Express Scripts National Preferred Formulary July 2021

National Preferred Formulary

July 2021

How to Use the Formulary The Formulary is a list of medications available to members under their pharmacy benefit. All drugs are listed by their generic names or most common proprietary (branded) name. Any drugs not found in this formulary listing or any formulary updates published by Express Scripts are considered non-formulary drugs and require prior authorization.

All drugs are listed in each category in alphabetical order by generic or brand name. If the generic drug is FDA approved, it will appear italicized in the formulary listing. Covered brand drugs appear in CAPITALIZED font.

Benefit Coverage and Limitations The Formulary applies only to outpatient drugs provided to members and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Wellfleet or Express Scripts at the phone numbers listed on their ID card.

Excluded Agents Any drugs not listed in this print formulary are considered excluded from the drug benefit and are not covered. As new drugs become available, they will be considered for coverage under the Formulary.

Non-Formulary and Step Therapy Exception Requests A member (or their appointed representative, prescribing physician, or authorized prescriber) may request a standard/non-urgent or expedited/urgent preservice/prior and current authorization for a drug that is subjected to utilization management tools such as step therapy. To initiate an exception request, contact 800-417-8164. Prior authorization guidelines will be made available to the member, member’s authorization representative, prescribing physician and other authorized prescriber upon request.

Table of Contents

ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ...... 21 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...... 34 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 61 DERMATOLOGICALS/TOPICAL THERAPY ...... 81 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 96 EAR, NOSE / THROAT MEDICATIONS ...... 107 ENDOCRINE/DIABETES ...... 109 GASTROENTEROLOGY ...... 143 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...... 153 MUSCULOSKELETAL / RHEUMATOLOGY ...... 161 OBSTETRICS / GYNECOLOGY ...... 164 OPHTHALMOLOGY ...... 175 RESPIRATORY AND ALLERGY ...... 181 UROLOGICALS ...... 190 VITAMINS, HEMATINICS / ELECTROLYTES ...... 193 Index ...... 217

1 List of Abbreviations

ACA: Affordable Care Act

AGE: Age Edit

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

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

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

SP: Specialty

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

2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES fluconazole in nacl 1 PA (iso-osm) ANTIFUNGAL AGENTS intravenous ABELCET 2 piggyback 100 INTRAVENOUS mg/50 ml, 200 SUSPENSION 5 mg/100 ml, 400 MG/ML mg/200 ml AMBISOME 2 fluconazole oral 1 INTRAVENOUS suspension for SUSPENSION FOR reconstitution 10 RECONSTITUTIO mg/ml, 40 mg/ml N 50 MG fluconazole oral 1 AMPHOTERICIN B 2 tablet 100 mg, 200 (BULK) POWDER mg, 50 mg amphotericin b 1 fluconazole oral 1 QL injection recon soln tablet 150 mg 50 mg FLUCYTOSINE 2 caspofungin 1 (BULK) POWDER intravenous recon 100 % soln 50 mg, 70 mg flucytosine oral 1 clotrimazole mucous 1 capsule 250 mg, 500 membrane troche 10 mg mg griseofulvin 1 CRESEMBA 2 PA microsize oral INTRAVENOUS suspension 125 mg/5 RECON SOLN 372 ml MG griseofulvin 1 CRESEMBA ORAL 2 PA microsize oral tablet CAPSULE 186 MG 500 mg ERAXIS(WATER 2 griseofulvin 1 DILUENT) ultramicrosize oral INTRAVENOUS tablet 125 mg, 250 RECON SOLN 100 mg MG, 50 MG ITRACONAZOLE 2 FLUCONAZOLE 2 (BULK) POWDER (BULK) POWDER itraconazole oral 1 QL 100 % capsule 100 mg itraconazole oral 1 solution 10 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KETOCONAZOLE 2 terbinafine hcl oral 1 (BULK) POWDER tablet 250 mg ketoconazole oral 1 VORICONAZOLE 2 tablet 200 mg (BULK) POWDER micafungin 1 100 % intravenous recon voriconazole 1 PA soln 100 mg, 50 mg intravenous recon soln 200 mg MICONAZOLE 2 (BULK) POWDER voriconazole oral 1 PA suspension for NOXAFIL 2 PA reconstitution 200 INTRAVENOUS mg/5 ml (40 mg/ml) SOLUTION 300 MG/16.7 ML voriconazole oral 1 PA tablet 200 mg, 50 mg NOXAFIL ORAL 2 PA SUSPENSION 200 ANTIVIRALS MG/5 ML (40 abacavir oral 1 SP MG/ML) solution 20 mg/ml NYSTATIN 2 abacavir oral tablet 1 SP (BULK) POWDER 300 mg 1 BILLION UNIT, 1 MILLION UNIT, 10 abacavir-lamivudine 1 SP BILLION UNIT, 15 oral tablet 600-300 BILLION UNIT, mg 150 MILLION abacavir- 1 SP UNIT, 2 BILLION lamivudine- UNIT, 5 BILLION zidovudine oral UNIT, 50 MILLION tablet 300-150-300 UNIT, 500 mg MILLION UNIT ACYCLOVIR 2 nystatin oral 1 (BULK) POWDER suspension 100,000 100 % unit/ml acyclovir oral 1 nystatin oral tablet 1 capsule 200 mg 500,000 unit acyclovir oral 1 posaconazole oral 1 PA suspension 200 mg/5 tablet,delayed ml release (dr/ec) 100 mg acyclovir oral tablet 1 400 mg, 800 mg TERBINAFINE 2 (BULK) POWDER 100 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acyclovir sodium 1 DESCOVY ORAL 2 SP intravenous recon TABLET 200-25 soln 1,000 mg, 500 MG mg didanosine oral 1 SP acyclovir sodium 1 capsule,delayed intravenous solution release(dr/ec) 250 50 mg/ml mg, 400 mg adefovir oral tablet 1 DOVATO ORAL 2 SP 10 mg TABLET 50-300 AMANTADINE 2 MG HCL (BULK) EDURANT ORAL 2 SP POWDER TABLET 25 MG amantadine hcl oral 1 efavirenz oral 1 SP capsule 100 mg capsule 200 mg, 50 mg amantadine hcl oral 1 solution 50 mg/5 ml efavirenz oral tablet 1 SP 600 mg amantadine hcl oral 1 tablet 100 mg efavirenz- 1 SP emtricitabin-tenofov APTIVUS (WITH 2 SP oral tablet 600-200- VITAMIN E) ORAL 300 mg SOLUTION 100 MG/ML efavirenz-lamivu- 1 SP tenofov disop oral APTIVUS ORAL 2 SP tablet 400-300-300 CAPSULE 250 MG mg, 600-300-300 mg atazanavir oral 1 SP emtricitabine oral capsule 150 mg, 200 1 SP capsule 200 mg mg, 300 mg emtricitabine- BIKTARVY ORAL 2 SP 1 SP tenofovir (tdf) oral TABLET 50-200-25 tablet 100-150 mg, MG 133-200 mg, 167- cidofovir 1 250 mg intravenous solution emtricitabine- 75 mg/ml 1 ACA; SP tenofovir (tdf) oral CIMDUO ORAL 2 SP tablet 200-300 mg TABLET 300-300 MG EMTRIVA ORAL 2 SP SOLUTION 10 CRIXIVAN ORAL 2 SP MG/ML CAPSULE 200 MG entecavir oral tablet 1 0.5 mg, 1 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EPCLUSA ORAL 2 PA; SP; QL ISENTRESS ORAL 2 SP TABLET 200-50 TABLET,CHEWAB MG, 400-100 MG LE 100 MG EPIVIR HBV 2 JULUCA ORAL 2 SP ORAL SOLUTION TABLET 50-25 MG 25 MG/5 ML (5 KALETRA ORAL 2 SP MG/ML) TABLET 100-25 famciclovir oral 1 QL MG, 200-50 MG tablet 125 mg, 250 lamivudine oral 1 SP mg, 500 mg solution 10 mg/ml fosamprenavir oral 1 SP lamivudine oral 1 tablet 700 mg tablet 100 mg foscarnet 1 lamivudine oral 1 SP intravenous solution tablet 150 mg, 300 24 mg/ml mg ganciclovir sodium 1 lamivudine- 1 SP intravenous recon zidovudine oral soln 500 mg tablet 150-300 mg ganciclovir sodium 1 LEXIVA ORAL 2 SP intravenous solution SUSPENSION 50 50 mg/ml MG/ML HARVONI ORAL 2 PA; SP; QL lopinavir-ritonavir 1 SP PELLETS IN oral solution 400- PACKET 33.75-150 100 mg/5 ml MG, 45-200 MG nevirapine oral 1 SP HARVONI ORAL 2 PA; SP; QL suspension 50 mg/5 TABLET 45-200 ml MG, 90-400 MG nevirapine oral 1 SP IDOXURIDINE 2 tablet 200 mg (BULK) POWDER 100 % nevirapine oral 1 SP tablet extended INTELENCE ORAL 2 SP release 24 hr 100 TABLET 25 MG mg, 400 mg INVIRASE ORAL 2 SP NORVIR ORAL 2 SP TABLET 500 MG POWDER IN ISENTRESS HD 2 SP PACKET 100 MG ORAL TABLET NORVIR ORAL 2 SP 600 MG SOLUTION 80 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ODEFSEY ORAL 2 SP stavudine oral 1 SP TABLET 200-25-25 capsule 15 mg, 20 MG mg, 30 mg, 40 mg oseltamivir oral 1 QL SYMFI LO ORAL 2 SP capsule 30 mg, 45 TABLET 400-300- mg, 75 mg 300 MG oseltamivir oral 1 QL SYMFI ORAL 2 SP suspension for TABLET 600-300- reconstitution 6 300 MG mg/ml SYMTUZA ORAL 2 SP PREZISTA ORAL 2 SP TABLET 800-150- TABLET 150 MG, 200-10 MG 75 MG SYNAGIS 2 PA; SP RAPIVAB (PF) 2 INTRAMUSCULA INTRAVENOUS R SOLUTION 100 SOLUTION 200 MG/ML, 50 MG/0.5 MG/20 ML (10 ML MG/ML) TEMIXYS ORAL 2 SP RETROVIR 2 SP TABLET 300-300 INTRAVENOUS MG SOLUTION 10 tenofovir disoproxil 1 SP MG/ML fumarate oral tablet ribavirin inhalation 1 300 mg recon soln 6 gram TIVICAY ORAL 2 SP ribavirin oral 1 ST; SP TABLET 10 MG, 25 capsule 200 mg MG, 50 MG ribavirin oral tablet 1 ST; SP TIVICAY PD 2 SP 200 mg ORAL TABLET rimantadine oral 1 FOR SUSPENSION tablet 100 mg 5 MG ritonavir oral tablet 1 SP TRIUMEQ ORAL 2 SP 100 mg TABLET 600-50- 300 MG SELZENTRY 2 SP ORAL SOLUTION TROGARZO 2 PA; SP 20 MG/ML INTRAVENOUS SOLUTION 200 SELZENTRY 2 SP MG/1.33 ML (150 ORAL TABLET MG/ML) 150 MG, 25 MG, 300 MG, 75 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRUVADA ORAL 2 SP AVYCAZ 2 ST TABLET 100-150 INTRAVENOUS MG, 133-200 MG, RECON SOLN 2.5 167-250 MG GRAM VALACYCLOVIR 2 cefaclor oral capsule 1 (BULK) POWDER 250 mg, 500 mg 100 % cefaclor oral 1 valacyclovir oral 1 QL suspension for tablet 1 gram, 500 reconstitution 125 mg mg/5 ml, 250 mg/5 ml, 375 mg/5 ml valganciclovir oral 1 recon soln 50 mg/ml cefaclor oral tablet 1 extended release 12 valganciclovir oral 1 hr 500 mg tablet 450 mg cefadroxil oral VEMLIDY ORAL 2 1 capsule 500 mg TABLET 25 MG cefadroxil oral VIRACEPT ORAL 2 SP 1 suspension for TABLET 250 MG reconstitution 250 VIREAD ORAL 2 SP mg/5 ml, 500 mg/5 POWDER 40 ml MG/SCOOP (40 cefadroxil oral tablet MG/GRAM) 1 1 gram VIREAD ORAL 2 SP cefazolin in dextrose TABLET 150 MG, 1 ST (iso-os) intravenous 200 MG, 250 MG piggyback 1 gram/50 VOSEVI ORAL 2 PA; SP; QL ml, 2 gram/50 ml TABLET 400-100- cefazolin in dextrose 100 MG 1 ST 5 % intravenous ZEPATIER ORAL 2 PA; SP; QL solution 2 gram/100 TABLET 50-100 ml MG cefazolin injection 1 ST zidovudine oral 1 SP recon soln 1 gram, capsule 100 mg 10 gram, 100 gram, zidovudine oral 1 SP 20 gram, 300 g, 500 syrup 10 mg/ml mg zidovudine oral 1 SP cefazolin 1 ST tablet 300 mg intravenous recon soln 1 gram CEPHALOSPORINS cefdinir oral capsule 1 300 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefdinir oral 1 cefpodoxime oral 1 suspension for suspension for reconstitution 125 reconstitution 100 mg/5 ml, 250 mg/5 mg/5 ml, 50 mg/5 ml ml cefpodoxime oral 1 cefditoren pivoxil 1 tablet 100 mg, 200 oral tablet 200 mg, mg 400 mg cefprozil oral 1 cefepime in 1 ST suspension for dextrose,iso-osm reconstitution 125 intravenous mg/5 ml, 250 mg/5 piggyback 1 gram/50 ml ml, 2 gram/100 ml cefprozil oral tablet 1 cefepime injection 1 ST 250 mg, 500 mg recon soln 1 gram, 2 CEFTAZIDIME 2 gram (BULK) POWDER cefixime oral 1 100 % capsule 400 mg CEFTAZIDIME IN 2 ST cefixime oral 1 D5W suspension for INTRAVENOUS reconstitution 100 PIGGYBACK 1 mg/5 ml, 200 mg/5 GRAM/50 ML, 2 ml GRAM/50 ML cefotaxime injection 1 ST ceftazidime injection 1 ST recon soln 1 gram recon soln 1 gram, 2 gram, 6 gram cefotetan injection 1 ST recon soln 1 gram, 2 ceftriaxone in 1 ST gram dextrose,iso-os intravenous cefotetan 1 ST intravenous recon piggyback 1 gram/50 ml, 2 gram/50 ml soln 10 gram ceftriaxone injection cefoxitin in dextrose, 1 ST 1 ST iso-osm intravenous recon soln 1 gram, 10 gram, 2 gram, piggyback 1 gram/50 250 mg, 500 mg ml, 2 gram/50 ml ceftriaxone cefoxitin intravenous 1 ST 1 ST intravenous recon recon soln 1 gram, soln 1 gram, 2 gram 10 gram, 2 gram CEFTRIAXONE 2 SODIUM (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefuroxime axetil 1 azithromycin 1 ST oral tablet 250 mg, intravenous recon 500 mg soln 500 mg cefuroxime sodium 1 ST azithromycin oral 1 injection recon soln suspension for 750 mg reconstitution 100 mg/5 ml, 200 mg/5 cefuroxime sodium 1 ST intravenous recon ml soln 1.5 gram, 7.5 azithromycin oral 1 gram tablet 250 mg, 500 mg, 600 mg cephalexin oral 1 capsule 250 mg, 500 CLARITHROMYCI 2 mg, 750 mg N (BULK) cephalexin oral 1 POWDER 100 % suspension for clarithromycin oral 1 reconstitution 125 suspension for mg/5 ml, 250 mg/5 reconstitution 125 ml mg/5 ml, 250 mg/5 ml cephalexin oral 1 tablet 250 mg, 500 clarithromycin oral 1 mg tablet 250 mg, 500 mg tazicef injection 1 ST recon soln 1 gram, 2 clarithromycin oral 1 gram, 6 gram tablet extended release 24 hr 500 mg tazicef intravenous 1 ST recon soln 1 gram, 2 e.e.s. 400 oral tablet 1 gram 400 mg TEFLARO 2 ST ery-tab oral 1 INTRAVENOUS tablet,delayed RECON SOLN 400 release (dr/ec) 250 MG, 600 MG mg, 333 mg ZERBAXA 2 ST erythrocin (as 1 INTRAVENOUS stearate) oral tablet RECON SOLN 1.5 250 mg GRAM ERYTHROCIN 2 ST ERYTHROMYCINS / OTHER INTRAVENOUS

MACROLIDES RECON SOLN 1,000 MG, 500 MG AZITHROMYCIN 2 (BULK) POWDER ERYTHROMYCIN 2 100 % (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ERYTHROMYCIN 2 AMIKACIN 2 ESTOLATE SULFATE (BULK) (BULK) POWDER POWDER 100 % AMINOSALICYLA 2 ERYTHROMYCIN 2 TE SODIUM ETHYLSUCCIN(B (BULK) POWDER ULK) POWDER 100 % erythromycin 1 AMINOSALICYLI 2 ethylsuccinate oral C ACID (BULK) suspension for POWDER reconstitution 200 atovaquone- 1 QL mg/5 ml, 400 mg/5 proguanil oral tablet ml 250-100 mg, 62.5-25 erythromycin 1 mg ethylsuccinate oral aztreonam injection 1 ST tablet 400 mg recon soln 1 gram, 2 erythromycin oral 1 gram capsule,delayed bacitracin (bulk) 1 release(dr/ec) 250 powder 5 million mg unit erythromycin oral 1 bacitracin 1 tablet 250 mg, 500 intramuscular recon mg soln 50,000 unit erythromycin oral 1 BACITRACIN, 2 tablet,delayed MICRONIZED release (dr/ec) 250 (BULK) POWDER mg, 333 mg, 500 mg 100 % MISCELLANEOUS BENZNIDAZOLE 2 QL ANTIINFECTIVES ORAL TABLET ALBENDAZOLE 2 100 MG, 12.5 MG (BULK) POWDER CAPASTAT 2 100 % INJECTION albendazole oral 1 QL RECON SOLN 1 tablet 200 mg GRAM ALINIA ORAL 2 QL CAYSTON 2 PA; SP; QL SUSPENSION FOR INHALATION RECONSTITUTIO SOLUTION FOR N 100 MG/5 ML NEBULIZATION 75 MG/ML amikacin injection 1 ST solution 1,000 mg/4 ml, 500 mg/2 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHLORAMPHENI 2 CLIOQUINOL 2 COL (BULK) (BULK) POWDER POWDER 100 % CLOFAZIMINE 2 CHLORAMPHENI 2 (BULK) POWDER COL COARTEM ORAL 2 QL PALMITAT(BULK) TABLET 20-120 POWDER MG chloramphenicol sod 1 COLISTIMETHAT 2 succinate E SODIUM (BULK) intravenous recon POWDER 390 soln 1 gram MCG/MG CHLOROQUINE 2 colistin 1 ST PHOSPHATE (colistimethate na) (BULK) POWDER injection recon soln chloroquine 1 150 mg phosphate oral COLISTIN 2 tablet 250 mg SULFATE (BULK) CLINDAMYCIN 2 POWDER 1 HCL (BULK) BILLION UNIT POWDER CYCLOSERINE 2 clindamycin hcl oral 1 (BULK) POWDER capsule 75 mg DALVANCE 2 ST clindamycin in 5 % 1 ST INTRAVENOUS dextrose intravenous SOLUTION 500 piggyback 300 MG mg/50 ml, 600 mg/50 DAPSONE (BULK) 2 ml, 900 mg/50 ml POWDER 98 % clindamycin 1 dapsone oral tablet 1 pediatric oral recon 100 mg, 25 mg soln 75 mg/5 ml daptomycin 1 ST CLINDAMYCIN 2 intravenous recon PHOSPHATE soln 500 mg (BULK) CRYSTALS EMVERM ORAL 2 QL TABLET,CHEWAB CLINDAMYCIN 2 LE 100 MG PHOSPHATE (BULK) POWDER ertapenem injection 1 ST recon soln 1 gram clindamycin 1 ST phosphate injection ethambutol oral 1 solution 150 mg/ml tablet 100 mg, 400 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FURAZOLIDONE 2 IODOQUINOL 2 (BULK) POWDER (BULK) POWDER 100 % 100 % GENTAMICIN 2 ISONIAZID 2 (BULK) POWDER (BULK) POWDER 590 MCG/MG isoniazid injection 1 gentamicin in nacl 1 ST solution 100 mg/ml (iso-osm) isoniazid oral 1 intravenous solution 50 mg/5 ml piggyback 100 mg/100 ml, 60 mg/50 isoniazid oral tablet 1 ml, 70 mg/50 ml, 80 100 mg, 300 mg mg/100 ml, 80 mg/50 IVERMECTIN 2 ml, 90 mg/100 ml (BULK) POWDER GENTAMICIN IN 2 ST ivermectin oral 1 QL NACL (ISO-OSM) tablet 3 mg INTRAVENOUS PIGGYBACK 100 KANAMYCIN 2 MG/50 ML (BULK) POWDER gentamicin injection 1 ST KITABIS PAK 2 PA; SP; QL solution 20 mg/2 ml, INHALATION 40 mg/ml SOLUTION FOR NEBULIZATION gentamicin sulfate 1 ST 300 MG/5 ML (ped) (pf) injection solution 20 mg/2 ml LINCOMYCIN 2 HCL (BULK) gentamicin sulfate 1 ST POWDER (pf) intravenous solution 100 mg/10 lincomycin injection 1 ST ml solution 300 mg/ml hydroxychloroquine 1 linezolid in dextrose 1 ST oral tablet 200 mg 5% intravenous piggyback 600 HYDROXYCHLOR 2 mg/300 ml OQUINE SULF (BULK) POWDER linezolid oral 1 PA suspension for imipenem-cilastatin 1 ST reconstitution 100 intravenous recon mg/5 ml soln 250 mg, 500 mg linezolid oral tablet 1 PA IMPAVIDO ORAL 2 PA; QL 600 mg CAPSULE 50 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits linezolid-0.9% 1 ST NICLOSAMIDE 2 sodium chloride (BULK) POWDER intravenous 100 % parenteral solution nitazoxanide oral 1 QL 600 mg/300 ml tablet 500 mg MEBENDAZOLE 2 ORBACTIV 2 ST (BULK) POWDER INTRAVENOUS mefloquine oral 1 QL RECON SOLN 400 tablet 250 mg MG meropenem 1 ST paromomycin oral 1 intravenous recon capsule 250 mg soln 1 gram, 500 mg PAROMOMYCIN 2 MEROPENEM- 2 ST SULFATE (BULK) 0.9% SODIUM POWDER 675 CHLORIDE MCG/MG INTRAVENOUS pentamidine 1 QL PIGGYBACK 1 inhalation recon GRAM/50 ML, 500 soln 300 mg MG/50 ML pentamidine 1 metro i.v. 1 ST injection recon soln intravenous 300 mg piggyback 500 mg/100 ml POLYMYXIN B 2 SULF,MICRON.(B METRONIDAZOL 2 ULK) POWDER E (BULK) 100 MILLION POWDER UNIT, 50 MILLION METRONIDAZOL 2 UNIT, 6,000 E BENZOATE UNIT/MG (BULK) POWDER polymyxin b sulfate 1 ST metronidazole in 1 ST injection recon soln nacl (iso-os) 500,000 unit intravenous PRAZIQUANTEL 2 piggyback 500 (BULK) POWDER mg/100 ml 98.5-101 % metronidazole oral 1 praziquantel oral 1 capsule 375 mg tablet 600 mg neomycin oral tablet 1 PRIFTIN ORAL 2 500 mg TABLET 150 MG NEOMYCIN 2 SULFATE (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PRIMAQUINE 2 QL STREPTOMYCIN 2 ST ORAL TABLET INTRAMUSCULA 26.3 MG R RECON SOLN 1 PYRANTEL 2 GRAM PAMOATE (BULK) STREPTOMYCIN 2 POWDER 100 % SULFATE (BULK) pyrazinamide oral 1 POWDER tablet 500 mg SYNERCID 2 ST PYRIMETHAMINE 2 PA INTRAVENOUS (BULK) POWDER RECON SOLN 500 MG pyrimethamine oral 1 PA; SP tablet 25 mg THIABENDAZOLE 2 (BULK) POWDER QUINACRINE 2 tigecycline (BULK) POWDER 1 ST intravenous recon QUININE HCL 2 soln 50 mg DIHYDRATE (BULK) POWDER TINIDAZOLE 2 100 % (BULK) POWDER 100 % QUININE 2 tinidazole oral tablet SULFATE (BULK) 1 QL 250 mg, 500 mg POWDER quinine sulfate oral 1 QL TOBI PODHALER 2 PA; SP; QL capsule 324 mg INHALATION CAPSULE, rifabutin oral 1 W/INHALATION capsule 150 mg DEVICE 28 MG RIFAMPIN (BULK) 2 TOBRAMYCIN 2 POWDER (BULK) POWDER rifampin intravenous 1 900 MCG/MG recon soln 600 mg (NOT LESS THAN, USP) rifampin oral 1 capsule 150 mg, 300 tobramycin in 0.225 1 PA; SP; QL mg % nacl inhalation solution for SIRTURO ORAL 2 PA nebulization 300 TABLET 100 MG, mg/5 ml 20 MG tobramycin in 0.9 % 1 ST SOLOSEC ORAL 2 QL nacl intravenous GRANULES DEL piggyback 60 mg/50 RELEASE IN ml PACKET 2 GRAM

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tobramycin 1 PA; SP; QL amoxicillin-pot 1 inhalation solution clavulanate oral for nebulization 300 suspension for mg/4 ml reconstitution 200- 28.5 mg/5 ml, 250- TOBRAMYCIN 2 62.5 mg/5 ml, 400- SULFATE (BULK) 57 mg/5 ml, 600- POWDER 634 42.9 mg/5 ml MCG/MG (NOT LESS THAN, USP) amoxicillin-pot 1 clavulanate oral tobramycin sulfate 1 ST tablet 250-125 mg, injection recon soln 500-125 mg, 875- 1.2 gram 125 mg tobramycin sulfate 1 ST amoxicillin-pot injection solution 10 1 clavulanate oral mg/ml, 40 mg/ml tablet extended PENICILLINS release 12 hr 1,000- 62.5 mg AMOXICILLIN 2 (BULK) POWDER amoxicillin-pot 1 100 % clavulanate oral tablet,chewable 200- amoxicillin oral 1 28.5 mg, 400-57 mg capsule 250 mg, 500 mg ampicillin oral 1 capsule 250 mg, 500 amoxicillin oral 1 suspension for mg reconstitution 125 ampicillin sodium 1 ST mg/5 ml, 200 mg/5 injection recon soln ml, 250 mg/5 ml, 400 1 gram, 10 gram, mg/5 ml 125 mg, 2 gram, 250 mg, 500 mg amoxicillin oral 1 tablet 500 mg, 875 ampicillin sodium 1 ST mg intravenous recon soln 1 gram, 2 gram amoxicillin oral 1 tablet,chewable 125 ampicillin-sulbactam 1 ST mg, 250 mg injection recon soln 1.5 gram, 15 gram, 3 gram ampicillin-sulbactam 1 ST intravenous recon soln 1.5 gram, 3 gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AUGMENTIN 2 PENICILLIN G 2 ST ORAL POT IN SUSPENSION FOR DEXTROSE RECONSTITUTIO INTRAVENOUS N 125-31.25 MG/5 PIGGYBACK 1 ML MILLION UNIT/50 BICILLIN L-A 2 ST ML, 2 MILLION INTRAMUSCULA UNIT/50 ML, 3 R SYRINGE MILLION UNIT/50 2,400,000 UNIT/4 ML ML, 600,000 penicillin g 1 ST UNIT/ML potassium injection recon soln 20 dicloxacillin oral 1 million unit, 5 capsule 250 mg, 500 million unit mg penicillin g procaine nafcillin in dextrose 1 ST 1 ST iso-osm intravenous intramuscular syringe 1.2 million piggyback 1 gram/50 unit/2 ml, 600,000 ml, 2 gram/100 ml unit/ml nafcillin injection 1 ST penicillin g sodium recon soln 1 gram, 1 ST injection recon soln 10 gram, 2 gram 5 million unit nafcillin intravenous 1 ST penicillin v recon soln 1 gram, 2 1 potassium oral recon gram soln 125 mg/5 ml, oxacillin in 1 ST 250 mg/5 ml dextrose(iso-osm) intravenous penicillin v 1 potassium oral tablet piggyback 1 gram/50 250 mg, 500 mg ml, 2 gram/50 ml pfizerpen-g injection oxacillin injection 1 ST 1 ST recon soln 20 recon soln 1 gram, million unit, 5 10 gram, 2 gram million unit oxacillin intravenous 1 ST piperacillin- recon soln 1 gram, 2 1 ST tazobactam gram intravenous recon soln 13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZOSYN IN 2 ST levofloxacin in d5w 1 ST DEXTROSE (ISO- intravenous OSM) piggyback 250 INTRAVENOUS mg/50 ml, 500 PIGGYBACK 2.25 mg/100 ml, 750 GRAM/50 ML, mg/150 ml 3.375 GRAM/50 levofloxacin 1 ST ML, 4.5 GRAM/100 intravenous solution ML 25 mg/ml QUINOLONES levofloxacin oral 1 BAXDELA 2 ST solution 250 mg/10 INTRAVENOUS ml RECON SOLN 300 levofloxacin oral 1 MG tablet 250 mg, 500 BAXDELA ORAL 2 QL mg, 750 mg TABLET 450 MG moxifloxacin oral 1 CIPROFLOXACIN 2 tablet 400 mg (BULK) MOXIFLOXACIN- 2 ST CRYSTALS 100 % SOD.ACE,SUL- CIPROFLOXACIN 2 WATER (BULK) POWDER INTRAVENOUS 100 % PIGGYBACK 400 MG/250 ML ciprofloxacin hcl 1 oral tablet 100 mg, moxifloxacin- 1 ST 250 mg, 500 mg, 750 sod.chloride(iso) mg intravenous piggyback 400 ciprofloxacin in 5 % 1 ST mg/250 ml dextrose intravenous piggyback 200 ofloxacin oral tablet 1 mg/100 ml, 400 300 mg, 400 mg mg/200 ml SULFA'S / RELATED AGENTS ciprofloxacin oral 1 SULFACETAMIDE 2 suspension,microcap (BULK) POWDER sule recon 250 mg/5 ml, 500 mg/5 ml SULFADIAZINE 2 (BULK) POWDER LEVOFLOXACIN 2 (BULK) POWDER sulfadiazine oral 1 100 % tablet 500 mg SULFAMERAZINE 2 (BULK) CRYSTALS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SULFAMETHOXA 2 doxycycline hyclate 1 ZOLE (BULK) oral capsule 100 mg, POWDER 50 mg sulfamethoxazole- 1 ST doxycycline hyclate 1 trimethoprim oral tablet 100 mg, intravenous solution 20 mg 400-80 mg/5 ml doxycycline hyclate 1 ST sulfamethoxazole- 1 oral tablet 150 mg, trimethoprim oral 50 mg, 75 mg suspension 200-40 doxycycline hyclate 1 ST mg/5 ml oral tablet,delayed SULFAPYRIDINE 2 release (dr/ec) 100 (BULK) POWDER mg, 150 mg, 200 mg, 50 mg, 75 mg sulfatrim oral 1 suspension 200-40 doxycycline 1 mg/5 ml monohydrate oral capsule 100 mg, 50 SULFISOXAZOLE 2 mg, 75 mg (BULK) CRYSTALS doxycycline 1 ST monohydrate oral TETRACYCLINES capsule 150 mg avidoxy oral tablet 1 doxycycline 1 100 mg monohydrate oral coremino oral tablet 1 ST suspension for extended release 24 reconstitution 25 hr 135 mg, 45 mg, mg/5 ml 90 mg doxycycline 1 demeclocycline oral 1 monohydrate oral tablet 150 mg, 300 tablet 150 mg, 50 mg mg, 75 mg doxy-100 1 ST MINOCIN 2 ST intravenous recon INTRAVENOUS soln 100 mg RECON SOLN 100 DOXYCYCLINE 2 MG HYCLATE (BULK) MINOCYCLINE 2 POWDER HCL (BULK) doxycycline hyclate 1 ST POWDER intravenous recon minocycline oral 1 soln 100 mg capsule 100 mg, 50 mg, 75 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits minocycline oral 1 methylene blue 1 tablet 100 mg, 50 (antidote) mg, 75 mg intravenous solution 1 % (10 mg/ml) minocycline oral 1 ST tablet extended NALIDIXIC ACID 2 release 24 hr 105 (BULK) POWDER mg, 115 mg, 135 mg, NITROFURANTOI 2 45 mg, 55 mg, 65 N (BULK) mg, 80 mg, 90 mg POWDER mondoxyne nl oral 1 nitrofurantoin 1 capsule 100 mg, 75 macrocrystal oral mg capsule 100 mg, 25 morgidox oral 1 mg, 50 mg capsule 100 mg, 50 nitrofurantoin 1 mg monohyd/m-cryst OXYTETRACYCLI 2 oral capsule 100 mg NE (BULK) nitrofurantoin oral 1 POWDER suspension 25 mg/5 TETRACYCLINE 2 ml HCL (BULK) TRIMETHOPRIM 2 POWDER (BULK) POWDER tetracycline oral 1 100 % capsule 250 mg, 500 trimethoprim oral 1 mg tablet 100 mg URINARY TRACT AGENTS TRIMETHOPRIM, 2 fosfomycin 1 MICRO (BULK) tromethamine oral POWDER 100 % packet 3 gram VANCOMYCIN METHENAMINE 2 VANCOMYCIN 2 (BULK) POWDER (BULK) POWDER 100 % 900 MCG/MG methenamine 1 (NOT LESS THAN) hippurate oral tablet VANCOMYCIN IN 2 ST 1 gram 0.9 % SODIUM METHENAMINE 2 CHL MANDELATE INTRAVENOUS (BULK) POWDER PIGGYBACK 1 methenamine 1 GRAM/200 ML, mandelate oral 500 MG/100 ML, tablet 0.5 g, 1 gram 750 MG/150 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VANCOMYCIN IN 2 ST VIBATIV 2 ST 0.9 % SODIUM INTRAVENOUS CHL RECON SOLN 750 INTRAVENOUS MG SOLUTION 1 GRAM/250 ML, ANTINEOPLASTIC / 1.25 GRAM/250 IMMUNOSUPPRESSANT ML, 1.5 GRAM/250 DRUGS ML, 1.5 GRAM/500 ML, 1.75 ADJUNCTIVE AGENTS GRAM/250 ML, dexrazoxane hcl 1 1.75 GRAM/500 intravenous recon ML, 2 GRAM/500 soln 250 mg, 500 mg ML, 750 MG/150 ML, 750 MG/250 ELITEK 2 ML INTRAVENOUS RECON SOLN 1.5 VANCOMYCIN IN 2 ST MG, 7.5 MG DEXTROSE 5 % INTRAVENOUS KEPIVANCE 2 SP PIGGYBACK 1 INTRAVENOUS GRAM/200 ML, RECON SOLN 6.25 500 MG/100 ML, MG 750 MG/150 ML LEUCOVORIN 2 VANCOMYCIN IN 2 ST CALCIUM (BULK) DEXTROSE 5 % POWDER INTRAVENOUS leucovorin calcium 1 SOLUTION 1 injection recon soln GRAM/250 ML, 100 mg, 200 mg, 350 1.25 GRAM/250 mg, 50 mg, 500 mg ML, 1.5 GRAM/250 leucovorin calcium 1 ML injection solution 10 vancomycin 1 ST mg/ml intravenous recon leucovorin calcium 1 soln 1,000 mg, 10 oral tablet 10 mg, 15 gram, 5 gram, 500 mg, 25 mg, 5 mg mg, 750 mg levoleucovorin 1 PA vancomycin oral 1 ST; QL calcium intravenous capsule 125 mg, 250 recon soln 50 mg mg levoleucovorin 1 PA vancomycin oral 1 QL calcium intravenous recon soln 50 mg/ml solution 10 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mesna intravenous 1 adrucil intravenous 1 solution 100 mg/ml solution 2.5 gram/50 ml MESNEX ORAL 2 TABLET 400 MG ALUNBRIG ORAL 2 PA; SP VISTOGARD 2 PA; SP TABLETS,DOSE ORAL GRANULES PACK 90 MG (7)- IN PACKET 10 180 MG (23) GRAM ANASTROZOLE 2 VORAXAZE 2 (BULK) POWDER INTRAVENOUS 100 % RECON SOLN anastrozole oral 1 ACA 1,000 UNIT tablet 1 mg XGEVA 2 PA; SP ARRANON 2 SP SUBCUTANEOUS INTRAVENOUS SOLUTION 120 SOLUTION 250 MG/1.7 ML (70 MG/50 ML MG/ML) azacitidine injection 1 SP ANTINEOPLASTIC / recon soln 100 mg

IMMUNOSUPPRESSANT DRUGS AZATHIOPRINE 2 abiraterone oral 1 PA; SP (BULK) POWDER tablet 250 mg, 500 azathioprine oral 1 SP mg tablet 50 mg ABRAXANE 2 SP azathioprine sodium 1 SP INTRAVENOUS injection recon soln SUSPENSION FOR 100 mg RECONSTITUTIO N 100 MG BESPONSA 2 PA; SP INTRAVENOUS ADAKVEO 2 PA; SP RECON SOLN 0.9 INTRAVENOUS MG (0.25 MG/ML SOLUTION 10 INITIAL) MG/ML bexarotene oral 1 PA; SP adriamycin 1 capsule 75 mg intravenous recon bicalutamide oral soln 10 mg 1 tablet 50 mg adriamycin 1 bleomycin injection intravenous solution 1 10 mg/5 ml, 2 mg/ml, recon soln 15 unit, 20 mg/10 ml, 50 30 unit mg/25 ml busulfan intravenous 1 solution 60 mg/10 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CABOMETYX 2 PA; SP CYCLOPHOSPHA 2 ORAL TABLET 20 MIDE (BULK) MG, 40 MG, 60 MG POWDER 100 % capecitabine oral 1 SP cyclophosphamide 1 tablet 150 mg, 500 intravenous recon mg soln 1 gram, 2 gram, 500 mg CAPRELSA ORAL 2 PA; SP TABLET 100 MG, cyclophosphamide 1 300 MG oral capsule 25 mg, 50 mg carboplatin 1 intravenous recon CYCLOSPORINE 2 soln 150 mg (BULK) POWDER carboplatin 1 cyclosporine 1 SP intravenous solution intravenous solution 10 mg/ml 250 mg/5 ml carmustine 1 PA cyclosporine 1 SP intravenous recon modified oral soln 100 mg capsule 100 mg, 25 mg, 50 mg CHLORAMBUCIL 2 (BULK) POWDER cyclosporine 1 SP modified oral cisplatin intravenous 1 solution 100 mg/ml solution 1 mg/ml cyclosporine oral cladribine 1 1 SP capsule 25 mg intravenous solution 10 mg/10 ml CYRAMZA 2 PA; SP clofarabine 1 INTRAVENOUS intravenous solution SOLUTION 10 20 mg/20 ml MG/ML cytarabine (pf) COMETRIQ ORAL 2 PA; SP 1 injection solution CAPSULE 100 100 mg/5 ml (20 MG/DAY(80 MG mg/ml), 2 gram/20 X1-20 MG X1), 140 ml (100 mg/ml), 20 MG/DAY(80 MG mg/ml X1-20 MG X3), 60 MG/DAY (20 MG X cytarabine injection 1 3/DAY) solution 20 mg/ml COTELLIC ORAL 2 PA; SP dacarbazine 1 TABLET 20 MG intravenous recon soln 100 mg, 200 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dactinomycin 1 ELIGARD (3 2 PA; SP intravenous recon MONTH) soln 0.5 mg SUBCUTANEOUS DARZALEX 2 PA; SP SYRINGE 22.5 MG INTRAVENOUS ELIGARD (4 2 PA; SP SOLUTION 20 MONTH) MG/ML SUBCUTANEOUS daunorubicin 1 SYRINGE 30 MG intravenous solution ELIGARD (6 2 PA; SP 5 mg/ml MONTH) decitabine 1 PA; SP SUBCUTANEOUS intravenous recon SYRINGE 45 MG soln 50 mg ELIGARD 2 PA; SP DOCEFREZ 2 SUBCUTANEOUS INTRAVENOUS SYRINGE 7.5 MG RECON SOLN 20 (1 MONTH) MG, 80 MG ELZONRIS 2 PA; SP docetaxel 1 INTRAVENOUS intravenous solution SOLUTION 1,000 160 mg/16 ml (10 MCG/ML mg/ml), 160 mg/8 ml EMCYT ORAL 2 (20 mg/ml), 20 mg/2 CAPSULE 140 MG ml (10 mg/ml), 20 ENSPRYNG 2 PA; SP mg/ml (1 ml), 80 SUBCUTANEOUS mg/4 ml (20 mg/ml), SYRINGE 120 80 mg/8 ml (10 MG/ML mg/ml) epirubicin 1 doxorubicin 1 intravenous recon intravenous recon soln 200 mg, 50 mg soln 50 mg epirubicin 1 doxorubicin 1 intravenous solution intravenous solution 200 mg/100 ml, 50 10 mg/5 ml, 2 mg/ml, mg/25 ml 20 mg/10 ml, 50 mg/25 ml ERBITUX 2 PA; SP INTRAVENOUS doxorubicin, peg- 1 SOLUTION 100 liposomal MG/50 ML, 200 intravenous MG/100 ML suspension 2 mg/ml ERIVEDGE ORAL 2 PA; SP CAPSULE 150 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ERLEADA ORAL 2 PA; SP FLUOROURACIL 2 TABLET 60 MG (BULK) POWDER erlotinib oral tablet 1 PA; SP 100 % 100 mg, 150 mg, 25 fluorouracil 1 mg intravenous solution 1 gram/20 ml, 2.5 ETOPOPHOS 2 gram/50 ml, 5 INTRAVENOUS gram/100 ml, 500 RECON SOLN 100 mg/10 ml MG flutamide oral ETOPOSIDE 2 1 capsule 125 mg (BULK) POWDER 100 % FOLOTYN 2 PA; SP etoposide 1 INTRAVENOUS intravenous solution SOLUTION 20 20 mg/ml MG/ML (1 ML), 40 MG/2 ML (20 etoposide oral 1 MG/ML) capsule 50 mg fulvestrant 1 PA everolimus 1 SP intramuscular (immunosuppressive syringe 250 mg/5 ml ) oral tablet 0.25 mg, 0.5 mg, 0.75 mg GAMIFANT 2 PA; SP INTRAVENOUS exemestane oral 1 ACA SOLUTION 5 tablet 25 mg MG/ML FIRMAGON KIT W 2 PA; SP GAVRETO ORAL 2 PA; SP DILUENT CAPSULE 100 MG SYRINGE SUBCUTANEOUS GAZYVA 2 PA; SP RECON SOLN 120 INTRAVENOUS MG, 80 MG SOLUTION 1,000 MG/40 ML FLOXURIDINE 2 gemcitabine (BULK) POWDER 1 intravenous recon 100 % soln 1 gram, 2 gram, floxuridine injection 1 200 mg recon soln 0.5 gram gemcitabine 1 fludarabine 1 intravenous solution intravenous recon 1 gram/26.3 ml (38 soln 50 mg mg/ml), 2 gram/52.6 fludarabine 1 ml (38 mg/ml), 200 intravenous solution mg/5.26 ml (38 50 mg/2 ml mg/ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gengraf oral capsule 1 SP ifosfamide 1 100 mg, 25 mg intravenous solution 1 gram/20 ml, 3 gengraf oral solution 1 SP gram/60 ml 100 mg/ml imatinib oral tablet GILOTRIF ORAL 2 PA; SP 1 PA; SP 100 mg, 400 mg TABLET 20 MG, 30 MG, 40 MG IMBRUVICA 2 PA; SP GLEOSTINE ORAL 2 ORAL CAPSULE CAPSULE 10 MG, 140 MG, 70 MG 100 MG, 40 MG IMBRUVICA 2 PA; SP HALAVEN 2 PA; SP ORAL TABLET INTRAVENOUS 140 MG, 280 MG, SOLUTION 1 MG/2 420 MG, 560 MG ML (0.5 MG/ML) IMFINZI 2 PA; SP HYCAMTIN ORAL 2 PA; SP INTRAVENOUS CAPSULE 0.25 SOLUTION 50 MG, 1 MG MG/ML HYDROXYUREA 2 INLYTA ORAL 2 PA; SP (BULK) POWDER TABLET 1 MG, 5 100 % MG hydroxyurea oral 1 IODOPEN 2 capsule 500 mg INTRAVENOUS SOLUTION 100 IBRANCE ORAL 2 PA; SP MCG/ML CAPSULE 100 MG, 125 MG, 75 MG IRESSA ORAL 2 PA; SP TABLET 250 MG IBRANCE ORAL 2 PA; SP irinotecan TABLET 100 MG, 1 intravenous solution 125 MG, 75 MG 100 mg/5 ml, 300 ICLUSIG ORAL 2 PA; SP mg/15 ml, 40 mg/2 TABLET 10 MG, 15 ml, 500 mg/25 ml MG, 30 MG, 45 MG ISTODAX 2 PA; SP idarubicin 1 INTRAVENOUS intravenous solution RECON SOLN 10 1 mg/ml MG/2 ML IDHIFA ORAL 2 PA; SP IXEMPRA 2 PA; SP TABLET 100 MG, INTRAVENOUS 50 MG RECON SOLN 15 ifosfamide 1 MG, 45 MG intravenous recon soln 1 gram, 3 gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits JAKAFI ORAL 2 ST; SP LENVIMA ORAL 2 PA; SP TABLET 10 MG, 15 CAPSULE 10 MG, 20 MG, 25 MG/DAY (10 MG X MG, 5 MG 1), 12 MG/DAY (4 JEVTANA 2 PA; SP MG X 3), 14 INTRAVENOUS MG/DAY(10 MG X SOLUTION 10 1-4 MG X 1), 18 MG/ML (FIRST MG/DAY (10 MG X DILUTION) 1-4 MG X2), 20 MG/DAY (10 MG X KADCYLA 2 PA; SP 2), 24 MG/DAY(10 INTRAVENOUS MG X 2-4 MG X 1), RECON SOLN 100 4 MG, 8 MG/DAY MG, 160 MG (4 MG X 2) KANJINTI 2 PA; SP LETROZOLE 2 INTRAVENOUS (BULK) POWDER RECON SOLN 150 100 % MG, 420 MG letrozole oral tablet 1 KEYTRUDA 2 PA; SP 2.5 mg INTRAVENOUS SOLUTION 25 LEUKERAN ORAL 2 MG/ML TABLET 2 MG KYMRIAH 2 PA; SP LEUPROLIDE 2 INTRAVENOUS (BULK) POWDER SUSPENSION 100 % 0.2X10EXP6 TO leuprolide 1 PA; SP 2.5X10EXP8 CELL, subcutaneous kit 1 0.6 TO 6 X 10EXP8 mg/0.2 ml CELL LEVAMISOLE 2 KYPROLIS 2 PA; SP (BULK) POWDER INTRAVENOUS LIBTAYO 2 PA; SP RECON SOLN 10 INTRAVENOUS MG, 30 MG, 60 MG SOLUTION 50 lapatinib oral tablet 1 PA; SP MG/ML 250 mg LONSURF ORAL 2 PA; SP TABLET 15-6.14 MG, 20-8.19 MG LORBRENA ORAL 2 PA; SP TABLET 100 MG, 25 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LUPRON DEPOT 2 PA; SP MEGESTROL 2 (3 MONTH) ACETATE,MICRO INTRAMUSCULA (BULK) POWDER R SYRINGE KIT 100 % 11.25 MG megestrol oral 1 LUPRON DEPOT 2 PA; SP suspension 400 INTRAMUSCULA mg/10 ml (10 ml), R SYRINGE KIT 400 mg/10 ml (40 3.75 MG mg/ml) LUPRON DEPOT- 2 PA; SP megestrol oral tablet 1 PED (3 MONTH) 20 mg, 40 mg INTRAMUSCULA MEKINIST ORAL 2 PA; SP R SYRINGE KIT TABLET 0.5 MG, 2 11.25 MG, 30 MG MG LUPRON DEPOT- 2 PA; SP melphalan hcl 1 PED intravenous recon INTRAMUSCULA soln 50 mg R KIT 11.25 MG, 15 MG, 7.5 MG (PED) melphalan oral 1 tablet 2 mg LUTATHERA 2 SP INTRAVENOUS MERCAPTOPURIN 2 SOLUTION 10 E (BULK) MCI/ML (370 POWDER 100 % MBQ/ML) mercaptopurine oral 1 LYNPARZA ORAL 2 PA; SP tablet 50 mg TABLET 100 MG, METHOTREXATE 2 150 MG (BULK) POWDER LYSODREN ORAL 2 SP 100 % TABLET 500 MG methotrexate sodium 1 MARQIBO 2 SP (pf) injection recon INTRAVENOUS soln 1 gram KIT 5 MG/31 methotrexate sodium 1 ML(0.16 MG/ML) (pf) injection FINAL solution 25 mg/ml MATULANE 2 SP methotrexate sodium 1 ORAL CAPSULE injection solution 25 50 MG mg/ml MECHLORETHAM 2 methotrexate sodium 1 INE (BULK) oral tablet 2.5 mg POWDER 98 % MITOMYCIN 2 (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mitomycin 1 nilutamide oral 1 PA intravenous recon tablet 150 mg soln 20 mg, 40 mg, 5 NINLARO ORAL 2 PA; SP mg CAPSULE 2.3 MG, MITOTANE 2 3 MG, 4 MG (BULK) POWDER NUBEQA ORAL 2 PA; SP 100 % TABLET 300 MG mitoxantrone 1 SP octreotide acetate 1 SP intravenous injection solution concentrate 2 mg/ml 1,000 mcg/ml, 100 mycophenolate 1 SP mcg/ml, 200 mcg/ml, mofetil (hcl) 50 mcg/ml, 500 intravenous recon mcg/ml soln 500 mg octreotide acetate 1 SP mycophenolate 1 SP injection syringe 100 mofetil oral capsule mcg/ml (1 ml), 50 250 mg mcg/ml (1 ml), 500 mcg/ml (1 ml) mycophenolate 1 SP mofetil oral ODOMZO ORAL 2 PA; SP suspension for CAPSULE 200 MG reconstitution 200 ONCASPAR 2 PA mg/ml INJECTION mycophenolate 1 SP SOLUTION 750 mofetil oral tablet UNIT/ML 500 mg ONIVYDE 2 PA; SP mycophenolate 1 SP INTRAVENOUS sodium oral DISPERSION 4.3 tablet,delayed MG/ML release (dr/ec) 180 OPDIVO 2 PA; SP mg, 360 mg INTRAVENOUS MYLERAN ORAL 2 SOLUTION 100 TABLET 2 MG MG/10 ML, 240 MYLOTARG 2 PA; SP MG/24 ML, 40 INTRAVENOUS MG/4 ML RECON SOLN 4.5 oxaliplatin 1 MG (1 MG/ML intravenous recon INITIAL CONC) soln 100 mg, 50 mg NERLYNX ORAL 2 PA; SP TABLET 40 MG NEXAVAR ORAL 2 PA; SP TABLET 200 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxaliplatin 1 REVLIMID ORAL 2 PA; SP intravenous solution CAPSULE 10 MG, 100 mg/20 ml, 200 15 MG, 2.5 MG, 20 mg/40 ml, 50 mg/10 MG, 25 MG, 5 MG ml (5 mg/ml) ROZLYTREK 2 PA; SP paclitaxel 1 ORAL CAPSULE intravenous 100 MG, 200 MG concentrate 6 mg/ml RUBRACA ORAL 2 PA; SP paraplatin 1 TABLET 200 MG, intravenous solution 250 MG, 300 MG 10 mg/ml RUXIENCE 2 PA; SP PERJETA 2 PA; SP INTRAVENOUS INTRAVENOUS SOLUTION 10 SOLUTION 420 MG/ML MG/14 ML (30 RYDAPT ORAL 2 PA; SP MG/ML) CAPSULE 25 MG PHOTOFRIN 2 SANDIMMUNE 2 SP INTRAVENOUS ORAL SOLUTION RECON SOLN 75 100 MG/ML MG SIGNIFOR 2 PA; SP POMALYST ORAL 2 PA; SP SUBCUTANEOUS CAPSULE 1 MG, 2 SOLUTION 0.3 MG, 3 MG, 4 MG MG/ML (1 ML), 0.6 POTELIGEO 2 PA; SP MG/ML (1 ML), 0.9 INTRAVENOUS MG/ML (1 ML) SOLUTION 4 SIMULECT 2 SP MG/ML INTRAVENOUS PROGRAF 2 SP RECON SOLN 10 INTRAVENOUS MG, 20 MG SOLUTION 5 SIROLIMUS 2 MG/ML (BULK) POWDER PROGRAF ORAL 2 SP 100 % GRANULES IN sirolimus oral 1 SP PACKET 0.2 MG, 1 solution 1 mg/ml MG sirolimus oral tablet 1 SP PURIXAN ORAL 2 SP 0.5 mg, 2 mg SUSPENSION 20 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SOMATULINE 2 PA; SP TALZENNA ORAL 2 PA; SP DEPOT CAPSULE 0.25 SUBCUTANEOUS MG, 1 MG SYRINGE 120 TAMOXIFEN 2 MG/0.5 ML, 60 (BULK) POWDER MG/0.2 ML, 90 MG/0.3 ML tamoxifen oral tablet 1 ACA 10 mg, 20 mg SPRYCEL ORAL 2 PA; SP TABLET 100 MG, TARGRETIN 2 PA; SP 140 MG, 20 MG, 50 TOPICAL GEL 1 % MG, 70 MG, 80 MG TASIGNA ORAL 2 PA; SP STIVARGA ORAL 2 PA; SP CAPSULE 150 MG, TABLET 40 MG 200 MG, 50 MG strontium-89 1 TECENTRIQ 2 PA; SP chloride intravenous INTRAVENOUS solution 1 mci/ml SOLUTION 1,200 MG/20 ML (60 SUTENT ORAL 2 PA; SP MG/ML), 840 CAPSULE 12.5 MG/14 ML (60 MG, 25 MG, 37.5 MG/ML) MG, 50 MG TEMODAR 2 SP SYLVANT 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 100 RECON SOLN 100 MG MG, 400 MG temozolomide oral 1 PA; SP SYNRIBO 2 PA; SP capsule 100 mg, 140 SUBCUTANEOUS mg, 180 mg, 20 mg, RECON SOLN 3.5 250 mg, 5 mg MG temsirolimus 1 PA; SP TACROLIMUS 2 intravenous recon ANHYDROUS soln 30 mg/3 ml (10 (BULK) POWDER mg/ml) (first) 100 % TENIPOSIDE 2 tacrolimus oral 1 SP INTRAVENOUS capsule 0.5 mg, 1 SOLUTION 50 mg, 5 mg MG/5 ML TAFINLAR ORAL 2 PA; SP THALOMID ORAL 2 PA; SP CAPSULE 50 MG, CAPSULE 100 MG, 75 MG 150 MG, 200 MG, TAGRISSO ORAL 2 PA; SP 50 MG TABLET 40 MG, 80 THIOGUANINE 2 MG (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits THIOTEPA 2 VANTAS 2 PA; SP (BULK) POWDER IMPLANT KIT 50 100 % MG (50 MCG/DAY) thiotepa injection 1 PA VECTIBIX 2 PA; SP recon soln 100 mg, INTRAVENOUS 15 mg SOLUTION 100 TIBSOVO ORAL 2 PA; SP MG/5 ML (20 TABLET 250 MG MG/ML), 400 MG/20 ML (20 toposar intravenous 1 MG/ML) solution 20 mg/ml VELCADE 2 SP topotecan 1 PA; SP INJECTION intravenous recon RECON SOLN 3.5 soln 4 mg MG topotecan 1 PA; SP VENCLEXTA 2 PA; SP intravenous solution ORAL TABLET 10 4 mg/4 ml (1 mg/ml) MG, 100 MG, 50 toremifene oral 1 MG tablet 60 mg VENCLEXTA 2 PA; SP TRAZIMERA 2 PA; SP STARTING PACK INTRAVENOUS ORAL RECON SOLN 150 TABLETS,DOSE MG, 420 MG PACK 10 MG-50 MG- 100 MG tretinoin 1 (antineoplastic) oral VERZENIO ORAL 2 PA; SP capsule 10 mg TABLET 100 MG, 150 MG, 200 MG, TRIPTODUR 2 PA; SP 50 MG INTRAMUSCULA R SUSPENSION vinblastine 1 FOR intravenous solution RECONSTITUTIO 1 mg/ml N 22.5 MG vincasar pfs 1 UNITUXIN 2 SP intravenous solution INTRAVENOUS 1 mg/ml, 2 mg/2 ml SOLUTION 3.5 vincristine 1 MG/ML intravenous solution valrubicin 1 PA; SP 1 mg/ml, 2 mg/2 ml intravesical solution vinorelbine 1 40 mg/ml intravenous solution 10 mg/ml, 50 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VITRAKVI ORAL 2 PA; SP YONDELIS 2 SP CAPSULE 100 MG, INTRAVENOUS 25 MG RECON SOLN 1 VITRAKVI ORAL 2 PA; SP MG SOLUTION 20 YONSA ORAL 2 PA; SP MG/ML TABLET 125 MG VIZIMPRO ORAL 2 PA; SP ZALTRAP 2 PA; SP TABLET 15 MG, 30 INTRAVENOUS MG, 45 MG SOLUTION 100 VOTRIENT ORAL 2 PA; SP MG/4 ML (25 TABLET 200 MG MG/ML), 200 MG/8 ML (25 MG/ML) VYXEOS 2 PA; SP INTRAVENOUS ZANOSAR 2 RECON SOLN 44- INTRAVENOUS 100 MG RECON SOLN 1 GRAM XALKORI ORAL 2 PA; SP CAPSULE 200 MG, ZEJULA ORAL 2 PA; SP 250 MG CAPSULE 100 MG XERMELO ORAL 2 PA; SP ZELBORAF ORAL 2 PA; SP TABLET 250 MG TABLET 240 MG XOFIGO 2 SP ZEVALIN (Y-90) 2 INTRAVENOUS INTRAVENOUS SOLUTION 1,100 KIT 3.2 MG/2 ML KBQ/ML(30 ZOLADEX 2 PA; SP MICROCURIE/ML) SUBCUTANEOUS XOSPATA ORAL 2 PA; SP IMPLANT 10.8 TABLET 40 MG MG, 3.6 MG XTANDI ORAL 2 PA; SP ZOLINZA ORAL 2 PA; SP CAPSULE 40 MG CAPSULE 100 MG YERVOY 2 PA; SP ZORTRESS ORAL 2 SP INTRAVENOUS TABLET 1 MG SOLUTION 200 ZYDELIG ORAL 2 PA; SP MG/40 ML (5 TABLET 100 MG, MG/ML), 50 MG/10 150 MG ML (5 MG/ML) ZYKADIA ORAL 2 PA; SP YESCARTA 2 PA; SP TABLET 150 MG INTRAVENOUS ZYTIGA ORAL 2 PA; SP SUSPENSION TABLET 500 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AUTONOMIC / CNS DRUGS, DIACOMIT ORAL 2 PA; SP CAPSULE 250 MG, NEUROLOGY / PSYCH 500 MG ANTICONVULSANTS DIACOMIT ORAL 2 PA; SP CARBAMAZEPINE 2 POWDER IN (BULK) POWDER PACKET 250 MG, 500 MG carbamazepine oral 1 capsule, er diazepam rectal kit 1 multiphase 12 hr 12.5-15-17.5-20 mg, 100 mg, 200 mg, 300 2.5 mg, 5-7.5-10 mg mg DILANTIN ORAL 2 carbamazepine oral 1 CAPSULE 30 MG suspension 100 mg/5 divalproex oral 1 ml, 200 mg/10 ml capsule, delayed rel carbamazepine oral 1 sprinkle 125 mg tablet 200 mg divalproex oral 1 carbamazepine oral 1 tablet extended tablet extended release 24 hr 250 release 12 hr 100 mg, 500 mg mg, 200 mg, 400 mg divalproex oral 1 carbamazepine oral 1 tablet,delayed tablet,chewable 100 release (dr/ec) 125 mg mg, 250 mg, 500 mg CELONTIN ORAL 2 EPIDIOLEX ORAL 2 PA; SP CAPSULE 300 MG SOLUTION 100 MG/ML clobazam oral 1 PA suspension 2.5 epitol oral tablet 200 1 mg/ml mg clobazam oral tablet 1 PA ETHOSUXIMIDE 2 10 mg, 20 mg (BULK) POWDER 100 % CLONAZEPAM 2 (BULK) POWDER ethosuximide oral 1 100 % capsule 250 mg clonazepam oral 1 ethosuximide oral 1 tablet 0.5 mg, 1 mg, solution 250 mg/5 ml 2 mg felbamate oral 1 clonazepam oral 1 suspension 600 mg/5 tablet,disintegrating ml 0.125 mg, 0.25 mg, felbamate oral tablet 1 0.5 mg, 1 mg, 2 mg 400 mg, 600 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fosphenytoin 1 lamotrigine oral 1 injection solution tablet, chewable 100 mg pe/2 ml, 500 dispersible 25 mg, 5 mg pe/10 ml mg FYCOMPA ORAL 2 lamotrigine oral 1 SUSPENSION 0.5 tablet,disintegrating MG/ML 100 mg, 200 mg, 25 mg, 50 mg FYCOMPA ORAL 2 TABLET 10 MG, 12 lamotrigine oral 1 MG, 2 MG, 4 MG, 6 tablets,dose pack 25 MG, 8 MG mg (35), 25 mg (42) -100 mg (7), 25 mg gabapentin oral 1 (84) -100 mg (14) capsule 100 mg, 300 mg, 400 mg LEVETIRACETAM 2 gabapentin oral 1 (BULK) POWDER solution 250 mg/5 100 % ml, 250 mg/5 ml (5 levetiracetam in nacl 1 ml), 300 mg/6 ml (6 (iso-os) intravenous ml) piggyback 1,000 mg/100 ml, 1,500 gabapentin oral 1 mg/100 ml, 500 tablet 600 mg, 800 mg/100 ml mg levetiracetam LAMOTRIGINE 2 1 intravenous solution (BULK) POWDER 500 mg/5 ml 100 % levetiracetam oral lamotrigine oral 1 1 solution 100 mg/ml, tablet 100 mg, 150 500 mg/5 ml (5 ml) mg, 200 mg, 25 mg levetiracetam oral lamotrigine oral 1 1 tablet disintegrating, tablet 1,000 mg, 250 mg, 500 mg, 750 mg dose pk 25 mg (21) - 50 mg (7), 25 levetiracetam oral 1 mg(14)-50 mg (14)- tablet extended 100 mg (7), 50 mg release 24 hr 500 (42) -100 mg (14) mg, 750 mg lamotrigine oral 1 NAYZILAM 2 PA; QL tablet extended NASAL release 24hr 100 mg, SPRAY,NON- 200 mg, 25 mg, 250 AEROSOL 5 mg, 300 mg, 50 mg MG/SPRAY (0.1 ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxcarbazepine oral 1 phenytoin sodium 1 suspension 300 mg/5 intravenous syringe ml (60 mg/ml) 50 mg/ml oxcarbazepine oral 1 pregabalin oral 1 tablet 150 mg, 300 capsule 100 mg, 150 mg, 600 mg mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 PHENOBARBITAL 2 mg, 75 mg (BULK) POWDER pregabalin oral phenobarbital oral 1 1 solution 20 mg/ml elixir 20 mg/5 ml (4 mg/ml) PRIMIDONE 2 phenobarbital oral 1 (BULK) POWDER tablet 100 mg, 15 100 % mg, 16.2 mg, 30 mg, primidone oral 1 32.4 mg, 60 mg, 64.8 tablet 250 mg, 50 mg mg, 97.2 mg QUDEXY XR 2 ST phenobarbital 1 ORAL sodium injection CAPSULE,SPRINK solution 130 mg/ml, LE,ER 24HR 100 65 mg/ml MG, 150 MG, 200 PHENYTOIN 2 MG, 25 MG, 50 MG (BULK) POWDER roweepra oral tablet 1 1,000 mg, 500 mg, phenytoin oral 1 750 mg suspension 125 mg/5 ml roweepra xr oral 1 tablet extended phenytoin oral 1 release 24 hr 500 tablet,chewable 50 mg, 750 mg mg subvenite oral tablet PHENYTOIN 2 1 100 mg, 150 mg, 200 SODIUM (BULK) mg, 25 mg POWDER subvenite starter phenytoin sodium 1 1 extended oral (blue) kit oral tablets,dose pack 25 capsule 100 mg, 200 mg (35) mg, 300 mg subvenite starter phenytoin sodium 1 1 (green) kit oral intravenous solution tablets,dose pack 25 50 mg/ml mg (84) -100 mg (14)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits subvenite starter 1 vigabatrin oral 1 PA; SP (orange) kit oral tablet 500 mg tablets,dose pack 25 vigadrone oral 1 PA; SP mg (42) -100 mg (7) powder in packet tiagabine oral tablet 1 500 mg 12 mg, 16 mg, 2 mg, VIMPAT 2 4 mg INTRAVENOUS TOPIRAMATE 2 SOLUTION 200 (BULK) POWDER MG/20 ML 99.7 % VIMPAT ORAL 2 topiramate oral 1 SOLUTION 10 capsule, sprinkle 15 MG/ML mg, 25 mg VIMPAT ORAL 2 topiramate oral 1 ST TABLET 100 MG, capsule,sprinkle,er 150 MG, 200 MG, 24hr 100 mg, 150 50 MG mg, 200 mg, 25 mg, zonisamide oral 1 50 mg capsule 100 mg, 25 topiramate oral 1 mg, 50 mg tablet 200 mg ANTIPARKINSONISM AGENTS VALPROATE 2 APOKYN 2 PA; SP; QL SODIUM (BULK) SUBCUTANEOUS POWDER 100 % CARTRIDGE 10 valproate sodium 1 MG/ML intravenous solution benztropine injection 500 mg/5 ml (100 1 solution 1 mg/ml mg/ml) benztropine oral 1 valproic acid (as 1 tablet 0.5 mg, 1 mg, sodium salt) oral 2 mg solution 250 mg/5 ml, 250 mg/5 ml (5 BROMOCRIPTINE 2 ml), 500 mg/10 ml (BULK) POWDER (10 ml) bromocriptine oral 1 VALPROIC ACID 2 capsule 5 mg (BULK) LIQUID bromocriptine oral 1 100 % tablet 2.5 mg valproic acid oral 1 CARBIDOPA 2 capsule 250 mg (BULK) POWDER vigabatrin oral 1 PA; SP carbidopa oral 1 PA powder in packet tablet 25 mg 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits carbidopa-levodopa 1 pramipexole oral 1 oral tablet 10-100 tablet extended mg, 25-100 mg, 25- release 24 hr 0.375 250 mg mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 carbidopa-levodopa 1 oral tablet extended mg, 4.5 mg release 25-100 mg, rasagiline oral tablet 1 50-200 mg 0.5 mg, 1 mg carbidopa-levodopa 1 ropinirole oral tablet 1 oral 0.25 mg, 0.5 mg, 1 tablet,disintegrating mg, 2 mg, 3 mg, 4 10-100 mg, 25-100 mg, 5 mg mg, 25-250 mg ropinirole oral tablet 1 carbidopa-levodopa- 1 extended release 24 entacapone oral hr 12 mg, 2 mg, 4 tablet 12.5-50-200 mg, 6 mg, 8 mg mg, 18.75-75-200 SELEGILINE HCL 2 mg, 25-100-200 mg, (BULK) POWDER 31.25-125-200 mg, 37.5-150-200 mg, selegiline hcl oral 1 50-200-200 mg capsule 5 mg entacapone oral 1 selegiline hcl oral 1 tablet 200 mg tablet 5 mg INBRIJA 2 PA; SP; QL tolcapone oral tablet 1 PA INHALATION 100 mg CAPSULE, trihexyphenidyl oral 1 W/INHALATION elixir 0.4 mg/ml DEVICE 42 MG trihexyphenidyl oral 1 KYNMOBI 2 PA; QL tablet 2 mg, 5 mg SUBLINGUAL MIGRAINE / CLUSTER HEADACHE FILM 10 MG, 15 MG, 20 MG, 25 THERAPY MG, 30 MG almotriptan malate 1 QL LEVODOPA 2 oral tablet 12.5 mg, (BULK) POWDER 6.25 mg pramipexole oral 1 dihydroergotamine 1 tablet 0.125 mg, 0.25 injection solution 1 mg, 0.5 mg, 0.75 mg, mg/ml 1 mg, 1.5 mg DIHYDROERGOT 2 AMINE MESYLT(BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dihydroergotamine 1 ST; QL rizatriptan oral 1 QL nasal spray,non- tablet 10 mg, 5 mg aerosol 0.5 mg/pump rizatriptan oral 1 QL act. (4 mg/ml) tablet,disintegrating eletriptan oral tablet 1 QL 10 mg, 5 mg 20 mg, 40 mg SUMATRIPTAN 2 EMGALITY PEN 2 PA; QL (BULK) POWDER SUBCUTANEOUS 100 % PEN INJECTOR sumatriptan nasal 1 QL 120 MG/ML spray,non-aerosol EMGALITY 2 PA; QL 20 mg/actuation, 5 SYRINGE mg/actuation SUBCUTANEOUS SUMATRIPTAN 2 SYRINGE 120 SUCCINATE MG/ML, 300 MG/3 (BULK) POWDER ML (100 MG/ML X 100 % 3) sumatriptan 1 QL ERGOTAMINE 2 succinate oral tablet TARTRATE 100 mg, 25 mg, 50 (BULK) POWDER mg ergotamine-caffeine 1 sumatriptan 1 QL oral tablet 1-100 mg succinate frovatriptan oral 1 QL subcutaneous tablet 2.5 mg cartridge 4 mg/0.5 ml, 6 mg/0.5 ml isometh-dichloral- 1 acetaminophn oral sumatriptan 1 QL capsule 65-100-325 succinate mg subcutaneous pen injector 4 mg/0.5 ml, ISOMETHEPTENE 2 6 mg/0.5 ml MUCATE (BULK) POWDER 100 % sumatriptan 1 QL succinate METHYSERGIDE 2 subcutaneous (BULK) POWDER solution 6 mg/0.5 ml 100 % sumatriptan migergot rectal 1 1 QL succinate suppository 2-100 subcutaneous mg syringe 6 mg/0.5 ml naratriptan oral 1 QL sumatriptan- tablet 1 mg, 2.5 mg 1 ST; QL naproxen oral tablet 85-500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits zolmitriptan oral 1 QL galantamine oral 1 tablet 2.5 mg, 5 mg capsule,ext rel. pellets 24 hr 16 mg, zolmitriptan oral 1 QL 24 mg, 8 mg tablet,disintegrating 2.5 mg, 5 mg galantamine oral 1 solution 4 mg/ml ZOMIG NASAL 2 ST; QL SPRAY,NON- galantamine oral 1 AEROSOL 2.5 MG, tablet 12 mg, 4 mg, 8 5 MG mg MISCELLANEOUS GILENYA ORAL 2 PA; SP

NEUROLOGICAL THERAPY CAPSULE 0.5 MG AUBAGIO ORAL 2 PA; SP glatiramer 1 PA; SP; QL TABLET 14 MG, 7 subcutaneous MG syringe 20 mg/ml, 40 mg/ml AUSTEDO ORAL 2 PA; SP; QL TABLET 12 MG, 6 glatopa 1 PA; SP; QL MG, 9 MG subcutaneous syringe 20 mg/ml, 40 BAFIERTAM 2 PA; SP mg/ml ORAL CAPSULE,DELAY KESIMPTA PEN 2 PA; SP ED SUBCUTANEOUS RELEASE(DR/EC) PEN INJECTOR 20 95 MG MG/0.4 ML dalfampridine oral 1 PA; SP MAYZENT ORAL 2 PA; SP; QL tablet extended TABLET 0.25 MG, release 12 hr 10 mg 2 MG dimethyl fumarate 1 PA; SP memantine oral 1 oral capsule,delayed capsule,sprinkle,er release(dr/ec) 120 24hr 14 mg, 21 mg, mg, 120 mg (14)- 28 mg, 7 mg 240 mg (46), 240 mg memantine oral 1 donepezil oral tablet 1 solution 2 mg/ml 10 mg, 5 mg memantine oral 1 donepezil oral tablet 1 PA tablet 10 mg, 5 mg 23 mg NAMZARIC ORAL 2 PA donepezil oral 1 CAP,SPRINKLE,ER tablet,disintegrating 24HR DOSE PACK 10 mg, 5 mg 7/14/21/28 MG-10 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NAMZARIC ORAL 2 PA TYSABRI 2 PA; SP CAPSULE,SPRINK INTRAVENOUS LE,ER 24HR 14-10 SOLUTION 300 MG, 21-10 MG, 28- MG/15 ML 10 MG, 7-10 MG VUMERITY ORAL 2 PA; SP NUEDEXTA ORAL 2 PA CAPSULE,DELAY CAPSULE 20-10 ED MG RELEASE(DR/EC) OCREVUS 2 PA; SP 231 MG INTRAVENOUS ZEPOSIA ORAL 2 PA; SP SOLUTION 30 CAPSULE 0.92 MG MG/ML ZEPOSIA 2 PA; SP RADICAVA 2 PA; SP STARTER KIT INTRAVENOUS ORAL SOLUTION 30 CAPSULE,DOSE MG/100 ML PACK 0.23-0.46- rivastigmine tartrate 1 0.92 MG oral capsule 1.5 mg, ZEPOSIA 2 PA; SP 3 mg, 4.5 mg, 6 mg STARTER PACK rivastigmine 1 ORAL transdermal patch CAPSULE,DOSE 24 hour 13.3 mg/24 PACK 0.23 MG (4)- hour, 4.6 mg/24 0.46 MG (3) hour, 9.5 mg/24 MUSCLE RELAXANTS /

hour ANTISPASMODIC THERAPY RUZURGI ORAL 2 PA; SP anectine injection 1 TABLET 10 MG solution 20 mg/ml SPINRAZA (PF) 2 PA; SP; QL atracurium 1 INTRATHECAL intravenous solution SOLUTION 12 10 mg/ml MG/5 ML baclofen intrathecal 1 TEGSEDI 2 PA; SP solution 10,000 SUBCUTANEOUS mcg/20ml (500 SYRINGE 284 mcg/ml), 20,000 MG/1.5 ML mcg/20ml (1,000 tetrabenazine oral 1 PA; SP; QL mcg/ml), 40,000 tablet 12.5 mg, 25 mcg/20ml (2,000 mg mcg/ml) baclofen oral tablet 1 10 mg, 20 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CARISOPRODOL 2 LIORESAL 2 (BULK) POWDER INTRATHECAL chlorzoxazone oral 1 SOLUTION 2,000 tablet 250 mg, 375 MCG/ML, 50 mg, 500 mg, 750 mg MCG/ML, 500 MCG/ML cisatracurium 1 metaxalone oral intravenous solution 1 10 mg/ml conc. (icu tablet 400 mg, 800 mg use only), 2 mg/ml cyclobenzaprine oral 1 METHOCARBAM 2 capsule,extended OL (BULK) release 24hr 15 mg, POWDER 100 % 30 mg methocarbamol 1 injection solution cyclobenzaprine oral 1 100 mg/ml tablet 5 mg, 7.5 mg methocarbamol oral DANTROLENE 2 1 tablet 500 mg, 750 (BULK) POWDER mg dantrolene 1 intravenous recon NEOSTIGMINE 2 soln 20 mg METHYLSULF (BULK) POWDER dantrolene oral 1 100 % capsule 100 mg, 25 neostigmine mg, 50 mg 1 methylsulfate EDROPHONIUM 2 intravenous solution CHLORIDE 0.5 mg/ml, 1 mg/ml (BULK) POWDER neostigmine 1 GABLOFEN 2 methylsulfate INTRATHECAL intravenous syringe SYRINGE 10,000 5 mg/5 ml (1 mg/ml) MCG/20ML (500 MCG/ML), 20,000 ORPHENADRINE 2 MCG/20ML (1,000 CITRATE (BULK) MCG/ML), 40,000 POWDER MCG/20ML (2,000 orphenadrine citrate 1 MCG/ML), 50 injection solution 30 MCG/ML (1 ML) mg/ml orphenadrine citrate 1 oral tablet extended release 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits orphenadrine-asa- 1 SUCCINYLCHOLI 2 caffeine oral tablet NE CL (BULK) 50-770-60 mg POWDER 100 % orphengesic forte 1 TIZANIDINE 2 oral tablet 50-770- (BULK) POWDER 60 mg 100 % pancuronium 1 tizanidine oral 1 intravenous solution capsule 2 mg, 4 mg, 1 mg/ml, 2 mg/ml 6 mg PYRIDOSTIGMINE 2 tizanidine oral tablet 1 BROMIDE (BULK) 2 mg, 4 mg POWDER 100 % vecuronium bromide 1 pyridostigmine 1 intravenous recon bromide oral syrup soln 10 mg, 20 mg 60 mg/5 ml NARCOTIC ANALGESICS pyridostigmine 1 acetaminophen-caff- 1 bromide oral tablet dihydrocod oral 60 mg capsule 320.5-30-16 pyridostigmine 1 mg bromide oral tablet acetaminophen-caff- 1 extended release 180 dihydrocod oral mg tablet 325-30-16 mg regonol injection 1 acetaminophen- 1 solution 5 mg/ml codeine oral solution revonto intravenous 1 120 mg-12 mg /5 ml recon soln 20 mg (5 ml), 120-12 mg/5 rocuronium 1 ml, 300 mg-30 mg intravenous solution /12.5 ml 10 mg/ml acetaminophen- 1 rocuronium 1 codeine oral tablet intravenous syringe 300-15 mg, 300-30 50 mg/5 ml (10 mg, 300-60 mg mg/ml) alfentanil injection 1 succinylcholine 1 solution 500 mcg/ml chloride injection ascomp with codeine 1 solution 20 mg/ml oral capsule 30-50- succinylcholine 1 325-40 mg chloride intravenous syringe 100 mg/5 ml (20 mg/ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BELBUCA 2 ST; QL butalbital- 1 BUCCAL FILM 150 acetaminophen-caff MCG, 300 MCG, oral capsule 50-300- 450 MCG, 600 40 mg, 50-325-40 MCG, 75 MCG, 750 mg MCG, 900 MCG butalbital- 1 BUPRENORPHINE 2 acetaminophen-caff HCL (BULK) oral tablet 50-325- POWDER 40 mg buprenorphine hcl 1 butalbital-aspirin- 1 injection solution 0.3 caffeine oral capsule mg/ml 50-325-40 mg buprenorphine hcl 1 butalbital-aspirin- 1 injection syringe 0.3 caffeine oral tablet mg/ml 50-325-40 mg buprenorphine hcl 1 CODEINE 2 sublingual tablet 2 PHOSPHATE mg, 8 mg (BULK) POWDER buprenorphine 1 ST 100 % transdermal patch codeine sulfate oral 1 weekly 10 mcg/hour, tablet 15 mg, 30 mg, 15 mcg/hour, 20 60 mg mcg/hour, 5 diskets oral 1 ST mcg/hour, 7.5 tablet,soluble 40 mg mcg/hour duramorph (pf) 1 butalbital compound 1 injection solution 0.5 w/codeine oral mg/ml, 1 mg/ml capsule 30-50-325- 40 mg dvorah oral tablet 1 325-30-16 mg butalbital- 1 acetaminop-caf-cod endocet oral tablet 1 oral capsule 50-300- 2.5-325 mg, 7.5-325 40-30 mg, 50-325- mg 40-30 mg FENTANYL 2 butalbital- 1 CITRATE (BULK) acetaminophen oral POWDER 100 % capsule 50-300 mg fentanyl citrate (pf) 1 butalbital- 1 injection solution 50 acetaminophen oral mcg/ml tablet 25-325 mg, 50-300 mg, 50-325 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fentanyl citrate (pf) 1 hydrocodone 1 ST; QL intravenous pt bitartrate oral controlled analgesia capsule, oral only, syring 1,000 mcg/20 er 12hr 10 mg, 15 ml (50 mcg/ml) mg, 20 mg, 30 mg, 40 mg, 50 mg fentanyl citrate (pf) 1 intravenous syringe hydrocodone 1 ST; QL 100 mcg/2 ml (50 bitartrate oral mcg/ml) tablet,oral only,ext.rel.24 hr fentanyl citrate (pf)- 1 0.9%nacl 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, intravenous solution 60 mg, 80 mg 5 mcg/ml hydrocodone- fentanyl citrate (pf)- 1 1 0.9%nacl acetaminophen oral solution 10-325 intravenous syringe mg/15 ml(15 ml), 10 mcg/ml 7.5-325 mg/15 ml fentanyl citrate 1 ST; QL buccal lozenge on a hydrocodone- 1 acetaminophen oral handle 1,200 mcg, 1,600 mcg, 200 mcg, tablet 10-300 mg, 400 mcg, 600 mcg, 2.5-325 mg, 5-300 mg, 7.5-300 mg, 7.5- 800 mcg 325 mg fentanyl transdermal 1 ST; QL hydrocodone- patch 72 hour 100 1 mcg/hr, 12 mcg/hr, ibuprofen oral tablet 25 mcg/hr, 37.5 10-200 mg, 5-200 mcg/hour, 50 mg, 7.5-200 mg mcg/hr, 62.5 HYDROMORPHO 2 mcg/hour, 75 NE (BULK) mcg/hr, 87.5 POWDER 100 % mcg/hour hydromorphone (pf) 1 HYDROCODONE 2 injection solution 10 BITARTRATE mg/ml, 2 mg/ml (BULK) hydromorphone (pf)- 1 CRYSTALS 0.9 % nacl HYDROCODONE 2 intravenous pt BITARTRATE controlled analgesia (BULK) POWDER syring 10 mg/50 ml 100 % (0.2 mg/ml), 15 mg/30 ml (0.5 mg/ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydromorphone 1 MEPERIDINE 2 injection solution 1 (BULK) POWDER mg/ml, 2 mg/ml 100 % hydromorphone 1 METHADONE 2 injection syringe 1 (BULK) POWDER mg/ml, 2 mg/ml, 4 100 % mg/ml methadone injection 1 hydromorphone oral 1 solution 10 mg/ml liquid 1 mg/ml methadone intensol 1 ST hydromorphone oral 1 oral concentrate 10 tablet 2 mg, 4 mg, 8 mg/ml mg methadone oral 1 ST hydromorphone oral 1 ST; QL concentrate 10 tablet extended mg/ml release 24 hr 12 mg, methadone oral 1 ST 16 mg, 32 mg, 8 mg solution 10 mg/5 ml, hydromorphone 1 5 mg/5 ml rectal suppository 3 methadone oral 1 ST mg tablet 10 mg, 5 mg HYSINGLA ER 2 ST; QL methadone oral 1 ST ORAL tablet,soluble 40 mg TABLET,ORAL ONLY,EXT.REL.24 methadose oral 1 ST HR 100 MG, 120 concentrate 10 MG, 20 MG, 30 mg/ml MG, 40 MG, 60 methadose oral 1 ST MG, 80 MG tablet,soluble 40 mg ibuprofen-oxycodone 1 MORPHINE 2 oral tablet 400-5 mg (BULK) POWDER INFUMORPH P/F 2 100 % INJECTION morphine (pf) in 0.9 1 SOLUTION 10 % sod chl MG/ML, 25 intravenous pt MG/ML controlled analgesia LEVORPHANOL 2 syring 30 mg/30 ml TARTRATE (1 mg/ml) (BULK) POWDER morphine (pf) in 0.9 1 100 % % sod chl levorphanol tartrate 1 intravenous solution oral tablet 2 mg, 3 1 mg/ml mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits morphine (pf) in 0.9 1 morphine oral 1 ST; QL % sod chl capsule, er intravenous syringe multiphase 24 hr 1 mg/ml, 2 mg/2 ml 120 mg, 30 mg, 45 (1 mg/ml), 5 mg/5 ml mg, 60 mg, 75 mg, (1 mg/ml) 90 mg morphine (pf) 1 morphine oral 1 ST; QL injection solution 0.5 capsule,extend.relea mg/ml, 1 mg/ml se pellets 10 mg, 100 mg, 20 mg, 30 mg, morphine 1 concentrate oral 40 mg, 50 mg, 60 mg, 80 mg solution 100 mg/5 ml (20 mg/ml) morphine oral 1 solution 10 mg/5 ml, morphine in 0.9 % 1 sodium chlor 20 mg/5 ml (4 intravenous pt mg/ml) controlled analgesia morphine oral tablet 1 syring 30 mg/30 ml 15 mg, 30 mg (1 mg/ml), 50 mg/50 morphine oral tablet 1 ST; QL ml (1 mg/ml) extended release 100 morphine injection 1 mg, 15 mg, 200 mg, solution 10 mg/ml, 8 30 mg, 60 mg mg/ml morphine rectal 1 morphine injection 1 suppository 10 mg, syringe 10 mg/ml, 2 20 mg, 30 mg, 5 mg mg/ml, 4 mg/ml, 5 OXYCODONE 2 mg/ml, 8 mg/ml (BULK) POWDER morphine 1 100 % intravenous pt oxycodone oral 1 controlled analgesia capsule 5 mg syring 30 mg/30 ml (1 mg/ml) oxycodone oral 1 concentrate 20 morphine 1 mg/ml intravenous solution 10 mg/ml, 4 mg/ml, oxycodone oral 1 50 mg/ml solution 5 mg/5 ml morphine 1 oxycodone oral 1 intravenous syringe tablet 10 mg, 15 mg, 10 mg/ml, 2 mg/ml, 4 20 mg, 30 mg, 5 mg mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxycodone- 1 sufentanil citrate 1 acetaminophen oral intravenous solution tablet 10-325 mg, 50 mcg/ml 2.5-300 mg, 2.5-325 tencon oral tablet 1 mg, 5-325 mg, 7.5- 50-325 mg 325 mg vicodin hp oral 1 oxycodone-aspirin 1 tablet 10-300 mg oral tablet 4.8355- 325 mg vtol lq oral solution 1 50-325-40 mg/15 ml OXYCONTIN 2 ST; QL ORAL zebutal oral capsule 1 TABLET,ORAL 50-325-40 mg ONLY,EXT.REL.12 NON-NARCOTIC ANALGESICS HR 15 MG, 20 MG, 30 MG, 40 MG, 60 ACETAMINOPHE 2 MG, 80 MG N (BULK) POWDER 100 % oxymorphone oral 1 tablet 10 mg, 5 mg acetaminophen 1 intravenous solution oxymorphone oral 1 ST; QL 1,000 mg/100 ml (10 tablet extended mg/ml) release 12 hr 10 mg, 15 mg, 20 mg, 30 ASPIRIN (BULK) 2 mg, 40 mg, 5 mg, 7.5 POWDER 100 % mg aspirin childrens 1 ACA; OTC prolate oral tablet 1 oral tablet,chewable 10-300 mg, 5-300 81 mg mg, 7.5-300 mg aspirin low dose 1 ACA; OTC remifentanil 1 oral tablet,delayed intravenous recon release (dr/ec) 81 soln 1 mg, 2 mg, 5 mg mg aspirin oral tablet 1 ACA; OTC SUBLOCADE 2 SP 325 mg SUBCUTANEOUS aspirin oral 1 ACA; OTC SOLUTION, tablet,chewable 81 EXTENDED REL mg SYRINGE 100 aspirin oral MG/0.5 ML, 300 1 ACA; OTC tablet,delayed MG/1.5 ML release (dr/ec) 325 SUFENTANIL 2 mg, 81 mg CITRATE (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits aspirin,buffd- 1 ACA; OTC cataflam oral tablet 1 calcium carb-mag 50 mg oral tablet 325 mg CELECOXIB 2 aspir-trin oral 1 ACA; OTC (BULK) POWDER tablet,delayed 100 % release (dr/ec) 325 celecoxib oral 1 ST mg capsule 100 mg, 200 bayer aspirin oral 1 ACA; OTC mg, 400 mg, 50 mg tablet 325 mg children's aspirin 1 ACA; OTC bufferin oral tablet 1 ACA; OTC oral tablet,chewable 325 mg 81 mg buprenorphine- 1 CHOLIN AND MG 2 naloxone sublingual SALICYLATE(BUL film 12-3 mg K) POWDER buprenorphine- 1 QL choline,magnesium 1 naloxone sublingual salicylate oral liquid film 2-0.5 mg, 4-1 500 mg/5 ml mg, 8-2 mg clonidine (pf) 1 buprenorphine- 1 QL epidural solution naloxone sublingual 5,000 mcg/10 ml tablet 2-0.5 mg diclofenac potassium 1 buprenorphine- 1 oral tablet 50 mg naloxone sublingual diclofenac sodium 1 tablet 8-2 mg oral tablet extended butorphanol 1 release 24 hr 100 mg injection solution 1 diclofenac sodium 1 mg/ml, 2 mg/ml oral tablet,delayed butorphanol nasal 1 QL release (dr/ec) 25 spray,non-aerosol mg, 50 mg, 75 mg 10 mg/ml diclofenac sodium 1 QL BUTORPHANOL 2 topical drops 1.5 % TARTRATE diclofenac sodium 1 ST; QL (BULK) POWDER topical gel 1 % 100 % diclofenac- 1 CALDOLOR 2 misoprostol oral INTRAVENOUS tablet,ir,delayed RECON SOLN 800 rel,biphasic 50-200 MG/8 ML (100 mg-mcg, 75-200 mg- MG/ML) mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diflunisal oral tablet 1 ibuprofen oral tablet 1 500 mg 600 mg ec-naproxen oral 1 INDOMETHACIN 2 tablet,delayed (BULK) POWDER release (dr/ec) 375 indomethacin oral 1 mg, 500 mg capsule 25 mg, 50 ecotrin low strength 1 ACA; OTC mg oral tablet,delayed indomethacin oral 1 release (dr/ec) 81 capsule, extended mg release 75 mg ecotrin oral 1 ACA; OTC indomethacin 1 tablet,delayed sodium intravenous release (dr/ec) 325 recon soln 1 mg mg ketoprofen oral 1 ST etodolac oral tablet 1 capsule 25 mg 400 mg, 500 mg ketoprofen oral 1 etodolac oral tablet 1 capsule 50 mg, 75 extended release 24 mg hr 400 mg, 500 mg, 600 mg ketoprofen oral 1 ST capsule,ext rel. EUFLEXXA 2 PA; SP pellets 24 hr 200 mg INTRA- ARTICULAR KETOPROFEN, 2 SYRINGE 10 MICRONIZED MG/ML(MW 2.4 - (BULK) POWDER 3.6 MILLION) 100 % fenoprofen oral 1 ST KETOROLAC 2 tablet 600 mg (BULK) POWDER 100 % FLURBIPROFEN 2 (BULK) POWDER ketorolac injection 1 cartridge 15 mg/ml, flurbiprofen oral 1 30 mg/ml tablet 100 mg ketorolac injection 1 ibu oral tablet 400 1 solution 15 mg/ml, mg, 600 mg, 800 mg 30 mg/ml, 30 mg/ml IBUPROFEN 2 (1 ml) (BULK) POWDER ketorolac injection 1 100 % syringe 15 mg/ml, 30 ibuprofen lysine (pf) 1 mg/ml intravenous solution 20 mg/2 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ketorolac 1 MONOVISC 2 PA; SP intramuscular INTRA- cartridge 60 mg/2 ml ARTICULAR ketorolac 1 SYRINGE 88 MG/4 intramuscular ML solution 60 mg/2 ml nabumetone oral 1 tablet 500 mg, 750 ketorolac 1 intramuscular mg syringe 60 mg/2 ml NABUMETONE, 2 ketorolac oral tablet 1 QL MICRONIZED 10 mg (BULK) POWDER 100 % LICART 2 ST; QL TRANSDERMAL NALBUPHINE 2 PATCH 24 HOUR (BULK) POWDER 1.3 % 100 % nalbuphine injection lite coat aspirin oral 1 ACA; OTC 1 solution 10 mg/ml, tablet 325 mg 20 mg/ml meclofenamate oral 1 capsule 100 mg, 50 NALOXONE 2 mg (BULK) POWDER naloxone injection MECLOFENAMAT 2 1 solution 0.4 mg/ml E SODIUM (BULK) POWDER naloxone injection 1 syringe 0.4 mg/ml, 1 MEFENAMIC 2 mg/ml ACID (BULK) POWDER 100 % NALTREXONE 2 mefenamic acid oral 1 HCL (BULK) capsule 250 mg POWDER 100 % MELOXICAM 2 NALTREXONE 2 (BULK) POWDER HCL 100 % DIHYDRATE(BUL K) POWDER 100 % meloxicam 1 ST submicronized oral naltrexone oral 1 tablet 50 mg capsule 10 mg meloxicam 1 ST; QL NAPROXEN 2 submicronized oral (BULK) POWDER capsule 5 mg naproxen oral 1 ST suspension 125 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits naproxen oral tablet 1 salsalate oral tablet 1 250 mg, 500 mg 500 mg, 750 mg naproxen oral 1 SODIUM 2 tablet,delayed SALICYLATE release (dr/ec) 375 (BULK) POWDER mg, 500 mg st joseph aspirin 1 ACA; OTC NAPROXEN 2 oral tablet,chewable SODIUM (BULK) 81 mg POWDER SULINDAC 2 naproxen sodium 1 (BULK) POWDER oral tablet 550 mg sulindac oral tablet 1 naproxen sodium 1 ST 150 mg, 200 mg oral tablet, er tolmetin oral capsule 1 ST multiphase 24 hr 400 mg 375 mg, 500 mg tolmetin oral tablet 1 naproxen- 1 ST 200 mg esomeprazole oral tablet,ir,delayed tolmetin oral tablet 1 ST rel,biphasic 375-20 600 mg mg, 500-20 mg TRAMADOL 2 ORTHOVISC 2 PA; SP HYDROCHLORID INTRA- E (BULK) ARTICULAR POWDER 100 % SYRINGE 30 MG/2 tramadol oral tablet 1 QL ML 50 mg oxaprozin oral tablet 1 tramadol oral tablet 1 ST; QL 600 mg extended release 24 PIROXICAM 2 hr 100 mg, 200 mg, (BULK) POWDER 300 mg 100 % tramadol oral tablet, 1 ST; QL piroxicam oral 1 er multiphase 24 hr capsule 10 mg, 20 100 mg, 200 mg, 300 mg mg PRIALT 2 SP tramadol- 1 QL INTRATHECAL acetaminophen oral SOLUTION 100 tablet 37.5-325 mg MCG/ML, 25 tri-buffered aspirin 1 ACA; OTC MCG/ML oral tablet 325 mg SALSALATE 2 (BULK) POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VIVITROL 2 SP alprazolam oral 1 INTRAMUSCULA tablet extended R release 24 hr 0.5 mg, SUSPENSION,EXT 1 mg, 2 mg, 3 mg ENDED REL alprazolam oral 1 RECON 380 MG tablet,disintegrating ZUBSOLV 2 QL 0.25 mg, 0.5 mg, 1 SUBLINGUAL mg, 2 mg TABLET 0.7-0.18 AMITRIPTYLINE 2 MG, 1.4-0.36 MG, (BULK) POWDER 2.9-0.71 MG, 5.7- 1.4 MG, 8.6-2.1 MG amitriptyline oral 1 tablet 10 mg, 100 ZUBSOLV 2 mg, 150 mg, 25 mg, SUBLINGUAL 50 mg, 75 mg TABLET 11.4-2.9 MG amitriptyline- 1 chlordiazepoxide PSYCHOTHERAPEUTIC DRUGS oral tablet 12.5-5 ABILIFY 2 mg, 25-10 mg MAINTENA amoxapine oral 1 INTRAMUSCULA tablet 100 mg, 150 R mg, 25 mg, 50 mg SUSPENSION,EXT ENDED REL amphetamine sulfate 1 ST; AGE RECON 300 MG, oral tablet 10 mg, 5 400 MG mg ABILIFY 2 AMYTAL 2 MAINTENA INJECTION INTRAMUSCULA RECON SOLN 500 R MG SUSPENSION,EXT aripiprazole oral 1 ENDED REL solution 1 mg/ml SYRING 300 MG, aripiprazole oral 1 QL 400 MG tablet 10 mg, 15 mg, ALPRAZOLAM 2 2 mg, 20 mg, 30 mg, (BULK) POWDER 5 mg 100 % aripiprazole oral 1 QL alprazolam intensol 1 tablet,disintegrating oral concentrate 1 10 mg, 15 mg mg/ml alprazolam oral 1 tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARISTADA INITIO 2 BUSPIRONE 2 INTRAMUSCULA (BULK) POWDER R 100 % SUSPENSION,EXT buspirone oral tablet 1 ENDED REL 10 mg, 15 mg, 30 SYRING 675 mg, 5 mg, 7.5 mg MG/2.4 ML BUTALBITAL 2 ARISTADA 2 (BULK) POWDER INTRAMUSCULA R CHLORAL 2 SUSPENSION,EXT HYDRATE (BULK) ENDED REL CRYSTALS SYRING 1,064 chlordiazepoxide hcl 1 MG/3.9 ML, 441 oral capsule 10 mg, MG/1.6 ML, 662 25 mg, 5 mg MG/2.4 ML, 882 MG/3.2 ML CHLORPROMAZI 2 NE (BULK) armodafinil oral 1 PA; QL POWDER 100 % tablet 150 mg, 200 mg, 250 mg, 50 mg chlorpromazine 1 injection solution 25 asenapine maleate 1 QL mg/ml sublingual tablet 10 mg, 2.5 mg, 5 mg chlorpromazine oral 1 tablet 10 mg, 100 atomoxetine oral 1 ST; AGE mg, 200 mg, 25 mg, capsule 10 mg, 100 50 mg mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg citalopram oral 1 solution 10 mg/5 ml BUPROPION HCL 2 (BULK) POWDER citalopram oral 1 QL 100 % tablet 10 mg, 20 mg, 40 mg bupropion hcl oral 1 tablet 100 mg, 75 mg CLOMIPRAMINE 2 (BULK) POWDER bupropion hcl oral 1 QL 100 % tablet extended release 24 hr 150 clomipramine oral 1 mg, 300 mg capsule 25 mg, 50 mg, 75 mg bupropion hcl oral 1 QL tablet sustained- clonidine hcl oral 1 ST; AGE release 12 hr 100 tablet extended mg, 150 mg, 200 mg release 12 hr 0.1 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clorazepate 1 dexmethylphenidate 1 ST; AGE dipotassium oral oral capsule,er tablet 15 mg, 3.75 biphasic 50-50 10 mg, 7.5 mg mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 clozapine oral tablet 1 100 mg, 200 mg, 25 mg, 40 mg, 5 mg mg, 50 mg dexmethylphenidate 1 ST; AGE oral tablet 10 mg, clozapine oral 1 2.5 mg, 5 mg tablet,disintegrating 100 mg, 12.5 mg, dextroamphetamine 1 ST; AGE 150 mg, 200 mg, 25 oral capsule, mg extended release 10 mg, 15 mg, 5 mg DAYTRANA 2 ST; AGE TRANSDERMAL dextroamphetamine 1 ST; AGE PATCH 24 HOUR oral solution 5 mg/5 10 MG/9 HR, 15 ml MG/9 HR, 20 MG/9 dextroamphetamine 1 ST; AGE HR, 30 MG/9 HR oral tablet 10 mg, 5 DESIPRAMINE 2 mg HCL (BULK) dextroamphetamine- 1 ST; AGE POWDER amphetamine oral desipramine oral 1 capsule,extended tablet 10 mg, 100 release 24hr 10 mg, mg, 150 mg, 25 mg, 15 mg, 20 mg, 25 50 mg, 75 mg mg, 30 mg, 5 mg desvenlafaxine 1 ST; AGE; QL dextroamphetamine- 1 ST; AGE succinate oral tablet amphetamine oral extended release 24 tablet 10 mg, 12.5 hr 100 mg, 25 mg, mg, 15 mg, 20 mg, 50 mg 30 mg, 5 mg, 7.5 mg dexmedetomidine in 1 DIAZEPAM 2 0.9 % nacl (BULK) POWDER intravenous solution 100 % 200 mcg/50 ml (4 diazepam injection 1 mcg/ml), 400 solution 5 mg/ml mcg/100 ml (4 mcg/ml), 80 mcg/20 diazepam injection 1 ml (4 mcg/ml) syringe 5 mg/ml dexmedetomidine 1 diazepam intensol 1 intravenous solution oral concentrate 5 100 mcg/ml mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diazepam oral 1 escitalopram oxalate 1 QL solution 5 mg/5 ml oral tablet 10 mg, 20 (1 mg/ml) mg, 5 mg diazepam oral tablet 1 estazolam oral tablet 1 10 mg, 2 mg, 5 mg 1 mg, 2 mg doxapram 1 eszopiclone oral 1 QL intravenous solution tablet 1 mg, 2 mg, 3 20 mg/ml mg DOXEPIN HCL 2 FETZIMA ORAL 2 ST; AGE; QL (BULK) POWDER CAPSULE,EXT doxepin oral capsule 1 REL 24HR DOSE 10 mg, 100 mg, 25 PACK 20 MG (2)- mg, 50 mg, 75 mg 40 MG (26) doxepin oral 1 FETZIMA ORAL 2 ST; AGE; QL concentrate 10 CAPSULE,EXTEN mg/ml DED RELEASE 24 HR 120 MG, 20 doxepin oral tablet 3 1 ST; AGE; QL MG, 40 MG, 80 MG mg, 6 mg flumazenil 1 DOXYLAMINE 2 intravenous solution SUCCINATE 0.1 mg/ml (BULK) POWDER FLUOXETINE 2 duloxetine oral 1 QL (BULK) POWDER capsule,delayed 100 % release(dr/ec) 20 fluoxetine oral mg, 30 mg, 60 mg 1 QL capsule 10 mg, 40 duloxetine oral 1 ST; AGE; QL mg capsule,delayed fluoxetine oral release(dr/ec) 40 mg 1 capsule 20 mg DYANAVEL XR 2 ST; AGE fluoxetine oral ORAL SUSPEN, IR 1 QL capsule,delayed - ER, BIPHASIC release(dr/ec) 90 mg 24HR 2.5 MG/ML fluoxetine oral ERGOLOID 2 1 solution 20 mg/5 ml (BULK) POWDER (4 mg/ml) 100 % fluoxetine oral tablet ergoloid oral tablet 1 1 ST; QL 10 mg 1 mg fluoxetine oral tablet escitalopram oxalate 1 1 ST 20 mg, 60 mg oral solution 5 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUPHENAZINE 2 haloperidol 1 DECANOATE decanoate (BULK) OIL 2.5 % intramuscular (W/W) solution 100 mg/ml, 50 mg/ml fluphenazine 1 decanoate injection haloperidol lactate 1 solution 25 mg/ml injection solution 5 mg/ml fluphenazine hcl 1 injection solution 2.5 haloperidol lactate 1 mg/ml intramuscular syringe 5 mg/ml fluphenazine hcl oral 1 concentrate 5 mg/ml haloperidol lactate 1 oral concentrate 2 fluphenazine hcl oral 1 mg/ml elixir 2.5 mg/5 ml haloperidol oral fluphenazine hcl oral 1 1 tablet 0.5 mg, 1 mg, tablet 1 mg, 10 mg, 10 mg, 2 mg, 20 mg, 2.5 mg, 5 mg 5 mg flurazepam oral 1 capsule 15 mg, 30 IMIPRAMINE 2 mg (BULK) POWDER 100 % fluvoxamine oral 1 ST; QL capsule,extended imipramine hcl oral 1 tablet 10 mg, 25 mg, release 24hr 100 mg, 50 mg 150 mg imipramine pamoate fluvoxamine oral 1 QL 1 oral capsule 100 mg, tablet 100 mg, 25 125 mg, 150 mg, 75 mg, 50 mg mg guanfacine oral 1 ST; AGE tablet extended LATUDA ORAL 2 QL release 24 hr 1 mg, 2 TABLET 120 MG, mg, 3 mg, 4 mg 20 MG, 40 MG, 60 MG, 80 MG guanidine oral tablet 1 125 mg LITHIUM 2 CARBONATE HALOPERIDOL 2 (BULK) POWDER (BULK) POWDER 99 % HALOPERIDOL 2 lithium carbonate 1 DECANOATE oral capsule 150 mg, (BULK) POWDER 300 mg, 600 mg 100 % lithium carbonate 1 oral tablet 300 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lithium carbonate 1 methylphenidate hcl 1 ST; AGE oral tablet extended oral cap,er release 300 mg, 450 sprinkle,biphasic 40- mg 60 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, lithium citrate oral 1 50 mg, 60 mg solution 8 meq/5 ml methylphenidate hcl LITHIUM 2 1 ST; AGE oral capsule, er CITRATE biphasic 30-70 10 TETRAHYD(BULK mg, 20 mg, 30 mg, ) POWDER 100 % 40 mg, 50 mg, 60 mg LORAZEPAM 2 methylphenidate hcl (BULK) POWDER 1 ST; AGE oral capsule,er 100 % biphasic 50-50 10 lorazepam injection 1 mg, 20 mg, 30 mg, solution 2 mg/ml, 4 40 mg, 60 mg mg/ml methylphenidate hcl 1 ST; AGE lorazepam injection 1 oral solution 10 syringe 2 mg/ml, 4 mg/5 ml, 5 mg/5 ml mg/ml methylphenidate hcl 1 ST; AGE lorazepam intensol 1 oral tablet 10 mg, 20 oral concentrate 2 mg, 5 mg mg/ml methylphenidate hcl 1 ST; AGE lorazepam oral 1 oral tablet extended concentrate 2 mg/ml release 10 mg, 20 lorazepam oral 1 mg tablet 1 mg, 2 mg methylphenidate hcl 1 ST; AGE loxapine succinate 1 oral tablet extended oral capsule 10 mg, release 24hr 18 mg, 25 mg, 5 mg, 50 mg 27 mg, 36 mg, 54 mg maprotiline oral 1 methylphenidate hcl 1 ST; AGE tablet 25 mg, 50 mg, oral tablet,chewable 75 mg 10 mg, 2.5 mg, 5 mg metadate er oral 1 ST; AGE MIDAZOLAM 2 tablet extended (BULK) POWDER release 20 mg 100 % methamphetamine 1 ST; AGE midazolam (pf) in 1 oral tablet 5 mg 0.9 % nacl intravenous solution METHYLPHENID 2 1 mg/ml ATE HCL (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits midazolam (pf) 1 olanzapine oral 1 QL injection cartridge 2 tablet 10 mg, 15 mg, mg/2 ml (1 mg/ml), 5 2.5 mg, 20 mg, 5 mg, mg/ml 7.5 mg midazolam (pf) 1 olanzapine oral 1 QL injection syringe 2 tablet,disintegrating mg/2 ml (1 mg/ml), 5 10 mg, 15 mg, 20 mg/ml mg, 5 mg midazolam injection 1 olanzapine- 1 solution 1 mg/ml, 5 fluoxetine oral mg/ml capsule 12-25 mg, 12-50 mg, 3-25 mg, midazolam oral 1 6-25 mg, 6-50 mg syrup 2 mg/ml paliperidone oral mirtazapine oral 1 1 QL tablet extended tablet 15 mg, 30 mg, release 24hr 1.5 mg, 45 mg, 7.5 mg 3 mg, 6 mg, 9 mg mirtazapine oral 1 paroxetine hcl oral tablet,disintegrating 1 QL tablet 10 mg, 20 mg, 15 mg, 30 mg, 45 mg 30 mg, 40 mg modafinil oral tablet 1 PA; QL paroxetine hcl oral 100 mg, 200 mg 1 ST; QL tablet extended molindone oral 1 release 24 hr 12.5 tablet 10 mg, 25 mg, mg, 25 mg, 37.5 mg 5 mg paroxetine 1 ST; QL MYDAYIS ORAL 2 ST; AGE mesylate(menop.sym CAPSULE, ER ) oral capsule 7.5 TRIPHASIC 24 HR mg 12.5 MG, 25 MG, 37.5 MG, 50 MG PENTOBARBITAL 2 SODIUM (BULK) NORTRIPTYLINE 2 POWDER 100 % (BULK) POWDER pentobarbital 1 nortriptyline oral 1 sodium injection capsule 10 mg, 25 solution 50 mg/ml mg, 50 mg, 75 mg perphenazine oral 1 nortriptyline oral 1 tablet 16 mg, 2 mg, 4 solution 10 mg/5 ml mg, 8 mg olanzapine 1 intramuscular recon soln 10 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits perphenazine- 1 ramelteon oral tablet 1 QL amitriptyline oral 8 mg tablet 2-10 mg, 2-25 RISPERDAL 2 mg, 4-10 mg, 4-25 CONSTA mg, 4-50 mg INTRAMUSCULA PHENELZINE 2 R (BULK) POWDER SUSPENSION,EXT 100 % ENDED REL phenelzine oral 1 RECON 12.5 MG/2 tablet 15 mg ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 pimozide oral tablet 1 MG/2 ML 1 mg, 2 mg risperidone oral 1 procentra oral 1 ST; AGE solution 1 mg/ml solution 5 mg/5 ml risperidone oral 1 QL protriptyline oral 1 tablet 0.25 mg, 0.5 tablet 10 mg, 5 mg mg, 1 mg, 2 mg, 3 quazepam oral tablet 1 mg, 4 mg 15 mg risperidone oral 1 QL quetiapine oral 1 QL tablet,disintegrating tablet 100 mg, 200 0.25 mg, 0.5 mg, 1 mg, 25 mg, 300 mg, mg, 2 mg, 3 mg, 4 400 mg, 50 mg mg quetiapine oral 1 QL seconal sodium oral 1 QL tablet extended capsule 100 mg release 24 hr 150 SERTRALINE 2 mg, 200 mg, 300 mg, (BULK) POWDER 400 mg, 50 mg 100 % QUILLICHEW ER 2 ST; AGE sertraline oral 1 ORAL concentrate 20 TABLET,CHEW,IR mg/ml - sertraline oral tablet ER.BIPHASIC24HR 1 QL 100 mg, 50 mg 20 MG, 30 MG, 40 MG SUNOSI ORAL 2 PA; QL QUILLIVANT XR 2 ST; AGE TABLET 150 MG, ORAL 75 MG SUSPENSION,EXT THIORIDAZINE 2 REL 24HR,RECON (BULK) POWDER 5 MG/ML (25 MG/5 100 % ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits thioridazine oral 1 VYVANSE ORAL 2 ST; AGE tablet 10 mg, 100 TABLET,CHEWAB mg, 25 mg, 50 mg LE 10 MG, 20 MG, thiothixene oral 1 30 MG, 40 MG, 50 capsule 1 mg, 10 mg, MG, 60 MG 2 mg, 5 mg XYREM ORAL 2 ST; SP; QL tranylcypromine 1 SOLUTION 500 oral tablet 10 mg MG/ML TRAZODONE 2 XYWAV ORAL 2 ST; SP; QL (BULK) POWDER SOLUTION 0.5 GRAM/ML trazodone oral tablet 1 100 mg, 300 mg, 50 zaleplon oral 1 QL capsule 10 mg, 5 mg mg zenzedi oral tablet triazolam oral tablet 1 1 ST; AGE 10 mg, 5 mg 0.125 mg, 0.25 mg ziprasidone hcl oral trifluoperazine oral 1 1 QL capsule 20 mg, 40 tablet 1 mg, 10 mg, 2 mg, 60 mg, 80 mg mg, 5 mg ziprasidone mesylate trimipramine oral 1 1 intramuscular recon capsule 100 mg, 25 soln 20 mg/ml (final mg, 50 mg conc.) venlafaxine oral 1 QL capsule,extended zolpidem oral tablet 1 QL 10 mg, 5 mg release 24hr 150 mg, 37.5 mg, 75 mg zolpidem oral 1 QL tablet,ext release venlafaxine oral 1 QL multiphase 12.5 mg, tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 6.25 mg 75 mg zolpidem sublingual 1 QL tablet 1.75 mg, 3.5 venlafaxine oral 1 ST; AGE; QL tablet extended mg release 24hr 150 mg, ZULRESSO 2 PA; SP 225 mg, 37.5 mg, 75 INTRAVENOUS mg SOLUTION 5 VYVANSE ORAL 2 ST; AGE MG/ML CAPSULE 10 MG, CARDIOVASCULAR, 60 MG HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits adenosine 1 lidocaine (pf) 1 (diagnostic) intravenous solution intravenous solution 20 mg/ml (2 %) 3 mg/ml lidocaine (pf) 1 adenosine 1 intravenous syringe intravenous solution 100 mg/5 ml (2 %), 3 mg/ml 50 mg/5 ml (1 %) adenosine 1 lidocaine in 5 % 1 intravenous syringe dextrose (pf) 3 mg/ml intravenous parenteral solution 4 amiodarone in 1 dextrose 5 % mg/ml (0.4 %), 8 mg/ml (0.8 %) intravenous solution 450 mg/250 ml (1.8 MEXILETINE 2 mg/ml) (BULK) POWDER amiodarone 1 100 % intravenous solution mexiletine oral 1 50 mg/ml capsule 150 mg, 200 mg, 250 mg amiodarone 1 intravenous syringe NEXTERONE 2 150 mg/3 ml INTRAVENOUS amiodarone oral 1 SOLUTION 150 tablet 100 mg, 200 MG/100 ML (1.5 mg, 400 mg MG/ML), 360 MG/200 ML (1.8 bretylium tosylate 1 MG/ML) injection solution 50 pacerone oral tablet mg/ml 1 100 mg, 200 mg, 400 dofetilide oral 1 mg capsule 125 mcg, 250 mcg, 500 mcg PROCAINAMIDE 2 HCL (BULK) flecainide oral tablet 1 POWDER 100 mg, 150 mg, 50 procainamide mg 1 injection solution ibutilide fumarate 1 100 mg/ml, 500 intravenous solution mg/ml 0.1 mg/ml propafenone oral 1 lidocaine (pf) in 1 capsule,extended d7.5w intrathecal release 12 hr 225 solution 50 mg/ml (5 mg, 325 mg, 425 mg %)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits propafenone oral 1 amiloride- 1 tablet 150 mg, 225 hydrochlorothiazide mg, 300 mg oral tablet 5-50 mg QUINIDINE 2 AMLODIPINE 2 SULFATE (BULK) BESYLATE CRYSTALS (BULK) POWDER QUINIDINE 2 100 % SULFATE (BULK) amlodipine oral 1 POWDER 100 % tablet 10 mg, 2.5 mg, 5 mg quinidine sulfate 1 oral tablet 200 mg, amlodipine- 1 300 mg benazepril oral capsule 10-20 mg, sorine oral tablet 1 120 mg, 160 mg, 240 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 80 mg mg, 5-40 mg sotalol af oral tablet 1 120 mg, 160 mg, 80 amlodipine- 1 olmesartan oral mg tablet 10-20 mg, 10- SOTALOL 2 40 mg, 5-20 mg, 5- INTRAVENOUS 40 mg SOLUTION 150 amlodipine- MG/10 ML (15 1 valsartan oral tablet MG/ML) 10-160 mg, 10-320 sotalol oral tablet 1 mg, 5-160 mg, 5-320 120 mg, 160 mg, 240 mg mg, 80 mg amlodipine- 1 SOTYLIZE ORAL 2 valsartan-hcthiazid SOLUTION 5 oral tablet 10-160- MG/ML 12.5 mg, 10-160-25 mg, 10-320-25 mg, ANTIHYPERTENSIVE THERAPY 5-160-12.5 mg, 5- ACEBUTOLOL 2 160-25 mg (BULK) POWDER ATENOLOL 2 acebutolol oral 1 (BULK) POWDER capsule 200 mg, 400 100 % mg atenolol oral tablet 1 aliskiren oral tablet 1 100 mg, 25 mg, 50 150 mg, 300 mg mg amiloride oral tablet 1 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits atenolol- 1 candesartan- 1 chlorthalidone oral hydrochlorothiazid tablet 100-25 mg, oral tablet 16-12.5 50-25 mg mg, 32-12.5 mg, 32- 25 mg BENAZEPRIL HCL 2 (BULK) POWDER CAPTOPRIL 2 100 % (BULK) POWDER benazepril oral 1 100 % tablet 10 mg, 20 mg, captopril oral tablet 1 40 mg, 5 mg 100 mg, 12.5 mg, 25 mg, 50 mg benazepril- 1 hydrochlorothiazide captopril- 1 oral tablet 10-12.5 hydrochlorothiazide mg, 20-12.5 mg, 20- oral tablet 25-15 mg, 25 mg, 5-6.25 mg 25-25 mg, 50-15 mg, 50-25 mg BETAHISTINE 2 (BULK) POWDER cartia xt oral 1 100 % capsule,extended release 24hr 180 mg, betaxolol oral tablet 1 240 mg, 300 mg 10 mg, 20 mg carvedilol oral tablet bisoprolol fumarate 1 1 12.5 mg, 25 mg, oral tablet 10 mg, 5 3.125 mg, 6.25 mg mg chlorothiazide oral bisoprolol- 1 1 hydrochlorothiazide tablet 500 mg oral tablet 10-6.25 chlorothiazide 1 mg, 2.5-6.25 mg, 5- sodium intravenous 6.25 mg recon soln 500 mg bumetanide injection 1 chlorthalidone oral 1 solution 0.25 mg/ml tablet 25 mg, 50 mg bumetanide oral 1 clonidine (pf) 1 tablet 0.5 mg, 1 mg, epidural solution 2 mg 1,000 mcg/10 ml (100 mcg/ml) BYSTOLIC ORAL 2 PA TABLET 5 MG CLONIDINE HCL 2 candesartan oral 1 (BULK) POWDER tablet 16 mg, 32 mg, clonidine hcl oral 1 4 mg, 8 mg tablet 0.1 mg, 0.2 mg, 0.3 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clonidine 1 QL diltiazem hcl oral 1 transdermal patch tablet extended weekly 0.1 mg/24 hr, release 24 hr 180 0.2 mg/24 hr, 0.3 mg, 240 mg, 300 mg, mg/24 hr 360 mg, 420 mg corlopam 1 dilt-xr oral 1 intravenous solution capsule,ext.rel 24h 10 mg/ml degradable 120 mg, 180 mg, 240 mg CYCLANDELATE 2 (BULK) POWDER doxazosin oral tablet 1 QL 1 mg, 2 mg, 4 mg, 8 DILTIAZEM HCL 2 mg (BULK) POWDER diltiazem hcl 1 ENALAPRIL 2 intravenous recon MALEATE (BULK) soln 100 mg POWDER 100 % enalapril maleate diltiazem hcl 1 1 oral tablet 10 mg, intravenous solution 2.5 mg, 20 mg, 5 mg 5 mg/ml enalaprilat diltiazem hcl oral 1 1 capsule,ext.rel 24h intravenous solution 1.25 mg/ml degradable 120 mg, 180 mg, 240 mg enalapril- 1 hydrochlorothiazide diltiazem hcl oral 1 capsule,extended oral tablet 10-25 mg, 5-12.5 mg release 12 hr 120 mg, 60 mg, 90 mg eplerenone oral 1 tablet 25 mg, 50 mg diltiazem hcl oral 1 capsule,extended epoprostenol 1 PA; SP release 24 hr 120 (glycine) mg, 180 mg, 240 mg, intravenous recon 300 mg, 360 mg, 420 soln 0.5 mg, 1.5 mg mg epoprostenol 1 PA; SP diltiazem hcl oral 1 intravenous recon capsule,extended soln 0.5 mg, 1.5 mg release 24hr 120 mg, eprosartan oral 1 180 mg, 240 mg, 300 tablet 600 mg mg, 360 mg diltiazem hcl oral 1 tablet 120 mg, 30 mg, 60 mg, 90 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits esmolol in nacl (iso- 1 furosemide oral 1 osm) intravenous solution 10 mg/ml, parenteral solution 40 mg/5 ml (8 2,000 mg/100 ml, mg/ml) 2,500 mg/250 ml (10 furosemide oral 1 mg/ml) tablet 20 mg, 40 mg, esmolol intravenous 1 80 mg solution 100 mg/10 GUANABENZ 2 ml (10 mg/ml) (BULK) POWDER esmolol intravenous 1 100 % syringe 100 mg/10 GUANETHIDINE 2 ml (10 mg/ml) SULFATE (BULK) ethacrynate sodium 1 POWDER intravenous recon guanfacine oral 1 soln 50 mg tablet 1 mg, 2 mg ethacrynic acid oral 1 HYDRALAZINE 2 tablet 25 mg HCL (BULK) felodipine oral tablet 1 POWDER extended release 24 hydralazine injection 1 hr 10 mg, 2.5 mg, 5 solution 20 mg/ml mg hydralazine oral 1 FLOLAN 2 PA; SP tablet 10 mg, 100 INTRAVENOUS mg, 25 mg, 50 mg RECON SOLN 0.5 MG, 1.5 MG HYDROCHLOROT 2 HIAZIDE (BULK) fosinopril oral tablet 1 POWDER 100 % 10 mg, 20 mg, 40 mg hydrochlorothiazide 1 fosinopril- 1 oral capsule 12.5 mg hydrochlorothiazide oral tablet 10-12.5 hydrochlorothiazide 1 mg, 20-12.5 mg oral tablet 12.5 mg, 25 mg, 50 mg FUROSEMIDE 2 (BULK) POWDER indapamide oral 1 tablet 1.25 mg, 2.5 furosemide injection 1 mg solution 10 mg/ml irbesartan oral 1 furosemide injection 1 tablet 150 mg, 300 syringe 10 mg/ml mg, 75 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits irbesartan- 1 mannitol 10 % 1 hydrochlorothiazide intravenous oral tablet 150-12.5 parenteral solution mg, 300-12.5 mg 10 % isradipine oral 1 mannitol 20 % 1 capsule 2.5 mg, 5 mg intravenous parenteral solution LABETALOL 2 20 % (BULK) POWDER mannitol 25 % labetalol 1 1 intravenous solution intravenous solution 25 % 5 mg/ml mannitol 5 % labetalol 1 1 intravenous intravenous syringe 20 mg/4 ml (5 parenteral solution 5 mg/ml), 25 mg/5 ml % (5 mg/ml) matzim la oral tablet 1 extended release 24 labetalol oral tablet 1 100 mg, 200 mg, 300 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg mg LISINOPRIL 2 methyldopa oral (BULK) POWDER 1 tablet 250 mg, 500 100 % mg lisinopril oral tablet 1 10 mg, 2.5 mg, 20 methyldopa- 1 mg, 30 mg, 40 mg, 5 hydrochlorothiazide oral tablet 250-15 mg mg, 250-25 mg lisinopril- 1 hydrochlorothiazide methyldopate 1 intravenous solution oral tablet 10-12.5 mg, 20-12.5 mg, 20- 250 mg/5 ml 25 mg metolazone oral 1 tablet 10 mg, 2.5 mg, losartan oral tablet 1 100 mg, 25 mg, 50 5 mg mg metoprolol succinate 1 oral tablet extended losartan- 1 hydrochlorothiazide release 24 hr 100 mg, 200 mg, 25 mg, oral tablet 100-12.5 mg, 100-25 mg, 50- 50 mg 12.5 mg MANNITOL 2 (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits metoprolol ta- 1 nifedipine oral tablet 1 hydrochlorothiaz extended release oral tablet 100-25 24hr 30 mg, 60 mg, mg, 100-50 mg, 50- 90 mg 25 mg nifedipine oral tablet 1 METOPROLOL 2 extended release 30 TARTRATE mg, 60 mg, 90 mg (BULK) POWDER nimodipine oral 1 100 % capsule 30 mg metoprolol tartrate 1 nisoldipine oral 1 intravenous solution tablet extended 5 mg/5 ml release 24 hr 17 mg, metoprolol tartrate 1 20 mg, 25.5 mg, 30 oral tablet 100 mg, mg, 34 mg, 40 mg, 25 mg, 37.5 mg, 50 8.5 mg mg, 75 mg NYLIDRIN (BULK) 2 metyrosine oral 1 PA POWDER 100 % capsule 250 mg olmesartan oral 1 MINOXIDIL 2 tablet 20 mg, 40 mg, (BULK) POWDER 5 mg minoxidil oral tablet 1 olmesartan- 1 10 mg, 2.5 mg amlodipin-hcthiazid oral tablet 20-5-12.5 moexipril oral tablet 1 mg, 40-10-12.5 mg, 15 mg, 7.5 mg 40-10-25 mg, 40-5- NADOLOL (BULK) 2 12.5 mg, 40-5-25 mg POWDER olmesartan- 1 nadolol oral tablet 1 hydrochlorothiazide 20 mg, 40 mg, 80 mg oral tablet 20-12.5 nadolol- 1 mg, 40-12.5 mg, 40- bendroflumethiazide 25 mg oral tablet 80-5 mg osmitrol 15 % 1 nicardipine 1 intravenous intravenous solution parenteral solution 25 mg/10 ml 15 % nicardipine oral 1 osmitrol 20 % 1 capsule 20 mg, 30 intravenous mg parenteral solution 20 % NIFEDIPINE 2 (BULK) POWDER PAPAVERINE 2 (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits papaverine injection 1 propranolol- 1 solution 30 mg/ml hydrochlorothiazid oral tablet 40-25 mg, perindopril 1 80-25 mg erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 1 10 mg, 20 mg, 40 PHENOXYBENZA 2 mg, 5 mg MINE (BULK) POWDER quinapril- 1 hydrochlorothiazide phenoxybenzamine 1 PA oral tablet 10-12.5 oral capsule 10 mg mg, 20-12.5 mg, 20- phentolamine 1 25 mg injection recon soln ramipril oral 5 mg 1 capsule 1.25 mg, 10 PHENTOLAMINE 2 mg, 2.5 mg, 5 mg MESYLATE (BULK) POWDER RESERPINE 2 (BULK) POWDER pindolol oral tablet 1 100 % 10 mg, 5 mg SODIUM NITRITE 2 prazosin oral 1 (BULK) capsule 1 mg, 2 mg, GRANULES 5 mg SPIRONOLACTON 2 PROPRANOLOL 2 E (BULK) (BULK) POWDER POWDER 100 % propranolol 1 SPIRONOLACTON 2 intravenous solution E MICRO (BULK) 1 mg/ml POWDER 100 % propranolol oral 1 spironolactone oral 1 capsule,extended tablet 100 mg, 25 release 24 hr 120 mg, 50 mg mg, 160 mg, 60 mg, spironolacton- 80 mg 1 hydrochlorothiaz propranolol oral 1 oral tablet 25-25 mg solution 20 mg/5 ml (4 mg/ml), 40 mg/5 taztia xt oral 1 capsule,extended ml (8 mg/ml) release 24 hr 120 propranolol oral 1 mg, 180 mg, 240 mg, tablet 10 mg, 20 mg, 300 mg, 360 mg 40 mg, 60 mg, 80 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TEKTURNA HCT 2 trandolapril oral 1 ORAL TABLET tablet 1 mg, 2 mg, 4 150-12.5 MG, 150- mg 25 MG, 300-12.5 trandolapril- 1 MG, 300-25 MG verapamil oral telmisartan oral 1 tablet, ir - er, tablet 20 mg, 40 mg, biphasic 24hr 1-240 80 mg mg, 2-180 mg, 2-240 mg, 4-240 mg telmisartan- 1 amlodipine oral treprostinil sodium 1 PA; SP tablet 40-10 mg, 40- injection solution 1 5 mg, 80-10 mg, 80- mg/ml, 10 mg/ml, 2.5 5 mg mg/ml, 5 mg/ml telmisartan- 1 TRIAMTERENE 2 hydrochlorothiazid (BULK) POWDER oral tablet 40-12.5 triamterene oral 1 mg, 80-12.5 mg, 80- capsule 100 mg, 50 25 mg mg terazosin oral 1 QL triamterene- 1 capsule 1 mg, 10 mg, hydrochlorothiazid 2 mg, 5 mg oral capsule 37.5-25 tiadylt er oral 1 mg capsule,extended triamterene- 1 release 24 hr 120 hydrochlorothiazid mg, 180 mg, 240 mg, oral tablet 37.5-25 300 mg, 360 mg, 420 mg mg TRICHLORMETHI 2 TIMOLOL 2 AZIDE (BULK) MALEATE (BULK) POWDER 100 % POWDER 100 % UPTRAVI ORAL 2 PA; SP timolol maleate oral 1 TABLET 1,000 tablet 10 mg, 20 mg, MCG, 1,200 MCG, 5 mg 1,400 MCG, 1,600 TOLAZOLINE 2 MCG, 200 MCG, (BULK) POWDER 400 MCG, 600 100 % MCG, 800 MCG torsemide oral tablet 1 UPTRAVI ORAL 2 PA; SP 10 mg, 100 mg, 20 TABLETS,DOSE mg, 5 mg PACK 200 MCG (140)- 800 MCG (60)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits valsartan oral tablet 1 digox oral tablet 125 1 160 mg, 320 mg, 40 mcg (0.125 mg), 250 mg, 80 mg mcg (0.25 mg) valsartan- 1 digoxin injection 1 hydrochlorothiazide solution 250 mcg/ml oral tablet 160-12.5 (0.25 mg/ml) mg, 160-25 mg, 320- digoxin injection 1 12.5 mg, 320-25 mg, syringe 250 mcg/ml 80-12.5 mg (0.25 mg/ml) veletri intravenous 1 PA; SP digoxin oral solution 1 recon soln 0.5 mg, 50 mcg/ml (0.05 1.5 mg mg/ml) VERAPAMIL 2 digoxin oral tablet 1 (BULK) POWDER 125 mcg (0.125 mg), 100 % 250 mcg (0.25 mg) verapamil 1 LANOXIN 2 intravenous solution PEDIATRIC 2.5 mg/ml INJECTION verapamil 1 SOLUTION 100 intravenous syringe MCG/ML (0.1 2.5 mg/ml MG/ML) verapamil oral 1 COAGULATION THERAPY capsule, 24 hr er ADVATE 2 PA; SP pellet ct 100 mg, 200 INTRAVENOUS mg, 300 mg RECON SOLN verapamil oral 1 1,000 (+/-) UNIT, capsule,ext rel. 1,500 (+/-) UNIT, pellets 24 hr 120 mg, 2,000 (+/-) UNIT, 180 mg, 240 mg, 360 250 (+/-) UNIT, mg 3,000 (+/-) UNIT, verapamil oral tablet 1 4,000 (+/-) UNIT, 120 mg, 40 mg, 80 500 (+/-) UNIT mg ADYNOVATE 2 PA; SP verapamil oral tablet 1 INTRAVENOUS extended release 120 SOLUTION 1,000 mg, 180 mg, 240 mg (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 CARDIAC GLYCOSIDES (+/-) UNIT, 250 (+/- digitek oral tablet 1 ) UNIT, 3,000 (+/-) 125 mcg (0.125 mg), UNIT, 500 (+/-) 250 mcg (0.25 mg) UNIT, 750 (+/-) UNIT You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AFSTYLA 2 PA; SP aminocaproic acid 1 INTRAVENOUS intravenous solution RECON SOLN 250 mg/ml 1,000 (+/-) UNIT aminocaproic acid 1 RANGE, 1,500 (+/-) oral solution 250 UNIT RANGE, mg/ml (25 %) 2,000 (+/-) UNIT RANGE, 2,500 (+/-) aminocaproic acid 1 UNIT RANGE, 250 oral tablet 1,000 mg, (+/-) UNIT RANGE, 500 mg 3,000 (+/-) UNIT aspirin-dipyridamole 1 RANGE, 500 (+/-) oral capsule, er UNIT RANGE multiphase 12 hr 25- ALPHANATE 2 PA; SP 200 mg INTRAVENOUS BENEFIX 2 PA; SP RECON SOLN INTRAVENOUS 1,000 (400 VWF) RECON SOLN UNIT/10 ML, 1,500 1,000 UNIT, 2,000 (600 VWF) UNIT, 250 UNIT, UNIT/10 ML, 2,000 3,000 UNIT, 500 (800 VWF) UNIT UNIT/10 ML, 250 (100 VWF) UNIT/5 bivalirudin 1 ML, 500 (200 VWF) intravenous recon UNIT/5 ML soln 250 mg ALPHANINE SD 2 PA; SP BRILINTA ORAL 2 INTRAVENOUS TABLET 60 MG, 90 RECON SOLN MG 1,000 (+/-) UNIT, CABLIVI 2 PA; SP 1,500 (+/-) UNIT, INJECTION KIT 11 500 (+/-) UNIT MG ALPROLIX 2 PA; SP CEPROTIN (BLUE 2 PA; SP INTRAVENOUS BAR) RECON SOLN INTRAVENOUS 1,000 UNIT, 2,000 RECON SOLN 500 UNIT, 250 UNIT, UNIT 3,000 UNIT, 4,000 CEPROTIN 2 PA; SP UNIT, 500 UNIT (GREEN BAR) AMINOCAPROIC 2 INTRAVENOUS ACID (BULK) RECON SOLN POWDER 100 % 1,000 UNIT cilostazol oral tablet 1 100 mg, 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clopidogrel oral 1 ELOCTATE 2 PA; SP tablet 300 mg, 75 mg INTRAVENOUS COAGADEX 2 PA; SP RECON SOLN INTRAVENOUS 1,000 UNIT, 1,500 RECON SOLN 250 UNIT, 2,000 UNIT, (+/-) UNIT RANGE, 250 UNIT, 3,000 500 (+/-) UNIT UNIT, 4,000 UNIT, RANGE 5,000 UNIT, 500 UNIT, 6,000 UNIT, CORIFACT 2 PA; SP 750 UNIT INTRAVENOUS enoxaparin RECON SOLN 1 SP subcutaneous 1,000-1,600 UNIT solution 300 mg/3 ml DICUMAROL 2 enoxaparin (BULK) POWDER 1 SP subcutaneous DIPYRIDAMOLE 2 syringe 100 mg/ml, (BULK) POWDER 120 mg/0.8 ml, 150 100 % mg/ml, 30 mg/0.3 ml, dipyridamole 1 40 mg/0.4 ml, 60 intravenous solution mg/0.6 ml, 80 mg/0.8 5 mg/ml ml dipyridamole oral 1 eptifibatide 1 tablet 25 mg, 50 mg, intravenous solution 75 mg 0.75 mg/ml, 2 mg/ml DOPTELET (10 2 PA; SP; QL ESPEROCT 2 PA; SP TAB PACK) ORAL INTRAVENOUS TABLET 20 MG RECON SOLN 1,000 (+/-) UNIT, DOPTELET (15 2 PA; SP; QL 1,500 (+/-) UNIT, TAB PACK) ORAL 2,000 (+/-) UNIT, TABLET 20 MG 3,000 (+/-) UNIT, DOPTELET (30 2 PA; SP; QL 500 (+/-) UNIT TAB PACK) ORAL FEIBA NF 2 PA; SP TABLET 20 MG INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 700- 1,300 UNIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fondaparinux 1 SP HEMOFIL M MID 2 PA; SP subcutaneous INTRAVENOUS syringe 10 mg/0.8 RECON SOLN 401- ml, 2.5 mg/0.5 ml, 5 800 UNIT mg/0.4 ml, 7.5 HEMOFIL M 2 PA; SP mg/0.6 ml SUPER HIGH FRAGMIN 2 SP INTRAVENOUS SUBCUTANEOUS RECON SOLN SOLUTION 25,000 1,501-2,000 UNIT ANTI-XA hep flush-10 (pf) 1 UNIT/ML intravenous solution FRAGMIN 2 SP 10 unit/ml SUBCUTANEOUS HEPARIN 2 SYRINGE 10,000 (PORCINE) ANTI-XA (BULK) POWDER UNIT/ML, 12,500 180 UNIT/MG ANTI-XA UNIT/0.5 (USP) ML, 15,000 ANTI- XA UNIT/0.6 ML, heparin (porcine) in 1 18,000 ANTI-XA 5 % dex intravenous UNIT/0.72 ML, parenteral solution 2,500 ANTI-XA 20,000 unit/500 ml UNIT/0.2 ML, 5,000 (40 unit/ml), 25,000 ANTI-XA UNIT/0.2 unit/250 ml(100 ML, 7,500 ANTI- unit/ml), 25,000 XA UNIT/0.3 ML unit/500 ml (50 unit/ml) HEMLIBRA 2 PA; SP SUBCUTANEOUS heparin (porcine) in 1 SOLUTION 105 nacl (pf) intravenous MG/0.7 ML, 150 parenteral solution MG/ML, 30 1,000 unit/500 ml, MG/ML, 60 MG/0.4 2,000 unit/1,000 ml ML heparin (porcine) 1 HEMOFIL M HIGH 2 PA; SP injection cartridge INTRAVENOUS 5,000 unit/ml (1 ml) RECON SOLN 801- heparin (porcine) 1 1,500 UNIT injection solution HEMOFIL M LOW 2 PA; SP 1,000 unit/ml, INTRAVENOUS 10,000 unit/ml, RECON SOLN 220- 20,000 unit/ml, 400 UNIT 5,000 unit/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits heparin (porcine) 1 heparin, porcine (pf) 1 injection syringe intravenous syringe 5,000 unit/ml 1 unit/ml, 10 unit/ml, 100 unit/ml heparin 1 flush(porcine)- HUMATE-P 2 PA; SP 0.9nacl intravenous INTRAVENOUS kit 100 unit/ml RECON SOLN heparin lock flush 1 1,000-2,400 UNIT, (porcine) 250-600 UNIT, 500- intravenous solution 1,200 UNIT 10 unit/ml, 100 IXINITY 2 PA; SP unit/ml INTRAVENOUS heparin lock flush 1 RECON SOLN intravenous solution 1,000 UNIT, 1,500 10 unit/ml UNIT, 2,000 UNIT, 250 UNIT, 3,000 heparin lock flush 1 UNIT, 500 UNIT intravenous syringe jantoven oral tablet 10 unit/ml 1 1 mg, 10 mg, 2 mg, heparin 1 2.5 mg, 3 mg, 4 mg, lockflush(porcine)(pf 5 mg, 6 mg, 7.5 mg ) intravenous syringe 10 unit/ml, 100 JIVI 2 PA; SP unit/ml INTRAVENOUS RECON SOLN heparin(porcine) in 1 1,000 (+/-) UNIT, 0.45% nacl 2,000 (+/-) UNIT, intravenous 3,000 (+/-) UNIT, parenteral solution 500 (+/-) UNIT 25,000 unit/250 ml, 25,000 unit/500 ml KOGENATE FS 2 PA; SP INTRAVENOUS heparin, porcine (pf) 1 RECON SOLN injection solution 1,000 (+/-) UNIT, 1,000 unit/ml, 5,000 2,000 (+/-) UNIT, unit/0.5 ml 250 (+/-) UNIT, heparin, porcine (pf) 1 3,000 (+/-) UNIT, injection syringe 500 (+/-) UNIT 5,000 unit/0.5 ml heparin, porcine (pf) 1 intravenous solution 100 unit/ml (1 ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KOVALTRY 2 PA; SP pentoxifylline oral 1 INTRAVENOUS tablet extended RECON SOLN release 400 mg 1,000 (+/-) UNIT, PHYTONADIONE 2 2,000 (+/-) UNIT, (VIT K1) (BULK) 250 (+/-) UNIT, LIQUID 100 % 3,000 (+/-) UNIT, 500 (+/-) UNIT phytonadione 1 (vitamin k1) MONONINE 2 PA; SP injection solution 10 INTRAVENOUS mg/ml RECON SOLN 1,000 (+/-) UNIT PHYTONADIONE 2 (VITAMIN K1) NOVOEIGHT 2 PA; SP INJECTION INTRAVENOUS SYRINGE 1 MG/0.5 RECON SOLN ML 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, phytonadione 1 QL 2,000 (+/-) UNIT, (vitamin k1) oral 250 (+/-) UNIT, tablet 5 mg 3,000 (+/-) UNIT, prasugrel oral tablet 1 500 (+/-) UNIT 10 mg, 5 mg NOVOSEVEN RT 2 PA; SP PROFILNINE 2 PA; SP INTRAVENOUS INTRAVENOUS RECON SOLN 1 RECON SOLN MG (1,000 MCG), 2 1,000 (+/-) UNIT, MG (2,000 MCG), 5 1,500 (+/-) UNIT, MG (5,000 MCG), 8 500 (+/-) UNIT MG (8,000 MCG) PROMACTA 2 PA; SP NPLATE 2 PA; SP ORAL POWDER IN SUBCUTANEOUS PACKET 12.5 MG, RECON SOLN 125 25 MG MCG, 250 MCG, 500 MCG PROMACTA 2 PA; SP ORAL TABLET OBIZUR 2 SP 12.5 MG, 25 MG, 50 INTRAVENOUS MG, 75 MG RECON SOLN 500 (+/-) UNIT RANGE protamine 1 intravenous solution PENTOXIFYLLINE 2 10 mg/ml (BULK) POWDER 100 % PROTAMINE 2 SULFATE (BULK) POWDER 100 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RIASTAP 2 PA; SP WARFARIN 2 INTRAVENOUS (BULK) POWDER RECON SOLN 1 100 % GRAM (900MG- warfarin oral tablet 1 1,300MG) 1 mg, 10 mg, 2 mg, SEVENFACT 2 PA; SP 2.5 mg, 3 mg, 4 mg, INTRAVENOUS 5 mg, 6 mg, 7.5 mg RECON SOLN 1 WILATE 2 PA; SP MG (1,000 MCG), 5 INTRAVENOUS MG (5,000 MCG) RECON SOLN surgifoam topical 1 1,000-1,000 UNIT, sponge 12-7 mm 500-500 UNIT THROMBATE III 2 XARELTO DVT-PE 2 PA INTRAVENOUS TREAT 30D RECON SOLN 500 START ORAL (+/-) UNIT TABLETS,DOSE TRANEXAMIC 2 PACK 15 MG (42)- ACID (BULK) 20 MG (9) POWDER XARELTO ORAL 2 PA tranexamic acid 1 TABLET 10 MG, 15 intravenous solution MG, 2.5 MG, 20 1,000 mg/10 ml (100 MG mg/ml) LIPID/CHOLESTEROL LOWERING

TRETTEN 2 PA; SP AGENTS INTRAVENOUS amlodipine- 1 QL RECON SOLN atorvastatin oral 2,500 UNIT tablet 10-10 mg, 10- vitamin k injection 1 20 mg, 10-40 mg, solution 1 mg/0.5 ml 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5- vitamin k1 injection 1 40 mg, 5-10 mg, 5- solution 10 mg/ml 20 mg, 5-40 mg, 5- VITAMIN K1 2 80 mg LIQUID 100 % atorvastatin oral 1 ACA; QL VONVENDI 2 PA; SP tablet 10 mg, 20 mg INTRAVENOUS atorvastatin oral 1 QL RECON SOLN tablet 40 mg, 80 mg 1,300 (+/-) UNIT RANGE, 650 (+/-) cholestyramine (with 1 UNIT RANGE sugar) oral powder 4 gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cholestyramine (with 1 fenofibric acid 1 sugar) oral powder (choline) oral in packet 4 gram capsule,delayed release(dr/ec) 135 cholestyramine light 1 mg, 45 mg oral powder 4 gram fenofibric acid oral cholestyramine light 1 1 oral powder in tablet 105 mg, 35 mg packet 4 gram fluvastatin oral 1 ACA; QL capsule 20 mg, 40 colesevelam oral 1 mg powder in packet 3.75 gram fluvastatin oral 1 ACA; QL tablet extended colesevelam oral 1 release 24 hr 80 mg tablet 625 mg colestipol oral 1 GEMFIBROZIL 2 granules 5 gram (BULK) POWDER gemfibrozil oral colestipol oral 1 1 tablet 600 mg packet 5 gram icosapent ethyl oral colestipol oral tablet 1 1 PA capsule 1 gram 1 gram ezetimibe oral tablet 1 PA JUXTAPID ORAL 2 PA; SP 10 mg CAPSULE 10 MG, 20 MG, 30 MG, 40 ezetimibe- 1 QL MG, 5 MG, 60 MG simvastatin oral tablet 10-10 mg, 10- LIPOFEN ORAL 2 20 mg, 10-40 mg, CAPSULE 150 MG, 10-80 mg 50 MG fenofibrate 1 LIVALO ORAL 2 ST; QL micronized oral TABLET 1 MG, 2 capsule 130 mg, 134 MG, 4 MG mg, 200 mg, 43 mg, lovastatin oral tablet 1 ACA; QL 67 mg 10 mg, 20 mg, 40 mg fenofibrate 1 NEXLETOL ORAL 2 PA nanocrystallized TABLET 180 MG oral tablet 145 mg, NEXLIZET ORAL 2 PA 48 mg TABLET 180-10 fenofibrate oral 1 ST MG tablet 120 mg, 40 mg NIACIN (BULK) 2 fenofibrate oral 1 POWDER tablet 160 mg, 54 mg niacin oral tablet 1 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits niacin oral tablet 1 simvastatin oral 1 ACA; QL extended release 24 tablet 10 mg, 20 mg, hr 1,000 mg, 500 40 mg, 5 mg mg, 750 mg simvastatin oral 1 QL NIACINAMIDE 2 tablet 80 mg (BULK) POWDER VASCEPA ORAL 2 PA 100 % CAPSULE 0.5 omega-3 acid ethyl 1 PA GRAM, 1 GRAM esters oral capsule 1 MISCELLANEOUS gram CARDIOVASCULAR AGENTS pravastatin oral 1 ACA; QL tablet 10 mg, 20 mg, ACTIVASE 2 40 mg, 80 mg INTRAVENOUS RECON SOLN 100 prevalite oral 1 MG, 50 MG powder 4 gram cardioplegic soln 1 prevalite oral 1 perfusion solution 16 powder in packet 4 meq/l (= k+) gram CATHFLO 2 REPATHA 2 PA ACTIVASE PUSHTRONEX INTRA- SUBCUTANEOUS CATHETER WEARABLE RECON SOLN 2 INJECTOR 420 MG MG/3.5 ML CORLANOR ORAL 2 PA REPATHA 2 PA SOLUTION 5 MG/5 SURECLICK ML SUBCUTANEOUS PEN INJECTOR CORLANOR ORAL 2 PA 140 MG/ML TABLET 5 MG, 7.5 MG REPATHA 2 PA dobutamine in d5w SYRINGE 1 intravenous SUBCUTANEOUS parenteral solution SYRINGE 140 1,000 mg/250 ml MG/ML (4,000 mcg/ml), 250 rosuvastatin oral 1 ACA; QL mg/250 ml (1 tablet 10 mg, 5 mg mg/ml), 500 mg/250 rosuvastatin oral 1 QL ml (2,000 mcg/ml) tablet 20 mg, 40 mg dobutamine 1 SIMVASTATIN 2 intravenous solution (BULK) POWDER 250 mg/20 ml (12.5 100 % mg/ml) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DOPAMINE 2 norepinephrine 1 (BULK) POWDER bitartrate intravenous solution dopamine in 5 % 1 dextrose intravenous 1 mg/ml solution 200 mg/250 norepinephrine 1 ml (800 mcg/ml), bitartrate-d5w 400 mg/250 ml intravenous solution (1,600 mcg/ml), 400 16 mg/250 ml (64 mg/500 ml (800 mcg/ml), 4 mg/250 mcg/ml), 800 ml (16 mcg/ml), 8 mg/250 ml (3,200 mg/250 ml (32 mcg/ml), 800 mcg/ml) mg/500 ml (1,600 norepinephrine 1 mcg/ml) bitartrate-nacl dopamine 1 intravenous solution intravenous solution 16 mg/250 ml (64 200 mg/5 ml (40 mcg/ml), 4 mg/250 mg/ml), 400 mg/10 ml (16 mcg/ml) ml (40 mg/ml), 400 phenylephrine hcl in 1 mg/5 ml (80 mg/ml), 0.9% nacl 800 mg/10 ml (80 intravenous solution mg/ml), 800 mg/5 ml 100 mg/250 ml (400 (160 mg/ml) mcg/ml), 25 mg/250 ENTRESTO ORAL 2 QL ml (100 mcg/ml), 40 TABLET 24-26 mg/250 ml (160 MG, 49-51 MG, 97- mcg/ml), 50 mg/250 103 MG ml (200 mcg/ml), 80 mg/250 ml (320 ephedrine sulfate 1 mcg/ml) intravenous solution 50 mg/ml phenylephrine hcl in 1 0.9% nacl isoproterenol hcl 1 intravenous syringe injection solution 0.2 20 mg/50 ml (400 mg/ml mcg/ml) milrinone in 5 % 1 dextrose intravenous phenylephrine hcl 1 injection solution 10 piggyback 20 mg/100 ml (200 mg/ml mcg/ml), 40 mg/200 ranolazine oral 1 ml (200 mcg/ml) tablet extended release 12 hr 1,000 milrinone 1 mg, 500 mg intravenous solution 1 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium nitroprusside 1 nitroglycerin in 5 % 1 intravenous solution dextrose intravenous 25 mg/ml solution 100 mg/250 ml (400 mcg/ml), VYNDAMAX 2 PA; SP 200 mg/500 ml (400 ORAL CAPSULE mcg/ml), 25 mg/250 61 MG ml (100 mcg/ml), 50 VYNDAQEL 2 PA; SP mg/250 ml (200 ORAL CAPSULE mcg/ml), 50 mg/500 20 MG ml (100 mcg/ml) NITRATES nitroglycerin 1 intravenous solution DILATRATE-SR 2 50 mg/10 ml (5 ORAL CAPSULE, mg/ml) EXTENDED RELEASE 40 MG nitroglycerin oral 1 capsule, extended ISOSORBIDE 2 release 2.5 mg, 6.5 (BULK) POWDER mg, 9 mg 98 % nitroglycerin isosorbide dinitrate 1 1 sublingual tablet 0.3 oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg, 0.4 mg, 0.6 mg mg nitroglycerin 1 transdermal patch isosorbide dinitrate 1 oral tablet extended 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 release 40 mg mg/hr, 0.6 mg/hr isosorbide 1 mononitrate oral nitroglycerin 1 translingual tablet 10 mg, 20 mg spray,non-aerosol isosorbide 1 400 mcg/spray mononitrate oral tablet extended nitro-time oral 1 capsule, extended release 24 hr 120 release 2.5 mg, 6.5 mg, 30 mg, 60 mg mg, 9 mg nitro-bid 1 transdermal DERMATOLOGICALS/TOPICA

ointment 2 % L THERAPY ANTIPSORIATIC /

ANTISEBORRHEIC acitretin oral 1 capsule 10 mg, 17.5 mg, 25 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTHRALIN 2 SELENIUM 2 (BULK) POWDER SULFIDE (BULK) CALCIPOTRIENE 2 POWDER 52-55.5 (BULK) POWDER % 100 % selenium sulfide 1 topical lotion 2.5 % calcipotriene scalp 1 QL solution 0.005 % selenium sulfide 1 topical shampoo calcipotriene topical 1 QL 2.25 %, 2.3 % cream 0.005 % calcipotriene topical 1 QL SKYRIZI 2 PA; SP; QL ointment 0.005 % SUBCUTANEOUS SYRINGE KIT calcipotriene- 1 ST; QL 150MG/1.66ML(75 betamethasone MG/0.83 ML X2) topical ointment 0.005-0.064 % STELARA 2 PA; SP; QL SUBCUTANEOUS calcipotriene- 1 QL SOLUTION 45 betamethasone MG/0.5 ML topical suspension 0.005-0.064 % STELARA 2 PA; SP; QL SUBCUTANEOUS calcitriol topical 1 SYRINGE 45 ointment 3 MG/0.5 ML, 90 mcg/gram MG/ML CHLOROXINE 2 sulfacetamide 1 (BULK) POWDER sodium topical 100 % cleanser 10 % COAL TAR 2 sulfacetamide 1 (BULK) TOPICAL sodium topical SOLUTION 20 % cleanser, gel 10 % COAL TAR 2 sulfacetamide 1 (CRUDE) (BULK) sodium topical SOLUTION shampoo 10 % COAL TAR 2 TALTZ 2 PA; SP; QL (CRUDE) (BULK) AUTOINJECTOR TAR (2 PACK) ENSTILAR 2 QL SUBCUTANEOUS TOPICAL FOAM AUTO-INJECTOR 0.005-0.064 % 80 MG/ML hydrocortisone- 1 pramoxine topical cream 2.5-1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TALTZ 2 PA; SP; QL RESORCINOL 2 AUTOINJECTOR (BULK) POWDER (3 PACK) SALICYLIC ACID 2 SUBCUTANEOUS (BULK) AUTO-INJECTOR CRYSTALS 80 MG/ML SALICYLIC ACID 2 TALTZ 2 PA; SP; QL (BULK) POWDER AUTOINJECTOR SUBCUTANEOUS SODIUM 2 AUTO-INJECTOR HYDROXIDE 80 MG/ML (BULK) SOLUTION 10 % TALTZ SYRINGE 2 PA; SP; QL SUBCUTANEOUS SULFUR 2 SYRINGE 80 SUBLIMED MG/ML (BULK) POWDER 100 % TREMFYA 2 PA; SP; QL SUBCUTANEOUS MISCELLANEOUS

AUTO-INJECTOR DERMATOLOGICALS 100 MG/ML ALLANTOIN 2 TREMFYA 2 PA; SP; QL (BULK) POWDER SUBCUTANEOUS ALUMINUM 2 SYRINGE 100 CHLORIDE MG/ML (BULK) POWDER BURN THERAPY AMINOBENZOIC 2 SILVER 2 ACID (BULK) SULFADIAZINE POWDER (BULK) POWDER AMMONIUM 2 100 % LACTATE (BULK) ssd topical cream 1 1 SOLUTION 70 % % ammonium lactate 1 OTC KERATOLYTICS topical cream 12 % PODOPHYLLUM 2 ammonium lactate 1 OTC RESIN (BULK) topical lotion 12 % POWDER BALSAM PERU 2 POTASSIUM 2 (BULK) LIQUID HYDROXIDE BENZALKONIUM 2 (BULK) PELLET CHLORIDE RESORCINOL 2 (BULK) (BULK) SOLUTION 50 % CRYSTALS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BENZETHONIUM 2 fluorouracil topical 1 CHLORIDE solution 2 %, 5 % (BULK) POWDER GUAIACOL 2 CALAMINE 2 LIQUID (BULK) POWDER HYDROQUINONE 2 CAMPHOR 2 (BULK) (BULK) CRYSTALS 100 % CRYSTALS ICHTHAMMOL 2 CANTHARIDIN 2 (BULK) LIQUID (BULK) POWDER 100 % CAPSAICIN 2 ICHTHAMMOL 2 (BULK) POWDER (BULK) POWDER CAPSICUM 2 IMIQUIMOD 2 OLEORESIN (BULK) POWDER (BULK) LIQUID 15 100 % % imiquimod topical 1 CHLORHEXIDINE 2 cream in packet 3.75 GLUCONATE %, 5 % (BULK) IODOFORM 2 SOLUTION 20 % (BULK) POWDER DICHLORACETIC 2 100 % ACID (BULK) MENTHOL 2 LIQUID 99 % (BULK) diclofenac sodium 1 PA; QL CRYSTALS topical gel 3 % METHOXSALEN 2 doxepin topical 1 ST; QL (BULK) cream 5 % CRYSTALS DUPIXENT PEN 2 PA; SP; QL METHOXSALEN 2 SUBCUTANEOUS (BULK) POWDER PEN INJECTOR methoxsalen oral 1 300 MG/2 ML capsule,liqd- DUPIXENT 2 PA; SP; QL filled,rapid rel 10 SYRINGE mg SUBCUTANEOUS methyl salicylate oil 1 SYRINGE 200 MG/1.14 ML, 300 MONOBENZONE 2 MG/2 ML (BULK) POWDER 100 % fluorouracil topical 1 cream 5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MONSEL'S 2 TACROLIMUS 2 TOPICAL (BULK) POWDER SOLUTION 0.2 TO 100 % 0.22 GRAM/ML tacrolimus topical 1 PA; QL IRON ointment 0.03 %, 0.1 MONSEL'S 2 % TOPICAL TANNIC ACID 2 SOLUTION WITH (BULK) POWDER APPLICATOR 0.2 TO 0.22 GRAM/ML TITANIUM 2 DIOXIDE (BULK) PICATO TOPICAL 2 LIQUID 30 % GEL 0.015 %, 0.05 % tri-chlor topical 1 solution 80 % pimecrolimus topical 1 PA; QL cream 1 % TRICHLOROACET 2 IC ACID (BULK) podofilox topical 1 CRYSTALS solution 0.5 % TRICHLOROACET 2 prudoxin topical 1 ST; QL IC ACID TOPICAL cream 5 % RECON SOLN 20 REGRANEX 2 QL %, 30 %, 35 %, 40 TOPICAL GEL 0.01 %, 50 %, 80 %, 85 % %, 90 % SAF-CLENS AF 2 UREA (BULK) 2 DERMAL WOUND BEADS 100 % TOPICAL UREA (BULK) 2 CLEANSER POWDER 100 % SILVER NITRATE 2 UVADEX 2 (BULK) INJECTION CRYSTALS SOLUTION 20 SILVER PROTEIN 2 MCG/ML MILD (BULK) VALCHLOR 2 PA; SP POWDER TOPICAL GEL skin treatment 1 OTC 0.016 % topical lotion 12 % wintergreen oil oil 1 SODIUM 2 WITCH HAZEL 2 HYALURONATE EXTRACT (BULK) (BULK) POWDER LIQUID 94 % ZINC OXIDE 2 (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZINC OXIDE 2 benzepro topical 1 TOPICAL PASTE towelette 6 % 25 % BENZOYL 2 THERAPY FOR ACNE PEROXIDE (BULK) POWDER accutane oral 1 65 TO 82 % capsule 20 mg, 30 mg, 40 mg benzoyl peroxide 1 topical cleanser 7 % adapalene topical 1 cream 0.1 % benzoyl peroxide 1 topical foam 5.3 %, adapalene topical 1 9.8 % gel 0.3 % bp 10-1 topical 1 ST adapalene topical 1 cleanser 10-1 % gel with pump 0.3 % bpo topical gel 4 %, 1 adapalene topical 1 8 % solution 0.1 % bpo topical towelette 1 adapalene topical 1 6 % swab 0.1 % claravis oral capsule 1 adapalene-benzoyl 1 10 mg, 20 mg, 30 peroxide topical gel mg, 40 mg with pump 0.1-2.5 % clindacin etz topical 1 amnesteem oral 1 swab 1 % capsule 10 mg, 20 mg, 40 mg clindacin p topical 1 swab 1 % AMZEEQ 2 ST TOPICAL FOAM 4 clindamycin 1 QL % phosphate topical foam 1 % avar topical cleanser 1 10-5 % (w/w) clindamycin 1 QL phosphate topical avita topical cream 1 gel 1 % 0.025 % clindamycin 1 QL AZELAIC ACID 2 phosphate topical (BULK) FLAKES lotion 1 % 100 %, 85 %, 88 % clindamycin 1 QL AZELAIC ACID 2 phosphate topical (BULK) POWDER solution 1 % 100 % clindamycin 1 azelaic acid topical 1 phosphate topical gel 15 % swab 1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clindamycin-benzoyl 1 metronidazole 1 peroxide topical gel topical gel with 1-5 %, 1.2 %(1 % pump 1 % base) -5 % metronidazole 1 clindamycin-benzoyl 1 topical lotion 0.75 % peroxide topical gel MIRVASO 2 PA with pump 1-5 %, TOPICAL GEL 1.2-2.5 % WITH PUMP 0.33 clindamycin- 1 % tretinoin topical gel myorisan oral 1 1.2-0.025 % capsule 10 mg, 20 dapsone topical gel 1 mg, 30 mg, 40 mg 5 % neuac topical gel 1.2 1 dapsone topical gel 1 %(1 % base) -5 % with pump 7.5 % ONEXTON 2 ST ery pads topical 1 TOPICAL GEL swab 2 % WITH PUMP 1.2 erygel topical gel 2 1 %(1 % BASE) -3.75 % % erythromycin with 1 RETINOIC ACID 2 ethanol topical gel 2 POWDER % rosadan topical 1 cream 0.75 % erythromycin with 1 ethanol topical rosadan topical gel 1 solution 2 % 0.75 % erythromycin- 1 rosula cleansing 1 benzoyl peroxide cloths topical pads, topical gel 3-5 % medicated 10-5 % FINACEA 2 ST sss 10-5 topical 1 TOPICAL FOAM cream 10-5 % (w/w) 15 % sss 10-5 topical 1 isotretinoin oral 1 foam 10-5 % capsule 10 mg, 20 sulfacetamide 1 mg, 30 mg, 40 mg sodium-sulfur metronidazole 1 topical cleanser 10-2 topical cream 0.75 %, 10-5 % (w/w), 9- % 4 %, 9-4.5 %, 9.8- 4.8 % metronidazole 1 topical gel 0.75 %, 1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sulfacetamide 1 tretinoin topical 1 sodium-sulfur cream 0.025 %, 0.05 topical cream 10-2 %, 0.1 % %, 10-5 % (w/w), tretinoin topical gel 1 9.8-4.8 % 0.01 %, 0.025 %, sulfacetamide 1 0.05 % sodium-sulfur zenatane oral 1 topical lotion 10-5 capsule 10 mg, 20 % (w/v), 10-5 % mg, 30 mg, 40 mg (w/w), 9.8-4.8 % TOPICAL ANESTHETICS sulfacetamide 1 sodium-sulfur BENZOCAINE 2 topical pads, (BULK) POWDER medicated 10-4 % BENZOCAINE 2 sulfacetamide 1 MICRONIZED sodium-sulfur (BULK) POWDER topical suspension 100 % 10-5 %, 8-4 % BUPIVACAINE 2 sulfacetamide- 1 (BULK) POWDER sulfur-cleansr23 100 % topical kit 9-4.5 % bupivacaine (pf) 1 sulfacleanse 8-4 1 ST injection solution topical suspension 8- 0.25 % (2.5 mg/ml), 4 % 0.5 % (5 mg/ml), 0.75 % (7.5 mg/ml) tazarotene topical 1 PA cream 0.1 % bupivacaine hcl 1 injection solution TAZORAC 2 PA 0.25 % (2.5 mg/ml), TOPICAL CREAM 0.5 % (5 mg/ml) 0.05 % bupivacaine- 1 TAZORAC 2 PA epinephrine (pf) TOPICAL GEL 0.05 injection solution %, 0.1 % 0.25 %-1:200,000, TRETINOIN 2 0.5 %-1:200,000 (BULK) POWDER bupivacaine- 1 tretinoin 1 epinephrine microspheres topical injection solution gel 0.04 %, 0.1 % 0.25 %-1:200,000, tretinoin 1 0.5 %-1:200,000 microspheres topical carbocaine (pf) 1 gel with pump 0.04 injection solution 15 %, 0.1 % mg/ml (1.5 %) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits chloroprocaine (pf) 1 lidocaine hcl mucous 1 QL injection solution 20 membrane jelly in mg/ml (2 %), 30 applicator 2 % mg/ml (3 %) lidocaine hcl mucous 1 COCAINE (BULK) 2 membrane solution 4 CRYSTALS 100 % % (40 mg/ml) DIBUCAINE HCL 2 lidocaine hcl(pf) in 1 (BULK) POWDER 0.9% nacl injection 100 % syringe 100 mg/10 ml (1 %) DYCLONINE HCL 2 (BULK) POWDER lidocaine hcl- 1 100 % hydrocortison ac topical cream 3-0.5 glydo mucous 1 QL membrane jelly in % applicator 2 % lidocaine in nacl,iso- 1 osmo(pf) injection LIDOCAINE 2 syringe 100 mg/10 (BULK) POWDER ml (1 %) lidocaine (pf) 1 lidocaine topical injection solution 10 1 ST mg/ml (1 %), 15 adhesive mg/ml (1.5 %), 20 patch,medicated 5 % mg/ml (2 %), 40 lidocaine topical 1 QL mg/ml (4 %), 5 ointment 5 % mg/ml (0.5 %) lidocaine viscous 1 lidocaine (pf) 1 mucous membrane injection syringe 50 solution 2 % mg/5 ml (1 %) lidocaine- 1 LIDOCAINE HCL 2 epinephrine (pf) (BULK) POWDER injection solution 1.5 100 % %-1:200,000, 2 %- 1:200,000 lidocaine hcl 1 injection solution 10 lidocaine- 1 mg/ml (1 %), 20 epinephrine mg/ml (2 %), 5 injection solution 0.5 mg/ml (0.5 %) %-1:200,000, 1 %- 1:100,000, 2 %- lidocaine hcl 1 laryngotracheal 1:100,000 solution 4 % lidocaine-prilocaine 1 QL topical cream 2.5- lidocaine hcl mucous 1 QL 2.5 % membrane jelly 2 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine-prilocaine 1 sensorcaine- 1 topical kit 2.5-2.5 % epinephrine injection solution lidocort topical 1 0.25 %-1:200,000, cream 3-0.5 % 0.5 %-1:200,000 lta pre-attached 1 laryngotracheal sensorcaine-mpf 1 injection solution 0.5 solution 4 % % (5 mg/ml) marcaine (pf) 1 injection solution SENSORCAINE- 2 0.75 % (7.5 mg/ml) MPF/EPINEPHRIN E INJECTION polocaine injection 1 SOLUTION 0.75 %- solution 1 % (10 1:200,000 mg/ml) TETRACAINE 2 POLOCAINE 2 (BULK) WAX 100 INJECTION % SOLUTION 2 % TETRACAINE 2 polocaine-mpf 1 HCL (BULK) injection solution 10 POWDER mg/ml (1 %), 15 mg/ml (1.5 %), 20 tetracaine hcl (pf) 1 injection solution 1 mg/ml (2 %) % (10 mg/ml) PRILOCAINE 2 xylocaine dental- (BULK) POWDER 1 epinephrine PROCAINE 2 injection cartridge 2 (BULK) %-1:100,000, 2 %- CRYSTALS 1:50,000 ropivacaine (pf) 1 ZTLIDO TOPICAL 2 ST injection solution 10 ADHESIVE mg/ml (1 %), 2 PATCH,MEDICAT mg/ml (0.2 %), 5 ED 1.8 % mg/ml (0.5 %), 7.5 mg/ml (0.75 %) TOPICAL ANTIBACTERIALS ROPIVACAINE 2 BACITRACIN ZN 2 HCL (BULK) MICRONIZED(BU POWDER 100 % LK) POWDER 40 UNIT/MG sensorcaine 1 injection solution 0.5 gentamicin topical 1 % (5 mg/ml) cream 0.1 % gentamicin topical 1 ointment 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lugols topical 1 ciclopirox topical 1 QL solution 5-10 % shampoo 1 % mafenide acetate 1 ciclopirox topical 1 topical packet 50 solution 8 % gram ciclopirox topical 1 QL MUPIROCIN 2 suspension 0.77 % (BULK) POWDER ciclopirox-ure- 1 100 % camph-menth-euc mupirocin topical 1 QL topical solution 8 % ointment 2 % CLOTRIMAZOLE 2 NITROFURAZONE 2 (BULK) POWDER (BULK) POWDER clotrimazole- 1 QL POVIDONE- 2 betamethasone IODINE (BULK) topical cream 1-0.05 POWDER 100 % % strong iodine topical 1 clotrimazole- 1 QL solution 5-10 % betamethasone topical lotion 1-0.05 sulfacetamide 1 sodium (acne) % topical suspension ECONAZOLE 2 10 % NITRATE (BULK) SULFAMYLON 2 POWDER TOPICAL CREAM econazole topical 1 QL 85 MG/G cream 1 % TRICLOSAN 2 GENTIAN VIOLET 2 (BULK) POWDER (BULK) 100 % CRYSTALS TOPICAL ANTIFUNGALS ketoconazole topical 1 QL cream 2 % ciclodan topical 1 QL cream 0.77 % ketoconazole topical 1 QL foam 2 % ciclodan topical 1 solution 8 % ketoconazole topical 1 QL shampoo 2 % CICLOPIROX 2 OLAMINE (BULK) ketodan kit topical 1 POWDER combo pack 2 % ciclopirox topical 1 QL ketodan topical foam 1 QL cream 0.77 % 2 % ciclopirox topical 1 QL gel 0.77 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MICONAZOLE 2 UNDECYLENIC 2 NITRATE (BULK) ACID (BULK) POWDER LIQUID 100 % naftifine topical 1 QL TOPICAL ANTIVIRALS cream 1 %, 2 % acyclovir topical 1 PA; QL naftifine topical gel 1 QL cream 5 % 1 % acyclovir topical 1 PA; QL nyamyc topical 1 QL ointment 5 % powder 100,000 unit/gram TOPICAL CORTICOSTEROIDS nystatin topical 1 QL alclometasone 1 cream 100,000 topical cream 0.05 unit/gram % nystatin topical 1 QL alclometasone 1 ointment 100,000 topical ointment unit/gram 0.05 % nystatin topical 1 QL amcinonide topical 1 ST powder 100,000 cream 0.1 % unit/gram amcinonide topical 1 ST nystatin- 1 QL lotion 0.1 % triamcinolone apexicon e topical 1 ST topical cream cream 0.05 % 100,000-0.1 unit/g- beser topical lotion 1 ST % 0.05 % nystatin- 1 QL triamcinolone BETAMETHASON 2 E DIPROPION topical ointment 100,000-0.1 (BULK) POWDER unit/gram-% betamethasone 1 dipropionate topical nystop topical 1 QL cream 0.05 % powder 100,000 unit/gram betamethasone 1 dipropionate topical oxiconazole topical 1 QL lotion 0.05 % cream 1 % betamethasone tavaborole topical 1 1 dipropionate topical solution with ointment 0.05 % applicator 5 % BETAMETHASON 2 TOLNAFTATE 2 E VALERATE (BULK) POWDER (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits betamethasone 1 clobetasol topical 1 ST; QL valerate topical shampoo 0.05 % cream 0.1 % clobetasol topical 1 ST; QL betamethasone 1 ST spray,non-aerosol valerate topical 0.05 % foam 0.12 % clobetasol-emollient 1 QL betamethasone 1 topical cream 0.05 valerate topical % lotion 0.1 % clobetasol-emollient 1 ST; QL betamethasone 1 topical foam 0.05 % valerate topical clodan topical 1 ST; QL ointment 0.1 % shampoo 0.05 % betamethasone, 1 desonide topical 1 augmented topical cream 0.05 % cream 0.05 % desonide topical gel 1 ST betamethasone, 1 0.05 % augmented topical gel 0.05 % desonide topical 1 ST lotion 0.05 % betamethasone, 1 augmented topical desonide topical 1 lotion 0.05 % ointment 0.05 % betamethasone, 1 DESONIDE, 2 augmented topical MICRONIZED ointment 0.05 % (BULK) POWDER CLOBETASOL 2 desoximetasone 1 ST PROPIONATE topical cream 0.05 (BULK) POWDER %, 0.25 % clobetasol scalp 1 QL desoximetasone 1 ST solution 0.05 % topical gel 0.05 % clobetasol topical 1 QL desoximetasone 1 ST cream 0.05 % topical ointment 0.05 %, 0.25 % clobetasol topical 1 ST; QL foam 0.05 % desoximetasone 1 ST topical spray,non- clobetasol topical 1 QL aerosol 0.25 % gel 0.05 % diflorasone topical 1 ST; QL clobetasol topical 1 ST; QL cream 0.05 % lotion 0.05 % diflorasone topical 1 ST; QL clobetasol topical 1 QL ointment 0.05 % ointment 0.05 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUOCINOLONE 2 flurandrenolide 1 ST; QL ACETONIDE topical ointment (BULK) POWDER 0.05 % fluocinolone and 1 FLUTICASONE 2 shower cap scalp oil PROP, MICRO 0.01 % (BULK) POWDER fluocinolone topical 1 100 % cream 0.01 %, 0.025 FLUTICASONE 2 % PROPIONATE fluocinolone topical 1 (BULK) POWDER oil 0.01 % 100 % fluticasone fluocinolone topical 1 1 propionate topical ointment 0.025 % cream 0.05 % fluocinolone topical 1 fluticasone solution 0.01 % 1 ST propionate topical fluocinonide topical 1 QL lotion 0.05 % cream 0.05 % fluticasone 1 fluocinonide topical 1 ST; QL propionate topical cream 0.1 % ointment 0.005 % fluocinonide topical 1 QL halcinonide topical 1 ST gel 0.05 % cream 0.1 % fluocinonide topical 1 QL halobetasol 1 ointment 0.05 % propionate topical fluocinonide topical 1 QL cream 0.05 % solution 0.05 % halobetasol 1 FLUOCINONIDE, 2 propionate topical MICRONIZED(BU ointment 0.05 % LK) POWDER 100 HYDROCORTISO 2 % NE (BULK) fluocinonide-e 1 QL POWDER topical cream 0.05 HYDROCORTISO 2 % NE ACETATE flurandrenolide 1 ST; QL (BULK) POWDER topical cream 0.05 hydrocortisone 1 QL % butyrate topical flurandrenolide 1 ST; QL cream 0.1 % topical lotion 0.05 % hydrocortisone 1 ST; QL butyrate topical lotion 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocortisone 1 ST prednicarbate 1 butyrate topical topical ointment 0.1 ointment 0.1 % % hydrocortisone 1 ST; QL scalacort topical 1 butyrate topical lotion 2 % solution 0.1 % tovet emollient 1 ST; QL hydrocortisone 1 QL topical foam 0.05 % butyr-emollient TRIAMCINOLONE 2 topical cream 0.1 % ACETONIDE hydrocortisone 1 (BULK) POWDER topical cream 2.5 % 100 % hydrocortisone 1 triamcinolone 1 ST; QL topical lotion 2.5 % acetonide topical aerosol 0.147 hydrocortisone 1 mg/gram topical ointment 2.5 % triamcinolone 1 acetonide topical hydrocortisone 1 valerate topical cream 0.025 %, 0.1 %, 0.5 % cream 0.2 % triamcinolone hydrocortisone 1 1 valerate topical acetonide topical lotion 0.025 %, 0.1 ointment 0.2 % % MOMETASONE 2 triamcinolone FUROATE (BULK) 1 acetonide topical POWDER 100 % ointment 0.025 %, mometasone topical 1 0.1 %, 0.5 % cream 0.1 % triamcinolone 1 ST mometasone topical 1 acetonide topical ointment 0.1 % ointment 0.05 % mometasone topical 1 trianex topical 1 ST solution 0.1 % ointment 0.05 % nolix topical cream 1 ST; QL triderm topical 1 0.05 % cream 0.1 % nolix topical lotion 1 ST; QL triderm topical 1 ST 0.05 % cream 0.5 % prednicarbate 1 TOPICAL ENZYMES topical cream 0.1 % COLLAGENASE 2 CLOS HIST. (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SANTYL TOPICAL 2 QL EDETATE 2 OINTMENT 250 DISODIUM UNIT/GRAM (BULK) POWDER 100 % TOPICAL SCABICIDES /

PEDICULICIDES PROTOPAM 2 CHLORIDE crotan topical lotion 1 INJECTION 10 % RECON SOLN 1 ivermectin topical 1 GRAM lotion 0.5 % ENZYMES lindane topical 1 CHYMOTRYPSIN 2 shampoo 1 % (BULK) POWDER malathion topical 1 coenzyme q10 oral 1 OTC lotion 0.5 % capsule 200 mg, 50 PERMETHRIN 2 mg, 60 mg (BULK) LIQUID 92 IRRIGATING SOLUTIONS % lactated ringers permethrin topical 1 1 irrigation solution cream 5 % neomycin-polymyxin PYRITHIONE 2 1 b gu irrigation ZINC (BULK) solution 40 mg- LIQUID 48 % 200,000 unit/ml spinosad topical 1 ringer's irrigation suspension 0.9 % 1 solution DIAGNOSTICS / tis-u-sol pentalyte 1 MISCELLANEOUS AGENTS irrigation irrigation solution 800-40-20- ANOREXIANTS 8.75- 6.25 mg/100 DIETHYLPROPIO 2 ml N HCL (BULK) POWDER 100 % MISCELLANEOUS AGENTS PHENTERMINE 2 2-DEOXY-D- 2 HCL (BULK) GLUCOSE (BULK) POWDER 100 % POWDER 2- 2 ANTIDOTES METHOXYESTRA acetylcysteine 1 DIOL (BULK) intravenous solution POWDER 100 % 200 mg/ml (20 %)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits 3,5- 2 aqua care sterile 1 DIIODOTHYRONI water irrigation NE (BULK) solution POWDER 100 % ARALAST NP 2 PA; SP acamprosate oral 1 INTRAVENOUS tablet,delayed RECON SOLN release (dr/ec) 333 1,000 MG, 500 MG mg bacteriostatic 1 ACD SOLUTION A 2 water(parabens) SOLUTION 2.45- injection solution 2.2 GRAM- 800 BARIUM 2 MG/100 ML SULFATE (BULK) acetic acid irrigation 1 POWDER solution 0.25 % bd pre-filled normal 1 ALPHA PINENE 2 saline injection (BULK) LIQUID syringe ALUMINUM, 2 BENZYL 2 (ACETATO- BENZOATE O)DIH(BULK) (BULK) LIQUID POWDER BETANAPHTHOL 2 AMMONIUM 2 (BULK) POWDER SULFATE (BULK) 99 % GRANULES BISMUTH 2 anagrelide oral 1 CITRATE (BULK) capsule 0.5 mg, 1 mg POWDER ANISINDIONE 2 BISMUTH 2 (BULK) POWDER SUBNITRATE 100 % (BULK) POWDER ANTICOAG 2 100 % CITRATE PHOS BREVITAL 2 DEXTROSE INJECTION SOLUTION 2.63- RECON SOLN 500 222 GRAM- MG MG/100ML BROMHEXINE 2 ANTIPYRINE 2 HCL (BULK) (BULK) POWDER POWDER 100 % BUFLOMEDIL 2 aqua care sodium 1 (BULK) POWDER chloride irrigation 100 % solution 0.9 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits bupivacaine- 1 citric acid 1 dextrose-water(pf) monohydrate (bulk) injection solution granules 100 % 0.75 % (7.5 mg/ml) clariscan 1 CAFFEINE (BULK) 2 (meglumine) POWDER 100 % intravenous solution 0.5 mmol/ml (376.9 caffeine citrate 1 mg/ml) intravenous solution 60 mg/3 ml (20 CLEMIZOLE HCL 2 mg/ml) (BULK) POWDER caffeine citrate oral 1 CLINIMIX 2 solution 60 mg/3 ml 4.25%/D5W (20 mg/ml) SULFIT FREE CALCITRIOL- 2 INTRAVENOUS ALMOND OIL PARENTERAL (BULK) LIQUID 1 SOLUTION 4.25 % MCG/ML CLINIMIX E 2 CARBAGLU ORAL 2 PA; SP 2.75%/D5W SULF TABLET, FREE DISPERSIBLE 200 INTRAVENOUS MG PARENTERAL SOLUTION 2.75 % CARBAZOCHROM 2 clovique oral E (BULK) 1 PA capsule 250 mg POWDER 100 % CESIUM 2 COUMARIN 2 CHLORIDE (BULK) POWDER (BULK) cryoserv solution 99 1 CRYSTALS 100 % % cevimeline oral 1 CYSTEAMINE 2 capsule 30 mg HCL (BULK) CHEMET ORAL 2 PA POWDER 100 % CAPSULE 100 MG d10 %-0.45 % 1 sodium chloride CHLORHEXIDINE 2 intravenous ACETATE (BULK) parenteral solution POWDER 100 % d2.5 %-0.45 % citric acid 1 1 anhydrous (bulk) sodium chloride intravenous granules 100 % parenteral solution

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits d5 % and 0.9 % 1 delflex-lc/4.25% 1 sodium chloride dextrose intravenous intraperitoneal parenteral solution solution ca 2.5 meq/l- mg 0.5 meq/l d5 %-0.45 % sodium 1 chloride intravenous DEOXYCHOLIC 2 parenteral solution ACID (BULK) DEANOL 2 POWDER 98 % BITARTRATE desflurane 1 (BULK) POWDER inhalation liquid 100 100 % % deferasirox oral 1 PA; SP DESOXIMETASON 2 granules in packet E, MICRO (BULK) 180 mg, 360 mg, 90 POWDER 100 % mg DEXTROSE 2 deferasirox oral 1 PA; SP (BULK) tablet 180 mg, 360 GRANULES mg, 90 mg DEXTROSE 2 deferasirox oral 1 PA; SP (BULK) POWDER tablet, dispersible dextrose 10 % and 1 125 mg, 250 mg, 500 0.2 % nacl mg intravenous deferiprone oral 1 PA; SP parenteral solution tablet 500 mg dextrose 10 % in 1 deferoxamine 1 water (d10w) injection recon soln intravenous 2 gram, 500 mg parenteral solution 10 % dehydrated alcohol 1 injection solution 98 dextrose 20 % in 1 % water (d20w) intravenous delflex-lc/1.5% 1 dextrose parenteral solution intraperitoneal 20 % solution ca 2.5 dextrose 25 % in 1 meq/l- mg 0.5 meq/l water (d25w) intravenous syringe delflex-lc/2.5% 1 dextrose dextrose 30 % in 1 intraperitoneal water (d30w) solution ca 2.5 intravenous meq/l- mg 0.5 meq/l parenteral solution

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dextrose 40 % in 1 DICHLORALPHEN 2 water (d40w) AZONE (BULK) intravenous POWDER 100 % parenteral solution diluent for 1 SP 40 % epoprostenol/flola dextrose 5 % in 1 intravenous solution ringer's intravenous diluent for 1 SP parenteral solution 5 treprostinil (gly) % intravenous solution dextrose 5 % in 1 DIMERCAPTOPRO 2 water (d5w) PANESULFONATE intravenous SOD POWDER 97 parenteral solution % dextrose 5 % in 1 DIMETHYL 2 water (d5w) SULFOXIDE intravenous (BULK) LIQUID piggyback 5 % 99.99 % dextrose 5 %- 1 DINITROCHLORO 2 lactated ringers BENZEN(2,4)(BUL intravenous K) CRYSTALS 100 parenteral solution % dextrose 5%-0.2 % 1 DIOSGENIN 2 sod chloride (BULK) POWDER intravenous parenteral solution DIPHENCYPRONE 2 (BULK) POWDER dextrose 5%-0.3 % 1 98 % sod.chloride intravenous DISULFIRAM 2 parenteral solution (BULK) POWDER 100 % dextrose 50 % in 1 water (d50w) disulfiram oral 1 intravenous tablet 250 mg, 500 parenteral solution mg dextrose 50 % in 1 DMPS CRYSTALS 2 water (d50w) DMSA (BULK) 2 intravenous syringe POWDER 98 % dextrose 70 % in 1 droxidopa oral 1 PA; SP water (d70w) capsule 100 mg, 200 intravenous mg, 300 mg parenteral solution D-XYLOSE 2 (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENFAMIL 2 OTC GLASSIA 2 PA; SP GLUCOSE ORAL INTRAVENOUS SOLUTION 5 % SOLUTION 1 EOVIST 2 GRAM/50 ML (2 INTRAVENOUS %) SOLUTION 0.25 GLUTOL GEL 2 OTC MMOL/ML (181.43 ORAL LIQUID 100 MG/ML) GRAM/180 ML ETHAMOLIN 2 GRAMICIDIN D 2 INTRAVENOUS (BULK) POWDER SOLUTION 5 % GRISEOFULVIN 2 etidronate disodium 1 (BULK) POWDER oral tablet 200 mg HEXTEND 2 ETOMIDATE 2 INTRAVENOUS (BULK) POWDER SOLUTION 6 % etomidate 1 HISTAMINE 2 intravenous solution PHOSPHATE 2 mg/ml (BULK) EXTRANEAL 7.5 2 CRYSTALS 100 % % HYDRAZINE 2 INTRAPERITONE SULFATE (BULK) AL SOLUTION CA CRYSTALS 100 % 3.5 MEQ/L- MG 0.5 HYDROXYPROPY 2 MEQ/L L CELLULOSE FERRIPROX (2 2 PA; SP POWDER TIMES A DAY) ic green injection 1 ORAL TABLET recon soln 25 mg 1,000 MG INCRELEX 2 PA; SP FERRIPROX ORAL 2 PA; SP SUBCUTANEOUS SOLUTION 100 SOLUTION 10 MG/ML MG/ML FERRIPROX ORAL 2 PA; SP indigo carmine 1 TABLET 1,000 MG, injection solution 8 500 MG mg/ml (0.8 %) fludeoxyglucose f-18 1 INDOCYANINE 2 intravenous solution GREEN (BULK) 20 mci to 500 mci/ml POWDER 100 % forane inhalation 1 indocyanine green 1 liquid 99.9 % injection recon soln 25 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits IODINE (BULK) 2 LEVOCARNITINE 2 CRYSTALS (BULK) POWDER IODINE (BULK) 2 levocarnitine (with 1 GRANULES 100 % sugar) oral solution 100 mg/ml IOPANOIC ACID 2 (BULK) POWDER levocarnitine oral 1 100 % solution 100 mg/ml isoflurane inhalation 1 levocarnitine oral 1 liquid 99.9 % tablet 330 mg isopropyl alcohol 1 OTC LEXISCAN 2 solution 91 %, 99 % INTRAVENOUS isosulfan blue 1 SYRINGE 0.4 MG/5 subcutaneous ML solution 1 % lmd 10 % in 0.9 % 1 sodium chlor KAOLIN (BULK) 2 intravenous POWDER parenteral solution KETAMINE 2 10 % (BULK) POWDER lmd 10 % in 5 % 100 % 1 dextrose intravenous ketamine in 0.9 % 1 parenteral solution sod chloride 10 % intravenous syringe 20 mg/2 ml (10 LOKELMA ORAL 2 QL mg/ml) POWDER IN PACKET 10 ketamine injection 1 GRAM, 5 GRAM solution 10 mg/ml, 100 mg/ml, 50 mg/ml M-CRESOL 2 ACETATE (BULK) kionex (with 1 LIQUID 100 % sorbitol) oral md-76 r injection suspension 15-19.3 1 solution 66-10 % gram/60 ml md-gastroview oral L-ALANINE 2 1 solution 66-10 % POWDER lanthanum oral 1 MECAMYLAMINE 2 tablet,chewable HCL (BULK) 1,000 mg, 500 mg, POWDER 750 mg MECLOFENOXAT 2 LEUCINE (BULK) 2 E HCL (BULK) POWDER POWDER 100 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MENADIONE 2 OMNIPAQUE 140 2 (BULK) POWDER INTRAVENOUS MEQUINOL 2 SOLUTION 140 (BULK) MG IODINE/ML CRYSTALS 100 % OMNIPAQUE 180 2 META-CRESOL 2 INTRATHECAL (BULK) LIQUID SOLUTION 180 100 % MG IODINE/ML METHACHOLINE 2 OMNIPAQUE 240 2 CHLORIDE INTRAVENOUS (BULK) POWDER SOLUTION 240 100 % MG IODINE/ML midodrine oral 1 OMNIPAQUE 300 2 tablet 10 mg, 2.5 mg, INTRAVENOUS 5 mg SOLUTION 300 MG IODINE/ML monoject 0.9% 1 sodium chloride OMNIPAQUE 350 2 injection syringe INTRAVENOUS SOLUTION 350 monoject prefill 1 MG IODINE/ML advanced ns injection syringe OXYQUINOLINE 2 SULFATE (BULK) MOXISYLYTE 2 POWDER 100 % (BULK) POWDER 100 % PARACHLOROPH 2 ENOL (BULK) MURI-LUBE OIL 2 POWDER 100 % NH4 2 PENTYLENETETR 2 TETRATHIOMOL AZOL (BULK) YBDATE (BULK) CRYSTALS POWDER 100 % PHENINDIONE 2 nitisinone oral 1 PA; SP (BULK) POWDER capsule 10 mg, 2 mg, 5 mg PHENOL (BULK) 2 LIQUID 89 % NITYR ORAL 2 PA; SP TABLET 10 MG, 2 PHENYLMERCURI 2 MG, 5 MG C NITRATE (BULK) normal saline flush 1 CRYSTALS injection syringe pilocarpine hcl oral 1 tablet 5 mg, 7.5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits POLYETHYLENE 2 SEROTONIN HCL 2 GLYCOL (BULK) POWDER 3350(BULK) 97 % POWDER sevelamer carbonate 1 POTASSIUM 2 oral powder in CITRATE M- packet 0.8 gram, 2.4 HYD(BULK) gram POWDER 100 % sevelamer carbonate 1 POVIDONE 2 oral tablet 800 mg (BULK) POWDER sevelamer hcl oral 1 K-30 tablet 400 mg, 800 PREGNENOLONE 2 mg (BULK) POWDER sevoflurane 1 PREGNENOLONE, 2 inhalation liquid MICRONIZED(BU sodium benzoate-sod 1 LK) POWDER 100 phenylacet % intravenous solution PROLASTIN-C 2 PA; SP 10-10 % INTRAVENOUS SODIUM BORATE 2 RECON SOLN (BULK) POWDER 1,000 MG SODIUM 2 PROLASTIN-C 2 PA; SP BROMIDE (BULK) INTRAVENOUS GRANULES SOLUTION 1,000 MG (+/-)/20 ML SODIUM 2 BUTYRATE propofol intravenous 1 (BULK) POWDER emulsion 10 mg/ml 100 % RAVICTI ORAL 2 PA; SP sodium chlor 0.9% 1 LIQUID 1.1 bacteriostat GRAM/ML injection solution 0.9 REVCOVI 2 PA; SP % INTRAMUSCULA sodium chloride 0.9 1 R SOLUTION 2.4 % (flush) injection MG/1.5 ML (1.6 syringe MG/ML) sodium chloride 0.9 1 riluzole oral tablet 1 PA % injection solution 50 mg sodium chloride 0.9 1 risedronate oral 1 QL % intravenous tablet 30 mg parenteral solution

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium chloride 0.9 1 sodium tetradecyl 1 % intravenous sulfate intravenous piggyback solution 3 % (30 mg/ml) sodium chloride 1 injection syringe 0.9 sodium thiosulfate 1 % intravenous solution 12.5 gram/50 ml sodium chloride 1 (250 mg/ml) irrigation solution 0.9 % SOLIRIS 2 PA; SP SODIUM CITRATE 2 INTRAVENOUS DIHYDRATE(BUL SOLUTION 300 K) GRANULES MG/30 ML sodium ferric 1 PA SOTRADECOL 2 gluconat-sucrose INTRAVENOUS intravenous solution SOLUTION 1 % (10 62.5 mg/5 ml MG/ML) sps (with sorbitol) SODIUM 2 1 oral suspension 15- PHENYLBUTYRA 20 gram/60 ml TE (BULK) POWDER 100 % sps (with sorbitol) 1 rectal enema 30-40 sodium 1 PA phenylbutyrate oral gram/120 ml powder 0.94 SQUARIC ACID 2 gram/gram (BULK) POWDER sodium 1 PA 100 % phenylbutyrate oral SQUARIC ACID 2 tablet 500 mg DIBUTYLEST.(BU sodium polystyrene 1 LK) LIQUID 100 % (sorb free) oral SQUARIC ACID 2 suspension 15 DIBUTYLEST.(BU gram/60 ml LK) POWDER sodium polystyrene 1 SQUARIC ACID IN 2 sulfonate oral BUTANOL LIQUID powder 150 MG SODIUM 2 SULFADIAZINE 2 TETRADECYL SODIUM (BULK) SULF (BULK) POWDER 100 % POWDER terrell inhalation 1 liquid 99.9 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits THEOBROMINE 2 XIAFLEX 2 PA; SP (BULK) POWDER INJECTION 100 % RECON SOLN 0.9 THYMOL (BULK) 2 MG CRYSTALS XURIDEN ORAL 2 PA; SP THYROGEN 2 SP GRANULES IN INTRAMUSCULA PACKET 2 GRAM R RECON SOLN YOHIMBINE HCL 2 1.1 MG (0.9 MG/ (BULK) POWDER ML FINAL CONC.) ZEMAIRA 2 PA; SP TRICITRASOL 2 INTRAVENOUS INJECTION RECON SOLN CONCENTRATE 1,000 MG 46.7 % ZINC SULFATE 2 trientine oral 1 PA HEPTAHYDRAT(B capsule 250 mg ULK) POWDER TRIOXSALEN 2 100 % (BULK) zoledronic acid- 1 PA; SP CRYSTALS 100 % mannitol-water intravenous VELPHORO ORAL 2 QL piggyback 5 mg/100 TABLET,CHEWAB ml LE 500 MG water for inject, 1 MISCELLANEOUS DEVICES bacteriostat alcohol, rubbing 1 OTC injection solution solution 70 % water for injection, 1 dy-o-derm solution 1 OTC sterile injection INSTACLEAN 2 OTC solution SOLUTION water for injection, 1 isopropyl alcohol sterile injection 1 OTC solution 70 % syringe water for injection, 1 NEUTRACEUTICALS sterile intravenous UTI-STAT ORAL 2 OTC parenteral solution LIQUID 3,875 water for irrigation, 1 MG/30 ML sterile irrigation SMOKING DETERRENTS solution bupropion hcl 1 ACA (smoking deter) oral tablet extended release 12 hr 150 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHANTIX 2 ACA nicotine (polacrilex) 1 ACA; OTC CONTINUING buccal mini lozenge MONTH BOX 2 mg, 4 mg ORAL TABLET 1 NICOTINE 2 MG POLACRILEX CHANTIX ORAL 2 ACA (BULK) POWDER TABLET 0.5 MG, 1 15 %, 20 % MG NICOTINE 2 CHANTIX 2 ACA TARTRATE STARTING POWDER 100 % MONTH BOX nicotine transdermal 1 ACA; OTC ORAL patch 24 hour 14 TABLETS,DOSE mg/24 hr, 21 mg/24 PACK 0.5 MG (11)- hr, 7 mg/24 hr 1 MG (42) nicotine transdermal 1 ACA; OTC NICODERM CQ 2 ACA; OTC patch, td daily, TRANSDERMAL sequential 21-14-7 PATCH 24 HOUR mg/24 hr 14 MG/24 HR, 21 MG/24 HR, 7 quit 2 buccal gum 2 1 ACA; OTC MG/24 HR mg NICORETTE 2 ACA; OTC quit 2 buccal 1 ACA; OTC BUCCAL GUM 2 lozenge 2 mg MG quit 4 buccal gum 4 1 ACA; OTC nicorette buccal gum 1 ACA; OTC mg 4 mg quit 4 buccal 1 ACA; OTC NICORETTE 2 ACA; OTC lozenge 4 mg BUCCAL stop smoking aid 1 ACA; OTC LOZENGE 2 MG, 4 buccal lozenge 2 mg, MG 4 mg NICORETTE 2 ACA; OTC EAR, NOSE / THROAT BUCCAL MINI LOZENGE 2 MG, 4 MEDICATIONS MG MISCELLANEOUS AGENTS nicotine (polacrilex) 1 ACA; OTC azelastine nasal 1 QL buccal gum 2 mg, 4 aerosol,spray 137 mg mcg (0.1 %) nicotine (polacrilex) 1 ACA; OTC azelastine nasal 1 buccal lozenge 2 mg, spray,non-aerosol 4 mg 205.5 mcg (0.15 %)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BECLOMETHASO 2 periogard mucous 1 NE DIPROP membrane (BULK) POWDER mouthwash 0.12 % CETYLPYRIDINIU 2 sf 5000 plus dental 1 M cream 1.1 % CHLORIDE(BULK) sf dental gel 1.1 % 1 CRYSTALS sodium fluoride 1 chlorhexidine 1 5000 plus dental gluconate mucous cream 1.1 % membrane mouthwash 0.12 % sodium fluoride-pot 1 nitrate dental paste denta 5000 plus 1 1.1-5 % dental cream 1.1 % triamcinolone 1 dentagel dental gel 1 acetonide dental 1.1 % paste 0.1 % EUGENOL (BULK) 2 XYLOMETAZOLI 2 LIQUID NE (BULK) fluoride (sodium) 1 POWDER 100 % dental cream 1.1 % MISCELLANEOUS OTIC

fluoride (sodium) 1 PREPARATIONS dental gel 1.1 % CARBAMIDE 2 fluoride (sodium) 1 PEROXIDE dental paste 1.1 % (BULK) POWDER ipratropium bromide 1 QL 100 % nasal spray,non- ciprofloxacin hcl 1 aerosol 21 mcg (0.03 otic (ear) %), 42 mcg (0.06 %) dropperette 0.2 % olopatadine nasal 1 QL flac otic oil otic 1 spray,non-aerosol (ear) drops 0.01 % 0.6 % fluocinolone 1 oralone dental paste 1 acetonide oil otic 0.1 % (ear) drops 0.01 % OXYMETAZOLIN 2 hydrocortisone- 1 E (BULK) acetic acid otic (ear) POWDER 100 % drops 1-2 % paroex oral rinse 1 ofloxacin otic (ear) 1 mucous membrane drops 0.3 % mouthwash 0.12 % OTIC STEROID / ANTIBIOTIC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ciprofloxacin- 1 BETAMETHASON 2 dexamethasone otic E (ear) ACET,MICRO(BUL drops,suspension K) POWDER 100 % 0.3-0.1 % betamethasone 1 neomycin- 1 acet,sod phos polymyxin-hc otic injection suspension (ear) 6 mg/ml drops,suspension BETAMETHASON 2 3.5-10,000-1 mg/ml- E SOD PHOS unit/ml-% (BULK) POWDER neomycin- 1 CORTICOTROPIN 2 polymyxin-hc otic (BULK) POWDER (ear) solution 3.5- 10,000-1 mg/ml- CORTISONE 2 unit/ml-% (BULK) POWDER OTOVEL OTIC 2 cosyntropin injection 1 (EAR) SOLUTION recon soln 0.25 mg 0.3-0.025 % (0.25 decadron oral tablet 1 ML) 0.5 mg, 0.75 mg, 4 mg, 6 mg ENDOCRINE/DIABETES DESOXYCORTICO 2 ADRENAL HORMONES STERONE AC a-hydrocort 1 (BULK) POWDER injection recon soln 100 % 100 mg dexabliss oral 1 PA ALDOSTERONE 2 tablets,dose pack 1.5 (BULK) POWDER mg (39 tabs) 97.5 % DEXAMETHASON 2 ARISTOSPAN 2 E AC, MICRO INTRA- (BULK) POWDER ARTICULAR 100 % INJECTION DEXAMETHASON 2 SUSPENSION 20 E ACETATE MG/ML (BULK) POWDER ARISTOSPAN 2 dexamethasone 1 INTRALESIONAL intensol oral drops 1 INJECTION mg/ml SUSPENSION 5 MG/ML DEXAMETHASON 2 E ISONIC (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits dexamethasone oral 1 fludrocortisone oral 1 elixir 0.5 mg/5 ml tablet 0.1 mg dexamethasone oral 1 hidex oral 1 PA solution 0.5 mg/5 ml tablets,dose pack 1.5 mg (21 tabs) dexamethasone oral 1 tablet 0.5 mg, 0.75 hydrocortisone oral 1 mg, 1 mg, 1.5 mg, 2 tablet 10 mg, 20 mg, mg, 4 mg, 6 mg 5 mg dexamethasone oral 1 PA METHYLPREDNIS 2 tablets,dose pack 1.5 OLON mg (21 tabs), 1.5 mg AC,MIC(BULK) (35 tabs), 1.5 mg (51 POWDER 100 % tabs) methylprednisolone 1 DEXAMETHASON 2 acetate injection E SOD PHOS suspension 40 (BULK) POWDER mg/ml, 80 mg/ml 100 % methylprednisolone 1 dexamethasone 1 oral tablet 16 mg, 32 sodium phos (pf) mg, 4 mg, 8 mg injection solution 10 methylprednisolone 1 mg/ml oral tablets,dose dexamethasone 1 pack 4 mg sodium phosphate methylprednisolone 1 injection solution 10 sodium succ mg/ml, 4 mg/ml injection recon soln dexamethasone 1 125 mg, 40 mg sodium phosphate methylprednisolone 1 injection syringe 4 sodium succ mg/ml intravenous recon DEXAMETHASON 2 soln 1,000 mg, 500 E,MICRONIZED(B mg ULK) POWDER METHYLPREDNIS 2 100 % OLONE, MIC dexamethasone-0.9 1 (BULK) POWDER % sod. chlor 100 % intravenous millipred dp oral 1 piggyback 10 mg/50 tablets,dose pack 5 ml mg (21 tabs), 5 mg FLUDROCORTISO 2 (48 tabs) NE (BULK) millipred oral tablet 1 POWDER 5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREDNISOLONE 2 prednisone oral 1 (BULK) POWDER tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, PREDNISOLONE 2 50 mg AC, MICRO (BULK) POWDER prednisone oral 1 100 % tablets,dose pack 10 mg, 5 mg prednisolone oral 1 solution 15 mg/5 ml SOLU-CORTEF 2 PREDNISOLONE 2 ACT-O-VIAL (PF) SOD PHOS (BULK) INJECTION POWDER RECON SOLN 1,000 MG/8 ML, prednisolone sodium 1 100 MG/2 ML, 250 phosphate oral MG/2 ML, 500 solution 10 mg/5 ml, MG/4 ML 15 mg/5 ml (3 mg/ml), 20 mg/5 ml SOLU-CORTEF 2 (4 mg/ml), 25 mg/5 INJECTION ml (5 mg/ml), 5 mg RECON SOLN 100 base/5 ml (6.7 mg/5 MG ml) TRIAMCIN 2 prednisolone sodium 1 DIACET, MICRO phosphate oral (BULK) POWDER tablet,disintegrating 100 % 10 mg, 15 mg, 30 mg TRIAMCINOLONE 2 PREDNISOLONE, 2 (BULK) POWDER MICRO (BULK) triamcinolone 1 POWDER 100 % acetonide injection suspension 10 PREDNISONE 2 mg/ml, 40 mg/ml (BULK) POWDER prednisone intensol 1 TRIAMCINOLONE 2 oral concentrate 5 DIACETATE mg/ml (BULK) POWDER veripred 20 oral PREDNISONE 2 1 solution 20 mg/5 ml MICRONIZED (4 mg/ml) (BULK) POWDER 100 % ANTITHYROID AGENTS prednisone oral 1 METHIMAZOLE 2 solution 5 mg/5 ml (BULK) POWDER 100 % methimazole oral 1 tablet 10 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits POTASSIUM 2 ACCU-CHEK 2 OTC IODIDE (BULK) MULTICLIX CRYSTALS 100 % LANCET KIT POTASSIUM 2 ACCU-CHEK 2 IODIDE (BULK) RAPID D GRANULES INFUSION POTASSIUM 2 SUBCUTANEOUS IODIDE (BULK) INFUSION SET 10 POWDER X 70 MM-CM, 6 X 50 MM-CM, 8 X 50 PROPYLTHIOURA 2 MM-CM, 8 X 70 CIL (BULK) MM-CM POWDER 100 % ACCU-CHEK 2 OTC propylthiouracil oral 1 SAFE-T-PRO 23 tablet 50 mg GAUGE DIABETES THERAPY ACCU-CHEK 2 OTC 1ST TIER UNILET 2 OTC SAFE-T-PRO PLUS COMFORTOUCH 23 GAUGE 28 GAUGE, 30 ACCU-CHEK 2 OTC GAUGE SOFT DEV 2-IN-1 LANCET 2 OTC LANCETS KIT DEVICE 30 ACCU-CHEK 2 OTC GAUGE SOFTCLIX acarbose oral tablet 1 LANCETS 100 mg, 25 mg, 50 ACCU-CHEK 2 mg SPIRIT ADAPTER ACCU-CHEK 2 ACCU-CHEK 2 COMBO SYSTEM SPIRIT KIT CARTRIDGE SYS ACCU-CHEK 2 OTC ACCU-CHEK 2 FASTCLIX TENDER LANCET DRUM SUBCUTANEOUS ACCU-CHEK 2 OTC INFUSION SET 13 FASTCLIX X 110 MM-CM, 13 LANCING DEV X 60 MM-CM, 13 X KIT 80 MM-CM, 17 X 110 MM-CM, 17 X ACCU-CHEK 2 OTC 60 MM-CM, 17 X MULTICLIX 80 MM-CM LANCET

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ACCU-CHEK 2 AEROCHAMBER 2 ULTRAFLEX PLUS FLOW-VU SUBCUTANEOUS SPACER INFUSION SET 10 AEROCHAMBER 2 X 110 MM-CM, 10 PLUS FLOW-VU,L X 60 MM-CM, 10 X MSK SPACER 80 MM-CM, 8 X 110 MM-CM, 8 X AEROCHAMBER 2 60 MM-CM, 8 X 80 PLUS FLOW-VU,M MM-CM MSK SPACER ACD-A SOLUTION 2 AEROCHAMBER 2 PLUS FLOW-VU,S ACE AEROSOL 2 MSK SPACER CLOUD ENHANCER AEROCHAMBER 2 SPACER PLUS Z STAT LG MSK SPACER acti-lance lancets 17 1 OTC gauge, 23 gauge, 28 AEROCHAMBER 2 gauge PLUS Z STAT MD MSK SPACER ADJUSTABLE 2 OTC LANCING DEVICE AEROCHAMBER 2 PLUS Z STAT SM ADVANCED 2 OTC MSK SPACER LANCING DEVICE KIT AEROCHAMBER 2 WITH ADVANCED 2 OTC FLOWSIGNAL TRAVEL SPACER LANCETS 28 GAUGE, 30 AEROCHAMBER 2 GAUGE Z-STAT PLUS- FLW SG SPACER ADVOCATE 2 OTC LANCET 26 AEROTRACH 2 GAUGE, 30 PLUS SPACER GAUGE AEROVENT PLUS 2 ADVOCATE 2 OTC SPACER LANCING DEVICE alcohol pads topical 1 OTC ADVOCATE 2 OTC pads, medicated RAPID-SAFE alcohol prep pads 1 OTC LANCING topical pads, AEROCHAMBER 2 medicated MINI SPACER alcohol swabs 1 OTC AEROCHAMBER 2 topical pads, MV SPACER medicated You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits alcohol wipes 1 OTC AUTOPEN 1 TO 21 2 OTC topical pads, UNITS medicated SUBCUTANEOUS ALTERNATE SITE 2 OTC INSULIN PEN LANCET 26 AUTOPEN 2 TO 42 2 OTC GAUGE UNITS ALTERNATE SITE 2 OTC SUBCUTANEOUS LANCING DEVICE INSULIN PEN AQUA LANCE 2 OTC AUTOSOFT 30 2 LANCING DEVICE INFUSION SET ASSURE 2 OTC AUTOSOFT 90 2 HAEMOLANCE INFUSION SET PLUS 1.2 MM, 18 AUTOSOFT XC 2 GAUGE, 21 INFUSION SET 23" GAUGE, 25 INFUSION SET GAUGE, 28 AUTOSOFT XC 2 GAUGE INFUSION SET 32" ASSURE LANCE 2 OTC INFUSION SET 25 GAUGE, 28 AUTOSOFT XC 2 GAUGE INFUSION SET 43" ASSURE LANCE 2 OTC INFUSION SET PLUS 21 GAUGE, BD ALCOHOL 2 OTC 25 GAUGE, 30 SWABS TOPICAL GAUGE PADS, AUTOJECT 2 2 OTC MEDICATED INJECTION BD AUTOSHIELD 2 OTC DEVICE DUO PEN NEEDLE SUBCUTANEOUS NEEDLE 30 INSULIN PEN GAUGE X 3/16" AUTO-LANCET 2 OTC BD ECLIPSE 2 MINI LUER-LOK AUTOLET 2 OTC NEEDLE 21 IMPRESSION GAUGE X 1 1/2", LANC DEV KIT 22 GAUGE X 1", 25 AUTOLET 2 OTC GAUGE X 1 1/2", LANCING DEVICE 30 X 1/2 " AUTOLET PLUS 2 OTC BD ECLIPSE 2 LANCING DEVICE LUER-LOK SYRINGE 1 ML 30 GAUGE X 1/2"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD ECLIPSE 2 BD INSULIN 2 NEEDLE 21 SYRINGE U-500 GAUGE X 1", 25 SYRINGE 1/2 ML GAUGE X 1" 31 GAUGE X BD FILTER 2 15/64" NEEDLE 5- BD INSULIN 2 MICRON NOKO SYRINGE ULTRA- NEEDLE 18 FINE SYRINGE 0.3 GAUGE X 1 1/2" ML 30 GAUGE X BD FILTER 2 1/2", 0.3 ML 31 NEEDLE-5 GAUGE X 5/16", MICRON NEEDLE 0.5 ML 30 GAUGE 19 X 1 1/2 " X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 BD INSULIN 2 ML 30 GAUGE X SYRINGE HALF 1/2", 1 ML 31 UNIT SYRINGE 0.3 GAUGE X 5/16 ML 31 GAUGE X 5/16" BD INTEGRA 2 NEEDLE NEEDLE BD INSULIN 2 23 GAUGE X 1" SYRINGE SAFETY-LOK BD 2 SYRINGE 1 ML 29 INTRADERMAL GAUGE X 1/2" BEVEL NEEDLES NEEDLE 26 BD INSULIN 2 GAUGE X 3/8" SYRINGE SLIP TIP SYRINGE 1 ML BD LO-DOSE 2 MICRO-FINE IV BD INSULIN 2 SYRINGE 1/2 ML SYRINGE 28 GAUGE X 1/2" SYRINGE 0.3 ML 29 GAUGE X 1/2", BD LO-DOSE 2 0.5 ML 29 GAUGE ULTRA-FINE X 1/2", 1 ML 25 SYRINGE 0.5 ML GAUGE X 5/8", 1 29 GAUGE X 1/2" ML 25 X 1", 1 ML BD MAGNI-GUIDE 2 OTC 26 X 1/2", 1 ML 27 SYRINGE GAUGE X 1/2", 1 MAGNIFI ML 29 GAUGE X BD 2 OTC 1/2" MICROTAINER LANCET 1.5 X 2 MM, 21 GAUGE, 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD NANO 2ND 2 OTC BD REGULAR 2 GEN PEN NEEDLE BEVEL NEEDLES NEEDLE 32 NEEDLE 18 GAUGE X 5/32" GAUGE X 1 1/2", BD NOKOR 2 18 GAUGE X 1", 19 ADMIX NEEDLE GAUGE X 1 1/2", NEEDLE 18 19 GAUGE X 1", 20 GAUGE X 1 1/2" GAUGE X 1 1/2", 20 GAUGE X 1", 21 BD 2 GAUGE X 1 1/2", PRECISIONGLIDE 21 GAUGE X 1", 22 NEEDLE 25 GAUGE X 1 1/2", GAUGE X 1", 27 22 GAUGE X 1", 23 GAUGE X 1 1/2" GAUGE X 3/4", 25 BD 2 GAUGE X 1 1/2", PRECISIONGLIDE 25 GAUGE X 5/8", NON-STERILE 26 GAUGE X 1/2", NEEDLE 18 27 GAUGE X 1/2" GAUGE X 1 1/2", BD SAFETYGLIDE 2 19 GAUGE X 1 INSULIN 1/2", 20 GAUGE X SYRINGE 1 1/2", 21 GAUGE SYRINGE 0.3 ML X 1 1/2", 22 29 GAUGE X 1/2", GAUGE X 1 1/2", 0.3 ML 31 GAUGE 23 GAUGE X 1", 25 X 15/64", 0.3 ML 31 GAUGE X 1", 25 GAUGE X 5/16", GAUGE X 5/8" 0.5 ML 30 GAUGE BD Q-SYTE MDV 2 OTC X 5/16", 0.5 ML 31 ADAPTER GAUGE X 15/64", 1 INFUSION SET ML 29 GAUGE X 1/2", 1 ML 31 BD Q-SYTE SPLIT- 2 OTC GAUGE X 15/64" SEPT DEVICE INFUSION SET BD SAFETYGLIDE 2 NEEDLE NEEDLE 18 GAUGE X 1 1/2", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 25 GAUGE X 1", 25 X 5/8 ", 27 X 5/8 "

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BD SAFETYGLIDE 2 BD VEO INSULIN 2 SYRINGE SYR HALF UNIT SYRINGE 1 ML 27 SYRINGE 0.3 ML GAUGE X 5/8" 31 GAUGE X BD SPECIALTY 2 15/64" USE NEEDLES BD VEO INSULIN 2 NEEDLE 16 SYRINGE UF GAUGE X 1 1/2", SYRINGE 0.3 ML 16 GAUGE X 1", 21 31 GAUGE X GAUGE X 2", 23 15/64", 1 ML 31 GAUGE X 1 1/4", GAUGE X 15/64", 25 GAUGE X 7/8", 1/2 ML 31 GAUGE 27 GAUGE X 1 X 15/64" 1/4", 30 GAUGE X BD YALE 2 1", 30 GAUGE X REGULAR BEVEL 1/2" NEEDLE 27 BD ULTRA FINE 2 OTC GAUGE X 1" LANCETS 33 BLUNT NEEDLE, 2 GAUGE DISPOSABLE BD ULTRA-FINE II 2 OTC NEEDLE 18 X 1 1/2 LANCETS 30 ", 22 X 1 1/2 " GAUGE BREATHERITE 2 BD ULTRA-FINE 2 OTC MDI SPACER MICRO PEN SPACER NEEDLE NEEDLE BREATHERITE 2 32 GAUGE X 1/4" SPACER-MASK, BD ULTRA-FINE 2 OTC NEO. SPACER MINI PEN BREATHERITE 2 NEEDLE NEEDLE SPACER- 31 GAUGE X 3/16" MASK,ADULT BD ULTRA-FINE 2 OTC SPACER NANO PEN BREATHERITE 2 NEEDLE NEEDLE SPACER- 32 GAUGE X 5/32" MASK,CHILD BD ULTRA-FINE 2 OTC SPACER ORIG PEN BREATHERITE 2 NEEDLE NEEDLE SPACER- 29 GAUGE X 1/2" MASK,INFANT BD ULTRA-FINE 2 SPACER SHORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BREATHERITE 2 CARETOUCH 2 OTC SPACER- LANCING DEVICE MASK,S.CHLD CARETOUCH 2 OTC SPACER TWIST LANCET 28 BREATHERITE 2 GAUGE, 30 VALVED MDI GAUGE, 33 CHAMBER GAUGE SPACER CLEVER CHEK 2 OTC BREATHERITE 2 LANCETS 30 VALVED MDI GAUGE SPACER SPACER CLEVER CHOICE 2 BULLSEYE MINI 2 OTC CHAMBER-LRG SAFETY MASK SPACER LANCETS 21 CLEVER CHOICE 2 GAUGE, 25 CHAMBER-MED GAUGE, 28 MASK SPACER GAUGE CLEVER CHOICE 2 BUTTERFLY 2 OTC CHAMBER-SM TOUCH LANCET MASK SPACER 30 GAUGE COAGUCHEK 2 OTC BYDUREON 2 PA; QL LANCETS BCISE SUBCUTANEOUS COLOR LANCETS 2 OTC AUTO-INJECTOR 21 GAUGE 2 MG/0.85 ML COMFORT EZ 2 OTC BYETTA 2 PA; QL LANCETS 23 SUBCUTANEOUS GAUGE, 28 PEN INJECTOR 10 GAUGE MCG/DOSE(250 COMFORT 2 MCG/ML) 2.4 ML, INFUSION SET 23" 5 MCG/DOSE (250 INFUSION SET MCG/ML) 1.2 ML COMFORT 2 CAREONE 2 OTC INFUSION SET 32" LANCING DEVICE INFUSION SET CAREONE ULTRA 2 OTC COMFORT 2 THIN LANCET INFUSION SET 43" CARETOUCH 2 OTC INFUSION SET ALCOHOL PREP COMFORT 2 OTC PAD TOPICAL LANCETS PADS, MEDICATED

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COMFORT SHORT 2 DEXCOM G4 2 INSULIN PUMP RECEIVER-SHARE 32" INFUSION SET (PED) COMPACT SPACE 2 DEXCOM G4 2 CHAMBER RECEIVER-SHARE SPACER KIT COMPACT SPACE 2 DEXCOM G4 2 QL CHAMBER-LRG TRANSMITTER MASK SPACER DEVICE COMPACT SPACE 2 DEXCOM G5 2 CHAMBER-MED RECEIVER MASK SPACER DEXCOM G5 2 QL COMPACT SPACE 2 TRANSMITTER CHAMBER-SM DEVICE MASK SPACER DEXCOM G5-G4 2 QL CONTACT 2 SENSOR DEVICE DETACH INFUS DEXCOM G6 2 SET 23" INFUSION RECEIVER SET DEXCOM G6 2 QL CONTACT 2 SENSOR DEVICE DETACH INFUS SET 32" INFUSION DEXCOM G6 2 QL SET TRANSMITTER DEVICE CURITY 2 OTC ALCOHOL SWABS DEXCOM 2 TOPICAL PADS, RECEIVER MEDICATED DIAZOXIDE 2 DERMAVIEW II 2 OTC (BULK) POWDER TOPICAL 100 % BANDAGE 2 3/8 X diazoxide oral 1 2 3/4 ", 4 X 4 1/2 " suspension 50 mg/ml DERMAVIEW 2 OTC DISPOSABLE 2 TOPICAL NEEDLES BANDAGE 4 X 5 " NEEDLE 22 DEXCOM G4 2 GAUGE X 3/4" RECEIVER DISPOSABLE 2 OTC DEXCOM G4 2 POWER RECEIVER DROPLET 2 OTC PEDIATRIC LANCETS 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DROPLET 2 OTC EASY TOUCH 2 OTC LANCING DEVICE SAFETY EASIVENT 2 LANCETS 21 HOLDING GAUGE, 23 CHAMBER GAUGE, 26 SPACER GAUGE, 28 GAUGE, 30 EASIVENT MASK 2 GAUGE, 32 LARGE DEVICE GAUGE EASIVENT MASK 2 EASY TOUCH 2 OTC MEDIUM DEVICE TWIST LANCETS EASIVENT MASK 2 26 GAUGE, 28 SMALL DEVICE GAUGE, 30 GAUGE, 32 EASY COMFORT 2 OTC GAUGE, 33 ALCOHOL PAD GAUGE TOPICAL PADS, MEDICATED EASY TWIST AND 2 OTC CAP LANCETS 28 EASY COMFORT 2 OTC GAUGE LANCETS 30 GAUGE EMBRACE 2 OTC LANCETS 30 EASY MINI EJECT 2 OTC GAUGE LANCING DEVICE EASY TOUCH 2 OTC ALCOHOL PREP PADS TOPICAL PADS, MEDICATED EASY TOUCH 2 OTC LANCETS 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE EASY TOUCH 2 OTC LANCING DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits EXEL 2 FEMCAP 2 ACA HYPODERMIC VAGINAL DEVICE NEEDLES 22 MM, 26 MM, 30 NEEDLE 18 MM GAUGE X 1 1/2", FIFTY50 SAFETY 2 OTC 19 GAUGE X 1", 20 SEAL LANCETS 30 GAUGE X 1 1/2", GAUGE, 32 20 GAUGE X 1", 20 GAUGE X 3/4 ", 21 GAUGE X 1 1/2", 21 FILTER NEEDLES 2 GAUGE X 1", 22 NEEDLE 18 GAUGE X 1 1/2", GAUGE X 1 1/2" 22 GAUGE X 1", 22 FINE 30 2 OTC GAUGE X 3/4", 23 UNIVERSAL GAUGE X 3/4", 25 LANCETS 30 GAUGE X 1 1/2", GAUGE 25 GAUGE X 1", 25 GAUGE X 3/4", 25 FINGERSTIX 2 OTC GAUGE X 5/8", 26 LANCETS GAUGE X 1 1/2", FLEXICHAMBER 2 26 GAUGE X 1/2", SPACER 26 GAUGE X 3/8", FLEXICHAMBER- 2 26 GAUGE X 5/8", LG CHILD MASK 27 GAUGE X 1/2", DEVICE 30 GAUGE X 1/2" FLEXICHAMBER- 2 e-z ject lancets , 26 1 OTC gauge, 30 gauge, 32 SM ADULT MASK DEVICE gauge, 33 gauge FLEXICHAMBER- 2 e-z ject thin lancets 1 OTC SM CHILD MASK 28 gauge DEVICE EZ SMART 2 OTC FLOW-EZE 2 LANCETS 28 VENTED NEEDLE GAUGE NEEDLE EZ-LETS 26 2 OTC FORA LANCING 2 OTC GAUGE DEVICE FARXIGA ORAL 2 ST; QL FORACARE 2 OTC TABLET 10 MG, 5 LANCETS 30 MG GAUGE FC2 FEMALE 2 ACA; OTC FREESTYLE 2 OTC CONDOM CONTROL SOLUTION

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FREESTYLE 2 OTC glipizide oral tablet 1 FREEDOM KIT 10 mg, 5 mg FREESTYLE 2 OTC glipizide oral tablet 1 FREEDOM LITE extended release KIT 24hr 10 mg, 2.5 mg, 5 mg FREESTYLE 2 OTC INSULINX glipizide-metformin 1 oral tablet 2.5-250 FREESTYLE 2 OTC mg, 2.5-500 mg, 5- INSULINX STRIP 500 mg FREESTYLE 2 OTC INSULINX TEST GLUCAGEN 2 STRIPS STRIP DIAGNOSTIC KIT INJECTION FREESTYLE 2 OTC RECON SOLN 1 LANCETS 28 MG/ML GAUGE GLUCAGEN 2 QL FREESTYLE 2 HYPOKIT LIBRE 14 DAY INJECTION READER RECON SOLN 1 FREESTYLE 2 QL MG LIBRE 14 DAY GLUCAGON 2 QL SENSOR KIT (HCL) FREESTYLE 2 EMERGENCY KIT LIBRE 2 READER INJECTION RECON SOLN 1 FREESTYLE 2 MG LIBRE 2 SENSOR KIT glucagon emergency 1 QL kit (human) injection FREESTYLE LITE 2 OTC recon soln 1 mg METER KIT GLUCOCOM 2 OTC FREESTYLE LITE 2 OTC LANCETS 28 STRIPS STRIP GAUGE, 30 FREESTYLE TEST 2 OTC GAUGE, 33 STRIP GAUGE FREESTYLE 2 OTC GLUCOSE 2 OTC UNISTIK 2 KETONE CONTROL SOLN glimepiride oral 1 SOLUTION tablet 1 mg, 2 mg, 4 mg GLYBURIDE 2 (BULK) POWDER GLIPIZIDE (BULK) 2 POWDER 100 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits glyburide 1 HEALTHY 2 OTC micronized oral ACCENTS UNILET tablet 1.5 mg, 3 mg, LANCET 30 6 mg GAUGE glyburide oral tablet 1 huber safety needles 1 1.25 mg, 2.5 mg, 5 (disp.) needle 22 x mg 3/4 " glyburide-metformin 1 HUMALOG 2 oral tablet 1.25-250 KWIKPEN mg, 2.5-500 mg, 5- INSULIN 500 mg SUBCUTANEOUS GOJJI LANCETS 2 OTC INSULIN PEN 100 30 GAUGE UNIT/ML GOJJI LANCING 2 OTC HUMULIN R 2 DEVICE REGULAR U-100 INSULN GVOKE HYPOPEN 2 QL INJECTION 1-PACK SOLUTION 100 SUBCUTANEOUS UNIT/ML AUTO-INJECTOR 0.5 MG/0.1 ML, 1 HUMULIN R U-500 2 MG/0.2 ML (CONC) INSULIN SUBCUTANEOUS GVOKE HYPOPEN 2 QL SOLUTION 500 2-PACK UNIT/ML SUBCUTANEOUS AUTO-INJECTOR HYPODERMIC 2 0.5 MG/0.1 ML, 1 NEEDLES MG/0.2 ML NEEDLE 21 GAUGE X 1", 23 GVOKE PFS 1- 2 QL GAUGE X 1 1/2", PACK SYRINGE 26 GAUGE X 5/8" SUBCUTANEOUS SYRINGE 0.5 HYPOLANCE AST 2 OTC MG/0.1 ML, 1 LANCING KIT MG/0.2 ML ID NOW COVID-19 2 ACA GVOKE PFS 2- 2 QL TEST KIT KIT PACK SYRINGE INCONTROL 2 OTC SUBCUTANEOUS ALCOHOL PADS SYRINGE 0.5 TOPICAL PADS, MG/0.1 ML, 1 MEDICATED MG/0.2 ML INCONTROL 2 OTC HEALTHY 2 OTC LANCING DEVICE ACCENTS AUTOLET You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INCONTROL 2 OTC INSULIN 2 SUPER THIN SYRINGE- LANCETS 30 NEEDLE U-100 GAUGE SYRINGE 1 ML 28 INCONTROL 2 OTC GAUGE X 1/2", 1 ULTRA THIN ML 30 GAUGE X LANCETS 28 1/2" GAUGE INVACARE 2 OTC INJECT EASE 2 OTC LANCETS 30 LANCETS 28 GAUGE GAUGE, 30 INVOKAMET 2 ST; QL GAUGE ORAL TABLET INSPIRACHAMBE 2 150-1,000 MG, 150- R SPACER 500 MG, 50-1,000 MG, 50-500 MG INSPIRACHAMBE 2 R WITH MASK- INVOKAMET XR 2 ST; QL LARGE SPACER ORAL TABLET, IR - ER, BIPHASIC INSPIRACHAMBE 2 24HR 150-1,000 R WITH MASK- MG, 150-500 MG, MED SPACER 50-1,000 MG, 50- INSPIRACHAMBE 2 500 MG R WITH MASK- INVOKANA ORAL 2 ST; QL SMALL SPACER TABLET 100 MG, INSULIN 2 300 MG SYRINGE IV 2 OTC MICROFINE ADMINISTRATIO SYRINGE 1 ML 27 N SET INFUSION GAUGE X 5/8" SET INSULIN 2 IV PREP WIPES 2 OTC SYRINGE TOPICAL PADS, NEEDLELESS MEDICATED SYRINGE 1 ML JANUMET ORAL 2 PA; QL INSULIN 2 TABLET 50-1,000 SYRINGE MG, 50-500 MG SYRINGE 0.5 ML 29 GAUGE X 1/2" JANUMET XR 2 PA; QL ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits JANUVIA ORAL 2 PA; QL LANTUS U-100 2 TABLET 100 MG, INSULIN 25 MG, 50 MG SUBCUTANEOUS JARDIANCE 2 ST; QL SOLUTION 100 ORAL TABLET 10 UNIT/ML MG, 25 MG LANZO LANCING 2 OTC KENDALL 2 OTC DEVICE KIT TOPICAL LEVEMIR 2 BANDAGE 2 X 2 FLEXTOUCH U- 3/4 " 100 INSULN LANCETS , 21 2 OTC SUBCUTANEOUS GAUGE, 26 INSULIN PEN 100 GAUGE, 28 UNIT/ML (3 ML) GAUGE, 30 LEVEMIR U-100 2 GAUGE, 33 INSULIN GAUGE SUBCUTANEOUS LANCETS, SUPER 2 OTC SOLUTION 100 THIN UNIT/ML LANCETS,THIN , 2 OTC LIFESHIELD 2 23 GAUGE, 28 BLUNT CANNULA GAUGE NEEDLE 18 GAUGE X 1" LANCETS,ULTRA 2 OTC THIN , 26 GAUGE LITE TOUCH 2 OTC LANCETS 28 LANCING DEVICE 2 OTC GAUGE, 30 LANCING DEVICE 2 OTC GAUGE, 33 WITH LANCETS GAUGE LANCING DEVICE 2 OTC LITE TOUCH 2 OTC WITH LANCETS LANCING DEVICE KIT LITE TOUCH- 2 LANCING 2 OTC MEDIUM MASK SYSTEM DEVICE LANTUS 2 LITEAIRE MDI 2 SOLOSTAR U-100 CHAMBER INSULIN SPACER SUBCUTANEOUS LITETOUCH- 2 INSULIN PEN 100 LARGE MASK UNIT/ML (3 ML) DEVICE LITETOUCH- 2 SMALL MASK DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MEDISENSE 2 OTC metformin oral 1 ST; QL COMBO PACK tablet,er gast.retention 24 hr MEDISENSE 2 OTC 1,000 mg, 500 mg GLUCOSE KETONE COMBO MICRO THIN 2 OTC PACK LANCETS 33 MEDISENSE MID 2 OTC GAUGE CONTROL MICROCHAMBER 2 SOLUTION SPACER MEDISENSE THIN 2 OTC MICROLET 2 2 OTC LANCETS 28 LANCING DEVICE GAUGE KIT medlance plus 1 OTC MICROLET 2 OTC lancets 21 gauge, 25 LANCET gauge, 30 gauge MICROLET NEXT 2 OTC MEDLANCE PLUS 2 OTC LANCING DEVICE SPECIAL BLADE KIT 0.8 X 2 MM MICROSPACER 2 MEDTRONIC 2 OTC SPACER REMOTE miglitol oral tablet 1 CONTROL 100 mg, 25 mg, 50 METFORMIN 2 mg (BULK) POWDER MINI LANCING 2 OTC 100 % DEVICE metformin oral 1 ST MINIMED 530G 2 solution 500 mg/5 ml INSULIN PUMP metformin oral 1 MINIMED 630G 2 tablet 1,000 mg, 500 INSULIN PUMP mg, 850 mg MINIMED 670G 2 metformin oral 1 QL INSULIN PUMP tablet extended release 24 hr 500 MINIMED 770G 2 mg, 750 mg INSULIN PUMP metformin oral 1 ST; QL MINIMED 2 tablet extended INFUSION SET- release 24hr 1,000 MMT 390 mg, 500 mg INFUSION SET MINIMED MIO 2 ADVANCE INF SET23" INFUSION SET You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MINIMED MIO 2 MONOJECT 2 ADVANCE INF BLOOD SET43" INFUSION COLLECTION SET NEEDLE 20 MINIMED QUICK 2 GAUGE X 1", 20 X SET 18" INFUSION 1 1/2 ", 21 GAUGE SET X 1", 22 GAUGE X 1" MINIMED QUICK 2 SET 23" INFUSION MONOJECT 2 SET FILTER ASPIRATOR MINIMED QUICK 2 NEEDLE 18 X 3 " SET 32" INFUSION SET MONOJECT 2 FILTER NEEDLE MINIMED QUICK 2 NEEDLE 5 SET 43" INFUSION MICRON 20 X 1 SET 1/2" MINIMED 2 MONOJECT 2 SILHOUETTE 18" HYPODERMIC INFUSION SET NEEDLES MINIMED 2 NEEDLE 14 SILHOUETTE 23" GAUGE X 1 1/2", INFUSION SET 18 GAUGE X 1 1/2", 18 GAUGE X MINIMED 2 1", 19 GAUGE X 1 SILHOUETTE 32" 1/2", 19 GAUGE X INFUSION SET 1", 20 GAUGE X 1 MINIMED 2 1/2", 20 GAUGE X SILHOUETTE 43" 1", 21 GAUGE X 1 INFUSION SET 1/2", 21 GAUGE X 1", 22 GAUGE X 1 MINIMED SURE T 2 1/2", 22 GAUGE X 18" INFUSION SET 1", 23 GAUGE X MINIMED SURE T 2 1", 25 GAUGE X 1 23" INFUSION SET 1/2", 25 GAUGE X MINIMED SURE T 2 1", 25 GAUGE X 32" INFUSION SET 5/8", 26 GAUGE X 1 1/2", 27 GAUGE MINIMED 2 X 1 1/2", 27 SYRINGE GAUGE X 1/2", 30 RESERVOIR 3 ML GAUGE X 3/4" MIO INFUSION 2 SET INFUSION SET You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MONOJECT 2 NEEDLE (DISP) 23 2 HYPODERMIC GAUGE NEEDLE POLYPROPYL 23 GAUGE X 1" NEEDLE 18 NEEDLES, HUBER 2 GAUGE X 1 1/2" DISPOSABLE MONOJECT 2 NEEDLE 22 X 1 " MEDICATION NEXCARE 2 OTC TRANSF NDL TEGADERM NEEDLE 20 X 1 " TOPICAL MONOLET 2 OTC BANDAGE 4 X 4 LANCETS 21 3/4 " GAUGE NOKOR NEEDLE 2 MONOLET THIN 2 OTC NEEDLE 16 LANCETS 28 GAUGE X 1", 18 GAUGE GAUGE X 1" MOUTHPIECE 2 OTC NOVA SAFETY 2 OTC DEVICE LANCETS 23 MULTI-DRAW 2 GAUGE, 28 NEEDLE NEEDLE GAUGE 20 GAUGE X 1", 21 NOVA SUREFLEX 2 OTC GAUGE X 1", 22 LANCETS GAUGE X 1" NOVAMAX PLUS 2 OTC MULTI-LANCET 2 OTC KETONE STRIP DEVICE 2 KIT NOVOFINE 32 2 OTC MYGLUCOHEALT 2 OTC NEEDLE 32 H LANCETS 30 GAUGE X 1/4" GAUGE NOVOFINE 2 OTC nateglinide oral 1 AUTOCOVER tablet 120 mg, 60 mg NEEDLE 30 NEEDLE (DISP) 16 2 GAUGE X 1/3" G NEEDLE 16 NOVOFINE PLUS 2 OTC GAUGE X 1" NEEDLE 32 NEEDLE (DISP) 18 2 GAUGE X 1/6" G NEEDLE 18 NOVOTWIST 2 OTC GAUGE X 1" NEEDLE 32 NEEDLE (DISP) 19 2 GAUGE X 1/5" G NEEDLE 19 OMNIPOD DASH 5 2 GAUGE X 1 1/2" PACK POD SUBCUTANEOUS CARTRIDGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OMNIPOD 2 ONETOUCH 2 OTC INSULIN ULTRA BLUE MANAGEMENT TEST STRIP STRIP OMNIPOD 2 ONETOUCH 2 OTC INSULIN REFILL ULTRA CONTROL SUBCUTANEOUS SOLUTION CARTRIDGE ONETOUCH 2 OTC ON CALL LANCET 2 OTC ULTRA2 METER 30 GAUGE ONETOUCH 2 OTC ON CALL 2 OTC ULTRAMINI KIT LANCING DEVICE ONETOUCH 2 OTC ON CALL PLUS 2 OTC ULTRASOFT LANCET 30 LANCETS GAUGE ONETOUCH 2 OTC ON CALL PLUS 2 OTC VERIO FLEX LANCING DEVICE METER ONE WAY 2 OTC ONETOUCH 2 OTC VALVED VERIO HIGH MOUTHPIECE CONTROL DEVICE SOLUTION ONETOUCH 2 OTC ONETOUCH 2 OTC DELICA LANC VERIO IQ METER DEVICE KIT ONETOUCH 2 OTC ONETOUCH 2 OTC VERIO METER DELICA LANCETS ONETOUCH 2 OTC 30 GAUGE, 33 VERIO MID GAUGE CONTROL ONETOUCH 2 OTC SOLUTION DELICA PLUS ONETOUCH 2 OTC LANC DEV KIT VERIO REFLECT ONETOUCH 2 OTC METER DELICA PLUS ONETOUCH 2 OTC LANCET 30 VERIO TEST GAUGE, 33 STRIPS STRIP GAUGE ON-THE-GO 2 OTC ONETOUCH 2 OTC LANCETS 30 SURESOFT GAUGE LANCING DEV 18 GAUGE, 21 OPTICHAMBER 2 GAUGE, 28 ADULT MASK- GAUGE LARGE DEVICE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OPTICHAMBER 2 pioglitazone oral 1 QL DIAMOND LG tablet 15 mg, 30 mg, MASK SPACER 45 mg OPTICHAMBER 2 pioglitazone- 1 QL DIAMOND VHC glimepiride oral SPACER tablet 30-2 mg, 30-4 mg OPTICHAMBER 2 DIAMOND-MED pioglitazone- 1 QL MSK SPACER metformin oral tablet 15-500 mg, OPTICHAMBER 2 15-850 mg DIAMOND-SML MASK SPACER PIP LANCET 28 2 OTC OZEMPIC 2 PA; QL GAUGE, 30 SUBCUTANEOUS GAUGE PEN INJECTOR POCKET 2 0.25 MG OR 0.5 CHAMBER MG(2 MG/1.5 ML), SPACER 1 MG/DOSE (2 POLY HUB 2 MG/1.5 ML) NEEDLE NEEDLE OZEMPIC 2 PA 18 GAUGE X 1 SUBCUTANEOUS 1/2", 18 GAUGE X PEN INJECTOR 1 1", 21 GAUGE X 1 MG/DOSE (4 MG/3 1/2", 21 GAUGE X ML) 1", 22 GAUGE X 1 PANDA MASK 2 OTC 1/2", 22 GAUGE X DEVICE 1", 23 GAUGE X 1 1/2", 23 GAUGE X PARADIGM 2 1", 25 GAUGE X 1 RESERVOIR 1.8 1/2", 25 GAUGE X ML, 3 ML 1", 25 GAUGE X PARADIGM 2 5/8", 27 GAUGE X SILHOUETTE 1 1/4", 27 GAUGE INFUS SET X 1/2", 30 GAUGE X 1/2" PEDIATRIC 2 OTC MEDIUM MASK POLYSKIN II 2 OTC DEVICE TOPICAL BANDAGE 4 X 4 PEDIATRIC 2 OTC 3/4 " PANDA MASK DEVICE PRECISION XTRA 2 OTC B-KETONE STRIP PEDIATRIC 2 OTC SMALL MASK DEVICE You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PRECISION XTRA 2 OTC PRODIGY 2 OTC KETONE- LANCETS 26 GLUCOSE KIT GAUGE, 28 PRECISION XTRA 2 OTC GAUGE MONITOR PRODIGY 2 OTC PRECISION XTRA 2 OTC LANCING DEVICE TEST STRIP PRODIGY TWIST 2 OTC PRESSURE 2 OTC TOP LANCET 28 ACTIVATED GAUGE LANCETS 21 PURE COMFORT 2 OTC GAUGE, 28 ALCOHOL PADS GAUGE TOPICAL PADS, PRIMEAIRE 2 MEDICATED SPACER PURE COMFORT 2 OTC PRO COMFORT 2 OTC LANCETS 30 ALCOHOL PADS GAUGE TOPICAL PADS, PURE COMFORT 2 OTC MEDICATED SAFETY PRO COMFORT 2 OTC LANCETS 30 LANCET 30 GAUGE GAUGE, 31 PUSH BUTTON 2 OTC GAUGE SAFETY PRO COMFORT 2 LANCETS 28 SPACER-ADULT GAUGE MASK SPACER QUICK-SET 2 PRO COMFORT 2 PARADIGM SPACER-CHILD INFUSION SET MASK SPACER READYLANCE 2 OTC PROCARE 2 SAFETY SPACER WITH LANCETS 21 ADULT MASK GAUGE, 23 SPACER GAUGE, 26 GAUGE, 28 PROCARE 2 GAUGE, 30 SPACER WITH GAUGE CHILD MASK SPACER RELIAMED 2 OTC LANCET 28 PROCHAMBER 2 GAUGE, 30 SPACER GAUGE RELIAMED MINI 2 OTC LANCING DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RELIAMED 2 OTC SAFE-CLIP 2 OTC SAFETY SEAL NEEDLE LANCETS 28 STORAGE DEV GAUGE, 30 DEVICE GAUGE SAFETY 2 OTC RELION THIN 2 OTC LANCETS 21 LANCETS 26 GAUGE, 26 GAUGE GAUGE, 28 RELION ULTRA 2 OTC GAUGE THIN PLUS SAFETY NEEDLES 2 LANCETS NEEDLE 18 repaglinide oral 1 GAUGE X 1 1/2" tablet 0.5 mg, 1 mg, SAFETY SEAL 2 OTC 2 mg LANCETS 28 repaglinide- 1 QL GAUGE, 30 metformin oral GAUGE tablet 1-500 mg, 2- SAFETY-LET 2 OTC 500 mg LANCETS 30 REVEL 2 GAUGE PEDIATRIC SEGLUROMET 2 ST; QL PROGRAM PUMP ORAL TABLET REVEL 2 2.5-1,000 MG, 2.5- PROGRAMMABLE 500 MG, 7.5-1,000 PUMP MG, 7.5-500 MG RIGHTEST GD500 2 OTC SIDESTREAM 2 OTC LANCING DEVICE PEDIATRIC FACE MASK DEVICE RIGHTEST GL300 2 OTC LANCETS 30 SILHOUETTE 23"- 2 GAUGE FULL SET INFUSION SET RITEFLO 2 AEROCHAMBER SILHOUETTE 43"- 2 SPACER FULL SET INFUSION SET RYBELSUS ORAL 2 PA; QL TABLET 14 MG, 3 SILICONE MASK - 2 MG, 7 MG INFANT DEVICE SAFE-CLIP BY 2 OTC SILICONE MASK - 2 OTC MAIL DEVICE PEDIATRIC DEVICE SIL-SERTER 2 OTC SINGLE-LET 2 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SMART SENSE 2 OTC SUPER THIN 2 OTC LANCETS 21 LANCETS 28 GAUGE, 26 GAUGE, 30 GAUGE, 33 GAUGE GAUGE SURE COMFORT 2 OTC SMARTDIABETES 2 OTC ALCOHOL PREP VANTAGE PADS TOPICAL SMARTEST 2 OTC PADS, LANCET MEDICATED SOFT TOUCH 2 OTC SURE COMFORT 2 OTC LANCETS LANCETS 18 GAUGE, 21 SOLIQUA 100/33 2 QL GAUGE, 23 SUBCUTANEOUS GAUGE, 28 INSULIN PEN 100 GAUGE, 30 UNIT-33 MCG/ML GAUGE SOLUS V2 2 OTC SURE COMFORT 2 OTC LANCETS 28 LANCING PEN GAUGE, 30 GAUGE SUREFLEX 2 OTC DEVICE WITH SOLUS V2 2 OTC LANCETS KIT LANCING DEVICE KIT SUREFLEX 2 OTC LANCING DEVICE SPACE CHAMBER 2 SPACER SURE-LANCE , 26 2 OTC GAUGE, 28 SPACE CHAMBER 2 GAUGE WITH LARGE MASK SPACER SURE-LANCE 2 OTC ULTRA THIN 30 SPACE CHAMBER 2 GAUGE WITH MEDIUM MASK SPACER SURE-PEN 2 OTC LANCING DEVICE SPACE CHAMBER 2 WITH SMALL SURE-PREP 2 OTC MASK SPACER ALCOHOL PREP PADS TOPICAL STEGLATRO 2 ST; QL PADS, ORAL TABLET 15 MEDICATED MG, 5 MG SURESITE 2 OTC STERILANCE TL 2 OTC MATRIX TOPICAL 30 GAUGE, 32 BANDAGE 6 X 8 " GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SURESITE 2 OTC SYNJARDY ORAL 2 ST; QL WINDOW TABLET 12.5-1,000 TOPICAL MG, 12.5-500 MG, BANDAGE 4 X 4 5-1,000 MG, 5-500 1/2 " MG SURE-T INFUSION 2 SYNJARDY XR 2 ST; QL SET ORAL TABLET, IR SURE-T 2 - ER, BIPHASIC PARADIGM 24HR 10-1,000 MG, INFUSION SET 12.5-1,000 MG, 25- 1,000 MG, 5-1,000 SURE-TOUCH 2 OTC MG LANCET T:30 INFUSION 2 SURGUARD2 2 SET INFUSION SAFETY NEEDLE SET 18 GAUGE X 1 1/2", 18 GAUGE X T:90 INFUSION 2 1", 19 GAUGE X 1 SET 23" INFUSION 1/2", 19 GAUGE X SET 1", 20 GAUGE X 1 T:90 INFUSION 2 1/2", 20 GAUGE X SET 43" INFUSION 1", 21 GAUGE X 1 SET 1/2", 21 GAUGE X T:FLEX 2 1", 22 GAUGE X 1 SUBCUTANEOUS 1/2", 22 GAUGE X CARTRIDGE 1", 23 GAUGE X 1 1/2", 23 GAUGE X T:SLIM G4 2 1", 25 GAUGE X 1 SUBCUTANEOUS 1/2", 25 GAUGE X CARTRIDGE 1", 25 X 5/8 ", 26 T:SLIM INSULIN 2 GAUGE X 1/2", 27 DELIVERY GAUGE X 1/2", 30 SYSTEM GAUGE X 1 1/2" T:SLIM 2 SYMLINPEN 120 2 ST; QL SUBCUTANEOUS SUBCUTANEOUS CARTRIDGE PEN INJECTOR 2,700 MCG/2.7 ML T:SLIM X2 2 SUBCUTANEOUS SYMLINPEN 60 2 ST; QL CARTRIDGE SUBCUTANEOUS PEN INJECTOR TECHLITE 2 OTC 1,500 MCG/1.5 ML LANCETS 25 GAUGE, 28 GAUGE, 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TEGADERM 2 OTC TOUJEO 2 FIRST AID STYLE SOLOSTAR U-300 TOPICAL INSULIN BANDAGE 2 3/8 X SUBCUTANEOUS 2 3/4 ", 4 X 4 3/4 " INSULIN PEN 300 TEGADERM 2 OTC UNIT/ML (1.5 ML) FRAME STYLE TRANSPARENT 2 OTC TOPICAL DRESSINGS BANDAGE 2 3/8 X TOPICAL 2 3/4 ", 4 X 10 ", 4 BANDAGE 2 X 2 X 4 3/4 ", 6 X 8 ", 8 3/4 ", 4 X 4 3/4 " X 12 " TRANSPARENT 2 OTC TEGADERM HP 2 OTC THIN FILM FRAME STYLE DRESSING TOPICAL TOPICAL BANDAGE 2 3/8 X BANDAGE 2 3/8 X 2 3/4 ", 4 1/2 X 4 3/4 2 3/4 " ", 4 X 4 1/2 " TRESIBA 2 TEGADERM 2 OTC FLEXTOUCH U- TOPICAL 100 BANDAGE 2 X 2 SUBCUTANEOUS 3/4 ", 2.375 X 4 ", 3 INSULIN PEN 100 1/2 X 4 ", 4 X 4 3/4 UNIT/ML (3 ML) " TRESIBA 2 TELCARE 2 OTC FLEXTOUCH U- LANCETS 30 200 GAUGE SUBCUTANEOUS THIN LANCETS 26 2 OTC INSULIN PEN 200 GAUGE UNIT/ML (3 ML) TOPCARE 2 OTC TRESIBA U-100 2 UNIVERSAL1 INSULIN LANCET , 33 SUBCUTANEOUS GAUGE SOLUTION 100 UNIT/ML TOUJEO MAX U- 2 300 SOLOSTAR TRUE COMFORT 2 OTC SUBCUTANEOUS ALCOHOL PADS INSULIN PEN 300 TOPICAL PADS, UNIT/ML (3 ML) MEDICATED TRUE COMFORT 2 OTC LANCET 30 GAUGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRUEDRAW 2 OTC ULTILET 2 OTC LANCING DEVICE LANCETS 28 TRUEPLUS 2 OTC GAUGE, 30 LANCETS 26 GAUGE, 33 GAUGE, 28 GAUGE GAUGE, 30 ULTILET SAFETY 2 OTC GAUGE, 33 LANCETS 23 GAUGE GAUGE TRULICITY 2 PA; QL ULTRA THIN II 2 OTC SUBCUTANEOUS LANCETS 30 PEN INJECTOR GAUGE 0.75 MG/0.5 ML, ULTRA THIN 2 OTC 1.5 MG/0.5 ML, 3 LANCETS , 28 MG/0.5 ML, 4.5 GAUGE, 30 MG/0.5 ML GAUGE, 31 TRUSTEEL 2 GAUGE, 33 INFUSION SET 23" GAUGE INFUSION SET ULTRA THIN 2 OTC TRUSTEEL 2 PLUS LANCETS 33 INFUSION SET 32" GAUGE INFUSION SET ULTRA TLC 2 OTC TWIST LANCETS 2 OTC LANCETS 30 GAUGE, 32 ULTRA-CARE 2 OTC GAUGE LANCETS 30 ULTI-LANCE 2 OTC GAUGE ULTI-LANCE KIT 2 OTC ULTRALANCE 2 OTC ULTILET 2 OTC LANCETS 26 ALCOHOL SWAB GAUGE, 28 TOPICAL PADS, GAUGE MEDICATED ULTRA-THIN II 2 OTC ULTILET BASIC 2 OTC LANCETS 28 LANCETS 30 GAUGE GAUGE UNILET 2 OTC ULTILET CLASSIC 2 OTC COMFORTOUCH LANCETS , 28 LANCET , 26 GAUGE, 30 GAUGE GAUGE, 33 UNILET 2 OTC GAUGE EXCELITE II LANCET

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UNILET 2 OTC UNISTIK 3 2 OTC EXCELITE NORMAL LANCET LANCET 23 UNILET GP 2 OTC GAUGE LANCET UNISTIK CZT 2 OTC UNILET LANCET 2 OTC LANCET 23 28 GAUGE, 33 GAUGE, 28 GAUGE GAUGE UNILET LANCETS 2 OTC UNISTIK PRO 2 OTC 30 GAUGE LANCET 21 GAUGE, 25 UNILET SUPER 2 OTC GAUGE, 28 THIN LANCETS 30 GAUGE GAUGE UNISTIK SAFETY 2 OTC UNISTIK 2 2 OTC 28 GAUGE, 30 DEVICE KIT GAUGE UNISTIK 2 2 OTC UNISTIK TOUCH 2 OTC NORMAL LANCETS 21 LANCET,DEVICE GAUGE, 23 KIT GAUGE, 28 UNISTIK 3 2 OTC GAUGE, 30 COMFORT GAUGE DEVICE KIT UNIVERSAL 1 2 OTC UNISTIK 3 2 OTC LANCETS 21 COMFORT GAUGE, 26 LANCET GAUGE, 30 GAUGE, 33 UNISTIK 3 EXTRA 2 OTC GAUGE LANCET 21 GAUGE VARISOFT 2 INFUSION SET 23" UNISTIK 3 2 OTC INFUSION SET GENTLE 30 GAUGE VARISOFT 2 INFUSION SET 32" UNISTIK 3 KIT 2 OTC INFUSION SET UNISTIK 3 2 OTC VARISOFT 2 LANCETS 21 INFUSION SET 43" GAUGE INFUSION SET UNISTIK 3 2 OTC V-GO 20 DEVICE 2 NEONATAL DEVICE KIT V-GO 30 DEVICE 2 V-GO 40 DEVICE 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VIVAGUARD 2 OTC ACTHREL 2 LANCET 30 INTRAVENOUS GAUGE RECON SOLN 100 VIVAGUARD 2 OTC MCG LANCING DEVICE ALDURAZYME 2 PA; SP VORTEX ADULT 2 OTC INTRAVENOUS MASK DEVICE SOLUTION 2.9 MG/5 ML VORTEX 2 HOLDING ANDRODERM 2 PA; QL CHAMBER TRANSDERMAL SPACER PATCH 24 HOUR 2 MG/24 HOUR, 4 VORTEX VHC 2 MG/24 HR FROG MASK- CHILD SPACER BRINEURA 2 PA; SP INTRAVENTRICU VORTEX VHC 2 LAR KIT 300 LADYBUG MASK- MG/10 ML TODDLR SPACER (150MG/5ML X2) WEBCOL 2 OTC cabergoline oral 1 QL TOPICAL PADS, tablet 0.5 mg MEDICATED calcitonin (salmon) 1 XIGDUO XR 2 ST; QL nasal spray,non- ORAL TABLET, IR aerosol 200 - ER, BIPHASIC unit/actuation 24HR 10-1,000 MG, calcitriol 10-500 MG, 2.5- 1 intravenous solution 1,000 MG, 5-1,000 1 mcg/ml MG, 5-500 MG calcitriol oral XULTOPHY 2 QL 1 capsule 0.25 mcg, 100/3.6 0.5 mcg SUBCUTANEOUS INSULIN PEN 100 calcitriol oral 1 UNIT-3.6 MG /ML solution 1 mcg/ml (3 ML) CERDELGA ORAL 2 PA; SP YALE 2 CAPSULE 84 MG DISPOSABLE CEREZYME 2 PA; SP NEEDLES INTRAVENOUS NEEDLE 21 RECON SOLN 400 GAUGE X 1 1/4" UNIT MISCELLANEOUS HORMONES CETROTIDE 2 SP SUBCUTANEOUS KIT 0.25 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CHOR 2 desmopressin nasal 1 GONADOTROPIN, spray with pump 10 HUM (BULK) mcg/spray (0.1 ml) POWDER 1 desmopressin nasal 1 MILLION UNIT, 2 spray,non-aerosol MILLION UNIT, 5 10 mcg/spray (0.1 MILLION UNIT ml) cinacalcet oral 1 ST desmopressin oral 1 tablet 30 mg, 60 mg, tablet 0.1 mg, 0.2 mg 90 mg doxercalciferol 1 CLOMIPHENE 2 intravenous solution CITRATE (BULK) 4 mcg/2 ml POWDER 100 % doxercalciferol oral 1 ST clomiphene citrate 1 capsule 0.5 mcg, 1 oral tablet 50 mg mcg, 2.5 mcg CRYSVITA 2 PA; SP; QL ELAPRASE 2 PA; SP SUBCUTANEOUS INTRAVENOUS SOLUTION 10 SOLUTION 6 MG/3 MG/ML, 20 ML MG/ML, 30 MG/ML FABRAZYME 2 PA; SP INTRAVENOUS DANAZOL (BULK) 2 RECON SOLN 35 POWDER MG, 5 MG danazol oral capsule 1 ganirelix 1 SP 100 mg, 200 mg, 50 subcutaneous mg syringe 250 mcg/0.5 DDAVP NASAL 2 ml SOLUTION 0.1 GONAL-F RFF 2 ST; SP MG/ML REDI-JECT (REFRIGERATE) SUBCUTANEOUS DEHYDROEPIAN 2 PEN INJECTOR DROSTERONE 300/0.5 UNIT/ML, (MICRO) POWDER 450/0.75 UNIT/ML, 100 % 900/1.5 UNIT/ML DESMOPRESSIN 2 GONAL-F RFF 2 ST; SP ACETATE (BULK) SUBCUTANEOUS POWDER RECON SOLN 75 desmopressin 1 SP UNIT injection solution 4 mcg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GONAL-F 2 ST; SP MYALEPT 2 PA; SP SUBCUTANEOUS SUBCUTANEOUS RECON SOLN RECON SOLN 5 1,050 UNIT, 450 MG/ML (FINAL UNIT CONC.) KANUMA 2 PA; SP NAGLAZYME 2 PA; SP INTRAVENOUS INTRAVENOUS SOLUTION 2 SOLUTION 5 MG/5 MG/ML ML LUMIZYME 2 PA; SP NANDROLONE 2 INTRAVENOUS DECANOATE RECON SOLN 50 (BULK) POWDER MG 100 % MENOPUR 2 SP NATESTO NASAL 2 PA; QL SUBCUTANEOUS GEL IN RECON SOLN 75 METERED-DOSE UNIT PUMP 5.5 MEPSEVII 2 PA; SP MG/0.122 INTRAVENOUS GRAM/ACTUATIO SOLUTION 2 N MG/ML NATPARA 2 PA; SP METHITEST 2 SUBCUTANEOUS ORAL TABLET 10 CARTRIDGE 100 MG MCG/DOSE, 25 MCG/DOSE, 50 METHYLTESTOST 2 MCG/DOSE, 75 ERONE (BULK) MCG/DOSE POWDER NOVAREL 2 SP; QL methyltestosterone 1 INTRAMUSCULA oral capsule 10 mg R RECON SOLN METHYLTESTOST 2 10,000 UNIT, 5,000 ERONE,MICRO(B UNIT ULK) POWDER ORILISSA ORAL 2 ST; QL 100 % TABLET 150 MG, MIACALCIN 2 200 MG INJECTION OVIDREL 2 SP SOLUTION 200 SUBCUTANEOUS UNIT/ML SYRINGE 250 miglustat oral 1 PA; SP MCG/0.5 ML capsule 100 mg OXANDROLONE 2 (BULK) POWDER 100 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxandrolone oral 1 STANOZOLOL 2 tablet 10 mg, 2.5 mg MICRONIZED PALYNZIQ 2 PA; SP; QL (BULK) POWDER SUBCUTANEOUS 100 % SYRINGE 10 STRENSIQ 2 PA; SP MG/0.5 ML, 2.5 SUBCUTANEOUS MG/0.5 ML, 20 SOLUTION 18 MG/ML MG/0.45 ML, 28 pamidronate 1 MG/0.7 ML, 40 intravenous recon MG/ML, 80 MG/0.8 soln 30 mg, 90 mg ML pamidronate 1 SYNAREL NASAL 2 intravenous solution SPRAY,NON- 30 mg/10 ml (3 AEROSOL 2 mg/ml), 60 mg/10 ml MG/ML (6 mg/ml), 90 mg/10 TESTOSTERONE 2 ml (9 mg/ml) (BULK) POWDER paricalcitol 1 TESTOSTERONE 2 intravenous solution CYP, MICRO 2 mcg/ml, 5 mcg/ml (BULK) POWDER paricalcitol oral 1 ST 100 % capsule 1 mcg, 2 TESTOSTERONE 2 mcg, 4 mcg CYPIONATE SAMSCA ORAL 2 PA; SP; QL (BULK) POWDER TABLET 15 MG 100 % testosterone sapropterin oral 1 PA; SP 1 PA cypionate powder in packet intramuscular oil 100 mg, 500 mg 100 mg/ml, 200 sapropterin oral 1 PA; SP mg/ml tablet,soluble 100 mg TESTOSTERONE 2 ENANTHATE serophene oral 1 (BULK) POWDER tablet 50 mg 100 % SOMAVERT 2 PA; SP testosterone 1 PA SUBCUTANEOUS enanthate RECON SOLN 10 intramuscular oil MG, 15 MG, 20 200 mg/ml MG, 25 MG, 30 MG TESTOSTERONE 2 STANOZOLOL 2 MICRONIZED (BULK) POWDER (BULK) POWDER 100 % 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 141 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TESTOSTERONE 2 zoledronic acid 1 SP PROPIONATE intravenous solution (BULK) POWDER 4 mg/5 ml testosterone 1 PA; QL zoledronic acid- 1 SP transdermal gel 50 mannitol-water mg/5 gram (1 %) intravenous piggyback 4 mg/100 testosterone 1 PA; QL transdermal gel in ml metered-dose pump THYROID HORMONES 10 mg/0.5 gram /actuation, 12.5 mg/ ARMOUR 2 1.25 gram (1 %), THYROID ORAL 20.25 mg/1.25 gram TABLET 120 MG, 15 MG, 180 MG, (1.62 %) 240 MG, 30 MG, testosterone 1 PA; QL 300 MG, 60 MG, 90 transdermal gel in MG packet 1 % (25 euthyrox oral tablet mg/2.5gram), 1 % 1 100 mcg, 112 mcg, (50 mg/5 gram), 125 mcg, 137 mcg, 1.62 % (20.25 150 mcg, 175 mcg, mg/1.25 gram), 1.62 200 mcg, 25 mcg, 50 % (40.5 mg/2.5 mcg, 75 mcg, 88 mcg gram) levo-t oral tablet 100 1 testosterone 1 PA; QL mcg, 112 mcg, 125 transdermal solution mcg, 137 mcg, 150 in metered pump mcg, 175 mcg, 200 w/app 30 mcg, 25 mcg, 300 mg/actuation (1.5 mcg, 50 mcg, 75 ml) mcg, 88 mcg TETRAHYDROBIO 2 LEVOTHYROXINE 2 PTERIN DI-HCL (BULK) POWDER POWDER , 100 % 1 MG/GRAM, 100 tolvaptan oral tablet 1 PA; SP; QL % 30 mg levothyroxine 1 VIMIZIM 2 PA; SP intravenous recon INTRAVENOUS soln 100 mcg, 200 SOLUTION 5 MG/5 mcg, 500 mcg ML (1 MG/ML) zoledronic acid 1 SP intravenous recon soln 4 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits levothyroxine oral 1 westhroid oral tablet 1 tablet 100 mcg, 112 130 mg, 195 mg, mcg, 125 mcg, 137 32.5 mg, 65 mg, 97.5 mcg, 150 mcg, 175 mg mcg, 200 mcg, 25 mcg, 300 mcg, 50 GASTROENTEROLOGY mcg, 75 mcg, 88 mcg ANTIDIARRHEALS /

LIOTHYRONINE 2 ANTISPASMODICS (BULK) POWDER anaspaz oral 1 1 MG/GRAM, 100 tablet,disintegrating % 0.125 mg liothyronine 1 atropine injection 1 intravenous solution solution 0.4 mg/ml, 1 10 mcg/ml mg/ml liothyronine oral 1 atropine injection 1 tablet 25 mcg, 5 syringe 0.05 mg/ml, mcg, 50 mcg 0.1 mg/ml np thyroid oral 1 atropine intravenous 1 tablet 120 mg, 15 syringe 0.8 mg/2 ml mg, 30 mg, 60 mg, (0.4 mg/ml) 90 mg ATTAPULGITE 2 PCCA T3 SODIUM 2 (BULK) POWDER DILUTION POWDER 1 BELLADONNA 2 MG/GRAM ALK LEAF EXT (BULK) POWDER PCCA T4 SODIUM 2 1.15 TO 1.35 % DILUTION POWDER 1 belladonna 1 MG/GRAM alkaloids-opium rectal suppository PROTIRELIN 2 16.2-30 mg, 16.2-60 (BULK) POWDER mg 98 % BELLADONNA 2 THYROID, PORK 2 TINCTURE (BULK) POWDER (BULK) LIQUID 30 100 % USP MG/100 ML unithroid oral tablet 1 BISMUTH 2 100 mcg, 112 mcg, SUBCARBONATE 125 mcg, 137 mcg, (BULK) POWDER 150 mcg, 175 mcg, 200 mcg, 25 mcg, BISMUTH 2 300 mcg, 50 mcg, 75 SUBGALLATE mcg, 88 mcg (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 143 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BISMUTH 2 glycopyrrolate 1 SUBSALICYLATE injection solution 0.2 (BULK) POWDER mg/ml chlordiazepoxide- 1 glycopyrrolate oral 1 clidinium oral tablet 1 mg, 1.5 mg, capsule 5-2.5 mg 2 mg CLIDINIUM 2 HOMATROPINE 2 BROMIDE (BULK) METHYLBROM POWDER 100 % (BULK) POWDER DICYCLOMINE 2 100 % (BULK) POWDER HYOSCYAMINE 2 100 % SULFATE (BULK) dicyclomine 1 POWDER intramuscular hyoscyamine sulfate 1 solution 10 mg/ml oral drops 0.125 mg/ml dicyclomine oral 1 capsule 10 mg hyoscyamine sulfate 1 oral elixir 0.125 dicyclomine oral 1 mg/5 ml solution 10 mg/5 ml hyoscyamine sulfate dicyclomine oral 1 1 oral tablet 0.125 mg tablet 20 mg hyoscyamine sulfate diphenoxylate- 1 1 oral tablet extended atropine oral liquid release 12 hr 0.375 2.5-0.025 mg/5 ml mg diphenoxylate- 1 hyoscyamine sulfate atropine oral tablet 1 oral 2.5-0.025 mg tablet,disintegrating ed-spaz oral 1 0.125 mg tablet,disintegrating hyoscyamine sulfate 0.125 mg 1 sublingual tablet GLYCOPYRROLA 2 0.125 mg TE (BULK) hyosyne oral drops POWDER 100 % 1 0.125 mg/ml glycopyrrolate (pf) 1 in water intravenous hyosyne oral elixir 1 0.125 mg/5 ml syringe 0.4 mg/2 ml (0.2 mg/ml), 1 mg/5 ISOPROPAMIDE 2 ml (0.2 mg/ml) IODIDE (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LEVSIN 2 PROPANTHELINE 2 INJECTION (BULK) POWDER SOLUTION 0.5 symax fastabs oral 1 MG/ML tablet,disintegrating LOPERAMIDE 2 0.125 mg (BULK) POWDER symax-sl sublingual 1 METHSCOPOLAM 2 tablet 0.125 mg INE BROMIDE symax-sr oral tablet 1 (BULK) POWDER extended release 12 METHSCOPOLAM 2 hr 0.375 mg INE NITRATE MISCELLANEOUS (BULK) POWDER GASTROINTESTINAL AGENTS 100 % opium tincture oral 1 5- 2 tincture 10 mg/ml AMINOSALICYLI (morphine) C ACID POWDER alophen (bisacodyl) oscimin oral tablet 1 1 ACA; OTC oral tablet,delayed 0.125 mg release (dr/ec) 5 mg oscimin sl sublingual 1 alosetron oral tablet tablet 0.125 mg 1 0.5 mg, 1 mg oscimin sr oral 1 tablet extended ALUMINUM 2 release 12 hr 0.375 HYDROXIDE GEL mg (BULK) POWDER alvimopan oral phenobarb-hyoscy- 1 1 atropine-scop oral capsule 12 mg elixir 16.2 mg- AMINOSALICYLI 2 0.1037 mg/5 ml (5 C ACID-5 ml), 16.2-0.1037 - POWDER 0.0194 mg/5 ml anucort-hc rectal 1 phenobarb-hyoscy- 1 suppository 25 mg atropine-scop oral APOMORPHINE 2 tablet 16.2-0.1037 - (BULK) POWDER 0.0194 mg aprepitant oral 1 QL phenohytro oral 1 capsule 125 mg, 40 elixir 16.2-0.1037 - mg, 80 mg 0.0194 mg/5 ml aprepitant oral 1 QL phenohytro oral 1 capsule,dose pack tablet 16.2-0.1037 - 125 mg (1)- 80 mg 0.0194 mg (2)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 145 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits balsalazide oral 1 CREON ORAL 2 capsule 750 mg CAPSULE,DELAY BISACODYL 2 ED (BULK) POWDER RELEASE(DR/EC) 12,000-38,000 - bisacodyl oral 1 ACA; OTC 60,000 UNIT, tablet,delayed 24,000-76,000 - release (dr/ec) 5 mg 120,000 UNIT, bisa-lax (bisacodyl) 1 ACA; OTC 3,000-9,500- 15,000 oral tablet,delayed UNIT, 36,000- release (dr/ec) 5 mg 114,000- 180,000 UNIT, 6,000-19,000 budesonide oral 1 -30,000 UNIT capsule,delayed,exte nd.release 3 mg cromolyn oral 1 concentrate 100 budesonide oral 1 mg/5 ml tablet,delayed and ext.release 9 mg CYSTADANE 2 SP ORAL POWDER 1 CHENODAL ORAL 2 PA; SP GRAM/1.7 ML TABLET 250 MG DIMENHYDRINAT 2 CHOLBAM ORAL 2 PA; SP E (BULK) CAPSULE 250 MG POWDER 100 % CHOLBAM ORAL 2 PA; SP; QL dimenhydrinate 1 CAPSULE 50 MG injection solution 50 CINVANTI 2 mg/ml INTRAVENOUS DIPHENIDOL 2 EMULSION 7.2 (BULK) POWDER MG/ML DOCUSATE 2 citrate of magnesia 1 ACA; OTC SODIUM (BULK) oral solution POWDER , 85 % citroma oral solution 1 ACA; OTC doxylamine- 1 QL clearlax oral powder 1 ACA; OTC pyridoxine (vit b6) 17 gram/dose oral tablet,delayed release (dr/ec) 10-10 clearlax oral powder 1 ACA; OTC mg in packet 17 gram dronabinol oral 1 PA compro rectal 1 capsule 10 mg, 2.5 suppository 25 mg mg, 5 mg constulose oral 1 DROPERIDOL 2 solution 10 gram/15 (BULK) POWDER ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits droperidol injection 1 glycolax oral 1 ACA; OTC solution 2.5 mg/ml powder 17 gram/dose dulcolax 1 ACA; OTC (magnesium granisetron (pf) 1 hydroxide) oral intravenous solution suspension 400 mg/5 1 mg/ml (1 ml), 100 ml mcg/ml ENTYVIO 2 PA; SP granisetron hcl 1 INTRAVENOUS intravenous solution RECON SOLN 300 1 mg/ml, 1 mg/ml (1 MG ml) enulose oral solution 1 granisetron hcl oral 1 QL 10 gram/15 ml tablet 1 mg fleet laxative 1 ACA; OTC healthylax oral 1 ACA; OTC (bisacodyl) oral powder in packet 17 tablet,delayed gram release (dr/ec) 5 mg hemmorex-hc rectal 1 fosaprepitant 1 suppository 25 mg intravenous recon hydrocortisone 1 soln 150 mg acetate rectal gavilax oral powder 1 ACA; OTC suppository 25 mg, 17 gram/dose 30 mg gavilyte-c oral recon 1 ACA hydrocortisone 1 soln 240-22.72-6.72 rectal enema 100 -5.84 gram mg/60 ml gavilyte-g oral recon 1 ACA hydrocortisone 1 soln 236-22.74-6.74 topical cream with -5.86 gram perineal applicator 1 % gavilyte-n oral recon 1 ACA soln 420 gram hydrocortisone- 1 pramoxine rectal generlac oral 1 cream 1-1 %, 2.5-1 solution 10 gram/15 % (4g) ml hydrocortisone- gentle laxative 1 ACA; OTC 1 ST (bisacodyl) oral pramoxine rectal tablet,delayed cream 2.5-1 % release (dr/ec) 5 mg KINEVAC 2 gentlelax oral 1 ACA; OTC INJECTION powder 17 RECON SOLN 5 gram/dose MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 147 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lactulose oral packet 1 magnesium citrate 1 ACA; OTC 10 gram oral solution lactulose oral 1 MAGNESIUM 2 solution 10 gram/15 SULFATE (BULK) ml, 10 gram/15 ml CRYSTALS 100 % (15 ml), 20 gram/30 MECLIZINE HCL 2 ml (BULK) POWDER laxaclear oral 1 ACA; OTC MESALAMINE 2 powder 17 (BULK) POWDER gram/dose mesalamine oral 1 laxative (bisacodyl) 1 ACA; OTC capsule (with del rel oral tablet 5 mg tablets) 400 mg laxative (bisacodyl) 1 ACA; OTC mesalamine oral 1 oral tablet,delayed capsule,extended release (dr/ec) 5 mg release 24hr 0.375 laxative peg 3350 1 ACA; OTC gram oral powder 17 mesalamine oral 1 gram/dose tablet,delayed lidocaine hcl- 1 release (dr/ec) 1.2 hydrocortison ac gram rectal cream 3-0.5 % mesalamine rectal 1 lidocaine hcl- 1 enema 4 gram/60 ml hydrocortison ac mesalamine rectal 1 rectal kit 2 %-2 % (7 suppository 1,000 gram), 3-0.5 %, 3-1 mg % (7 gram) mesalamine with 1 lidocaine- 1 cleansing wipe hydrocortisone-aloe rectal enema kit 4 rectal gel 2.8-0.55 % gram/60 ml lidocaine- 1 METOCLOPRAMI 2 hydrocortisone-aloe DE (BULK) rectal kit 3-2.5 % (7 POWDER gram) metoclopramide hcl 1 LINZESS ORAL 2 QL injection solution 5 CAPSULE 145 mg/ml MCG, 290 MCG, 72 MCG metoclopramide hcl 1 injection syringe 5 MAGNESIUM 2 mg/ml CITRATE (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits metoclopramide hcl 1 ondansetron hcl oral 1 QL oral solution 5 mg/5 solution 4 mg/5 ml ml ondansetron hcl oral 1 QL metoclopramide hcl 1 tablet 24 mg oral tablet 10 mg, 5 ondansetron oral 1 QL mg tablet,disintegrating metoclopramide hcl 1 4 mg, 8 mg oral oral saline laxative 1 ACA; OTC tablet,disintegrating oral liquid 7.2-2.7 10 mg, 5 mg gram/15 ml milk of magnesia 1 ACA; OTC palonosetron 1 concentrated oral intravenous solution suspension 2,400 0.25 mg/5 ml mg/10 ml palonosetron 1 milk of magnesia 1 ACA; OTC intravenous syringe oral suspension 400 0.25 mg/5 ml mg/5 ml PANCREATIN 2 miralax oral powder 1 ACA; OTC (BULK) POWDER in packet 17 gram PANCREAZE 2 MOVANTIK ORAL 2 QL ORAL TABLET 12.5 MG, CAPSULE,DELAY 25 MG ED natura-lax oral 1 ACA; OTC RELEASE(DR/EC) powder 17 10,500-35,500- gram/dose 61,500 UNIT, OCALIVA ORAL 2 PA; SP; QL 16,800-56,800- TABLET 10 MG, 5 98,400 UNIT, 2,600- MG 6,200- 10,850 UNIT, 21,000-54,700- ONDANSETRON 2 83,900 UNIT, 4,200- HCL (BULK) 14,200- 24,600 POWDER 100 % UNIT ondansetron hcl (pf) 1 peg 3350- 1 ACA injection solution 4 electrolytes oral mg/2 ml recon soln 236- ondansetron hcl (pf) 1 22.74-6.74 -5.86 injection syringe 4 gram mg/2 ml peg3350-sod sul- 1 ACA ondansetron hcl 1 nacl-kcl-asb-c oral intravenous solution powder in packet 2 mg/ml 100-7.5-2.691 gram

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 149 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits peg-electrolyte soln 1 ACA PROCHLORPERAZ 2 oral recon soln 420 INE gram MALEATE(BULK) peg-prep oral kit 5- 1 ACA POWDER 210 mg-gram prochlorperazine 1 rectal suppository 25 PENTASA ORAL 2 mg CAPSULE, EXTENDED procto-pak topical 1 RELEASE 250 MG, cream with perineal 500 MG applicator 1 % phosphate laxative 1 ACA; OTC proctosol hc topical 1 oral liquid 7.2-2.7 cream with perineal gram/15 ml applicator 2.5 % polyethylene glycol 1 ACA; OTC purelax oral powder 1 ACA; OTC 3350 oral powder 17 17 gram/dose gram/dose purelax oral powder 1 ACA; OTC polyethylene glycol 1 ACA in packet 17 gram 3350 oral powder in RECTIV RECTAL 2 packet 17 gram OINTMENT 0.4 % powderlax oral 1 ACA; OTC (W/W) powder 17 RELISTOR ORAL 2 ST gram/dose TABLET 150 MG powderlax oral 1 ACA; OTC RELISTOR 2 ST powder in packet 17 SUBCUTANEOUS gram SOLUTION 12 PRAMOXINE HCL 2 MG/0.6 ML (BULK) POWDER RELISTOR 2 ST prochlorperazine 1 SUBCUTANEOUS edisylate injection SYRINGE 12 solution 10 mg/2 ml MG/0.6 ML, 8 (5 mg/ml), 5 mg/ml MG/0.4 ML PROCHLORPERAZ 2 REMICADE 2 PA; SP INE INTRAVENOUS EDISYLT(BULK) RECON SOLN 100 POWDER 100 % MG prochlorperazine 1 scopolamine base 1 maleate oral tablet transdermal patch 3 10 mg, 5 mg day 1 mg over 3 days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 150 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SCOPOLAMINE 2 UCERIS RECTAL 2 HBR (BULK) FOAM 2 POWDER MG/ACTUATION SIMETHICONE 2 URSODIOL 2 (BULK) LIQUID (BULK) POWDER smoothlax oral 1 ACA; OTC 100 % powder 17 ursodiol oral 1 gram/dose capsule 300 mg smoothlax oral 1 ACA; OTC ursodiol oral tablet 1 powder in packet 17 250 mg, 500 mg gram VARUBI ORAL 2 QL SODIUM 2 TABLET 90 MG PHOSPHATE,DIBA VIBERZI ORAL 2 SIC(BULK) TABLET 100 MG, POWDER 75 MG SUCRAID ORAL 2 PA; SP VIOKACE ORAL 2 SOLUTION 8,500 TABLET 10,440- UNIT/ML 39,150- 39,150 SULFASALAZINE 2 UNIT, 20,880- (BULK) POWDER 78,300- 78,300 sulfasalazine oral 1 UNIT tablet 500 mg woman's laxative 1 ACA; OTC (bisacodyl) oral sulfasalazine oral 1 tablet,delayed tablet 5 mg release (dr/ec) 500 women's gentle 1 ACA; OTC mg laxative(bisac) oral tablet,delayed SYMPROIC ORAL 2 release (dr/ec) 5 mg TABLET 0.2 MG women's laxative trilyte with flavor 1 ACA 1 ACA; OTC packets oral recon (bisacodyl) oral tablet 5 mg soln 420 gram women's laxative TRIMETHOBENZA 2 1 ACA; OTC (bisacodyl) oral MIDE (BULK) tablet,delayed POWDER 100 % release (dr/ec) 5 mg trimethobenzamide 1 oral capsule 300 mg TRULANCE ORAL 2 TABLET 3 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 151 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZENPEP ORAL 2 esomeprazole 1 ST; QL CAPSULE,DELAY magnesium oral ED granules dr for susp RELEASE(DR/EC) in packet 10 mg, 20 10,000-32,000 - mg 42,000 UNIT, esomeprazole 1 ST 15,000-47,000 - magnesium oral 63,000 UNIT, granules dr for susp 20,000-63,000- in packet 40 mg 84,000 UNIT, 25,000-79,000- esomeprazole 1 105,000 UNIT, sodium intravenous 3,000-10,000 - recon soln 20 mg, 40 14,000-UNIT, mg 40,000-126,000- FAMOTIDINE 2 168,000 UNIT, (BULK) POWDER 5,000-17,000- 100 % 24,000 UNIT famotidine (pf) 1 ULCER THERAPY intravenous solution amoxicil- 1 QL 20 mg/2 ml clarithromy- famotidine (pf)-nacl 1 lansopraz oral (iso-os) intravenous combo pack 500- piggyback 20 mg/50 500-30 mg ml CIMETIDINE 2 famotidine 1 (BULK) POWDER intravenous solution cimetidine hcl oral 1 10 mg/ml solution 300 mg/5 ml famotidine oral 1 cimetidine oral 1 suspension 40 mg/5 tablet 300 mg, 400 ml (8 mg/ml) mg, 800 mg famotidine oral 1 esomeprazole 1 QL tablet 40 mg magnesium oral LANSOPRAZOLE 2 capsule,delayed (BULK) POWDER release(dr/ec) 20 mg 100 % esomeprazole 1 lansoprazole oral 1 magnesium oral capsule,delayed capsule,delayed release(dr/ec) 30 mg release(dr/ec) 40 mg lansoprazole oral 1 QL tablet,disintegrat, delay rel 15 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 152 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lansoprazole oral 1 pantoprazole oral 1 ST tablet,disintegrat, granules dr for susp delay rel 30 mg in packet 40 mg MISOPROSTOL 2 pantoprazole oral 1 QL (BULK) POWDER tablet,delayed 1 % release (dr/ec) 20 mg misoprostol oral 1 tablet 100 mcg, 200 pantoprazole oral 1 mcg tablet,delayed release (dr/ec) 40 nizatidine oral 1 mg capsule 150 mg, 300 mg rabeprazole oral 1 tablet,delayed nizatidine oral 1 release (dr/ec) 20 solution 150 mg/10 mg ml ranitidine hcl oral OMEPRAZOLE 2 1 tablet 300 mg (BULK) POWDER 100 % SUCRALFATE 2 omeprazole oral 1 QL (BULK) POWDER capsule,delayed sucralfate oral tablet 1 release(dr/ec) 10 mg 1 gram omeprazole oral 1 TALICIA ORAL 2 QL capsule,delayed CAPSULE,IR - release(dr/ec) 20 DELAY mg, 40 mg REL,BIPHASE 10- omeprazole-sodium 1 PA 250-12.5 MG bicarbonate oral IMMUNOLOGY, VACCINES / capsule 40-1.1 mg- BIOTECHNOLOGY gram omeprazole-sodium 1 PA; QL BIOTECHNOLOGY DRUGS bicarbonate oral ACTIMMUNE 2 PA; SP packet 20-1,680 mg SUBCUTANEOUS omeprazole-sodium 1 PA SOLUTION 100 bicarbonate oral MCG/0.5 ML packet 40-1,680 mg ALFERON N 2 pantoprazole 1 INJECTION intravenous recon SOLUTION 5 soln 40 mg MILLION UNIT/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 153 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AVONEX 2 PA; SP; QL ILARIS (PF) 2 SP INTRAMUSCULA SUBCUTANEOUS R PEN INJECTOR SOLUTION 150 KIT 30 MCG/0.5 MG/ML ML INTRON A 2 SP AVONEX 2 PA; SP; QL INJECTION INTRAMUSCULA RECON SOLN 10 R SYRINGE KIT 30 MILLION UNIT (1 MCG/0.5 ML ML), 18 MILLION BETASERON 2 PA; SP; QL UNIT (1 ML), 50 SUBCUTANEOUS MILLION UNIT (1 KIT 0.3 MG ML) EGRIFTA SV 2 PA; SP INTRON A 2 SP SUBCUTANEOUS INJECTION RECON SOLN 2 SOLUTION 10 MG MILLION UNIT/ML, 6 FULPHILA 2 PA; SP; QL MILLION SUBCUTANEOUS UNIT/ML SYRINGE 6 MG/0.6 ML LEUKINE 2 PA; SP INJECTION GENOTROPIN 2 PA; SP RECON SOLN 250 MINIQUICK MCG SUBCUTANEOUS SYRINGE 0.2 MOZOBIL 2 SP MG/0.25 ML, 0.4 SUBCUTANEOUS MG/0.25 ML, 0.6 SOLUTION 24 MG/0.25 ML, 0.8 MG/1.2 ML (20 MG/0.25 ML, 1 MG/ML) MG/0.25 ML, 1.2 NIVESTYM 2 PA; SP MG/0.25 ML, 1.4 INJECTION MG/0.25 ML, 1.6 SOLUTION 300 MG/0.25 ML, 1.8 MCG/ML, 480 MG/0.25 ML, 2 MCG/1.6 ML MG/0.25 ML NIVESTYM 2 PA; SP GENOTROPIN 2 PA; SP SUBCUTANEOUS SUBCUTANEOUS SYRINGE 300 CARTRIDGE 12 MCG/0.5 ML, 480 MG/ML (36 MCG/0.8 ML UNIT/ML), 5 MG/ML (15 UNIT/ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 154 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NORDITROPIN 2 PA; SP REBIF (WITH 2 PA; SP; QL FLEXPRO ALBUMIN) SUBCUTANEOUS SUBCUTANEOUS PEN INJECTOR 10 SYRINGE 22 MG/1.5 ML (6.7 MCG/0.5 ML, 44 MG/ML), 15 MCG/0.5 ML MG/1.5 ML (10 REBIF REBIDOSE 2 PA; SP; QL MG/ML), 30 MG/3 SUBCUTANEOUS ML (10 MG/ML), 5 PEN INJECTOR 22 MG/1.5 ML (3.3 MCG/0.5 ML, 44 MG/ML) MCG/0.5 ML, NYVEPRIA 2 PA; SP; QL 8.8MCG/0.2ML-22 SUBCUTANEOUS MCG/0.5ML (6) SYRINGE 6 MG/0.6 REBIF TITRATION 2 PA; SP; QL ML PACK PLEGRIDY 2 PA; SP; QL SUBCUTANEOUS SUBCUTANEOUS SYRINGE PEN INJECTOR 8.8MCG/0.2ML-22 125 MCG/0.5 ML, MCG/0.5ML (6) 63 MCG/0.5 ML- 94 RETACRIT 2 PA; SP MCG/0.5 ML INJECTION PLEGRIDY 2 PA; SP; QL SOLUTION 10,000 SUBCUTANEOUS UNIT/ML, 2,000 SYRINGE 125 UNIT/ML, 20,000 MCG/0.5 ML, 63 UNIT/2 ML, 20,000 MCG/0.5 ML- 94 UNIT/ML, 3,000 MCG/0.5 ML UNIT/ML, 4,000 PROCRIT 2 PA; SP UNIT/ML, 40,000 INJECTION UNIT/ML SOLUTION 2,000 SERMORELIN 2 UNIT/ML, 20,000 ACETATE (BULK) UNIT/2 ML, 20,000 POWDER 100 % UNIT/ML, 3,000 SEROSTIM 2 PA; SP UNIT/ML, 4,000 SUBCUTANEOUS UNIT/ML RECON SOLN 4 PROLEUKIN 2 PA; SP MG, 5 MG, 6 MG INTRAVENOUS ZARXIO 2 PA; SP RECON SOLN 22 INJECTION MILLION UNIT SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 155 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZIEXTENZO 2 PA; SP AFLURIA QUAD 2 ACA SUBCUTANEOUS 2020-2021(6MO SYRINGE 6 MG/0.6 UP) ML INTRAMUSCULA R SUSPENSION 60 VACCINES / MISCELLANEOUS MCG (15 MCG X IMMUNOLOGICALS 4)/0.5 ML ACTHIB (PF) 2 ACA APLISOL 2 INTRAMUSCULA INTRADERMAL R RECON SOLN 10 SOLUTION 5 TUB. MCG/0.5 ML UNIT /0.1 ML ADACEL(TDAP 2 ACA ATGAM 2 PA ADOLESN/ADULT INTRAVENOUS )(PF) SOLUTION 50 INTRAMUSCULA MG/ML R SUSPENSION 2 LF-(2.5-5-3-5 BCG VACCINE, 2 ACA MCG)-5LF/0.5 ML LIVE (PF) PERCUTANEOUS ADACEL(TDAP 2 ACA SUSPENSION FOR ADOLESN/ADULT RECONSTITUTIO )(PF) N 50 MG INTRAMUSCULA R SYRINGE 2 LF- BEXSERO 2 ACA (2.5-5-3-5 MCG)- INTRAMUSCULA 5LF/0.5 ML R SYRINGE 50-50- 50-25 MCG/0.5 ML AFLURIA QD 2 ACA 2020-21(3YR BIOTHRAX 2 ACA UP)(PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION 0.5 R SYRINGE 60 ML/DOSE MCG (15 MCG X BOOSTRIX TDAP 2 ACA 4)/0.5 ML INTRAMUSCULA AFLURIA QD 2 ACA R SYRINGE 2.5-8-5 2020-21(6- LF-MCG-LF/0.5ML 35MO)(PF) BOTOX 2 PA; SP INTRAMUSCULA INJECTION R SYRINGE 30 RECON SOLN 100 MCG (7.5 MCG X UNIT, 200 UNIT 4)/0.25 ML candin intradermal 1 allergen fda standard

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 156 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CROFAB 2 FLUARIX QUAD 2 ACA INJECTION 2020-2021 (PF) RECON SOLN INTRAMUSCULA CYTOGAM 2 PA; SP R SYRINGE 60 INTRAVENOUS MCG (15 MCG X SOLUTION 50 4)/0.5 ML MG/ML FLUBLOK QUAD 2 ACA DAPTACEL (DTAP 2 ACA 2020-2021 (PF) PEDIATRIC) (PF) INTRAMUSCULA INTRAMUSCULA R SYRINGE 180 R SUSPENSION MCG (45 MCG X 15-10-5 LF-MCG- 4)/0.5 ML LF/0.5ML FLUCELVAX 2 ACA ENGERIX-B (PF) 2 ACA QUAD 2020-2021 INTRAMUSCULA (PF) R SUSPENSION 20 INTRAMUSCULA MCG/ML R SYRINGE 60 MCG (15 MCG X ENGERIX-B (PF) 2 ACA 4)/0.5 ML INTRAMUSCULA R SYRINGE 20 FLUCELVAX 2 ACA MCG/ML QUAD 2020-2021 INTRAMUSCULA ENGERIX-B 2 ACA R SUSPENSION 60 PEDIATRIC (PF) MCG (15 MCG X INTRAMUSCULA 4)/0.5 ML R SYRINGE 10 MCG/0.5 ML FLULAVAL QUAD 2 ACA 2020-2021 (PF) FLUAD 2020-2021 2 ACA INTRAMUSCULA (65 YR UP)(PF) R SYRINGE 60 INTRAMUSCULA MCG (15 MCG X R SYRINGE 45 4)/0.5 ML MCG (15 MCG X 3)/0.5 ML FLUZONE 2 ACA HIGHDOSE QUAD FLUAD QUAD 2 ACA 20-21 PF 2020-21(65Y INTRAMUSCULA UP)(PF) R SYRINGE 240 INTRAMUSCULA MCG/0.7 ML R SYRINGE 60 MCG (15 MCG X FLUZONE QUAD 2 ACA 4)/0.5 ML 2020-2021 (PF) INTRAMUSCULA R SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 157 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUZONE QUAD 2 ACA GAMUNEX-C 2 PA; SP 2020-2021 (PF) INJECTION INTRAMUSCULA SOLUTION 1 R SYRINGE 60 GRAM/10 ML (10 MCG (15 MCG X %), 10 GRAM/100 4)/0.5 ML ML (10 %), 2.5 FLUZONE QUAD 2 ACA GRAM/25 ML (10 2020-2021 %), 20 GRAM/200 INTRAMUSCULA ML (10 %), 40 R SUSPENSION 60 GRAM/400 ML (10 MCG (15 MCG X %), 5 GRAM/50 ML 4)/0.5 ML (10 %) fomepizole 1 HAVRIX (PF) 2 ACA intravenous solution INTRAMUSCULA 1 gram/ml R SUSPENSION 1,440 ELISA GAMASTAN 2 SP UNIT/ML INTRAMUSCULA R SOLUTION 15-18 HAVRIX (PF) 2 ACA % RANGE INTRAMUSCULA R SYRINGE 1,440 GAMASTAN S/D 2 SP ELISA UNIT/ML, INTRAMUSCULA 720 ELISA R SOLUTION 15-18 UNIT/0.5 ML % RANGE HEPAGAM B 2 GAMMAGARD 2 PA; SP INJECTION LIQUID SOLUTION >312 INJECTION UNIT/ML, SOLUTION 10 % GREATR THAN GAMMAGARD S- 2 PA; SP 312 UNIT/ML (5 D (IGA < 1 ML) MCG/ML) HIBERIX (PF) 2 ACA INTRAVENOUS INTRAMUSCULA RECON SOLN 10 R RECON SOLN 10 GRAM, 5 GRAM MCG/0.5 ML HISTATROL 2 INTRADERMAL SOLUTION 0.1 (0.275) MG/ML HYPERHEP B 2 INTRAMUSCULA R SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 158 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HYPERHEP B 2 INFANRIX (DTAP) 2 ACA INTRAMUSCULA (PF) R SYRINGE 220 INTRAMUSCULA UNIT/ML R SUSPENSION HYPERHEP B 2 25-58-10 LF-MCG- NEONATAL LF/0.5ML INTRAMUSCULA INFANRIX (DTAP) 2 ACA R SYRINGE 110 (PF) UNIT/0.5 ML INTRAMUSCULA HYPERRAB (PF) 2 R SYRINGE 25-58- INTRAMUSCULA 10 LF-MCG- R SOLUTION 300 LF/0.5ML UNIT/ML IPOL INJECTION 2 ACA HYPERRAB S/D 2 SUSPENSION 40-8- (PF) 32 UNIT/0.5 ML INTRAMUSCULA IXIARO (PF) 2 ACA R SOLUTION 150 INTRAMUSCULA UNIT/ML R SYRINGE 6 HYPERRHO S/D 2 MCG/0.5 ML INTRAMUSCULA JANSSEN COVID- 2 ACA R SYRINGE 1,500 19 VACCINE UNIT (300 MCG), (EUA) 250 UNIT (50 INTRAMUSCULA MCG) R SUSPENSION 0.5 HYPERTET S/D 2 ML (PF) MENACTRA (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 250 R SOLUTION 4 UNIT MCG/0.5 ML IMOGAM RABIES- 2 MODERNA 2 ACA HT (PF) COVID-19 INTRAMUSCULA VACCINE (EUA) R SOLUTION 150 INTRAMUSCULA UNIT/ML R SUSPENSION IMOVAX RABIES 2 ACA 100 MCG/0.5 ML VACCINE (PF) MYOBLOC 2 PA; SP INTRAMUSCULA INTRAMUSCULA R RECON SOLN R SOLUTION 2.5 UNIT 10,000 UNIT/2 ML, 2,500 UNIT/0.5 ML, 5,000 UNIT/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 159 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PEDIARIX (PF) 2 ACA SHINGRIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SYRINGE 10 R SUSPENSION MCG-25LF-25 FOR MCG-10LF/0.5 ML RECONSTITUTIO PENTACEL (PF) 2 ACA N 50 MCG/0.5 ML INTRAMUSCULA STAMARIL (PF) 2 ACA R KIT 15 LF UNIT- SUBCUTANEOUS 20 MCG-5 LF/0.5 SUSPENSION FOR ML, 15LF-48MCG- RECONSTITUTIO 62DU -10 N 1,000 UNIT/0.5 MCG/0.5ML ML PENTACEL 2 ACA TDVAX 2 ACA ACTHIB INTRAMUSCULA COMPONENT (PF) R SUSPENSION 2- INTRAMUSCULA 2 LF UNIT/0.5 ML R RECON SOLN 10 TETANUS,DIPHTH 2 ACA MCG/0.5 ML ERIA TOX PFIZER COVID-19 2 ACA PED(PF) VACCINE (EUA) INTRAMUSCULA INTRAMUSCULA R SUSPENSION 5- R SUSPENSION 25 LF UNIT/0.5 ML FOR THYMOGLOBULI 2 SP RECONSTITUTIO N INTRAVENOUS N 30 MCG/0.3 ML RECON SOLN 25 PROVENGE 2 SP MG INTRAVENOUS TICE BCG 2 SUSPENSION 50 INTRAVESICAL MILLION SUSPENSION FOR CELL/250 ML RECONSTITUTIO QUADRACEL (PF) 2 ACA N 50 MG INTRAMUSCULA TUBERSOL 2 R SUSPENSION 15 INTRADERMAL LF-48 MCG- 5 LF SOLUTION 5 TUB. UNIT/0.5ML UNIT /0.1 ML RABAVERT (PF) 2 ACA TWINRIX (PF) 2 ACA INTRAMUSCULA INTRAMUSCULA R SUSPENSION R SYRINGE 720 FOR ELISA UNIT- 20 RECONSTITUTIO MCG/ML N 2.5 UNIT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 160 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TYPHIM VI 2 ACA COLCHICINE 2 INTRAMUSCULA (BULK) POWDER R SOLUTION 25 colchicine oral 1 MCG/0.5 ML tablet 0.6 mg TYPHIM VI 2 ACA febuxostat oral 1 ST INTRAMUSCULA tablet 40 mg, 80 mg R SYRINGE 25 MCG/0.5 ML KRYSTEXXA 2 PA; SP INTRAVENOUS VARIZIG 2 ACA SOLUTION 8 INTRAMUSCULA MG/ML R SOLUTION 125 UNIT/1.2 ML MITIGARE ORAL 2 CAPSULE 0.6 MG XEMBIFY 2 PA; SP SUBCUTANEOUS probenecid oral 1 SOLUTION 1 tablet 500 mg GRAM/5 ML (20 probenecid- 1 %), 10 GRAM/50 colchicine oral ML (20 %), 2 tablet 500-0.5 mg GRAM/10 ML (20 %), 4 GRAM/20 ML OSTEOPOROSIS THERAPY (20 %) alendronate oral 1 QL YF-VAX (PF) 2 ACA solution 70 mg/75 ml SUBCUTANEOUS alendronate oral 1 QL SUSPENSION FOR tablet 10 mg, 35 mg, RECONSTITUTIO 5 mg, 70 mg N 10 EXP4.74 UNIT/0.5 ML FORTEO 2 PA; SP; QL SUBCUTANEOUS MUSCULOSKELETAL / PEN INJECTOR 20

RHEUMATOLOGY MCG/DOSE (600MCG/2.4ML) GOUT THERAPY ibandronate 1 PA; SP ALLOPURINOL 2 intravenous solution (BULK) POWDER 3 mg/3 ml allopurinol oral 1 ibandronate 1 PA; SP tablet 100 mg, 300 intravenous syringe mg 3 mg/3 ml allopurinol sodium 1 ibandronate oral 1 QL intravenous recon tablet 150 mg soln 500 mg raloxifene oral tablet 1 ACA aloprim intravenous 1 60 mg recon soln 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 161 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits risedronate oral 1 QL ENBREL 2 PA; SP; QL tablet 150 mg, 35 SUBCUTANEOUS mg, 5 mg SOLUTION 25 risedronate oral 1 QL MG/0.5 ML tablet,delayed ENBREL 2 PA; SP; QL release (dr/ec) 35 SUBCUTANEOUS mg SYRINGE 25 TYMLOS 2 PA; SP; QL MG/0.5 ML (0.5) SUBCUTANEOUS ENBREL 2 PA; SP; QL PEN INJECTOR 80 SURECLICK MCG (3,120 SUBCUTANEOUS MCG/1.56 ML) PEN INJECTOR 50 MG/ML (1 ML) OTHER RHEUMATOLOGICALS GOLD SODIUM 2 ACTEMRA 2 PA; SP; QL THIOMALATE ACTPEN (BULK) POWDER SUBCUTANEOUS PEN INJECTOR HUMIRA PEN 2 PA; SP; QL 162 MG/0.9 ML CROHNS-UC-HS START ACTEMRA 2 PA; SP SUBCUTANEOUS INTRAVENOUS PEN INJECTOR SOLUTION 200 KIT 40 MG/0.8 ML MG/10 ML (20 MG/ML), 400 HUMIRA PEN 2 PA; SP; QL MG/20 ML (20 PSOR-UVEITS- MG/ML), 80 MG/4 ADOL HS ML (20 MG/ML) SUBCUTANEOUS PEN INJECTOR ACTEMRA 2 PA; SP; QL KIT 40 MG/0.8 ML SUBCUTANEOUS SYRINGE 162 HUMIRA PEN 2 PA; SP; QL MG/0.9 ML SUBCUTANEOUS PEN INJECTOR D-PENAMINE 2 PA KIT 40 MG/0.8 ML ORAL TABLET 125 MG HUMIRA 2 PA; SP; QL SUBCUTANEOUS ENBREL MINI 2 PA; SP; QL SYRINGE KIT 40 SUBCUTANEOUS MG/0.8 ML CARTRIDGE 50 MG/ML (1 ML) ENBREL 2 PA; SP; QL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 162 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMIRA(CF) PEDI 2 PA; SP; QL OTEZLA 2 PA; SP; QL CROHNS STARTER ORAL STARTER TABLETS,DOSE SUBCUTANEOUS PACK 10 MG (4)- SYRINGE KIT 80 20 MG (4)-30 MG MG/0.8 ML, 80 (47), 10 MG (4)-20 MG/0.8 ML-40 MG (4)-30 MG(19) MG/0.4 ML PENICILLAMINE 2 HUMIRA(CF) PEN 2 PA; SP; QL (BULK) POWDER CROHNS-UC-HS penicillamine oral 1 PA SUBCUTANEOUS capsule 250 mg PEN INJECTOR KIT 80 MG/0.8 ML penicillamine oral 1 PA tablet 250 mg HUMIRA(CF) PEN 2 PA; SP; QL PSOR-UV-ADOL PENICILLAMINE( 2 HS D-) POWDER SUBCUTANEOUS RASUVO (PF) 2 ST PEN INJECTOR SUBCUTANEOUS KIT 80 MG/0.8 ML- AUTO-INJECTOR 40 MG/0.4 ML 10 MG/0.2 ML, 12.5 HUMIRA(CF) PEN 2 PA; SP; QL MG/0.25 ML, 15 SUBCUTANEOUS MG/0.3 ML, 17.5 PEN INJECTOR MG/0.35 ML, 20 KIT 40 MG/0.4 ML MG/0.4 ML, 22.5 MG/0.45 ML, 25 HUMIRA(CF) PEN 2 PA; SP MG/0.5 ML, 30 SUBCUTANEOUS MG/0.6 ML, 7.5 PEN INJECTOR MG/0.15 ML KIT 80 MG/0.8 ML RIDAURA ORAL 2 HUMIRA(CF) 2 PA; SP; QL CAPSULE 3 MG SUBCUTANEOUS SYRINGE KIT 10 RINVOQ ORAL 2 PA; SP; QL MG/0.1 ML, 20 TABLET MG/0.2 ML, 40 EXTENDED MG/0.4 ML RELEASE 24 HR 15 MG leflunomide oral 1 QL tablet 10 mg, 20 mg SAVELLA ORAL 2 ST; AGE; QL TABLET 100 MG, OTEZLA ORAL 2 PA; SP; QL 12.5 MG, 25 MG, 50 TABLET 30 MG MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 163 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SAVELLA ORAL 2 ST; AGE; QL deblitane oral tablet 1 ACA TABLETS,DOSE 0.35 mg PACK 12.5 MG (5)- DEPO-ESTRADIOL 2 25 MG(8)-50 INTRAMUSCULA MG(42) R OIL 5 MG/ML SIMPONI 2 PA; SP; QL DIVIGEL 2 QL SUBCUTANEOUS TRANSDERMAL PEN INJECTOR GEL IN PACKET 100 MG/ML 0.25 MG/0.25 SIMPONI 2 PA; SP; QL GRAM (0.1 %), 0.5 SUBCUTANEOUS MG/0.5 GRAM (0.1 SYRINGE 100 %), 0.75 MG/0.75 MG/ML GRAM (0.1%), 1 XELJANZ ORAL 2 PA; SP MG/GRAM (0.1 %), SOLUTION 1 1.25 MG/1.25 MG/ML GRAM (0.1 %) dotti transdermal XELJANZ ORAL 2 PA; SP; QL 1 QL patch semiweekly TABLET 10 MG, 5 0.025 mg/24 hr, MG 0.0375 mg/24 hr, XELJANZ XR 2 PA; SP; QL 0.05 mg/24 hr, 0.075 ORAL TABLET mg/24 hr, 0.1 mg/24 EXTENDED hr RELEASE 24 HR eemt hs oral tablet 11 MG, 22 MG 1 0.625-1.25 mg OBSTETRICS / GYNECOLOGY eemt oral tablet 1 ESTROGENS / PROGESTINS 1.25-2.5 mg amabelz oral tablet 1 ENDOMETRIN 2 SP 0.5-0.1 mg, 1-0.5 mg VAGINAL INSERT 100 MG camila oral tablet 1 ACA 0.35 mg errin oral tablet 0.35 1 ACA mg COMBIPATCH 2 TRANSDERMAL ESTRADIOL 2 PATCH (BULK) POWDER SEMIWEEKLY 100 % 0.05-0.25 MG/24 ESTRADIOL 2 HR BENZOATE covaryx h.s. oral 1 (BULK) POWDER tablet 0.625-1.25 mg ESTRADIOL 2 covaryx oral tablet 1 CYPIONATE 1.25-2.5 mg (BULK) POWDER You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 164 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ESTRADIOL 2 ESTRING 2 HEMIHYD,MICRO VAGINAL RING 2 (BULK) POWDER MG (7.5 MCG /24 100 % HOUR) ESTRADIOL 2 estrogens- 1 MICRONIZED methyltestosterone (BULK) POWDER oral tablet 0.625- 100 % 1.25 mg, 1.25-2.5 mg estradiol oral tablet 1 0.5 mg, 1 mg, 2 mg ESTRONE (BULK) 2 estradiol 1 QL CRYSTALS transdermal patch ESTRONE (BULK) 2 semiweekly 0.025 POWDER 100 % mg/24 hr, 0.0375 ETHINYL 2 mg/24 hr, 0.05 ESTRADIOL mg/24 hr, 0.075 (BULK) POWDER mg/24 hr, 0.1 mg/24 hr fyavolv oral tablet 1 0.5-2.5 mg-mcg, 1-5 estradiol 1 QL mg-mcg transdermal patch weekly 0.025 mg/24 heather oral tablet 1 ACA hr, 0.0375 mg/24 hr, 0.35 mg 0.05 mg/24 hr, 0.06 hydroxyprogest(pf)(p 1 PA; SP mg/24 hr, 0.075 reg presv) mg/24 hr, 0.1 mg/24 intramuscular oil hr 250 mg/ml (1 ml) estradiol vaginal 1 hydroxyprogesterone 1 PA; SP cream 0.01 % (0.1 cap(ppres) mg/gram) intramuscular oil estradiol vaginal 1 250 mg/ml tablet 10 mcg HYDROXYPROGE 2 ESTRADIOL 2 STERONE VALERATE CAPR(BULK) (BULK) POWDER POWDER 100 % estradiol valerate 1 hydroxyprogesterone 1 intramuscular oil 20 caproate mg/ml, 40 mg/ml intramuscular oil 250 mg/ml estradiol- 1 norethindrone acet incassia oral tablet 1 ACA oral tablet 0.5-0.1 0.35 mg mg, 1-0.5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 165 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits jencycla oral tablet 1 ACA NORETHINDRON 2 0.35 mg E ACETATE jinteli oral tablet 1-5 1 (BULK) POWDER mg-mcg norethindrone 1 acetate oral tablet 5 lyleq oral tablet 0.35 1 ACA mg mg norethindrone ac-eth lyllana transdermal 1 QL 1 estradiol oral tablet patch semiweekly 0.025 mg/24 hr, 0.5-2.5 mg-mcg, 1-5 0.0375 mg/24 hr, mg-mcg 0.05 mg/24 hr, 0.075 norlyda oral tablet 1 ACA mg/24 hr, 0.1 mg/24 0.35 mg hr PREMARIN 2 lyza oral tablet 0.35 1 ACA INJECTION mg RECON SOLN 25 MEDROXYPROGE 2 MG ST, AC PREMARIN 2 MICRO(BULK) VAGINAL CREAM POWDER 100 % 0.625 MG/GRAM medroxyprogesteron 1 ACA; QL PROGESTERONE 2 e intramuscular (BULK) POWDER suspension 150 100 % mg/ml progesterone 1 SP medroxyprogesteron 1 ACA; QL intramuscular oil 50 e intramuscular mg/ml syringe 150 mg/ml PROGESTERONE 2 medroxyprogesteron 1 MICRONIZED e oral tablet 10 mg, (BULK) POWDER 2.5 mg, 5 mg 100 % mimvey oral tablet 1 progesterone 1 1-0.5 mg micronized oral capsule 100 mg, 200 nora-be oral tablet 1 ACA mg 0.35 mg sharobel oral tablet NORETHINDRON 2 1 ACA 0.35 mg E (BULK) POWDER 100 % tulana oral tablet 1 ACA 0.35 mg norethindrone 1 ACA (contraceptive) oral yuvafem vaginal 1 tablet 0.35 mg tablet 10 mcg MISCELLANEOUS OB/GYN You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 166 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clindamycin 1 MIRENA 2 ACA; SP phosphate vaginal INTRAUTERINE cream 2 % INTRAUTERINE eluryng vaginal ring 1 ACA DEVICE 20 0.12-0.015 mg/24 hr MCG/24 HOURS (6 YRS) 52 MG etonogestrel-ethinyl 1 ACA estradiol vaginal NEXPLANON 2 ACA; SP ring 0.12-0.015 SUBDERMAL mg/24 hr IMPLANT 68 MG fem ph vaginal gel 1 ORIAHNN ORAL 2 PA 0.9-0.025 % CAPSULE, SEQUENTIAL 300- gynol ii vaginal gel 3 1 ACA; OTC 1-0.5MG(AM) /300 % MG(PM) ISOXSUPRINE 2 SKYLA 2 ACA; SP HCL (BULK) INTRAUTERINE POWDER 100 % INTRAUTERINE isoxsuprine oral 1 DEVICE 14 tablet 10 mg, 20 mg MCG/24 HRS (3 YRS) 13.5 MG KYLEENA 2 ACA; SP INTRAUTERINE SULFANILAMIDE 2 INTRAUTERINE (BULK) POWDER DEVICE 17.5 SULFATHIAZOLE 2 MCG/24 HRS (5 (BULK) POWDER YRS) 19.5 MG terconazole vaginal 1 LUPANETA PACK 2 PA; SP cream 0.4 %, 0.8 % (1 MONTH) KIT. terconazole vaginal SYRINGE AND 1 suppository 80 mg TABLET 3.75 MG - 5 MG (30) TODAY 2 ACA; OTC LUPANETA PACK 2 PA; SP CONTRACEPTIVE (3 MONTH) KIT. SPONGE SYRINGE AND VAGINAL TABLET 11.25 MG CONTRACEPTIVE -5 MG (90) SPONGE 1,000 MG tranexamic acid oral metronidazole 1 1 tablet 650 mg vaginal gel 0.75 % miconazole-3 1 TRIMO-SAN 2 vaginal suppository JELLY VAGINAL 200 mg GEL 0.025-0.01 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 167 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VAGINAL 2 ACA; OTC aubra eq oral tablet 1 ACA CONTRACEPTIVE 0.1-20 mg-mcg FILM VAGINAL aubra oral tablet 1 ACA FILM 28 % 0.1-20 mg-mcg vaginal 1 ACA; OTC aurovela 1.5/30 (21) 1 ACA contraceptive foam oral tablet 1.5-30 vaginal foam 12.5 % mg-mcg vandazole vaginal 1 aurovela 1/20 (21) 1 ACA gel 0.75 % oral tablet 1-20 mg- VCF 2 ACA; OTC mcg CONTRACEPTIVE aurovela 24 fe oral 1 ACA GEL VAGINAL tablet 1 mg-20 mcg GEL 4 % (24)/75 mg (4) xulane transdermal 1 ACA aurovela fe 1.5/30 1 ACA patch weekly 150-35 (28) oral tablet 1.5 mcg/24 hr mg-30 mcg (21)/75 zafemy transdermal 1 ACA mg (7) patch weekly 150-35 aurovela fe 1-20 1 ACA mcg/24 hr (28) oral tablet 1 ORAL CONTRACEPTIVES / mg-20 mcg (21)/75

RELATED AGENTS mg (7) afirmelle oral tablet 1 ACA aviane oral tablet 1 ACA 0.1-20 mg-mcg 0.1-20 mg-mcg altavera (28) oral 1 ACA ayuna oral tablet 1 ACA tablet 0.15-0.03 mg 0.15-0.03 mg alyacen 7/7/7 (28) 1 ACA azurette (28) oral 1 ACA oral tablet 0.5/0.75/1 tablet 0.15-0.02 mg- 35 mcg mgx21 /0.01 mg x 5 amethia oral 1 ACA balziva (28) oral 1 ACA tablets,dose pack,3 tablet 0.4-35 mg- month 0.15 mg-30 mcg mcg (84)/10 mcg (7) bekyree (28) oral 1 ACA amethyst (28) oral 1 ACA tablet 0.15-0.02 tablet 90-20 mcg mgx21 /0.01 mg x 5 (28) blisovi 24 fe oral 1 ACA apri oral tablet 0.15- 1 ACA tablet 1 mg-20 mcg 0.03 mg (24)/75 mg (4) aranelle (28) oral 1 ACA blisovi fe 1.5/30 (28) 1 ACA tablet 0.5/1/0.5-35 oral tablet 1.5 mg-30 mg-mcg mcg (21)/75 mg (7) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 168 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits blisovi fe 1/20 (28) 1 ACA dasetta 7/7/7 (28) 1 ACA oral tablet 1 mg-20 oral tablet 0.5/0.75/1 mcg (21)/75 mg (7) mg- 35 mcg briellyn oral tablet 1 ACA daysee oral 1 ACA 0.4-35 mg-mcg tablets,dose pack,3 month 0.15 mg-30 camrese lo oral 1 ACA tablets,dose pack,3 mcg (84)/10 mcg (7) month 0.10 mg-20 desog- 1 ACA mcg (84)/10 mcg (7) e.estradiol/e.estradio l oral tablet 0.15- camrese oral 1 ACA tablets,dose pack,3 0.02 mgx21 /0.01 mg x 5 month 0.15 mg-30 mcg (84)/10 mcg (7) desogestrel-ethinyl 1 ACA estradiol oral tablet caziant (28) oral 1 ACA 0.15-0.03 mg tablet 0.1/.125/.15- 25 mg-mcg drospirenone- 1 ACA e.estradiol-lm.fa charlotte 24 fe oral 1 ACA oral tablet 3-0.02- tablet,chewable 1 mg-20 mcg(24) /75 0.451 mg (24) (4), 3- 0.03-0.451 mg (21) mg (4) (7) chateal (28) oral 1 ACA drospirenone-ethinyl tablet 0.15-0.03 mg 1 ACA estradiol oral tablet chateal eq (28) oral 1 ACA 3-0.02 mg, 3-0.03 tablet 0.15-0.03 mg mg cryselle (28) oral 1 ACA econtra ez oral 1 ACA; OTC; tablet 0.3-30 mg- tablet 1.5 mg QL mcg econtra one-step 1 ACA; OTC; cyclafem 1/35 (28) 1 ACA oral tablet 1.5 mg QL oral tablet 1-35 mg- elinest oral tablet mcg 1 ACA 0.3-30 mg-mcg cyclafem 7/7/7 (28) 1 ACA emoquette oral oral tablet 0.5/0.75/1 1 ACA tablet 0.15-0.03 mg mg- 35 mcg enpresse oral tablet cyred eq oral tablet 1 ACA 1 ACA 50-30 (6)/75-40 0.15-0.03 mg (5)/125-30(10) cyred oral tablet 1 ACA enskyce oral tablet 0.15-0.03 mg 1 ACA 0.15-0.03 mg dasetta 1/35 (28) 1 ACA estarylla oral tablet oral tablet 1-35 mg- 1 ACA 0.25-35 mg-mcg mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 169 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ethynodiol diac-eth 1 ACA jolessa oral 1 ACA estradiol oral tablet tablets,dose pack,3 1-35 mg-mcg, 1-50 month 0.15 mg-30 mg-mcg mcg (91) falmina (28) oral 1 ACA juleber oral tablet 1 ACA tablet 0.1-20 mg- 0.15-0.03 mg mcg junel 1.5/30 (21) 1 ACA fayosim oral 1 ACA oral tablet 1.5-30 tablets,dose pack,3 mg-mcg month 0.15 mg-20 junel 1/20 (21) oral 1 ACA mcg/ 0.15 mg-25 tablet 1-20 mg-mcg mcg junel fe 1.5/30 (28) 1 ACA femynor oral tablet 1 ACA oral tablet 1.5 mg-30 0.25-35 mg-mcg mcg (21)/75 mg (7) gemmily oral 1 ACA junel fe 1/20 (28) 1 ACA capsule 1 mg-20 oral tablet 1 mg-20 mcg (24)/75 mg (4) mcg (21)/75 mg (7) hailey 24 fe oral 1 ACA junel fe 24 oral 1 ACA tablet 1 mg-20 mcg tablet 1 mg-20 mcg (24)/75 mg (4) (24)/75 mg (4) hailey fe 1.5/30 (28) 1 ACA kaitlib fe oral 1 ACA oral tablet 1.5 mg-30 tablet,chewable mcg (21)/75 mg (7) 0.8mg-25mcg(24) hailey fe 1/20 (28) 1 ACA and 75 mg (4) oral tablet 1 mg-20 kalliga oral tablet 1 ACA mcg (21)/75 mg (7) 0.15-0.03 mg hailey oral tablet 1 ACA kariva (28) oral 1 ACA 1.5-30 mg-mcg tablet 0.15-0.02 iclevia oral 1 ACA mgx21 /0.01 mg x 5 tablets,dose pack,3 kelnor 1/35 (28) oral 1 ACA month 0.15 mg-30 tablet 1-35 mg-mcg mcg (91) kelnor 1-50 (28) oral 1 ACA isibloom oral tablet 1 ACA tablet 1-50 mg-mcg 0.15-0.03 mg kurvelo (28) oral 1 ACA jaimiess oral 1 ACA tablet 0.15-0.03 mg tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) jasmiel (28) oral 1 ACA tablet 3-0.02 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 170 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits l norgest/e.estradiol- 1 ACA levonorgestrel- 1 ACA e.estrad oral ethinyl estrad oral tablets,dose pack,3 tablet 0.1-20 mg- month 0.10 mg-20 mcg, 0.15-0.03 mg, mcg (84)/10 mcg (7), 90-20 mcg (28) 0.15 mg-20 mcg/ levonorgestrel- 1 ACA 0.15 mg-25 mcg, ethinyl estrad oral 0.15 mg-30 mcg tablets,dose pack,3 (84)/10 mcg (7) month 0.15 mg-30 larin 1.5/30 (21) 1 ACA mcg (91) oral tablet 1.5-30 levonorg-eth estrad 1 ACA mg-mcg triphasic oral tablet larin 1/20 (21) oral 1 ACA 50-30 (6)/75-40 tablet 1-20 mg-mcg (5)/125-30(10) larin 24 fe oral 1 ACA levora-28 oral tablet 1 ACA tablet 1 mg-20 mcg 0.15-0.03 mg (24)/75 mg (4) lillow (28) oral 1 ACA larin fe 1.5/30 (28) 1 ACA tablet 0.15-0.03 mg oral tablet 1.5 mg-30 lojaimiess oral 1 ACA mcg (21)/75 mg (7) tablets,dose pack,3 larin fe 1/20 (28) 1 ACA month 0.10 mg-20 oral tablet 1 mg-20 mcg (84)/10 mcg (7) mcg (21)/75 mg (7) loryna (28) oral 1 ACA larissia oral tablet 1 ACA tablet 3-0.02 mg 0.1-20 mg-mcg low-ogestrel (28) 1 ACA layolis fe oral 1 ACA oral tablet 0.3-30 tablet,chewable mg-mcg 0.8mg-25mcg(24) lo-zumandimine (28) 1 ACA and 75 mg (4) oral tablet 3-0.02 mg leena 28 oral tablet 1 ACA lutera (28) oral 1 ACA 0.5/1/0.5-35 mg-mcg tablet 0.1-20 mg- lessina oral tablet 1 ACA mcg 0.1-20 mg-mcg merzee oral capsule 1 ACA levonest (28) oral 1 ACA 1 mg-20 mcg (24)/75 tablet 50-30 (6)/75- mg (4) 40 (5)/125-30(10) mibelas 24 fe oral 1 ACA levonorgestrel oral 1 ACA; OTC; tablet,chewable 1 tablet 1.5 mg QL mg-20 mcg(24) /75 mg (4)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 171 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits microgestin 1.5/30 1 ACA norethindrone- 1 ACA (21) oral tablet 1.5- e.estradiol-iron oral 30 mg-mcg capsule 1 mg-20 mcg (24)/75 mg (4) microgestin 1/20 1 ACA (21) oral tablet 1-20 norethindrone- 1 ACA mg-mcg e.estradiol-iron oral tablet 1 mg-20 mcg microgestin fe 1.5/30 1 ACA (21)/75 mg (7), 1.5 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg-30 mcg (21)/75 mg (7) mg (7) norethindrone- microgestin fe 1/20 1 ACA 1 ACA e.estradiol-iron oral (28) oral tablet 1 mg-20 mcg (21)/75 tablet,chewable 1 mg-20 mcg(24) /75 mg (7) mg (4) mili oral tablet 0.25- 1 ACA norgestimate-ethinyl 35 mg-mcg 1 ACA estradiol oral tablet mono-linyah oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.25-35 mg- 25 mcg, mcg 0.18/0.215/0.25 mg- my choice oral tablet 1 ACA; OTC; 35 mcg (28), 0.25-35 1.5 mg QL mg-mcg my way oral tablet 1 ACA; OTC; nortrel 0.5/35 (28) 1 ACA 1.5 mg QL oral tablet 0.5-35 mg-mcg necon 0.5/35 (28) 1 ACA oral tablet 0.5-35 nortrel 1/35 (21) 1 ACA mg-mcg oral tablet 1-35 mg- mcg (21) new day oral tablet 1 ACA; OTC; 1.5 mg QL nortrel 1/35 (28) 1 ACA oral tablet 1-35 mg- noreth-ethinyl 1 ACA mcg estradiol-iron oral tablet,chewable nortrel 7/7/7 (28) 1 ACA 0.4mg-35mcg(21) oral tablet 0.5/0.75/1 and 75 mg (7), mg- 35 mcg 0.8mg-25mcg(24) nylia 7/7/7 (28) oral 1 ACA and 75 mg (4) tablet 0.5/0.75/1 mg- norethindrone ac-eth 1 ACA 35 mcg estradiol oral tablet nymyo oral tablet 1 ACA 1-20 mg-mcg, 1.5-30 0.25-35 mg-mcg mg-mcg ocella oral tablet 3- 1 ACA 0.03 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 172 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits opcicon one-step 1 ACA; OTC; sronyx oral tablet 1 ACA oral tablet 1.5 mg QL 0.1-20 mg-mcg option-2 oral tablet 1 ACA; OTC; syeda oral tablet 3- 1 ACA 1.5 mg QL 0.03 mg orsythia oral tablet 1 ACA tarina 24 fe oral 1 ACA 0.1-20 mg-mcg tablet 1 mg-20 mcg (24)/75 mg (4) philith oral tablet 1 ACA 0.4-35 mg-mcg tarina fe 1/20 (28) 1 ACA oral tablet 1 mg-20 pimtrea (28) oral 1 ACA mcg (21)/75 mg (7) tablet 0.15-0.02 mgx21 /0.01 mg x 5 tarina fe 1-20 eq 1 ACA (28) oral tablet 1 pirmella oral tablet 1 ACA 0.5/0.75/1 mg- 35 mg-20 mcg (21)/75 mg (7) mcg, 1-35 mg-mcg tilia fe oral tablet 1- portia 28 oral tablet 1 ACA 1 ACA 20(5)/1-30(7) /1mg- 0.15-0.03 mg 35mcg (9) previfem oral tablet 1 ACA tri femynor oral 0.25-35 mg-mcg 1 ACA tablet reclipsen (28) oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.15-0.03 mg 35 mcg (28) rivelsa oral 1 ACA tri-estarylla oral 1 ACA tablets,dose pack,3 tablet month 0.15 mg-20 0.18/0.215/0.25 mg- mcg/ 0.15 mg-25 35 mcg (28) mcg tri-legest fe oral 1 ACA setlakin oral 1 ACA tablet 1-20(5)/1- tablets,dose pack,3 30(7) /1mg-35mcg month 0.15 mg-30 (9) mcg (91) tri-linyah oral tablet 1 ACA simliya (28) oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.15-0.02 35 mcg (28) mgx21 /0.01 mg x 5 tri-lo-estarylla oral 1 ACA simpesse oral 1 ACA tablet tablets,dose pack,3 0.18/0.215/0.25 mg- month 0.15 mg-30 25 mcg mcg (84)/10 mcg (7) tri-lo-mili oral tablet 1 ACA sprintec (28) oral 1 ACA 0.18/0.215/0.25 mg- tablet 0.25-35 mg- 25 mcg mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 173 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tri-lo-sprintec oral 1 ACA volnea (28) oral 1 ACA tablet tablet 0.15-0.02 0.18/0.215/0.25 mg- mgx21 /0.01 mg x 5 25 mcg vyfemla (28) oral 1 ACA tri-mili oral tablet 1 ACA tablet 0.4-35 mg- 0.18/0.215/0.25 mg- mcg 35 mcg (28) vylibra oral tablet 1 ACA tri-nymyo oral tablet 1 ACA 0.25-35 mg-mcg 0.18/0.215/0.25 mg- wera (28) oral tablet 1 ACA 35 mcg (28) 0.5-35 mg-mcg tri-previfem (28) 1 ACA wymzya fe oral 1 ACA oral tablet tablet,chewable 0.18/0.215/0.25 mg- 0.4mg-35mcg(21) 35 mcg (28) and 75 mg (7) tri-sprintec (28) oral 1 ACA zarah oral tablet 3- 1 ACA tablet 0.03 mg 0.18/0.215/0.25 mg- 35 mcg (28) zovia 1/35e (28) oral 1 ACA tablet 1-35 mg-mcg trivora (28) oral 1 ACA tablet 50-30 (6)/75- zovia 1-35 (28) oral 1 ACA 40 (5)/125-30(10) tablet 1-35 mg-mcg tri-vylibra lo oral 1 ACA zumandimine (28) 1 ACA tablet oral tablet 3-0.03 mg 0.18/0.215/0.25 mg- OXYTOCICS 25 mcg HEMABATE 2 tri-vylibra oral 1 ACA INTRAMUSCULA tablet R SOLUTION 250 0.18/0.215/0.25 mg- MCG/ML 35 mcg (28) methergine oral 1 ST; QL tydemy oral tablet 3- 1 ACA tablet 0.2 mg 0.03-0.451 mg (21) (7) methylergonovine 1 injection solution 0.2 velivet triphasic 1 ACA mg/ml (1 ml) regimen (28) oral tablet 0.1/.125/.15- methylergonovine 1 ST; QL 25 mg-mcg oral tablet 0.2 mg vestura (28) oral 1 ACA OXYTOCIN 2 tablet 3-0.02 mg (BULK) POWDER vienva oral tablet 1 ACA oxytocin injection 1 0.1-20 mg-mcg solution 10 unit/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 174 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OPHTHALMOLOGY moxifloxacin 1 ophthalmic (eye) ANTIBIOTICS drops, viscous 0.5 % ak-poly-bac 1 NATACYN 2 ophthalmic (eye) OPHTHALMIC ointment 500-10,000 (EYE) unit/gram DROPS,SUSPENSI AZASITE 2 ON 5 % OPHTHALMIC neomycin- 1 (EYE) DROPS 1 % bacitracin- bacitracin 1 polymyxin ophthalmic (eye) ophthalmic (eye) ointment 500 ointment 3.5-400- unit/gram 10,000 mg-unit- unit/g bacitracin- 1 polymyxin b neomycin- 1 ophthalmic (eye) polymyxin- ointment 500-10,000 gramicidin unit/gram ophthalmic (eye) drops 1.75 mg- ciprofloxacin hcl 1 10,000 unit- ophthalmic (eye) 0.025mg/ml drops 0.3 % neo-polycin 1 erythromycin 1 ophthalmic (eye) ophthalmic (eye) ointment 3.5-400- ointment 5 mg/gram 10,000 mg-unit- (0.5 %) unit/g gatifloxacin 1 ofloxacin ophthalmic 1 ophthalmic (eye) (eye) drops 0.3 % drops 0.5 % polycin ophthalmic 1 gentak ophthalmic 1 (eye) ointment 500- (eye) ointment 0.3 % 10,000 unit/gram (3 mg/gram) polymyxin b sulf- 1 gentamicin 1 trimethoprim ophthalmic (eye) ophthalmic (eye) drops 0.3 % drops 10,000 unit- 1 levofloxacin 1 mg/ml ophthalmic (eye) tobramycin 1 drops 0.5 % ophthalmic (eye) moxifloxacin 1 drops 0.3 % ophthalmic (eye) ANTIVIRALS drops 0.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 175 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRIFLURIDINE 2 PHOSPHOLINE 2 (BULK) POWDER IODIDE 100 % OPHTHALMIC VIDARABINE 2 (EYE) DROPS (BULK) POWDER 0.125 % 100 % CYCLOPLEGIC MYDRIATICS VIDARABINE 2 ATROPINE 2 MONOHYDRATE (BULK) POWDER (BULK) POWDER atropine ophthalmic 1 91.5 % (84.5-98.5%) (eye) drops 1 % BETA-BLOCKERS atropine ophthalmic 1 betaxolol ophthalmic 1 (eye) ointment 1 % (eye) drops 0.5 % CYCLOPENTOLA 2 carteolol ophthalmic 1 TE (BULK) (eye) drops 1 % POWDER 100 % levobunolol 1 cyclopentolate 1 ophthalmic (eye) ophthalmic (eye) drops 0.5 % drops 0.5 %, 1 %, 2 % metipranolol 1 ophthalmic (eye) homatropaire 1 drops 0.3 % ophthalmic (eye) drops 5 % timolol maleate (pf) 1 ophthalmic (eye) TROPICAMIDE 2 dropperette 0.5 % (BULK) POWDER timolol maleate 1 tropicamide 1 ophthalmic (eye) ophthalmic (eye) drops 0.5 % drops 0.5 %, 1 % timolol maleate 1 DIRECT ACTING MIOTICS ophthalmic (eye) ACETYLCHOLINE 2 drops, once daily 0.5 CHLORIDE % (BULK) POWDER timolol maleate 1 ophthalmic (eye) gel PILOCARPINE 2 HCL (BULK) forming solution POWDER 0.25 %, 0.5 % pilocarpine hcl 1 CHOLINESTERASE INHIBITOR ophthalmic (eye) MIOTICS drops 1 %, 2 %, 4 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 176 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PILOCARPINE 2 FLUORESCEIN 2 NITRATE (BULK) (BULK) POWDER POWDER 100 % MISCELLANEOUS fluorescein- 1

OPHTHALMOLOGICS proparacaine ophthalmic (eye) altacaine ophthalmic 1 drops 0.25-0.5 % (eye) drops 0.5 % fluorescite 1 azelastine 1 intravenous solution ophthalmic (eye) 500 mg/5 ml (10 %) drops 0.05 % ful-glo ophthalmic 1 balanced salt 1 (eye) strip 1 mg intraocular solution glostrips ophthalmic 1 bioglo ophthalmic 1 (eye) strip 1 mg (eye) strip 1 mg HYALURONIDAS 2 biolon intraocular 1 E, BOVINE syringe 10 mg/ml (BULK) POWDER bss intraocular 1 1 MILLION UNIT solution KETOTIFEN 2 cromolyn 1 FUMARATE ophthalmic (eye) (BULK) POWDER drops 4 % 100 % CYSTARAN 2 PA; SP lidocaine- 1 OPHTHALMIC phenylephrn in (EYE) DROPS 0.44 water intraocular % solution 1-1.5 % DAPIPRAZOLE 2 LUXTURNA 2 PA; SP (BULK) POWDER SUBRETINAL SUSPENSION 1.5 epinastine 1 ophthalmic (eye) X 10EXP11 VG/0.3 ML (FNL) drops 0.05 % ocucoat intraocular 1 EYLEA 2 PA; SP syringe 2 % INTRAVITREAL SOLUTION 2 olopatadine 1 MG/0.05 ML ophthalmic (eye) drops 0.1 %, 0.2 % EYLEA 2 PA; SP INTRAVITREAL OXERVATE 2 PA; SP SYRINGE 2 OPHTHALMIC MG/0.05 ML (EYE) DROPS 0.002 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 177 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits POLYVINYL 2 diclofenac sodium 1 ALCOHOL (BULK) ophthalmic (eye) POWDER 100 % drops 0.1 % PROPARACAINE 2 flurbiprofen sodium 1 (BULK) POWDER ophthalmic (eye) 100 % drops 0.03 % proparacaine 1 ketorolac 1 ophthalmic (eye) ophthalmic (eye) drops 0.5 % drops 0.4 %, 0.5 % RESTASIS 2 PA; QL ORAL DRUGS FOR GLAUCOMA MULTIDOSE ACETAZOLAMID 2 OPHTHALMIC E (BULK) (EYE) DROPS 0.05 POWDER % acetazolamide oral 1 RESTASIS 2 PA; QL capsule, extended OPHTHALMIC release 500 mg (EYE) DROPPERETTE acetazolamide oral 1 0.05 % tablet 125 mg, 250 mg tetracaine hcl 1 ophthalmic (eye) acetazolamide 1 drops 0.5 % sodium injection recon soln 500 mg VISUDYNE 2 SP INTRAVENOUS METHAZOLAMID 2 RECON SOLN 15 E (BULK) MG POWDER XIIDRA 2 PA; QL methazolamide oral 1 OPHTHALMIC tablet 25 mg, 50 mg (EYE) OTHER GLAUCOMA DRUGS DROPPERETTE 5 % AZOPT 2 OPHTHALMIC ZERVIATE 2 ST (EYE) OPHTHALMIC DROPS,SUSPENSI (EYE) ON 1 % DROPPERETTE 0.24 % bimatoprost 1 ST; AGE ophthalmic (eye) NON-STEROIDAL ANTI- drops 0.03 % INFLAMMATORY AGENTS brinzolamide 1 bromfenac 1 ophthalmic (eye) ophthalmic (eye) drops,suspension 1 drops 0.09 % % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 178 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CARBACHOL 2 ZIOPTAN (PF) 2 ST; AGE (BULK) POWDER OPHTHALMIC 99 % (EYE) COMBIGAN 2 DROPPERETTE OPHTHALMIC 0.0015 % (EYE) DROPS 0.2- STEROID-ANTIBIOTIC

0.5 % COMBINATIONS DEMECARIUM 2 neomycin- 1 BROMIDE (BULK) bacitracin-poly-hc POWDER 100 % ophthalmic (eye) dorzolamide 1 ointment 3.5-400- ophthalmic (eye) 10,000 mg-unit/g- drops 2 % 1% dorzolamide-timolol 1 neomycin-polymyxin 1 (pf) ophthalmic (eye) b-dexameth dropperette 2-0.5 % ophthalmic (eye) drops,suspension dorzolamide-timolol 1 3.5mg/ml-10,000 ophthalmic (eye) unit/ml-0.1 % drops 22.3-6.8 mg/ml neomycin-polymyxin 1 b-dexameth latanoprost 1 ST; AGE ophthalmic (eye) ophthalmic (eye) ointment 3.5 mg/g- drops 0.005 % 10,000 unit/g-0.1 % LUMIGAN 2 ST; AGE neo-polycin hc 1 OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.01 ointment 3.5-400- % 10,000 mg-unit/g- miostat intraocular 1 1% solution 0.01 % TOBRADEX 2 physostigmine 1 OPHTHALMIC salicylate injection (EYE) OINTMENT solution 1 mg/ml 0.3-0.1 % RHOPRESSA 2 TOBRADEX ST 2 OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.02 (EYE) % DROPS,SUSPENSI ON 0.3-0.05 % travoprost 1 ST; AGE ophthalmic (eye) drops 0.004 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 179 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tobramycin- 1 loteprednol 1 dexamethasone etabonate ophthalmic (eye) ophthalmic (eye) drops,suspension drops,suspension 0.5 0.3-0.1 % % ZYLET 2 OZURDEX 2 SP OPHTHALMIC INTRAVITREAL (EYE) IMPLANT 0.7 MG DROPS,SUSPENSI prednisolone sodium 1 ON 0.3-0.5 % phosphate STEROIDS ophthalmic (eye) drops 1 % dexamethasone 1 sodium phosphate STEROID-SULFONAMIDE

ophthalmic (eye) COMBINATIONS drops 0.1 % sulfacetamide- 1 fluorometholone 1 prednisolone ophthalmic (eye) ophthalmic (eye) drops,suspension 0.1 drops 10 %-0.23 % % (0.25 %) INVELTYS 2 SULFONAMIDES OPHTHALMIC (EYE) SULFACETAMIDE 2 DROPS,SUSPENSI SOD, MONO ON 1 % (BULK) POWDER 100 % LOTEMAX 2 OPHTHALMIC SULFACETAMIDE 2 (EYE) DROPS,GEL SODIUM (BULK) 0.5 % POWDER sulfacetamide LOTEMAX 2 1 sodium ophthalmic OPHTHALMIC (eye) drops 10 % (EYE) OINTMENT 0.5 % sulfacetamide 1 sodium ophthalmic LOTEMAX SM 2 (eye) ointment 10 % OPHTHALMIC (EYE) DROPS,GEL SYMPATHOMIMETICS 0.38 % ALPHAGAN P 2 loteprednol 1 OPHTHALMIC etabonate (EYE) DROPS 0.1 ophthalmic (eye) % drops,gel 0.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 180 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits apraclonidine 1 carbinoxamine 1 ophthalmic (eye) maleate oral liquid 4 drops 0.5 % mg/5 ml brimonidine 1 carbinoxamine 1 ophthalmic (eye) maleate oral tablet 4 drops 0.2 % mg BRIMONIDINE 2 carbinoxamine 1 ST TARTRATE maleate oral tablet 6 (BULK) POWDER mg 100 % CHLORPHENIRA 2 VASOCONSTRICTOR MINE

DECONGESTANTS MALEATE(BULK) POWDER PHENYLEPHRINE 2 HCL (BULK) CLEMASTINE 2 POWDER 100 % FUMARATE (BULK) POWDER phenylephrine hcl 1 ophthalmic (eye) clemastine oral 1 drops 10 %, 2.5 % tablet 2.68 mg TETRAHYDROZO 2 codeine-guaifenesin 1 LINE HCL (BULK) oral liquid 10-100 POWDER mg/5 ml RESPIRATORY AND CYPROHEPTADIN 2 E (BULK) ALLERGY POWDER 100 % ANTIHISTAMINE / cyproheptadine oral 1 ANTIALLERGENIC AGENTS syrup 2 mg/5 ml adrenalin injection 1 cyproheptadine oral 1 solution 1 mg/ml, 1 tablet 4 mg mg/ml (1 ml) desloratadine oral 1 QL benzonatate oral 1 tablet 5 mg capsule 100 mg, 150 desloratadine oral 1 QL mg, 200 mg tablet,disintegrating BROMPHENIRAMI 2 2.5 mg, 5 mg NE MALEATE dexchlorpheniramin 1 (BULK) POWDER e maleate oral brompheniramine- 1 solution 2 mg/5 ml pseudoeph-dm oral DEXTROMETHOR 2 syrup 2-30-10 mg/5 PHAN HBR ml (BULK) POWDER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 181 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DIPHENHYDRAMI 2 epinephrine 1 NE (BULK) injection syringe 0.1 POWDER mg/ml diphenhydramine hcl 1 EPIPEN 2-PAK 2 PA; QL injection solution 50 INJECTION AUTO- mg/ml INJECTOR 0.3 diphenhydramine hcl 1 MG/0.3 ML injection syringe 50 EPIPEN 2 PA; QL mg/ml INJECTION AUTO- EPINEPHRINE 2 INJECTOR 0.3 (BULK) POWDER MG/0.3 ML EPINEPHRINE 2 EPIPEN JR 2-PAK 2 PA; QL BITARTRATE INJECTION AUTO- (BULK) POWDER INJECTOR 0.15 MG/0.3 ML epinephrine hcl in 1 0.9 % nacl EPIPEN JR 2 PA; QL intravenous solution INJECTION AUTO- 2 mg/250 ml (8 INJECTOR 0.15 mcg/ml), 8 mg/250 MG/0.3 ML ml (32 mcg/ml) g tussin ac oral 1 liquid 10-100 mg/5 epinephrine hcl in 1 0.9 % nacl ml intravenous syringe guaiatussin ac oral 1 1 mg/10 ml (100 liquid 10-100 mg/5 mcg/ml), 100 mcg/10 ml ml (10 mcg/ml) GUAIFENESIN 2 epinephrine hcl in 1 (BULK) POWDER 5% dextrose 100 % intravenous solution guaifenesin ac oral 1 2 mg/250 ml (8 liquid 10-100 mg/5 mcg/ml), 4 mg/250 ml ml (16 mcg/ml) guaifenesin dac oral 1 epinephrine 1 QL syrup 30-10-100 injection auto- mg/5 ml injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml hydrocodone- 1 chlorpheniramine epinephrine 1 oral injection solution 1 suspension,extended mg/ml, 1 mg/ml (1 rel 12 hr 10-8 mg/5 ml) ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 182 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocodone- 1 PROMETHAZINE 2 homatropine oral (BULK) POWDER syrup 5-1.5 mg/5 ml 100 % hydrocodone- 1 promethazine 1 homatropine oral injection solution 25 tablet 5-1.5 mg mg/ml, 50 mg/ml hydromet oral syrup 1 promethazine oral 1 5-1.5 mg/5 ml syrup 6.25 mg/5 ml HYDROXYZINE 2 promethazine oral 1 HCL (BULK) tablet 12.5 mg, 25 POWDER mg, 50 mg hydroxyzine hcl 1 promethazine rectal 1 intramuscular suppository 12.5 mg, solution 25 mg/ml, 25 mg, 50 mg 50 mg/ml promethazine vc oral 1 hydroxyzine hcl oral 1 syrup 6.25-5 mg/5 solution 10 mg/5 ml ml hydroxyzine hcl oral 1 promethazine vc- 1 tablet 10 mg, 25 mg, codeine oral syrup 50 mg 6.25-5-10 mg/5 ml HYDROXYZINE 2 promethazine- 1 PAMOATE (BULK) codeine oral syrup POWDER 6.25-10 mg/5 ml hydroxyzine 1 promethazine-dm 1 pamoate oral oral syrup 6.25-15 capsule 100 mg, 25 mg/5 ml mg, 50 mg promethazine- 1 LEVOCETIRIZINE 2 phenyleph-codeine (BULK) POWDER oral syrup 6.25-5-10 mg/5 ml LORATADINE 2 (BULK) POWDER promethazine- 1 100 % phenylephrine oral syrup 6.25-5 mg/5 maxi-tuss ac oral 1 ml liquid 10-100 mg/5 ml promethegan rectal 1 suppository 12.5 mg, m-clear wc oral 1 25 mg, 50 mg liquid 6.3-100 mg/5 ml PSEUDOEPHEDRI 2 phenadoz rectal 1 NE HCL (BULK) suppository 25 mg POWDER 100 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 183 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PYRILAMINE 2 ALBUTEROL 2 MALEATE (BULK) SULFATE (BULK) POWDER POWDER rydex oral liquid 1 albuterol sulfate 1 QL 1.3-10-6.3 mg/5 ml inhalation hfa aerosol inhaler 90 SYMJEPI 2 QL mcg/actuation INJECTION SYRINGE 0.15 albuterol sulfate 1 MG/0.3 ML, 0.3 inhalation solution MG/0.3 ML for nebulization 0.63 mg/3 ml, 1.25 mg/3 TRIPELENNAMIN 2 ml, 2.5 mg /3 ml E (BULK) (0.083 %), 2.5 POWDER 100 % mg/0.5 ml, 5 mg/ml TRIPROLIDINE 2 albuterol sulfate oral HCL (BULK) 1 syrup 2 mg/5 ml POWDER 100 % albuterol sulfate oral virtussin ac oral 1 1 tablet 2 mg, 4 mg liquid 10-100 mg/5 ml albuterol sulfate oral 1 tablet extended virtussin dac oral 1 release 12 hr 4 mg, 8 syrup 30-10-100 mg mg/5 ml alyq oral tablet 20 1 PA; SP; QL PULMONARY AGENTS mg ACETYLCYSTEIN 2 ambrisentan oral 1 PA; SP E (BULK) tablet 10 mg, 5 mg POWDER AMINOPHYLLINE 2 acetylcysteine 1 (BULK) POWDER solution 100 mg/ml (10 %), 200 mg/ml aminophylline 1 (20 %) intravenous solution 250 mg/10 ml, 500 ADEMPAS ORAL 2 PA; SP mg/20 ml TABLET 0.5 MG ANORO ELLIPTA 2 QL ADVAIR HFA 2 ST; QL INHALATION INHALATION HFA BLISTER WITH AEROSOL DEVICE 62.5-25 INHALER 115-21 MCG/ACTUATION MCG/ACTUATION , 230-21 MCG/ACTUATION , 45-21 MCG/ACTUATION You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 184 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARNUITY 2 QL BEVESPI 2 QL ELLIPTA AEROSPHERE INHALATION INHALATION HFA BLISTER WITH AEROSOL DEVICE 100 INHALER 9-4.8 MCG/ACTUATION MCG , 200 bosentan oral tablet 1 PA; SP MCG/ACTUATION 125 mg, 62.5 mg , 50 MCG/ACTUATION BREO ELLIPTA 2 ST; QL INHALATION ASMANEX HFA 2 QL BLISTER WITH INHALATION HFA DEVICE 100-25 AEROSOL MCG/DOSE, 200-25 INHALER 100 MCG/DOSE MCG/ACTUATION , 200 BREZTRI 2 QL MCG/ACTUATION AEROSPHERE , 50 INHALATION HFA MCG/ACTUATION AEROSOL INHALER 160-9- ASMANEX 2 QL 4.8 TWISTHALER MCG/ACTUATION INHALATION AEROSOL POWDR budesonide 1 QL BREATH inhalation ACTIVATED 110 suspension for MCG/ nebulization 0.25 ACTUATION (30), mg/2 ml, 0.5 mg/2 220 MCG/ ml, 1 mg/2 ml ACTUATION (120), BUDESONIDE, 2 220 MCG/ MICRONIZED ACTUATION (14), (BULK) POWDER 220 MCG/ 100 % ACTUATION (30), 220 MCG/ caffeine-sodium 1 ACTUATION (60) benzoate injection solution 250 mg/ml azelastine- 1 QL (125 mg/ml caffeine) fluticasone nasal spray,non-aerosol CINRYZE 2 PA; SP 137-50 mcg/spray INTRAVENOUS RECON SOLN 500 UNIT (5 ML)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 185 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits COMBIVENT 2 QL ESBRIET ORAL 2 PA; SP; QL RESPIMAT TABLET 267 MG INHALATION ESBRIET ORAL 2 PA; SP MIST 20-100 TABLET 801 MG MCG/ACTUATION FASENRA PEN 2 PA; SP CROMOLYN 2 SUBCUTANEOUS (BULK) POWDER AUTO-INJECTOR cromolyn inhalation 1 30 MG/ML solution for FASENRA 2 PA; SP nebulization 20 mg/2 SUBCUTANEOUS ml SYRINGE 30 DALIRESP ORAL 2 PA; QL MG/ML TABLET 250 MCG FLOVENT DISKUS 2 QL DALIRESP ORAL 2 PA INHALATION TABLET 500 MCG BLISTER WITH DULERA 2 ST; QL DEVICE 100 INHALATION HFA MCG/ACTUATION AEROSOL , 250 INHALER 100-5 MCG/ACTUATION MCG/ACTUATION , 50 , 200-5 MCG/ACTUATION MCG/ACTUATION FLOVENT HFA 2 QL , 50-5 INHALATION HFA MCG/ACTUATION AEROSOL DYPHYLLINE 2 INHALER 110 (BULK) POWDER MCG/ACTUATION 100 % , 220 MCG/ACTUATION EPHEDRINE HCL 2 , 44 (BULK) POWDER MCG/ACTUATION EPHEDRINE 2 FLUNISOLIDE 2 SULFATE (BULK) (BULK) POWDER POWDER 100 % ephedrine sulfate 1 flunisolide nasal 1 QL injection solution 50 spray,non-aerosol mg/ml 25 mcg (0.025 %) epinephrine hcl 1 fluticasone 1 QL nasal solution 1 propionate nasal mg/ml spray,suspension 50 ESBRIET ORAL 2 PA; SP; QL mcg/actuation CAPSULE 267 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 186 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluticasone propion- 1 ST; QL KALYDECO ORAL 2 PA; SP; QL salmeterol TABLET 150 MG inhalation blister levalbuterol hcl 1 with device 100-50 inhalation solution mcg/dose, 250-50 for nebulization 0.31 mcg/dose, 500-50 mg/3 ml, 0.63 mg/3 mcg/dose ml, 1.25 mg/0.5 ml, FORMOTEROL 2 1.25 mg/3 ml FUMARATE metaproterenol oral 1 (BULK) POWDER syrup 10 mg/5 ml 100 % METAPROTEREN 2 icatibant 1 PA; SP OL SULFATE subcutaneous (BULK) POWDER syringe 30 mg/3 ml mometasone nasal 1 QL INCRUSE 2 QL spray,non-aerosol ELLIPTA 50 mcg/actuation INHALATION BLISTER WITH MONTELUKAST 2 DEVICE 62.5 (BULK) POWDER MCG/ACTUATION montelukast oral 1 IPRATROPIUM 2 granules in packet 4 BROMIDE (BULK) mg POWDER montelukast oral 1 ipratropium bromide 1 tablet 10 mg inhalation solution montelukast oral 1 0.02 % tablet,chewable 4 ipratropium- 1 QL mg, 5 mg albuterol inhalation nebusal inhalation 1 solution for solution for nebulization 0.5 mg- nebulization 3 % 3 mg(2.5 mg base)/3 ml NUCALA 2 PA; SP; QL SUBCUTANEOUS ISOPROTERENOL 2 AUTO-INJECTOR HCL (BULK) 100 MG/ML POWDER NUCALA 2 PA; SP; QL KALYDECO ORAL 2 PA; SP SUBCUTANEOUS GRANULES IN RECON SOLN 100 PACKET 25 MG MG KALYDECO ORAL 2 PA; SP; QL GRANULES IN PACKET 50 MG, 75 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 187 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NUCALA 2 PA; SP; QL QNASL NASAL 2 QL SUBCUTANEOUS HFA AEROSOL SYRINGE 100 INHALER 40 MG/ML MCG/ACTUATION OFEV ORAL 2 PA; SP; QL , 80 CAPSULE 100 MG, MCG/ACTUATION 150 MG QVAR 2 QL OPSUMIT ORAL 2 PA; SP REDIHALER TABLET 10 MG INHALATION HFA AEROSOL ORKAMBI ORAL 2 PA; SP; QL BREATH GRANULES IN ACTIVATED 40 PACKET 100-125 MCG/ACTUATION MG, 150-188 MG RACEPINEPHRINE 2 ORKAMBI ORAL 2 PA; SP; QL (BULK) POWDER TABLET 100-125 100 % MG, 200-125 MG RUCONEST 2 PA; SP PERFOROMIST 2 QL INTRAVENOUS INHALATION RECON SOLN SOLUTION FOR 2,100 UNIT NEBULIZATION 20 MCG/2 ML SEREVENT 2 QL DISKUS PULMICORT 2 QL INHALATION FLEXHALER BLISTER WITH INHALATION DEVICE 50 AEROSOL POWDR MCG/DOSE BREATH sildenafil ACTIVATED 180 1 PA; SP (pulm.hypertension) MCG/ACTUATION intravenous solution , 90 10 mg/12.5 ml MCG/ACTUATION sildenafil pulmosal inhalation 1 1 PA; SP; QL solution for (pulm.hypertension) oral suspension for nebulization 7 % reconstitution 10 PULMOZYME 2 PA; SP mg/ml INHALATION sildenafil SOLUTION 1 1 PA; SP; QL (pulm.hypertension) MG/ML oral tablet 20 mg sodium chloride 1 inhalation solution for nebulization 0.9 %, 10 %, 3 %, 7 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 188 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SPIRIVA 2 QL terbutaline 1 RESPIMAT subcutaneous INHALATION solution 1 mg/ml MIST 1.25 TERBUTALINE 2 MCG/ACTUATION SULFATE (BULK) , 2.5 POWDER MCG/ACTUATION theochron oral tablet 1 SPIRIVA WITH 2 QL extended release 12 HANDIHALER hr 100 mg, 200 mg INHALATION CAPSULE, THEOPHYLLINE 2 W/INHALATION (BULK) POWDER DEVICE 18 MCG theophylline in 1 STIOLTO 2 QL dextrose 5 % RESPIMAT intravenous INHALATION parenteral solution MIST 2.5-2.5 200 mg/100 ml, 200 MCG/ACTUATION mg/50 ml, 400 mg/250 ml, 800 SYMBICORT 2 ST; QL mg/250 ml INHALATION HFA AEROSOL theophylline oral 1 INHALER 160-4.5 elixir 80 mg/15 ml MCG/ACTUATION theophylline oral 1 , 80-4.5 solution 80 mg/15 ml MCG/ACTUATION theophylline oral 1 SYMDEKO ORAL 2 PA; SP; QL tablet extended TABLETS, release 12 hr 450 mg SEQUENTIAL 100- 150 MG (D)/ 150 theophylline oral 1 MG (N), 50-75 MG tablet extended (D)/ 75 MG (N) release 24 hr 400 mg, 600 mg tadalafil (pulm. 1 PA; SP; QL hypertension) oral TRACLEER ORAL 2 PA; SP tablet 20 mg TABLET FOR SUSPENSION 32 TAKHZYRO 2 PA; SP MG SUBCUTANEOUS SOLUTION 300 TRELEGY 2 QL MG/2 ML (150 ELLIPTA MG/ML) INHALATION BLISTER WITH terbutaline oral 1 DEVICE 100-62.5- tablet 2.5 mg, 5 mg 25 MCG, 200-62.5- 25 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 189 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRIKAFTA ORAL 2 PA; SP; QL XOLAIR 2 PA; SP; QL TABLETS, SUBCUTANEOUS SEQUENTIAL 100- SYRINGE 150 50-75 MG(D) /150 MG/ML, 75 MG/0.5 MG (N) ML TYVASO 2 PA; SP YUPELRI 2 QL INHALATION INHALATION SOLUTION FOR SOLUTION FOR NEBULIZATION NEBULIZATION 1.74 MG/2.9 ML 175 MCG/3 ML (0.6 MG/ML) zafirlukast oral 1 TYVASO 2 PA; SP tablet 10 mg, 20 mg INSTITUTIONAL zileuton oral tablet, 1 PA START KIT er multiphase 12 hr INHALATION 600 mg SOLUTION FOR NEBULIZATION UROLOGICALS 1.74 MG/2.9 ML ANTICHOLINERGICS /

TYVASO REFILL 2 PA; SP ANTISPASMODICS KIT INHALATION SOLUTION FOR darifenacin oral 1 NEBULIZATION tablet extended 1.74 MG/2.9 ML release 24 hr 15 mg, (0.6 MG/ML) 7.5 mg TYVASO 2 PA; SP flavoxate oral tablet 1 STARTER KIT 100 mg INHALATION GELNIQUE 2 QL SOLUTION FOR TRANSDERMAL NEBULIZATION GEL IN PACKET 1.74 MG/2.9 ML 10 % (100 wixela inhub 1 ST; QL MG/GRAM) inhalation blister MYRBETRIQ 2 with device 100-50 ORAL TABLET mcg/dose, 250-50 EXTENDED mcg/dose, 500-50 RELEASE 24 HR mcg/dose 25 MG, 50 MG XOLAIR 2 PA; SP; QL OXYBUTYNIN 2 SUBCUTANEOUS CHLORIDE RECON SOLN 150 (BULK) POWDER MG oxybutynin chloride 1 oral syrup 5 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 190 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxybutynin chloride 1 finasteride oral 1 oral tablet 5 mg tablet 5 mg oxybutynin chloride 1 silodosin oral 1 oral tablet extended capsule 4 mg, 8 mg release 24hr 10 mg, tamsulosin oral 1 15 mg, 5 mg capsule 0.4 mg solifenacin oral 1 CHOLINERGIC STIMULANTS tablet 10 mg, 5 mg BETHANECHOL 2 tolterodine oral 1 capsule,extended CHLORIDE (BULK) POWDER release 24hr 2 mg, 4 mg bethanechol chloride 1 oral tablet 10 mg, 25 tolterodine oral 1 mg, 5 mg, 50 mg tablet 1 mg, 2 mg TOVIAZ ORAL 2 MISCELLANEOUS UROLOGICALS TABLET ALPROSTADIL 2 EXTENDED (BULK) POWDER RELEASE 24 HR 4 100 % MG, 8 MG alprostadil injection 1 trospium oral 1 solution 500 mcg/ml capsule,extended AMMONIUM 2 release 24hr 60 mg CHLORIDE trospium oral tablet 1 (BULK) 20 mg GRANULES BENIGN PROSTATIC CAVERJECT 2 PA; QL

HYPERPLASIA(BPH) THERAPY IMPULSE INTRACAVERNOS alfuzosin oral tablet 1 AL KIT 10 MCG, extended release 24 20 MCG hr 10 mg CAVERJECT 2 PA; QL dutasteride oral 1 PA INTRACAVERNOS capsule 0.5 mg AL RECON SOLN dutasteride- 1 PA 20 MCG, 40 MCG tamsulosin oral CAVERJECT 2 PA; QL capsule, er INTRACAVERNOS multiphase 24 hr AL SYRINGE 10 0.5-0.4 mg MCG, 20 MCG FINASTERIDE 2 CYSTAGON ORAL 2 PA; SP (BULK) POWDER CAPSULE 150 MG, 100 % 50 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 191 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ELMIRON ORAL 2 RENACIDIN 2 CAPSULE 100 MG IRRIGATION glycine urologic 1 SOLUTION 1980.6 irrigation solution MG-59.4 MG- 1.5 % 980.4MG/30ML glycine urologic 1 SILDENAFIL 2 solution irrigation (BULK) POWDER solution 1.5 % 100 % sildenafil oral tablet hyophen oral tablet 1 1 ST; QL 100 mg, 25 mg, 50 81.6-0.12-10.8 mg mg K-PHOS 2 tadalafil oral tablet ORIGINAL ORAL 1 ST; QL 10 mg, 2.5 mg, 20 TABLET,SOLUBL mg, 5 mg E 500 MG uretron d-s oral methen-sod phos- 1 1 meth blue-hyos oral tablet 81.6-10.8-40.8 mg tablet 81.6-40.8-0.12 mg urimar-t oral tablet 1 120-0.12-10.8 mg METHIONINE 2 (BULK) POWDER urin ds oral tablet 1 81.6-10.8-40.8 mg MUSE INTRA- 2 PA; QL URETHRAL uro-458 oral tablet 1 SUPPOSITORY 81-10.8-40.8 mg 1,000 MCG, 125 urogesic-blue oral 1 MCG, 250 MCG, tablet 81.6-40.8-0.12 500 MCG mg PENTOSAN 2 uro-mp oral capsule 1 POLYSULFATE 118-10-40.8-36 mg NA (BULK) POWDER 100 % uryl oral tablet 81.6- 1 40.8-0.12 mg phosphasal oral 1 tablet 81.6-10.8-40.8 ustell oral capsule 1 mg 120-0.12 mg potassium citrate 1 utira-c oral tablet 1 oral tablet extended 81.6-10.8-40.8 mg release 10 meq vardenafil oral 1 ST; QL (1,080 mg), 15 meq, tablet 10 mg, 2.5 mg, 5 meq (540 mg) 20 mg, 5 mg vardenafil oral 1 ST; QL tablet,disintegrating 10 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 192 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits URINARY ANESTHETICS buminate 5 % 1 intravenous PHENAZOPYRIDI 2 parenteral solution 5 NE (BULK) % POWDER 100 % plasbumin 25 % 1 VITAMINS, HEMATINICS / intravenous ELECTROLYTES parenteral solution 25 % BLOOD DERIVATIVES plasbumin 5 % 1 albumin, human 25 1 intravenous % intravenous parenteral solution 5 parenteral solution % 25 % ELECTROLYTES albumin, human 5 % 1 intravenous ADDAMEL N 2 parenteral solution 5 INTRAVENOUS % SOLUTION 5.33- 0.34-0.54 MCG- albuminar 25 % 1 intravenous MG-MG/ML parenteral solution calcium 1 25 % acetate(phosphat bind) oral capsule alburx (human) 25 1 667 mg % intravenous parenteral solution calcium 1 25 % acetate(phosphat bind) oral tablet 667 alburx (human) 5 % 1 mg intravenous parenteral solution 5 calcium chloride 1 % intravenous solution 100 mg/ml (10 %) albutein 25 % 1 intravenous calcium chloride 1 parenteral solution intravenous syringe 25 % 100 mg/ml (10 %) albutein 5 % 1 CALCIUM 2 intravenous GLUCON parenteral solution 5 MONOHYD % (BULK) POWDER 100 % buminate 25 % 1 intravenous calcium gluconate in 1 parenteral solution 0.9% nacl 25 % intravenous solution 1 gram/100 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 193 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits calcium gluconate 1 k-tab oral tablet 1 intravenous solution extended release 8 100 mg/ml (10%) meq chromium chloride 1 lactated ringers 1 intravenous solution intravenous 4 mcg/ml parenteral solution copper chloride 1 lugols oral solution 1 intravenous solution 5 % 0.4 mg/ml MAGNESIUM 2 effer-k oral tablet, 1 CHLORIDE effervescent 25 meq (BULK) GLYCOPHOS 2 CRYSTALS INTRAVENOUS magnesium chloride 1 SOLUTION 1 injection solution MMOL/ML 200 mg/ml (20 %) klor-con 10 oral 1 MAGNESIUM 2 tablet extended OXIDE (BULK) release 10 meq POWDER 100 % klor-con 8 oral 1 MAGNESIUM 2 tablet extended SULFATE IN D5W release 8 meq INTRAVENOUS klor-con m10 oral 1 PIGGYBACK 1 tablet,er GRAM/100 ML particles/crystals 10 magnesium sulfate in 1 meq water intravenous parenteral solution klor-con m15 oral 1 tablet,er 20 gram/500 ml (4 %), 40 gram/1,000 particles/crystals 15 ml (4 %) meq magnesium sulfate in klor-con m20 oral 1 1 tablet,er water intravenous piggyback 2 gram/50 particles/crystals 20 ml (4 %), 4 meq gram/100 ml (4 %), klor-con oral packet 1 4 gram/50 ml (8 %) 20 meq magnesium sulfate 1 klor-con/ef oral 1 injection solution 4 tablet, effervescent meq/ml (50 %) 25 meq magnesium sulfate 1 injection syringe 4 meq/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 194 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MANGANESE 2 PHOSLYRA ORAL 2 CHLORIDE SOLUTION 667 (BULK) POWDER MG (169 MG 100 % CALCIUM)/5 ML manganese chloride 1 POTASSIUM 2 intravenous solution ACETATE (BULK) 0.1 mg/ml POWDER 100 % MANGANESE 2 potassium acetate 1 SULFATE (BULK) intravenous solution POWDER 2 meq/ml MULTITRACE-4 2 potassium chlorid- 1 CONCENTRATE d5-0.45%nacl INTRAVENOUS intravenous SOLUTION 10 parenteral solution MCG-1 MG- 0.5 10 meq/l, 20 meq/l, MG-5 MG/ML 30 meq/l, 40 meq/l MULTITRACE-4 2 POTASSIUM 2 NEONATAL CHLORIDE INTRAVENOUS (BULK) POWDER SOLUTION 0.85 potassium chloride 1 MCG-0.1 MG - in 0.9%nacl 25MCG-1.5MG/ML intravenous multitrace-4 1 parenteral solution pediatric 20 meq/l, 40 meq/l intravenous solution potassium chloride 1 1 mcg-0.1 mg-25 in 5 % dex mcg-1 mg/ml intravenous NORMOSOL-R IN 2 parenteral solution 5 % DEXTROSE 20 meq/l, 30 meq/l, INTRAVENOUS 40 meq/l PARENTERAL potassium chloride 1 SOLUTION 5 % in lr-d5 intravenous nutrilyte intravenous 1 parenteral solution solution 25-40.6-5 20 meq/l, 40 meq/l meq/20 ml PEDITRACE 2 INTRAVENOUS SOLUTION 521- 53.7-3.6 MCG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 195 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits potassium chloride 1 potassium chloride- 1 in water intravenous d5-0.3%nacl piggyback 10 intravenous meq/100 ml, 10 parenteral solution meq/50 ml, 20 20 meq/l meq/100 ml, 20 potassium chloride- 1 meq/50 ml, 30 d5-0.9%nacl meq/100 ml, 40 intravenous meq/100 ml parenteral solution potassium chloride 1 20 meq/l, 40 meq/l intravenous solution POTASSIUM 2 2 meq/ml GLUCONATE potassium chloride 1 (BULK) POWDER oral capsule, POTASSIUM 2 extended release 10 PERMANGANATE meq, 8 meq (BULK) potassium chloride 1 GRANULES oral liquid 20 potassium phosphate 1 meq/15 ml, 40 m-/d-basic meq/15 ml intravenous solution potassium chloride 1 3 mmol/ml oral packet 20 meq POTASSIUM 2 potassium chloride 1 PHOSPHATE,DIB oral tablet extended (BULK) POWDER release 10 meq, 20 100 % meq, 8 meq ringer's intravenous 1 potassium chloride 1 parenteral solution oral tablet,er selenium 1 particles/crystals 10 intravenous solution meq, 20 meq 40 mcg/ml potassium chloride- 1 SODIUM 2 0.45 % nacl ACETATE (BULK) intravenous POWDER parenteral solution 20 meq/l sodium acetate 1 intravenous solution potassium chloride- 1 2 meq/ml, 4 meq/ml d5-0.2%nacl intravenous sodium bicarbonate 1 parenteral solution in d5w intravenous 10 meq/l, 20 meq/l, solution 150 30 meq/l, 40 meq/l meq/1,000 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 196 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium bicarbonate 1 strong iodine oral 1 intravenous solution solution 5 % 1 meq/ml (8.4 %), TPN 2 4.2 % ELECTROLYTES sodium bicarbonate 1 II INTRAVENOUS intravenous syringe SOLUTION 18-18- 10 meq/10 ml (8.4 5-4.5-35 MEQ/20 %), 4.2 % (0.5 ML meq/ml), 7.5 % (0.9 TRACE 2 meq/ml), 8.4 % (1 ELEMENTS meq/ml) 4/PEDIATRIC SODIUM 2 INTRAVENOUS CHLORIDE SOLUTION 1 (BULK) MCG-0.1 MG-30 GRANULES MCG-0.5 MG/ML SODIUM 2 ZINC ACETATE 2 CHLORIDE DIHYDRATE (BULK) POWDER (BULK) sodium chloride 0.45 1 CRYSTALS 100 % % intravenous ZINC CHLORIDE 2 parenteral solution (BULK) 0.45 % GRANULES sodium chloride 3 % 1 zinc chloride 1 intravenous intravenous solution parenteral solution 3 1 mg/ml % ZINC SULFATE 2 sodium chloride 5 % 1 (BULK) POWDER intravenous , 100 % parenteral solution 5 zinc sulfate 1 % intravenous solution sodium chloride 1 1 mg/ml, 5 mg/ml intravenous MISCELLANEOUS NUTRITION parenteral solution 2.5 meq/ml, 4 PRODUCTS meq/ml ADVANTAGE 2 OTC SODIUM 2 WITH IRON ORAL LACTATE (BULK) POWDER 2.07-5.6 SOLUTION 60 % GRAM/100 KCAL amino acid oral sodium phosphate 1 1 OTC capsule intravenous solution 3 mmol/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 197 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AMINOSYN 10 % 2 AMINOSYN M 3.5 2 INTRAVENOUS % INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 10 % SOLUTION 3.5 % AMINOSYN 7 % 2 AMINOSYN-HBC 2 WITH 7% ELECTROLYTES INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 7 % SOLUTION 7 % AMINOSYN-PF 10 2 AMINOSYN 8.5 % 2 % INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 10 % SOLUTION 8.5 % AMINOSYN-PF 7 2 AMINOSYN 8.5 %- 2 % (SULFITE- ELECTROLYTES FREE) INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 8.5 % SOLUTION 7 % AMINOSYN II 10 2 AMINOSYN-RF 5.2 2 % INTRAVENOUS % INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 10 % SOLUTION 5.2 % AMINOSYN II 15 2 ARGININE (L- 2 % INTRAVENOUS ARGININE) PARENTERAL (BULK) POWDER SOLUTION 15 % 100 % AMINOSYN II 7 % 2 ARGININE HCL(L- 2 INTRAVENOUS ARGININE)(BULK PARENTERAL ) POWDER 100 % SOLUTION 7 % BAL IN OIL 2 AMINOSYN II 8.5 2 INTRAMUSCULA % INTRAVENOUS R SOLUTION 100 PARENTERAL MG/ML SOLUTION 8.5 % BCAD 1 ORAL 2 OTC AMINOSYN II 8.5 2 POWDER 16.2-500 %- GRAM-KCAL/100 ELECTROLYTES G INTRAVENOUS benecalorie oral 1 OTC PARENTERAL liquid 7.5 kcal/ml SOLUTION 8.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 198 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BOOST BREEZE 2 OTC CALCILO XD 2 OTC NUTRITIONAL ORAL POWDER ORAL LIQUID CALCIUM 2 0.04-1.05 GRAM- DISODIUM KCAL/ML VERSENATE boost high protein 1 OTC INJECTION oral liquid 0.06 SOLUTION 200 gram- 1 kcal/ml MG/ML boost kid essentials 1 OTC CLINIMIX 2 oral liquid 0.03-1 5%/D15W gram-kcal/ml, 0.04- SULFITE FREE 1.5 gram-kcal/ml INTRAVENOUS BOOST KID 2 OTC PARENTERAL ESSENTIALS W- SOLUTION 5 % FIBER ORAL CLINIMIX 2 LIQUID 0.04-1.5 4.25%/D10W SULF GRAM-KCAL/ML FREE BOOST MAX 2 OTC INTRAVENOUS ORAL LIQUID 0.09 PARENTERAL GRAM- 0.5 SOLUTION 4.25 % KCAL/ML CLINIMIX 5%- 2 boost oral liquid 1 OTC D20W(SULFITE- 0.04 gram- 1 kcal/ml FREE) INTRAVENOUS boost plus oral 1 OTC PARENTERAL liquid 0.06 gram- SOLUTION 5 % 1.5 kcal/ml CLINIMIX 6%- 2 BOOST PUDDING 2 OTC D5W (SULFITE- ORAL PUDDING FREE) BOOST SOOTHE 2 OTC INTRAVENOUS ORAL LIQUID 0.04 PARENTERAL GRAM- 1.27 SOLUTION 6-5 % KCAL/ML CLINIMIX 8%- 2 BOOST VHC 2 OTC D10W(SULFITE- ORAL LIQUID FREE) 0.09-2.25 GRAM- INTRAVENOUS KCAL/ML PARENTERAL SOLUTION 8-10 % BREAKFAST 2 OTC ESSENTIALS ORAL LIQUID 41 GRAM-240 KCAL/237 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 199 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLINIMIX 8%- 2 COMPLEAT 2 OTC D14W(SULFITE- FEEDING TUBE FREE) LIQUID 0.05 INTRAVENOUS GRAM- 1.06 PARENTERAL KCAL/ML SOLUTION 8-14 % compleat pediatric 1 OTC CLINIMIX E 2 reduced cal oral 4.25%/D10W SUL liquid 0.03-0.6 FREE gram-kcal/ml INTRAVENOUS complete amino acid 1 OTC PARENTERAL mix oral powder 82- SOLUTION 4.25 % 328 gram-kcal/100 g CLINIMIX E 2 CYCLINEX-1 2 OTC 4.25%/D5W SULF ORAL POWDER FREE 7.5-510 G- INTRAVENOUS KCAL/100 G PARENTERAL SOLUTION 4.25 % CYSTEINE HCL(L- 2 CYSTEINE)(BULK CLINIMIX E 2 ) POWDER 5%/D15W SULFIT FREE DAILY AMINO 2 OTC INTRAVENOUS ORAL PARENTERAL TABLET,CHEWAB SOLUTION 5 % LE CLINIMIX E 2 DUOCAL ORAL 2 OTC 5%/D20W SULFIT POWDER FREE EDETATE 2 INTRAVENOUS CALCIUM PARENTERAL DISODIUM(BULK) SOLUTION 5 % POWDER 100 % CLINIMIX E 8%- 2 ELECARE INFANT 2 OTC D10W FORMULA ORAL SULFITEFREE POWDER 3.1-4.8- INTRAVENOUS 10.7 GRAM/100 PARENTERAL KCAL SOLUTION 8-10 % electrolyte-48 in d5w 1 CLINIMIX E 8%- 2 intravenous D14W parenteral solution SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-14 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 200 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENFAGROW 2 OTC ENFAMIL INFANT 2 OTC TODDLR ORAL POWDER 2- TRANSITION SOY 5.3 GRAM/100 ORAL POWDER KCAL 3.3-4.4 GRAM/100 ENFAMIL INFANT 2 OTC KCAL ORAL POWDER IN enfamil a.r. oral 1 OTC PACKET 2-5.3 powder 2.5-5.1-11.3 GRAM/100 KCAL gram/100 kcal ENFAMIL 2 OTC ENFAMIL 2 OTC NEWBORN NON- ENFACARE ORAL GMO ORAL POWDER 2.8-5.3 POWDER 2.1-5.3 GRAM/100 KCAL GRAM/100 KCAL ENFAMIL 2 OTC ENFAMIL 2 OTC GENTLEASE NEWBORN ORAL NON-GMO ORAL LIQUID 2.1-5.3 POWDER 2.3-5.3 GRAM/100 KCAL GRAM/100 KCAL ENFAMIL 2 OTC ENFAMIL 2 OTC NEWBORN ORAL GENTLEASE POWDER 2.1-5.3 ORAL LIQUID 2.3- GRAM/100 KCAL 5.3 GRAM/100 ENFAMIL 2 OTC KCAL PROSOBEE LIPIL ENFAMIL 2 OTC ORAL GENTLEASE CONCENTRATE ORAL POWDER ENFAMIL 2 OTC 2.3-5.3 GRAM/100 PROSOBEE LIPIL KCAL ORAL LIQUID ENFAMIL INFANT 2 OTC ENFAMIL 2 OTC NON-GMO ORAL PROSOBEE ORAL POWDER 2-5.3 POWDER 2.5-5.3 GRAM/100 KCAL GRAM/100 KCAL ENFAMIL INFANT 2 OTC ENFAPORT ORAL 2 OTC ORAL LIQUID 3.5-5.5-10 CONCENTRATE 2- GRAM/100 KCAL 5.3 GRAM/100 KCAL ensure active heart 1 OTC health oral liquid ENFAMIL INFANT 2 OTC ORAL LIQUID 2- ensure active high 1 OTC 5.3 GRAM/100 protein oral liquid KCAL ensure active light 1 OTC oral liquid You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 201 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ensure active 1 OTC ENSURE 2 OTC protein-muscle oral PUDDING ORAL liquid PUDDING ensure clear oral 1 OTC EO28 SPLASH 2 OTC liquid ORAL LIQUID ENSURE CLEAR 2 OTC EQUACARE JR 2 OTC THERAPEUTIC ORAL POWDER ORAL LIQUID 14.3 GRAM-469 0.035-1 GRAM- KCAL/100 GRAM KCAL/ML FIBERSOURCE HN 2 OTC ensure compact oral 1 OTC FEEDING TUBE liquid LIQUID 0.05 ENSURE ENLIVE 2 OTC GRAM- 1.2 ORAL LIQUID 0.08 KCAL/ML GRAM-1.5 freamine iii 10 % 1 KCAL/ML intravenous parenteral solution ensure high protein 1 OTC 10 % oral liquid ensure high protein 1 OTC GERBER GOOD 2 OTC oral powder START GENTLE NOGMO ORAL ensure max protein 1 OTC POWDER 2.1-5.1- oral liquid 11.4 GRAM/100 ENSURE MUSCLE 2 OTC KCAL HEALTH ORAL GERBER GOOD 2 OTC LIQUID START GENTLE ensure oral liquid 1 OTC ORAL LIQUID 2.2- 5.1-11.6 GRAM/100 ENSURE ORAL 2 OTC KCAL POWDER GERBER GOOD 2 OTC ensure original oral 1 OTC START SOY ORAL liquid , 0.04-1.05 LIQUID 2.5-5.1 gram-kcal/ml GRAM/100 KCAL ENSURE 2 OTC GERBER GOOD 2 OTC ORIGINAL ORAL START SOY ORAL POWDER POWDER 2.5-5.1 ensure plant-based 1 OTC GRAM/100 KCAL protein oral liquid ENSURE PLUS 2 OTC ORAL LIQUID 0.05-1.5 GRAM- KCAL/ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 202 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GERBER GS 2 OTC high-protein 1 OTC GENTLEPRO 2 nutritional shake NO-GMO ORAL oral liquid POWDER 1.9-5.1- HISTIDINE HCL(L- 2 11.9 GRAM/100 HISTID)(BULK) KCAL POWDER GERBER GS 2 OTC HOMINEX-1 2 OTC GNTLPR ORAL POWDER NOGMO(B.LACT) 15-480 GRAM- ORAL POWDER KCAL 2.2-5.1-11.2 G/100 KCAL intralipid 1 intravenous GLUTAREX-1 2 OTC emulsion 20 % ORAL POWDER 15-480 G- IONOSOL-B IN 2 KCAL/100 G D5W INTRAVENOUS GLYCOSADE 2 OTC PARENTERAL ORAL POWDER IN SOLUTION 5 % PACKET 212 KCAL/60 GRAM IONOSOL-MB IN 2 D5W G-PREPROTEIN 2 OTC INTRAVENOUS ORAL LIQUID 15- PARENTERAL 60 GRAM- SOLUTION 5 % KCAL/30 ML ISOLYTE S PH 7.4 2 HCY 1 POWDER 2 OTC INTRAVENOUS ORAL POWDER PARENTERAL 16.2-500 GRAM- SOLUTION KCAL/100 G ISOLYTE-P IN 5 % 2 HEPATAMINE 8% 2 DEXTROSE INTRAVENOUS INTRAVENOUS PARENTERAL PARENTERAL SOLUTION 8 % SOLUTION 5 % hetastarch 6 % in 1 ISOLYTE-S 2 0.9 % nacl INTRAVENOUS intravenous solution PARENTERAL 6 % SOLUTION HI-CAL ORAL 2 OTC ISOMIL 2 OTC LIQUID ADVANCE ORAL high protein oral 1 OTC LIQUID tablet ISOMIL DF ORAL 2 OTC LIQUID

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 203 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ISOMIL/IRON 2 OTC NORMOSOL-R PH 2 ORAL LIQUID 7.4 isosource 1.5 cal 1 OTC INTRAVENOUS feeding tube liquid PARENTERAL 0.07 gram-1.5 SOLUTION kcal/ml NOURISH 2 OTC isosource hn feeding 1 OTC ORIGINAL tube liquid 0.05 FORMULA ORAL gram- 1.2 kcal/ml LIQUID I-VALEX-1 ORAL 2 OTC NUTRA PRO HIGH 2 OTC POWDER 15 PROTEIN ORAL GRAM-480 POWDER KCAL/100 GRAM nutrafit oral liquid 1 OTC JEVITY 1 CAL 2 OTC nutrafit plus oral 1 OTC ORAL LIQUID 0.04 liquid GRAM-1.06 NUTRAMIGEN 2 OTC KCAL/ML DHA-ARA ORAL JEVITY 1.2 CAL 2 OTC CONCENTRATE ORAL LIQUID 0.06 2.8-5.3-10.3 GRAM-1.2 GRAM/100 KCAL KCAL/ML NUTRAMIGEN 2 OTC JEVITY 1.5 CAL 2 OTC DHA-ARA ORAL ORAL LIQUID 0.06 LIQUID 2.8-5.3- GRAM-1.5 10.3 GRAM/100 KCAL/ML KCAL KETONEX-1 2 OTC NUTRAMIGEN 2 OTC ORAL POWDER TODDLER 15-480 G-KCAL ENFLORA-LGG MSUD ANALOG 2 OTC ORAL POWDER ORAL POWDER 2.5-4.3 GRAM/100 13-475 GRAM- KCAL KCAL/100 G NUTRAMIGEN 2 OTC NEPHRAMINE 5.4 2 WITH ENFLORA % INTRAVENOUS LGG ORAL PARENTERAL POWDER 2.8-5.3- SOLUTION 5.4 % 10.3 GRAM/100 KCAL NORMOSOL-M IN 2 nutren 1.0 feeding 5 % DEXTROSE 1 OTC tube liquid 0.04 INTRAVENOUS gram-1 kcal/ml PARENTERAL SOLUTION

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 204 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nutren 1.5 feeding 1 OTC OA 1 POWDER 2 OTC tube liquid 0.07 ORAL POWDER gram-1.5 kcal/ml 15.7-500 G- nutren 2.0 feeding 1 OTC KCAL/100 G tube liquid 0.08 ORANGE 2 OTC gram-2 kcal/ml CHICKN- nutren junior fiber 1 OTC CARROT-BRWN oral liquid 0.03-1 RICE ORAL gram-kcal/ml LIQUID nutren junior oral 1 OTC ORNITHINE 2 liquid 0.03-1 gram- HYDROCHLORID kcal/ml E (BULK) POWDER 100 % NUTRISURE 2 OTC ORIGINAL ORAL OSMOLITE 1 CAL 2 OTC LIQUID 0.04-0.93 ORAL LIQUID 0.04 GRAM-KCAL/ML GRAM-1.06 KCAL/ML NUTRISURE PLUS 2 OTC ORAL LIQUID OSMOLITE 1.2 2 OTC 0.05-1.5 GRAM- CAL ORAL KCAL/ML LIQUID 0.06 GRAM-1.2 nutritional drink mix 1 OTC KCAL/ML oral powder osmolite 1.5 cal oral 1 OTC nutritional drink 1 OTC liquid 0.06 gram-1.5 oral liquid kcal/ml nutritional drink 1 OTC PEDIASURE 2 OTC plus oral liquid ENTERAL ORAL nutritional shake 1 OTC LIQUID 0.03-1 oral liquid , 0.04- GRAM-KCAL/ML 1.05 gram-kcal/ml PEDIASURE 2 OTC NUTRITIONAL 2 OTC GROW-GAIN SHAKE ORAL ORAL LIQUID LIQUID 0.04-0.93 0.03-1 GRAM- GRAM-KCAL/ML KCAL/ML nutritional shake 1 OTC PEDIASURE ORAL 2 OTC plus oral liquid LIQUID 0.03-1 GRAM-KCAL/ML, NUTRITIONAL 2 OTC 0.06-1.5 GRAM- SHAKE PLUS KCAL/ML ORAL LIQUID 0.05-1.5 GRAM- pediasure peptide 1 OTC KCAL/ML 1.0 cal oral liquid 0.03-1 gram-kcal/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 205 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PEDIASURE 2 OTC phlexy-vits oral 1 OTC PEPTIDE 1.5 CAL packet ORAL LIQUID PLASMA-LYTE 2 0.045-1.5 GRAM- 148 KCAL/ML INTRAVENOUS PEDIASURE 2 OTC PARENTERAL SIDEKICKS ORAL SOLUTION LIQUID 0.03-0.6 PLASMA-LYTE A 2 GRAM-KCAL/ML INTRAVENOUS pediatric balanced 1 OTC PARENTERAL nutrition oral liquid SOLUTION 0.03-1 gram-kcal/ml plasmanate 1 pediatric peptide 1.0 1 OTC intravenous oral liquid 0.04 parenteral solution 5 gram-1 kcal/ml % pediatric peptide 1 OTC plenamine 1 formula 1.5 oral intravenous liquid 0.05 gram-1.5 parenteral solution kcal/ml 15 % pediatric standard 1 OTC PRE PROTEIN 2 OTC formula 1.2 oral ORAL TABLET liquid 0.05 gram-1.2 PREGESTIMIL 2 OTC kcal/ml ORAL LIQUID 2.8- peptamen 1.5 cal 1 OTC 5.6 GRAM/ 100 with prebio1 oral KCAL (5 OZ), 2.8- liquid 0.068 gram- 5.6 GRAM/ 100 1.5 kcal/ml KCAL(4.2OZ) peptamen junior 1 OTC PREGESTIMIL 2 OTC fiber oral liquid ORAL POWDER 0.03-1 gram-kcal/ml premasol 10 % 1 PEPTAMEN 2 OTC intravenous JUNIOR ORAL parenteral solution LIQUID 0.03-1 10 % GRAM-KCAL/ML PREMIUM 2 OTC peptamen w-prebio1 1 OTC INFANT oral liquid 0.04 FORMULA ORAL gram- 1 kcal/ml POWDER 2.1-5.3 PFD TODDLER 2 OTC GRAM/100 KCAL ORAL POWDER pre-protein oral 1 OTC 530 KCAL/100 liquid 15-60 gram- GRAM kcal/30 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 206 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PROCALAMINE 2 prosource no carb 1 OTC 3% oral liquid in packet INTRAVENOUS 15-60 gram-kcal/30 PARENTERAL ml SOLUTION 3 % PROSOURCE 2 OTC procel 100 oral 1 OTC ORAL LIQUID 10- powder 100 GRAM- procel singles oral 1 OTC KCAL/30 ML packet prosource oral 1 OTC powder procel whey oral 1 OTC powder pro-stat awc oral 1 OTC liquid 17-100 gram- PRODUCT 3232A 2 OTC kcal/30 ml ORAL POWDER 22-33-14.8 G-G- pro-stat awc oral 1 OTC MG/100 G liquid in packet 17- 100 gram-kcal/30 ml PROMOD 2 OTC PROTEIN ORAL PRO-STAT SUGAR 2 OTC LIQUID FREE ORAL PROMOTE ORAL 2 OTC LIQUID 15-100 LIQUID 0.06 GRAM-KCAL/30 GRAM-1 ML KCAL/ML PRO-STAT SUGAR 2 OTC PROMOTE WITH 2 OTC FREE ORAL FIBER ORAL LIQUID IN LIQUID 0.06 PACKET 15 GRAM-1 GRAM- 100 KCAL/ML KCAL/30 ML protein oral powder PRO-PHREE ORAL 2 OTC 1 OTC POWDER 5.5-12.7 PROTEINEX 2 OTC GRAM/100 KCAL ORAL LIQUID 15- PROPIMEX-1 2 OTC 60 GRAM- ORAL POWDER KCAL/30 ML 15-480 G- PROTEINEX-100 2 OTC KCAL/100 G ORAL LIQUID 18 PROSOL 20 % 2 GRAM-100 INTRAVENOUS KCAL/30 ML PARENTERAL PROTEINEX-18 2 OTC SOLUTION ORAL LIQUID 18- prosource no carb 1 OTC 72 GRAM- oral liquid 15-60 KCAL/30 ML gram-kcal/30 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 207 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PROVIMIN ORAL 2 OTC SIMILAC 2 OTC POWDER 73 ADVANCE ORAL GRAM-313 POWDER IN KCAL/100 GRAM PACKET 2.07 QUINOA-KALE- 2 OTC GRAM/100 HEMP ORAL KCAL(17.4 GRAM) LIQUID SIMILAC 2 OTC RCF SOY 2 OTC ADVANCE PROTEIN ORGANIC ORAL FORMULA BASE LIQUID 2.07 ORAL GRAM-5.4 CONCENTRATE GRAM/100 KCAL similac advance replete fiber oral 1 OTC 1 OTC organic oral powder liquid 0.06 gram- 1 2.07 gram-5.63 kcal/ml gram/100 kcal replete oral liquid 1 OTC 0.06 gram-1 kcal/ml SIMILAC 2 OTC ADVANCE WITH resource 2.0 oral 1 OTC IRON ORAL liquid POWDER 2.07-5.6 R-GENE 10 2 GRAM/100 KCAL INTRAVENOUS similac alimentum 1 OTC PARENTERAL oral powder 2.75- SOLUTION 10 % 5.54-10.2 gram/100 SALMON-OATS- 2 OTC kcal SQUASH ORAL similac expert care 1 OTC LIQUID alimentum oral scandishake (lactose 1 OTC powder 2.75-5.54- free) oral packet 10.2 gram/100 kcal SIMILAC 2 OTC SIMILAC EXPERT 2 OTC ADVANCE ORAL CARE CONCENTRATE ALIMENTUM ORAL SIMILAC 2 OTC SUSPENSION 2.75- ADVANCE ORAL 5.54-10.2 LIQUID 2.07-5.40- GRAM/100 KCAL 11.2 GRAM/100 KCAL SIMILAC EXPERT 2 OTC CARE NEOSURE ORAL POWDER 2.8-5.5 GRAM/100 KCAL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 208 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SIMILAC EXPERT 2 OTC SIMILAC PRO- 2 OTC CARE ORAL SENSITIVE NON- LIQUID GMO ORAL SIMILAC FOR 2 OTC LIQUID 2.1-5.4- SPIT-UP ORAL 10.9 GRAM/100 LIQUID 2.14-5.4-11 KCAL GRAM/100 KCAL similac sensitive fuss 1 OTC and gas oral SIMILAC FOR 2 OTC concentrate 2.1-5.4- SPIT-UP ORAL 11.1 gram/100 kcal POWDER 2.14-5.4- 11 GRAM/100 SIMILAC 2 OTC KCAL SENSITIVE FUSS SIMILAC HUMAN 2 OTC AND GAS ORAL MILK FORTIFIER LIQUID 2.14-5.4- ORAL LIQUID IN 11.1 GRAM/100 PACKET 0.349-6.85 KCAL GRAM-KCAL/5 SIMILAC 2 OTC ML SENSITIVE FUSS SIMILAC HUMAN 2 OTC AND GAS ORAL MILK FORTIFIER POWDER 2.1-5.4- ORAL POWDER IN 11.1 GRAM/100 PACKET 0.25 KCAL, 2.2-5.4-11 GRAM-3.5 GRAM/100 KCAL KCAL/0.9 GRAM similac sensitive 1 OTC fuss-gas oral powder SIMILAC LOW- 2 OTC 2.1-5.4-10.9 IRON ORAL gram/100 kcal LIQUID similac neosure oral 1 OTC SIMILAC 2 OTC liquid 2.8-5.5-10.1 SENSITIVE gram/100 kcal ISOMIL SOY ORAL POWDER IN SIMILAC PM 2 OTC PACKET 2.45 ORAL POWDER GRAM/100 SIMILAC PRO- 2 OTC KCAL(17.6 GRAM) ADVANCE NON- SIMILAC 2 OTC GMO ORAL SENSITIVE ORAL LIQUID 2.07-5.4-11 SUSPENSION 2.14- GRAM/100 KCAL 5.4-10.7 G/100 KCAL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 209 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SIMILAC SOY 2 OTC standard 1.4 oral 1 OTC ISOMIL ORAL liquid 0.06 gram-1.4 LIQUID 2.45-5.46 kcal/ml GRAM/100 KCAL travasol 10 % 1 SIMILAC SOY 2 OTC intravenous ISOMIL ORAL parenteral solution POWDER 2.45-5.46 10 % GRAM/100 KCAL TROMETHAMINE 2 SIMILAC SPECIAL 2 OTC (BULK) POWDER CARE 24 ORAL 100 % LIQUID 3-5.43 TROPHAMINE 10 2 GRAM/100 KCAL % INTRAVENOUS SIMILAC SPECIAL 2 OTC PARENTERAL CARE 30 ORAL SOLUTION 10 % SUSPENSION 3- TWOCAL HN 2 OTC 6.61 GRAM/100 ORAL LIQUID KCAL 0.08-2 GRAM- SIMILAC 2 OTC KCAL/ML SUPPLEMENTATI TYREX-1 ORAL 2 OTC ON ORAL LIQUID POWDER 15-480 2.07-5.4-11.3 GRAM-KCAL GRAM/100 KCAL TYROS 1 ORAL 2 OTC SIMILAC 2 OTC POWDER 16.7-500 SUPPLEMENTATI G-KCAL ON ORAL POWDER 2.07-5.6- VITAL HIGH 2 OTC 10.8 GRAM/100 NITROGEN ORAL KCAL PACKET SIMILAC TOTAL 2 OTC XLEU ANALOG 2 OTC COMFORT NON- ORAL POWDER 13 GMO ORAL GRAM-475 POWDER 2.32-5.4 KCAL/100 GRAM GRAM/100 KCAL XLYS- XTRP 2 OTC SIMILAC TOTAL 2 OTC ANALOG ORAL COMFORT ORAL POWDER 13-475 LIQUID 2.32-5.4 GRAM-KCAL/100 GRAM/100 KCAL G SIMILAC TOTAL 2 OTC XMET ANALOG 2 OTC COMFORT ORAL ORAL POWDER POWDER 2.32-5.4 13-475 G- GRAM/100 KCAL KCAL/100 G

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 210 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XMTVI ANALOG 2 OTC balance b-100 (folic 1 ACA; OTC ORAL POWDER acid) oral tablet 0.4 13-475 G- mg KCAL/100 G balance b-50 (with 1 ACA; OTC XPHE, XTYR 2 OTC folic acid) oral ANALOG ORAL tablet 0.4 mg POWDER 13-475 balanced b-100 1 ACA; OTC G-KCAL complex oral tablet XPTM ANALOG 2 OTC extended release 100 ORAL POWDER mg 13-475 G-KCAL balanced b-100 oral 1 ACA; OTC VITAMINS / HEMATINICS tablet 0.4 mg AQUASOL A 2 balanced b-50 oral 1 ACA; OTC INTRAMUSCULA tablet R SOLUTION bal-care dha oral 1 50,000 UNIT/ML combo pack,tablet ascorbic acid 1 and cap,dr 27-1-430 (vitamin c) injection mg solution 500 mg/ml b-complex injection 1 ASCORBIC 2 injection solution ACID(VITAMIN 100-2-100-2-2 C)(BULK) mg/ml GRANULES 100 % b-complex with 1 ACA; OTC b complex 1 (with 1 ACA; OTC vitamin c oral tablet folic acid) oral , 400-500 mcg-mg tablet 0.4 mg children's iron oral 1 ACA; OTC b complex 100 1 drops 15 mg iron (75 injection solution mg)/ml 100-2-100-2-2 classic prenatal oral 1 ACA; OTC mg/ml tablet 28 mg iron- b complex 100 oral 1 ACA; OTC 800 mcg tablet 0.4 mg c-nate dha oral 1 b complex-vitamin 1 ACA; OTC capsule 28 mg iron- b12 oral tablet 1 mg -200 mg b complex-vitamin c- 1 ACA; OTC complete natal dha 1 folic acid oral tablet oral combo pack 29- 400 mcg 1-250-200 mg b-100 complex oral 1 ACA; OTC completenate oral 1 OTC tablet extended tablet,chewable 29 release 100 mg mg iron- 1 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 211 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits complex b-100 oral 1 ACA; OTC fluoride (sodium) 1 ACA; OTC tablet extended oral tablet,chewable release 0.25 mg(0.55 mg sod. fluoride), 0.5 cyanocobalamin 1 (vitamin b-12) mg (1.1 mg sodium fluorid), 1 mg (2.2 injection solution mg sod. fluoride) 1,000 mcg/ml folic acid injection CYANOCOBALA 2 1 solution 5 mg/ml MIN(VIT B- 12)(BULK) folic acid oral tablet 1 POWDER 1 mg daily prenatal oral 1 ACA; OTC folic acid oral tablet 1 ACA; OTC combo pack 28-800- 400 mcg, 800 mcg 440 mg-mcg-mg folivane-ob oral 1 dialyvite 800 oral 1 ACA; OTC capsule 85-1 mg tablet 0.8 mg foltabs 800 oral 1 ACA; OTC elite-ob oral tablet 1 tablet 0.8-10-115 50 mg iron- 1.25 mg mg-mg-mcg ERGOCALCIFERO 2 full spectrum b- 1 ACA; OTC L (VIT D2) (BULK) vitamin c oral tablet POWDER 0.8 mg FERAHEME 2 PA hydroxocobalamin 1 INTRAVENOUS intramuscular SOLUTION 510 solution 1,000 MG/17 ML (30 mcg/ml MG/ML) infed injection 1 PA FERRIC 2 solution 50 mg/ml SUBSULFATE INFUVITE 2 (BULK) POWDER PEDIATRIC FERRIC 2 INTRAVENOUS SUBSULFATE SOLUTION 80 MG- (BULK) 400 UNIT- 200 SOLUTION 20 TO MCG/5 ML 22 GRAM/100 ML kobee oral tablet 0.4 1 ACA; OTC ferrous sulfate oral 1 ACA; OTC mg drops 15 mg iron (75 kpn oral tablet 1 ACA; OTC mg)/ml fluoride (sodium) 1 ACA; OTC oral drops 0.5 mg (1.1 mg sod.fluorid)/ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 212 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ludent fluoride oral 1 ACA; OTC multivitamins with 1 ACA; OTC tablet,chewable 0.25 fluoride oral mg(0.55 mg sod. tablet,chewable 0.25 fluoride), 0.5 mg mg, 0.5 mg, 1 mg (1.1 mg sodium multivit-fluor (vit e 1 ACA; OTC fluorid), 1 mg (2.2 acetate) oral drops mg sod. fluoride) 0.25 mg/ml m.v.i. adult 1 mvc-fluoride oral 1 ACA; OTC intravenous solution tablet,chewable 0.25 3,300 unit- 150 mg, 0.5 mg, 1 mg mcg/10 ml mynatal advance 1 M.V.I. PEDIATRIC 2 oral tablet 90-1-50 INTRAVENOUS mg RECON SOLN 80- 400-200 MG-UNIT- mynatal oral capsule 1 MCG 65 mg iron- 1 mg M.V.I.-12 2 mynatal oral tablet 1 (WITHOUT 90-1-50 mg VITAMIN K) mynatal plus oral 1 INTRAVENOUS tablet 65 mg iron- 1 SOLUTION 3,300 mg UNIT-200 UNIT/10 ML mynatal-z oral tablet 1 65 mg iron- 1 mg m-natal plus oral 1 tablet 27 mg iron- 1 mynate 90 plus oral 1 mg tablet extended release 90 mg iron-1 multi-vit with 1 OTC mg fluoride-iron oral drops 0.25mg NASCOBAL 2 fluoride -10 mg NASAL iron/ml SPRAY,NON- AEROSOL 500 multi-vitamin with 1 ACA; OTC MCG/SPRAY fluoride oral drops 0.25 mg/ml, 0.5 natural b-100 1 ACA; OTC mg/ml complex oral tablet 100 mg multivitamin with 1 ACA; OTC fluoride oral newgen oral tablet 1 tablet,chewable 0.5 32-1,000 mg-mcg mg obstetrix dha oral 1 combo pack,tablet and cap,dr 29 mg iron-1 mg -50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 213 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits one daily prenatal 1 ACA; OTC prena1 pearl oral 1 oral combo pack 28- capsule,ir - delay 800-440 mg-mcg-mg rel,biphase 30-1.4- 200 mg pedia iron oral 1 ACA; OTC drops 15 mg iron (75 prena1 true oral 1 mg)/ml combo pack 30 mg iron- 1.4 mg-300 mg perry prenatal oral 1 ACA; OTC capsule 13.5-0.4 mg prenaissance oral 1 capsule 29-1.25-55- pnv 29-1 oral tablet 1 325 mg 29 mg iron- 1 mg prenaissance plus pnv-dha + docusate 1 1 oral capsule 28-1- oral capsule 27- 50-250 mg 1.25-55-300 mg prenatabs fa oral pnv-dha oral capsule 1 1 27 mg iron-1 mg - tablet 29-1 mg 300 mg prenatabs rx oral 1 tablet 29 mg iron- 1 pnv-omega oral 1 mg capsule 28-1-300 mg prenatal complete pnv-select oral tablet 1 1 ACA; OTC oral tablet 14 mg 27-1 mg iron- 400 mcg pr natal 400 ec oral 1 combo pack,tablet prenatal low iron 1 oral tablet 27 mg and cap,dr 29-1-400 iron- 1 mg mg prenatal multi-dha pr natal 400 oral 1 1 ACA; OTC (algal oil) oral combo pack 29-1- capsule 27mg iron- 400 mg 800 mcg-250 mg pr natal 430 ec oral 1 combo pack,tablet prenatal 1 ACA; OTC multivitamins oral and cap,dr 29-1-430 tablet 28 mg iron- mg 800 mcg pr natal 430 oral 1 prenatal one daily combo pack 29 mg 1 ACA; OTC oral tablet 27 mg iron-1 mg -430 mg iron- 800 mcg prena1 chew oral 1 tablet,chew,ir - prenatal oral tablet 1 ACA; OTC 28 mg iron- 800 mcg dr,biphase 1.4 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 214 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prenatal plus 1 RIBOFLAVIN 2 (calcium carb) oral (VITAMIN B2) tablet 27 mg iron- 1 (BULK) POWDER mg RIBOFLAVIN 2 prenatal plus oral 1 5PHOSPHAT tablet 29 mg iron- 1 SOD(BULK) mg POWDER prenatal tablet oral 1 ACA; OTC se-natal 19 chewable 1 tablet 28 mg iron- oral tablet,chewable 800 mcg 29 mg iron- 1 mg prenatal vitamin 1 ACA; OTC se-natal-19 oral 1 oral tablet 27 mg tablet 29 mg iron- 1 iron- 0.8 mg mg prenatal vitamin 1 stress formula 600 c 1 ACA; OTC plus low iron oral oral tablet tablet 27 mg iron- 1 stress formula oral 1 ACA; OTC mg tablet prenatal vit-iron 1 ACA; OTC stress formula with 1 ACA; OTC fum-folic ac oral iron oral tablet 500 tablet 28 mg iron- mg-400 mcg- 18 mg 800 mcg iron prenatal vits96-iron 1 ACA; OTC stress formula with 1 ACA; OTC fum-folic oral tablet iron(sulf) oral tablet 27 mg iron- 800 mcg 500 mg-400 mcg- 27 prenatal-u oral 1 mg iron capsule 106.5-1 mg super b complex- 1 ACA; OTC preplus oral tablet 1 vitamin c oral tablet 27 mg iron- 1 mg super b maxi 1 ACA; OTC pretab oral tablet 1 complex oral tablet 29-1 mg 0.4 mg PYRIDOXINE 2 super quints b-50 1 ACA; OTC (BULK) POWDER oral tablet 100 % super quints oral 1 ACA; OTC pyridoxine (vitamin 1 tablet 0.4 mg b6) injection taron-c dha oral 1 solution 100 mg/ml capsule 35-1-200 mg rena-vite oral tablet 1 ACA; OTC taron-prex prenatal- 1 0.8 mg dha oral capsule 30 mg iron-1.2 mg-55 mg-265 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 215 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits thiamine hcl 1 virt-pn dha oral 1 (vitamin b1) capsule 27 mg iron- injection solution 1 mg -300 mg 100 mg/ml virt-pn plus oral 1 trinatal rx 1 oral 1 capsule 28-1-300 mg tablet 60 mg iron-1 vitamin b complex 1 ACA; OTC mg oral tablet trinate oral tablet 28 1 vitamin b complex- 1 ACA; OTC mg iron- 1 mg folic acid oral tablet triveen-duo dha oral 1 0.4 mg combo pack 29-1- vitamins a,c,d and 1 ACA; OTC 400 mg fluoride oral drops tri-vitamin with 1 ACA; OTC 0.25 mg fluor. (0.55 fluoride oral drops mg)/ml, 0.5 mg 0.25 mg fluor. (0.55 fluoride (1.1 mg)/ml mg)/ml, 0.5 mg vitamins b complex 1 ACA; OTC fluoride (1.1 mg)/ml oral tablet tri-vite with fluoride 1 ACA; OTC vp-ch-pnv oral 1 oral drops 0.25 mg capsule 30 mg iron- fluor. (0.55 mg)/ml, 1 mg -50 mg-260 mg 0.5 mg fluoride (1.1 mg)/ml westab plus oral 1 tablet 27 mg iron- 1 VENOFER 2 PA mg INTRAVENOUS SOLUTION 100 westgel dha oral 1 MG IRON/5 ML, capsule 31 mg iron- 200 MG IRON/10 1 mg-200 mg ML, 50 MG zatean-pn dha oral 1 IRON/2.5 ML capsule 27 mg iron- virt-c dha oral 1 1 mg -300 mg capsule 35-1-200 mg zatean-pn plus oral 1 virt-nate dha oral 1 capsule 28-1-300 mg capsule 28 mg iron- zingiber oral tablet 1 1 mg -200 mg 1.2 mg-40 mg- 124.1 mg-100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 216 Index

1 ACCU-CHEK SPIRIT adefovir ...... 5 1ST TIER UNILET CARTRIDGE SYS ...... 112 ADEMPAS ...... 184 COMFORTOUCH ...... 112 ACCU-CHEK TENDER .... 112 adenosine ...... 62 2 ACCU-CHEK ULTRAFLEX adenosine (diagnostic) ...... 62 2-DEOXY-D-GLUCOSE ...... 113 ADJUSTABLE LANCING (BULK) ...... 96 accutane ...... 86 DEVICE ...... 113 2-IN-1 LANCET DEVICE. 112 ACD SOLUTION A ...... 97 adrenalin ...... 181 2-METHOXYESTRADIOL ACD-A ...... 113 adriamycin ...... 22 (BULK) ...... 96 ACE AEROSOL CLOUD adrucil ...... 22 3 ENHANCER ...... 113 ADVAIR HFA ...... 184 3,5-DIIODOTHYRONINE acebutolol ...... 63 ADVANCED LANCING (BULK) ...... 97 ACEBUTOLOL (BULK) ..... 63 DEVICE ...... 113 5 acetaminophen ...... 48 ADVANCED TRAVEL 5-AMINOSALICYLIC ACID ACETAMINOPHEN (BULK) LANCETS ...... 113 ...... 145 ...... 48 ADVANTAGE WITH IRON A acetaminophen-caff- ...... 197 abacavir ...... 4 dihydrocod ...... 43 ADVATE ...... 71 abacavir-lamivudine ...... 4 acetaminophen-codeine ...... 43 ADVOCATE LANCET ..... 113 abacavir-lamivudine- acetazolamide ...... 178 ADVOCATE LANCING zidovudine ...... 4 ACETAZOLAMIDE (BULK) DEVICE ...... 113 ABELCET ...... 3 ...... 178 ADVOCATE RAPID-SAFE ABILIFY MAINTENA ...... 53 acetazolamide sodium ...... 178 LANCING ...... 113 abiraterone ...... 22 acetic acid ...... 97 ADYNOVATE ...... 71 ABRAXANE ...... 22 ACETYLCHOLINE AEROCHAMBER MINI ... 113 acamprosate ...... 97 CHLORIDE (BULK) ..... 176 AEROCHAMBER MV ...... 113 acarbose ...... 112 acetylcysteine ...... 96, 184 AEROCHAMBER PLUS ACCU-CHEK COMBO ACETYLCYSTEINE (BULK) FLOW-VU ...... 113 SYSTEM ...... 112 ...... 184 AEROCHAMBER PLUS ACCU-CHEK FASTCLIX acitretin ...... 81 FLOW-VU,L MSK ...... 113 LANCET DRUM ...... 112 ACTEMRA ...... 162 AEROCHAMBER PLUS ACCU-CHEK FASTCLIX ACTEMRA ACTPEN ...... 162 FLOW-VU,M MSK ...... 113 LANCING DEV ...... 112 ACTHIB (PF) ...... 156 AEROCHAMBER PLUS ACCU-CHEK MULTICLIX ACTHREL...... 138 FLOW-VU,S MSK ...... 113 LANCET ...... 112 acti-lance lancets ...... 113 AEROCHAMBER PLUS Z ACCU-CHEK RAPID D ACTIMMUNE ...... 153 STAT LG MSK ...... 113 INFUSION ...... 112 ACTIVASE ...... 79 AEROCHAMBER PLUS Z ACCU-CHEK SAFE-T-PRO acyclovir ...... 4, 92 STAT MD MSK ...... 113 ...... 112 ACYCLOVIR (BULK) ...... 4 AEROCHAMBER PLUS Z ACCU-CHEK SAFE-T-PRO acyclovir sodium ...... 5 STAT SM MSK ...... 113 PLUS ...... 112 ADACEL(TDAP AEROCHAMBER WITH ACCU-CHEK SOFT DEV ADOLESN/ADULT)(PF) FLOWSIGNAL ...... 113 LANCETS ...... 112 ...... 156 AEROCHAMBER Z-STAT ACCU-CHEK SOFTCLIX ADAKVEO ...... 22 PLUS-FLW SG ...... 113 LANCETS ...... 112 adapalene ...... 86 AEROTRACH PLUS ...... 113 ACCU-CHEK SPIRIT adapalene-benzoyl peroxide . 86 AEROVENT PLUS ...... 113 ADAPTER ...... 112 ADDAMEL N ...... 193 afirmelle ...... 168

217 AFLURIA QD 2020-21(3YR alprazolam intensol...... 53 AMINOSALICYLIC ACID-5 UP)(PF) ...... 156 ALPROLIX ...... 72 ...... 145 AFLURIA QD 2020-21(6- alprostadil ...... 191 AMINOSYN 10 % ...... 198 35MO)(PF) ...... 156 ALPROSTADIL (BULK) .. 191 AMINOSYN 7 % WITH AFLURIA QUAD 2020- altacaine ...... 177 ELECTROLYTES ...... 198 2021(6MO UP) ...... 156 altavera (28) ...... 168 AMINOSYN 8.5 % ...... 198 AFSTYLA ...... 72 ALTERNATE SITE LANCET AMINOSYN 8.5 %- a-hydrocort ...... 109 ...... 114 ELECTROLYTES ...... 198 ak-poly-bac ...... 175 ALTERNATE SITE AMINOSYN II 10 % ...... 198 albendazole ...... 11 LANCING DEVICE ...... 114 AMINOSYN II 15 % ...... 198 ALBENDAZOLE (BULK) .. 11 ALUMINUM CHLORIDE AMINOSYN II 7 % ...... 198 albumin, human 25 %...... 193 (BULK) ...... 83 AMINOSYN II 8.5 % ...... 198 albumin, human 5 %...... 193 ALUMINUM HYDROXIDE AMINOSYN II 8.5 %- albuminar 25 % ...... 193 GEL (BULK) ...... 145 ELECTROLYTES ...... 198 alburx (human) 25 % ...... 193 ALUMINUM, (ACETATO- AMINOSYN M 3.5 % ...... 198 alburx (human) 5 % ...... 193 O)DIH(BULK) ...... 97 AMINOSYN-HBC 7% ...... 198 albutein 25 % ...... 193 ALUNBRIG ...... 22 AMINOSYN-PF 10 % ...... 198 albutein 5 % ...... 193 alvimopan ...... 145 AMINOSYN-PF 7 % albuterol sulfate ...... 184 alyacen 7/7/7 (28) ...... 168 (SULFITE-FREE) ...... 198 ALBUTEROL SULFATE alyq ...... 184 AMINOSYN-RF 5.2 % ...... 198 (BULK) ...... 184 amabelz ...... 164 amiodarone ...... 62 alclometasone ...... 92 amantadine hcl ...... 5 amiodarone in dextrose 5 % . 62 alcohol pads ...... 113 AMANTADINE HCL (BULK) amitriptyline ...... 53 alcohol prep pads ...... 113 ...... 5 AMITRIPTYLINE (BULK) . 53 alcohol swabs ...... 113 AMBISOME ...... 3 amitriptyline-chlordiazepoxide alcohol wipes ...... 114 ambrisentan ...... 184 ...... 53 alcohol, rubbing ...... 106 amcinonide ...... 92 amlodipine ...... 63 ALDOSTERONE (BULK) 109 amethia ...... 168 AMLODIPINE BESYLATE ALDURAZYME ...... 138 amethyst (28) ...... 168 (BULK) ...... 63 alendronate ...... 161 amikacin ...... 11 amlodipine-atorvastatin ...... 77 alfentanil ...... 43 AMIKACIN SULFATE amlodipine-benazepril ...... 63 ALFERON N...... 153 (BULK) ...... 11 amlodipine-olmesartan ...... 63 alfuzosin ...... 191 amiloride ...... 63 amlodipine-valsartan ...... 63 ALINIA ...... 11 amiloride-hydrochlorothiazide amlodipine-valsartan-hcthiazid aliskiren ...... 63 ...... 63 ...... 63 ALLANTOIN (BULK) ...... 83 amino acid ...... 197 AMMONIUM CHLORIDE allopurinol ...... 161 AMINOBENZOIC ACID (BULK) ...... 191 ALLOPURINOL (BULK) . 161 (BULK) ...... 83 ammonium lactate ...... 83 allopurinol sodium...... 161 aminocaproic acid...... 72 AMMONIUM LACTATE almotriptan malate ...... 38 AMINOCAPROIC ACID (BULK) ...... 83 alophen (bisacodyl) ...... 145 (BULK) ...... 72 AMMONIUM SULFATE aloprim ...... 161 aminophylline ...... 184 (BULK) ...... 97 alosetron ...... 145 AMINOPHYLLINE (BULK) amnesteem ...... 86 ALPHA PINENE (BULK) ... 97 ...... 184 amoxapine ...... 53 ALPHAGAN P ...... 180 AMINOSALICYLATE amoxicil-clarithromy-lansopraz ALPHANATE ...... 72 SODIUM (BULK) ...... 11 ...... 152 ALPHANINE SD ...... 72 AMINOSALICYLIC ACID amoxicillin ...... 16 alprazolam ...... 53 (BULK) ...... 11 AMOXICILLIN (BULK) ..... 16 ALPRAZOLAM (BULK) .... 53 amoxicillin-pot clavulanate .. 16

218 amphetamine sulfate ...... 53 armodafinil ...... 54 AUTOLET IMPRESSION amphotericin b ...... 3 ARMOUR THYROID ...... 142 LANC DEV ...... 114 AMPHOTERICIN B (BULK) 3 ARNUITY ELLIPTA ...... 185 AUTOLET LANCING ampicillin ...... 16 ARRANON ...... 22 DEVICE ...... 114 ampicillin sodium ...... 16 ascomp with codeine ...... 43 AUTOLET PLUS LANCING ampicillin-sulbactam ...... 16 ascorbic acid (vitamin c) .... 211 DEVICE ...... 114 AMYTAL ...... 53 ASCORBIC ACID(VITAMIN AUTOPEN 1 TO 21 UNITS AMZEEQ ...... 86 C)(BULK) ...... 211 ...... 114 anagrelide ...... 97 asenapine maleate ...... 54 AUTOPEN 2 TO 42 UNITS anaspaz ...... 143 ASMANEX HFA ...... 185 ...... 114 anastrozole ...... 22 ASMANEX TWISTHALER AUTOSOFT 30 ...... 114 ANASTROZOLE (BULK) .. 22 ...... 185 AUTOSOFT 90 ...... 114 ANDRODERM ...... 138 aspirin ...... 48 AUTOSOFT XC INFUSION anectine...... 41 ASPIRIN (BULK) ...... 48 SET 23 ...... 114 ANISINDIONE (BULK) ..... 97 aspirin childrens ...... 48 AUTOSOFT XC INFUSION ANORO ELLIPTA ...... 184 aspirin low dose ...... 48 SET 32 ...... 114 ANTHRALIN (BULK) ...... 82 aspirin,buffd-calcium carb-mag AUTOSOFT XC INFUSION ANTICOAG CITRATE PHOS ...... 49 SET 43 ...... 114 DEXTROSE ...... 97 aspirin-dipyridamole ...... 72 avar ...... 86 ANTIPYRINE (BULK) ...... 97 aspir-trin ...... 49 aviane ...... 168 anucort-hc ...... 145 ASSURE HAEMOLANCE avidoxy ...... 19 apexicon e ...... 92 PLUS ...... 114 avita ...... 86 APLISOL ...... 156 ASSURE LANCE ...... 114 AVONEX ...... 154 APOKYN ...... 37 ASSURE LANCE PLUS.... 114 AVYCAZ ...... 8 APOMORPHINE (BULK) 145 atazanavir...... 5 ayuna ...... 168 apraclonidine ...... 181 atenolol ...... 63 azacitidine ...... 22 aprepitant ...... 145 ATENOLOL (BULK) ...... 63 AZASITE ...... 175 apri ...... 168 atenolol-chlorthalidone ...... 64 azathioprine ...... 22 APTIVUS ...... 5 ATGAM ...... 156 AZATHIOPRINE (BULK) .. 22 APTIVUS (WITH VITAMIN atomoxetine ...... 54 azathioprine sodium ...... 22 E) ...... 5 atorvastatin ...... 77 azelaic acid ...... 86 aqua care sodium chloride .... 97 atovaquone-proguanil ...... 11 AZELAIC ACID (BULK) .... 86 aqua care sterile water ...... 97 atracurium ...... 41 azelastine ...... 107, 177 AQUA LANCE LANCING atropine ...... 143, 176 azelastine-fluticasone ...... 185 DEVICE ...... 114 ATROPINE (BULK) ...... 176 azithromycin ...... 10 AQUASOL A ...... 211 ATTAPULGITE (BULK) .. 143 AZITHROMYCIN (BULK) . 10 ARALAST NP ...... 97 AUBAGIO...... 40 AZOPT ...... 178 aranelle (28)...... 168 aubra ...... 168 aztreonam ...... 11 ARGININE (L-ARGININE) aubra eq ...... 168 azurette (28) ...... 168 (BULK) ...... 198 AUGMENTIN ...... 17 B ARGININE HCL(L- aurovela 1.5/30 (21) ...... 168 b complex 1 (with folic acid) ARGININE)(BULK) ...... 198 aurovela 1/20 (21) ...... 168 ...... 211 aripiprazole ...... 53 aurovela 24 fe ...... 168 b complex 100 ...... 211 ARISTADA ...... 54 aurovela fe 1.5/30 (28) ...... 168 b complex-vitamin b12 ...... 211 ARISTADA INITIO ...... 54 aurovela fe 1-20 (28) ...... 168 b complex-vitamin c-folic acid ARISTOSPAN INTRA- AUSTEDO ...... 40 ...... 211 ARTICULAR ...... 109 AUTOJECT 2 INJECTION b-100 complex ...... 211 ARISTOSPAN DEVICE ...... 114 bacitracin ...... 11, 175 INTRALESIONAL ...... 109 AUTO-LANCET MINI ...... 114 bacitracin (bulk) ...... 11

219 BACITRACIN ZN BD INSULIN SYRINGE BD VEO INSULIN SYR MICRONIZED(BULK) ... 90 ULTRA-FINE ...... 115 HALF UNIT ...... 117 BACITRACIN, BD INTEGRA NEEDLE ... 115 BD VEO INSULIN SYRINGE MICRONIZED (BULK) .. 11 BD INTRADERMAL BEVEL UF ...... 117 bacitracin-polymyxin b ...... 175 NEEDLES ...... 115 BD YALE REGULAR baclofen ...... 41 BD LO-DOSE MICRO-FINE BEVEL ...... 117 bacteriostatic water(parabens) IV ...... 115 BECLOMETHASONE ...... 97 BD LO-DOSE ULTRA-FINE DIPROP (BULK) ...... 108 BAFIERTAM ...... 40 ...... 115 bekyree (28) ...... 168 BAL IN OIL ...... 198 BD MAGNI-GUIDE BELBUCA ...... 44 balance b-100 (folic acid) ... 211 SYRINGE MAGNIFI..... 115 BELLADONNA ALK LEAF balance b-50 (with folic acid) BD MICROTAINER EXT (BULK) ...... 143 ...... 211 LANCET ...... 115 belladonna alkaloids-opium 143 balanced b-100 ...... 211 BD NANO 2ND GEN PEN BELLADONNA TINCTURE balanced b-100 complex..... 211 NEEDLE ...... 116 (BULK) ...... 143 balanced b-50 ...... 211 BD NOKOR ADMIX benazepril ...... 64 balanced salt ...... 177 NEEDLE ...... 116 BENAZEPRIL HCL (BULK) bal-care dha ...... 211 BD PRECISIONGLIDE ..... 116 ...... 64 balsalazide ...... 146 BD PRECISIONGLIDE NON- benazepril-hydrochlorothiazide BALSAM PERU (BULK) ... 83 STERILE ...... 116 ...... 64 balziva (28) ...... 168 bd pre-filled normal saline ... 97 benecalorie ...... 198 BARIUM SULFATE (BULK) BD Q-SYTE MDV ADAPTER BENEFIX ...... 72 ...... 97 ...... 116 BENZALKONIUM BAXDELA ...... 18 BD Q-SYTE SPLIT-SEPT CHLORIDE (BULK) ...... 83 bayer aspirin ...... 49 DEVICE ...... 116 benzepro ...... 86 BCAD 1 ...... 198 BD REGULAR BEVEL BENZETHONIUM BCG VACCINE, LIVE (PF) NEEDLES ...... 116 CHLORIDE (BULK) ...... 84 ...... 156 BD SAFETYGLIDE INSULIN BENZNIDAZOLE ...... 11 b-complex injection ...... 211 SYRINGE ...... 116 BENZOCAINE (BULK) ...... 88 b-complex with vitamin c ... 211 BD SAFETYGLIDE NEEDLE BENZOCAINE BD ALCOHOL SWABS ... 114 ...... 116 MICRONIZED (BULK) .. 88 BD AUTOSHIELD DUO PEN BD SAFETYGLIDE benzonatate ...... 181 NEEDLE ...... 114 SYRINGE ...... 117 benzoyl peroxide ...... 86 BD ECLIPSE...... 115 BD SPECIALTY USE BENZOYL PEROXIDE BD ECLIPSE LUER-LOK. 114 NEEDLES ...... 117 (BULK) ...... 86 BD FILTER NEEDLE 5- BD ULTRA FINE LANCETS benztropine ...... 37 MICRON NOKO ...... 115 ...... 117 BENZYL BENZOATE BD FILTER NEEDLE-5 BD ULTRA-FINE II (BULK) ...... 97 MICRON ...... 115 LANCETS ...... 117 beser ...... 92 BD INSULIN SYRINGE ... 115 BD ULTRA-FINE MICRO BESPONSA ...... 22 BD INSULIN SYRINGE PEN NEEDLE ...... 117 BETAHISTINE (BULK) ...... 64 HALF UNIT ...... 115 BD ULTRA-FINE MINI PEN BETAMETHASONE BD INSULIN SYRINGE NEEDLE ...... 117 ACET,MICRO(BULK) .. 109 SAFETY-LOK ...... 115 BD ULTRA-FINE NANO betamethasone acet,sod phos BD INSULIN SYRINGE SLIP PEN NEEDLE ...... 117 ...... 109 TIP ...... 115 BD ULTRA-FINE ORIG PEN BETAMETHASONE BD INSULIN SYRINGE U- NEEDLE ...... 117 DIPROPION (BULK) ...... 92 500 ...... 115 BD ULTRA-FINE SHORT betamethasone dipropionate . 92 PEN NEEDLE ...... 117

220 BETAMETHASONE SOD BOOST BREEZE BROMOCRIPTINE (BULK) PHOS (BULK) ...... 109 NUTRITIONAL ...... 199 ...... 37 betamethasone valerate ...... 93 boost high protein ...... 199 BROMPHENIRAMINE BETAMETHASONE boost kid essentials ...... 199 MALEATE (BULK) ...... 181 VALERATE (BULK) ...... 92 BOOST KID ESSENTIALS brompheniramine-pseudoeph- betamethasone, augmented... 93 W-FIBER...... 199 dm ...... 181 BETANAPHTHOL (BULK) 97 BOOST MAX...... 199 bss ...... 177 BETASERON ...... 154 boost plus ...... 199 budesonide ...... 146, 185 betaxolol ...... 64, 176 BOOST PUDDING ...... 199 BUDESONIDE, bethanechol chloride ...... 191 BOOST SOOTHE ...... 199 MICRONIZED (BULK) 185 BETHANECHOL CHLORIDE BOOST VHC ...... 199 bufferin ...... 49 (BULK) ...... 191 BOOSTRIX TDAP...... 156 BUFLOMEDIL (BULK) ...... 97 BEVESPI AEROSPHERE . 185 bosentan ...... 185 BULLSEYE MINI SAFETY bexarotene ...... 22 BOTOX ...... 156 LANCETS ...... 118 BEXSERO ...... 156 bp 10-1 ...... 86 bumetanide ...... 64 bicalutamide ...... 22 bpo ...... 86 buminate 25 % ...... 193 BICILLIN L-A ...... 17 BREAKFAST ESSENTIALS buminate 5 % ...... 193 BIKTARVY ...... 5 ...... 199 BUPIVACAINE (BULK) .... 88 bimatoprost ...... 178 BREATHERITE MDI bupivacaine (pf) ...... 88 bioglo ...... 177 SPACER ...... 117 bupivacaine hcl ...... 88 biolon ...... 177 BREATHERITE SPACER- bupivacaine-dextrose-water(pf) BIOTHRAX ...... 156 MASK, NEO...... 117 ...... 98 bisacodyl...... 146 BREATHERITE SPACER- bupivacaine-epinephrine ...... 88 BISACODYL (BULK) ...... 146 MASK,ADULT ...... 117 bupivacaine-epinephrine (pf) 88 bisa-lax (bisacodyl) ...... 146 BREATHERITE SPACER- buprenorphine ...... 44 BISMUTH CITRATE (BULK) MASK,CHILD ...... 117 buprenorphine hcl ...... 44 ...... 97 BREATHERITE SPACER- BUPRENORPHINE HCL BISMUTH MASK,INFANT ...... 117 (BULK) ...... 44 SUBCARBONATE (BULK) BREATHERITE SPACER- buprenorphine-naloxone ...... 49 ...... 143 MASK,S.CHLD ...... 118 bupropion hcl ...... 54 BISMUTH SUBGALLATE BREATHERITE VALVED BUPROPION HCL (BULK) 54 (BULK) ...... 143 MDI CHAMBER ...... 118 bupropion hcl (smoking deter) BISMUTH SUBNITRATE BREATHERITE VALVED ...... 106 (BULK) ...... 97 MDI SPACER ...... 118 buspirone ...... 54 BISMUTH BREO ELLIPTA ...... 185 BUSPIRONE (BULK) ...... 54 SUBSALICYLATE bretylium tosylate ...... 62 busulfan ...... 22 (BULK) ...... 144 BREVITAL ...... 97 BUTALBITAL (BULK) ...... 54 bisoprolol fumarate ...... 64 BREZTRI AEROSPHERE. 185 butalbital compound w/codeine bisoprolol-hydrochlorothiazide briellyn...... 169 ...... 44 ...... 64 BRILINTA ...... 72 butalbital-acetaminop-caf-cod bivalirudin ...... 72 brimonidine ...... 181 ...... 44 bleomycin ...... 22 BRIMONIDINE TARTRATE butalbital-acetaminophen ..... 44 blisovi 24 fe ...... 168 (BULK) ...... 181 butalbital-acetaminophen-caff blisovi fe 1.5/30 (28) ...... 168 BRINEURA...... 138 ...... 44 blisovi fe 1/20 (28) ...... 169 brinzolamide ...... 178 butalbital-aspirin-caffeine ..... 44 BLUNT NEEDLE, bromfenac ...... 178 butorphanol ...... 49 DISPOSABLE ...... 117 BROMHEXINE HCL (BULK) BUTORPHANOL boost ...... 199 ...... 97 TARTRATE (BULK) ...... 49 bromocriptine ...... 37

221 BUTTERFLY TOUCH captopril-hydrochlorothiazide cefepime ...... 9 LANCET ...... 118 ...... 64 cefepime in dextrose,iso-osm . 9 BYDUREON BCISE ...... 118 CARBACHOL (BULK) ..... 179 cefixime ...... 9 BYETTA ...... 118 CARBAGLU ...... 98 cefotaxime ...... 9 BYSTOLIC ...... 64 carbamazepine ...... 34 cefotetan ...... 9 C CARBAMAZEPINE (BULK) cefoxitin ...... 9 cabergoline ...... 138 ...... 34 cefoxitin in dextrose, iso-osm . 9 CABLIVI ...... 72 CARBAMIDE PEROXIDE cefpodoxime ...... 9 CABOMETYX...... 23 (BULK) ...... 108 cefprozil ...... 9 CAFFEINE (BULK) ...... 98 CARBAZOCHROME (BULK) ceftazidime ...... 9 caffeine citrate ...... 98 ...... 98 CEFTAZIDIME (BULK) ...... 9 caffeine-sodium benzoate ... 185 carbidopa ...... 37 CEFTAZIDIME IN D5W ...... 9 CALAMINE (BULK) ...... 84 CARBIDOPA (BULK) ...... 37 ceftriaxone ...... 9 CALCILO XD ...... 199 carbidopa-levodopa ...... 38 ceftriaxone in dextrose,iso-os . 9 calcipotriene ...... 82 carbidopa-levodopa- CEFTRIAXONE SODIUM CALCIPOTRIENE (BULK) 82 entacapone ...... 38 (BULK) ...... 9 calcipotriene-betamethasone 82 carbinoxamine maleate ...... 181 cefuroxime axetil ...... 10 calcitonin (salmon) ...... 138 carbocaine (pf) ...... 88 cefuroxime sodium ...... 10 calcitriol ...... 82, 138 carboplatin ...... 23 celecoxib ...... 49 CALCITRIOL-ALMOND OIL cardioplegic soln...... 79 CELECOXIB (BULK) ...... 49 (BULK) ...... 98 CAREONE LANCING CELONTIN ...... 34 calcium acetate(phosphat bind) DEVICE ...... 118 cephalexin ...... 10 ...... 193 CAREONE ULTRA THIN CEPROTIN (BLUE BAR) ... 72 calcium chloride ...... 193 LANCET ...... 118 CEPROTIN (GREEN BAR) 72 CALCIUM DISODIUM CARETOUCH ALCOHOL CERDELGA ...... 138 VERSENATE...... 199 PREP PAD ...... 118 CEREZYME ...... 138 CALCIUM GLUCON CARETOUCH LANCING CESIUM CHLORIDE MONOHYD (BULK) .... 193 DEVICE ...... 118 (BULK) ...... 98 calcium gluconate ...... 194 CARETOUCH TWIST CETROTIDE ...... 138 calcium gluconate in 0.9% nacl LANCET ...... 118 CETYLPYRIDINIUM ...... 193 CARISOPRODOL (BULK) . 42 CHLORIDE(BULK) ...... 108 CALDOLOR ...... 49 carmustine ...... 23 cevimeline ...... 98 camila ...... 164 carteolol ...... 176 CHANTIX ...... 107 CAMPHOR (BULK)...... 84 cartia xt ...... 64 CHANTIX CONTINUING camrese ...... 169 carvedilol ...... 64 MONTH BOX ...... 107 camrese lo ...... 169 caspofungin ...... 3 CHANTIX STARTING candesartan ...... 64 cataflam ...... 49 MONTH BOX ...... 107 candesartan-hydrochlorothiazid CATHFLO ACTIVASE ...... 79 charlotte 24 fe ...... 169 ...... 64 CAVERJECT ...... 191 chateal (28) ...... 169 candin ...... 156 CAVERJECT IMPULSE ... 191 chateal eq (28) ...... 169 CANTHARIDIN (BULK) ... 84 CAYSTON ...... 11 CHEMET ...... 98 CAPASTAT ...... 11 caziant (28) ...... 169 CHENODAL ...... 146 capecitabine ...... 23 cefaclor ...... 8 children's aspirin ...... 49 CAPRELSA ...... 23 cefadroxil ...... 8 children's iron ...... 211 CAPSAICIN (BULK) ...... 84 cefazolin ...... 8 CHLORAL HYDRATE CAPSICUM OLEORESIN cefazolin in dextrose (iso-os) . 8 (BULK) ...... 54 (BULK) ...... 84 cefazolin in dextrose 5 % ...... 8 CHLORAMBUCIL (BULK) 23 captopril ...... 64 cefdinir...... 8, 9 CHLORAMPHENICOL CAPTOPRIL (BULK)...... 64 cefditoren pivoxil ...... 9 (BULK) ...... 12

222 CHLORAMPHENICOL cinacalcet ...... 139 clindamycin phosphate .. 12, 86, PALMITAT(BULK) ...... 12 CINRYZE ...... 185 167 chloramphenicol sod succinate CINVANTI ...... 146 CLINDAMYCIN ...... 12 ciprofloxacin ...... 18 PHOSPHATE (BULK) .... 12 chlordiazepoxide hcl ...... 54 CIPROFLOXACIN (BULK) 18 clindamycin-benzoyl peroxide chlordiazepoxide-clidinium 144 ciprofloxacin hcl ... 18, 108, 175 ...... 87 CHLORHEXIDINE ciprofloxacin in 5 % dextrose clindamycin-tretinoin ...... 87 ACETATE (BULK) ...... 98 ...... 18 CLINIMIX 5%/D15W chlorhexidine gluconate ..... 108 ciprofloxacin-dexamethasone SULFITE FREE ...... 199 CHLORHEXIDINE ...... 109 CLINIMIX 4.25%/D10W GLUCONATE (BULK) ... 84 cisatracurium ...... 42 SULF FREE ...... 199 chloroprocaine (pf) ...... 89 cisplatin ...... 23 CLINIMIX 4.25%/D5W chloroquine phosphate...... 12 citalopram ...... 54 SULFIT FREE ...... 98 CHLOROQUINE citrate of magnesia...... 146 CLINIMIX 5%- PHOSPHATE (BULK) .... 12 citric acid anhydrous (bulk) .. 98 D20W(SULFITE-FREE) 199 chlorothiazide ...... 64 citric acid monohydrate (bulk) CLINIMIX 6%-D5W chlorothiazide sodium ...... 64 ...... 98 (SULFITE-FREE) ...... 199 CHLOROXINE (BULK) ..... 82 citroma ...... 146 CLINIMIX 8%- CHLORPHENIRAMINE cladribine ...... 23 D10W(SULFITE-FREE) 199 MALEATE(BULK) ...... 181 claravis...... 86 CLINIMIX 8%- chlorpromazine ...... 54 clariscan (meglumine) ...... 98 D14W(SULFITE-FREE) 200 CHLORPROMAZINE clarithromycin ...... 10 CLINIMIX E 2.75%/D5W (BULK) ...... 54 CLARITHROMYCIN (BULK) SULF FREE ...... 98 chlorthalidone ...... 64 ...... 10 CLINIMIX E 4.25%/D10W chlorzoxazone...... 42 classic prenatal ...... 211 SUL FREE ...... 200 CHOLBAM ...... 146 clearlax ...... 146 CLINIMIX E 4.25%/D5W cholestyramine (with sugar) 77, clemastine ...... 181 SULF FREE ...... 200 78 CLEMASTINE FUMARATE CLINIMIX E 5%/D15W cholestyramine light ...... 78 (BULK) ...... 181 SULFIT FREE ...... 200 CHOLIN AND MG CLEMIZOLE HCL (BULK) 98 CLINIMIX E 5%/D20W SALICYLATE(BULK) .... 49 CLEVER CHEK LANCETS SULFIT FREE ...... 200 choline,magnesium salicylate ...... 118 CLINIMIX E 8%-D10W ...... 49 CLEVER CHOICE SULFITEFREE ...... 200 CHOR GONADOTROPIN, CHAMBER-LRG MASK CLINIMIX E 8%-D14W HUM (BULK) ...... 139 ...... 118 SULFITEFREE ...... 200 chromium chloride ...... 194 CLEVER CHOICE CLIOQUINOL (BULK) ...... 12 CHYMOTRYPSIN (BULK) 96 CHAMBER-MED MASK clobazam ...... 34 ciclodan ...... 91 ...... 118 clobetasol ...... 93 ciclopirox ...... 91 CLEVER CHOICE CLOBETASOL CICLOPIROX OLAMINE CHAMBER-SM MASK. 118 PROPIONATE (BULK) ... 93 (BULK) ...... 91 CLIDINIUM BROMIDE clobetasol-emollient ...... 93 ciclopirox-ure-camph-menth- (BULK) ...... 144 clodan ...... 93 euc ...... 91 clindacin etz ...... 86 clofarabine ...... 23 cidofovir ...... 5 clindacin p ...... 86 CLOFAZIMINE (BULK) .... 12 cilostazol...... 72 clindamycin hcl ...... 12 clomiphene citrate ...... 139 CIMDUO ...... 5 CLINDAMYCIN HCL CLOMIPHENE CITRATE cimetidine ...... 152 (BULK) ...... 12 (BULK) ...... 139 CIMETIDINE (BULK) ...... 152 clindamycin in 5 % dextrose 12 clomipramine ...... 54 cimetidine hcl ...... 152 clindamycin pediatric ...... 12 CLOMIPRAMINE (BULK) . 54

223 clonazepam ...... 34 COMFORT LANCETS ...... 118 CURITY ALCOHOL SWABS CLONAZEPAM (BULK) .... 34 COMFORT SHORT INSULIN ...... 119 clonidine ...... 65 PUMP 32 ...... 119 cyanocobalamin (vitamin b-12) clonidine (pf) ...... 49, 64 COMPACT SPACE ...... 212 clonidine hcl ...... 54, 64 CHAMBER ...... 119 CYANOCOBALAMIN(VIT CLONIDINE HCL (BULK) 64 COMPACT SPACE B-12)(BULK) ...... 212 clopidogrel ...... 73 CHAMBER-LRG MASK cyclafem 1/35 (28) ...... 169 clorazepate dipotassium ...... 55 ...... 119 cyclafem 7/7/7 (28) ...... 169 clotrimazole ...... 3 COMPACT SPACE CYCLANDELATE (BULK) 65 CLOTRIMAZOLE (BULK) 91 CHAMBER-MED MASK CYCLINEX-1 ...... 200 clotrimazole-betamethasone . 91 ...... 119 cyclobenzaprine ...... 42 clovique ...... 98 COMPACT SPACE cyclopentolate ...... 176 clozapine...... 55 CHAMBER-SM MASK. 119 CYCLOPENTOLATE c-nate dha ...... 211 COMPLEAT ...... 200 (BULK) ...... 176 COAGADEX ...... 73 compleat pediatric reduced cal cyclophosphamide ...... 23 COAGUCHEK LANCETS 118 ...... 200 CYCLOPHOSPHAMIDE COAL TAR (BULK) ...... 82 complete amino acid mix ... 200 (BULK) ...... 23 COAL TAR (CRUDE) complete natal dha ...... 211 CYCLOSERINE (BULK) .... 12 (BULK) ...... 82 completenate ...... 211 cyclosporine ...... 23 COARTEM ...... 12 complex b-100 ...... 212 CYCLOSPORINE (BULK) . 23 COCAINE (BULK)...... 89 compro ...... 146 cyclosporine modified ...... 23 CODEINE PHOSPHATE constulose ...... 146 cyproheptadine ...... 181 (BULK) ...... 44 CONTACT DETACH INFUS CYPROHEPTADINE (BULK) codeine sulfate ...... 44 SET 23 ...... 119 ...... 181 codeine-guaifenesin ...... 181 CONTACT DETACH INFUS CYRAMZA ...... 23 coenzyme q10 ...... 96 SET 32 ...... 119 cyred ...... 169 colchicine ...... 161 copper chloride ...... 194 cyred eq ...... 169 COLCHICINE (BULK) ..... 161 coremino ...... 19 CYSTADANE ...... 146 colesevelam ...... 78 CORIFACT ...... 73 CYSTAGON ...... 191 colestipol ...... 78 CORLANOR ...... 79 CYSTARAN ...... 177 COLISTIMETHATE corlopam ...... 65 CYSTEAMINE HCL (BULK) SODIUM (BULK)...... 12 CORTICOTROPIN (BULK) ...... 98 colistin (colistimethate na) ... 12 ...... 109 CYSTEINE HCL(L- COLISTIN SULFATE CORTISONE (BULK) ...... 109 CYSTEINE)(BULK) ...... 200 (BULK) ...... 12 cosyntropin ...... 109 cytarabine ...... 23 COLLAGENASE CLOS COTELLIC ...... 23 cytarabine (pf) ...... 23 HIST. (BULK) ...... 95 COUMARIN (BULK) ...... 98 CYTOGAM ...... 157 COLOR LANCETS ...... 118 covaryx ...... 164 D COMBIGAN ...... 179 covaryx h.s...... 164 d10 %-0.45 % sodium chloride COMBIPATCH ...... 164 CREON ...... 146 ...... 98 COMBIVENT RESPIMAT 186 CRESEMBA ...... 3 d2.5 %-0.45 % sodium COMETRIQ ...... 23 CRIXIVAN ...... 5 chloride ...... 98 COMFORT EZ LANCETS 118 CROFAB ...... 157 d5 % and 0.9 % sodium COMFORT INFUSION SET cromolyn ...... 146, 177, 186 chloride ...... 99 23 ...... 118 CROMOLYN (BULK)...... 186 d5 %-0.45 % sodium chloride COMFORT INFUSION SET crotan ...... 96 ...... 99 32 ...... 118 cryoserv ...... 98 dacarbazine ...... 23 COMFORT INFUSION SET cryselle (28) ...... 169 dactinomycin ...... 24 43 ...... 118 CRYSVITA ...... 139 DAILY AMINO ...... 200

224 daily prenatal ...... 212 DESIPRAMINE HCL (BULK) DEXCOM G5 RECEIVER 119 dalfampridine ...... 40 ...... 55 DEXCOM G5 DALIRESP ...... 186 desloratadine ...... 181 TRANSMITTER ...... 119 DALVANCE ...... 12 desmopressin ...... 139 DEXCOM G5-G4 SENSOR danazol ...... 139 DESMOPRESSIN ACETATE ...... 119 DANAZOL (BULK) ...... 139 (BULK) ...... 139 DEXCOM G6 RECEIVER 119 dantrolene ...... 42 desog-e.estradiol/e.estradiol DEXCOM G6 SENSOR ..... 119 DANTROLENE (BULK) .... 42 ...... 169 DEXCOM G6 DAPIPRAZOLE (BULK) .. 177 desogestrel-ethinyl estradiol TRANSMITTER ...... 119 dapsone ...... 12, 87 ...... 169 DEXCOM RECEIVER ...... 119 DAPSONE (BULK) ...... 12 desonide ...... 93 dexmedetomidine ...... 55 DAPTACEL (DTAP DESONIDE, MICRONIZED dexmedetomidine in 0.9 % nacl PEDIATRIC) (PF)...... 157 (BULK) ...... 93 ...... 55 daptomycin ...... 12 desoximetasone ...... 93 dexmethylphenidate ...... 55 darifenacin ...... 190 DESOXIMETASONE, dexrazoxane hcl ...... 21 DARZALEX ...... 24 MICRO (BULK) ...... 99 dextroamphetamine ...... 55 dasetta 1/35 (28) ...... 169 DESOXYCORTICOSTERON dextroamphetamine- dasetta 7/7/7 (28) ...... 169 E AC (BULK) ...... 109 amphetamine ...... 55 daunorubicin ...... 24 desvenlafaxine succinate ...... 55 DEXTROMETHORPHAN daysee ...... 169 dexabliss ...... 109 HBR (BULK) ...... 181 DAYTRANA ...... 55 dexamethasone ...... 110 DEXTROSE (BULK) ...... 99 DDAVP ...... 139 DEXAMETHASONE AC, dextrose 10 % and 0.2 % nacl DEANOL BITARTRATE MICRO (BULK) ...... 109 ...... 99 (BULK) ...... 99 DEXAMETHASONE dextrose 10 % in water (d10w) deblitane ...... 164 ACETATE (BULK) ...... 109 ...... 99 decadron ...... 109 dexamethasone intensol ...... 109 dextrose 20 % in water (d20w) decitabine ...... 24 DEXAMETHASONE ISONIC ...... 99 deferasirox ...... 99 (BULK) ...... 109 dextrose 25 % in water (d25w) deferiprone ...... 99 DEXAMETHASONE SOD ...... 99 deferoxamine ...... 99 PHOS (BULK) ...... 110 dextrose 30 % in water (d30w) dehydrated alcohol ...... 99 dexamethasone sodium phos ...... 99 DEHYDROEPIANDROSTER (pf) ...... 110 dextrose 40 % in water (d40w) ONE (MICRO) ...... 139 dexamethasone sodium ...... 100 delflex-lc/1.5% dextrose...... 99 phosphate ...... 110, 180 dextrose 5 % in ringer's ...... 100 delflex-lc/2.5% dextrose...... 99 DEXAMETHASONE,MICRO dextrose 5 % in water (d5w) delflex-lc/4.25% dextrose..... 99 NIZED(BULK) ...... 110 ...... 100 DEMECARIUM BROMIDE dexamethasone-0.9 % sod. dextrose 5 %-lactated ringers (BULK) ...... 179 chlor ...... 110 ...... 100 demeclocycline ...... 19 dexchlorpheniramine maleate dextrose 5%-0.2 % sod denta 5000 plus...... 108 ...... 181 chloride ...... 100 dentagel ...... 108 DEXCOM G4 RECEIVER 119 dextrose 5%-0.3 % DEOXYCHOLIC ACID DEXCOM G4 RECEIVER sod.chloride ...... 100 (BULK) ...... 99 PEDIATRIC ...... 119 dextrose 50 % in water (d50w) DEPO-ESTRADIOL ...... 164 DEXCOM G4 RECEIVER- ...... 100 DERMAVIEW ...... 119 SHARE (PED) ...... 119 dextrose 70 % in water (d70w) DERMAVIEW II ...... 119 DEXCOM G4 RECEIVER- ...... 100 DESCOVY ...... 5 SHARE KIT ...... 119 DIACOMIT ...... 34 desflurane ...... 99 DEXCOM G4 dialyvite 800 ...... 212 desipramine ...... 55 TRANSMITTER ...... 119 diazepam ...... 34, 55, 56

225 DIAZEPAM (BULK) ...... 55 DIPHENHYDRAMINE doxycycline monohydrate .... 19 diazepam intensol ...... 55 (BULK) ...... 182 DOXYLAMINE SUCCINATE diazoxide ...... 119 diphenhydramine hcl ...... 182 (BULK) ...... 56 DIAZOXIDE (BULK) ...... 119 DIPHENIDOL (BULK) ..... 146 doxylamine-pyridoxine (vit b6) DIBUCAINE HCL (BULK) 89 diphenoxylate-atropine ...... 144 ...... 146 DICHLORACETIC ACID dipyridamole ...... 73 D-PENAMINE ...... 162 (BULK) ...... 84 DIPYRIDAMOLE (BULK) . 73 dronabinol ...... 146 DICHLORALPHENAZONE diskets ...... 44 droperidol ...... 147 (BULK) ...... 100 DISPOSABLE NEEDLES . 119 DROPERIDOL (BULK) .... 146 diclofenac potassium ...... 49 DISPOSABLE POWER ..... 119 DROPLET LANCETS ...... 119 diclofenac sodium .. 49, 84, 178 disulfiram...... 100 DROPLET LANCING diclofenac-misoprostol ...... 49 DISULFIRAM (BULK) ..... 100 DEVICE ...... 120 dicloxacillin ...... 17 divalproex ...... 34 drospirenone-e.estradiol-lm.fa DICUMAROL (BULK) ...... 73 DIVIGEL ...... 164 ...... 169 dicyclomine ...... 144 DMPS ...... 100 drospirenone-ethinyl estradiol DICYCLOMINE (BULK) . 144 DMSA (BULK) ...... 100 ...... 169 didanosine...... 5 dobutamine ...... 79 droxidopa ...... 100 DIETHYLPROPION HCL dobutamine in d5w ...... 79 dulcolax (magnesium (BULK) ...... 96 DOCEFREZ ...... 24 hydroxide) ...... 147 diflorasone ...... 93 docetaxel ...... 24 DULERA ...... 186 diflunisal ...... 50 DOCUSATE SODIUM duloxetine ...... 56 digitek ...... 71 (BULK) ...... 146 DUOCAL ...... 200 digox ...... 71 dofetilide ...... 62 DUPIXENT PEN ...... 84 digoxin ...... 71 donepezil ...... 40 DUPIXENT SYRINGE ...... 84 dihydroergotamine ...... 38, 39 dopamine ...... 80 duramorph (pf) ...... 44 DIHYDROERGOTAMINE DOPAMINE (BULK) ...... 80 dutasteride ...... 191 MESYLT(BULK) ...... 38 dopamine in 5 % dextrose .... 80 dutasteride-tamsulosin ...... 191 DILANTIN ...... 34 DOPTELET (10 TAB PACK) dvorah ...... 44 DILATRATE-SR ...... 81 ...... 73 D-XYLOSE (BULK) ...... 100 diltiazem hcl ...... 65 DOPTELET (15 TAB PACK) DYANAVEL XR ...... 56 DILTIAZEM HCL (BULK) 65 ...... 73 DYCLONINE HCL (BULK) dilt-xr ...... 65 DOPTELET (30 TAB PACK) ...... 89 diluent for epoprostenol/flola ...... 73 dy-o-derm ...... 106 ...... 100 dorzolamide ...... 179 DYPHYLLINE (BULK) .... 186 diluent for treprostinil (gly) 100 dorzolamide-timolol ...... 179 E dimenhydrinate ...... 146 dorzolamide-timolol (pf) .... 179 e.e.s. 400 ...... 10 DIMENHYDRINATE dotti ...... 164 EASIVENT HOLDING (BULK) ...... 146 DOVATO ...... 5 CHAMBER ...... 120 DIMERCAPTOPROPANESU doxapram ...... 56 EASIVENT MASK LARGE LFONATE SOD ...... 100 doxazosin ...... 65 ...... 120 dimethyl fumarate ...... 40 doxepin ...... 56, 84 EASIVENT MASK MEDIUM DIMETHYL SULFOXIDE DOXEPIN HCL (BULK) ..... 56 ...... 120 (BULK) ...... 100 doxercalciferol ...... 139 EASIVENT MASK SMALL DINITROCHLOROBENZEN( doxorubicin ...... 24 ...... 120 2,4)(BULK) ...... 100 doxorubicin, peg-liposomal .. 24 EASY COMFORT DIOSGENIN (BULK)...... 100 doxy-100 ...... 19 ALCOHOL PAD ...... 120 DIPHENCYPRONE (BULK) doxycycline hyclate ...... 19 EASY COMFORT LANCETS ...... 100 DOXYCYCLINE HYCLATE ...... 120 (BULK) ...... 19

226 EASY MINI EJECT elite-ob ...... 212 ENSPRYNG ...... 24 LANCING DEVICE ...... 120 ELMIRON ...... 192 ENSTILAR ...... 82 EASY TOUCH ALCOHOL ELOCTATE ...... 73 ensure ...... 202 PREP PADS ...... 120 eluryng ...... 167 ENSURE ...... 202 EASY TOUCH LANCETS 120 ELZONRIS ...... 24 ensure active heart health ... 201 EASY TOUCH LANCING EMBRACE LANCETS ...... 120 ensure active high protein ... 201 DEVICE ...... 120 EMCYT ...... 24 ensure active light ...... 201 EASY TOUCH SAFETY EMGALITY PEN...... 39 ensure active protein-muscle LANCETS ...... 120 EMGALITY SYRINGE ...... 39 ...... 202 EASY TOUCH TWIST emoquette ...... 169 ensure clear ...... 202 LANCETS ...... 120 emtricitabine ...... 5 ENSURE CLEAR EASY TWIST AND CAP emtricitabine-tenofovir (tdf) ... 5 THERAPEUTIC ...... 202 LANCETS ...... 120 EMTRIVA ...... 5 ensure compact ...... 202 ec-naproxen ...... 50 EMVERM ...... 12 ENSURE ENLIVE ...... 202 econazole ...... 91 enalapril maleate...... 65 ensure high protein ...... 202 ECONAZOLE NITRATE ENALAPRIL MALEATE ensure max protein ...... 202 (BULK) ...... 91 (BULK) ...... 65 ENSURE MUSCLE HEALTH econtra ez...... 169 enalaprilat ...... 65 ...... 202 econtra one-step...... 169 enalapril-hydrochlorothiazide ensure original ...... 202 ecotrin ...... 50 ...... 65 ENSURE ORIGINAL ...... 202 ecotrin low strength ...... 50 ENBREL ...... 162 ensure plant-based protein .. 202 EDETATE CALCIUM ENBREL MINI ...... 162 ENSURE PLUS ...... 202 DISODIUM(BULK) ...... 200 ENBREL SURECLICK ..... 162 ENSURE PUDDING ...... 202 EDETATE DISODIUM endocet...... 44 entacapone ...... 38 (BULK) ...... 96 ENDOMETRIN...... 164 entecavir ...... 5 EDROPHONIUM CHLORIDE ENFAGROW TODDLR ENTRESTO ...... 80 (BULK) ...... 42 TRANSITION SOY ...... 201 ENTYVIO ...... 147 ed-spaz ...... 144 enfamil a.r...... 201 enulose ...... 147 EDURANT ...... 5 ENFAMIL ENFACARE .... 201 EO28 SPLASH ...... 202 eemt ...... 164 ENFAMIL GENTLEASE .. 201 EOVIST ...... 101 eemt hs...... 164 ENFAMIL GENTLEASE EPCLUSA ...... 6 efavirenz ...... 5 NON-GMO ...... 201 EPHEDRINE HCL (BULK) efavirenz-emtricitabin-tenofov ENFAMIL GLUCOSE ...... 101 ...... 186 ...... 5 ENFAMIL INFANT...... 201 ephedrine sulfate ...... 80, 186 efavirenz-lamivu-tenofov disop ENFAMIL INFANT NON- EPHEDRINE SULFATE ...... 5 GMO ...... 201 (BULK) ...... 186 effer-k ...... 194 ENFAMIL NEWBORN ..... 201 EPIDIOLEX ...... 34 EGRIFTA SV ...... 154 ENFAMIL NEWBORN NON- epinastine ...... 177 ELAPRASE ...... 139 GMO ...... 201 epinephrine ...... 182 ELECARE INFANT ENFAMIL PROSOBEE ..... 201 EPINEPHRINE (BULK) .... 182 FORMULA ...... 200 ENFAMIL PROSOBEE LIPIL EPINEPHRINE electrolyte-48 in d5w ...... 200 ...... 201 BITARTRATE (BULK) . 182 eletriptan ...... 39 ENFAPORT ...... 201 epinephrine hcl ...... 186 ELIGARD ...... 24 ENGERIX-B (PF) ...... 157 epinephrine hcl in 0.9 % nacl ELIGARD (3 MONTH) ...... 24 ENGERIX-B PEDIATRIC ...... 182 ELIGARD (4 MONTH) ...... 24 (PF) ...... 157 epinephrine hcl in 5% dextrose ELIGARD (6 MONTH) ...... 24 enoxaparin ...... 73 ...... 182 elinest ...... 169 enpresse ...... 169 EPIPEN ...... 182 ELITEK ...... 21 enskyce ...... 169 EPIPEN 2-PAK ...... 182

227 EPIPEN JR ...... 182 estazolam ...... 56 EXTRANEAL 7.5 % ...... 101 EPIPEN JR 2-PAK ...... 182 estradiol ...... 165 EYLEA ...... 177 epirubicin ...... 24 ESTRADIOL (BULK) ...... 164 e-z ject lancets ...... 121 epitol ...... 34 ESTRADIOL BENZOATE e-z ject thin lancets ...... 121 EPIVIR HBV...... 6 (BULK) ...... 164 EZ SMART LANCETS ..... 121 eplerenone ...... 65 ESTRADIOL CYPIONATE ezetimibe ...... 78 epoprostenol ...... 65 (BULK) ...... 164 ezetimibe-simvastatin ...... 78 epoprostenol (glycine) ...... 65 ESTRADIOL EZ-LETS ...... 121 eprosartan ...... 65 HEMIHYD,MICRO F eptifibatide ...... 73 (BULK) ...... 165 FABRAZYME ...... 139 EQUACARE JR ...... 202 ESTRADIOL MICRONIZED falmina (28) ...... 170 ERAXIS(WATER DILUENT) (BULK) ...... 165 famciclovir ...... 6 ...... 3 estradiol valerate...... 165 famotidine ...... 152 ERBITUX...... 24 ESTRADIOL VALERATE FAMOTIDINE (BULK) ..... 152 ERGOCALCIFEROL (VIT (BULK) ...... 165 famotidine (pf) ...... 152 D2) (BULK) ...... 212 estradiol-norethindrone acet famotidine (pf)-nacl (iso-os) ergoloid...... 56 ...... 165 ...... 152 ERGOLOID (BULK) ...... 56 ESTRING ...... 165 FARXIGA ...... 121 ERGOTAMINE TARTRATE estrogens-methyltestosterone FASENRA ...... 186 (BULK) ...... 39 ...... 165 FASENRA PEN ...... 186 ergotamine-caffeine ...... 39 ESTRONE (BULK) ...... 165 fayosim ...... 170 ERIVEDGE ...... 24 eszopiclone ...... 56 FC2 FEMALE CONDOM . 121 ERLEADA ...... 25 ethacrynate sodium ...... 66 febuxostat ...... 161 erlotinib ...... 25 ethacrynic acid ...... 66 FEIBA NF ...... 73 errin ...... 164 ethambutol ...... 12 felbamate ...... 34 ertapenem ...... 12 ETHAMOLIN ...... 101 felodipine ...... 66 ery pads ...... 87 ETHINYL ESTRADIOL fem ph ...... 167 erygel ...... 87 (BULK) ...... 165 FEMCAP ...... 121 ery-tab...... 10 ethosuximide ...... 34 femynor ...... 170 ERYTHROCIN ...... 10 ETHOSUXIMIDE (BULK) . 34 fenofibrate ...... 78 erythrocin (as stearate) ...... 10 ethynodiol diac-eth estradiol fenofibrate micronized ...... 78 erythromycin ...... 11, 175 ...... 170 fenofibrate nanocrystallized . 78 ERYTHROMYCIN (BULK)10 etidronate disodium ...... 101 fenofibric acid ...... 78 ERYTHROMYCIN etodolac ...... 50 fenofibric acid (choline) ...... 78 ESTOLATE (BULK) ...... 11 etomidate ...... 101 fenoprofen ...... 50 ERYTHROMYCIN ETOMIDATE (BULK) ...... 101 fentanyl ...... 45 ETHYLSUCCIN(BULK). 11 etonogestrel-ethinyl estradiol fentanyl citrate ...... 45 erythromycin ethylsuccinate 11 ...... 167 FENTANYL CITRATE erythromycin with ethanol ... 87 ETOPOPHOS ...... 25 (BULK) ...... 44 erythromycin-benzoyl peroxide etoposide ...... 25 fentanyl citrate (pf) ...... 44, 45 ...... 87 ETOPOSIDE (BULK) ...... 25 fentanyl citrate (pf)-0.9%nacl ESBRIET ...... 186 EUFLEXXA ...... 50 ...... 45 escitalopram oxalate ...... 56 EUGENOL (BULK)...... 108 FERAHEME ...... 212 esmolol ...... 66 euthyrox ...... 142 FERRIC SUBSULFATE esmolol in nacl (iso-osm) ..... 66 everolimus (BULK) ...... 212 esomeprazole magnesium .. 152 (immunosuppressive) ...... 25 FERRIPROX ...... 101 esomeprazole sodium ...... 152 EXEL HYPODERMIC FERRIPROX (2 TIMES A ESPEROCT ...... 73 NEEDLES ...... 121 DAY) ...... 101 estarylla ...... 169 exemestane ...... 25 ferrous sulfate ...... 212

228 FETZIMA...... 56 fludeoxyglucose f-18 ...... 101 FLUZONE QUAD 2020-2021 FIBERSOURCE HN ...... 202 fludrocortisone...... 110 ...... 158 FIFTY50 SAFETY SEAL FLUDROCORTISONE FLUZONE QUAD 2020-2021 LANCETS ...... 121 (BULK) ...... 110 (PF) ...... 157, 158 FILTER NEEDLES...... 121 FLULAVAL QUAD 2020- folic acid ...... 212 FINACEA...... 87 2021 (PF) ...... 157 folivane-ob ...... 212 finasteride ...... 191 flumazenil ...... 56 FOLOTYN ...... 25 FINASTERIDE (BULK).... 191 flunisolide ...... 186 foltabs 800 ...... 212 FINE 30 UNIVERSAL FLUNISOLIDE (BULK) ... 186 fomepizole ...... 158 LANCETS ...... 121 fluocinolone ...... 94 fondaparinux ...... 74 FINGERSTIX LANCETS . 121 FLUOCINOLONE FORA LANCING DEVICE FIRMAGON KIT W ACETONIDE (BULK)..... 94 ...... 121 DILUENT SYRINGE ...... 25 fluocinolone acetonide oil .. 108 FORACARE LANCETS .... 121 flac otic oil ...... 108 fluocinolone and shower cap 94 forane ...... 101 flavoxate ...... 190 fluocinonide ...... 94 FORMOTEROL FUMARATE flecainide ...... 62 FLUOCINONIDE, (BULK) ...... 187 fleet laxative (bisacodyl) .... 147 MICRONIZED(BULK) ... 94 FORTEO ...... 161 FLEXICHAMBER ...... 121 fluocinonide-e ...... 94 fosamprenavir ...... 6 FLEXICHAMBER-LG FLUORESCEIN (BULK) .. 177 fosaprepitant ...... 147 CHILD MASK ...... 121 fluorescein-proparacaine .... 177 foscarnet ...... 6 FLEXICHAMBER-SM fluorescite ...... 177 fosfomycin tromethamine ..... 20 ADULT MASK ...... 121 fluoride (sodium) ...... 108, 212 fosinopril ...... 66 FLEXICHAMBER-SM fluorometholone ...... 180 fosinopril-hydrochlorothiazide CHILD MASK ...... 121 fluorouracil ...... 25, 84 ...... 66 FLOLAN ...... 66 FLUOROURACIL (BULK) 25 fosphenytoin ...... 35 FLOVENT DISKUS ...... 186 fluoxetine ...... 56 FRAGMIN ...... 74 FLOVENT HFA ...... 186 FLUOXETINE (BULK)...... 56 freamine iii 10 % ...... 202 FLOW-EZE VENTED fluphenazine decanoate ...... 57 FREESTYLE CONTROL .. 121 NEEDLE ...... 121 FLUPHENAZINE FREESTYLE FREEDOM .. 122 floxuridine ...... 25 DECANOATE (BULK) ... 57 FREESTYLE FREEDOM FLOXURIDINE (BULK) .... 25 fluphenazine hcl ...... 57 LITE ...... 122 FLUAD 2020-2021 (65 YR flurandrenolide ...... 94 FREESTYLE INSULINX .. 122 UP)(PF) ...... 157 flurazepam ...... 57 FREESTYLE INSULINX FLUAD QUAD 2020-21(65Y flurbiprofen ...... 50 TEST STRIPS ...... 122 UP)(PF) ...... 157 FLURBIPROFEN (BULK) .. 50 FREESTYLE LANCETS ... 122 FLUARIX QUAD 2020-2021 flurbiprofen sodium ...... 178 FREESTYLE LIBRE 14 DAY (PF) ...... 157 flutamide ...... 25 READER ...... 122 FLUBLOK QUAD 2020-2021 FLUTICASONE PROP, FREESTYLE LIBRE 14 DAY (PF) ...... 157 MICRO (BULK) ...... 94 SENSOR ...... 122 FLUCELVAX QUAD 2020- fluticasone propionate .. 94, 186 FREESTYLE LIBRE 2 2021 ...... 157 FLUTICASONE READER ...... 122 FLUCELVAX QUAD 2020- PROPIONATE (BULK)... 94 FREESTYLE LIBRE 2 2021 (PF) ...... 157 fluticasone propion-salmeterol SENSOR ...... 122 fluconazole ...... 3 ...... 187 FREESTYLE LITE METER FLUCONAZOLE (BULK) .... 3 fluvastatin ...... 78 ...... 122 fluconazole in nacl (iso-osm) . 3 fluvoxamine ...... 57 FREESTYLE LITE STRIPS flucytosine ...... 3 FLUZONE HIGHDOSE ...... 122 FLUCYTOSINE (BULK) ...... 3 QUAD 20-21 PF ...... 157 FREESTYLE TEST ...... 122 fludarabine ...... 25 FREESTYLE UNISTIK 2 .. 122

229 frovatriptan ...... 39 GENTIAN VIOLET (BULK) GLYCOSADE ...... 203 ful-glo ...... 177 ...... 91 glydo ...... 89 full spectrum b-vitamin c ... 212 gentle laxative (bisacodyl).. 147 GOJJI LANCETS ...... 123 FULPHILA...... 154 gentlelax ...... 147 GOJJI LANCING DEVICE fulvestrant ...... 25 GERBER GOOD START ...... 123 FURAZOLIDONE (BULK) 13 GENTLE ...... 202 GOLD SODIUM furosemide ...... 66 GERBER GOOD START THIOMALATE (BULK)162 FUROSEMIDE (BULK) ...... 66 GENTLE NOGMO ...... 202 GONAL-F ...... 140 fyavolv ...... 165 GERBER GOOD START GONAL-F RFF ...... 139 FYCOMPA ...... 35 SOY ...... 202 GONAL-F RFF REDI-JECT G GERBER GS GENTLEPRO 2 ...... 139 g tussin ac ...... 182 NO-GMO...... 203 G-PREPROTEIN ...... 203 gabapentin ...... 35 GERBER GS GNTLPR GRAMICIDIN D (BULK) . 101 GABLOFEN...... 42 NOGMO(B.LACT) ...... 203 granisetron (pf) ...... 147 galantamine ...... 40 GILENYA ...... 40 granisetron hcl ...... 147 GAMASTAN ...... 158 GILOTRIF ...... 26 GRISEOFULVIN (BULK) 101 GAMASTAN S/D ...... 158 GLASSIA ...... 101 griseofulvin microsize ...... 3 GAMIFANT ...... 25 glatiramer...... 40 griseofulvin ultramicrosize ..... 3 GAMMAGARD LIQUID .. 158 glatopa ...... 40 GUAIACOL ...... 84 GAMMAGARD S-D (IGA < 1 GLEOSTINE ...... 26 guaiatussin ac ...... 182 MCG/ML) ...... 158 glimepiride...... 122 GUAIFENESIN (BULK) ... 182 GAMUNEX-C ...... 158 glipizide ...... 122 guaifenesin ac ...... 182 ganciclovir sodium ...... 6 GLIPIZIDE (BULK) ...... 122 guaifenesin dac ...... 182 ganirelix ...... 139 glipizide-metformin ...... 122 GUANABENZ (BULK) ...... 66 gatifloxacin ...... 175 glostrips ...... 177 GUANETHIDINE SULFATE gavilax ...... 147 GLUCAGEN DIAGNOSTIC (BULK) ...... 66 gavilyte-c ...... 147 KIT ...... 122 guanfacine ...... 57, 66 gavilyte-g ...... 147 GLUCAGEN HYPOKIT ... 122 guanidine ...... 57 gavilyte-n ...... 147 GLUCAGON (HCL) GVOKE HYPOPEN 1-PACK GAVRETO ...... 25 EMERGENCY KIT ...... 122 ...... 123 GAZYVA ...... 25 glucagon emergency kit GVOKE HYPOPEN 2-PACK GELNIQUE ...... 190 (human) ...... 122 ...... 123 gemcitabine ...... 25 GLUCOCOM LANCETS .. 122 GVOKE PFS 1-PACK gemfibrozil ...... 78 GLUCOSE KETONE SYRINGE ...... 123 GEMFIBROZIL (BULK) .... 78 CONTROL SOLN ...... 122 GVOKE PFS 2-PACK gemmily ...... 170 GLUTAREX-1 ...... 203 SYRINGE ...... 123 generlac ...... 147 GLUTOL GEL ...... 101 gynol ii ...... 167 gengraf ...... 26 glyburide ...... 123 H GENOTROPIN ...... 154 GLYBURIDE (BULK) ...... 122 hailey ...... 170 GENOTROPIN MINIQUICK glyburide micronized ...... 123 hailey 24 fe ...... 170 ...... 154 glyburide-metformin ...... 123 hailey fe 1.5/30 (28) ...... 170 gentak ...... 175 glycine urologic ...... 192 hailey fe 1/20 (28) ...... 170 gentamicin ...... 13, 90, 175 glycine urologic solution .... 192 HALAVEN ...... 26 GENTAMICIN (BULK) ...... 13 glycolax ...... 147 halcinonide ...... 94 gentamicin in nacl (iso-osm) 13 GLYCOPHOS ...... 194 halobetasol propionate ...... 94 GENTAMICIN IN NACL glycopyrrolate ...... 144 haloperidol ...... 57 (ISO-OSM) ...... 13 GLYCOPYRROLATE HALOPERIDOL (BULK) .... 57 gentamicin sulfate (ped) (pf) 13 (BULK) ...... 144 haloperidol decanoate ...... 57 gentamicin sulfate (pf) ...... 13 glycopyrrolate (pf) in water 144

230 HALOPERIDOL HISTIDINE HCL(L- HYDROCORTISONE DECANOATE (BULK) ... 57 HISTID)(BULK) ...... 203 (BULK) ...... 94 haloperidol lactate ...... 57 homatropaire ...... 176 hydrocortisone acetate ...... 147 HARVONI ...... 6 HOMATROPINE HYDROCORTISONE HAVRIX (PF) ...... 158 METHYLBROM (BULK) ACETATE (BULK) ...... 94 HCY 1 POWDER...... 203 ...... 144 hydrocortisone butyrate .. 94, 95 HEALTHY ACCENTS HOMINEX-1 ...... 203 hydrocortisone butyr-emollient AUTOLET ...... 123 huber safety needles (disp.) 123 ...... 95 HEALTHY ACCENTS HUMALOG KWIKPEN hydrocortisone valerate ...... 95 UNILET LANCET ...... 123 INSULIN ...... 123 hydrocortisone-acetic acid .. 108 healthylax ...... 147 HUMATE-P ...... 75 hydrocortisone-pramoxine ... 82, heather ...... 165 HUMIRA ...... 162 147 HEMABATE ...... 174 HUMIRA PEN ...... 162 hydromet ...... 183 HEMLIBRA ...... 74 HUMIRA PEN CROHNS-UC- hydromorphone ...... 46 hemmorex-hc ...... 147 HS START ...... 162 HYDROMORPHONE HEMOFIL M HIGH...... 74 HUMIRA PEN PSOR- (BULK) ...... 45 HEMOFIL M LOW ...... 74 UVEITS-ADOL HS ...... 162 hydromorphone (pf) ...... 45 HEMOFIL M MID ...... 74 HUMIRA(CF) ...... 163 hydromorphone (pf)-0.9 % HEMOFIL M SUPER HIGH74 HUMIRA(CF) PEDI nacl ...... 45 hep flush-10 (pf) ...... 74 CROHNS STARTER ..... 163 HYDROQUINONE (BULK) HEPAGAM B ...... 158 HUMIRA(CF) PEN ...... 163 ...... 84 heparin (porcine) ...... 74, 75 HUMIRA(CF) PEN hydroxocobalamin ...... 212 HEPARIN (PORCINE) CROHNS-UC-HS ...... 163 hydroxychloroquine ...... 13 (BULK) ...... 74 HUMIRA(CF) PEN PSOR- HYDROXYCHLOROQUINE heparin (porcine) in 5 % dex 74 UV-ADOL HS ...... 163 SULF (BULK) ...... 13 heparin (porcine) in nacl (pf) 74 HUMULIN R REGULAR U- hydroxyprogest(pf)(preg presv) heparin flush(porcine)-0.9nacl 100 INSULN ...... 123 ...... 165 ...... 75 HUMULIN R U-500 (CONC) hydroxyprogesterone heparin lock flush ...... 75 INSULIN ...... 123 cap(ppres) ...... 165 heparin lock flush (porcine) . 75 HYALURONIDASE, HYDROXYPROGESTERON heparin lockflush(porcine)(pf) BOVINE (BULK) ...... 177 E CAPR(BULK) ...... 165 ...... 75 HYCAMTIN ...... 26 hydroxyprogesterone caproate heparin(porcine) in 0.45% nacl hydralazine ...... 66 ...... 165 ...... 75 HYDRALAZINE HCL HYDROXYPROPYL heparin, porcine (pf) ...... 75 (BULK) ...... 66 CELLULOSE ...... 101 HEPATAMINE 8%...... 203 HYDRAZINE SULFATE hydroxyurea ...... 26 hetastarch 6 % in 0.9 % nacl (BULK) ...... 101 HYDROXYUREA (BULK) . 26 ...... 203 hydrochlorothiazide ...... 66 hydroxyzine hcl ...... 183 HEXTEND ...... 101 HYDROCHLOROTHIAZIDE HYDROXYZINE HCL HIBERIX (PF)...... 158 (BULK) ...... 66 (BULK) ...... 183 HI-CAL ...... 203 hydrocodone bitartrate ...... 45 hydroxyzine pamoate ...... 183 hidex ...... 110 HYDROCODONE HYDROXYZINE PAMOATE high protein ...... 203 BITARTRATE (BULK)... 45 (BULK) ...... 183 high-protein nutritional shake hydrocodone-acetaminophen 45 hyophen ...... 192 ...... 203 hydrocodone-chlorpheniramine hyoscyamine sulfate ...... 144 HISTAMINE PHOSPHATE ...... 182 HYOSCYAMINE SULFATE (BULK) ...... 101 hydrocodone-homatropine .. 183 (BULK) ...... 144 HISTATROL ...... 158 hydrocodone-ibuprofen ...... 45 hyosyne ...... 144 hydrocortisone ...... 95, 110, 147 HYPERHEP B ...... 158, 159

231 HYPERHEP B NEONATAL INCONTROL ALCOHOL IODOFORM (BULK) ...... 84 ...... 159 PADS ...... 123 IODOPEN ...... 26 HYPERRAB (PF) ...... 159 INCONTROL LANCING IODOQUINOL (BULK) ...... 13 HYPERRAB S/D (PF) ...... 159 DEVICE ...... 123 IONOSOL-B IN D5W ...... 203 HYPERRHO S/D ...... 159 INCONTROL SUPER THIN IONOSOL-MB IN D5W .... 203 HYPERTET S/D (PF) ...... 159 LANCETS ...... 124 IOPANOIC ACID (BULK) 102 HYPODERMIC NEEDLES INCONTROL ULTRA THIN IPOL ...... 159 ...... 123 LANCETS ...... 124 ipratropium bromide ... 108, 187 HYPOLANCE AST INCRELEX ...... 101 IPRATROPIUM BROMIDE LANCING ...... 123 INCRUSE ELLIPTA ...... 187 (BULK) ...... 187 HYSINGLA ER ...... 46 indapamide ...... 66 ipratropium-albuterol ...... 187 I indigo carmine ...... 101 irbesartan ...... 66 ibandronate ...... 161 indocyanine green...... 101 irbesartan-hydrochlorothiazide IBRANCE ...... 26 INDOCYANINE GREEN ...... 67 ibu ...... 50 (BULK) ...... 101 IRESSA ...... 26 ibuprofen ...... 50 indomethacin ...... 50 irinotecan ...... 26 IBUPROFEN (BULK) ...... 50 INDOMETHACIN (BULK) 50 ISENTRESS ...... 6 ibuprofen lysine (pf) ...... 50 indomethacin sodium ...... 50 ISENTRESS HD ...... 6 ibuprofen-oxycodone ...... 46 INFANRIX (DTAP) (PF) ... 159 isibloom ...... 170 ibutilide fumarate ...... 62 infed ...... 212 isoflurane ...... 102 ic green ...... 101 INFUMORPH P/F ...... 46 ISOLYTE S PH 7.4 ...... 203 icatibant ...... 187 INFUVITE PEDIATRIC .... 212 ISOLYTE-P IN 5 % ICHTHAMMOL (BULK) .... 84 INJECT EASE LANCETS . 124 DEXTROSE ...... 203 iclevia ...... 170 INLYTA ...... 26 ISOLYTE-S ...... 203 ICLUSIG ...... 26 INSPIRACHAMBER ...... 124 isometh-dichloral- icosapent ethyl ...... 78 INSPIRACHAMBER WITH acetaminophn ...... 39 ID NOW COVID-19 TEST MASK-LARGE ...... 124 ISOMETHEPTENE MUCATE KIT ...... 123 INSPIRACHAMBER WITH (BULK) ...... 39 idarubicin ...... 26 MASK-MED ...... 124 ISOMIL ADVANCE ...... 203 IDHIFA ...... 26 INSPIRACHAMBER WITH ISOMIL DF ...... 203 IDOXURIDINE (BULK) ...... 6 MASK-SMALL...... 124 ISOMIL/IRON ...... 204 ifosfamide ...... 26 INSTACLEAN ...... 106 isoniazid ...... 13 ILARIS (PF) ...... 154 INSULIN SYRINGE ...... 124 ISONIAZID (BULK) ...... 13 imatinib...... 26 INSULIN SYRINGE ISOPROPAMIDE IODIDE IMBRUVICA ...... 26 MICROFINE ...... 124 (BULK) ...... 144 IMFINZI ...... 26 INSULIN SYRINGE isopropyl alcohol ...... 102, 106 imipenem-cilastatin ...... 13 NEEDLELESS ...... 124 isoproterenol hcl ...... 80 IMIPRAMINE (BULK) ...... 57 INSULIN SYRINGE- ISOPROTERENOL HCL imipramine hcl...... 57 NEEDLE U-100 ...... 124 (BULK) ...... 187 imipramine pamoate ...... 57 INTELENCE ...... 6 ISOSORBIDE (BULK) ...... 81 imiquimod ...... 84 intralipid ...... 203 isosorbide dinitrate ...... 81 IMIQUIMOD (BULK) ...... 84 INTRON A ...... 154 isosorbide mononitrate ...... 81 IMOGAM RABIES-HT (PF) INVACARE LANCETS .... 124 isosource 1.5 cal ...... 204 ...... 159 INVELTYS ...... 180 isosource hn ...... 204 IMOVAX RABIES VACCINE INVIRASE ...... 6 isosulfan blue ...... 102 (PF) ...... 159 INVOKAMET ...... 124 isotretinoin ...... 87 IMPAVIDO ...... 13 INVOKAMET XR ...... 124 isoxsuprine ...... 167 INBRIJA...... 38 INVOKANA ...... 124 ISOXSUPRINE HCL (BULK) incassia ...... 165 IODINE (BULK) ...... 102 ...... 167

232 isradipine ...... 67 KAOLIN (BULK) ...... 102 labetalol ...... 67 ISTODAX ...... 26 kariva (28) ...... 170 LABETALOL (BULK) ...... 67 itraconazole ...... 3 kelnor 1/35 (28) ...... 170 lactated ringers ...... 96, 194 ITRACONAZOLE (BULK) .. 3 kelnor 1-50 (28) ...... 170 lactulose ...... 148 IV ADMINISTRATION SET KENDALL ...... 125 L-ALANINE ...... 102 ...... 124 KEPIVANCE ...... 21 lamivudine ...... 6 IV PREP WIPES ...... 124 KESIMPTA PEN ...... 40 lamivudine-zidovudine ...... 6 I-VALEX-1 ...... 204 ketamine ...... 102 lamotrigine ...... 35 ivermectin ...... 13, 96 KETAMINE (BULK)...... 102 LAMOTRIGINE (BULK) .... 35 IVERMECTIN (BULK) ...... 13 ketamine in 0.9 % sod chloride LANCETS ...... 125 IXEMPRA ...... 26 ...... 102 LANCETS, SUPER THIN . 125 IXIARO (PF) ...... 159 ketoconazole ...... 4, 91 LANCETS,THIN ...... 125 IXINITY ...... 75 KETOCONAZOLE (BULK) . 4 LANCETS,ULTRA THIN . 125 J ketodan ...... 91 LANCING DEVICE ...... 125 jaimiess ...... 170 ketodan kit ...... 91 LANCING DEVICE WITH JAKAFI ...... 27 KETONEX-1 ...... 204 LANCETS ...... 125 JANSSEN COVID-19 ketoprofen ...... 50 LANCING SYSTEM ...... 125 VACCINE (EUA) ...... 159 KETOPROFEN, LANOXIN PEDIATRIC ...... 71 jantoven ...... 75 MICRONIZED (BULK) .. 50 lansoprazole ...... 152, 153 JANUMET ...... 124 ketorolac ...... 50, 51, 178 LANSOPRAZOLE (BULK) JANUMET XR ...... 124 KETOROLAC (BULK) ...... 50 ...... 152 JANUVIA...... 125 KETOTIFEN FUMARATE lanthanum ...... 102 JARDIANCE ...... 125 (BULK) ...... 177 LANTUS SOLOSTAR U-100 jasmiel (28) ...... 170 KEYTRUDA ...... 27 INSULIN ...... 125 jencycla...... 166 KINEVAC ...... 147 LANTUS U-100 INSULIN 125 JEVITY 1 CAL ...... 204 kionex (with sorbitol) ...... 102 LANZO LANCING DEVICE JEVITY 1.2 CAL ...... 204 KITABIS PAK ...... 13 ...... 125 JEVITY 1.5 CAL ...... 204 klor-con ...... 194 lapatinib ...... 27 JEVTANA ...... 27 klor-con 10 ...... 194 larin 1.5/30 (21) ...... 171 jinteli...... 166 klor-con 8 ...... 194 larin 1/20 (21) ...... 171 JIVI ...... 75 klor-con m10 ...... 194 larin 24 fe ...... 171 jolessa ...... 170 klor-con m15 ...... 194 larin fe 1.5/30 (28) ...... 171 juleber ...... 170 klor-con m20 ...... 194 larin fe 1/20 (28) ...... 171 JULUCA...... 6 klor-con/ef ...... 194 larissia ...... 171 junel 1.5/30 (21) ...... 170 kobee ...... 212 latanoprost ...... 179 junel 1/20 (21) ...... 170 KOGENATE FS ...... 75 LATUDA ...... 57 junel fe 1.5/30 (28) ...... 170 KOVALTRY ...... 76 laxaclear ...... 148 junel fe 1/20 (28) ...... 170 K-PHOS ORIGINAL ...... 192 laxative (bisacodyl) ...... 148 junel fe 24 ...... 170 kpn ...... 212 laxative peg 3350 ...... 148 JUXTAPID ...... 78 KRYSTEXXA ...... 161 layolis fe ...... 171 K k-tab ...... 194 leena 28 ...... 171 KADCYLA ...... 27 kurvelo (28) ...... 170 leflunomide ...... 163 kaitlib fe...... 170 KYLEENA ...... 167 LENVIMA ...... 27 KALETRA ...... 6 KYMRIAH ...... 27 lessina ...... 171 kalliga ...... 170 KYNMOBI ...... 38 letrozole ...... 27 KALYDECO ...... 187 KYPROLIS ...... 27 LETROZOLE (BULK) ...... 27 KANAMYCIN (BULK) ...... 13 L LEUCINE (BULK) ...... 102 KANJINTI ...... 27 l norgest/e.estradiol-e.estrad leucovorin calcium ...... 21 KANUMA ...... 140 ...... 171

233 LEUCOVORIN CALCIUM LIDOCAINE (BULK) ...... 89 LITETOUCH-LARGE MASK (BULK) ...... 21 lidocaine (pf) ...... 62, 89 ...... 125 LEUKERAN ...... 27 lidocaine hcl ...... 89 LITETOUCH-SMALL MASK LEUKINE...... 154 LIDOCAINE HCL (BULK) . 89 ...... 125 leuprolide ...... 27 lidocaine hcl(pf) in 0.9% nacl lithium carbonate ...... 57, 58 LEUPROLIDE (BULK) ...... 27 ...... 89 LITHIUM CARBONATE levalbuterol hcl ...... 187 lidocaine hcl-hydrocortison ac (BULK) ...... 57 LEVAMISOLE (BULK) ...... 27 ...... 89, 148 lithium citrate ...... 58 LEVEMIR FLEXTOUCH U- lidocaine in 5 % dextrose (pf) LITHIUM CITRATE 100 INSULN ...... 125 ...... 62 TETRAHYD(BULK) ...... 58 LEVEMIR U-100 INSULIN lidocaine in nacl,iso-osmo(pf) LIVALO ...... 78 ...... 125 ...... 89 lmd 10 % in 0.9 % sodium levetiracetam ...... 35 lidocaine viscous ...... 89 chlor ...... 102 LEVETIRACETAM (BULK) lidocaine-epinephrine ...... 89 lmd 10 % in 5 % dextrose ... 102 ...... 35 lidocaine-epinephrine (pf) .... 89 lojaimiess ...... 171 levetiracetam in nacl (iso-os) 35 lidocaine-hydrocortisone-aloe LOKELMA ...... 102 levobunolol ...... 176 ...... 148 LONSURF ...... 27 levocarnitine ...... 102 lidocaine-phenylephrn in water LOPERAMIDE (BULK) .... 145 LEVOCARNITINE (BULK) ...... 177 lopinavir-ritonavir ...... 6 ...... 102 lidocaine-prilocaine ...... 89, 90 LORATADINE (BULK) .... 183 levocarnitine (with sugar)... 102 lidocort...... 90 lorazepam ...... 58 LEVOCETIRIZINE (BULK) LIFESHIELD BLUNT LORAZEPAM (BULK) ...... 58 ...... 183 CANNULA ...... 125 lorazepam intensol ...... 58 LEVODOPA (BULK) ...... 38 lillow (28) ...... 171 LORBRENA ...... 27 levofloxacin ...... 18, 175 lincomycin ...... 13 loryna (28) ...... 171 LEVOFLOXACIN (BULK) 18 LINCOMYCIN HCL (BULK) losartan ...... 67 levofloxacin in d5w ...... 18 ...... 13 losartan-hydrochlorothiazide 67 levoleucovorin calcium ...... 21 lindane ...... 96 LOTEMAX ...... 180 levonest (28) ...... 171 linezolid ...... 13 LOTEMAX SM ...... 180 levonorgestrel ...... 171 linezolid in dextrose 5% ...... 13 loteprednol etabonate ...... 180 levonorgestrel-ethinyl estrad linezolid-0.9% sodium chloride lovastatin ...... 78 ...... 171 ...... 14 low-ogestrel (28) ...... 171 levonorg-eth estrad triphasic LINZESS ...... 148 loxapine succinate ...... 58 ...... 171 LIORESAL ...... 42 lo-zumandimine (28) ...... 171 levora-28...... 171 liothyronine ...... 143 lta pre-attached ...... 90 levorphanol tartrate ...... 46 LIOTHYRONINE (BULK) 143 ludent fluoride ...... 213 LEVORPHANOL LIPOFEN...... 78 lugols ...... 91, 194 TARTRATE (BULK) ...... 46 lisinopril...... 67 LUMIGAN ...... 179 levo-t...... 142 LISINOPRIL (BULK) ...... 67 LUMIZYME ...... 140 levothyroxine ...... 142, 143 lisinopril-hydrochlorothiazide LUPANETA PACK (1 LEVOTHYROXINE (BULK) ...... 67 MONTH) ...... 167 ...... 142 lite coat aspirin ...... 51 LUPANETA PACK (3 LEVSIN ...... 145 LITE TOUCH LANCETS.. 125 MONTH) ...... 167 LEXISCAN ...... 102 LITE TOUCH LANCING LUPRON DEPOT ...... 28 LEXIVA ...... 6 DEVICE ...... 125 LUPRON DEPOT (3 LIBTAYO ...... 27 LITE TOUCH-MEDIUM MONTH) ...... 28 LICART ...... 51 MASK ...... 125 LUPRON DEPOT-PED ...... 28 lidocaine ...... 89 LITEAIRE MDI CHAMBER LUPRON DEPOT-PED (3 lidocaine (pf) in d7.5w ...... 62 ...... 125 MONTH) ...... 28

234 LUTATHERA ...... 28 md-76 r ...... 102 MEQUINOL (BULK) ...... 103 lutera (28) ...... 171 md-gastroview ...... 102 mercaptopurine ...... 28 LUXTURNA ...... 177 MEBENDAZOLE (BULK) . 14 MERCAPTOPURINE (BULK) lyleq ...... 166 MECAMYLAMINE HCL ...... 28 lyllana ...... 166 (BULK) ...... 102 meropenem ...... 14 LYNPARZA...... 28 MECHLORETHAMINE MEROPENEM-0.9% LYSODREN...... 28 (BULK) ...... 28 SODIUM CHLORIDE ..... 14 lyza ...... 166 MECLIZINE HCL (BULK) merzee ...... 171 M ...... 148 mesalamine ...... 148 m.v.i. adult ...... 213 meclofenamate...... 51 MESALAMINE (BULK) ... 148 M.V.I. PEDIATRIC ...... 213 MECLOFENAMATE mesalamine with cleansing M.V.I.-12 (WITHOUT SODIUM (BULK) ...... 51 wipe ...... 148 VITAMIN K) ...... 213 MECLOFENOXATE HCL mesna ...... 22 mafenide acetate ...... 91 (BULK) ...... 102 MESNEX ...... 22 magnesium chloride ...... 194 MEDISENSE...... 126 META-CRESOL (BULK) .. 103 MAGNESIUM CHLORIDE MEDISENSE GLUCOSE metadate er ...... 58 (BULK) ...... 194 KETONE ...... 126 metaproterenol ...... 187 magnesium citrate ...... 148 MEDISENSE MID METAPROTERENOL MAGNESIUM CITRATE CONTROL ...... 126 SULFATE (BULK) ...... 187 (BULK) ...... 148 MEDISENSE THIN metaxalone ...... 42 MAGNESIUM OXIDE LANCETS ...... 126 metformin ...... 126 (BULK) ...... 194 medlance plus lancets ...... 126 METFORMIN (BULK) ...... 126 magnesium sulfate ...... 194 MEDLANCE PLUS SPECIAL METHACHOLINE MAGNESIUM SULFATE BLADE ...... 126 CHLORIDE (BULK) ..... 103 (BULK) ...... 148 MEDROXYPROGEST, AC methadone ...... 46 MAGNESIUM SULFATE IN MICRO(BULK) ...... 166 METHADONE (BULK) ...... 46 D5W ...... 194 medroxyprogesterone ...... 166 methadone intensol ...... 46 magnesium sulfate in water 194 MEDTRONIC REMOTE methadose ...... 46 malathion ...... 96 CONTROL ...... 126 methamphetamine ...... 58 manganese chloride ...... 195 mefenamic acid...... 51 methazolamide ...... 178 MANGANESE CHLORIDE MEFENAMIC ACID (BULK) METHAZOLAMIDE (BULK) (BULK) ...... 195 ...... 51 ...... 178 MANGANESE SULFATE mefloquine ...... 14 METHENAMINE (BULK) .. 20 (BULK) ...... 195 megestrol ...... 28 methenamine hippurate ...... 20 MANNITOL (BULK) ...... 67 MEGESTROL methenamine mandelate ...... 20 mannitol 10 % ...... 67 ACETATE,MICRO METHENAMINE mannitol 20 % ...... 67 (BULK) ...... 28 MANDELATE (BULK) ... 20 mannitol 25 % ...... 67 MEKINIST ...... 28 methen-sod phos-meth blue- mannitol 5 % ...... 67 MELOXICAM (BULK) ...... 51 hyos ...... 192 maprotiline ...... 58 meloxicam submicronized .... 51 methergine ...... 174 marcaine (pf) ...... 90 melphalan ...... 28 methimazole ...... 111 MARQIBO ...... 28 melphalan hcl ...... 28 METHIMAZOLE (BULK) 111 MATULANE ...... 28 memantine ...... 40 METHIONINE (BULK) .... 192 matzim la ...... 67 MENACTRA (PF) ...... 159 METHITEST ...... 140 maxi-tuss ac ...... 183 MENADIONE (BULK) ..... 103 methocarbamol ...... 42 MAYZENT ...... 40 MENOPUR ...... 140 METHOCARBAMOL m-clear wc ...... 183 MENTHOL (BULK) ...... 84 (BULK) ...... 42 M-CRESOL ACETATE MEPERIDINE (BULK) ...... 46 METHOTREXATE (BULK) (BULK) ...... 102 MEPSEVII...... 140 ...... 28

235 methotrexate sodium ...... 28 metronidazole in nacl (iso-os) MINIMED 770G INSULIN methotrexate sodium (pf) ..... 28 ...... 14 PUMP ...... 126 methoxsalen ...... 84 metyrosine ...... 68 MINIMED INFUSION SET- METHOXSALEN (BULK) . 84 mexiletine ...... 62 MMT 390 ...... 126 METHSCOPOLAMINE MEXILETINE (BULK) ...... 62 MINIMED MIO ADVANCE BROMIDE (BULK) ...... 145 MIACALCIN ...... 140 INF SET23 ...... 126 METHSCOPOLAMINE mibelas 24 fe ...... 171 MINIMED MIO ADVANCE NITRATE (BULK) ...... 145 micafungin ...... 4 INF SET43 ...... 127 methyl salicylate ...... 84 MICONAZOLE (BULK) ...... 4 MINIMED QUICK SET 18127 methyldopa ...... 67 MICONAZOLE NITRATE MINIMED QUICK SET 23127 methyldopa- (BULK) ...... 92 MINIMED QUICK SET 32127 hydrochlorothiazide ...... 67 miconazole-3 ...... 167 MINIMED QUICK SET 43127 methyldopate ...... 67 MICRO THIN LANCETS . 126 MINIMED SILHOUETTE 18 methylene blue (antidote) ..... 20 MICROCHAMBER ...... 126 ...... 127 methylergonovine ...... 174 microgestin 1.5/30 (21) ...... 172 MINIMED SILHOUETTE 23 methylphenidate hcl ...... 58 microgestin 1/20 (21) ...... 172 ...... 127 METHYLPHENIDATE HCL microgestin fe 1.5/30 (28) .. 172 MINIMED SILHOUETTE 32 (BULK) ...... 58 microgestin fe 1/20 (28) ..... 172 ...... 127 METHYLPREDNISOLON MICROLET 2 LANCING MINIMED SILHOUETTE 43 AC,MIC(BULK) ...... 110 DEVICE ...... 126 ...... 127 methylprednisolone ...... 110 MICROLET LANCET ...... 126 MINIMED SURE T 18 ...... 127 methylprednisolone acetate 110 MICROLET NEXT MINIMED SURE T 23 ...... 127 methylprednisolone sodium LANCING DEVICE ...... 126 MINIMED SURE T 32 ...... 127 succ ...... 110 MICROSPACER ...... 126 MINIMED SYRINGE METHYLPREDNISOLONE, midazolam ...... 59 RESERVOIR ...... 127 MIC (BULK) ...... 110 MIDAZOLAM (BULK)...... 58 MINOCIN ...... 19 methyltestosterone ...... 140 midazolam (pf) ...... 59 minocycline ...... 19, 20 METHYLTESTOSTERONE midazolam (pf) in 0.9 % nacl MINOCYCLINE HCL (BULK) ...... 140 ...... 58 (BULK) ...... 19 METHYLTESTOSTERONE, midodrine...... 103 minoxidil ...... 68 MICRO(BULK) ...... 140 migergot...... 39 MINOXIDIL (BULK) ...... 68 METHYSERGIDE (BULK) 39 miglitol ...... 126 MIO INFUSION SET ...... 127 metipranolol ...... 176 miglustat ...... 140 miostat ...... 179 METOCLOPRAMIDE mili...... 172 miralax ...... 149 (BULK) ...... 148 milk of magnesia ...... 149 MIRENA ...... 167 metoclopramide hcl .... 148, 149 milk of magnesia concentrated mirtazapine ...... 59 metolazone ...... 67 ...... 149 MIRVASO ...... 87 metoprolol succinate ...... 67 millipred ...... 110 misoprostol ...... 153 metoprolol ta-hydrochlorothiaz millipred dp ...... 110 MISOPROSTOL (BULK) .. 153 ...... 68 milrinone ...... 80 MITIGARE ...... 161 metoprolol tartrate ...... 68 milrinone in 5 % dextrose .... 80 mitomycin ...... 29 METOPROLOL TARTRATE mimvey ...... 166 MITOMYCIN (BULK) ...... 28 (BULK) ...... 68 MINI LANCING DEVICE 126 MITOTANE (BULK) ...... 29 metro i.v...... 14 MINIMED 530G INSULIN mitoxantrone ...... 29 metronidazole ...... 14, 87, 167 PUMP ...... 126 m-natal plus ...... 213 METRONIDAZOLE (BULK) MINIMED 630G INSULIN modafinil ...... 59 ...... 14 PUMP ...... 126 MODERNA COVID-19 METRONIDAZOLE MINIMED 670G INSULIN VACCINE (EUA) ...... 159 BENZOATE (BULK) ...... 14 PUMP ...... 126 moexipril ...... 68

236 molindone ...... 59 MSUD ANALOG...... 204 nalbuphine ...... 51 mometasone ...... 95, 187 MULTI-DRAW NEEDLE . 128 NALBUPHINE (BULK) ...... 51 MOMETASONE FUROATE MULTI-LANCET DEVICE 2 NALIDIXIC ACID (BULK) 20 (BULK) ...... 95 ...... 128 naloxone ...... 51 mondoxyne nl ...... 20 MULTITRACE-4 NALOXONE (BULK) ...... 51 MONOBENZONE (BULK) 84 CONCENTRATE ...... 195 naltrexone ...... 51 monoject 0.9% sodium MULTITRACE-4 NALTREXONE HCL (BULK) chloride ...... 103 NEONATAL ...... 195 ...... 51 MONOJECT BLOOD multitrace-4 pediatric ...... 195 NALTREXONE HCL COLLECTION ...... 127 multi-vit with fluoride-iron 213 DIHYDRATE(BULK) ..... 51 MONOJECT FILTER multivitamin with fluoride.. 213 NAMZARIC ...... 40, 41 ASPIRATOR ...... 127 multi-vitamin with fluoride 213 NANDROLONE MONOJECT FILTER multivitamins with fluoride 213 DECANOATE (BULK) . 140 NEEDLE ...... 127 multivit-fluor (vit e acetate) 213 naproxen ...... 51, 52 MONOJECT HYPODERMIC mupirocin...... 91 NAPROXEN (BULK) ...... 51 NEEDLES ...... 127 MUPIROCIN (BULK) ...... 91 naproxen sodium ...... 52 MONOJECT HYPODERMIC MURI-LUBE ...... 103 NAPROXEN SODIUM POLYPROPYL ...... 128 MUSE ...... 192 (BULK) ...... 52 MONOJECT MEDICATION mvc-fluoride ...... 213 naproxen-esomeprazole ...... 52 TRANSF NDL ...... 128 my choice ...... 172 naratriptan ...... 39 monoject prefill advanced ns my way ...... 172 NASCOBAL ...... 213 ...... 103 MYALEPT ...... 140 NATACYN ...... 175 MONOLET LANCETS ..... 128 mycophenolate mofetil ...... 29 nateglinide ...... 128 MONOLET THIN LANCETS mycophenolate mofetil (hcl) 29 NATESTO ...... 140 ...... 128 mycophenolate sodium ...... 29 NATPARA ...... 140 mono-linyah ...... 172 MYDAYIS ...... 59 natural b-100 complex ...... 213 MONONINE ...... 76 MYGLUCOHEALTH natura-lax ...... 149 MONOVISC...... 51 LANCETS ...... 128 NAYZILAM ...... 35 MONSEL'S ...... 85 MYLERAN ...... 29 nebusal ...... 187 montelukast ...... 187 MYLOTARG ...... 29 necon 0.5/35 (28) ...... 172 MONTELUKAST (BULK) 187 mynatal ...... 213 NEEDLE (DISP) 16 G ...... 128 morgidox ...... 20 mynatal advance ...... 213 NEEDLE (DISP) 18 G ...... 128 morphine...... 47 mynatal plus ...... 213 NEEDLE (DISP) 19 G ...... 128 MORPHINE (BULK) ...... 46 mynatal-z ...... 213 NEEDLE (DISP) 23 GAUGE morphine (pf)...... 47 mynate 90 plus...... 213 ...... 128 morphine (pf) in 0.9 % sod chl MYOBLOC ...... 159 NEEDLES, HUBER ...... 46, 47 myorisan ...... 87 DISPOSABLE ...... 128 morphine concentrate ...... 47 MYRBETRIQ ...... 190 neomycin ...... 14 morphine in 0.9 % sodium N NEOMYCIN SULFATE chlor ...... 47 nabumetone ...... 51 (BULK) ...... 14 MOUTHPIECE ...... 128 NABUMETONE, neomycin-bacitracin-poly-hc MOVANTIK ...... 149 MICRONIZED (BULK) .. 51 ...... 179 moxifloxacin...... 18, 175 nadolol ...... 68 neomycin-bacitracin- MOXIFLOXACIN- NADOLOL (BULK) ...... 68 polymyxin ...... 175 SOD.ACE,SUL-WATER . 18 nadolol-bendroflumethiazide 68 neomycin-polymyxin b gu .... 96 moxifloxacin-sod.chloride(iso) nafcillin ...... 17 neomycin-polymyxin b- ...... 18 nafcillin in dextrose iso-osm 17 dexameth ...... 179 MOXISYLYTE (BULK) ... 103 naftifine ...... 92 neomycin-polymyxin- MOZOBIL ...... 154 NAGLAZYME ...... 140 gramicidin ...... 175

237 neomycin-polymyxin-hc .... 109 NITROFURAZONE (BULK) NOVA SAFETY LANCETS neo-polycin ...... 175 ...... 91 ...... 128 neo-polycin hc ...... 179 nitroglycerin ...... 81 NOVA SUREFLEX NEOSTIGMINE nitroglycerin in 5 % dextrose 81 LANCETS ...... 128 METHYLSULF (BULK) . 42 nitro-time ...... 81 NOVAMAX PLUS KETONE neostigmine methylsulfate.... 42 NITYR ...... 103 ...... 128 NEPHRAMINE 5.4 % ...... 204 NIVESTYM ...... 154 NOVAREL ...... 140 NERLYNX ...... 29 nizatidine ...... 153 NOVOEIGHT ...... 76 neuac...... 87 NOKOR NEEDLE ...... 128 NOVOFINE 32 ...... 128 nevirapine ...... 6 nolix ...... 95 NOVOFINE AUTOCOVER new day ...... 172 nora-be ...... 166 ...... 128 newgen ...... 213 NORDITROPIN FLEXPRO NOVOFINE PLUS ...... 128 NEXAVAR ...... 29 ...... 155 NOVOSEVEN RT ...... 76 NEXCARE TEGADERM .. 128 norepinephrine bitartrate ...... 80 NOVOTWIST ...... 128 NEXLETOL ...... 78 norepinephrine bitartrate-d5w NOXAFIL ...... 4 NEXLIZET...... 78 ...... 80 np thyroid ...... 143 NEXPLANON ...... 167 norepinephrine bitartrate-nacl NPLATE ...... 76 NEXTERONE ...... 62 ...... 80 NUBEQA ...... 29 NH4 noreth-ethinyl estradiol-iron NUCALA ...... 187, 188 TETRATHIOMOLYBDAT ...... 172 NUEDEXTA ...... 41 E (BULK) ...... 103 NORETHINDRONE (BULK) NUTRA PRO HIGH niacin ...... 78, 79 ...... 166 PROTEIN ...... 204 NIACIN (BULK) ...... 78 norethindrone (contraceptive) nutrafit ...... 204 NIACINAMIDE (BULK) .... 79 ...... 166 nutrafit plus ...... 204 nicardipine ...... 68 norethindrone acetate ...... 166 NUTRAMIGEN DHA-ARA NICLOSAMIDE (BULK) .... 14 NORETHINDRONE ...... 204 NICODERM CQ ...... 107 ACETATE (BULK) ...... 166 NUTRAMIGEN TODDLER nicorette ...... 107 norethindrone ac-eth estradiol ENFLORA-LGG ...... 204 NICORETTE ...... 107 ...... 166, 172 NUTRAMIGEN WITH nicotine ...... 107 norethindrone-e.estradiol-iron ENFLORA LGG ...... 204 nicotine (polacrilex) ...... 107 ...... 172 nutren 1.0 ...... 204 NICOTINE POLACRILEX norgestimate-ethinyl estradiol nutren 1.5 ...... 205 (BULK) ...... 107 ...... 172 nutren 2.0 ...... 205 NICOTINE TARTRATE ... 107 norlyda ...... 166 nutren junior ...... 205 nifedipine ...... 68 normal saline flush ...... 103 nutren junior fiber ...... 205 NIFEDIPINE (BULK) ...... 68 NORMOSOL-M IN 5 % nutrilyte ...... 195 nilutamide ...... 29 DEXTROSE ...... 204 NUTRISURE ORIGINAL . 205 nimodipine ...... 68 NORMOSOL-R IN 5 % NUTRISURE PLUS ...... 205 NINLARO ...... 29 DEXTROSE ...... 195 nutritional drink ...... 205 nisoldipine ...... 68 NORMOSOL-R PH 7.4 ..... 204 nutritional drink mix ...... 205 nitazoxanide ...... 14 nortrel 0.5/35 (28)...... 172 nutritional drink plus ...... 205 nitisinone ...... 103 nortrel 1/35 (21)...... 172 nutritional shake ...... 205 nitro-bid ...... 81 nortrel 1/35 (28)...... 172 NUTRITIONAL SHAKE ... 205 nitrofurantoin ...... 20 nortrel 7/7/7 (28) ...... 172 nutritional shake plus ...... 205 NITROFURANTOIN (BULK) nortriptyline ...... 59 NUTRITIONAL SHAKE ...... 20 NORTRIPTYLINE (BULK) 59 PLUS ...... 205 nitrofurantoin macrocrystal .. 20 NORVIR ...... 6 nyamyc ...... 92 nitrofurantoin monohyd/m- NOURISH ORIGINAL nylia 7/7/7 (28) ...... 172 cryst ...... 20 FORMULA ...... 204 NYLIDRIN (BULK) ...... 68

238 nymyo ...... 172 ONCASPAR ...... 29 OPSUMIT ...... 188 nystatin ...... 4, 92 ondansetron ...... 149 OPTICHAMBER ADULT NYSTATIN (BULK) ...... 4 ondansetron hcl...... 149 MASK-LARGE ...... 129 nystatin-triamcinolone ...... 92 ONDANSETRON HCL OPTICHAMBER DIAMOND nystop ...... 92 (BULK) ...... 149 LG MASK ...... 130 NYVEPRIA ...... 155 ondansetron hcl (pf)...... 149 OPTICHAMBER DIAMOND O one daily prenatal ...... 214 VHC ...... 130 OA 1 POWDER ...... 205 ONE WAY VALVED OPTICHAMBER DIAMOND- OBIZUR ...... 76 MOUTHPIECE ...... 129 MED MSK ...... 130 obstetrix dha ...... 213 ONETOUCH DELICA LANC OPTICHAMBER DIAMOND- OCALIVA ...... 149 DEVICE ...... 129 SML MASK ...... 130 ocella ...... 172 ONETOUCH DELICA option-2 ...... 173 OCREVUS ...... 41 LANCETS ...... 129 oral saline laxative ...... 149 octreotide acetate ...... 29 ONETOUCH DELICA PLUS oralone ...... 108 ocucoat ...... 177 LANC DEV ...... 129 ORANGE CHICKN- ODEFSEY ...... 7 ONETOUCH DELICA PLUS CARROT-BRWN RICE 205 ODOMZO ...... 29 LANCET ...... 129 ORBACTIV ...... 14 OFEV ...... 188 ONETOUCH SURESOFT ORIAHNN ...... 167 ofloxacin ...... 18, 108, 175 LANCING DEV ...... 129 ORILISSA ...... 140 olanzapine...... 59 ONETOUCH ULTRA BLUE ORKAMBI ...... 188 olanzapine-fluoxetine ...... 59 TEST STRIP...... 129 ORNITHINE olmesartan ...... 68 ONETOUCH ULTRA HYDROCHLORIDE olmesartan-amlodipin- CONTROL ...... 129 (BULK) ...... 205 hcthiazid ...... 68 ONETOUCH ULTRA2 orphenadrine citrate ...... 42 olmesartan- METER ...... 129 ORPHENADRINE CITRATE hydrochlorothiazide ...... 68 ONETOUCH ULTRAMINI (BULK) ...... 42 olopatadine ...... 108, 177 ...... 129 orphenadrine-asa-caffeine .... 43 omega-3 acid ethyl esters ..... 79 ONETOUCH ULTRASOFT orphengesic forte ...... 43 omeprazole ...... 153 LANCETS ...... 129 orsythia ...... 173 OMEPRAZOLE (BULK) .. 153 ONETOUCH VERIO FLEX ORTHOVISC ...... 52 omeprazole-sodium METER ...... 129 oscimin ...... 145 bicarbonate ...... 153 ONETOUCH VERIO HIGH oscimin sl ...... 145 OMNIPAQUE 140 ...... 103 CONTROL ...... 129 oscimin sr ...... 145 OMNIPAQUE 180 ...... 103 ONETOUCH VERIO IQ oseltamivir ...... 7 OMNIPAQUE 240 ...... 103 METER ...... 129 osmitrol 15 % ...... 68 OMNIPAQUE 300 ...... 103 ONETOUCH VERIO METER osmitrol 20 % ...... 68 OMNIPAQUE 350 ...... 103 ...... 129 OSMOLITE 1 CAL ...... 205 OMNIPOD DASH 5 PACK ONETOUCH VERIO MID OSMOLITE 1.2 CAL ...... 205 POD ...... 128 CONTROL ...... 129 osmolite 1.5 cal ...... 205 OMNIPOD INSULIN ONETOUCH VERIO OTEZLA ...... 163 MANAGEMENT ...... 129 REFLECT METER ...... 129 OTEZLA STARTER ...... 163 OMNIPOD INSULIN REFILL ONETOUCH VERIO TEST OTOVEL ...... 109 ...... 129 STRIPS ...... 129 OVIDREL ...... 140 ON CALL LANCET ...... 129 ONEXTON ...... 87 oxacillin ...... 17 ON CALL LANCING ONIVYDE ...... 29 oxacillin in dextrose(iso-osm) DEVICE ...... 129 ON-THE-GO LANCETS ... 129 ...... 17 ON CALL PLUS LANCET129 opcicon one-step ...... 173 oxaliplatin ...... 29, 30 ON CALL PLUS LANCING OPDIVO ...... 29 oxandrolone ...... 141 DEVICE ...... 129 opium tincture...... 145

239 OXANDROLONE (BULK) PAROMOMYCIN SULFATE PENTACEL ACTHIB ...... 140 (BULK) ...... 14 COMPONENT (PF) ...... 160 oxaprozin ...... 52 paroxetine hcl ...... 59 pentamidine ...... 14 oxcarbazepine ...... 36 paroxetine PENTASA ...... 150 OXERVATE ...... 177 mesylate(menop.sym)...... 59 pentobarbital sodium ...... 59 oxiconazole...... 92 PCCA T3 SODIUM PENTOBARBITAL SODIUM oxybutynin chloride.... 190, 191 DILUTION ...... 143 (BULK) ...... 59 OXYBUTYNIN CHLORIDE PCCA T4 SODIUM PENTOSAN POLYSULFATE (BULK) ...... 190 DILUTION ...... 143 NA (BULK) ...... 192 oxycodone ...... 47 pedia iron ...... 214 pentoxifylline ...... 76 OXYCODONE (BULK) ...... 47 PEDIARIX (PF) ...... 160 PENTOXIFYLLINE (BULK) oxycodone-acetaminophen ... 48 PEDIASURE ...... 205 ...... 76 oxycodone-aspirin ...... 48 PEDIASURE ENTERAL ... 205 PENTYLENETETRAZOL OXYCONTIN ...... 48 PEDIASURE GROW-GAIN (BULK) ...... 103 OXYMETAZOLINE (BULK) ...... 205 peptamen 1.5 cal with prebio1 ...... 108 pediasure peptide 1.0 cal .... 205 ...... 206 oxymorphone ...... 48 PEDIASURE PEPTIDE 1.5 PEPTAMEN JUNIOR ...... 206 OXYQUINOLINE SULFATE CAL ...... 206 peptamen junior fiber ...... 206 (BULK) ...... 103 PEDIASURE SIDEKICKS 206 peptamen w-prebio1 ...... 206 OXYTETRACYCLINE pediatric balanced nutrition 206 PERFOROMIST ...... 188 (BULK) ...... 20 PEDIATRIC MEDIUM perindopril erbumine ...... 69 oxytocin ...... 174 MASK ...... 130 periogard ...... 108 OXYTOCIN (BULK) ...... 174 PEDIATRIC PANDA MASK PERJETA ...... 30 OZEMPIC ...... 130 ...... 130 permethrin ...... 96 OZURDEX ...... 180 pediatric peptide 1.0 ...... 206 PERMETHRIN (BULK) ...... 96 P pediatric peptide formula 1.5 perphenazine ...... 59 pacerone ...... 62 ...... 206 perphenazine-amitriptyline ... 60 paclitaxel ...... 30 PEDIATRIC SMALL MASK perry prenatal ...... 214 paliperidone ...... 59 ...... 130 PFD TODDLER ...... 206 palonosetron ...... 149 pediatric standard formula 1.2 PFIZER COVID-19 PALYNZIQ ...... 141 ...... 206 VACCINE (EUA) ...... 160 pamidronate ...... 141 PEDITRACE ...... 195 pfizerpen-g ...... 17 PANCREATIN (BULK) .... 149 peg 3350-electrolytes ...... 149 phenadoz ...... 183 PANCREAZE ...... 149 peg3350-sod sul-nacl-kcl-asb-c PHENAZOPYRIDINE pancuronium ...... 43 ...... 149 (BULK) ...... 193 PANDA MASK...... 130 peg-electrolyte soln ...... 150 phenelzine ...... 60 pantoprazole ...... 153 peg-prep ...... 150 PHENELZINE (BULK) ...... 60 papaverine ...... 69 penicillamine ...... 163 PHENINDIONE (BULK) .. 103 PAPAVERINE (BULK) ...... 68 PENICILLAMINE (BULK) phenobarb-hyoscy-atropine- PARACHLOROPHENOL ...... 163 scop ...... 145 (BULK) ...... 103 PENICILLAMINE(D-) ...... 163 phenobarbital ...... 36 PARADIGM RESERVOIR 130 PENICILLIN G POT IN PHENOBARBITAL (BULK) PARADIGM SILHOUETTE DEXTROSE ...... 17 ...... 36 INFUS SET ...... 130 penicillin g potassium ...... 17 phenobarbital sodium ...... 36 paraplatin ...... 30 penicillin g procaine ...... 17 phenohytro ...... 145 paricalcitol ...... 141 penicillin g sodium ...... 17 PHENOL (BULK) ...... 103 paroex oral rinse ...... 108 penicillin v potassium ...... 17 phenoxybenzamine ...... 69 paromomycin ...... 14 PENTACEL (PF) ...... 160 PHENOXYBENZAMINE (BULK) ...... 69

240 PHENTERMINE HCL plasbumin 25 % ...... 193 potassium chloride-0.45 % nacl (BULK) ...... 96 plasbumin 5 % ...... 193 ...... 196 phentolamine ...... 69 PLASMA-LYTE 148 ...... 206 potassium chloride-d5- PHENTOLAMINE PLASMA-LYTE A ...... 206 0.2%nacl ...... 196 MESYLATE (BULK) ...... 69 plasmanate ...... 206 potassium chloride-d5- phenylephrine hcl ...... 80, 181 PLEGRIDY ...... 155 0.3%nacl ...... 196 PHENYLEPHRINE HCL plenamine ...... 206 potassium chloride-d5- (BULK) ...... 181 pnv 29-1 ...... 214 0.9%nacl ...... 196 phenylephrine hcl in 0.9% nacl pnv-dha ...... 214 potassium citrate ...... 192 ...... 80 pnv-dha + docusate ...... 214 POTASSIUM CITRATE M- PHENYLMERCURIC pnv-omega ...... 214 HYD(BULK) ...... 104 NITRATE (BULK) ...... 103 pnv-select...... 214 POTASSIUM GLUCONATE phenytoin ...... 36 POCKET CHAMBER ...... 130 (BULK) ...... 196 PHENYTOIN (BULK) ...... 36 podofilox ...... 85 POTASSIUM HYDROXIDE phenytoin sodium ...... 36 PODOPHYLLUM RESIN (BULK) ...... 83 PHENYTOIN SODIUM (BULK) ...... 83 POTASSIUM IODIDE (BULK) ...... 36 polocaine ...... 90 (BULK) ...... 112 phenytoin sodium extended .. 36 POLOCAINE ...... 90 POTASSIUM philith ...... 173 polocaine-mpf ...... 90 PERMANGANATE phlexy-vits ...... 206 POLY HUB NEEDLE...... 130 (BULK) ...... 196 PHOSLYRA ...... 195 polycin ...... 175 potassium phosphate m-/d- phosphasal ...... 192 polyethylene glycol 3350 ... 150 basic ...... 196 phosphate laxative ...... 150 POLYETHYLENE GLYCOL POTASSIUM PHOSPHOLINE IODIDE .. 176 3350(BULK) ...... 104 PHOSPHATE,DIB (BULK) PHOTOFRIN ...... 30 POLYMYXIN B ...... 196 physostigmine salicylate .... 179 SULF,MICRON.(BULK) . 14 POTELIGEO ...... 30 PHYTONADIONE (VIT K1) polymyxin b sulfate ...... 14 POVIDONE (BULK) ...... 104 (BULK) ...... 76 polymyxin b sulf-trimethoprim POVIDONE-IODINE (BULK) phytonadione (vitamin k1) ... 76 ...... 175 ...... 91 PHYTONADIONE POLYSKIN II...... 130 powderlax ...... 150 (VITAMIN K1) ...... 76 POLYVINYL ALCOHOL pr natal 400 ...... 214 PICATO ...... 85 (BULK) ...... 178 pr natal 400 ec ...... 214 pilocarpine hcl ...... 103, 176 POMALYST ...... 30 pr natal 430 ...... 214 PILOCARPINE HCL (BULK) portia 28 ...... 173 pr natal 430 ec ...... 214 ...... 176 posaconazole ...... 4 pramipexole ...... 38 PILOCARPINE NITRATE potassium acetate ...... 195 PRAMOXINE HCL (BULK) (BULK) ...... 177 POTASSIUM ACETATE ...... 150 pimecrolimus ...... 85 (BULK) ...... 195 prasugrel ...... 76 pimozide ...... 60 potassium chlorid-d5- pravastatin ...... 79 pimtrea (28) ...... 173 0.45%nacl ...... 195 praziquantel ...... 14 pindolol...... 69 potassium chloride ...... 196 PRAZIQUANTEL (BULK) . 14 pioglitazone ...... 130 POTASSIUM CHLORIDE prazosin ...... 69 pioglitazone-glimepiride .... 130 (BULK) ...... 195 PRE PROTEIN ...... 206 pioglitazone-metformin ...... 130 potassium chloride in 0.9%nacl PRECISION XTRA B- PIP LANCET ...... 130 ...... 195 KETONE ...... 130 piperacillin-tazobactam ...... 17 potassium chloride in 5 % dex PRECISION XTRA pirmella...... 173 ...... 195 KETONE-GLUCOSE .... 131 piroxicam ...... 52 potassium chloride in lr-d5 . 195 PRECISION XTRA PIROXICAM (BULK) ...... 52 potassium chloride in water 196 MONITOR ...... 131

241 PRECISION XTRA TEST . 131 prenatal vits96-iron fum-folic PROCRIT ...... 155 prednicarbate ...... 95 ...... 215 procto-pak ...... 150 prednisolone ...... 111 prenatal-u ...... 215 proctosol hc ...... 150 PREDNISOLONE (BULK)111 preplus ...... 215 PRODIGY LANCETS ...... 131 PREDNISOLONE AC, pre-protein ...... 206 PRODIGY LANCING MICRO (BULK) ...... 111 PRESSURE ACTIVATED DEVICE ...... 131 PREDNISOLONE SOD PHOS LANCETS ...... 131 PRODIGY TWIST TOP (BULK) ...... 111 pretab ...... 215 LANCET ...... 131 prednisolone sodium phosphate prevalite ...... 79 PRODUCT 3232A ...... 207 ...... 111, 180 previfem...... 173 PROFILNINE ...... 76 PREDNISOLONE, MICRO PREZISTA ...... 7 progesterone ...... 166 (BULK) ...... 111 PRIALT ...... 52 PROGESTERONE (BULK) prednisone ...... 111 PRIFTIN ...... 14 ...... 166 PREDNISONE (BULK) .... 111 PRILOCAINE (BULK) ...... 90 progesterone micronized .... 166 prednisone intensol ...... 111 PRIMAQUINE ...... 15 PROGESTERONE PREDNISONE PRIMEAIRE ...... 131 MICRONIZED (BULK) 166 MICRONIZED (BULK) 111 primidone...... 36 PROGRAF ...... 30 pregabalin ...... 36 PRIMIDONE (BULK) ...... 36 PROLASTIN-C ...... 104 PREGESTIMIL ...... 206 PRO COMFORT ALCOHOL prolate ...... 48 PREGNENOLONE (BULK) PADS ...... 131 PROLEUKIN ...... 155 ...... 104 PRO COMFORT LANCET PROMACTA ...... 76 PREGNENOLONE, ...... 131 promethazine ...... 183 MICRONIZED(BULK) . 104 PRO COMFORT SPACER- PROMETHAZINE (BULK) PREMARIN ...... 166 ADULT MASK ...... 131 ...... 183 premasol 10 % ...... 206 PRO COMFORT SPACER- promethazine vc ...... 183 PREMIUM INFANT CHILD MASK ...... 131 promethazine vc-codeine .... 183 FORMULA ...... 206 probenecid ...... 161 promethazine-codeine ...... 183 prena1 chew...... 214 probenecid-colchicine ...... 161 promethazine-dm ...... 183 prena1 pearl ...... 214 procainamide ...... 62 promethazine-phenyleph- prena1 true ...... 214 PROCAINAMIDE HCL codeine ...... 183 prenaissance ...... 214 (BULK) ...... 62 promethazine-phenylephrine prenaissance plus ...... 214 PROCAINE (BULK) ...... 90 ...... 183 prenatabs fa ...... 214 PROCALAMINE 3% ...... 207 promethegan ...... 183 prenatabs rx ...... 214 PROCARE SPACER WITH PROMOD PROTEIN ...... 207 prenatal ...... 214 ADULT MASK ...... 131 PROMOTE ...... 207 prenatal complete ...... 214 PROCARE SPACER WITH PROMOTE WITH FIBER . 207 prenatal low iron...... 214 CHILD MASK ...... 131 propafenone ...... 62, 63 prenatal multi-dha (algal oil) procel 100 ...... 207 PROPANTHELINE (BULK) ...... 214 procel singles ...... 207 ...... 145 prenatal multivitamins ...... 214 procel whey ...... 207 proparacaine ...... 178 prenatal one daily ...... 214 procentra ...... 60 PROPARACAINE (BULK) prenatal plus ...... 215 PROCHAMBER ...... 131 ...... 178 prenatal plus (calcium carb)215 prochlorperazine ...... 150 PRO-PHREE ...... 207 prenatal tablet ...... 215 prochlorperazine edisylate .. 150 PROPIMEX-1 ...... 207 prenatal vitamin ...... 215 PROCHLORPERAZINE propofol ...... 104 prenatal vitamin plus low iron EDISYLT(BULK) ...... 150 propranolol ...... 69 ...... 215 prochlorperazine maleate ... 150 PROPRANOLOL (BULK) .. 69 prenatal vit-iron fum-folic ac PROCHLORPERAZINE propranolol-hydrochlorothiazid ...... 215 MALEATE(BULK) ...... 150 ...... 69

242 propylthiouracil ...... 112 PYRIMETHAMINE (BULK) REBIF (WITH ALBUMIN) PROPYLTHIOURACIL ...... 15 ...... 155 (BULK) ...... 112 PYRITHIONE ZINC (BULK) REBIF REBIDOSE ...... 155 PROSOL 20 % ...... 207 ...... 96 REBIF TITRATION PACK prosource ...... 207 Q ...... 155 PROSOURCE ...... 207 QNASL ...... 188 reclipsen (28) ...... 173 prosource no carb ...... 207 QUADRACEL (PF) ...... 160 RECTIV ...... 150 pro-stat awc ...... 207 quazepam ...... 60 regonol ...... 43 PRO-STAT SUGAR FREE 207 QUDEXY XR...... 36 REGRANEX ...... 85 protamine ...... 76 quetiapine ...... 60 RELIAMED LANCET ...... 131 PROTAMINE SULFATE QUICK-SET PARADIGM. 131 RELIAMED MINI LANCING (BULK) ...... 76 QUILLICHEW ER ...... 60 DEVICE ...... 131 protein...... 207 QUILLIVANT XR ...... 60 RELIAMED SAFETY SEAL PROTEINEX ...... 207 QUINACRINE (BULK)...... 15 LANCETS ...... 132 PROTEINEX-100 ...... 207 quinapril...... 69 RELION THIN LANCETS 132 PROTEINEX-18 ...... 207 quinapril-hydrochlorothiazide RELION ULTRA THIN PLUS PROTIRELIN (BULK) ...... 143 ...... 69 LANCETS ...... 132 PROTOPAM CHLORIDE ... 96 quinidine sulfate ...... 63 RELISTOR ...... 150 protriptyline ...... 60 QUINIDINE SULFATE REMICADE ...... 150 PROVENGE...... 160 (BULK) ...... 63 remifentanil ...... 48 PROVIMIN ...... 208 QUININE HCL DIHYDRATE RENACIDIN ...... 192 prudoxin ...... 85 (BULK) ...... 15 rena-vite ...... 215 PSEUDOEPHEDRINE HCL quinine sulfate ...... 15 repaglinide ...... 132 (BULK) ...... 183 QUININE SULFATE (BULK) repaglinide-metformin ...... 132 PULMICORT FLEXHALER ...... 15 REPATHA PUSHTRONEX 79 ...... 188 QUINOA-KALE-HEMP .... 208 REPATHA SURECLICK .... 79 pulmosal ...... 188 quit 2 ...... 107 REPATHA SYRINGE ...... 79 PULMOZYME...... 188 quit 4 ...... 107 replete ...... 208 PURE COMFORT ALCOHOL QVAR REDIHALER ...... 188 replete fiber ...... 208 PADS ...... 131 R RESERPINE (BULK) ...... 69 PURE COMFORT LANCETS RABAVERT (PF) ...... 160 RESORCINOL (BULK) ...... 83 ...... 131 rabeprazole ...... 153 resource 2.0 ...... 208 PURE COMFORT SAFETY RACEPINEPHRINE (BULK) RESTASIS ...... 178 LANCETS ...... 131 ...... 188 RESTASIS MULTIDOSE .. 178 purelax ...... 150 RADICAVA ...... 41 RETACRIT ...... 155 PURIXAN ...... 30 raloxifene ...... 161 RETINOIC ACID ...... 87 PUSH BUTTON SAFETY ramelteon ...... 60 RETROVIR ...... 7 LANCETS ...... 131 ramipril ...... 69 REVCOVI ...... 104 PYRANTEL PAMOATE ranitidine hcl ...... 153 REVEL PEDIATRIC (BULK) ...... 15 ranolazine ...... 80 PROGRAM PUMP ...... 132 pyrazinamide ...... 15 RAPIVAB (PF) ...... 7 REVEL PROGRAMMABLE pyridostigmine bromide ...... 43 rasagiline ...... 38 PUMP ...... 132 PYRIDOSTIGMINE RASUVO (PF) ...... 163 REVLIMID ...... 30 BROMIDE (BULK) ...... 43 RAVICTI ...... 104 revonto ...... 43 PYRIDOXINE (BULK) ..... 215 RCF SOY PROTEIN R-GENE 10 ...... 208 pyridoxine (vitamin b6) ...... 215 FORMULA BASE ...... 208 RHOPRESSA ...... 179 PYRILAMINE MALEATE READYLANCE SAFETY RIASTAP ...... 77 (BULK) ...... 184 LANCETS ...... 131 ribavirin ...... 7 pyrimethamine ...... 15

243 RIBOFLAVIN (VITAMIN SAFE-CLIP NEEDLE sevelamer hcl ...... 104 B2) (BULK) ...... 215 STORAGE DEV ...... 132 SEVENFACT ...... 77 RIBOFLAVIN 5PHOSPHAT SAFETY LANCETS ...... 132 sevoflurane ...... 104 SOD(BULK) ...... 215 SAFETY NEEDLES ...... 132 sf 108 RIDAURA ...... 163 SAFETY SEAL LANCETS sf 5000 plus ...... 108 rifabutin ...... 15 ...... 132 sharobel ...... 166 rifampin ...... 15 SAFETY-LET LANCETS . 132 SHINGRIX (PF) ...... 160 RIFAMPIN (BULK) ...... 15 SALICYLIC ACID (BULK) 83 SIDESTREAM PEDIATRIC RIGHTEST GD500 SALMON-OATS-SQUASH FACE MASK ...... 132 LANCING DEVICE ...... 132 ...... 208 SIGNIFOR ...... 30 RIGHTEST GL300 LANCETS salsalate ...... 52 sildenafil ...... 192 ...... 132 SALSALATE (BULK)...... 52 SILDENAFIL (BULK) ...... 192 riluzole ...... 104 SAMSCA...... 141 sildenafil (pulm.hypertension) rimantadine ...... 7 SANDIMMUNE ...... 30 ...... 188 ringer's ...... 96, 196 SANTYL ...... 96 SILHOUETTE 23 ...... 132 RINVOQ ...... 163 sapropterin ...... 141 SILHOUETTE 43 ...... 132 risedronate ...... 104, 162 SAVELLA ...... 163, 164 SILICONE MASK - INFANT RISPERDAL CONSTA ...... 60 scalacort ...... 95 ...... 132 risperidone ...... 60 scandishake (lactose free) ... 208 SILICONE MASK - RITEFLO AEROCHAMBER scopolamine base ...... 150 PEDIATRIC ...... 132 ...... 132 SCOPOLAMINE HBR silodosin ...... 191 ritonavir ...... 7 (BULK) ...... 151 SIL-SERTER ...... 132 rivastigmine ...... 41 seconal sodium ...... 60 SILVER NITRATE (BULK) 85 rivastigmine tartrate...... 41 SEGLUROMET ...... 132 SILVER PROTEIN MILD rivelsa ...... 173 selegiline hcl ...... 38 (BULK) ...... 85 rizatriptan ...... 39 SELEGILINE HCL (BULK) 38 SILVER SULFADIAZINE rocuronium ...... 43 selenium...... 196 (BULK) ...... 83 ropinirole ...... 38 selenium sulfide ...... 82 SIMETHICONE (BULK) .. 151 ropivacaine (pf) ...... 90 SELENIUM SULFIDE SIMILAC ADVANCE ...... 208 ROPIVACAINE HCL (BULK) (BULK) ...... 82 similac advance organic ..... 208 ...... 90 SELZENTRY ...... 7 SIMILAC ADVANCE rosadan ...... 87 se-natal 19 chewable ...... 215 ORGANIC ...... 208 rosula cleansing cloths ...... 87 se-natal-19 ...... 215 SIMILAC ADVANCE WITH rosuvastatin...... 79 sensorcaine ...... 90 IRON ...... 208 roweepra ...... 36 sensorcaine-epinephrine ...... 90 similac alimentum ...... 208 roweepra xr ...... 36 sensorcaine-mpf...... 90 SIMILAC EXPERT CARE 209 ROZLYTREK ...... 30 SENSORCAINE- similac expert care alimentum RUBRACA...... 30 MPF/EPINEPHRINE ...... 90 ...... 208 RUCONEST ...... 188 SEREVENT DISKUS ...... 188 SIMILAC EXPERT CARE RUXIENCE ...... 30 SERMORELIN ACETATE ALIMENTUM ...... 208 RUZURGI ...... 41 (BULK) ...... 155 SIMILAC EXPERT CARE RYBELSUS ...... 132 serophene ...... 141 NEOSURE ...... 208 RYDAPT ...... 30 SEROSTIM ...... 155 SIMILAC FOR SPIT-UP ... 209 rydex ...... 184 SEROTONIN HCL (BULK) SIMILAC HUMAN MILK S ...... 104 FORTIFIER ...... 209 SAF-CLENS AF DERMAL sertraline ...... 60 SIMILAC LOW-IRON ...... 209 WOUND...... 85 SERTRALINE (BULK) ...... 60 similac neosure ...... 209 SAFE-CLIP BY MAIL ...... 132 setlakin...... 173 SIMILAC PM ...... 209 sevelamer carbonate ...... 104

244 SIMILAC PRO-ADVANCE SODIUM BORATE (BULK) sodium thiosulfate ...... 105 NON-GMO...... 209 ...... 104 SOFT TOUCH LANCETS . 133 SIMILAC PRO-SENSITIVE SODIUM BROMIDE (BULK) solifenacin ...... 191 NON-GMO...... 209 ...... 104 SOLIQUA 100/33 ...... 133 SIMILAC SENSITIVE ...... 209 SODIUM BUTYRATE SOLIRIS ...... 105 similac sensitive fuss and gas (BULK) ...... 104 SOLOSEC ...... 15 ...... 209 sodium chlor 0.9% bacteriostat SOLU-CORTEF ...... 111 SIMILAC SENSITIVE FUSS ...... 104 SOLU-CORTEF ACT-O- AND GAS ...... 209 sodium chloride .. 105, 188, 197 VIAL (PF) ...... 111 similac sensitive fuss-gas ... 209 SODIUM CHLORIDE SOLUS V2 LANCETS ...... 133 SIMILAC SENSITIVE (BULK) ...... 197 SOLUS V2 LANCING ISOMIL SOY ...... 209 sodium chloride 0.45 % ...... 197 DEVICE ...... 133 SIMILAC SOY ISOMIL .... 210 sodium chloride 0.9 % 104, 105 SOMATULINE DEPOT ...... 31 SIMILAC SPECIAL CARE 24 sodium chloride 0.9 % (flush) SOMAVERT ...... 141 ...... 210 ...... 104 sorine ...... 63 SIMILAC SPECIAL CARE 30 sodium chloride 3 % ...... 197 sotalol ...... 63 ...... 210 sodium chloride 5 % ...... 197 SOTALOL ...... 63 SIMILAC SODIUM CITRATE sotalol af ...... 63 SUPPLEMENTATION .. 210 DIHYDRATE(BULK) ... 105 SOTRADECOL ...... 105 SIMILAC TOTAL sodium ferric gluconat-sucrose SOTYLIZE ...... 63 COMFORT...... 210 ...... 105 SPACE CHAMBER ...... 133 SIMILAC TOTAL sodium fluoride 5000 plus .. 108 SPACE CHAMBER WITH COMFORT NON-GMO 210 sodium fluoride-pot nitrate . 108 LARGE MASK ...... 133 simliya (28) ...... 173 SODIUM HYALURONATE SPACE CHAMBER WITH simpesse ...... 173 (BULK) ...... 85 MEDIUM MASK ...... 133 SIMPONI ...... 164 SODIUM HYDROXIDE SPACE CHAMBER WITH SIMULECT ...... 30 (BULK) ...... 83 SMALL MASK ...... 133 simvastatin ...... 79 SODIUM LACTATE (BULK) spinosad ...... 96 SIMVASTATIN (BULK) .... 79 ...... 197 SPINRAZA (PF) ...... 41 SINGLE-LET ...... 132 SODIUM NITRITE (BULK) SPIRIVA RESPIMAT ...... 189 sirolimus ...... 30 ...... 69 SPIRIVA WITH SIROLIMUS (BULK) ...... 30 sodium nitroprusside ...... 81 HANDIHALER ...... 189 SIRTURO ...... 15 sodium phenylbutyrate ...... 105 spironolactone ...... 69 skin treatment ...... 85 SODIUM SPIRONOLACTONE (BULK) SKYLA...... 167 PHENYLBUTYRATE ...... 69 SKYRIZI ...... 82 (BULK) ...... 105 SPIRONOLACTONE MICRO SMART SENSE LANCETS sodium phosphate ...... 197 (BULK) ...... 69 ...... 133 SODIUM spironolacton-hydrochlorothiaz SMARTDIABETES PHOSPHATE,DIBASIC(B ...... 69 VANTAGE...... 133 ULK) ...... 151 sprintec (28) ...... 173 SMARTEST LANCET ...... 133 sodium polystyrene (sorb free) SPRYCEL ...... 31 smoothlax ...... 151 ...... 105 sps (with sorbitol) ...... 105 sodium acetate ...... 196 sodium polystyrene sulfonate SQUARIC ACID (BULK) . 105 SODIUM ACETATE (BULK) ...... 105 SQUARIC ACID ...... 196 SODIUM SALICYLATE DIBUTYLEST.(BULK) . 105 sodium benzoate-sod (BULK) ...... 52 SQUARIC ACID IN phenylacet...... 104 SODIUM TETRADECYL BUTANOL ...... 105 sodium bicarbonate ...... 197 SULF (BULK) ...... 105 sronyx ...... 173 sodium bicarbonate in d5w 196 sodium tetradecyl sulfate .... 105 ssd ...... 83

245 sss 10-5 ...... 87 sulfacetamide-prednisolone 180 SUREFLEX LANCING st joseph aspirin ...... 52 sulfacetamide-sulfur-cleansr23 DEVICE ...... 133 STAMARIL (PF) ...... 160 ...... 88 SURE-LANCE ...... 133 standard 1.4 ...... 210 sulfacleanse 8-4 ...... 88 SURE-LANCE ULTRA THIN STANOZOLOL (BULK) ... 141 sulfadiazine ...... 18 ...... 133 STANOZOLOL SULFADIAZINE (BULK) .. 18 SURE-PEN LANCING MICRONIZED (BULK) 141 SULFADIAZINE SODIUM DEVICE ...... 133 stavudine...... 7 (BULK) ...... 105 SURE-PREP ALCOHOL STEGLATRO...... 133 SULFAMERAZINE (BULK) PREP PADS ...... 133 STELARA ...... 82 ...... 18 SURESITE MATRIX ...... 133 STERILANCE TL...... 133 SULFAMETHOXAZOLE SURESITE WINDOW ...... 134 STIOLTO RESPIMAT ...... 189 (BULK) ...... 19 SURE-T INFUSION SET .. 134 STIVARGA ...... 31 sulfamethoxazole-trimethoprim SURE-T PARADIGM ...... 134 stop smoking aid...... 107 ...... 19 SURE-TOUCH LANCET .. 134 STRENSIQ ...... 141 SULFAMYLON ...... 91 surgifoam ...... 77 STREPTOMYCIN ...... 15 SULFANILAMIDE (BULK) SURGUARD2 SAFETY .... 134 STREPTOMYCIN SULFATE ...... 167 SUTENT ...... 31 (BULK) ...... 15 SULFAPYRIDINE (BULK) 19 syeda ...... 173 stress formula ...... 215 sulfasalazine ...... 151 SYLVANT ...... 31 stress formula 600 c...... 215 SULFASALAZINE (BULK) symax fastabs ...... 145 stress formula with iron ...... 215 ...... 151 symax-sl ...... 145 stress formula with iron(sulf) SULFATHIAZOLE (BULK) symax-sr ...... 145 ...... 215 ...... 167 SYMBICORT ...... 189 strong iodine ...... 91, 197 sulfatrim...... 19 SYMDEKO ...... 189 strontium-89 chloride ...... 31 SULFISOXAZOLE (BULK)19 SYMFI ...... 7 SUBLOCADE ...... 48 SULFUR SUBLIMED SYMFI LO ...... 7 subvenite...... 36 (BULK) ...... 83 SYMJEPI ...... 184 subvenite starter (blue) kit .... 36 sulindac ...... 52 SYMLINPEN 120 ...... 134 subvenite starter (green) kit .. 36 SULINDAC (BULK) ...... 52 SYMLINPEN 60 ...... 134 subvenite starter (orange) kit 37 sumatriptan ...... 39 SYMPROIC ...... 151 succinylcholine chloride ...... 43 SUMATRIPTAN (BULK) ... 39 SYMTUZA ...... 7 SUCCINYLCHOLINE CL sumatriptan succinate ...... 39 SYNAGIS ...... 7 (BULK) ...... 43 SUMATRIPTAN SYNAREL ...... 141 SUCRAID ...... 151 SUCCINATE (BULK) ..... 39 SYNERCID ...... 15 sucralfate ...... 153 sumatriptan-naproxen ...... 39 SYNJARDY ...... 134 SUCRALFATE (BULK).... 153 SUNOSI...... 60 SYNJARDY XR ...... 134 sufentanil citrate ...... 48 super b complex-vitamin c . 215 SYNRIBO ...... 31 SUFENTANIL CITRATE super b maxi complex...... 215 T (BULK) ...... 48 super quints...... 215 T SULFACETAMIDE (BULK) super quints b-50 ...... 215 30 INFUSION SET ...... 134 ...... 18 SUPER THIN LANCETS .. 133 90 INFUSION SET 23 ... 134 SULFACETAMIDE SOD, SURE COMFORT ALCOHOL 90 INFUSION SET 43 ... 134 MONO (BULK) ...... 180 PREP PADS ...... 133 FLEX ...... 134 sulfacetamide sodium ... 82, 180 SURE COMFORT LANCETS SLIM ...... 134 sulfacetamide sodium (acne) 91 ...... 133 SLIM G4 ...... 134 SULFACETAMIDE SODIUM SURE COMFORT LANCING SLIM INSULIN (BULK) ...... 180 PEN ...... 133 DELIVERY SYSTEM134 sulfacetamide sodium-sulfur 87, SUREFLEX DEVICE WITH SLIM X2 ...... 134 88 LANCETS ...... 133 tacrolimus ...... 31, 85

246 TACROLIMUS (BULK) ..... 85 telmisartan-hydrochlorothiazid theochron ...... 189 TACROLIMUS ...... 70 theophylline ...... 189 ANHYDROUS (BULK) .. 31 TEMIXYS ...... 7 THEOPHYLLINE (BULK)189 tadalafil ...... 192 TEMODAR ...... 31 theophylline in dextrose 5 % tadalafil (pulm. hypertension) temozolomide ...... 31 ...... 189 ...... 189 temsirolimus ...... 31 THIABENDAZOLE (BULK) TAFINLAR ...... 31 tencon ...... 48 ...... 15 TAGRISSO ...... 31 TENIPOSIDE ...... 31 thiamine hcl (vitamin b1) ... 216 TAKHZYRO ...... 189 tenofovir disoproxil fumarate . 7 THIN LANCETS ...... 135 TALICIA ...... 153 terazosin...... 70 THIOGUANINE (BULK) .... 31 TALTZ AUTOINJECTOR .. 83 TERBINAFINE (BULK) ...... 4 thioridazine ...... 61 TALTZ AUTOINJECTOR (2 terbinafine hcl ...... 4 THIORIDAZINE (BULK) ... 60 PACK) ...... 82 terbutaline ...... 189 thiotepa ...... 32 TALTZ AUTOINJECTOR (3 TERBUTALINE SULFATE THIOTEPA (BULK) ...... 32 PACK) ...... 83 (BULK) ...... 189 thiothixene ...... 61 TALTZ SYRINGE ...... 83 terconazole...... 167 THROMBATE III ...... 77 TALZENNA...... 31 terrell ...... 105 THYMOGLOBULIN ...... 160 tamoxifen ...... 31 testosterone ...... 142 THYMOL (BULK) ...... 106 TAMOXIFEN (BULK) ...... 31 TESTOSTERONE (BULK) THYROGEN ...... 106 tamsulosin...... 191 ...... 141 THYROID, PORK (BULK) TANNIC ACID (BULK) ..... 85 TESTOSTERONE CYP, ...... 143 TARGRETIN ...... 31 MICRO (BULK) ...... 141 tiadylt er ...... 70 tarina 24 fe ...... 173 testosterone cypionate ...... 141 tiagabine ...... 37 tarina fe 1/20 (28) ...... 173 TESTOSTERONE TIBSOVO ...... 32 tarina fe 1-20 eq (28) ...... 173 CYPIONATE (BULK) ... 141 TICE BCG ...... 160 taron-c dha ...... 215 testosterone enanthate...... 141 tigecycline ...... 15 taron-prex prenatal-dha ...... 215 TESTOSTERONE tilia fe ...... 173 TASIGNA ...... 31 ENANTHATE (BULK) . 141 timolol maleate ...... 70, 176 tavaborole ...... 92 TESTOSTERONE TIMOLOL MALEATE tazarotene ...... 88 MICRONIZED (BULK) 141 (BULK) ...... 70 tazicef ...... 10 TESTOSTERONE timolol maleate (pf) ...... 176 TAZORAC ...... 88 PROPIONATE (BULK). 142 tinidazole ...... 15 taztia xt ...... 69 TETANUS,DIPHTHERIA TINIDAZOLE (BULK) ...... 15 TDVAX ...... 160 TOX PED(PF) ...... 160 tis-u-sol pentalyte ...... 96 TECENTRIQ ...... 31 tetrabenazine ...... 41 TITANIUM DIOXIDE TECHLITE LANCETS ...... 134 TETRACAINE (BULK) ...... 90 (BULK) ...... 85 TEFLARO ...... 10 tetracaine hcl...... 178 TIVICAY ...... 7 TEGADERM ...... 135 TETRACAINE HCL (BULK) TIVICAY PD ...... 7 TEGADERM FIRST AID ...... 90 tizanidine ...... 43 STYLE ...... 135 tetracaine hcl (pf)...... 90 TIZANIDINE (BULK) ...... 43 TEGADERM FRAME STYLE tetracycline ...... 20 TOBI PODHALER ...... 15 ...... 135 TETRACYCLINE HCL TOBRADEX ...... 179 TEGADERM HP FRAME (BULK) ...... 20 TOBRADEX ST ...... 179 STYLE ...... 135 TETRAHYDROBIOPTERIN tobramycin ...... 16, 175 TEGSEDI ...... 41 DI-HCL ...... 142 TOBRAMYCIN (BULK) ..... 15 TEKTURNA HCT ...... 70 TETRAHYDROZOLINE HCL tobramycin in 0.225 % nacl .. 15 TELCARE LANCETS ...... 135 (BULK) ...... 181 tobramycin in 0.9 % nacl ...... 15 telmisartan ...... 70 THALOMID ...... 31 tobramycin sulfate ...... 16 telmisartan-amlodipine ...... 70 THEOBROMINE (BULK) 106

247 TOBRAMYCIN SULFATE TRELEGY ELLIPTA...... 189 tri-linyah ...... 173 (BULK) ...... 16 TREMFYA ...... 83 tri-lo-estarylla ...... 173 tobramycin-dexamethasone 180 treprostinil sodium ...... 70 tri-lo-mili ...... 173 TODAY CONTRACEPTIVE TRESIBA FLEXTOUCH U- tri-lo-sprintec ...... 174 SPONGE ...... 167 100 ...... 135 trilyte with flavor packets ... 151 TOLAZOLINE (BULK) ...... 70 TRESIBA FLEXTOUCH U- trimethobenzamide ...... 151 tolcapone ...... 38 200 ...... 135 TRIMETHOBENZAMIDE tolmetin...... 52 TRESIBA U-100 INSULIN (BULK) ...... 151 TOLNAFTATE (BULK) ..... 92 ...... 135 trimethoprim ...... 20 tolterodine...... 191 tretinoin ...... 88 TRIMETHOPRIM (BULK) . 20 tolvaptan ...... 142 tretinoin (antineoplastic)...... 32 TRIMETHOPRIM, MICRO TOPCARE UNIVERSAL1 TRETINOIN (BULK) ...... 88 (BULK) ...... 20 LANCET ...... 135 tretinoin microspheres ...... 88 tri-mili ...... 174 topiramate ...... 37 TRETTEN ...... 77 trimipramine ...... 61 TOPIRAMATE (BULK)...... 37 tri femynor ...... 173 TRIMO-SAN JELLY ...... 167 toposar ...... 32 TRIAMCIN DIACET, MICRO trinatal rx 1 ...... 216 topotecan ...... 32 (BULK) ...... 111 trinate ...... 216 toremifene...... 32 TRIAMCINOLONE (BULK) tri-nymyo ...... 174 torsemide ...... 70 ...... 111 TRIOXSALEN (BULK) .... 106 TOUJEO MAX U-300 triamcinolone acetonide ...... 95, TRIPELENNAMINE (BULK) SOLOSTAR ...... 135 108, 111 ...... 184 TOUJEO SOLOSTAR U-300 TRIAMCINOLONE tri-previfem (28) ...... 174 INSULIN ...... 135 ACETONIDE (BULK)..... 95 TRIPROLIDINE HCL tovet emollient ...... 95 TRIAMCINOLONE (BULK) ...... 184 TOVIAZ ...... 191 DIACETATE (BULK) ... 111 TRIPTODUR ...... 32 TPN ELECTROLYTES II . 197 triamterene ...... 70 tri-sprintec (28) ...... 174 TRACE ELEMENTS TRIAMTERENE (BULK) ... 70 TRIUMEQ ...... 7 4/PEDIATRIC ...... 197 triamterene-hydrochlorothiazid triveen-duo dha ...... 216 TRACLEER ...... 189 ...... 70 tri-vitamin with fluoride ..... 216 tramadol ...... 52 trianex ...... 95 tri-vite with fluoride ...... 216 TRAMADOL triazolam ...... 61 trivora (28) ...... 174 HYDROCHLORIDE tri-buffered aspirin ...... 52 tri-vylibra ...... 174 (BULK) ...... 52 tri-chlor ...... 85 tri-vylibra lo ...... 174 tramadol-acetaminophen ...... 52 TRICHLORMETHIAZIDE TROGARZO ...... 7 trandolapril ...... 70 (BULK) ...... 70 TROMETHAMINE (BULK) trandolapril-verapamil ...... 70 TRICHLOROACETIC ACID ...... 210 tranexamic acid ...... 77, 167 ...... 85 TROPHAMINE 10 % ...... 210 TRANEXAMIC ACID TRICHLOROACETIC ACID tropicamide ...... 176 (BULK) ...... 77 (BULK) ...... 85 TROPICAMIDE (BULK) .. 176 TRANSPARENT TRICITRASOL ...... 106 trospium ...... 191 DRESSINGS ...... 135 TRICLOSAN (BULK) ...... 91 TRUE COMFORT TRANSPARENT THIN FILM triderm ...... 95 ALCOHOL PADS ...... 135 DRESSING ...... 135 trientine ...... 106 TRUE COMFORT LANCET tranylcypromine ...... 61 tri-estarylla...... 173 ...... 135 travasol 10 % ...... 210 trifluoperazine ...... 61 TRUEDRAW LANCING travoprost ...... 179 TRIFLURIDINE (BULK) .. 176 DEVICE ...... 136 TRAZIMERA...... 32 trihexyphenidyl ...... 38 TRUEPLUS LANCETS ..... 136 trazodone ...... 61 TRIKAFTA ...... 190 TRULANCE ...... 151 TRAZODONE (BULK) ...... 61 tri-legest fe ...... 173 TRULICITY ...... 136

248 TRUSTEEL INFUSION SET UNILET EXCELITE II V 23 ...... 136 LANCET ...... 136 VAGINAL TRUSTEEL INFUSION SET UNILET EXCELITE CONTRACEPTIVE FILM 32 ...... 136 LANCET ...... 137 ...... 168 TRUVADA ...... 8 UNILET GP LANCET ...... 137 vaginal contraceptive foam . 168 TUBERSOL ...... 160 UNILET LANCET ...... 137 valacyclovir ...... 8 tulana ...... 166 UNILET LANCETS...... 137 VALACYCLOVIR (BULK) .. 8 TWINRIX (PF) ...... 160 UNILET SUPER THIN VALCHLOR ...... 85 TWIST LANCETS ...... 136 LANCETS ...... 137 valganciclovir ...... 8 TWOCAL HN ...... 210 UNISTIK 2 DEVICE ...... 137 valproate sodium ...... 37 tydemy ...... 174 UNISTIK 2 NORMAL VALPROATE SODIUM TYMLOS ...... 162 LANCET,DEVICE...... 137 (BULK) ...... 37 TYPHIM VI ...... 161 UNISTIK 3 ...... 137 valproic acid ...... 37 TYREX-1 ...... 210 UNISTIK 3 COMFORT valproic acid (as sodium salt) TYROS 1 ...... 210 DEVICE ...... 137 ...... 37 TYSABRI ...... 41 UNISTIK 3 COMFORT VALPROIC ACID (BULK) . 37 TYVASO ...... 190 LANCET ...... 137 valrubicin ...... 32 TYVASO INSTITUTIONAL UNISTIK 3 EXTRA LANCET valsartan ...... 71 START KIT...... 190 ...... 137 valsartan-hydrochlorothiazide TYVASO REFILL KIT ..... 190 UNISTIK 3 GENTLE ...... 137 ...... 71 TYVASO STARTER KIT . 190 UNISTIK 3 LANCETS ...... 137 vancomycin ...... 21 U UNISTIK 3 NEONATAL VANCOMYCIN (BULK) .... 20 UCERIS ...... 151 DEVICE ...... 137 VANCOMYCIN IN 0.9 % ULTI-LANCE ...... 136 UNISTIK 3 NORMAL SODIUM CHL ...... 20, 21 ULTILET ALCOHOL SWAB LANCET ...... 137 VANCOMYCIN IN ...... 136 UNISTIK CZT LANCET ... 137 DEXTROSE 5 % ...... 21 ULTILET BASIC LANCETS UNISTIK PRO LANCET .. 137 vandazole ...... 168 ...... 136 UNISTIK SAFETY ...... 137 VANTAS ...... 32 ULTILET CLASSIC UNISTIK TOUCH LANCETS vardenafil ...... 192 LANCETS ...... 136 ...... 137 VARISOFT INFUSION SET ULTILET LANCETS ...... 136 unithroid ...... 143 23 ...... 137 ULTILET SAFETY UNITUXIN ...... 32 VARISOFT INFUSION SET LANCETS ...... 136 UNIVERSAL 1 LANCETS 137 32 ...... 137 ULTRA THIN II LANCETS UPTRAVI ...... 70 VARISOFT INFUSION SET ...... 136 UREA (BULK)...... 85 43 ...... 137 ULTRA THIN LANCETS . 136 uretron d-s...... 192 VARIZIG ...... 161 ULTRA THIN PLUS urimar-t ...... 192 VARUBI ...... 151 LANCETS ...... 136 urin ds ...... 192 VASCEPA ...... 79 ULTRA TLC LANCETS ... 136 uro-458 ...... 192 VCF CONTRACEPTIVE GEL ULTRA-CARE LANCETS 136 urogesic-blue ...... 192 ...... 168 ULTRALANCE LANCETS uro-mp ...... 192 VECTIBIX ...... 32 ...... 136 ursodiol ...... 151 vecuronium bromide ...... 43 ULTRA-THIN II LANCETS URSODIOL (BULK) ...... 151 VELCADE ...... 32 ...... 136 uryl...... 192 veletri ...... 71 UNDECYLENIC ACID ustell ...... 192 velivet triphasic regimen (28) (BULK) ...... 92 utira-c...... 192 ...... 174 UNILET COMFORTOUCH UTI-STAT ...... 106 VELPHORO ...... 106 LANCET ...... 136 UVADEX ...... 85 VEMLIDY ...... 8 VENCLEXTA ...... 32

249 VENCLEXTA STARTING VIVAGUARD LANCET ... 138 women's laxative (bisacodyl) PACK ...... 32 VIVAGUARD LANCING ...... 151 venlafaxine ...... 61 DEVICE ...... 138 wymzya fe ...... 174 VENOFER ...... 216 VIVITROL ...... 53 X verapamil ...... 71 VIZIMPRO ...... 33 XALKORI ...... 33 VERAPAMIL (BULK) ...... 71 volnea (28) ...... 174 XARELTO ...... 77 veripred 20...... 111 VONVENDI ...... 77 XARELTO DVT-PE TREAT VERZENIO ...... 32 VORAXAZE ...... 22 30D START ...... 77 vestura (28) ...... 174 voriconazole ...... 4 XELJANZ ...... 164 V-GO 20 ...... 137 VORICONAZOLE (BULK) .. 4 XELJANZ XR ...... 164 V-GO 30 ...... 137 VORTEX ADULT MASK . 138 XEMBIFY ...... 161 V-GO 40 ...... 137 VORTEX HOLDING XERMELO ...... 33 VIBATIV ...... 21 CHAMBER ...... 138 XGEVA ...... 22 VIBERZI ...... 151 VORTEX VHC FROG XIAFLEX ...... 106 vicodin hp ...... 48 MASK-CHILD ...... 138 XIGDUO XR ...... 138 VIDARABINE (BULK) .... 176 VORTEX VHC LADYBUG XIIDRA ...... 178 VIDARABINE MASK-TODDLR ...... 138 XLEU ANALOG ...... 210 MONOHYDRATE (BULK) VOSEVI ...... 8 XLYS- XTRP ANALOG ... 210 ...... 176 VOTRIENT ...... 33 XMET ANALOG ...... 210 vienva ...... 174 vp-ch-pnv...... 216 XMTVI ANALOG ...... 211 vigabatrin ...... 37 vtol lq ...... 48 XOFIGO ...... 33 vigadrone ...... 37 VUMERITY ...... 41 XOLAIR ...... 190 VIMIZIM ...... 142 vyfemla (28) ...... 174 XOSPATA ...... 33 VIMPAT...... 37 vylibra ...... 174 XPHE, XTYR ANALOG ... 211 vinblastine ...... 32 VYNDAMAX ...... 81 XPTM ANALOG ...... 211 vincasar pfs ...... 32 VYNDAQEL ...... 81 XTANDI ...... 33 vincristine ...... 32 VYVANSE ...... 61 xulane ...... 168 vinorelbine ...... 32 VYXEOS ...... 33 XULTOPHY 100/3.6 ...... 138 VIOKACE ...... 151 W XURIDEN ...... 106 VIRACEPT ...... 8 warfarin ...... 77 xylocaine dental-epinephrine 90 VIREAD ...... 8 WARFARIN (BULK) ...... 77 XYLOMETAZOLINE virt-c dha ...... 216 water for inject, bacteriostat (BULK) ...... 108 virt-nate dha...... 216 ...... 106 XYREM ...... 61 virt-pn dha ...... 216 water for injection, sterile ... 106 XYWAV ...... 61 virt-pn plus ...... 216 water for irrigation, sterile .. 106 Y virtussin ac...... 184 WEBCOL ...... 138 YALE DISPOSABLE virtussin dac...... 184 wera (28)...... 174 NEEDLES ...... 138 VISTOGARD ...... 22 westab plus ...... 216 YERVOY ...... 33 VISUDYNE ...... 178 westgel dha ...... 216 YESCARTA ...... 33 VITAL HIGH NITROGEN 210 westhroid ...... 143 YF-VAX (PF) ...... 161 vitamin b complex ...... 216 WILATE ...... 77 YOHIMBINE HCL (BULK) vitamin b complex-folic acid wintergreen oil ...... 85 ...... 106 ...... 216 WITCH HAZEL EXTRACT YONDELIS ...... 33 vitamin k ...... 77 (BULK) ...... 85 YONSA ...... 33 vitamin k1 ...... 77 wixela inhub ...... 190 YUPELRI ...... 190 VITAMIN K1 ...... 77 woman's laxative (bisacodyl) yuvafem ...... 166 vitamins a,c,d and fluoride . 216 ...... 151 Z vitamins b complex ...... 216 women's gentle laxative(bisac) zafemy ...... 168 VITRAKVI...... 33 ...... 151 zafirlukast ...... 190

250 zaleplon ...... 61 ZEVALIN (Y-90) ...... 33 zoledronic acid ...... 142 ZALTRAP ...... 33 zidovudine ...... 8 zoledronic acid-mannitol-water ZANOSAR ...... 33 ZIEXTENZO ...... 156 ...... 106, 142 zarah ...... 174 zileuton ...... 190 ZOLINZA ...... 33 ZARXIO ...... 155 ZINC ACETATE zolmitriptan ...... 40 zatean-pn dha...... 216 DIHYDRATE (BULK) .. 197 zolpidem ...... 61 zatean-pn plus ...... 216 zinc chloride ...... 197 ZOMIG ...... 40 zebutal ...... 48 ZINC CHLORIDE (BULK) zonisamide ...... 37 ZEJULA ...... 33 ...... 197 ZORTRESS ...... 33 ZELBORAF ...... 33 ZINC OXIDE ...... 86 ZOSYN IN DEXTROSE (ISO- ZEMAIRA ...... 106 ZINC OXIDE (BULK) ...... 85 OSM) ...... 18 zenatane ...... 88 zinc sulfate ...... 197 zovia 1/35e (28) ...... 174 ZENPEP ...... 152 ZINC SULFATE (BULK) . 197 zovia 1-35 (28) ...... 174 zenzedi ...... 61 ZINC SULFATE ZTLIDO ...... 90 ZEPATIER ...... 8 HEPTAHYDRAT(BULK) ZUBSOLV ...... 53 ZEPOSIA ...... 41 ...... 106 ZULRESSO ...... 61 ZEPOSIA STARTER KIT ... 41 zingiber ...... 216 zumandimine (28) ...... 174 ZEPOSIA STARTER PACK ZIOPTAN (PF) ...... 179 ZYDELIG ...... 33 ...... 41 ziprasidone hcl ...... 61 ZYKADIA ...... 33 ZERBAXA ...... 10 ziprasidone mesylate ...... 61 ZYLET ...... 180 ZERVIATE ...... 178 ZOLADEX ...... 33 ZYTIGA ...... 33

251