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

For the most current information about the MHS Pharmacy Program you may call Member Services at 1-877-647-4848 (TTY/TTD 1-800-743-3333) or visit the MHS website at mhsindiana.com.

Preferred Drug List The MHS Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs that members can receive at retail pharmacies. The MHS PDL is continually evaluated by the MHS Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians, pharmacists, and specialists.

Pharmacy Benefit Manager Envolve Pharmacy Solutions (EPS) is our Pharmacy Benefit Manager. MHS works with EPS to process all pharmacy claims for prescribed drugs. Some drugs on the MHS PDL require PA, and EPS is responsible for administering this process.

Specialty Drugs Certain medications are only covered when supplied by MHS’ specialty pharmacy provider. AcariaHealth is our specialty pharmacy provider. A medical provider can obtain specialty medications through Acaria Health. Acaria Health will ship these medications to the medical provider’s office. Some selected medications are also available through the medical benefit upon administration within the medical provider’s office for providers who choose to inventory these medications for office administration. Billing instructions for this situation can be found in the provider handbook.

The MHS Pharmacy Director and MHS Medical Director oversee the clinical review of these medications and AcariaHealth provides members with the following services: • Deliver drugs to the member’s home or provider’s office • Provide staff pharmacists who can help 24 hours a day, seven days a week to answer member questions and offer help with drugs • Give information, materials, and ongoing support to help members take the drug(s) to appropriately manage their health condition(s)

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These drugs are not usually available at retail pharmacies. Additional information about the drugs that AcariaHealth provides is in the Biopharmaceutical Pharmacy Program document located on the MHS website at mhsindiana.com.

Mental Health Drugs In accordance with Indiana law, all antianxiety, antidepressant, and antipsychotic drugs are considered as being preferred and do not require prior authorizations. If such a mental health drug is not listed on the PDL it is still considered preferred. Although considered preferred and no prior authorization is required, mental health drugs may be subject to utilizations edits such as quantity and age limits, duplicate therapy edits and other authorization requirements.

Dispensing Limits Drugs may be dispensed up to a maximum 30-day supply for each new prescription or refill. A total of 80% of the days’ supply or 25 days must have elapsed before the prescription can be refilled for 30-day supply, non-controlled-substance PDL drugs. A total of 88% of the days’ supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs.

Maintenance medications can be filled up to 90 days through mail order or at most retail pharmacies for Hoosier Care Connect, Hoosier Healthwise and HIP Plus members. HIP Basic members are limited to a 30 day supply. You can find a complete list of maintenance medications on the MHS website mhsindiana.com. Visit the MHS website for more information on how to enroll your prescription in our HomeScripts mail order program or for a listing of participating pharmacies.

Appropriate Use and Safety Edits Member health and safety is a priority for MHS. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on the Food and Drug Administration (FDA) recommendations and promote safe and effective medication utilization. A primary example of these recommendations would be limiting the number of fills each month to one medication in the same therapy classes.

Additional information about the drugs that are part of the these edits can be found in the Appropriate Use and Safety Edits document located on the MHS website at mhsindiana.com.

Prior Authorizations Some medications listed on the MHS PDL may require PA. The information should be submitted by the practitioner or pharmacist to EPS on the Medication Prior Authorization Form. This document is located on the MHS website at mhsindiana.com. The completed form and all clinicals to support the request should be faxed to EPS at 1-866-399-0929.

MHS will cover the medication if it is determined that:

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1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the MHS P&T Committee. If the request is approved, EPS notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

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

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

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

Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. MHS requires: . Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or . Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or . Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

All reviews are performed by a licensed clinical pharmacist or physician using the criteria established by the MHS P&T Committee. If the clinical information provided does not meet the

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coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy may enter a PA override code into their system at the point of sale to allow for the emergency supply to process.

Exclusions The following drug categories are not part of the MHS PDL and are not covered by the 72 hour emergency supply policy: . Drugs that are considered experimental . Drug Efficacy Study and Implementation (DESI) drugs . Drugs prescribed for weight loss (with the exception of Orlistat) . Drugs prescribed for infertility . Drugs prescribed for erectile dysfunction . Drugs prescribed for cosmetic purposes or hair growth . Cough and cold preparations, minus those covered by OTC program . Infusion therapy and supplies . Physician administered drugs that are not listed in the PDL, Specialty Drug Benefit, or the Physician Administered Drug Prior Authorization List . Medications Carved out to the Fee For Service Program o Examples . Hepatitis C Agents . Hemophilia Products (Blood Factor) . Some Spinal Muscular Atrophy Agents . Some Cystic Fibrosis Agents:

Any MHS member requesting a carved out medication will need to have their physician send the prior authorization (PA) request to: o Optum Clinical Call Center o Phone: 855-577-6317 o Fax: 855-577-6384

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

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Over-the-Counter Medications The MHS OTC list covers a variety of medications. A list of covered OTC medications can be found in the MHS PDL document. These OTCs are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Tobacco Cessation Medications The following types of tobacco cessation medications will be covered by MHS: generic nicotine replacement products (gum, lozenges, and patches), Bupropion SR 150mg (Zyban), Commit lozenges, Nicoderm, Nicorette, Nicotine gum, and Nicotine patches. A prescription will be required for all tobacco cessation medications.

MHS authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines, and manufacturers’ recommendations.

Generic Drugs When generic drugs are available, the brand-name drug will not be covered without prior MHS authorization. Generic drugs have the same active ingredient, work the same as brand-name drugs, and have lower copayments. If the member or their practitioner feels a brand-name drug is medically necessary, the practitioner can request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If MHS does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process.

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

Filling a Prescription A member can have prescriptions filled at an MHS network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting MHS Member Services or by visiting mhsindiana.com. At the pharmacy the member will need to provide the pharmacist with the prescription and their MHS ID card.

Ordering, Prescribing and Referring (OPR) Provider Requirements To ensure compliance with Indiana Medicaid and the Center for Medicaid and Medicare Services (CMS) regulations, MHS and EPS edit pharmacy claims for the presence of a participating Medicaid provider or an enrolled ordering, prescribing, or referring (OPR)

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provider. All pharmacy claims must contain the NPI of the prescribing provider. All prescriptions written by a non-registered or non-OPR prescriber will result in a claim denial. Pharmacies will be notified through claim transactions if the submitted prescribing provider is not enrolled with the Department of Community Health (DCH) as a participating provider or an ordering, prescribing or rendering provider. Pharmacies will also receive a claims message if their own store NPI is not enrolled in Indiana Medicaid.

Copayments (Copays) The table below lists the copayment for the drugs according to the actual cost of the prescription. Copayments are not required for pregnant women, family planning supplies, members in the hospital or a nursing home, or Native Americans.

Plan Type Generic /Preferred Drug Non-Preferred Drug HIP State Basic $4.00 $8.00 HIP Basic $4.00 $8.00 HIP Plus, State Plus No Cost No Cost HCC $3.00 $3.00

Generic, Single Source Multiple Source Brand Plan Type Brand, Compound Medications Medications HHW - Package A No Cost No Cost Standard Plan HHW - Package C $3.00 $10.00 CHIP

Contact Information MHS Member & Provider Services Phone: 1-877-647-4848 Fax: 1-866-714-7993 TTY/TDD: 1-800-743-3333 Envolve Pharmacy Solutions Prior Phone: 1-855-772-7125 Authorizations Fax: 1-866-399-0929 Specialty Medication Prior Authorization Fax Fax: 1-855-678-6976 CVS Pharmacy Help Desk Phone: 1-800-311-0557- HIP 1-800-378-0779 – HCC 1-800-378-0815 - HHW

AcariaHealth Specialty Medication Shipping Phone: 1-855-535-1815 Questions

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Preferred Drug List Abbreviations Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

Abbreviation Term What it means Tier 1 Preferred Generic Generic drugs are preferred generic drugs. These will have the lowest plan copay if your plan has copays. Tier 2 Preferred Brand Brand drugs are preferred brand drugs. These will have the highest plan copay if your plan has copays. AL Age Limit Some drugs are only covered for certain ages. CO Carved Out Medication is available only through the state pharmacy benefit. NP Non-preferred These drugs are on formulary that may still need to meet prior authorization/class criteria before they will be covered. PA Prior Your doctor must ask for approval from Authorization MHS before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. RX/OTC Prescription and These drugs are made in both prescription OTC form and Over-the-counter (OTC) form. ST Step Therapy In some cases, you must first try certain drugs before MHS covers another drug for your medical condition. For example, if Drug A and Drug B both treat your medical condition, MHS may not cover Drug B unless you try Drug A first. SP Specialty Certain medications are only covered when Pharmacy supplied by MHS’ specialty pharmacy provider.

0818.PH.O.FL 9/18 1-877-647-4848 l TTY/TDD: 1-800-743-3333 l mhsindiana.com Allwell from MHS l Ambetter from MHS l Healthy Indiana Plan (HIP) l Hoosier Care Connect l Hoosier Healthwise Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(3 ea daily); OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine tabs AL(At least 3 ADHD, Sleep and Eating Disorders 1.875 mg-1.875 mg-1.875 yrs old) mg-1.875 mg, 3.125 mg- Amphetamines 3.125 mg-3.125 mg-3.125 ADDERALL TABS (Use QL(3 ea daily); mg, 3.75 mg-3.75 mg-3.75 1 amphetamine- NP AL(At least 3 mg-3.75 mg, 1.25 mg-1.25 dextroamphetamine) yrs old) mg-1.25 mg-1.25 mg, 2.5 ADDERALL XR CP24 1.25 QL(1 ea daily); mg-2.5 mg-2.5 mg-2.5 mg, MG-1.25 MG-1.25 MG-1.25 AL(At least 6 5 mg-5 mg-5 mg-5 mg, 7.5 MG, 2.5 MG-2.5 MG-2.5 yrs old) mg-7.5 mg-7.5 mg-7.5 mg MG-2.5 MG, 3.75 MG-3.75 NP DESOXYN TABS (Use NP AL(At least 6 MG-3.75 MG-3.75 MG methamphetamine hcl) yrs old) (Use amphetamine- DEXEDRINE CP24 (Use QL(2 ea daily); dextroamphetamine) dextroamphetamine NP AL(At least 6 ADDERALL XR CP24 5 QL(2 ea daily); sulfate) yrs old) MG-5 MG-5 MG-5 MG, AL(At least 6 QL(2 ea daily); 6.25 MG-6.25 MG-6.25 yrs old) dextroamphetamine sulfate 1 AL(At least 6 cp24 10 mg, 15 mg, 5 mg MG-6.25 MG, 7.5 MG-7.5 NP yrs old) MG-7.5 MG-7.5 MG (Use amphetamine- QL(40 ml dextroamphetamine sulfate 1 daily); AL(At dextroamphetamine) soln 5 mg/5ml least 3 yrs old) QL(16 ml ADZENYS ER SUER (Use NP daily); AL(At QL(4 ea daily); amphetamine) dextroamphetamine sulfate 1 AL(At least 3 least 6 yrs old) tabs 10 mg yrs old) QL(1 ea daily); ADZENYS XR-ODT TBED 2 AL(At least 6 QL(1 ea daily); dextroamphetamine sulfate 1 AL(At least 3 yrs old) tabs 15 mg, 2.5 mg, 5 mg yrs old) QL(16 ml amphetamine suer 1 daily); AL(At QL(2 ea daily); dextroamphetamine sulfate 1 AL(At least 3 least 6 yrs old) tabs 20 mg, 30 mg, 7.5 mg yrs old) QL(6 ea daily); amphetamine sulfate tabs 1 AL(At least 3 QL(8 ml daily); 10 mg yrs old) DYANAVEL XR SUER 2 AL(At least 6 yrs old) QL(2 ea daily); amphetamine sulfate tabs 1 AL(At least 3 QL(2 ea daily); 5 mg yrs old) EVEKEO ODT TBDP 2 AL(At least 6 yrs old) amphetamine- QL(1 ea daily); dextroamphetamine cp24 AL(At least 6 EVEKEO TABS 10 MG QL(6 ea daily); NP AL(At least 3 1.25 mg-1.25 mg-1.25 mg- 1 yrs old) (Use amphetamine sulfate) 1.25 mg, 2.5 mg-2.5 mg- yrs old) 2.5 mg-2.5 mg, 3.75 mg- QL(2 ea daily); EVEKEO TABS 5 MG (Use NP 3.75 mg-3.75 mg-3.75 mg amphetamine sulfate) AL(At least 3 amphetamine- QL(2 ea daily); yrs old) AL(At least 6 dextroamphetamine cp24 5 AL(At least 6 methamphetamine hcl tabs 1 yrs old) mg-5 mg-5 mg-5 mg, 6.25 1 yrs old) mg-6.25 mg-6.25 mg-6.25 mg, 7.5 mg-7.5 mg-7.5 mg- 7.5 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYDAYIS CP24 12.5 MG- QL(1 ea daily); QL(2 ea daily); 12.5 MG-12.5 MG-12.5 2 AL(At least 18 WAKIX TABS 2 AL(At least 18 MG, 9.375 MG-9.375 MG- yrs old) yrs old) 9.375 MG-9.375 MG Stimulants - Misc. MYDAYIS CP24 3.125 QL(1 ea daily); QL(1 ea daily); MG-3.125 MG-3.125 MG- 2 AL(At least 13 2 3.125 MG, 6.25 MG-6.25 yrs old) ADHANSIA XR CP24 AL(At least 6 yrs old) MG-6.25 MG-6.25 MG QL(1 ea daily); QL(1 ea daily); APTENSIO XR CP24 (Use NP AL(At least 6 VYVANSE CAPS 2 AL(At least 6 methylphenidate hcl) yrs old) yrs old) QL(1 ea daily); QL(1 ea daily); armodafinil tabs 200 mg, 1 AL(At least 18 VYVANSE CHEW 2 AL(At least 6 150 mg, 250 mg yrs old) yrs old) QL(2 ea daily); Analeptics armodafinil tabs 50 mg 1 AL(At least 18 CAFCIT SOLN (Use NP QL(45 ml per yrs old) caffeine citrate) fill retail) CONCERTA TBCR 18 MG, QL(1 ea daily); QL(45 ml per 27 MG ( NP caffeine citrate soln 1 Use AL(At least 6 fill retail) methylphenidate hcl) yrs old) DOPRAM SOLN 2 CONCERTA TBCR 36 MG, QL(2 ea daily); 54 MG (Use NP AL(At least 6 Attention-Deficit/Hyperactivity Disorder (ADHD) methylphenidate hcl) yrs old) atomoxetine hcl caps 10 QL(2 ea daily) QL(2 ea daily); 1 COTEMPLA XR-ODT 2 mg, 18 mg, 25 mg, 40 mg TBED 17.3 MG, 25.9 MG AL(At least 6 yrs old) atomoxetine hcl caps 100 1 QL(1 ea daily) mg, 60 mg, 80 mg QL(1 ea daily); COTEMPLA XR-ODT 2 TBED 8.6 MG AL(At least 6 clonidine hcl (adhd) tb12 1 QL(4 ea daily) yrs old) QL(1 ea daily) QL(1 ea daily); guanfacine hcl (adhd) tb24 1 DAYTRANA PTCH 2 AL(At least 6 yrs old) INTUNIV TB24 (Use NP QL(1 ea daily) guanfacine hcl (adhd)) dexmethylphenidate hcl QL(1 ea daily); cp24 35 mg, 40 mg, 10 mg, AL(At least 6 KAPVAY TB12 (Use NP QL(4 ea daily) 1 clonidine hcl (adhd)) 15 mg, 20 mg, 25 mg, 30 yrs old) mg, 5 mg STRATTERA CAPS 10 QL(2 ea daily) MG, 18 MG, 25 MG, 40 MG NP QL(4 ea daily); dexmethylphenidate hcl 1 AL(At least 3 (Use atomoxetine hcl) tabs 10 mg yrs old) STRATTERA CAPS 100 QL(1 ea daily) MG, 60 MG, 80 MG (Use NP QL(2 ea daily); dexmethylphenidate hcl 1 AL(At least 3 atomoxetine hcl) tabs 2.5 mg, 5 mg yrs old) Dopamine and Norepinephrine Reuptake FOCALIN TABS 10 MG QL(4 ea daily); QL(1 ea daily); (Use dexmethylphenidate NP AL(At least 3 SUNOSI TABS 2 AL(At least 18 hcl) yrs old) yrs old) FOCALIN TABS 2.5 MG, 5 QL(2 ea daily); Histamine H3-Receptor Antagonist/Inverse MG (Use NP AL(At least 3 dexmethylphenidate hcl) yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); METHYLPHENIDATE QL(1 ea daily); FOCALIN XR CP24 (Use NP 2 dexmethylphenidate hcl) AL(At least 6 HYDROCHLORIDE ER AL(At least 6 yrs old) TBCR yrs old) QL(1 ea daily); QL(1 ea daily); JORNAY PM CP24 2 AL(At least 6 modafinil tabs 100 mg 1 AL(At least 6 yrs old) yrs old) METHYLIN SOLN 10 QL(30 ml QL(2 ea daily); MG/5ML (Use NP daily); AL(At modafinil tabs 200 mg 1 AL(At least 6 methylphenidate hcl) least 3 yrs old) yrs old) METHYLIN SOLN 5 QL(60 ml NUVIGIL TABS 200 MG, QL(1 ea daily); MG/5ML (Use NP daily); AL(At 150 MG, 250 MG (Use NP AL(At least 18 methylphenidate hcl) least 3 yrs old) armodafinil) yrs old) QL(3 ea daily); QL(2 ea daily); methylphenidate hcl chew 1 AL(At least 3 NUVIGIL TABS 50 MG NP AL(At least 18 10 mg, 2.5 mg, 5 mg (Use armodafinil) yrs old) yrs old) methylphenidate hcl cp24 QL(1 ea daily); PROVIGIL TABS 100 MG QL(1 ea daily); 1 AL(At least 6 NP 10 mg, 15 mg, 20 mg, 30 (Use modafinil) AL(At least 6 mg, 40 mg, 50 mg, 60 mg yrs old) yrs old) QL(2 ea daily); QL(2 ea daily); methylphenidate hcl cp24 1 AL(At least 6 PROVIGIL TABS 200 MG NP AL(At least 6 30 mg (Use modafinil) yrs old) yrs old) methylphenidate hcl cpcr QL(1 ea daily); QL(1 ea daily); 40 mg, 10 mg, 20 mg, 30 1 AL(At least 6 QUILLICHEW ER CHER 2 20 MG, 40 MG AL(At least 6 mg, 50 mg, 60 mg yrs old) yrs old) QL(30 ml methylphenidate hcl soln QL(2 ea daily); 1 daily); AL(At QUILLICHEW ER CHER 2 AL(At least 6 10 mg/5ml 30 MG least 3 yrs old) yrs old) QL(60 ml methylphenidate hcl soln 5 QL(12 ml 1 daily); AL(At QUILLIVANT XR SRER 2 daily); AL(At mg/5ml least 3 yrs old) least 6 yrs old) QL(3 ea daily); methylphenidate hcl tabs QL(1 ea daily); 1 AL(At least 3 RELEXXII TBCR 2 AL(At least 6 10 mg, 20 mg, 5 mg yrs old) yrs old) QL(1 ea daily); RITALIN LA CP24 10 MG, QL(1 ea daily); methylphenidate hcl tb24 1 AL(At least 6 NP 18 mg, 27 mg 20 MG, 40 MG (Use AL(At least 6 yrs old) methylphenidate hcl) yrs old) QL(2 ea daily); QL(2 ea daily); methylphenidate hcl tb24 1 AL(At least 6 RITALIN LA CP24 30 MG NP AL(At least 6 36 mg, 54 mg (Use methylphenidate hcl) yrs old) yrs old) QL(3 ea daily); QL(3 ea daily); methylphenidate hcl tbcr 10 1 AL(At least 6 RITALIN TABS (Use NP mg, 20 mg methylphenidate hcl) AL(At least 3 yrs old) yrs old) QL(1 ea daily); methylphenidate hcl tbcr 18 1 AL(At least 6 ALLERGENIC EXTRACTS/BIOLOGICALS MISC mg, 27 mg yrs old) Allergenic Extracts QL(2 ea daily); methylphenidate hcl tbcr 36 1 AL(At least 6 mg, 54 mg yrs old) MHS Indiana Preferred Drug List Updated June 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); AMINOGLYCOSIDES - Drugs to Treat Bacterial ORALAIR ADULT SAMPLE 2 AL(At least 10 Infections KIT SUBL yrs old - Up to 65 yrs old) Aminoglycosides QL(1 ea daily); ARIKAYCE SUSP 2 PA ORALAIR ADULT 2 AL(At least 10 STARTER PACK SUBL yrs old - Up to BETHKIS NEBU (Use NP PA; SP 65 yrs old) tobramycin) QL(3 ea daily); KITABIS PAK NEBU (Use NP PA; SP ORALAIR tobramycin) 2 AL(At least 10 CHILDREN/ADOLESCENT yrs old - Up to S STARTER PACK SUBL 1 65 yrs old) neomycin sulfate tabs QL(1 ea daily); TOBI NEBU (Use NP PA; SP AL(At least 10 tobramycin) ORALAIR SUBL 2 yrs old - Up to PA; SP 65 yrs old) TOBI PODHALER CAPS 2 PA; SP ALTERNATIVE MEDICINES tobramycin nebu 1 Alternative Medicine - M's tobramycin sulfate soln 1 PA CVS MELATONIN CHEW 2 tobramycin sulfate solr 1 PA CVS MELATONIN 2 GUMMIES CHEW ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint MELATONIN CAPS OR 1 2 MG, 3 MG Conditions Anti-TNF-alpha - Monoclonal Antibodies melatonin caps or 3 mg, 5 1 mg, 10 mg HUMIRA PEDIATRIC PA; SP CROHNS DISEASE 2 melatonin chew or 2.5 mg 1 STARTER PACK PSKT PA; SP MELATONIN CHEW OR 5 2 HUMIRA PEN PNKT 2 MG HUMIRA PEN-CD/UC/HS PA; SP MELATONIN EXTRA 2 2 STRENGTH CHEW STARTER PNKT MELATONIN LIQD OR 1 HUMIRA PEN-PEDIATRIC PA; SP MG/4ML, 2.5 MG/10ML, 5 2 UC STARTER PACK 2 MG/ML PNKT HUMIRA PEN-PS/UV PA; SP melatonin liqd or 1 mg/ml, 1 2 5 mg/15ml STARTER PNKT PA; SP MELATONIN TABS OR 2 HUMIRA PSKT 2 200 MCG PA; SP melatonin tabs or 3 mg, 5 1 QL(1 ea daily) SIMPONI ARIA SOLN 2 mg SIMPONI SOAJ 2 PA; SP melatonin tabs or 300 mcg, 1 1 mg, 10 mg SIMPONI SOSY 2 PA; SP SLEEP SOUNDLY LIQD 2 Antirheumatic - Enzyme Inhibitors

MHS Indiana Preferred Drug List Updated June 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XELJANZ TABS 10 MG, 5 2 PA; SP diclofenac sodium tb24 1 MG XELJANZ XR TB24 2 PA; SP diclofenac sodium tbec 1 Antirheumatic Antimetabolites EC-NAPROSYN TBEC NP QL(2 ea daily) (Use naproxen) METHOTREXATE TABS 2 etodolac caps 1 OTREXUP SOAJ 2 PA; SP etodolac tabs 1 RASUVO SOAJ 2 PA; SP etodolac tb24 1 Interleukin-1 Blockers FELDENE CAPS (Use NP ARCALYST SOLR 2 PA; SP piroxicam) flurbiprofen tabs 1 Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY 2 PA; SP ibuprofen chew 100 mg 1 Interleukin-6 Receptor Inhibitors ibuprofen susp 100 mg/5ml 1 RX/OTC ACTEMRA SOLN 2 PA; SP ibuprofen susp 40 mg/ml, 1 50 mg/1.25ml ACTEMRA SOSY 2 PA; SP ibuprofen tabs 400 mg, 600 1 mg, 800 mg, 200 mg KEVZARA SOAJ 2 PA indomethacin caps 25 mg, 1 50 mg KEVZARA SOSY 2 PA indomethacin cpcr 75 mg 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) INFANTS ADVIL SUSP ADVIL TABS (Use NP NP ibuprofen) (Use ibuprofen) ketoprofen caps 50 mg, 75 ALEVE ARTHRITIS TABS NP QL(2 ea daily) 1 (Use naproxen sodium) mg ketoprofen cp24 200 mg 1 ALEVE TABS (Use NP QL(2 ea daily) naproxen sodium) QL(0.67 ea CELEBREX CAPS (Use QL(2 ea daily) NP ketorolac tromethamine 1 daily); AL(At celecoxib) tabs or 10 mg least 17 yrs celecoxib caps 1 QL(2 ea daily) old) LODINE TABS (Use NP CHILDRENS ADVIL SUSP NP RX/OTC etodolac) (Use ibuprofen) meloxicam tabs 15 mg, 7.5 1 CHILDRENS MOTRIN NP RX/OTC mg SUSP (Use ibuprofen) MOBIC TABS (Use NP DAYPRO TABS (Use NP meloxicam) oxaprozin) MOTRIN CHILDRENS NP diclofenac potassium tabs 1 CHEW (Use ibuprofen)

MHS Indiana Preferred Drug List Updated June 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOTRIN INFANTS ENBREL SOLR 25 MG 2 PA; SP DROPS SUSP (Use NP ibuprofen) ENBREL SOSY 25 2 PA; SP MG/0.5ML, 50 MG/ML nabumetone tabs 1 ENBREL SURECLICK 2 PA; SP NAPROSYN SUSP (Use NP SOAJ naproxen) ANALGESICS - NonNarcotic - Drugs to Treat NAPROSYN TABS (Use NP Pain, Muscle and Joint Conditions naproxen) Analgesic Combinations naproxen sodium tabs 220 1 QL(2 ea daily) mg aspirin-acetaminophen- 1 caffeine tabs naproxen sodium tabs 550 1 mg, 275 mg butalbital-acetaminophen 1 tabs 325 mg-50 mg naproxen susp 125 mg/5ml 1 butalbital-acetaminophen- QL(4 ea daily) caffeine caps 325 mg-40 1 naproxen tabs 250 mg, 375 1 mg, 500 mg mg-50 mg butalbital-acetaminophen- QL(4 ea daily) naproxen tbec 375 mg, 500 1 QL(2 ea daily) mg caffeine tabs 325 mg-40 1 mg-50 mg oxaprozin tabs 1 butalbital-aspirin-caffeine 1 QL(4 ea daily) caps piroxicam caps 1 BUTALBITAL/ACETAMINO PHEN CAPS (Use NF sulindac tabs 1 butalbital-acetaminophen) Phosphodiesterase 4 (PDE4) Inhibitors BUTALBITAL/ASPIRIN/CA 2 QL(4 ea daily) FFEINE TABS PA; SP OTEZLA TABS 2 ESGIC TABS (Use QL(4 ea daily) PA; SP butalbital-acetaminophen- NP OTEZLA TBPK 2 caffeine) Pyrimidine Synthesis Inhibitors EXCEDRIN EXTRA STRENGTH TABS (Use NP ARAVA TABS (Use NP QL(1 ea daily) aspirin-acetaminophen- leflunomide) caffeine) leflunomide tabs 1 QL(1 ea daily) EXCEDRIN MIGRAINE TABS (Use aspirin- NP Selective Costimulation Modulators acetaminophen-caffeine) ORENCIA CLICKJECT PA; SP 2 FIORINAL CAPS (Use NP QL(4 ea daily) SOAJ butalbital-aspirin-caffeine) ORENCIA SOLR IV 250 2 PA; SP Analgesics Other MG acetaminophen caps or 1 ORENCIA SOSY SC 125 2 PA; SP 500 mg MG/ML acetaminophen chew or 80 1 Soluble Tumor Necrosis Factor Receptor Agents mg, 160 mg PA; SP ENBREL MINI SOCT 2 acetaminophen liqd or 160 1 mg/5ml

MHS Indiana Preferred Drug List Updated June 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acetaminophen soln or 100 1 QL(30 ml per aspirin tabs or 325 mg $0 PV mg/ml fill retail) acetaminophen soln or 160 aspirin tbec or 325 mg, 81 $0 PV mg/5ml, 325 mg/10.15ml, 1 mg 650 mg/20.3ml BUFFERIN TABS (Use aspirin buffered (cal carb- NP acetaminophen supp re 1 QL(0.4 ea 650 mg, 120 mg daily) mag carb-mag oxide)) acetaminophen susp or QL(240 ml per diflunisal tabs 1 160 mg/5ml, 650 1 fill retail) mg/20.3ml, 80 mg/2.5ml ECOTRIN REGULAR PV STRENGTH TBEC (Use NP acetaminophen tabs or 325 1 mg, 500 mg aspirin) ECOTRIN TBEC (Use PV FEVERALL INFANTS 2 NP SUPP aspirin) FEVERALL JUNIOR 2 QL(0.4 ea salsalate tabs 1 STRENGTH SUPP daily) ANALGESICS - OPIOID - Drugs to Treat Pain, NORTEMP INFANTS 2 SUSP Muscle and Joint Conditions TYLENOL CHILDRENS Opioid Agonists CHEWABLES/PAIN + NP CODEINE SULFATE TABS 2 AL(At least 12 FEVER CHEW (Use 15 MG, 60 MG yrs old) acetaminophen) AL(At least 12 codeine sulfate tabs 30 mg 1 TYLENOL CHILDRENS QL(240 ml per yrs old) SUSP (Use NP fill retail) CONZIP CP24 (Use NF acetaminophen) tramadol hcl) TYLENOL EXTRA DILAUDID SOLN IJ 1 STRENGTH TABS (Use NP MG/ML, 2 MG/ML (Use NF acetaminophen) hydromorphone hcl) TYLENOL INFANTS QL(240 ml per DILAUDID TABS OR 2 MG NP QL(8 ea daily) PAIN+FEVER SUSP (Use NP fill retail) (Use hydromorphone hcl) acetaminophen) DILAUDID TABS OR 4 MG NP TYLENOL INFANTS SUSP NP QL(240 ml per (Use hydromorphone hcl) (Use acetaminophen) fill retail) DILAUDID TABS OR 8 MG NP QL(4 ea daily) TYLENOL TABS (Use NP (Use hydromorphone hcl) acetaminophen) DOLOPHINE TABS (Use NP PA Analgesics-Peptide Channel Blockers methadone hcl) PA; SP PRIALT SOLN 2 DURAGESIC PT72 (Use NP QL(0.34 ea fentanyl) daily) Salicylates fentanyl pt72 td 100 QL(0.34 ea mcg/hr, 12 mcg/hr, 25 daily) aspirin buffered (cal carb- 1 1 mag carb-mag oxide) tabs mcg/hr, 50 mcg/hr, 75 mcg/hr aspirin chew or 81 mg $0 PV FENTORA TABS (Use NF fentanyl citrate) ASPIRIN SUPP RE 300 2 QL(0.4 ea MG, 600 MG daily) HYDROMORPHONE HCL 2 QL(2 ea daily) SUPP RE 3 MG

MHS Indiana Preferred Drug List Updated June 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydromorphone hcl tabs or 1 QL(8 ea daily) oxycodone hcl conc 100 1 QL(120 ml per 2 mg mg/5ml fill retail) hydromorphone hcl tabs or 1 oxycodone hcl soln 5 1 QL(30 ml daily) 4 mg mg/5ml hydromorphone hcl tabs or 1 QL(4 ea daily) oxycodone hcl tabs 10 mg, 1 QL(6 ea daily) 8 mg 20 mg, 15 mg, 30 mg meperidine hcl soln or 50 1 oxycodone hcl tabs 5 mg 1 QL(8 ea daily) mg/5ml ROXICODONE TABS 15 QL(6 ea daily) meperidine hcl tabs or 100 1 QL(6 ea daily) mg MG, 30 MG (Use NP oxycodone hcl) meperidine hcl tabs or 50 1 QL(12 ea daily) mg ROXICODONE TABS 5 NP QL(8 ea daily) MG (Use oxycodone hcl) methadone hcl tabs or 5 1 PA mg, 10 mg QL(8 ea daily); MORPHINE SULFATE tramadol hcl tabs 50 mg 1 AL(At least 18 SOLN IV 10 MG/ML (Use NF yrs old) morphine sulfate) ULTRAM TABS ( QL(8 ea daily); Use NP AL(At least 18 morphine sulfate soln or 10 1 QL(30 ml daily) tramadol hcl) mg/5ml yrs old) Opioid Combinations morphine sulfate soln or 1 QL(240 ml per 100 mg/5ml, 20 mg/ml fill retail) QL(167 ml acetaminophen w/ codeine morphine sulfate soln or 20 QL(15 ml daily) 1 daily); AL(At 1 soln 12 mg/5ml-120 least 12 yrs mg/5ml mg/5ml old) morphine sulfate supp re QL(6 ea daily) 1 QL(13 ea 10 mg acetaminophen w/ codeine 1 daily); AL(At morphine sulfate supp re 1 QL(3 ea daily) tabs 15 mg-300 mg, 30 mg- least 12 yrs 20 mg 300 mg old) morphine sulfate supp re 1 QL(2 ea daily) QL(7 ea daily); 30 mg acetaminophen w/ codeine 1 AL(At least 12 tabs 300 mg-60 mg morphine sulfate supp re 5 1 QL(12 ea daily) yrs old) mg butalbital-acetaminophen- QL(4 ea daily); morphine sulfate tabs or 15 QL(6 ea daily) 1 caffeine w/ codeine caps 1 AL(At least 12 mg, 30 mg 30 mg-325 mg-40 mg-50 yrs old) morphine sulfate tbcr or QL(3 ea daily) mg 100 mg, 15 mg, 200 mg, 30 1 QL(4 ea daily); mg, 60 mg butalbital-aspirin-caffeine 1 AL(At least 12 w/cod caps yrs old) MS CONTIN TBCR (Use NP QL(3 ea daily) morphine sulfate) FIORINAL/CODEINE #3 QL(4 ea daily); NUCYNTA ER TB12 2 PA CAPS (Use butalbital- NP AL(At least 12 aspirin-caffeine w/cod) yrs old) NUCYNTA TABS 2 PA hydrocodone- QL(180 ml acetaminophen soln 108 daily) OXAYDO TABS 5 MG 2 QL(8 ea daily) mg/5ml-2.5 mg/5ml, 217 1 mg/10ml-5 mg/10ml, 325 oxycodone hcl caps 5 mg 1 QL(8 ea daily) mg/15ml-7.5 mg/15ml

MHS Indiana Preferred Drug List Updated June 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone- QL(6 ea daily) buprenorphine hcl subl sl 2 1 QL(3 ea daily) acetaminophen tabs 10 1 mg, 8 mg mg-325 mg buprenorphine hcl- hydrocodone- QL(12 ea daily) naloxone hcl dihydrate film 1 acetaminophen tabs 325 1 0.5 mg-2 mg, 1 mg-4 mg, mg-5 mg 12 mg-3 mg, 2 mg-8 mg hydrocodone- QL(8 ea daily) buprenorphine hcl- QL(3 ea daily) acetaminophen tabs 325 1 naloxone hcl dihydrate subl 1 mg-7.5 mg 0.5 mg-2 mg, 2 mg-8 mg NORCO TABS 10 MG-325 QL(6 ea daily) PROBUPHINE IMPLANT 2 PA; SP MG (Use hydrocodone- NP KIT IMPL acetaminophen) SUBOXONE FILM (Use NORCO TABS 325 MG-5 QL(12 ea daily) buprenorphine hcl- NP MG (Use hydrocodone- NP naloxone hcl dihydrate) acetaminophen) ZUBSOLV SUBL 2 QL(1 ea daily) NORCO TABS 325 MG-7.5 QL(8 ea daily) MG (Use hydrocodone- NP ANDROGENS-ANABOLIC - Drugs to Regulate acetaminophen) Hormones oxycodone w/ QL(6 ea daily) Androgens acetaminophen tabs 10 1 mg-325 mg, 325 mg-7.5 ANDRODERM PT24 2 QL(1 ea daily) mg oxycodone w/ QL(8 ea daily) ANDROGEL GEL 25 acetaminophen tabs 325 1 MG/2.5GM, 50 MG/5GM NF mg-5 mg (Use testosterone) QL(6 ea daily) danazol caps 100 mg, 50 1 QL(2 ea daily) oxycodone-aspirin tabs 1 mg PERCOCET TABS 10 MG- QL(6 ea daily) danazol caps 200 mg 1 QL(4 ea daily) 325 MG, 325 MG-7.5 MG NP (Use oxycodone w/ DEPO-TESTOSTERONE QL(0.134 ml acetaminophen) SOLN 200 MG/ML (Use NP daily) PERCOCET TABS 325 QL(8 ea daily) testosterone cypionate) MG-5 MG (Use oxycodone NP METHITEST TABS 2 w/ acetaminophen) QL(8 ea daily); TESTIM GEL (Use NF tramadol-acetaminophen 1 AL(At least 18 testosterone) tabs yrs old) testosterone cypionate soln 1 QL(0.134 ml im 200 mg/ml daily) TYLENOL/CODEINE #3 QL(13 ea NP daily); AL(At VOGELXO GEL (Use NF TABS (Use acetaminophen ) w/ codeine) least 12 yrs testosterone old) VOGELXO PUMP GEL NF TYLENOL/CODEINE #4 QL(7 ea daily); (Use testosterone) TABS (Use acetaminophen NP AL(At least 12 w/ codeine) yrs old) ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching QL(8 ea daily); ULTRACET TABS (Use NP Intrarectal Steroids tramadol-acetaminophen) AL(At least 18 yrs old) CORTENEMA ENEM (Use NP hydrocortisone (intrarectal)) Opioid Partial Agonists MHS Indiana Preferred Drug List Updated June 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone (intrarectal) 1 alum & mag hydrox- QL(24 ml daily) enem simethicone susp 0.2 %-40 mg/10ml-400 mg/10ml-400 Rectal Combinations mg/10ml, 120 mg/30ml- phenylephrine in hard fat 1 1200 mg/30ml-1200 1 supp mg/30ml, 20 mg/5ml-20 mg/5ml-200 mg/5ml-200 phenylephrine-cocoa butter 1 supp 0.25 %-88.44 % mg/5ml-200 mg/5ml-200 mg/5ml phenylephrine-mineral oil- 1 petrolatum oint alum & mag hydrox- simethicone susp 240 phenylephrine-shark liver 1 oil-cocoa butter supp mg/30ml-2400 mg/30ml- 2400 mg/30ml, 40 mg/5ml- 1 phenylephrine-shark liver QL(1 gm daily) 40 mg/5ml-400 mg/5ml-400 oil-mineral oil-petrolatum 1 mg/5ml-400 mg/5ml-400 oint mg/5ml, 80 mg/10ml-800 PREPARATION H OINT mg/10ml-800 mg/10ml RE 0.25 %-14 %-74.9 % NP aluminum hydroxide-mag 1 (Use phenylephrine- carb chew mineral oil-petrolatum) aluminum hydroxide-mag 1 Rectal Local Anesthetics carb susp dibucaine (rectal) oint 1 QL(1 gm daily) calcium carbonate-mag hydrox susp 135 mg/5ml- 1 NUPERCAINAL OINT (Use NP QL(1 gm daily) 400 mg/5ml dibucaine (rectal)) GAVISCON EXTRA Rectal Steroids STRENGTH CHEW (Use NP aluminum hydroxide-mag ANUSOL-HC CREA (Use NP hydrocortisone (rectal)) carb) GAVISCON EXTRA hydrocortisone (rectal) crea 1 2.5 % STRENGTH RELIEF FORMULA SUSP (Use NP ANTACIDS aluminum hydroxide-mag carb) Antacid Combinations GAVISCON EXTRA alum & mag hydrox- STRENGTH SUSP (Use NP simethicone chew 200 mg- 1 aluminum hydroxide-mag 200 mg-25 mg carb) alum & mag hydrox- QL(24 ml daily) GAVISCON SUSP 358 simethicone liqd 20 1 MG/15ML-358 MG/15ML- mg/5ml-200 mg/5ml-200 95 MG/15ML-95 MG/15ML NP mg/5ml (Use aluminum hydroxide- alum & mag hydrox- mag carb) simethicone liqd 40 1 GELUSIL CHEW (Use mg/5ml-400 mg/5ml-400 alum & mag hydrox- NP mg/5ml simethicone)

MHS Indiana Preferred Drug List Updated June 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYVEE ADVANCED QL(12 ea ANTACID MAXIMUM BILTRICIDE TABS (Use NP daily)1 rtl MAX STRENGTH SUSP (Use NP praziquantel) fill,30 rtl day(s) alum & mag hydrox- supply, simethicone) QL(1 ea per 14 EMVERM CHEW 2 Antacids - Aluminum Salts days retail) QL(8 ea daily)1 ALUMINUM HYDROXIDE 2 SUSP OR ivermectin tabs 1 rtl MAX fill,30 rtl day(s) supply, Antacids - Bicarbonate QL(12 ea sodium bicarbonate QL(16.54 ea 1 1 daily)1 rtl MAX (antacid) tabs daily) praziquantel tabs fill,30 rtl day(s) Antacids - Calcium Salts supply, calcium carbonate QL(8 ea daily)1 STROMECTOL TABS (Use NP (antacid) chew 1000 mg, 1 ivermectin) rtl MAX fill,30 rtl 500 mg, 750 mg day(s) supply, calcium carbonate QL(16.67 ml ANTI-INFECTIVE AGENTS - MISC. - Drugs to (antacid) susp 1250 1 daily) Treat Bacterial Infections mg/5ml Anti-infective Agents - Misc. TUMS CHEW (Use calcium NP carbonate (antacid)) AEMCOLO TBEC 2 PA TUMS CHEWY BITES FLAGYL TABS 500 MG NP CHEW (Use calcium NP (Use metronidazole) carbonate (antacid)) METRONIDAZOLE QL(150 ml per TUMS E-X 750 CHEW BENZOATE/SYRSPEND 2 fill retail) (Use calcium carbonate NP SF PH4 SUSR (antacid)) metronidazole tabs or 250 1 TUMS EXTRA STRENGTH mg, 500 mg 750 CHEW (Use calcium NP carbonate (antacid)) trimethoprim tabs 1 TUMS LASTING EFFECTS CHEW (Use calcium NP Anti-infective Misc. - Combinations carbonate (antacid)) BACTRIM DS TABS (Use TUMS SMOOTHIES sulfamethoxazole- NP CHEW (Use calcium NP trimethoprim) carbonate (antacid)) BACTRIM TABS (Use TUMS ULTRA 1000 CHEW sulfamethoxazole- NP (Use calcium carbonate NP trimethoprim) (antacid)) methenamine-hyosc- methylene blue-sod phos- Antacids - Magnesium Salts phenyl sal tabs 0.12 mg- 1 magnesium oxide tabs 400 1 10.8 mg-36.2 mg-40.8 mg- mg 81.6 mg ANTHELMINTICS - Drugs to Treat Worm sulfamethoxazole- Infections trimethoprim susp or 200 1 mg/5ml-40 mg/5ml Anthelmintics

MHS Indiana Preferred Drug List Updated June 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfamethoxazole- MACROBID CAPS (Use trimethoprim tabs or 160 1 nitrofurantoin monohyd NP mg-800 mg, 400 mg-80 mg macro) Cyclic Lipopeptides MACRODANTIN CAPS 100 MG, 50 MG (Use NP DAPTOMYCIN SOLR 350 NF ) MG (Use daptomycin) nitrofurantoin macrocrystal methenamine mandelate 1 Glycopeptides tabs QL(300 ml per FIRVANQ SOLR 2 nitrofurantoin macrocrystal 1 fill retail) caps 100 mg, 50 mg VANCOCIN CAPS (Use QL(8 ea daily) NP nitrofurantoin monohyd 1 vancomycin hcl) macro caps VANCOCIN HCL CAPS NP QL(4 ea daily) QL(40 ml daily) (Use vancomycin hcl) nitrofurantoin susp 1 vancomycin hcl caps or 1 QL(4 ea daily) ANTIANGINAL AGENTS - Drugs to Treat Chest 125 mg Pain vancomycin hcl caps or 1 QL(8 ea daily) 250 mg Nitrates ISORDIL TITRADOSE vancomycin hcl solr iv 1 1 QL(14 ea per gm, 1000 mg fill retail) TABS 5 MG (Use NP isosorbide dinitrate) vancomycin hcl solr iv 500 1 QL(0.467 ea mg daily) isosorbide dinitrate tabs 30 1 mg, 10 mg, 20 mg, 5 mg VANCOMYCIN QL(300 ml per HYDROCHLORIDE SOLR 2 fill retail) isosorbide dinitrate tbcr 40 1 OR 250 MG/5ML mg isosorbide mononitrate tabs 1 QL(2 ea daily) Leprostatics 10 mg, 20 mg dapsone tabs 1 isosorbide mononitrate 1 QL(1 ea daily) tb24 120 mg, 30 mg, 60 mg Lincosamides NITRO-BID OINT 2 CLEOCIN CAPS OR 150 MG, 300 MG (Use NP NITRO-DUR PT24 0.1 clindamycin hcl) MG/HR, 0.2 MG/HR, 0.4 NP CLEOCIN PEDIATRIC QL(300 ml per MG/HR, 0.6 MG/HR (Use nitroglycerin) GRANULES SOLR (Use NP fill retail) clindamycin palmitate nitroglycerin cpcr or 2.5 1 hydrochloride) mg, 6.5 mg, 9 mg clindamycin hcl caps 150 1 nitroglycerin pt24 td 0.1 mg, 300 mg mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr clindamycin palmitate 1 QL(300 ml per hydrochloride solr fill retail) nitroglycerin subl sl 0.3 mg, 1 Oxazolidinones 0.4 mg, 0.6 mg NITROSTAT SUBL (Use SIVEXTRO TABS OR 2 PA; QL(6 ea NP per fill retail) nitroglycerin) Urinary Anti-infectives ANTIANXIETY AGENTS - Drugs to Treat Anxiety FURADANTIN SUSP (Use NP QL(40 ml daily) Antianxiety Agents - Misc. nitrofurantoin) MHS Indiana Preferred Drug List Updated June 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits buspirone hcl tabs or 10 1 QL(4 ea daily) diazepam conc or 5 mg/ml 1 QL(8 ml daily) mg DIAZEPAM SOAJ IM 10 buspirone hcl tabs or 30 1 QL(2 ea daily) 2 mg MG/2ML DIAZEPAM SOLN IJ 5 buspirone hcl tabs or 5 mg, 1 QL(3 ea daily) 2 7.5 mg, 15 mg MG/ML diazepam soln ij 5 mg/ml, 1 DROPERIDOL POWD XX 2 50 mg/10ml droperidol soln ij 1 diazepam soln or 5 mg/5ml 1 hydroxyzine hcl soln im 25 1 diazepam tabs or 10 mg, 2 1 QL(4 ea daily) mg/ml, 50 mg/ml mg, 5 mg hydroxyzine hcl syrp or 10 1 QL(100 ml lorazepam conc or 2 mg/ml 1 mg/5ml daily) lorazepam soln ij 4 mg/ml, hydroxyzine hcl tabs or 10 1 QL(4 ea daily) 1 mg, 25 mg 2 mg/ml, 20 mg/10ml lorazepam tabs or 0.5 mg, QL(4 ea daily) hydroxyzine hcl tabs or 50 1 QL(8 ea daily) 1 mg 1 mg, 2 mg QL(4 ea daily) hydroxyzine pamoate caps 1 QL(4 ea daily) oxazepam caps 1 or 100 mg, 25 mg, 50 mg TRANXENE T TABS (Use QL(4 ea daily) HYDROXYZINE 2 NP PAMOATE POWD XX clorazepate dipotassium) QL(4 ea daily) VALIUM TABS (Use NP QL(4 ea daily) meprobamate tabs 1 diazepam) XANAX TABS (Use QL(4 ea daily) VISTARIL CAPS (Use NP QL(4 ea daily) NP hydroxyzine pamoate) alprazolam) Benzodiazepines XANAX XR TB24 (Use NP QL(1 ea daily) alprazolam) ALPRAZOLAM INTENSOL 2 QL(4 ml daily) CONC ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms alprazolam tabs or 0.25 1 QL(4 ea daily) mg, 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-A alprazolam tb24 or 0.5 mg, QL(1 ea daily) 1 disopyramide phosphate 1 1 mg, 2 mg, 3 mg caps alprazolam tbdp or 0.25 QL(4 ea daily) 1 NORPACE CAPS (Use 2 mg, 0.5 mg, 1 mg, 2 mg disopyramide phosphate) ATIVAN SOLN IJ 4 NORPACE CR CP12 150 2 MG/ML, 2 MG/ML (Use NP MG lorazepam) quinidine gluconate tbcr 1 ATIVAN TABS OR 0.5 MG, QL(4 ea daily) 1 MG, 2 MG (Use NP lorazepam) quinidine sulfate tabs 1 chlordiazepoxide hcl caps 1 QL(4 ea daily) Antiarrhythmics Type I-B mexiletine hcl caps 150 1 clorazepate dipotassium 1 QL(4 ea daily) mg, 200 mg, 250 mg tabs Antiarrhythmics Type I-C

MHS Indiana Preferred Drug List Updated June 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flecainide acetate tabs 1 SINGULAIR PACK (Use NP QL(1 ea daily) montelukast sodium) propafenone hcl tabs 150 1 SINGULAIR TABS (Use NP QL(1 ea daily) mg, 225 mg, 300 mg montelukast sodium) Antiarrhythmics Type III Steroid Inhalants amiodarone hcl tabs or 200 1 QL(1 ea daily) mg ARNUITY ELLIPTA AEPB 2 QL(120 ml per dofetilide caps 1 budesonide (inhalation) 1 fill retail); susp 0.25 mg/2ml, 0.5 AL(Up to 8 yrs TIKOSYN CAPS (Use NP mg/2ml dofetilide) old ) ANTIASTHMATIC AND BRONCHODILATOR QL(2 ml daily); budesonide (inhalation) 1 AL(Up to 8 yrs AGENTS - Drugs to Treat Lung Conditions susp 1 mg/2ml old ) Anti-Inflammatory Agents FLOVENT DISKUS AEPB 2 QL(2 ea daily) cromolyn sodium nebu 1 QL(8 ml daily) FLOVENT HFA AERO 110 2 QL(0.4 gm Antiasthmatic - Monoclonal Antibodies MCG/ACT, 220 MCG/ACT daily) CINQAIR SOLN 2 PA; SP FLOVENT HFA AERO 44 2 QL(0.367 gm MCG/ACT daily) PA; SP FASENRA SOSY 2 PULMICORT FLEXHALER 2 QL(1 ea per fill AEPB retail) PA; SP NUCALA SOLR 100 MG 2 PULMICORT SUSP 0.25 QL(120 ml per fill retail); PA; SP MG/2ML, 0.5 MG/2ML (Use NP XOLAIR SOLR 150 MG 2 budesonide (inhalation)) AL(Up to 8 yrs old ) XOLAIR SOSY 150 2 PA PULMICORT SUSP 1 QL(2 ml daily); MG/ML, 75 MG/0.5ML MG/2ML (Use budesonide NP AL(Up to 8 yrs Bronchodilators - Anticholinergics (inhalation)) old ) QVAR REDIHALER AERB QL(0.36 gm ATROVENT HFA AERS 2 QL(0.86 gm 2 daily) 40 MCG/ACT daily) INCRUSE ELLIPTA AEPB 2 QVAR REDIHALER AERB 2 QL(0.72 gm 80 MCG/ACT daily) QL(12.5 ml ipratropium bromide soln 1 Sympathomimetics daily) ADVAIR DISKUS AEPB QL(2 ea daily) 1 rtl pack lmt (Use fluticasone- NP SPIRIVA RESPIMAT 2 AERS 1.25 MCG/ACT amt,30 rtl pack salmeterol) lmt day(s), albuterol sulfate aers in 108 1 QL(13.4 gm per Leukotriene Modulators mcg/act 30 days retail) QL(1 ea daily) montelukast sodium chew 1 albuterol sulfate aers in 108 1 QL(36 gm per mcg/act 30 days retail) QL(1 ea daily) montelukast sodium pack 1 albuterol sulfate aers in 108 1 QL(17 gm per mcg/act 30 days retail) montelukast sodium tabs 1 QL(1 ea daily) albuterol sulfate nebu in QL(12.5 ml 0.083 %, 0.63 mg/3ml, 1.25 1 daily) SINGULAIR CHEW (Use NP QL(1 ea daily) mg/3ml montelukast sodium) MHS Indiana Preferred Drug List Updated June 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALBUTEROL SULFATE 2 VENTOLIN HFA AERS 2 NEBU IN 0.5 % (Use albuterol sulfate) albuterol sulfate nebu in 1 XOPENEX 0.5 %, 2.5 mg/0.5ml CONCENTRATE NEBU NP (Use levalbuterol hcl) albuterol sulfate syrp or 2 1 mg/5ml XOPENEX HFA AERO NP (Use levalbuterol tartrate) albuterol sulfate tabs or 2 1 mg, 4 mg XOPENEX NEBU (Use NP levalbuterol hcl) albuterol sulfate tb12 or 4 1 mg, 8 mg Xanthines budesonide-formoterol 1 QL(22 gm per fumarate dihydrate aero 15 days retail) ELIXOPHYLLIN ELIX 2 COMBIVENT RESPIMAT 2 QL(0.134 gm THEO-24 CP24 2 AERS daily) fluticasone-salmeterol aepb QL(2 ea daily) theophylline soln 80 1 QL(475 ml per 50 mcg/dose-500 mg/15ml fill retail) mcg/dose, 100 mcg/act-50 theophylline tb12 100 mg, 1 mcg/act, 100 mcg/dose-50 1 200 mg, 300 mg, 450 mg mcg/dose, 250 mcg/act-50 theophylline tb24 400 mg, 1 mcg/act, 250 mcg/dose-50 600 mg mcg/dose ipratropium-albuterol soln 1 QL(12 ml daily) ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants levalbuterol hcl nebu 1 COUMADIN TABS (Use NP warfarin sodium) levalbuterol tartrate aero 1 warfarin sodium tabs 1 metaproterenol sulfate tabs 1 Direct Factor Xa Inhibitors PROAIR DIGIHALER 2 AEPB ELIQUIS STARTER PACK 2 QL(4 ea daily) TBPK PROAIR HFA AERS (Use 2 albuterol sulfate) ELIQUIS TABS 2 QL(4 ea daily) PROAIR RESPICLICK 2 AEPB Heparins And Heparinoid-Like Agents ARIXTRA SOLN (Use PA; SP PROVENTIL HFA AERS 2 NP (Use albuterol sulfate) fondaparinux sodium) enoxaparin sodium soln 1 PROVENTIL HFA AERS NF (Use albuterol sulfate) fondaparinux sodium soln 1 PA; SP SEREVENT DISKUS 2 AEPB PA; SP SYMBICORT AERO (Use QL(22 gm per FRAGMIN SOLN 2 budesonide-formoterol NP 15 days retail) HEPARIN LOCK FLUSH fumarate dihydrate) SOLN (Use heparin sodium NF (porcine) lock flush) terbutaline sulfate tabs or 1 2.5 mg, 5 mg heparin sodium (porcine) 1 lock flush soln 10 unit/ml

MHS Indiana Preferred Drug List Updated June 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits heparin sodium (porcine) 1 Anticonvulsants - Misc. soln carbamazepine chew or 1 HEPARIN 100 mg SODIUM/SODIUM carbamazepine cp12 or CHLORIDE 0.9% SOLN IV NF 1 0.9 %-1000 UNIT/500ML 100 mg, 200 mg, 300 mg (Use heparin (porcine) in CARBAMAZEPINE POWD 2 sodium chloride) XX carbamazepine susp or LOVENOX SOLN (Use NP 1 enoxaparin sodium) 100 mg/5ml carbamazepine tabs or 200 1 ANTICONVULSANTS - Drugs to Treat Seizures mg Anticonvulsants - Benzodiazepines carbamazepine tb12 or 100 1 mg, 200 mg, 400 mg clobazam susp 2.5 mg/ml 1 QL(32 ml daily) CARBATROL CP12 (Use NP carbamazepine) clobazam tabs 10 mg 1 QL(8 ea daily) FINTEPLA SOLN 2 PA clobazam tabs 20 mg 1 QL(4 ea daily) gabapentin caps 1 clonazepam tabs 1 QL(3 ea daily) gabapentin soln 1 clonazepam tbdp 1 QL(3 ea daily) gabapentin tabs 1 DIASTAT ACUDIAL GEL QL(1 ea per fill (Use diazepam 2 retail); AL(Up to KEPPRA SOLN (Use NP (anticonvulsant)) 21 yrs old ) levetiracetam) DIASTAT PEDIATRIC GEL QL(1 ea per fill KEPPRA TABS (Use NP (Use diazepam 2 retail); AL(Up to levetiracetam) (anticonvulsant)) 21 yrs old ) KEPPRA XR TB24 (Use NP QL(1 ea per fill levetiracetam) diazepam (anticonvulsant) 2 retail); AL(Up to gel 10 mg LAMICTAL CHEWABLE 21 yrs old ) DISPERSIBLE CHEW (Use NP QL(1 ea per fill lamotrigine) diazepam (anticonvulsant) 1 retail); AL(Up to gel 2.5 mg, 20 mg 21 yrs old ) LAMICTAL ODT KIT 2 KLONOPIN TABS (Use QL(3 ea daily) NP LAMICTAL ODT KIT (Use NP clonazepam) lamotrigine) ONFI SUSP 2.5 MG/ML NP QL(32 ml daily) LAMICTAL ODT TBDP 100 (Use clobazam) MG, 200 MG, 25 MG, 50 NP MG (Use lamotrigine) ONFI TABS 10 MG (Use NP QL(8 ea daily) clobazam) LAMICTAL STARTER/NOT TAKING ONFI TABS 20 MG (Use NP QL(4 ea daily) NP clobazam) CARBAMAZEPINE KIT (Use lamotrigine) SYMPAZAN FILM 10 MG, 2 QL(8 ea daily) 5 MG SYMPAZAN FILM 20 MG 2 QL(4 ea daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL LYRICA CAPS 100 MG, QL(3 ea daily) STARTER/TAKING 150 MG, 200 MG, 25 MG, NP CARBAMAZEPINE/NOT NP 50 MG, 75 MG (Use TAKING VALPROATE KIT pregabalin) (Use lamotrigine) LYRICA CAPS 225 MG, NP QL(2 ea daily) LAMICTAL 300 MG (Use pregabalin) STARTER/TAKING NP LYRICA SOLN 20 MG/ML NP QL(30 ml daily) VALPROATE KIT (Use (Use pregabalin) lamotrigine) MYSOLINE TABS (Use NP LAMICTAL TABS (Use NP primidone) lamotrigine) NEURONTIN CAPS (Use NP LAMICTAL XR KIT 2 gabapentin) NEURONTIN SOLN (Use NP LAMICTAL XR TB24 100 gabapentin) MG, 200 MG, 250 MG, 300 NP MG, 25 MG, 50 MG (Use NEURONTIN TABS (Use NP lamotrigine) gabapentin) lamotrigine chew 1 oxcarbazepine susp 1 lamotrigine kit 1 oxcarbazepine tabs 1 lamotrigine tabs 1 OXTELLAR XR TB24 2 pregabalin caps 100 mg, QL(3 ea daily) lamotrigine tb24 1 150 mg, 200 mg, 25 mg, 50 1 mg, 75 mg lamotrigine tbdp 1 pregabalin caps 225 mg, 1 QL(2 ea daily) 300 mg levetiracetam in sodium 1 chloride soln pregabalin soln 20 mg/ml 1 QL(30 ml daily) LEVETIRACETAM SOLN IV 1000 MG/100ML-750 primidone tabs 1 MG/100ML, 1500 MG/100ML-540 NP QUDEXY XR CS24 (Use NP QL(2 ea daily) MG/100ML, 500 topiramate) MG/100ML-820 MG/100ML TEGRETOL SUSP (Use NP (Use levetiracetam in carbamazepine) sodium chloride) TEGRETOL TABS (Use NP levetiracetam soln iv 500 1 carbamazepine) mg/5ml TEGRETOL-XR TB12 (Use NP levetiracetam soln or 100 1 carbamazepine) mg/ml, 500 mg/5ml TOPAMAX SPRINKLE NP levetiracetam tabs or 250 CPSP (Use topiramate) mg, 1000 mg, 750 mg, 500 1 mg TOPAMAX TABS (Use NP topiramate) levetiracetam tb24 or 500 1 mg, 750 mg topiramate cpsp 15 mg, 25 1 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits topiramate cs24 100 mg, QL(2 ea daily) DILANTIN INFATABS 2 150 mg, 200 mg, 25 mg, 50 1 CHEW (Use phenytoin) mg DILANTIN-125 SUSP (Use 2 topiramate tabs 100 mg, 1 phenytoin) 200 mg, 25 mg, 50 mg phenytoin chew 1 TRILEPTAL SUSP (Use NP oxcarbazepine) phenytoin sodium extended 1 caps 100 mg TRILEPTAL TABS (Use NP oxcarbazepine) phenytoin susp 1 TROKENDI XR CP24 2 QL(2 ea daily) Succinimides VIMPAT SOLN IV 200 2 MG/20ML ethosuximide caps 1 ZONEGRAN CAPS (Use NP zonisamide) ethosuximide soln 1 zonisamide caps 1 ZARONTIN CAPS (Use 2 ethosuximide) Carbamates ZARONTIN SOLN (Use 2 ethosuximide) felbamate susp 1 Valproic Acid felbamate tabs 1 DEPACON SOLN (Use NP valproate sodium) FELBATOL SUSP (Use NP ) DEPAKENE CAPS (Use NP felbamate valproic acid) FELBATOL TABS (Use NP ) DEPAKENE SOLN (Use NP felbamate valproate sodium) GABA Modulators DEPAKOTE ER TB24 (Use NP GABITRIL TABS (Use NP divalproex sodium) tiagabine hcl) DEPAKOTE SPRINKLES SABRIL PACK (Use NP PA; SP CSDR (Use divalproex NP vigabatrin) sodium) SABRIL TABS (Use NP PA; SP DEPAKOTE TBEC (Use NP vigabatrin) divalproex sodium) tiagabine hcl tabs 1 divalproex sodium csdr or 1 125 mg PA; SP vigabatrin pack 1 divalproex sodium tb24 or 1 250 mg, 500 mg PA; SP vigabatrin tabs 1 divalproex sodium tbec or 1 125 mg, 250 mg, 500 mg Hydantoins valproate sodium soln iv 1 DILANTIN CAPS 100 MG 100 mg/ml, 500 mg/5ml (Use phenytoin sodium 2 valproate sodium soln or 1 extended) 250 mg/5ml DILANTIN CAPS 30 MG 2 valproic acid caps or 1

MHS Indiana Preferred Drug List Updated June 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDEPRESSANTS - Drugs to Treat SPRAVATO 84MG DOSE 2 AL(At least 18 Depression SOPK yrs old) Alpha-2 Receptor Antagonists (Tetracyclics) Selective Serotonin Reuptake Inhibitors (SSRIs) QL(1 ea daily) CELEXA TABS 10 MG, 20 QL(1.5 ea mirtazapine tabs 1 MG (Use citalopram NP daily) hydrobromide) mirtazapine tbdp 1 QL(1 ea daily) CELEXA TABS 40 MG QL(1 ea daily) (Use citalopram NP REMERON SOLTAB TBDP NP QL(1 ea daily) (Use mirtazapine) hydrobromide) citalopram hydrobromide QL(20 ml daily) REMERON TABS (Use NP QL(1 ea daily) 1 mirtazapine) soln 10 mg/5ml Antidepressants - Misc. citalopram hydrobromide 1 QL(1.5 ea tabs 10 mg, 20 mg daily) APLENZIN TB24 2 QL(1 ea daily) citalopram hydrobromide 1 QL(1 ea daily) tabs 40 mg bupropion hcl tabs or 100 1 QL(4 ea daily) mg, 75 mg escitalopram oxalate soln 5 1 QL(20 ml daily) mg/5ml bupropion hcl tb12 or 100 1 QL(2 ea daily) mg, 150 mg, 200 mg escitalopram oxalate tabs 1 QL(1.5 ea 10 mg, 20 mg daily) bupropion hcl tb24 or 450 1 QL(1 ea daily) mg, 300 mg, 150 mg escitalopram oxalate tabs 5 1 QL(1 ea daily) mg FORFIVO XL TB24 (Use NP QL(1 ea daily) bupropion hcl) fluoxetine hcl caps or 10 1 QL(1 ea daily) mg maprotiline hcl tabs 1 QL(3 ea daily) fluoxetine hcl caps or 20 1 QL(4 ea daily) mg WELLBUTRIN SR TB12 NP QL(2 ea daily) ) (Use bupropion hcl fluoxetine hcl caps or 40 1 QL(2 ea daily) mg WELLBUTRIN XL TB24 NP QL(1 ea daily) (Use bupropion hcl) QL(0.143 ea fluoxetine hcl cpdr or 90 mg 1 daily) Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl soln or 20 QL(20 ml daily) QL(1 ea daily) 1 EMSAM PT24 2 mg/5ml QL(1.5 ea QL(3 ea daily) fluoxetine hcl tabs or 10 mg 1 MARPLAN TABS 2 daily) QL(4 ea daily) NARDIL TABS (Use NP QL(6 ea daily) fluoxetine hcl tabs or 20 mg 1 phenelzine sulfate) QL(1 ea daily) PARNATE TABS (Use NP QL(6 ea daily) fluoxetine hcl tabs or 60 mg 1 tranylcypromine sulfate) FLUOXETINE QL(1 ea daily) QL(6 ea daily) phenelzine sulfate tabs or 1 HYDROCHLORIDE TABS NP (Use fluoxetine hcl) tranylcypromine sulfate 1 QL(6 ea daily) tabs fluvoxamine maleate cp24 1 QL(2 ea daily) 100 mg, 150 mg N-Methyl-D-aspartic acid (NMDA) Receptor fluvoxamine maleate tabs 1 QL(3 ea daily) SPRAVATO 56MG DOSE 2 AL(At least 18 100 mg SOPK yrs old) fluvoxamine maleate tabs 1 QL(1 ea daily) 25 mg, 50 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXAPRO TABS 10 MG, QL(1.5 ea sertraline hcl tabs or 100 1 QL(3 ea daily) 20 MG (Use escitalopram NP daily) mg oxalate) sertraline hcl tabs or 25 1 QL(2 ea daily) LEXAPRO TABS 5 MG NP QL(1 ea daily) mg, 50 mg (Use escitalopram oxalate) ZOLOFT CONC 20 MG/ML NP QL(10 ml daily) QL(1.5 ea (Use sertraline hcl) daily); AL(At paroxetine hcl tabs 10 mg 1 ZOLOFT TABS 100 MG NP QL(3 ea daily) least 18 yrs (Use sertraline hcl) old) ZOLOFT TABS 25 MG, 50 NP QL(2 ea daily) QL(1 ea daily); MG (Use sertraline hcl) paroxetine hcl tabs 20 mg 1 AL(At least 18 yrs old) Serotonin Modulators QL(2 ea daily); nefazodone hcl tabs 1 QL(2 ea daily) paroxetine hcl tabs 30 mg, 1 AL(At least 18 40 mg yrs old) TRAZODONE HCL POWD 2 QL(1 ea daily); XX paroxetine hcl tb24 37.5 1 AL(At least 18 trazodone hcl tabs or 100 QL(3 ea daily) mg, 12.5 mg, 25 mg 1 yrs old) mg, 150 mg QL(1 ea daily); trazodone hcl tabs or 300 1 QL(2 ea daily) PAXIL CR TB24 (Use NP mg, 50 mg paroxetine hcl) AL(At least 18 yrs old) TRINTELLIX TABS 2 QL(1 ea daily) QL(40 ml VIIBRYD STARTER PACK 2 daily); AL(At 2 PAXIL SUSP 10 MG/5ML least 18 yrs KIT old) VIIBRYD TABS 2 QL(1 ea daily) QL(1.5 ea PAXIL TABS 10 MG (Use NP daily); AL(At Serotonin-Norepinephrine Reuptake Inhibitors paroxetine hcl) least 18 yrs old) CYMBALTA CPEP (Use NP QL(2 ea daily) duloxetine hcl) QL(1 ea daily); PAXIL TABS 20 MG (Use NP DESVENLAFAXINE ER QL(2 ea daily) paroxetine hcl) AL(At least 18 2 yrs old) TB24 100 MG QL(2 ea daily); DESVENLAFAXINE ER 2 QL(1 ea daily) PAXIL TABS 30 MG, 40 NP TB24 50 MG MG (Use paroxetine hcl) AL(At least 18 yrs old) desvenlafaxine succinate 1 QL(2 ea daily) QL(1 ea daily); tb24 100 mg PEXEVA TABS 2 AL(At least 18 desvenlafaxine succinate 1 QL(1 ea daily) yrs old) tb24 25 mg, 50 mg desvenlafaxine tb24 100 QL(2 ea daily) PROZAC CAPS 10 MG NP QL(1 ea daily) 1 (Use fluoxetine hcl) mg QL(1 ea daily) PROZAC CAPS 20 MG NP QL(4 ea daily) desvenlafaxine tb24 50 mg 1 (Use fluoxetine hcl) DRIZALMA SPRINKLE QL(2 ea daily) PROZAC CAPS 40 MG NP QL(2 ea daily) 2 (Use fluoxetine hcl) CSDR QL(2 ea daily) sertraline hcl conc or 20 1 QL(10 ml daily) duloxetine hcl cpep 1 mg/ml EFFEXOR XR CP24 150 NP QL(2 ea daily) MG (Use venlafaxine hcl)

MHS Indiana Preferred Drug List Updated June 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EFFEXOR XR CP24 37.5 NP QL(1 ea daily) ANAFRANIL CAPS 75 MG NP QL(3 ea daily) MG (Use venlafaxine hcl) (Use clomipramine hcl) EFFEXOR XR CP24 75 NP QL(3 ea daily) clomipramine hcl caps 25 1 QL(2 ea daily) MG (Use venlafaxine hcl) mg FETZIMA CP24 2 QL(1 ea daily) clomipramine hcl caps 50 1 QL(5 ea daily) mg FETZIMA TITRATION QL(1 ea daily) 2 clomipramine hcl caps 75 1 QL(3 ea daily) PACK C4PK mg KHEDEZLA TB24 100 MG QL(2 ea daily) NP DESIPRAMINE HCL 2 (Use desvenlafaxine) POWD XX KHEDEZLA TB24 50 MG QL(1 ea daily) NP desipramine hcl tabs or 10 1 QL(4 ea daily) (Use desvenlafaxine) mg PRISTIQ TB24 100 MG QL(2 ea daily) desipramine hcl tabs or 100 1 QL(3 ea daily) (Use desvenlafaxine NP mg succinate) desipramine hcl tabs or 150 1 QL(2 ea daily) PRISTIQ TB24 25 MG, 50 QL(1 ea daily) mg, 75 mg, 25 mg, 50 mg MG (Use desvenlafaxine NP QL(4 ea daily) succinate) doxepin hcl caps or 10 mg 1 venlafaxine hcl cp24 150 1 QL(2 ea daily) doxepin hcl caps or 150 QL(2 ea daily) mg mg, 100 mg, 25 mg, 50 mg, 1 venlafaxine hcl cp24 37.5 1 QL(1 ea daily) 75 mg mg doxepin hcl conc or 10 1 QL(30 ml daily) venlafaxine hcl cp24 75 mg 1 QL(3 ea daily) mg/ml IMIPRAMINE HCL POWD 2 venlafaxine hcl tabs 100 QL(3 ea daily) XX mg, 25 mg, 37.5 mg, 50 1 imipramine hcl tabs or 10 1 QL(2 ea daily) mg, 75 mg mg venlafaxine hcl tb24 150 QL(2 ea daily) 1 imipramine hcl tabs or 25 1 QL(1 ea daily) mg mg venlafaxine hcl tb24 225 QL(1 ea daily) 1 imipramine hcl tabs or 50 1 QL(6 ea daily) mg, 37.5 mg mg venlafaxine hcl tb24 75 mg 1 QL(3 ea daily) imipramine pamoate caps 1 QL(3 ea daily) 100 mg Tricyclic Agents imipramine pamoate caps 1 QL(2 ea daily) amitriptyline hcl tabs or 10 QL(3 ea daily) 125 mg, 150 mg mg, 150 mg, 50 mg, 100 1 imipramine pamoate caps 1 QL(1 ea daily) mg, 25 mg, 75 mg 75 mg amoxapine tabs 100 mg, QL(4 ea daily) 1 NORPRAMIN TABS 10 MG NP QL(4 ea daily) 50 mg (Use desipramine hcl) amoxapine tabs 150 mg, QL(2 ea daily) 1 NORPRAMIN TABS 25 MG NP QL(2 ea daily) 25 mg (Use desipramine hcl) ANAFRANIL CAPS 25 MG QL(2 ea daily) NP nortriptyline hcl caps or 10 1 QL(4 ea daily) (Use clomipramine hcl) mg, 25 mg ANAFRANIL CAPS 50 MG QL(5 ea daily) NP nortriptyline hcl caps or 50 1 QL(3 ea daily) (Use clomipramine hcl) mg

MHS Indiana Preferred Drug List Updated June 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nortriptyline hcl caps or 75 1 QL(2 ea daily) Antidiabetic Combinations mg ACTOPLUS MET TABS QL(2 ea daily) NORTRIPTYLINE HCL 2 (Use pioglitazone hcl- NP POWD XX metformin hcl) nortriptyline hcl soln or 10 QL(20 ml daily) 1 alogliptin-metformin hcl 1 QL(2 ea daily) mg/5ml tabs PAMELOR CAPS 10 MG, QL(4 ea daily) QL(1 ea daily) 25 MG (Use nortriptyline NP alogliptin-pioglitazone tabs 1 hcl) glipizide-metformin hcl tabs 1 PAMELOR CAPS 50 MG NP QL(3 ea daily) (Use nortriptyline hcl) glyburide-metformin tabs 1 PAMELOR CAPS 75 MG NP QL(2 ea daily) (Use nortriptyline hcl) PA; QL(2 ea QL(4 ea daily) 2 daily); AL(At protriptyline hcl tabs 1 JENTADUETO TABS least 18 yrs SURMONTIL CAPS 100 QL(3 ea daily) old) MG (Use trimipramine NP KAZANO TABS (Use NF maleate) alogliptin-metformin hcl) SURMONTIL CAPS 25 QL(1 ea daily) OSENI TABS (Use NF MG, 50 MG (Use NP alogliptin-pioglitazone) trimipramine maleate) pioglitazone hcl-metformin 1 QL(2 ea daily) hcl tabs TOFRANIL TABS 10 MG NP QL(2 ea daily) (Use imipramine hcl) SEGLUROMET TABS 2 QL(2 ea daily) TOFRANIL TABS 25 MG NP QL(1 ea daily) (Use imipramine hcl) Biguanides TOFRANIL TABS 50 MG QL(6 ea daily) NP metformin hcl tabs 1000 1 (Use imipramine hcl) mg, 850 mg trimipramine maleate caps 1 QL(3 ea daily) QL(5 ea daily) or 100 mg metformin hcl tabs 500 mg 1 QL(4 ea daily) trimipramine maleate caps 1 QL(1 ea daily) metformin hcl tb24 500 mg 1 or 25 mg, 50 mg QL(3 ea daily) TRIMIPRAMINE MALEATE 2 metformin hcl tb24 750 mg 1 POWD XX ANTIDIABETICS - Drugs to Regulate Blood Diabetic Other Sugar BAQSIMI ONE PACK 2 QL(2 ea per 30 POWD days retail) Alpha-Glucosidase Inhibitors BAQSIMI TWO PACK 2 QL(2 ea per 30 acarbose tabs 1 QL(3 ea daily) POWD days retail) BD GLUCOSE CHEW 2 PRECOSE TABS (Use NP QL(3 ea daily) acarbose) CVS GLUCOSE CHEW 4 2 QL(1.67 ea Antidiabetic - Amylin Analogs GM daily) QL(0.36 ml SYMLINPEN 120 SOPN 2 CVS SOFT GLUCOSE 2 QL(1.67 ea daily) CHEW daily) QL(0.2 ml SYMLINPEN 60 SOPN 2 DEX4 QUICK DISSOLVE 2 QL(1.67 ea daily) GLUCOSE CHEW daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextrose (diabetic use) gel 1 PA; QL(3.4 ml 15 gm/38gm, 40 % BYDUREON BCISE AUIJ 2 per 28 days retail) GLUCAGEN HYPOKIT 2 QL(1 ea per fill SOLR retail) PA; Limit 4 per QL(1 ea per fill 28 glucagon (rdna) kit 1 retail) BYDUREON PEN PEN 2 days;QL(0.143 ea daily); AL(At GLUCAGON QL(1 ea per fill least 18 yrs EMERGENCY KIT KIT NP retail) old) (Use glucagon (rdna)) PA; Limit 2.4ml QL(1.67 ea GLUCOSE CHEW 4 GM 2 per daily) BYETTA SOPN 10 2 month;QL(0.08 GNP GLUCOSE CHEW 4 2 QL(1.67 ea MCG/0.04ML ml daily); AL(At GM daily) least 18 yrs old) GNP QUICK DISSOLVE 2 QL(1.67 ea GLUCOSE CHEW daily) PA; Limit 1.2ml per GVOKE HYPOPEN 1- 2 QL(0..2 ml per PACK SOAJ 0.5 MG/0.1ML 30 days retail) BYETTA SOPN 5 2 month;QL(0.04 MCG/0.02ML ml daily); AL(At GVOKE HYPOPEN 1- 2 QL(0..4 ml per PACK SOAJ 1 MG/0.2ML 30 days retail) least 18 yrs old) GVOKE HYPOPEN 2- QL(0..2 ml per 2 PA; QL(0.3 ml PACK SOAJ 0.5 MG/0.1ML 30 days retail) VICTOZA SOPN 2 daily) GVOKE HYPOPEN 2- 2 QL(0..4 ml per PACK SOAJ 1 MG/0.2ML 30 days retail) Insulin Sensitizing Agents ACTOS TABS (Use QL(1 ea daily) GVOKE PFS SOSY 0.5 2 QL(0..2 ml per NP MG/0.1ML 30 days retail) pioglitazone hcl) QL(1 ea daily) GVOKE PFS SOSY 1 2 QL(0..4 ml per pioglitazone hcl tabs 1 MG/0.2ML 30 days retail) LEADER QUICK QL(1.67 ea Insulin DISSOLVE GLUCOSE 2 daily) QL(1 ml daily) CHEW ADMELOG SOLN 2 ADMELOG SOLOSTAR QL(1 ml daily) SM GLUCOSE CHEW 4 2 QL(1.67 ea 2 GM daily) SOPN BASAGLAR KWIKPEN QL(1 ml daily) WALGREENS GLUCOSE 2 QL(1.67 ea 2 CHEW 4 GM daily) SOPN Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HUMALOG MIX 50/50 2 QL(1 ml daily) KWIKPEN SUPN alogliptin benzoate tabs 1 QL(1 ea daily) HUMALOG MIX 50/50 2 QL(1.34 ml SUSP daily) NESINA TABS (Use NF alogliptin benzoate) HUMALOG MIX 75/25 2 QL(1 ml daily) PA; QL(1 ea KWIKPEN SUPN HUMALOG MIX 75/25 QL(1.34 ml 2 daily); AL(At 2 TRADJENTA TABS least 18 yrs SUSP daily) old) HUMULIN 70/30 KWIKPEN 2 QL(1 ml daily) Incretin Mimetic Agents (GLP-1 Receptor SUPN HUMULIN 70/30 SUSP 2 QL(1.34 ml daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMULIN N KWIKPEN 2 QL(1 ml daily) nateglinide tabs 1 QL(3 ea daily) SUPN STARLIX TABS (Use QL(3 ea daily) HUMULIN N SUSP 2 QL(1.34 ml NP daily) nateglinide) HUMULIN R SOLN 2 QL(1.34 ml Sodium-Glucose Co-Transporter 2 (SGLT2) daily) STEGLATRO TABS 2 QL(1 ea daily) INSULIN ASPART QL(1 ml daily) PROTAMINE/INSULIN 2 Sulfonylureas ASPART FLEXPEN SUPN AMARYL TABS 1 MG, 2 NP QL(4 ea daily) INSULIN ASPART QL(1.34 ml MG (Use glimepiride) PROTAMINE/INSULIN 2 daily) ASPART SUSP AMARYL TABS 4 MG (Use NP QL(2 ea daily) glimepiride) INSULIN LISPRO QL(1 ml daily) PROTAMINE/INSULIN 2 glimepiride tabs 1 mg, 2 mg 1 QL(4 ea daily) LISPRO KWIKPEN SUPN glimepiride tabs 4 mg 1 QL(2 ea daily) NOVOLIN 70/30 FLEXPEN 2 QL(1 ml daily) RELION SUPN glipizide tabs 1 NOVOLIN 70/30 FLEXPEN 2 QL(1 ml daily) SUPN glipizide tb24 1 NOVOLIN 70/30 RELION 2 QL(1.34 ml SUSP daily) GLUCOTROL TABS (Use NP glipizide) NOVOLIN 70/30 SUSP 2 QL(1.34 ml daily) GLUCOTROL XL TB24 NP (Use glipizide) NOVOLIN N FLEXPEN 2 QL(1 ml daily) RELION SUPN glyburide micronized tabs 1 NOVOLIN N FLEXPEN 2 QL(1 ml daily) SUPN glyburide tabs 1 NOVOLIN N RELION 2 QL(1.34 ml SUSP daily) GLYNASE TABS (Use NP glyburide micronized) QL(1.34 ml NOVOLIN N SUSP 2 daily) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea NOVOLIN R RELION 2 QL(1.34 ml SOLN daily) Antidiarrheal/Probiotic Agents - Misc. NOVOLIN R SOLN 2 QL(1.34 ml daily) bismuth subsalicylate chew 1 NOVOLOG MIX 70/30 QL(1 ml daily) bismuth subsalicylate susp 1 PREFILLED FLEXPEN 2 SUPN bismuth subsalicylate tabs 1 NOVOLOG MIX 70/30 2 QL(1.34 ml SUSP daily) PEPTO BISMOL TABS NP (Use bismuth subsalicylate) SEMGLEE SOLN 2 QL(1 ml daily) PEPTO-BISMOL CHEW NP (Use bismuth subsalicylate) SEMGLEE SOPN 2 QL(1 ml daily) PEPTO-BISMOL MAX Meglitinide Analogues STRENGTH SUSP (Use NP bismuth subsalicylate)

MHS Indiana Preferred Drug List Updated June 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEPTO-BISMOL SUSP NP naloxone hcl soln 0.4 1 QL(2 ml per 90 (Use bismuth subsalicylate) mg/ml days retail) PEPTO-BISMOL TO-GO naltrexone hcl tabs 1 CHEW (Use bismuth NP subsalicylate) QL(2 ea per 90 NARCAN LIQD 2 Antiperistaltic Agents days retail) ANTI-DIARRHEAL LIQD 2 QL(40 ml daily) VIVITROL SUSR 2 ANTIEMETICS - Drugs to Treat Nausea and diphenoxylate w/ atropine 1 liqd Vomiting diphenoxylate w/ atropine 1 5-HT3 Receptor Antagonists tabs ondansetron hcl soln 1 IMODIUM A-D CAPS 2 MG NP QL(8 ea daily); (Use loperamide hcl) RX/OTC ondansetron hcl tabs 1 IMODIUM A-D TABS 2 MG NP QL(8 ea daily) (Use loperamide hcl) ondansetron tbdp 1 LOMOTIL TABS (Use NP diphenoxylate w/ atropine) ZOFRAN TABS (Use NP ondansetron hcl) QL(8 ea daily); loperamide hcl caps 2 mg 1 RX/OTC Antiemetics - Anticholinergic loperamide hcl tabs 2 mg 1 QL(8 ea daily) dimenhydrinate tabs or 50 1 QL(24 ea per mg fill retail) ANTIDOTES AND SPECIFIC ANTAGONISTS DRAMAMINE CHEW 2

Antidotes - Chelating Agents DRAMAMINE TABS (Use NP QL(24 ea per dimenhydrinate) fill retail) CHEMET CAPS 2 meclizine hcl chew 1 RX/OTC deferasirox pack 1 PA; SP meclizine hcl tabs 1 RX/OTC deferasirox tabs 1 PA; SP Substance P/Neurokinin 1 (NK1) Receptor deferasirox tbso 1 PA; SP EMEND SOLR IV 150 MG (Use fosaprepitant NF EXJADE TBSO (Use NP PA; SP dimeglumine) deferasirox) ANTIFUNGALS - Drugs to Treat Fungal Infections JADENU SPRINKLE PACK NP PA; SP (Use deferasirox) Antifungals JADENU TABS (Use NP PA; SP deferasirox) griseofulvin microsize susp 1 Antidotes and Specific Antagonists griseofulvin microsize tabs 1 deferoxamine mesylate solr 1 PA; SP griseofulvin ultramicrosize 1 tabs DESFERAL SOLR (Use NP PA; SP deferoxamine mesylate) nystatin tabs 1 QL(6 ea daily) Opioid Antagonists

MHS Indiana Preferred Drug List Updated June 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea BENADRYL ALLERGY QL(240 ml per 1 terbinafine hcl tabs daily,90 ea per CHILDRENS LIQD 12.5 NP fill retail) 120 days retail) MG/5ML (Use diphenhydramine hcl) Imidazole-Related Antifungals BENADRYL ALLERGY QL(4 ea daily) DIFLUCAN SUSR 10 QL(70 ml per NP TABS (Use NP MG/ML, 40 MG/ML (Use fill retail) ) fluconazole) diphenhydramine hcl clemastine fumarate tabs 1 QL(2 ea daily) DIFLUCAN TABS 100 MG, NP 1.34 mg 200 MG (Use fluconazole) diphenhydramine hcl caps 1 QL(4 ea daily) DIFLUCAN TABS 150 MG NP QL(2 ea per fill or 50 mg, 25 mg (Use fluconazole) retail) diphenhydramine hcl liqd or QL(240 ml per DIFLUCAN TABS 50 MG NP QL(3 ea per 14 12.5 mg/5ml, 25 mg/10ml, 1 fill retail) (Use fluconazole) days retail) 50 mg/20ml QL(70 ml per fluconazole susr 10 mg/ml, 1 diphenhydramine hcl tabs QL(4 ea daily) 40 mg/ml fill retail) 1 or 25 mg fluconazole tabs 100 mg, 1 200 mg Antihistamines - Non-Sedating QL(2 ea per fill ALLEGRA ALLERGY fluconazole tabs 150 mg 1 retail) CHILDRENS SUSP 30 NP MG/5ML (Use fexofenadine QL(3 ea per 14 fluconazole tabs 50 mg 1 hcl) days retail) ALLEGRA ALLERGY QL(1 ea daily) PA; QL(1 ea itraconazole caps 100 mg 1 TABS 180 MG (Use NP daily) fexofenadine hcl) SPORANOX CAPS 100 NP PA; QL(1 ea ALLEGRA ALLERGY QL(2 ea daily) MG (Use itraconazole) daily) TABS 60 MG (Use NP SPORANOX PULSEPAK NP PA; QL(1 ea fexofenadine hcl) CAPS (Use itraconazole) daily) cetirizine hcl chew 5 mg, 10 1 QL(1 ea daily) ANTIHISTAMINES - Drugs to Treat Allergies mg QL(240 ml per Antihistamines - Alkylamines cetirizine hcl soln 1 mg/ml, 1 fill retail); 5 mg/5ml CHLOR-TRIMETON SYRP RX/OTC 2 MG/5ML (Use NP QL(240 ml per chlorpheniramine maleate) cetirizine hcl syrp 1 mg/ml, 1 fill retail); 5 mg/5ml CHLOR-TRIMETON TABS QL(120 ea per RX/OTC 4 MG (Use NP fill retail) cetirizine hcl tabs 5 mg, 10 1 QL(1 ea daily) chlorpheniramine maleate) mg chlorpheniramine maleate 1 CLARITIN ALLERGY QL(240 ml per syrp 2 mg/5ml CHILDRENS SYRP (Use NP fill retail) loratadine) chlorpheniramine maleate 1 QL(120 ea per tabs 4 mg fill retail) CLARITIN REDITABS QL(1 ea daily) TBDP 10 MG (Use NP dexchlorpheniramine 1 maleate soln loratadine) Antihistamines - Ethanolamines CLARITIN SYRP 5 NP QL(240 ml per MG/5ML (Use loratadine) fill retail) BENADRYL ALLERGY QL(4 ea daily) CAPS (Use NP CLARITIN TABS 10 MG NP QL(1 ea daily) diphenhydramine hcl) (Use loratadine) MHS Indiana Preferred Drug List Updated June 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fexofenadine hcl susp 30 1 VYTORIN TABS (Use NP ST; QL(1 ea mg/5ml ezetimibe-simvastatin) daily); PV fexofenadine hcl tabs 180 1 QL(1 ea daily) Antihyperlipidemics - Misc. mg LOVAZA CAPS (Use NP fexofenadine hcl tabs 60 1 QL(2 ea daily) omega-3-acid ethyl esters) mg omega-3-acid ethyl esters 1 levocetirizine 1 RX/OTC caps dihydrochloride tabs 5 mg Bile Acid Sequestrants QL(240 ml per loratadine soln 5 mg/5ml 1 fill retail) cholestyramine light pack 1 QL(240 ml per loratadine syrp 5 mg/5ml 1 fill retail) cholestyramine light powd 1 QL(1 ea daily) loratadine tabs 10 mg 1 cholestyramine pack 1 QL(1 ea daily) loratadine tbdp 10 mg 1 cholestyramine powd 1 XYZAL ALLERGY 24HR RX/OTC COLESTID FLAVORED TABS (Use levocetirizine NP GRAN 5 GM (Use NP dihydrochloride) colestipol hcl) ZYRTEC ALLERGY TABS QL(1 ea daily) NP COLESTID GRAN 5 GM NP (Use cetirizine hcl) (Use colestipol hcl) ZYRTEC CHILDRENS QL(240 ml per COLESTID TABS 1 GM NP ALLERGY SOLN (Use NP fill retail); (Use colestipol hcl) cetirizine hcl) RX/OTC 1 Antihistamines - Phenothiazines colestipol hcl gran 5 gm promethazine hcl soln or 1 AL(At least 2 colestipol hcl tabs 1 gm 1 6.25 mg/5ml yrs old) QL(12 ea per QUESTRAN LIGHT POWD NP promethazine hcl supp re 1 fill retail); AL(At (Use cholestyramine light) 12.5 mg, 25 mg least 2 yrs old) QUESTRAN PACK (Use NP cholestyramine) promethazine hcl syrp or 1 AL(At least 2 6.25 mg/5ml yrs old) QUESTRAN POWD (Use NP cholestyramine) promethazine hcl tabs or 1 AL(At least 2 25 mg, 12.5 mg, 50 mg yrs old) Fibric Acid Derivatives Antihistamines - Piperidines fenofibrate micronized caps 1 QL(1 ea daily) 134 mg, 200 mg cyproheptadine hcl syrp or 1 2 mg/5ml fenofibrate micronized caps 1 QL(2 ea daily) 67 mg cyproheptadine hcl tabs or 1 4 mg fenofibrate tabs 54 mg 1 QL(3 ea daily) ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol FIBRICOR TABS (Use NF fenofibric acid) Antihyperlipidemics - Combinations gemfibrozil tabs 1 QL(2 ea daily) ST; QL(1 ea ezetimibe-simvastatin tabs $0 daily); PV LIPOFEN CAPS (Use NF fenofibrate)

MHS Indiana Preferred Drug List Updated June 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPID TABS (Use NP QL(2 ea daily) $0 copay for gemfibrozil) Generic only, ZOCOR TABS (Use NP ) age 40 to HMG CoA Reductase Inhibitors simvastatin 75;QL(1 ea $0 copay for daily); PV Generic only, atorvastatin calcium tabs 1 age 40 to Intestinal Cholesterol Absorption Inhibitors 75;QL(1 ea ezetimibe tabs 1 ST daily); PV ST; $0 copay ZETIA TABS (Use NP ST for Generic ezetimibe) CRESTOR TABS (Use NP ) only, age 40 to Nicotinic Acid Derivatives rosuvastatin calcium 75;QL(1 ea daily) niacin (antihyperlipidemic) 1 tabs $0 copay for Generic only, niacin (antihyperlipidemic) 1 LIPITOR TABS (Use NP tbcr atorvastatin calcium) age 40 to 75;QL(1 ea NIASPAN TBCR (Use NP daily); PV niacin (antihyperlipidemic)) $0 copay for Proprotein Convertase Subtilisin/Kexin Type 9 Generic only, PA; SP lovastatin tabs 10 mg, 20 1 age 40 to PRALUENT SOAJ 2 mg 75;QL(1 ea REPATHA PUSHTRONEX 2 PA daily); PV SYSTEM SOCT $0 copay for PA Generic only, REPATHA SOSY 2 lovastatin tabs 40 mg 1 age 40 to 75;QL(2 ea REPATHA SURECLICK 2 PA daily); PV SOAJ $0 copay for ANTIHYPERTENSIVES - Drugs to Treat High Generic only, Blood Pressure PRAVACHOL TABS (Use NP ) age 40 to ACE Inhibitors pravastatin sodium 75;QL(1 ea daily); PV ACCUPRIL TABS (Use NP quinapril hcl) $0 copay for Generic only, ALTACE CAPS (Use NP QL(2 ea daily) pravastatin sodium tabs 1 age 40 to ramipril) 75;QL(1 ea benazepril hcl tabs 10 mg, 1 QL(1 ea daily) daily); PV 20 mg, 5 mg ST; $0 copay benazepril hcl tabs 40 mg 1 QL(2 ea daily) for Generic rosuvastatin calcium tabs 1 only, age 40 to captopril tabs 1 QL(3 ea daily) 75;QL(1 ea daily) enalapril maleate tabs 1 QL(2 ea daily) $0 copay for Generic only, fosinopril sodium tabs 1 QL(1 ea daily) simvastatin tabs 80 mg, 10 1 age 40 to mg, 20 mg, 40 mg, 5 mg 75;QL(1 ea lisinopril tabs 1 daily); PV

MHS Indiana Preferred Drug List Updated June 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTENSIN TABS 10 MG, NP QL(1 ea daily) CATAPRES TABS 0.1 MG, NP QL(10 ea daily) 20 MG (Use benazepril hcl) 0.2 MG (Use clonidine hcl) LOTENSIN TABS 40 MG NP QL(2 ea daily) CATAPRES TABS 0.3 MG NP QL(8 ea daily) (Use benazepril hcl) (Use clonidine hcl) PRINIVIL TABS (Use NP QL(0.143 ea lisinopril) CATAPRES-TTS-1 PTWK NP daily,4 ea per (Use clonidine) 28 days retail) quinapril hcl tabs 1 QL(0.143 ea CATAPRES-TTS-2 PTWK NP daily,4 ea per ramipril caps 1 QL(2 ea daily) (Use clonidine) 28 days retail) trandolapril tabs 1 mg, 2 1 QL(1 ea daily) QL(0.286 ea mg CATAPRES-TTS-3 PTWK NP daily,8 ea per (Use clonidine) 28 days retail) trandolapril tabs 4 mg 1 QL(2 ea daily) CLONIDINE HCL POWD 2 VASOTEC TABS (Use NP QL(2 ea daily) XX enalapril maleate) clonidine hcl tabs or 0.1 1 QL(10 ea daily) ZESTRIL TABS (Use NP mg, 0.2 mg lisinopril) clonidine hcl tabs or 0.3 mg 1 QL(8 ea daily) Angiotensin II Receptor Antagonists CLONIDINE ATACAND TABS (Use NP 2 candesartan cilexetil) HYDROCHLORIDE POWD AVAPRO TABS (Use QL(1 ea daily) QL(0.143 ea NP clonidine ptwk 0.1 mg/24hr, 1 daily,4 ea per irbesartan) 0.2 mg/24hr 28 days retail) BENICAR TABS (Use NP ST olmesartan medoxomil) QL(0.286 ea clonidine ptwk 0.3 mg/24hr 1 daily,8 ea per candesartan cilexetil tabs 1 28 days retail) doxazosin mesylate tabs or COZAAR TABS (Use NP QL(1 ea daily) 1 losartan potassium) 1 mg, 2 mg, 4 mg, 8 mg guanfacine hcl tabs 1 DIOVAN TABS (Use NP QL(1 ea daily) valsartan) methyldopa tabs 1 irbesartan tabs 1 QL(1 ea daily) MINIPRESS CAPS (Use NP losartan potassium tabs or 1 QL(1 ea daily) prazosin hcl) 100 mg, 25 mg, 50 mg prazosin hcl caps 1 MICARDIS TABS (Use NP QL(1 ea daily) telmisartan) PRAZOSIN 2 olmesartan medoxomil tabs 1 ST HYDROCHLORIDE POWD terazosin hcl caps 1 telmisartan tabs 1 QL(1 ea daily) QL(1 ea daily) Antihypertensive Combinations valsartan tabs 1 ACCURETIC TABS 10 QL(3 ea daily) Antiadrenergic Antihypertensives MG-12.5 MG (Use NP quinapril- CARDURA TABS (Use NP hydrochlorothiazide) doxazosin mesylate)

MHS Indiana Preferred Drug List Updated June 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCURETIC TABS 12.5 QL(4 ea daily) EXFORGE HCT TABS 2 ST MG-20 MG (Use quinapril- NP hydrochlorothiazide) EXFORGE TABS (Use ST ACCURETIC TABS 20 QL(2 ea daily) amlodipine besylate- NP MG-25 MG (Use quinapril- NP valsartan) hydrochlorothiazide) fosinopril sodium & 1 QL(1 ea daily) hydrochlorothiazide tabs amlodipine besylate- 1 QL(1 ea daily) benazepril hcl caps HYZAAR TABS (Use QL(1 ea daily) losartan potassium & NP amlodipine besylate- 1 ST olmesartan medoxomil tabs hydrochlorothiazide) irbesartan- QL(1 ea daily) amlodipine besylate- 1 ST 1 valsartan tabs hydrochlorothiazide tabs lisinopril & amlodipine-valsartan- 1 ST 1 hydrochlorothiazide tabs hydrochlorothiazide tabs ATACAND HCT TABS losartan potassium & 1 QL(1 ea daily) (Use candesartan cilexetil- NP hydrochlorothiazide tabs hydrochlorothiazide) LOTENSIN HCT TABS QL(1 ea daily) (Use benazepril & NP atenolol & chlorthalidone 1 QL(2 ea daily) tabs hydrochlorothiazide) AVALIDE TABS (Use QL(1 ea daily) LOTREL CAPS (Use QL(1 ea daily) irbesartan- NP amlodipine besylate- NP hydrochlorothiazide) benazepril hcl) AZOR TABS (Use ST MICARDIS HCT TABS QL(1 ea daily) amlodipine besylate- NP (Use telmisartan- NP olmesartan medoxomil) hydrochlorothiazide) olmesartan medoxomil- ST benazepril & 1 QL(1 ea daily) hydrochlorothiazide tabs amlodipine- 1 BENICAR HCT TABS (Use ST hydrochlorothiazide tabs olmesartan medoxomil- NP olmesartan medoxomil- 1 ST hydrochlorothiazide) hydrochlorothiazide tabs propranolol & QL(2 ea daily) bisoprolol & 1 QL(1 ea daily) 1 hydrochlorothiazide tabs hydrochlorothiazide tabs quinapril- QL(3 ea daily) candesartan cilexetil- 1 hydrochlorothiazide tabs hydrochlorothiazide tabs 10 1 captopril & QL(2 ea daily) mg-12.5 mg quinapril- QL(4 ea daily) hydrochlorothiazide tabs 15 1 mg-25 mg, 15 mg-50 mg, hydrochlorothiazide tabs 1 25 mg-25 mg 12.5 mg-20 mg captopril & QL(3 ea daily) quinapril- QL(2 ea daily) hydrochlorothiazide tabs 25 1 hydrochlorothiazide tabs 20 1 mg-50 mg mg-25 mg DIOVAN HCT TABS (Use QL(1 ea daily) TARKA TBCR (Use NP valsartan- NP trandolapril-verapamil hcl) hydrochlorothiazide) telmisartan-amlodipine tabs 1 enalapril maleate & 1 QL(2 ea daily) hydrochlorothiazide tabs telmisartan- 1 QL(1 ea daily) hydrochlorothiazide tabs

MHS Indiana Preferred Drug List Updated June 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TENORETIC 100 TABS QL(2 ea daily) chloroquine phosphate tabs 1 QL(1 ea daily) (Use atenolol & NP 500 mg chlorthalidone) hydroxychloroquine sulfate 1 TENORETIC 50 TABS QL(2 ea daily) tabs (Use atenolol & NP KRINTAFEL TABS 2 QL(2 ea per 30 chlorthalidone) days retail) trandolapril-verapamil hcl 1 tbcr mefloquine hcl tabs 1 TRIBENZOR TABS (Use ST PLAQUENIL TABS (Use NP olmesartan medoxomil- NP hydroxychloroquine sulfate) amlodipine- hydrochlorothiazide) primaquine phosphate tabs 1 TWYNSTA TABS (Use NP PRIMAQUINE telmisartan-amlodipine) PHOSPHATE TABS (Use NP primaquine phosphate) valsartan- 1 QL(1 ea daily) hydrochlorothiazide tabs ANTIMYASTHENIC/CHOLINERGIC AGENTS VASERETIC TABS (Use QL(2 ea daily) enalapril maleate & NP Antimyasthenic/Cholinergic Agents hydrochlorothiazide) MESTINON TABS 60 MG ZESTORETIC TABS (Use (Use pyridostigmine NP lisinopril & NP bromide) hydrochlorothiazide) MESTINON TIMESPAN ZIAC TABS (Use bisoprolol NP QL(1 ea daily) TBCR (Use pyridostigmine NP & hydrochlorothiazide) bromide) Antihypertensives - Misc. pyridostigmine bromide 1 tabs 60 mg VECAMYL TABS 2 PA; SP pyridostigmine bromide tbcr 1 Direct Renin Inhibitors 180 mg PA; QL(10 ea TEKTURNA TABS (Use NF RUZURGI TABS 2 aliskiren fumarate) daily) Vasodilators ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) hydralazine hcl tabs or 100 1 mg, 50 mg, 10 mg, 25 mg Antimycobacterial Agents minoxidil tabs 10 mg 1 QL(10 ea daily) ethambutol hcl tabs 1 minoxidil tabs 2.5 mg 1 QL(3 ea daily) isoniazid syrp or 50 mg/5ml 1

ANTIMALARIALS - Drugs to Treat Malaria isoniazid tabs or 100 mg, 1 (Parasitic Infections) 300 mg MYAMBUTOL TABS (Use NP Antimalarial Combinations ethambutol hcl) COARTEM TABS 2 QL(24 ea per fill retail) pyrazinamide tabs 1

Antimalarials RIFADIN CAPS OR 150 NP MG, 300 MG (Use rifampin) chloroquine phosphate 1 tabs 250 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits rifampin caps or 150 mg, 1 decitabine solr 1 PA; SP 300 mg GEMCITABINE TRECATOR TABS 2 HYDROCHLORIDE SOLN 1 GM/10ML, 2 GM/20ML, NF ANTINEOPLASTICS AND ADJUNCTIVE 200 MG/2ML (Use THERAPIES - Drugs to Treat Cancer gemcitabine hcl) Alkylating Agents mercaptopurine tabs 1 ALKERAN SOLR IV 50 MG NP PA; SP (Use melphalan hcl) methotrexate sodium soln ij 250 mg/10ml, 50 mg/2ml, 1 1 ALKERAN TABS OR 2 MG NP (Use melphalan) gm/40ml PA; SP methotrexate sodium tabs 1 BELRAPZO SOLN 2 or 2.5 mg BENDAMUSTINE 2 PA; SP PURIXAN SUSP 2 HYDROCHLORIDE SOLN PA; SP BENDEKA SOLN 2 PA; SP TABLOID TABS 2

CYCLOPHOSPHAMIDE 2 TREXALL TABS 2 TABS OR 25 MG, 50 MG VIDAZA SUSR (Use NP PA; SP LEUKERAN TABS 2 azacitidine) PA; SP XELODA TABS (Use NP PA; SP melphalan hcl solr 1 capecitabine) melphalan tabs 1 Antineoplastic - Angiogenesis Inhibitors AVASTIN SOLN 2 PA; SP MYLERAN TABS 2 PA; SP TEMODAR CAPS OR 100 PA INLYTA TABS 2 MG, 140 MG, 180 MG, 20 NP PA; SP MG, 250 MG, 5 MG (Use ZALTRAP SOLN 2 temozolomide) Antineoplastic - Anti-HER2 Agents TEMODAR SOLR IV 100 2 PA MG PERJETA SOLN 2 PA; SP PA temozolomide caps 1 Antineoplastic - Antibodies TEPADINA SOLR (Use NF ADCETRIS SOLR 2 PA; SP thiotepa) PA; SP TREANDA SOLR 2 PA; SP ARZERRA CONC 2 Antimetabolites KADCYLA SOLR 2 PA; SP PA; SP azacitidine susr 1 RITUXAN SOLN 2 PA; SP PA; SP capecitabine tabs 1 YERVOY SOLN 2 PA; SP DACOGEN SOLR (Use NP PA; SP decitabine) Antineoplastic - Cellular Immunotherapy

MHS Indiana Preferred Drug List Updated June 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KYMRIAH SUSP CO ERLEADA TABS 2 PA; SP

YESCARTA SUSP CO exemestane tabs 1 PA; SP

Antineoplastic - EGFR Inhibitors FARESTON TABS (Use NP PA toremifene citrate) ERBITUX SOLN 2 PA; SP FASLODEX SOLN (Use NF fulvestrant) erlotinib hcl tabs 1 PA; SP FEMARA TABS (Use NP letrozole) GILOTRIF TABS 2 PA; SP FIRMAGON SOLR 2 PA; SP TARCEVA TABS (Use NP PA; SP erlotinib hcl) flutamide caps 1 VECTIBIX SOLN 2 PA; SP PA; Limit 5ml Antineoplastic - Hedgehog Pathway Inhibitors per hydroxyprogesterone month;QL(0.16 caproate (antineoplastic) 1 ERIVEDGE CAPS 2 PA; SP 7 ml daily); soln AL(At least 16 ODOMZO CAPS 2 PA; SP yrs old); SP Antineoplastic - Hormonal and Related Agents letrozole tabs 1 abiraterone acetate tabs PA; SP QL(1 ea per 28 1 leuprolide acetate kit 1 250 mg days retail); SP anastrozole tabs 1 LUPRON DEPOT (1- 2 QL(1 ea per 28 MONTH) KIT days retail); SP ARIMIDEX TABS (Use NP LUPRON DEPOT (3- 2 QL(1 ea per 84 anastrozole) MONTH) KIT days retail); SP AROMASIN TABS (Use NP PA; SP QL(1 ea per exemestane) LUPRON DEPOT (4- 2 MONTH) KIT 112 days bicalutamide tabs 1 QL(1 ea daily) retail); SP QL(1 ea per CASODEX TABS (Use QL(1 ea daily) LUPRON DEPOT (6- 2 NP MONTH) KIT 168 days bicalutamide) retail); SP DEPO-PROVERA SUSP 2 LYSODREN TABS 2 PA; SP

ELIGARD KIT 22.5 MG 2 QL(1 ea per 84 days retail); SP megestrol acetate susp 1 QL(1 ea per megestrol acetate tabs 1 ELIGARD KIT 30 MG 2 112 days retail); SP tamoxifen citrate tabs $0 PV QL(1 ea per ELIGARD KIT 45 MG 2 168 days toremifene citrate tabs 1 PA retail); SP TRELSTAR MIXJECT QL(1 ea per 84 ELIGARD KIT 7.5 MG 2 QL(1 ea per 28 2 days retail); SP SUSR 11.25 MG days retail); SP EMCYT CAPS 2 PA; SP

MHS Indiana Preferred Drug List Updated June 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea per AFINITOR TABS 2.5 MG, 5 PA; SP TRELSTAR MIXJECT 2 MG, 7.5 MG (Use NP SUSR 22.5 MG 168 days retail); SP everolimus) TRELSTAR MIXJECT 2 QL(1 ea per 28 BALVERSA TABS 2 PA SUSR 3.75 MG days retail); SP QL(1 ea per BOSULIF TABS 100 MG, 2 PA; SP VANTAS KIT 2 365 days 500 MG retail); SP BRAFTOVI CAPS 2 PA XTANDI CAPS 40 MG 2 PA; SP COTELLIC TABS 2 PA; SP QL(1 ea per 84 ZOLADEX IMPL 10.8 MG 2 days retail); SP everolimus tabs 1 PA; SP QL(1 ea per 28 ZOLADEX IMPL 3.6 MG 2 days retail); SP FARYDAK CAPS 2 PA; SP ZYTIGA TABS 250 MG NP PA; SP (Use abiraterone acetate) GLEEVEC TABS (Use NP PA; SP imatinib mesylate) Antineoplastic - Immunomodulators IBRANCE CAPS 100 MG, 2 PA; SP POMALYST CAPS 2 PA; SP 125 MG, 75 MG IBRANCE TABS 100 MG, 2 PA Antineoplastic - XPO1 Inhibitors 125 MG, 75 MG ICLUSIG TABS 10 MG, 15 PA; QL(1 ea XPOVIO 100 MG ONCE 2 PA 2 WEEKLY TBPK MG, 30 MG, 45 MG daily); SP PA; SP XPOVIO 60 MG ONCE 2 PA imatinib mesylate tabs 1 WEEKLY TBPK ISTODAX (OVERFILL) PA; SP XPOVIO 80 MG ONCE 2 PA 2 WEEKLY TBPK SOLR PA; SP XPOVIO 80 MG TWICE 2 PA JAKAFI TABS 2 WEEKLY TBPK PA Antineoplastic Antibiotics KYPROLIS SOLR 60 MG 2 DAUNORUBICIN lapatinib ditosylate tabs 1 PA; SP HYDROCHLORIDE SOLN NF 20 MG/4ML (Use PA; SP daunorubicin hcl) MEKINIST TABS 2 mitoxantrone hcl conc 1 PA; SP MEKTOVI TABS 2 PA valrubicin soln 1 PA; SP NEXAVAR TABS 2 PA; SP

VALSTAR SOLN (Use NP PA; SP NINLARO CAPS 2 PA; SP valrubicin) Antineoplastic Enzyme Inhibitors PIQRAY 200MG DAILY 2 PA DOSE TBPK AFINITOR DISPERZ TBSO 2 PA; SP PIQRAY 250MG DAILY 2 PA DOSE TBPK AFINITOR TABS 10 MG 2 PA; SP PIQRAY 300MG DAILY 2 PA DOSE TBPK

MHS Indiana Preferred Drug List Updated June 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROMIDEPSIN SOLR 10 2 PA; SP PROLEUKIN SOLR 2 PA; SP MG PA; SP SPRYCEL TABS 2 PA; SP SYLATRON KIT 2 PA; SP STIVARGA TABS 2 PA; SP SYNRIBO SOLR 2 PA; SP TARGRETIN CAPS OR 75 NP PA; SP SUTENT CAPS 2 MG (Use bexarotene) TAFINLAR CAPS 2 PA; SP tretinoin (chemotherapy) 1 PA; SP caps TASIGNA CAPS 150 MG, 2 PA; SP Chemotherapy Adjuncts 200 MG KEPIVANCE SOLR 2 PA temsirolimus soln 1 PA; SP Chemotherapy Rescue/Antidote/Protective Agents TORISEL SOLN (Use NP PA; SP temsirolimus) FUSILEV SOLR (Use NP PA; SP levoleucovorin calcium) TYKERB TABS (Use NP PA; SP lapatinib ditosylate) leucovorin calcium tabs or 1 25 mg, 5 mg, 10 mg, 15 mg VELCADE SOLR 2 PA; SP levoleucovorin calcium soln 1 PA; SP VOTRIENT TABS 2 PA; SP levoleucovorin calcium solr 1 PA; SP XALKORI CAPS 2 PA; SP mesna soln 1 PA; SP ZELBORAF TABS 2 PA; SP MESNEX SOLN IV 100 NP PA; SP MG/ML (Use mesna) ZOLINZA CAPS 2 PA; SP MESNEX TABS OR 400 2 PA; SP ZYKADIA CAPS 2 PA; SP MG Mitotic Inhibitors Antineoplastic Enzymes etoposide caps or 50 mg 1 PA ONCASPAR SOLN 2 PA; SP etoposide soln iv 100 1 PA Antineoplastics Misc. mg/5ml ACTIMMUNE SOLN 2 PA; SP HALAVEN SOLN 2 PA; SP bexarotene caps 1 PA; SP IXEMPRA KIT SOLR 2 PA; SP PA; SP HYDREA CAPS (Use NP JEVTANA SOLN 2 hydroxyurea) TAXOTERE CONC (Use NF hydroxyurea caps 1 docetaxel) INTRON A SOLN 2 PA; SP Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 2 PA; SP INTRON A SOLR 2 PA; SP MG, 1 MG PA; SP HYCAMTIN SOLR IV 4 MG NP PA; SP MATULANE CAPS 2 (Use topotecan hcl)

MHS Indiana Preferred Drug List Updated June 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits topotecan hcl soln 4 1 PA; SP PARLODEL CAPS (Use NP mg/4ml bromocriptine mesylate) TOPOTECAN HCL SOLN 2 PA; SP PARLODEL TABS (Use NP 4 MG/4ML bromocriptine mesylate) TOPOTECAN HCL SOLN PA; SP pramipexole QL(3 ea daily); 4 MG/4ML (Use topotecan NP dihydrochloride tabs 0.125 1 AL(At least 18 hcl) mg, 0.25 mg, 0.5 mg, 0.75 yrs old) mg, 1 mg, 1.5 mg topotecan hcl solr 4 mg 1 PA; SP ropinirole hydrochloride 1 QL(6 ea daily) ANTIPARKINSON AND RELATED THERAPY tabs 0.25 mg, 3 mg, 4 mg AGENTS - Drugs to Treat Parkinson's Disease ropinirole hydrochloride QL(3 ea daily) tabs 0.5 mg, 1 mg, 2 mg, 5 1 Antiparkinson Adjunctive Therapy mg carbidopa tabs 1 SINEMET CR TBCR (Use NP carbidopa-levodopa) LODOSYN TABS (Use NP carbidopa) SINEMET TABS (Use NP carbidopa-levodopa) Antiparkinson Anticholinergics STALEVO 100 TABS (Use benztropine mesylate soln 1 carbidopa-levodopa- NF entacapone) benztropine mesylate tabs 1 STALEVO 125 TABS (Use carbidopa-levodopa- NF COGENTIN SOLN (Use NP entacapone) benztropine mesylate) STALEVO 150 TABS (Use trihexyphenidyl hcl soln 0.4 1 QL(16.67 ml carbidopa-levodopa- NF mg/ml daily) entacapone) trihexyphenidyl hcl tabs 2 1 STALEVO 200 TABS (Use mg, 5 mg carbidopa-levodopa- NF Antiparkinson Dopaminergics entacapone) STALEVO 50 TABS (Use amantadine hcl caps 100 1 mg carbidopa-levodopa- NF entacapone) amantadine hcl syrp 50 1 mg/5ml STALEVO 75 TABS (Use carbidopa-levodopa- NF bromocriptine mesylate 1 entacapone) caps Antiparkinson Monoamine Oxidase Inhibitors bromocriptine mesylate 1 tabs selegiline hcl caps or 1 carbidopa-levodopa tabs 10 mg-100 mg, 100 mg-25 1 SELEGILINE HCL POWD 2 mg, 25 mg-250 mg XX carbidopa-levodopa tbcr selegiline hcl tabs or 1 100 mg-25 mg, 200 mg-50 1 mg ANTIPSYCHOTICS/ANTIMANIC AGENTS - MIRAPEX TABS (Use QL(3 ea daily); Drugs to Treat Mood Disorders pramipexole NP AL(At least 18 Antimanic Agents dihydrochloride) yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lithium carbonate caps or 1 QL(1 ea 300 mg, 150 mg, 600 mg VRAYLAR CPPK 2 daily,28 day(s) limit) LITHIUM CARBONATE 2 POWD XX QL(2 ea daily); ziprasidone hcl caps 20 1 AL(At least 10 lithium carbonate tabs or 1 mg, 40 mg 300 mg yrs old) lithium carbonate tbcr or QL(3 ea daily); 1 ziprasidone hcl caps 60 1 AL(At least 10 300 mg, 450 mg mg, 80 mg yrs old) LITHIUM SOLN 2 AL(At least 18 ziprasidone mesylate solr 1 yrs old) LITHOBID TBCR (Use NP lithium carbonate) Benzisoxazoles Antipsychotics - Misc. QL(2 ea daily); QL(1 ea daily); FANAPT TABS 2 AL(At least 18 CAPLYTA CAPS 2 AL(At least 18 yrs old) yrs old) QL(2 ea daily); FANAPT TITRATION 2 QL(4 ea daily) PACK TABS AL(At least 18 EQUETRO CP12 100 MG 2 yrs old) QL(8 ea daily) Limit 1 syringe EQUETRO CP12 200 MG 2 each QL(5 ea daily) INVEGA SUSTENNA 2 month;QL(0.02 EQUETRO CP12 300 MG 2 SUSY 117 MG/0.75ML 7 ml daily); GEODON CAPS OR 20 QL(2 ea daily); AL(At least 18 MG, 40 MG (Use NP AL(At least 10 yrs old) ziprasidone hcl) yrs old) Limit 1 syringe GEODON CAPS OR 60 QL(3 ea daily); each MG, 80 MG (Use NP AL(At least 10 INVEGA SUSTENNA 2 month;QL(0.03 ziprasidone hcl) yrs old) SUSY 156 MG/ML 6 ml daily); AL(At least 18 GEODON SOLR IM 20 MG NP AL(At least 18 yrs old) (Use ziprasidone mesylate) yrs old) Limit 1 syringe QL(1 ea daily); each LATUDA TABS 120 MG, 2 AL(At least 10 20 MG, 40 MG, 60 MG INVEGA SUSTENNA 2 month;QL(0.05 yrs old) SUSY 234 MG/1.5ML 4 ml daily); QL(2 ea daily); AL(At least 18 LATUDA TABS 80 MG 2 AL(At least 10 yrs old) yrs old) Limit 1 syringe NUPLAZID CAPS 2 QL(1 ea daily) each INVEGA SUSTENNA 2 month;QL(0.00 NUPLAZID TABS 2 QL(1 ea daily) SUSY 39 MG/0.25ML 9 ml daily); AL(At least 18 QL(2 ea daily); yrs old) VRAYLAR CAPS 1.5 MG 2 AL(At least 18 Limit 1 syringe yrs old) each QL(1 ea daily); INVEGA SUSTENNA 2 month;QL(0.01 VRAYLAR CAPS 3 MG, 2 SUSY 78 MG/0.5ML 8 ml daily); 4.5 MG, 6 MG AL(At least 18 yrs old) AL(At least 18 yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 18 INVEGA TB24 1.5 MG, 3 QL(1 ea daily) haloperidol decanoate soln 1 MG, 9 MG (Use NP yrs old) paliperidone) haloperidol lactate conc 1 INVEGA TB24 6 MG (Use NP QL(2 ea daily) paliperidone) haloperidol lactate soln 1 Limit 1 syringe every 3 haloperidol tabs or 0.5 mg, QL(3 ea daily) months;1 rtl 1 mg, 10 mg, 2 mg, 20 mg, 1 pack lmt 5 mg INVEGA TRINZA SUSY 2 amt,84 rtl pack Dibenzapines lmt day(s),; AL(At least 18 ADASUVE AEPB 2 yrs old) asenapine maleate subl 10 1 QL(2 ea daily) paliperidone tb24 1.5 mg, 3 1 QL(1 ea daily) mg, 2.5 mg, 5 mg mg, 9 mg QL(6 ea daily); paliperidone tb24 6 mg 1 QL(2 ea daily) clozapine tabs 100 mg 1 AL(At least 18 yrs old) QL(1 ea per 28 days retail); QL(3 ea daily); PERSERIS PRSY 2 clozapine tabs 200 mg, 25 1 AL(At least 18 AL(At least 18 mg, 50 mg yrs old) yrs old) QL(0.072 ea QL(6 ea daily); clozapine tbdp 100 mg 1 AL(At least 18 RISPERDAL CONSTA 2 daily); AL(At SRER least 18 yrs yrs old) old) QL(3 ea daily); clozapine tbdp 12.5 mg, 1 AL(At least 18 RISPERDAL SOLN 1 NP QL(8 ml daily) 150 mg, 200 mg, 25 mg MG/ML (Use risperidone) yrs old) RISPERDAL TABS 0.25 QL(2 ea daily) QL(6 ea daily); CLOZARIL TABS 100 MG NP AL(At least 18 MG, 0.5 MG, 1 MG, 2 MG, NP (Use clozapine) 3 MG, 4 MG (Use yrs old) risperidone) CLOZARIL TABS 200 MG, QL(3 ea daily); QL(8 ml daily) 25 MG, 50 MG (Use NP AL(At least 18 risperidone soln 1 mg/ml 1 clozapine) yrs old) risperidone tabs 0.25 mg, QL(2 ea daily) QL(6 ea daily); FAZACLO TBDP 100 MG NP AL(At least 18 0.5 mg, 1 mg, 2 mg, 3 mg, 1 (Use clozapine) 4 mg yrs old) risperidone tbdp 0.25 mg, QL(2 ea daily) FAZACLO TBDP 12.5 MG, QL(3 ea daily); 0.5 mg, 1 mg, 2 mg, 3 mg, 1 150 MG, 200 MG, 25 MG NP AL(At least 18 4 mg (Use clozapine) yrs old) Butyrophenones QL(4 ea daily); loxapine succinate caps 1 AL(At least 18 HALDOL DECANOATE AL(At least 18 yrs old) 100 SOLN (Use haloperidol NP yrs old) decanoate) olanzapine solr im 10 mg 1 HALDOL DECANOATE 50 AL(At least 18 olanzapine tabs or 10 mg, 1 QL(2 ea daily) SOLN (Use haloperidol NP yrs old) 15 mg decanoate) olanzapine tabs or 2.5 mg, 1 QL(1 ea daily) HALDOL SOLN (Use NP 5 mg, 7.5 mg haloperidol lactate) MHS Indiana Preferred Drug List Updated June 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine tabs or 20 mg 1 QL(3 ea daily) SEROQUEL XR TB24 50 QL(2 ea daily) MG (Use quetiapine NP fumarate) olanzapine tbdp or 10 mg, 1 QL(2 ea daily) 15 mg QL(12 ml olanzapine tbdp or 20 mg 1 QL(3 ea daily) 2 daily); AL(At VERSACLOZ SUSP least 18 yrs old) olanzapine tbdp or 5 mg 1 QL(1 ea daily) QL(0.072 ea quetiapine fumarate tabs QL(3 ea daily) ZYPREXA RELPREVV 2 daily); AL(At 100 mg, 50 mg, 200 mg, 25 1 SUSR 210 MG, 300 MG least 18 yrs mg old) quetiapine fumarate tabs 1 QL(4 ea daily) QL(0.036 ea 300 mg, 400 mg ZYPREXA RELPREVV 2 daily); AL(At SUSR 405 MG least 18 yrs quetiapine fumarate tb24 1 QL(1 ea daily) 150 mg, 200 mg old) ZYPREXA SOLR IM 10 quetiapine fumarate tb24 1 QL(3 ea daily) NP 300 mg MG (Use olanzapine) ZYPREXA TABS OR 10 QL(2 ea daily) quetiapine fumarate tb24 1 QL(4 ea daily) 400 mg MG, 15 MG (Use NP olanzapine) quetiapine fumarate tb24 1 QL(2 ea daily) 50 mg ZYPREXA TABS OR 2.5 QL(1 ea daily) MG, 5 MG, 7.5 MG (Use NP SAPHRIS SUBL 10 MG, QL(2 ea daily) olanzapine) 2.5 MG (Use asenapine NP maleate) ZYPREXA TABS OR 20 NP QL(3 ea daily) MG (Use olanzapine) SAPHRIS SUBL 5 MG NF (Use asenapine maleate) ZYPREXA ZYDIS TBDP 10 QL(2 ea daily) MG, 15 MG (Use NP QL(1 ea daily); olanzapine) SECUADO PT24 2 AL(At least 18 yrs old) ZYPREXA ZYDIS TBDP 20 NP QL(3 ea daily) MG (Use olanzapine) SEROQUEL TABS 100 QL(3 ea daily) ZYPREXA ZYDIS TBDP 5 QL(1 ea daily) MG, 50 MG, 200 MG, 25 NP NP MG (Use quetiapine MG (Use olanzapine) fumarate) Dihydroindolones SEROQUEL TABS 300 QL(4 ea daily) molindone hcl tabs 10 mg, 1 QL(4 ea daily) MG, 400 MG (Use NP 5 mg quetiapine fumarate) QL(9 ea daily) SEROQUEL XR TB24 150 QL(1 ea daily) molindone hcl tabs 25 mg 1 MG, 200 MG (Use NP quetiapine fumarate) Phenothiazines SEROQUEL XR TB24 300 QL(3 ea daily) chlorpromazine hcl soln ij 1 MG (Use quetiapine NP 25 mg/ml, 50 mg/2ml fumarate) chlorpromazine hcl tabs or QL(4 ea daily) SEROQUEL XR TB24 400 QL(4 ea daily) 10 mg, 100 mg, 200 mg, 25 1 MG (Use quetiapine NP mg, 50 mg fumarate) fluphenazine decanoate 1 AL(At least 18 soln yrs old) fluphenazine hcl conc or 5 1 AL(At least 18 mg/ml yrs old) MHS Indiana Preferred Drug List Updated June 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluphenazine hcl elix or 2.5 1 AL(At least 18 aripiprazole tabs 10 mg, 15 1 QL(1 ea daily) mg/5ml yrs old) mg, 2 mg, 30 mg fluphenazine hcl soln ij 2.5 1 AL(At least 18 aripiprazole tabs 20 mg 1 QL(2 ea daily) mg/ml yrs old) QL(1.5 ea QL(4 ea daily); aripiprazole tabs 5 mg 1 fluphenazine hcl tabs or 1 1 AL(At least 18 daily) mg, 10 mg, 2.5 mg, 5 mg yrs old) aripiprazole tbdp 10 mg, 15 1 QL(2 ea daily) QL(4 ea daily); mg perphenazine tabs 1 AL(At least 12 Limit 1 syringe yrs old) each month;QL(2.4 prochlorperazine edisylate 1 soln ARISTADA INITIO PRSY 2 ml per 180 days retail); PROCHLORPERAZINE 2 MALEATE POWD XX AL(At least 18 yrs old) prochlorperazine maleate 1 tabs or 10 mg, 5 mg 1 rtl pack lmt amt,56 rtl pack ARISTADA PRSY 1064 prochlorperazine supp 1 2 lmt day(s),; MG/3.9ML AL(At least 18 thioridazine hcl tabs 1 QL(4 ea daily) yrs old) Limit 1 syringe trifluoperazine hcl tabs 1 1 QL(2 ea daily) each mg, 2 mg, 5 mg ARISTADA PRSY 441 2 month;QL(0.05 trifluoperazine hcl tabs 10 1 QL(4 ea daily) MG/1.6ML 7 ml daily); mg AL(At least 18 Quinolinone Derivatives yrs old) QL(0.36 ea Limit 1 syringe daily,1 ea per each ABILIFY MAINTENA PRSY 2 28 days retail); ARISTADA PRSY 662 2 month;QL(0.08 AL(At least 18 MG/2.4ML 6 ml daily); yrs old) AL(At least 18 yrs old) QL(0.36 ea daily,1 ea per Limit 1 syringe ABILIFY MAINTENA SRER 2 28 days retail); each AL(At least 18 ARISTADA PRSY 882 2 month;QL(0.11 yrs old) MG/3.2ML 43 ml daily); AL(At least 18 QL(1 ea daily); yrs old) ABILIFY MYCITE TABS 2 AL(At least 18 yrs old) QL(1 ea daily); REXULTI TABS 2 AL(At least 18 ABILIFY TABS 10 MG, 15 QL(1 ea daily) yrs old) MG, 2 MG, 30 MG (Use NP aripiprazole) Thioxanthenes QL(3 ea daily) ABILIFY TABS 20 MG (Use NP QL(2 ea daily) thiothixene caps 1 aripiprazole) ABILIFY TABS 5 MG (Use NP QL(1.5 ea ANTISEPTICS & DISINFECTANTS aripiprazole) daily) Antiseptics & Disinfectants aripiprazole soln 1 mg/ml 1 QL(30 ml daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(90 ml per ATRIPLA TABS (Use QL(1 ea daily) formaldehyde soln 10 % 1 fill retail) efavirenz-emtricitabine- NP tenofovir disoproxil Chlorine Antiseptics fumarate) chlorhexidine gluconate 1 QL(1 ea daily) liqd 4 % BIKTARVY TABS 2 DAKINS SOLUTION FULL QL(1 ea daily) STRENGTH SOLN (Use NP CIMDUO TABS 2 sodium hypochlorite) COMBIVIR TABS (Use NP QL(2 ea daily) DAKINS SOLUTION HALF lamivudine-zidovudine) STRENGTH SOLN (Use NP COMPLERA TABS 2 ST; QL(1 ea sodium hypochlorite) daily) DAKINS SOLUTION CRIXIVAN CAPS 200 MG 2 QL(9 ea daily) QUARTER STRENGTH NP SOLN (Use sodium QL(6 ea daily) hypochlorite) CRIXIVAN CAPS 400 MG 2 HIBICLENS LIQD (Use NP DELSTRIGO TABS 2 ST; QL(1 ea chlorhexidine gluconate) daily) sodium hypochlorite soln 1 DESCOVY TABS 2 QL(1 ea daily)

Iodine Antiseptics didanosine cpdr 1 QL(1 ea daily) BETADINE SOLN 10 % NP (Use povidone-iodine) DOVATO TABS 2 QL(1 ea daily) povidone-iodine soln 10 % 1 EDURANT TABS 2 QL(1 ea daily) ANTIVIRALS - Drugs to Treat Viral Infections efavirenz caps 200 mg 1 QL(1 ea daily) Antiretrovirals efavirenz caps 50 mg 1 QL(2 ea daily) abacavir sulfate soln 20 1 QL(30 ml daily) mg/ml efavirenz tabs 600 mg 1 QL(1 ea daily) abacavir sulfate tabs 300 1 QL(2 ea daily) mg efavirenz-emtricitabine- QL(1 ea daily) tenofovir disoproxil 1 abacavir sulfate-lamivudine 1 QL(1 ea daily) tabs fumarate tabs efavirenz-lamivudine- QL(1 ea daily) abacavir sulfate- 1 QL(2 ea daily) lamivudine-zidovudine tabs tenofovir disoproxil 1 fumarate tabs APTIVUS CAPS 250 MG 2 QL(4 ea daily) emtricitabine caps 1 QL(1 ea daily) APTIVUS SOLN 100 2 QL(10 ml daily) MG/ML emtricitabine-tenofovir 1 QL(1 ea daily) disoproxil fumarate tabs atazanavir sulfate caps 150 1 QL(2 ea daily) mg, 200 mg EMTRIVA CAPS 200 MG NP QL(1 ea daily) (Use emtricitabine) atazanavir sulfate caps 300 1 mg EMTRIVA SOLN 10 2 QL(24 ml daily) MG/ML EPIVIR SOLN 10 MG/ML NP QL(30 ml daily) (Use lamivudine)

MHS Indiana Preferred Drug List Updated June 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPIVIR TABS 150 MG NP QL(2 ea daily) LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily) (Use lamivudine) LEXIVA TABS 700 MG QL(4 ea daily) EPIVIR TABS 300 MG NP QL(1 ea daily) (Use lamivudine) (Use fosamprenavir NP EPZICOM TABS (Use QL(1 ea daily) calcium) abacavir sulfate- NP lopinavir-ritonavir soln 1 QL(16 ml daily) lamivudine) QL(40 ml daily) EVOTAZ TABS 2 QL(1 ea daily) nevirapine susp 50 mg/5ml 1 QL(2 ea daily) fosamprenavir calcium tabs 1 QL(4 ea daily) nevirapine tabs 200 mg 1 QL(3 ea daily) FUZEON SOLR 2 nevirapine tb24 100 mg 1 QL(1 ea daily) GENVOYA TABS 2 QL(1 ea daily) nevirapine tb24 400 mg 1

INTELENCE TABS 100 2 QL(4 ea daily) NORVIR PACK 100 MG 2 MG, 25 MG NORVIR SOLN 80 MG/ML 2 QL(15 ml daily) INTELENCE TABS 200 2 QL(2 ea daily) MG NORVIR TABS 100 MG NP QL(12 ea daily) INVIRASE TABS 2 QL(4 ea daily) (Use ritonavir) ST; QL(1 ea ODEFSEY TABS 2 ISENTRESS CHEW 100 2 QL(6 ea daily) daily) MG PIFELTRO TABS 2 QL(1 ea daily) ISENTRESS CHEW 25 MG 2 QL(12 ea daily) PREZCOBIX TABS 2 QL(1 ea daily) ISENTRESS HD TABS 2 QL(2 ea daily) PREZISTA SUSP 100 2 QL(12 ml daily) ISENTRESS PACK 100 2 QL(2 ea daily) MG/ML MG PREZISTA TABS 150 MG 2 QL(3 ea daily) ISENTRESS TABS 400 2 QL(2 ea daily) MG PREZISTA TABS 600 MG, 2 QL(2 ea daily) JULUCA TABS 2 QL(1 ea daily) 75 MG QL(1 ea daily) KALETRA SOLN 100 QL(16 ml daily) PREZISTA TABS 800 MG 2 MG/5ML-400 MG/5ML NP (Use lopinavir-ritonavir) RESCRIPTOR TABS 2 QL(6 ea daily) KALETRA TABS 100 MG- QL(4 ea daily) 2 RETROVIR CAPS 100 MG NP QL(6 ea daily) 25 MG (Use zidovudine) KALETRA TABS 200 MG- QL(6 ea daily) 2 RETROVIR IV INFUSION 2 50 MG SOLN QL(30 ml daily) lamivudine soln 10 mg/ml 1 RETROVIR SYRP 50 NP QL(60 ml daily) MG/5ML (Use zidovudine) QL(2 ea daily) lamivudine tabs 150 mg 1 REYATAZ CAPS 150 MG, QL(2 ea daily) 200 MG (Use atazanavir NP lamivudine tabs 300 mg 1 QL(1 ea daily) sulfate) QL(2 ea daily) REYATAZ CAPS 300 MG NP lamivudine-zidovudine tabs 1 (Use atazanavir sulfate)

MHS Indiana Preferred Drug List Updated June 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REYATAZ PACK 50 MG 2 QL(6 ea daily) TROGARZO SOLN 2 ritonavir tabs 1 QL(12 ea daily) TRUVADA TABS (Use QL(1 ea daily) emtricitabine-tenofovir NP disoproxil fumarate) SELZENTRY SOLN 20 2 QL(35 ml daily) MG/ML QL(1 ea daily); TYBOST TABS 2 AL(At least 18 SELZENTRY TABS 150 2 QL(2 ea daily) MG, 25 MG, 75 MG yrs old) QL(1 ea daily) SELZENTRY TABS 300 2 QL(4 ea daily) VIDEX EC CPDR 125 MG 2 MG VIDEX EC CPDR 200 MG, QL(1 ea daily) stavudine caps 15 mg, 20 1 QL(2 ea daily) mg, 30 mg, 40 mg 250 MG, 400 MG (Use NF didanosine) STAVUDINE CAPS 15 MG, 2 QL(2 ea daily) 20 MG, 30 MG, 40 MG VIDEXPEDIATRIC SOLR 2 QL(20 ml daily) STRIBILD TABS 2 QL(1 ea daily) VIRACEPT TABS 250 MG 2 QL(9 ea daily) SUSTIVA CAPS 200 MG NP QL(1 ea daily) (Use efavirenz) VIRACEPT TABS 625 MG 2 QL(4 ea daily) SUSTIVA CAPS 50 MG QL(2 ea daily) NP VIRAMUNE SUSP 50 NP QL(40 ml daily) (Use efavirenz) MG/5ML (Use nevirapine) SUSTIVA TABS 600 MG QL(1 ea daily) NP VIRAMUNE TABS 200 MG NP QL(2 ea daily) (Use efavirenz) (Use nevirapine) SYMFI LO TABS (Use QL(1 ea daily) VIRAMUNE XR TB24 (Use NP QL(1 ea daily) efavirenz-lamivudine- NP nevirapine) tenofovir disoproxil fumarate) VIREAD POWD 40 MG/GM 2 QL(8 gm daily) SYMFI TABS (Use QL(1 ea daily) VIREAD TABS 150 MG, 2 QL(1 ea daily) efavirenz-lamivudine- NP 200 MG, 250 MG tenofovir disoproxil fumarate) VIREAD TABS 300 MG QL(1 ea daily) (Use tenofovir disoproxil NP SYMTUZA TABS 2 ST; QL(1 ea fumarate) daily) ZIAGEN SOLN 20 MG/ML NP QL(30 ml daily) TEMIXYS TABS 2 QL(1 ea daily) (Use abacavir sulfate) ZIAGEN TABS 300 MG QL(2 ea daily) tenofovir disoproxil 1 QL(1 ea daily) NP fumarate tabs (Use abacavir sulfate) QL(6 ea daily) TIVICAY TABS 10 MG, 25 2 zidovudine caps 100 mg 1 MG zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) TIVICAY TABS 50 MG 2 QL(2 ea daily) QL(2 ea daily) QL(1 ea daily); zidovudine tabs 300 mg 1 TRIUMEQ TABS 2 AL(At least 18 yrs old) CMV Agents TRIZIVIR TABS (Use QL(2 ea daily) VALCYTE TABS 450 MG NP QL(2 ea daily) abacavir sulfate- NP (Use valganciclovir hcl) lamivudine-zidovudine) valganciclovir hcl tabs 450 1 QL(2 ea daily) mg

MHS Indiana Preferred Drug List Updated June 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Hepatitis Agents VOSEVI TABS CO adefovir dipivoxil tabs 1 PA ZEPATIER TABS CO BARACLUDE TABS 0.5 NP PA MG, 1 MG (Use entecavir) Herpes Agents QL(1.67 ea acyclovir caps 200 mg 1 DAKLINZA TABS CO daily) PA QL(13.34 ml entecavir tabs 1 acyclovir susp 200 mg/5ml 1 daily) EPCLUSA TABS 100 MG- CO QL(3 ea daily) 400 MG, 200 MG-50 MG acyclovir tabs 400 mg 1 QL(1.67 ea HARVONI PACK 150 MG- CO acyclovir tabs 800 mg 1 33.75 MG, 200 MG-45 MG daily) HARVONI TABS 200 MG- CO famciclovir tabs 1 45 MG, 400 MG-90 MG valacyclovir hcl tabs 1 gm, QL(42 ea per HEPSERA TABS (Use NP PA 1 adefovir dipivoxil) 1000 mg 21 days retail) valacyclovir hcl tabs 500 QL(2 ea daily) LEDIPASVIR/SOFOSBUVI CO 1 R TABS mg VALTREX TABS 1 GM NP QL(42 ea per MAVYRET TABS CO (Use valacyclovir hcl) 21 days retail) PEGASYS PROCLICK CO VALTREX TABS 500 MG NP QL(2 ea daily) SOLN (Use valacyclovir hcl) PEGASYS SOLN CO ZOVIRAX CAPS OR 200 NP QL(1.67 ea MG (Use acyclovir) daily) PEGINTRON KIT CO ZOVIRAX SUSP OR 200 NP QL(13.34 ml MG/5ML (Use acyclovir) daily) REBETOL SOLN CO ZOVIRAX TABS OR 400 NP QL(3 ea daily) MG (Use acyclovir) RIBASPHERE RIBAPAK CO TBPK ZOVIRAX TABS OR 800 NP QL(1.67 ea MG (Use acyclovir) daily) RIBASPHERE RIBAPAK CO PA TBPK 400 MG, 600 MG Influenza Agents FLUMADINE TABS (Use NF RIBASPHERE TABS CO rimantadine hydrochloride) ribavirin (hepatitis c) caps CO oseltamivir phosphate caps 1 QL(20 ea per or 30 mg 30 days retail) ribavirin (hepatitis c) tabs CO oseltamivir phosphate caps 1 QL(10 ea per or 45 mg, 75 mg 30 days retail) SOFOSBUVIR/VELPATAS CO oseltamivir phosphate susr 1 QL(120 ml per VIR TABS or 6 mg/ml 30 days retail) SOVALDI PACK CO RELENZA DISKHALER 2 AL(At least 6 AEPB yrs old) SOVALDI TABS CO TAMIFLU CAPS 30 MG QL(20 ea per (Use oseltamivir NP 30 days retail) VIEKIRA PAK TBPK CO phosphate)

MHS Indiana Preferred Drug List Updated June 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAMIFLU CAPS 45 MG, 75 QL(10 ea per metoprolol tartrate tabs or 1 QL(4 ea daily) MG (Use oseltamivir NP 30 days retail) 25 mg, 50 mg phosphate) TENORMIN TABS (Use NP QL(2 ea daily) TAMIFLU SUSR 6 MG/ML QL(120 ml per atenolol) (Use oseltamivir NP 30 days retail) TOPROL XL TB24 100 QL(4 ea daily) phosphate) MG, 25 MG, 50 MG (Use NP BETA BLOCKERS - Drugs to Treat High Blood metoprolol succinate) Pressure TOPROL XL TB24 200 MG NP QL(2 ea daily) (Use metoprolol succinate) Alpha-Beta Blockers Beta Blockers Non-Selective carvedilol phosphate cp24 1 QL(1 ea daily) BETAPACE AF TABS (Use NP QL(2 ea daily) sotalol hcl (afib/afl)) carvedilol tabs 12.5 mg, 1 QL(2 ea daily) 3.125 mg, 6.25 mg BETAPACE TABS (Use NP carvedilol tabs 25 mg 1 QL(4 ea daily) sotalol hcl) CORGARD TABS (Use NP QL(2 ea daily) COREG CR CP24 (Use NP QL(1 ea daily) nadolol) carvedilol phosphate) COREG TABS 12.5 MG, QL(2 ea daily) HEMANGEOL SOLN 2 3.125 MG, 6.25 MG (Use NP INDERAL LA CP24 (Use NP carvedilol) propranolol hcl) COREG TABS 25 MG (Use NP QL(4 ea daily) carvedilol) INDERAL XL CP24 2 labetalol hcl tabs or 100 mg 1 QL(3 ea daily) INNOPRAN XL CP24 2 labetalol hcl tabs or 200 mg 1 QL(6 ea daily) nadolol tabs 1 QL(2 ea daily) labetalol hcl tabs or 300 mg 1 QL(8 ea daily) pindolol tabs 1 Beta Blockers Cardio-Selective propranolol hcl cp24 or 60 mg, 80 mg, 120 mg, 160 1 acebutolol hcl caps 1 mg QL(2 ea daily) PROPRANOLOL HCL 2 atenolol tabs 1 POWD XX propranolol hcl soln iv 1 bisoprolol fumarate tabs or 1 QL(1 ea daily) 1 10 mg, 5 mg mg/ml LOPRESSOR TABS 100 QL(4.5 ea propranolol hcl soln or 20 1 MG (Use metoprolol NP daily) mg/5ml, 40 mg/5ml tartrate) propranolol hcl tabs or 10 LOPRESSOR TABS 50 QL(4 ea daily) mg, 20 mg, 80 mg, 40 mg, 1 MG (Use metoprolol NP 60 mg tartrate) sotalol hcl (afib/afl) tabs 1 QL(2 ea daily) metoprolol succinate tb24 1 QL(4 ea daily) 100 mg, 25 mg, 50 mg sotalol hcl tabs 1 metoprolol succinate tb24 1 QL(2 ea daily) 200 mg SOTYLIZE SOLN 2 metoprolol tartrate tabs or 1 QL(4.5 ea 100 mg daily) MHS Indiana Preferred Drug List Updated June 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits timolol maleate tabs 1 nicardipine hcl caps or 20 1 mg, 30 mg CALCIUM CHANNEL BLOCKERS - Drugs to nifedipine caps 10 mg, 20 1 QL(4 ea daily) Treat High Blood Pressure mg Calcium Channel Blockers nifedipine tb24 30 mg, 90 1 QL(1 ea daily) mg ADALAT CC TB24 30 MG, NP QL(1 ea daily) 90 MG (Use nifedipine) nifedipine tb24 60 mg 1 QL(2 ea daily) ADALAT CC TB24 60 MG NP QL(2 ea daily) (Use nifedipine) NORVASC TABS (Use NP QL(1 ea daily) amlodipine besylate) amlodipine besylate tabs 1 QL(1 ea daily) PROCARDIA CAPS (Use NP QL(4 ea daily) nifedipine) CALAN SR TBCR (Use NP QL(2 ea daily) verapamil hcl) PROCARDIA XL TB24 30 QL(1 ea daily) MG, 90 MG (Use NP CALAN TABS (Use NP QL(3 ea daily) nifedipine) verapamil hcl) PROCARDIA XL TB24 60 NP QL(2 ea daily) CARDIZEM CD CP24 120 QL(1 ea daily) MG (Use nifedipine) MG, 180 MG, 300 MG (Use NP diltiazem hcl coated beads) TIAZAC CP24 240 MG QL(2 ea daily) (Use diltiazem hcl extended NP CARDIZEM CD CP24 240 QL(2 ea daily) release beads) MG (Use diltiazem hcl NP coated beads) TIAZAC CP24 420 MG, QL(1 ea daily) 120 MG, 180 MG, 300 MG, NP CARDIZEM TABS (Use NP QL(3 ea daily) 360 MG (Use diltiazem hcl diltiazem hcl) extended release beads) diltiazem hcl coated beads QL(1 ea daily) verapamil hcl cp24 or 100 1 QL(2 ea daily) cp24 120 mg, 180 mg, 300 1 mg, 200 mg mg verapamil hcl cp24 or 300 QL(1 ea daily) diltiazem hcl coated beads 1 QL(2 ea daily) mg, 360 mg, 120 mg, 180 1 cp24 240 mg mg, 240 mg diltiazem hcl cp12 or 120 QL(2 ea daily) 1 verapamil hcl tabs or 40 1 QL(3 ea daily) mg, 60 mg, 90 mg mg, 120 mg, 80 mg diltiazem hcl cp24 or 120 QL(1 ea daily) 1 verapamil hcl tbcr or 120 1 QL(2 ea daily) mg, 180 mg mg, 180 mg, 240 mg diltiazem hcl cp24 or 240 QL(2 ea daily) 1 VERELAN CP24 (Use NP QL(1 ea daily) mg verapamil hcl) diltiazem hcl extended QL(2 ea daily) VERELAN PM CP24 100 QL(2 ea daily) release beads cp24 240 1 MG, 200 MG (Use NP mg verapamil hcl) diltiazem hcl extended QL(1 ea daily) VERELAN PM CP24 300 NP QL(1 ea daily) release beads cp24 420 1 MG (Use verapamil hcl) mg, 120 mg, 180 mg, 300 mg, 360 mg CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm diltiazem hcl tabs or 120 1 QL(3 ea daily) mg, 30 mg, 60 mg, 90 mg Cardiac Glycosides QL(1 ea daily) felodipine tb24 1 digoxin soln or 0.05 mg/ml 1

MHS Indiana Preferred Drug List Updated June 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits digoxin tabs or 0.25 mg, TRACLEER TABS 125 PA; SP 250 mcg, 0.125 mg, 125 1 MG, 62.5 MG (Use NP mcg bosentan) LANOXIN TABS OR 250 TRACLEER TBSO 32 MG 2 PA; SP MCG, 125 MCG (Use 2 digoxin) Pulmonary Hypertension - Phosphodiesterase CARDIOVASCULAR AGENTS - MISC. - Drugs to ADCIRCA TABS (Use PA; SP Treat Heart and Circulation Conditions tadalafil (pulmonary NP Cardioplegic Solutions hypertension)) REVATIO SOLN (Use PA; SP PLEGISOL SOLN (Use NF cardioplegic soln) sildenafil citrate (pulmonary NP hypertension)) Peripheral Vasodilators REVATIO SUSR (Use PA; SP isoxsuprine hcl tabs 1 sildenafil citrate (pulmonary NP hypertension)) Prostaglandin Vasodilators REVATIO TABS (Use PA; SP PA; SP sildenafil citrate (pulmonary NP epoprostenol sodium solr 1 hypertension)) sildenafil citrate (pulmonary PA; SP FLOLAN SOLR (Use NP PA; SP 1 epoprostenol sodium) hypertension) soln ORENITRAM TBCR 0.125 PA; SP sildenafil citrate (pulmonary 1 PA; SP MG, 0.25 MG, 1 MG, 2.5 2 hypertension) susr MG sildenafil citrate (pulmonary 1 PA; SP REMODULIN SOLN 2 PA; SP hypertension) tabs tadalafil (pulmonary 1 PA; SP treprostinil soln 1 PA; SP hypertension) tabs Pulmonary Hypertension - Sol Guanylate Cyclase TYVASO REFILL SOLN 2 PA; SP ADEMPAS TABS 2 PA; SP TYVASO SOLN 2 PA; SP Transthyretin Stabilizers PA; SP TYVASO STARTER SOLN 2 VYNDAMAX CAPS 2 PA; QL(1 ea daily) VELETRI SOLR (Use PA; SP NP VYNDAQEL CAPS 2 PA; QL(4 ea epoprostenol sodium) daily) PA; SP VENTAVIS SOLN 2 CEPHALOSPORINS - Drugs to Treat Bacterial Infections Pulmonary Hypertension - Endothelin Receptor Cephalosporins - 1st Generation ambrisentan tabs 1 PA; SP cefadroxil caps 1 bosentan tabs 1 PA; SP cefadroxil susr 1 LETAIRIS TABS (Use NP PA; SP ambrisentan) cefadroxil tabs 1 OPSUMIT TABS 2 PA; SP cephalexin caps 250 mg, 1 500 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cephalexin susr 125 1 BUSPIRONE 2 mg/5ml, 250 mg/5ml HYDROCHLORIDE POWD KEFLEX CAPS 250 MG, NP Bulk Chemicals - C's 500 MG (Use cephalexin) CHLORPROMAZINE HCL 2 Cephalosporins - 2nd Generation POWD XX cefaclor caps 1 CYPROHEPTADINE HCL 2 POWD XX cefaclor susr 1 Bulk Chemicals - D's cefprozil susr 125 mg/5ml, 1 AL(Up to 12 yrs DIAZEPAM POWD XX 2 250 mg/5ml old ) DIVALPROEX SODIUM 2 cefprozil tabs 250 mg, 500 1 QL(20 ea per POWD XX mg fill retail) QL(20 ea per DOXEPIN HCL POWD XX 2 cefuroxime axetil tabs 1 fill retail) DOXEPIN 2 Cephalosporins - 3rd Generation HYDROCHLORIDE POWD QL(20 ea per cefdinir caps 300 mg 1 Bulk Chemicals - F's fill retail) FLUOXETINE HCL POWD 2 cefdinir susr 125 mg/5ml, 1 XX 250 mg/5ml Bulk Chemicals - H's ceftriaxone sodium solr ij 1 1 QL(3 ea per fill gm, 250 mg, 500 mg retail) HALOPERIDOL POWD XX 2 ceftriaxone sodium solr iv 1 1 QL(3 ea per fill gm retail) HYDROXYZINE HCL 2 POWD XX CHEMICALS Bulk Chemicals - L's Bulk Chemicals - A's LORAZEPAM POWD XX 2 ALPRAZOLAM POWD XX 2 Bulk Chemicals - P's PHENELZINE SULFATE AMITRIPTYLINE HCL 2 2 POWD XX POWD XX AMITRIPTYLINE 2 Bulk Chemicals - S's HYDROCHLORIDE POWD SERTRALINE HCL POWD 2 ARGININE HCL POWD 2 RX/OTC XX Bulk Chemicals - V's L-ARGININE HCL POWD 2 RX/OTC SODIUM VALPROATE 2 Bulk Chemicals - B's POWD VALPROATE SODIUM BUPROPION HCL POWD 2 2 XX POWD XX CONTRACEPTIVES - Drugs to Prevent BUPROPION 2 HYDROCHLORIDE POWD Pregnancy BUSPIRONE HCL POWD 2 Combination Contraceptives - Oral XX desogestrel & ethinyl $0 PV estradiol tabs

MHS Indiana Preferred Drug List Updated June 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desogestrel-ethinyl $0 PV norgestrel & ethinyl PV estradiol (biphasic) tabs estradiol tabs 0.5 mg-50 $0 mcg desogestrel-ethinyl $0 PV estradiol (triphasic) tabs ORTHO TRI-CYCLEN LO PV drospirenone-ethinyl QL(1 ea daily); TABS (Use norgestimate- NP estradiol tabs 0.02 mg-3 $0 PV ethinyl estradiol (triphasic)) mg ORTHO-CYCLEN TABS PV drospirenone-ethinyl PV (Use norgestimate-ethinyl NP estradiol tabs 0.03 mg-3 $0 estradiol) mg ORTHO-NOVUM 1/35 PV ESTROSTEP FE TABS TABS (Use norethindrone NP (Use norethindrone NP & eth estradiol) acetate-ethinyl estradiol-fe) ORTHO-NOVUM 7/7/7 PV TABS (Use norethindrone- NP ethynodiol diacet & eth $0 PV estrad tabs eth estradiol (triphasic)) GENERESS FE CHEW SEASONIQUE TABS (Use QL(1 ea daily); (Use norethindrone & NP levonorgestrel-ethinyl NP PV ethinyl estradiol-fe) estradiol (91-day)) PV levonorgestrel & eth $0 PV TYBLUME CHEW $0 estradiol tabs YASMIN 28 TABS (Use PV levonorgestrel-eth estradiol $0 PV (triphasic) tabs drospirenone-ethinyl NP estradiol) levonorgestrel-ethinyl $0 QL(1 ea daily); estradiol (91-day) tabs PV YAZ TABS (Use QL(1 ea daily); drospirenone-ethinyl NP PV MIRCETTE TABS (Use PV estradiol) desogestrel-ethinyl NP estradiol (biphasic)) Combination Contraceptives - Transdermal norethin acet & estrad-fe PV norelgestromin-ethinyl $0 QL(0.11 ea tabs 1 mg-20 mcg-75 mg, $0 estradiol ptwk daily); PV 1.5 mg-30 mcg-75 mg Combination Contraceptives - Vaginal norethindrone & eth PV $0 etonogestrel-ethinyl $0 QL(1 ea per fill estradiol tabs estradiol ring retail); PV norethindrone & ethinyl $0 NUVARING RING (Use QL(1 ea per fill estradiol-fe chew etonogestrel-ethinyl NP retail); PV norethindrone acet & eth $0 PV estradiol) estra tabs Emergency Contraceptives norethindrone acetate- $0 QL(4 ea per ethinyl estradiol-fe tabs ELLA TABS $0 365 days norethindrone-eth estradiol $0 PV retail); PV (triphasic) tabs levonorgestrel (emergency $0 QL(1 ea per 21 norgestimate-ethinyl $0 PV oc) tabs days retail); PV estradiol (triphasic) tabs PLAN B ONE-STEP TABS QL(1 ea per 21 norgestimate-ethinyl $0 PV (Use levonorgestrel NP days retail); PV estradiol tabs (emergency oc)) norgestrel & ethinyl QL(2 ea daily); Progestin Contraceptives - IUD estradiol tabs 0.3 mg-30 $0 PV mcg MHS Indiana Preferred Drug List Updated June 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KYLEENA IUD $0 SP DEPO-MEDROL SUSP 40 MG/ML (Use NF LILETTA IUD $0 SP methylprednisolone acetate) SP MIRENA IUD $0 dexamethasone elix 0.5 1 mg/5ml SKYLA IUD $0 SP; PV dexamethasone sodium QL(5 ml daily) phosphate soln ij 120 1 Progestin Contraceptives - Implants mg/30ml, 20 mg/5ml, 4 mg/ml NEXPLANON IMPL $0 SP; PV DEXAMETHASONE QL(5 ml daily) Progestin Contraceptives - Injectable SODIUM PHOSPHATE 2 SOLN IJ 4 MG/ML DEPO-PROVERA QL(1 ml per fill dexamethasone soln 0.5 CONTRACEPTIVE SUSP NP retail); PV 1 (Use medroxyprogesterone mg/5ml acetate (contraceptive)) dexamethasone tabs 1 mg, DEPO-PROVERA QL(1 ml per fill 1.5 mg, 2 mg, 4 mg, 0.5 1 mg, 0.75 mg, 6 mg CONTRACEPTIVE SUSY NP retail); PV (Use medroxyprogesterone hydrocortisone tabs 1 acetate (contraceptive)) KENALOG-40 SUSP (Use DEPO-SUBQ PROVERA $0 QL(1 ml per fill NF 104 SUSY retail); PV triamcinolone acetonide) medroxyprogesterone QL(1 ml per fill MEDROL DOSEPAK TBPK NP acetate (contraceptive) $0 retail); PV (Use methylprednisolone) susp MEDROL TABS 8 MG, 4 medroxyprogesterone QL(1 ml per fill MG (Use NP acetate (contraceptive) $0 retail); PV methylprednisolone) susy methylprednisolone tabs 8 1 mg, 4 mg Progestin Contraceptives - Oral methylprednisolone tbpk 4 norethindrone $0 PV 1 (contraceptive) tabs mg ORTHO MICRONOR PV MILLIPRED TABS 5 MG 2 TABS (Use norethindrone NP (contraceptive)) PEDIAPRED SOLN (Use prednisolone sodium NP CORTICOSTEROIDS - Steroid Hormone Drugs to phosphate) Treat Systemic Swelling Conditions prednisolone sodium QL(240 ml per Glucocorticosteroids phosphate soln or 15 1 fill retail) CELESTONE-SOLUSPAN mg/5ml prednisolone sodium QL(150 ml per SUSP (Use NF betamethasone sod phosphate soln or 20 1 fill retail) phosphate & acetate) mg/5ml prednisolone sodium CORTEF TABS (Use NP hydrocortisone) phosphate soln or 5 1 mg/5ml, 6.7 mg/5ml cortisone acetate tabs 1 prednisolone soln 1

MHS Indiana Preferred Drug List Updated June 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISONE INTENSOL 2 ADVIL COLD & SINUS CONC TABS (Use NP pseudoephedrine- prednisone soln 1 ibuprofen) prednisone tabs 1 BIOSPEC DMX LIQD 2 prednisone tbpk 1 brompheniramine & QL(120 ml per phenyleph elix 1 mg/5ml-1 1 fill retail) VERIPRED 20 SOLN (Use QL(150 ml per mg/5ml-2.5 mg/5ml-2.5 prednisolone sodium NP fill retail) mg/5ml phosphate) brompheniramine & 1 QL(120 ml per Mineralocorticoids pseudoeph elix fill retail) brompheniramine & QL(120 ml per fludrocortisone acetate 1 1 tabs pseudoeph liqd fill retail) cetirizine-pseudoephedrine 1 QL(2 ea daily) COUGH/COLD/ALLERGY - Drugs to Treat tb12 Cough, Cold and Allergy Symptoms CHERACOL PLUS LIQD QL(240 ml per Antitussives (Use dextromethorphan- NP fill retail) AL(At least 10 guaifenesin) benzonatate caps 100 mg 1 yrs old) CHERACOL-D COUGH QL(240 ml per QL(30 ea per LIQD (Use NP fill retail) dextromethorphan- 1 fill retail); AL(At benzonatate caps 200 mg least 10 yrs guaifenesin) old) CLARITIN-D 12 HOUR QL(2 ea daily) DELSYM COUGH TB12 (Use loratadine & NP pseudoephedrine) CHILDRENS SUER (Use NP dextromethorphan CLARITIN-D 24 HOUR QL(1 ea daily) polistirex) TB24 (Use loratadine & NP DELSYM SUER (Use pseudoephedrine) dextromethorphan NP CLEAR COUGH PM polistirex) MULTI-SYMPTOM LIQD (Use dextromethorphan- NP dextromethorphan 1 polistirex lqcr doxylamine- acetaminophen) dextromethorphan 1 polistirex suer DAY TIME MULTI- HYCODAN SYRP (Use AL(At least 18 SYMPTOM COLD/FLU hydrocodone w/ NP yrs old) RELIEF CAPS (Use NP homatropine) dextromethorphan- phenylephrine- hydrocodone w/ AL(At least 18 acetaminophen) homatropine syrp 1.5 1 yrs old) mg/5ml-5 mg/5ml dextromethorphan- doxylamine-acetaminophen TESSALON PERLES NP AL(At least 10 liqd 10 %-15 mg/15ml-15 CAPS (Use benzonatate) yrs old) mg/15ml-500 mg/15ml-500 Cough/Cold/Allergy Combinations mg/15ml-6.25 mg/15ml- 1 6.25 mg/15ml, 1000 mg/30ml-12.5 mg/30ml-30 mg/30ml, 15 mg/15ml-500 mg/15ml-6.25 mg/15ml MHS Indiana Preferred Drug List Updated June 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- QL(240 ml per loratadine & QL(2 ea daily) guaifenesin liqd 10 mg/5ml- fill retail) pseudoephedrine tb12 120 1 200 mg/5ml, 20 mg/10ml- mg-5 mg 400 mg/10ml, 10 mg/5ml- 1 loratadine & QL(1 ea daily) 100 mg/5ml, 15 mg/7.5ml- pseudoephedrine tb24 10 1 150 mg/7.5ml, 20 mg/10ml- mg-10 mg-240 mg-240 mg 200 mg/10ml MAXI-TUSS PE MAX LIQD 2 QL(240 ml per dextromethorphan- 6 days retail) guaifenesin liqd 20 mg/5ml- 20 mg/5ml-300 mg/5ml-300 MUCINEX D MAXIMUM STRENGTH TB12 (Use mg/5ml, 200 mg/5ml-200 1 NP mg/5ml-30 mg/5ml-30 pseudoephedrine- mg/5ml, 100 mg/5ml-5 guaifenesin) mg/5ml, 20 mg/20ml-400 MUCINEX D TB12 (Use QL(210 ea per mg/20ml pseudoephedrine- NP fill retail) dextromethorphan- QL(240 ml per guaifenesin) MUCINEX DM TB12 (Use QL(2 ea guaifenesin syrp 10 1 fill retail) mg/5ml-10 mg/5ml-100 dextromethorphan- NP daily,210 ea mg/5ml-100 mg/5ml guaifenesin) per fill retail) dextromethorphan- PECGEN DMX LIQD 2 guaifenesin tabs 20 mg-20 1 mg-400 mg-400 mg phenylephrine-chlorphen- QL(240 ml per dextromethorphan- QL(2 ea dm liqd 10 mg/5ml-15 1 fill retail) guaifenesin tb12 30 mg- 1 daily,210 ea mg/5ml-4 mg/5ml QL(240 ml per 600 mg per fill retail) phenylephrine-dm liqd 1 dextromethorphan- fill retail) QL(240 ml per phenylephrine- phenylephrine-dm soln 1 fill retail) acetaminophen caps 10 1 mg-10 mg-325 mg-325 mg- QL(240 ml per 5 mg-5 mg, 10 mg-325 mg- promethazine & 1 6 days retail); 5 mg phenylephrine syrp AL(At least 2 DIMETAPP COLD & QL(120 ml per yrs old) ALLERGY ELIX (Use NP fill retail) QL(240 ml per brompheniramine & promethazine w/codeine 1 fill retail); AL(At phenyleph) soln least 18 yrs QL(240 ml per old) ED BRON GP LIQD 2 6 days retail) QL(240 ml per promethazine w/codeine fill retail); AL(At G-ZYNCOF SYRP 2 1 syrp least 18 yrs old) guaifenesin-codeine liqd 10 1 mg/5ml-100 mg/5ml QL(240 ml per promethazine-dm soln 1 fill retail); AL(At guaifenesin-codeine soln 1 10 mg/5ml-100 mg/5ml least 2 yrs old) QL(240 ml per guaifenesin-codeine syrp 1 10 mg/5ml-100 mg/5ml promethazine-dm syrp 1 fill retail); AL(At QL(240 ml per least 2 yrs old) LOHIST-D LIQD 2 fill retail) pseudoephed-bromphen- 1 QL(240 ml per dm syrp fill retail)

MHS Indiana Preferred Drug List Updated June 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pseudoephedrine w/ QL(240 ml per MUCINEX MAXIMUM codeine-gg soln 10 1 6 days retail) STRENGTH TB12 (Use NP mg/5ml-100 mg/5ml-30 guaifenesin) mg/5ml-70 % QL(2 ea MUCINEX TB12 (Use NP pseudoephedrine- guaifenesin) daily,40 ea per guaifenesin tb12 120 mg- 1 fill retail) 1200 mg Misc. Respiratory Inhalants pseudoephedrine- QL(210 ea per 1 fill retail) HYPER-SAL NEBU (Use NP guaifenesin tb12 60 mg- sodium chloride (inhalant)) 600 mg pseudoephedrine-ibuprofen HYPERSAL NEBU 7 % 1 (Use sodium chloride NP tabs (inhalant)) QC TRIACTING DAYTIME 2 QL(240 ml per sodium chloride (inhalant) CHILDRENS SYRP fill retail) nebu 0.9 %, 10 %, 3 %, 7 1 ROBITUSSIN PEAK COLD QL(240 ml per % DM SYRP (Use NP fill retail) dextromethorphan- Mucolytics guaifenesin) acetylcysteine soln 1 SUPRESS DM PEDIATRIC 2 LIQD DERMATOLOGICALS - Drugs to Treat Skin TRIAMINIC COLD & QL(240 ml per Conditions COUGH DAY TIME 2 fill retail) Acne Products CHILDRENS SYRP ABSORICA CAPS 10 MG, TRISPEC DMX LIQD 2 20 MG, 40 MG (Use NF isotretinoin) TRISPEC DMX 2 ACNE MEDICATION 10 2 PEDIATRIC LIQD LOTN ZYNCOF SYRP 2 ACNE MEDICATION 5 2 LOTN ZYRTEC-D QL(2 ea daily) BENZAC AC WASH LIQD RX/OTC ALLERGY/CONGESTION NP NP TB12 (Use cetirizine- (Use benzoyl peroxide) pseudoephedrine) BENZOYL PEROXIDE 2 CLEANSER LIQD Expectorants benzoyl peroxide crea 10 1 guaifenesin liqd 100 QL(240 ml per % mg/5ml, 200 mg/10ml, 400 1 6 days retail) mg/20ml benzoyl peroxide gel 2.5 %, 1 5 %, 10 % guaifenesin soln 100 QL(240 ml per mg/5ml, 200 mg/10ml, 300 1 6 days retail) benzoyl peroxide liqd 4 %, 1 mg/15ml 10 % RX/OTC guaifenesin syrp 100 1 QL(240 ml per benzoyl peroxide liqd 5 % 1 mg/5ml, 200 mg/10ml 6 days retail) CLEOCIN-T GEL (Use guaifenesin tb12 1200 mg 1 clindamycin phosphate NF (topical)) QL(2 ea guaifenesin tb12 600 mg 1 daily,40 ea per CLEOCIN-T LOTN (Use fill retail) clindamycin phosphate NP (topical)) MHS Indiana Preferred Drug List Updated June 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDAGEL GEL (Use QL(15 gm per clindamycin phosphate NF 1 fill retail); (topical)) tretinoin gel 0.01 % AL(Up to 35 yrs old ) clindamycin phosphate 1 AL(Up to 35 yrs (topical) gel tretinoin gel 0.025 % 1 old ) clindamycin phosphate 1 (topical) lotn Anti-inflammatory Agents - Topical clindamycin phosphate 1 diclofenac sodium (topical) 1 QL(6.68 gm (topical) soln gel 1 % daily); RX/OTC ERYGEL GEL (Use NP FLECTOR PTCH (Use NF erythromycin (acne aid)) diclofenac epolamine) erythromycin (acne aid) gel 1 VOLTAREN GEL (Use NP QL(6.68 gm diclofenac sodium (topical)) daily); RX/OTC erythromycin (acne aid) 1 soln Antibiotics - Topical QL(2 ea daily); BACIGUENT OINT EX NP isotretinoin caps 10 mg, 20 1 AL(At least 12 (Use bacitracin (topical)) mg, 40 mg yrs old) bacitracin (topical) oint 1 KLARON LOTN (Use QL(120 ml per QL(30 gm per sulfacetamide sodium NP fill retail) bacitracin zinc oint 1 (acne)) fill retail) QL(20 gm per RETIN-A CREA 0.025 %, bacitracin-polymyxin b oint 1 NP fill retail); 0.05 %, 0.1 % (Use AL(Up to 35 yrs 1 package / tretinoin) claim;QL(30 old ) CENTANY OINT 2 QL(15 gm per gm per fill retail) RETIN-A GEL 0.01 % (Use NP fill retail); tretinoin) AL(Up to 35 yrs 1 package / old ) gentamicin sulfate (topical) 1 claim;QL(30 crea gm per fill RETIN-A GEL 0.025 % NP AL(Up to 35 yrs (Use tretinoin) old ) retail) 1 package / 1 package / SODIUM claim;QL(30 gentamicin sulfate (topical) 1 claim;QL(30 SULFACETAMIDE/SULFU 2 oint gm per fill R SUSP gm per fill retail) retail) 1 package / sulfacetamide sodium 1 QL(120 ml per (acne) lotn fill retail) 1 claim;QL(30 mupirocin oint gm per fill 1 package / retail) sulfacetamide sodium w/ 1 claim;QL(60 sulfur lotn 10 %-5 % gm per fill neomycin-bacitracin- 1 QL(1 gm daily) retail) polymyxin oint QL(20 gm per neomycin-polymyxin w/ 1 QL(0.5 gm pramoxine crea daily) tretinoin crea 0.025 %, 0.05 1 fill retail); %, 0.1 % AL(Up to 35 yrs NEOSPORIN ORIGINAL QL(1 gm daily) old ) OINT (Use neomycin- NP bacitracin-polymyxin)

MHS Indiana Preferred Drug List Updated June 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOSPORIN PLUS PAIN QL(0.5 gm MICATIN CREA (Use NP QL(1.5 ml RELIEF MAXIMUM daily) miconazole nitrate (topical)) daily) STRENGTH CREA (Use NP miconazole nitrate (topical) 1 neomycin-polymyxin w/ aero pramoxine) miconazole nitrate (topical) 1 POLYSPORIN OINT (Use NP aerp bacitracin-polymyxin b) miconazole nitrate (topical) 1 QL(1.5 ml Antifungals - Topical crea daily) CICLODAN SOLUTION NF miconazole nitrate (topical) 1 KIT KIT (Use ciclopirox) powd RX/OTC clotrimazole (topical) crea 1 NIZORAL SHAM (Use NP QL(4 ml daily) ketoconazole (topical)) clotrimazole (topical) soln 1 RX/OTC 1 package / claim;QL(30 nystatin (topical) crea 1 clotrimazole w/ 1 QL(1.5 gm gm per fill betamethasone crea daily) retail) clotrimazole w/ 1 QL(1 ml daily) betamethasone lotn nystatin (topical) oint 1 QL(30 gm per econazole nitrate crea 1 nystatin (topical) powd 1 fill retail) EXELDERM CREA (Use NF nystatin-triamcinolone crea 1 sulconazole nitrate) nystatin-triamcinolone oint 1 EXELDERM SOLN (Use NF sulconazole nitrate) terbinafine hcl (topical) crea 1 ketoconazole (topical) crea 1 2 % TINACTIN AERO (Use NP ketoconazole (topical) 1 QL(4 ml daily) tolnaftate) sham 2 % TINACTIN AERP (Use NP LAMISIL AT CREA (Use NP tolnaftate) terbinafine hcl (topical)) TINACTIN CREA (Use NP QL(30 gm per LAMISIL AT JOCK ITCH tolnaftate) fill retail) CREA (Use terbinafine hcl NP TINACTIN DEODORANT NP (topical)) AERP (Use tolnaftate) LOTRIMIN AF CREA (Use RX/OTC NP TINACTIN JOCK ITCH NP clotrimazole (topical)) AERP (Use tolnaftate) LOTRIMIN AF JOCK ITCH RX/OTC CREA (Use clotrimazole NP tolnaftate aero 1 (topical)) LOTRIMIN ANTIFUNGAL tolnaftate aerp 1 AERO (Use miconazole NP QL(30 gm per tolnaftate crea 1 nitrate (topical)) fill retail) LOTRISONE CREA (Use QL(1.5 gm clotrimazole w/ NP daily) tolnaftate powd 1 betamethasone) VUSION OINT (Use LUZU CREA (Use NF miconazole-zinc oxide- NF luliconazole) white petrolatum)

MHS Indiana Preferred Drug List Updated June 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antihistamines-Topical QL(2 gm daily); tazarotene crea 1 AL(Up to 21 yrs ITCH RELIEF CREA 2 old ) QL(2 gm daily); Antineoplastic or Premalignant Lesion Agents - TAZORAC CREA 0.05 % 2 AL(Up to 21 yrs CARAC CREA (Use NP old ) fluorouracil (topical)) QL(2 gm daily); EFUDEX CREA (Use QL(40 gm per TAZORAC CREA 0.1 % NP AL(Up to 21 yrs NP (Use tazarotene) fluorouracil (topical)) fill retail) old ) fluorouracil (topical) crea 1 QL(2 gm daily); 0.5 % TAZORAC GEL 0.05 %, 2 0.1 % AL(Up to 21 yrs old ) fluorouracil (topical) crea 5 1 QL(40 gm per % fill retail) TREMFYA SOPN 2 PA fluorouracil (topical) soln 2 1 QL(10 ml per %, 5 % fill retail) VECTICAL OINT (Use NF calcitriol (topical)) TARGRETIN GEL EX 1 % 2 PA; SP Antiseborrheic Products Antipruritics - Topical OVACE PLUS WASH LIQD (Use sulfacetamide NP camphor & menthol lotn 0.5 1 %-0.5 % sodium) OVACE WASH LIQD (Use PRUDOXIN CREA (Use NF NP doxepin hcl (antipruritic)) sulfacetamide sodium) SARNA LOTN (Use NP selenium sulfide lotn 1 % 1 camphor & menthol) QL(120 ml per ZONALON CREA (Use NF selenium sulfide lotn 2.5 % 1 doxepin hcl (antipruritic)) fill retail) Antipsoriatics selenium sulfide sham 1 % 1 calcipotriene crea 1 QL(2 gm daily) SELSUN BLUE DAILY LOTN (Use selenium NP calcipotriene soln 1 QL(2 ml daily) sulfide) SELSUN BLUE LOTN (Use NP COSENTYX 2 PA; SP selenium sulfide) SENSOREADY PEN SOAJ SELSUN BLUE COSENTYX SOSY 2 PA; SP MEDICATED LOTN (Use NP selenium sulfide) DOVONEX CREA (Use NP QL(2 gm daily) calcipotriene) SELSUN BLUE MOISTURIZING LOTN NP SKYRIZI PSKT 75 2 PA (Use selenium sulfide) MG/0.83ML sulfacetamide sodium liqd 1 STELARA SOSY SC 45 2 PA; SP MG/0.5ML, 90 MG/ML Antivirals - Topical TALTZ SOAJ 2 PA ABREVA CREA (Use NP docosanol) TALTZ SOSY 2 PA acyclovir topical crea 1

MHS Indiana Preferred Drug List Updated June 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acyclovir topical oint 1 QL(1 gm daily) desoximetasone gel 0.05 % 1 QL(2 gm daily) docosanol crea 1 desoximetasone oint 0.25 1 QL(2 gm daily) % ZOVIRAX CREA EX 5 % NP DIPROLENE AF CREA (Use acyclovir topical) (Use betamethasone NP dipropionate augmented) ZOVIRAX OINT EX 5 % NP QL(1 gm daily) (Use acyclovir topical) ELOCON CREA (Use NP Burn Products mometasone furoate) SILVADENE CREA (Use NP EPIFOAM FOAM 2 silver sulfadiazine) fluocinonide crea 0.05 % 1 silver sulfadiazine crea 1 fluocinonide emulsified 1 Corticosteroids - Topical base crea betamethasone 1 1 rtl pack lmt dipropionate (topical) crea per fill, fluocinonide gel 0.05 % 1 betamethasone fluocinonide oint 0.05 % 1 dipropionate augmented 1 crea fluocinonide soln 0.05 % 1 betamethasone valerate 1 crea 0.1 % fluticasone propionate crea 1 0.05 % betamethasone valerate 1 lotn 0.1 % fluticasone propionate oint 1 0.005 % betamethasone valerate 1 oint 0.1 % hydrocortisone (topical) 1 crea 0.5 % clobetasol propionate crea 1 hydrocortisone (topical) 1 RX/OTC crea 1 % clobetasol propionate 1 emollient base crea hydrocortisone (topical) 1 QL(4 gm daily) crea 2.5 % clobetasol propionate gel 1 hydrocortisone (topical) lotn 1 clobetasol propionate oint 1 2.5 %, 1 % hydrocortisone (topical) oint 1 QL(2 gm daily); clobetasol propionate soln 1 1 % RX/OTC hydrocortisone (topical) oint 1 CLODERM CREA (Use NF 2.5 %, 0.5 % clocortolone pivalate) HYDROCORTISONE 1 rtl pack lmt desonide crea 1 ACETATE/LIDOCAINE per fill, HYDROCHLORIDE CREA NF 1 rtl pack lmt desonide oint 1 (Use lidocaine- per fill, hydrocortisone acetate) DESOWEN CREA (Use 1 rtl pack lmt NP hydrocortisone butyrate 1 desonide) per fill, soln desoximetasone crea 0.25 QL(2 gm daily) 1 hydrocortisone-aloe vera 1 % crea 1 %

MHS Indiana Preferred Drug List Updated June 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOCOID SOLN (Use NP CEROVEL LOTN 2 hydrocortisone butyrate) HYDRO 35 FOAM (Use NF mometasone furoate crea 1 urea in lactic acid vehicle) mometasone furoate oint 1 urea crea 40 % 1 RX/OTC mometasone furoate soln 1 urea lotn 40 % 1 MONISTAT SOOTHING RX/OTC Emollients CARE ITCH RELIEF CREA NP (Use hydrocortisone A + D PERSONAL CARE 2 (topical)) LOTION LOTN ALOE AFTERSUN TACLONEX SUSP (Use 2 LOTION LOTN calcipotriene- NF betamethasone AMLACTIN ULTRA CREA 2 dipropionate) AQUA GLYCOLIC FACE TEMOVATE CREA (Use NP 2 clobetasol propionate) CREAM CREA AQUA GLYCOLIC HAND & TEMOVATE OINT (Use NP 2 clobetasol propionate) BODYLOTION LOTN AQUA LACTEN LOTN 2 TOPICORT CREA 0.25 % NP QL(2 gm daily) (Use desoximetasone) AQUAMED LOTN 2 TOPICORT GEL 0.05 % NP QL(2 gm daily) (Use desoximetasone) AQUAPHILIC OINT 2 TOPICORT OINT 0.25 % NP QL(2 gm daily) (Use desoximetasone) AQUAPHOR ADVANCED 2 triamcinolone acetonide 1 QL(4 gm daily) THERAPY BABY OINT (topical) crea 0.025 % AQUAPHOR ADVANCED 2 triamcinolone acetonide 1 THERAPY HEALING OINT (topical) crea 0.5 %, 0.1 % AQUAPHOR ADVANCED 2 triamcinolone acetonide THERAPY OINT (topical) lotn 0.025 %, 0.1 1 % AQUAPHOR OINT 2 triamcinolone acetonide AVEENO ACTIVE (topical) oint 0.025 %, 0.1 1 NATURALS DAILY 2 %, 0.5 % MOISTURIZING BODY YOGURT LOTN TRIDESILON CREA (Use NP 1 rtl pack lmt desonide) per fill, AVEENO ACTIVE Diaper Rash Products NATURALS SKIN RELIEF 2 MOISTURE REPAIR diaper rash products oint 1 CREA AVEENO DAILY Eczema Agents MOISTURIZINGSPF 15 2 DUPIXENT SOSY 200 2 PA; SP LOTN MG/1.14ML, 300 MG/2ML AVEENO INTENSE 2 Emollient/Keratolytic Agents RELIEF HAND CREA

MHS Indiana Preferred Drug List Updated June 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVEENO POSITIVELY CERAVE PM LOTN 2 AGELESSFIRMING BODY 2 LOTN CERAVE RENEWING SA 2 CREA AVEENO POSITIVELY 2 RADIANT LOTN CERAVE SA RENEWING 2 AVEENO POSITIVELY LOTN RADIANTOVERNIGHT 2 CERAVE SA/ROUGH AND 2 HYDRATING FACIAL BUMPYSKIN CREA MOISTURI CREA CERAVE SA/ROUGH AND 2 AVEENO RESTORATIVE BUMPYSKIN LOTN SKIN THERAPY OAT 2 CETAPHIL DAILY REPAIRING CREA ADVANCE ULTRA 2 AVEENO STRESS RELIEF 2 HYDRATING LOTN MOISTURIZING LOTN CETAPHIL DAILY FACIAL 2 BAG BALM OINT 2 MOISTURIZER LOTN CETAPHIL BASLE CREA 2 DERMACONTROL 2 MOISTURIZER/SPF 30 BETA CARE CREA 2 LOTN CETAPHIL BETA CARE LOTN 2 MOISTURIZING CREA NP (Use emollient) BETA XMA CREA 2 CETAPHIL 2 MOISTURIZING LOTN BOUDREAUXS BABY BUTT SMOOTH DRY SKIN 2 CETAPHIL 2 OINT RESTORADERM LOTN CETAPHIL THERAPEUTIC 2 CAM LOTN 2 HAND CREA CERAVE AM FACIAL CICAPLAST BAUME B5 MOISTURIZING 2 SOOTHING MULTI- 2 LOTION/SPF30 LOTN PURPOSE BALM CREA CLN FACIAL CERAVE AM SPF 30 2 LOTN MOISTURIZER 2 NOURISHING LOTN CERAVE CREA 2 COCOA BUTTER HAND & 2 BODYLOTION LOTN CERAVE DAILY 2 MOISTURIZING LOTN COCOA BUTTER LOTN 2 CERAVE HEALING OINT 2 COCONUT OIL BEAUTY 2 CREA CERAVE LOTN 2 CVS BEAUTY 360 DRY 2 CERAVE MOISTURIZING 2 SKIN LOTN CREA CVS DAILY ULTRA 2 CERAVE PM FACIAL MOISTURELOTION LOTN MOISTURIZING LOTION 2 CVS DRY SKIN THERAPY 2 ULTRA LIGHTWEIGHT CREA LOTN

MHS Indiana Preferred Drug List Updated June 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS MOISTURIZING 2 DML FORTE CREA 2 CREAM CREA ELON SKIN REPAIR DAILY CONDITIONING 2 2 TREATMENT OINT SYSTEM CREA DAILY MOISTURIZING 2 EMOLLIA-CREME CREA 2 LOTION LOTN DAILY MOISTURIZING 2 EMOLLIA-LOTION LOTN 2 LOTN emollient crea 1 DERMABASEOIL IN 2 WATER CREA emollient lotn 1 DERMAIDE ALOE CREA 2 DERMAL THERAPY emollient oint 1 EXTRA STRENGTH BODY 2 LOTION LOTN EPILYT LOTN 2 DERMAL THERAPY FACE EQ THERAPEUTIC DRY 2 CAREMOISTURIZING 2 SKIN CREA LOTION LOTN EQ THERAPEUTIC DERMAL THERAPY FOOT 2 MOISTURIZING CREAM 2 MASSAGE LOTN CREA DERMAL THERAPY HAND EQL ADVANCED ELBOW & KNEE CREAM 2 RECOVERY SKIN CARE 2 LOTN LOTN DERMAL THERAPY HEEL 2 EQL MOISTURIZING 2 CARE LOTN CREAM CREA DERMEND ALPHA + EQL ULTRA BETA HYDROXY 2 MOISTURIZING DAILY 2 THERAPY CREA LOTION LOTN DERMEND ALPHA + EUCERIN ADVANCED 2 BETA HYDROXY 2 REPAIR CREA THERAPY LOTN DERMEND FRAGILE SKIN EUCERIN BABY LOTN 2 MOISTURIZING 2 EUCERIN CALMING FORMULA CREA DAILY MOISTURIZER NP DERMEND CREA (Use emollient) MOISTURIZING BRUISE 2 EUCERIN DAILY FORMULA CREA PROTECTION/SPF 30 2 DIABETIDERM CREA 2 LOTN EUCERIN INTENSIVE 2 DIABETIDERM FOOT 2 REPAIR LOTN REJUVENATING CREA EUCERIN INTENSIVE 2 DIABETIDERM HAND & 2 REPAIRHAND CREA BODY LOTN EUCERIN LOTN 2 DIABETIDERM LOTN 2 EUCERIN ORIGINAL DMAE CREA 2 HEALINGSOOTHING 2 REPAIR LOTN

MHS Indiana Preferred Drug List Updated June 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCERIN PLUS CREA 2 GOLD BOND ULTIMATE ROUGH& BUMPY SKIN 2 EUCERIN PLUS LOTN 2 CREA GOLD BOND ULTIMATE EUCERIN SHEERRIBBONS 2 PROFESSIONAL REPAIR 2 PEARLRADIANCE LOTN RICH FEEL LOTN GOLD BOND ULTIMATE EUCERIN ROUGHNESS 2 SHEERRIBBONS 2 RELIEF CREA SILKSOFTNESS LOTN EUCERIN ROUGHNESS 2 GOLD BOND ULTIMATE 2 RELIEF LOTN SOFTENING LOTN EUCERIN SKIN CALMING GOLD BOND ULTIMATE 2 DAILY MOISTURIZING NP SOOTHING CREA CREA (Use emollient) GOLD BOND ULTIMATE 2 EUCERIN SMOOTHING SOOTHING LOTN REPAIRADVANCED 2 FORMULA LOTN GRX VITAMIN E LOTN 2 GENTLE CREA 2 HYDRASYN25 CREA 2 glycerin (topical) liqd 1 HYDRAZONE LOTION 2 LOTN GOLD BOND MEDICATED BODYLOTION EXTRA 2 J & J BURN CREAM CREA 2 STRENGTH LOTN KERADAN CREA 2 GOLD BOND MEDICATED 2 BODYLOTION LOTN KERI ADVANCED GOLD BOND ULTIMATE MOISTURE THERAPY 2 DIABETICS DRY SKIN 2 LOTN RELIEF LOTN KERI BASIC ESSENTIALS 2 GOLD BOND ULTIMATE LOTN DIABETICS' DRY RELIEF 2 KERI LONG LASTING 2 LOTN CREA GOLD BOND ULTIMATE 2 KERI NOURISHING SHEA 2 HEALING CREA BUTTER LOTN GOLD BOND ULTIMATE 2 KERI ORIGINAL DAILY 2 HEALING LOTN MOISTURE LOTN GOLD BOND ULTIMATE 2 HEALING OINT KERI ORIGINAL LOTN 2 GOLD BOND ULTIMATE 2 KERI OVERNIGHT LOTN 2 LOTN KERI RENEWAL MILK GOLD BOND ULTIMATE 2 2 OVERNIGHT LOTN BODY LOTN KERI RENEWAL SKIN GOLD BOND ULTIMATE 2 2 PROTECTION LOTN FIRMING LOTN KERI RENEWAL GOLD BOND ULTIMATE 2 RESTORING LOTN STRETCH MARK 2 MINIMIZER LOTN

MHS Indiana Preferred Drug List Updated June 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERI SENSITIVE SKIN 2 MEDERMA AG FACE 2 LOTN CREAM CREA LAC-HYDRIN CREA (Use RX/OTC MEDERMA AG HAND & 2 lactic acid (ammonium NP BODY LOTION LOTN lactate)) MEDERMA STRETCH 2 LAC-HYDRIN TWELVE RX/OTC MARKS THERAPY CREA LOTN (Use lactic acid NP MOISTURIZING CREAM 2 (ammonium lactate)) CREA lactic acid (ammonium 1 RX/OTC lactate) crea 12 % MOTHERS FRIEND CREA 2 lactic acid (ammonium 1 RX/OTC MOTHERS FRIEND LOTN 2 lactate) lotn 12 % LACTINOL HX CREA 2 MSM SKIN LOTION LOTN 2 LADY ESTHER 4 NEUTROGENA BODY PURPOSE FACE CREAM 2 LIGHT SESAME 2 CREA FORMULA LOTN NEUTROGENA HAND 2 2 LANAPHILIC OINT CREA LEADER FINGER CREAM 2 NEUTROGENA HEALTHY 2 CREA SKIN CREA LUBRIDERM ADVANCED 2 NEUTROGENA HEALTHY 2 THERAPY LOTN SKIN FACE SPF 15 LOTN LUBRIDERM DAILY NEUTROGENA MOISTURE/NORMAL TO 2 MOISTURE SENSITIVE 2 DRY SKIN LOTN SKIN LOTN LUBRIDERM DAILY NISEKO HYDRATING MOISTURESHEA + 2 FACIAL MOISTURIZER 2 CALMING LAVENDER CREA JASMINE LOTN NIVEA CREA 2 LUBRIDERM INTENSE 2 SKIN REPAIR LOTN NIVEA EXTRA ENRICHED 2 LOTION LOTN LUBRIDERM LOTN 2 NIVEA EXTRA ENRICHED 2 LUBRIDERM MENS 3-IN-1 2 LOTN LOTN NIVEA GENTLE BODY 2 LUBRIDERM SERIOUSLY 2 EXFOLIATOR LOTN SENSITIVE LOTN NIVEA LIGHT CREA 2 LUBRIDERM SKIN NOURISHINGWITH SHEA 2 AND COCOA BUTTERS NIVEA LIGHT LOTN 2 LOTN NIVEA LOTN 2 LUBRISOFT LOTN 2 NIVEA ORIGINAL LOTN 2 MAXAM LOTN 2 NIVEA ORIGINAL 2 MOISTURE LOTN

MHS Indiana Preferred Drug List Updated June 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVEA SOFT CREA 2 PALMERS COCOA BUTTER FORMULA 2 NIVEA VISAGE CREA 2 MASSAGE LOTION/STRETCH NIVEA VISAGE INNER MARKS LOTN BEAUTY NIGHTTIME 2 PALMERS COCOA RENEWAL CREA BUTTER FORMULA 2 NIGHT CREAM NIVEA VISAGE LOTN 2 MOISTURE RICH CREA NUTRADERM ADVANCED 2 PALMERS COCONUT OIL FORMULA LOTN FORMULA BODY LOTION 2 NUTRADERM CREA 2.5 LOTN %-2.5 %-2.5 %-2.5 %-2.5 2 PALMERS COCONUT OIL %-2.5 % FORMULA HAND CREAM 2 NUTRADERM LOTN 2.5 CREA %-2.5 %-2.5 %-2.5 %-2.5 2 PEN-KERA CREA 2 % OINTMENT BASE OINT 2 PENTRAVAN CREA 2

OKEEFFES WORKING 2 PENTRAVAN PLUS CREA 2 HANDS CREA PALMERS COCOA PETROLATUM OINT 2 BUTTER FORMULA 2 CONCENTRATED CREAM PRETTY FEET & HANDS 2 CREA CREA PALMERS COCOA RA ADVANCED HEALING 2 BUTTER FORMULA 2 OINT CREAM CREA RA DAYLOGIC HEALING PALMERS COCOA DRY SKIN THERAPY 2 LOTN BUTTER FORMULA 2 INTENSIVE RELIEF HAND RA RENEWAL DRY SKIN 2 CREAM CREA THERAPY LOTN PALMERS COCOA RADIAGUARD 2 BUTTER FORMULA 2 ADVANCED LOTN LOTION FRAGRANCE FREE LOTN RESTA CREA 2 PALMERS COCOA RESTA LITE LOTN 2 BUTTER FORMULA 2 LOTION LOTN RISABAL-PH CREA 2 PALMERS COCOA BUTTER FORMULA ROC DEEP WRINKLE 2 MASSAGE 2 SERUM LOTN CREAM/STRETCH ROC MULTI CORREXION MARKS CREA 5 IN1 RESTORING EYE 2 CREAM CREA ROC MULTI CORREXION 5 IN1 RESTORING NIGHT 2 CREAM CREA

MHS Indiana Preferred Drug List Updated June 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROC RETINOL 2 UDDERLY SMOOTH 2 CORREXION CREA EXTRA CARE20 CREA ROC RETINOL 2 VANICREAM CREA 2 CORREXION MAX CREA ROC RETINOL VANICREAM LOTN 2 CORREXION NIGHT 2 CREA VANICREAM OINT 2 ROC RETINOL CORREXION SENSITIVE 2 VELVACHOL CREA 2 EYE CREA ROC RETINOL VITAMIN E WITH 2 CORREXION SENSITIVE 2 PANTHENOL CREA NIGHT CREA vitamins a & d (topical) oint 1 ROSE MILK LOTN 2 WIBI LOTN 2 SKIN REPAIR LOTN 2 ZIMS CRACK CREME 2 SOOTHE & COOL DAYTIME CREA MOISTURIZING BODY 2 Immunomodulating Agents - Topical LOTION WITH ALOE ALDARA CREA (Use NP QL(48 ea per LOTN imiquimod) 180 days retail) SOOTHE & COOL SKIN QL(48 ea per imiquimod crea 5 % 1 CREAMWITH ALOE & 2 180 days retail) VITAMINS A, D & E CREA ZYCLARA CREA (Use NF SORBOLENE CREA 2 imiquimod) ZYCLARA PUMP CREA NF SPECIAL CARE CREAM 2 3.75 % (Use imiquimod) CREA ST IVES SWISS Immunosuppressive Agents - Topical FORMULA 24HOUR 2 PA; QL(1 gm ELIDEL CREA (Use NP MOISTURE LOTN pimecrolimus) daily); AL(At STUDIO 35 EXTRA least 2 yrs old) MOISTURIZING LOTION 2 PA; QL(1 gm LOTN pimecrolimus crea 1 daily); AL(At STUDIO 35 least 2 yrs old) MOISTURIZING SKIN 2 PA; QL(1 gm PROTOPIC OINT 0.03 % NP daily); AL(At CREA (Use tacrolimus (topical)) least 2 yrs old) THERABETIC SKIN CARE 2 LOTN PA; QL(1 gm PROTOPIC OINT 0.1 % daily); AL(At THERAPEUTIC 2 NP MOISTURIZING CREA (Use tacrolimus (topical)) least 16 yrs old) THERAPLEX 2 HYDROLOTION LOTN PA; QL(1 gm tacrolimus (topical) oint 1 daily); AL(At 0.03 % UDDERLY SMOOTH 2 least 2 yrs old) CREA UDDERLY SMOOTH 2 EXTRA CARE CREA

MHS Indiana Preferred Drug List Updated June 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 gm ALOE VESTA SKIN tacrolimus (topical) oint 0.1 1 daily); AL(At CONDITIONER LOTN NP % least 16 yrs (Use dimethicone (topical)) old) ANTI-BACTERIAL HAND 2 Keratolytic/Antimitotic Agents LOTION LOTN AQUANIL SKIN 2 podofilox soln 1 CLEANSER LOTN Local Anesthetics - Topical AVEENO POSITIVELY RADIANTCLEANSER 2 ARTHRITIS PAIN 2 LOTN RELIEVING CREA BASIS FACIAL 2 capsaicin crea 0.025 % 1 QL(2 ml daily) MOISTURIZER CREA capsaicin crea 0.075 %, 1 BASIS OVERNIGHT CREA 2 0.1 % CARRINGTON MOISTURE 2 CAPZASIN-HP CREA (Use NP BARRIER CREA capsaicin) CARRINGTON MOISTURE 2 dibucaine oint 1 QL(1 gm daily) BARRIER/ZINC CREA lidocaine crea ex 3 % 1 COOL BOTTOMS CREA 2 Limit 30gms corn starch powd 1 lidocaine crea ex 4 % 1 per month;QL(1 gm daily) DERMACINRX SKIN 2 REPAIR CREA lidocaine hcl crea ex 3 % 1 RX/OTC DIABETIDERM 2 QL(30 ml per CLEANSING LOTN lidocaine hcl gel ex 2 % 1 fill retail) dimethicone (topical) crea 2 1 QL(30 ml per % lidocaine hcl gel ex 2 % 1 fill retail); dimethicone (topical) lotn 1 1 RX/OTC %, 3 % QL(30 ml per EUCERIN CREA (Use skin lidocaine hcl prsy ex 2 % 1 NP fill retail) protectants, misc.) lidocaine ptch ex 5 % 1 QL(3 ea daily) GENTLE SKIN CLEANSER 2 LOTN QL(30 gm per lidocaine-prilocaine crea 1 fill retail) HYDROCERIN CREA 2 LIDODERM PTCH (Use NP QL(3 ea daily) MOISTURE GUARD CREA 2 lidocaine) Limit 30gms NEUTRAPHOR CREA 2 LMX 4 CREA (Use NP lidocaine) per month;QL(1 gm daily) NEUTRAPHORUS REX 2 CREA Misc. Topical NIVEA MOISTURIZING 2 4-N-1 CREA 2 BODY WASH 2 IN 1 LOTN ALOE VESTA DAILY NIVEA MOISTURIZING 2 BODY WASH LOTN MOISTURIZER LOTN (Use NP dimethicone (topical)) MHS Indiana Preferred Drug List Updated June 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVEA TOUCH OF AVEENO ACTIVE SMOOTHNESS 2 NATURALS 2 MOISTURIZING BODY PROTECT+HYDRATE/SP WASH LOTN F 30 LOTN NIVEA VISAGE GENTLE 2 AVEENO BABY CLEANSING LOTN CONTINUOUS 2 PROTECTION LOTN OCUSOFT HAND SOAP 2 LOTN AVEENO BABY CONTINUOUS PROSHIELD PLUS SKIN 2 2 PROTECTANT CREA PROTECTION SPF50 LOTN REMEDY CLEANSING 2 BODY LOTION LOTN AVEENO KIDS CONTINUOUS 2 REMEDY DIMETHICONE PROTECTION SPF 50 MOISTURE BARRIER 2 LOTN CREA AVEENO POSITIVELY REMEDY NUTRASHIELD 2 RADIANTDAILY 2 CREA MOISTURIZER SPF15 REMEDY PHYTOPLEX 2 LOTN HYDRAGUARD CREA AVEENO POSITIVELY REMEDY SKIN REPAIR 2 RADIANTDAILY 2 CREA MOISTURIZER SPF30 LOTN SENSI-CARE 2 MOISTURIZING CREA AVEENO PROTECT + 2 skin protectants, misc. crea 1 HYDRATESPF 30 LOTN AVEENO PROTECT + 2 SM SKIN CLEANSER HYDRATESPF 50 LOTN GENTLE/SENSITIVE SKIN 2 AVEENO PROTECT + 2 LOTN HYDRATESPF 60 LOTN SORBIDON HYDRATE 2 AVEENO PROTECT + 2 CREA HYDRATESPF 70 LOTN SUMMERS EVE AVEENO ULTRA- FEMININE POWD (Use NP CALMING DAILY 2 corn starch) MOISTURIZER SPF15 THERASEAL HAND 2 LOTN PROTECTION LOTN AVEENO ULTRA- zinc oxide (topical) oint 20 1 CALMING DAILY 2 % MOISTURIZER SPF30 Protectives Against UV Radiation LOTN BULL FROG ANTHELIOS 60 MELT-IN 2 SUNSCREEN LOTN SUPERBLOCK SPF50 2 LOTN ANTHELIOS MELT-IN MILK SUNSCREEN SPF 2 BULL FROG ULTIMATE 100 LOTN SHEERPROTECTION 2 FACE SUNBLOCK SPF 30 AVEENO ABSOLUTELY LOTN AGELESSLEAVE-ON DAY 2 MASK SPF 30 LOTN

MHS Indiana Preferred Drug List Updated June 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BULL FROG ULTIMATE NEUTROGENA ULTRA SHEERPROTECTION 2 SHEER DRY-TOUCH SPF 2 SUNBLOCK SPF 30 LOTN 45 LOTN BULL FROG WATER NEUTROGENA ULTRA ARMOR SPORT FACE 2 SHEER DRY-TOUCH 2 SPF 30 LOTN WITH HELIOPLEX SPF 100 LOTN CERAVE SUNSCREEN 2 FACE/SPF50 LOTN NEUTROGENA ULTRA SHEER DRY-TOUCH CHANTAL SUN SCREEN 2 2 SPF 30 LOTN WITH HELIOPLEX SPF 55 LOTN COTZ LOTN 2 NEUTROGENA ULTRA DIABETIDERM SHEER DRY-TOUCH 2 SUNSCREEN SPF15 2 WITH HELIOPLEX SPF 70 LOTN LOTN NIVEA HAND THERAPY 2 FACE COTZ LOTN 2 LOTN HUGGIES LITTLE NIVEA VISAGE UV CARE 2 SWIMMERS SPF50 LOTN 2 DAILY FACIAL LOTN 0.8 %-1 %-5 %-5 %-7.5 % PRE SUN KIDS LOTN 2 KERI AGE DEFY & 2 PROTECT LOTN PURE & FREE BABY NEUTROGENA AGE SUNSCREEN BROAD 2 SHIELD FACE SPECTRUM SPF 50 SUNBLOCK WITH 2 PURESCREEN LOTN HELIOPLEX SPF110 QC ULTIMATE 2 LOTN SUNSCREEN LOTN NEUTROGENA AGE ROC MULTI CORREXION 5 IN1 DAILY SHIELD FACE 2 2 SUNBLOCK WITH MOISTURIZER SPF 30 HELIOPLEX SPF70 LOTN LOTN NEUTROGENA BEACH ROC RETINOL DEFENSESPF 70 LOTN 2 CORREXION SPF30 2 10 %-3 %-4 %-4.5 %-5 % LOTN SHADE SUNBLOCK SPF NEUTROGENA CLEAR 2 NP FACE SPF 55 LOTN 45 LOTN (Use sunscreens) NEUTROGENA HEALTHY SHADE UVAGUARD SPF NP 15 LOTN (Use sunscreens) DEFENSE DAILY 2 MOISTURIZER PURESCREEN LOTN SOLBAR AVO LOTN 2 NEUTROGENA MEN SPF 2 SOLBAR PF SPF15 LOTN 2 20 LOTN 6 %-7.5 % NEUTROGENA SPORT SUNSCREEN SPF 2 MOISTURE 2 50 LOTN SPF15UNTINTED LOTN SUNSCREEN KIDS 2 NEUTROGENA SPORT SPF50+ LOTN FACE SUNBLOCK WITH 2 HELIOPLEX SPF70 LOTN MHS Indiana Preferred Drug List Updated June 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUNSCREEN ULTRA 2 1 package / SHEER LOTN ELIMITE CREA (Use NP claim;QL(60 sunscreens lotn 1 %-1 %-2 permethrin) gm per fill %-4 %, 1.8 %-5 %-7 %, 10 retail) %-10 %-3 %-5 %, 10 %-13 EURAX CREA 2 QL(2 gm daily) %-3 %-5 %-6 %, 10 %-15 %-3 %-5 %-6 %, 10 %-2 EURAX LOTN (Use NF %-2 %-2 %-5 %, 10 %-3 crotamiton) %-4.5 %-8 %, 10 %-3 %- QL(59 ml per malathion lotn 1 4.5 %-9 %, 10.5 %-2 %-2 fill retail) %-2 %-5 %, 13 %-2 %-2 1 %-4 %-5 %, 13 %-3 %-4 NATROBA SUSP (Use NP AL(At least 1 %-5 %-7 %, 2 %-3 %-6 %- spinosad) yrs old) 7.5 %, 2 %-5 %-6 %-7.5 %- NIX CREME RINSE LIQD NP 8 %, 24.08 %, 3 %-4.5 %-6 (Use permethrin) %-8 %, 3 %-4.5 %-9 %-9 OVIDE LOTN (Use NP QL(59 ml per %, 3 %-5 %-7.5 %, 4.5 %- malathion) fill retail) 7.5 %-9.7 %, 4.7 %-4.9 %, 1 package / 5.5 %-8 %, 9.1 % claim;QL(60 permethrin crea 5 % 1 TOTAL BLOCK SPF 60 2 gm per fill COVERUP LOTN retail) TOTAL BLOCK SPF 65 2 CLEAR LOTN permethrin liqd 1 % 1 QL(4 ml daily) WATER BABIES SPF 30 NP permethrin lotn 1 % 1 LOTN (Use sunscreens) Rosacea Agents pyrethrins-piperonyl 1 butoxide liqd 0.33 %-4 % METROCREAM CREA QL(1.5 gm (Use metronidazole NP daily) pyrethrins-piperonyl (topical)) butoxide sham 0.33 %-4 %, 1 0.3 %-0.33 %-4 % METROLOTION LOTN (Use metronidazole NP pyrethrins-piperonyl (topical)) butoxide-permethrin-nit 1 remover kit metronidazole (topical) 1 QL(1.5 gm crea 0.75 % daily) RID COMPLETE LICE ELIMINATION KIT (Use metronidazole (topical) gel 1 QL(1.5 gm pyrethrins-piperonyl NP 0.75 % daily) butoxide-permethrin-nit metronidazole (topical) lotn 1 remover) 0.75 % RID LIQD (Use pyrethrins- NP ORACEA CPDR (Use NF piperonyl butoxide) doxycycline (rosacea)) AL(At least 1 spinosad susp 1 SOOLANTRA CREA (Use NF yrs old) ivermectin (rosacea)) Tar Products Scabicides & Pediculicides coal tar extract sham 0.5 % 1 crotamiton lotn 1 DHS TAR GEL SHAM (Use NP CVS LICE SOLUTION KIT 2 coal tar extract) 3-STEP KIT

MHS Indiana Preferred Drug List Updated June 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DHS TAR SHAM (Use coal NP INSULIN tar extract) USERS NEUTROGENA T/GEL LIMITED TO SHAM (Use coal tar NP 150 PER 30 extract) ACCU-CHEK SMARTVIEW 2 DAYS, NON- STRIPS STRP INSULIN NEUTROGENA T/GEL USERS STUBBORN ITCH NP LIMITED TO CONTROL SHAM (Use 100 PER 90 coal tar extract) DAYS;RX/OTC DIAGNOSTIC PRODUCTS CHEMSTRIP-K STRP 2 Diagnostic Drugs INSULIN USERS CORTROSYN SOLR (Use NP PA; SP cosyntropin) LIMITED TO 150 PER 30 cosyntropin solr 1 PA; SP FREESTYLE INSULINX BLOODGLUCOSE TEST 2 DAYS, NON- INSULIN GLUCAGEN DIAGNOSTIC 2 QL(1 ea per fill STRIPS STRP SOLR retail) USERS LIMITED TO THYROGEN SOLR 2 PA; SP 100 PER 90 DAYS;RX/OTC Diagnostic Tests INSULIN INSULIN USERS USERS LIMITED TO LIMITED TO 150 PER 30 150 PER 30 FREESTYLE INSULINX DAYS, NON- ACCU-CHEK AVIVA PLUS DAYS, NON- BLOODGLUCOSE TEST 2 2 STRP INSULIN STRP VI INSULIN USERS USERS LIMITED TO LIMITED TO 100 PER 90 100 PER 90 DAYS;RX/OTC DAYS;RX/OTC INSULIN INSULIN USERS USERS LIMITED TO LIMITED TO 150 PER 30 150 PER 30 FREESTYLE LITE TEST 2 DAYS, NON- ACCU-CHEK GUIDE 2 DAYS, NON- STRIPS STRP INSULIN STRP VI INSULIN USERS USERS LIMITED TO LIMITED TO 100 PER 90 100 PER 90 DAYS;RX/OTC DAYS;RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN LIPICHOL 540 CAPS 2 USERS LIMITED TO LISTER-V CAPS 2 150 PER 30 FREESTYLE TEST 2 DAYS, NON- STRIPS STRP INSULIN LORMATE CAPS 2 USERS LIMITED TO METHAVER CAPS 2 100 PER 90 DAYS;RX/OTC METHAZEL CAPS 2 KETONE STRP 2 NEUREPA CAPS 2

KETONE TEST STRIPS 2 STRP PERCURA CAPS 2 KETOSTIX STRP 2 PROLEEVA CAPS 2

RELION KETONE TEST 2 PULMONA CAPS 2 STRIPS STRP INSULIN RHEUMATE CAPS 2 USERS LIMITED TO RIBOZEL CAPS 2 150 PER 30 RELION TRUE METRIX 2 DAYS, NON- SENTRA AM CAPS 2 BLOODGLUCOSE TEST INSULIN STRIPS STRP USERS SENTRA PM CAPS 2 LIMITED TO 100 PER 90 2 DAYS;RX/OTC SULFZIX CAPS INSULIN T-SUPPORT MAX CAPS 2 USERS LIMITED TO THERAMINE CAPS 2 150 PER 30 TRUE METRIX BLOOD GLUCOSETEST STRIPS 2 DAYS, NON- TL-ICARE CAPS 2 INSULIN STRP USERS LIMITED TO TOBAKIENT CAPS 2 100 PER 90 DAYS;RX/OTC TREPADONE CAPS 2 DIETARY PRODUCTS/DIETARY MANAGEMENT DIGESTIVE AIDS - Drugs to Treat Low Digestive PRODUCTS Enzymes Dietary Management Products Digestive Enzymes ENLYTE CAPS 2 CREON CPEP 2

FOSTEUM PLUS CAPS 2 PANCREAZE CPEP 2

GABADONE CAPS 2 DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure HYPERTENSA CAPS 2 Carbonic Anhydrase Inhibitors

MHS Indiana Preferred Drug List Updated June 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acetazolamide cp12 1 torsemide tabs 10 mg, 100 1 QL(1 ea daily) mg, 5 mg acetazolamide tabs 1 torsemide tabs 20 mg 1 methazolamide tabs 1 Potassium Sparing Diuretics ALDACTONE TABS (Use NP Diuretic Combinations spironolactone) ALDACTAZIDE TABS 25 amiloride hcl tabs 1 QL(4 ea daily) MG-25 MG (Use NP spironolactone & hydrochlorothiazide) spironolactone tabs 1 amiloride & 1 QL(1 ea daily) hydrochlorothiazide tabs Thiazides and Thiazide-Like Diuretics QL(2 ea daily) DYAZIDE CAPS (Use chlorothiazide tabs 250 mg 1 triamterene & NP hydrochlorothiazide) chlorothiazide tabs 500 mg 1 QL(4 ea daily) MAXZIDE TABS (Use triamterene & NP chlorthalidone tabs 1 hydrochlorothiazide) MAXZIDE-25 TABS (Use QL(2 ea daily) hydrochlorothiazide caps 1 triamterene & NP hydrochlorothiazide) hydrochlorothiazide tabs 1 spironolactone & 1 indapamide tabs 1 hydrochlorothiazide tabs triamterene & metolazone tabs 1 hydrochlorothiazide caps 1 25 mg-37.5 mg ENDOCRINE AND METABOLIC AGENTS - triamterene & QL(2 ea daily) MISC. - Drugs to Treat Bone Disease and hydrochlorothiazide tabs 25 1 Regulate Hormones mg-37.5 mg Bone Density Regulators triamterene & ACTONEL TABS 35 MG NP PA; QL(0.143 hydrochlorothiazide tabs 50 1 (Use risedronate sodium) ea daily) mg-75 mg ACTONEL TABS 5 MG NP PA; QL(1 ea Loop Diuretics (Use risedronate sodium) daily) bumetanide tabs or 0.5 mg, 1 alendronate sodium soln 70 1 QL(10 ml daily) 1 mg, 2 mg mg/75ml BUMEX TABS (Use NP alendronate sodium tabs 1 QL(1 ea daily) bumetanide) 40 mg, 10 mg, 5 mg DEMADEX TABS (Use QL(1 ea daily) NP alendronate sodium tabs 1 QL(0.15 ea torsemide) 70 mg, 35 mg daily) furosemide soln 1 ATELVIA TBEC (Use NP PA; QL(0.143 risedronate sodium) ea daily) furosemide tabs 1 BONIVA SOLN IV 3 PA; SP MG/3ML (Use ibandronate NP LASIX TABS (Use NP sodium) furosemide)

MHS Indiana Preferred Drug List Updated June 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcitonin (salmon) soln ij 1 QL(2 ml per fill NOVAREL SOLR 10000 2 PA 200 unit/ml retail) UNIT calcitonin (salmon) soln na 1 PREGNYL W/DILUENT PA 200 unit/act BENZYLALCOHOL/NACL 2 SOLR etidronate disodium tabs 1 Growth Hormone Receptor Antagonists FOSAMAX TABS (Use NP QL(0.15 ea PA; SP alendronate sodium) daily) SOMAVERT SOLR 2 ibandronate sodium soln iv 1 PA; SP Growth Hormone Releasing Hormones (GHRH) 3 mg/3ml EGRIFTA SOLR 2 PA; SP MIACALCIN SOLN (Use NP QL(2 ml per fill calcitonin (salmon)) retail) EGRIFTA SV SOLR 2 PA; SP pamidronate disodium soln 1 PA; SP 30 mg/10ml, 90 mg/10ml Growth Hormones PAMIDRONATE PA; SP DISODIUM SOLN 6 2 GENOTROPIN MINIQUICK 2 PA MG/ML SOLR GENOTROPIN SOLR 2 PA pamidronate disodium solr 1 PA; SP 30 mg, 90 mg HUMATROPE COMBO 2 PA PROLIA SOSY 2 PA; SP PACK SOLR HUMATROPE SOLR 2 PA RECLAST SOLN (Use NP PA; SP zoledronic acid) NORDITROPIN FLEXPRO 2 PA risedronate sodium tabs 30 1 PA; QL(1 ea SOPN mg, 5 mg daily) NUTROPIN AQ NUSPIN 2 PA risedronate sodium tabs 35 1 PA; QL(0.143 10 SOPN mg ea daily) NUTROPIN AQ NUSPIN 2 PA risedronate sodium tbec 35 1 PA; QL(0.143 20 SOPN mg ea daily) NUTROPIN AQ NUSPIN 5 2 PA XGEVA SOLN 2 PA; SP SOPN OMNITROPE SOCT 2 PA zoledronic acid conc 4 1 PA; SP mg/5ml OMNITROPE SOLR 2 PA ZOLEDRONIC ACID SOLN 2 PA; SP 4 MG/100ML SAIZEN SOLR 2 PA; SP zoledronic acid soln 4 1 PA; SP mg/100ml, 5 mg/100ml SAIZENPREP PA; SP ZOLEDRONIC ACID SOLR 2 PA; SP RECONSTITUTIONKIT 2 4 MG SOLR Corticotropin SEROSTIM SOLR 2 PA; SP ACTHAR GEL 2 PA; SP ZOMACTON SOLR 2 PA Fertility Regulators ZORBTIVE SOLR 2 PA; SP CHORIONIC 2 PA GONADOTROPIN SOLR Hormone Receptor Modulators

MHS Indiana Preferred Drug List Updated June 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVISTA TABS (Use NP QL(1 ea daily); FABRAZYME SOLR 2 PA; SP raloxifene hcl) PV QL(1 ea daily); PA; QL(0.5 ea raloxifene hcl tabs $0 GALAFOLD CAPS 2 PV daily) Insulin-Like Growth Factors (Somatomedins) KUVAN PACK (Use PA; SP sapropterin NP INCRELEX SOLN 2 PA; SP dihydrochloride) KUVAN TABS (Use PA; SP LHRH/GnRH Agonist Analog Pituitary sapropterin NP FENSOLVI KIT 2 PA; SP dihydrochloride) levocarnitine (metabolic 1 QL(30 ml daily) LUPANETA PACK KIT 2 PA; SP modifiers) soln 1 gm/10ml levocarnitine (metabolic 1 QL(3 ea daily) LUPRON DEPOT-PED (1- 2 SP modifiers) tabs 330 mg MONTH) KIT LUMIZYME SOLR 2 PA; SP LUPRON DEPOT-PED (3- 2 SP MONTH) KIT MYALEPT SOLR 2 PA; SP SUPPRELIN LA KIT 2 PA; SP NAGLAZYME SOLN 2 PA; SP SYNAREL SOLN 2 SP paricalcitol soln iv 2 1 PA; SP Metabolic Modifiers mcg/ml, 5 mcg/ml ALDURAZYME SOLN 2 PA; SP RAVICTI LIQD 2 PA; SP ROCALTROL CAPS 0.25 BUPHENYL POWD (Use NP PA; SP sodium phenylbutyrate) MCG, 0.5 MCG (Use NP calcitriol) BUPHENYL TABS (Use NP PA; SP sodium phenylbutyrate) sapropterin dihydrochloride 1 PA; SP pack calcitriol caps or 0.25 mcg, 1 0.5 mcg sapropterin dihydrochloride 1 PA; SP tabs CARBAGLU TABS 2 PA; SP SENSIPAR TABS (Use NP PA; SP CARNITOR SF SOLN (Use QL(30 ml daily) cinacalcet hcl) levocarnitine (metabolic NP sodium phenylbutyrate 1 PA; SP modifiers)) powd CARNITOR SOLN OR 1 QL(30 ml daily) sodium phenylbutyrate tabs 1 PA; SP GM/10ML (Use NP levocarnitine (metabolic PA; SP modifiers)) VIMIZIM SOLN 2 CARNITOR TABS OR 330 QL(3 ea daily) ZEMPLAR SOLN IV 2 PA; SP MG (Use levocarnitine NP MCG/ML, 5 MCG/ML (Use NP (metabolic modifiers)) paricalcitol) cinacalcet hcl tabs 1 PA; SP Posterior Pituitary Hormones DDAVP SOLN IJ 4 PA; SP CYSTADANE POWD 2 PA; SP MCG/ML (Use NP desmopressin acetate) ELAPRASE SOLN 2 PA; SP

MHS Indiana Preferred Drug List Updated June 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DDAVP SOLN NA 0.01 % 2 QL(5 ml per fill Limit 8 patches retail) per COMBIPATCH PTTW 2 DDAVP SOLN NA 0.01 % PA; QL(5 ml month;QL(0.29 (Use desmopressin acetate NP per fill retail) ea daily) spray) estradiol & norethindrone 1 QL(1 ea daily) DDAVP TABS OR 0.1 MG, QL(6 ea daily) acetate tabs 0.2 MG (Use desmopressin NP FEMHRT TABS (Use acetate) norethindrone acetate- NP ethinyl estradiol) desmopressin acetate soln 1 PA; SP ij 4 mcg/ml norethindrone acetate- $0 ethinyl estradiol tabs desmopressin acetate 1 QL(5 ml per fill spray refrigerated soln retail) PREMPRO TABS 2 desmopressin acetate 1 PA; QL(5 ml spray soln per fill retail) Estrogens desmopressin acetate tabs QL(6 ea daily) QL(0.286 ea 1 ALORA PTTW 2 or 0.1 mg, 0.2 mg daily) PA; SP STIMATE SOLN 2 CLIMARA PTWK (Use NP QL(0.143 ea estradiol) daily) Somatostatic Agents ESTRACE TABS OR 0.5 PA; SP MG, 1 MG, 2 MG (Use NP octreotide acetate soln 1 estradiol) estradiol pttw td 0.025 QL(0.286 ea SANDOSTATIN LAR 2 PA; SP DEPOT KIT mg/24hr, 0.05 mg/24hr, 1 daily) 0.075 mg/24hr, 0.1 SANDOSTATIN SOLN NP PA; SP (Use octreotide acetate) mg/24hr PA; SP estradiol pttw td 0.0375 1 SIGNIFOR SOLN 2 mg/24hr estradiol ptwk td 0.075 QL(0.143 ea SOMATULINE DEPOT 2 PA; SP SOLN mg/24hr, 0.1 mg/24hr, daily) 0.025 mg/24hr, 0.05 1 Vasopressin Receptor Antagonists mg/24hr, 0.06 mg/24hr, JYNARQUE TABS 15 MG, 2 PA; SP 37.5 mcg/24hr 30 MG estradiol tabs or 0.5 mg, 1 1 JYNARQUE TBPK 15 MG, 2 PA mg, 2 mg MINIVELLE PTTW 0.025 QL(0.286 ea SAMSCA TABS (Use PA; SP NP MG/24HR, 0.05 MG/24HR, NP daily) tolvaptan) 0.075 MG/24HR, 0.1 tolvaptan tabs 1 PA; SP MG/24HR (Use estradiol) MINIVELLE PTTW 0.0375 NP ESTROGENS - Hormone Replacement/Modifying MG/24HR (Use estradiol) Drugs PREMARIN TABS OR 0.3 QL(1 ea daily) Estrogen Combinations MG, 0.45 MG, 0.625 MG, 2 0.9 MG, 1.25 MG ACTIVELLA TABS (Use QL(1 ea daily) estradiol & norethindrone NP acetate)

MHS Indiana Preferred Drug List Updated June 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVELLE-DOT PTTW QL(0.286 ea Farnesoid X Receptor (FXR) Agonists 0.025 MG/24HR, 0.05 daily) MG/24HR, 0.075 NP OCALIVA TABS 2 PA; SP MG/24HR, 0.1 MG/24HR (Use estradiol) Gallstone Solubilizing Agents VIVELLE-DOT PTTW ACTIGALL CAPS (Use NP 0.0375 MG/24HR (Use NP ursodiol) estradiol) URSO 250 TABS (Use NP QL(7 ea daily) FLUOROQUINOLONES - Drugs to Treat Bacterial ursodiol) Infections ursodiol caps 300 mg 1 Fluoroquinolones ursodiol tabs 250 mg 1 QL(7 ea daily) CIPRO TABS 250 MG, 500 NP MG (Use ciprofloxacin hcl) Gastrointestinal Chloride Channel Activators ciprofloxacin hcl tabs 100 QL(6 ea per fill 1 AMITIZA CAPS (Use NP QL(2 ea daily) mg retail) lubiprostone) ciprofloxacin hcl tabs 250 1 QL(2 ea daily) mg, 500 mg, 750 mg lubiprostone caps 1 QL(1 ea LEVAQUIN TABS (Use NP Gastrointestinal Stimulants levofloxacin) daily,14 ea per fill retail) metoclopramide hcl soln or 1 10 mg/10ml, 5 mg/5ml QL(1 ea levofloxacin tabs or 250 1 daily,14 ea per metoclopramide hcl tabs or mg, 500 mg, 750 mg 1 fill retail) 10 mg, 5 mg QL(56 ea per REGLAN TABS (Use ofloxacin tabs 1 NP fill retail) metoclopramide hcl) GASTROINTESTINAL AGENTS - MISC. - Inflammatory Bowel Agents Miscellaneous Gastrointestinal Drugs APRISO CP24 (Use NP mesalamine) Antiflatulents ASACOL HD TBEC (Use GAS-X CHEW (Use NP NF simethicone) mesalamine) MYLICON INFANTS GAS QL(1 ml daily) AZULFIDINE EN-TABS NP RELIEF DYE FREE SUSP NP TBEC (Use sulfasalazine) (Use simethicone) AZULFIDINE TABS (Use NP MYLICON INFANTS GAS QL(1 ml daily) sulfasalazine) RELIEF SUSP (Use NP balsalazide disodium caps 1 QL(9 ea daily) simethicone) PA; SP simethicone chew 80 mg 1 CIMZIA KIT 2 PA; SP simethicone liqd 20 1 CIMZIA STARTER KIT KIT 2 mg/0.3ml, 40 mg/0.6ml COLAZAL CAPS (Use NP QL(9 ea daily) simethicone susp 20 1 QL(1 ml daily) balsalazide disodium) mg/0.3ml, 40 mg/0.6ml DELZICOL CPDR (Use NP Bile Acid Synthesis Disorder Agents mesalamine) CHOLBAM CAPS 2 PA; QL(5 ea PA; SP daily); SP ENTYVIO SOLR 2

MHS Indiana Preferred Drug List Updated June 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INFLECTRA SOLR 2 PA; SP UROCIT-K 10 TBCR (Use potassium citrate NP (alkalinizer)) LIALDA TBEC (Use NP mesalamine) UROCIT-K 5 TBCR (Use potassium citrate NP mesalamine cp24 or 0.375 1 gm (alkalinizer)) mesalamine cpdr or 400 1 Cystinosis Agents mg CYSTAGON CAPS 2 PA; SP mesalamine enem re 4 gm 1 QL(60 ml daily) PROCYSBI CPDR 25 MG, 2 PA; SP mesalamine tbec or 1.2 gm 1 75 MG Genitourinary Irrigants mesalamine tbec or 800 1 QL(3 ea daily) mg sodium chloride (gu 1 irrigant) soln REMICADE SOLR 2 PA; SP Interstitial Cystitis Agents PA; SP RENFLEXIS SOLR 2 ELMIRON CAPS 2 QL(3 ea daily) SFROWASA ENEM 2 Prostatic Hypertrophy Agents QL(1 ea daily) STELARA SOLN IV 130 2 PA; SP finasteride tabs 1 MG/26ML FLOMAX CAPS (Use NP QL(2 ea daily) sulfasalazine tabs 1 tamsulosin hcl) PROSCAR TABS (Use NP QL(1 ea daily) sulfasalazine tbec 1 finasteride) Intestinal Acidifiers RAPAFLO CAPS 4 MG NF (Use silodosin) lactulose (encephalopathy) 1 soln tamsulosin hcl caps 1 QL(2 ea daily) Phosphate Binder Agents Urinary Analgesics calcium acetate (phosphate 1 phenazopyridine hcl tabs 1 binder) caps 100 mg, 200 mg, 95 mg Short Bowel Syndrome (SBS) Agents PYRIDIUM TABS (Use NP GATTEX KIT 2 PA; SP phenazopyridine hcl) GOUT AGENTS - Drugs to Treat Gout GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Gout Agent Combinations Organs and Urinary System colchicine w/ probenecid 1 Alkalinizers tabs potassium citrate Gout Agents (alkalinizer) tbcr 1080 mg, 1 540 mg allopurinol tabs 1 sodium citrate & citric acid QL(16.67 ml QL(6 ea per fill 1 colchicine tabs 1 soln daily); RX/OTC retail) COLCRYS TABS (Use NP QL(6 ea per fill colchicine) retail) MHS Indiana Preferred Drug List Updated June 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KRYSTEXXA SOLN 2 PA; SP HUMATE-P SOLR CO

MITIGARE CAPS (Use NF IDELVION SOLR CO colchicine) ZYLOPRIM TABS (Use NP IXINITY SOLR CO allopurinol) Uricosurics JIVI SOLR CO probenecid tabs 1 KCENTRA KIT CO

HEMATOLOGICAL AGENTS - MISC. - Drugs to KOATE SOLR CO Treat Blood Disorders Antihemophilic Products KOATE-DVI SOLR CO

ADVATE SOLR CO KOGENATE FS KIT CO

ADYNOVATE SOLR CO KOVALTRY SOLR CO

AFSTYLA KIT CO MONOCLATE-P KIT CO

ALPHANATE SOLR CO MONONINE SOLR CO ALPHANATE/VON WILLEBRANDFACTOR CO NOVOEIGHT SOLR CO COMPLEX/HUMAN SOLR NOVOSEVEN RT SOLR CO ALPHANINE SD SOLR CO NUWIQ KIT CO ALPROLIX SOLR CO NUWIQ SOLR CO BENEFIX KIT CO OBIZUR SOLR CO COAGADEX SOLR CO PROFILNINE SD SOLR CO CORIFACT KIT CO PROFILNINE SOLR CO ELOCTATE SOLR CO REBINYN SOLR CO ESPEROCT SOLR CO RECOMBINATE SOLR CO FEIBA SOLR CO RIASTAP SOLR CO FIBRYGA SOLR CO RIXUBIS SOLR CO HELIXATE FS KIT CO SEVENFACT SOLR CO HEMLIBRA SOLN CO TRETTEN SOLR CO HEMOFIL M SOLR CO VONVENDI SOLR CO

MHS Indiana Preferred Drug List Updated June 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WILATE KIT CO cilostazol tabs 1 QL(2 ea daily)

XYNTHA KIT CO clopidogrel bisulfate tabs 1 QL(1 ea daily) 75 mg XYNTHA SOLOFUSE KIT CO dipyridamole tabs 1

Bradykinin B2 Receptor Antagonists EFFIENT TABS (Use NP QL(1 ea daily) prasugrel hcl) FIRAZYR SOLN (Use NP PA; SP icatibant acetate) PLAVIX TABS (Use NP QL(1 ea daily) clopidogrel bisulfate) icatibant acetate soln 1 PA; SP prasugrel hcl tabs 1 QL(1 ea daily) Complement Inhibitors PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat BERINERT KIT 2 Blood Disorders CINRYZE SOLR 2 PA; SP Agents for Gaucher Disease CERDELGA CAPS 2 PA; SP RUCONEST SOLR 2 PA; SP CEREZYME SOLR 2 PA; SP SOLIRIS SOLN 2 PA; SP miglustat caps 1 PA; SP Hemataologic - Tyrosine Kinase Inhibitors PA; SP TAVALISSE TABS 2 PA VPRIV SOLR 2

Hematorheologic Agents ZAVESCA CAPS (Use NP PA; SP miglustat) pentoxifylline tbcr 1 Agents for Sickle Cell Disease Human Protein C ADAKVEO SOLN CO CEPROTIN SOLR 2 PA; SP DROXIA CAPS 2 Plasma Kallikrein Inhibitors OXBRYTA TABS CO KALBITOR SOLN 2 PA; SP Cobalamins Plasma Proteins B-12 CAPS 1000 MCG 2 THROMBATE III SOLR 2 PA; SP B12 CAPS 2 THROMBATE III W/10 ML 2 PA; SP STERILE WATER SOLR cyanocobalamin liqd or 1 1000 mcg/15ml THROMBATE III W/20 ML 2 PA; SP STERILE WATER SOLR cyanocobalamin soln ij 1 QL(10 ml per Platelet Aggregation Inhibitors 1000 mcg/ml 270 days retail) cyanocobalamin subl sl AGRYLIN CAPS (Use NP 1 anagrelide hcl) 1000 mcg cyanocobalamin tabs or 1 anagrelide hcl caps 1 1000 mcg BRILINTA TABS 2 QL(2 ea daily) Folic Acid/Folates

MHS Indiana Preferred Drug List Updated June 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits folic acid tabs or 1 mg $0 RX/OTC; PV UDENYCA SOSY 2 SP folic acid tabs or 800 mcg, $0 QL(1 ea daily); ZARXIO SOSY 2 SP 400 mcg PV Hematopoietic Growth Factors ZIEXTENZO SOSY 2 SP ARANESP ALBUMIN 2 PA; SP FREE SOLN Hematopoietic Mixtures ferrous fumarate-fa-b QL(1 ea daily) ARANESP ALBUMIN 2 PA; SP FREE SOSY complex-c-zn-mg-mn-cu 1 tabs EPOGEN SOLN 2 PA; SP NOVAFERRUM 125 LIQD 2 SP FULPHILA SOSY 2 Iron LEUKINE SOLR 2 PA; SP FE GLUCONATE TABS 2 MIRCERA SOSY 100 PA; SP QL(3.4 ml MCG/0.3ML, 200 FER-IN-SOL SOLN (Use NP ferrous sulfate) daily); AL(Up to MCG/0.3ML, 50 2 18 yrs old ); PV MCG/0.3ML, 75 QL(2 ea daily) MCG/0.3ML FERRETTS TABS 2 NEULASTA ONPRO KIT PA; SP 2 FERROUS GLUCONATE 2 PSKT TABS 324 MG PA; SP NEULASTA SOSY 2 ferrous gluconate tabs 324 1 mg, 240 mg, 27 mg NIVESTYM SOSY 300 PA ferrous sulfate elix 220 $0 PV MCG/0.5ML, 480 2 mg/5ml MCG/0.8ML FERROUS SULFATE LIQD 2 NPLATE SOLR 250 MCG, 2 PA; SP 220 MG/5ML 500 MCG QL(3.4 ml SP ferrous sulfate soln 15 $0 daily); AL(Up to NYVEPRIA SOSY 2 mg/ml 18 yrs old ); PV PROCRIT SOLN 10000 PA; SP UNIT/ML, 2000 UNIT/ML, ferrous sulfate tabs 325 $0 PV 20000 UNIT/ML, 3000 2 mg, 65 mg UNIT/ML, 4000 UNIT/ML, FERROUS SULFATE 2 40000 UNIT/ML TBEC 324 MG PV PROMACTA PACK 12.5 2 PA ferrous sulfate tbec 325 mg $0 MG PA; SP IRON CHEWS PEDIATRIC 2 PROMACTA PACK 25 MG 2 CHEW NOVAFERRUM PROMACTA TABS 12.5 2 PA; SP 2 MG, 25 MG, 50 MG, 75 MG PEDIATRIC DROPS LIQD RETACRIT SOLN 10000 PA polysaccharide iron 1 QL(1 ea daily) UNIT/ML, 2000 UNIT/ML, complex caps 20000 UNIT/2ML, 20000 2 Stem Cell Mobilizers UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 MOZOBIL SOLN 2 PA; SP UNIT/ML

MHS Indiana Preferred Drug List Updated June 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEMOSTATICS - Drugs to Stop Bleeding/Treat ibuprofen-diphenhydramine 1 Blood Disorders citrate tabs ibuprofen-diphenhydramine Hemostatics - Systemic 1 hcl caps AMICAR TABS 500 MG NP QL(24 ea per (Use aminocaproic acid) fill retail); SP naproxen sodium- 1 diphenhydramine hcl tabs aminocaproic acid tabs or 1 QL(24 ea per 500 mg fill retail); SP NYTOL MAXIMUM STRENGTH TABS (Use NP QL(30 ea per 5 diphenhydramine hcl LYSTEDA TABS (Use NP days retail); (sleep)) tranexamic acid) AL(At least 12 yrs old) TYLENOL PM EXTRA STRENGTH LIQD (Use NP QL(30 ea per 5 diphenhydramine- tranexamic acid tabs or 1 days retail); acetaminophen (sleep)) 650 mg AL(At least 12 yrs old) TYLENOL PM EXTRA STRENGTH TABS (Use NP HYPNOTICS/SEDATIVES/SLEEP DISORDER diphenhydramine- AGENTS acetaminophen (sleep)) Antihistamine Hypnotics UNISOM PM PAIN TABS 2 ADVIL PM CAPS (Use ibuprofen-diphenhydramine NP UNISOM SLEEPGELS hcl) CAPS (Use NP diphenhydramine hcl ADVIL PM TABS (Use (sleep)) ibuprofen-diphenhydramine NP citrate) UNISOM SLEEPMELTS TBDP (Use NP ALEVE PM TABS (Use diphenhydramine hcl naproxen sodium- NP (sleep)) diphenhydramine hcl) UNISOM SLEEPTABS diphenhydramine hcl 1 TABS (Use doxylamine NP (sleep) caps succinate (sleep)) diphenhydramine hcl 1 WAL-SLEEP Z LIQUID 2 (sleep) liqd SHOTS LIQD diphenhydramine hcl 1 ZZZQUIL CAPS (Use (sleep) tabs diphenhydramine hcl NP diphenhydramine hcl 1 (sleep)) (sleep) tbdp ZZZQUIL LIQD (Use diphenhydramine- 1 diphenhydramine hcl NP acetaminophen (sleep) liqd (sleep)) diphenhydramine- Barbiturate Hypnotics acetaminophen (sleep) 1 tabs AMYTAL SODIUM SOLR 2 doxylamine succinate 1 (sleep) tabs BUTISOL SODIUM TABS 2 EXCEDRIN PM TABS (Use NEMBUTAL SODIUM diphenhydramine- NP SOLN (Use pentobarbital NP acetaminophen (sleep)) sodium)

MHS Indiana Preferred Drug List Updated June 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTOBARBITAL 2 LUNESTA TABS (Use NP QL(1 ea daily) SODIUM POWD XX eszopiclone) pentobarbital sodium soln ij 1 midazolam hcl soln ij 10 mg/2ml, 2 mg/2ml, 5 mg/5ml, 5 mg/ml, 10 1 phenobarbital elix or 20 1 mg/5ml mg/10ml, 50 mg/10ml, 25 mg/5ml PHENOBARBITAL POWD 2 XX midazolam hcl syrp or 2 1 mg/ml PHENOBARBITAL 2 SODIUM POWD XX MIDAZOLAM 2 HYDROCHLORIDE SOLN phenobarbital sodium soln 1 ij 130 mg/ml, 65 mg/ml MIDAZOLAM HYDROCHLORIDE/SODIU phenobarbital soln or 20 1 mg/5ml M CHLORIDE SOLN 0.8 2 %-100 MG/100ML, 0.8 %- phenobarbital tabs or 100 50 MG/50ML mg, 15 mg, 30 mg, 60 mg, 1 64.8 mg, 97.2 mg, 16.2 mg, MIDAZOLAM SOLN IV 100 2 32.4 mg MG/100ML MIDAZOLAM SOSY IJ 2 2 SECONAL SODIUM CAPS 2 MG/2ML Hypnotics - Tricyclic Agents MIDAZOLAM/SYRSPEND 2 SF PH4 SUSP doxepin hcl (sleep) tabs 1 QL(1 ea daily) quazepam tabs 1 SILENOR TABS (Use NP QL(1 ea daily) doxepin hcl (sleep)) RESTORIL CAPS (Use NP QL(1 ea daily) temazepam) Non-Barbiturate Hypnotics temazepam caps 1 QL(1 ea daily) AMBIEN CR TBCR (Use NP QL(1 ea daily) zolpidem tartrate) triazolam tabs 1 QL(1 ea daily) AMBIEN TABS (Use NP QL(1 ea daily) zolpidem tartrate) zaleplon caps 1 QL(2 ea daily) CHLORAL HYDRATE 2 CRYS zolpidem tartrate subl 1 QL(1 ea daily) DORAL TABS (Use NP quazepam) zolpidem tartrate tabs 1 QL(1 ea daily) QL(1 ea daily) EDLUAR SUBL 2 zolpidem tartrate tbcr 1 QL(1 ea daily) QL(1 ea daily) estazolam tabs 1 ZOLPIMIST SOLN 2 QL(2 ml daily) QL(1 ea daily) eszopiclone tabs 1 Orexin Receptor Antagonists QL(1 ea daily) flurazepam hcl caps 1 QL(1 ea daily) BELSOMRA TABS 2 QL(1 ea daily); HALCION TABS (Use NP QL(1 ea daily) triazolam) DAYVIGO TABS 2 AL(At least 18 yrs old) INTERMEZZO SUBL (Use NP QL(1 ea daily) zolpidem tartrate) Selective Melatonin Receptor Agonists

MHS Indiana Preferred Drug List Updated June 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea METAMUCIL 2 HETLIOZ CAPS 2 daily); AL(At MULTIHEALTH FIBER least 3 yrs old); SINGLES PACK SP METAMUCIL ORIGINAL PA; QL(5 ml TEXTURE POWD (Use NP 2 daily); AL(At psyllium) HETLIOZ LQ SUSP least 3 yrs old); SP METAMUCIL PACK 28 % 2 QL(1 ea daily) ramelteon tabs 1 METAMUCIL POWD 48.57 NP % (Use psyllium) ROZEREM TABS (Use QL(1 ea daily) NP psyllium caps 0.52 gm, 520 1 ramelteon) mg LAXATIVES - Bowel Treatment Drugs psyllium powd 33 %, 68 %, 30 %, 95 %, 100 %, 30.9 1 Bulk Laxatives %, 48.57 %, 58.6 %, 28.3 % calcium polycarbophil tabs 1 QL(10 ea daily) Laxative Combinations CVS NATURAL FIBER 2 COLYTE-FLAVOR PACKS SUPPLEMENT PACK SOLR (Use peg 3350-kcl- NF EVAC POWD (Use NP sod bicarb-sod chloride-sod psyllium) sulfate) FIBERCON TABS (Use NP QL(10 ea daily) GOLYTELY SOLR 2.97 PV calcium polycarbophil) GM-22.74 GM-236 GM- 5.86 GM-6.74 GM (Use NP HYDROCIL INSTANT NP POWD (Use psyllium) peg 3350-kcl-sod bicarb- KONSYL DAILY FIBER sod chloride-sod sulfate) PACK 100 %, 28.3 %, 60.3 2 NULYTELY SOLR (Use % peg 3350-potassium NP KONSYL DAILY FIBER chloride-sod bicarbonate- POWD 100 % (Use NP sod chloride) psyllium) NULYTELY/FLAVOR PACKS SOLR (Use peg KONSYL DAILY FIBER 2 POWD 60.3 % 3350-potassium chloride- NP sod bicarbonate-sod KONSYL ORIGINAL DAILY 2 chloride) FIBER PACK peg 3350-kcl-sod bicarb- PV KONSYL PACK 2 sod chloride-sod sulfate $0 solr 2.97 gm-22.74 gm-236 KONSYL POWD 2 gm-5.86 gm-6.74 gm peg 3350-kcl-sod bicarb- KONSYL-D POWD 2 sod chloride-sod sulfate 1 solr 2.98 gm-22.72 gm-240 METAMUCIL CAPS 0.52 NP gm-5.84 gm-6.72 gm GM (Use psyllium) peg 3350-potassium METAMUCIL chloride-sod bicarbonate- 1 MULTIHEALTH FIBER 2 sod chloride solr POWD sennosides-docusate 1 QL(4 ea daily) sodium tabs MHS Indiana Preferred Drug List Updated June 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENOKOT S TABS (Use QL(4 ea daily) DULCOLAX SUPP RE 10 NP QL(12 ea per sennosides-docusate NP MG (Use bisacodyl) fill retail) sodium) DULCOLAX TBEC OR 5 NP QL(1 ea daily) Laxatives - Miscellaneous MG (Use bisacodyl) EX-LAX TABS (Use NP glycerin (laxative) supp 1 sennosides) GLYCERIN ADULT SUPP NP SENNA SYRP 2 (Use glycerin (laxative)) lactulose soln 10 gm/15ml, 1 sennosides liqd 8.8 mg/5ml 1 20 gm/30ml MIRALAX POWD 17 QL(34 gm sennosides syrp 8.8 1 GM/SCOOP (Use NP daily) mg/5ml polyethylene glycol 3350) sennosides tabs 17.2 mg, 1 PEDIA-LAX SUPP RE 1 15 mg, 25 mg, 8.6 mg GM (Use glycerin NP SENOKOT TABS (Use NP (laxative)) sennosides) PEDIA-LAX SUPP RE 2.8 2 Surfactant Laxatives GM COLACE CAPS (Use NP QL(3 ea daily) polyethylene glycol 3350 1 QL(34 gm docusate sodium) powd or 17 gm/scoop daily) COLACE CLEAR CAPS NP SORBITOL SOLN OR 70 2 (Use docusate sodium) % docusate calcium caps 1 Saline Laxatives docusate sodium caps or QL(3 ea daily) FLEET ENEMA ENEM NP 1 (Use sodium phosphates) 250 mg, 100 mg FLEET ENEMA SIX PACK docusate sodium caps or 1 ENEM (Use sodium NP 50 mg phosphates) docusate sodium liqd or 1 150 mg/15ml, 50 mg/5ml FLEET PEDIATRIC ENEM NP (Use sodium phosphates) docusate sodium syrp or 60 1 mg/15ml magnesium citrate soln 1 1.745 gm/30ml, docusate sodium tabs or 1 magnesium hydroxide susp QL(32 ml daily) 100 mg 1200 mg/15ml, 2400 1 LOCAL ANESTHETICS-Parenteral - Drugs for mg/30ml, 400 mg/5ml, 7.75 Numbing % Local Anesthetics - Amides magnesium hydroxide susp 1 2400 mg/10ml MARCAINE SOLN 0.5 % NF (Use bupivacaine hcl) sodium phosphates enem 1 NAROPIN SOLN 5 MG/ML, 2 MG/ML (Use ropivacaine NF Stimulant Laxatives hcl) QL(12 ea per bisacodyl supp re 10 mg 1 ZINGO JTAJ (Use fill retail) lidocaine hcl (local NF bisacodyl tbec or 5 mg 1 QL(1 ea daily) anesth.))

MHS Indiana Preferred Drug List Updated June 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACROLIDES - Drugs to Treat Bacterial erythromycin base tabs 250 1 Infections mg erythromycin base tbec 250 Azithromycin 1 mg, 333 mg, 500 mg azithromycin susr or 100 1 mg/5ml, 200 mg/5ml erythromycin ethylsuccinate susr 200 1 azithromycin tabs or 250 1 QL(6 ea per fill mg/5ml, 400 mg/5ml mg retail) MEDICAL DEVICES AND SUPPLIES azithromycin tabs or 500 1 QL(4 ea daily) mg Bandages-Dressings-Tape azithromycin tabs or 600 1 QL(0.286 ea mg daily) ADHESIVE 2 PADS/LARGE/3"X4" PADS ZITHROMAX PACK OR 1 NF GM (Use azithromycin) ADHESIVE PADS/MEDIUM/2"X3" 2 ZITHROMAX SUSR OR PADS 100 MG/5ML, 200 MG/5ML NP (Use azithromycin) ALLEVYN PLUS CAVITY 2 RX/OTC PADS ZITHROMAX TABS OR NP QL(6 ea per fill 250 MG (Use azithromycin) retail) ALLEVYN THIN PADS 2 RX/OTC ZITHROMAX TABS OR QL(4 ea daily) NP AMD FOAM DRESSING 2 RX/OTC 500 MG (Use azithromycin) 4"X4" PADS ZITHROMAX TABS OR NP QL(0.286 ea AMD FOAM RX/OTC 600 MG (Use azithromycin) daily) DRESSING/TOPSHEET 2 ZITHROMAX TRI-PAK NP QL(4 ea daily) 4"X4" PADS TABS (Use azithromycin) BAND-AID ALL-IN-ONE ZITHROMAX Z-PAK TABS NP QL(6 ea per fill ADHESIVE GAUZE 2 (Use azithromycin) retail) PAD/LARGE PADS Clarithromycin BAND-AID ALL-IN-ONE ADHESIVE GAUZE 2 clarithromycin susr 125 1 mg/5ml, 250 mg/5ml PAD/MEDIUM PADS BAND-AID GAUZE PADS RX/OTC clarithromycin tabs 250 mg, 1 QL(28 ea per 2 500 mg fill retail) LARGE4" X 4" PADS QL(14 ea per BAND-AID GAUZE PADS clarithromycin tb24 500 mg 1 2 fill retail) MEDIUM 3" X 3" PADS BAND-AID GAUZE PADS 2 RX/OTC Erythromycins SMALL2" X 2" PADS E.E.S. GRANULES SUSR BAND-AID HURT-FREE (Use erythromycin NP NON-STICK PADS LARGE 2 ethylsuccinate) 3" X 4" PADS ERYPED 200 SUSR (Use BAND-AID HURT-FREE erythromycin NP NON-STICK PADS 2 ethylsuccinate) MEDIUM 2" X 3" PADS ERYPED 400 SUSR (Use BAND-AID MIRASORB RX/OTC erythromycin NP GAUZE SPONGES 2 ethylsuccinate) LARGE 4" X 4" PADS erythromycin base cpep 1 250 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BAND-AID QUILTVENT CURITY ALL PURPOSE 2 RX/OTC WATERPROOF PAD 2 SPONGES 4"X4" PADS LARGE 2.875" X 4" PADS CURITY AMD RX/OTC BIOGUARD GAUZE RX/OTC ANTIMICROBIALGAUZE 2 SPONGE 2"X2" 8 PLY 2 SPONGES 2"X2" 8 PLY PADS PADS BIOGUARD GAUZE RX/OTC CURITY AMD RX/OTC 2 SPONGES 4"X4" 12 PLY ANTIMICROBIALGAUZE 2 PADS SPONGES 4"X4" 12 PLY PADS BORDERED GAUZE 2 RX/OTC PADS CURITY COVER SPONGE 2 RX/OTC 4"X4" PADS CARRASMART FOAM 2 RX/OTC PADS CURITY COVER 2 SPONGES 3"X3" PADS CARRASMART PADS XX 2 RX/OTC CURITY COVER 2 RX/OTC COPA ISLAND RX/OTC SPONGES 4"X4" PADS BORDERED FOAM 2 CURITY DRESSING RX/OTC DRESSING 4"X4" PADS SPONGES 4"X4" 6 PLY 2 COPA PLUS RX/OTC PADS HYDROPHILIC FOAM 2 CURITY GAUZE PADS 2 RX/OTC DRESSING 4"X4" PADS 2"X2" 12 PLY PADS COVRSITE COVER RX/OTC 2 CURITY GAUZE PADS 2 RX/OTC DRESSING PADS 2"X2" PADS COVRSITE PLUS RX/OTC CURITY GAUZE PADS 2 COMPOSITE DRESSING 2 3"X3" PADS PADS CURITY GAUZE PADS 2 RX/OTC CRUAD GAUZE PADS 4" 2 RX/OTC 4"X4" 12 PLY PADS X 4" PADS CURITY GAUZE SPONGE 2 RX/OTC CURAD NON-STICK 2"X2" 8 PLY PADS PADS WITHADHESIVE 2 CURITY GAUZE SPONGE 2 RX/OTC TABS 3"X4" PADS 2"X2"12 PLY PADS CURITY ALL PURPOSE RX/OTC CURITY GAUZE SPONGE 2 SPONGES 2"X2" 4PLY 2 3"X3" 12 PLY PADS PADS CURITY GAUZE SPONGE 2 RX/OTC CURITY ALL PURPOSE 2 RX/OTC 4"X4" 12 PLY PADS SPONGES 2"X2" PADS CURITY GAUZE SPONGE 2 RX/OTC CURITY ALL PURPOSE 4"X4" 16 PLY PADS SPONGES 3"X3" 4PLY 2 PADS CURITY GAUZE SPONGE 2 RX/OTC 4"X4" 8 PLY PADS CURITY ALL PURPOSE 2 RX/OTC SPONGES 4 PLY PADS CURITY GAUZE SPONGE 2 RX/OTC 4"X4"16 PLY PADS CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 4PLY 2 CURITY GAUZE RX/OTC PADS SPONGES 4"X4" 12 PLY 2 PADS CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 2 CURITY GAUZE RX/OTC 4PLY/SOFT POUCH PADS SPONGES 4"X4" 8 PLY 2 PADS MHS Indiana Preferred Drug List Updated June 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY NON-ADHERENT 2 DERMACEA I.V. DRAIN 2 RX/OTC STRIPS 3"X3" PADS SPONGES 2"X2" PADS CURITY RX/OTC DERMACEA I.V. DRAIN 2 RX/OTC SPONGES/CELLULOSEFI 2 SPONGES 4"X4" PADS LLED/2"X2" PADS DERMACEA I.V. 2 RX/OTC CURITY RX/OTC SPONGES 2"X2" PADS SPONGES/CELLULOSEFI 2 DERMACEA NON-WOVEN RX/OTC LLED/4"X4" PADS SPONGES 2"X2" 4 PLY 2 CVS ADHESIVE PAD 2 PADS 4"X4" PADS DERMACEA NON-WOVEN CVS ADHESIVE PAD 2 SPONGES 3"X3" 4 PLY 2 6"X6" PADS PADS CVS ADHESIVE PADS 2 DERMACEA NON-WOVEN RX/OTC 2.25"X3" PADS SPONGES 4"X4" 4 PLY 2 PADS CVS GAUZE PAD 3"X3" 2 PADS DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" 6 PLY 2 CVS GAUZE PADS 2"X2" 2 RX/OTC 12-PLY PADS PADS DERMACEA TYPE VII RX/OTC CVS GAUZE PADS 4"X4" 2 RX/OTC 12-PLY PADS GAUZE 2"X2" 12 PLY 2 PADS CVS GAUZE PADS RX/OTC STERILE 4"X4" 12-PLY 2 DERMACEA TYPE VII 2 RX/OTC PADS GAUZE 2"X2" 8 PLY PADS DERMACEA TYPE VII DERMACEA DRAIN 2 RX/OTC SPONGES 4"X4" PADS GAUZE 3"X3" 12 PLY 2 PADS DERMACEA GAUZE RX/OTC SPONGE 2"X2" 12 PLY 2 DERMACEA TYPE VII PADS GAUZE 3"X3" 12PLY 2 PADS DERMACEA GAUZE RX/OTC SPONGE 2"X2" 8 PLY 2 DERMACEA TYPE VII RX/OTC PADS GAUZE 4"X4" 12 PLY 2 PADS DERMACEA GAUZE SPONGE 3"X3" 12 PLY 2 DERMACEA TYPE VII RX/OTC PADS GAUZE 4"X4" 16 PLY 2 PADS DERMACEA GAUZE SPONGE 3"X3" 8 PLY 2 DERMACEA TYPE VII 2 RX/OTC PADS GAUZE 4"X4" 8 PLY PADS DERMACEA GAUZE RX/OTC DERMACEA X-RAY RX/OTC SPONGE 4"X4" 12 PLY 2 SPONGES 4"X4" 16 PLY 2 PADS PADS DERMACEA GAUZE RX/OTC DERMALEVIN ADHESIVE RX/OTC SPONGE 4"X4" 16 PLY 2 FOAMDRESSING 4"X4" 2 PADS PADS DERMACEA GAUZE RX/OTC DRYMAX EXTRA PADS 2 RX/OTC SPONGE 4"X4" 8 PLY 2 PADS EQL GAUZE PADS 2 RX/OTC 2"X2"/SMALL PADS

MHS Indiana Preferred Drug List Updated June 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL GAUZE PADS 2 RX/OTC J & J GAUZE 4"X4" 12 PLY 2 RX/OTC 4"X4"/LARGE PADS PADS EQL GAUZE STERILE 2 J & J GAUZE 4"X4" 8 PLY 2 RX/OTC PADS 3"X3" PADS PADS EXCILON AMD RX/OTC J & J GAUZE SPONGES 2 RX/OTC ANTIMICROBIALDRAIN 2 12-PLY 4" X 4" MISC SPONGES 4"X4" 6 PLY J & J GAUZE SPONGES 2 RX/OTC PADS 16-PLY 4" X 4" MISC EXCILON AMD RX/OTC J & J GAUZE SPONGES 2 RX/OTC ANTIMICROBIALNON- 2 8-PLY4" X 4" MISC WOVEN SPONGES 4"X4" 6 PLY PADS J & J NON-STICK PADS 2 100LARGE PADS EXCILON DRAIN 2 RX/OTC SPONGE 4"X4" PADS KENDALL HYDROPHILIC RX/OTC FOAMDRESSING 2"X2" 2 EXCILON DRAIN RX/OTC PADS SPONGES 4"X4" 6 PLY 2 PADS KENDALL HYDROPHILIC FOAMDRESSING 3"X3" 2 EXCILON I.V. SPONGES 2 RX/OTC PADS 2"X2" 6 PLY PADS KENDALL HYDROPHILIC RX/OTC GAUZE DRESSING 4"X4" 2 RX/OTC FOAMDRESSING 4"X4" 2 PADS PADS GAUZE PADS 2"X2" PADS 2 RX/OTC KENDALL HYDROPHILIC RX/OTC FOAMPLUS DRESSING 2 GAUZE PADS 3"X3" PADS 2 2"X2" PADS KENDALL HYDROPHILIC GAUZE PADS 4"X4" PADS 2 RX/OTC FOAMPLUS DRESSING 2 3"X3" PADS GAUZE SPONGE TYPE RX/OTC VII MEDI-PAK 2"X2" 8PLY 2 KERLIX SPONGES 4" X 4" 2 RX/OTC PADS 12 PLY PADS KERLIX SPONGES 4" X 4" RX/OTC GAUZE SPONGES 4"X4" 2 RX/OTC 2 12 PLY PADS 16 PLY PADS HM ADHESIVE PADS MIRASORB SPONGES 2" 2 RX/OTC ANTIBACTERIAL/SHEER 2 X 2" MISC PADS MIRASORB SPONGES 4" 2 RX/OTC X 4" MISC HM STERILE PADS 2"X2" 2 RX/OTC PADS MOLESKIN FOAM 2 RX/OTC PADDING PADS HM STERILE PADS PADS 2 NEXCARE ABSOLUTE WATERPROOF PAD 2 HYDROCELL ADHESIVE 2 RX/OTC DRESSING 4"X4" PADS PADS NU GAUZE 4PLY 4"X4" RX/OTC HYDROCELL DRESSING 2 RX/OTC 2 4"X4" PADS PADS NU GAUZE GENERAL- RX/OTC J & J ADHESIVE LARGE 2 PADS USE SPONGES 4"X4" 4 2 PLY MISC J & J GAUZE 2"X2" 8 PLY 2 RX/OTC PADS OPTIFOAM PADS 2 RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLYMEM FILM DOT 2 SM GAUZE PADS 3"X3" 2 PADS PADS POLYMEM NON- 2 RX/OTC SM GAUZE PADS 4"X4" 2 RX/OTC ADHESIVE PAD PADS PADS QC ALL PURPOSE 2 RX/OTC SM STERILE PADS 2"X2" 2 RX/OTC DRESSINGS4"X4" PADS PADS QC BORDER ISLAND 2 RX/OTC SM STERILE PADS PADS 2 RX/OTC GAUZE PAD 2"X2" PADS RX/OTC SOF-SET ADHESIVE 2 QC STERILE PADS PADS 2 PATCH PADS QC STERILE PADS PADS 2 SOF-WICK 4"X4" PADS 2 RX/OTC

RA FIRST AID NON-STICK 2 STERILE GAUZE PADS 2 RX/OTC PADS PADS 2"X2" PADS RA SHEER ADHESIVE 2 STERILE GAUZE PADS 2 LARGE PADS 3"X3" PADS RA STERILE PADS 2"X2" 2 RX/OTC STERILE PADS 2"X2" 2 RX/OTC PADS PADS RA STERILE PADS 3"X3" 2 STERILE PADS 3"X3" 2 PADS PADS RA STERILE PADS 4"X4" 2 RX/OTC STERILE PADS 4"X4" 2 RX/OTC PADS PADS RAY-TEC X-RAY RX/OTC SURGICAL GAUZE 2 RX/OTC DETECTABLESPONGES 2 SPONGE PADS 4" X 4" 16 PLY MISC TEGADERM FOAM 2 RX/OTC RESTORE CONTACT RX/OTC DRESSING 2"X2" PADS LAYER/NON-ADHERENT 2 TEGADERM FOAM 2 RX/OTC 2"X2" PADS DRESSING 4"X4" PADS RESTORE FOAM RX/OTC RX/OTC DRESSING BORDERED 2 THERAGAUZE PADS 2 4"X4" PADS TOPPER DRESSING 2 RX/OTC RESTORE FOAM RX/OTC SPONGES 4"X4" MISC DRESSING NON- 2 BORDERED 4"X4" PADS Contraceptives RESTORE ODOR RX/OTC AIMSCO LUBRICATED $0 QL(1.2 ea ABSORBING DRESSING 2 MISC daily); PV 4"X4" PADS DUREX EXTRA $0 QL(1.2 ea RESTORE TRIO SENSITIVE DEVI daily); PV ABSORBENT DRESSING 2 FANTASY LUBRICATED $0 QL(1.2 ea 3"X3" PADS MISC daily); PV FANTASY QL(1.2 ea SM ADHESIVE PADS 2 2"X3" PADS LUBRICATED/SPERMICID $0 daily); PV E MISC SM ADHESIVE PADS 2 3"X4" PADS K-Y ME & YOU EXTRA $0 QL(1.2 ea LUBRICATED DEVI daily); PV SM GAUZE PADS 2"X2" 2 RX/OTC PADS K-Y ME & YOU INTENSE $0 QL(1.2 ea DEVI daily); PV

MHS Indiana Preferred Drug List Updated June 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KAMELEON LUBRICATED QL(1.2 ea $0 TRUSTEX LUBRICATED $0 QL(1.2 ea MISC daily); PV MISC daily); PV QL(1.2 ea TRUSTEX QL(1.2 ea KIMONO COLORS DEVI $0 daily); PV LUBRICATED/RIBBED/ST $0 daily); PV UDDED MISC KIMONO LUBRICATED $0 QL(1.2 ea MISC daily); PV TRUSTEX QL(1.2 ea KIMONO MICRO THIN QL(1.2 ea LUBRICATED/SPERMICID $0 daily); PV PLUS SPERMICIDE $0 daily); PV E EXTRA LARGE MISC LUBRICATED MISC TRUSTEX QL(1.2 ea KIMONO PLUS QL(1.2 ea LUBRICATED/SPERMICID $0 daily); PV SPERMICIDE $0 daily); PV E EXTRA STRENGTH LUBRICATED MISC MISC KIMONO PLUS QL(1.2 ea TRUSTEX QL(1.2 ea SPERMICIDE/LUBRICATE $0 daily); PV LUBRICATED/SPERMICID $0 daily); PV D MISC E MISC TRUSTEX NATURAL QL(1.2 ea KIMONO PS LUBRICATED $0 QL(1.2 ea MISC daily); PV CONDOMS $0 daily); PV +LUBE/LUBRICATED KIMONO PS PLUS QL(1.2 ea MISC SPERMICIDE/LUBRICATE $0 daily); PV D MISC TRUSTEX WITH QL(1.2 ea NONOXYNOL- $0 daily); PV KIMONO SENSATION $0 QL(1.2 ea 9/RIBBED/STUDDED LUBRICATED MISC daily); PV MISC KIMONO SENSATION QL(1.2 ea TRUSTEX/RIA $0 QL(1.2 ea PLUS SPERMICIDE $0 daily); PV LUBRICATED MISC daily); PV LUBRICATED MISC TRUSTEX/RIA QL(1.2 ea QL(1.2 ea KIMONO SPECIAL DEVI $0 LUBRICATED $0 daily); PV daily); PV SPERMICIDE MISC QL(1.2 ea MAXX LUBRICATED MISC $0 TRUSTEX/RIA QL(1.2 ea daily); PV LUBRICATED/SPERMICID $0 daily); PV MAXX PLUS SPERMICIDE $0 QL(1.2 ea E MISC LUBRICATED MISC daily); PV Diabetic Supplies PREMIUM CONDOMS $0 QL(1.2 ea LUBRICATED MISC daily); PV 1ST TIER UNILET QL(6.85 ea COMFORTOUCH 2 daily) REALITY LATEX QL(1.2 ea LANCETS 28G MISC CONDOMS/LUBRICATED $0 daily); PV MISC 1ST TIER UNILET QL(6.85 ea COMFORTOUCH 2 daily) REALITY LATEX/ULTRA $0 QL(1.2 ea LANCETS 30G MISC TEXTURED DEVI daily); PV ACCU-CHEK FASTCLIX 2 QL(6.85 ea REALITY LATEX/ULTRA $0 QL(1.2 ea LANCETS MISC daily) THIN DEVI daily); PV ACCU-CHEK SOFTCLIX 2 QL(6.85 ea TRUSTEX COLOR $0 QL(1.2 ea LANCETS MISC daily) CONDOMS + LUBE MISC daily); PV ACTI-LANCE LANCETS 2 QL(6.85 ea TRUSTEX LUBRICATED $0 QL(1.2 ea 28G MISC daily) EXTRALARGE MISC daily); PV ACTI-LANCE LITE QL(6.85 ea TRUSTEX LUBRICATED $0 QL(1.2 ea SAFETY LANCETS 28G 2 daily) EXTRASTRENGTH MISC daily); PV MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTI-LANCE SPECIAL QL(6.85 ea ASSURE LANCE PLUS QL(6.85 ea SAFETY LANCETS 17G 2 daily) SAFETYLANCETS 25G 2 daily) MISC MISC ACTI-LANCE UNIVERSAL QL(6.85 ea ASSURE LANCE PLUS QL(6.85 ea SAFETY LANCETS 23G 2 daily) SAFETYLANCETS 30G 2 daily) MISC MISC ADJUSTABLE LANCING QL(1 ea per 2 AURORA LANCET SUPER 2 QL(6.85 ea DEVICE MISC 180 days retail) THIN30G MISC daily) ADVOCATE LANCING QL(1 ea per 2 AURORA LANCET THIN 2 QL(6.85 ea DEVICE MISC 180 days retail) 23G MISC daily) ADVOCATE RAPID-SAFE QL(1 ea per QL(1 ea per 2 AUTO-LANCET MINI MISC 2 LANCING DEVICE MISC 180 days retail) 180 days retail) AGAMATRIX ULTRA-THIN QL(6.85 ea 2 AUTO-LANCET MISC 2 QL(1 ea per LANCETS 33G MISC daily) 180 days retail) AIMSCO TWIST LANCETS 2 QL(6.85 ea AUTOLET IMPRESSION 2 QL(1 ea per 32G MISC daily) LANCING DEVICE MISC 180 days retail) AIMSCO TWIST LANCETS 2 QL(6.85 ea AUTOLET LANCING 2 QL(1 ea per 33G MISC daily) DEVICE MISC 180 days retail) ALTERNATE SITE QL(1 ea per 2 AUTOLET MINI MISC 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) 180 days retail) AQUA LANCE QL(1 ea per AUTOLET PLUS MISC 2 QL(1 ea per ADJUSTABLE LANCING 2 180 days retail) 180 days retail) DEVICE DEVI BD LANCET ULTRAFINE 2 QL(6.85 ea ASSURE COMFORT QL(6.85 ea 30G MISC daily) LANCETS ULTRA THIN 2 daily) BD MICROTAINER 2 QL(6.85 ea 28G MISC LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.85 ea BULLSEYE MINI SAFETY 2 QL(6.85 ea PLUS HIGH FLOW 18G 2 daily) LANCETS MISC daily) MISC BULLSEYE SAFETY 2 QL(6.85 ea ASSURE HAEMOLANCE QL(6.85 ea LANCETS MISC daily) PLUS LOW FLOW 25G 2 daily) MISC CARDIOCOM LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) ASSURE HAEMOLANCE QL(6.85 ea PLUS MICRO FLOW 28G 2 daily) CAREONE ADVANCED 2 QL(1 ea per MISC LANCINGDEVICE MISC 180 days retail) ASSURE HAEMOLANCE QL(6.85 ea CAREONE LANCET 2 QL(6.85 ea PLUS NORMAL FLOW 2 daily) SUPER THIN/30G MISC daily) 21G MISC CAREONE LANCET THIN 2 QL(6.85 ea ASSURE HAEMOLANCE QL(6.85 ea MISC daily) PLUS PEDIATRIC BLADE 2 daily) CARESENS LANCETS 2 QL(6.85 ea MISC MISC daily) CARETOUCH LANCING QL(1 ea per ASSURE LANCE 2 QL(6.85 ea LANCETS 21G MISC daily) DEVICEWITH EJECTOR 2 180 days retail) MISC ASSURE LANCE 2 QL(6.85 ea LANCETS MISC daily) CARETOUCH TWIST 2 QL(6.85 ea LANCETS 30G MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEANLET LANCETS 28G 2 QL(6.85 ea DRUG MART ON-THE-GO QL(6.85 ea MISC daily) LANCETS GENTLE 30G 2 daily) COMFORT ASSURED QL(6.85 ea MISC LANCETS MICRO THIN 2 daily) DRUG MART UNILET QL(6.85 ea 33G MISC LANCETSSUPER THIN 2 daily) COMFORT ASSURED QL(6.85 ea 30G MISC LANCETS SUPER THIN 2 daily) DRUG MART UNILET QL(6.85 ea 28G MISC LANCETSULTRA THIN 2 daily) 28G MISC COMFORT LANCETS 2 QL(6.85 ea MISC daily) E-Z JECT LANCETS 21G 2 QL(6.85 ea MISC daily) 2 QL(6.85 ea CVS LANCETS 21G MISC daily) E-Z JECT LANCETS 2 QL(6.85 ea COLOR MISC daily) CVS LANCETS MICRO 2 QL(6.85 ea THIN 33G MISC daily) E-Z JECT LANCETS MISC 2 QL(6.85 ea daily) CVS LANCETS MICRO- 2 QL(6.85 ea THIN 33G MISC daily) E-Z JECT LANCETS 2 QL(6.85 ea SUPER THIN 30G MISC daily) CVS LANCETS ORIGINAL 2 QL(6.85 ea MISC daily) E-Z JECT LANCETS THIN 2 QL(6.85 ea 26G MISC daily) CVS LANCETS THIN 26G 2 QL(6.85 ea MISC daily) E-ZJECT LANCETS 2 QL(6.85 ea MICRO-THIN 33G MISC daily) CVS LANCETS ULTRA 2 QL(6.85 ea THIN 30G MISC daily) EASY MINI EJECT 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) CVS LANCETS ULTRA- 2 QL(6.85 ea THIN 30G MISC daily) EASY MINI LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) CVS LANCING DEVICE 2 QL(1 ea per MISC 180 days retail) EASY TOUCH LANCETS 2 QL(6.85 ea 26G/PULL-TOP MISC daily) CVS ULTRA THIN 2 QL(6.85 ea LANCETS MISC daily) EASY TOUCH LANCETS 2 QL(6.85 ea 28G/PULL-TOP MISC daily) DIATHRIVE LANCETS 2 QL(6.85 ea MISC daily) EASY TOUCH LANCETS 2 QL(6.85 ea 28G/TWIST MISC daily) DIATHRIVE LANCETS 2 QL(6.85 ea ULTRA THIN 30G MISC daily) EASY TOUCH LANCETS QL(6.85 ea 30G/BUTTON-ACTIVATED 2 daily) DIATHRIVE LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) MISC EASY TOUCH LANCETS QL(6.85 ea DROPLET GENTEEL 2 QL(1 ea per 2 LANCING DEVICE MISC 180 days retail) 30G/PULL-TOP MISC daily) EASY TOUCH LANCETS QL(6.85 ea DROPLET LANCETS 2 QL(6.85 ea 2 ULTRA THIN 30G MISC daily) 30G/TWIST MISC daily) EASY TOUCH LANCETS QL(6.85 ea DROPLET LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) 32G/PRESSURE 2 daily) ACTIVATED MISC DRUG MART QL(1 ea per ADJUSTABLE LANCING 2 180 days retail) EASY TOUCH LANCETS 2 QL(6.85 ea DEVICE MISC 32G/PULL-TOP MISC daily) EASY TOUCH LANCETS QL(6.85 ea DRUG MART LANCETS 2 QL(6.85 ea 2 THIN MISC daily) 32G/TWIST MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 2 QL(6.85 ea FREDS PHARMACY QL(1 ea per 33G/TWIST MISC daily) AUTOLET LANCING 2 180 days retail) DEVICE MISC EASY TOUCH LANCING 2 QL(1 ea per DEVICE/EJECTOR MISC 180 days retail) FREDS PHARMACY QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea UNILET LANCETS SUPER 2 daily) LANCETS21G/PRESSURE 2 daily) THIN 30G MISC ACTIVATED MISC FREDS PHARMACY QL(6.85 ea EASY TOUCH SAFETY QL(6.85 ea UNILET LANCETS ULTRA 2 daily) LANCETS28G/BUTTON 2 daily) THIN 28G MISC ACTIVATED MISC GENTEEL LANCING QL(1 ea per DEVICE/GLORIOUS 2 180 days retail) EASY TWIST & CAP 2 QL(6.85 ea LANCETS MISC daily) GOLD MISC EMBRACE LANCING QL(1 ea per GENTEEL LANCING QL(1 ea per DEVICE WITH EJECTOR 2 180 days retail) DEVICE/PRECIOUS 2 180 days retail) MISC PLATINUM MISC GENTEEL LANCING QL(1 ea per EQL COLOR LANCETS 2 QL(6.85 ea 21G MISC daily) DEVICE/STATELY SILVER 2 180 days retail) MISC EQL COLOR LANCETS 2 QL(6.85 ea MICRO THIN 33G MISC daily) GENTEEL PLUS LANCING QL(1 ea per DEVICE/BUFF BLACK 2 180 days retail) EQL SUPER THIN 2 QL(6.85 ea MISC LANCETS 30G MISC daily) GENTEEL PLUS LANCING QL(1 ea per EQL THIN LANCETS 26G 2 QL(6.85 ea DEVICE/BUTTERFLY 2 180 days retail) MISC daily) BLUE MISC EZ-LETS LANCETS 21G 2 QL(6.85 ea GENTEEL PLUS LANCING QL(1 ea per MISC daily) DEVICE/PLAYFUL 2 180 days retail) EZ-LETS LANCETS 26G 2 QL(6.85 ea PURPLE MISC SUPER-SOFT MISC daily) GENTEEL PLUS LANCING QL(1 ea per EZ-LETS LANCETS 28G 2 QL(6.85 ea DEVICE/PRINCESS PINK 2 180 days retail) ULTRA-SOFT MISC daily) MISC EZ-LETS LANCETS 30G 2 QL(6.85 ea GENTEEL PLUS LANCING QL(1 ea per MISC daily) DEVICE/WILLOWY WHITE 2 180 days retail) MISC FIFTY50 SAFETY SEAL 2 QL(6.85 ea LANCETS 32G MISC daily) GENTLE-LET GP 2 QL(6.85 ea LANCETS MISC daily) FIFTY50 UNILET 2 QL(6.85 ea LANCETS 33G MISC daily) GENTLE-LET LANCETS QL(6.85 ea GENERAL PURPOSE 2 daily) FINE 30 MISC 2 QL(6.85 ea daily) STYLE/FINE POINT MISC GENTLE-LET LANCETS QL(6.85 ea FINGERSTIX LANCETS 2 QL(6.85 ea MISC daily) GENERAL PURPOSE 2 daily) STYLE/MEDIUM POINT FORA LANCETS MISC 2 QL(6.85 ea daily) MISC GENTLE-LET LANCETS QL(6.85 ea FORA LANCING DEVICE 2 QL(1 ea per MISC 180 days retail) SAFETY STYLE/FINE 2 daily) POINT MISC FORA LANCING 2 QL(1 ea per DEVICE/CLEARCAP MISC 180 days retail) GENTLE-LET LANCETS QL(6.85 ea SAFETY STYLE/MEDIUM 2 daily) POINT MISC MHS Indiana Preferred Drug List Updated June 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL LANCING 2 QL(1 ea per HEALTH CARE LANCING 2 QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) GLUCOCOM LANCETS 2 QL(6.85 ea HEALTHY ACCENTS QL(1 ea per 33G MISC daily) AUTOLET IMPRESSION 2 180 days retail) QL(6.85 ea LANCING DEVICE MISC GNP LANCETS 21G MISC 2 daily) HEALTHY ACCENTS QL(6.85 ea UNILET LANCETS SUPER 2 daily) GNP LANCETS MICRO 2 QL(6.85 ea THIN 33G MISC daily) THIN 30G MISC QL(6.85 ea GNP LANCETS SUPER 2 QL(6.85 ea HY-VEE LANCETS MISC 2 THIN 30G MISC daily) daily) HY-VEE THIN LANCETS QL(6.85 ea GNP LANCETS THIN 26G 2 QL(6.85 ea 2 MISC daily) MISC daily) IN TOUCH LANCING QL(1 ea per GNP LANCETS THIN 2 QL(6.85 ea 2 MISC daily) DEVICE MISC 180 days retail) QL(6.85 ea GOJJI LANCING QL(1 ea per KINNEY LANCETS MISC 2 DEVICE/CLEAR CAP 2 180 days retail) daily) MISC KINNEY THIN LANCETS 2 QL(6.85 ea MISC daily) GOJJI STERILE LANCETS 2 QL(6.85 ea 30G MISC daily) KROGER AUTOLET 2 QL(1 ea per LANCING DEVICE MISC 180 days retail) GOODSENSE LANCETS 2 QL(6.85 ea MICRO-THIN 33G MISC daily) KROGER HEALTHPRO QL(6.85 ea TWIST LANCETS/26G 2 daily) GOODSENSE LANCETS 2 QL(6.85 ea ULTRA-THIN 30G MISC daily) MISC KROGER LANCETS 21G QL(6.85 ea GOODSENSE LANCING 2 QL(1 ea per 2 DEVICE MISC 180 days retail) MISC daily) H-E-B INCONTROL QL(1 ea per KROGER LANCETS 2 QL(6.85 ea ADVANCEDLANCING 2 180 days retail) MICRO THIN33G MISC daily) DEVICE MISC QL(6.85 ea KROGER LANCETS MISC 2 H-E-B INCONTROL QL(6.85 ea daily) LANCETS MICRO THIN 2 daily) KROGER LANCETS 2 QL(6.85 ea 33G MISC SUPER THIN MISC daily) H-E-B INCONTROL QL(6.85 ea KROGER LANCETS THIN 2 QL(6.85 ea LANCETS SUPER THIN 2 daily) 26G MISC daily) 30G MISC KROGER LANCETS THIN 2 QL(6.85 ea H-E-B INCONTROL QL(6.85 ea MISC daily) LANCETS ULTRA THIN 2 daily) KROGER LANCETS 2 QL(6.85 ea 28G MISC ULTRATHIN30G MISC daily) HAEMOLANCE LOW QL(6.85 ea 2 KROGER LANCING 2 QL(1 ea per FLOW LANCETS MISC daily) DEVICE MISC 180 days retail) QL(6.85 ea HAEMOLANCE MISC 2 LANCET DEVICE 2 QL(1 ea per daily) ADJUSTABLE MISC 180 days retail) HAEMOLANCE PLUS QL(6.85 ea 2 LANCET DEVICE WITH 2 QL(1 ea per LOW FLOW MISC daily) EJECTOR MISC 180 days retail) HAEMOLANCE PLUS QL(6.85 ea 2 LANCETS 26G TWIST 2 QL(6.85 ea MISC daily) TOP MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.85 ea LIFESCAN UNISTIK II QL(6.85 ea LANCETS 28G MISC 2 2 daily) LANCETS MISC daily) QL(6.85 ea LITE TOUCH LANCETS QL(6.85 ea LANCETS 30G MISC 2 2 daily) MISC daily) LANCETS 31G TWIST 2 QL(6.85 ea LITE TOUCH LANCING 2 QL(1 ea per TOP MISC daily) PEN MISC 180 days retail) LANCETS MICRO THIN 2 QL(6.85 ea LITETOUCH LANCETS 2 QL(6.85 ea 33G MISC daily) MICRO THIN 33G MISC daily) QL(6.85 ea LIVE BETTER ADVANCED QL(1 ea per LANCETS MISC 2 2 daily) LANCING DEVICE MISC 180 days retail) LANCETS SAFETY SEAL 2 QL(6.85 ea LIVE BETTER LANCET 2 QL(6.85 ea 21G MISC daily) SUPERTHIN 30G MISC daily) LANCETS SAFETY SEAL 2 QL(6.85 ea LIVE BETTER LANCET 2 QL(6.85 ea 26G MISC daily) ULTRATHIN 28G MISC daily) LANCETS SAFETY SEAL 2 QL(6.85 ea LONGS LANCETS 2 QL(6.85 ea 28G MISC daily) STANDARD MISC daily) LANCETS SAFETY SEAL 2 QL(6.85 ea LONGS LANCETS THIN 2 QL(6.85 ea 30G MISC daily) MISC daily) LANCETS SUPER THIN 2 QL(6.85 ea LONGS LANCETS ULTRA 2 QL(6.85 ea 28G MISC daily) THIN MISC daily) QL(6.85 ea MEDICHOICE PRE-SET QL(6.85 ea LANCETS THIN MISC 2 daily) SAFETY LANCET DUAL 2 daily) USE MISC LANCETS ULTRA FINE 2 QL(6.85 ea MISC daily) MEDICHOICE PRE-SET QL(6.85 ea SAFETY LANCET LOW 2 daily) LANCETS ULTRA THIN 2 QL(6.85 ea 30G MISC daily) FLOW MISC MEDICHOICE PRE-SET QL(6.85 ea LANCETS ULTRA THIN 2 QL(6.85 ea MISC daily) SAFETY LANCET 2 daily) MEDIUM FLOW MISC LANCETSBULLSEYE 2 QL(6.85 ea SAFETY MISC daily) MEDICHOICE PRE-SET QL(6.85 ea SAFETY LANCET 2 daily) LANCING DEVICE 2 QL(1 ea per MODERATE FLOW MISC ADJUSTABLE MISC 180 days retail) MEDICHOICE SAFETY 2 QL(6.85 ea LANCING DEVICE MISC 2 QL(1 ea per LANCETEXTRA MISC daily) 180 days retail) MEDICHOICE SAFETY 2 QL(6.85 ea LANZO MISC 2 QL(1 ea per LANCETNORMAL MISC daily) 180 days retail) MEDISENSE THIN 2 QL(6.85 ea LEADER ADVANCED 2 QL(1 ea per LANCETS MISC daily) LANCING DEVICE MISC 180 days retail) MEDLANCE PLUS EXTRA 2 QL(6.85 ea LIBERTY MEDICAL 2 QL(6.85 ea LANCETS 21G MISC daily) LANCETS 30G MISC daily) MEDLANCE PLUS 2 QL(6.85 ea LIBERTY MINI LANCING 2 QL(1 ea per LANCETS LITE 25G MISC daily) DEVICE MISC 180 days retail) MEDLANCE PLUS 2 QL(6.85 ea LIFESCAN UNISTIK 2 QL(6.85 ea LANCETS MISC daily) DEEP PENETRATION 2 daily) QL(6.85 ea MISC MEDLANCE PLUS LITE 2 LANCETS 25G MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDLANCE PLUS QL(6.85 ea MULTI-LANCET DEVICE 2 QL(1 ea per SPECIAL LANCETS 2 daily) MISC 180 days retail) 0.8MM MISC NOVA SUREFLEX 2 QL(6.85 ea MEDLANCE PLUS QL(6.85 ea LANCETS MISC daily) SUPERLITE daily) 2 NOVA SUREFLEX 2 QL(1 ea per 30G/COMFORT MAX LANCING DEVICE MISC 180 days retail) MISC PA MEDLANCE PLUS QL(6.85 ea OMNIPOD 5 PACK MISC 2 UNIVERSAL LANCETS 2 daily) OMNIPOD DASH 5 PACK 2 PA 21G MISC MISC QL(6.85 ea MEDLANCE/EXTRA MISC 2 OMNIPOD DASH SYSTEM 2 PA daily) KIT QL(6.85 ea MEDLANCE/LITE MISC 2 OMNIPOD STARTER KIT 2 PA daily) KIT MEDLANCE/UNIVERSAL QL(6.85 ea 2 ON CALL LANCING 2 QL(1 ea per MISC daily) DEVICE MISC 180 days retail) MEIJER COLOR QL(6.85 ea ON CALL PLUS LANCING 2 QL(1 ea per LANCETS UNIVERSAL 2 daily) DEVICE MISC 180 days retail) 33G MISC ONETOUCH CLUB QL(6.85 ea QL(6.85 ea MEIJER LANCETS MISC 2 LANCETS FINE POINT 2 daily) daily) MISC MEIJER LANCETS THIN 2 QL(6.85 ea ONETOUCH DELICA QL(6.85 ea MISC daily) LANCETS EXTRA FINE 2 daily) MEIJER LANCETS 2 QL(6.85 ea 33G MISC UNIVERSAL21G MISC daily) ONETOUCH DELICA 2 QL(6.85 ea MEIJER LANCETS 2 QL(6.85 ea LANCETS FINE 30G MISC daily) UNIVERSAL30G MISC daily) ONETOUCH DELICA 2 QL(1 ea per MEIJER LANCETS 2 QL(6.85 ea LANCING DEVICE MISC 180 days retail) UNIVERSAL33G MISC daily) ONETOUCH DELICA QL(1 ea per MEIJER SUPER THIN 2 QL(6.85 ea PLUS LANCING DEVICE 2 180 days retail) LANCETS MISC daily) MISC MICROLET LANCETS QL(6.85 ea 2 ONETOUCH ULTRASOFT 2 QL(6.85 ea MISC daily) LANCETS MISC daily) QL(1 ea per MICROLET NEXT MISC 2 PC LANCETS SUPER 2 QL(6.85 ea 180 days retail) THIN 30G MISC daily) MINI LANCING DEVICE QL(1 ea per 2 PERFECT LANCETS 30G 2 QL(6.85 ea MISC 180 days retail) MISC daily) MM LANCING DEVICE QL(1 ea per 2 PHARMACY COUNTER 2 QL(6.85 ea MISC 180 days retail) LANCETS MISC daily) MONOLET LANCETS QL(6.85 ea 2 PRECISION THINS GP 2 QL(6.85 ea MISC daily) LANCET MISC daily) MONOLET OPD LANCETS 2 QL(6.85 ea PREFERRED PLUS QL(6.85 ea MISC daily) LANCETS COLORED 21G 2 daily) MISC MONOLETTOR SAFETY 2 QL(6.85 ea LANCETS MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(6.85 ea RELION 2-IN-1 LANCET 2 QL(1 ea per LANCETS SUPER THIN 2 daily) DEVICES 30G MISC 180 days retail) 30G MISC RELION 2-IN-1 LANCING 2 QL(1 ea per PREFERRED PLUS 2 QL(6.85 ea DEVICE 25G MISC 180 days retail) LANCETS THIN 26G MISC daily) RELION 2-IN-1 LANCING 2 QL(1 ea per PRESSURE ACTIVATED QL(6.85 ea DEVICE 30G MISC 180 days retail) SAFETYLANCET 21G 2 daily) RELION LANCETS 2 QL(6.85 ea MISC MICRO-THIN33G MISC daily) PRODIGY LANCING QL(1 ea per 2 RELION LANCETS THIN 2 QL(6.85 ea DEVICE MISC 180 days retail) 26G MISC daily) PRODIGY TWIST TOP QL(6.85 ea 2 RELION LANCETS 2 QL(6.85 ea LANCETS MISC daily) ULTRA-THIN30G MISC daily) PSS SELECT GP QL(6.85 ea 2 RELION LANCING 2 QL(1 ea per LANCETS MISC daily) DEVICE MISC 180 days retail) PSS SELECT SAFETY QL(6.85 ea 2 RELION ULTRA THIN 2 QL(6.85 ea LANCETS MISC daily) LANCETS/30G MISC daily) PUSH BUTTON SAFETY QL(6.85 ea 2 RELION ULTRA THIN 2 QL(6.85 ea LANCETS 21G MISC daily) LANCETS30G MISC daily) PUSH BUTTON SAFETY 2 QL(6.85 ea RELION ULTRA THIN QL(6.85 ea LANCETS 28G MISC daily) PLUS LANCETS 32G 2 daily) PX ADVANCED LANCING 2 QL(1 ea per MISC DEVICE MISC 180 days retail) RELION ULTRA THIN QL(6.85 ea PX LANCET AUTO 2 QL(1 ea per PLUS LANCETS 33G 2 daily) INJECTOR MISC 180 days retail) MISC PX LANCETS ULTRA QL(6.85 ea 2 REXALL LANCETS ULTRA 2 QL(6.85 ea THIN MISC daily) THIN MISC daily) QC ADVANCED LANCING QL(1 ea per 2 RIGHTEST GD500 2 QL(1 ea per DEVICE MISC 180 days retail) LANCING DEVICE MISC 180 days retail) QC LANCETS SUPER QL(6.85 ea 2 RIGHTEST GL300 2 QL(6.85 ea THIN MISC daily) LANCETS MISC daily) QC LANCETS ULTRA QL(6.85 ea 2 SAFE-T-LANCE LOW 2 QL(6.85 ea THIN MISC daily) FLOW 25G MISC daily) QC UNILET LANCETS QL(6.85 ea 2 SAFE-T-LANCE NORMAL 2 QL(6.85 ea 28G/ULTRA THIN MISC daily) FLOW21G MISC daily) QC UNILET LANCETS 2 QL(6.85 ea SAFE-T-LANCE PLUS QL(6.85 ea 33G/MICRO THIN MISC daily) SAFETYLANCET LOW 2 daily) FLOW MISC RA E-ZJECT LANCETS 2 QL(6.85 ea 28G MISC daily) SAFE-T-LANCE PLUS QL(6.85 ea SAFETYLANCET 2 daily) RA E-ZJECT LANCETS 2 QL(6.85 ea THIN 26G MISC daily) NORMAL FLOW MISC SAFETY LANCETS 28G QL(6.85 ea RA E-ZJECT LANCETS 2 QL(6.85 ea 2 THIN 28G MISC daily) MISC daily) SAFETY LET LANCETS QL(6.85 ea RA E-ZJECT LANCETS 2 QL(6.85 ea 2 ULTRATHIN 30G MISC daily) MISC daily) SAFETY SEAL LANCETS QL(6.85 ea REALITY LANCETS MISC 2 QL(6.85 ea 2 daily) 28G MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY SEAL LANCETS 2 QL(6.85 ea SOLUS V2 LANCING 2 QL(1 ea per 30G MISC daily) DEVICE MISC 180 days retail) QL(6.85 ea QL(6.85 ea SB LANCETS THIN MISC 2 STERILANCE TL MISC 2 daily) daily) SB LANCETS ULTRA 2 QL(6.85 ea SUPER THIN LANCETS 2 QL(6.85 ea THIN MISC daily) MISC daily) SELECT-LITE LANCING 2 QL(1 ea per SURE COMFORT 2 QL(1 ea per DEVICE MISC 180 days retail) LANCING PEN MISC 180 days retail) SHOPKO AUTOLET QL(1 ea per 2 SURE-LANCE THIN 2 QL(6.85 ea LANCING DEVICE MISC 180 days retail) LANCETS 28G MISC daily) SHOPKO ON-THE-GO QL(6.85 ea SURE-LANCE ULTRA 2 QL(6.85 ea COMFORTLANCETS 30G 2 daily) THIN LANCETS MISC daily) MISC SURE-PEN MISC 2 QL(1 ea per SHOPKO UNILET QL(6.85 ea 180 days retail) LANCETS SUPER THIN 2 daily) SURE-TOUCH LANCETS 2 QL(6.85 ea 30G MISC UNIVERSAL MISC daily) SHOPKO UNILET QL(6.85 ea SURELITE LANCETS 2 QL(6.85 ea LANCETS ULTRA THIN 2 daily) MISC daily) 28G MISC TECHLITE AST LANCETS 2 QL(6.85 ea SIDE BUTTON SAFETY 2 QL(6.85 ea MISC daily) LANCET21G MISC daily) TECHLITE LANCETS 30G 2 QL(6.85 ea SIMPLE DIAGNOSTICS 2 QL(1 ea per MISC daily) LANCING DEVICE MISC 180 days retail) TECHLITE LANCETS 2 QL(6.85 ea SINGLE-LET MISC 2 QL(6.85 ea MISC daily) daily) TGT LANCET MICRO 2 QL(6.85 ea SM MICRO THIN 2 QL(6.85 ea THIN 33G MISC daily) LANCETS 33G MISC daily) TGT LANCET THIN 26G 2 QL(6.85 ea SM TRUEDRAW LANCING 2 QL(1 ea per MISC daily) DEVICE MISC 180 days retail) TGT LANCET ULTRA 2 QL(6.85 ea SMART DIABETES QL(1 ea per THIN 30G MISC daily) VANTAGE LANCING 2 180 days retail) DEVICE MISC TGT LANCING DEVICE 2 QL(1 ea per MISC 180 days retail) SMART SENSE COLOR QL(6.85 ea LANCETS UNIVERSAL 2 daily) THINLETS GP LANCETS 2 QL(6.85 ea 33G MISC MISC daily) SMART SENSE QL(6.85 ea TODAYS HEALTH QL(1 ea per STANDARD LANCETS 2 daily) ADVANCED LANCING 2 180 days retail) UNIVERSAL 21G MISC DEVICE MISC SMART SENSE SUPER QL(6.85 ea TODAYS HEALTH SUPER 2 QL(6.85 ea THIN LANCETS 2 daily) THINLANCETS 30G MISC daily) UNIVERSAL 30G MISC TODAYS HEALTH ULTRA 2 QL(6.85 ea SMART SENSE THIN QL(6.85 ea THINLANCETS 28G MISC daily) LANCETSUNIVERSAL 2 daily) TOPCARE LANCETS 2 QL(6.85 ea 26G MISC MICRO-THIN 33G MISC daily) TRAVEL LANCETS 30G QL(6.85 ea SMARTEST LANCETS 2 QL(6.85 ea 2 28G MISC daily) MISC daily)

MHS Indiana Preferred Drug List Updated June 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRAVEL LANCETS 2 QL(6.85 ea UNILET GP 28 ULTRA 2 QL(6.85 ea ADVANCED 28G MISC daily) THIN MISC daily) TRUE METRIX CONTROL UNILET LANCET MISC 2 QL(6.85 ea SOLUTION LEVEL 1 2 daily) SOLN UNILET LANCETS 2 QL(6.85 ea TRUE METRIX CONTROL MICRO-THIN33G MISC daily) SOLUTION LEVEL 2 2 UNILET LANCETS 2 QL(6.85 ea SOLN SUPER-THIN30G MISC daily) TRUE METRIX CONTROL UNILET LANCETS 2 QL(6.85 ea SOLUTION LEVEL 3 2 ULTRA-THIN 28G MISC daily) SOLN UNILET SUPERLITE 2 QL(6.85 ea TRUEDRAW LANCING 2 QL(1 ea per LANCET MISC daily) DEVICE MISC 180 days retail) UNISTIK TOUCH SAFETY 2 QL(6.85 ea TRUEPLUS LANCETS 2 QL(6.85 ea LANCETS 23G MISC daily) 26G MISC daily) UNIVERSAL 1 LANCETS 2 QL(6.85 ea TRUEPLUS LANCETS 2 QL(6.85 ea THIN26G MISC daily) 28G MISC daily) UNIVERSAL 1 LANCETS 2 QL(6.85 ea TRUEPLUS LANCETS 2 QL(6.85 ea ULTRA THIN 30G MISC daily) 28G SUPER THIN MISC daily) UNIVERSAL 1 QL(6.85 ea TRUEPLUS LANCETS 2 QL(6.85 ea LANCETS/33G/MICRO- 2 daily) 30G MISC daily) THIN MISC TRUEPLUS LANCETS 2 QL(6.85 ea PA 30G ULTRA THIN MISC daily) V-GO 20 KIT 2 TRUEPLUS LANCETS QL(6.85 ea 2 V-GO 30 KIT 2 PA 33G MISC daily) PA TRUEPLUS SAFETY 2 QL(6.85 ea V-GO 40 KIT 2 LANCETS 28G MISC daily) VALUE PLUS LANCETS QL(6.85 ea ULTI-LANCE AUTOMATIC/ 2 QL(1 ea per 2 CLEAR TIP MISC 180 days retail) STANDARD 21G MISC daily) VALUE PLUS LANCETS QL(6.85 ea ULTILET CLASSIC 2 QL(6.85 ea 2 LANCETS MISC daily) SUPERTHIN 30G MISC daily) VALUE PLUS LANCETS QL(6.85 ea ULTILET LANCETS 33G 2 QL(6.85 ea 2 MISC daily) THIN 26G MISC daily) VALUE PLUS LANCING QL(1 ea per ULTILET LANCETS MISC 2 QL(6.85 ea 2 daily) DEVICE MISC 180 days retail) VALUMARK LANCET QL(6.85 ea UNILET COMFORTOUCH 2 QL(6.85 ea 2 LANCET MISC daily) SUPER THIN 30G MISC daily) VALUMARK LANCET QL(6.85 ea UNILET EXCELITE II MISC 2 QL(6.85 ea 2 daily) ULTRA THIN 28G MISC daily) VIDA MIA AUTOLET QL(1 ea per UNILET EXCELITE MISC 2 QL(6.85 ea 2 daily) LANCINGDEVICE MISC 180 days retail) VIDA MIA UNILET QL(6.85 ea UNILET G.P. LANCET 2 QL(6.85 ea MISC daily) LANCETS SUPER THIN 2 daily) 30G MISC UNILET G.P. SUPERLITE 2 QL(6.85 ea LANCET MISC daily) VIDA MIA UNILET QL(6.85 ea LANCETS ULTRA THIN 2 daily) 28G MISC MHS Indiana Preferred Drug List Updated June 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITALET PRO PLUS 2 QL(6.85 ea EQL ALCOHOL SWABS 2 QL(16.67 ea LANCETS MISC daily) PADS daily); RX/OTC VIVAGUARD LANCING 2 QL(1 ea per FIFTY50 ALCOHOL PREP 2 QL(16.67 ea DEVICE MISC 180 days retail) PADS PADS daily); RX/OTC WALGREENS COMFORT QL(6.85 ea GNP ALCOHOL SWABS 2 QL(16.67 ea ASSUREDLANCETS 2 daily) PADS daily); RX/OTC MICRO THIN/33G MISC H-E-B INCONTROL 2 QL(16.67 ea WALGREENS COMFORT QL(6.85 ea ALCOHOL PADS PADS daily); RX/OTC ASSUREDLANCETS 2 daily) HM STERILE ALCOHOL 2 QL(16.67 ea SUPER THIN/28G MISC PREP PADS PADS daily); RX/OTC WALGREENS LANCETS 2 QL(6.85 ea MEIJER ALCOHOL QL(16.67 ea MISC daily) SWABS EXTRA-THICK 2 daily); RX/OTC WALGREENS THIN 2 QL(6.85 ea PADS LANCETS MISC daily) PRO COMFORT 2 QL(16.67 ea WALGREENS ULTRA 2 QL(6.85 ea ALCOHOL PADS PADS daily); RX/OTC THIN LANCETS MISC daily) QC ALCOHOL SWABS 2 QL(16.67 ea Misc. Devices PADS daily); RX/OTC RA ALCOHOL SWABS QL(16.67 ea ALCOHOL PREP PADS 2 QL(16.67 ea 2 PADS daily); RX/OTC PADS daily); RX/OTC QL(16.67 ea ALCOHOL SWABS PADS 2 QL(16.67 ea REALITY SWABS PADS 2 daily); RX/OTC daily); RX/OTC RELION ALCOHOL QL(16.67 ea ALCOHOL SWABSTICK 2 QL(16.67 ea 2 PADS daily); RX/OTC SWABS PADS daily); RX/OTC SB ALCOHOL PREP QL(16.67 ea ALCOHOL WIPES PADS 2 QL(16.67 ea 2 XX daily); RX/OTC PADS PADS daily); RX/OTC SHOPKO ALCOHOL QL(16.67 ea APLICARE ALCOHOL 2 QL(16.67 ea 2 SWABSTICK PADS daily); RX/OTC SWABS PADS daily); RX/OTC SM ALCOHOL PREP QL(16.67 ea BD SWABS SINGLE USE 2 QL(16.67 ea 2 BUTTERFLY PADS daily); RX/OTC PADS PADS daily); RX/OTC TGT ALCOHOL SWABS QL(16.67 ea BD SWABS SINGLE USE 2 QL(16.67 ea 2 PADS daily); RX/OTC PADS daily); RX/OTC ULTICARE ALCOHOL QL(16.67 ea CARETOUCH ALCOHOL 2 QL(16.67 ea 2 PREP PADS PADS daily); RX/OTC SWABS PADS daily); RX/OTC CURITY ALCOHOL QL(16.67 ea WEBCOL ALCOHOL QL(16.67 ea PREPS/MEDIUM 2 PLY 2 daily); RX/OTC PREP LARGE 1 PLY 2 daily); RX/OTC PADS PADS WEBCOL ALCOHOL QL(16.67 ea CURITY ALCOHOL 2 QL(16.67 ea SWABS PADS daily); RX/OTC PREP LARGE 2 PLY 2 daily); RX/OTC PADS CVS ALCOHOL PREP 2 QL(16.67 ea PADS PADS daily); RX/OTC WEBCOL ALCOHOL QL(16.67 ea 2 QL(16.67 ea PREP MEDIUM 2 PLY daily); RX/OTC CVS PREP PADS PADS 2 PADS daily); RX/OTC EASY TOUCH ALCOHOL QL(16.67 ea Parenteral Therapy Supplies PREP PADS/MEDIUM 2 daily); RX/OTC 1ST TIER UNIFINE QL(5 ea daily); PADS PENTIPS/MINI/31GX5MM 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); PENTIPS29GX12MM 2 RX/OTC SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/29GX1/2" MISC 1ST TIER UNIFINE 2 QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); PENTIPS31GX6MM MISC SYRINGE/U- 2 RX/OTC 100/0.3ML/30GX5/16" 1ST TIER UNIFINE 2 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC MISC ADVOCATE INSULIN QL(5 ea daily) 1ST TIER UNIFINE 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC SYRINGE/U- 2 100/0.3ML/31GX5/16" 1ST TIER UNIFINE 2 QL(5 ea daily) MISC PENTIPS32GX6MM MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC PENTIPSPLUS 31GX8MM 2 RX/OTC 100/0.5ML/29GX1/2" MISC MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC PENTIPSPLUS 32GX4MM 2 RX/OTC 100/0.5ML/30GX5/16" MISC MISC 1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) PENTIPSPLUS/MINI/31GX 2 RX/OTC SYRINGE/U- 2 5MM MISC 100/0.5ML/31GX5/16" 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPSPLUS/ORIGINAL/ 2 RX/OTC ADVOCATE INSULIN QL(5 ea daily); 29GX12MM MISC SYRINGE/U- 2 RX/OTC 1ST TIER UNIFINE QL(5 ea daily) 100/1ML/29GX1/2" MISC PENTIPSPLUS/ULTRA 2 ADVOCATE INSULIN QL(5 ea daily); SHORT/31GX6MM MISC SYRINGE/U- 2 RX/OTC ABOUTTIME PEN 2 QL(5 ea daily); 100/1ML/30GX5/16" MISC NEEDLE 32GX 5/32" MISC RX/OTC ADVOCATE INSULIN QL(5 ea daily) ABOUTTIME PEN QL(5 ea daily); SYRINGE/U- 2 NEEDLES 30GX 5/16" 2 RX/OTC 100/1ML/31GX5/16" MISC MISC ASSURE ID INSULIN QL(5 ea daily); ABOUTTIME PEN QL(5 ea daily); SAFETYSYRINGE/U- 2 RX/OTC NEEDLES 31G X 3/16" 2 RX/OTC 100/0.5ML/29G X 1/2" MISC MISC ABOUTTIME PEN QL(5 ea daily); ASSURE ID INSULIN QL(5 ea daily); NEEDLES 31G X 5/16" 2 RX/OTC SAFETYSYRINGE/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC ADVOCATE INSULIN PEN QL(5 ea daily) ASSURE ID SAFETY PEN QL(5 ea daily); NEEDLES 29GX12.7MM 2 NEEDLES 30G X 5/16" 2 RX/OTC MISC MISC ADVOCATE INSULIN PEN QL(5 ea daily); ASSURE ID SAFETY PEN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC NEEDLES 31G X 3/16" 2 RX/OTC MISC MISC ADVOCATE INSULIN PEN QL(5 ea daily); AURORA PEN NEEDLES 2 QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC 29GX12MM MISC RX/OTC MISC AURORA PEN NEEDLES 2 QL(5 ea daily) 31G X6MM MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AURORA PEN NEEDLES 2 QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) 31G X8MM MISC RX/OTC ULTRA-FINE/0.5ML/31G X 2 8MM MISC AURORA UNIFINE 2 QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily) AURORA UNIFINE QL(5 ea daily); ULTRA-FINE/1/2 2 PENTIPS/MINI/31GX3/16" 2 RX/OTC UNIT/0.3ML/31G X 8MM MISC MISC PA; RX/OTC BD INSULIN SYRINGE QL(5 ea daily) AUTOJECT 2 MISC 2 ULTRA-FINE/1ML/30G X 2 B-D INSULIN SYRINGE QL(5 ea daily) 12.7MM MISC ULTRAFINE II/0.3ML/31G 2 BD INSULIN SYRINGE QL(5 ea daily) X 5/16" MISC ULTRA-FINE/1ML/31G X 2 B-D INSULIN SYRINGE QL(5 ea daily) 8MM MISC ULTRAFINE II/0.5ML/31G 2 BD INSULIN SYRINGE QL(5 ea daily) X 5/16" MISC ULTRAFINE HALF- 2 B-D INSULIN SYRINGE QL(5 ea daily) UNIT/0.3ML/31G X 5/16" ULTRAFINE II/1ML/31G X 2 MISC 5/16" MISC BD INSULIN SYRINGE B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X 2 ULTRAFINE/0.3ML/30G X 2 1/2" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD LO-DOSE INSULIN QL(5 ea daily); ULTRAFINE/0.3ML/31G X 2 SYRINGE MICROFINE 2 RX/OTC 5/16" MISC IV/0.5ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/31G X 2 5/16" MISC MICROFINE IV/U- 2 RX/OTC 100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/1ML/30G X 2 BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE IV/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/28G X 1/2" MISC ULTRAFINE/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.3ML/29G X 1/2" MISC MICROFINE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily); MISC ULTRAFINE/U- 2 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.5ML/29G X 1/2" MICROFINE/U- 2 RX/OTC MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- 2 RX/OTC SAFETYGLIDE/1ML/29G X 2 RX/OTC 100/1ML/29G X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE ULTRAFINE/U- 2 ULTRA-FINE/0.3ML/30G X 2 100/1ML/31G X 5/16" 12.7MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily); ULTRA-FINE/0.3ML/31G X 2 SYRINGE/0.3ML/29G X 2 RX/OTC 8MM MISC 12.7MM MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN QL(5 ea daily); BD SAFETYGLIDE QL(5 ea daily); 2 SYRINGE/0.5ML/29G X RX/OTC INSULIN 2 RX/OTC 12.7MM MISC SYSYRINGE/0.5ML/30G X BD INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/29G X 2 RX/OTC BD VEO INSULIN QL(5 ea daily); 12.7MM MISC SYRINGE ULTRA- 2 RX/OTC BD PEN QL(5 ea daily) AFINE/0.3ML/31G X 6MM NEEDLE/MICRO/ULTRA- 2 MISC FINE/32G X 6MM MISC BD VEO INSULIN QL(5 ea daily); BD PEN QL(5 ea daily); SYRINGE ULTRA- 2 RX/OTC NEEDLE/MINI/ULTRA- 2 RX/OTC FINE/0.3ML/31G X 6MM FINE/31G X 5MM MISC MISC BD PEN NEEDLE/NANO QL(5 ea daily); BD VEO INSULIN QL(5 ea daily); 2ND GEN/32G X 5/32" 2 RX/OTC SYRINGE ULTRA- 2 RX/OTC MISC FINE/1/2 UNIT/0.3ML/31G X 6MM MISC BD PEN QL(5 ea daily); NEEDLE/NANO/ULTRA- 2 RX/OTC BD VEO INSULIN QL(5 ea daily); FINE/32G X 4MM MISC SYRINGE ULTRA-FINE/U- 2 RX/OTC 100/0.3ML/31G X 15/64" BD PEN QL(5 ea daily) MISC NEEDLE/ORIGINAL/ULTR 2 A-FINE/29G X 12.7MM CAREFINE PEN NEEDLE 2 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC BD PEN QL(5 ea daily); CAREFINE PEN 2 QL(5 ea daily); NEEDLE/SHORT/ULTRA- 2 RX/OTC NEEDLES 29GX1/2" MISC RX/OTC FINE/31G X 8MM MISC CAREFINE PEN QL(5 ea daily); BD SAFETY-GLIDE QL(5 ea daily); NEEDLES 30GX5/16" 2 RX/OTC MISC INSULIN 2 RX/OTC SYRINGE/0.5ML/29G X CAREFINE PEN QL(5 ea daily) 1/2" MISC NEEDLES 31GX6MM 2 BD SAFETY-LOK INSULIN QL(5 ea daily); MISC SYRINGE/PERM 2 RX/OTC CAREFINE PEN QL(5 ea daily); NEEDLE/UF/1ML/29G X NEEDLES 31GX8MM 2 RX/OTC 1/2" MISC MISC BD SAFETYGLIDE QL(5 ea daily); CAREFINE PEN QL(5 ea daily) INSULIN 2 RX/OTC NEEDLES 32GX6MM 2 SYRINGE/0.3ML/29G X MISC 1/2" MISC CAREONE INSULIN BD SAFETYGLIDE QL(5 ea daily); SYRINGES/0.3ML/30G X 2 INSULIN 2 RX/OTC 1/2" MISC SYRINGE/0.3ML/31G X CAREONE INSULIN QL(5 ea daily) 15/64" MISC SYRINGES/0.3ML/31G X 2 BD SAFETYGLIDE QL(5 ea daily) 5/16" MISC INSULIN 2 CAREONE INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X SYRINGES/0.5ML/31G X 2 5/16" MISC 5/16" MISC CAREONE INSULIN QL(5 ea daily) SYRINGES/1ML/30G X 2 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE INSULIN QL(5 ea daily) CEQUR SIMPLICITY 2 PA SYRINGES/1ML/31GX5/16 2 STARTERKIT KIT " MISC CLEVER CHOICE QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC PENTIPS 29GX12MM 2 RX/OTC PEN NEEDLES 31GX8MM MISC MISC CAREONE UNIFINE 2 QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS 31GX5MM MISC RX/OTC COMFORT EZINSULIN 2 RX/OTC SYRINGE/0.3ML/29G X CAREONE UNIFINE 2 QL(5 ea daily) PENTIPS 31GX6MM MISC 1/2" MISC CLEVER CHOICE CAREONE UNIFINE 2 QL(5 ea daily); PENTIPS 31GX8MM MISC RX/OTC COMFORT EZINSULIN 2 SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PEN NEEDLES 2 RX/OTC 32GX4MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE QL(5 ea daily); SYRINGE/0.3ML/30G X PENTIPS PLUS PEN 2 RX/OTC 5/16" MISC NEEDLES 29GX12MM MISC CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 CAREONE UNIFINE QL(5 ea daily); SYRINGE/0.3ML/31G X PENTIPS PLUS PEN 2 RX/OTC 5/16" MISC NEEDLES 31GX5MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE QL(5 ea daily) SYRINGE/0.5ML/28G X PENTIPS PLUS PEN 2 1/2" MISC NEEDLES 31GX6MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE QL(5 ea daily); SYRINGE/0.5ML/29G X PENTIPS PLUS PEN 2 RX/OTC 1/2" MISC NEEDLES 31GX8MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC CAREONE UNIFINE QL(5 ea daily); SYRINGE/0.5ML/30G X PENTIPS PLUS PEN 2 RX/OTC 5/16" MISC NEEDLES 32GX4MM MISC CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 2 CARETOUCH PEN QL(5 ea daily) SYRINGE/0.5ML/31G X NEEDLES 31G X 6 MM 2 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); COMFORT EZINSULIN 2 NEEDLES 31GX 5MM 2 RX/OTC SYRINGE/1.0ML/30G X MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31GX 8MM 2 RX/OTC COMFORT EZINSULIN 2 RX/OTC MISC SYRINGE/1ML/28G X 1/2" CARETOUCH PEN QL(5 ea daily); MISC NEEDLES 32GX 4MM 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN QL(5 ea daily); COMFORT EZINSULIN 2 RX/OTC NEEDLES 31G X 3/16" 2 RX/OTC SYRINGE/1ML/29G X 1/2" MISC MISC CLICKFINE PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31G X 5/16" 2 RX/OTC COMFORT EZINSULIN 2 RX/OTC MISC SYRINGE/1ML/30G X CLICKFINE PEN QL(5 ea daily); 5/16" MISC NEEDLES 31G X 8MM 2 RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 2 CLICKFINE PEN QL(5 ea daily); SYRINGE/U- NEEDLES 32G X 5/32" 2 RX/OTC 100/1ML/31GX5/16" MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN 2 QL(5 ea daily) COMFORT EZPEN 2 RX/OTC NEEDLES/31GX1/4" MISC NEEDLES 29GX12MM MISC CLICKFINE UNIVERSAL QL(5 ea daily); PEN NEEDLES 31GX5/16" 2 RX/OTC CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZPEN 2 RX/OTC NEEDLES 31GX5MM COMFORT ASSIST QL(5 ea daily); MISC INSULIN SYRINGE 2 RX/OTC 0.3ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 2 NEEDLES 31GX6MM INSULIN 2 RX/OTC MISC SYRINGE/0.3ML/30G X 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) COMFORT EZPEN 2 RX/OTC NEEDLES 31GX8MM INSULIN 2 MISC SYRINGE/0.3ML/31G X 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 2 RX/OTC NEEDLES 32GX4MM INSULIN 2 RX/OTC MISC SYRINGE/0.5ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 2 NEEDLES 32GX6MM INSULIN 2 RX/OTC MISC SYRINGE/0.5ML/30G X 5/16" MISC CLICKFINE PEN NEEDLE 2 QL(5 ea daily); 32GX5/32" MISC RX/OTC COMFORT ASSIST QL(5 ea daily) INSULIN 2 CLICKFINE PEN NEEDLE QL(5 ea daily) SYRINGE/0.5ML/31G X UNIVERSAL/31GX1/4" 2 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); CLICKFINE PEN NEEDLE QL(5 ea daily); INSULIN 2 RX/OTC UNIVERSAL/31GX5/16" 2 RX/OTC SYRINGE/1ML/29G X 1/2" MISC MISC CLICKFINE PEN QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); NEEDLES 31G X 1/4" 2 INSULIN 2 RX/OTC MISC SYRINGE/1ML/30G X 5/16" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); INSULIN 2 SYRINGE U- 2 RX/OTC SYRINGE/1ML/31G X 100/0.3ML/30G X 5/16" 5/16" MISC MISC COMFORT EZ INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE U- 2 RX/OTC 100/0.5ML/31G X 5/16" 100/0.3ML/31G X 15/64" MISC MISC COMFORT EZ INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 SYRINGE U- 2 RX/OTC X 5/16" MISC 100/0.5ML/30G X 5/16" MISC COMFORT EZ 2 QL(5 ea daily); MICRO/32G X 4MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) SYRINGE U- COMFORT EZ 2 QL(5 ea daily); 2 SHORT/31G X 8MM MISC RX/OTC 100/0.5ML/31G X 5/16" MISC COMFORT EZ/31G X 5MM 2 QL(5 ea daily); MISC RX/OTC DROPLET INSULIN QL(5 ea daily) SYRINGE U-100/1ML/30G 2 COMFORT EZ/31G X 6MM 2 QL(5 ea daily) X 1/2" MISC MISC DROPLET INSULIN QL(5 ea daily); DIATHRIVE PEN QL(5 ea daily) SYRINGE U-100/1ML/30G 2 RX/OTC NEEDLE/31 G X 6MM 2 X 5/16" MISC MISC DROPLET INSULIN QL(5 ea daily) DIATHRIVE PEN QL(5 ea daily); SYRINGE U-100/1ML/31G 2 NEEDLE/31 GX 8MM 2 RX/OTC X 5/16" MISC MISC DROPLET INSULIN QL(5 ea daily); DIATHRIVE PEN QL(5 ea daily); 2 SYRINGE/U- 2 RX/OTC NEEDLE/31GX 5MM MISC RX/OTC 100/0.3ML/31G X 15/64" DIATHRIVE PEN 2 QL(5 ea daily); MISC NEEDLE/32GX 4MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE 0.3ML/29G X 2 RX/OTC 100/0.3ML/31G X 5/16" 1/2" MISC MISC DROPLET INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE 0.5ML/29G X 2 RX/OTC SYRINGE/U- 2 1/2" MISC 100/0.5ML/31G X 5/16" DROPLET INSULIN QL(5 ea daily); MISC SYRINGE 1ML/29G X 1/2" 2 RX/OTC DROPLET INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/30G 2 DROPLET INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE U-100/0.3/31G 2 DROPLET INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U-100/1ML/31G 2 DROPLET INSULIN X 5/16" MISC SYRINGE U- 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); 100/0.3ML/30G X 1/2" 29G X1/2" MISC RX/OTC MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); 29GX12MM MISC RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES 2 QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily) 30G X 5/16" MISC RX/OTC SYRINGE/0.5ML/31G X 2 5/16" MISC DROPLET PEN NEEDLES 2 QL(5 ea daily); 31G X3/16" MISC RX/OTC EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC DROPLET PEN NEEDLES 2 QL(5 ea daily); 31G X5/16" MISC RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 2 QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGE/1ML/31G X 2 5/16" MISC DROPLET PEN NEEDLES 2 QL(5 ea daily) 31GX6MM MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 2 DROPLET PEN NEEDLES 2 QL(5 ea daily); X 1/2" MISC 31GX8MM MISC RX/OTC EASY COMFORT PEN 2 QL(5 ea daily) DROPLET PEN NEEDLES 2 QL(5 ea daily) NEEDLES31GX1/4" MISC 32G X 1/4" MISC EASY COMFORT PEN 2 QL(5 ea daily); DROPLET PEN NEEDLES 2 QL(5 ea daily); NEEDLES31GX3/16" MISC RX/OTC 32G X 3/16" MISC RX/OTC EASY COMFORT PEN 2 QL(5 ea daily); DROPLET PEN NEEDLES 2 QL(5 ea daily); NEEDLES31GX5/16" MISC RX/OTC 32G X 5/32" MISC RX/OTC EASY COMFORT PEN 2 QL(5 ea daily); DROPLET PEN NEEDLES 2 QL(5 ea daily); NEEDLES32GX5/32" MISC RX/OTC 32GX4MM MISC RX/OTC EASY TOUCH 32GX6MM 2 QL(5 ea daily) DROPLET PEN NEEDLES 2 QL(5 ea daily) MISC 32GX6MM MISC EASY TOUCH FLIPLOCK QL(5 ea daily); DROPSAFE SAFETY PEN QL(5 ea daily); SAFETY INSULIN 2 RX/OTC NEEDLES/31G X 5/16" 2 RX/OTC SYRINGE 1ML/29GX1/2" MISC MISC DROPSAFE SAFTEY PEN QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily) NEEDLES/31G X 1/4" 2 SAFETY INSULIN 2 MISC SYRINGE 1ML/30GX1/2" DRUG MART UNIFINE 2 QL(5 ea daily); MISC PENTIPS 31GX5MM MISC RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); DRUG MART UNIFINE QL(5 ea daily); SAFETY INSULIN 2 RX/OTC PENTIPS29G X 12MM 2 RX/OTC SYRINGE 1ML/30GX5/16" MISC MISC DRUG MART UNIFINE 2 QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily) PENTIPS31GX6MM MISC SAFETY INSULIN 2 SYRINGE 1ML/31GX5/16" DRUG MART UNIFINE 2 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC MISC EASY TOUCH INSULIN QL(5 ea daily); DRUG MART UNIFINE 2 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC DRUG MART UNIFINE QL(5 ea daily); 5/16" MISC PENTIPSPLUS 32GX4MM 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 2 EASY COMFORT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X 2 RX/OTC 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC NEEDLE 30G X 5/16" 2 RX/OTC 5/16" MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN 2 QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC NEEDLES 29GX1/2" MISC RX/OTC 5/16" MISC EASY TOUCH PEN 2 QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); NEEDLES 31GX1/4" MISC SYRINGE/SAFETY/U- 2 RX/OTC EASY TOUCH PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES 31GX5/16" 2 RX/OTC MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN 2 QL(5 ea daily) SYRINGE/SAFETY/U- 2 RX/OTC NEEDLES 32GX1/4" MISC 100/0.5ML/30G X 5/16" MISC EASY TOUCH PEN QL(5 ea daily); NEEDLES 32GX5/32" 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/U- 2 RX/OTC 100/1ML/29G X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); NEEDLES/31G X 3/16" 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/SAFETY/U- 2 100/1ML/30G X 1/2" MISC EASY TOUCH SAFETY QL(5 ea daily); PEN NEEDLES/30G X 2 RX/OTC EASY TOUCH INSULIN 5/16" MISC SYRINGE/U- 2 100/0.3ML/30G X 1/2" EASY TOUCH QL(5 ea daily); MISC SHEATHLOCK SAFETY 2 RX/OTC INSULIN SYRINGE EASY TOUCH INSULIN QL(5 ea daily); 1ML/29GX1/2" MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" EASY TOUCH QL(5 ea daily); MISC SHEATHLOCK SAFETY 2 RX/OTC INSULIN SYRINGE EASY TOUCH INSULIN QL(5 ea daily); 1ML/30GX5/16" MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" EASY TOUCH QL(5 ea daily) MISC SHEATHLOCK SAFETY 2 INSULIN SYRINGE EASY TOUCH INSULIN QL(5 ea daily) 1ML/31GX5/16" MISC SYRINGE/U- 2 100/0.5ML/31G X 5/16" EASY TOUCH QL(5 ea daily) MISC SHEATHLOCK SAFETY 2 SYRINGE 1ML/30GX1/2" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U-100/1ML/30G 2 X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 2 X 5/16" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC INSULIN PEN NEEDLES 2 RX/OTC 5/16" MISC 29G X 12MM MISC ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily) SYRINGE/U- 2 RX/OTC INSULIN PEN NEEDLES 2 100/0.5ML/28G X 1/2" 31G X 6MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN PEN NEEDLES 2 RX/OTC SYRINGE/U- 2 31G X 8MM MISC 100/0.5ML/31G X 5/16" EXEL COMFORT POINT QL(5 ea daily); MISC INSULIN 2 RX/OTC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/U-100/1ML/28G 2 RX/OTC 1/2" MISC X 1/2" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC SYRINGE/0.3ML/30G X X 1/2" MISC 5/16" MISC ELITE-THIN INSULIN QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 INSULIN 2 RX/OTC X 5/16" MISC SYRINGE/0.5ML/28G X EQL INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/29G X 2 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 1/2" MISC INSULIN 2 RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X SYRINGE/0.3ML/30G X 2 RX/OTC 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily) INSULIN 2 RX/OTC SYRINGE/0.3ML/31G X 2 SYRINGE/0.5ML/30G X 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC INSULIN 2 RX/OTC 1/2" MISC SYRINGE/1ML/28G X 1/2" MISC EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN 2 RX/OTC SYRINGE/1ML/29G X 1/2" EQL INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN 2 RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/1ML/30G X SYRINGE/1ML/29G X 1/2" 2 RX/OTC 5/16" MISC MISC FIFTY50 PEN NEEDLES 2 QL(5 ea daily); EQL INSULIN QL(5 ea daily); 31G X3/16" (5MM) MISC RX/OTC SYRINGE/1ML/30G X 2 RX/OTC 5/16" MISC FIFTY50 PEN NEEDLES 2 QL(5 ea daily); 31G X5/16" (8MM) MISC RX/OTC EQL INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 2 FIFTY50 PEN NEEDLES 2 QL(5 ea daily); 5/16" MISC 31GX5MM MISC RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/31GX8MM 2 RX/OTC PEN NEEDLES 2 RX/OTC MISC 29GX12MM MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX4MM 2 RX/OTC PEN NEEDLES 31GX8MM 2 RX/OTC MISC MISC FIFTY50 PEN QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX6MM 2 PEN NEEDLES 32GX4MM 2 RX/OTC MISC MISC FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); COMFORTINSULIN 2 PEN NEEEDLES 2 RX/OTC SYRINGE/0.3ML/31G X 31GX5MM MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 2 RX/OTC COMFORTINSULIN 2 SYRINGE/0.3ML/31G X SYRINGE/0.5ML/31G X 15/64" MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily) FIFTY50 SUPERIOR QL(5 ea daily) INSULINSYRINGE/U- 2 COMFORTINSULIN 2 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); PEN NEEDLES 32GX4MM 2 RX/OTC UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 32GX4MM GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC FREDS PHARMACY QL(5 ea daily); 100/0.3ML/29G X 1/2" UNIFINE PENTIPS PLUS 2 RX/OTC MISC 31GX5MM MISC GLOBAL INJECT EASE FREDS PHARMACY QL(5 ea daily); INSULIN SYRINGE/U- 2 UNIFINE PENTIPS PLUS 2 RX/OTC 100/0.3ML/30G X 1/2" 31GX8MM MISC MISC FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/30G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGE/U- 2 INSULIN SYRINGE/U- 2 100/0.5ML/31G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGE/U- 2 INSULIN SYRINGE/U- 2 RX/OTC 100/1ML/31G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGES/U- 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U- 2 100/0.5ML/31G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U-100/1ML/30G 2 100/1ML/28G X 1/2" MISC X 1/2" MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE/U-100/1ML/30G 2 RX/OTC 100/1ML/29G X 1/2" MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 SYRINGE/U-100/1ML/31G 2 100/1ML/30G X 1/2" MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily); GNP CLICKFINE QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC UNIVERSAL PEN 2 100/1ML/30G X 5/16" NEEDLES 31GX1/4" MISC MISC GNP CLICKFINE QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily) UNIVERSAL PEN 2 RX/OTC INSULIN SYRINGE/U- 2 NEEDLES 31GX5/16" 100/1ML/31G X 5/16" MISC MISC GNP INSULIN QL(5 ea daily); GLOBAL INSULIN SYRINGE/0.3ML/29G X 2 RX/OTC SYRINGE/U- 2 1/2" MISC 100/0.3ML/30G X 1/2" GNP INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 2 RX/OTC GLOBAL INSULIN QL(5 ea daily); 5/16" MISC SYRINGES/U- 2 RX/OTC GNP INSULIN QL(5 ea daily) 100/0.3ML/30GX5/16" SYRINGE/0.3ML/31G X 2 MISC 5/16" MISC GLUCOPRO INSULIN GNP INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/0.5ML/28G X 2 RX/OTC 100/0.3ML/30G X 1/2" 1/2" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/U- 2 RX/OTC 1/2" MISC 100/0.3ML/30G X 5/16" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 2 100/0.3ML/31G X 5/16" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 2 5/16" MISC GNP INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP INSULIN QL(5 ea daily); GOODSENSE PEN QL(5 ea daily); 2 SYRINGE/1ML/29G X 1/2" RX/OTC NEEDLE/PENFINE 2 RX/OTC MISC CLASSIC/31G X 3/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 2 RX/OTC GOODSENSE PEN QL(5 ea daily); 5/16" MISC NEEDLE/PENFINE 2 RX/OTC GNP INSULIN QL(5 ea daily) CLASSIC/31G X 5/16" SYRINGE/1ML/31G X 2 MISC 5/16" MISC GOODSENSE PEN QL(5 ea daily) GNP ULTICARE PEN QL(5 ea daily); NEEDLE/PENFINE 2 NEEDLES/31GX5/16" 2 RX/OTC CLASSIC/32G X 1/4" MISC MISC GOODSENSE PEN QL(5 ea daily); GNP ULTICARE PEN QL(5 ea daily); NEEDLE/PENFINE 2 RX/OTC NEEDLES/32GX 5/32" 2 RX/OTC CLASSIC/32G X 5/32" MISC MISC H-E-B IN CONTROL PEN QL(5 ea daily); GNP ULTICARE PEN 2 QL(5 ea daily) 2 NEEDLES/32GX1/4" MISC NEEDLE 31GX3/16" MISC RX/OTC GNP ULTICARE PEN QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily); NEEDLES31G X 5MM 2 RX/OTC NEEDLES 31GX5MM 2 RX/OTC MISC MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily) NEEDLES 31GX6MM 2 INSULIN 2 RX/OTC SYRINGE/0.3ML/29G X MISC 1/2" MISC H-E-B IN CONTROL PEN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC MISC INSULIN 2 RX/OTC SYRINGE/0.3ML/30G X H-E-B IN CONTROL PEN QL(5 ea daily); 5/16" SHORT MISC NEEDLES/NANO/32GX4M 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); M MISC INSULIN 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily) SYRINGE/0.5ML/28G X UNIFINEPENTIPS PLUS 2 1/2" MISC 31GX1/4" MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL QL(5 ea daily); INSULIN 2 RX/OTC UNIFINEPENTIPS PLUS 2 RX/OTC SYRINGE/0.5ML/29G X 31GX3/16" MISC 1/2" MISC H-E-B IN CONTROL QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); UNIFINEPENTIPS PLUS 2 RX/OTC INSULIN 2 RX/OTC 31GX5/16" MISC SYRINGE/1ML/28G X 1/2" H-E-B IN CONTROL QL(5 ea daily); MISC UNIFINEPENTIPS PLUS 2 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); 31GX5MM MISC INSULIN 2 RX/OTC H-E-B IN CONTROL QL(5 ea daily); SYRINGE/1ML/29G X 1/2" UNIFINEPENTIPS PLUS 2 RX/OTC MISC 32GX4MM MISC GOODSENSE CLICKFINE QL(5 ea daily); H-E-B IN CONTROL QL(5 ea daily); SAFETY PEN 2 RX/OTC UNIFINEPENTIPS PLUS 2 RX/OTC NEEDLE/31G X 3/16" 32GX5/32" MISC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL PEN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); 2 NEEDLES 29GX12MM RX/OTC UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 29GX12MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.3ML/30G X 5/16" UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 31GX5MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 HEALTHY ACCENTS QL(5 ea daily) 100/0.3ML/31G X 5/16" UNIFINE PENTIPS PEN 2 MISC NEEDLES 31GX6MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- 2 RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/30G X 5/16" UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 31GX8MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/31G X 5/16" UNIFINE PENTIPS PEN 2 RX/OTC MISC NEEDLES 32GX4MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 2 RX/OTC HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/1ML/30G X 1/2" 2 HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 2 HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- 2 HEALTHWISE MICRON QL(5 ea daily); 100/0.3ML/31G X 5/16" PEN NEEDLES/32G X 2 RX/OTC MISC 5/32" MISC HM ULTICARE MINI PEN QL(5 ea daily); HEALTHWISE MINI PEN QL(5 ea daily) NEEDLES/31G X 5MM 2 RX/OTC NEEDLES 31GX6MM 2 (3/16") MISC MISC HM ULTICARE SHORT QL(5 ea daily); HEALTHWISE PEN QL(5 ea daily); PEN NEEDLES 31GX8MM 2 RX/OTC NEEDLES 29GX12MM 2 RX/OTC MISC MISC HUMATROPEN FOR 2 PA; RX/OTC HEALTHWISE SHORT QL(5 ea daily); 12MG DEVI PEN NEEDLES 31GX8MM 2 RX/OTC HUMATROPEN FOR 2 PA; RX/OTC MISC 24MG DEVI HEALTHWISE SHORT QL(5 ea daily); HUMATROPEN FOR 6MG 2 PA; RX/OTC PEN NEEDLES/31G X 2 RX/OTC DEVI 3/16" MISC INJECT-EASE PA; RX/OTC HEALTHWISE SHORT QL(5 ea daily); AUTOMATIC INJECTOR 2 PEN NEEDLES/31G X 2 RX/OTC MISC 5/16" MISC INJECT-EASE MISC 2 PA; RX/OTC HEALTHWISE UNIFINE QL(5 ea daily); PENTIPS PEN NEEDLES 2 RX/OTC INSULIN QL(5 ea daily); 32GX4MM MISC SYRINGE/0.3ML/29G X 2 RX/OTC 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC 100/0.3ML/29G X 1/2" 2 RX/OTC 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.3ML/31G X 2 100/0.5ML/29G X 1/2" 2 RX/OTC 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 QL(5 ea daily); SYRINGE/0.5ML/28G X 2 RX/OTC 100/1ML/29G X 1/2" MISC RX/OTC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" 2 SYRINGE/0.5ML/30G X 2 RX/OTC MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" 2 RX/OTC SYRINGE/0.5ML/31G X 2 MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 2 SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/0.5ML/28GX1/ 2 RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC 2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/0.5ML/29GX1/ 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC 2" MISC 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/0.5ML/30GX5/ 2 RX/OTC SYRINGE/NEEDLE 2 RX/OTC 16" MISC 0.3ML/30G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGES/0.5ML/31GX 2 SYRINGE/NEEDLE 2 5/16" MISC 0.3ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/0.5ML/31GX5/ 2 SYRINGE/NEEDLE 2 RX/OTC 16" MISC 0.5ML/29G X 1/2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGES/1ML/28GX1/2" 2 RX/OTC SYRINGE/NEEDLE 2 RX/OTC MISC 0.5ML/30G X 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGES/1ML/29GX1/2" 2 RX/OTC SYRINGE/NEEDLE 2 MISC 0.5ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/1ML/30GX1/2" 2 SYRINGE/NEEDLE 2 RX/OTC MISC 1ML/29G X 1/2" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGES/1ML/31GX5/16 2 SYRINGE/NEEDLE 2 RX/OTC " MISC 1ML/30G X 5/16" MISC INSUPEN 29G X 12MM 2 QL(5 ea daily); INSULIN QL(5 ea daily) MISC RX/OTC SYRINGE/NEEDLE 2 1ML/31G X 5/16" MISC MHS Indiana Preferred Drug List Updated June 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSUPEN 31G X 5MM 2 QL(5 ea daily); KROGER INSULIN QL(5 ea daily); MISC RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC INSUPEN 31G X 8MM 2 QL(5 ea daily); MISC RX/OTC KROGER INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 INSUPEN 32G X 4MM 2 QL(5 ea daily); MISC RX/OTC 5/16" MISC KROGER INSULIN QL(5 ea daily); INSUPEN PEN NEEDLES 2 QL(5 ea daily); 32G X4MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC INSUPEN SENSITIVE 2 QL(5 ea daily) 32GX6MM MISC KROGER INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC INSUPEN ULTRAFIN 2 QL(5 ea daily); 5/16" MISC 29GX12MM MISC RX/OTC KROGER INSULIN QL(5 ea daily) INSUPEN ULTRAFIN 2 QL(5 ea daily); SYRINGE/1ML/31G X 2 30GX8MM MISC RX/OTC 5/16" MISC INSUPEN ULTRAFIN QL(5 ea daily) 2 KROGER PEN NEEDLES 2 QL(5 ea daily); 31GX6MM MISC 29G X12MM MISC RX/OTC INSUPEN ULTRAFIN QL(5 ea daily); 2 KROGER PEN NEEDLES 2 QL(5 ea daily); 31GX8MM MISC RX/OTC 31G X8MM MISC RX/OTC J-TIP KIT W/VIAL PA 2 KROGER PEN NEEDLES 2 QL(5 ea daily) ADAPTERS KIT 31GX1/4" MISC KINRAY INSULIN QL(5 ea daily) KROGER PEN 2 QL(5 ea daily) SYRINGE PREFERRED 2 NEEDLES/31G X1/4" MISC PLUS/0.3ML/31G X 5/16" MISC KROGER PEN QL(5 ea daily); NEEDLES/31G X3/16" 2 RX/OTC KINRAY INSULIN QL(5 ea daily) MISC SYRINGE PREFERRED 2 PLUS/0.5ML/31G X 5/16" KROGER PEN QL(5 ea daily); MISC NEEDLES/31G X5/16" 2 RX/OTC MISC KINRAY INSULIN QL(5 ea daily) KROGER PEN QL(5 ea daily); SYRINGE PREFERRED 2 PLUS/1ML/31G X 5/16" NEEDLES/32G X5/32" 2 RX/OTC MISC MISC KINRAY INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/0.3ML/29G X 2 RX/OTC 1/2" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC 1/2" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/0.3ML/31G X 2 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 2 SYRINGE/0.5ML/28G X 2 RX/OTC 5/16" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGE/0.5ML/29G X 2 RX/OTC 1/2" MISC 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/0.5ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 2 SYRINGE/0.5ML/31G X 2 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 2 RX/OTC SYRINGE/1ML/30G X 2 RX/OTC MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/30G X 5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 2 LEADER INSULIN QL(5 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X 2 MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 2 RX/OTC PLUS/MINI/31GX3/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 2 RX/OTC PLUS/SHORT/31GX5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 2 RX/OTC PENTIPS/MINI/31GX3/16" 2 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) PENTIPS/NANO/32GX5/32 2 RX/OTC SYRINGE/U- 2 " MISC 100/0.5ML/31G X 5/16" MISC LEADER UNIFINE QL(5 ea daily); PENTIPS/PLUS/32GX5/32 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily); " MISC SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC LITETOUCH INSULIN PEN QL(5 ea daily); NEEDLES/32G X 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 4MM/MINI MISC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/30G 2 RX/OTC X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 2 X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 2 LITETOUCH PEN QL(5 ea daily) 5/16" MISC NEEDLES 29GX12.7MM 2 MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH PEN QL(5 ea daily) MARATHON MEDICAL 2 QL(5 ea daily); NEEDLES 31G X 6MM 2 PENTIPS31GX5MM MISC RX/OTC MISC MARATHON MEDICAL 2 QL(5 ea daily); LITETOUCH PEN QL(5 ea daily) PENTIPS31GX8MM MISC RX/OTC NEEDLES 31G X 2 MARATHON MEDICAL 2 QL(5 ea daily); 6MM/ULTRA SHORT PENTIPS32GX4MM MISC RX/OTC MISC MAXI-COMFORT INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 2 RX/OTC NEEDLES 31GX8MM 2 RX/OTC 100/0.5ML/28GX1/2" MISC SHORT MISC MAXI-COMFORT INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 2 RX/OTC NEEDLES/31G X 3/16" 2 RX/OTC 100/1ML/28GX1/2" MISC MISC MAXICOMFORT II PEN QL(5 ea daily) LITETOUCH PEN QL(5 ea daily); NEEDLES/31G X 1/4" 2 NEEDLES/31G X 2 RX/OTC MISC 5MM/MINI MISC MEDIC INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); SYRINGE/0.3ML/30G X 2 RX/OTC NEEDLES/31G X 2 RX/OTC 5/16" MISC 8MM/SHORT MISC MEDIC INSULIN QL(5 ea daily); LONGS INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/0.5ML/31G X 2 5/16" MISC 5/16" MISC MEDICINE SHOPPE PEN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); NEEDLES 29G X 12MM 2 RX/OTC SAFETY SYRINGE/U- 2 RX/OTC MISC 100/0.3ML/29G X 1/2" MISC MEDICINE SHOPPE PEN QL(5 ea daily) NEEDLES 31G X 6MM 2 MAGELLAN INSULIN QL(5 ea daily); MISC SAFETY SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" MEDICINE SHOPPE PEN QL(5 ea daily); MISC NEEDLES 31G X 8MM 2 RX/OTC MISC MAGELLAN INSULIN QL(5 ea daily); MEIJER PEN NEEDLES QL(5 ea daily); SAFETY SYRINGE/U- 2 RX/OTC 2 100/0.5ML/29G X 1/2" 29G X12MM MISC RX/OTC MISC MEIJER PEN NEEDLES 2 QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily); 31G X6MM MISC MEIJER PEN NEEDLES QL(5 ea daily); SAFETY SYRINGE/U- 2 RX/OTC 2 100/0.5ML/30G X 5/16" 31G X8MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily); NEEDLE/31G X 6 MM 2 SAFETY SYRINGE/U- 2 RX/OTC MISC 100/1ML/29G X 1/2" MISC MICRODOT PEN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); NEEDLE/32G X 4 MM 2 RX/OTC MISC SAFETY SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.3ML/30G X 5/16" 2 RX/OTC MARATHON MEDICAL QL(5 ea daily); MISC PENTIPS29GX12MM 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" 2 SYRINGE/SAFETY/PERM 2 RX/OTC MISC NEEDLE/1ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/1/2ML/30G X 5/16" 2 RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SOFTPACK/U- 2 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/0.5ML/28G X 1/2" 100/1/2ML/31G X 5/16" 2 MISC MISC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 2 RX/OTC 100/1ML/30G X 5/16" 2 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 2 SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/30G X 5/16" MISC MM PEN NEEDLES 31G X 2 QL(5 ea daily) 1/4" MISC MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 2 RX/OTC MM PEN NEEDLES 31G X 2 QL(5 ea daily); X 1/2" MISC 3/16" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); MM PEN NEEDLES 31G X 2 QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC 5/16" MISC RX/OTC X 5/16" MISC MM PEN NEEDLES 32G X 2 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 5/32" MISC RX/OTC COMFORT INSULIN 2 RX/OTC MONOJECT INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X SYRINGE/1ML/31G X 2 1/2" MISC 5/16" MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN 2 RX/OTC SYRINGE/PERM 2 RX/OTC SYRINGE/0.3ML/30G X NEEDLE/1ML/28G X 1/2" 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN 2 SYRINGE/PERM 2 RX/OTC SYRINGE/0.3ML/31G X NEEDLE/U-100/0.5ML/28G 5/16" MISC X 1/2" MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN 2 RX/OTC SYRINGE/SAFETY/PERM 2 RX/OTC SYRINGE/0.5ML/28G X NEEDLE/0.3ML/29G X 1/2" 1/2" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN 2 RX/OTC SYRINGE/SAFETY/PERM 2 RX/OTC SYRINGE/0.5ML/29G X NEEDLE/0.3ML/29GX1/2" 1/2" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN 2 RX/OTC SYRINGE/SAFETY/PERM 2 RX/OTC SYRINGE/0.5ML/30G X NEEDLE/0.5ML/29G X 1/2" 5/16" MISC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily) PEN NEEDLES 29GX1/2" 2 QL(5 ea daily); COMFORT INSULIN 2 MISC RX/OTC SYRINGE/0.5ML/31G X PEN NEEDLES 2 QL(5 ea daily); 5/16" MISC 29GX12MM MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 30GX5/16" 2 QL(5 ea daily); COMFORT INSULIN 2 RX/OTC MISC RX/OTC SYRINGE/1ML/28G X 1/2" MISC PEN NEEDLES 30GX8MM 2 QL(5 ea daily); MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 31G X 1/4" QL(5 ea daily) COMFORT INSULIN 2 RX/OTC 2 SYRINGE/1ML/29G X 1/2" SHORT MISC MISC PEN NEEDLES 31G X 2 QL(5 ea daily); MS INSULIN QL(5 ea daily) 3/16" MISC RX/OTC SYRINGE/0.3ML/31G X 2 PEN NEEDLES 31G X 2 QL(5 ea daily); 5/16" MISC 5MM MISC RX/OTC MS INSULIN QL(5 ea daily) PEN NEEDLES 31G X 2 QL(5 ea daily) SYRINGE/0.5ML/31G X 2 6MM MISC 5/16" MISC PEN NEEDLES 31G X 2 QL(5 ea daily); MS INSULIN QL(5 ea daily) 8MM MISC RX/OTC SYRINGE/1ML/31G X 2 PEN NEEDLES 31GX5/16" 2 QL(5 ea daily); 5/16" MISC MISC RX/OTC NORDIPEN 5 INJECTION PA; RX/OTC 2 PEN NEEDLES 31GX6MM 2 QL(5 ea daily) DEVICE MISC (1/4") MISC NORDIPEN DELIVERY PA; RX/OTC 2 PEN NEEDLES 31GX8MM 2 QL(5 ea daily); SYSTEM MISC (5/16") MISC RX/OTC NOVOFINE 32GX6MM QL(5 ea daily) 2 PEN NEEDLES 31GX8MM 2 QL(5 ea daily); MISC MISC RX/OTC NOVOFINE AUTOCOVER QL(5 ea daily); 2 PEN NEEDLES 32G X 2 QL(5 ea daily); 30GX8MM MISC RX/OTC 4MM MISC RX/OTC NOVOFINE PLUS QL(5 ea daily); 2 PEN NEEDLES 32G X 2 QL(5 ea daily) 32GX4MM MISC RX/OTC 6MM MISC OMNITROPE PEN 10 PA; RX/OTC 2 PEN NEEDLES 32GX4MM 2 QL(5 ea daily); INJECTION DEVICE MISC MISC RX/OTC OMNITROPE PEN 5 PA; RX/OTC 2 PEN NEEDLES/29G X 1/2" 2 QL(5 ea daily); INJECTION DEVICE MISC MISC RX/OTC PC UNIFINE PENTIPS QL(5 ea daily); 2 PEN NEEDLES/31G X 1/4" 2 QL(5 ea daily) 29G X1/2" MISC RX/OTC MISC PC UNIFINE PENTIPS QL(5 ea daily); 2 PEN NEEDLES/31G X 2 QL(5 ea daily); 31G X5MM MINI MISC RX/OTC 3/16" MISC RX/OTC PC UNIFINE PENTIPS QL(5 ea daily) PEN NEEDLES/31G X 2 QL(5 ea daily); 31G X6MM ULTRA 2 5/16" MISC RX/OTC SHORT MISC PEN NEEDLES/31G X 2 QL(5 ea daily) PC UNIFINE PENTIPS 2 QL(5 ea daily); 6MM MISC 31G X8MM SHORT MISC RX/OTC PEN NEEDLES/32G X 2 QL(5 ea daily); PEN NEEDLES 29G X 2 QL(5 ea daily); 5/32" MISC RX/OTC 12MM MISC RX/OTC PENTIPS 29G X 12MM 2 QL(5 ea daily); MISC RX/OTC MHS Indiana Preferred Drug List Updated June 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTIPS 29GX12MM 2 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 31G X 5MM 2 QL(5 ea daily); MISC RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PENTIPS 31G X 8MM 2 QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 31GX5MM MISC 2 QL(5 ea daily); MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 31GX6MM MISC 2 QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/30G X 5/16" QL(5 ea daily); PENTIPS 31GX8MM MISC 2 MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 32G X 4MM 2 QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC MISC RX/OTC 100/1ML/28G X 1/2" MISC QL(5 ea daily); PENTIPS 32GX4MM MISC 2 PREFERRED PLUS QL(5 ea daily); RX/OTC INSULIN SYRINGE/U- 2 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); 100/1ML/29G X 1/2" MISC INSULIN 2 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/30G X INSULIN SYRINGE/U- 2 RX/OTC 5/16" MISC 100/1ML/30G X 5/16" PRECISION SURE-DOSE QL(5 ea daily); MISC INSULIN 2 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.5ML/28G X UNIFINE PENTIPS 29G X 2 RX/OTC 1/2" MISC 12MM MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily) INSULIN RX/OTC 2 UNIFINE PENTIPS 31G X 2 SYRINGE/0.5ML/29G X 6MM ULTRA SHORT 1/2" MISC MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); INSULIN 2 RX/OTC UNIFINE PENTIPS 31G X 2 RX/OTC SYRINGE/1ML/28G X 1/2" 8MM SHORT MISC MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); UNIFINE PENTIPS 2 RX/OTC PLUSINSULIN 2 RX/OTC 32GX4MM MISC SYRINGE/0.3ML/29G X 1/2" MISC PREFERRED PLUS QL(5 ea daily); UNIFINE 2 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PENTIPS/MINI/31GX5MM PLUSINSULIN 2 RX/OTC MISC SYRINGE/1ML/29G X 1/2" MISC PREVENT SAFETY PEN 2 QL(5 ea daily) NEEDLES 31GX1/4" MISC PREFERRED PLUS QL(5 ea daily); PREVENT SAFETY PEN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" NEEDLES 31GX5/16" 2 RX/OTC MISC MISC PREFERRED PLUS QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); SYRINGES/0.5ML/30G X 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" 5/16" MISC MISC MHS Indiana Preferred Drug List Updated June 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(5 ea daily) QC PEN NEEDLES 29G X 2 QL(5 ea daily); SYRINGES/0.5ML/31G X 2 12MM MISC RX/OTC 5/16" MISC QC PEN NEEDLES 31G X 2 QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily) 6MM MISC SYRINGES/1ML/30G X 2 QC PEN NEEDLES 31G X 2 QL(5 ea daily); 1/2" MISC 8MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily); QC UNIFINE PENTIPS 2 QL(5 ea daily); SYRINGES/1ML/30G X 2 RX/OTC 32GX4MM MISC RX/OTC 5/16" MISC RA INSULIN QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 2 RX/OTC SYRINGES/1ML/31G X 2 1/2" MISC 5/16" MISC RA INSULIN QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 2 RX/OTC NEEDLES/31G X 8MM 2 RX/OTC MISC MISC RA INSULIN SYRINGE/U- QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); 100/0.5ML/30G X 5/16" 2 RX/OTC NEEDLES/32G X 4MM 2 RX/OTC MISC MISC RA INSULIN SYRINGE/U- QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily) 100/1 ML/30G X 5/16" 2 RX/OTC NEEDLES/32G X 6MM 2 MISC MISC RA PEN NEEDLES 31G X 2 QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) 5MM3/16" MISC RX/OTC SYRING/U-100/0.3ML/31G 2 X 5/16" MISC RA PEN NEEDLES 31G X 2 QL(5 ea daily); 8MM5/16" MISC RX/OTC PRODIGY INSULIN QL(5 ea daily) SYRINGE/1/2ML/31G X 2 REALITY INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" PRODIGY INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 2 RX/OTC MISC REALITY INSULIN QL(5 ea daily); SYRINGE/U- 2 RX/OTC PURE COMFORT PEN 2 QL(5 ea daily) 100/0.5ML/29G X 1/2" NEEDLE 32G X6MM MISC MISC PURE COMFORT PEN 2 QL(5 ea daily); REALITY INSULIN QL(5 ea daily); NEEDLE/32G X4MM MISC RX/OTC SYRINGE/U-100/1ML/28G 2 RX/OTC PX EXTRA SHORT PEN QL(5 ea daily) X 1/2" MISC NEEDLES 31GX6MM 2 REALITY INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 2 RX/OTC PX MINI PEN NEEDLES 2 QL(5 ea daily); X 1/2" MISC 31GX5MM MISC RX/OTC RELION INSULIN QL(5 ea daily); PX PEN NEEDLE 2 QL(5 ea daily); SYRINGE/U- 2 RX/OTC 29GX12MM MISC RX/OTC 100/0.3ML/30G X 5/16" MISC PX PEN NEEDLE 2 QL(5 ea daily); 31GX8MM MISC RX/OTC RELION INSULIN QL(5 ea daily); PX SHORTLENGTH PEN QL(5 ea daily); SYRINGE/U- 2 RX/OTC NEEDLES/31GX8MM 2 RX/OTC 100/0.3ML/31G X 15/64" MISC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION INSULIN QL(5 ea daily) SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U- 2 SYRINGE/0.5ML/29G X 2 RX/OTC 100/0.3ML/31G X 5/16" 1/2" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC SYRINGE/U- 2 RX/OTC 5/16" MISC 100/0.5ML/29G X 1/2" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 2 RX/OTC RELION INSULIN QL(5 ea daily) MISC SYRINGE/U- 2 SAFESNAP INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/1ML/29G X 1/2" 2 RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC SYRINGES 2 RX/OTC X 5/16" MISC 0.5ML/29GX1/2" MISC RELION INSULIN QL(5 ea daily) SAFETY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 SYRINGES 2 RX/OTC X 5/16" MISC 0.5ML/30GX5/16" MISC RELION MINI PEN QL(5 ea daily) SAFETY INSULIN QL(5 ea daily); NEEDLES 31GX6MM 2 SYRINGES 1ML/29GX1/2" 2 RX/OTC MISC MISC RELION PEN NEEDLES 2 QL(5 ea daily); SAFETY INSULIN QL(5 ea daily) 29GX12MM MISC RX/OTC SYRINGES 1ML/30GX1/2" 2 RELION PEN NEEDLES 2 QL(5 ea daily) MISC 31G X6MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); RELION PEN NEEDLES 2 QL(5 ea daily); 100/0.5ML/29G X 1/2" 2 RX/OTC 31G X8MM MISC RX/OTC MISC RELION PEN NEEDLES 2 QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); 31GX5/16" MISC RX/OTC 100/0.5ML/30G X 5/16" 2 RX/OTC MISC RELION PEN NEEDLES 2 QL(5 ea daily) 31GX6MM MISC SB INSULIN SYRINGE/U- 2 QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); 31GX8MM MISC RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/30G X 5/16" 2 RX/OTC RELION PEN NEEDLES 2 QL(5 ea daily); 32G X4MM MISC RX/OTC MISC SB INSULIN SYRINGE/U- QL(5 ea daily) RELION PEN NEEDLES 2 QL(5 ea daily); 32G X5/32" MISC RX/OTC 100/1ML/31G X 5/16" 2 MISC RELION PEN NEEDLES 2 QL(5 ea daily); 32GX4MM MISC RX/OTC SECURESAFE SAFETY QL(5 ea daily); INSULIN SYRINGES/U- 2 RX/OTC RELION PEN QL(5 ea daily) 100/0.5ML/29GX1/2" MISC NEEDLES/31G X1/4" 2 MISC SECURESAFE SAFETY QL(5 ea daily); INSULIN SYRINGES/U- 2 RX/OTC RELION SHORT PEN 2 QL(5 ea daily); 100/1ML/29GX1/2" MISC NEEDLES31GX8MM MISC RX/OTC SECURESAFE SAFETY QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); PEN NEEDLES/30G X 2 RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC 5/16" MISC 5/16" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily) PENTIPS PEN 2 RX/OTC INSULIN SYRINGE/U- 2 NEEDLES/MICRO/32GX4 100/0.3ML/31G X 5/16" MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); PENTIPS PEN 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC NEEDLES/MINI/31GX5MM 100/0.5ML/28G X 1/2" MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); PENTIPS PEN 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC NEEDLES/ORIGINAL/29G 100/0.5ML/29G X 1/2" X12MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); PENTIPS PEN 2 RX/OTC INSULIN SYRINGE/U- 2 RX/OTC NEEDLES/SHORT/31GX8 100/0.5ML/30G X 5/16" MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily) PENTIPS PLUS PEN 2 RX/OTC INSULIN SYRINGE/U- 2 NEEDLES/MICRO/REMOV 100/0.5ML/31G X 5/16 R/32GX4MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); 2 PENTIPS PLUS PEN 2 RX/OTC INSULIN SYRINGE/U- RX/OTC NEEDLES/MINI/REMOVE 100/1ML/28G X 1/2" MISC R/31GX5MM MISC SURE COMFORT QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC PENTIPS PLUS PEN 2 RX/OTC 100/1ML/29G X 1/2" MISC NEEDLES/REMOVER/29G SURE COMFORT QL(5 ea daily) X12MM MISC INSULIN SYRINGE/U- 2 SHOPKO UNIFINE QL(5 ea daily); 100/1ML/30G X 1/2" MISC PENTIPS PLUS PEN 2 RX/OTC SURE COMFORT QL(5 ea daily); NEEDLES/SHORT/REMO INSULIN SYRINGE/U- 2 RX/OTC VR/31GX8MM MISC 100/1ML/30G X 5/16" SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 2 RX/OTC SURE COMFORT QL(5 ea daily) 100/0.3ML/29G X 1/2" INSULIN SYRINGE/U- 2 MISC 100/1ML/31G X 5/16" SURE COMFORT MISC INSULIN SYRINGE/U- 2 SURE COMFORT PEN QL(5 ea daily) 100/0.3ML/30G X 1/2" NEEDLES29GX1/2" 2 MISC 12.7MM MISC SURE COMFORT QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC NEEDLES30GX5/16" 2 RX/OTC 100/0.3ML/30G X 5/16" SHORT MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily) NEEDLES31GX3/16" 2 RX/OTC INSULIN SYRINGE/U- 2 (5MM) MISC 100/0.3ML/31G X 5/16 MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES31GX5/16" 2 RX/OTC SYRINGE/U-100/1ML/29G 2 RX/OTC (8MM) MISC X 1/2" MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES32GX5/32" 2 RX/OTC SYRINGE/U-100/1ML/30G 2 RX/OTC MISC X 5/16" MISC SURE COMFORT PEN 2 QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily) NEEDLES32GX6MM MISC SYRINGE/U-100/1ML/31G 2 SURE-FINE PEN QL(5 ea daily) X 5/16" MISC NEEDLES 29GX1/2" 2 TECHLITE INSULIN QL(5 ea daily); 12.7MM MISC SYRINGEU- 2 RX/OTC SURE-FINE PEN QL(5 ea daily); 100/0.3ML/29G X 1/2" NEEDLES 31GX3/16" 2 RX/OTC MISC 5MM MISC TECHLITE INSULIN SURE-FINE PEN QL(5 ea daily); SYRINGEU- 2 NEEDLES 31GX5/16" 2 RX/OTC 100/0.3ML/30G X 1/2" 8MM MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGEU- RX/OTC SYRINGE/U- 2 RX/OTC 2 100/0.3ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGEU- RX/OTC SYRINGE/U- 2 RX/OTC 2 100/0.3ML/30G X 5/16" 100/0.3ML/31G X 15/64" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) SYRINGEU- SYRINGE/U- 2 2 100/0.3ML/31G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGEU- RX/OTC SYRINGE/U- 2 RX/OTC 2 100/0.5ML/28G X 1/2" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGEU- RX/OTC SYRINGE/U- 2 RX/OTC 2 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGEU- SYRINGE/U- 2 RX/OTC 2 100/0.5ML/30G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGEU-100/1ML/29G 2 RX/OTC SYRINGE/U- 2 100/0.5ML/31G X 5/16" X 1/2" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 2 SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC X 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGEU-100/1ML/30G 2 RX/OTC COMFORT INSULIN 2 RX/OTC X 5/16" MISC SYRINGE/0.5ML/30G X TECHLITE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEU-100/1ML/31G 2 TOPCARE ULTRA QL(5 ea daily) X 5/16" MISC COMFORT INSULIN 2 SYRINGE/0.5ML/31G X TECHLITE PEN NEEDLES 2 QL(5 ea daily); 29GX 12 MM MISC RX/OTC 5/16" MISC TOPCARE ULTRA QL(5 ea daily); TECHLITE PEN NEEDLES 2 QL(5 ea daily); 31GX 5MM MISC RX/OTC COMFORT INSULIN 2 RX/OTC SYRINGE/1ML/30G X TECHLITE PEN QL(5 ea daily); 5/16" MISC NEEDLES/31GX 5MM 2 RX/OTC MISC TOPCARE ULTRA QL(5 ea daily) COMFORT INSULIN 2 TECHLITE PEN QL(5 ea daily) SYRINGE/1ML/31G X NEEDLES/31GX 6 MM 2 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TECHLITE PEN QL(5 ea daily); COMFORT INSULIN RX/OTC NEEDLES/31GX 8MM 2 RX/OTC SYRINGE/U- 2 MISC 100/0.3ML/29G X 1/2" TECHLITE PEN QL(5 ea daily); MISC NEEDLES/32GX 4MM 2 RX/OTC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN RX/OTC TECHLITE PEN QL(5 ea daily) SYRINGE/U- 2 NEEDLES/32GX 6MM 2 100/0.5ML/29G X 1/2" MISC MISC TODAYS HEALTH MINI QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); PEN NEEDLES 31G X 1/4" 2 COMFORT INSULIN 2 RX/OTC MISC SYRINGE/U-100/1ML/29G TODAYS HEALTH QL(5 ea daily); X 1/2" MISC ORIGINAL PEN NEEDLES 2 RX/OTC TRUE COMFORT INSULIN QL(5 ea daily) 29G X 1/2" MISC SYRINGE/0.5ML/31G X 2 TODAYS HEALTH SHORT QL(5 ea daily); 5/16" MISC PEN NEEDLES 31G X 2 RX/OTC TRUE COMFORT INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/1ML/31G X 2 TOPCARE CLICKFINE QL(5 ea daily) 5/16" MISC UNIVERSAL PEN EEDLES 2 TRUE COMFORT PEN QL(5 ea daily); 31GX1/4" MISC NEEDLES31G X 5MM 2 RX/OTC TOPCARE CLICKFINE QL(5 ea daily); MISC UNIVERSAL PEN EEDLES 2 RX/OTC TRUE COMFORT PEN QL(5 ea daily) 31GX5/16" MISC NEEDLES31G X 6MM 2 TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN 2 RX/OTC TRUE COMFORT PEN QL(5 ea daily); SYRINGE/0.3ML/30G X NEEDLES32G X 4MM 2 RX/OTC 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUE COMFORT PRO QL(5 ea daily) COMFORT INSULIN 2 INSULINSYRINGE/0.5ML/ 2 SYRINGE/0.3ML/31G X 31G X 5/16" MISC 5/16" MISC MHS Indiana Preferred Drug List Updated June 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT PRO QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); 2 INSULINSYRINGE/1ML/31 SYRINGE/U- 2 RX/OTC G X 5/16" MISC 100/0.5ML/28G X 1/2" TRUE COMFORT PRO QL(5 ea daily); MISC PEN NEEDLES 31G X 2 RX/OTC TRUEPLUS INSULIN QL(5 ea daily); 5MM MISC SYRINGE/U- 2 RX/OTC TRUE COMFORT PRO QL(5 ea daily) 100/0.5ML/29G X 1/2" PEN NEEDLES 31G X 2 MISC 6MM MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); SYRINGE/U- 2 RX/OTC PEN NEEDLES 31G X 2 RX/OTC 100/0.5ML/30G X 5/16" 8MM MISC MISC TRUE COMFORT PRO QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) PEN NEEDLES 32G X 2 RX/OTC SYRINGE/U- 2 4MM MISC 100/0.5ML/31G X 5/16" MISC TRUE COMFORT PRO QL(5 ea daily) PEN NEEDLES 32G X 2 TRUEPLUS INSULIN QL(5 ea daily); 6MM MISC SYRINGE/U-100/1ML/28G 2 RX/OTC X 1/2" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily) NEEDLES 29GX12.7MM 2 TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 2 RX/OTC X 1/2" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 31GX5MM 2 RX/OTC TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 2 RX/OTC X 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily) NEEDLES 31GX6MM 2 TRUEPLUS INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 2 X 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 29GX12MM 2 RX/OTC MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 32GX4MM 2 RX/OTC TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 31GX5MM 2 RX/OTC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS PEN QL(5 ea daily) SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" NEEDLES 31GX6MM 2 MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS PEN QL(5 ea daily); NEEDLES 31GX8MM 2 RX/OTC SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) NEEDLES 32GX4MM 2 RX/OTC MISC SYRINGE/U- 2 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SAFETY 2 RX/OTC SYRINGE/0.5ML/29G X 1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SAFETY 2 RX/OTC SYRINGE/SHORT/1ML/30 2 RX/OTC SYRINGE/1ML/29G X 1/2" G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/31 2 SYRINGE/0.3ML/29G X 2 RX/OTC G X 5/16" MISC 1/2" MISC ULTICARE INSULIN ULTICARE INSULIN SYRINGE/U- 2 SYRINGE/0.3ML/30G X 2 100/0.3ML/30G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 2 RX/OTC SYRINGE/U- 2 5/16" MISC 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/28G X 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 2 ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/29G X 2 RX/OTC MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 SYRINGE/0.5ML/30G X 2 RX/OTC X 1/2" MISC 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 SYRINGE/1ML/28G X 1/2" 2 RX/OTC X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGEULTRAFINE U- 2 SYRINGE/1ML/29G X 1/2" 2 RX/OTC 100/0.3ML/31G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 2 SYRINGEULTRAFINE U- 2 MISC 100/0.5ML/31G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEULTRAFINE U- 2 100/1ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.3ML/3 2 RX/OTC 0G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily); NEEDLES 31G X 8MM 2 RX/OTC ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/0.3ML/3 2 1G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily); NEEDLES 32G X 4MM 2 RX/OTC ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 2 RX/OTC 0G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily) NEEDLES/31G X 1/4" 2 ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/0.5ML/3 2 1G X 5/16" MISC ULTICARE MICRO PEN QL(5 ea daily); NEEDLES/31G X 5/16" 2 RX/OTC MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE MICRO PEN QL(5 ea daily); ULTIGUARD SAFEPACK QL(5 ea daily) NEEDLES/32G X 4MM 2 RX/OTC INSULIN SYRINGE 1ML 2 MISC 31G X 5/16"/SHARPS CO ULTICARE MICRO PEN QL(5 ea daily); MISC NEEDLES/32G X 5/32" 2 RX/OTC ULTIGUARD SAFEPACK MISC INSULIN 2 ULTICARE MINI PEN QL(5 ea daily) SYRINGE/0.3ML/30G X NEEDLES 31GX6MM 2 1/2"/SHARPS C MISC MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily) INSULIN 2 NEEDLES ULTI-FINE IV 2 SYRINGE/0.3ML/31G X MISC 5/16"/SHARPS MISC ULTICARE MINI PEN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily); NEEDLES/31G X 6MM 2 MINI PEN NEEDLE/31G X 2 RX/OTC MISC 3/16"/SHARPS CONTAI MISC ULTICARE MINI PEN QL(5 ea daily) NEEDLES/32G X 1/4" 2 ULTIGUARD SAFEPACK QL(5 ea daily) MISC PEN NEEDLE/29G X 2 1/2"/SHARPS CONTAINER ULTICARE MINI PEN 2 QL(5 ea daily) MISC NEEDLES31GX6MM MISC ULTIGUARD QL(5 ea daily); ULTICARE ORIGINAL QL(5 ea daily) SAFEPACK/MICROPEN RX/OTC PEN NEEDLES ULTI-FINE 2 NEEDLE/32G X 2 MISC 5/32"/SHARPS CONTA ULTICARE PEN NEEDLES 2 QL(5 ea daily); MISC 31GX 5MM/MINI MISC RX/OTC ULTIGUARD QL(5 ea daily) ULTICARE PEN QL(5 ea daily) SAFEPACK/MINI PEN NEEDLES/29GX 12.7MM 2 NEEDLE/31G X 2 MISC 1/4"/SHARPS CONTAIN ULTICARE SHORT PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 2 RX/OTC ULTIGUARD QL(5 ea daily); MISC SAFEPACK/MINI PEN RX/OTC ULTICARE SHORT PEN QL(5 ea daily); NEEDLE/31G X 2 NEEDLES ULTI-FINE IV 2 RX/OTC 3/16"/SHARPS CONTAI MISC MISC ULTICARE SHORT PEN QL(5 ea daily); ULTIGUARD QL(5 ea daily) NEEDLES/31G X 8MM 2 RX/OTC SAFEPACK/MINI PEN MISC NEEDLE/32G X 2 ULTICARE SHORT QL(5 ea daily); 1/4"/SHARPS CONTAIN SAFETY PEN NEEDLES 2 RX/OTC MISC 30G X 5/16" MISC ULTIGUARD QL(5 ea daily); ULTIGUARD SAFEPACK SAFEPACK/SHORTPEN RX/OTC NEEDLE/31G X 2 INSULIN SYRINGE 2 0.3ML/30G X 5/16"/SHARPS CONTA 1/2"/SHARPS C MISC MISC ULTIGUARD SAFEPACK QL(5 ea daily) INSULIN SYRINGE 1ML 2 30G X 1/2"/SHARPS CON MISC MHS Indiana Preferred Drug List Updated June 1, 2021

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIGUARD QL(5 ea daily) ULTILET PEN NEEDLE 2 QL(5 ea daily); SAFEPACK/SYRINGE/NE 31GX5MM MISC RX/OTC EDLE/31G X 2 ULTILET PEN NEEDLE 2 QL(5 ea daily); 5/16"/SHARPS CONTAIN 31GX8MM MISC RX/OTC MISC ULTILET PEN NEEDLE 2 QL(5 ea daily); ULTILET INSULIN 2 QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE 31X6MM MISC RX/OTC ULTILET PEN NEEDLE 2 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); 32GX4MM/SHORT MISC RX/OTC SYRINGE/0.3ML/30G X 2 RX/OTC 8MM MISC ULTILET SHORT PEN QL(5 ea daily); NEEDLES 31GX5/16" 2 RX/OTC ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 2 8MM MISC ULTILET SHORT PEN 2 QL(5 ea daily); NEEDLES31GX3/16" MISC RX/OTC ULTILET INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 2 RX/OTC ULTRA COMFORT QL(5 ea daily); 8MM MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 2 RX/OTC 8MM MISC ULTRA FLO INSULIN PEN 2 QL(5 ea daily); NEEDLE 31GX5MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 2 ULTRA FLO INSULIN PEN 2 QL(5 ea daily); 8MM MISC NEEDLE 32GX4MM MISC RX/OTC ULTILET INSULIN ULTRA FLO INSULIN PEN 2 QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 2 NEEDLES MISC RX/OTC 0G X 12.7MM MISC ULTRA FLO INSULIN PEN 2 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEELE 31GX8MM MISC RX/OTC SYRINGE/SHORT/0.3ML/3 2 RX/OTC ULTRA FLO INSULIN QL(5 ea daily); 0G X 5/16" MISC SYRINGE 0.3ML/29G X 2 RX/OTC ULTILET INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/SHORT/0.3ML/3 2 ULTRA FLO INSULIN 1G X 5/16" MISC SYRINGE 0.3ML/30GX1/2" 2 ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 2 RX/OTC ULTRA FLO INSULIN QL(5 ea daily); 0G X 5/16" MISC SYRINGE 2 RX/OTC ULTILET INSULIN QL(5 ea daily) 0.3ML/30GX5/16" MISC SYRINGE/SHORT/0.5ML/3 2 ULTRA FLO INSULIN QL(5 ea daily) 1G X 5/16" MISC SYRINGE 2 ULTILET INSULIN QL(5 ea daily); 0.3ML/31GX5/16" MISC SYRINGE/SHORT/1ML/30 2 RX/OTC ULTRA FLO INSULIN QL(5 ea daily); G X 5/16" MISC SYRINGE 0.5ML/29GX1/2" 2 RX/OTC ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/1ML/31 2 ULTRA FLO INSULIN QL(5 ea daily); G X 5/16" MISC SYRINGE 2 RX/OTC ULTILET INSULIN QL(5 ea daily) 0.5ML/30GX5/16" MISC SYRINGE/U-100/1ML/30G 2 ULTRA FLO INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE 2 0.5ML/31GX5/16" MISC ULTILET PEN NEEDLE 2 QL(5 ea daily) 29GX12.7MM MISC MHS Indiana Preferred Drug List Updated June 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN ULTRA-COMFORT QL(5 ea daily); SYRINGE 1/2 2 INSULIN SYRINGE/U- 2 RX/OTC UNIT/0.3ML/30GX1/2" 100/0.5ML/30G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) SYRINGE 1/2 2 RX/OTC INSULIN SYRINGE/U- 2 UNIT/0.3ML/30GX5/16" 100/0.5ML/31G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE 1/2 2 INSULIN SYRINGE/U- 2 RX/OTC UNIT/0.3ML/31GX5/16" 100/1ML/28G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 1M/29GX1/2" 2 RX/OTC 100/1ML/29G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 2 RX/OTC SYRINGE 1ML/30GX1/2" 2 100/1ML/30G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) 2 SYRINGE 1ML/30GX5/16" RX/OTC INSULIN SYRINGE/U- 2 MISC 100/1ML/31G X 5/16" ULTRA FLO INSULIN QL(5 ea daily) MISC SYRINGE 1ML/31GX5/16" 2 ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- 2 RX/OTC ULTRA THIN PEN QL(5 ea daily); 100/0.3ML/30GX5/16" NEEDLES 32G X 4MM 2 RX/OTC MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE SHORT/U- 2 100/0.3ML/31GX5/16" INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/29G X 1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE SHORT/U- 2 RX/OTC 100/0.5ML/30GX5/16" INSULIN SYRINGE/U- 2 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily) SYRINGE SHORT/U- 2 100/0.5ML/31GX5/16" INSULIN SYRINGE/U- 2 100/0.3ML/31G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE SHORT/U- 2 RX/OTC 100/1ML/30GX5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC 100/0.5ML/28G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily) MISC SYRINGE SHORT/U- 2 ULTRA-COMFORT QL(5 ea daily); 100/1ML/31GX5/16" MISC INSULIN SYRINGE/U- 2 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SYRINGE/U- 2 RX/OTC MISC 100/0.5ML/29GX1/2" MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE PEN QL(5 ea daily); SYRINGE/U- 2 RX/OTC NEEDLES/32G X 5/32" 2 RX/OTC 100/1ML/29GX1/2" MISC MISC ULTRA-THIN II MINI PEN QL(5 ea daily); UNIFINE PEN 2 QL(5 ea daily); NEEEDLES/31GX3/16" 2 RX/OTC NEEDLE/32G X4MM MISC RX/OTC MISC UNIFINE PENTIPS 2 QL(5 ea daily); ULTRA-THIN II PEN 2 QL(5 ea daily) 29GX12MM MISC RX/OTC NEEDLES 29GX1/2" MISC UNIFINE PENTIPS 31G X 2 QL(5 ea daily); ULTRA-THIN II PEN QL(5 ea daily); 3/16" MISC RX/OTC NEEDLES/SHORT/31GX5/ 2 RX/OTC UNIFINE PENTIPS 2 QL(5 ea daily); 16" MISC 31GX5MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); UNIFINE PENTIPS 2 QL(5 ea daily) SYRINGE/U- 2 RX/OTC 31GX6MM MISC 100/0.3ML/30G X 5/16" MISC UNIFINE PENTIPS 2 QL(5 ea daily); 31GX8MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily) UNIFINE PENTIPS QL(5 ea daily); SYRINGE/U- 2 2 100/0.3ML/31G X 5/16" 32GX4MM MISC RX/OTC MISC UNIFINE PENTIPS 2 QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily); 32GX6MM MISC UNIFINE PENTIPS PLUS QL(5 ea daily); SYRINGE/U- 2 RX/OTC 2 100/0.5ML/30G X 5/16" 29GX12MM MISC RX/OTC MISC UNIFINE PENTIPS PLUS 2 QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) 31GX5MM MISC RX/OTC SYRINGE/U- 2 UNIFINE PENTIPS PLUS 2 QL(5 ea daily) 100/0.5ML/31G X 5/16" 31GX6MM MISC MISC UNIFINE PENTIPS PLUS 2 QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE/U-100/1ML/30G 2 UNIFINE PENTIPS PLUS 2 QL(5 ea daily); X 1/2" MISC 32GX4MM MISC RX/OTC ULTRACARE INSULIN QL(5 ea daily); UNIFINE SAFECONTROL QL(5 ea daily); SYRINGE/U-100/1ML/30G 2 RX/OTC PEN NEEDLE/30G X 5/16" 2 RX/OTC X 5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) VALUE HEALTH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 2 SYRINGE/U- 2 RX/OTC X 5/16" MISC 100/0.5ML/29G X 1/2" ULTRACARE PEN QL(5 ea daily) MISC NEEDLES/31G X 1/4" 2 VALUE HEALTH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 2 RX/OTC ULTRACARE PEN QL(5 ea daily); X 1/2" MISC NEEDLES/31G X 3/16" 2 RX/OTC VALUMARK PEN QL(5 ea daily); MISC NEEDLES 29GX12MM 2 RX/OTC ULTRACARE PEN QL(5 ea daily); MISC NEEDLES/31G X 5/16" 2 RX/OTC VALUMARK PEN QL(5 ea daily) MISC NEEDLES 31GX 6MM 2 ULTRACARE PEN QL(5 ea daily) MISC NEEDLES/32G X 1/14" 2 MISC

MHS Indiana Preferred Drug List Updated June 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALUMARK PEN QL(5 ea daily); QL(2 ea per NEEDLES 31GX 8MM 2 RX/OTC AEROCHAMBER MV 2 MISC 360 days MISC retail); RX/OTC VANISHPOINT INSULIN QL(5 ea daily); QL(2 ea per SYRINGE/0.5ML/30G X 2 RX/OTC AEROCHAMBER PLUS 2 FLOW VU MISC 360 days 5/16" MISC retail); RX/OTC VANISHPOINT INSULIN QL(5 ea daily); QL(2 ea per SYRINGE/1ML/29G X 1/2" 2 RX/OTC AEROCHAMBER PLUS 2 FLOW-VU MISC 360 days MISC retail); RX/OTC VANISHPOINT INSULIN QL(5 ea daily); AEROCHAMBER PLUS QL(2 ea per SYRINGE/1ML/30G X 2 RX/OTC FLOW-VU/LARGE MASK 2 360 days 5/16" MISC MISC retail); RX/OTC VIDA MIA UNIFINE QL(5 ea daily); 2 AEROCHAMBER PLUS QL(2 ea per PENTIPS32GX4MM MISC RX/OTC 2 360 days FLOW-VU/MASK MISC VIDA MIA UNIFINE QL(5 ea daily) retail); RX/OTC PENTIPSMINI 31GX6MM 2 AEROCHAMBER PLUS QL(2 ea per MISC FLOW-VU/MEDIUM MASK 2 360 days VIDA MIA UNIFINE QL(5 ea daily); MISC retail); RX/OTC PENTIPSORIGINAL 2 RX/OTC AEROCHAMBER PLUS QL(2 ea per 29GX12MM MISC FLOW-VU/SMALL MASK 2 360 days VIDA MIA UNIPFINE QL(5 ea daily); MISC retail); RX/OTC PENTIPSSHORT 2 RX/OTC AEROCHAMBER Z-STAT QL(2 ea per 31GX8MM MISC PLUS VALVED HOLDING 2 360 days VP INSULIN SYRINGE/U- QL(5 ea daily); CHAMBER W/FLOW VU retail); RX/OTC 100/0.3ML/29G X 1/2" 2 RX/OTC MISC MISC QL(2 ea per AEROCHAMBER Z-STAT 2 360 days WEGMANS UNIFINE QL(5 ea daily); PLUS/FLOWSIGNAL MISC PENTIPS PLUS 32GX4MM 2 RX/OTC retail); RX/OTC MISC QL(2 ea per AEROCHAMBER Z-STAT 2 WEGMANS UNIFINE QL(5 ea daily); PLUS/LARGE MASK MISC 360 days retail); RX/OTC PENTIPS 2 RX/OTC PLUS/MINI/31GX5MM AEROCHAMBER Z-STAT QL(2 ea per MISC PLUS/MEDIUM MASK 2 360 days WEGMANS UNIFINE QL(5 ea daily); MISC retail); RX/OTC PENTIPS 2 RX/OTC QL(2 ea per PLUS/SHORT/31GX8MM AEROCHAMBER Z-STAT 2 PLUS/SMALL MASK MISC 360 days MISC retail); RX/OTC WEGMANS UNIFINE QL(5 ea daily) QL(2 ea per PENTIPS PLUS/ULTRA 2 AEROCHAMBER/FLOWSI 2 GNAL MISC 360 days SHORT/31GX6MM MISC retail); RX/OTC Respiratory Therapy Supplies AEROVENT PLUS QL(2 ea per HOLDING 360 days RX/OTC 2 ADULT MASK DEVI 2 CHAMBER/COLLAPSIBLE retail); RX/OTC DEVI AEROBIKA DEVI 2 RX/OTC ALL FLOW 1000 PFT 2 RX/OTC AEROCHAMBER MINI QL(2 ea per FILTER DEVI AEROSOLCHAMBER 2 360 days ALL FLOW 2000 PFT 2 RX/OTC DEVI retail); RX/OTC FILTER DEVI MHS Indiana Preferred Drug List Updated June 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALL FLOW 3000 PFT 2 RX/OTC BREATHERITE VALVED RX/OTC FILTER DEVI MDI 2 CHAMBER/COLLAPSIBLE ALL FLOW 4000 PFT 2 RX/OTC FILTER DEVI DEVI BREATHERITE VALVED RX/OTC ALL FLOW 5000 PFT 2 RX/OTC FILTER DEVI MDI CHAMBER/RIGID 2 DEVI ALL FLOW 6000 PFT 2 RX/OTC FILTER DEVI QL(2 ea per BREATHERITE W/LARGE 2 360 days MASK MISC ALL FLOW 7000 PFT 2 RX/OTC retail); RX/OTC FILTER DEVI QL(2 ea per QL(2 ea per BREATHERITE 2 W/MEDIUM MASK MISC 360 days ARIAL CHAMBER DEVI 2 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per QL(2 ea per BREATHERITE W/SMALL 2 360 days BREATHE EASE/LARGE 2 MASK MISC MASK DEVI 360 days retail); RX/OTC retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED 360 days BREATHE EASE/MEDIUM 2 360 days MASK DEVI HOLDING 2 retail); RX/OTC retail); RX/OTC CHAMBER/ADULT LARGE QL(2 ea per DEVI BREATHE EASE/SMALL 2 MASK DEVI 360 days CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED 2 360 days BREATHERITE QL(2 ea per HOLDING retail); RX/OTC COLLAPSIBLEADULT 2 360 days CHAMBER/MEDIUM DEVI SPACER W/MASK MISC retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per BREATHERITE QL(2 ea per STATICVALVED 360 days COLLAPSIBLECHILD 2 360 days HOLDING 2 retail); RX/OTC SPACER W/MASK MISC retail); RX/OTC CHAMBER/MEDIUM/3 BREATHERITE QL(2 ea per YEA DEVI COLLAPSIBLEINFANT 2 360 days CLEVER CHOICE ANTI- QL(2 ea per SPACER W/MASK MISC retail); RX/OTC STATICVALVED 2 360 days BREATHERITE QL(2 ea per HOLDING retail); RX/OTC CHAMBER/SMALL DEVI COLLAPSIBLESMALL 2 360 days CHILD SPACER W/MASK retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per MISC STATICVALVED 360 days BREATHERITE QL(2 ea per HOLDING 2 retail); RX/OTC COLLAPSIBLESPACER 2 360 days CHAMBER/SMALL W/ NEONATE MASK MISC retail); RX/OTC INFANT DEVI QL(2 ea per CO MONITOR DEVI 2 RX/OTC BREATHERITE MISC 2 360 days retail); RX/OTC COMPACT SPACE QL(2 ea per QL(2 ea per CHAMBER/ANTI-STATIC 2 360 days BREATHERITE RIGID 2 360 days DEVI retail); RX/OTC SPACERW/MASK MISC retail); RX/OTC COMPACT SPACE QL(2 ea per CHAMBER/ANTI- 2 360 days STATIC/LARGE MASK retail); RX/OTC DEVI

MHS Indiana Preferred Drug List Updated June 1, 2021

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPACT SPACE QL(2 ea per EQ SPACE CHAMBER QL(2 ea per CHAMBER/ANTI- 2 360 days ANTI-STATIC/MEDIUM 2 360 days STATIC/MEDIUM MASK retail); RX/OTC MASK DEVI retail); RX/OTC DEVI EQ SPACE CHAMBER QL(2 ea per COMPACT SPACE QL(2 ea per ANTI-STATIC/SMALL 2 360 days CHAMBER/ANTI- 2 360 days MASK DEVI retail); RX/OTC STATIC/SMALL MASK retail); RX/OTC QL(2 ea per DEVI FLEXICHAMBER DEVI 2 360 days QL(2 ea per retail); RX/OTC EASIVENT MISC 2 360 days IN-CHECK DIAL RX/OTC retail); RX/OTC INSPIRATORYFLOW 2 QL(2 ea per TRAINER DEVI EASIVENT/MASK-LARGE 2 360 days MISC IN-CHECK INSPIRATORY RX/OTC retail); RX/OTC FLOWMETER/NASAL 2 QL(2 ea per WITH MASK DEVI EASIVENT/MASK- 2 360 days MEDIUM MISC IN-CHECK INSPIRATORY 2 RX/OTC retail); RX/OTC FLOWMETER/ORAL DEVI QL(2 ea per INSPIRACHAMBER/ANTI- QL(2 ea per EASIVENT/MASK-SMALL 2 360 days MISC STATIC 2 360 days retail); RX/OTC VALVED/MOUTHPIECE retail); RX/OTC EASY FLOW BLACK/BLUE 2 RX/OTC DEVI DEVI QL(2 ea per EASY FLOW RX/OTC INSPIRACHAMBER/LARG 2 2 E DEVI 360 days BLACK/ORANGE DEVI retail); RX/OTC EASY FLOW BLACK/RED 2 RX/OTC INSPIRACHAMBER/SOOT QL(2 ea per DEVI HERMASK/INSPIRAMASK 2 360 days /MEDIUM DEVI retail); RX/OTC EASY FLOW 2 RX/OTC BLACK/WHITE DEVI INSPIRACHAMBER/SOOT QL(2 ea per HERMASK/INSPIRAMASK 2 360 days EASY FLOW 2 RX/OTC BLACK/YELLOW DEVI /SMALL DEVI retail); RX/OTC EASY FLOW WHITE/BLUE RX/OTC QL(2 ea per 2 INSPIREASE DRUG 2 DEVI DELIVERYSYSTEM MISC 360 days retail); RX/OTC EASY FLOW 2 RX/OTC WHITE/GREEN DEVI INSPIREASE RESERVOIR 2 QL(3 ea per BAGS MISC 180 days retail) EASY FLOW WHITE/PINK 2 RX/OTC DEVI QL(2 ea per LITEAIRE DEVI 2 360 days EASY FLOW 2 RX/OTC retail); RX/OTC WHITE/WHITE DEVI QL(2 ea per EASY FLOW 2 RX/OTC MICROCHAMBER DEVI 2 360 days WHITE/YELLOW DEVI retail); RX/OTC QL(2 ea per QL(2 ea per EQ SPACE CHAMBER 2 360 days ANTI-STATIC DEVI MICROCHAMBER MISC 2 360 days retail); RX/OTC retail); RX/OTC EQ SPACE CHAMBER QL(2 ea per QL(2 ea per ANTI-STATIC/LARGE 2 360 days MICROSPACER MISC 2 360 days MASK DEVI retail); RX/OTC retail); RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MISTASSIST DEVI 2 RX/OTC PARI TREK S COMBO 2 RX/OTC PACK DEVI NEBULIZER CUP/TUBING 2 RX/OTC QL(2 ea per DEVI POCKET CHAMBER DEVI 2 360 days retail); RX/OTC OMBRA TABLE TOP 2 RX/OTC COMPRESSOR DEVI QL(2 ea per ONE FLOW FVC RX/OTC POCKET SPACER DEVI 2 360 days MONITORING 2 retail); RX/OTC SPIROMETER DEVI PRIMEAIRE DUAL- RX/OTC OPTICHAMBER QL(2 ea per VALVED HOLDING 2 ADVANTAGE/LARGE 2 360 days CHAMBER DEVI MASK MISC retail); RX/OTC PRO COMFORT INHALER QL(2 ea per OPTICHAMBER QL(2 ea per SPACER CHAMBER 2 360 days ADVANTAGE/MEDIUM 2 360 days ADULT MISC retail); RX/OTC FACE MASK MISC retail); RX/OTC PRO COMFORT INHALER QL(2 ea per OPTICHAMBER QL(2 ea per SPACER CHAMBER 2 360 days ADVANTAGE/SMALL 2 360 days CHILD MISC retail); RX/OTC FACE MASK MISC retail); RX/OTC PRO COMFORT INHALER QL(2 ea per QL(2 ea per SPACER CHAMBER 2 360 days OPTICHAMBER 2 360 days INFANT DEVI retail); RX/OTC DIAMOND MISC retail); RX/OTC PROCARE SPACER QL(2 ea per OPTICHAMBER QL(2 ea per CHAMBER W/ADULT 2 360 days DIAMOND/LARGEFACE 2 360 days MASK DEVI retail); RX/OTC MASK DEVI retail); RX/OTC PROCARE SPACER QL(2 ea per OPTICHAMBER QL(2 ea per CHAMBER W/CHILD 2 360 days DIAMOND/MEDIUM FACE 2 360 days MASK DEVI retail); RX/OTC MASK MISC retail); RX/OTC QUAKE DEVI 2 RX/OTC OPTICHAMBER QL(2 ea per DIAMOND/SMALLFACE 2 360 days QL(2 ea per MASK MISC retail); RX/OTC RITEFLO DEVI 2 360 days QL(2 ea per retail); RX/OTC OPTICHAMBER FACE 2 MASK/LARGE MISC 360 days SPIRO PD DEVI 2 RX/OTC retail); RX/OTC QL(2 ea per THRESHOLD PEP DEVI 2 RX/OTC OPTICHAMBER FACE 2 MASK/MEDIUM MISC 360 days retail); RX/OTC QL(2 ea per VALVED HOLDING 2 360 days QL(2 ea per CHAMBER DEVI OPTICHAMBER FACE 2 retail); RX/OTC MASK/SMALL MISC 360 days retail); RX/OTC VORTEX HOLDING RX/OTC QL(2 ea per CHAMBER/MASK/CHILDS 2 OPTIHALER MDI DRUG 2 DEVI DELIVERY SYSTEM DEVI 360 days retail); RX/OTC VORTEX HOLDING RX/OTC QL(2 ea per CHAMBER/MASK/CHILDS 2 OPTIHALER MISC 2 360 days /FROG DEVI retail); RX/OTC VORTEX HOLDING RX/OTC CHAMBER/MASK/TODDL 2 PARI MANUAL 2 RX/OTC INTERRUPTER DEVI ER DEVI

MHS Indiana Preferred Drug List Updated June 1, 2021

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.083 ml VORTEX HOLDING RX/OTC IMITREX SOLN SC 6 CHAMBER/MASK/TODDL 2 daily); AL(At MG/0.5ML (Use NP ER/LADY BUG DEVI sumatriptan succinate) least 12 yrs VORTEX VALVED QL(2 ea per old) HOLDING CHAMBER 2 360 days QL(0.067 ml IMITREX STATDOSE DEVI retail); RX/OTC daily,30 day(s) REFILL SOCT 6 MG/0.5ML NP limit); AL(At QL(2 ea per (Use sumatriptan WATCHHALER DEVI 2 360 days succinate) least 12 yrs retail); RX/OTC old) IMITREX STATDOSE QL(0.067 ml MIGRAINE PRODUCTS - Drugs to Treat Migraine SYSTEM SOAJ 6 NP daily); AL(At Headaches MG/0.5ML (Use least 12 yrs Calcitonin Gene-Related Peptide (CGRP) sumatriptan succinate) old) PA; QL(0.04 ml QL(0.6 ea AIMOVIG SOAJ 2 IMITREX TABS OR 50 MG, daily); AL(At daily) 100 MG, 25 MG (Use NP PA; QL(1.5 ml sumatriptan succinate) least 12 yrs AJOVY SOAJ 2 per 30 days old) retail) QL(0.4 ea MAXALT TABS (Use NP PA; QL(1.5 ml rizatriptan benzoate) daily); AL(At AJOVY SOSY 2 per 30 days least 6 yrs old) retail) MAXALT-MLT TBDP (Use NP QL(0.4 ea rizatriptan benzoate) daily) EMGALITY SOAJ 2 PA; QL(0.07 ml daily) QL(0.6 ea daily); AL(At EMGALITY SOSY 2 PA; QL(0.07 ml naratriptan hcl tabs 1 daily) least 18 yrs old) Migraine Products RELPAX TABS (Use NP QL(0.2 ea D.H.E. 45 SOLN (Use eletriptan hydrobromide) daily) dihydroergotamine NP QL(0.4 ea mesylate) rizatriptan benzoate tabs 1 daily); AL(At 10 mg, 5 mg dihydroergotamine 1 least 6 yrs old) mesylate soln ij 1 mg/ml rizatriptan benzoate tbdp 1 QL(0.4 ea dihydroergotamine 2 10 mg, 5 mg daily) mesylate soln na 4 mg/ml QL(0.2 ea MIGRANAL SOLN (Use 1 daily); AL(At dihydroergotamine 2 sumatriptan soln least 12 yrs mesylate) old) Serotonin Agonists QL(0.067 ml QL(0.6 ea sumatriptan succinate soaj 1 daily); AL(At sc 6 mg/0.5ml least 12 yrs AMERGE TABS (Use NP daily); AL(At naratriptan hcl) least 18 yrs old) old) QL(0.067 ml daily,30 day(s) eletriptan hydrobromide 1 QL(0.2 ea sumatriptan succinate soct tabs daily) 1 limit); AL(At sc 6 mg/0.5ml least 12 yrs QL(0.2 ea old) IMITREX SOLN NA 20 daily); AL(At MG/ACT, 5 MG/ACT (Use NP sumatriptan) least 12 yrs old) MHS Indiana Preferred Drug List Updated June 1, 2021

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.083 ml calcium carbonate- sumatriptan succinate soln 1 daily); AL(At cholecalciferol caps 500 1 sc 6 mg/0.5ml least 12 yrs unit-600 mg old) calcium carbonate- QL(0.067 ml cholecalciferol chew 100 sumatriptan succinate sosy 1 daily); AL(At unit-500 mg, 500 mg-600 1 sc 6 mg/0.5ml least 12 yrs unit, 10 mcg-500 mg, 400 old) unit-500 mg QL(0.6 ea calcium carbonate- QL(2 ea daily) sumatriptan succinate tabs 1 daily); AL(At cholecalciferol tabs 10 or 50 mg, 100 mg, 25 mg least 12 yrs mcg-600 mg, 400 unit-600 1 old) mg, 20 mcg-600 mg, 400 QL(0.2 ea unit-600 mg-600 mg-800 unit 1 daily); AL(At zolmitriptan soln na 5 mg least 12 yrs calcium carbonate- old) cholecalciferol tabs 125 unit-250 mg, 125 unit-500 zolmitriptan tabs or 2.5 mg, 1 QL(0.2 ea 5 mg daily) mg, 250 mg-3.12 mcg, 15 mcg-500 mg, 200 unit-600 1 zolmitriptan tbdp or 2.5 mg, 1 QL(0.2 ea mg, 5 mcg-600 mg, 500 5 mg daily) mg-600 unit, 10 mcg-500 QL(0.2 ea mg, 400 unit-400 unit-500 ZOMIG SOLN NA 5 MG NP daily); AL(At mg-500 mg, 200 unit-500 (Use zolmitriptan) least 12 yrs mg, 5 mcg-500 mg old) calcium carbonate-vitamin 1 ZOMIG TABS OR 2.5 MG, NP QL(0.2 ea d caps 200 unit-600 mg 5 MG (Use zolmitriptan) daily) calcium carbonate-vitamin 1 ZOMIG ZMT TBDP (Use NP QL(0.2 ea d chew 400 unit-600 mg zolmitriptan) daily) calcium carbonate-vitamin MINERALS & ELECTROLYTES d tabs 125 unit-250 mg, 125 unit-600 mg, 125 unit- 1 Calcium 500 mg, 400 unit-500 mg, 200 unit-200 unit-500 mg- CAL-CITRATE PLUS 2 VITAMIND TABS 500 mg calcium carbonate-vitamin QL(2 ea daily) CAL-QUICK LIQD 2 d tabs 200 unit-600 mg, 1 400 unit-600 mg CALCET CREAMY BITES 2 CHEW CALCIUM CHEW 100 2 UNIT-500 MG CALCI-CHEW CHEW 2 CALCIUM CHEW 500 MG 2 CALCIUM 1000 + D TABS 2 CALCIUM CHEWS CHEW 2 CALCIUM CARBONATE 2 CHEW 500 MG calcium citrate tabs 200 1 mg, 950 mg calcium carbonate tabs 1 1250 mg, 500 mg CALCIUM CITRATE W/D 2 TABS CALCIUM CITRATE 2 W/VITAMIN D TABS MHS Indiana Preferred Drug List Updated June 1, 2021

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium citrate-vitamin d 1 oyster shell tabs 1 chew calcium citrate-vitamin d 1 PARVA-CAL TABS 2 tabs CALCIUM RA CALCIUM TABS 2 CITRATE/VITAMIN D3 2 LIQD UPCAL D PACK 2 CALCIUM PLUS D3 2 ABSORBABLE CAPS UPCAL D POWD 2 CALCIUM PLUS VITAMIN 2 D CAPS Electrolyte Mixtures CERALYTE 70 SOLN 20 CALCIUM TABS 200 UNIT- 2 600 MG MEQ/L-30 MEQ/L-60 2 MEQ/L-70 MEQ/L CALCIUM/VITAMIN D 2 CAPS CERASPORT EX1 SOLN 2 CALTRATE 600+D3 SOFT 2 CERASPORT SOLN 18 CHEWS CHEW MEQ/L-20 MEQ/L-4 2 CALTRATE 600+D3 TABS QL(2 ea daily) MEQ/L-6 MEQ/L (Use calcium carbonate- NP DEXTROSE 5%/NACL cholecalciferol) 0.3% SOLN (Use dextrose NF CHEWABLE CALCIUM/D3 2 w/ sodium chloride) WAFR ENFAMIL ENFALYTE 2 CITRACAL + D3 SOLN MAXIMUM TABS (Use NP EQUALYTE SOLN (Use NP calcium citrate-vitamin d) oral electrolytes) CITRACAL MAXIMUM HYDRALYTE FREEZER 2 TABS (Use calcium citrate- NP POPS SOLN vitamin d) HYDRALYTE SOLN 16 CITRACAL GM/L-20 MEQ/L-45 PETITES/VITAMIND TABS NP MEQ/L-45 MEQ/L-90 2 (Use calcium citrate- MEQ/L, 210 MG/250ML- vitamin d) 270 MG/250ML EQL CALCIUM/VITAMIN D 2 KINDERLYTE PREMAX CAPS SOLN 3.1 MG/360ML-320 LIQUID CALCIUM WITH MG/360ML-620 D3 MAXIMUM STRENGTH 2 MG/360ML-630 2 CAPS MG/360ML, 3.1 MG/360ML-330 MAGNEBIND 300 TABS 2 MG/360ML-620 MG/360ML-630 MG/360ML OSTEO-PORETICAL 2 TABS KINDERLYTE SOLN 3.1 OYSTER SHELL MG/360ML-300 CALCIUM PLUS VITAMIN 2 MG/360ML-445 D TABS MG/360ML-560 2 MG/360ML, 3.1 OYSTER SHELL MG/360ML-300 CALCIUM/VITAMIN D 2 MG/360ML-460 TABS MG/360ML-570 MG/360ML MHS Indiana Preferred Drug List Updated June 1, 2021

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oral electrolytes soln 1 K-PHOS NEUTRAL TABS QL(8 ea daily) (Use pot phosphate PEDIALYTE ADVANCED monobasic w/ sod NP CARE SOLN (Use oral NP phosphate dibasic & electrolytes) monobasic) PEDIALYTE FREEZER pot phosphate monobasic QL(8 ea daily) POPS SOLN (Use oral NP w/ sod phosphate dibasic & 1 electrolytes) monobasic tabs PEDIALYTE SINGLES Potassium SOLN (Use oral NP K-TAB TBCR (Use NP electrolytes) potassium chloride) PEDIALYTE SOLN 0.5 MG/59ML-1.2 MEQ/59ML- potassium bicarbonate tbef 1 1.5 GM/59ML-2.1 MEQ/59ML-2.7 potassium chloride cpcr or 1 MEQ/59ML, 10.6 10 meq MEQ/237ML-4.7 potassium chloride cpcr or 1 QL(1 ea daily) MEQ/237ML-8.3 8 meq MEQ/237ML, 20 GM/L-20 NP potassium chloride MEQ/L-35 MEQ/L-45 microencapsulated crystals 1 MEQ/L-5 GM/L, 20 MEQ/L- er tbcr 25 GM/L-30 MEQ/L-35 potassium chloride pack or 1 MEQ/L-45 MEQ/L, 20 20 meq MEQ/L-25 GM/L-35 MEQ/L-45 MEQ/L-7.8 potassium chloride soln or 1 MG/L (Use oral 20 %, 10 % electrolytes) potassium chloride tbcr or 1 20 meq, 10 meq, 8 meq Fluoride Sodium sodium fluoride chew 0.25 $0 AL(Up to 15 yrs mg, 0.5 mg, 1 mg, 2.2 mg old ); PV sodium chloride flush soln 1 AL(Up to 15 yrs sodium fluoride soln 0.5 $0 old ); RX/OTC; sodium chloride soln ij 0.9 mg/ml 1 PV % sodium chloride soln iv 0.9 1 Magnesium % MAGDELAY TBEC 2 Zinc QL(3.34 ea zinc sulfate caps or 220 mg 1 MAGNEBIND 400 TABS 2 daily) magnesium oxide (mg 1 supplement) tabs 400 mg MISCELLANEOUS THERAPEUTIC CLASSES MAGOX 400 TABS (Use Chelating Agents magnesium oxide (mg NP DEPEN TITRATABS TABS NP supplement)) (Use penicillamine) Phosphate penicillamine tabs 1

SYPRINE CAPS (Use NP PA; SP trientine hcl)

MHS Indiana Preferred Drug List Updated June 1, 2021

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trientine hcl caps 1 PA; SP cyclosporine modified (for 1 microemulsion) soln Enzymes cyclosporine soln iv 50 1 PA; SP mg/ml XIAFLEX SOLR 2 PA; SP everolimus 1 PA Homeopathic Products (immunosuppressant) tabs IMURAN TABS (Use COLD-EEZE LOZG (Use NP NP homeopathic products) azathioprine) COLD-EEZE PLUS mycophenolate mofetil 1 DEFENSE LOZG MT (Use NP caps or 250 mg homeopathic products) mycophenolate mofetil hcl 1 PA; SP COLD-EEZE PLUS solr NATURAL MULTI- mycophenolate mofetil susr 1 SYMPTOM RELIEF LOZG NP or 200 mg/ml (Use homeopathic mycophenolate mofetil tabs 1 products) or 500 mg COLD-EEZE SUGAR mycophenolate sodium 1 FREE LOZG (Use NP tbec homeopathic products) MYFORTIC TBEC (Use NP homeopathic products lozg 1 mycophenolate sodium) NEORAL CAPS (Use Immunomodulators cyclosporine modified (for NP microemulsion)) REVLIMID CAPS 2 PA; SP NEORAL SOLN (Use THALOMID CAPS 2 PA; SP cyclosporine modified (for NP microemulsion)) Immunosuppressive Agents NULOJIX SOLR 2 PA; SP AZASAN TABS 2 PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG (Use NP azathioprine tabs or 50 mg 1 tacrolimus) PROGRAF PACK OR 0.2 PA CELLCEPT CAPS (Use NP 2 mycophenolate mofetil) MG, 1 MG CELLCEPT PA; SP PROGRAF SOLN IV 5 2 PA; SP MG/ML INTRAVENOUS SOLR NP (Use mycophenolate RAPAMUNE SOLN (Use NP mofetil hcl) sirolimus) CELLCEPT SUSR (Use NP RAPAMUNE TABS (Use NP mycophenolate mofetil) sirolimus) CELLCEPT TABS (Use NP SANDIMMUNE CAPS OR mycophenolate mofetil) 100 MG, 25 MG (Use 2 cyclosporine) cyclosporine caps or 100 1 mg, 25 mg SANDIMMUNE SOLN IV PA; SP 50 MG/ML (Use 2 cyclosporine modified (for 1 microemulsion) caps cyclosporine) sirolimus soln 1

MHS Indiana Preferred Drug List Updated June 1, 2021

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sirolimus tabs 1 triamcinolone acetonide 1 (mouth) pste tacrolimus caps 1 Throat Products - Misc. ZORTRESS TABS 0.25 PA pilocarpine hcl (oral) tabs 5 1 QL(6 ea daily) mg MG, 0.5 MG, 0.75 MG (Use NP everolimus SALAGEN TABS 5 MG NP QL(6 ea daily) (immunosuppressant)) (Use pilocarpine hcl (oral)) Potassium Removing Agents MULTIVITAMINS sodium polystyrene 1 sulfonate powd B-Complex w/ Folic Acid b-complex w/ c & folic acid QL(1 ea daily); sodium polystyrene 1 sulfonate susp caps 1 mg-1.5 mg-1.7 mg- 1 RX/OTC 10 mg-100 mg-150 mcg-20 Systemic Lupus Erythematosus Agents mg-5 mg-6 mcg BENLYSTA SOLR IV 120 2 PA; SP B-Complex w/ Minerals MG, 400 MG b-complex w/ minerals liqd 1 MOUTH/THROAT/DENTAL AGENTS Multiple Vitamins w/ Minerals Anesthetics Topical Oral ICAPS LUTEIN & 2 lidocaine hcl (mouth-throat) 1 QL(100 ml per ZEAXANTHIN TBEC soln 2 % fill retail) multiple vitamins w/ 1 Anti-infectives - Throat minerals tbef nystatin (mouth-throat) 1 Ped MV w/ Iron susp ANIMAL SHAPES/IRON 2 Antiseptics - Mouth/Throat CHEW chlorhexidine gluconate 1 DINO-LIFE W/IRON & 2 (mouth-throat) soln ZINC CHEW PERIDEX SOLN (Use HONEY BEARS W/IRON 2 chlorhexidine gluconate NP AND ZINC CHEW (mouth-throat)) MULTIVITAMIN PLUS 2 Dental Products IRON CHILDRENS CHEW PREVIDENT 5000 DRY QL(2 ml daily) pediatric multiple vitamins 1 MOUTH GEL (Use sodium NP w/ iron chew fluoride (dental)) SCOOBY-DOO ONE A 2 PREVIDENT 5000 PLUS QL(2 gm daily) DAY CHEW CREA (Use sodium fluoride NP Ped Multiple Vitamins w/ Minerals (dental)) CENTRUM FLAVOR 2 PREVIDENT FLUORIDE QL(2 ml daily) BURST KIDS CHEW GEL (Use sodium fluoride NP (dental)) CENTRUM KIDS CHEW 2 sodium fluoride (dental) 1 QL(2 gm daily) crea dt 1.1 % FLINTSTONES GUMMIES CHEW (Use pediatric NP sodium fluoride (dental) gel 1 QL(2 ml daily) multiple vitamin w/ minerals dt 1.1 % & c) Steroids - Mouth/Throat/Dental MHS Indiana Preferred Drug List Updated June 1, 2021

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLINTSTONES GUMMIES ATABEX PRENATAL 2 COMPLETE CHEW (Use NP CHEW pediatric multiple vitamin w/ minerals & c) CADEAU DHA CAPS 2 FLINTSTONES GUMMIES CALNA TABS 2 PLUSIMMUNITY SUPPORT/EXTRA C NP CENTRUM SPECIALIST 2 CHEW (Use pediatric PRENATAL MISC multiple vitamin w/ minerals CLASSIC PRENATAL 2 & c) TABS FLINTSTONES SOUR CLINICAL NUTRIENTS GUMMIES CHEW (Use NP PRENATAL FORMULA 2 pediatric multiple vitamin w/ TABS minerals & c) RX/OTC FLINTSTONES CO-NATAL FA TABS 2 TODDLER/TASTISMOOTH 2 CHEW COMPLETENATE CHEW 2 GNP CHILDRENS CVS PRENATAL COMPLETE CHEWABLES 2 GUMMY/DHA/FOLIC ACID 2 CHEW CHEW HEALTHY KIDS GUMMIES 2 CVS PRENATAL 2 CHEW MULTI+DHA CAPS JUST 4 KIDZ MULTIVITAMIN+PROBIOT 2 CVS PRENATAL TABS 2 IC CHEW CVS WOMENS 2 MVW COMPLETE 2 PRENATAL+DHA MISC FORMULATION CHEW NF FORMULAS ENFAMIL EXPECTA MISC 2 CHILDRENS CHEWABLE 2 EQL PRENATAL 2 CHEW FORMULA TABS ONE-A-DAY SCOOBY- GNP PRENATAL TABS 2 DOO GUMMIES CHEW NP (Use pediatric multiple GOODSENSE PRENATAL 2 vitamin w/ minerals & c) VITAMINS TABS ONE-A-DAY/JOLLY HEALTHY MAMA BE 2 RANCHER CHEW (Use NP WELL ROUNDED THPK pediatric multiple vitamin w/ minerals & c) HM ONE DAILY 2 PRENATAL COMBO MISC pediatric multiple vitamin w/ 1 minerals & c chew HM PRENATAL TABS 2 VITALETS CHILDRENS 2 KP PRENATAL 2 CHEW MULTIVITAMINS TABS VITAMAX CHEW 2 KPN PRENATAL TABS 2 ZOO FRIENDS 2 RX/OTC COMPLETE CHEW M-NATAL PLUS TABS 2 Prenatal Vitamins MTERYTI FOLIC 5 TBPK 2

MHS Indiana Preferred Drug List Updated June 1, 2021

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MTERYTI TBPK 2 PRENATAL 19 CHEW 1 MG-100 MG-1000 UNIT-12 MULTI PRENATAL TABS 2 MCG-15 MG-20 MG-20 2 MG-200 MG-29 MG-3 MG- 3 MG-30 UNIT-400 UNIT-7 MYNATAL ADVANCE 2 TABS MG PRENATAL 19 TABS 1 QL(1 ea daily); MYNATAL PLUS TABS 2 MG-100 MG-1000 UNIT-12 RX/OTC MCG-15 MG-20 MG-20 MYNATAL ULTRACAPLET 2 2 TABS MG-200 MG-25 MG-29 MG-3 MG-3 MG-30 UNIT- MYNATAL-Z TABS 2 400 UNIT-7 MG QL(1 ea daily) PRENATAL AND IRON 2 RX/OTC MYNATE 90 PLUS TBCR 2 TABS PRENATAL COMPLETE 2 NATALVIT TABS 2 TABS NEONATAL COMPLETE RX/OTC 2 PRENATAL FORMULA A- 2 TABS FREE TABS RX/OTC NEONATAL PLUS TABS 2 PRENATAL FORMULA 2 CAPS NEONATAL VITAMIN 2 RX/OTC TABS PRENATAL FORTE TABS 2 RX/OTC NIVA-PLUS TABS 2 PRENATAL LOW IRON 2 TABS O-CAL FA TABS 2 RX/OTC PRENATAL MULTI + DHA CAPS 1.5 MG-1.7 MG-11 O-CAL PRENATAL TABS 2 UNIT-18 MG-2.6 MG-25 2 MG-250 MG-27 MG-38 ONE A DAY WOMENS 2 MG-4 MCG-400 UNIT-4000 PRENATAL/DHA MISC UNIT-60 MG-800 MCG ONE A DAY WOMENS 2 PRENATAL MULTI +DHA 2 PRENATAL1 CAPS CAPS ONE VITE WOMENS RX/OTC PRENATAL PRENATALVITAMIN PLUS 2 MULTIVITAMIN + DHA 2 TABS MISC ONE VITE WOMENS 2 PRENATAL PRENATALVITAMIN TABS MULTIVITAMIN PLUS 2 DHA CAPS ONE-A-DAY WOMENS 2 PRENATAL MISC PRENATAL MULTIVITAMIN PLUS 2 PERRY PRENATAL CAPS 2 DHA MISC PRENATAL PRE-NATAL FORMULA 2 RX/OTC 2 TABS MULTIVITAMIN TABS PRENATABS FA TABS 2 RX/OTC PRENATAL ONE DAILY 2 TABS

MHS Indiana Preferred Drug List Updated June 1, 2021

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 0.5 MG- PRENATAL VITAMIN 2 0.5 MG-0.5 MG-0.75 MG- TABS 0.75 MG-100 UNIT-15 MG- PRENATAL 2 2.5 MCG-2.5 MG-200 VITAMIN/IRON TABS MCG-25 MCG-25 MG-3.75 MG-3.75 UNIT-5 MG-50 PRENATAL VITAMINS 2 RX/OTC MG-500 UNIT-6.75 MG, PLUS LOW IRON TABS 0.8 MG-1.5 MG-1.7 MG- PRENATAL VITAMINS 2 100 MG-11 UNIT-18 MG- TABS 2.6 MG-25 MG-263 MG-27 PRENATAL+DHA MISC 2 MG-4 MCG-400 UNIT- 4000 UNIT, 0.8 MG-1.7 PRENATAL/OMEGA- 2 MG-1.8 MG-120 MG-2.6 3/FOLIC ACID/IRON CAPS MG-20 MG-200 MG-25 PRENATRIX TABS 2 RX/OTC MG-28 MG-30 UNIT-400 2 UNIT-4000 UNIT-8 MCG, 1.5 MG-1.7 MG-10 MCG- PRENATRYL TABS 2 RX/OTC 100 MG-1200 MCG-18 MG-2.6 MG-200 MG-25 PRENATVITE RX TABS 2 RX/OTC MG-27 MG-4 MCG-5 MG- 800 MCG, 1.7 MG-1.8 MG- PREPLUS TABS 2 RX/OTC 120 MG-2.6 MG-20 MG- 200 MG-25 MG-28 MG-30 PRETAB TABS 2 RX/OTC UNIT-400 UNIT-4000 UNIT-8 MCG-800 MCG, PX PRENATAL 2 1.7 MG-1.84 MG-100 MG- MULTIVITAMINS TABS 11 UNIT-160 MG-18 MG- 2.6 MG-200 MG-25 MG-27 QC PRENATAL TABS 2 MG-4 MCG-400 UNIT- RA PRENATAL 4000 UNIT-800 MCG FORMULA/FOLICACID 2 PRENATAL TABS 0.8 MG- RX/OTC TABS 1.7 MG-1.84 MG-100 MG- 11 UNIT-18 MG-2.6 MG- 2 RA PRENATAL TABS 2 200 MG-25 MG-27 MG-4 RIGHT STEP PRENATAL 2 MCG-400 UNIT-4000 UNIT TABS PRENATAL TABS 1 MG- RX/OTC 1.84 MG-10 MG-12 MCG- SE-NATAL 19 CHEW 2 120 MG-2 MG-20 MG-200 2 QL(1 ea daily); SE-NATAL 19 TABS 2 MG-22 MG-25 MG-27 MG- RX/OTC 3 MG-400 UNIT-4000 UNIT SIMILAC PRENATAL 2 prenatal vit w/ docusate-fe 1 QL(1 ea daily); EARLY SHIELD MISC fumarate-folic acid tabs RX/OTC SM ONE DAILY 2 prenatal vit w/ docusate- 1 PRENATAL MISC iron carbonyl-folic acid tabs SM PRENATAL VITAMINS 2 prenatal vit w/ ferrous 1 TABS fumarate-folic acid chew STUART ONE CAPS 2 prenatal vit w/ ferrous 1 fumarate-folic acid tabs THERANATAL 2 PRENATAL VITAMIN & 2 COMPLETE MISC MINERAL TABS MHS Indiana Preferred Drug List Updated June 1, 2021

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THERANATAL CORE 2 RX/OTC NASAL AGENTS - SYSTEMIC AND TOPICAL - NUTRITION TABS Drugs to treat the Nose or Sinus THERANATAL ONE CAPS 2 Nasal Agents - Misc. OCEAN NASAL SPRAY THERANATAL OVAVITE 2 NP THPK SOLN (Use saline) TRICARE TABS 2 RX/OTC saline soln 0.002 %-0.65 % 1

TRINATAL RX 1 TABS 2 Nasal Antiallergy azelastine hcl soln 1 VINATE ONE TABS 2 cromolyn sodium (nasal) 1 QL(0.867 ml VITAFOL-OB TABS 2 aers daily) NASALCROM AERS (Use NP QL(0.867 ml VITATHELY/GINGER 2 RX/OTC cromolyn sodium (nasal)) daily) TABS Nasal Anticholinergics VOL-NATE TABS 2 ipratropium bromide (nasal) 1 QL(1 ml daily) soln 0.03 % VOL-PLUS TABS 2 RX/OTC ipratropium bromide (nasal) 1 QL(0.5 ml soln 0.06 % daily) WEGMANS COMPLETE 2 PRENATAL+DHA MISC Nasal Steroids RX/OTC QL(0.6 ml WESTAB PLUS TABS 2 budesonide (nasal) susp 1 daily) YOUR LIFE MULTI 2 PRENATAL CAPS FLONASE ALLERGY QL(16 ml per RELIEF CHILDRENS NP fill retail); MUSCULOSKELETAL THERAPY AGENTS - SUSP (Use fluticasone RX/OTC Drugs to Treat Spasms propionate (nasal)) Central Muscle Relaxants FLONASE ALLERGY QL(16 ml per RELIEF SUSP (Use fill retail); baclofen tabs or 10 mg, 20 1 NP mg fluticasone propionate RX/OTC (nasal)) chlorzoxazone tabs 500 mg 1 QL(0.834 ml flunisolide (nasal) soln 1 daily) cyclobenzaprine hcl tabs 1 QL(3 ea daily) 10 mg, 5 mg QL(16 ml per fluticasone propionate 1 fill retail); (nasal) susp cyclobenzaprine hcl tabs 1 QL(4 ea daily) RX/OTC 7.5 mg QL(17 ml per methocarbamol tabs or 500 1 fill retail,17 ml mg, 750 mg NASACORT ALLERGY 2 per fill mail); 24HR AERO orphenadrine citrate tb12 1 AL(At least 2 or 100 mg yrs old) ROBAXIN-750 TABS (Use QL(17 ml per NP NASACORT ALLERGY methocarbamol) fill retail,17 ml 24HR AERO (Use NP per fill mail); tizanidine hcl tabs 4 mg, 2 1 triamcinolone acetonide mg (nasal)) AL(At least 2 yrs old) ZANAFLEX TABS 4 MG NP (Use tizanidine hcl) MHS Indiana Preferred Drug List Updated June 1, 2021

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(17 ml per PA; SP NASACORT ALLERGY MYOBLOC SOLN 2 fill retail,17 ml 24HR CHILDRENS AERO NP per fill mail); (Use triamcinolone XEOMIN SOLR 2 PA; SP acetonide (nasal)) AL(At least 2 yrs old) Spinal Muscular Atrophy Agents (SMA) QL(17 ml per fill retail,17 ml EVRYSDI SOLR CO triamcinolone acetonide 1 per fill mail); (nasal) aero AL(At least 2 SPINRAZA SOLN CO yrs old) ZOLGENSMA 10.1-10.5 CO Sympathomimetic Decongestants KG KIT phenylephrine hcl (oral) QL(24 ea per 1 ZOLGENSMA 10.6-11.0 CO tabs fill retail) KG KIT pseudoephedrine hcl liqd 1 ZOLGENSMA 11.1-11.5 CO 15 mg/5ml KG KIT pseudoephedrine hcl tabs 1 ZOLGENSMA 11.6-12.0 CO 60 mg, 30 mg KG KIT pseudoephedrine hcl tb12 QL(2 ea daily) 1 ZOLGENSMA 12.1-12.5 CO 120 mg KG KIT SUDAFED CHILDRENS ZOLGENSMA 12.6-13.0 CO LIQD (Use NP KG KIT pseudoephedrine hcl) ZOLGENSMA 13.1-13.5 CO SUDAFED CONGESTION KG KIT TABS (Use NP ZOLGENSMA 2.6-3.0 KG CO pseudoephedrine hcl) KIT SUDAFED PE SINUS QL(24 ea per ZOLGENSMA 3.1-3.5 KG CO CONGESTION TABS (Use NP fill retail) KIT phenylephrine hcl (oral)) ZOLGENSMA 3.6-4.0 KG CO SUDAFED SINUS KIT CONGESTION TABS (Use NP pseudoephedrine hcl) ZOLGENSMA 4.1-4.5 KG CO KIT NEUROMUSCULAR AGENTS - Drugs to ZOLGENSMA 4.6-5.0 KG CO Relax/Paralyze Muscles KIT Muscular Dystrophy Agents ZOLGENSMA 5.1-5.5 KG CO KIT AMONDYS 45 SOLN CO ZOLGENSMA 5.6-6.0 KG CO EXONDYS 51 SOLN CO KIT ZOLGENSMA 6.1-6.5 KG CO VILTEPSO SOLN CO KIT ZOLGENSMA 6.6-7.0 KG CO VYONDYS 53 SOLN CO KIT ZOLGENSMA 7.1-7.5 KG CO Neuromuscular Blocking Agent - Neurotoxins KIT PA; SP BOTOX SOLR 2 ZOLGENSMA 7.6-8.0 KG CO KIT DYSPORT SOLR 2 PA; SP

MHS Indiana Preferred Drug List Updated June 1, 2021

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOLGENSMA 8.1-8.5 KG CO omega-3 fatty acids caps QL(6 ea daily) KIT 108 mg-1200 mg-180 mg- 360 mg, 12 mg-1200 mg- ZOLGENSMA 8.6-9.0 KG CO KIT 360 mg-360 mg, 120 mg- 1200 mg-180 mg-60 mg, ZOLGENSMA 9.1-9.5 KG CO 1200 mg-144 mg-15 unit- KIT 216 mg, 1200 mg-144 mg- ZOLGENSMA 9.6-10.0 KG CO 180 mg, 1200 mg-144 mg- KIT 216 mg, 1200 mg-144 mg- 216 mg-360 mg, 1200 mg- NUTRIENTS 2 unit, 1200 mg-216 mg- Lipotropics 324 mg-600 mg, 1200 mg- 276 mg-336 mg, 1200 mg- inositol tabs 1 PA 300 mg-360 mg-60 mg, 1200 mg-600 mg, 1 gm- INOSITOL-5 TABS 2 PA 120 mg-180 mg-300 mg, 1 mg-1000 mg-120 mg-180 Misc. Nutritional Substances mg, 1 unit-1000 mg-1000 mg-300 mg, 1 unit-1000 mg-120 mg-180 mg, 1 unit- 1 1000 mg-120 mg-180 mg- 340 mg, 1 unit-1000 mg- 200 mg-300 mg, 1 unit- 1000 mg-300 mg, 1.8 unit- 120 mg-180 mg, 10 unit- 100 mg-1000 mg-500 mg, 100 mg-1000 mg-150 mg- 300 mg, 100 mg-1000 mg- 160 mg, 1000 mg-108 mg- 162 mg-3 mg, 1000 mg- 120 mg-180 mg-300 mg, 1000 mg-180 mg-270 mg, 1000 mg-210 mg-75 mg-90 mg, 1000 mg-250 mg-350 mg, 1000 mg-250 mg-500 mg, 1000 mg-300 mg-400 mg, 1000 mg-350 mg, 1000 mg-360 mg-455 mg-900 mg, 1000 mg-600 mg, 120 mg-180 mg-5 unit Proteins arginine caps 500 mg 1

arginine powd 1

ARGININE TABS 500 MG 2

arginine tabs 500 mg, 1000 1 mg L-ARGININE BASE POWD 2 RX/OTC

MHS Indiana Preferred Drug List Updated June 1, 2021

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits L-ARGININE POWD OR NP REFRESH DIGITAL SOLN 2 (Use arginine) REFRESH LIQUIGEL GEL L-ARGININE POWD XX 2 RX/OTC (Use NP carboxymethylcellulose L-TRYPTOPHAN POWD 2 RX/OTC XX sodium (ophth)) REFRESH OPTIVE L-TRYPTOPHAN TABS 2 2 OR ADVANCED SOLN REFRESH OPTIVE SOLN PURE L-CITRULLINE 2 CAPS 0.5 %-0.9 % (Use NP carboxymethylcellulose- TRYPTOPHAN POWD 2 RX/OTC glycerin) REFRESH PLUS SOLN OPHTHALMIC AGENTS - Drugs to Treat the Eye (Use NP carboxymethylcellulose Artificial Tears and Lubricants sodium (ophth)) artificial tear solution soln 1 REFRESH RELIEVA SOLN (Use NP carboxymethylcellulose 1 carboxymethylcellulose- sodium (ophth) gel 1 % glycerin) carboxymethylcellulose REFRESH REPAIR SOLN sodium (ophth) soln 1 %, 1 (Use NP 0.5 % carboxymethylcellulose- glycerin) carboxymethylcellulose- 1 glycerin soln REFRESH SOLN 2 DAKRINA SOLN 2 REFRESH TEARS SOLN DWELLE SOLN 2 (Use NP carboxymethylcellulose sodium (ophth)) FRESHKOTE SOLN 2 SYSTANE COMPLETE GONIOVISC SOLN 2 SOLN (Use propylene NP glycol (ophth)) HYPOTEARS SOLN 2 SYSTANE SOLN (Use polyethylene glycol- NP ISOPTO TEARS SOLN 2 propylene glycol (ophth)) SYSTANE ULTRA HOME polyethylene glycol- & AWAY PACK SOLN (Use NP propylene glycol (ophth) 1 polyethylene glycol- soln propylene glycol (ophth)) polyvinyl alcohol soln 1 QL(1 ml daily) SYSTANE ULTRA SOLN (Use polyethylene glycol- NP polyvinyl alcohol-povidone 1 propylene glycol (ophth)) (ophth) soln TEARS NATURALE PM propylene glycol (ophth) 1 OINT (Use white NP soln petrolatum-mineral oil) PURE & GENTLE 2 white petrolatum-mineral oil 1 LUBRICANT SOLN oint

MHS Indiana Preferred Drug List Updated June 1, 2021

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Beta-blockers - Ophthalmic ISOPTO ATROPINE SOLN 2 1 package / betaxolol hcl (ophth) soln 1 claim;QL(10 ml MYDRIACYL SOLN (Use NP per fill retail) tropicamide) Limit 15mls per phenylephrine hcl 1 QL(0.167 ml carteolol hcl (ophth) soln 1 month;QL(0.5 (mydriatic) soln 2.5 % daily) ml daily) tropicamide soln 1 COSOPT SOLN (Use QL(0.34 ml dorzolamide hcl-timolol NF daily) Miotics maleate) ISOPTO CARPINE SOLN NP dorzolamide hcl-timolol QL(0.34 ml (Use pilocarpine hcl) maleate soln 0.5 %-2 %, 20 1 daily) mg/ml-5 mg/ml, 22.3 pilocarpine hcl soln 1 mg/ml-6.8 mg/ml Ophthalmic - Angiogenesis Inhibitors QL(0.5 ml levobunolol hcl soln 1 PA; SP daily) EYLEA SOLN 2 1 package / LUCENTIS SOLN 0.3 PA; SP timolol maleate (ophth) 1 claim;QL(10 ml soln 0.25 % MG/0.05ML, 0.5 2 per fill retail) MG/0.05ML 1 package / PA; SP timolol maleate (ophth) 1 claim;QL(15 ml MACUGEN SOLN 2 soln 0.5 % per fill retail) Ophthalmic Adrenergic Agents 1 package / timolol maleate (ophth) 1 claim;QL(60 ea soln 0.5 % apraclonidine hcl soln 1 per fill retail) brimonidine tartrate soln 1 1 package / 0.2 % TIMOPTIC OCUDOSE 2 claim;QL(60 ea SOLN 0.25 % per fill retail) IOPIDINE SOLN 2 TIMOPTIC OCUDOSE 1 package / SOLN 0.5 % (Use timolol NP claim;QL(60 ea Ophthalmic Anti-infectives maleate (ophth)) per fill retail) QL(0.134 gm bacitracin (ophthalmic) oint 1 TIMOPTIC SOLN 0.25 % 1 package / daily) (Use timolol maleate NP claim;QL(10 ml bacitracin-polymyxin b 1 QL(0.134 gm (ophth)) per fill retail) (ophth) oint daily) TIMOPTIC SOLN 0.5 % 1 package / BLEPH-10 SOLN (Use QL(15 ml per (Use timolol maleate NP claim;QL(15 ml sulfacetamide sodium NP fill retail) (ophth)) per fill retail) (ophth)) TIMOPTIC-XE SOLG (Use NF CILOXAN OINT 2 timolol maleate (ophth)) Cycloplegic Mydriatics CILOXAN SOLN (Use NP ciprofloxacin hcl (ophth)) ATROPINE SULFATE 2 SOLN OP 1 % ciprofloxacin hcl (ophth) 1 soln CYCLOGYL SOLN (Use NP cyclopentolate hcl) erythromycin (ophth) oint 1 cyclopentolate hcl soln 1 gentamicin sulfate (ophth) 1 QL(4 gm per fill oint retail)

MHS Indiana Preferred Drug List Updated June 1, 2021

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gentamicin sulfate (ophth) 1 VISINE SOLN (Use soln tetrahydrozoline hcl NP (ophth)) moxifloxacin hcl (ophth) 1 QL(3 ml per fill soln retail) Ophthalmic Gene Therapy neomycin-bacitracin zn- 1 QL(4 gm per fill polymyxin oint retail) LUXTURNA SUSP CO neomycin-polymyxin- 1 Ophthalmic Local Anesthetics gramicidin soln 1 package / tetracaine hcl (ophth) soln 1 OCUFLOX SOLN (Use NP ofloxacin (ophth)) claim;QL(10 ml per fill retail) Ophthalmic Photodynamic Therapy Agents 1 package / VISUDYNE SOLR 2 PA; SP ofloxacin (ophth) soln 1 claim;QL(10 ml per fill retail) Ophthalmic Steroids BLEPHAMIDE S.O.P. polymyxin b-trimethoprim 1 QL(0.34 ml 2 soln daily) OINT 1 rtl pack lmt POLYTRIM SOLN (Use NP QL(0.34 ml polymyxin b-trimethoprim) daily) BLEPHAMIDE SUSP 2 amt,31 rtl pack lmt day(s), sulfacetamide sodium 1 QL(0.134 gm (ophth) oint daily) dexamethasone sodium 1 phosphate (ophth) soln sulfacetamide sodium 1 QL(15 ml per (ophth) soln fill retail) fluorometholone (ophth) 1 QL(0.167 ml susp tobramycin (ophth) soln 1 daily) FML LIQUIFILM SUSP (Use fluorometholone NP TOBREX OINT 2 (ophth)) QL(0.134 gm TOBREX SOLN (Use NP QL(0.167 ml FML OINT 2 tobramycin (ophth)) daily) daily) QL(0.267 ml MAXITROL OINT 0.1 %- QL(4 gm per fill trifluridine soln 1 daily) 10000 UNIT/GM-3.5 NP retail) MG/GM (Use neomycin- VIGAMOX SOLN (Use NP QL(3 ml per fill moxifloxacin hcl (ophth)) retail) polymy-dexameth) MAXITROL SUSP 0.1 %- QL(5 ml per fill Ophthalmic Decongestants 10000 UNIT/ML-3.5 NP retail) naphazoline w/ MG/ML (Use neomycin- pheniramine soln 0.025 %- 1 polymy-dexameth) 0.3 % neomycin-polymy- QL(4 gm per fill NAPHCON-A SOLN (Use dexameth oint 0.1 %-10000 1 retail) naphazoline w/ NP unit/gm-3.5 mg/gm pheniramine) neomycin-polymy- QL(5 ml per fill tetrahydrozoline hcl (ophth) 1 dexameth susp 0.1 %- 1 retail) soln 10000 unit/ml-3.5 mg/ml VISINE RED EYE neomycin-polymyxin-hc 1 QL(0.5 ml COMFORT SOLN (Use NP (ophth) susp daily) tetrahydrozoline hcl PRED FORTE SUSP (Use (ophth)) prednisolone acetate NF (ophth))

MHS Indiana Preferred Drug List Updated June 1, 2021

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DORZOLAMIDE HCL QL(0.34 ml PRED MILD SUSP 2 QL(0.34 ml 2 daily) SOLN daily) QL(0.167 ml PRED-G SUSP 2 flurbiprofen sodium soln 1 daily) prednisolone acetate QL(15 ml per 1 ketorolac tromethamine 1 (ophth) susp fill retail) (ophth) soln 0.4 % 1 package / PREDNISOLONE 1 package / 2 claim;QL(15 ml ketorolac tromethamine 1 claim;QL(10 ml ACETATE P-F SUSP (ophth) soln 0.5 % per fill retail) per fill retail) PREDNISOLONE SODIUM ketotifen fumarate (ophth) 1 PHOSPHATE SOLN OP 1 2 soln % TRUSOPT SOLN (Use NP QL(0.34 ml sulfacetamide sod- 1 QL(0.34 ml dorzolamide hcl) daily) prednisolone soln daily) ZADITOR SOLN (Use NP TOBRADEX OINT 2 QL(0.134 gm ketotifen fumarate (ophth)) daily) Prostaglandins - Ophthalmic TOBRADEX SUSP (Use QL(0.084 ml tobramycin- NP latanoprost soln 1 dexamethasone) daily) tobramycin- 1 rtl pack lmt 1 XALATAN SOLN (Use NF dexamethasone susp latanoprost) amt,30 rtl pack lmt day(s), Ophthalmics - Misc. ACULAR LS SOLN (Use OTIC AGENTS - Drugs to Treat the Ear ketorolac tromethamine NP (ophth)) Otic Agents - Miscellaneous QL(0.5 ml ACULAR SOLN (Use 1 package / acetic acid (otic) soln 1 daily) ketorolac tromethamine NP claim;QL(10 ml (ophth)) per fill retail) carbamide peroxide (otic) 1 QL(0.5 ml ST; QL(0.167 soln daily) ALOCRIL SOLN 2 ml daily) DEBROX SOLN (Use NP QL(0.5 ml )) ST; QL(0.34 ml carbamide peroxide (otic daily) ALOMIDE SOLN 2 daily) Otic Anti-infectives QL(6 ml per fill azelastine hcl (ophth) soln 1 CETRAXAL SOLN (Use NF retail) ciprofloxacin hcl (otic)) AZOPT SUSP (Use NP FLOXIN OTIC SOLN (Use NP QL(10 ml per brinzolamide) ofloxacin (otic)) 30 days retail) QL(10 ml per brinzolamide susp 1 ofloxacin (otic) soln 1 30 days retail) QL(10 ml per Otic Combinations fill retail,1 ml cromolyn sodium (ophth) 1 per fill mail,1 QL(7.5 ml per soln CIPRODEX SUSP (Use claims per fill ciprofloxacin- NP fill retail)1 rtl retail) dexamethasone) MAX fill,30 rtl day(s) supply, diclofenac sodium (ophth) 1 QL(0.1 ml soln daily) QL(0.34 ml dorzolamide hcl soln 1 daily) MHS Indiana Preferred Drug List Updated June 1, 2021

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(7.5 ml per GAMMAGARD LIQUID 2 PA ciprofloxacin- 1 fill retail)1 rtl SOLN dexamethasone susp MAX fill,30 rtl GAMMAGARD S/D IGA PA day(s) supply, LESS THAN 1MCG/ML 2 neomycin-polymyxin-hc 1 QL(10 ml per SOLR (otic) soln fill retail) GAMMAKED SOLN 2 PA neomycin-polymyxin-hc 1 (otic) susp GAMMAPLEX SOLN 2 PA OTICIN HC NR SOLN (Use pramoxine-hc- NP GAMUNEX-C SOLN 2 PA chloroxylenol) OTOVEL SOLN (Use HEPAGAM B SOLN 2 PA; SP ciprofloxacin-fluocinolone NF acetonide) HIZENTRA SOLN 1 PA; SP GM/5ML, 10 GM/50ML, 2 2 pramoxine-hc-chloroxylenol 1 soln GM/10ML, 4 GM/20ML PA; SP Otic Steroids HYPERHEP B SOLN 2 DERMOTIC OIL (Use HYPERRHO S/D MINI- 2 PA fluocinolone acetonide NP DOSE SOSY (otic)) HYPERRHO S/D SOSY 2 PA fluocinolone acetonide 1 (otic) oil MICRHOGAM ULTRA- 2 PA FILTEREDPLUS SOSY hydrocortisone w/acetic 1 QL(10 ml per acid soln fill retail) NABI-HB SOLN 2 PA; SP OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding OCTAGAM SOLN 1 PA GM/20ML, 10 GM/100ML, Oxytocics 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 2 methylergonovine maleate 1 tabs or 0.2 mg 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, PASSIVE IMMUNIZING AND TREATMENT 5 GM/50ML AGENTS - Antibody Drugs to Treat Low Immune System PRIVIGEN SOLN 2 PA Immune Serums RHOGAM ULTRA- 2 PA BIVIGAM SOLN 2 PA FILTERED PLUS SOSY RHOPHYLAC SOSY 2 PA CARIMUNE 2 PA NANOFILTERED SOLR WINRHO SDF SOLN 2 PA CUVITRU SOLN 2 PA; SP Monoclonal Antibodies CYTOGAM INJ 2 PA; SP SYNAGIS SOLN 2 PA; SP PA FLEBOGAMMA DIF SOLN 2 Passive Immunizing Agents - Combinations GAMASTAN INJ 2 PA; SP HYQVIA KIT 2 PA; SP

MHS Indiana Preferred Drug List Updated June 1, 2021

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUGMENTIN TABS 125 QL(30 ea per PENICILLINS - Drugs to Treat Bacterial Infections MG-500 MG (Use NP fill retail) Aminopenicillins amoxicillin & pot clavulanate) amoxicillin caps 250 mg, 1 500 mg Penicillinase-Resistant Penicillins amoxicillin chew 125 mg, 1 dicloxacillin sodium caps 1 250 mg amoxicillin susr 200 PHARMACEUTICAL ADJUVANTS mg/5ml, 250 mg/5ml, 400 1 mg/5ml, 125 mg/5ml Internal Vehicle Ingredients/Agents amoxicillin tabs 875 mg 1 SIMPLYTHICK EASY MIX 2 QL(1816 ml per GEL fill retail) ampicillin caps 1 SIMPLYTHICK EASYMIX 2 QL(1816 ml per GEL fill retail) Natural Penicillins QL(1816 ml per SIMPLYTHICK GEL 2 penicillin v potassium solr 1 fill retail) starch-maltodextrin 1 penicillin v potassium tabs 1 (thickening) powd THICK-IT ORIGINAL Penicillin Combinations POWD (Use starch- NP amoxicillin & pot QL(20 ea per maltodextrin (thickening)) clavulanate chew 200 mg- 1 fill retail) Liquid Vehicles 28.5 mg, 400 mg-57 mg CHERRY CONCENTRATE 2 RX/OTC amoxicillin & pot SYRP clavulanate susr 200 CHERRY SYRUP SYRP 2 RX/OTC mg/5ml-28.5 mg/5ml, 250 1 mg/5ml-62.5 mg/5ml, 400 mg/5ml-57 mg/5ml, 42.9 FLAVOR BLEND SUSP 2 RX/OTC mg/5ml-600 mg/5ml RX/OTC amoxicillin & pot QL(30 ea per FLAVOR PLUS LIQD 2 clavulanate tabs 125 mg- 1 fill retail) 250 mg, 125 mg-500 mg FLAVOR SWEET SYRP 2 RX/OTC amoxicillin & pot QL(20 ea per FLAVOR SWEET-SF 2 RX/OTC clavulanate tabs 125 mg- 1 fill retail) SYRP 875 mg PA; SP amoxicillin & pot QL(2 ea daily) glycine diluent soln 1 clavulanate tb12 1000 mg- 1 RX/OTC 62.5 mg GRAPE SYRUP SYRP 2 AUGMENTIN ES-600 RX/OTC SUSR (Use amoxicillin & NP MX-SOL BLEND SF SUSP 2 pot clavulanate) MX-SOL BLEND SUSP 2 RX/OTC AUGMENTIN SUSR 125 2 MG/5ML-31.25 MG/5ML MX-SOL SF SYRP 2 RX/OTC AUGMENTIN SUSR 250 RX/OTC MG/5ML-62.5 MG/5ML NP MX-SOL SUSPEND SUSP 2 (Use amoxicillin & pot clavulanate)

MHS Indiana Preferred Drug List Updated June 1, 2021

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MX-SOL SYRP 2 RX/OTC STERILE DILUENT FOR PA; SP TREPROSTINIL 2 ORA-BLEND SF SUSP 2 RX/OTC INJECTION SOLN SUSPENDOL-S LIQD 2 ORA-BLEND SUSP 2 RX/OTC SUSPENDRX WITH RX/OTC RX/OTC ORA-PLUS LIQD 2 BITTER- 2 BLOC/SWEETENED ORA-SWEET SF SYRP 2 RX/OTC SUSP SUSPENDRX WITH RX/OTC RX/OTC ORA-SWEET SYRP 2 BITTER- 2 BLOC/UNSWEETENED ORAL MIX FLAVORED RX/OTC SUSP SUSPENDING VEHICLE 2 SUSPENSION VEHICLE 2 RX/OTC SUSP SUSP ORAL MIX SF SUSP 2 RX/OTC SWEETENING RX/OTC SUSPENDING 2 ORAL SUSPEND LIQD 2 RX/OTC COMPOUND SYRP SYRPALTA SYRP 2 RX/OTC ORAL SUSPENDING 2 RX/OTC COMPOUNDPLUS SUSP SYRSPEND SF LIQD 2 RX/OTC ORAL SYRUP FLAVORED 2 RX/OTC VEHICLE SYRP SYRUP NF SYRP 2 RX/OTC ORAL SYRUP SF SYRP 2 RX/OTC SYRUP VEHICLE SF 2 RX/OTC PCCA SWEET-SF SYRP 2 RX/OTC SYRP SYRUP VEHICLE SYRP 2 RX/OTC PCCA SYRUP VEHICLE 2 RX/OTC SYRP UNISPEND ANHYDROUS 2 RX/OTC PCCA-PLUS SUSP 2 RX/OTC SWEETENED SUSP UNISPEND ANHYDROUS 2 RX/OTC PH 12 STERILE DILUENT PA; SP UNSWEETENED SUSP FORFLOLAN SOLN (Use NP glycine diluent) VERSAFREE SYRP 2 RX/OTC RX/OTC SIMPLE SYRUP SYRP 2 VERSAPLUS SYRP 2 RX/OTC RX/OTC SOLVATECH PLUS SUSP 2 Semi Solid Vehicles POLYETHYLENE GLYCOL QL(34 gm SOLVATECH SWEET SF 2 RX/OTC 2 SYRP 3350 POWD XX daily); RX/OTC SORBITOL SOLN XX 70 2 RX/OTC PROGESTINS - Hormone Replacement/Modifying %, Drugs SOSWEET SYRP 2 RX/OTC Progestins AYGESTIN TABS (Use NP PV STERILE DILUENT FOR PA; SP norethindrone acetate) FLOLAN SOLN (Use NP glycine diluent)

MHS Indiana Preferred Drug List Updated June 1, 2021

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(5 ml per fill ACETYL L-CARNITINE 2 hydroxyprogesterone 1 retail,21 ml per CAPS caproate oil 180 days ARICEPT TABS (Use NP QL(1 ea daily) retail); SP donepezil hydrochloride) MAKENA OIL IM 250 QL(5 ml per fill donepezil hydrochloride 1 QL(1 ea daily) MG/ML (Use NP retail,21 ml per tabs hydroxyprogesterone 180 days caproate) retail); SP donepezil hydrochloride 1 QL(1 ea daily) tbdp QL(5.5 ml per EXELON PT24 (Use QL(1 ea daily) MAKENA SOAJ SC 275 2 fill retail,23.1 ml NP MG/1.1ML per 180 days rivastigmine) retail); SP galantamine hydrobromide 1 QL(1 ea daily) cp24 16 mg, 24 mg, 8 mg medroxyprogesterone 1 acetate tabs galantamine hydrobromide 1 QL(6 ml daily) soln 4 mg/ml norethindrone acetate tabs $0 PV galantamine hydrobromide 1 QL(2 ea daily) tabs 12 mg, 4 mg, 8 mg progesterone caps or 100 1 QL(1 ea daily) mg memantine hcl cp24 14 mg, 1 QL(1 ea daily) 21 mg, 28 mg, 7 mg progesterone caps or 200 1 QL(2 ea daily) mg memantine hcl soln 10 1 QL(10 ml daily) mg/5ml, 2 mg/ml PROMETRIUM CAPS 100 NP QL(1 ea daily) ) MG (Use progesterone memantine hcl tabs 10 mg, 1 QL(2 ea daily) 5 mg PROMETRIUM CAPS 200 NP QL(2 ea daily) ) MG (Use progesterone NAMENDA TABS (Use NP QL(2 ea daily) PROVERA TABS (Use memantine hcl) medroxyprogesterone 2 NAMENDA TITRATION QL(2 ea daily) acetate) PAK TABS (Use NP memantine hcl) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and NAMENDA XR CP24 (Use NP QL(1 ea daily) Emotional Conditions memantine hcl) NAMENDA XR TITRATION QL(1 ea daily) Agents for Chemical Dependency 2 PACK CP24 ANTABUSE TABS 250 MG NP (Use disulfiram) NAMZARIC C4PK 2 QL(1 ea daily) disulfiram tabs 250 mg 1 NAMZARIC CP24 2 QL(1 ea daily) Anti-Cataplectic Agents RAZADYNE ER CP24 (Use NP QL(1 ea daily) QL(18 ml galantamine hydrobromide) daily); AL(At XYREM SOLN 2 RAZADYNE TABS (Use NP QL(2 ea daily) least 7 yrs old); galantamine hydrobromide) SP QL(1 ea daily) PA; QL(18 ml rivastigmine pt24 1 2 daily); AL(At QL(2 ea daily) XYWAV SOLN least 7 yrs old); rivastigmine tartrate caps 1 SP Combination Psychotherapeutics Antidementia Agents chlordiazepoxide- 1 amitriptyline tabs

MHS Indiana Preferred Drug List Updated June 1, 2021

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PLEGRIDY SOPN 2 PA; SP olanzapine-fluoxetine hcl 1 AL(At least 10 caps yrs old) PLEGRIDY SOSY 2 PA; SP perphenazine-amitriptyline 1 tabs PLEGRIDY STARTER 2 PA; SP QL(1 ea daily); PACK SOPN SYMBYAX CAPS (Use NP PLEGRIDY STARTER PA; SP olanzapine-fluoxetine hcl) AL(At least 10 2 yrs old) PACK SOSY Fibromyalgia Agents REBIF REBIDOSE SOAJ 2 PA; SP SAVELLA TABS 2 REBIF REBIDOSE 2 PA; SP TITRATIONPACK SOAJ SAVELLA TITRATION 2 PACK MISC REBIF SOSY 2 PA; SP Movement Disorder Drug Therapy REBIF TITRATION PACK 2 PA; SP tetrabenazine tabs 1 SP SOSY TECFIDERA CPDR (Use NP PA; SP XENAZINE TABS (Use NP SP dimethyl fumarate) tetrabenazine) TECFIDERA STARTER PA; SP Multiple Sclerosis Agents PACK MISC (Use dimethyl NP fumarate) AMPYRA TB12 (Use NP PA; SP dalfampridine) TYSABRI CONC 2 PA; SP AUBAGIO TABS 2 PA; SP Premenstrual Dysphoric Disorder (PMDD) Agents PA; SP AVONEX PEN AJKT 2 fluoxetine hcl (pmdd) caps 1 QL(1 ea daily) 10 mg PA; SP AVONEX PSKT 2 fluoxetine hcl (pmdd) caps 1 QL(4 ea daily) 20 mg BETASERON KIT 2 PA; SP fluoxetine hcl (pmdd) tabs 1 QL(1.5 ea 10 mg daily) COPAXONE SOSY (Use NP PA; SP glatiramer acetate) fluoxetine hcl (pmdd) tabs 1 QL(4 ea daily) 20 mg dalfampridine tb12 1 PA; SP SARAFEM TABS 10 MG NP QL(1.5 ea (Use fluoxetine hcl (pmdd)) daily) dimethyl fumarate cpdr 1 PA; SP SARAFEM TABS 20 MG NP QL(4 ea daily) (Use fluoxetine hcl (pmdd)) dimethyl fumarate misc 1 PA; SP Psychotherapeutic and Neurological Agents - GILENYA CAPS 0.5 MG 2 PA; SP ergoloid mesylates tabs 1 QL(3 ea daily) glatiramer acetate sosy 1 PA; SP pimozide tabs 1 mg 1 QL(10 ea daily) LEMTRADA SOLN 2 PA; SP pimozide tabs 2 mg 1 QL(5 ea daily) PA MAVENCLAD TBPK 2 Smoking Deterrents OCREVUS SOLN 2 PA; SP bupropion hcl (smoking $0 QL(2 ea daily); deterrent) tb12 PV

MHS Indiana Preferred Drug List Updated June 1, 2021

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHANTIX CONTINUING $0 QL(2 ea daily); Cystic Fibrosis Agents MONTHPAK TABS PV KALYDECO PACK CO CHANTIX STARTING $0 QL(2 ea daily); MONTH PAK TABS PV KALYDECO TABS CO CHANTIX TABS $0 QL(2 ea daily); PV ORKAMBI PACK CO NICODERM CQ PT24 (Use NP QL(1 ea daily); nicotine) PV ORKAMBI TABS CO NICORETTE GUM 4 MG, 2 QL(24 ea MG (Use nicotine NP daily); PV PULMOZYME SOLN 2 PA; SP polacrilex) NICORETTE LOZG 2 MG, QL(20 ea SYMDEKO TBPK CO 4 MG (Use nicotine NP daily); PV polacrilex) TRIKAFTA TBPK CO NICORETTE MINI LOZG NP QL(20 ea (Use nicotine polacrilex) daily); PV Pulmonary Fibrosis Agents NICORETTE STARTER QL(24 ea ESBRIET CAPS 267 MG 2 PA; SP KIT GUM (Use nicotine NP daily); PV polacrilex) TETRACYCLINES - Drugs to Treat Bacterial Infections nicotine polacrilex gum 4 $0 QL(24 ea mg, 2 mg daily); PV Tetracyclines nicotine polacrilex lozg 2 QL(20 ea $0 doxycycline (monohydrate) 1 mg, 4 mg daily); PV caps 50 mg, 100 mg QL(1 ea daily); nicotine pt24 $0 doxycycline (monohydrate) 1 PV tabs 50 mg, 100 mg NICOTINE PV doxycycline hyclate caps or 1 TRANSDERMAL SYSTEM $0 50 mg, 100 mg KIT doxycycline hyclate tabs or 1 NICOTROL INHALER $0 QL(16.8 ea 100 mg INHA daily); PV MINOCIN CAPS OR 50 NP NICOTROL NS SOLN $0 QL(4 ml daily); MG (Use minocycline hcl) PV minocycline hcl caps 100 1 ZYBAN TB12 (Use QL(2 ea daily); mg, 50 mg, 75 mg bupropion hcl (smoking NP PV deterrent)) TARGADOX TABS (Use NF doxycycline hyclate) RESPIRATORY AGENTS - MISC. - Drugs to VIBRAMYCIN CAPS 100 Treat Lung Conditions MG (Use doxycycline NP Alpha-Proteinase Inhibitor (Human) hyclate) PA; SP XIMINO CP24 135 MG, 45 ARALAST NP SOLR 2 MG, 90 MG (Use NF minocycline hcl) GLASSIA SOLN 2 PA; SP THYROID AGENTS - Drugs to Regulate Thyroid PROLASTIN-C SOLR 1000 2 PA; SP Hormones MG Antithyroid Agents ZEMAIRA SOLR 2 PA; SP methimazole tabs 1

MHS Indiana Preferred Drug List Updated June 1, 2021

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propylthiouracil tabs 1 TDVAX SUSP $0 AL(At least 19 yrs old) TAPAZOLE TABS (Use NP TENIVAC INJ $0 AL(At least 19 methimazole) yrs old) Thyroid Hormones TETANUS/DIPHTHERIA AL(At least 19 TOXOIDS-ADSORBED $0 yrs old) ARMOUR THYROID TABS NP 120 MG (Use thyroid) ADULT SUSP ARMOUR THYROID TABS ULCER DRUGS - Drugs to Treat Bowel, Intestine 15 MG, 30 MG, 60 MG, 90 2 and Stomach Conditions MG (Use thyroid) Antispasmodics ARMOUR THYROID TABS 2 dicyclomine hcl caps or 10 1 180 MG, 240 MG, 300 MG mg CYTOMEL TABS (Use NP dicyclomine hcl soln or 10 1 QL(16.54 ml liothyronine sodium) mg/5ml daily) levothyroxine sodium tabs dicyclomine hcl tabs or 20 1 or 300 mcg, 100 mcg, 112 mg mcg, 125 mcg, 137 mcg, 1 150 mcg, 175 mcg, 200 glycopyrrolate tabs or 1 1 QL(4 ea daily) mcg, 25 mcg, 50 mcg, 75 mg, 2 mg mcg, 88 mcg hyoscyamine sulfate elix or 1 0.125 mg/5ml liothyronine sodium tabs or 1 25 mcg, 5 mcg, 50 mcg hyoscyamine sulfate soln 1 or 0.125 mg/ml SYNTHROID TABS (Use 2 levothyroxine sodium) hyoscyamine sulfate subl sl 1 0.125 mg thyroid tabs 1 hyoscyamine sulfate tabs 1 or 0.125 mg TOXOIDS hyoscyamine sulfate tb12 1 QL(4 ea daily) Toxoid Combinations or 0.375 mg hyoscyamine sulfate tbdp ADACEL SUSP $0 AL(At least 19 1 yrs old) or 0.125 mg LEVBID TB12 (Use QL(4 ea daily) BOOSTRIX SUSP $0 AL(At least 19 NP yrs old) hyoscyamine sulfate) DIPHTHERIA/TETANUS AL(At least 19 H-2 Antagonists TOXOIDS ADSORBED $0 yrs old) cimetidine hcl soln 300 1 PEDIATRIC SUSP mg/5ml INFANRIX SUSP $0 AL(At least 19 RX/OTC yrs old) cimetidine tabs 200 mg 1 AL(At least 19 KINRIX SUSP $0 cimetidine tabs 300 mg, 1 yrs old) 400 mg, 800 mg AL(At least 19 PEDIARIX SUSP $0 famotidine susr or 40 1 yrs old) mg/5ml PENTACEL SUSR $0 AL(At least 19 RX/OTC yrs old) famotidine tabs or 20 mg 1 famotidine tabs or 40 mg, QUADRACEL SUSP $0 AL(At least 19 1 yrs old) 10 mg

MHS Indiana Preferred Drug List Updated June 1, 2021

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEPCID AC MAXIMUM RX/OTC NEXIUM PACK 10 MG, 20 STRENGTH TABS (Use NP MG, 40 MG (Use NP famotidine) esomeprazole magnesium) PEPCID AC TABS 10 MG NP omeprazole cpdr 10 mg 1 PA (Use famotidine) QL(2 ea daily); PEPCID AC TABS 20 MG NP RX/OTC omeprazole cpdr 20 mg 1 (Use famotidine) RX/OTC QL(2 ea daily) PEPCID TABS 20 MG (Use NP RX/OTC omeprazole cpdr 40 mg 1 famotidine) omeprazole magnesium PA PEPCID TABS 40 MG (Use NP 1 famotidine) cpdr 20 mg, 20.6 mg QL(1 ea daily) TAGAMET HB TABS (Use NP RX/OTC omeprazole tbec 20 mg 1 cimetidine) pantoprazole sodium pack 1 Misc. Anti-Ulcer or 40 mg CARAFATE SUSP 1 QL(420 ml per NP pantoprazole sodium tbec 1 QL(1 ea daily) GM/10ML (Use sucralfate) fill retail) or 20 mg CARAFATE TABS 1 GM QL(4 ea daily) NP pantoprazole sodium tbec 1 QL(2 ea daily) (Use sucralfate) or 40 mg QL(420 ml per sucralfate susp 1 gm/10ml 1 PREVACID 24HR CPDR NP QL(2 ea daily); fill retail) (Use lansoprazole) RX/OTC QL(4 ea daily) sucralfate tabs 1 gm 1 PREVACID CPDR 15 MG NP QL(2 ea daily); (Use lansoprazole) RX/OTC Proton Pump Inhibitors PREVACID CPDR 30 MG NP QL(2 ea daily) (Use lansoprazole) esomeprazole magnesium 1 QL(1 ea daily); cpdr 20 mg RX/OTC PROTONIX PACK OR 40 MG (Use pantoprazole NP esomeprazole magnesium 1 cpdr 40 mg sodium) PROTONIX TBEC OR 20 QL(1 ea daily) esomeprazole magnesium 1 pack 10 mg, 20 mg, 40 mg MG (Use pantoprazole NP QL(2 ea daily); sodium) lansoprazole cpdr 15 mg 1 RX/OTC PROTONIX TBEC OR 40 QL(2 ea daily) QL(2 ea daily) MG (Use pantoprazole NP lansoprazole cpdr 30 mg 1 sodium) NEXIUM 24HR CLEAR QL(1 ea daily); Ulcer Drugs - Prostaglandins MINIS CPDR (Use NP RX/OTC CYTOTEC TABS (Use NP esomeprazole magnesium) misoprostol) NEXIUM 24HR CPDR (Use NP QL(1 ea daily); esomeprazole magnesium) RX/OTC misoprostol tabs 1 NEXIUM CPDR 20 MG QL(1 ea daily); URINARY ANTISPASMODICS - Drugs to Treat (Use esomeprazole NP RX/OTC Miscellaneous Bladder Spasms magnesium) NEXIUM CPDR 40 MG Urinary Antispasmodic - Antimuscarinics (Use esomeprazole NP DETROL LA CP24 (Use NP QL(1 ea daily) magnesium) tolterodine tartrate) DETROL TABS (Use NP QL(2 ea daily) tolterodine tartrate)

MHS Indiana Preferred Drug List Updated June 1, 2021

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DITROPAN XL TB24 (Use NP QL(2 ea daily) QL(3 ml per oxybutynin chloride) 999 days PEDVAX HIB SUSP $0 retail); AL(At oxybutynin chloride syrp 5 1 QL(16 ml daily) mg/5ml least 19 yrs old) oxybutynin chloride tabs 5 1 QL(3 ea daily) mg PNEUMOVAX 23 INJ $0 AL(At least 19 yrs old) oxybutynin chloride tb24 10 1 QL(2 ea daily) mg, 15 mg, 5 mg PNEUMOVAX 23/1 DOSE $0 AL(At least 19 INJ yrs old) tolterodine tartrate cp24 2 1 QL(1 ea daily) mg, 4 mg PREVNAR 13 SUSP $0 AL(At least 19 yrs old) tolterodine tartrate tabs 1 QL(2 ea daily) 1 AL(At least 19 mg, 2 mg TRUMENBA SUSY $0 yrs old) trospium chloride tabs 20 1 QL(2 ea daily) mg Viral Vaccines Urinary Antispasmodics - Cholinergic Agonists 1 rtl MAX fill,180 rtl bethanechol chloride tabs 1 AFLURIA 2018-2019 SUSP $0 day(s) supply,; AL(At least 19 URECHOLINE TABS (Use NP yrs old) bethanechol chloride) 1 rtl MAX Urinary Antispasmodics - Direct Muscle Relaxants fill,180 rtl AFLURIA PF 2018-2019 $0 day(s) supply,; flavoxate hcl tabs 1 SUSY AL(At least 19 yrs old) VACCINES 1 rtl MAX Bacterial Vaccines fill,180 rtl AFLURIA QUADRIVALENT $0 day(s) supply,; QL(4 ea per 2018-2019 SUSP AL(At least 19 999 days yrs old) ACTHIB SOLR $0 retail); AL(At least 19 yrs 1 rtl MAX old) fill,180 rtl AFLURIA QUADRIVALENT $0 day(s) supply,; AL(At least 19 2018-2019 SUSY BEXSERO SUSY $0 AL(At least 19 yrs old) yrs old) QL(4 ea per 1 rtl MAX 999 days fill,180 rtl HIBERIX SOLR $0 retail); AL(At AFLURIA QUADRIVALENT $0 day(s) supply,; least 19 yrs 2019-2020 SUSP AL(At least 19 old) yrs old) AL(At least 19 MENACTRA INJ $0 1 rtl MAX yrs old) fill,180 rtl AL(At least 19 AFLURIA QUADRIVALENT MENQUADFI INJ $0 $0 day(s) supply,; yrs old) 2019-2020 SUSY AL(At least 19 yrs old) MENVEO SOLR $0 AL(At least 19 yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl MAX 1 rtl MAX fill,180 rtl fill,180 rtl AFLURIA QUADRIVALENT $0 FLUARIX QUADRIVALENT $0 2020-2021 SUSP day(s) supply,; day(s) supply,; AL(At least 19 2019-2020 SUSY AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX fill,180 rtl fill,180 rtl AFLURIA QUADRIVALENT $0 FLUARIX QUADRIVALENT $0 2020-2021 SUSY day(s) supply,; day(s) supply,; AL(At least 19 2020-2021 SUSY AL(At least 19 yrs old) yrs old) ASTRAZENECA COVID-19 CO 1 rtl MAX VACCINE SUSP FLUBLOK fill,180 rtl QL(4 ml per QUADRIVALENT 2018- $0 day(s) supply,; 999 days 2019 SOSY AL(At least 19 ENGERIX-B INJ $0 retail); AL(At yrs old) least 19 yrs 1 rtl MAX old) FLUBLOK fill,180 rtl QL(4 ml per QUADRIVALENT 2019- $0 day(s) supply,; 999 days 2020 SOSY AL(At least 19 ENGERIX-B SUSP $0 retail); AL(At yrs old) least 19 yrs 1 rtl MAX old) FLUBLOK fill,180 rtl 1 rtl MAX QUADRIVALENT 2020- $0 day(s) supply,; fill,180 rtl 2021 SOSY AL(At least 19 FLUAD 2018-2019 SUSY $0 day(s) supply,; yrs old) AL(At least 19 1 rtl MAX yrs old) FLUCELVAX fill,180 rtl 1 rtl MAX QUADRIVALENT 2018- $0 day(s) supply,; fill,180 rtl 2019 SUSP AL(At least 19 FLUAD 2019-2020 SUSY $0 day(s) supply,; yrs old) AL(At least 19 1 rtl MAX yrs old) FLUCELVAX fill,180 rtl 1 rtl MAX QUADRIVALENT 2018- $0 day(s) supply,; fill,180 rtl 2019 SUSY AL(At least 19 FLUAD 2020-2021 SUSY $0 day(s) supply,; yrs old) AL(At least 19 1 rtl MAX yrs old) FLUCELVAX fill,180 rtl 1 rtl MAX QUADRIVALENT 2019- $0 day(s) supply,; FLUAD QUADRIVALENT fill,180 rtl 2020 SUSP AL(At least 19 INFLUENZA VACCINE $0 day(s) supply,; yrs old) FOR ADULTS PRSY AL(At least 65 1 rtl MAX yrs old) FLUCELVAX fill,180 rtl 1 rtl MAX QUADRIVALENT 2019- $0 day(s) supply,; fill,180 rtl 2020 SUSY AL(At least 19 FLUARIX QUADRIVALENT $0 day(s) supply,; yrs old) 2018-2019 SUSY AL(At least 19 yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl MAX 1 rtl MAX FLUCELVAX fill,180 rtl fill,180 rtl QUADRIVALENT 2020- $0 day(s) supply,; FLUZONE HIGH-DOSE PF $0 2019-2020 SUSY day(s) supply,; 2021 SUSP AL(At least 19 AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLUCELVAX fill,180 rtl fill,180 rtl QUADRIVALENT 2020- $0 day(s) supply,; FLUZONE HIGH-DOSE PF $0 2020-2021 SUSY day(s) supply,; 2021 SUSY AL(At least 19 AL(At least 65 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLULAVAL fill,180 rtl FLUZONE fill,180 rtl QUADRIVALENT 2018- $0 day(s) supply,; QUADRIVALENT 2018- $0 day(s) supply,; 2019 SUSP AL(At least 19 2019 SUSP AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLULAVAL fill,180 rtl FLUZONE fill,180 rtl QUADRIVALENT 2018- $0 day(s) supply,; QUADRIVALENT 2018- $0 day(s) supply,; 2019 SUSY AL(At least 19 2019 SUSY AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLULAVAL fill,180 rtl FLUZONE fill,180 rtl QUADRIVALENT 2019- $0 day(s) supply,; QUADRIVALENT 2019- $0 day(s) supply,; 2020 SUSP AL(At least 19 2020 SUSP AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLULAVAL fill,180 rtl FLUZONE fill,180 rtl QUADRIVALENT 2019- $0 day(s) supply,; QUADRIVALENT 2019- $0 day(s) supply,; 2020 SUSY AL(At least 19 2020 SUSY AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX FLULAVAL fill,180 rtl FLUZONE fill,180 rtl QUADRIVALENT 2020- $0 day(s) supply,; QUADRIVALENT 2020- $0 day(s) supply,; 2021 SUSY AL(At least 19 2021 SUSP AL(At least 19 yrs old) yrs old) 1 rtl MAX 1 rtl MAX fill,180 rtl FLUMIST FLUZONE fill,180 rtl $0 day(s) supply,; QUADRIVALENT 2020- $0 day(s) supply,; QUADRIVALENT SUSP AL(At least 19 2021 SUSY AL(At least 19 yrs old) yrs old) 1 rtl MAX GARDASIL 9 SUSP $0 AL(At least 19 fill,180 rtl yrs old) FLUZONE HIGH-DOSE PF $0 day(s) supply,; 2018-2019 SUSY GARDASIL 9 SUSY $0 AL(At least 19 AL(At least 19 yrs old) yrs old) QL(2 ml per 999 days HAVRIX SUSP $0 retail); AL(At least 19 yrs old)

MHS Indiana Preferred Drug List Updated June 1, 2021

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JANSSEN COVID-19 CO GYNAZOLE-1 CREA 2 VACCINE SUSP GYNE-LOTRIMIN 3 CREA QL(1 gm daily) M-M-R II SOLR $0 AL(At least 19 NP yrs old) (Use clotrimazole vaginal) GYNE-LOTRIMIN CREA QL(1.5 gm MODERNA COVID-19 CO NP VACCINE SUSP (Use clotrimazole vaginal) daily) PFIZER-BIONTECH Limit 70gms CO METROGEL-VAGINAL per COVID-19VACCINE SUSP GEL (Use metronidazole NP QL(4 ml per vaginal) month;QL(2.34 999 days gm daily) RECOMBIVAX HB SUSP $0 retail); AL(At Limit 70gms per least 19 yrs metronidazole vaginal gel 1 old) month;QL(2.34 QL(2 ea per gm daily) 999 days miconazole nitrate vaginal 1 QL(1.5 gm SHINGRIX SUSR 2 retail); AL(At crea 4 %, 2 % daily) least 50 yrs miconazole nitrate vaginal 1 old) kit AL(At least 19 TWINRIX SUSY $0 miconazole nitrate vaginal 1 QL(0.234 ea yrs old) supp 100 mg daily) QL(2 ml per miconazole nitrate vaginal 1 999 days supp 200 mg VAQTA SUSP $0 retail); AL(At MONISTAT 1 COMBO least 19 yrs PACK KIT (Use miconazole NP old) nitrate vaginal) QL(2 ea per MONISTAT 1 DAY OR 999 days NIGHT COMBO PACK KIT NP VARIVAX INJ $0 retail); AL(At (Use miconazole nitrate least 19 yrs vaginal) old) MONISTAT 3 QL(1 ea per COMBINATION PACK KIT NP 999 days (Use miconazole nitrate ZOSTAVAX SUSR $0 retail); AL(At vaginal) least 50 yrs old) MONISTAT 3 CREA (Use NP QL(1.5 gm miconazole nitrate vaginal) daily) VAGINAL AND RELATED PRODUCTS MONISTAT 7 SIMPLY QL(1.5 gm CURE CREA (Use NP daily) Vaginal Anti-infectives miconazole nitrate vaginal) CLEOCIN CREA VA 2 % (Use clindamycin NP terconazole vaginal crea 1 phosphate vaginal) terconazole vaginal supp 1 clindamycin phosphate 1 vaginal crea tioconazole vaginal oint 1 clotrimazole vaginal crea 1 1 QL(1.5 gm % daily) Vaginal Estrogens clotrimazole vaginal crea 2 1 QL(1 gm daily) %

MHS Indiana Preferred Drug List Updated June 1, 2021

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESTRACE CREA VA 0.1 QL(1.5 gm cholecalciferol caps 400 $0 PV MG/GM (Use estradiol NP daily) unit vaginal) cholecalciferol chew 1000 1 estradiol vaginal crea 0.1 1 QL(1.5 gm unit, 25 mcg mg/gm daily) cholecalciferol chew 400 $0 PV estradiol vaginal tabs 10 1 unit mcg cholecalciferol liqd 10 $0 PV PREMARIN CREA VA 2 mcg/ml, 400 unit/ml 0.625 MG/GM cholecalciferol liqd 400 1 VAGIFEM TABS (Use NP ut/0.028ml, 5000 unit/ml estradiol vaginal) cholecalciferol tabs 400 $0 PV VASOPRESSORS - Drugs to Treat Heart and unit Circulation Conditions cholecalciferol tabs 5000 unit, 2000 unit, 50 mcg, 1 Anaphylaxis Therapy Agents 1000 unit, 25 mcg ADRENALIN SOLN IJ 30 MG/30ML (Use NF D-VI-SOL LIQD (Use NP PV epinephrine (anaphylaxis)) cholecalciferol) epinephrine (anaphylaxis) QL(4 ea per DRISDOL CAPS (Use NP PV soaj 0.15 mg/0.3ml, 0.3 1 350 days retail) ergocalciferol) mg/0.3ml ergocalciferol caps $0 PV EPIPEN 2-PAK SOAJ (Use NF QL(4 ea per epinephrine (anaphylaxis)) 350 days retail) ergocalciferol soln $0 PV EPIPEN-JR 2-PAK SOAJ MEPHYTON TABS (Use NP (Use epinephrine NF phytonadione) (anaphylaxis)) Vasopressors phytonadione tabs or 5 mg 1 midodrine hcl tabs 1 VITAMIN D3 TABS 10000 2 UNIT VITAMINS Water Soluble Vitamins Oil Soluble Vitamins ASCOCID POWD 2 AQUA-E LIQD 20 UNIT 2 ascorbic acid chew or 500 1 QL(3.34 ea mg, 500 mg-7.5 mg daily) BABY DDROPS LIQD 400 ASCORBIC ACID POWD 2 UT/0.028ML (Use NP OR cholecalciferol) ascorbic acid tabs or 250 QL(3.34 ea Limit 4 per 28 mg, 1000 mg, 1000 mg-37 daily) cholecalciferol caps 1.25 1 days;QL(0.286 mg, 50000 unit mg, 10 mg-500 mg, 14 mg- 1 ea daily) 25 mg-500 mg, 25 mg-35 cholecalciferol caps 1000 1 QL(100 ea per mg-500 mg, 37 mg-500 mg unit, 25 mcg fill retail) ascorbic acid tbcr or 1500 1 cholecalciferol caps 125 1 QL(2 ea daily) mg mcg, 5000 unit B-6 TABS 2 cholecalciferol caps 2000 1 unit, 50 mcg biotin caps or 5 mg, 5000 1 mcg MHS Indiana Preferred Drug List Updated June 1, 2021

163 Drug Requirements/ Drug Name Tier Limits niacin cpcr 1 niacin tabs 1 niacin tbcr 1

NIACIN TR TBCR 2 pyridoxine hcl tabs or 500 mg, 25 mg, 250 mg, 50 mg, 1 100 mg riboflavin tabs 50 mg, 100 1 QL(3.34 ea mg daily) SLO-NIACIN TBCR (Use NP niacin) thiamine hcl tabs or 50 mg, 1 QL(3.34 ea 250 mg, 100 mg daily) QL(3.34 ea thiamine mononitrate tabs 1 daily) VITAMIN C POWD 2

MHS Indiana Preferred Drug List Updated June 1, 2021

164 Index 1ST TIER UNIFINE ACCU-CHEK GUIDE 69 ADHESIVE PENTIPS/MINI/31GX5MM 99 ACCU-CHEK SMARTVIEW PADS/LARGE/3"X4" 84 1ST TIER UNIFINE STRIPS 69 ADHESIVE PENTIPS29GX12MM 100 ACCU-CHEK SOFTCLIX PADS/MEDIUM/2"X3" 84 1ST TIER UNIFINE LANCETS 89 ADJUSTABLE LANCING PENTIPS31GX6MM 100 ACCUPRIL 28 DEVICE 90 1ST TIER UNIFINE ADMELOG 23 ACCURETIC 29,30 PENTIPS31GX8MM 100 ADMELOG SOLOSTAR 23 1ST TIER UNIFINE acebutolol hcl 45 ADRENALIN 163 PENTIPS32GX4MM 100 acetaminophen 6,7 1ST TIER UNIFINE ADULT MASK 131 acetaminophen w/ codeine 8 PENTIPS32GX6MM 100 ADVAIR DISKUS 14 1ST TIER UNIFINE acetazolamide 71 ADVATE 77 PENTIPSPLUS 31GX8MM 100 acetic acid (otic) 150 ADVIL 5 1ST TIER UNIFINE ACETYL L-CARNITINE 154 PENTIPSPLUS 32GX4MM 100 ADVIL COLD & SINUS 51 acetylcysteine 53 1ST TIER UNIFINE ADVIL PM 80 PENTIPSPLUS/MINI/31GX5MM ACNE MEDICATION 10 53 ADVOCATE INSULIN PEN 100 ACNE MEDICATION 5 53 1ST TIER UNIFINE NEEDLES 29GX12.7MM 100 PENTIPSPLUS/ORIGINAL/29GX ACTEMRA 5 ADVOCATE INSULIN PEN 12MM 100 ACTHAR 72 NEEDLES 31GX5MM 100 1ST TIER UNIFINE ADVOCATE INSULIN PEN ACTHIB 159 NEEDLES 31GX8MM 100 PENTIPSPLUS/ULTRA ACTI-LANCE LANCETS ADVOCATE INSULIN SHORT/31GX6MM 100 28G 89 1ST TIER UNILET SYRINGE/U- ACTI-LANCE LITE SAFETY 100/0.3ML/29GX1/2" 100 COMFORTOUCH LANCETS LANCETS 28G 89 ADVOCATE INSULIN 28G 89 ACTI-LANCE SPECIAL 1ST TIER UNILET SYRINGE/U- SAFETY LANCETS 17G 90 100/0.3ML/30GX5/16" 100 COMFORTOUCH LANCETS ACTI-LANCE UNIVERSAL ADVOCATE INSULIN 30G 89 SAFETY LANCETS 23G 90 SYRINGE/U- 4-N-1 65 ACTIGALL 75 100/0.3ML/31GX5/16" 100 A + D PERSONAL CARE ACTIMMUNE 35 ADVOCATE INSULIN LOTION 58 ACTIVELLA 74 SYRINGE/U- abacavir sulfate 41 100/0.5ML/29GX1/2" 100 ACTONEL 71 abacavir sulfate-lamivudine 41 ADVOCATE INSULIN abacavir sulfate-lamivudine- ACTOPLUS MET 22 SYRINGE/U- zidovudine 41 ACTOS 23 100/0.5ML/30GX5/16" 100 ABILIFY 40 ACULAR 150 ADVOCATE INSULIN SYRINGE/U- ABILIFY MAINTENA 40 ACULAR LS 150 100/0.5ML/31GX5/16" 100 ABILIFY MYCITE 40 acyclovir 44 ADVOCATE INSULIN abiraterone acetate 33 acyclovir topical 56 SYRINGE/U-100/1ML/29GX1/2" 100 ABOUTTIME PEN NEEDLE ADACEL 157 32GX 5/32" 100 ADVOCATE INSULIN ABOUTTIME PEN NEEDLES ADAKVEO 78 SYRINGE/U-100/1ML/30GX5/16" 30GX 5/16" 100 ADALAT CC 46 100 ABOUTTIME PEN NEEDLES ADASUVE 38 ADVOCATE INSULIN SYRINGE/U-100/1ML/31GX5/16" 31G X 3/16" 100 ADCETRIS 32 ABOUTTIME PEN NEEDLES 100 31G X 5/16" 100 ADCIRCA 47 ADVOCATE LANCING ABREVA 56 ADDERALL 1 DEVICE 90 ADVOCATE RAPID-SAFE ABSORICA 53 ADDERALL XR 1 LANCING DEVICE 90 acarbose 22 adefovir dipivoxil 44 ADYNOVATE 77 ACCU-CHEK AVIVA PLUS 69 ADEMPAS 47 ADZENYS ER 1 ACCU-CHEK FASTCLIX ADHANSIA XR 2 ADZENYS XR-ODT 1 LANCETS 89

Index 1 AEMCOLO 11 albuterol sulfate 15 ALPRAZOLAM 48 AEROBIKA 131 ALCOHOL PREP PADS 99 ALPRAZOLAM INTENSOL 13 AEROCHAMBER MINI ALCOHOL SWABS 99 ALPROLIX 77 AEROSOLCHAMBER 131 ALCOHOL SWABSTICK 99 ALTACE 28 AEROCHAMBER MV 131 ALCOHOL WIPES 99 ALTERNATE SITE LANCING AEROCHAMBER PLUS FLOW ALDACTAZIDE 71 DEVICE 90 VU 131 alum & mag hydrox- AEROCHAMBER PLUS FLOW- ALDACTONE 71 simethicone 10 VU 131 ALDARA 64 ALUMINUM HYDROXIDE 11 AEROCHAMBER PLUS FLOW- VU/LARGE MASK 131 ALDURAZYME 73 aluminum hydroxide-mag AEROCHAMBER PLUS FLOW- alendronate sodium 71 carb 10 VU/MASK 131 ALEVE 5 amantadine hcl 36 AEROCHAMBER PLUS FLOW- ALEVE ARTHRITIS 5 AMARYL 24 VU/MEDIUM MASK 131 AMBIEN 81 AEROCHAMBER PLUS FLOW- ALEVE PM 80 VU/SMALL MASK 131 ALKERAN 32 AMBIEN CR 81 AEROCHAMBER Z-STAT PLUS ALL FLOW 1000 PFT ambrisentan 47 VALVED HOLDING CHAMBER FILTER 131 AMD FOAM DRESSING W/FLOW VU 131 ALL FLOW 2000 PFT 4"X4" 84 AEROCHAMBER Z-STAT FILTER 131 AMD FOAM PLUS/FLOWSIGNAL 131 ALL FLOW 3000 PFT DRESSING/TOPSHEET AEROCHAMBER Z-STAT FILTER 132 4"X4" 84 PLUS/LARGE MASK 131 ALL FLOW 4000 PFT AMERGE 135 AEROCHAMBER Z-STAT FILTER 132 AMICAR 80 PLUS/MEDIUM MASK 131 ALL FLOW 5000 PFT AEROCHAMBER Z-STAT amiloride & FILTER 132 hydrochlorothiazide 71 PLUS/SMALL MASK 131 ALL FLOW 6000 PFT AEROCHAMBER/FLOWSIGNAL FILTER 132 amiloride hcl 71 131 ALL FLOW 7000 PFT aminocaproic acid 80 AEROVENT PLUS HOLDING FILTER 132 amiodarone hcl 14 CHAMBER/COLLAPSIBLE 131 ALLEGRA ALLERGY 26 AMITIZA 75 AFINITOR 34 ALLEGRA ALLERGY amitriptyline hcl 21 AFINITOR DISPERZ 34 CHILDRENS 26 AMITRIPTYLINE HCL 48 AFLURIA 2018-2019 159 ALLEVYN PLUS CAVITY 84 AMITRIPTYLINE AFLURIA PF 2018-2019 159 ALLEVYN THIN 84 HYDROCHLORIDE 48 AFLURIA QUADRIVALENT allopurinol 76 AMLACTIN ULTRA 58 2018-2019 159 ALOCRIL 150 AFLURIA QUADRIVALENT amlodipine besylate 46 ALOE AFTERSUN amlodipine besylate-benazepril 2019-2020 159 LOTION 58 AFLURIA QUADRIVALENT hcl 30 ALOE VESTA DAILY amlodipine besylate-olmesartan 2020-2021 160 MOISTURIZER 65 AFSTYLA 77 medoxomil 30 ALOE VESTA SKIN amlodipine besylate- AGAMATRIX ULTRA-THIN CONDITIONER 65 valsartan 30 LANCETS 33G 90 alogliptin benzoate 23 amlodipine-valsartan- AGRYLIN 78 alogliptin-metformin hcl 22 hydrochlorothiazide 30 AIMOVIG 135 alogliptin-pioglitazone 22 AMONDYS 45 145 AIMSCO LUBRICATED 88 ALOMIDE 150 amoxapine 21 AIMSCO TWIST LANCETS amoxicillin 152 32G 90 ALORA 74 ALPHANATE 77 amoxicillin & pot AIMSCO TWIST LANCETS clavulanate 152 33G 90 ALPHANATE/VON amphetamine 1 AJOVY 135 WILLEBRANDFACTOR amphetamine sulfate 1 albuterol sulfate 14 COMPLEX/HUMAN 77 ALPHANINE SD 77 amphetamine- ALBUTEROL SULFATE 15 alprazolam 13 dextroamphetamine 1

Index 2 ampicillin 152 ARGININE HCL 48 ASSURE ID SAFETY PEN AMPYRA 155 ARIAL CHAMBER 132 NEEDLES 31G X 3/16" 100 ASSURE LANCE LANCETS 90 AMYTAL SODIUM 80 ARICEPT 154 ASSURE LANCE LANCETS ANAFRANIL 21 ARIKAYCE 4 21G 90 anagrelide hcl 78 ARIMIDEX 33 ASSURE LANCE PLUS anastrozole 33 aripiprazole 40 SAFETYLANCETS 25G 90 ASSURE LANCE PLUS ANDRODERM 9 ARISTADA 40 SAFETYLANCETS 30G 90 ANDROGEL 9 ARISTADA INITIO 40 ASTRAZENECA COVID-19 ANIMAL SHAPES/IRON 140 ARIXTRA 15 VACCINE 160 ANTABUSE 154 armodafinil 2 ATABEX PRENATAL 141 ANTHELIOS 60 MELT-IN ARMOUR THYROID 157 ATACAND 29 SUNSCREEN 66 ARNUITY ELLIPTA 14 ATACAND HCT 30 ANTHELIOS MELT-IN MILK atazanavir sulfate 41 SUNSCREEN SPF 100 66 AROMASIN 33 ANTI-BACTERIAL HAND ARTHRITIS PAIN ATELVIA 71 LOTION 65 RELIEVING 65 atenolol 45 ANTI-DIARRHEAL 25 artificial tear solution 147 atenolol & chlorthalidone 30 ANUSOL-HC 10 ARZERRA 32 ATIVAN 13 APLENZIN 19 ASACOL HD 75 atomoxetine hcl 2 APLICARE ALCOHOL ASCOCID 163 atorvastatin calcium 28 SWABSTICK 99 ascorbic acid 163 ATRIPLA 41 apraclonidine hcl 148 ASCORBIC ACID 163 ATROPINE SULFATE 148 APRISO 75 ascorbic acid 163 ATROVENT HFA 14 APTENSIO XR 2 asenapine maleate 38 AUBAGIO 155 APTIVUS 41 aspirin 7 AQUA GLYCOLIC FACE AUGMENTIN 152 CREAM 58 ASPIRIN 7 AUGMENTIN ES-600 152 AQUA GLYCOLIC HAND & aspirin 7 AURORA LANCET SUPER BODYLOTION 58 aspirin buffered (cal carb-mag THIN30G 90 AQUA LACTEN 58 carb-mag oxide) 7 AURORA LANCET THIN AQUA LANCE ADJUSTABLE aspirin-acetaminophen- 23G 90 LANCING DEVICE 90 caffeine 6 AURORA PEN NEEDLES AQUA-E 163 ASSURE COMFORT 29GX12MM 100 LANCETS ULTRA THIN AURORA PEN NEEDLES 31G AQUAMED 58 28G 90 X6MM 100 AQUANIL SKIN CLEANSER 65 ASSURE HAEMOLANCE AURORA PEN NEEDLES 31G AQUAPHILIC 58 PLUS HIGH FLOW 18G 90 X8MM 101 ASSURE HAEMOLANCE AURORA UNIFINE AQUAPHOR 58 PLUS LOW FLOW 25G 90 PENTIPS/32GX5/32" 101 AQUAPHOR ADVANCED ASSURE HAEMOLANCE AURORA UNIFINE THERAPY 58 PLUS MICRO FLOW 28G 90 PENTIPS/MINI/31GX3/16" 101 AQUAPHOR ADVANCED ASSURE HAEMOLANCE AUTO-LANCET 90 THERAPY BABY 58 PLUS NORMAL FLOW AUTO-LANCET MINI 90 AQUAPHOR ADVANCED 21G 90 THERAPY HEALING 58 ASSURE HAEMOLANCE AUTOJECT 2 101 ARALAST NP 156 PLUS PEDIATRIC BLADE 90 AUTOLET IMPRESSION ARANESP ALBUMIN FREE 79 ASSURE ID INSULIN LANCING DEVICE 90 AUTOLET LANCING ARAVA 6 SAFETYSYRINGE/U- 100/0.5ML/29G X 1/2" 100 DEVICE 90 ARCALYST 5 ASSURE ID INSULIN AUTOLET MINI 90 arginine 146 SAFETYSYRINGE/U- AUTOLET PLUS 90 ARGININE 146 100/1ML/29G X 1/2" 100 AVALIDE 30 arginine 146 ASSURE ID SAFETY PEN NEEDLES 30G X 5/16" 100 AVAPRO 29

Index 3 AVASTIN 32 AVONEX PEN 155 BAND-AID GAUZE PADS AVEENO ABSOLUTELY AYGESTIN 153 LARGE4" X 4" 84 BAND-AID GAUZE PADS AGELESSLEAVE-ON DAY azacitidine 32 MASK SPF 30 66 MEDIUM 3" X 3" 84 AVEENO ACTIVE NATURALS AZASAN 139 BAND-AID GAUZE PADS DAILY MOISTURIZING BODY azathioprine 139 SMALL2" X 2" 84 BAND-AID HURT-FREE NON- YOGURT 58 azelastine hcl 144 AVEENO ACTIVE NATURALS STICK PADS LARGE 3" X PROTECT+HYDRATE/SPF azelastine hcl (ophth) 150 4" 84 30 66 azithromycin 84 BAND-AID HURT-FREE NON- AVEENO ACTIVE NATURALS AZOPT 150 STICK PADS MEDIUM 2" X 3" 84 SKIN RELIEF MOISTURE AZOR 30 REPAIR 58 BAND-AID MIRASORB GAUZE AVEENO BABY CONTINUOUS AZULFIDINE 75 SPONGES LARGE 4" X 4" 84 PROTECTION 66 AZULFIDINE EN-TABS 75 BAND-AID QUILTVENT WATERPROOF PAD LARGE AVEENO BABY CONTINUOUS B-12 78 PROTECTION SPF50 66 2.875" X 4" 85 AVEENO DAILY B-6 163 BAQSIMI ONE PACK 22 MOISTURIZINGSPF 15 58 b-complex w/ c & folic BAQSIMI TWO PACK 22 acid 140 AVEENO INTENSE RELIEF BARACLUDE 44 HAND 58 b-complex w/ minerals 140 AVEENO KIDS CONTINUOUS B-D INSULIN SYRINGE BASAGLAR KWIKPEN 23 PROTECTION SPF 50 66 ULTRAFINE II/0.3ML/31G X BASIS FACIAL AVEENO POSITIVELY 5/16" 101 MOISTURIZER 65 AGELESSFIRMING BODY 59 B-D INSULIN SYRINGE BASIS OVERNIGHT 65 AVEENO POSITIVELY ULTRAFINE II/0.5ML/31G X BASLE 59 RADIANT 59 5/16" 101 BD LO-DOSE INSULIN AVEENO POSITIVELY B-D INSULIN SYRINGE SYRINGE MICROFINE RADIANTCLEANSER 65 ULTRAFINE II/1ML/31G X IV/0.5ML/28G X 1/2" 101 AVEENO POSITIVELY 5/16" 101 RADIANTDAILY MOISTURIZER B-D INSULIN SYRINGE BD GLUCOSE 22 SPF15 66 ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE AVEENO POSITIVELY 1/2" 101 MICROFINE IV/U- RADIANTDAILY MOISTURIZER B12 78 100/0.5ML/28G X 1/2" 101 BD INSULIN SYRINGE SPF30 66 BABY DDROPS 163 AVEENO POSITIVELY MICROFINE IV/U-100/1ML/28G RADIANTOVERNIGHT BACIGUENT 54 X 1/2" 101 HYDRATING FACIAL bacitracin (ophthalmic) 148 BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X MOISTURI 59 bacitracin (topical) 54 AVEENO PROTECT + 1/2" 101 HYDRATESPF 30 66 bacitracin zinc 54 BD INSULIN SYRINGE AVEENO PROTECT + bacitracin-polymyxin b 54 MICROFINE/U-100/1ML/28G X HYDRATESPF 50 66 bacitracin-polymyxin b 1/2" 101 AVEENO PROTECT + (ophth) 148 BD INSULIN SYRINGE HYDRATESPF 60 66 baclofen 144 SAFETYGLIDE/1ML/29G X 1/2" 101 AVEENO PROTECT + BACTRIM 11 HYDRATESPF 70 66 BD INSULIN SYRINGE ULTRA- AVEENO RESTORATIVE SKIN BACTRIM DS 11 FINE/0.3ML/30G X 12.7MM101 THERAPY OAT REPAIRING59 BAG BALM 59 BD INSULIN SYRINGE ULTRA- AVEENO STRESS RELIEF balsalazide disodium 75 FINE/0.3ML/31G X 8MM 101 MOISTURIZING 59 BD INSULIN SYRINGE ULTRA- AVEENO ULTRA-CALMING BALVERSA 34 FINE/0.5ML/31G X 8MM 101 DAILY MOISTURIZER BAND-AID ALL-IN-ONE BD INSULIN SYRINGE ULTRA- SPF15 66 ADHESIVE GAUZE FINE/1/2 UNIT/0.3ML/31G X AVEENO ULTRA-CALMING PAD/LARGE 84 8MM 101 DAILY MOISTURIZER BAND-AID ALL-IN-ONE BD INSULIN SYRINGE ULTRA- SPF30 66 ADHESIVE GAUZE FINE/1ML/30G X 12.7MM 101 AVONEX 155 PAD/MEDIUM 84 BD INSULIN SYRINGE ULTRA- FINE/1ML/31G X 8MM 101

Index 4 BD INSULIN SYRINGE BD SAFETY-LOK INSULIN BETA XMA 59 ULTRAFINE HALF- SYRINGE/PERM BETADINE 41 101 UNIT/0.3ML/31G X 5/16" NEEDLE/UF/1ML/29G X betamethasone dipropionate BD INSULIN SYRINGE 1/2" 102 ULTRAFINE/0.3ML/30G X BD SAFETYGLIDE INSULIN (topical) 57 101 betamethasone dipropionate 1/2" SYRINGE/0.3ML/29G X augmented 57 BD INSULIN SYRINGE 1/2" 102 ULTRAFINE/0.3ML/31G X BD SAFETYGLIDE INSULIN betamethasone valerate 57 5/16" 101 SYRINGE/0.3ML/31G X BETAPACE 45 BD INSULIN SYRINGE 15/64" 102 BETAPACE AF 45 ULTRAFINE/0.5ML/31G X BD SAFETYGLIDE INSULIN BETASERON 155 5/16" 101 SYRINGE/0.3ML/31G X BD INSULIN SYRINGE 5/16" 102 betaxolol hcl (ophth) 148 ULTRAFINE/1ML/30G X BD SAFETYGLIDE INSULIN bethanechol chloride 159 1/2" 101 SYSYRINGE/0.5ML/30G X BETHKIS 4 BD INSULIN SYRINGE 5/16" 102 bexarotene 35 ULTRAFINE/U-100/0.3ML/29G X BD SWABS SINGLE USE 99 1/2" 101 BD SWABS SINGLE USE BEXSERO 159 BD INSULIN SYRINGE BUTTERFLY 99 bicalutamide 33 ULTRAFINE/U-100/0.5ML/29G X BD VEO INSULIN SYRINGE BIKTARVY 41 1/2" 101 ULTRA-AFINE/0.3ML/31G X BILTRICIDE 11 BD INSULIN SYRINGE 6MM 102 ULTRAFINE/U-100/1ML/29G X BD VEO INSULIN SYRINGE BIOGUARD GAUZE SPONGE 1/2" 101 ULTRA-FINE/0.3ML/31G X 2"X2" 8 PLY 85 BIOGUARD GAUZE SPONGES BD INSULIN SYRINGE 6MM 102 ULTRAFINE/U-100/1ML/31G X BD VEO INSULIN SYRINGE 4"X4" 12 PLY 85 5/16" 101 ULTRA-FINE/1/2 BIOSPEC DMX 51 BD INSULIN UNIT/0.3ML/31G X 6MM 102 biotin 163 SYRINGE/0.3ML/29G X BD VEO INSULIN SYRINGE bisacodyl 83 12.7MM 101 ULTRA-FINE/U-100/0.3ML/31G bismuth subsalicylate 24 BD INSULIN X 15/64" 102 bisoprolol & SYRINGE/0.5ML/29G X BELRAPZO 32 12.7MM 102 hydrochlorothiazide 30 BD INSULIN SYRINGE/1ML/29G BELSOMRA 81 bisoprolol fumarate 45 X 12.7MM 102 BENADRYL ALLERGY 26 BIVIGAM 151 BD LANCET ULTRAFINE BENADRYL ALLERGY BLEPH-10 148 30G 90 CHILDRENS 26 BD MICROTAINER benazepril & BLEPHAMIDE 149 LANCETS 90 hydrochlorothiazide 30 BLEPHAMIDE S.O.P. 149 BD PEN benazepril hcl 28 BONIVA 71 NEEDLE/MICRO/ULTRA- BENDAMUSTINE BOOSTRIX 157 FINE/32G X 6MM 102 HYDROCHLORIDE 32 BD PEN NEEDLE/MINI/ULTRA- BORDERED GAUZE 85 BENDEKA 32 FINE/31G X 5MM 102 bosentan 47 BD PEN NEEDLE/NANO 2ND BENEFIX 77 BOSULIF 34 GEN/32G X 5/32" 102 BENICAR 29 BOTOX 145 BD PEN BENICAR HCT 30 NEEDLE/NANO/ULTRA- BOUDREAUXS BABY BUTT FINE/32G X 4MM 102 BENLYSTA 140 SMOOTH DRY SKIN 59 BD PEN BENZAC AC WASH 53 BRAFTOVI 34 NEEDLE/ORIGINAL/ULTRA- benzonatate 51 BREATHE EASE/LARGE FINE/29G X 12.7MM 102 benzoyl peroxide 53 MASK 132 BD PEN BREATHE EASE/MEDIUM NEEDLE/SHORT/ULTRA- BENZOYL PEROXIDE CLEANSER 53 MASK 132 FINE/31G X 8MM 102 BREATHE EASE/SMALL BD SAFETY-GLIDE INSULIN benztropine mesylate 36 MASK 132 SYRINGE/0.5ML/29G X BERINERT 78 BREATHERITE 132 1/2" 102 BETA CARE 59

Index 5 BREATHERITE BUPHENYL 73 calcium carbonate- COLLAPSIBLEADULT SPACER buprenorphine hcl 9 cholecalciferol 136 W/MASK 132 calcium carbonate-mag BREATHERITE buprenorphine hcl-naloxone hcl hydrox 10 COLLAPSIBLECHILD SPACER dihydrate 9 calcium carbonate-vitamin W/MASK 132 bupropion hcl 19 d 136 BREATHERITE BUPROPION HCL 48 CALCIUM CHEWS 136 COLLAPSIBLEINFANT SPACER bupropion hcl (smoking calcium citrate 136 W/MASK 132 deterrent) 155 BREATHERITE BUPROPION CALCIUM CITRATE W/D 136 COLLAPSIBLESMALL CHILD HYDROCHLORIDE 48 CALCIUM CITRATE W/VITAMIN SPACER W/MASK 132 buspirone hcl 13 D 136 calcium citrate-vitamin d 137 BREATHERITE BUSPIRONE HCL 48 COLLAPSIBLESPACER W/ CALCIUM CITRATE/VITAMIN NEONATE MASK 132 BUSPIRONE D3 137 BREATHERITE RIGID HYDROCHLORIDE 48 CALCIUM PLUS D3 SPACERW/MASK 132 butalbital-acetaminophen 6 ABSORBABLE 137 BREATHERITE VALVED MDI butalbital-acetaminophen- CALCIUM PLUS VITAMIN CHAMBER/COLLAPSIBLE 132 caffeine 6 D 137 BREATHERITE VALVED MDI butalbital-acetaminophen- calcium polycarbophil 82 caffeine w/ codeine 8 CHAMBER/RIGID 132 CALCIUM/VITAMIN D 137 BREATHERITE W/LARGE butalbital-aspirin-caffeine 6 MASK 132 butalbital-aspirin-caffeine CALNA 141 BREATHERITE W/MEDIUM w/cod 8 CALTRATE 600+D3 137 MASK 132 BUTALBITAL/ACETAMINOPH CALTRATE 600+D3 SOFT BREATHERITE W/SMALL EN 6 CHEWS 137 MASK 132 BUTALBITAL/ASPIRIN/CAFFEI CAM 59 BRILINTA 78 NE 6 camphor & menthol 56 BUTISOL SODIUM 80 brimonidine tartrate 148 candesartan cilexetil 29 brinzolamide 150 BYDUREON BCISE 23 candesartan cilexetil- bromocriptine mesylate 36 BYDUREON PEN 23 hydrochlorothiazide 30 brompheniramine & BYETTA 23 capecitabine 32 phenyleph 51 CADEAU DHA 141 CAPLYTA 37 brompheniramine & pseudoeph 51 CAFCIT 2 capsaicin 65 budesonide (inhalation) 14 caffeine citrate 2 captopril 28 budesonide (nasal) 144 CAL-CITRATE PLUS captopril & VITAMIND 136 hydrochlorothiazide 30 budesonide-formoterol fumarate dihydrate 15 CAL-QUICK 136 CAPZASIN-HP 65 BUFFERIN 7 CALAN 46 CARAC 56 BULL FROG SUPERBLOCK CALAN SR 46 CARAFATE 158 SPF50 66 CALCET CREAMY CARBAGLU 73 BULL FROG ULTIMATE BITES 136 carbamazepine 16 SHEERPROTECTION FACE CALCI-CHEW 136 CARBAMAZEPINE 16 SUNBLOCK SPF 30 66 calcipotriene 56 BULL FROG ULTIMATE carbamazepine 16 calcitonin (salmon) 72 SHEERPROTECTION carbamide peroxide (otic) 150 SUNBLOCK SPF 30 67 calcitriol 73 CARBATROL 16 BULL FROG WATER ARMOR CALCIUM 136,137 SPORT FACE SPF 30 67 carbidopa 36 CALCIUM 1000 + D 136 BULLSEYE MINI SAFETY carbidopa-levodopa 36 LANCETS 90 calcium acetate (phosphate binder) 76 carboxymethylcellulose sodium BULLSEYE SAFETY (ophth) 147 LANCETS 90 CALCIUM CARBONATE 136 carboxymethylcellulose-glycerin bumetanide 71 calcium carbonate 136 147 BUMEX 71 calcium carbonate CARDIOCOM LANCING (antacid) 11 DEVICE 90

Index 6 CARDIZEM 46 CAREONE UNIFINE PENTIPS CENTRUM KIDS 140 CARDIZEM CD 46 PLUS PEN NEEDLES CENTRUM SPECIALIST 32GX4MM 103 PRENATAL 141 CARDURA 29 CARESENS LANCETS 90 CAREFINE PEN NEEDLE cephalexin 47,48 CARETOUCH ALCOHOL CEPROTIN 78 32GX4MM 102 PREP PADS 99 CAREFINE PEN NEEDLES CARETOUCH LANCING CEQUR SIMPLICITY 29GX1/2" 102 DEVICEWITH EJECTOR 90 STARTERKIT 103 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CERALYTE 70 137 30GX5/16" 102 31G X 6 MM 103 CERASPORT 137 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CERASPORT EX1 137 31GX6MM 102 31GX 5MM 103 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CERAVE 59 31GX8MM 102 31GX 8MM 103 CERAVE AM FACIAL CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES MOISTURIZING 32GX6MM 102 32GX 4MM 103 LOTION/SPF30 59 CAREONE ADVANCED CARETOUCH TWIST CERAVE AM SPF 30 59 LANCINGDEVICE 90 LANCETS 30G 90 CERAVE DAILY CAREONE INSULIN CARIMUNE MOISTURIZING 59 SYRINGES/0.3ML/30G X NANOFILTERED 151 1/2" 102 CERAVE HEALING 59 CAREONE INSULIN CARNITOR 73 CERAVE MOISTURIZING 59 SYRINGES/0.3ML/31G X CARNITOR SF 73 CERAVE PM 59 5/16" 102 CARRASMART 85 CERAVE PM FACIAL CAREONE INSULIN CARRASMART FOAM 85 MOISTURIZING LOTION ULTRA SYRINGES/0.5ML/31G X CARRINGTON MOISTURE LIGHTWEIGHT 59 5/16" 102 BARRIER 65 CERAVE RENEWING SA 59 CAREONE INSULIN CARRINGTON MOISTURE SYRINGES/1ML/30G X CERAVE SA RENEWING 59 BARRIER/ZINC 65 1/2" 102 CERAVE SA/ROUGH AND CAREONE INSULIN carteolol hcl (ophth) 148 BUMPYSKIN 59 SYRINGES/1ML/31GX5/16" carvedilol 45 CERAVE SUNSCREEN 103 carvedilol phosphate 45 FACE/SPF50 67 CERDELGA 78 CAREONE LANCET SUPER CASODEX 33 THIN/30G 90 CEREZYME 78 CATAPRES 29 CAREONE LANCET THIN 90 CEROVEL 58 CATAPRES-TTS-1 29 CAREONE UNIFINE PENTIPS CETAPHIL DAILY ADVANCE 29GX12MM 103 CATAPRES-TTS-2 29 ULTRA HYDRATING 59 CAREONE UNIFINE PENTIPS CATAPRES-TTS-3 29 CETAPHIL DAILY FACIAL 31GX5MM 103 cefaclor 48 MOISTURIZER 59 CAREONE UNIFINE PENTIPS CETAPHIL DERMACONTROL 31GX6MM 103 cefadroxil 47 MOISTURIZER/SPF 30 59 CAREONE UNIFINE PENTIPS cefdinir 48 31GX8MM 103 CETAPHIL MOISTURIZING 59 CAREONE UNIFINE PENTIPS cefprozil 48 CETAPHIL PEN NEEDLES 32GX4MM 103 ceftriaxone sodium 48 RESTORADERM 59 CAREONE UNIFINE PENTIPS cefuroxime axetil 48 CETAPHIL THERAPEUTIC HAND 59 PLUS PEN NEEDLES CELEBREX 5 29GX12MM 103 cetirizine hcl 26 CAREONE UNIFINE PENTIPS celecoxib 5 cetirizine-pseudoephedrine 51 PLUS PEN NEEDLES CELESTONE-SOLUSPAN 50 CETRAXAL 150 31GX5MM 103 CELEXA 19 CHANTAL SUN SCREEN SPF CAREONE UNIFINE PENTIPS CELLCEPT 139 30 67 PLUS PEN NEEDLES 31GX6MM 103 CELLCEPT CHANTIX 156 CAREONE UNIFINE PENTIPS INTRAVENOUS 139 CHANTIX CONTINUING PLUS PEN NEEDLES CENTANY 54 MONTHPAK 156 31GX8MM 103 CENTRUM FLAVOR BURST CHANTIX STARTING MONTH KIDS 140 PAK 156

Index 7 CHEMET 25 ciprofloxacin-dexamethasone CLEVER CHOICE COMFORT CHEMSTRIP-K 69 151 EZINSULIN citalopram hydrobromide 19 SYRINGE/0.3ML/30G X CHERACOL PLUS 51 CITRACAL + D3 5/16" 103 CHERACOL-D COUGH 51 MAXIMUM 137 CLEVER CHOICE COMFORT CHERRY CONCENTRATE 152 CITRACAL MAXIMUM 137 EZINSULIN CHERRY SYRUP 152 CITRACAL SYRINGE/0.3ML/31G X PETITES/VITAMIND 137 5/16" 103 CHEWABLE CALCIUM/D3 137 CLEVER CHOICE COMFORT CHILDRENS ADVIL 5 clarithromycin 84 EZINSULIN CHILDRENS MOTRIN 5 CLARITIN 26 SYRINGE/0.5ML/28G X CLARITIN ALLERGY 1/2" 103 CHLOR-TRIMETON 26 CHILDRENS 26 CLEVER CHOICE COMFORT CHLORAL HYDRATE 81 CLARITIN REDITABS 26 EZINSULIN chlordiazepoxide hcl 13 CLARITIN-D 12 HOUR 51 SYRINGE/0.5ML/29G X 1/2" 103 chlordiazepoxide-amitriptyline CLARITIN-D 24 HOUR 51 154 CLEVER CHOICE COMFORT chlorhexidine gluconate 41 CLASSIC PRENATAL 141 EZINSULIN chlorhexidine gluconate (mouth- CLEANLET LANCETS SYRINGE/0.5ML/30G X throat) 140 28G 91 5/16" 103 CLEAR COUGH PM MULTI- CLEVER CHOICE COMFORT chloroquine phosphate 31 SYMPTOM 51 EZINSULIN chlorothiazide 71 clemastine fumarate 26 SYRINGE/0.5ML/31G X chlorpheniramine maleate 26 CLEOCIN 12,162 5/16" 103 CLEVER CHOICE COMFORT chlorpromazine hcl 39 CLEOCIN PEDIATRIC EZINSULIN CHLORPROMAZINE HCL 48 GRANULES 12 SYRINGE/1.0ML/30G X chlorthalidone 71 CLEOCIN-T 53 1/2" 103 chlorzoxazone 144 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT STATICVALVED HOLDING CHOLBAM 75 EZINSULIN SYRINGE/1ML/28G CHAMBER/ADULT X 1/2" 103 cholecalciferol 163 LARGE 132 CLEVER CHOICE COMFORT cholestyramine 27 CLEVER CHOICE ANTI- EZINSULIN SYRINGE/1ML/29G STATICVALVED HOLDING X 1/2" 104 cholestyramine light 27 CHAMBER/MEDIUM 132 CHORIONIC CLEVER CHOICE COMFORT CLEVER CHOICE ANTI- EZINSULIN SYRINGE/1ML/30G GONADOTROPIN 72 STATICVALVED HOLDING CICAPLAST BAUME B5 X 5/16" 104 CHAMBER/MEDIUM/3 CLEVER CHOICE COMFORT SOOTHING MULTI-PURPOSE YEA 132 BALM 59 EZINSULIN SYRINGE/U- CLEVER CHOICE ANTI- 100/1ML/31GX5/16" 104 CICLODAN SOLUTION KIT 55 STATICVALVED HOLDING CLEVER CHOICE COMFORT cilostazol 78 CHAMBER/SMALL 132 EZPEN NEEDLES CILOXAN 148 CLEVER CHOICE ANTI- 29GX12MM 104 STATICVALVED HOLDING CIMDUO 41 CLEVER CHOICE COMFORT CHAMBER/SMALL EZPEN NEEDLES cimetidine 157 INFANT 132 31GX5MM 104 cimetidine hcl 157 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT CIMZIA 75 EZINSULIN PEN NEEDLES EZPEN NEEDLES 31GX8MM 103 31GX6MM 104 CIMZIA STARTER KIT 75 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT cinacalcet hcl 73 EZINSULIN EZPEN NEEDLES CINQAIR 14 SYRINGE/0.3ML/29G X 31GX8MM 104 CINRYZE 78 1/2" 103 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZPEN NEEDLES CIPRO 75 EZINSULIN 32GX4MM 104 CIPRODEX 150 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT ciprofloxacin hcl 75 1/2" 103 EZPEN NEEDLES ciprofloxacin hcl (ophth) 148 32GX6MM 104

Index 8 CLICKFINE PEN NEEDLE CO MONITOR 132 COMFORT ASSIST INSULIN 32GX5/32" 104 CO-NATAL FA 141 SYRINGE/1ML/29G X 1/2" 104 CLICKFINE PEN NEEDLE COMFORT ASSIST INSULIN UNIVERSAL/31GX1/4" 104 COAGADEX 77 SYRINGE/1ML/30G X CLICKFINE PEN NEEDLE coal tar extract 68 5/16" 104 UNIVERSAL/31GX5/16" 104 COARTEM 31 COMFORT ASSIST INSULIN CLICKFINE PEN NEEDLES 31G SYRINGE/1ML/31G X X 1/4" 104 COCOA BUTTER 59 5/16" 105 CLICKFINE PEN NEEDLES 31G COCOA BUTTER HAND & COMFORT ASSURED X 3/16" 104 BODYLOTION 59 LANCETS MICRO THIN CLICKFINE PEN NEEDLES 31G COCONUT OIL BEAUTY 59 33G 91 X 5/16" 104 CODEINE SULFATE 7 COMFORT ASSURED CLICKFINE PEN NEEDLES 31G codeine sulfate 7 LANCETS SUPER THIN X 8MM 104 28G 91 CLICKFINE PEN NEEDLES 32G COGENTIN 36 COMFORT EZ INSULIN X 5/32" 104 COLACE 83 SYRINGE/U-100/0.5ML/31G X CLICKFINE PEN COLACE CLEAR 83 5/16" 105 NEEDLES/31GX1/4" 104 COLAZAL 75 COMFORT EZ INSULIN CLICKFINE UNIVERSAL PEN SYRINGE/U-100/1ML/31G X NEEDLES 31GX5/16" 104 colchicine 76 5/16" 105 CLIMARA 74 colchicine w/ probenecid 76 COMFORT EZ MICRO/32G X CLINDAGEL 54 COLCRYS 76 4MM 105 COMFORT EZ SHORT/31G X clindamycin hcl 12 COLD-EEZE 139 8MM 105 clindamycin palmitate COLD-EEZE PLUS COMFORT EZ/31G X 5MM 105 hydrochloride 12 DEFENSE 139 clindamycin phosphate COLD-EEZE PLUS NATURAL COMFORT EZ/31G X 6MM 105 (topical) 54 MULTI-SYMPTOM COMFORT LANCETS 91 clindamycin phosphate RELIEF 139 COMPACT SPACE vaginal 162 COLD-EEZE SUGAR CHAMBER/ANTI-STATIC 132 CLINICAL NUTRIENTS FREE 139 COMPACT SPACE PRENATAL FORMULA 141 COLESTID 27 CHAMBER/ANTI- CLN FACIAL MOISTURIZER COLESTID FLAVORED 27 STATIC/LARGE MASK 132 NOURISHING 59 COMPACT SPACE clobazam 16 colestipol hcl 27 CHAMBER/ANTI- clobetasol propionate 57 COLYTE-FLAVOR PACKS82 STATIC/MEDIUM MASK 133 clobetasol propionate emollient COMBIPATCH 74 COMPACT SPACE base 57 COMBIVENT RESPIMAT 15 CHAMBER/ANTI-STATIC/SMALL CLODERM 57 MASK 133 COMBIVIR 41 COMPLERA 41 clomipramine hcl 21 COMFORT ASSIST INSULIN COMPLETENATE 141 clonazepam 16 SYRINGE 0.3ML/29G X CONCERTA 2 clonidine 29 1/2" 104 COMFORT ASSIST INSULIN CONZIP 7 CLONIDINE HCL 29 SYRINGE/0.3ML/30G X COOL BOTTOMS 65 clonidine hcl 29 5/16" 104 COPA ISLAND BORDERED clonidine hcl (adhd) 2 COMFORT ASSIST INSULIN SYRINGE/0.3ML/31G X FOAM DRESSING 4"X4" 85 CLONIDINE COPA PLUS HYDROPHILIC HYDROCHLORIDE 29 5/16" 104 COMFORT ASSIST INSULIN FOAM DRESSING 4"X4" 85 clopidogrel bisulfate 78 SYRINGE/0.5ML/29G X COPAXONE 155 clorazepate dipotassium 13 1/2" 104 COREG 45 clotrimazole (topical) 55 COMFORT ASSIST INSULIN COREG CR 45 clotrimazole vaginal 162 SYRINGE/0.5ML/30G X CORGARD 45 5/16" 104 clotrimazole w/ COMFORT ASSIST INSULIN CORIFACT 77 betamethasone 55 SYRINGE/0.5ML/31G X corn starch 65 clozapine 38 5/16" 104 CORTEF 50 CLOZARIL 38 CORTENEMA 9

Index 9 cortisone acetate 50 CURITY COVER SPONGES CVS GAUZE PADS 4"X4" 12- CORTROSYN 69 3"X3" 85 PLY 86 CURITY COVER SPONGES CVS GAUZE PADS STERILE COSENTYX 56 4"X4" 85 4"X4" 12-PLY 86 COSENTYX SENSOREADY CURITY DRESSING CVS GLUCOSE 22 PEN 56 SPONGES 4"X4" 6 PLY 85 CVS LANCETS 21G 91 COSOPT 148 CURITY GAUZE PADS CVS LANCETS MICRO THIN cosyntropin 69 2"X2" 85 CURITY GAUZE PADS 2"X2" 33G 91 COTELLIC 34 12 PLY 85 CVS LANCETS MICRO-THIN COTEMPLA XR-ODT 2 CURITY GAUZE PADS 33G 91 COTZ 67 3"X3" 85 CVS LANCETS ORIGINAL 91 COUMADIN 15 CURITY GAUZE PADS 4"X4" CVS LANCETS THIN 26G 91 12 PLY 85 COVRSITE COVER CVS LANCETS ULTRA THIN CURITY GAUZE SPONGE 30G 91 DRESSING 85 2"X2" 8 PLY 85 COVRSITE PLUS COMPOSITE CVS LANCETS ULTRA-THIN CURITY GAUZE SPONGE 30G 91 DRESSING 85 2"X2"12 PLY 85 COZAAR 29 CVS LANCING DEVICE 91 CURITY GAUZE SPONGE CVS LICE SOLUTION KIT 3- CREON 70 3"X3" 12 PLY 85 STEP 68 CRESTOR 28 CURITY GAUZE SPONGE 4"X4" 12 PLY 85 CVS MELATONIN 4 CRIXIVAN 41 CURITY GAUZE SPONGE CVS MELATONIN GUMMIES 4 cromolyn sodium 14 4"X4" 16 PLY 85 CVS MOISTURIZING cromolyn sodium (nasal) 144 CURITY GAUZE SPONGE CREAM 60 cromolyn sodium (ophth) 150 4"X4" 8 PLY 85 CVS NATURAL FIBER CURITY GAUZE SPONGE SUPPLEMENT 82 crotamiton 68 4"X4"16 PLY 85 CVS PRENATAL 141 CRUAD GAUZE PADS 4" X CURITY GAUZE SPONGES CVS PRENATAL 4" 85 4"X4" 12 PLY 85 GUMMY/DHA/FOLIC ACID 141 CURAD NON-STICK PADS CURITY GAUZE SPONGES CVS PRENATAL WITHADHESIVE TABS 4"X4" 8 PLY 85 MULTI+DHA 141 3"X4" 85 CURITY NON-ADHERENT CVS PREP PADS 99 CURITY ALCOHOL STRIPS 3"X3" 86 PREPS/MEDIUM 2 PLY 99 CURITY CVS SOFT GLUCOSE 22 CURITY ALCOHOL SWABS 99 SPONGES/CELLULOSEFILLE CVS ULTRA THIN CURITY ALL PURPOSE D/2"X2" 86 LANCETS 91 SPONGES 2"X2" 85 CURITY CVS WOMENS CURITY ALL PURPOSE SPONGES/CELLULOSEFILLE PRENATAL+DHA 141 SPONGES 2"X2" 4PLY 85 D/4"X4" 86 cyanocobalamin 78 CURITY ALL PURPOSE CUVITRU 151 cyclobenzaprine hcl 144 SPONGES 3"X3" 4PLY 85 CVS ADHESIVE PAD CYCLOGYL 148 CURITY ALL PURPOSE 4"X4" 86 SPONGES 4 PLY 85 CVS ADHESIVE PAD cyclopentolate hcl 148 CURITY ALL PURPOSE 6"X6" 86 CYCLOPHOSPHAMIDE 32 SPONGES 4"X4" 85 CVS ADHESIVE PADS cyclosporine 139 CURITY ALL PURPOSE 2.25"X3" 86 cyclosporine modified (for SPONGES 4"X4" 4PLY 85 CVS ALCOHOL PREP microemulsion) 139 CURITY ALL PURPOSE PADS 99 CYMBALTA 20 SPONGES 4"X4" 4PLY/SOFT CVS BEAUTY 360 DRY POUCH 85 SKIN 59 cyproheptadine hcl 27 CURITY AMD CVS DAILY ULTRA CYPROHEPTADINE HCL 48 ANTIMICROBIALGAUZE MOISTURELOTION 59 CYSTADANE 73 SPONGES 2"X2" 8 PLY 85 CVS DRY SKIN THERAPY59 CYSTAGON 76 CURITY AMD CVS GAUZE PAD 3"X3" 86 ANTIMICROBIALGAUZE CYTOGAM 151 SPONGES 4"X4" 12 PLY 85 CVS GAUZE PADS 2"X2" 12- PLY 86 CYTOMEL 157 CURITY COVER SPONGE CYTOTEC 158 4"X4" 85

Index 10 D-VI-SOL 163 DEPO-TESTOSTERONE 9 DERMAL THERAPY FOOT D.H.E. 45 135 DERMABASEOIL IN MASSAGE 60 DERMAL THERAPY HAND DACOGEN 32 WATER 60 DERMACEA DRAIN ELBOW & KNEE CREAM 60 DAILY CONDITIONING SPONGES 4"X4" 86 DERMAL THERAPY HEEL TREATMENT 60 DERMACEA GAUZE SPONGE CARE 60 DAILY MOISTURIZING 60 2"X2" 12 PLY 86 DERMALEVIN ADHESIVE DAILY MOISTURIZING DERMACEA GAUZE SPONGE FOAMDRESSING 4"X4" 86 LOTION 60 2"X2" 8 PLY 86 DERMEND ALPHA + BETA DAKINS SOLUTION FULL DERMACEA GAUZE SPONGE HYDROXY THERAPY 60 STRENGTH 41 3"X3" 12 PLY 86 DERMEND FRAGILE SKIN DAKINS SOLUTION HALF DERMACEA GAUZE SPONGE MOISTURIZING FORMULA 60 STRENGTH 41 3"X3" 8 PLY 86 DERMEND MOISTURIZING DAKINS SOLUTION QUARTER DERMACEA GAUZE SPONGE BRUISE FORMULA 60 STRENGTH 41 4"X4" 12 PLY 86 DERMOTIC 151 DAKLINZA 44 DERMACEA GAUZE SPONGE DESCOVY 41 DAKRINA 147 4"X4" 16 PLY 86 DESFERAL 25 DERMACEA GAUZE SPONGE dalfampridine 155 4"X4" 8 PLY 86 DESIPRAMINE HCL 21 danazol 9 DERMACEA I.V. DRAIN desipramine hcl 21 dapsone 12 SPONGES 2"X2" 86 desmopressin acetate 74 DAPTOMYCIN 12 DERMACEA I.V. DRAIN SPONGES 4"X4" 86 desmopressin acetate spray 74 DAUNORUBICIN DERMACEA I.V. SPONGES desmopressin acetate spray HYDROCHLORIDE 34 2"X2" 86 refrigerated 74 DAY TIME MULTI-SYMPTOM DERMACEA NON-WOVEN desogestrel & ethinyl COLD/FLU RELIEF 51 SPONGES 2"X2" 4 PLY 86 estradiol 48 DAYPRO 5 DERMACEA NON-WOVEN desogestrel-ethinyl estradiol DAYTRANA 2 SPONGES 3"X3" 4 PLY 86 (biphasic) 49 desogestrel-ethinyl estradiol DAYVIGO 81 DERMACEA NON-WOVEN SPONGES 4"X4" 4 PLY 86 (triphasic) 49 DDAVP 73,74 DERMACEA NON-WOVEN desonide 57 DEBROX 150 SPONGES 4"X4" 6 PLY 86 DESOWEN 57 decitabine 32 DERMACEA TYPE VII GAUZE desoximetasone 57 2"X2" 12 PLY 86 deferasirox 25 DERMACEA TYPE VII GAUZE DESOXYN 1 deferoxamine mesylate 25 2"X2" 8 PLY 86 desvenlafaxine 20 DELSTRIGO 41 DERMACEA TYPE VII GAUZE DESVENLAFAXINE ER 20 DELSYM 51 3"X3" 12 PLY 86 DERMACEA TYPE VII GAUZE desvenlafaxine succinate 20 DELSYM COUGH 3"X3" 12PLY 86 DETROL 158 CHILDRENS 51 DERMACEA TYPE VII GAUZE DELZICOL 75 DETROL LA 158 4"X4" 12 PLY 86 DEX4 QUICK DISSOLVE DEMADEX 71 DERMACEA TYPE VII GAUZE GLUCOSE 22 DEPACON 18 4"X4" 16 PLY 86 DERMACEA TYPE VII GAUZE dexamethasone 50 DEPAKENE 18 4"X4" 8 PLY 86 dexamethasone sodium DEPAKOTE 18 DERMACEA X-RAY phosphate 50 DEPAKOTE ER 18 SPONGES 4"X4" 16 PLY 86 DEXAMETHASONE SODIUM PHOSPHATE 50 DEPAKOTE SPRINKLES 18 DERMACINRX SKIN REPAIR 65 dexamethasone sodium DEPEN TITRATABS 138 DERMAIDE ALOE 60 phosphate (ophth) 149 DEPO-MEDROL 50 dexchlorpheniramine DERMAL THERAPY EXTRA maleate 26 DEPO-PROVERA 33 STRENGTH BODY DEXEDRINE 1 DEPO-PROVERA LOTION 60 CONTRACEPTIVE 50 DERMAL THERAPY FACE dexmethylphenidate hcl 2 DEPO-SUBQ PROVERA CAREMOISTURIZING dextroamphetamine sulfate 1 104 50 LOTION 60 dextromethorphan polistirex 51

Index 11 dextromethorphan-doxylamine- digoxin 46,47 DOVATO 41 acetaminophen 51 dihydroergotamine DOVONEX 56 dextromethorphan-guaifenesin mesylate 135 doxazosin mesylate 29 52 DILANTIN 18 dextromethorphan- doxepin hcl 21 DILANTIN INFATABS 18 phenylephrine-acetaminophen DOXEPIN HCL 48 52 DILANTIN-125 18 doxepin hcl (sleep) 81 dextrose (diabetic use) 23 DILAUDID 7 DOXEPIN DEXTROSE 5%/NACL diltiazem hcl 46 HYDROCHLORIDE 48 0.3% 137 diltiazem hcl coated beads 46 doxycycline (monohydrate) 156 DHS TAR 69 diltiazem hcl extended release doxycycline hyclate 156 DHS TAR GEL 68 beads 46 doxylamine succinate DIABETIDERM 60 dimenhydrinate 25 (sleep) 80 DIABETIDERM CLEANSING65 DIMETAPP COLD & DRAMAMINE 25 DIABETIDERM FOOT ALLERGY 52 DRISDOL 163 REJUVENATING 60 dimethicone (topical) 65 DRIZALMA SPRINKLE 20 DIABETIDERM HAND & dimethyl fumarate 155 DROPERIDOL 13 BODY 60 DINO-LIFE W/IRON & DIABETIDERM SUNSCREEN ZINC 140 droperidol 13 SPF15 67 DIOVAN 29 DROPLET GENTEEL LANCING diaper rash products 58 DEVICE 91 DIOVAN HCT 30 DIASTAT ACUDIAL 16 DROPLET INSULIN SYRINGE diphenhydramine hcl 26 DIASTAT PEDIATRIC 16 0.3ML/29G X 1/2" 105 diphenhydramine hcl DROPLET INSULIN SYRINGE DIATHRIVE LANCETS 91 (sleep) 80 0.5ML/29G X 1/2" 105 DIATHRIVE LANCETS ULTRA diphenhydramine- DROPLET INSULIN SYRINGE THIN 30G 91 acetaminophen (sleep) 80 1ML/29G X 1/2" 105 DIATHRIVE LANCING diphenoxylate w/ atropine 25 DROPLET INSULIN SYRINGE DEVICE 91 DIPHTHERIA/TETANUS U-100/0.3/31G X 5/16" 105 DIATHRIVE PEN NEEDLE/31 G TOXOIDS ADSORBED DROPLET INSULIN SYRINGE X 6MM 105 PEDIATRIC 157 U-100/0.3ML/30G X 1/2" 105 DIATHRIVE PEN NEEDLE/31 DIPROLENE AF 57 DROPLET INSULIN SYRINGE GX 8MM 105 U-100/0.3ML/30G X 5/16" 105 DIATHRIVE PEN NEEDLE/31GX dipyridamole 78 DROPLET INSULIN SYRINGE 5MM 105 disopyramide phosphate 13 U-100/0.3ML/31G X 15/64" 105 DIATHRIVE PEN NEEDLE/32GX disulfiram 154 DROPLET INSULIN SYRINGE 4MM 105 U-100/0.5ML/30G X 5/16" 105 diazepam 13 DITROPAN XL 159 DROPLET INSULIN SYRINGE DIAZEPAM 13 divalproex sodium 18 U-100/0.5ML/31G X 5/16" 105 DIVALPROEX SODIUM 48 DROPLET INSULIN SYRINGE diazepam 13 U-100/1ML/30G X 1/2" 105 DIAZEPAM 48 DMAE 60 DROPLET INSULIN SYRINGE diazepam (anticonvulsant) 16 DML FORTE 60 U-100/1ML/30G X 5/16" 105 dibucaine 65 docosanol 57 DROPLET INSULIN SYRINGE docusate calcium 83 U-100/1ML/31G X 5/16" 105 dibucaine (rectal) 10 DROPLET INSULIN diclofenac potassium 5 docusate sodium 83 SYRINGE/U-100/0.3ML/31G X diclofenac sodium 5 dofetilide 14 15/64" 105 DROPLET INSULIN diclofenac sodium (ophth) 150 DOLOPHINE 7 donepezil hydrochloride 154 SYRINGE/U-100/0.3ML/31G X diclofenac sodium (topical) 54 5/16" 105 dicloxacillin sodium 152 DOPRAM 2 DROPLET INSULIN dicyclomine hcl 157 DORAL 81 SYRINGE/U-100/0.5ML/31G X dorzolamide hcl 150 5/16" 105 didanosine 41 DROPLET INSULIN DIFLUCAN 26 DORZOLAMIDE HCL 150 SYRINGE/U-100/1ML/30G X dorzolamide hcl-timolol 1/2" 105 diflunisal 7 maleate 148

Index 12 DROPLET INSULIN DRUG MART UNILET EASY COMFORT PEN SYRINGE/U-100/1ML/31G X LANCETSSUPER THIN NEEDLES31GX5/16" 106 5/16" 105 30G 91 EASY COMFORT PEN DROPLET LANCETS ULTRA DRUG MART UNILET NEEDLES32GX5/32" 106 THIN 30G 91 LANCETSULTRA THIN EASY FLOW BLACK/BLUE133 DROPLET LANCING 28G 91 EASY FLOW DEVICE 91 DRYMAX EXTRA 86 BLACK/ORANGE 133 DROPLET PEN NEEDLES 29G DULCOLAX 83 EASY FLOW BLACK/RED 133 X1/2" 105 DROPLET PEN NEEDLES duloxetine hcl 20 EASY FLOW 29GX12MM 105 DUPIXENT 58 BLACK/WHITE 133 DROPLET PEN NEEDLES 30G EASY FLOW DURAGESIC 7 BLACK/YELLOW 133 X 5/16" 106 DUREX EXTRA DROPLET PEN NEEDLES 31G EASY FLOW WHITE/BLUE 133 SENSITIVE 88 X3/16" 106 EASY FLOW DROPLET PEN NEEDLES 31G DWELLE 147 WHITE/GREEN 133 X5/16" 106 DYANAVEL XR 1 EASY FLOW WHITE/PINK 133 DROPLET PEN NEEDLES DYAZIDE 71 EASY FLOW 31GX5MM 106 DYSPORT 145 WHITE/WHITE 133 DROPLET PEN NEEDLES EASY FLOW 31GX6MM 106 E-Z JECT LANCETS 91 WHITE/YELLOW 133 DROPLET PEN NEEDLES E-Z JECT LANCETS 21G 91 EASY MINI EJECT LANCING 31GX8MM 106 E-Z JECT LANCETS DEVICE 91 DROPLET PEN NEEDLES 32G COLOR 91 EASY MINI LANCING X 1/4" 106 E-Z JECT LANCETS SUPER DEVICE 91 DROPLET PEN NEEDLES 32G THIN 30G 91 EASY TOUCH 32GX6MM 106 X 3/16" 106 E-Z JECT LANCETS THIN EASY TOUCH ALCOHOL PREP DROPLET PEN NEEDLES 32G 26G 91 PADS/MEDIUM 99 X 5/32" 106 E-ZJECT LANCETS MICRO- EASY TOUCH FLIPLOCK DROPLET PEN NEEDLES THIN 33G 91 SAFETY INSULIN SYRINGE 32GX4MM 106 E.E.S. GRANULES 84 1ML/29GX1/2" 106 DROPLET PEN NEEDLES EASY TOUCH FLIPLOCK 32GX6MM 106 EASIVENT 133 EASIVENT/MASK-LARGE SAFETY INSULIN SYRINGE DROPSAFE SAFETY PEN 1ML/30GX1/2" 106 NEEDLES/31G X 5/16" 106 133 EASIVENT/MASK-MEDIUM EASY TOUCH FLIPLOCK DROPSAFE SAFTEY PEN SAFETY INSULIN SYRINGE NEEDLES/31G X 1/4" 106 133 EASIVENT/MASK-SMALL 1ML/30GX5/16" 106 drospirenone-ethinyl EASY TOUCH FLIPLOCK estradiol 49 133 EASY COMFORT INSULIN SAFETY INSULIN SYRINGE DROXIA 78 1ML/31GX5/16" 106 DRUG MART ADJUSTABLE SYRINGE/0.5ML/30G X 5/16" 106 EASY TOUCH INSULIN LANCING DEVICE 91 SYRINGE/0.3ML/30G X DRUG MART LANCETS EASY COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" 106 THIN 91 EASY TOUCH INSULIN DRUG MART ON-THE-GO 5/16" 106 EASY COMFORT INSULIN SYRINGE/0.3ML/31G X LANCETS GENTLE 30G 91 5/16" 106 DRUG MART UNIFINE PENTIPS SYRINGE/1ML/30G X 5/16" 106 EASY TOUCH INSULIN 31GX5MM 106 SYRINGE/0.5ML/29G X DRUG MART UNIFINE EASY COMFORT INSULIN SYRINGE/1ML/31G X 1/2" 106 PENTIPS29G X 12MM 106 EASY TOUCH INSULIN DRUG MART UNIFINE 5/16" 106 EASY COMFORT INSULIN SYRINGE/0.5ML/30G X PENTIPS31GX6MM 106 5/16" 107 DRUG MART UNIFINE SYRINGE/U-100/1ML/30G X 1/2" 106 EASY TOUCH INSULIN PENTIPS31GX8MM 106 SYRINGE/1ML/30G X DRUG MART UNIFINE EASY COMFORT PEN NEEDLES31GX1/4" 106 5/16" 107 PENTIPS32GX4MM 106 EASY TOUCH INSULIN DRUG MART UNIFINE EASY COMFORT PEN NEEDLES31GX3/16" 106 SYRINGE/SAFETY/U- PENTIPSPLUS 32GX4MM 106 100/0.5ML/29G X 1/2" 107

Index 13 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES ELIDEL 64 SYRINGE/SAFETY/U- 29GX1/2" 107 ELIGARD 33 100/0.5ML/30G X 5/16" 107 EASY TOUCH PEN NEEDLES EASY TOUCH INSULIN 31GX1/4" 107 ELIMITE 68 SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLES ELIQUIS 15 100/1ML/29G X 1/2" 107 31GX5/16" 107 ELIQUIS STARTER PACK 15 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES ELITE-THIN INSULIN SYRINGE/SAFETY/U- 32GX1/4" 107 SYRINGE/0.3ML/31G X 100/1ML/30G X 1/2" 107 EASY TOUCH PEN NEEDLES 5/16" 107 EASY TOUCH INSULIN 32GX5/32" 107 ELITE-THIN INSULIN SYRINGE/U-100/0.3ML/30G X EASY TOUCH PEN SYRINGE/0.5ML/29G X 107 1/2" 107 NEEDLES/31G X 3/16" 1/2" 107 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X LANCETS21G/PRESSURE SYRINGE/0.5ML/30G X 92 1/2" 107 ACTIVATED 5/16" 107 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/29G X LANCETS28G/BUTTON SYRINGE/1ML/30G X 92 1/2" 107 ACTIVATED 5/16" 108 EASY TOUCH INSULIN EASY TOUCH SAFETY PEN ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X NEEDLES/30G X 5/16" 107 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/28G X 5/16" 107 1/2" 108 EASY TOUCH INSULIN SAFETY INSULIN SYRINGE ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X 1ML/29GX1/2" 107 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/31G X 1/2" 107 5/16" 108 EASY TOUCH INSULIN SAFETY INSULIN SYRINGE ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X 1ML/30GX5/16" 107 EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/28G X 1/2" 107 1/2" 108 EASY TOUCH INSULIN SAFETY INSULIN SYRINGE ELITE-THIN INSULIN SYRINGE/U-100/1ML/30G X 1ML/31GX5/16" 107 EASY TOUCH SHEATHLOCK SYRINGE/U-100/1ML/29G X 1/2" 107 1/2" 108 EASY TOUCH INSULIN SAFETY SYRINGE ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X 1ML/30GX1/2" 107 EASY TWIST & CAP SYRINGE/U-100/1ML/31G X 5/16" 107 5/16" 108 EASY TOUCH LANCETS LANCETS 92 26G/PULL-TOP 91 EC-NAPROSYN 5 ELIXOPHYLLIN 15 EASY TOUCH LANCETS econazole nitrate 55 ELLA 49 28G/PULL-TOP 91 ECOTRIN 7 ELMIRON 76 EASY TOUCH LANCETS ELOCON 57 28G/TWIST 91 ECOTRIN REGULAR EASY TOUCH LANCETS STRENGTH 7 ELOCTATE 77 30G/BUTTON-ACTIVATED 91 ED BRON GP 52 ELON SKIN REPAIR EASY TOUCH LANCETS EDLUAR 81 SYSTEM 60 EMBRACE LANCING DEVICE 30G/PULL-TOP 91 EDURANT 41 EASY TOUCH LANCETS WITH EJECTOR 92 30G/TWIST 91 efavirenz 41 EMCYT 33 EASY TOUCH LANCETS efavirenz-emtricitabine- EMEND 25 32G/PRESSURE tenofovir disoproxil ACTIVATED 91 fumarate 41 EMGALITY 135 EASY TOUCH LANCETS efavirenz-lamivudine-tenofovir EMOLLIA-CREME 60 32G/PULL-TOP 91 disoproxil fumarate 41 EMOLLIA-LOTION 60 EASY TOUCH LANCETS EFFEXOR XR 20,21 emollient 60 32G/TWIST 91 EFFIENT 78 EASY TOUCH LANCETS EMSAM 19 33G/TWIST 92 EFUDEX 56 emtricitabine 41 EASY TOUCH LANCING EGRIFTA 72 emtricitabine-tenofovir disoproxil DEVICE/EJECTOR 92 EGRIFTA SV 72 fumarate 41 EASY TOUCH PEN NEEDLE ELAPRASE 73 EMTRIVA 41 30G X 5/16" 107 eletriptan hydrobromide 135 EMVERM 11

Index 14 enalapril maleate 28 EQL INSULIN ESPEROCT 77 enalapril maleate & SYRINGE/0.3ML/30G X estazolam 81 5/16" 108 hydrochlorothiazide 30 ESTRACE 74,163 ENBREL 6 EQL INSULIN SYRINGE/0.3ML/31G X estradiol 74 ENBREL MINI 6 5/16" 108 estradiol & norethindrone ENBREL SURECLICK 6 EQL INSULIN acetate 74 ENFAMIL ENFALYTE 137 SYRINGE/0.5ML/29G X estradiol vaginal 163 1/2" 108 ENFAMIL EXPECTA 141 EQL INSULIN ESTROSTEP FE 49 ENGERIX-B 160 SYRINGE/0.5ML/30G X eszopiclone 81 ENLYTE 70 5/16" 108 ethambutol hcl 31 enoxaparin sodium 15 EQL INSULIN ethosuximide 18 SYRINGE/0.5ML/31G X entecavir 44 ethynodiol diacet & eth 5/16" 108 estrad 49 ENTYVIO 75 EQL INSULIN etidronate disodium 72 EPCLUSA 44 SYRINGE/1ML/29G X etodolac 5 EPIFOAM 57 1/2" 108 EQL INSULIN etonogestrel-ethinyl estradiol49 EPILYT 60 SYRINGE/1ML/30G X etoposide 35 epinephrine (anaphylaxis) 163 5/16" 108 EUCERIN 60 EPIPEN 2-PAK 163 EQL INSULIN SYRINGE/1ML/31G X EUCERIN ADVANCED EPIPEN-JR 2-PAK 163 5/16" 108 REPAIR 60 EPIVIR 41,42 EQL MOISTURIZING EUCERIN BABY 60 EPOGEN 79 CREAM 60 EUCERIN CALMING DAILY epoprostenol sodium 47 EQL PRENATAL MOISTURIZER 60 FORMULA 141 EUCERIN DAILY EPZICOM 42 EQL SUPER THIN LANCETS PROTECTION/SPF 30 60 EQ SPACE CHAMBER ANTI- 30G 92 EUCERIN INTENSIVE STATIC 133 EQL THIN LANCETS 26G 92 REPAIR 60 EQ SPACE CHAMBER ANTI- EQL ULTRA MOISTURIZING EUCERIN INTENSIVE STATIC/LARGE MASK 133 REPAIRHAND 60 EQ SPACE CHAMBER ANTI- DAILY LOTION 60 EQUALYTE 137 EUCERIN ORIGINAL STATIC/MEDIUM MASK 133 HEALINGSOOTHING EQ SPACE CHAMBER ANTI- EQUETRO 37 REPAIR 60 STATIC/SMALL MASK 133 ERBITUX 33 EUCERIN PLUS 61 EQ THERAPEUTIC DRY ergocalciferol 163 SKIN 60 EUCERIN PROFESSIONAL EQ THERAPEUTIC ergoloid mesylates 155 REPAIR RICH FEEL 61 MOISTURIZING CREAM 60 ERIVEDGE 33 EUCERIN ROUGHNESS RELIEF 61 EQL ADVANCED RECOVERY ERLEADA 33 SKIN CARE 60 EUCERIN SKIN CALMING erlotinib hcl 33 DAILY MOISTURIZING 61 EQL ALCOHOL SWABS 99 ERYGEL 54 EUCERIN SMOOTHING EQL CALCIUM/VITAMIN D 137 REPAIRADVANCED 84 EQL COLOR LANCETS 21G92 ERYPED 200 FORMULA 61 EQL COLOR LANCETS MICRO ERYPED 400 84 EURAX 68 THIN 33G 92 erythromycin (acne aid) 54 EVAC 82 EQL GAUZE PADS erythromycin (ophth) 148 EVEKEO 1 2"X2"/SMALL 86 EQL GAUZE PADS erythromycin base 84 EVEKEO ODT 1 4"X4"/LARGE 87 erythromycin everolimus 34 ethylsuccinate 84 EQL GAUZE STERILE PADS everolimus 3"X3" 87 ESBRIET 156 (immunosuppressant) 139 EQL INSULIN escitalopram oxalate 19 EVISTA 73 SYRINGE/0.3ML/29G X ESGIC 6 1/2" 108 EVOTAZ 42 esomeprazole EVRYSDI 145 magnesium 158

Index 15 EX-LAX 83 EXONDYS 51 145 FERROUS SULFATE 79 EXCEDRIN EXTRA EYLEA 148 ferrous sulfate 79 STRENGTH 6 EZ-LETS LANCETS 21G 92 FETZIMA 21 EXCEDRIN MIGRAINE 6 EZ-LETS LANCETS 26G FETZIMA TITRATION PACK21 EXCEDRIN PM 80 SUPER-SOFT 92 FEVERALL INFANTS 7 EXCILON AMD EZ-LETS LANCETS 28G ANTIMICROBIALDRAIN ULTRA-SOFT 92 FEVERALL JUNIOR STRENGTH 7 SPONGES 4"X4" 6 PLY 87 EZ-LETS LANCETS 30G 92 fexofenadine hcl 27 EXCILON AMD ezetimibe 28 ANTIMICROBIALNON-WOVEN FIBERCON 82 ezetimibe-simvastatin 27 SPONGES 4"X4" 6 PLY 87 FIBRICOR 27 EXCILON DRAIN SPONGE FABRAZYME 73 FIBRYGA 77 4"X4" 87 FACE COTZ 67 EXCILON DRAIN SPONGES FIFTY50 ALCOHOL PREP 4"X4" 6 PLY 87 famciclovir 44 PADS 99 EXCILON I.V. SPONGES 2"X2" 6 famotidine 157 FIFTY50 PEN NEEDLES 31G PLY 87 FANAPT 37 X3/16" (5MM) 108 FIFTY50 PEN NEEDLES 31G EXEL COMFORT POINT FANAPT TITRATION INSULIN PEN NEEDLES 29G X X5/16" (8MM) 108 PACK 37 FIFTY50 PEN NEEDLES 12MM 108 FANTASY LUBRICATED 88 EXEL COMFORT POINT 31GX5MM 108 FANTASY FIFTY50 PEN INSULIN PEN NEEDLES 31G X LUBRICATED/SPERMICIDE 6MM 108 NEEDLES/31GX8MM 109 EXEL COMFORT POINT 88 FIFTY50 PEN INSULIN PEN NEEDLES 31G X FARESTON 33 NEEDLES/32GX4MM 109 8MM 108 FARYDAK 34 FIFTY50 PEN EXEL COMFORT POINT NEEDLES/32GX6MM 109 FASENRA 14 FIFTY50 SAFETY SEAL INSULIN SYRINGE/0.3ML/29G X FASLODEX 33 1/2" 108 LANCETS 32G 92 EXEL COMFORT POINT FAZACLO 38 FIFTY50 SUPERIOR INSULIN SYRINGE/0.3ML/30G X FE GLUCONATE 79 COMFORTINSULIN SYRINGE/0.3ML/31G X 5/16" 108 FEIBA 77 EXEL COMFORT POINT 5/16" 109 INSULIN SYRINGE/0.5ML/28G X felbamate 18 FIFTY50 SUPERIOR 1/2" 108 FELBATOL 18 COMFORTINSULIN EXEL COMFORT POINT SYRINGE/0.5ML/31G X FELDENE 5 5/16" 109 INSULIN SYRINGE/0.5ML/29G X felodipine 46 1/2" 108 FIFTY50 SUPERIOR EXEL COMFORT POINT FEMARA 33 COMFORTINSULIN INSULIN SYRINGE/0.5ML/30G X FEMHRT 74 SYRINGE/1ML/31G X 5/16" 109 5/16" 108 fenofibrate 27 EXEL COMFORT POINT FIFTY50 UNILET LANCETS INSULIN SYRINGE/1ML/28G X fenofibrate micronized 27 33G 92 1/2" 108 FENSOLVI 73 finasteride 76 EXEL COMFORT POINT fentanyl 7 FINE 30 92 INSULIN SYRINGE/1ML/29G X FENTORA 7 FINGERSTIX LANCETS 92 1/2" 108 EXEL COMFORT POINT FER-IN-SOL 79 FINTEPLA 16 INSULIN SYRINGE/1ML/30G X FERRETTS 79 FIORINAL 6 5/16" 108 ferrous fumarate-fa-b complex- FIORINAL/CODEINE #3 8 EXELDERM 55 c-zn-mg-mn-cu 79 FIRAZYR 78 FERROUS GLUCONATE 79 EXELON 154 FIRMAGON 33 ferrous gluconate 79 exemestane 33 FIRVANQ 12 ferrous sulfate 79 EXFORGE 30 FLAGYL 11 FERROUS SULFATE 79 EXFORGE HCT 30 FLAVOR BLEND 152 ferrous sulfate 79 EXJADE 25 FLAVOR PLUS 152

Index 16 FLAVOR SWEET 152 fluconazole 26 fondaparinux sodium 15 FLAVOR SWEET-SF 152 fludrocortisone acetate 51 FORA LANCETS 92 flavoxate hcl 159 FLULAVAL QUADRIVALENT FORA LANCING DEVICE 92 FLEBOGAMMA DIF 151 2018-2019 161 FORA LANCING FLULAVAL QUADRIVALENT flecainide acetate 14 DEVICE/CLEARCAP 92 2019-2020 161 FORFIVO XL 19 FLECTOR 54 FLULAVAL QUADRIVALENT formaldehyde 41 FLEET ENEMA 83 2020-2021 161 FOSAMAX 72 FLEET ENEMA SIX PACK 83 FLUMADINE 44 FLUMIST fosamprenavir calcium 42 FLEET PEDIATRIC 83 QUADRIVALENT 161 fosinopril sodium 28 FLEXICHAMBER 133 flunisolide (nasal) 144 fosinopril sodium & FLINTSTONES GUMMIES 140 fluocinolone acetonide hydrochlorothiazide 30 FLINTSTONES GUMMIES (otic) 151 FOSTEUM PLUS 70 COMPLETE 141 fluocinonide 57 FRAGMIN 15 FLINTSTONES GUMMIES fluocinonide emulsified PLUSIMMUNITY FREDS PHARMACY AUTOLET base 57 LANCING DEVICE 92 SUPPORT/EXTRA C 141 fluorometholone (ophth) 149 FLINTSTONES SOUR FREDS PHARMACY UNIFINE GUMMIES 141 fluorouracil (topical) 56 PENTIPS PEN NEEDLES FLINTSTONES fluoxetine hcl 19 32GX4MM 109 TODDLER/TASTISMOOTH FREDS PHARMACY UNIFINE FLUOXETINE HCL 48 PENTIPS PLUS 31GX5MM 109 141 fluoxetine hcl (pmdd) 155 FLOLAN 47 FREDS PHARMACY UNIFINE FLUOXETINE PENTIPS PLUS 31GX8MM 109 FLOMAX 76 HYDROCHLORIDE 19 FREDS PHARMACY UNILET FLONASE ALLERGY fluphenazine decanoate 39 LANCETS SUPER THIN RELIEF 144 fluphenazine hcl 39,40 30G 92 FLONASE ALLERGY RELIEF FREDS PHARMACY UNILET CHILDRENS 144 flurazepam hcl 81 LANCETS ULTRA THIN FLOVENT DISKUS 14 flurbiprofen 5 28G 92 FLOVENT HFA 14 flurbiprofen sodium 150 FREESTYLE INSULINX BLOODGLUCOSE TEST 69 FLOXIN OTIC 150 flutamide 33 FREESTYLE INSULINX FLUAD 2018-2019 160 fluticasone propionate 57 BLOODGLUCOSE TEST FLUAD 2019-2020 160 fluticasone propionate STRIPS 69 FLUAD 2020-2021 160 (nasal) 144 FREESTYLE LITE TEST fluticasone-salmeterol 15 STRIPS 69 FLUAD QUADRIVALENT FREESTYLE PRECISION INFLUENZA VACCINE FOR fluvoxamine maleate 19 FLUZONE HIGH-DOSE PF INSULIN SYRINGE/U- ADULTS 160 100/0.5ML/30G X 5/16" 109 FLUARIX QUADRIVALENT 2018-2019 161 FLUZONE HIGH-DOSE PF FREESTYLE PRECISION 2018-2019 160 INSULIN SYRINGE/U- FLUARIX QUADRIVALENT 2019-2020 161 100/0.5ML/31G X 5/16" 109 2019-2020 160 FLUZONE HIGH-DOSE PF 2020-2021 161 FREESTYLE PRECISION FLUARIX QUADRIVALENT INSULIN SYRINGE/U- 2020-2021 160 FLUZONE QUADRIVALENT FLUBLOK QUADRIVALENT 2018-2019 161 100/1ML/31G X 5/16" 109 FREESTYLE PRECISION 2018-2019 160 FLUZONE QUADRIVALENT FLUBLOK QUADRIVALENT 2019-2020 161 INSULIN SYRINGES/U- 2019-2020 160 FLUZONE QUADRIVALENT 100/1ML/30G X 5/16" 109 FLUBLOK QUADRIVALENT 2020-2021 161 FREESTYLE TEST STRIPS 70 2020-2021 160 FML 149 FRESHKOTE 147 FLUCELVAX QUADRIVALENT FML LIQUIFILM 149 FULPHILA 79 2018-2019 160 FLUCELVAX QUADRIVALENT FOCALIN 2 FURADANTIN 12 2019-2020 160 FOCALIN XR 3 furosemide 71 FLUCELVAX QUADRIVALENT folic acid 79 FUSILEV 35 2020-2021 161

Index 17 FUZEON 42 GENTEEL PLUS LANCING GLOBAL INJECT EASE INSULIN G-ZYNCOF 52 DEVICE/PRINCESS PINK 92 SYRINGE/U-100/0.3ML/30G X GENTEEL PLUS LANCING 5/16" 109 GABADONE 70 DEVICE/WILLOWY GLOBAL INJECT EASE INSULIN gabapentin 16 WHITE 92 SYRINGE/U-100/0.3ML/31G X GABITRIL 18 GENTLE 61 5/16" 109 GLOBAL INJECT EASE INSULIN GALAFOLD 73 GENTLE SKIN CLEANSER 65 SYRINGE/U-100/0.5ML/28G X galantamine hydrobromide 154 GENTLE-LET GP 1/2" 109 GAMASTAN 151 LANCETS 92 GLOBAL INJECT EASE INSULIN GAMMAGARD LIQUID 151 GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/29G X GAMMAGARD S/D IGA LESS GENERAL PURPOSE 1/2" 109 STYLE/FINE POINT 92 GLOBAL INJECT EASE INSULIN THAN 1MCG/ML 151 SYRINGE/U-100/0.5ML/30G X GAMMAKED 151 GENTLE-LET LANCETS GENERAL PURPOSE 5/16" 110 GAMMAPLEX 151 STYLE/MEDIUM POINT 92 GLOBAL INJECT EASE INSULIN GAMUNEX-C 151 GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/31G X GARDASIL 9 161 SAFETY STYLE/FINE 5/16" 110 POINT 92 GLOBAL INJECT EASE INSULIN GAS-X 75 GENTLE-LET LANCETS SYRINGE/U-100/1ML/28G X GATTEX 76 SAFETY STYLE/MEDIUM 1/2" 110 GAUZE DRESSING 4"X4" 87 POINT 92 GLOBAL INJECT EASE INSULIN GENVOYA 42 SYRINGE/U-100/1ML/29G X GAUZE PADS 2"X2" 87 1/2" 110 GAUZE PADS 3"X3" 87 GEODON 37 GLOBAL INJECT EASE INSULIN GAUZE PADS 4"X4" 87 GILENYA 155 SYRINGE/U-100/1ML/30G X GAUZE SPONGE TYPE VII GILOTRIF 33 1/2" 110 MEDI-PAK 2"X2" 8PLY 87 GLASSIA 156 GLOBAL INJECT EASE INSULIN GAUZE SPONGES 4"X4" 12 SYRINGE/U-100/1ML/30G X PLY 87 glatiramer acetate 155 5/16" 110 GAVISCON 10 GLEEVEC 34 GLOBAL INJECT EASE INSULIN GAVISCON EXTRA glimepiride 24 SYRINGE/U-100/1ML/31G X 10 5/16" 110 STRENGTH glipizide 24 GLOBAL INSULIN SYRINGE/U- GAVISCON EXTRA STRENGTH glipizide-metformin hcl 22 RELIEF FORMULA 10 100/0.3ML/30G X 1/2" 110 GLOBAL EASE INJECT PEN GLOBAL INSULIN SYRINGES/U- GELUSIL 10 NEEDLES 29GX12MM 109 100/0.3ML/30GX5/16" 110 GEMCITABINE GLOBAL EASE INJECT PEN GLOBAL LANCING DEVICE 93 HYDROCHLORIDE 32 NEEDLES 31GX8MM 109 GLUCAGEN DIAGNOSTIC 69 gemfibrozil 27 GLOBAL EASE INJECT PEN GENERESS FE 49 NEEDLES 32GX4MM 109 GLUCAGEN HYPOKIT 23 GENOTROPIN 72 GLOBAL EASE INJECT PEN glucagon (rdna) 23 NEEEDLES 31GX5MM 109 GLUCAGON EMERGENCY GENOTROPIN MINIQUICK 72 GLOBAL EASY GLIDE KIT 23 gentamicin sulfate (ophth) 148 INSULIN SYRINGE/0.3ML/31G GLUCOCOM LANCETS gentamicin sulfate (topical) 54 X 15/64" 109 33G 93 GENTEEL LANCING GLOBAL EASY GLIDE GLUCOPRO INSULIN DEVICE/GLORIOUS GOLD 92 INSULINSYRINGE/U- SYRINGE/U-100/0.3ML/30G X GENTEEL LANCING 100/0.3ML/31G X 5/16" 109 1/2" 110 DEVICE/PRECIOUS GLOBAL EASY GLIDE PEN GLUCOPRO INSULIN PLATINUM 92 NEEDLES 32GX4MM 109 SYRINGE/U-100/0.3ML/30G X GENTEEL LANCING GLOBAL INJECT EASE 5/16" 110 DEVICE/STATELY SILVER 92 INSULIN SYRINGE/U- GLUCOPRO INSULIN GENTEEL PLUS LANCING 100/0.3ML/29G X 1/2" 109 SYRINGE/U-100/0.3ML/31G X DEVICE/BUFF BLACK 92 GLOBAL INJECT EASE 5/16" 110 GENTEEL PLUS LANCING INSULIN SYRINGE/U- GLUCOPRO INSULIN DEVICE/BUTTERFLY BLUE 92 100/0.3ML/30G X 1/2" 109 SYRINGE/U-100/0.5ML/30G X GENTEEL PLUS LANCING 5/16" 110 DEVICE/PLAYFUL PURPLE 92

Index 18 GLUCOPRO INSULIN GNP INSULIN GOLD BOND ULTIMATE SYRINGE/U-100/0.5ML/31G X SYRINGE/1ML/29G X DIABETICS' DRY RELIEF 61 5/16" 110 1/2" 111 GOLD BOND ULTIMATE GLUCOPRO INSULIN GNP INSULIN HEALING 61 SYRINGE/U-100/1ML/30G X SYRINGE/1ML/30G X GOLD BOND ULTIMATE 1/2" 110 5/16" 111 OVERNIGHT 61 GLUCOPRO INSULIN GNP INSULIN GOLD BOND ULTIMATE SYRINGE/U-100/1ML/30G X SYRINGE/1ML/31G X PROTECTION 61 5/16" 110 5/16" 111 GOLD BOND ULTIMATE GLUCOPRO INSULIN GNP LANCETS 21G 93 RESTORING 61 SYRINGE/U-100/1ML/31G X GNP LANCETS MICRO THIN GOLD BOND ULTIMATE 5/16" 110 33G 93 ROUGH& BUMPY SKIN 61 GLUCOSE 23 GNP LANCETS SUPER THIN GOLD BOND ULTIMATE 30G 93 SHEERRIBBONS GLUCOTROL 24 PEARLRADIANCE 61 GLUCOTROL XL 24 GNP LANCETS THIN 93 GOLD BOND ULTIMATE glyburide 24 GNP LANCETS THIN 26G 93 SHEERRIBBONS glyburide micronized 24 GNP PRENATAL 141 SILKSOFTNESS 61 GOLD BOND ULTIMATE glyburide-metformin 22 GNP QUICK DISSOLVE GLUCOSE 23 SOFTENING 61 glycerin (laxative) 83 GNP ULTICARE PEN GOLD BOND ULTIMATE glycerin (topical) 61 NEEDLES/31GX5/16" 111 SOOTHING 61 GLYCERIN ADULT 83 GNP ULTICARE PEN GOLYTELY 82 NEEDLES/32GX 5/32" 111 glycine diluent 152 GONIOVISC 147 GNP ULTICARE PEN GOODSENSE CLICKFINE glycopyrrolate 157 NEEDLES/32GX1/4" 111 SAFETY PEN NEEDLE/31G X GLYNASE 24 GNP ULTICARE PEN 3/16" 111 GNP ALCOHOL SWABS 99 NEEDLES31G X 5MM 111 GOODSENSE LANCETS GNP ULTRA COMFORT MICRO-THIN 33G 93 GNP CHILDRENS COMPLETE INSULIN SYRINGE/0.3ML/29G CHEWABLES 141 GOODSENSE LANCETS X 1/2" 111 ULTRA-THIN 30G 93 GNP CLICKFINE UNIVERSAL GNP ULTRA COMFORT PEN NEEDLES 31GX1/4" 110 GOODSENSE LANCING INSULIN SYRINGE/0.3ML/30G DEVICE 93 GNP CLICKFINE UNIVERSAL X 5/16" SHORT 111 PEN NEEDLES 31GX5/16" 110 GOODSENSE PEN GNP ULTRA COMFORT NEEDLE/PENFINE GNP GLUCOSE 23 INSULIN SYRINGE/0.5ML/28G GNP INSULIN CLASSIC/31G X 3/16" 111 X 1/2" 111 GOODSENSE PEN SYRINGE/0.3ML/29G X GNP ULTRA COMFORT 1/2" 110 NEEDLE/PENFINE INSULIN SYRINGE/0.5ML/29G CLASSIC/31G X 5/16" 111 GNP INSULIN X 1/2" 111 SYRINGE/0.3ML/30G X GOODSENSE PEN GNP ULTRA COMFORT NEEDLE/PENFINE 5/16" 110 INSULIN SYRINGE/1ML/28G X GNP INSULIN CLASSIC/32G X 1/4" 111 1/2" 111 GOODSENSE PEN SYRINGE/0.3ML/31G X GNP ULTRA COMFORT 5/16" 110 NEEDLE/PENFINE INSULIN SYRINGE/1ML/29G X CLASSIC/32G X 5/32" 111 GNP INSULIN 1/2" 111 SYRINGE/0.5ML/28G X GOODSENSE PRENATAL GOJJI LANCING VITAMINS 141 1/2" 110 DEVICE/CLEAR CAP 93 GNP INSULIN GOJJI STERILE LANCETS GRAPE SYRUP 152 SYRINGE/0.5ML/29G X 30G 93 griseofulvin microsize 25 1/2" 110 GOLD BOND MEDICATED griseofulvin ultramicrosize 25 GNP INSULIN BODYLOTION 61 GRX VITAMIN E 61 SYRINGE/0.5ML/30G X GOLD BOND MEDICATED 5/16" 110 BODYLOTION EXTRA guaifenesin 53 GNP INSULIN STRENGTH 61 guaifenesin-codeine 52 SYRINGE/0.5ML/31G X GOLD BOND ULTIMATE 61 guanfacine hcl 29 5/16" 110 GOLD BOND ULTIMATE GNP INSULIN guanfacine hcl (adhd) 2 DIABETICS DRY SKIN GVOKE HYPOPEN 1-PACK 23 SYRINGE/1ML/28G X 1/2" 110 RELIEF 61

Index 19 GVOKE HYPOPEN 2-PACK 23 HALDOL DECANOATE HEALTHY ACCENTS UNIFINE GVOKE PFS 23 100 38 PENTIPS PEN NEEDLES HALDOL DECANOATE 50 38 31GX8MM 112 GYNAZOLE-1 162 haloperidol 38 HEALTHY ACCENTS UNIFINE GYNE-LOTRIMIN 162 PENTIPS PEN NEEDLES HALOPERIDOL 48 GYNE-LOTRIMIN 3 162 32GX4MM 112 H-E-B IN CONTROL PEN haloperidol decanoate 38 HEALTHY ACCENTS UNILET NEEDLE 31GX3/16" 111 haloperidol lactate 38 LANCETS SUPER THIN H-E-B IN CONTROL PEN HARVONI 44 30G 93 HEALTHY KIDS GUMMIES141 NEEDLES 31GX5MM 111 HAVRIX 161 H-E-B IN CONTROL PEN HEALTHY MAMA BE WELL NEEDLES 31GX6MM 111 HEALTH CARE LANCING ROUNDED 141 H-E-B IN CONTROL PEN DEVICE 93 HEALTHWISE INSULIN HELIXATE FS 77 NEEDLES 31GX8MM 111 HEMANGEOL 45 H-E-B IN CONTROL PEN SYRINGE/U-100/0.3ML/30G X NEEDLES/NANO/32GX4MM 5/16" 112 HEMLIBRA 77 111 HEALTHWISE INSULIN HEMOFIL M 77 H-E-B IN CONTROL SYRINGE/U-100/0.3ML/31G X 5/16" 112 HEPAGAM B 151 UNIFINEPENTIPS PLUS HEPARIN LOCK FLUSH 15 31GX1/4" 111 HEALTHWISE INSULIN H-E-B IN CONTROL SYRINGE/U-100/0.5ML/30G X heparin sodium (porcine) 16 UNIFINEPENTIPS PLUS 5/16" 112 heparin sodium (porcine) lock 31GX3/16" 111 HEALTHWISE INSULIN flush 15 H-E-B IN CONTROL SYRINGE/U-100/0.5ML/31G X HEPARIN SODIUM/SODIUM UNIFINEPENTIPS PLUS 5/16" 112 CHLORIDE 0.9% 16 31GX5/16" 111 HEALTHWISE INSULIN HEPSERA 44 SYRINGE/U-100/1ML/30G X H-E-B IN CONTROL HETLIOZ 82 UNIFINEPENTIPS PLUS 5/16" 112 31GX5MM 111 HEALTHWISE INSULIN HETLIOZ LQ 82 H-E-B IN CONTROL SYRINGE/U-100/1ML/31G X HIBERIX 159 UNIFINEPENTIPS PLUS 5/16" 112 HEALTHWISE MICRON PEN HIBICLENS 41 32GX4MM 111 HIZENTRA 151 H-E-B IN CONTROL NEEDLES/32G X 5/32" 112 HEALTHWISE MINI PEN HM ADHESIVE PADS UNIFINEPENTIPS PLUS ANTIBACTERIAL/SHEER 87 32GX5/32" 111 NEEDLES 31GX6MM 112 HEALTHWISE PEN NEEDLES HM ONE DAILY PRENATAL H-E-B INCONTROL COMBO 141 ADVANCEDLANCING 29GX12MM 112 HEALTHWISE SHORT PEN DEVICE 93 HM PRENATAL 141 H-E-B INCONTROL ALCOHOL NEEDLES 31GX8MM 112 HM STERILE ALCOHOL PREP HEALTHWISE SHORT PEN PADS 99 PADS 99 NEEDLES/31G X 3/16" 112 HM STERILE PADS 87 H-E-B INCONTROL LANCETS HEALTHWISE SHORT PEN MICRO THIN 33G 93 NEEDLES/31G X 5/16" 112 HM STERILE PADS 2"X2" 87 H-E-B INCONTROL LANCETS HEALTHWISE UNIFINE HM ULTICARE INSULIN SUPER THIN 30G 93 PENTIPS PEN NEEDLES SYRINGE/1ML/30G X 1/2" 112 H-E-B INCONTROL LANCETS HM ULTICARE INSULIN ULTRA THIN 28G 93 32GX4MM 112 HEALTHY ACCENTS SYRINGE/U-100/0.3ML/31G X H-E-B INCONTROL PEN 5/16" 112 NEEDLES 29GX12MM 112 AUTOLET IMPRESSION LANCING DEVICE 93 HM ULTICARE MINI PEN HAEMOLANCE 93 HEALTHY ACCENTS UNIFINE NEEDLES/31G X 5MM HAEMOLANCE LOW FLOW PENTIPS PEN NEEDLES (3/16") 112 LANCETS 93 29GX12MM 112 HM ULTICARE SHORT PEN HAEMOLANCE PLUS 93 HEALTHY ACCENTS UNIFINE NEEDLES 31GX8MM 112 HAEMOLANCE PLUS LOW PENTIPS PEN NEEDLES homeopathic products 139 FLOW 93 31GX5MM 112 HONEY BEARS W/IRON AND HALAVEN 35 HEALTHY ACCENTS UNIFINE ZINC 140 HALCION 81 PENTIPS PEN NEEDLES HUGGIES LITTLE SWIMMERS 31GX6MM 112 SPF50 67 HALDOL 38 HUMALOG MIX 50/50 23

Index 20 HUMALOG MIX 50/50 hydrocortisone 50 imipramine hcl 21 KWIKPEN 23 hydrocortisone (intrarectal) 10 imipramine pamoate 21 HUMALOG MIX 75/25 23 hydrocortisone (rectal) 10 imiquimod 64 HUMALOG MIX 75/25 KWIKPEN 23 hydrocortisone (topical) 57 IMITREX 135 HUMATE-P 77 HYDROCORTISONE IMITREX STATDOSE ACETATE/LIDOCAINE REFILL 135 HUMATROPE 72 HYDROCHLORIDE 57 IMITREX STATDOSE HUMATROPE COMBO hydrocortisone butyrate 57 SYSTEM 135 PACK 72 IMODIUM A-D 25 HUMATROPEN FOR hydrocortisone w/acetic 12MG 112 acid 151 IMURAN 139 HUMATROPEN FOR hydrocortisone-aloe vera 57 IN TOUCH LANCING 24MG 112 HYDROMORPHONE HCL 7 DEVICE 93 HUMATROPEN FOR 6MG 112 hydromorphone hcl 8 IN-CHECK DIAL INSPIRATORYFLOW HUMIRA 4 hydroxychloroquine sulfate 31 TRAINER 133 HUMIRA PEDIATRIC CROHNS hydroxyprogesterone IN-CHECK INSPIRATORY DISEASE STARTER PACK 4 caproate 154 FLOWMETER/NASAL WITH HUMIRA PEN 4 hydroxyprogesterone caproate MASK 133 HUMIRA PEN-CD/UC/HS (antineoplastic) 33 IN-CHECK INSPIRATORY STARTER 4 hydroxyurea 35 FLOWMETER/ORAL 133 HUMIRA PEN-PEDIATRIC UC hydroxyzine hcl 13 INCRELEX 73 STARTER PACK 4 HUMIRA PEN-PS/UV HYDROXYZINE HCL 48 INCRUSE ELLIPTA 14 STARTER 4 hydroxyzine pamoate 13 indapamide 71 HUMULIN 70/30 23 HYDROXYZINE INDERAL LA 45 HUMULIN 70/30 KWIKPEN 23 PAMOATE 13 INDERAL XL 45 hyoscyamine sulfate 157 HUMULIN N 24 indomethacin 5 HYPER-SAL 53 HUMULIN N KWIKPEN 24 INFANRIX 157 HYPERHEP B 151 HUMULIN R 24 INFANTS ADVIL 5 HYPERRHO S/D 151 HY-VEE LANCETS 93 INFLECTRA 76 HYPERRHO S/D MINI- HY-VEE THIN LANCETS 93 DOSE 151 INJECT-EASE 112 HYCAMTIN 35 HYPERSAL 53 INJECT-EASE AUTOMATIC HYCODAN 51 INJECTOR 112 HYPERTENSA 70 INLYTA 32 hydralazine hcl 31 HYPOTEARS 147 INNOPRAN XL 45 HYDRALYTE 137 HYQVIA 151 inositol 146 HYDRALYTE FREEZER HYVEE ADVANCED ANTACID POPS 137 MAXIMUM STRENGTH 11 INOSITOL-5 146 HYDRASYN25 61 HYZAAR 30 INSPIRACHAMBER/ANTI- HYDRAZONE LOTION 61 STATIC ibandronate sodium 72 VALVED/MOUTHPIECE 133 HYDREA 35 IBRANCE 34 INSPIRACHAMBER/LARGE HYDRO 35 58 ibuprofen 5 133 HYDROCELL ADHESIVE ibuprofen-diphenhydramine INSPIRACHAMBER/SOOTHER DRESSING 4"X4" 87 citrate 80 MASK/INSPIRAMASK/MEDIUM HYDROCELL DRESSING ibuprofen-diphenhydramine 133 4"X4" 87 hcl 80 INSPIRACHAMBER/SOOTHER HYDROCERIN 65 ICAPS LUTEIN & MASK/INSPIRAMASK/SMALL 133 hydrochlorothiazide 71 ZEAXANTHIN 140 icatibant acetate 78 INSPIREASE DRUG HYDROCIL INSTANT 82 DELIVERYSYSTEM 133 hydrocodone w/ ICLUSIG 34 INSPIREASE RESERVOIR homatropine 51 IDELVION 77 BAGS 133 hydrocodone- imatinib mesylate 34 acetaminophen 8,9 IMIPRAMINE HCL 21

Index 21 INSULIN ASPART INSULIN ISENTRESS 42 PROTAMINE/INSULIN SYRINGES/0.5ML/30GX5/16" ISENTRESS HD 42 ASPART 24 113 INSULIN ASPART INSULIN isoniazid 31 PROTAMINE/INSULIN ASPART SYRINGES/0.5ML/31GX ISOPTO ATROPINE 148 FLEXPEN 24 5/16" 113 ISOPTO CARPINE 148 INSULIN LISPRO INSULIN PROTAMINE/INSULIN LISPRO SYRINGES/0.5ML/31GX5/16" ISOPTO TEARS 147 KWIKPEN 24 113 ISORDIL TITRADOSE 12 INSULIN SYRINGE/0.3ML/29G X INSULIN isosorbide dinitrate 12 1/2" 112 SYRINGES/1ML/28GX1/2" isosorbide mononitrate 12 INSULIN SYRINGE/0.3ML/30G X 113 5/16" 113 INSULIN isotretinoin 54 INSULIN SYRINGE/0.3ML/31G X SYRINGES/1ML/29GX1/2" isoxsuprine hcl 47 5/16" 113 113 ISTODAX (OVERFILL) 34 INSULIN SYRINGE/0.5ML/28G X INSULIN ITCH RELIEF 56 1/2" 113 SYRINGES/1ML/30GX1/2" INSULIN SYRINGE/0.5ML/30G X 113 itraconazole 26 5/16" 113 INSULIN ivermectin 11 INSULIN SYRINGE/0.5ML/31G X SYRINGES/1ML/31GX5/16" IXEMPRA KIT 35 5/16" 113 113 IXINITY 77 INSULIN SYRINGE/1ML/28G X INSUPEN 29G X 12MM 113 1/2" 113 J & J ADHESIVE LARGE 87 INSUPEN 31G X 5MM 114 INSULIN SYRINGE/1ML/29G X J & J BURN CREAM 61 1/2" 113 INSUPEN 31G X 8MM 114 J & J GAUZE 2"X2" 8 PLY 87 INSULIN SYRINGE/1ML/30G X INSUPEN 32G X 4MM 114 5/16" 113 INSUPEN PEN NEEDLES 32G J & J GAUZE 4"X4" 12 PLY 87 INSULIN SYRINGE/NEEDLE X4MM 114 J & J GAUZE 4"X4" 8 PLY 87 0.3ML/30G X 5/16" 113 INSUPEN SENSITIVE J & J GAUZE SPONGES 12-PLY INSULIN SYRINGE/NEEDLE 32GX6MM 114 4" X 4" 87 0.3ML/31G X 5/16" 113 INSUPEN ULTRAFIN J & J GAUZE SPONGES 16-PLY INSULIN SYRINGE/NEEDLE 29GX12MM 114 4" X 4" 87 0.5ML/29G X 1/2" 113 INSUPEN ULTRAFIN J & J GAUZE SPONGES 8- INSULIN SYRINGE/NEEDLE 30GX8MM 114 PLY4" X 4" 87 0.5ML/30G X 5/16" 113 INSUPEN ULTRAFIN J & J NON-STICK PADS INSULIN SYRINGE/NEEDLE 31GX6MM 114 100LARGE 87 0.5ML/31G X 5/16" 113 INSUPEN ULTRAFIN J-TIP KIT W/VIAL INSULIN SYRINGE/NEEDLE 31GX8MM 114 ADAPTERS 114 1ML/29G X 1/2" 113 INTELENCE 42 JADENU 25 INSULIN SYRINGE/NEEDLE 1ML/30G X 5/16" 113 INTERMEZZO 81 JADENU SPRINKLE 25 INSULIN SYRINGE/NEEDLE INTRON A 35 JAKAFI 34 1ML/31G X 5/16" 113 INTUNIV 2 JANSSEN COVID-19 INSULIN SYRINGE/U- INVEGA 38 VACCINE 162 100/0.3ML/29G X 1/2" 113 JENTADUETO 22 INSULIN SYRINGE/U- INVEGA SUSTENNA 37 JEVTANA 35 100/0.5ML/29G X 1/2" 113 INVEGA TRINZA 38 JIVI 77 INSULIN SYRINGE/U- INVIRASE 42 100/1ML/29G X 1/2" 113 JORNAY PM 3 IOPIDINE 148 INSULIN SYRINGE/U- JULUCA 42 100/1ML/30G X 5/16" 113 ipratropium bromide 14 JUST 4 KIDZ INSULIN SYRINGE/U- ipratropium bromide 100/1ML/31G X 5/16" 113 MULTIVITAMIN+PROBIOTIC (nasal) 144 141 INSULIN ipratropium-albuterol 15 SYRINGES/0.5ML/28GX1/2" JYNARQUE 74 113 irbesartan 29 K-PHOS NEUTRAL 138 INSULIN irbesartan-hydrochlorothiazide 30 K-TAB 138 SYRINGES/0.5ML/29GX1/2" K-Y ME & YOU EXTRA 113 IRON CHEWS PEDIATRIC 79 LUBRICATED 88

Index 22 K-Y ME & YOU INTENSE 88 ketoprofen 5 KONSYL 82 KADCYLA 32 ketorolac tromethamine 5 KONSYL DAILY FIBER 82 KALBITOR 78 ketorolac tromethamine KONSYL ORIGINAL DAILY KALETRA 42 (ophth) 150 FIBER 82 KETOSTIX 70 KONSYL-D 82 KALYDECO 156 ketotifen fumarate (ophth)150 KOVALTRY 77 KAMELEON LUBRICATED 89 KEVZARA 5 KP PRENATAL KAPVAY 2 KHEDEZLA 21 MULTIVITAMINS 141 KAZANO 22 KPN PRENATAL 141 KIMONO COLORS 89 KCENTRA 77 KRINTAFEL 31 KIMONO LUBRICATED 89 KEFLEX 48 KROGER AUTOLET LANCING KIMONO MICRO THIN PLUS KENALOG-40 50 DEVICE 93 SPERMICIDE KROGER HEALTHPRO TWIST KENDALL HYDROPHILIC LUBRICATED 89 FOAMDRESSING 2"X2" 87 LANCETS/26G 93 KIMONO PLUS SPERMICIDE KROGER INSULIN KENDALL HYDROPHILIC LUBRICATED 89 FOAMDRESSING 3"X3" 87 SYRINGE/0.3ML/29G X KIMONO PLUS 1/2" 114 KENDALL HYDROPHILIC SPERMICIDE/LUBRICATED FOAMDRESSING 4"X4" 87 KROGER INSULIN 89 SYRINGE/0.3ML/30G X KENDALL HYDROPHILIC KIMONO PS FOAMPLUS DRESSING 5/16" 114 LUBRICATED 89 KROGER INSULIN 2"X2" 87 KIMONO PS PLUS KENDALL HYDROPHILIC SYRINGE/0.3ML/31G X SPERMICIDE/LUBRICATED 5/16" 114 FOAMPLUS DRESSING 89 3"X3" 87 KROGER INSULIN KIMONO SENSATION SYRINGE/0.5ML/29G X KEPIVANCE 35 LUBRICATED 89 1/2" 114 KEPPRA 16 KIMONO SENSATION PLUS KROGER INSULIN SPERMICIDE SYRINGE/0.5ML/30G X KEPPRA XR 16 LUBRICATED 89 KERADAN 61 5/16" 114 KIMONO SPECIAL 89 KROGER INSULIN KERI ADVANCED MOISTURE KINDERLYTE 137 SYRINGE/0.5ML/31G X THERAPY 61 KINDERLYTE PREMAX 137 5/16" 114 KERI AGE DEFY & KROGER INSULIN PROTECT 67 KINERET 5 SYRINGE/1ML/29G X 1/2" 114 KERI BASIC ESSENTIALS 61 KINNEY LANCETS 93 KROGER INSULIN KERI LONG LASTING 61 KINNEY THIN LANCETS 93 SYRINGE/1ML/30G X KERI NOURISHING SHEA KINRAY INSULIN SYRINGE 5/16" 114 BUTTER 61 PREFERRED KROGER INSULIN KERI ORIGINAL 61 PLUS/0.3ML/31G X 5/16" 114 SYRINGE/1ML/31G X KERI ORIGINAL DAILY KINRAY INSULIN SYRINGE 5/16" 114 MOISTURE 61 PREFERRED KROGER LANCETS 93 KERI OVERNIGHT 61 PLUS/0.5ML/31G X 5/16" 114 KROGER LANCETS 21G 93 KERI RENEWAL MILK KINRAY INSULIN SYRINGE KROGER LANCETS MICRO BODY 61 PREFERRED PLUS/1ML/31G THIN33G 93 KERI RENEWAL SKIN X 5/16" 114 KROGER LANCETS SUPER FIRMING 61 KINRAY INSULIN THIN 93 KERI RENEWAL STRETCH SYRINGE/0.5ML/29G X KROGER LANCETS THIN 93 1/2" 114 MARK MINIMIZER 61 KROGER LANCETS THIN KERI SENSITIVE SKIN 62 KINRIX 157 26G 93 KERLIX SPONGES 4" X 4" 12 KITABIS PAK 4 KROGER LANCETS PLY 87 KLARON 54 ULTRATHIN30G 93 KERLIX SPONGES 4" X 4" 16 KLONOPIN 16 KROGER LANCING PLY 87 DEVICE 93 ketoconazole (topical) 55 KOATE 77 KROGER PEN NEEDLES 29G KETONE 70 KOATE-DVI 77 X12MM 114 KOGENATE FS 77 KROGER PEN NEEDLES 31G KETONE TEST STRIPS 70 X8MM 114

Index 23 KROGER PEN NEEDLES LANCETS 26G TWIST LEADER INSULIN 31GX1/4" 114 TOP 93 SYRINGE/0.5ML/30G X KROGER PEN NEEDLES/31G LANCETS 28G 94 5/16" 115 X1/4" 114 LANCETS 30G 94 LEADER INSULIN KROGER PEN NEEDLES/31G SYRINGE/0.5ML/31G X LANCETS 31G TWIST X3/16" 114 5/16" 115 KROGER PEN NEEDLES/31G TOP 94 LEADER INSULIN LANCETS MICRO THIN X5/16" 114 SYRINGE/1ML/28G X 1/2" 115 KROGER PEN NEEDLES/32G 33G 94 LEADER INSULIN LANCETS SAFETY SEAL X5/32" 114 SYRINGE/1ML/29G X 1/2" 115 21G 94 KRYSTEXXA 77 LEADER INSULIN LANCETS SAFETY SEAL SYRINGE/1ML/30G X KUVAN 73 26G 94 LANCETS SAFETY SEAL 5/16" 115 KYLEENA 50 LEADER INSULIN KYMRIAH 33 28G 94 LANCETS SAFETY SEAL SYRINGE/1ML/31G X KYPROLIS 34 30G 94 5/16" 115 L-ARGININE 147 LANCETS SUPER THIN LEADER QUICK DISSOLVE 28G 94 GLUCOSE 23 L-ARGININE BASE 146 LEADER UNIFINE PENTIPS L-ARGININE HCL 48 LANCETS THIN 94 PLUS/MINI/31GX3/16" 115 L-TRYPTOPHAN 147 LANCETS ULTRA FINE 94 LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16" 115 labetalol hcl 45 LANCETS ULTRA THIN 94 LANCETS ULTRA THIN LEADER UNIFINE LAC-HYDRIN 62 30G 94 PENTIPS/MINI/31GX3/16" 115 LAC-HYDRIN TWELVE 62 LANCETSBULLSEYE LEADER UNIFINE lactic acid (ammonium SAFETY 94 PENTIPS/NANO/32GX5/32" lactate) 62 LANCING DEVICE 94 115 LACTINOL HX 62 LEADER UNIFINE LANCING DEVICE PENTIPS/PLUS/32GX5/32" lactulose 83 ADJUSTABLE 94 115 lactulose (encephalopathy) 76 LANOXIN 47 LEDIPASVIR/SOFOSBUVIR LADY ESTHER 4 PURPOSE lansoprazole 158 44 FACE CREAM 62 LANZO 94 leflunomide 6 LAMICTAL 17 lapatinib ditosylate 34 LEMTRADA 155 LAMICTAL CHEWABLE LASIX 71 LETAIRIS 47 DISPERSIBLE 16 letrozole 33 LAMICTAL ODT 16 latanoprost 150 LAMICTAL STARTER/NOT LATUDA 37 leucovorin calcium 35 TAKING CARBAMAZEPINE 16 LEADER ADVANCED LEUKERAN 32 LAMICTAL STARTER/TAKING LANCING DEVICE 94 LEUKINE 79 CARBAMAZEPINE/NOT TAKING LEADER FINGER CREAM 62 leuprolide acetate 33 VALPROATE 17 LEADER INSULIN LAMICTAL STARTER/TAKING SYRINGE/0.3ML/29G X levalbuterol hcl 15 VALPROATE 17 1/2" 114 levalbuterol tartrate 15 LAMICTAL XR 17 LEADER INSULIN LEVAQUIN 75 LAMISIL AT 55 SYRINGE/0.3ML/30G X LEVBID 157 5/16" 114 LAMISIL AT JOCK ITCH 55 LEADER INSULIN LEVETIRACETAM 17 lamivudine 42 SYRINGE/0.3ML/31G X levetiracetam 17 lamivudine-zidovudine 42 5/16" 114 levetiracetam in sodium lamotrigine 17 LEADER INSULIN chloride 17 SYRINGE/0.5ML/28G X LANAPHILIC 62 levobunolol hcl 148 1/2" 114 levocarnitine (metabolic LANCET DEVICE LEADER INSULIN ADJUSTABLE 93 modifiers) 73 SYRINGE/0.5ML/29G X levocetirizine dihydrochloride27 LANCET DEVICE WITH 1/2" 114 EJECTOR 93 levofloxacin 75 LANCETS 94 levoleucovorin calcium 35

Index 24 levonorgestrel & eth LITETOUCH INSULIN lithium carbonate 37 estradiol 49 SYRINGE/0.5ML/30G X LITHIUM CARBONATE 37 levonorgestrel (emergency 5/16" 115 oc) 49 LITETOUCH INSULIN lithium carbonate 37 levonorgestrel-eth estradiol SYRINGE/0.5ML/31G X LITHOBID 37 (triphasic) 49 5/16" 115 LIVE BETTER ADVANCED levonorgestrel-ethinyl estradiol LITETOUCH INSULIN LANCING DEVICE 94 (91-day) 49 SYRINGE/1ML/30G X LIVE BETTER LANCET levothyroxine sodium 157 5/16" 115 SUPERTHIN 30G 94 LEXAPRO 20 LITETOUCH INSULIN LIVE BETTER LANCET SYRINGE/U-100/0.3ML/30G X ULTRATHIN 28G 94 LEXIVA 42 5/16" 115 LMX 4 65 LIALDA 76 LITETOUCH INSULIN LOCOID 58 LIBERTY MEDICAL LANCETS SYRINGE/U-100/0.3ML/31G X 30G 94 5/16" 115 LODINE 5 LIBERTY MINI LANCING LITETOUCH INSULIN LODOSYN 36 DEVICE 94 SYRINGE/U-100/0.5ML/28G X LOHIST-D 52 1/2" 115 lidocaine 65 LOMOTIL 25 lidocaine hcl 65 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X LONGS INSULIN lidocaine hcl (mouth-throat) 140 1/2" 115 SYRINGE/0.5ML/31G X lidocaine-prilocaine 65 LITETOUCH INSULIN 5/16" 116 LONGS LANCETS LIDODERM 65 SYRINGE/U-100/0.5ML/30G X 5/16" 115 STANDARD 94 LIFESCAN UNISTIK 2 DEEP LONGS LANCETS THIN 94 PENETRATION 94 LITETOUCH INSULIN LIFESCAN UNISTIK II SYRINGE/U-100/0.5ML/31G X LONGS LANCETS ULTRA LANCETS 94 5/16" 115 THIN 94 LILETTA 50 LITETOUCH INSULIN loperamide hcl 25 SYRINGE/U-100/1ML/28G X LOPID 28 liothyronine sodium 157 1/2" 115 LIPICHOL 540 70 LITETOUCH INSULIN lopinavir-ritonavir 42 LIPITOR 28 SYRINGE/U-100/1ML/29G X LOPRESSOR 45 1/2" 115 LIPOFEN 27 loratadine 27 LITETOUCH INSULIN loratadine & LIQUID CALCIUM WITH D3 SYRINGE/U-100/1ML/30G X MAXIMUM STRENGTH 137 pseudoephedrine 52 5/16" 115 lorazepam 13 lisinopril 28 LITETOUCH INSULIN lisinopril & SYRINGE/U-100/1ML/31G X LORAZEPAM 48 hydrochlorothiazide 30 5/16" 115 LORMATE 70 LISTER-V 70 LITETOUCH LANCETS MICRO losartan potassium 29 LITE TOUCH LANCETS 94 THIN 33G 94 losartan potassium & LITETOUCH PEN NEEDLES LITE TOUCH LANCING hydrochlorothiazide 30 29GX12.7MM 115 PEN 94 LITETOUCH PEN NEEDLES LOTENSIN 29 LITEAIRE 133 31G X 6MM 116 LOTENSIN HCT 30 LITETOUCH INSULIN PEN LITETOUCH PEN NEEDLES LOTREL 30 NEEDLES/32G X 31G X 6MM/ULTRA LOTRIMIN AF 55 4MM/MINI 115 SHORT 116 LITETOUCH INSULIN LITETOUCH PEN NEEDLES LOTRIMIN AF JOCK ITCH 55 SYRINGE/0.3ML/29G X 31GX8MM SHORT 116 LOTRIMIN ANTIFUNGAL 55 1/2" 115 LITETOUCH PEN LOTRISONE 55 LITETOUCH INSULIN NEEDLES/31G X 3/16" 116 SYRINGE/0.3ML/30G X LITETOUCH PEN lovastatin 28 5/16" 115 NEEDLES/31G X LOVAZA 27 LITETOUCH INSULIN 5MM/MINI 116 LOVENOX 16 SYRINGE/0.3ML/31G X LITETOUCH PEN loxapine succinate 38 5/16" 115 NEEDLES/31G X 8MM/SHORT 116 lubiprostone 75 LITHIUM 37 LUBRIDERM 62

Index 25 LUBRIDERM ADVANCED MAGELLAN INSULIN SAFETY MEDERMA AG FACE THERAPY 62 SYRINGE/U-100/0.5ML/30G X CREAM 62 LUBRIDERM DAILY 5/16" 116 MEDERMA AG HAND & BODY MOISTURE/NORMAL TO DRY MAGELLAN INSULIN SAFETY LOTION 62 SKIN 62 SYRINGE/U-100/1ML/29G X MEDERMA STRETCH MARKS LUBRIDERM DAILY 1/2" 116 THERAPY 62 MOISTURESHEA + CALMING MAGELLAN INSULIN SAFETY MEDIC INSULIN LAVENDER JASMINE 62 SYRINGE/U-100/1ML/30G X SYRINGE/0.3ML/30G X LUBRIDERM INTENSE SKIN 5/16" 116 5/16" 116 REPAIR 62 MAGNEBIND 300 137 MEDIC INSULIN LUBRIDERM MENS 3-IN-1 62 MAGNEBIND 400 138 SYRINGE/0.5ML/30G X 5/16" 116 LUBRIDERM SERIOUSLY magnesium citrate 83 SENSITIVE 62 MEDICHOICE PRE-SET LUBRIDERM SKIN magnesium hydroxide 83 SAFETY LANCET DUAL NOURISHINGWITH SHEA AND magnesium oxide 11 USE 94 COCOA BUTTERS 62 magnesium oxide (mg MEDICHOICE PRE-SET LUBRISOFT 62 supplement) 138 SAFETY LANCET LOW FLOW 94 LUCENTIS 148 MAGOX 400 138 MEDICHOICE PRE-SET LUMIZYME 73 MAKENA 154 SAFETY LANCET MEDIUM LUNESTA 81 malathion 68 FLOW 94 maprotiline hcl 19 MEDICHOICE PRE-SET LUPANETA PACK 73 SAFETY LANCET MODERATE MARATHON MEDICAL LUPRON DEPOT (1- FLOW 94 MONTH) 33 PENTIPS29GX12MM 116 MEDICHOICE SAFETY MARATHON MEDICAL LUPRON DEPOT (3- LANCETEXTRA 94 MONTH) 33 PENTIPS31GX5MM 116 MEDICHOICE SAFETY MARATHON MEDICAL LUPRON DEPOT (4- LANCETNORMAL 94 MONTH) 33 PENTIPS31GX8MM 116 MEDICINE SHOPPE PEN MARATHON MEDICAL LUPRON DEPOT (6- NEEDLES 29G X 12MM 116 MONTH) 33 PENTIPS32GX4MM 116 MEDICINE SHOPPE PEN LUPRON DEPOT-PED (1- MARCAINE 83 NEEDLES 31G X 6MM 116 MONTH) 73 MARPLAN 19 MEDICINE SHOPPE PEN LUPRON DEPOT-PED (3- MATULANE 35 NEEDLES 31G X 8MM 116 MONTH) 73 MEDISENSE THIN LUXTURNA 149 MAVENCLAD 155 LANCETS 94 LUZU 55 MAVYRET 44 MEDLANCE PLUS EXTRA LYRICA 17 MAXALT 135 LANCETS 21G 94 MAXALT-MLT 135 MEDLANCE PLUS LYSODREN 33 LANCETS 94 LYSTEDA 80 MAXAM 62 MEDLANCE PLUS LANCETS M-M-R II 162 MAXI-COMFORT INSULIN LITE 25G 94 SYRINGE/U- MEDLANCE PLUS LITE M-NATAL PLUS 141 100/0.5ML/28GX1/2" 116 LANCETS 25G 94 MACROBID 12 MAXI-COMFORT INSULIN MEDLANCE PLUS SPECIAL MACRODANTIN 12 SYRINGE/U- LANCETS 0.8MM 95 MACUGEN 148 100/1ML/28GX1/2" 116 MEDLANCE PLUS SUPERLITE MAXI-TUSS PE MAX 52 30G/COMFORT MAX 95 MAGDELAY 138 MAXICOMFORT II PEN MEDLANCE PLUS UNIVERSAL MAGELLAN INSULIN SAFETY NEEDLES/31G X 1/4" 116 LANCETS 21G 95 SYRINGE/U-100/0.3ML/29G X MAXITROL 149 MEDLANCE/EXTRA 95 1/2" 116 MAGELLAN INSULIN SAFETY MAXX LUBRICATED 89 MEDLANCE/LITE 95 SYRINGE/U-100/0.3ML/30G X MAXX PLUS SPERMICIDE MEDLANCE/UNIVERSAL 95 5/16" 116 LUBRICATED 89 MEDROL 50 MAGELLAN INSULIN SAFETY MAXZIDE 71 MEDROL DOSEPAK 50 SYRINGE/U-100/0.5ML/29G X MAXZIDE-25 71 medroxyprogesterone 1/2" 116 meclizine hcl 25 acetate 154

Index 26 medroxyprogesterone acetate METAMUCIL MULTIHEALTH MICRHOGAM ULTRA- (contraceptive) 50 FIBER 82 FILTEREDPLUS 151 mefloquine hcl 31 METAMUCIL MULTIHEALTH MICROCHAMBER 133 megestrol acetate 33 FIBER SINGLES 82 MICRODOT PEN NEEDLE/31G METAMUCIL ORIGINAL X 6 MM 116 MEIJER ALCOHOL SWABS TEXTURE 82 EXTRA-THICK 99 MICRODOT PEN NEEDLE/32G MEIJER COLOR LANCETS metaproterenol sulfate 15 X 4 MM 116 UNIVERSAL 33G 95 metformin hcl 22 MICROLET LANCETS 95 MEIJER LANCETS 95 methadone hcl 8 MICROLET NEXT 95 MEIJER LANCETS THIN 95 methamphetamine hcl 1 MICROSPACER 133 MEIJER LANCETS METHAVER 70 MIDAZOLAM 81 UNIVERSAL21G 95 METHAZEL 70 midazolam hcl 81 MEIJER LANCETS UNIVERSAL30G 95 methazolamide 71 MIDAZOLAM MEIJER LANCETS methenamine mandelate 12 HYDROCHLORIDE 81 MIDAZOLAM UNIVERSAL33G 95 methenamine-hyosc-methylene MEIJER PEN NEEDLES 29G HYDROCHLORIDE/SODIUM blue-sod phos-phenyl sal 11 CHLORIDE 81 X12MM 116 methimazole 156 MEIJER PEN NEEDLES 31G MIDAZOLAM/SYRSPEND SF X6MM 116 METHITEST 9 PH4 81 MEIJER PEN NEEDLES 31G methocarbamol 144 midodrine hcl 163 X8MM 116 METHOTREXATE 5 miglustat 78 MEIJER SUPER THIN methotrexate sodium 32 MIGRANAL 135 LANCETS 95 MILLIPRED 50 MEKINIST 34 methyldopa 29 methylergonovine MINI LANCING DEVICE 95 MEKTOVI 34 maleate 151 MINIPRESS 29 MELATONIN 4 METHYLIN 3 MINIVELLE 74 melatonin 4 methylphenidate hcl 3 MINOCIN 156 MELATONIN 4 METHYLPHENIDATE minocycline hcl 156 melatonin 4 HYDROCHLORIDE ER 3 minoxidil 31 MELATONIN 4 methylprednisolone 50 MIRALAX 83 melatonin 4 metoclopramide hcl 75 MELATONIN EXTRA metolazone 71 MIRAPEX 36 STRENGTH 4 metoprolol succinate 45 MIRASORB SPONGES 2" X meloxicam 5 2" 87 metoprolol tartrate 45 MIRASORB SPONGES 4" X melphalan 32 METROCREAM 68 4" 87 melphalan hcl 32 METROGEL-VAGINAL 162 MIRCERA 79 memantine hcl 154 METROLOTION 68 MIRCETTE 49 MENACTRA 159 metronidazole 11 MIRENA 50 MENQUADFI 159 metronidazole (topical) 68 mirtazapine 19 MENVEO 159 METRONIDAZOLE misoprostol 158 meperidine hcl 8 BENZOATE/SYRSPEND SF MISTASSIST 134 PH4 11 MEPHYTON 163 MITIGARE 77 metronidazole vaginal 162 meprobamate 13 mitoxantrone hcl 34 mexiletine hcl 13 mercaptopurine 32 MM INSULIN SYRINGE/U- MIACALCIN 72 mesalamine 76 100/0.3ML/30G X 5/16" 116 MICARDIS 29 MM INSULIN SYRINGE/U- mesna 35 MICARDIS HCT 30 100/0.3ML/31G X 5/16" 117 MESNEX 35 MM INSULIN SYRINGE/U- MICATIN 55 MESTINON 31 100/1/2ML/30G X 5/16" 117 miconazole nitrate (topical)55 MESTINON TIMESPAN 31 MM INSULIN SYRINGE/U- miconazole nitrate 100/1/2ML/31G X 5/16" 117 METAMUCIL 82 vaginal 162

Index 27 MM INSULIN SYRINGE/U- MONOJECT INSULIN MORPHINE SULFATE 8 100/1ML/30G X 5/16" 117 SYRINGE/SOFTPACK/U- morphine sulfate 8 MM INSULIN SYRINGE/U- 100/0.5ML/28G X 1/2" 117 100/1ML/31G X 5/16" 117 MONOJECT INSULIN MOTHERS FRIEND 62 MM LANCING DEVICE 95 SYRINGE/U-100/0.3ML/30G X MOTRIN CHILDRENS 5 MM PEN NEEDLES 31G X 5/16" 117 MOTRIN INFANTS DROPS 6 MONOJECT INSULIN 1/4" 117 moxifloxacin hcl (ophth) 149 MM PEN NEEDLES 31G X SYRINGE/U-100/0.5ML/30G X 3/16" 117 5/16" 117 MOZOBIL 79 MM PEN NEEDLES 31G X MONOJECT INSULIN MS CONTIN 8 5/16" 117 SYRINGE/U-100/1ML/28G X MS INSULIN MM PEN NEEDLES 32G X 1/2" 117 SYRINGE/0.3ML/31G X 5/32" 117 MONOJECT INSULIN 5/16" 118 MOBIC 5 SYRINGE/U-100/1ML/30G X MS INSULIN 5/16" 117 modafinil 3 SYRINGE/0.5ML/31G X MONOJECT ULTRA 5/16" 118 MODERNA COVID-19 COMFORT INSULIN MS INSULIN SYRINGE/1ML/31G VACCINE 162 SYRINGE/0.3ML/29G X X 5/16" 118 MOISTURE GUARD 65 1/2" 117 MSM SKIN LOTION 62 MOISTURIZING CREAM 62 MONOJECT ULTRA MTERYTI 142 MOLESKIN FOAM COMFORT INSULIN PADDING 87 SYRINGE/0.3ML/30G X MTERYTI FOLIC 5 141 molindone hcl 39 5/16" 117 MUCINEX 53 MONOJECT ULTRA mometasone furoate 58 MUCINEX D 52 COMFORT INSULIN MUCINEX D MAXIMUM MONISTAT 1 COMBO SYRINGE/0.3ML/31G X STRENGTH 52 PACK 162 5/16" 117 MONISTAT 1 DAY OR NIGHT MONOJECT ULTRA MUCINEX DM 52 COMBO PACK 162 COMFORT INSULIN MUCINEX MAXIMUM MONISTAT 3 162 SYRINGE/0.5ML/28G X STRENGTH 53 MONISTAT 3 COMBINATION 1/2" 117 MULTI PRENATAL 142 PACK 162 MONOJECT ULTRA MULTI-LANCET DEVICE 95 MONISTAT 7 SIMPLY COMFORT INSULIN multiple vitamins w/ CURE 162 SYRINGE/0.5ML/29G X minerals 140 MONISTAT SOOTHING CARE 1/2" 117 MULTIVITAMIN PLUS IRON ITCH RELIEF 58 MONOJECT ULTRA CHILDRENS 140 MONOCLATE-P 77 COMFORT INSULIN mupirocin 54 MONOJECT INSULIN SYRINGE/0.5ML/30G X MVW COMPLETE SYRINGE/1ML/31G X 5/16" 117 FORMULATION 141 5/16" 117 MONOJECT ULTRA MONOJECT INSULIN COMFORT INSULIN MX-SOL 153 SYRINGE/PERM SYRINGE/0.5ML/31G X MX-SOL BLEND 152 NEEDLE/1ML/28G X 1/2" 117 5/16" 118 MX-SOL BLEND SF 152 MONOJECT INSULIN MONOJECT ULTRA MX-SOL SF 152 SYRINGE/PERM NEEDLE/U- COMFORT INSULIN 100/0.5ML/28G X 1/2" 117 SYRINGE/1ML/28G X MX-SOL SUSPEND 152 MONOJECT INSULIN 1/2" 118 MYALEPT 73 SYRINGE/SAFETY/PERM MONOJECT ULTRA MYAMBUTOL 31 NEEDLE/0.3ML/29G X 1/2" 117 COMFORT INSULIN mycophenolate mofetil 139 MONOJECT INSULIN SYRINGE/1ML/29G X SYRINGE/SAFETY/PERM 1/2" 118 mycophenolate mofetil hcl 139 NEEDLE/0.3ML/29GX1/2" 117 MONOLET LANCETS 95 mycophenolate sodium 139 MONOJECT INSULIN MONOLET OPD MYDAYIS 2 SYRINGE/SAFETY/PERM LANCETS 95 MYDRIACYL 148 NEEDLE/0.5ML/29G X 1/2" 117 MONOLETTOR SAFETY MONOJECT INSULIN LANCETS 95 MYFORTIC 139 SYRINGE/SAFETY/PERM MONONINE 77 MYLERAN 32 NEEDLE/1ML/29G X 1/2" 117 montelukast sodium 14

Index 28 MYLICON INFANTS GAS neomycin-bacitracin-polymyxin NEUTROGENA SPORT FACE RELIEF 75 54 SUNBLOCK WITH HELIOPLEX MYLICON INFANTS GAS neomycin-polymy- SPF70 67 RELIEF DYE FREE 75 dexameth 149 NEUTROGENA T/GEL 69 MYNATAL ADVANCE 142 neomycin-polymyxin w/ NEUTROGENA T/GEL MYNATAL PLUS 142 pramoxine 54 STUBBORN ITCH neomycin-polymyxin-gramicidin MYNATAL ULTRACAPLET 142 CONTROL 69 149 NEUTROGENA ULTRA SHEER MYNATAL-Z 142 neomycin-polymyxin-hc DRY-TOUCH SPF 45 67 MYNATE 90 PLUS 142 (ophth) 149 NEUTROGENA ULTRA SHEER neomycin-polymyxin-hc MYOBLOC 145 DRY-TOUCH WITH HELIOPLEX (otic) 151 SPF 100 67 MYSOLINE 17 NEONATAL COMPLETE 142 NEUTROGENA ULTRA SHEER NABI-HB 151 NEONATAL PLUS 142 DRY-TOUCH WITH HELIOPLEX nabumetone 6 NEONATAL VITAMIN 142 SPF 55 67 nadolol 45 NEUTROGENA ULTRA SHEER NEORAL 139 DRY-TOUCH WITH HELIOPLEX NAGLAZYME 73 NEOSPORIN ORIGINAL 54 SPF 70 67 naloxone hcl 25 NEOSPORIN PLUS PAIN nevirapine 42 naltrexone hcl 25 RELIEF MAXIMUM NEXAVAR 34 STRENGTH 55 NAMENDA 154 NEXCARE ABSOLUTE NAMENDA TITRATION NESINA 23 WATERPROOF PAD 87 PAK 154 NEULASTA 79 NEXIUM 158 NAMENDA XR 154 NEULASTA ONPRO KIT 79 NEXIUM 24HR 158 NAMENDA XR TITRATION NEUREPA 70 NEXIUM 24HR CLEAR PACK 154 NEURONTIN 17 MINIS 158 NAMZARIC 154 NEUTRAPHOR 65 NEXPLANON 50 naphazoline w/ NEUTRAPHORUS REX 65 NF FORMULAS CHILDRENS pheniramine 149 CHEWABLE 141 NAPHCON-A 149 NEUTROGENA AGE SHIELD FACE SUNBLOCK WITH niacin 164 NAPROSYN 6 HELIOPLEX SPF110 67 niacin (antihyperlipidemic) 28 naproxen 6 NEUTROGENA AGE SHIELD NIACIN TR 164 naproxen sodium 6 FACE SUNBLOCK WITH NIASPAN 28 HELIOPLEX SPF70 67 naproxen sodium- nicardipine hcl 46 diphenhydramine hcl 80 NEUTROGENA BEACH naratriptan hcl 135 DEFENSESPF 70 67 NICODERM CQ 156 NEUTROGENA BODY LIGHT NICORETTE 156 NARCAN 25 SESAME FORMULA 62 NARDIL 19 NEUTROGENA CLEAR FACE NICORETTE MINI 156 NICORETTE STARTER NAROPIN 83 SPF 55 67 NEUTROGENA HAND 62 KIT 156 NASACORT ALLERGY nicotine 156 24HR 144 NEUTROGENA HEALTHY NASACORT ALLERGY 24HR DEFENSE DAILY nicotine polacrilex 156 CHILDRENS 145 MOISTURIZER NICOTINE TRANSDERMAL NASALCROM 144 PURESCREEN 67 SYSTEM 156 NATALVIT 142 NEUTROGENA HEALTHY NICOTROL INHALER 156 SKIN 62 NICOTROL NS 156 nateglinide 24 NEUTROGENA HEALTHY NATROBA 68 SKIN FACE SPF 15 62 nifedipine 46 NEBULIZER CUP/TUBING 134 NEUTROGENA MEN SPF NINLARO 34 20 67 NISEKO HYDRATING FACIAL nefazodone hcl 20 NEUTROGENA MOISTURE MOISTURIZER 62 NEMBUTAL SODIUM 80 SENSITIVE SKIN 62 NITRO-BID 12 neomycin sulfate 4 NEUTROGENA MOISTURE NITRO-DUR 12 SPF15UNTINTED 67 neomycin-bacitracin zn- nitrofurantoin 12 polymyxin 149

Index 29 nitrofurantoin macrocrystal 12 norethindrone acetate-ethinyl NU GAUZE GENERAL-USE nitrofurantoin monohyd estradiol-fe 49 SPONGES 4"X4" 4 PLY 87 macro 12 norethindrone-eth estradiol NUCALA 14 nitroglycerin 12 (triphasic) 49 NUCYNTA 8 norgestimate-ethinyl NITROSTAT 12 estradiol 49 NUCYNTA ER 8 NIVA-PLUS 142 norgestimate-ethinyl estradiol NULOJIX 139 NIVEA 62 (triphasic) 49 NULYTELY 82 norgestrel & ethinyl NIVEA EXTRA ENRICHED 62 NULYTELY/FLAVOR estradiol 49 PACKS 82 NIVEA EXTRA ENRICHED NORPACE 13 LOTION 62 NUPERCAINAL 10 NIVEA GENTLE BODY NORPACE CR 13 NUPLAZID 37 EXFOLIATOR 62 NORPRAMIN 21 NUTRADERM 63 NIVEA HAND THERAPY 67 NORTEMP INFANTS 7 NUTRADERM ADVANCED NIVEA LIGHT 62 nortriptyline hcl 21,22 FORMULA 63 NIVEA MOISTURIZING BODY NORTRIPTYLINE HCL 22 NUTROPIN AQ NUSPIN 10 72 WASH 65 NUTROPIN AQ NUSPIN 20 72 NIVEA MOISTURIZING BODY nortriptyline hcl 22 WASH 2 IN 1 65 NORVASC 46 NUTROPIN AQ NUSPIN 5 72 NIVEA ORIGINAL 62 NORVIR 42 NUVARING 49 NIVEA ORIGINAL NOVA SUREFLEX NUVIGIL 3 MOISTURE 62 LANCETS 95 NUWIQ 77 NOVA SUREFLEX LANCING NIVEA SOFT 63 nystatin 25 NIVEA TOUCH OF DEVICE 95 SMOOTHNESS MOISTURIZING NOVAFERRUM 125 79 nystatin (mouth-throat) 140 BODY WASH 66 NOVAFERRUM PEDIATRIC nystatin (topical) 55 NIVEA VISAGE 63 DROPS 79 nystatin-triamcinolone 55 NIVEA VISAGE GENTLE NOVAREL 72 NYTOL MAXIMUM CLEANSING 66 NOVOEIGHT 77 STRENGTH 80 NIVEA VISAGE INNER BEAUTY NOVOFINE 32GX6MM 118 NYVEPRIA 79 NIGHTTIME RENEWAL 63 O-CAL FA 142 NIVEA VISAGE UV CARE DAILY NOVOFINE AUTOCOVER FACIAL 67 30GX8MM 118 O-CAL PRENATAL 142 NOVOFINE PLUS OBIZUR 77 NIVESTYM 79 32GX4MM 118 NIX CREME RINSE 68 NOVOLIN 70/30 24 OCALIVA 75 NIZORAL 55 NOVOLIN 70/30 OCEAN NASAL SPRAY 144 NORCO 9 FLEXPEN 24 OCREVUS 155 NORDIPEN 5 INJECTION NOVOLIN 70/30 FLEXPEN OCTAGAM 151 RELION 24 DEVICE 118 octreotide acetate 74 NORDIPEN DELIVERY NOVOLIN 70/30 RELION 24 OCUFLOX 149 SYSTEM 118 NOVOLIN N 24 OCUSOFT HAND SOAP 66 NORDITROPIN FLEXPRO 72 NOVOLIN N FLEXPEN 24 norelgestromin-ethinyl NOVOLIN N FLEXPEN ODEFSEY 42 estradiol 49 RELION 24 ODOMZO 33 norethin acet & estrad-fe 49 NOVOLIN N RELION 24 ofloxacin 75 norethindrone & eth estradiol49 NOVOLIN R 24 ofloxacin (ophth) 149 norethindrone & ethinyl estradiol- NOVOLIN R RELION 24 ofloxacin (otic) 150 fe 49 norethindrone NOVOLOG MIX 70/30 24 OINTMENT BASE 63 (contraceptive) 50 NOVOLOG MIX 70/30 OKEEFFES WORKING norethindrone acet & eth PREFILLED FLEXPEN 24 HANDS 63 estra 49 NOVOSEVEN RT 77 olanzapine 38,39 norethindrone acetate 154 NPLATE 79 olanzapine-fluoxetine hcl 155 norethindrone acetate-ethinyl NU GAUZE 4PLY 4"X4" 87 olmesartan medoxomil 29 estradiol 74

Index 30 olmesartan medoxomil- OPSUMIT 47 ORENCIA 6 amlodipine-hydrochlorothiazide OPTICHAMBER ORENCIA CLICKJECT 6 30 ADVANTAGE/LARGE ORENITRAM 47 olmesartan medoxomil- MASK 134 hydrochlorothiazide 30 OPTICHAMBER ORKAMBI 156 OMBRA TABLE TOP ADVANTAGE/MEDIUM FACE orphenadrine citrate 144 COMPRESSOR 134 MASK 134 ORTHO MICRONOR 50 omega-3 fatty acids 146 OPTICHAMBER ORTHO TRI-CYCLEN LO 49 omega-3-acid ethyl esters 27 ADVANTAGE/SMALL FACE ORTHO-CYCLEN 49 omeprazole 158 MASK 134 OPTICHAMBER ORTHO-NOVUM 1/35 49 omeprazole magnesium 158 DIAMOND 134 ORTHO-NOVUM 7/7/7 49 OMNIPOD 5 PACK 95 OPTICHAMBER oseltamivir phosphate 44 OMNIPOD DASH 5 PACK 95 DIAMOND/LARGEFACE OSENI 22 OMNIPOD DASH SYSTEM 95 MASK 134 OPTICHAMBER OSTEO-PORETICAL 137 OMNIPOD STARTER KIT 95 DIAMOND/MEDIUM FACE OTEZLA 6 OMNITROPE 72 MASK 134 OMNITROPE PEN 10 OPTICHAMBER OTICIN HC NR 151 INJECTION DEVICE 118 DIAMOND/SMALLFACE OTOVEL 151 OMNITROPE PEN 5 INJECTION MASK 134 OTREXUP 5 OPTICHAMBER FACE DEVICE 118 OVACE PLUS WASH 56 ON CALL LANCING MASK/LARGE 134 DEVICE 95 OPTICHAMBER FACE OVACE WASH 56 ON CALL PLUS LANCING MASK/MEDIUM 134 OVIDE 68 DEVICE 95 OPTICHAMBER FACE oxaprozin 6 MASK/SMALL 134 ONCASPAR 35 OXAYDO 8 ondansetron 25 OPTIFOAM 87 OPTIHALER 134 oxazepam 13 ondansetron hcl 25 OXBRYTA 78 ONE A DAY WOMENS OPTIHALER MDI DRUG PRENATAL/DHA 142 DELIVERY SYSTEM 134 oxcarbazepine 17 ONE A DAY WOMENS ORA-BLEND 153 OXTELLAR XR 17 PRENATAL1 142 ORA-BLEND SF 153 oxybutynin chloride 159 ONE FLOW FVC MONITORING ORA-PLUS 153 oxycodone hcl 8 SPIROMETER 134 ONE VITE WOMENS ORA-SWEET 153 oxycodone w/ acetaminophen 9 PRENATALVITAMIN 142 ORA-SWEET SF 153 oxycodone-aspirin 9 ONE VITE WOMENS ORACEA 68 oyster shell 137 PRENATALVITAMIN PLUS 142 oral electrolytes 138 OYSTER SHELL CALCIUM ONE-A-DAY SCOOBY-DOO PLUS VITAMIN D 137 GUMMIES 141 ORAL MIX FLAVORED SUSPENDING VEHICLE 153 OYSTER SHELL ONE-A-DAY WOMENS CALCIUM/VITAMIN D 137 PRENATAL 142 ORAL MIX SF 153 ONE-A-DAY/JOLLY ORAL SUSPEND 153 paliperidone 38 RANCHER 141 ORAL SUSPENDING PALMERS COCOA BUTTER ONETOUCH CLUB LANCETS COMPOUNDPLUS 153 FORMULA CONCENTRATED FINE POINT 95 ORAL SYRUP FLAVORED CREAM 63 ONETOUCH DELICA LANCETS VEHICLE 153 PALMERS COCOA BUTTER EXTRA FINE 33G 95 ORAL SYRUP SF 153 FORMULA CREAM 63 ONETOUCH DELICA LANCETS PALMERS COCOA BUTTER FINE 30G 95 ORALAIR 4 FORMULA INTENSIVE RELIEF ONETOUCH DELICA LANCING ORALAIR ADULT SAMPLE HAND CREAM 63 DEVICE 95 KIT 4 PALMERS COCOA BUTTER ONETOUCH DELICA PLUS ORALAIR ADULT STARTER FORMULA LOTION 63 LANCING DEVICE 95 PACK 4 PALMERS COCOA BUTTER ONETOUCH ULTRASOFT ORALAIR FORMULA LOTION LANCETS 95 CHILDREN/ADOLESCENTS FRAGRANCE FREE 63 ONFI 16 STARTER PACK 4

Index 31 PALMERS COCOA BUTTER pediatric multiple vitamin w/ PEN NEEDLES/32G X FORMULA MASSAGE minerals & c 141 5/32" 118 CREAM/STRETCH MARKS 63 pediatric multiple vitamins w/ PEN-KERA 63 PALMERS COCOA BUTTER iron 140 penicillamine 138 FORMULA MASSAGE PEDVAX HIB 159 penicillin v potassium 152 LOTION/STRETCH MARKS 63 peg 3350-kcl-sod bicarb-sod PALMERS COCOA BUTTER chloride-sod sulfate 82 PENTACEL 157 FORMULA NIGHT CREAM peg 3350-potassium chloride- PENTIPS 29G X 12MM 118 MOISTURE RICH 63 sod bicarbonate-sod PENTIPS 29GX12MM 119 PALMERS COCONUT OIL chloride 82 PENTIPS 31G X 5MM 119 FORMULA BODY LOTION 63 PEGASYS 44 PALMERS COCONUT OIL PENTIPS 31G X 8MM 119 PEGASYS PROCLICK 44 FORMULA HAND CREAM 63 PENTIPS 31GX5MM 119 22 PEGINTRON 44 PAMELOR PENTIPS 31GX6MM 119 pamidronate disodium 72 PEN NEEDLES 29G X 12MM 118 PENTIPS 31GX8MM 119 72 PAMIDRONATE DISODIUM PEN NEEDLES PENTIPS 32G X 4MM 119 72 pamidronate disodium 29GX1/2" 118 PENTIPS 32GX4MM 119 70 PEN NEEDLES PANCREAZE PENTOBARBITAL SODIUM 81 158 29GX12MM 118 pantoprazole sodium PEN NEEDLES pentobarbital sodium 81 PARI MANUAL 30GX5/16" 118 pentoxifylline 78 INTERRUPTER 134 PEN NEEDLES PARI TREK S COMBO 30GX8MM 118 PENTRAVAN 63 PACK 134 PEN NEEDLES 31G X 1/4" PENTRAVAN PLUS 63 paricalcitol 73 SHORT 118 PEPCID 158 PARLODEL 36 PEN NEEDLES 31G X PEPCID AC 158 PARNATE 19 3/16" 118 PEN NEEDLES 31G X PEPCID AC MAXIMUM paroxetine hcl 20 5MM 118 STRENGTH 158 PARVA-CAL 137 PEN NEEDLES 31G X PEPTO BISMOL 24 PAXIL 20 6MM 118 PEPTO-BISMOL 24 PEN NEEDLES 31G X PEPTO-BISMOL MAX PAXIL CR 20 8MM 118 PC LANCETS SUPER THIN STRENGTH 24 PEN NEEDLES PEPTO-BISMOL TO-GO 25 30G 95 31GX5/16" 118 PC UNIFINE PENTIPS 29G PEN NEEDLES 31GX6MM PERCOCET 9 X1/2" 118 (1/4") 118 PERCURA 70 PC UNIFINE PENTIPS 31G PEN NEEDLES PERFECT LANCETS 30G 95 X5MM MINI 118 31GX8MM 118 PC UNIFINE PENTIPS 31G PEN NEEDLES 31GX8MM PERIDEX 140 X6MM ULTRA SHORT 118 (5/16") 118 PERJETA 32 PC UNIFINE PENTIPS 31G PEN NEEDLES 32G X permethrin 68 X8MM SHORT 118 4MM 118 perphenazine 40 PCCA SWEET-SF 153 PEN NEEDLES 32G X PCCA SYRUP VEHICLE 153 6MM 118 perphenazine-amitriptyline 155 PCCA-PLUS 153 PEN NEEDLES PERRY PRENATAL 142 32GX4MM 118 PERSERIS 38 PECGEN DMX 52 PEN NEEDLES/29G X PEDIA-LAX 83 1/2" 118 PETROLATUM 63 PEDIALYTE 138 PEN NEEDLES/31G X PEXEVA 20 PEDIALYTE ADVANCED 1/4" 118 PFIZER-BIONTECH COVID- CARE 138 PEN NEEDLES/31G X 19VACCINE 162 PEDIALYTE FREEZER 3/16" 118 PH 12 STERILE DILUENT POPS 138 PEN NEEDLES/31G X FORFLOLAN 153 5/16" 118 PHARMACY COUNTER PEDIALYTE SINGLES 138 PEN NEEDLES/31G X LANCETS 95 PEDIAPRED 50 6MM 118 phenazopyridine hcl 76 PEDIARIX 157 phenelzine sulfate 19

Index 32 PHENELZINE SULFATE 48 podofilox 65 PRECISION SURE-DOSE phenobarbital 81 polyethylene glycol 3350 83 INSULIN SYRINGE/1ML/28G X 1/2" 119 PHENOBARBITAL 81 POLYETHYLENE GLYCOL PRECISION SURE-DOSE phenobarbital 81 3350 153 PLUSINSULIN polyethylene glycol-propylene SYRINGE/0.3ML/29G X PHENOBARBITAL SODIUM 81 glycol (ophth) 147 1/2" 119 phenobarbital sodium 81 POLYMEM FILM DOT 88 PRECISION SURE-DOSE phenylephrine hcl POLYMEM NON-ADHESIVE PLUSINSULIN (mydriatic) 148 PAD 88 SYRINGE/1ML/29G X 1/2" 119 phenylephrine hcl (oral) 145 polymyxin b-trimethoprim 149 PRECISION THINS GP phenylephrine in hard fat 10 polysaccharide iron LANCET 95 phenylephrine-chlorphen-dm complex 79 PRECOSE 22 52 POLYSPORIN 55 PRED FORTE 149 phenylephrine-cocoa butter 10 POLYTRIM 149 PRED MILD 150 phenylephrine-dm 52 polyvinyl alcohol 147 PRED-G 150 phenylephrine-mineral oil- polyvinyl alcohol-povidone prednisolone 50 petrolatum 10 (ophth) 147 phenylephrine-shark liver oil- prednisolone acetate POMALYST 34 (ophth) 150 cocoa butter 10 pot phosphate monobasic w/ phenylephrine-shark liver oil- PREDNISOLONE ACETATE P- sod phosphate dibasic & F 150 mineral oil-petrolatum 10 monobasic 138 phenytoin 18 prednisolone sodium potassium bicarbonate 138 phosphate 50 phenytoin sodium extended 18 potassium chloride 138 PREDNISOLONE SODIUM phytonadione 163 potassium chloride PHOSPHATE 150 PIFELTRO 42 microencapsulated crystals prednisone 51 pilocarpine hcl 148 er 138 PREDNISONE INTENSOL 51 potassium citrate pilocarpine hcl (oral) 140 PREFERRED PLUS INSULIN (alkalinizer) 76 SYRINGE/U-100/0.3ML/29G X pimecrolimus 64 povidone-iodine 41 1/2" 119 pimozide 155 PRALUENT 28 PREFERRED PLUS INSULIN pindolol 45 pramipexole SYRINGE/U-100/0.3ML/30G X pioglitazone hcl 23 dihydrochloride 36 5/16" 119 pramoxine-hc-chloroxylenol PREFERRED PLUS INSULIN pioglitazone hcl-metformin SYRINGE/U-100/0.5ML/28G X hcl 22 151 prasugrel hcl 78 1/2" 119 PIQRAY 200MG DAILY PREFERRED PLUS INSULIN DOSE 34 PRAVACHOL 28 SYRINGE/U-100/0.5ML/29G X PIQRAY 250MG DAILY pravastatin sodium 28 1/2" 119 DOSE 34 praziquantel 11 PREFERRED PLUS INSULIN PIQRAY 300MG DAILY SYRINGE/U-100/0.5ML/30G X DOSE 34 prazosin hcl 29 5/16" 119 piroxicam 6 PRAZOSIN PREFERRED PLUS INSULIN PLAN B ONE-STEP 49 HYDROCHLORIDE 29 SYRINGE/U-100/1ML/28G X PLAQUENIL 31 PRE SUN KIDS 67 1/2" 119 PLAVIX 78 PRE-NATAL FORMULA 142 PREFERRED PLUS INSULIN PRECISION SURE-DOSE SYRINGE/U-100/1ML/29G X PLEGISOL 47 INSULIN SYRINGE/0.3ML/30G 1/2" 119 PLEGRIDY 155 X 5/16" 119 PREFERRED PLUS INSULIN PLEGRIDY STARTER PRECISION SURE-DOSE SYRINGE/U-100/1ML/30G X PACK 155 INSULIN SYRINGE/0.5ML/28G 5/16" 119 PNEUMOVAX 23 159 X 1/2" 119 PREFERRED PLUS LANCETS COLORED 21G 95 PNEUMOVAX 23/1 DOSE 159 PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/29G PREFERRED PLUS LANCETS POCKET CHAMBER 134 X 1/2" 119 SUPER THIN 30G 96 POCKET SPACER 134 PREFERRED PLUS LANCETS THIN 26G 96

Index 33 PREFERRED PLUS UNIFINE PRENATAL/OMEGA-3/FOLIC PRO COMFORT INSULIN PENTIPS 29G X 12MM 119 ACID/IRON 143 SYRINGES/1ML/30G X PREFERRED PLUS UNIFINE PRENATRIX 143 1/2" 120 PENTIPS 31G X 6MM ULTRA PRENATRYL 143 PRO COMFORT INSULIN SHORT 119 SYRINGES/1ML/30G X PREFERRED PLUS UNIFINE PRENATVITE RX 143 5/16" 120 PENTIPS 31G X 8MM PREPARATION H 10 PRO COMFORT INSULIN SHORT 119 PREPLUS 143 SYRINGES/1ML/31G X PREFERRED PLUS UNIFINE PRESSURE ACTIVATED 5/16" 120 PENTIPS 32GX4MM 119 SAFETYLANCET 21G 96 PRO COMFORT PEN PREFERRED PLUS UNIFINE NEEDLES/31G X 8MM 120 PENTIPS/MINI/31GX5MM 119 PRETAB 143 PRO COMFORT PEN pregabalin 17 PRETTY FEET & HANDS 63 NEEDLES/32G X 4MM 120 PREGNYL W/DILUENT PREVACID 158 PRO COMFORT PEN BENZYLALCOHOL/NACL 72 PREVACID 24HR 158 NEEDLES/32G X 6MM 120 PREMARIN 74,163 PREVENT SAFETY PEN PROAIR DIGIHALER 15 PREMIUM CONDOMS NEEDLES 31GX1/4" 119 PROAIR HFA 15 LUBRICATED 89 PREVENT SAFETY PEN PROAIR RESPICLICK 15 PREMPRO 74 NEEDLES 31GX5/16" 119 probenecid 77 PRENATABS FA 142 PREVIDENT 5000 DRY MOUTH 140 PROBUPHINE IMPLANT KIT 9 PRENATAL 143 PREVIDENT 5000 PLUS 140 PROCARDIA 46 PRENATAL 19 142 PREVIDENT FLUORIDE 140 PROCARDIA XL 46 PRENATAL AND IRON 142 PREVNAR 13 159 PROCARE SPACER CHAMBER PRENATAL COMPLETE 142 PREZCOBIX 42 W/ADULT MASK 134 PRENATAL FORMULA 142 PROCARE SPACER CHAMBER PREZISTA 42 W/CHILD MASK 134 PRENATAL FORMULA A- FREE 142 PRIALT 7 prochlorperazine 40 PRENATAL FORTE 142 primaquine phosphate 31 prochlorperazine edisylate 40 PRENATAL LOW IRON 142 PRIMAQUINE PROCHLORPERAZINE PHOSPHATE 31 MALEATE 40 PRENATAL MULTI + DHA 142 PRIMEAIRE DUAL-VALVED prochlorperazine maleate 40 PRENATAL MULTI +DHA 142 HOLDING CHAMBER 134 PROCRIT 79 PRENATAL primidone 17 PROCYSBI 76 MULTIVITAMIN 142 PRINIVIL 29 PRENATAL MULTIVITAMIN + PRODIGY INSULIN SYRING/U- DHA 142 PRISTIQ 21 100/0.3ML/31G X 5/16" 120 PRENATAL MULTIVITAMIN PRIVIGEN 151 PRODIGY INSULIN PLUS DHA 142 PRO COMFORT ALCOHOL SYRINGE/1/2ML/31G X PRENATAL ONE DAILY 142 PADS 99 5/16" 120 PRODIGY INSULIN prenatal vit w/ docusate-fe PRO COMFORT INHALER SPACER CHAMBER SYRINGE/1ML/28G X 1/2" 120 fumarate-folic acid 143 PRODIGY LANCING prenatal vit w/ docusate-iron ADULT 134 PRO COMFORT INHALER DEVICE 96 carbonyl-folic acid 143 PRODIGY TWIST TOP prenatal vit w/ ferrous fumarate- SPACER CHAMBER LANCETS 96 folic acid 143 CHILD 134 PROFILNINE 77 PRENATAL VITAMIN 143 PRO COMFORT INHALER SPACER CHAMBER PRENATAL VITAMIN & PROFILNINE SD 77 INFANT 134 progesterone 154 MINERAL 143 PRO COMFORT INSULIN PRENATAL SYRINGES/0.5ML/30G X PROGRAF 139 VITAMIN/IRON 143 5/16" 119 PROLASTIN-C 156 PRENATAL VITAMINS 143 PRO COMFORT INSULIN PROLEEVA 70 PRENATAL VITAMINS PLUS SYRINGES/0.5ML/31G X LOW IRON 143 5/16" 120 PROLEUKIN 35 PRENATAL+DHA 143 PROLIA 72 PROMACTA 79

Index 34 promethazine & PURIXAN 32 QC UNILET LANCETS phenylephrine 52 PUSH BUTTON SAFETY 28G/ULTRA THIN 96 promethazine hcl 27 LANCETS 21G 96 QC UNILET LANCETS promethazine w/codeine 52 PUSH BUTTON SAFETY 33G/MICRO THIN 96 QUADRACEL 157 promethazine-dm 52 LANCETS 28G 96 PX ADVANCED LANCING QUAKE 134 PROMETRIUM 154 DEVICE 96 quazepam 81 propafenone hcl 14 PX EXTRA SHORT PEN propranolol & NEEDLES 31GX6MM 120 QUDEXY XR 17 hydrochlorothiazide 30 PX LANCET AUTO QUESTRAN 27 propranolol hcl 45 INJECTOR 96 QUESTRAN LIGHT 27 PX LANCETS ULTRA PROPRANOLOL HCL 45 THIN 96 quetiapine fumarate 39 propranolol hcl 45 PX MINI PEN NEEDLES QUILLICHEW ER 3 propylene glycol (ophth) 147 31GX5MM 120 QUILLIVANT XR 3 propylthiouracil 157 PX PEN NEEDLE quinapril hcl 29 29GX12MM 120 PROSCAR 76 PX PEN NEEDLE quinapril-hydrochlorothiazide PROSHIELD PLUS SKIN 31GX8MM 120 30 PROTECTANT 66 PX PRENATAL quinidine gluconate 13 PROTONIX 158 MULTIVITAMINS 143 quinidine sulfate 13 PROTOPIC 64 PX SHORTLENGTH PEN QVAR REDIHALER 14 NEEDLES/31GX8MM 120 protriptyline hcl 22 RA ADVANCED HEALING 63 pyrazinamide 31 PROVENTIL HFA 15 pyrethrins-piperonyl RA ALCOHOL SWABS 99 PROVERA 154 butoxide 68 RA CALCIUM 137 PROVIGIL 3 pyrethrins-piperonyl butoxide- RA DAYLOGIC HEALING DRY PROZAC 20 permethrin-nit remover 68 SKIN THERAPY 63 PYRIDIUM 76 RA E-ZJECT LANCETS 28G96 PRUDOXIN 56 pyridostigmine bromide 31 RA E-ZJECT LANCETS THIN pseudoephed-bromphen-dm 52 pyridoxine hcl 164 26G 96 pseudoephedrine hcl 145 RA E-ZJECT LANCETS THIN QC ADVANCED LANCING 28G 96 pseudoephedrine w/ codeine- DEVICE 96 gg 53 RA E-ZJECT LANCETS pseudoephedrine-guaifenesin QC ALCOHOL SWABS 99 ULTRATHIN 30G 96 53 QC ALL PURPOSE RA FIRST AID NON-STICK pseudoephedrine-ibuprofen 53 DRESSINGS4"X4" 88 PADS 88 QC BORDER ISLAND GAUZE RA INSULIN PSS SELECT GP LANCETS 96 PAD 2"X2" 88 SYRINGE/0.5ML/29G X PSS SELECT SAFETY QC LANCETS SUPER 1/2" 120 LANCETS 96 THIN 96 RA INSULIN SYRINGE/1ML/29G psyllium 82 QC LANCETS ULTRA X 1/2" 120 PULMICORT 14 THIN 96 RA INSULIN SYRINGE/U- QC PEN NEEDLES 29G X PULMICORT FLEXHALER 14 100/0.5ML/30G X 5/16" 120 12MM 120 RA INSULIN SYRINGE/U-100/1 PULMONA 70 QC PEN NEEDLES 31G X ML/30G X 5/16" 120 PULMOZYME 156 6MM 120 RA PEN NEEDLES 31G X PURE & FREE BABY QC PEN NEEDLES 31G X 5MM3/16" 120 SUNSCREEN BROAD 8MM 120 RA PEN NEEDLES 31G X SPECTRUM SPF 50 QC PRENATAL 143 8MM5/16" 120 PURESCREEN 67 QC STERILE PADS 88 RA PRENATAL 143 PURE & GENTLE QC TRIACTING DAYTIME RA PRENATAL LUBRICANT 147 CHILDRENS 53 FORMULA/FOLICACID 143 PURE COMFORT PEN NEEDLE QC ULTIMATE RA RENEWAL DRY SKIN 32G X6MM 120 SUNSCREEN 67 THERAPY 63 PURE COMFORT PEN QC UNIFINE PENTIPS RA SHEER ADHESIVE NEEDLE/32G X4MM 120 32GX4MM 120 LARGE 88 PURE L-CITRULLINE 147 RA STERILE PADS 2"X2" 88

Index 35 RA STERILE PADS 3"X3" 88 REGLAN 75 RELION TRUE METRIX RA STERILE PADS 4"X4" 88 RELENZA DISKHALER 44 BLOODGLUCOSE TEST STRIPS 70 RADIAGUARD ADVANCED 63 RELEXXII 3 RELION ULTRA THIN raloxifene hcl 73 RELION 2-IN-1 LANCET LANCETS/30G 96 ramelteon 82 DEVICES 30G 96 RELION ULTRA THIN RELION 2-IN-1 LANCING LANCETS30G 96 ramipril 29 DEVICE 25G 96 RELION ULTRA THIN PLUS RAPAFLO 76 RELION 2-IN-1 LANCING LANCETS 32G 96 RAPAMUNE 139 DEVICE 30G 96 RELION ULTRA THIN PLUS RELION ALCOHOL RASUVO 5 LANCETS 33G 96 SWABS 99 RELPAX 135 RAVICTI 73 RELION INSULIN SYRINGE/U- REMEDY CLEANSING BODY RAY-TEC X-RAY 100/0.3ML/30G X 5/16" 120 LOTION 66 DETECTABLESPONGES 4" X 4" RELION INSULIN SYRINGE/U- REMEDY DIMETHICONE 16 PLY 88 100/0.3ML/31G X 15/64" 120 MOISTURE BARRIER 66 RAZADYNE 154 RELION INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 121 REMEDY NUTRASHIELD 66 RAZADYNE ER 154 RELION INSULIN SYRINGE/U- REMEDY PHYTOPLEX REALITY INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 121 HYDRAGUARD 66 100/0.5ML/28G X 1/2" 120 RELION INSULIN SYRINGE/U- REMEDY SKIN REPAIR 66 REALITY INSULIN SYRINGE/U- 100/0.5ML/31G X 5/16" 121 100/0.5ML/29G X 1/2" 120 REMERON 19 RELION INSULIN SYRINGE/U- REMERON SOLTAB 19 REALITY INSULIN SYRINGE/U- 100/1ML/30G X 5/16" 121 100/1ML/28G X 1/2" 120 RELION INSULIN SYRINGE/U- REMICADE 76 REALITY INSULIN SYRINGE/U- 100/1ML/31G X 5/16" 121 REMODULIN 47 100/1ML/29G X 1/2" 120 RELION KETONE TEST RENFLEXIS 76 REALITY LANCETS 96 STRIPS 70 REALITY LATEX RELION LANCETS MICRO- REPATHA 28 CONDOMS/LUBRICATED 89 THIN33G 96 REPATHA PUSHTRONEX REALITY LATEX/ULTRA RELION LANCETS THIN SYSTEM 28 TEXTURED 89 26G 96 REPATHA SURECLICK 28 REALITY LATEX/ULTRA RELION LANCETS ULTRA- RESCRIPTOR 42 THIN 89 THIN30G 96 RESTA 63 REALITY SWABS 99 RELION LANCING RESTA LITE 63 REBETOL 44 DEVICE 96 RELION MINI PEN NEEDLES RESTORE CONTACT REBIF 155 31GX6MM 121 LAYER/NON-ADHERENT REBIF REBIDOSE 155 RELION PEN NEEDLES 2"X2" 88 REBIF REBIDOSE 29GX12MM 121 RESTORE FOAM DRESSING TITRATIONPACK 155 RELION PEN NEEDLES 31G BORDERED 4"X4" 88 REBIF TITRATION PACK 155 X6MM 121 RESTORE FOAM DRESSING RELION PEN NEEDLES 31G NON-BORDERED 4"X4" 88 REBINYN 77 X8MM 121 RESTORE ODOR ABSORBING RECLAST 72 RELION PEN NEEDLES DRESSING 4"X4" 88 RECOMBINATE 77 31GX5/16" 121 RESTORE TRIO ABSORBENT RECOMBIVAX HB 162 RELION PEN NEEDLES DRESSING 3"X3" 88 31GX6MM 121 RESTORIL 81 REFRESH 147 RELION PEN NEEDLES RETACRIT 79 REFRESH DIGITAL 147 31GX8MM 121 RETIN-A 54 REFRESH LIQUIGEL 147 RELION PEN NEEDLES 32G X4MM 121 RETROVIR 42 REFRESH OPTIVE 147 RELION PEN NEEDLES 32G RETROVIR IV INFUSION 42 REFRESH OPTIVE X5/32" 121 ADVANCED 147 RELION PEN NEEDLES REVATIO 47 REFRESH PLUS 147 32GX4MM 121 REVLIMID 139 REFRESH RELIEVA 147 RELION PEN NEEDLES/31G REXALL LANCETS ULTRA REFRESH REPAIR 147 X1/4" 121 THIN 96 RELION SHORT PEN REXULTI 40 REFRESH TEARS 147 NEEDLES31GX8MM 121

Index 36 REYATAZ 42,43 ROC RETINOL CORREXION SAFETY SEAL LANCETS RHEUMATE 70 MAX 64 28G 96 ROC RETINOL CORREXION SAFETY SEAL LANCETS RHOGAM ULTRA-FILTERED NIGHT 64 30G 97 PLUS 151 ROC RETINOL CORREXION SAIZEN 72 RHOPHYLAC 151 SENSITIVE EYE 64 SAIZENPREP RIASTAP 77 ROC RETINOL CORREXION RECONSTITUTIONKIT 72 RIBASPHERE 44 SENSITIVE NIGHT 64 SALAGEN 140 ROC RETINOL CORREXION RIBASPHERE RIBAPAK 44 SPF30 67 saline 144 ribavirin (hepatitis c) 44 ROCALTROL 73 salsalate 7 riboflavin 164 ROMIDEPSIN 35 SAMSCA 74 RIBOZEL 70 ropinirole hydrochloride 36 SANDIMMUNE 139 RID 68 ROSE MILK 64 SANDOSTATIN 74 RID COMPLETE LICE rosuvastatin calcium 28 SANDOSTATIN LAR ELIMINATION 68 DEPOT 74 ROXICODONE 8 RIFADIN 31 SAPHRIS 39 ROZEREM 82 rifampin 32 sapropterin dihydrochloride 73 RUCONEST 78 RIGHT STEP PRENATAL 143 SARAFEM 155 RUZURGI 31 RIGHTEST GD500 LANCING SARNA 56 DEVICE 96 SABRIL 18 SAVELLA 155 RIGHTEST GL300 SAFE-T-LANCE LOW FLOW LANCETS 96 25G 96 SAVELLA TITRATION RISABAL-PH 63 SAFE-T-LANCE NORMAL PACK 155 SB ALCOHOL PREP PADS 99 risedronate sodium 72 FLOW21G 96 SAFE-T-LANCE PLUS SB INSULIN SYRINGE/U- RISPERDAL 38 SAFETYLANCET LOW 100/0.5ML/29G X 1/2" 121 RISPERDAL CONSTA 38 FLOW 96 SB INSULIN SYRINGE/U- risperidone 38 SAFE-T-LANCE PLUS 100/0.5ML/30G X 5/16" 121 SB INSULIN SYRINGE/U- RITALIN 3 SAFETYLANCET NORMAL FLOW 96 100/1ML/29G X 1/2" 121 RITALIN LA 3 SAFESNAP INSULIN SB INSULIN SYRINGE/U- RITEFLO 134 SYRINGE/0.3ML/30G X 100/1ML/30G X 5/16" 121 ritonavir 43 5/16" 121 SB INSULIN SYRINGE/U- SAFESNAP INSULIN 100/1ML/31G X 5/16" 121 RITUXAN 32 SYRINGE/0.5ML/29G X SB LANCETS THIN 97 rivastigmine 154 1/2" 121 SB LANCETS ULTRA THIN 97 rivastigmine tartrate 154 SAFESNAP INSULIN SCOOBY-DOO ONE A RIXUBIS 77 SYRINGE/0.5ML/30G X DAY 140 5/16" 121 SE-NATAL 19 143 rizatriptan benzoate 135 SAFESNAP INSULIN ROBAXIN-750 144 SYRINGE/1ML/28G X SEASONIQUE 49 ROBITUSSIN PEAK COLD 1/2" 121 SECONAL SODIUM 81 DM 53 SAFESNAP INSULIN SECUADO 39 ROC DEEP WRINKLE SYRINGE/1ML/29G X SECURESAFE SAFETY SERUM 63 1/2" 121 INSULIN SYRINGES/U- ROC MULTI CORREXION 5 IN1 SAFETY INSULIN SYRINGES 100/0.5ML/29GX1/2" 121 DAILY MOISTURIZER SPF 0.5ML/29GX1/2" 121 SECURESAFE SAFETY 30 67 SAFETY INSULIN SYRINGES INSULIN SYRINGES/U- ROC MULTI CORREXION 5 IN1 0.5ML/30GX5/16" 121 100/1ML/29GX1/2" 121 RESTORING EYE CREAM 63 SAFETY INSULIN SYRINGES SECURESAFE SAFETY PEN ROC MULTI CORREXION 5 IN1 1ML/29GX1/2" 121 NEEDLES/30G X 5/16" 121 RESTORING NIGHT SAFETY INSULIN SYRINGES CREAM 63 1ML/30GX1/2" 121 SEGLUROMET 22 ROC RETINOL SAFETY LANCETS 28G 96 SELECT-LITE LANCING CORREXION 64 DEVICE 97 SAFETY LET LANCETS 96 selegiline hcl 36

Index 37 SELEGILINE HCL 36 SHOPKO UNIFINE PENTIPS SKYLA 50 selenium sulfide 56 PEN SKYRIZI 56 NEEDLES/SHORT/31GX8MM SELSUN BLUE 56 122 SLEEP SOUNDLY 4 SELSUN BLUE DAILY 56 SHOPKO UNIFINE PENTIPS SLO-NIACIN 164 SELSUN BLUE PLUS PEN SM ADHESIVE PADS 2"X3" 88 MEDICATED 56 NEEDLES/MICRO/REMOVR/3 SM ADHESIVE PADS 3"X4" 88 SELSUN BLUE 2GX4MM 122 MOISTURIZING 56 SHOPKO UNIFINE PENTIPS SM ALCOHOL PREP PADS 99 SELZENTRY 43 PLUS PEN SM GAUZE PADS 2"X2" 88 SEMGLEE 24 NEEDLES/MINI/REMOVER/31 SM GAUZE PADS 3"X3" 88 GX5MM 122 SENNA 83 SHOPKO UNIFINE PENTIPS SM GAUZE PADS 4"X4" 88 sennosides 83 PLUS PEN SM GLUCOSE 23 sennosides-docusate NEEDLES/REMOVER/29GX12 SM MICRO THIN LANCETS sodium 82 MM 122 33G 97 SENOKOT 83 SHOPKO UNIFINE PENTIPS SM ONE DAILY PRENATAL 143 SENOKOT S 83 PLUS PEN NEEDLES/SHORT/REMOVR/3 SM PRENATAL VITAMINS 143 SENSI-CARE 1GX8MM 122 MOISTURIZING 66 SM SKIN CLEANSER SHOPKO UNILET LANCETS GENTLE/SENSITIVE SKIN 66 SENSIPAR 73 SUPER THIN 30G 97 SM STERILE PADS 88 SENTRA AM 70 SHOPKO UNILET LANCETS SM STERILE PADS 2"X2" 88 SENTRA PM 70 ULTRA THIN 28G 97 SIDE BUTTON SAFETY SM TRUEDRAW LANCING SEREVENT DISKUS 15 LANCET21G 97 DEVICE 97 SEROQUEL 39 SIGNIFOR 74 SMART DIABETES VANTAGE SEROQUEL XR 39 LANCING DEVICE 97 sildenafil citrate (pulmonary SMART SENSE COLOR SEROSTIM 72 hypertension) 47 LANCETS UNIVERSAL 33G 97 sertraline hcl 20 SILENOR 81 SMART SENSE STANDARD SERTRALINE HCL 48 SILVADENE 57 LANCETS UNIVERSAL 21G 97 silver sulfadiazine 57 SMART SENSE SUPER THIN SEVENFACT 77 LANCETS UNIVERSAL 30G 97 SFROWASA 76 simethicone 75 SMART SENSE THIN SHADE SUNBLOCK SPF 4567 SIMILAC PRENATAL EARLY LANCETSUNIVERSAL 26G 97 SHIELD 143 SMARTEST LANCETS 28G 97 SHADE UVAGUARD SPF SIMPLE DIAGNOSTICS 15 67 LANCING DEVICE 97 sodium bicarbonate (antacid) 11 SHINGRIX 162 SIMPLE SYRUP 153 SHOPKO ALCOHOL sodium chloride 138 SIMPLYTHICK 152 SWABS 99 sodium chloride (gu irrigant) 76 SIMPLYTHICK EASY SHOPKO AUTOLET LANCING sodium chloride (inhalant) 53 DEVICE 97 MIX 152 SHOPKO ON-THE-GO SIMPLYTHICK EASYMIX 152 sodium chloride flush 138 COMFORTLANCETS 30G 97 SIMPONI 4 sodium citrate & citric acid 76 SHOPKO UNIFINE PENTIPS SIMPONI ARIA 4 sodium fluoride 138 PEN NEEDLES/MICRO/32GX4MM simvastatin 28 sodium fluoride (dental) 140 122 SINEMET 36 sodium hypochlorite 41 SHOPKO UNIFINE PENTIPS SINEMET CR 36 sodium phenylbutyrate 73 PEN NEEDLES/MINI/31GX5MM SINGLE-LET 97 sodium phosphates 83 122 SINGULAIR 14 sodium polystyrene SHOPKO UNIFINE PENTIPS sulfonate 140 PEN sirolimus 139 SODIUM NEEDLES/ORIGINAL/29GX12M SIVEXTRO 12 SULFACETAMIDE/SULFUR M 122 skin protectants, misc. 66 54 SKIN REPAIR 64 SODIUM VALPROATE 48

Index 38 SOF-SET ADHESIVE STALEVO 50 36 SULFZIX 70 PATCH 88 STALEVO 75 36 sulindac 6 SOF-WICK 4"X4" 88 starch-maltodextrin sumatriptan 135 SOFOSBUVIR/VELPATASVIR (thickening) 152 sumatriptan succinate 135,136 44 STARLIX 24 SOLBAR AVO 67 SUMMERS EVE FEMININE 66 stavudine 43 SOLBAR PF SPF15 67 SUNOSI 2 STAVUDINE 43 SOLIRIS 78 SUNSCREEN KIDS SPF50+67 STEGLATRO 24 SOLUS V2 LANCING SUNSCREEN ULTRA DEVICE 97 STELARA 56,76 SHEER 68 SOLVATECH PLUS 153 STERILANCE TL 97 sunscreens 68 SOLVATECH SWEET SF 153 STERILE DILUENT FOR SUPER THIN LANCETS 97 FLOLAN 153 SUPPRELIN LA 73 SOMATULINE DEPOT 74 STERILE DILUENT FOR SOMAVERT 72 TREPROSTINIL SUPRESS DM PEDIATRIC 53 SOOLANTRA 68 INJECTION 153 SURE COMFORT INSULIN SOOTHE & COOL STERILE GAUZE PADS SYRINGE/U-100/0.3ML/29G X MOISTURIZING BODY LOTION 2"X2" 88 1/2" 122 WITH ALOE 64 STERILE GAUZE PADS SURE COMFORT INSULIN SOOTHE & COOL SKIN 3"X3" 88 SYRINGE/U-100/0.3ML/30G X CREAMWITH ALOE & STERILE PADS 2"X2" 88 1/2" 122 VITAMINS A, D & E 64 SURE COMFORT INSULIN STERILE PADS 3"X3" 88 SYRINGE/U-100/0.3ML/30G X SORBIDON HYDRATE 66 STERILE PADS 4"X4" 88 5/16" 122 SORBITOL 83,153 STIMATE 74 SURE COMFORT INSULIN SORBOLENE 64 STIVARGA 35 SYRINGE/U-100/0.3ML/31G X SOSWEET 153 5/16 122 STRATTERA 2 SURE COMFORT INSULIN sotalol hcl 45 STRIBILD 43 SYRINGE/U-100/0.3ML/31G X sotalol hcl (afib/afl) 45 STROMECTOL 11 5/16" 122 SOTYLIZE 45 STUART ONE 143 SURE COMFORT INSULIN SOVALDI 44 SYRINGE/U-100/0.5ML/28G X STUDIO 35 EXTRA 1/2" 122 SPECIAL CARE CREAM 64 MOISTURIZING LOTION 64 SURE COMFORT INSULIN spinosad 68 STUDIO 35 MOISTURIZING SYRINGE/U-100/0.5ML/29G X SKIN 64 SPINRAZA 145 1/2" 122 SUBOXONE 9 SURE COMFORT INSULIN SPIRIVA RESPIMAT 14 sucralfate 158 SYRINGE/U-100/0.5ML/30G X SPIRO PD 134 SUDAFED CHILDRENS 145 5/16" 122 spironolactone 71 SUDAFED SURE COMFORT INSULIN spironolactone & CONGESTION 145 SYRINGE/U-100/0.5ML/31G X hydrochlorothiazide 71 SUDAFED PE SINUS 5/16 122 SPORANOX 26 CONGESTION 145 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X SPORANOX PULSEPAK 26 SUDAFED SINUS CONGESTION 145 1/2" 122 SPORT SUNSCREEN SPF sulfacetamide sod- SURE COMFORT INSULIN 50 67 prednisolone 150 SYRINGE/U-100/1ML/29G X SPRAVATO 56MG DOSE 19 sulfacetamide sodium 56 1/2" 122 SURE COMFORT INSULIN SPRAVATO 84MG DOSE 19 sulfacetamide sodium SPRYCEL 35 SYRINGE/U-100/1ML/30G X (acne) 54 1/2" 122 ST IVES SWISS FORMULA sulfacetamide sodium SURE COMFORT INSULIN 24HOUR MOISTURE 64 (ophth) 149 SYRINGE/U-100/1ML/30G X sulfacetamide sodium w/ STALEVO 100 36 5/16" 122 STALEVO 125 36 sulfur 54 SURE COMFORT INSULIN sulfamethoxazole-trimethoprim SYRINGE/U-100/1ML/31G X STALEVO 150 36 11,12 5/16" 122 STALEVO 200 36 sulfasalazine 76

Index 39 SURE COMFORT LANCING SURE-LANCE ULTRA THIN tadalafil (pulmonary PEN 97 LANCETS 97 hypertension) 47 SURE COMFORT PEN SURE-PEN 97 TAFINLAR 35 NEEDLES29GX1/2" SURE-TOUCH LANCETS TAGAMET HB 158 12.7MM 122 UNIVERSAL 97 TALTZ 56 SURE COMFORT PEN SURELITE LANCETS 97 NEEDLES30GX5/16" TAMIFLU 44,45 SURGICAL GAUZE SHORT 122 tamoxifen citrate 33 SURE COMFORT PEN SPONGE 88 NEEDLES31GX3/16" SURMONTIL 22 tamsulosin hcl 76 (5MM) 122 SUSPENDOL-S 153 TAPAZOLE 157 SURE COMFORT PEN SUSPENDRX WITH BITTER- TARCEVA 33 NEEDLES31GX5/16" BLOC/SWEETENED 153 TARGADOX 156 (8MM) 123 SUSPENDRX WITH BITTER- SURE COMFORT PEN BLOC/UNSWEETENED 153 TARGRETIN 35,56 NEEDLES32GX5/32" 123 SUSPENSION VEHICLE 153 TARKA 30 SURE COMFORT PEN SUSTIVA 43 TASIGNA 35 NEEDLES32GX6MM 123 SURE-FINE PEN NEEDLES SUTENT 35 TAVALISSE 78 29GX1/2" 12.7MM 123 SWEETENING SUSPENDING TAXOTERE 35 SURE-FINE PEN NEEDLES COMPOUND 153 tazarotene 56 31GX3/16" 5MM 123 SYLATRON 35 TAZORAC 56 SURE-FINE PEN NEEDLES SYMBICORT 15 31GX5/16" 8MM 123 TDVAX 157 SURE-JECT INSULIN SYMBYAX 155 TEARS NATURALE PM 147 SYRINGE/U-100/0.3ML/29G X SYMDEKO 156 TECFIDERA 155 1/2" 123 SYMFI 43 TECFIDERA STARTER SURE-JECT INSULIN SYMFI LO 43 PACK 155 SYRINGE/U-100/0.3ML/30G X TECHLITE AST LANCETS 97 5/16" 123 SYMLINPEN 120 22 SURE-JECT INSULIN SYMLINPEN 60 22 TECHLITE INSULIN SYRINGEU- 100/0.3ML/29G X 1/2" 123 SYRINGE/U-100/0.3ML/31G X SYMPAZAN 16 5/16" 123 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN SYMTUZA 43 100/0.3ML/30G X 1/2" 123 SYRINGE/U-100/0.5ML/28G X SYNAGIS 151 TECHLITE INSULIN SYRINGEU- 100/0.3ML/30G X 5/16" 123 1/2" 123 SYNAREL 73 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SYNRIBO 35 100/0.3ML/31G X 15/64" 123 SYRINGE/U-100/0.5ML/29G X TECHLITE INSULIN SYRINGEU- 1/2" 123 SYNTHROID 157 SYPRINE 138 100/0.3ML/31G X 5/16" 123 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/30G X SYRPALTA 153 100/0.5ML/29G X 1/2" 123 5/16" 123 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN SYRSPEND SF 153 SYRUP NF 153 100/0.5ML/30G X 5/16" 123 SYRINGE/U-100/0.5ML/31G X TECHLITE INSULIN SYRINGEU- 5/16" 123 SYRUP VEHICLE 153 100/0.5ML/31G X 5/16" 123 SURE-JECT INSULIN SYRUP VEHICLE SF 153 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/28G X 100/1ML/29G X 1/2" 123 1/2" 123 SYSTANE 147 SYSTANE COMPLETE 147 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN 100/1ML/30G X 1/2" 123 SYRINGE/U-100/1ML/29G X SYSTANE ULTRA 147 TECHLITE INSULIN SYRINGEU- 1/2" 123 SYSTANE ULTRA HOME & 100/1ML/30G X 5/16" 124 SURE-JECT INSULIN AWAY PACK 147 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/30G X T-SUPPORT MAX 70 100/1ML/31G X 5/16" 124 5/16" 123 SURE-JECT INSULIN TABLOID 32 TECHLITE LANCETS 97 SYRINGE/U-100/1ML/31G X TACLONEX 58 TECHLITE LANCETS 30G 97 5/16" 123 tacrolimus 140 TECHLITE PEN NEEDLES 29GX SURE-LANCE THIN LANCETS 12 MM 124 28G 97 tacrolimus (topical) 64,65

Index 40 TECHLITE PEN NEEDLES 31GX TGT LANCET MICRO THIN TIVICAY 43 5MM 124 33G 97 tizanidine hcl 144 TECHLITE PEN NEEDLES/31GX TGT LANCET THIN 26G 97 TL-ICARE 70 5MM 124 TGT LANCET ULTRA THIN TECHLITE PEN NEEDLES/31GX 30G 97 TOBAKIENT 70 6 MM 124 TGT LANCING DEVICE 97 TOBI 4 TECHLITE PEN NEEDLES/31GX 8MM 124 THALOMID 139 TOBI PODHALER 4 TECHLITE PEN NEEDLES/32GX THEO-24 15 TOBRADEX 150 4MM 124 theophylline 15 tobramycin 4 TECHLITE PEN NEEDLES/32GX tobramycin (ophth) 149 6MM 124 THERABETIC SKIN CARE64 TEGADERM FOAM DRESSING THERAGAUZE 88 tobramycin sulfate 4 2"X2" 88 THERAMINE 70 tobramycin- TEGADERM FOAM DRESSING THERANATAL dexamethasone 150 4"X4" 88 COMPLETE 143 TOBREX 149 TEGRETOL 17 THERANATAL CORE TODAYS HEALTH ADVANCED TEGRETOL-XR 17 NUTRITION 144 LANCING DEVICE 97 THERANATAL ONE 144 TODAYS HEALTH MINI PEN TEKTURNA 31 NEEDLES 31G X 1/4" 124 telmisartan 29 THERANATAL OVAVITE 144 TODAYS HEALTH ORIGINAL telmisartan-amlodipine 30 THERAPEUTIC PEN NEEDLES 29G X 1/2" 124 MOISTURIZING 64 telmisartan-hydrochlorothiazide TODAYS HEALTH SHORT PEN THERAPLEX NEEDLES 31G X 5/16" 124 30 HYDROLOTION 64 temazepam 81 TODAYS HEALTH SUPER THERASEAL HAND THINLANCETS 30G 97 TEMIXYS 43 PROTECTION 66 TODAYS HEALTH ULTRA TEMODAR 32 thiamine hcl 164 THINLANCETS 28G 97 TEMOVATE 58 thiamine mononitrate 164 TOFRANIL 22 temozolomide 32 THICK-IT ORIGINAL 152 tolnaftate 55 temsirolimus 35 THINLETS GP LANCETS 97 tolterodine tartrate 159 TENIVAC 157 thioridazine hcl 40 tolvaptan 74 tenofovir disoproxil fumarate 43 thiothixene 40 TOPAMAX 17 TENORETIC 100 31 THRESHOLD PEP 134 TOPAMAX SPRINKLE 17 TENORETIC 50 31 THROMBATE III 78 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES TENORMIN 45 THROMBATE III W/10 ML STERILE WATER 78 31GX1/4" 124 TEPADINA 32 THROMBATE III W/20 ML TOPCARE CLICKFINE terazosin hcl 29 STERILE WATER 78 UNIVERSAL PEN EEDLES terbinafine hcl 26 THYROGEN 69 31GX5/16" 124 TOPCARE LANCETS MICRO- terbinafine hcl (topical) 55 thyroid 157 THIN 33G 97 terbutaline sulfate 15 tiagabine hcl 18 TOPCARE ULTRA COMFORT terconazole vaginal 162 TIAZAC 46 INSULIN SYRINGE/0.3ML/30G X 5/16" 124 TESSALON PERLES 51 TIKOSYN 14 TOPCARE ULTRA COMFORT TESTIM 9 timolol maleate 46 INSULIN SYRINGE/0.3ML/31G X testosterone cypionate 9 timolol maleate (ophth) 148 5/16" 124 TETANUS/DIPHTHERIA TIMOPTIC 148 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G X TOXOIDS-ADSORBED TIMOPTIC OCUDOSE 148 ADULT 157 5/16" 124 tetrabenazine 155 TIMOPTIC-XE 148 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X tetracaine hcl (ophth) 149 TINACTIN 55 TINACTIN DEODORANT 55 5/16" 124 tetrahydrozoline hcl (ophth) 149 TOPCARE ULTRA COMFORT TGT ALCOHOL SWABS 99 TINACTIN JOCK ITCH 55 INSULIN SYRINGE/1ML/30G X tioconazole vaginal 162 5/16" 124

Index 41 TOPCARE ULTRA COMFORT TREXALL 32 TRUE COMFORT PRO INSULIN SYRINGE/1ML/31G X triamcinolone acetonide INSULINSYRINGE/1ML/31G X 5/16" 124 (mouth) 140 5/16" 125 TOPCARE ULTRA COMFORT triamcinolone acetonide TRUE COMFORT PRO PEN INSULIN SYRINGE/U- (nasal) 145 NEEDLES 31G X 5MM 125 100/0.3ML/29G X 1/2" 124 triamcinolone acetonide TRUE COMFORT PRO PEN TOPCARE ULTRA COMFORT (topical) 58 NEEDLES 31G X 6MM 125 INSULIN SYRINGE/U- TRIAMINIC COLD & COUGH TRUE COMFORT PRO PEN 100/0.5ML/29G X 1/2" 124 DAY TIME CHILDRENS 53 NEEDLES 31G X 8MM 125 TOPCARE ULTRA COMFORT triamterene & TRUE COMFORT PRO PEN INSULIN SYRINGE/U- hydrochlorothiazide 71 NEEDLES 32G X 4MM 125 100/1ML/29G X 1/2" 124 triazolam 81 TRUE COMFORT PRO PEN TOPICORT 58 NEEDLES 32G X 6MM 125 TRIBENZOR 31 TRUE METRIX BLOOD topiramate 17,18 TRICARE 144 GLUCOSETEST STRIPS 70 topotecan hcl 36 TRIDESILON 58 TRUE METRIX CONTROL SOLUTION LEVEL 1 98 TOPOTECAN HCL 36 trientine hcl 139 topotecan hcl 36 TRUE METRIX CONTROL trifluoperazine hcl 40 SOLUTION LEVEL 2 98 TOPPER DRESSING SPONGES TRUE METRIX CONTROL 4"X4" 88 trifluridine 149 trihexyphenidyl hcl 36 SOLUTION LEVEL 3 98 TOPROL XL 45 TRUEDRAW LANCING toremifene citrate 33 TRIKAFTA 156 DEVICE 98 TORISEL 35 TRILEPTAL 18 TRUEPLUS 5-BEVEL PEN trimethoprim 11 NEEDLES 29GX12.7MM 125 torsemide 71 TRUEPLUS 5-BEVEL PEN TOTAL BLOCK SPF 60 trimipramine maleate 22 NEEDLES 31GX5MM 125 COVERUP 68 TRIMIPRAMINE TRUEPLUS 5-BEVEL PEN TOTAL BLOCK SPF 65 MALEATE 22 NEEDLES 31GX6MM 125 CLEAR 68 TRINATAL RX 1 144 TRUEPLUS 5-BEVEL PEN TRACLEER 47 TRINTELLIX 20 NEEDLES 31GX8MM 125 TRADJENTA 23 TRISPEC DMX 53 TRUEPLUS 5-BEVEL PEN tramadol hcl 8 NEEDLES 32GX4MM 125 TRISPEC DMX TRUEPLUS INSULIN tramadol-acetaminophen 9 PEDIATRIC 53 SYRINGE/U-100/0.3ML/29G X trandolapril 29 TRIUMEQ 43 1/2" 125 trandolapril-verapamil hcl 31 TRIZIVIR 43 TRUEPLUS INSULIN TROGARZO 43 SYRINGE/U-100/0.3ML/30G X tranexamic acid 80 5/16" 125 TRANXENE T 13 TROKENDI XR 18 TRUEPLUS INSULIN tranylcypromine sulfate 19 tropicamide 148 SYRINGE/U-100/0.3ML/31G X TRAVEL LANCETS 30G 97 trospium chloride 159 5/16" 125 TRAVEL LANCETS ADVANCED TRUE COMFORT INSULIN TRUEPLUS INSULIN 28G 98 SYRINGE/0.5ML/31G X SYRINGE/U-100/0.5ML/28G X 1/2" 125 TRAZODONE HCL 20 5/16" 124 TRUE COMFORT INSULIN TRUEPLUS INSULIN trazodone hcl 20 SYRINGE/1ML/31G X SYRINGE/U-100/0.5ML/29G X TREANDA 32 5/16" 124 1/2" 125 TRECATOR 32 TRUE COMFORT PEN TRUEPLUS INSULIN NEEDLES31G X 5MM 124 SYRINGE/U-100/0.5ML/30G X TRELSTAR MIXJECT 33,34 TRUE COMFORT PEN 5/16" 125 TREMFYA 56 NEEDLES31G X 6MM 124 TRUEPLUS INSULIN TREPADONE 70 TRUE COMFORT PEN SYRINGE/U-100/0.5ML/31G X 5/16" 125 treprostinil 47 NEEDLES32G X 4MM 124 TRUE COMFORT PRO TRUEPLUS INSULIN tretinoin 54 INSULINSYRINGE/0.5ML/31G SYRINGE/U-100/1ML/28G X tretinoin (chemotherapy) 35 X 5/16" 124 1/2" 125 TRETTEN 77

Index 42 TRUEPLUS INSULIN TRUSTEX/RIA LUBRICATED ULTICARE INSULIN SAFETY SYRINGE/U-100/1ML/29G X SPERMICIDE 89 SYRINGE/1ML/29G X 1/2" 126 1/2" 125 TRUSTEX/RIA ULTICARE INSULIN TRUEPLUS INSULIN LUBRICATED/SPERMICIDE SYRINGE/0.3ML/29G X SYRINGE/U-100/1ML/30G X 89 1/2" 126 5/16" 125 TRUVADA 43 ULTICARE INSULIN TRUEPLUS INSULIN TRYPTOPHAN 147 SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G X 1/2" 126 5/16" 125 TUMS 11 ULTICARE INSULIN TRUEPLUS LANCETS 26G 98 TUMS CHEWY BITES 11 SYRINGE/0.3ML/30G X TRUEPLUS LANCETS 28G 98 TUMS E-X 750 11 5/16" 126 TUMS EXTRA STRENGTH ULTICARE INSULIN TRUEPLUS LANCETS 28G SYRINGE/0.5ML/28G X SUPER THIN 98 750 11 TUMS LASTING 1/2" 126 TRUEPLUS LANCETS 30G 98 ULTICARE INSULIN TRUEPLUS LANCETS 30G EFFECTS 11 TUMS SMOOTHIES 11 SYRINGE/0.5ML/29G X ULTRA THIN 98 1/2" 126 TRUEPLUS LANCETS 33G 98 TUMS ULTRA 1000 11 ULTICARE INSULIN TRUEPLUS PEN NEEDLES TWINRIX 162 SYRINGE/0.5ML/30G X 29GX12MM 125 TWYNSTA 31 5/16" 126 TRUEPLUS PEN NEEDLES ULTICARE INSULIN 31GX5MM 125 TYBLUME 49 SYRINGE/1ML/28G X 1/2" 126 TRUEPLUS PEN NEEDLES TYBOST 43 ULTICARE INSULIN 31GX6MM 125 TYKERB 35 SYRINGE/1ML/29G X 1/2" 126 TRUEPLUS PEN NEEDLES TYLENOL 7 ULTICARE INSULIN 31GX8MM 125 SYRINGE/1ML/30G X 1/2" 126 TRUEPLUS PEN NEEDLES TYLENOL CHILDRENS 7 ULTICARE INSULIN 32GX4MM 125 TYLENOL CHILDRENS SYRINGE/1ML/30G X TRUEPLUS SAFETY LANCETS CHEWABLES/PAIN + 5/16" 126 28G 98 FEVER 7 ULTICARE INSULIN TRUMENBA 159 TYLENOL EXTRA SYRINGE/SHORT/0.3ML/30G X STRENGTH 7 TRUSOPT 150 5/16" 126 TYLENOL INFANTS 7 ULTICARE INSULIN TRUSTEX COLOR CONDOMS + SYRINGE/SHORT/0.3ML/31G X LUBE 89 TYLENOL INFANTS PAIN+FEVER 7 5/16" 126 TRUSTEX LUBRICATED 89 TYLENOL PM EXTRA ULTICARE INSULIN TRUSTEX LUBRICATED STRENGTH 80 SYRINGE/SHORT/0.5ML/30G X EXTRALARGE 89 TYLENOL/CODEINE #3 9 5/16" 126 TRUSTEX LUBRICATED ULTICARE INSULIN EXTRASTRENGTH 89 TYLENOL/CODEINE #4 9 SYRINGE/SHORT/0.5ML/31G X TRUSTEX TYSABRI 155 5/16" 126 LUBRICATED/RIBBED/STUDDE TYVASO 47 ULTICARE INSULIN D 89 TYVASO REFILL 47 SYRINGE/SHORT/1ML/30G X TRUSTEX 5/16" 126 LUBRICATED/SPERMICIDE TYVASO STARTER 47 ULTICARE INSULIN 89 UDDERLY SMOOTH 64 SYRINGE/SHORT/1ML/31G X TRUSTEX UDDERLY SMOOTH EXTRA 5/16" 126 LUBRICATED/SPERMICIDE CARE 64 ULTICARE INSULIN EXTRA LARGE 89 UDDERLY SMOOTH EXTRA SYRINGE/U-100/0.3ML/30G X TRUSTEX CARE20 64 1/2" 126 LUBRICATED/SPERMICIDE UDENYCA 79 ULTICARE INSULIN EXTRA STRENGTH 89 ULTI-LANCE AUTOMATIC/ SYRINGE/U-100/0.3ML/31G X TRUSTEX NATURAL CLEAR TIP 98 5/16" 126 CONDOMS ULTICARE ALCOHOL ULTICARE INSULIN +LUBE/LUBRICATED 89 SWABS 99 SYRINGE/U-100/0.5ML/31G X TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN SAFETY 5/16" 126 9/RIBBED/STUDDED 89 SYRINGE/0.5ML/29G X ULTICARE INSULIN TRUSTEX/RIA 1/2" 125 SYRINGE/U-100/1ML/30G X LUBRICATED 89 1/2" 126

Index 43 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/U-100/1ML/31G X INSULIN SYRINGE/0.3ML/30G SYRINGE/SHORT/0.3ML/31G X 5/16" 126 X 1/2"/SHARPS C 127 5/16" 128 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGEULTRAFINE U- INSULIN SYRINGE/0.3ML/31G SYRINGE/SHORT/0.5ML/30G X 100/0.3ML/31G X 5/16" 126 X 5/16"/SHARPS 127 5/16" 128 ULTICARE INSULIN ULTIGUARD SAFEPACK MINI ULTILET INSULIN SYRINGEULTRAFINE U- PEN NEEDLE/31G X SYRINGE/SHORT/0.5ML/31G X 100/0.5ML/31G X 5/16" 126 3/16"/SHARPS CONTAI 127 5/16" 128 ULTICARE INSULIN ULTIGUARD SAFEPACK PEN ULTILET INSULIN SYRINGEULTRAFINE U- NEEDLE/29G X 1/2"/SHARPS SYRINGE/SHORT/1ML/30G X 100/1ML/31G X 5/16" 126 CONTAINER 127 5/16" 128 ULTICARE MICRO PEN ULTIGUARD ULTILET INSULIN NEEDLES 31G X 8MM 126 SAFEPACK/MICROPEN SYRINGE/SHORT/1ML/31G X ULTICARE MICRO PEN NEEDLE/32G X 5/32"/SHARPS 5/16" 128 NEEDLES 32G X 4MM 126 CONTA 127 ULTILET INSULIN SYRINGE/U- ULTICARE MICRO PEN ULTIGUARD SAFEPACK/MINI 100/1ML/30G X 1/2" 128 NEEDLES/31G X 1/4" 126 PEN NEEDLE/31G X ULTILET LANCETS 98 ULTICARE MICRO PEN 1/4"/SHARPS CONTAIN 127 ULTILET LANCETS 33G 98 NEEDLES/31G X 5/16" 126 ULTIGUARD SAFEPACK/MINI ULTICARE MICRO PEN ULTILET PEN NEEDLE PEN NEEDLE/31G X 29GX12.7MM 128 NEEDLES/32G X 4MM 127 3/16"/SHARPS CONTAI 127 ULTICARE MICRO PEN ULTIGUARD SAFEPACK/MINI ULTILET PEN NEEDLE NEEDLES/32G X 5/32" 127 31GX5MM 128 PEN NEEDLE/32G X ULTILET PEN NEEDLE ULTICARE MINI PEN NEEDLES 1/4"/SHARPS CONTAIN 127 31GX6MM 127 31GX8MM 128 ULTIGUARD ULTILET PEN NEEDLE ULTICARE MINI PEN NEEDLES SAFEPACK/SHORTPEN ULTI-FINE IV 127 32GX4MM 128 NEEDLE/31G X 5/16"/SHARPS ULTILET PEN NEEDLE ULTICARE MINI PEN CONTA 127 NEEDLES/31G X 6MM 127 32GX4MM/SHORT 128 ULTIGUARD ULTILET SHORT PEN ULTICARE MINI PEN SAFEPACK/SYRINGE/NEEDL NEEDLES/32G X 1/4" 127 NEEDLES 31GX5/16" 128 E/31G X 5/16"/SHARPS ULTILET SHORT PEN ULTICARE MINI PEN CONTAIN 128 NEEDLES31GX6MM 127 NEEDLES31GX3/16" 128 ULTILET CLASSIC ULTRA COMFORT INSULIN ULTICARE ORIGINAL PEN LANCETS 98 NEEDLES ULTI-FINE 127 SYRINGE/U-100/0.3ML/30G X ULTILET INSULIN SYRINGE 5/16" 128 ULTICARE PEN NEEDLES 31X6MM 128 31GX 5MM/MINI 127 ULTRA FLO INSULIN PEN ULTILET INSULIN NEEDLE 31GX5MM 128 ULTICARE PEN SYRINGE/0.3ML/30G X NEEDLES/29GX 12.7MM 127 ULTRA FLO INSULIN PEN 8MM 128 NEEDLE 32GX4MM 128 ULTICARE SHORT PEN ULTILET INSULIN NEEDLES 31GX8MM 127 ULTRA FLO INSULIN PEN SYRINGE/0.3ML/31G X NEEDLES 128 ULTICARE SHORT PEN 8MM 128 NEEDLES ULTI-FINE IV 127 ULTRA FLO INSULIN PEN ULTILET INSULIN NEELE 31GX8MM 128 ULTICARE SHORT PEN SYRINGE/0.5ML/30G X NEEDLES/31G X 8MM 127 ULTRA FLO INSULIN SYRINGE 8MM 128 0.3ML/29G X 1/2" 128 ULTICARE SHORT SAFETY ULTILET INSULIN PEN NEEDLES 30G X ULTRA FLO INSULIN SYRINGE SYRINGE/1ML/30G X 0.3ML/30GX1/2" 128 5/16" 127 8MM 128 ULTIGUARD SAFEPACK ULTRA FLO INSULIN SYRINGE ULTILET INSULIN 0.3ML/30GX5/16" 128 INSULIN SYRINGE 0.3ML/30G X SYRINGE/1ML/31G X 1/2"/SHARPS C 127 ULTRA FLO INSULIN SYRINGE 8MM 128 0.3ML/31GX5/16" 128 ULTIGUARD SAFEPACK ULTILET INSULIN INSULIN SYRINGE 1ML 30G X ULTRA FLO INSULIN SYRINGE SYRINGE/SHORT/0.3ML/30G 0.5ML/29GX1/2" 128 1/2"/SHARPS CON 127 X 12.7MM 128 ULTIGUARD SAFEPACK ULTRA FLO INSULIN SYRINGE ULTILET INSULIN 0.5ML/30GX5/16" 128 INSULIN SYRINGE 1ML 31G X SYRINGE/SHORT/0.3ML/30G 5/16"/SHARPS CO 127 ULTRA FLO INSULIN SYRINGE X 5/16" 128 0.5ML/31GX5/16" 128

Index 44 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN UNIFINE PEN NEEDLE/32G 1/2 UNIT/0.3ML/30GX1/2" 129 SYRINGE SHORT/U- X4MM 130 ULTRA FLO INSULIN SYRINGE 100/0.5ML/30GX5/16" 129 UNIFINE PENTIPS 1/2 UNIT/0.3ML/30GX5/16" ULTRA-THIN II INSULIN 29GX12MM 130 129 SYRINGE SHORT/U- UNIFINE PENTIPS 31G X ULTRA FLO INSULIN SYRINGE 100/0.5ML/31GX5/16" 129 3/16" 130 1/2 UNIT/0.3ML/31GX5/16" ULTRA-THIN II INSULIN UNIFINE PENTIPS 129 SYRINGE SHORT/U- 31GX5MM 130 ULTRA FLO INSULIN SYRINGE 100/1ML/30GX5/16" 129 UNIFINE PENTIPS 1M/29GX1/2" 129 ULTRA-THIN II INSULIN 31GX6MM 130 ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- UNIFINE PENTIPS 1ML/30GX1/2" 129 100/1ML/31GX5/16" 129 31GX8MM 130 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN UNIFINE PENTIPS 1ML/30GX5/16" 129 SYRINGE/U- 32GX4MM 130 ULTRA FLO INSULIN SYRINGE 100/0.5ML/29GX1/2" 129 UNIFINE PENTIPS 1ML/31GX5/16" 129 ULTRA-THIN II INSULIN 32GX6MM 130 ULTRA THIN PEN NEEDLES SYRINGE/U- UNIFINE PENTIPS PLUS 32G X 4MM 129 100/1ML/29GX1/2" 130 29GX12MM 130 ULTRA-COMFORT INSULIN ULTRA-THIN II MINI PEN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.3ML/29G X NEEEDLES/31GX3/16" 130 31GX5MM 130 1/2" 129 ULTRA-THIN II PEN NEEDLES UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN 29GX1/2" 130 31GX6MM 130 SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II PEN UNIFINE PENTIPS PLUS 5/16" 129 NEEDLES/SHORT/31GX5/16" 31GX8MM 130 ULTRA-COMFORT INSULIN 130 UNIFINE PENTIPS PLUS SYRINGE/U-100/0.3ML/31G X ULTRACARE INSULIN 32GX4MM 130 5/16" 129 SYRINGE/U-100/0.3ML/30G X UNIFINE SAFECONTROL PEN ULTRA-COMFORT INSULIN 5/16" 130 NEEDLE/30G X 5/16" 130 SYRINGE/U-100/0.5ML/28G X ULTRACARE INSULIN UNILET COMFORTOUCH 1/2" 129 SYRINGE/U-100/0.3ML/31G X LANCET 98 ULTRA-COMFORT INSULIN 5/16" 130 UNILET EXCELITE 98 SYRINGE/U-100/0.5ML/29G X ULTRACARE INSULIN UNILET EXCELITE II 98 1/2" 129 SYRINGE/U-100/0.5ML/30G X UNILET G.P. LANCET 98 ULTRA-COMFORT INSULIN 5/16" 130 SYRINGE/U-100/0.5ML/30G X ULTRACARE INSULIN UNILET G.P. SUPERLITE 5/16" 129 SYRINGE/U-100/0.5ML/31G X LANCET 98 ULTRA-COMFORT INSULIN 5/16" 130 UNILET GP 28 ULTRA THIN98 SYRINGE/U-100/0.5ML/31G X ULTRACARE INSULIN UNILET LANCET 98 5/16" 129 SYRINGE/U-100/1ML/30G X UNILET LANCETS MICRO- ULTRA-COMFORT INSULIN 1/2" 130 THIN33G 98 SYRINGE/U-100/1ML/28G X ULTRACARE INSULIN UNILET LANCETS SUPER- 1/2" 129 SYRINGE/U-100/1ML/30G X THIN30G 98 ULTRA-COMFORT INSULIN 5/16" 130 UNILET LANCETS ULTRA-THIN SYRINGE/U-100/1ML/29G X ULTRACARE INSULIN 28G 98 1/2" 129 SYRINGE/U-100/1ML/31G X UNILET SUPERLITE ULTRA-COMFORT INSULIN 5/16" 130 LANCET 98 SYRINGE/U-100/1ML/30G X ULTRACARE PEN UNISOM PM PAIN 80 5/16" 129 NEEDLES/31G X 1/4" 130 UNISOM SLEEPGELS 80 ULTRA-COMFORT INSULIN ULTRACARE PEN SYRINGE/U-100/1ML/31G X NEEDLES/31G X 3/16" 130 UNISOM SLEEPMELTS 80 5/16" 129 ULTRACARE PEN UNISOM SLEEPTABS 80 ULTRA-THIN II INSULIN NEEDLES/31G X 5/16" 130 UNISPEND ANHYDROUS SYRINGE SHORT/U- ULTRACARE PEN SWEETENED 153 100/0.3ML/30GX5/16" 129 NEEDLES/32G X 1/14" 130 UNISPEND ANHYDROUS ULTRA-THIN II INSULIN ULTRACARE PEN UNSWEETENED 153 SYRINGE SHORT/U- NEEDLES/32G X 5/32" 130 UNISTIK TOUCH SAFETY 100/0.3ML/31GX5/16" 129 ULTRACET 9 LANCETS 23G 98 ULTRAM 8 UNIVERSAL 1 LANCETS THIN26G 98

Index 45 UNIVERSAL 1 LANCETS ULTRA VALVED HOLDING VIDA MIA UNILET LANCETS THIN 30G 98 CHAMBER 134 ULTRA THIN 28G 98 UNIVERSAL 1 VANCOCIN 12 VIDA MIA UNIPFINE LANCETS/33G/MICRO-THIN VANCOCIN HCL 12 PENTIPSSHORT 98 31GX8MM 131 UPCAL D 137 vancomycin hcl 12 VIDAZA 32 VANCOMYCIN urea 58 HYDROCHLORIDE 12 VIDEX EC 43 URECHOLINE 159 VANICREAM 64 VIDEXPEDIATRIC 43 UROCIT-K 10 76 VANISHPOINT INSULIN VIEKIRA PAK 44 UROCIT-K 5 76 SYRINGE/0.5ML/30G X vigabatrin 18 URSO 250 75 5/16" 131 VIGAMOX 149 VANISHPOINT INSULIN ursodiol 75 SYRINGE/1ML/29G X VIIBRYD 20 V-GO 20 98 1/2" 131 VIIBRYD STARTER PACK 20 V-GO 30 98 VANISHPOINT INSULIN VILTEPSO 145 SYRINGE/1ML/30G X V-GO 40 98 5/16" 131 VIMIZIM 73 VAGIFEM 163 VANTAS 34 VIMPAT 18 valacyclovir hcl 44 VAQTA 162 VINATE ONE 144 VALCYTE 43 VARIVAX 162 VIRACEPT 43 valganciclovir hcl 43 VASERETIC 31 VIRAMUNE 43 VALIUM 13 VASOTEC 29 VIRAMUNE XR 43 valproate sodium 18 VECAMYL 31 VIREAD 43 VALPROATE SODIUM 48 VECTIBIX 33 VISINE 149 valproic acid 18 VECTICAL 56 VISINE RED EYE valrubicin 34 COMFORT 149 VELCADE 35 VISTARIL 13 valsartan 29 VELETRI 47 VISUDYNE 149 valsartan-hydrochlorothiazide VELVACHOL 64 31 VITAFOL-OB 144 VALSTAR 34 venlafaxine hcl 21 VITALET PRO PLUS VALTREX 44 VENTAVIS 47 LANCETS 99 VALUE HEALTH INSULIN VENTOLIN HFA 15 VITALETS CHILDRENS 141 SYRINGE/U-100/0.5ML/29G X verapamil hcl 46 VITAMAX 141 1/2" 130 VERELAN 46 VITAMIN C 164 VALUE HEALTH INSULIN VERELAN PM 46 VITAMIN D3 163 SYRINGE/U-100/1ML/29G X VITAMIN E WITH 1/2" 130 VERIPRED 20 51 PANTHENOL 64 VALUE PLUS LANCETS VERSACLOZ 39 vitamins a & d (topical) 64 STANDARD 21G 98 VERSAFREE 153 VALUE PLUS LANCETS VITATHELY/GINGER 144 SUPERTHIN 30G 98 VERSAPLUS 153 VIVAGUARD LANCING VALUE PLUS LANCETS THIN VIBRAMYCIN 156 DEVICE 99 26G 98 VICTOZA 23 VIVELLE-DOT 75 VALUE PLUS LANCING VIDA MIA AUTOLET DEVICE 98 VIVITROL 25 LANCINGDEVICE 98 VOGELXO 9 VALUMARK LANCET SUPER VIDA MIA UNIFINE THIN 30G 98 PENTIPS32GX4MM 131 VOGELXO PUMP 9 VALUMARK LANCET ULTRA VIDA MIA UNIFINE VOL-NATE 144 THIN 28G 98 PENTIPSMINI 31GX6MM131 VOL-PLUS 144 VALUMARK PEN NEEDLES VIDA MIA UNIFINE 29GX12MM 130 PENTIPSORIGINAL VOLTAREN 54 VALUMARK PEN NEEDLES 29GX12MM 131 VONVENDI 77 31GX 6MM 130 VIDA MIA UNILET LANCETS VORTEX HOLDING VALUMARK PEN NEEDLES SUPER THIN 30G 98 CHAMBER/MASK/CHILDS 134 31GX 8MM 131

Index 46 VORTEX HOLDING WEGMANS UNIFINE PENTIPS ZALTRAP 32 CHAMBER/MASK/CHILDS/FRO PLUS/ULTRA ZANAFLEX 144 G 134 SHORT/31GX6MM 131 VORTEX HOLDING WELLBUTRIN SR 19 ZARONTIN 18 CHAMBER/MASK/TODDLER WELLBUTRIN XL 19 ZARXIO 79 134 ZAVESCA 78 VORTEX HOLDING WESTAB PLUS 144 CHAMBER/MASK/TODDLER/LA white petrolatum-mineral ZELBORAF 35 DY BUG 135 oil 147 ZEMAIRA 156 VORTEX VALVED HOLDING WIBI 64 ZEMPLAR 73 CHAMBER 135 WILATE 78 ZEPATIER 44 VOSEVI 44 WINRHO SDF 151 ZESTORETIC 31 VOTRIENT 35 XALATAN 150 ZESTRIL 29 VP INSULIN SYRINGE/U- 100/0.3ML/29G X 1/2" 131 XALKORI 35 ZETIA 28 VPRIV 78 XANAX 13 ZIAC 31 VRAYLAR 37 XANAX XR 13 ZIAGEN 43 VUSION 55 XELJANZ 5 zidovudine 43 VYNDAMAX 47 XELJANZ XR 5 ZIEXTENZO 79 VYNDAQEL 47 XELODA 32 ZIMS CRACK CREME DAYTIME 64 145 XENAZINE 155 VYONDYS 53 zinc oxide (topical) 66 27 XEOMIN 145 VYTORIN zinc sulfate 138 2 XGEVA 72 VYVANSE ZINGO 83 2 XIAFLEX 139 WAKIX ziprasidone hcl 37 WAL-SLEEP Z LIQUID XIMINO 156 SHOTS 80 XOLAIR 14 ziprasidone mesylate 37 WALGREENS COMFORT XOPENEX 15 ZITHROMAX 84 ASSUREDLANCETS MICRO XOPENEX ZITHROMAX TRI-PAK 84 THIN/33G 99 WALGREENS COMFORT CONCENTRATE 15 ZITHROMAX Z-PAK 84 ASSUREDLANCETS SUPER XOPENEX HFA 15 ZOCOR 28 THIN/28G 99 XPOVIO 100 MG ONCE ZOFRAN 25 WALGREENS GLUCOSE 23 WEEKLY 34 XPOVIO 60 MG ONCE ZOLADEX 34 WALGREENS LANCETS 99 WEEKLY 34 zoledronic acid 72 WALGREENS THIN XPOVIO 80 MG ONCE ZOLEDRONIC ACID 72 LANCETS 99 WEEKLY 34 zoledronic acid 72 WALGREENS ULTRA THIN XPOVIO 80 MG TWICE LANCETS 99 WEEKLY 34 ZOLEDRONIC ACID 72 warfarin sodium 15 XTANDI 34 ZOLGENSMA 10.1-10.5 WATCHHALER 135 KG 145 XYNTHA 78 ZOLGENSMA 10.6-11.0 WATER BABIES SPF 30 68 XYNTHA SOLOFUSE 78 KG 145 WEBCOL ALCOHOL PREP XYREM 154 ZOLGENSMA 11.1-11.5 LARGE 1 PLY 99 XYWAV 154 KG 145 WEBCOL ALCOHOL PREP ZOLGENSMA 11.6-12.0 LARGE 2 PLY 99 XYZAL ALLERGY 24HR 27 KG 145 WEBCOL ALCOHOL PREP YASMIN 28 49 ZOLGENSMA 12.1-12.5 MEDIUM 2 PLY 99 YAZ 49 KG 145 WEGMANS COMPLETE ZOLGENSMA 12.6-13.0 PRENATAL+DHA 144 YERVOY 32 KG 145 WEGMANS UNIFINE PENTIPS YESCARTA 33 ZOLGENSMA 13.1-13.5 PLUS 32GX4MM 131 YOUR LIFE MULTI KG 145 WEGMANS UNIFINE PENTIPS PRENATAL 144 ZOLGENSMA 2.6-3.0 KG 145 PLUS/MINI/31GX5MM 131 ZADITOR 150 WEGMANS UNIFINE PENTIPS ZOLGENSMA 3.1-3.5 KG 145 PLUS/SHORT/31GX8MM 131 zaleplon 81 ZOLGENSMA 3.6-4.0 KG 145

Index 47 ZOLGENSMA 4.1-4.5 KG 145 ZOLGENSMA 4.6-5.0 KG 145 ZOLGENSMA 5.1-5.5 KG 145 ZOLGENSMA 5.6-6.0 KG 145 ZOLGENSMA 6.1-6.5 KG 145 ZOLGENSMA 6.6-7.0 KG 145 ZOLGENSMA 7.1-7.5 KG 145 ZOLGENSMA 7.6-8.0 KG 145 ZOLGENSMA 8.1-8.5 KG 146 ZOLGENSMA 8.6-9.0 KG 146 ZOLGENSMA 9.1-9.5 KG 146 ZOLGENSMA 9.6-10.0 KG 146 ZOLINZA 35 zolmitriptan 136 ZOLOFT 20 zolpidem tartrate 81 ZOLPIMIST 81 ZOMACTON 72 ZOMIG 136 ZOMIG ZMT 136 ZONALON 56 ZONEGRAN 18 zonisamide 18 ZOO FRIENDS COMPLETE 141 ZORBTIVE 72 ZORTRESS 140 ZOSTAVAX 162 ZOVIRAX 44,57 ZUBSOLV 9 ZYBAN 156 ZYCLARA 64 ZYCLARA PUMP 64 ZYKADIA 35 ZYLOPRIM 77 ZYNCOF 53 ZYPREXA 39 ZYPREXA RELPREVV 39 ZYPREXA ZYDIS 39 ZYRTEC ALLERGY 27 ZYRTEC CHILDRENS ALLERGY 27 ZYRTEC-D ALLERGY/CONGESTION 53 ZYTIGA 34 ZZZQUIL 80

Index 48