 camrese lo ...... 68 BRAFTOVI ...... 10 calcium 600 + d(3) ...... 94 capecitabine ...... 10 briellyn ...... 68 calcium 600 + minerals ...... 105 CAPLYTA ...... 25 BRILINTA ...... 31 calcium 600 with vitamin d3 94 CAPRELSA ...... 10 brimonidine ...... 76 CALCIUM 600 WITH captopril-hydrochlorothiazide brohist d ...... 78 VITAMIN D3 ...... 94 ...... 29 bromocriptine ...... 16 calcium 600-d3 plus (mag- CARBAGLU ...... 43 brompheniramine-pseudoeph- zinc) ...... 105 carbamazepine ...... 14 dm ...... 78 calcium acetate(phosphat bind) carbidopa ...... 16 broncotron ped ...... 78 ...... 94 carbidopa-levodopa ...... 16 BRONKIDS ...... 78 calcium antacid ...... 94 carbidopa-levodopa- brotapp dm...... 78 calcium carb and citrate-vitd3 entacapone ...... 16 BRUKINSA ...... 10 ...... 94 carbinoxamine maleate ...... 79 bss ...... 74 calcium carbonate ...... 94 carboplatin ...... 10

123 carmustine ...... 10 cetiri-d ...... 79 CHILDREN'S DELSYM carteolol ...... 73 cetirizine ...... 79 COUGH ...... 80 cartia xt ...... 29 cetirizine-pseudoephedrine ... 79 children's dibromm cold-allerg carvedilol ...... 29 cevimeline ...... 43 ...... 80 castor oil ...... 55 chateal (28) ...... 68 children's dibromm dm cold- CAVILON DURABLE chateal eq (28) ...... 69 cou ...... 80 BARRIER ...... 35 CHEMET ...... 43 children's easy-melts ...... 20 CAYA CONTOURED ...... 49 CHENODAL ...... 55 children's flu relief ...... 80 CAYSTON ...... 7 chest congestion relief ...... 79 children's ibuprofen ...... 20 caziant (28) ...... 68 chest congestion relief dm .... 79 children's iron ...... 106 cefaclor ...... 6 chest congestion relief pe ..... 79 children's mapap ...... 20 cefadroxil ...... 6 chest congestion-cough relief CHILDREN'S MOTRIN ...... 20 cefdinir ...... 6 ...... 79 CHILDREN'S MUCINEX cefditoren pivoxil ...... 6 chest-sinus congestion relief 79 COLD-FEVER ...... 80 cefprozil ...... 6 child allergy relf(cetirizine) .. 79 children's mucinex cough ..... 80 cefuroxime axetil ...... 6 child allergy relief (diphen) .. 79 CHILDREN'S MUCINEX celecoxib...... 20 child benadryl plus congestion MULTI-SYMP ...... 80 centamin ...... 106 ...... 79 children's non-aspirin ...... 20 centratex ...... 106 child chest congestion-cough 79 children's pain relief ...... 20 centravites...... 106 child fever reducer-pain relvr children's pain-fever relief .... 20 centravites 50 plus ...... 106 ...... 20 children's pepto ...... 55 CENTRUM ...... 106 CHILD MUCINEX COUGH childrens plus cold ...... 80 CENTRUM COMPLETE .. 106 MINI-MELTS ...... 79 children's plus flu ...... 80 CENTRUM MEN ...... 106 child mucus relief cough ...... 79 CHILDRENS PLUS MULTI- CENTRUM SILVER ...... 106 child mucus relief expectorant SYMP COLD ...... 80 CENTRUM SILVER ULTRA ...... 79 children's profen ib ...... 20 MEN'S ...... 106 CHILD MULTI-SYMPTOM children's saline nasal spray . 46 CENTRUM SPECIALIST COLD/COUGH ...... 79 children's silfedrine ...... 80 HEART ...... 106 child pain rel-fever reducer .. 20 children's soothe ...... 55 CENTRUM ULTRA MEN'S child triaminic cold-allergy .. 79 CHILDREN'S SUDAFED ... 80 ...... 106 child wal-tap cold-allergy ..... 79 children's sudafed pe cough .. 80 centrum women ...... 106 children's acetaminophen ..... 20 CHILDREN'S SUDAFED PE century ...... 106 children's advil ...... 20 NASAL ...... 80 century adults 50 plus ...... 106 children's allegra allergy ...... 79 CHILDREN'S TYLENOL ... 20 century cardio ...... 106 children's allergy (diphenhyd) children's wal-dryl allergy .... 80 century mature ...... 106 ...... 79 children's wal-zyr ...... 80 CENTURY ULTIMATE children's allergy relief(lor) .. 79 CHILDREN'S WAL-ZYR ... 80 MEN'S ...... 106 children's benadryl allergy ... 79 child's all day allergy(cetir) .. 80 century ultimate women's ... 106 children's cetirizine ...... 79 childs triacting cold-cough ... 80 cephalexin...... 6 children's chest congestion ... 79 childs/iron ...... 106 CERAVE ...... 35 children's chewable vitamin106 chlordiazepoxide hcl ...... 25 CERAVE FOAMING CHILDREN'S CLARITIN ... 79 chlorhexidine gluconate .. 35, 46 FACIAL ...... 35 children's cold and cough (pe) chlorhist ...... 80 CERDELGA...... 50 ...... 79 chloroquine phosphate ...... 7 cerovite jr...... 106 children's cold-allergy (pe) ... 79 chlorpheniramine maleate .... 80 cerovite senior ...... 106 CHILDREN'S COLD- chlorpromazine ...... 25 certa plus ...... 106 COUGH-SORE ...... 80 chlortabs ...... 80 certavite senior ...... 106 children's cough ...... 80 chlorthalidone ...... 29 certavite-antioxidant ...... 106 CHILDREN'S COUGH DM CHLOR-TRIMETON ...... 80 CETAPHIL ...... 35 ER ...... 80 chlorzoxazone ...... 17 cetaphil gentle cleanser ...... 35 chocolate laxative ...... 55

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CHOLBAM ...... 55 clomiphene citrate ...... 50 comfort gel ...... 55 cholecalciferol (vitamin d3) 107 clomipramine ...... 25 comfort gel extra strength ..... 55 CHOLECALCIFEROL clonazepam ...... 14 COMPLERA ...... 4 (VITAMIN D3) ...... 107 clonidine ...... 29 complete ...... 107 cholestyramine (with sugar) . 32 clonidine hcl ...... 29 complete 50 plus ...... 107 cholestyramine light ...... 32 clopidogrel ...... 31 complete allergy medicine .... 81 choline,magnesium salicylate clorazepate dipotassium ...... 25 complete amino acid mix ...... 97 ...... 20 clotrimazole ...... 3, 40, 67 complete lice treatment ...... 42 ciclodan ...... 39, 40 clotrimazole-3 ...... 67 complete multivitamin-mineral ciclopirox ...... 40 clotrimazole-betamethasone . 40 ...... 107 cidatrine ...... 20 clozapine ...... 25 complete mv adult 50 plus .. 107 cidofovir ...... 3 c-nate dha ...... 107 complete natal dha ...... 107 cilostazol...... 31 COARTEM ...... 7 complete premium vitamin ... 45 CIMDUO ...... 3 cod liver oil ...... 107 complete senior ...... 107 cimetidine ...... 62 codeine sulfate ...... 18 completenate ...... 107 cimetidine hcl ...... 62 codeine-butalbital-asa-caff ... 18 complex b-100 ...... 107 cinacalcet ...... 50 COLACE ...... 55 compro ...... 55 CINRYZE ...... 91 COLCHICINE ...... 65 conex ...... 81 ciprofloxacin...... 8 cold and allergy ...... 81 constulose ...... 55 ciprofloxacin hcl ...... 8, 48, 72 cold and allergy (bromphen-pe) CONTAC COLD-FLU NIGHT cisplatin ...... 10 ...... 81 ...... 81 citalopram ...... 25 cold and allergy pe ...... 81 conti castile soap ...... 35 CITRACAL + D MAXIMUM cold and cough dm ...... 81 cool bottoms ...... 35 ...... 95 cold and cough elixir ...... 81 COPIKTRA ...... 10 CITRACAL REGULAR ...... 95 COLD AND FLU SEVERE . 81 CORICIDIN HBP CHEST CITRACAL-D3 PETITES ... 95 cold and sinus pain relief ...... 81 CONG-COUGH ...... 81 CITRACAL-D3 SLOW COLD HEAD CONGESTION CORICIDIN HBP COLD- RELEASE ...... 95 DAY/NITE ...... 81 MULTI SYMPT ...... 81 citrate of magnesia ...... 55 COLD HEAD CONGESTION CORICIDIN HBP COUGH citroma ...... 55 DAYTIME ...... 81 AND COLD ...... 81 citrucel ...... 55 cold head congestion nighttime CORIFACT ...... 31 CITRUCEL (SUCROSE) ..... 55 ...... 81 CORLANOR ...... 33 CITRUCEL SUGAR FREE . 55 COLD HEAD CONGESTION corn starch ...... 43 citrus calcium-vitamin d3 ..... 95 SEVER DAY ...... 81 CORRECTOL ...... 55 cladribine ...... 10 COLD MULTI-SYMPTOM 81 CORTIFOAM ...... 55 claravis ...... 37 COLD MULTI-SYMPTOM cortisone (hydrocortisone) .... 41 clarithromycin ...... 6 (CHLORPHEN) ...... 81 cortisone with aloe ...... 41 CLARITIN ...... 80 COLD MULTI-SYMPTOM cortizone-10 ...... 41 CLARITIN LIQUI-GEL ...... 80 DAY/NIGHT ...... 81 corvita ...... 107 CLARITIN REDITABS ...... 80 COLD MULTI-SYMPTOM corvita 150 ...... 107 CLARITIN-D 12 HOUR ...... 81 NIGHTTIME ...... 81 COTELLIC ...... 10 CLARITIN-D 24 HOUR ...... 81 COLD RELIEF ...... 81 COUGH AND COLD classic prenatal ...... 107 cold relief m/s day/night ...... 81 (CHLORPHEN-DM) ...... 81 clear anti-itch ...... 35 cold relief plus ...... 81 COUGH AND COLD clearlax ...... 55 cold-flu relief ...... 81 MUCUS RELIEF CF ...... 81 clemastine ...... 81 cold-sinus relief ...... 81 COUGH DM ER ...... 81 clindacin p ...... 37 colestipol ...... 32 cough formula dm ...... 81 clindamycin hcl ...... 7 colistin (colistimethate na) ..... 7 cough relief ...... 81 clindamycin pediatric ...... 7 col-rite ...... 55 cough syrup ...... 82 clindamycin phosphate ... 37, 67 COMBIVENT RESPIMAT . 91 cough syrup dm ...... 82 clobetasol ...... 41 COMBIVIR ...... 3 cough-sore throat night ...... 82

125 covaryx ...... 66 darifenacin ...... 92 despec dm-g ...... 82 covaryx h.s...... 66 dasetta 1/35 (28) ...... 69 despec eda cough-cold drops 82 CREON ...... 55 dasetta 7/7/7 (28) ...... 69 despec-dm (phenyleph-dm- CRESEMBA ...... 3 DAURISMO ...... 10 guaif) ...... 82 CRINONE ...... 66 DAY TIME PE ...... 82 DESPEC-DM (PSEUDOEPH- critic-aid clear af(miconazol) 40 dayhist allergy ...... 82 DM-GUAIF) ...... 82 cromolyn...... 55, 74, 91 daysee ...... 69 desvenlafaxine succinate ...... 25 cryoserv ...... 43 DAYTIME ...... 82 dex4 glucose ...... 43 cryselle (28) ...... 69 DAYTIME AND dex4 glucose bits ...... 43 CUTEMOL ...... 35 NIGHTTIME COLD ...... 82 dexamethasone ...... 48 cyanocobalamin (vitamin b-12) DAYTIME COLD-FLU ...... 82 dexamethasone intensol ...... 48 ...... 107 DAYTIME COLD-FLU dexamethasone sodium phos CYANOCOBALAMIN RELIEF (PE) ...... 82 (pf) ...... 48 (VITAMIN B-12) ...... 107 day-time cough ...... 82 dexamethasone sodium cyclafem 1/35 (28) ...... 69 deblitane ...... 66 phosphate ...... 48, 76 cyclafem 7/7/7 (28) ...... 69 DECARA ...... 108 dexmethylphenidate ...... 25 CYCLINEX-1 ...... 97 DECONEX DMX ...... 82 dextroamphetamine ...... 25 CYCLINEX-2 ...... 97 DECONEX IR ...... 82 dextroamphetamine- cyclobenzaprine ...... 17 decongestant inhaler ...... 46 amphetamine ...... 25 cyclopentolate...... 73 deep sea nasal ...... 46 dextromethorphan polistirex . 82 cyclophosphamide ...... 10 deferasirox ...... 43 dextromethorphan-guaifenesin cyclosporine ...... 10 deferiprone ...... 43 ...... 82 cyclosporine modified ...... 10 deferoxamine ...... 43 diabetic siltussin-dm max str 82 cyproheptadine ...... 82 DELSTRIGO ...... 4 diabetic tussin dm ...... 82 cyred ...... 69 DELSYM 12 HOUR ...... 82 diabetic tussin ex ...... 82 cyred eq ...... 69 delsym cough-chest congest DIABETISOURCE AC ...... 97 CYSTADANE ...... 55 dm ...... 82 DIACOMIT ...... 14 CYSTAGON ...... 93 delta d3 ...... 108 dialyvite ...... 108 CYSTARAN ...... 74 demeclocycline ...... 8 dialyvite 800 ...... 108 cytarabine ...... 10 denta 5000 plus ...... 46 dialyvite vitamin d ...... 108 cytarabine (pf) ...... 10 dentagel ...... 46 diamode ...... 52 cytra-2...... 93 DEPO-SUBQ PROVERA 104 diaper rash ...... 35 cytra-3...... 93 ...... 66 DIAPER RASH ...... 35 cytra-k...... 93 dermabase ...... 35 diarrhea relief (bismuth subs) D dermamed (aluminum ...... 52 d3-2000 ...... 108 hydroxide) ...... 35 diazepam ...... 14, 25 dacarbazine ...... 10 DERMAPHOR ...... 35 diazepam intensol ...... 25 DAILY MULTIPLE FOR dermarest eczema (hydrocort) diazoxide ...... 49 WOMEN ...... 108 ...... 41 diclofenac potassium ...... 21 daily multivitamin-minerals108 DESCOVY ...... 4 diclofenac sodium ...... 21, 75 daily value ...... 108 desenex ...... 40 diclofenac-misoprostol ...... 21 daily vitamin formula ...... 108 desgen dm ...... 82 dicloxacillin ...... 8 daily vitamin formula-iron . 108 desipramine ...... 25 dicyclomine ...... 52 daily vites/iron ...... 108 DESITIN ...... 35 DI-DAK-SOL ...... 43 daily-vite...... 108 DESITIN MULTI-PURPOSE didanosine ...... 4 dakin's solution ...... 43 ...... 35 diflunisal ...... 21 DAKIN'S SOLUTION ...... 43 DESITIN RAPID RELIEF ... 35 DIGESTIVE PROBIOTIC ... 52 dalfampridine ...... 17 desloratadine ...... 82 digestive relief ...... 52 danazol ...... 50 desmopressin ...... 50, 51 digitek ...... 31 dantrolene ...... 17 desog-e.estradiol/e.estradiol . 69 digox ...... 31 dapsone ...... 7 desogestrel-ethinyl estradiol . 69 digoxin ...... 31

126

DILANTIN ...... 15 doxycycline hyclate ...... 8 ELECARE INFANT diltiazem hcl ...... 29 doxycycline monohydrate .. 8, 9 FORMULA ...... 98 dilt-xr ...... 29 DR. SMITH'S DIAPER ...... 35 ELECARE JR ...... 98 diluent for epoprostenol/flola dramamine ...... 56 elfolate ...... 108 ...... 43 dramamine less drowsy ...... 56 elinest ...... 69 dimaphen dm ...... 82 driminate ...... 56 ELIQUIS ...... 31 dimenhydrinate ...... 55 dristan cold ...... 83 ELIQUIS DVT-PE TREAT DIMETAPP COLD- dristan long lasting ...... 46 30D START ...... 31 ALLERGY (PE) ...... 82 drospirenone-ethinyl estradiol ELLA ...... 69 dimetapp cold-congestion .... 82 ...... 69 ELMIRON ...... 93 dimetapp dm cold-cough (pe) DROXIA ...... 10 ELOCTATE ...... 31 ...... 82 dry eye relief ...... 74 eluryng ...... 67 dino-life extra c multivitamin dss ...... 56 EMCYT ...... 10 ...... 108 dulcoease ...... 56 EMEND ...... 56 dino-life multivitamin ...... 108 DULCOLAX (BISACODYL) EMETROL ...... 56 dino-life with iron-zinc...... 108 ...... 56 EMFLAZA ...... 48 diocto ...... 55 duloxetine ...... 25 EMGALITY PEN ...... 16 diotame ...... 52 DUPIXENT PEN ...... 35 EMGALITY SYRINGE ...... 16 diphedryl allergy ...... 82 DUPIXENT SYRINGE ...... 35 emollient ...... 35 diphen ...... 82 DURAFLU ...... 83 emoquette ...... 69 diphenhist ...... 82 dutasteride ...... 92 emtricitabine ...... 4 diphenhydramine hcl ...... 83 dutasteride-tamsulosin ...... 92 emtricitabine-tenofovir (tdf) ... 4 diphenoxylate-atropine ...... 52 d-vi-sol ...... 108 EMVERM ...... 7 dipyridamole ...... 31 dy-o-derm ...... 45 enalapril maleate ...... 29 diskets ...... 18 E enalapril-hydrochlorothiazide disulfiram ...... 44 e.e.s. 400 ...... 6 ...... 29 divalproex ...... 15 EAA SUPPLEMENT ...... 97 ENBREL ...... 65 dm max ...... 83 ear care ...... 97 ENBREL MINI ...... 65 docetaxel...... 10 ear health formula ...... 97 ENBREL SURECLICK ...... 65 docu ...... 55 eazzze the pain ...... 21 endacof - dm ...... 83 docuprene ...... 55 econtra ez ...... 69 ENDARI ...... 44 DOCUSATE CALCIUM ..... 56 ECOTRIN ...... 21 endocet ...... 18 docusate sodium ...... 56 ecotrin low strength ...... 21 endur-acin ...... 32 DOCUSOL ...... 56 ed a-hist ...... 83 enema ...... 56 dofetilide...... 28 ed a-hist dm ...... 83 enema disposable ...... 56 DOJOLVI ...... 97 ed bron gp ...... 83 ENEMEEZ ...... 56 dok ...... 56 ed chlorped jr ...... 83 ENEMEEZ PLUS ...... 56 DOMEBORO ...... 35 ed-apap ...... 21 ENFAGROW TODDLR dometuss-dmx ...... 83 ed-spaz ...... 53 TRANSITION SOY ...... 98 dona ...... 21 EDURANT ...... 4 enfamil a.r...... 98 donepezil ...... 17 efavirenz ...... 4 ENFAMIL ENFACARE ...... 98 dorzolamide ...... 75 efavirenz-emtricitabin-tenofov ENFAMIL ENFALYTE ...... 95 dorzolamide-timolol ...... 75 ...... 4 ENFAMIL GENTLEASE .... 98 DOUBLE ANTIBIOTIC efavirenz-lamivu-tenofov disop ENFAMIL GLUCOSE ...... 44 (B.TRACN ZN) ...... 38 ...... 4 ENFAMIL INFANT ...... 98 DOVATO ...... 4 effer-k ...... 95 ENFAMIL NEWBORN ...... 98 doxazosin ...... 29 efferves pain relief antacid ... 21 ENFAMIL NEWBORN NON- doxepin ...... 25, 35 effervescent pain relief ...... 21 GMO ...... 98 doxercalciferol ...... 51 EGRIFTA SV ...... 64 ENFAMIL PROSOBEE LIPIL doxorubicin...... 10 ELAPRASE ...... 51 ...... 98 doxorubicin, peg-liposomal .. 10 eldertonic ...... 108 enfamil water ...... 44

127

ENFAPORT ...... 98 etidronate disodium ...... 44 fenofibric acid ...... 32 enoxaparin ...... 31 etodolac ...... 21 fenofibric acid (choline) ...... 32 enpresse ...... 69 etonogestrel-ethinyl estradiol67 fenoprofen ...... 21 enskyce ...... 69 ETOPOPHOS ...... 10 fentanyl ...... 18 ENSURE CLEAR etoposide ...... 10 fentanyl citrate ...... 18 THERAPEUTIC ...... 98 euthyrox ...... 51 feosol ...... 109 entacapone ...... 16 evac-u-gen (sennosides) ...... 56 FEOSOL ...... 109 entecavir ...... 4 everolimus (antineoplastic) .. 10 FEOSOL BIFERA ...... 108 ENTEX T ...... 83 everolimus ferate ...... 109 ENTRESTO ...... 33 (immunosuppressive) ...... 10 FERGON ...... 109 enulose ...... 56 EVOTAZ ...... 4 FER-IN-SOL ...... 109 EO28 SPLASH ...... 98 EXCEDRIN EXTRA ferocon ...... 109 ephrine ...... 46 STRENGTH ...... 21 ferosul ...... 109 epinastine ...... 74 EXCEDRIN MIGRAINE ..... 21 ferretts ...... 109 epinephrine ...... 83 EXCEDRIN TENSION ferrex 150 ...... 109 epitol ...... 15 HEADACHE ...... 21 ferrex 150 forte ...... 109 EPIVIR ...... 4 exemestane ...... 10 ferrex 150 forte plus ...... 109 EPIVIR HBV...... 4 EX-LAX (SENNOSIDES) ... 56 ferrex 150 plus ...... 109 epoprostenol (glycine) ...... 29 EX-LAX MAXIMUM ferrex 28 ...... 109 epsom salt (laxative)...... 56 STRENGTH ...... 56 ferric x-150 ...... 109 EPZICOM ...... 4 EXPECTA PRENATAL .... 108 FERRIMIN 150 ...... 109 ergocalciferol (vitamin d2) . 108 expectorant ...... 83 FERRIPROX ...... 44 ERGOCALCIFEROL EXTAVIA ...... 64 ferrocite ...... 109 (VITAMIN D2) ...... 108 EXTRA STRENGTH BAYER ferro-time ...... 109 ergoloid...... 26 ...... 21 ferrous fumarate ...... 109 ergotamine-caffeine ...... 16 extraprin ...... 21 ferrous gluconate ...... 109 ERIVEDGE ...... 10 eye health plus lutein ...... 108 ferrous sulfate ...... 109 ERLEADA ...... 10 ezetimibe ...... 32 feverall ...... 21 erlotinib ...... 10 ezfe 200 ...... 108 FEVERALL ...... 21 errin ...... 66 F fexofenadine ...... 83 ery pads ...... 37 fabb ...... 108 fexofenadine-pseudoephedrine ery-tab...... 6 falmina (28) ...... 69 ...... 83 erythrocin (as stearate) ...... 6 famciclovir ...... 4 fiber (calcium polycarbophil) erythromycin ...... 7, 72 famotidine ...... 62 ...... 56 erythromycin ethylsuccinate .. 7 famotidine (pf) ...... 62 fiber (dextrin) ...... 56 erythromycin with ethanol ... 37 FAST ACTING NASAL ...... 46 fiber (psyllium husk) ...... 56 ESBRIET ...... 91 fe c ...... 108 fiber (psyllium husk-sugar) .. 56 escitalopram oxalate ...... 26 fe c plus ...... 108 fiber (with aspartame) ...... 56 essentia ...... 108 febuxostat ...... 65 fiber laxative (ca polycarbo) . 56 essential amino acid mix ...... 98 FEIBA NF ...... 31 fiber laxative (methylcellulo) estarylla ...... 69 felbamate ...... 15 ...... 56 estazolam ...... 26 felodipine ...... 29 fiber laxative (psyllium husk) ESTER-C WITH fem ph ...... 67 ...... 56 BIOFLAVONOIDS ...... 108 FEMCAP ...... 49 fiber supplement (inulin) ...... 56 estradiol ...... 66 femynor ...... 69 fiber therapy (ca polycarboph) estradiol valerate ...... 66 fenesin dm ir ...... 83 ...... 57 estradiol-norethindrone acet . 66 fenesin ir ...... 83 fiber therapy (m-cell/sugar) .. 57 ethacrynic acid...... 29 fenesin pe ir ...... 83 fiber therapy (m-cellulose) ... 57 ethambutol ...... 7 fenofibrate ...... 32 fiber therapy laxative (husk) . 57 ethosuximide ...... 15 fenofibrate micronized ...... 32 FIBERCON ...... 57 ethynodiol diac-eth estradiol 69 fenofibrate nanocrystallized . 32 fiber-tabs ...... 57

128 finasteride ...... 92 flunisolide ...... 91 fyavolv ...... 66 finger cream...... 35 fluocinolone ...... 41 G FINTEPLA ...... 15 fluocinolone acetonide oil .... 48 GA GEL ...... 98 first aid antibiotic-pain rlf .... 38 fluocinonide ...... 41 GA POWDER ...... 98 first aid antiseptic(povidone) 38 fluorescein-proparacaine ...... 74 gabapentin ...... 15 FISH OIL ...... 98 fluoride (sodium) .... 46, 47, 109 GALAFOLD ...... 51 fish oil-dha-epa ...... 109 fluorometholone ...... 76 galantamine ...... 17 FISH,BORA,FLAX OILS- fluorouracil ...... 11, 35 GAMMAGARD LIQUID .... 64 OM3,6,9NO1 ...... 98 fluoxetine ...... 26 GAMMAGARD S-D (IGA < 1 flanax (naproxen) ...... 21 fluphenazine decanoate ...... 26 MCG/ML) ...... 64 flavor chews antacid ...... 95 fluphenazine hcl ...... 26 GAMUNEX-C ...... 64 flavoxate ...... 92 flurazepam ...... 26 ganciclovir sodium ...... 4 flaxseed oil ...... 45 flurbiprofen ...... 21 garlic ...... 45 flecainide ...... 28 flurbiprofen sodium ...... 75 gavilax ...... 57 fleet enema ...... 57 FLU-SEVERE COLD- gavilyte-c ...... 57 fleet glycerin (adult) ...... 57 COUGH DAYTIME ...... 83 gavilyte-g ...... 57 FLEET GLYCERIN (CHILD) flutamide ...... 11 gavilyte-n ...... 57 ...... 57 fluticasone propionate .... 42, 91 GAVISCON ...... 57 fleet laxative (bisacodyl) ...... 57 fluvoxamine ...... 26 GAVISCON EXTRA FLEET MINERAL OIL ...... 57 FLUZONE QUAD 2021-2022 STRENGTH ...... 57 FLEET PEDIATRIC ...... 57 ...... 64 GAVRETO ...... 11 FLINTSTONES COMPLETE FLUZONE QUAD 2021-2022 GELUSIL ANTACID AND (IRON) ...... 109 (PF) ...... 64 ANTI-GAS ...... 57 FLINTSTONES foaming antacid ...... 57 gemcitabine ...... 11 MULTIVITAMIN ...... 109 folbee ...... 109 gemfibrozil ...... 32 FLINTSTONES/EXTRA C 109 folbee plus ...... 110 generlac ...... 57 floranex...... 98 folbic ...... 110 gengraf ...... 11 FLORANEX...... 98 folic acid ...... 110 genicin ...... 21 florastor ...... 53 folitab ...... 110 gentak ...... 72 FLOVENT DISKUS ...... 91 folivane-f ...... 110 gentamicin ...... 38, 72 FLOVENT HFA ...... 91 folivane-ob ...... 110 gentle laxative (bisacodyl) .... 57 flu relief therapy daytime ..... 83 folivane-plus ...... 110 gentle skin cleanser ...... 35 flu relief therapy nighttime ... 83 folplex 2.2 ...... 110 gentlelax ...... 57 flu severe cold-night(diph-pe) foltabs 800 ...... 110 GENVOYA ...... 4 ...... 83 foltanx ...... 110 GERBER GOOD START FLUAD QUAD 2021-22(65Y fondaparinux ...... 31 GENTLE ...... 98 UP)(PF) ...... 64 foot and sneaker ...... 40 GERBER GOOD START FLUARIX QUAD 2021-2022 for sty relief ...... 74 GENTLE NOGMO ...... 98 (PF) ...... 64 forane ...... 44 GERBER GOOD START FLUBLOK QUAD 2021-2022 formula 3 ...... 40 SOY ...... 98 (PF) ...... 64 fosamprenavir ...... 4 gerber good start water ...... 44 FLUCELVAX QUAD 2021- fosfree ...... 110 geri-dryl ...... 83 2022 ...... 64 fosinopril-hydrochlorothiazide geri-kot ...... 57 FLUCELVAX QUAD 2021- ...... 29 geri-lanta ...... 57 2022 (PF) ...... 64 fruit c ...... 110 geri-mox antacid-antigas ...... 57 fluconazole ...... 3 fruit c-500 ...... 110 GERI-MUCIL flucytosine ...... 3 full spectrum b-vitamin c ... 110 (ASPARTAME) ...... 57 fludarabine ...... 11 fungoid tincture ...... 40 geri-pectate ...... 53 fludrocortisone ...... 48 fungoid-d ...... 40 GERITOL COMPLETE ..... 110 FLULAVAL QUAD 2021- furosemide ...... 29 GERITOL TONIC WITH 2022 (PF) ...... 64 FUZEON ...... 4 FERREX 18 ...... 110

129 geri-tussin ...... 83 gormel ...... 35 hematogen fa ...... 110 GILENYA ...... 17 gormel ten ...... 35 hematogen forte ...... 110 GILOTRIF ...... 11 granisetron (pf) ...... 57 hemmorex-hc ...... 58 glatopa ...... 17 granisetron hcl ...... 57 HEMOCYTE ...... 110 glenmax peb dm ...... 83 GRANIX ...... 64 heparin (porcine) ...... 31 glimepiride ...... 49 green soap ...... 35 HETLIOZ ...... 26 glipizide ...... 49 griseofulvin microsize ...... 3 HETLIOZ LQ ...... 26 glipizide-metformin ...... 49 g-tron ped ...... 83 hibiclens ...... 36 GLUCAGEN HYPOKIT ..... 49 G-TUSICOF ...... 83 hi-cal plus vit d ...... 95 GLUCAGON (HCL) guaiasorb dm ...... 83 high potency iron ...... 110 EMERGENCY KIT ...... 49 guaifenesin ...... 84 HIZENTRA ...... 64 GLUCAGON EMERGENCY guanfacine ...... 26, 29 homatropaire ...... 73 KIT (HUMAN) ...... 49 gummi bear multivitamin ... 110 HOMINEX-1 ...... 99 GLUCERNA ...... 98 GYNE-LOTRIMIN ...... 67 HOMINEX-2 ...... 99 GLUCERNA ADVANCE ... 98 GYNE-LOTRIMIN 7 ...... 67 honey bears multivitamin ... 110 GLUCERNA HUNGER gynol ii ...... 67 HUMALOG MIX 50-50 SMART ...... 98 G-ZYNCOF ...... 84 INSULN U-100 ...... 49 GLUCERNA THERAPEUTIC H HUMALOG MIX 50-50 NUTRITION ...... 98 hailey ...... 69 KWIKPEN ...... 49 gluco burst ...... 44 hailey 24 fe ...... 69 HUMALOG MIX 75-25 GLUCOSAMINE HCL ...... 44 hailey fe 1.5/30 (28) ...... 69 KWIKPEN ...... 49 glucosamine relief ...... 21 hailey fe 1/20 (28) ...... 69 HUMALOG MIX 75-25(U- glucosamine sulfate ...... 21 hair vitamins ...... 110 100)INSULN ...... 49 glucose ...... 44 hair,skin and nails ...... 110 HUMATE-P ...... 31 glucose bits ...... 44 halls defense ...... 110 HUMIRA ...... 65 glucose gel ...... 44 haloperidol ...... 26 HUMIRA PEN ...... 65 GLUTARADE JUNIOR ...... 98 haloperidol decanoate ...... 26 HUMIRA(CF) ...... 65 GLUTAREX-1 ...... 98 haloperidol lactate ...... 26 HUMIRA(CF) PEDI GLUTAREX-2 ...... 98 hand wash ...... 36 CROHNS STARTER ...... 65 GLUTOSE-15 ...... 44 h-chlor 12 ...... 44 HUMIRA(CF) PEN ...... 65 glyburide...... 49 H-CHLOR 6 ...... 44 HUMIRA(CF) PEN glyburide micronized...... 49 HCU COOLER...... 99 PEDIATRIC UC ...... 65 glyburide-metformin ...... 49 hcu express powder ...... 99 HUMIRA(CF) PEN PSOR- glycerin (adult) ...... 57 HCU GEL POWDER ...... 99 UV-ADOL HS ...... 66 glycerin (child) ...... 57 HCU LOPHLEX ...... 99 HUMULIN 70/30 U-100 glycine urologic ...... 93 HCY 1 POWDER ...... 99 INSULIN ...... 50 glycine urologic solution ...... 93 HCY 2 ...... 99 HUMULIN 70/30 U-100 glycopyrrolate...... 53 headache pm ...... 21 KWIKPEN ...... 50 GLYCOSADE ...... 99 headache relief (asa-acet-caf) HUMULIN N NPH INSULIN glydo ...... 37 ...... 21 KWIKPEN ...... 50 GLYTACTIN 15 PE headache relief pm ...... 21 HUMULIN N NPH U-100 COMPLETE ...... 99 HEALTHY EYES ...... 110 INSULIN ...... 50 GLYTACTIN 20PE healthy eyes supervision ..... 110 HUMULIN R REGULAR U- BETTERMILK LITE ...... 99 heartburn antacid ...... 57 100 INSULN ...... 50 GLYTROL ...... 99 heartburn prevention ...... 62 HUMULIN R U-500 (CONC) GLYXAMBI ...... 49 heartburn relief ...... 57 INSULIN ...... 50 GOLD BOND MEDICATED heartburn relief (cimetidine) . 62 HUMULIN R U-500 (CONC) ANTI-ITCH ...... 47 heartburn relief (famotidine) 62 KWIKPEN ...... 50 gonak ...... 74 heather ...... 66 HYCAMTIN ...... 11 goniotaire ...... 74 hematinic plus vit/minerals 110 hydralazine ...... 29 goniovisc ...... 74 hematinic/folic acid ...... 110 hydrochlorothiazide ...... 29

130

HYDROCIL ...... 58 IMPACT PEPTIDE 1.5 CAL isoniazid ...... 7 HYDROCIL INSTANT ...... 58 ...... 99 ISOPTO TEARS ...... 74 hydrocodone-acetaminophen 18 INBRIJA ...... 16 isosorbide dinitrate ...... 33 hydrocortisone ...... 42, 48, 58 INCRELEX ...... 44 isosorbide mononitrate ...... 33 hydrocortisone acetate ...... 42 INCRUSE ELLIPTA ...... 91 isoxsuprine ...... 67 hydrocortisone plus ...... 42 indapamide ...... 29 isradipine ...... 29 hydrocortisone-aloe vera ...... 42 indomethacin ...... 22 itch relief (clotrimazole) ...... 40 hydrocortisone-pramoxine ... 58 infant fever reducer-pain relf 22 itraconazole ...... 3 hydrocream ...... 42 infant pain reliever ...... 22 I-VALEX-1 ...... 99 hydrogen peroxide ...... 44 infant's advil ...... 22 I-VALEX-2 ...... 99 hydromorphone ...... 18 infant's ibuprofen ...... 22 ivermectin ...... 7 HYDROPHOR ...... 36 infant's motrin ...... 22 i-vite ...... 111 hydroxychloroquine ...... 7 infants' pain and fever ...... 22 IXINITY ...... 31 hydroxyurea ...... 11 infants' pain relief ...... 22 J hydroxyzine hcl ...... 84 infants profenib ...... 22 jaimiess ...... 69 hydroxyzine pamoate ...... 84 infed ...... 110 JAKAFI ...... 11 hyophen ...... 93 INGREZZA ...... 17 JANSSEN COVID-19 hyoscyamine sulfate ...... 53 INGREZZA INITIATION VACCINE (EUA) ...... 64 hyosyne ...... 53 PACK ...... 17 jantoven ...... 31 hysept ...... 44 INLYTA ...... 11 JANUMET ...... 50 I inositol ...... 99 JANUMET XR ...... 50 ibandronate ...... 65 INQOVI ...... 11 JANUVIA ...... 50 IBRANCE ...... 11 INREBIC ...... 11 JARDIANCE ...... 50 ibu ...... 21 INSTACLEAN ...... 45 jasmiel (28) ...... 69 ibuprofen ...... 22 INTELENCE ...... 4 jencycla ...... 66 ibuprofen cold-sinus(with pse) INTRON A ...... 64 jinteli ...... 66 ...... 84 INVIRASE ...... 4 jock itch ...... 40 ibuprofen ib ...... 21 inzo antifungal ...... 40 jock itch (clotrimazole) ...... 40 ibuprofen jr strength ...... 22 iodine-sodium iodide ...... 36 jock itch (terbinafine) ...... 40 ibuprofen pm ...... 22 ipecac ...... 58 jolessa ...... 69 icaps areds ...... 110 ipratropium bromide ...... 47, 91 jr. acetaminophen ...... 22 ICAR ...... 110 ipratropium-albuterol ...... 91 jr. str non-aspirin pain ...... 22 ICAR-C ...... 110 irbesartan ...... 29 jr. strength pain reliever ...... 22 icatibant ...... 91 irbesartan-hydrochlorothiazide juleber ...... 69 ICLUSIG ...... 11 ...... 29 JULUCA ...... 4 IDHIFA ...... 11 IRESSA ...... 11 junel 1.5/30 (21) ...... 69 iferex 150...... 110 irinotecan ...... 11 junel 1/20 (21) ...... 69 iferex 150 forte ...... 110 iron ...... 111 junel fe 1.5/30 (28) ...... 69 ifosfamide ...... 11 iron (dried) ...... 111 junel fe 1/20 (28) ...... 69 imatinib ...... 11 iron 100 plus ...... 111 junel fe 24 ...... 70 IMBRUVICA ...... 11 iron chews ...... 111 JUVEN ...... 99 imipramine hcl...... 26 iron, carbonyl ...... 111 JUXTAPID ...... 32 imipramine pamoate ...... 26 iron,carbonyl-vitamin c ...... 111 JYNARQUE ...... 51 imiquimod ...... 36 ISENTRESS ...... 4 K immulife ...... 99 ISENTRESS HD ...... 4 kaitlib fe ...... 70 IMODIUM A-D ...... 53 isibloom ...... 69 KALETRA ...... 4 IMODIUM MULTI- isoflurane ...... 44 KALYDECO ...... 91 SYMPTOM RELIEF ...... 53 ISOLEUCINE ...... 99 kaopectate (bismuth subsalicy) IMPACT 1 CAL ...... 99 ISOMIL ADVANCE ...... 99 ...... 53 IMPACT ADVANCED ISOMIL DF ...... 99 KAOPECTATE (DOCUSATE RECOVERY ...... 99 ISOMIL/IRON ...... 99 CALCIUM) ...... 58

131 kaopectate ex str (bismuth ss) lansoprazole ...... 63 lice solution ...... 43 ...... 53 lapatinib ...... 11 lice treatment ...... 43 kariva (28) ...... 70 larin 1.5/30 (21) ...... 70 lidocaine ...... 38 kelnor 1/35 (28) ...... 70 larin 1/20 (21) ...... 70 lidocaine hcl ...... 37 kelnor 1-50 (28) ...... 70 larin 24 fe ...... 70 lidocaine hcl-hydrocortison ac ketoconazole ...... 3, 40 larin fe 1.5/30 (28) ...... 70 ...... 38, 58 ketodan ...... 40 larin fe 1/20 (28) ...... 70 LIDOCAINE PAIN RELIEF 38 KETONEX-1 ...... 99 larissia ...... 70 lidocaine viscous ...... 38 KETONEX-2 ...... 99 latanoprost ...... 75 lidocaine-hydrocortisone-aloe ketoprofen...... 22 laxacin ...... 58 ...... 58 ketorolac ...... 22, 75 laxaclear ...... 58 lidocaine-prilocaine ...... 38 KETOVOLVE ...... 99 laxative (bisacodyl) ...... 58 LIDOCARE ...... 38 KIDS MULTIVITAMIN- laxative (glycerin-pediatric) . 58 lillow (28) ...... 70 MINERALS ...... 111 laxative (sennosides) ...... 58 linezolid ...... 7 kids vitamin d3 ...... 111 laxative peg 3350 ...... 58 LIORESAL ...... 17 KITABIS PAK ...... 7 laxative pills ...... 58 liothyronine ...... 52 klor-con ...... 95 laxative pills regular ...... 58 lipistart ...... 100 klor-con 10 ...... 95 laxative plus stool softener ... 58 LIPO-FLAVONOID PLUS 100 klor-con 8 ...... 95 layolis fe ...... 70 liquibid d-r ...... 84 klor-con m10 ...... 95 l-carnitine ...... 44 LIQUIBID PD-R ...... 84 klor-con m15 ...... 96 lecithin ...... 100 LIQUID B-12 ...... 111 klor-con m20 ...... 96 leena 28 ...... 70 LIQUID CALCIUM WITH klor-con/ef ...... 96 leflunomide ...... 66 VITAMIN D ...... 96 kobee ...... 111 LENVIMA ...... 11 lisinopril ...... 29 konsyl (sugar) ...... 58 lessina ...... 70 lisinopril-hydrochlorothiazide konsyl sugar-free ...... 58 letrozole ...... 11 ...... 29 KOSELUGO ...... 11 leucovorin calcium ...... 9 lithium carbonate ...... 26 k-pec antidiarrheal (bism sub) LEU-FREE COOLER ...... 100 little animals ...... 111 ...... 53 LEUKERAN ...... 11 little animals-iron ...... 111 K-PHOS NO 2 ...... 93 LEUKINE ...... 64 LITTLE NOSES ...... 47 K-PHOS ORIGINAL ...... 93 leuprolide ...... 11 little remedies ...... 47 k-phos-neutral...... 96 levetiracetam ...... 15 little remedies fever and pain 22 kpn ...... 111 levobunolol ...... 73 l-lysine ...... 100 KPN ...... 111 levocarnitine ...... 44 LMD POWDER ...... 100 k-tab ...... 96 levocarnitine (with sugar) ..... 44 lohist - d ...... 84 kurvelo (28) ...... 70 levocetirizine ...... 84 lohist-dm ...... 84 L levofloxacin ...... 8, 73 lojaimiess ...... 70 l norgest/e.estradiol-e.estrad . 70 levonest (28) ...... 70 LONSURF ...... 11 l.acidophilus-bifido.longum . 53 levonorgestrel ...... 70 loperamide ...... 53 labetalol ...... 29 levonorgestrel-ethinyl estrad 70 LOPHLEX ...... 100 LACTINEX ...... 99 levonorg-eth estrad triphasic 70 lopinavir-ritonavir ...... 4 lactobacillus acidophilus ...... 99 levora-28 ...... 70 lorata-d ...... 84 LACTOBACILLUS levo-t ...... 52 loratadine ...... 84 ACIDOPHILUS ...... 99 levothyroxine ...... 52 loratadine-d ...... 84 lactulose ...... 58 levoxyl ...... 52 lorazepam ...... 26 lamisil af ...... 40 LEXIVA ...... 4 lorazepam intensol ...... 26 lamisil at ...... 40 lice bedding spray ...... 42 LORBRENA ...... 11 lamivudine ...... 4 lice complete kit 1-2-3 ...... 42 loryna (28) ...... 70 lamivudine-zidovudine ...... 4 lice killing ...... 42 losartan ...... 29 lamotrigine ...... 15 lice killing (permethrin) ...... 42 losartan-hydrochlorothiazide 29 LANAFLEX ...... 100 lice pyrinyl shampoo ...... 42 LOTRIMIN AF ...... 40

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LOTRIMIN AF magnesium citrate ...... 58 MESNEX ...... 9 (CLOTRIMAZOLE) ...... 40 magnesium gluconate ...... 96 metadate er ...... 26 lotrimin af powder ...... 40 MAGNESIUM GLUCONATE metafolbic ...... 111 LOTRIMIN ULTRA ...... 40 ...... 96 metafolbic plus ...... 100 lovastatin ...... 32 magnesium oxide ...... 96 METAMUCIL ...... 59 low-ogestrel (28) ...... 70 MAGOX ...... 96 METAMUCIL (WITH loxapine succinate ...... 26 mapap (acetaminophen) ...... 22 SUGAR) ...... 59 lo-zumandimine (28) ...... 70 mapap arthritis pain ...... 22 METAMUCIL FIBER l-phenylalanine ...... 100 mapap cold formula ...... 84 SINGLES ...... 59 lta pre-attached ...... 38 maprotiline ...... 26 METAMUCIL FIBER THIN lubricant (p-glycol-glycerin) 74 marlissa (28) ...... 70 ...... 59 LUBRICANT EYE ...... 74 masophen ...... 22 METAMUCIL FREE ...... 59 LUBRICANT EYE (PG-PEG MATULANE ...... 12 METAMUCIL 400) ...... 74 matzim la ...... 29 MULTIHEALTH FIBER . 59 lubricant eye drops ...... 74 MAVENCLAD (4 TABLET METAMUCIL SUGAR-FREE LUBRICANT EYE DROPS 74 PACK) ...... 17 (ASPART) ...... 59 lubricating plus ...... 74 MAVYRET ...... 4 METAMUCIL SUNRISE .... 59 lubrifresh pm ...... 74 maxepa ...... 32 metaproterenol ...... 91 LUCEMYRA ...... 22 MAXIMUM D3 ...... 111 metformin ...... 50 ludent fluoride ...... 111 maximum daily multivitamin methadone ...... 18 lugols ...... 96 ...... 111 methadose ...... 18 LUPANETA PACK (1 MAYZENT ...... 17 methamphetamine ...... 26 MONTH) ...... 67 MAYZENT STARTER PACK methenamine hippurate ...... 9 LUPANETA PACK (3 ...... 17 methenamine mandelate ...... 9 MONTH) ...... 67 m-clear wc ...... 84 methen-sod phos-meth blue- LUPRON DEPOT ...... 11 mct pro-cal ...... 100 hyos ...... 93 LUPRON DEPOT (3 meclizine ...... 58 methergine ...... 72 MONTH) ...... 11 meclofenamate ...... 22 methimazole ...... 49 LUPRON DEPOT (4 medi-meclizine ...... 58 METHIONAID ...... 100 MONTH) ...... 11 mediproxen ...... 23 METHITEST ...... 51 LUPRON DEPOT (6 medi-seltzer ...... 23 methocarbamol ...... 17 MONTH) ...... 12 medroxyprogesterone ...... 66 methotrexate sodium ...... 12 LUPRON DEPOT-PED ...... 12 mefloquine ...... 7 methotrexate sodium (pf) ..... 12 LUPRON DEPOT-PED (3 mega multiple/chelated mineral methoxsalen ...... 36 MONTH) ...... 12 ...... 111 methyldopa ...... 30 lutera (28) ...... 70 megestrol ...... 12 methyldopa- LYNPARZA...... 12 MEKINIST ...... 12 hydrochlorothiazide ...... 30 lysine ...... 100 MEKTOVI ...... 12 methylergonovine ...... 72 lysine hcl ...... 100 meloxicam ...... 23 methylphenidate hcl ...... 26 LYSINE HCL ...... 100 melphalan ...... 12 methylprednisolone ...... 48 lysiplex plus ...... 111 memantine ...... 17 methylprednisolone acetate .. 48 LYSODREN...... 12 MENACTRA (PF) ...... 64 methyltestosterone ...... 51 lyza ...... 66 MENEST ...... 66 metipranolol ...... 73 M MENQUADFI (PF) ...... 65 metoclopramide hcl ...... 59 MAALOX ADVANCED ..... 58 men's daily multivit-mineral metolazone ...... 30 maalox maximum strength ... 58 ...... 111 metoprolol succinate ...... 30 macuvite eye care ...... 111 men's one daily ...... 111 metoprolol tartrate ...... 30 mafenide acetate ...... 38 MENSTRUAL RELIEF ...... 23 metronidazole ...... 7, 37, 67 MAG-AL ...... 58 mercaptopurine ...... 12 metyrosine ...... 30 mag-g ...... 96 MERIBIN ...... 111 mexiletine ...... 28 magnesium ...... 58, 96 mesalamine ...... 58 mgo ...... 96

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MG-PLUS-PROTEIN ...... 96 molindone ...... 27 mucosa ...... 84 micatin ...... 40 mometasone ...... 42 mucosa dm ...... 85 miconazole nitrate ...... 40, 67 mondoxyne nl ...... 9 mucus relief ...... 85 MICONAZOLE NITRATE . 67 MONISTAT 1 COMBO MUCUS RELIEF COLD AND miconazole-3 ...... 67 PACK ...... 67 SINUS ...... 85 miconazole-7 ...... 67 MONISTAT 3 ...... 67 MUCUS RELIEF COLD- miconazorb af ...... 40 MONISTAT 7 ...... 67 FLU-SORE THR ...... 85 microgestin 1.5/30 (21) ...... 70 mono-linyah ...... 70 MUCUS RELIEF microgestin 1/20 (21) ...... 70 MONONINE ...... 31 CONGESTION-COUGH . 85 microgestin fe 1.5/30 (28) .... 70 MONSEL'S ...... 36 mucus relief cough ...... 85 microgestin fe 1/20 (28) ...... 70 montelukast ...... 91 mucus relief d (pseudoephed) micro-guard ...... 40 morgidox ...... 9 ...... 85 midazolam ...... 26 morphine ...... 18 mucus relief dm ...... 85 midodrine ...... 44 morphine concentrate ...... 18 mucus relief dm max ...... 85 midol pm ...... 23 motion sickness ...... 59 mucus relief er ...... 85 migergot ...... 16 motion sickness (meclizine) . 59 mucus relief pe ...... 85 miglitol ...... 50 motion sickness relief ...... 59 MUCUS RELIEF SEV miglustat ...... 51 motion sickness relief(mecliz) CONGEST-COLD ...... 85 migraine formula ...... 23 ...... 59 mucus relief sinus ...... 85 migraine relief ...... 23 motion-time ...... 59 MULPLETA ...... 31 mili ...... 70 MOTRIN IB ...... 23 multi antibiotic plus ...... 38 milk of magnesia ...... 59 motrin pm ...... 23 multi complete with iron .... 111 milk of magnesia concentrated MOVANTIK ...... 59 multi for her ...... 111 ...... 59 move it along ...... 59 multi-day with iron ...... 111 millipred dp ...... 49 moxifloxacin ...... 8 multi-delyn with iron ...... 111 milltrium senior ...... 111 MSUD AID ...... 100 multigen ...... 111 mimvey ...... 66 MSUD ANALOG ...... 100 multigen folic ...... 111 mineral oil ...... 44 MSUD COOLER ...... 100 multigen plus ...... 111 MINERAL OIL ...... 59 MSUD EXPRESS COOLER multiple vitamin-minerals .. 111 mineral oil extra heavy ...... 59 ...... 100 multiple vitamins ...... 112 MINERAL OIL HEAVY .... 44, MSUD GEL POWDER ...... 100 MULTI-SYMPTOM COLD 59 MSUD LOPHLEX ...... 100 (PE) ...... 85 minocycline ...... 9 MSUD MAXAMAID ...... 100 multi-vit with fluoride-iron . 112 minoxidil ...... 30 MSUD MAXAMUM ...... 100 multivitamin ...... 112 mintox ...... 59 mucinex ...... 84 multivitamin 50 plus ...... 112 mintox maximum strength ... 59 MUCINEX ...... 84 multivitamin with fluoride .. 112 mintox plus ...... 59 mucinex d ...... 84 multi-vitamin with fluoride 112 MIRALAX ...... 59 mucinex d maximum strength multivitamin with iron ...... 112 mirtazapine ...... 27 ...... 84 multivitamin with minerals . 112 misoprostol ...... 63 mucinex dm ...... 84 multivitamins with fluoride 112 mitomycin ...... 12 MUCINEX DM ...... 84 mupirocin ...... 38 mitoxantrone ...... 12 mucinex fast-max cold-flu-thrt MURI-LUBE ...... 44 MMA-PA COOLER15 ...... 100 ...... 84 mvc-fluoride ...... 112 MMA-PA EXPRESS15 ..... 100 MUCINEX FAST-MAX my way ...... 70 MMA-PA GEL ...... 100 COLD-SINUS ...... 84 MYALEPT ...... 51 modafinil ...... 27 MUCINEX FAST-MAX mycophenolate mofetil ...... 12 MODERNA COVID-19 CONGEST-COUGH ...... 84 mycophenolate sodium ...... 12 VACCINE (EUA) ...... 65 mucinex fast-max dm max ... 84 myferon 150 ...... 112 moexipril ...... 30 mucinex sinus-max ...... 47 myferon 150 forte ...... 112 moisture barrier ointment ..... 36 MUCINEX SINUS-MAX SEV MYLERAN ...... 12 moisture drops ...... 74 CONGESTN ...... 84 mynatal ...... 112

134 mynatal plus ...... 112 natural vegetable powder ...... 60 NEUTROGENA ACNE mynatal-z ...... 112 natura-lax ...... 60 CLEANSING SOAP ...... 36 mynephrocaps...... 112 nausea control ...... 60 NEUTROGENA FACIAL mynephron ...... 112 nausea relief ...... 60 SOAP ...... 36 myorisan ...... 37 NAYZILAM ...... 15 nevirapine ...... 5 my-vitalife ...... 112 nebusal ...... 91 newgen ...... 112 N necon 0.5/35 (28) ...... 71 NEXAVAR ...... 12 nabumetone ...... 23 neilmed nasaflo ...... 47 NEXIUM 24HR ...... 63 nadolol ...... 30 neilmed pediat sinus rinse ref NEXLETOL ...... 32 nadolol-bendroflumethiazide 30 ...... 47 niacin ...... 33 naloxone ...... 23 neilmed sinus rinse complete 47 NIACIN ...... 33 naltrexone ...... 23 neilmed sinus rinse refill ...... 47 niacin (inositol niacinate) .... 32, naproxen ...... 23 NEOCATE INFANT DHA- 100 naproxen sodium ...... 23 ARA ...... 100 niacin (niacinamide) ...... 32 naratriptan...... 16 NEOCATE JUNIOR ...... 100 niacin flush free ...... 101 NARCAN ...... 23 NEOCATE JUNIOR WITH NIACIN FLUSH FREE ...... 101 nasadock plus kit ...... 47 PREBIOTICS ...... 100 NIACIN NO FLUSH ...... 101 nasaflo porcelain kit ...... 47 NEOCATE NUTRA ...... 100 niacinamide ...... 33 nasal allergy...... 91 NEOCATE SPLASH ...... 100 NICODERM CQ ...... 45 nasal allergy symptom control neomycin ...... 7 NICORETTE ...... 45 ...... 91 neomycin-bacitracin-poly-hc 75 nicotine ...... 45 nasal decongestant (oxymetazl) neomycin-bacitracin- nicotine (polacrilex) ...... 45, 46 ...... 47 polymyxin ...... 73 NICOTINE (POLACRILEX) nasal decongestant (pe) ...... 85 neomycin-polymyxin b- ...... 45, 46 nasal decongestant dexameth ...... 75 NICOTROL ...... 46 (pseudoeph) ...... 85 neomycin-polymyxin- NICOTROL NS ...... 46 nasal four ...... 47 gramicidin ...... 73 nifedipine ...... 30 nasal mist ...... 47 neomycin-polymyxin-hc 48, 75 night time ...... 85 nasal moisturizing ...... 47 neo-polycin ...... 73 night time cold and flu relief 85 nasal relief sinus wash w/neti neo-polycin hc ...... 75 night time cold-flu ...... 85 ...... 47 NEOSPORIN (NEO-BAC- night time pain medicine ...... 23 nasal relief sinus wash-bottle 47 POLYM) ...... 38 nightime sleep ...... 85 nasal spray (oxymetazoline) . 47 NEOSPORIN PLUS PAIN nighttime allergy relief ...... 85 nasal spray (sodium chloride) RELIEF ...... 38 nighttime cold-flu ...... 85 ...... 47 NEO-SYNEPHRINE NIGHTTIME COLD-FLU nasal spray (PHENYLEPHRINE) ...... 47 RELIEF ...... 85 12hr(oxymetazoline ...... 47 neo-tuss ...... 85 nighttime cough ...... 85 nasal spray long acting ...... 47 NEOTUSS PLUS ...... 85 nighttime sleep aid (diphen) . 85 NASALCROM ...... 91 NEOTUSS-D (IMPROVED nikki (28) ...... 71 NATACYN ...... 73 FORMULA) ...... 85 nilutamide ...... 12 nateglinide ...... 50 nephplex rx ...... 112 NINLARO ...... 12 NATPARA ...... 51 nephronex ...... 112 nitazoxanide ...... 7 natural b-100 complex ...... 112 NEPHRO-VITE ...... 112 NITE TIME COLD-FLU natural fiber laxative...... 59 nephro-vite rx ...... 112 RELIEF ...... 85 natural fiber laxative (sugar) 59 NEPRO CARB STEADY .. 100 nite time-d cold-flu relief ...... 85 natural fiber laxative(aspart) 59 NERLYNX ...... 12 nitetime multi-symptom ...... 85 natural tears (pf) ...... 74 NEULASTA ...... 64 nitisinone ...... 44 natural veg laxative(sennosid) NEUPOGEN ...... 64 nitro-bid ...... 33 ...... 59 neutraphor ...... 36 nitrofurantoin macrocrystal .... 9 natural vegetable ...... 59 NEUTROGENA ...... 36 nitrofurantoin monohyd/m- natural vegetable (psyllium) . 60 cryst ...... 9

135 nitroglycerin ...... 33 NUTRAMIGEN WITH one daily maximum ...... 113 nitro-time ...... 33 ENFLORA LGG ...... 101 one daily men's 50 plus NIX CREME RINSE ...... 43 NUTREN PULMONARY . 101 memory ...... 113 nizatidine ...... 63 NUTRIHEP ...... 101 one daily multi-vit w-mineral NIZORAL A-D ...... 40 nyamyc ...... 40 ...... 113 no drip ...... 47 nystatin ...... 3, 40 one daily multivitamin ...... 113 noble formula ...... 43 nystop ...... 40 one daily multivit-iron(folic) noble formula hc...... 42 O ...... 113 nohist-dm ...... 86 OA 1 POWDER ...... 101 one daily plus iron ...... 113 nohist-lq ...... 86 OA2 POWDER ...... 101 one daily plus minerals ...... 113 non-aspirin ...... 23 OCALIVA ...... 60 ONE DAILY PRENATAL . 113 non-aspirin extra strength ..... 23 ocean nasal ...... 47 ONE DAILY WOMEN 50 non-aspirin flu ...... 86 ocella ...... 71 PLUS ...... 113 non-aspirin pain relief ...... 23 octreotide acetate ...... 12 one daily women's ...... 113 non-aspirin pm ...... 23 ocusoft hand soap ...... 36 one daily womens 50 plus .. 113 nora-be ...... 66 ocutabs ...... 112 one daily women's health ... 113 NORDITROPIN FLEXPRO 64 OCUVITE WITH LUTEIN 112 one-a-day essential ...... 113 NOREL AD ...... 86 ODEFSEY ...... 5 one-a-day maximum formula noreth-ethinyl estradiol-iron . 71 odor control foot-sneaker ..... 41 ...... 113 norethindrone (contraceptive) ODORLESS GARLIC ...... 45 ONE-A-DAY MEN'S ...... 66 OFEV ...... 91 50PLUS(GINKGO) ...... 113 norethindrone acetate ...... 66 ofloxacin ...... 8, 48, 73 one-a-day teen advantage ... 113 norethindrone ac-eth estradiol olanzapine ...... 27 ONE-A-DAY TRUBIOTICS ...... 67, 71 olanzapine-fluoxetine ...... 27 ...... 53 norethindrone-e.estradiol-iron olmesartan-amlodipin- ONE-A-DAY WOMENS ...... 71 hcthiazid ...... 30 FORMULA ...... 113 norgestimate-ethinyl estradiol olopatadine ...... 47, 74 opcicon one-step ...... 71 ...... 71 OMEGA 3-DHA-EPA-FISH OPSUMIT ...... 91 norlyda ...... 67 OIL ...... 101 option-2 ...... 71 nortemp...... 23 omega-3 acid ethyl esters ..... 33 opti-vitamins ...... 113 nortrel 0.5/35 (28) ...... 71 OMEGA-3 FATTY ACIDS- oral saline laxative ...... 60 nortrel 1/35 (21) ...... 71 FISH OIL ...... 101 oralone ...... 47 nortrel 1/35 (28) ...... 71 omega-3 flaxseed oil ...... 45 oralyte ...... 96 nortrel 7/7/7 (28) ...... 71 omeprazole ...... 63 ORFADIN ...... 44 nortriptyline ...... 27 omeprazole magnesium ...... 63 ORIAHNN ...... 67 NORVIR ...... 5 omnicap ...... 112 original nasal spray ...... 47 norwegian cod liver oil ...... 112 OMNITROPE ...... 64 ORILISSA ...... 51 nose drops ...... 47 ONCASPAR ...... 12 ORKAMBI ...... 91 NOVAFERRUM ...... 112 ONCOVITE ...... 112 orphenadrine citrate ...... 17 novasource renal 2 cal ...... 101 ondansetron ...... 60 orsythia ...... 71 NOVOSEVEN RT ...... 31 ondansetron hcl ...... 60 OS-CAL 500 + D3...... 96 NOXAFIL ...... 3 ondansetron hcl (pf) ...... 60 oscimin ...... 53 np thyroid ...... 52 one daily ...... 112 oscimin sl ...... 53 NUBEQA ...... 12 one daily calcium/iron ...... 112 oscimin sr ...... 53 NUEDEXTA ...... 17 one daily complete ...... 112 oseltamivir ...... 5 NU-IRON ...... 112 one daily energy ...... 112 OTEZLA ...... 66 NUTRAMIGEN DHA-ARA one daily essential ...... 113 OTEZLA STARTER ...... 66 ...... 101 one daily for men ...... 113 oxandrolone ...... 51 NUTRAMIGEN TODDLER one daily for men 50+ oxazepam ...... 27 ENFLORA-LGG ...... 101 advanced ...... 113 OXBRYTA ...... 44 one daily for women ...... 113 oxcarbazepine ...... 15

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OXEPA ...... 101 PEGASYS ...... 64 PHENYLADE ESSENTIAL OXERVATE ...... 74 peg-electrolyte soln ...... 60 ...... 101 oxybutynin chloride...... 92 peg-prep ...... 60 phenylephrine hcl ...... 76 oxycodone ...... 19 PEMAZYRE ...... 12 PHENYL-FREE 1 ...... 101 oxycodone-acetaminophen ... 19 penicillamine ...... 66 PHENYL-FREE 2 PKU ..... 101 oxymetazoline ...... 47 penicillin v potassium ...... 8 phenytoin ...... 15 oysco 500/d ...... 96 pentoxifylline ...... 31 phenytoin sodium extended .. 15 oyster shell calcium 500 ...... 96 pepcid ac ...... 63 philith ...... 71 oyster shell calcium-vit d3 ... 96 PEPCID AC ...... 63 PHILLIPS ...... 96 oystercal-d ...... 96 PEPCID AC MAXIMUM PHILLIPS' COLON HEALTH P STRENGTH ...... 63 ...... 53 pacerone ...... 28 PEPTAMEN ...... 101 PHILLIPS' LIQUI-GELS ..... 60 paclitaxel ...... 12 PEPTAMEN 1.5 ...... 101 PHILLIPS MILK OF pain relief (acetaminophen) .. 23 PEPTAMEN JUNIOR 1.5 .. 101 MAGNESIA ...... 60 pain relief adult...... 23 peptic relief ...... 53 PHLEXY-10 DRINK MIX pain relief allergy sinus ...... 86 PEPTO-BISMOL ...... 53 POWDER ...... 101 pain relief pm ...... 23 PEPTO-BISMOL MAX ST . 53 phos-nak ...... 96 pain relief pm rapid release .. 23 pepto-bismol to-go ...... 53 phospha 250 neutral ...... 96 pain relief regular strength ... 23 PERATIVE ...... 101 phosphasal ...... 93 pain reliever (acetam-aspirin) percogesic ...... 24 phosphate laxative ...... 60 ...... 23 percogesic extra strength ...... 24 phospho-trin 250 neutral ...... 96 pain reliever (acetaminophen) perdiem overnight relief ...... 60 phytonadione (vitamin k1) ... 32 ...... 23 PERFOROMIST ...... 91 PHYTONADIONE pain reliever extra strength ... 23 PERIANAL CLEANSING ... 36 (VITAMIN K1) ...... 32 pain reliever plus ...... 24 PERIFLEX ADVANCE ..... 101 PIFELTRO ...... 5 pain-off ...... 24 PERIFLEX INFANT ...... 101 pilocarpine hcl ...... 44, 73 paliperidone ...... 27 PERIFLEX JUNIOR ...... 101 pimozide ...... 27 pamidronate ...... 51 PERIFRESH ...... 36 pimtrea (28) ...... 71 pantoprazole ...... 63 perindopril erbumine ...... 30 pindolol ...... 30 paromomycin ...... 7 periogard ...... 47 pink bismuth ...... 53 paroxetine hcl ...... 27 permethrin ...... 43 pink bismuth maximum p-col rite ...... 60 perphenazine ...... 27 strength ...... 53 PECGEN DMX ...... 86 perphenazine-amitriptyline ... 27 pioglitazone ...... 50 pedia relief infant nasal ...... 86 perry prenatal ...... 113 pioglitazone-glimepiride ...... 50 pediacare fever reducer ...... 24 petrolatum, yellow (bulk) ..... 36 pioglitazone-metformin ...... 50 pediacare multi-symptom cold PFD 2 ...... 101 PIQRAY ...... 12 ...... 86 PFD TODDLER ...... 101 pirmella ...... 71 PEDIA-LAX...... 60 PFIZER COVID-19 piroxicam ...... 24 PEDIA-LAX STOOL VACCINE (EUA) ...... 65 pivot 1.5 cal ...... 101 SOFTENER ...... 60 pharbechlor ...... 86 PKU COOLER 10 ...... 102 pedialyte ...... 96 pharbedryl ...... 86 PKU COOLER 15 ...... 102 PEDIALYTE ADVANCED pharbetol ...... 24 PKU COOLER 20 ...... 102 CARE ...... 96 PHENAGIL ...... 86 PKU LOPHLEX ...... 102 pedialyte singles ...... 96 phenazopyridine ...... 93 PLAN B ONE-STEP ...... 71 pediatric cough and cold ...... 86 phenelzine ...... 27 PLEGRIDY ...... 64 pediatric electrolyte ...... 96 PHENEX-1 ...... 101 PNEUMOVAX-23 ...... 65 pediatric enema ...... 60 PHENEX-2 ...... 101 pnv 29-1 ...... 113 pediatric freezer pops ...... 96 phenobarbital ...... 15 pnv-dha ...... 113 pediatric oint (cod liver oil) .. 36 phenoxybenzamine ...... 30 pnv-omega ...... 113 PEDI-BORO SOAK ...... 36 PHENYLADE 60 ...... 101 pnv-select ...... 113 peg 3350-electrolytes ...... 60 podofilox ...... 36

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POLY BACITRACIN (ZINC) prenatal 19 ...... 114 procto-pak ...... 60 ...... 38 prenatal complete ...... 114 proctosol hc ...... 60 polycin ...... 73 PRENATAL FORMULA ... 114 proctozone-hc ...... 60 polyethylene glycol 3350 ..... 60 prenatal low iron ...... 114 PRODUCT 3232A ...... 102 poly-iron 150 forte ...... 113 PRENATAL MULTI-DHA PROFERRIN-FORTE ...... 114 polymyxin b sulf-trimethoprim (ALGAL OIL) ...... 114 PROFILNINE ...... 32 ...... 73 PRENATAL MULTI- progesterone micronized ...... 67 polysaccharide iron complex DHA(WITH VIT K) ...... 114 PROGRAF ...... 12 ...... 113 prenatal multivitamins ...... 114 PROLEUKIN ...... 64 POLYSPORIN prenatal one daily ...... 114 PROMACTA ...... 32 (BACITRACIN ZINC) .... 39 prenatal plus ...... 114 promethazine ...... 86 polyvinyl alcohol ...... 74 prenatal tablet ...... 114 promethazine vc ...... 86 POMALYST ...... 12 prenatal vitamin ...... 114 promethegan ...... 86 portia 28...... 71 prenatal vitamin plus low iron promolaxin ...... 60 posaconazole ...... 3 ...... 114 propafenone ...... 28 pot,sodium citrate-citric acid 93 prenatal vits96-iron fum-folic proparacaine ...... 74 potassium chloride...... 97 ...... 114 PRO-PHREE ...... 102 potassium citrate-citric acid . 93 prenatal-u ...... 114 PROPIMEX-1 ...... 102 potassium gluconate ...... 97 PREPARATION H PROPIMEX-2 ...... 102 povidone-iodine ...... 39 HYDROCORTISONE ..... 42 propranolol ...... 30 powderlax ...... 60 preplus ...... 114 propranolol-hydrochlorothiazid pr natal 400 ...... 113 pres gen ...... 86 ...... 30 pr natal 400 ec ...... 113 PRES GEN PEDIATRIC ..... 86 propylthiouracil ...... 49 pr natal 430 ...... 113 PRESERVISION AREDS .. 114 PROSHIELD FOAM/SPRAY pr natal 430 ec ...... 113 PRESGEN B ...... 86 CLEANSER ...... 36 PRALUENT PEN ...... 33 pretab ...... 114 protriptyline ...... 27 pramipexole ...... 16 PRETOMANID ...... 7 PROVIMIN ...... 97 pravastatin ...... 33 PRETTY FEET HANDS ...... 36 prudoxin ...... 36 praziquantel ...... 7 PREVACID 24HR ...... 63 pseudoephedrine hcl ...... 86 prazosin ...... 30 prevalite ...... 33 psyllium husk ...... 60 PRED MILD ...... 76 previfem ...... 71 PULMOCARE ...... 102 prednicarbate ...... 42 PREVNAR 13 (PF) ...... 65 pulmosal ...... 91 prednisolone ...... 49 PREVYMIS ...... 5 PULMOZYME ...... 91 prednisolone acetate ...... 76 PREZCOBIX ...... 5 PURAMINO TODDLER ... 102 prednisolone sodium phosphate PREZISTA ...... 5 pure and gentle eye ...... 74 ...... 49, 76 PRIFTIN ...... 7 purelax ...... 61 prednisone ...... 49 PRILOSEC OTC ...... 63 purevit dualfe plus ...... 114 prednisone intensol ...... 49 primidone ...... 15 PURIXAN ...... 12 pregabalin ...... 15 PRIVIGEN ...... 65 pyrazinamide ...... 7 PREGESTIMIL ...... 102 PRO FE ...... 114 pyridostigmine bromide ...... 17 pre-menstrual relief ...... 24 PROAIR RESPICLICK ...... 91 pyridoxine (vitamin b6) ...... 114 PREMIUM INFANT probenecid ...... 65 pyrimethamine ...... 7 FORMULA ...... 102 probenecid-colchicine ...... 65 Q prena1 chew...... 114 probiotic ...... 53, 102 QINLOCK ...... 12 prena1 pearl ...... 114 probiotic colon care ...... 53 quetiapine ...... 27 prena1 true ...... 114 procentra ...... 27 quinapril ...... 30 prenatabs fa ...... 114 prochlorperazine ...... 60 quinapril-hydrochlorothiazide prenatabs rx ...... 114 prochlorperazine edisylate .... 60 ...... 30 prenatal ...... 114 prochlorperazine maleate ..... 60 quinidine gluconate ...... 28 prenatal + dha ...... 114 PROCRIT ...... 64 quinidine sulfate ...... 28 PRENATAL + DHA ...... 114 procto-med hc ...... 60 quinine sulfate ...... 8

138 quintabs-m iron free ...... 114 rescon-gg ...... 86 RUKOBIA ...... 5 quit 2 ...... 46 RETAINE PM ...... 75 RYDAPT ...... 13 quit 4 ...... 46 RETEVMO ...... 12 rydex ...... 87 R RETROVIR ...... 5 rynex dm ...... 87 rabeprazole ...... 63 REVLIMID ...... 13 rynex pe ...... 87 raloxifene ...... 65 REYATAZ ...... 5 rynex pse ...... 87 ramelteon ...... 27 RIASTAP ...... 32 S ramipril ...... 30 ribavirin ...... 5 SAF-CLENS AF DERMAL rasagiline ...... 16 riboflavin (vitamin b2) ...... 115 WOUND ...... 36 RAVICTI ...... 44 rid complete lice elim kit ...... 43 SAFE TUSSIN DM ...... 87 RCF SOY PROTEIN RID COMPLETE LICE ELIM safe wash ...... 45 FORMULA BASE ...... 102 KIT ...... 43 saline mist ...... 47 READY-TO-USE ENEMA RID LICE KILLING ...... 43 saline nasal ...... 47 (MIN OIL) ...... 61 RIDAURA ...... 66 saline wound wash ...... 45 REBIF (WITH ALBUMIN) . 64 rifabutin ...... 8 salsalate ...... 24 REBIF REBIDOSE ...... 64 rifampin ...... 8 SAMSCA ...... 51 REBIF TITRATION PACK 64 riluzole ...... 44 SANDIMMUNE ...... 13 reclipsen (28) ...... 71 rimantadine ...... 5 SANDOSTATIN LAR RECOMBINATE ...... 32 RISA-BID ...... 53 DEPOT ...... 13 RECTIV ...... 61 risacal-d ...... 115 SANTYL ...... 42 refenesen...... 86 risamine ...... 36 sapropterin ...... 51 refenesen dm ...... 86 risaquad ...... 54 SAVELLA ...... 66 refenesen pe ...... 86 risaquad-2 ...... 54 SAVISION ...... 115 REFRESH CELLUVISC ..... 74 risedronate ...... 45, 65 scalacort ...... 42 REFRESH CONTACTS ...... 75 RISPERDAL CONSTA ...... 27 scalpicin anti-itch ...... 42 REFRESH LACRI-LUBE ... 75 risperidone ...... 27 SCOOBY-DOO ONE A DAY REFRESH LIQUIGEL ...... 75 ritonavir ...... 5 ...... 115 REFRESH PLUS ...... 75 RITUXAN ...... 13 SCOT-TUSSIN DIABETES REFRESH TEARS ...... 75 rivastigmine ...... 17 CF ...... 87 REGRANEX ...... 36 rivastigmine tartrate ...... 17 scot-tussin dm ...... 87 RELENZA DISKHALER ...... 5 rivelsa ...... 71 scot-tussin expectorant ...... 87 remedy antifungal ...... 41 rizatriptan ...... 16 SCOT-TUSSIN SENIOR ..... 87 remedy cleansing body ...... 36 robafen ...... 86 seconal sodium ...... 27 REMEDY NUTRASHIELD robafen cf (phenylephrine) ... 86 SECUADO ...... 27 SKIN PROTEC ...... 36 robafen dm cough ...... 86 secura antifungal ...... 41 remedy phytoplex antifungal 41 robafen dm cough-chest SECURA EXTRA REMODULIN ...... 30 congest ...... 86 PROTECTIVE ...... 36 RENA START ...... 102 robitussin cough and cold cf . 86 SEGLUROMET ...... 50 RENACIDIN ...... 93 robitussin cough-chest cong selegiline hcl ...... 16 renal caps ...... 114 dm ...... 86 SELZENTRY ...... 5 rena-vite ...... 114 ROBITUSSIN LONG- se-natal 19 chewable ...... 115 rena-vite rx ...... 115 ACTING ...... 87 se-natal-19 ...... 115 reno caps ...... 115 ropinirole ...... 16 senexon-s ...... 61 repaglinide ...... 50 rosadan ...... 37 senior tabs ...... 115 repaglinide-metformin ...... 50 rosula cleansing cloths ...... 37 senna ...... 61 REPATHA PUSHTRONEX 33 rosuvastatin ...... 33 senna laxative ...... 61 REPATHA SURECLICK .... 33 roweepra ...... 15 senna plus ...... 61 REPATHA SYRINGE ...... 33 ROZLYTREK ...... 13 senna with docusate sodium . 61 replesta ...... 115 RUBRACA ...... 13 senna-s ...... 61 REPLESTA NX ...... 115 rufinamide ...... 15 senna-time s ...... 61 RESCON-DM ...... 86 RU-HIST D ...... 87 sennosides-docusate sodium . 61

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SENOKOT ...... 61 SIMILAC HUMAN MILK sinus relief (oxymetazoline) . 48 SENOKOT EXTRA FORTIFIER ...... 102 sinus rinse pediatric ...... 48 STRENGTH ...... 61 SIMILAC LOW-IRON ...... 102 sinus rinse pediatric starter ... 48 SENOKOT-S ...... 61 SIMILAC NEOSURE ...... 102 sinus wash ...... 48 sen-o-tab ...... 61 SIMILAC PM ...... 102 SINUS WASH ...... 48 sentry ...... 115 SIMILAC PRO-ADVANCE sinus-allergy (phenylephrine) sentry senior ...... 115 NON-GMO ...... 102 ...... 87 serophene ...... 51 SIMILAC PRO-SENSITIVE sirolimus ...... 13 sertraline ...... 27 NON-GMO ...... 102 SIRTURO ...... 8 se-tan plus ...... 115 SIMILAC SENSITIVE ...... 102 skin cleanser ...... 36 setlakin ...... 71 similac sensitive fuss and gas SKYRIZI ...... 34 sevelamer carbonate ...... 45 ...... 102 sleep aid (diphenhydramine)87, severe allergy...... 24 SIMILAC SENSITIVE FUSS 88 SEVERE ALLERGY-SINUS AND GAS ...... 103 SLEEP AID HEADACHE ...... 87 SIMILAC SENSITIVE FUSS- (DIPHENHYDRAMINE) 87 severe cold ...... 87 GAS ...... 103 sleep ii ...... 88 SEVERE COLD AND FLU- SIMILAC SENSITIVE SLEEP TIME ...... 88 DAY (DM) ...... 87 ISOMIL SOY ...... 103 sleep-tabs ...... 88 SEVERE COLD MULTI- SIMILAC SOY ISOMIL .... 103 slo-niacin ...... 33 SYMPTOM ...... 87 SIMILAC SPECIAL CARE 24 SLO-NIACIN ...... 33 sevoflurane ...... 45 ...... 103 SLOW FE ...... 115 sf 47 SIMILAC SPECIAL CARE 30 slow release iron ...... 115 sf 5000 plus ...... 48 ...... 103 SLOW RELEASE IRON ... 115 shake that ache ...... 24 similac sterilized water ...... 45 smooth antacid ...... 97 sharobel ...... 67 SIMILAC smoothlax ...... 61 SHINGRIX (PF) ...... 65 SUPPLEMENTATION .. 103 sodium bicarbonate ...... 61 SIGNIFOR ...... 13 SIMILAC TOTAL sodium chloride ...... 92 silace ...... 61 COMFORT ...... 103 sodium citrate-citric acid ...... 93 siladryl sa...... 87 SIMILAC TOTAL sodium ferric gluconat-sucrose silapap...... 24 COMFORT NON-GMO 103 ...... 45 sildenafil (pulm.hypertension) simliya (28) ...... 71 sodium phenylbutyrate ...... 45 ...... 91 simpesse ...... 71 sodium polystyrene sulfonate siltussin dm das ...... 87 simply sleep ...... 87 ...... 45 siltussin sa ...... 87 simvastatin ...... 33 sof-lax ...... 61 siltussin-dm ...... 87 sinugator nasal wash kit ...... 48 SOFOSBUVIR- SILVASORB ...... 39 sinus 12 hour ...... 87 VELPATASVIR ...... 5 silver sulfadiazine ...... 34 sinus and allergy pe ...... 87 SOMAVERT ...... 51 SILVERMED ...... 39 SINUS CONGESTION AND soothe (bismuth subsalicylate) SIMILAC ADVANCE ...... 102 PAIN ...... 87 ...... 54 similac advance organic ..... 102 sinus congestion-pain(chlorph) soothe and cool body powder SIMILAC ADVANCE ...... 87 ...... 45 ORGANIC ...... 102 SINUS CONGESTION- SOOTHE NIGHT TIME SIMILAC ADVANCE WITH PAIN(GUAIF) ...... 87 LUBRICANT ...... 75 IRON ...... 102 SINUS CONGEST-PAIN soothe regular strength ...... 54 similac alimentum ...... 102 DAY-NIGHT ...... 87 SOOTHE XP ...... 103 SIMILAC EXPERT CARE 102 sinus decongestant (pe) ...... 87 soothing care (hydrocortisone) SIMILAC EXPERT CARE sinus headache pe ...... 87 ...... 42 ALIMENTUM ...... 102 sinus nasal spray ...... 48 soothing pureway-c ...... 115 SIMILAC EXPERT CARE sinus pain relief ...... 87 sorbidon hydrate ...... 36 NEOSURE ...... 102 sinus pe decongestant ...... 87 sorbugen nr ...... 88 SIMILAC FOR SPIT-UP ... 102 sinus relief (non-drowsy) ...... 87 sorine ...... 28

140 sotalol ...... 28 sulfamethoxazole-trimethoprim SYSTANE NIGHTTIME ..... 75 sotalol af ...... 28 ...... 8 SYSTANE ULTRA ...... 75 SOTYLIZE ...... 28 SULFAMYLON ...... 39 T spectravite adult 50 plus ..... 115 sulfasalazine ...... 61 tab-a-vite ...... 116 spectravite advanced formula sulfatrim ...... 8 tab-a-vite multivitamin w-iron ...... 115 sulfo-lo ...... 34 ...... 116 spectravite men's ...... 115 sulindac ...... 24 TABLOID ...... 13 spironolactone ...... 30 sumatriptan ...... 16 TABRECTA ...... 13 spironolacton-hydrochlorothiaz sumatriptan succinate ..... 16, 17 tacrolimus ...... 13, 36 ...... 30 sunvite ...... 115 tactinal ...... 24 sprintec (28)...... 71 super b complex-vitamin c . 115 TAFINLAR ...... 13 SPRYCEL ...... 13 super b maxi complex ...... 115 tagamet hb ...... 63 sps (with sorbitol) ...... 45 super b/c ...... 115 TAGRISSO ...... 13 sronyx ...... 71 super calcium ...... 97 TALZENNA ...... 13 ssd ...... 34 super multiple ...... 115 tamoxifen ...... 13 stavudine...... 5 super multivitamin ...... 115 tamsulosin ...... 92 STEGLATRO...... 50 super probiotic ...... 54 tarina 24 fe ...... 71 stimulant laxative plus ...... 61 super quints ...... 116 tarina fe 1/20 (28) ...... 71 STIVARGA ...... 13 super quints b-50 ...... 116 taron forte ...... 116 stomach relief ...... 54 super thera vite m ...... 116 taron-c dha ...... 116 stool softener ...... 61 suphedrin ...... 88 TASIGNA ...... 13 STOOL SOFTENER ...... 61 suphedrine ...... 88 tazarotene ...... 37 stool softener (docusate cal) . 61 suphedrine 12 hour ...... 88 TAZORAC ...... 37 stool softener-laxative ...... 61 suphedrine pe ...... 88 taztia xt ...... 30 stool softener-stimulant laxat 61 suphedrine pe cold and allergy TAZVERIK ...... 13 stop smoking aid...... 46 ...... 88 TEGSEDI ...... 17 STRENSIQ ...... 51 SUPHEDRINE PE SINUS temazepam ...... 27 stress b with zinc ...... 115 HEADACHE ...... 88 TEMIXYS ...... 5 stress formula ...... 115 SUPLENA CARB STEADY temozolomide ...... 13 stress formula with iron ...... 115 ...... 103 tencon ...... 19 stress formula with iron(sulf) support ...... 116 tenofovir disoproxil fumarate . 5 ...... 115 supress dx ...... 88 TENSION HEADACHE ...... 24 stress formula with zinc...... 115 surfak ...... 61 TENSION HEADACHE PAIN STRIBILD ...... 5 SUSTIVA ...... 5 RELIEVER ...... 24 STRIVERDI RESPIMAT .... 92 SUTENT ...... 13 terazosin ...... 30 strong iodine ...... 39, 97 SWEEN 24 ...... 36 terbinafine hcl ...... 3, 41 SUBLOCADE ...... 19 sween prep ...... 41 terbutaline ...... 92 SUBOXONE ...... 24 syeda ...... 71 terconazole ...... 68 SUCRAID ...... 61 symax fastabs ...... 54 terrell ...... 45 sucralfate ...... 63 symax-sl ...... 54 testosterone ...... 51 SUDAFED ...... 88 symax-sr ...... 54 testosterone cypionate ...... 51 SUDAFED 12 HOUR ...... 88 SYMDEKO ...... 92 testosterone enanthate ...... 51 SUDAFED 24 HOUR ...... 88 SYMLINPEN 120 ...... 50 tetrabenazine ...... 17 sudogest ...... 88 SYMLINPEN 60 ...... 50 tetracaine hcl ...... 75 sudogest 12-hour ...... 88 SYMTUZA ...... 5 tetracycline ...... 9 sudogest cold and allergy ..... 88 SYNAGIS ...... 5 THALOMID ...... 13 sudogest sinus and allergy .... 88 SYNJARDY ...... 50 the magic bullet ...... 61 sulfacetamide sodium ...... 76 SYNJARDY XR ...... 50 theophylline ...... 92 sulfacetamide-prednisolone .. 76 synovacin ...... 24 thera-d ...... 116 sulfadiazine...... 8 SYSTANE (PROPYLENE THERAFLU EXPRESSMAX GLYCOL) ...... 75 COLD DAY ...... 88

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THERAFLU FLU-SORE toposar ...... 13 triple antibiotic ...... 39 THROAT ...... 88 toremifene ...... 13 TRIPLE ANTIBIOTIC ...... 39 theralogix companion ...... 116 torsemide ...... 30 triple antibiotic plus ...... 39 thera-m ...... 116 total allergy medicine ...... 88 triple antibiotic-pain relief .... 39 therapeutic liquid ...... 116 TRACLEER ...... 92 triple omega 3-6-9 ...... 103 therapeutic-m ...... 116 tramadol ...... 24 tri-previfem (28) ...... 72 theraseal ...... 36 tramadol-acetaminophen ...... 24 tri-sprintec (28) ...... 72 thera-tabs ...... 116 trandolapril ...... 30 TRIUMEQ ...... 5 thera-tabs m ...... 116 trandolapril-verapamil ...... 30 triveen-duo dha ...... 116 THERATEARS ...... 75 tranexamic acid ...... 68 tri-vitamin with fluoride ..... 116 theratrum complete 50 plus/lut tranylcypromine ...... 27 trivora (28) ...... 72 ...... 116 travel sickness ...... 61 tri-vylibra ...... 72 theratrum complete 50 plus-lyc trazodone ...... 27 tri-vylibra lo ...... 72 ...... 116 tretinoin ...... 37 TRIZIVIR ...... 6 theratrum complete with lutein tretinoin (antineoplastic) ...... 13 tropicamide ...... 73 ...... 116 TRETTEN ...... 32 TRULANCE ...... 62 therems-m ...... 116 TREXALL ...... 13 TRUMENBA ...... 65 thermotabs ...... 97 tri femynor ...... 71 TRUVADA ...... 6 thiamine hcl (vitamin b1) ... 116 TRIAD WOUND DRESSING TUKYSA ...... 13 thiamine mononitrate (vit b1) ...... 36 TUMS ...... 97 ...... 116 triamcinolone acetonide 42, 48, TUMS E-X ...... 97 thioridazine ...... 27 92 TUMS EXTRA STRENGTH thiothixene ...... 27 TRIAMINIC COLD AND SMOOTHIES ...... 97 THYROGEN ...... 45 COUGH (PE) ...... 88 tums ultra ...... 62, 97 THYROLAR-1 ...... 52 triamterene-hydrochlorothiazid TURALIO ...... 13 THYROLAR-1/2 ...... 52 ...... 30 TUSICOF ...... 88 THYROLAR-1/4 ...... 52 tri-buffered aspirin ...... 24 tusnel diabetic ...... 88 THYROLAR-2 ...... 52 tricitrates ...... 93 TUSNEL NEW FORMULA 88 THYROLAR-3 ...... 52 tricon ...... 116 tusnel pediatric ...... 88 tiadylt er...... 30 triderm ...... 42 tussi pres-b ...... 88 tiagabine ...... 15 tri-estarylla ...... 71 TUSSI PRES-B ...... 88 TIBSOVO ...... 13 trifluoperazine ...... 27 tussin ...... 89 tilia fe...... 71 trifluridine ...... 73 tussin cf (pe-dm-guaif) ...... 88 timolol maleate ...... 30, 73 trigels-f forte ...... 116 TUSSIN CF MAX ...... 88 tinactin ...... 41 trihexyphenidyl ...... 16 tussin chest congestion ...... 88 TINACTIN ...... 41 TRIKAFTA ...... 92 tussin cough (dm only) ...... 88 tinidazole ...... 8 tri-legest fe ...... 72 tussin cough-chest congestion tioconazole-1 ...... 68 tri-linyah ...... 72 ...... 88 TIVICAY ...... 5 tri-lo-estarylla ...... 72 tussin dm ...... 89 TIVICAY PD ...... 5 tri-lo-marzia ...... 72 tussin dm clear ...... 89 tizanidine ...... 17 tri-lo-mili ...... 72 tussin dm cough and chest .... 89 tobramycin ...... 73 tri-lo-sprintec ...... 72 tussin dm max ...... 89 tobramycin in 0.225 % nacl.... 8 trilyte with flavor packets ..... 61 tussin expectorant ...... 89 tobramycin-dexamethasone .. 75 trimethobenzamide ...... 62 tussin honey ...... 89 tolcapone ...... 16 trimethoprim ...... 9 tussin long-acting ...... 89 TOLEREX ...... 103 tri-mili ...... 72 tussin maximum strength tolmetin ...... 24 trimipramine ...... 27 cough ...... 89 tolnaftate ...... 41 TRIMO-SAN JELLY ...... 68 tussi-pres ...... 89 TOLSURA ...... 3 trinatal rx 1 ...... 116 TUSSI-PRES PEDIATRIC .. 89 tolvaptan ...... 51 trinate ...... 116 TYKERB ...... 13 topiramate ...... 15 triphrocaps ...... 116 TYLENOL ...... 24

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TYLENOL ARTHRITIS PAIN VANACOF ...... 89 virt-nate dha ...... 117 ...... 24 vancomycin ...... 9 virt-phos 250 neutral ...... 97 TYLENOL EXTRA vandazole ...... 68 virt-pn dha ...... 117 STRENGTH ...... 24 vanicream ...... 37 virt-pn plus ...... 117 TYLENOL PM EXTRA VARUBI ...... 62 virtrate-2 ...... 93 STRENGTH ...... 24 v-c forte ...... 116 virtrate-3 ...... 93 tylophen ...... 24 vegetable laxative ...... 62 virtrate-k ...... 93 TYMLOS ...... 65 veletri ...... 31 VISINE TIRED EYE RELIEF tyr cooler ...... 103 velivet triphasic regimen (28) ...... 75 TYR EXPRESS20 ...... 103 ...... 72 VISION FORMULA (WITH TYR GEL POWDER ...... 103 VELTASSA ...... 45 LUTEIN) ...... 117 TYREX-1 ...... 103 VEMLIDY ...... 6 VISION PLUS LUTEIN .... 117 TYREX-2 ...... 103 VENCLEXTA ...... 13 VISTOGARD ...... 9 TYROS 1 ...... 103 VENCLEXTA STARTING vit 3 ...... 117 TYROS 2 ...... 103 PACK ...... 13 vita-c ...... 117 TYVASO ...... 92 venlafaxine ...... 27, 28 vitacel (with lutein) ...... 117 TYVASO REFILL KIT ...... 92 VENOFER ...... 116 VITAFOL-OB ...... 117 TYVASO STARTER KIT ... 92 VENTAVIS ...... 92 vitajoy daily d ...... 117 U verapamil ...... 31 VITAL 1.0 CAL ...... 103 UCD ANAMIX JUNIOR ... 103 veripred 20 ...... 49 VITAL 1.5 CAL ...... 103 ultra fresh...... 75 VERZENIO ...... 14 VITAL AF 1.2 CAL ...... 103 ULTRA FRESH PM ...... 75 vestura (28) ...... 72 VITAL HIGH PROTEIN ... 103 ULTRA LUBRICANT EYE 75 VIBERZI ...... 62 vitalee ...... 117 ultra mide 25...... 36 vic-forte ...... 116 vitalets ...... 117 ultra omega-3...... 103 vicks dayquil cold-flu relief . 89 vitamin a and d diaper rash ... 37 UNIFIBER ...... 62 VICKS DAYQUIL COLD- vitamin b complex ...... 117 unisom sleepgels ...... 89 FLU RELIEF ...... 89 vitamin b complex-folic acid unithroid ...... 52 vicks dayquil cough ...... 89 ...... 117 UPTRAVI ...... 31 VICKS DAYQUIL SEVERE vitamin b-1 ...... 117 uretron d-s ...... 93 COLD-FLU ...... 89 vitamin b-12 ...... 117 urimar-t ...... 93 vicks nyquil cold/flu liquicap VITAMIN B-12 ...... 117 uro-458 ...... 93 ...... 89 vitamin b-2 ...... 117 urogesic-blue ...... 93 VICKS NYQUIL SEVERE vitamin b-6 ...... 117 URO-MAG ...... 97 COLD-FLU ...... 89 vitamin c ...... 117 uro-mp ...... 93 vicks qlearquil(oxymetazoline) vitamin c drops ...... 117 ursodiol ...... 62 ...... 48 vitamin c with rose hips ...... 117 uryl ...... 93 vicks sinex 12-hour ...... 48 vitamin d3 ...... 117, 118 ustell ...... 93 vicks sinex ultra fine mist 12 48 vitamins a and d ...... 118 utira-c ...... 93 vienva ...... 72 vitamins a,c,d and fluoride . 118 V vigabatrin ...... 15 vitamins b complex ...... 118 valacyclovir ...... 6 VIMPAT ...... 16 vitamins for hair ...... 118 valganciclovir ...... 6 vinblastine ...... 14 vitatrum ...... 118 valproate sodium ...... 15 vincasar pfs ...... 14 VITRAKVI ...... 14 valproic acid ...... 15 vincristine ...... 14 vitrum senior ...... 118 valproic acid (as sodium salt) vinorelbine ...... 14 VITRUM SENIOR ...... 118 ...... 15 VIOKACE ...... 62 VIVITROL ...... 24 valsartan ...... 31 viorele (28) ...... 72 VIVONEX PEDIATRIC .... 103 valsartan-hydrochlorothiazide VIRACEPT ...... 6 VIVONEX PLUS ...... 103 ...... 31 VIREAD ...... 6 vivonex rtf ...... 103 VALTOCO ...... 15 virt-c dha ...... 116 VIVONEX T.E.N...... 103 valu-tapp ...... 89 virt-gard ...... 116 VIZIMPRO ...... 14

143 volnea (28)...... 72 wal-tussin cough and cold cf 90 XPTM ANALOG ...... 104 VONVENDI ...... 32 wal-tussin dm ...... 90 XTANDI ...... 14 voriconazole ...... 3 wal-tussin max strength cough XTRACAL PLUS ...... 104 VOSEVI ...... 6 ...... 90 xulane ...... 68 VOTRIENT ...... 14 wal-zyr (cetirizine) ...... 90 XURIDEN ...... 45 VPRIV ...... 51 wal-zyr d ...... 90 XYNTHA ...... 32 vp-vite rx ...... 118 warfarin ...... 32 XYNTHA SOLOFUSE ...... 32 VUMERITY ...... 17 wee care ...... 118 XYREM ...... 28 vyfemla (28) ...... 72 wera (28) ...... 72 Y VYNDAMAX ...... 33 westhroid ...... 52 yelets ...... 118 VYNDAQEL ...... 33 WHITE PETROLATUM ..... 37 yuvafem ...... 67 VYVANSE ...... 28 white petroleum jelly ...... 37 Z W witch hazel ...... 37 zafirlukast ...... 92 wal-act d cold and allergy .... 89 wixela inhub ...... 92 zaleplon ...... 28 wal-dram...... 62 WND 2 ...... 103 zarah ...... 72 wal-dryl allergy ...... 89 woman's laxative (bisacodyl)62 ZARXIO ...... 64 wal-dryl severe allergy-sinus 89 women's daily formula ...... 118 zatean-pn dha ...... 118 wal-dryl-d allergy and sinus . 89 WOMEN'S DAILY zatean-pn plus ...... 118 wal-fex allergy...... 89 FORMULA ...... 118 zebutal ...... 19 wal-fex d 12 hour ...... 89 women's gentle laxative(bisac) ZEGERID OTC ...... 63 wal-fex d 24 hour ...... 89 ...... 62 ZEJULA ...... 14 wal-finate ...... 89 women's laxative (bisacodyl)62 ZELBORAF ...... 14 wal-finate-d ...... 89 WOMEN'S ONE DAILY ... 118 ZEMAIRA ...... 45 wal-flu night severe cold ...... 89 women's prenatal plus dha .. 118 zenatane ...... 37 WAL-FLU NIGHT TIME .... 89 wymzya fe ...... 72 zenzedi ...... 28 WAL-FLU SEVERE COLD- X zidovudine ...... 6 COUGH ...... 89 XALKORI ...... 14 zinc ...... 97 wal-four ...... 48 XARELTO ...... 32 zinc gluconate ...... 97 walgreens dry skin treatment 37 XARELTO DVT-PE TREAT zinc oxide ...... 37 wal-itin ...... 90 30D START ...... 32 zingiber ...... 118 wal-itin d ...... 89 XERMELO ...... 14 ziprasidone hcl ...... 28 wal-itin d 12 hour ...... 90 XIFAXAN ...... 8 ZOLADEX ...... 14 wal-mucil fiber ...... 62 XIIDRA ...... 75 zoledronic acid ...... 51 wal-mucil fiber (aspartame) . 62 XLEU ANALOG ...... 103 ZOLINZA ...... 14 wal-mucil fiber (sugar) ...... 62 XLEU MAXAMAID ...... 104 zolmitriptan ...... 17 wal-mucil natural fiber lax ... 62 XLYS- XTRP ANALOG ... 104 zolpidem ...... 28 wal-phed ...... 90 XLYS, XTRP MAXAMAID zonisamide ...... 16 wal-phed 12 hour ...... 90 ...... 104 ZORTRESS ...... 14 wal-phed pe ...... 90 XLYS, XTRP MAXAMUM ZOSTAVAX (PF) ...... 65 wal-phed pe nighttime cold .. 90 ...... 104 zovia 1/35e (28) ...... 72 wal-phed pe sinus and allergy XMET ANALOG ...... 104 zumandimine (28) ...... 72 ...... 90 XMET MAXAMUM ...... 104 ZYDELIG ...... 14 wal-profen ...... 24 XMTVI ANALOG ...... 104 ZYKADIA ...... 14 wal-profen cold-sinus ...... 90 xmtvi maxamaid ...... 104 zyncof ...... 90 wal-profen d cold and sinus . 90 xmtvi maxamum ...... 104 ZYNCOF ...... 90 wal-proxen ...... 24 XOFLUZA ...... 6 ZYRTEC ...... 90 WAL-SLEEP Z ...... 90 XPHE MAXAMAID ...... 104 ZYRTEC-D ...... 90 wal-som (diphenhydramine) 90 XPHE, XTRP MAXAMAID ZYTIGA ...... 14 wal-sporin ...... 39 ...... 104 ZZZQUIL ...... 90 wal-tap dm ...... 90 XPHE, XTYR ANALOG ... 104 wal-tussin cough ...... 90 XPOVIO ...... 14

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145 55 Water Street, New York, NY 10041-8190 | emblemhealth.com

This formulary was updated on 4/1/2021. For more recent information or other questions, please contact EmblemHealth Medicaid at 855-283-2146 or for TTY users: 711, Monday to Friday, 8 am to 6 pm, or visit emblemhealth.com/medicaid.

EmblemHealth insurance plans are underwritten by Group Health Incorporated (GHI), HIP Health Plan of New York (HIP) and HIP Insurance Company of New York.

45-9360PD 10/21