CCA One Care Options Formulary

Commonwealth Care Alliance One Care Plan (Medicare-Medicaid Plan)

2021 List of Covered Drugs (Formulary)

30 Winter Street • Boston, MA 02108

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN For more recent information or other questions, contact Commonwealth Care Alliance Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. – 8 p.m., 7 days a week, or visit www.commonwealthonecare.org

H0137_CF2021 Approved Formulary: ID 00021588 • Version 13 • Updated on 08/01/2021 One Care Plan | 2021 List of Covered Drugs (Formulary)

Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs, over-the-counter drugs and items are covered by Commonwealth Care Alliance. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by One Care. Key terms and their definitions appear in the last chapter of the Member Handbook.

Table of Contents

A. Disclaimers ...... 4

B. Frequently Asked Questions (FAQ) ...... 5

What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) ...... 5

B2. Does the Drug List ever change? ...... 5

B3. What happens when there is a change to the Drug List? ...... 6

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? ...... 7

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? ...... 8

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ...... 8

B7. How can you find a drug on the Drug List? ...... 8

B8. What if the drug you want to take is not on the Drug List? ...... 9

B9. What if you are a new Commonwealth Care Alliance member and can’t find your drug on the Drug List or have a problem getting your drug? ...... 9

B10. Can you ask for an exception to cover your drug? ...... 10

B11. How can you ask for an exception? ...... 10

B12. How long does it take to get an exception? ...... 10

B13. What are generic drugs? ...... 11

B14. What are OTC drugs? ...... 11 If you have questions, please call Commonwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m – 8 p.m., 7 days a week. The call is free. For more information, visit ? www.commonwealthonecare.org 2 B15. Does Commonwealth Care Alliance cover OTC non-drug products? ...... 11

B16. Does Commonwealth Care Alliance cover long-term supplies of prescriptions? ... 11

B17. Can you get prescriptions delivered to your home from your local pharmacy? .... 11

B18. What is your copay? ...... 12

B19. What are drug tiers? ...... 12

C. List of Covered Drugs ...... 13

D. List of Drugs by Medical Condition ...... 16

E. Index of Covered Drugs ...... 141

This is a list of drugs that members can get in One Care.

• Commonwealth Care Alliance (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees.

• The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

• Benefits may change on January 1 of each year.

• You can always check Commonwealth Care Alliance’s up-to-date List of Covered Drugs online at www.commonwealthonecare.org or by calling 1-866-610-2273 (TTY: call MassRelay at 711).

• Limitations and restrictions may apply. For more information, call Commonwealth Care Alliance Member Services or read the Commonwealth Care Alliance Member Handbook.

• ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. – 8 p.m., 7 days a week. The call is free.

• ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-610-2273 (TTY: llamar a MassRelay al 711), 8 a.m. – 8 p.m., 7 días a la semana. Este es un servicio gratuito.

• You can get this document for free in other formats, such as large print, formats that work with screen reader technology, braille, or audio. Call 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. – 8 p.m., 7 days a week. The call is free.

• For purposes of future mailings, we will keep your request for alternative formats and/or special languages on file.

• Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

• Commonwealth Care Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

• Commonwealth Care Alliance cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

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

What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 15 are the drugs covered by Commonwealth Care Alliance’s One Care. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” • Commonwealth Care Alliance will cover all drugs on the Drug List if:

o your doctor or other prescriber says you need them to get better or stay healthy, o Commonwealth Care Alliance agrees that the drug is medically necessary for you, and o you fill the prescription at a Commonwealth Care Alliance network pharmacy. • In some cases, you have to do something before you can get a drug (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at commonwealthonecare.org or call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711).

B2. Does the Drug List ever change? Yes, and Commonwealth Care Alliance must follow Medicare and MassHealth rules when making changes.

We may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could: • Decide to require or not require prior approval for a drug. (Prior approval is permission from Commonwealth Care Alliance before you can get a drug.) • Add or change the amount of a drug you can get (called quantity limits). • Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or • we learn that drug is not safe, or • a drug is removed from the market.

Questions B3 and B6 below have more information on what happens when the Drug List changes. • You can always check Commonwealth Care Alliance’s up to date Drug List online at www.commonwealthonecare.org. • You can also call Member Services to check the current Drug List at 1-866-610- 2273 (TTY: call MassRelay at 711).

B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: • A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug, but there will still be no cost to you for the new drug.

• When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.

o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know.

o If you are notified that a drug you are taking is taken off the market follow one of the below steps. . Speak with you CCA care partner or . Immediately contact your prescriber to seek an alternative prescription.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: • The FDA provides new guidance or there are new clinical guidelines about a drug. • We add a generic drug and

o Replace a brand name drug currently on the Drug List or o Change the coverage rules or limits for the brand name drug.

When these changes happen, we will • Tell you at least 30 days before we make the change to the Drug List or • Let you know and give you a 31 day supply of the drug after you ask for a refill.

This will give you time to talk to your doctor or other prescriber. They can help you decide: • If there is a similar drug on the Drug List you can take instead or • Whether to ask for an exception from these changes. Please see question B10 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases, you or your doctor or other prescriber must do something before you can get the drug. For example: • Prior authorization (or prior approval): For some drugs, you or your doctor or other prescriber must get approval from Commonwealth Care Alliance before you fill your prescription. Commonwealth Care Alliance may not cover the drug if you do not get approval. • Quantity limits: Sometimes Commonwealth Care Alliance limits the amount of a drug you can get. • Step therapy: Sometimes Commonwealth Care Alliance requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

Effective January 1, 2020, Commonwealth Care Alliance will limit coverage of blood glucose meters and test strips to the following Abbott Diabetes Care products: • FreeStyle Lite® Meter • FreeStyle Freedom Lite® Meter • Freestyle Precision Xtra® Meter • Freestyle Precision Xtra® Blood Glucose Test Strips

• FreeStyle Lite® Blood Glucose Test Strips *compatible with either Lite Meter*

Effective January 17, 2020 CCA members will be able to obtain certain Continuous Glucose Monitoring (CGM) systems at network pharmacies with a valid prescription. CCA will cover the following CGM’s with an approved prior authorization. • Freestyle Libre® • Dexcom G6® You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 15. You can also get more information by visiting our website at www.commonwealthonecare.org. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. They can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10-B12 for more information about exceptions.

B5. How will you know if the drug you want has limits or if there are required actions to take to get the drug? The List of Covered Drugs on page 15 has a column labeled “Necessary actions, restrictions, or limits on use.”

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

B7. How can you find a drug on the Drug List? There are two ways to find a drug: • You can search alphabetically, or

• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 139. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 15. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711) and ask about it. If you learn that Commonwealth Care Alliance will not cover the drug, you can do one of these things: • Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. They can prescribe a drug on the Drug List that is like the one you want to take Or • You can ask the health plan to make an exception to cover your drug. Please see questions B10- B12 for more information about exceptions.

B9. What if you are a new Commonwealth Care Alliance member and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a member of Commonwealth Care Alliance. This will give you time to talk to your doctor or other prescriber. They can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 31 days of medication.

We will cover a 31-day supply of your drug if: • you are taking a drug that is not on our Drug List, or • health plan rules do not let you get the amount ordered by your prescriber, or • the drug requires prior approval by Commonwealth Care Alliance, or • you are taking a drug that is part of a step therapy restriction.

If you are taking a drug that Commonwealth Care Alliance does not consider to be a Part D drug, you have the right to get a one-time, 72-hour supply of the drug. You can find more information about getting a temporary supply of a drug in Chapter 5 of your Member Handbook.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away: • We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Commonwealth Care Alliance member. • This is in addition to the temporary supply during the first 90 days you are a member of Commonwealth Care Alliance

For current enrollees with level-of-care changes, we will provide an emergency supply of at least 31 days (unless the prescription is written for fewer days) for all non-formulary medications including those that may have step therapy or prior authorization requirements. An unplanned level of care transition could be any of the following: • a discharge or admission to a Long Term Care facility • a discharge or admission to a hospital, or • a nursing facility skilled level change

B10. Can you ask for an exception to cover your drug? Yes. You can ask Commonwealth Care Alliance to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. • For example, Commonwealth Care Alliance may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. • Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements.

B11. How can you ask for an exception? To ask for an exception, call your Care Partner or Member Services. Your Care Partner or a Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9, of the Member Handbook to learn more about exceptions.

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

will give you a decision within 24 hours of getting your prescriber’s supporting statement.

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

Commonwealth Care Alliance covers both brand name drugs and generic drugs.

B14. What are OTC drugs? OTC stands for “over-the-counter”. Commonwealth Care Alliance covers some OTC drugs when they are written as prescriptions by your provider. You can read the Commonwealth Care Alliance Drug List to see what OTC drugs are covered.

B15. Does Commonwealth Care Alliance cover non-drug OTC products? Commonwealth Care Alliance covers some non-drug OTC products when they are written as prescriptions by your provider. Examples of non-drug OTC products include diabetic supplies.

You can read the Commonwealth Care Alliance Drug List to see what non-drug OTC products are covered.

B16. Does Commonwealth Care Alliance cover long-term supplies of prescriptions? • Mail-Order Programs. We offer a mail-order program that allows you to get up to a 90- day supply of your prescription drugs sent directly to your home. Maintenance drugs are prescription drugs that you use on an ongoing basis, for a chronic or long term medical condition. There is no copay for mail order drugs.

• 90-Day Retail Pharmacy Programs. Some retail pharmacies may also offer up to a 90- day supply of covered prescription drugs. A 90-day supply has the same copay as a one-month supply.

B17. Can you get prescriptions delivered to your home from your local pharmacy? Your local pharmacy may be able to deliver your prescription to your home. You can call your pharmacy to find out if they offer home delivery.

If you have questions, please call Commonwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m – 8 p.m., 7 days a week. The call is free. For more information, visit ? www.commonwealthonecare.org 11 B18. What is your copay? Commonwealth Care Alliance’s members have no copays for prescription and OTC drugs as long as the member follows the plan’s rules.

B19. What are drug tiers? Tiers are groups of drugs on our Drug List. Every drug on the plan’s Drug List is one of five tiers. • Tier 1 drugs are Preferred Generic

• Tier 2 drugs are Generic

• Tier 3 drugs are Preferred Brand/Specialty

• Tier 4 drugs are Non-Preferred Brands

• Tier 5 drugs are Non-Medicare Rx/OTC

All five tiers consist of both part D drugs and non-Medicare covered drugs, and /or non- Medicare covered OTC drugs.

All tiers have no copay. As a member of our plan, you pay nothing for all covered drugs no matter what tier they are in.

C. List of Covered Drugs The following list of covered drugs gives you information about the drugs covered by Commonwealth Care Alliance. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 139. The index alphabetically lists all drugs covered by Commonwealth Care Alliance.

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

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

Note: The DP next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). • In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box

Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

• These drugs have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or MassHealth.

• If you or your doctor disagrees with our decision, you can appeal.

• If you ever have a question, call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711). You can also read Chapter 9 of the Member Handbook to learn how to appeal a decision.

List of Abbreviations

Dual Demonstration Plan (DP): This item is covered under your MassHealth benefits. The DP next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug you want is not covered or is no longer covered by Medicare or MassHealth. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services. You can also read the Member Handbook to learn how to appeal a decision.

Limited Distribution (LD): Limited Availability. The symbol [LD] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs.

Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary via retail or mail order. Drugs noted with “NDS” are limited to a 1-month supply for both Retail and Mail Order

Prior Authorization (PA): Commonwealth Care Alliance (CCA) requires a provider to submit a request for coverage based on a member’s medical need for a particular drug. This means that you will need to get approval from CCA before you fill your prescription(s). If you don’t get approval, CCA may not cover the drug.

Prior Authorization Restriction for Part B vs Part D Determination (B/D): This drug may be eligible for payment under Medicare Part B or Medicare Part D. You [or your physician] are required to get prior authorization from Commonwealth Care Alliance (CCA) to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CCA may not cover this drug.

Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, you [or your physician] are required to get prior authorization from CCA before you fill your prescription for this drug. Without prior approval, CCA may not cover this drug.

Quantity Limits (QL): For certain drugs, Commonwealth Care Alliance (CCA) limits the amount of the drug that it will cover due to potential safety and utilization concerns. Due to these concerns, CCA has placed dispensing limits on some drugs. This means that only a certain quantity of drug can be dispensed by the pharmacy within a given time period. This could include a: per fill, daily, monthly, or yearly limitation. These quantities are based on standards of care from organizations such as the Food and Drug Administration.

Step Therapy (ST): In some cases, Commonwealth Care Alliance (CCA) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if

If you have questions, please call Commonwealth Care Alliance at 1-866-610-2273 (TTY: call ? MassRelay at 711), 8 a.m-8 p.m., 7 days a week. The call is free. For more information, visit commonwealthonecare.org. 14

Drug A and Drug B both treat your medical condition, CCA may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCA will then cover Drug B.

Step Therapy for New Starts Only (ST_NSO): If a drug is new to the member, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

List of Drugs by Medical Condition

The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, "Cardiovascular Agents". That is where you will find drugs that treat heart conditions. Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to treat ADHD, sleep disorders, and weight loss AMPHETAMINES - Drugs to treat ADHD, sleep disorders, and weight loss amphetamine-dextroamphetamine 10mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 10mg tab $0 (Tier 2) amphetamine-dextroamphetamine 12.5mg tab $0 (Tier 2) amphetamine-dextroamphetamine 15mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 15mg tab $0 (Tier 2) amphetamine-dextroamphetamine 20mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 20mg tab $0 (Tier 2) amphetamine-dextroamphetamine 25mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 30mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 30mg tab $0 (Tier 2) amphetamine-dextroamphetamine 5mg ER cap $0 (Tier 2) amphetamine-dextroamphetamine 5mg tab $0 (Tier 2) amphetamine-dextroamphetamine 7.5mg tab $0 (Tier 2) dextroamphetamine sulfate 10mg er cap $0 (Tier 2) dextroamphetamine sulfate 10mg tab $0 (Tier 2) dextroamphetamine sulfate 15mg er cap $0 (Tier 2) dextroamphetamine sulfate 1mg/ml oral soln $0 (Tier 2) dextroamphetamine sulfate 5mg er cap $0 (Tier 2) dextroamphetamine sulfate 5mg tab $0 (Tier 2) procentra 5mg/5ml oral soln $0 (Tier 2) ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS - Drugs to treat ADHD and sleep disorders atomoxetine 100mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 10mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 18mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 25mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 40mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 60mg cap $0 (Tier 2) QL=60 EA/30 Days atomoxetine 80mg cap $0 (Tier 2) QL=60 EA/30 Days clonidine 0.1mg er tab $0 (Tier 2) guanfacine 1mg er tab $0 (Tier 1) guanfacine 2mg er tab $0 (Tier 1) guanfacine 3mg er tab $0 (Tier 1) guanfacine 4mg er tab $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 16 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS) - drugs to treat sleep disorders SUNOSI 150MG TAB $0 (Tier 3) PA QL=30 EA/30 Days SUNOSI 75MG TAB $0 (Tier 3) PA QL=30 EA/30 Days HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS - drugs to treat sleep disorders WAKIX 17.8MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days WAKIX 4.45MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days STIMULANTS - MISC. - Miscellaneous stimulant drugs armodafinil 150mg tab $0 (Tier 2) PA QL=30 EA/30 Days armodafinil 200mg tab $0 (Tier 2) PA QL=30 EA/30 Days armodafinil 250mg tab $0 (Tier 2) PA QL=30 EA/30 Days armodafinil 50mg tab $0 (Tier 2) PA QL=30 EA/30 Days dexmethylphenidate 10mg er cap $0 (Tier 2) dexmethylphenidate 10mg tab $0 (Tier 2) dexmethylphenidate 15mg er cap $0 (Tier 2) dexmethylphenidate 2.5mg tab $0 (Tier 2) dexmethylphenidate 20mg er cap $0 (Tier 2) dexmethylphenidate 25mg er cap $0 (Tier 2) dexmethylphenidate 30mg er cap $0 (Tier 2) dexmethylphenidate 35mg er cap $0 (Tier 2) dexmethylphenidate 40mg er cap $0 (Tier 2) dexmethylphenidate 5mg er cap $0 (Tier 2) dexmethylphenidate 5mg tab $0 (Tier 2) methylphenidate 10mg chew tab $0 (Tier 2) methylphenidate 10mg cr cap $0 (Tier 2) methylphenidate 10mg er tab $0 (Tier 2) methylphenidate 10mg la cap $0 (Tier 2) methylphenidate 10mg tab $0 (Tier 2) METHYLPHENIDATE 18MG ER TAB $0 (Tier 3) methylphenidate 18mg er tab $0 (Tier 2) methylphenidate 1mg/ml oral soln $0 (Tier 2) methylphenidate 2.5mg chew tab $0 (Tier 2) methylphenidate 20mg cr cap $0 (Tier 2) methylphenidate 20mg er tab $0 (Tier 2) methylphenidate 20mg la cap $0 (Tier 2) methylphenidate 20mg tab $0 (Tier 2) methylphenidate 27mg sr tab $0 (Tier 2) methylphenidate 2mg/ml oral soln $0 (Tier 2) methylphenidate 30mg cr cap $0 (Tier 2) methylphenidate 30mg la cap $0 (Tier 2) methylphenidate 36mg sr tab $0 (Tier 2) methylphenidate 40mg cr cap $0 (Tier 2) methylphenidate 40mg la cap $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 17 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) methylphenidate 50mg cr cap $0 (Tier 2) methylphenidate 54mg sr tab $0 (Tier 2) methylphenidate 5mg chew tab $0 (Tier 2) methylphenidate 5mg tab $0 (Tier 2) methylphenidate 60mg cr cap $0 (Tier 2) methylphenidate 60mg la cap $0 (Tier 2) modafinil 100mg tab $0 (Tier 2) PA QL=60 EA/30 Days modafinil 200mg tab $0 (Tier 2) PA QL=60 EA/30 Days ALTERNATIVE MEDICINES - Miscellaneous alternatives to conventional medicine ALTERNATIVE MEDICINE - A'S - Miscellaneous alternatives to conventional medicine alpha-lipoic acid (thioctic acid) cap 600 mg $0 (Tier 5) ALTERNATIVE MEDICINE - C'S - Miscellaneous alternatives to conventional medicine COENZYME Q-10 ER CAP 100MG $0 (Tier 5) coenzyme Q10 10mg cap $0 (Tier 5) coenzyme Q10 150mg cap $0 (Tier 5) coenzyme Q10 30mg cap $0 (Tier 5) coenzyme Q10 50mg cap $0 (Tier 5) coenzyme Q10 60mg cap $0 (Tier 5) coenzyme Q10 cap 100mg $0 (Tier 5) coenzyme q10 cap 200 mg $0 (Tier 5) coenzyme Q10 cap 75mg $0 (Tier 5) COENZYME Q10 CHEW TAB 100MG $0 (Tier 5) COENZYME Q10 CHEW TAB 30MG $0 (Tier 5) COENZYME Q10 CHEW TAB 600MG $0 (Tier 5) COENZYME Q10 TAB 100MG $0 (Tier 5) COENZYME Q10 TAB 50MG $0 (Tier 5) LIQSORB LIQUID 100MG/ML $0 (Tier 5) ALTERNATIVE MEDICINE - M'S - Miscellaneous alternatives to conventional medicine melatonin 300mcg tab $0 (Tier 5) melatonin 3mg tab $0 (Tier 5) melatonin 5mg odt $0 (Tier 5) melatonin chew tab 2.5 mg $0 (Tier 5) melatonin liquid $0 (Tier 5) MELATONIN LIQUID 1MG/4ML $0 (Tier 5) melatonin tab 1 mg $0 (Tier 5) melatonin tab 5 mg $0 (Tier 5) ALTERNATIVE MEDICINE - U - Miscellaneous alternatives to conventional medicine ubiquinol cap 100 mg $0 (Tier 5) UBIQUINONE CAP 75 MG $0 (Tier 5) ALTERNATIVE MEDICINE COMBINATIONS - Miscellaneous alternatives to conventional medicine melatonin/pyridoxine 5-10mg tab $0 (Tier 5) MELATONIN/PYRIDOXINE TAB 1-10MG $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 18 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) MELATONIN/PYRIDOXINE TAB 3-10MG $0 (Tier 5) NIACIN-PANTETHINE TAB ER 500-200 MG $0 (Tier 5) AMINOGLYCOSIDES - Drugs to treat bacterial infections AMINOGLYCOSIDES - Drugs to treat infections amikacin 250mg/ml inj $0 (Tier 2) GENTAMICIN 0.8MG/ML INJ $0 (Tier 2) gentamicin 1.2mg/ml inj $0 (Tier 2) GENTAMICIN 1.6MG/ML INJ $0 (Tier 2) GENTAMICIN 1MG/ML INJ $0 (Tier 2) gentamicin 40mg/ml inj $0 (Tier 2) neomycin sulfate 500mg tab $0 (Tier 1) paromomycin 250mg cap $0 (Tier 4) STREPTOMYCIN 1000MG INJ $0 (Tier 4) TOBRAMYCIN 10MG/ML INJ $0 (Tier 2) tobramycin 40mg/ml inj $0 (Tier 2) tobramycin 60mg/ml inh soln $0 (Tier 4) NDS PA QL=300 ML/30 Days ANALGESICS - ANTI-INFLAMMATORY - Drugs to treat pain and inflammation ANTIRHEUMATIC - ENZYME INHIBITORS - Drugs to treat disorders of the immune system OLUMIANT 1MG TAB $0 (Tier 3) PA QL=30 EA/30 Days OLUMIANT 2MG TAB $0 (Tier 3) PA QL=30 EA/30 Days RINVOQ 15MG ER TAB $0 (Tier 3) PA QL=30 EA/30 Days XELJANZ 10MG TAB $0 (Tier 3) PA QL=60 EA/30 Days XELJANZ 11MG ER TAB $0 (Tier 3) PA QL=30 EA/30 Days XELJANZ 1MG/ML ORAL SOLN $0 (Tier 3) PA XELJANZ 22MG ER TAB $0 (Tier 3) PA QL=30 EA/30 Days XELJANZ 5MG TAB $0 (Tier 3) PA QL=60 EA/30 Days ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES - Drugs to treat disorders of the immune system HUMIRA 10MG/0.1ML SYRINGE $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 20MG/0.2ML SYRINGE $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 40MG/0.4ML AUTO-INJECTOR $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 40MG/0.4ML SYRINGE $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 40MG/0.8ML AUTO-INJECTOR $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 40MG/0.8ML SYRINGE $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA 80MG/0.8ML AUTO-INJECTOR $0 (Tier 3) PA QL=6 EA/28 Days HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) $0 (Tier 3) PA 80MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER PACK $0 (Tier 3) PA SYRINGE (2) 40MG/0.4ML HUMIRA PEN - CROHN'S STARTER PACK $0 (Tier 3) NDS PA 40MG/0.8ML INJ HUMIRA PEN - CROHN'S STARTER PACK $0 (Tier 3) NDS PA QL=6 EA/28 Days 80MG/0.8ML INJ

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 19 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) HUMIRA PEN - PEDIATRIC UC STARTER PACK $0 (Tier 3) PA QL=6 EA/28 Days 80MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER PACK $0 (Tier 3) NDS PA 40MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER PACK $0 (Tier 3) PA 80MG/0.8ML INJ SIMPONI 100MG/ML AUTO-INJECTOR $0 (Tier 3) PA SIMPONI 100MG/ML SYRINGE $0 (Tier 3) PA SIMPONI 50MG/0.5ML AUTO-INJECTOR $0 (Tier 3) PA SIMPONI 50MG/0.5ML SYRINGE $0 (Tier 3) PA GOLD COMPOUNDS - Drugs to treat disorders of the immune system RIDAURA 3MG CAP $0 (Tier 3) INTERLEUKIN-1 BLOCKERS - Drugs to treat disorders of the immune system ARCALYST 220MG INJ $0 (Tier 4) NDS PA INTERLEUKIN-6 RECEPTOR INHIBITORS - Drugs to treat rheumatoid arthritis ACTEMRA 162MG/0.9ML AUTO-INJECTOR $0 (Tier 3) PA QL=3.60 ML/28 Days ACTEMRA 162MG/0.9ML SYRINGE $0 (Tier 3) PA QL=3.60 ML/28 Days KEVZARA 150MG/1.14ML AUTO-INJECTOR $0 (Tier 3) PA KEVZARA 150MG/1.14ML SYRINGE $0 (Tier 3) PA KEVZARA 200MG/1.14ML AUTO-INJECTOR $0 (Tier 3) PA KEVZARA 200MG/1.14ML SYRINGE $0 (Tier 3) PA NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) - Drugs to treat pain and inflammation celecoxib 100mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 200mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 400mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 50mg cap $0 (Tier 1) QL=60 EA/30 Days diclofenac potassium 50mg tab $0 (Tier 2) diclofenac sodium 100mg er tab $0 (Tier 2) diclofenac sodium 25mg dr tab $0 (Tier 2) diclofenac sodium 50mg dr tab $0 (Tier 2) diclofenac sodium 50mg/misoprostol 0.2mg dr tab $0 (Tier 2) diclofenac sodium 75mg dr tab $0 (Tier 2) diclofenac sodium 75mg/misoprostol 0.2mg dr tab $0 (Tier 2) etodolac 200mg cap $0 (Tier 2) etodolac 300mg cap $0 (Tier 2) etodolac 400mg er tab $0 (Tier 2) etodolac 400mg tab $0 (Tier 2) etodolac 500mg er tab $0 (Tier 2) etodolac 500mg tab $0 (Tier 2) etodolac 600mg er tab $0 (Tier 2) flurbiprofen 100mg tab $0 (Tier 1) ibu 600mg tab $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 20 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ibu 800mg tab $0 (Tier 1) ibuprofen 20mg/ml susp $0 (Tier 2) ibuprofen 400mg tab $0 (Tier 1) ibuprofen 600mg tab $0 (Tier 1) ibuprofen 800mg tab $0 (Tier 1) ibuprofen cap 200mg $0 (Tier 5) ibuprofen chew tab 100mg $0 (Tier 5) ibuprofen susp 20mg/ml $0 (Tier 5) ibuprofen susp 40mg/ml $0 (Tier 5) ibuprofen tab 200mg $0 (Tier 5) meloxicam 15mg tab $0 (Tier 1) meloxicam 7.5mg tab $0 (Tier 1) nabumetone 500mg tab $0 (Tier 2) nabumetone 750mg tab $0 (Tier 2) naproxen 250mg tab $0 (Tier 1) naproxen 375mg dr tab $0 (Tier 1) naproxen 375mg tab $0 (Tier 1) naproxen 500mg dr tab $0 (Tier 1) naproxen 500mg tab $0 (Tier 1) naproxen sodium 275mg tab $0 (Tier 2) naproxen sodium 550mg tab $0 (Tier 2) naproxen sodium cap 220mg $0 (Tier 5) naproxen sodium tab 220mg $0 (Tier 5) oxaprozin 600mg tab $0 (Tier 2) piroxicam 10mg cap $0 (Tier 2) piroxicam 20mg cap $0 (Tier 2) sulindac 150mg tab $0 (Tier 1) sulindac 200mg tab $0 (Tier 1) PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - Drugs to treat disorders of the immune system OTEZLA 28-DAY STARTER PACK $0 (Tier 3) PA OTEZLA 30MG TAB $0 (Tier 3) PA PYRIMIDINE SYNTHESIS INHIBITORS - Drugs to treat disorders of the immune system leflunomide 10mg tab $0 (Tier 2) leflunomide 20mg tab $0 (Tier 2) SELECTIVE COSTIMULATION MODULATORS - Drugs to treat disorders of the immune system ORENCIA 125MG/ML AUTO-INJECTOR $0 (Tier 3) PA QL=4 ML/28 Days ORENCIA 125MG/ML SYRINGE $0 (Tier 3) PA QL=4 ML/28 Days ORENCIA 50MG/0.4ML SYRINGE $0 (Tier 3) PA QL=1.60 ML/28 Days ORENCIA 87.5MG/0.7ML SYRINGE $0 (Tier 3) PA QL=2.80 ML/28 Days SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS - Drugs to treat disorders of the immune system ENBREL 25MG INJ $0 (Tier 3) PA QL=8 EA/28 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 21 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ENBREL 25MG/0.5ML INJ $0 (Tier 3) PA QL=8 ML/28 Days ENBREL 25MG/0.5ML SYRINGE $0 (Tier 3) PA QL=8 ML/28 Days ENBREL 50MG/ML AUTO-INJECTOR $0 (Tier 3) PA QL=8 ML/28 Days ENBREL 50MG/ML CARTRIDGE $0 (Tier 3) PA QL=8 ML/28 Days ENBREL 50MG/ML SYRINGE $0 (Tier 3) PA QL=8 ML/28 Days ANALGESICS - NONNARCOTIC - Drugs to treat pain ANALGESIC COMBINATIONS - Drugs to treat pain ACETAMINOPHEN W/ PAMABROM TAB 325-25 MG $0 (Tier 5) ACETAMINOPHEN-MAGNESIUM $0 (Tier 5) SALICYLATE-CAFF TAB 250-290-50 MG acetaminophen-pamabrom-pyrilamine tab 500-25-15 $0 (Tier 5) mg ASPIRIN-ACETAMINOPHEN-CAFFEINE POWD $0 (Tier 5) PACK 500-325-65 MG ASPIRIN-ACETAMINOPHEN-CAFFEINE POWD $0 (Tier 5) PACK 520-260-32.5 MG ASPIRIN-APAP-SALICYLAMIDE-CAFFEINE TAB $0 (Tier 5) 162-110-152-32.4 MG ASPIRIN-CAFFEINE POWDER PACKET 1000-65 MG $0 (Tier 5) ASPIRIN-CAFFEINE POWDER PACKET 845-65 MG $0 (Tier 5) ASPIRIN-CAFFEINE TAB 400-32 MG $0 (Tier 5) aspirin/acetaminophen/caffeine tab 250-250-65mg $0 (Tier 5) ANALGESICS OTHER - Drugs to treat pain acetaminophen cap 500mg $0 (Tier 5) acetaminophen chew tab 160mg $0 (Tier 5) acetaminophen CR tab 650mg $0 (Tier 5) acetaminophen disintegrating tab 80 mg $0 (Tier 5) acetaminophen dispersible tab 160mg $0 (Tier 5) acetaminophen dispersible tab 80mg $0 (Tier 5) acetaminophen elixir 160 mg/5ml $0 (Tier 5) acetaminophen liquid 160mg/5ml $0 (Tier 5) acetaminophen liquid 167 mg/5ml $0 (Tier 5) acetaminophen soln 160mg/5ml $0 (Tier 5) acetaminophen suppos 120 mg $0 (Tier 5) ACETAMINOPHEN SUPPOS 325 MG $0 (Tier 5) acetaminophen suppos 650 mg $0 (Tier 5) ACETAMINOPHEN SUPPOS 80 MG $0 (Tier 5) acetaminophen susp 160mg/5ml $0 (Tier 5) ACETAMINOPHEN SUSP 80 MG/0.8ML $0 (Tier 5) acetaminophen susp 80 mg/0.8ml $0 (Tier 5) acetaminophen tab 325 mg $0 (Tier 5) acetaminophen tab 500mg $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 22 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) SALICYLATES - Drugs to treat pain ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) $0 (Tier 5) TAB 325 MG aspirin buffered tab 325mg $0 (Tier 5) aspirin chew tab 81mg $0 (Tier 5) aspirin effervescent tab $0 (Tier 5) ASPIRIN SUPP 300MG $0 (Tier 5) ASPIRIN SUPP 600MG $0 (Tier 5) aspirin tab 325mg $0 (Tier 5) ASPIRIN TAB DELAYED RELEASE 325 MG $0 (Tier 5) aspirin tab delayed release 325 mg $0 (Tier 5) aspirin tab delayed release 500 mg $0 (Tier 5) aspirin tab delayed release 81 mg $0 (Tier 5) diflunisal 500mg tab $0 (Tier 2) ANALGESICS - OPIOID - Drugs to treat pain OPIOID AGONISTS - Drugs to treat pain CODEINE SULFATE 15MG TAB $0 (Tier 3) QL=240 EA/30 Days codeine sulfate 30mg tab $0 (Tier 2) QL=240 EA/30 Days codeine sulfate 60mg tab $0 (Tier 2) QL=180 EA/30 Days fentanyl 0.012mg/hr patch $0 (Tier 2) QL=10 EA/30 Days fentanyl 0.025mg/hr patch $0 (Tier 2) QL=10 EA/30 Days fentanyl 0.05mg/hr patch $0 (Tier 2) QL=10 EA/30 Days fentanyl 0.075mg/hr patch $0 (Tier 2) QL=10 EA/30 Days fentanyl 0.1mg/hr patch $0 (Tier 2) QL=10 EA/30 Days fentanyl 0.2mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days fentanyl 0.4mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days fentanyl 0.6mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days fentanyl 0.8mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days fentanyl 1.2mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days fentanyl 1.6mg lozenge $0 (Tier 2) PA QL=120 EA/30 Days hydromorphone 10mg/ml (1ml) inj $0 (Tier 2) hydromorphone 10mg/ml (5ml) inj $0 (Tier 2) hydromorphone 1mg/ml oral soln $0 (Tier 2) QL=2400 ML/30 Days hydromorphone 2mg tab $0 (Tier 2) QL=450 EA/30 Days hydromorphone 4mg tab $0 (Tier 2) QL=240 EA/30 Days hydromorphone 8mg tab $0 (Tier 2) QL=120 EA/30 Days methadone 10mg tab $0 (Tier 2) QL=360 EA/30 Days methadone 5mg tab $0 (Tier 2) QL=360 EA/30 Days morphine sulfate 100mg er tab $0 (Tier 2) QL=120 EA/30 Days morphine sulfate 15mg er tab $0 (Tier 2) QL=120 EA/30 Days morphine sulfate 15mg tab $0 (Tier 2) QL=180 EA/30 Days morphine sulfate 200mg er tab $0 (Tier 2) QL=120 EA/30 Days morphine sulfate 20mg/ml oral soln $0 (Tier 2) QL=180 ML/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 23 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) morphine sulfate 2mg/ml oral soln $0 (Tier 2) QL=1800 ML/30 Days morphine sulfate 30mg er tab $0 (Tier 2) QL=120 EA/30 Days morphine sulfate 30mg tab $0 (Tier 2) QL=180 EA/30 Days morphine sulfate 4mg/ml oral soln $0 (Tier 2) QL=900 ML/30 Days morphine sulfate 60mg er tab $0 (Tier 2) QL=120 EA/30 Days oxycodone 10mg tab $0 (Tier 2) QL=180 EA/30 Days oxycodone 15mg tab $0 (Tier 2) QL=180 EA/30 Days oxycodone 1mg/ml oral soln $0 (Tier 2) QL=5400 ML/30 Days oxycodone 20mg tab $0 (Tier 2) QL=180 EA/30 Days oxycodone 20mg/ml oral soln $0 (Tier 2) QL=270 ML/30 Days oxycodone 30mg tab $0 (Tier 2) QL=180 EA/30 Days oxycodone 5mg cap $0 (Tier 2) QL=360 EA/30 Days oxycodone 5mg tab $0 (Tier 2) QL=360 EA/30 Days OXYCONTIN 10MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 15MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 20MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 30MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 40MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 60MG ER TAB $0 (Tier 3) QL=60 EA/30 Days OXYCONTIN 80MG ER TAB $0 (Tier 3) QL=120 EA/30 Days oxymorphone 10mg tab $0 (Tier 2) QL=360 EA/30 Days oxymorphone 5mg tab $0 (Tier 2) QL=360 EA/30 Days tramadol 100mg er tab $0 (Tier 2) QL=60 EA/30 Days tramadol 100mg er tab (matrix delivery) $0 (Tier 2) QL=60 EA/30 Days tramadol 200mg er tab $0 (Tier 2) QL=60 EA/30 Days tramadol 200mg er tab (matrix delivery) $0 (Tier 2) QL=60 EA/30 Days tramadol 300mg er tab $0 (Tier 2) QL=60 EA/30 Days tramadol 300mg er tab (matrix delivery) $0 (Tier 2) QL=60 EA/30 Days tramadol 50mg tab $0 (Tier 2) QL=240 EA/30 Days OPIOID COMBINATIONS - Drugs to treat pain acetaminophen 21.7mg/ml/hydrocodone bitartrate $0 (Tier 2) QL=5400 ML/30 Days 0.5mg/ml oral soln acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml $0 (Tier 2) QL=4980 ML/30 Days oral soln acetaminophen 300mg/codeine phosphate 15mg tab $0 (Tier 2) QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 30mg tab $0 (Tier 2) QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 60mg tab $0 (Tier 2) QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 10mg $0 (Tier 2) QL=390 EA/30 Days tab acetaminophen 300mg/hydrocodone bitartrate 5mg $0 (Tier 2) QL=390 EA/30 Days tab acetaminophen 300mg/hydrocodone bitartrate 7.5mg $0 (Tier 2) QL=390 EA/30 Days tab You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 24 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) acetaminophen 325mg/hydrocodone bitartrate 10mg $0 (Tier 2) QL=360 EA/30 Days tab acetaminophen 325mg/hydrocodone bitartrate 5mg $0 (Tier 2) QL=360 EA/30 Days tab acetaminophen 325mg/hydrocodone bitartrate 7.5mg $0 (Tier 2) QL=360 EA/30 Days tab acetaminophen 325mg/oxycodone 10mg tab $0 (Tier 2) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 2.5mg tab $0 (Tier 2) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 5mg tab $0 (Tier 2) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 7.5mg tab $0 (Tier 2) QL=360 EA/30 Days acetaminophen 325mg/tramadol 37.5mg tab $0 (Tier 2) QL=360 EA/30 Days ASPIRIN 325MG/OXYCODONE 4.84MG TAB $0 (Tier 2) QL=360 EA/30 Days endocet 325-10mg tab $0 (Tier 2) QL=360 EA/30 Days endocet 325-5mg tab $0 (Tier 2) QL=360 EA/30 Days endocet 325-7.5mg tab $0 (Tier 2) QL=360 EA/30 Days hydrocodone bitartrate 10mg/ibuprofen 200mg tab $0 (Tier 2) QL=480 EA/30 Days hydrocodone bitartrate 5mg/ibuprofen 200mg tab $0 (Tier 2) QL=480 EA/30 Days hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab $0 (Tier 2) QL=480 EA/30 Days OPIOID PARTIAL AGONISTS - Drugs to treat pain buprenorphine 0.005mg/hr weekly patch $0 (Tier 2) QL=4 EA/28 Days buprenorphine 0.0075mg/hr weekly patch $0 (Tier 2) QL=4 EA/28 Days buprenorphine 0.015mg/hr weekly patch $0 (Tier 2) QL=4 EA/28 Days buprenorphine 0.01mg/hr weekly patch $0 (Tier 2) QL=4 EA/28 Days buprenorphine 0.02mg/hr weekly patch $0 (Tier 2) QL=4 EA/28 Days buprenorphine 12mg/naloxone 3mg sublingual film $0 (Tier 1) buprenorphine 2mg sl tab $0 (Tier 1) buprenorphine 2mg/naloxone 0.5mg sl tab $0 (Tier 1) buprenorphine 2mg/naloxone 0.5mg sublingual film $0 (Tier 1) buprenorphine 4mg/naloxone 1mg sublingual film $0 (Tier 1) buprenorphine 8mg sl tab $0 (Tier 1) buprenorphine 8mg/naloxone 2mg sl tab $0 (Tier 1) buprenorphine 8mg/naloxone 2mg sublingual film $0 (Tier 1) butorphanol tartrate 1mg/act nasal inhaler $0 (Tier 2) QL=10 ML/30 Days ZUBSOLV 0.7-0.18MG SL TAB $0 (Tier 3) QL=60 EA/30 Days ZUBSOLV 1.4-0.36MG SL TAB $0 (Tier 3) QL=90 EA/30 Days ZUBSOLV 11.4-2.9MG SL TAB $0 (Tier 3) QL=60 EA/30 Days ZUBSOLV 2.9-0.71MG SL TAB $0 (Tier 3) QL=90 EA/30 Days ZUBSOLV 5.7-1.4MG SL TAB $0 (Tier 3) QL=90 EA/30 Days ZUBSOLV 8.6-2.1MG SL TAB $0 (Tier 3) QL=60 EA/30 Days ANDROGENS-ANABOLIC - Drugs to regulate male hormones ANABOLIC STEROIDS - Drugs used to gain weight oxandrolone 10mg tab $0 (Tier 2) PA oxandrolone 10mg tab $0 (Tier 5) PA You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 25 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) oxandrolone 2.5mg tab $0 (Tier 2) PA oxandrolone 2.5mg tab $0 (Tier 5) PA ANDROGENS - Drugs to treat low testosterone level ANDRODERM 2MG/24HR PATCH $0 (Tier 3) PA QL=60 EA/30 Days ANDRODERM 4MG/24HR PATCH $0 (Tier 3) PA QL=30 EA/30 Days danazol 100mg cap $0 (Tier 2) danazol 200mg cap $0 (Tier 2) danazol 50mg cap $0 (Tier 2) testosterone 1% (25mg) gel packet $0 (Tier 2) PA QL=300 GM/30 Days testosterone 1% (50mg) gel packet $0 (Tier 2) PA QL=300 GM/30 Days testosterone 1.62% (1.25gm) gel packet $0 (Tier 2) PA QL=75 GM/30 Days testosterone 1.62% (2.5gm) gel packet $0 (Tier 2) PA QL=150 GM/30 Days TESTOSTERONE 12.5MG/ACT GEL PUMP $0 (Tier 4) PA QL=300 GM/30 Days testosterone 20.25mg/act gel pump $0 (Tier 2) PA QL=150 GM/30 Days testosterone 30mg/act topical soln $0 (Tier 2) PA QL=180 ML/30 Days testosterone cypionate 100mg/ml inj $0 (Tier 2) testosterone cypionate 200mg/ml (1ml) inj $0 (Tier 2) testosterone cypionate 200mg/ml inj $0 (Tier 2) TESTOSTERONE ENANTHATE 200MG/ML INJ $0 (Tier 2) ANORECTAL AGENTS - Drugs to treat problems related to the rectum INTRARECTAL STEROIDS - Drugs to treat systemic swelling conditions hydrocortisone 1.67mg/ml enema $0 (Tier 2) UCERIS 2MG/ACT RECTAL FOAM $0 (Tier 4) PA VASODILATING AGENTS - Drugs to treat anal fissures RECTIV 0.4% RECTAL OINTMENT $0 (Tier 4) QL=30 GM/30 Days ANORECTAL AND RELATED PRODUCTS - Drugs to treat problems related to the rectum RECTAL COMBINATIONS - Drugs to treat systemic swelling conditions hydrocortisone/pramoxine 1-1% rectal cream $0 (Tier 2) RECTAL STEROIDS - Drugs to treat systemic swelling conditions procto-med 2.5% cream $0 (Tier 2) procto-pak 1% rectal cream $0 (Tier 2) proctosol 2.5% cream $0 (Tier 2) proctozone hc 2.5% cream $0 (Tier 2) ANTACIDS - Drugs to treat ulcer and stomach acid ANTACID COMBINATIONS - Drugs to treat ulcer and stomach acid alum/mag hydroxide-simethicone chew tab $0 (Tier 5) 200-200-25 mg aluminum hydroxide/magnesium carbonate chew tab $0 (Tier 5) 160-105mg aluminum hydroxide/magnesium carbonate susp $0 (Tier 5) 95-358mg/15ml

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 26 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) aluminum/magnesium hydroxide/simethicone susp $0 (Tier 5) 200-200-20mg/5ml aluminum/magnesium hydroxide/simethicone susp $0 (Tier 5) 400-400-40mg/5ml calcium carbonate chew tab 1000-60mg $0 (Tier 5) MAG-AL LIQUID $0 (Tier 5) MAGNESIUM OXIDE-ASAFOETIDA LIQD 250 MG-6 $0 (Tier 5) MIN/5ML ANTACIDS - ALUMINUM SALTS - Drugs to treat ulcer and stomach acid ALUMINUM HYDROXIDE GEL SUSP 320MG/5ML $0 (Tier 5) ANTACIDS - BICARBONATE - Drugs to treat ulcer and stomach acid sodium bicarbonate tab 325mg $0 (Tier 5) sodium bicarbonate tab 650mg $0 (Tier 5) ANTACIDS - CALCIUM SALTS - Drugs to treat ulcer and stomach acid calcium carbonate (antacid) chew tab 1000mg $0 (Tier 5) calcium carbonate (antacid) chew tab 420 mg $0 (Tier 5) calcium carbonate (antacid) chew tab 500mg $0 (Tier 5) calcium carbonate (antacid) chew tab 750mg $0 (Tier 5) CALCIUM CARBONATE (ANTACID) TAB 648 MG $0 (Tier 5) calcium carbonate susp 1250mg/5ml $0 (Tier 5) ANTACIDS - MAGNESIUM SALTS - Drugs to treat ulcer and stomach acid MAGNESIUM OXIDE 400MG CAP $0 (Tier 5) magnesium oxide tab 250mg $0 (Tier 5) magnesium oxide tab 400mg $0 (Tier 5) magnesium oxide tab 420 mg $0 (Tier 5) URO-MAG 140MG CAP $0 (Tier 5) ANTHELMINTICS - Drugs to treat worm infections ANTHELMINTICS - Drugs to treat parasites albendazole 200mg tab $0 (Tier 2) BENZNIDAZOLE 100MG TAB $0 (Tier 3) PA BENZNIDAZOLE 12.5MG TAB $0 (Tier 3) PA ivermectin 3mg tab $0 (Tier 2) pyrantel pamoate susp 144mg/ml $0 (Tier 5) ANTIANGINAL AGENTS - Drugs to treat chest pain ANTIANGINALS-OTHER - Drugs to treat chest pain ranolazine 1000mg er tab $0 (Tier 2) ranolazine 500mg er tab $0 (Tier 2) NITRATES - Drugs to treat chest pain isosorbide dinitrate 10mg tab $0 (Tier 1) isosorbide dinitrate 20mg tab $0 (Tier 1) isosorbide dinitrate 30mg tab $0 (Tier 1) isosorbide dinitrate 40mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 27 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) isosorbide dinitrate 5mg tab $0 (Tier 1) isosorbide mononitrate 10mg tab $0 (Tier 1) isosorbide mononitrate 120mg er tab $0 (Tier 1) isosorbide mononitrate 20mg tab $0 (Tier 1) isosorbide mononitrate 30mg er tab $0 (Tier 1) isosorbide mononitrate 60mg er tab $0 (Tier 1) minitran 0.1mg/hr patch $0 (Tier 1) minitran 0.2mg/hr patch $0 (Tier 1) minitran 0.4mg/hr patch $0 (Tier 1) minitran 0.6mg/hr patch $0 (Tier 1) NITRO-BID 2% OINTMENT $0 (Tier 3) NITRO-DUR 0.3MG/HR PATCH $0 (Tier 4) NITRO-DUR 0.8MG/HR PATCH $0 (Tier 4) nitroglycerin 0.1mg/hr patch $0 (Tier 1) nitroglycerin 0.2mg/hr patch $0 (Tier 1) nitroglycerin 0.3mg sl tab $0 (Tier 1) nitroglycerin 0.4mg sl tab $0 (Tier 1) nitroglycerin 0.4mg/act spray $0 (Tier 2) nitroglycerin 0.4mg/hr patch $0 (Tier 1) nitroglycerin 0.6mg sl tab $0 (Tier 1) nitroglycerin 0.6mg/hr patch $0 (Tier 1) ANTIANXIETY AGENTS - Drugs to treat anxiety ANTIANXIETY AGENTS - MISC. - Miscellaneous anti-anxiety drugs buspirone 10mg tab $0 (Tier 1) buspirone 15mg tab $0 (Tier 1) buspirone 30mg tab $0 (Tier 1) buspirone 5mg tab $0 (Tier 1) buspirone 7.5mg tab $0 (Tier 1) hydroxyzine 10mg tab $0 (Tier 1) hydroxyzine 25mg tab $0 (Tier 1) hydroxyzine 2mg/ml oral soln $0 (Tier 2) hydroxyzine 50mg tab $0 (Tier 1) HYDROXYZINE PAMOATE 100MG CAP $0 (Tier 2) hydroxyzine pamoate 25mg cap $0 (Tier 1) hydroxyzine pamoate 50mg cap $0 (Tier 1) BENZODIAZEPINES - Drugs to treat anxiety alprazolam 0.25mg odt $0 (Tier 2) alprazolam 0.25mg tab $0 (Tier 1) alprazolam 0.5mg er tab $0 (Tier 2) alprazolam 0.5mg odt $0 (Tier 2) alprazolam 0.5mg tab $0 (Tier 1) alprazolam 1mg er tab $0 (Tier 2) alprazolam 1mg odt $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 28 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) alprazolam 1mg tab $0 (Tier 1) alprazolam 2mg er tab $0 (Tier 2) alprazolam 2mg odt $0 (Tier 2) alprazolam 2mg tab $0 (Tier 1) alprazolam 3mg er tab $0 (Tier 2) chlordiazepoxide 10mg cap $0 (Tier 1) chlordiazepoxide 25mg cap $0 (Tier 1) chlordiazepoxide 5mg cap $0 (Tier 1) clorazepate dipotassium 15mg tab $0 (Tier 2) clorazepate dipotassium 3.75mg tab $0 (Tier 2) clorazepate dipotassium 7.5mg tab $0 (Tier 2) diazepam 10mg tab $0 (Tier 1) DIAZEPAM 1MG/ML ORAL SOLN $0 (Tier 2) diazepam 2mg tab $0 (Tier 1) diazepam 5mg tab $0 (Tier 1) diazepam 5mg/ml oral soln $0 (Tier 2) lorazepam 0.5mg tab $0 (Tier 1) lorazepam 1mg tab $0 (Tier 1) lorazepam 2mg tab $0 (Tier 1) lorazepam 2mg/ml oral soln $0 (Tier 2) OXAZEPAM 10MG CAP $0 (Tier 3) OXAZEPAM 15MG CAP $0 (Tier 3) OXAZEPAM 30MG CAP $0 (Tier 3) ANTIARRHYTHMICS - Drugs to control heart rhythm ANTIARRHYTHMICS TYPE I-A - Drugs to control heart rhythm disopyramide 100mg cap $0 (Tier 2) disopyramide 150mg cap $0 (Tier 2) NORPACE 100MG ER CAP $0 (Tier 3) PA NORPACE 150MG ER CAP $0 (Tier 2) PA quinidine gluconate 324mg er tab $0 (Tier 2) QUINIDINE SULFATE 200MG TAB $0 (Tier 2) QUINIDINE SULFATE 300MG TAB $0 (Tier 2) ANTIARRHYTHMICS TYPE I-B - Drugs to control heart rhythm mexiletine 150mg cap $0 (Tier 3) mexiletine 200mg cap $0 (Tier 3) mexiletine 250mg cap $0 (Tier 3) ANTIARRHYTHMICS TYPE I-C - Drugs to control heart rhythm flecainide acetate 100mg tab $0 (Tier 2) flecainide acetate 150mg tab $0 (Tier 2) flecainide acetate 50mg tab $0 (Tier 2) propafenone 150mg tab $0 (Tier 2) propafenone 225mg er cap $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 29 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) propafenone 225mg tab $0 (Tier 2) propafenone 300mg tab $0 (Tier 2) propafenone 325mg er cap $0 (Tier 2) propafenone 425mg er cap $0 (Tier 2) ANTIARRHYTHMICS TYPE III - Drugs to control heart rhythm amiodarone 200mg tab $0 (Tier 1) amiodarone 400mg tab $0 (Tier 2) dofetilide 0.125mg cap $0 (Tier 2) dofetilide 0.25mg cap $0 (Tier 2) dofetilide 0.5mg cap $0 (Tier 2) MULTAQ 400MG TAB $0 (Tier 3) pacerone 200mg tab $0 (Tier 1) pacerone 400mg tab $0 (Tier 2) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to treat asthma and COPD ANTIASTHMATIC - MONOCLONAL ANTIBODIES - Drugs to treat asthma NUCALA 100MG INJ $0 (Tier 4) NDS PA NUCALA 100MG/ML AUTO-INJECTOR $0 (Tier 4) NDS PA NUCALA 100MG/ML SYRINGE $0 (Tier 4) NDS PA XOLAIR 150MG INJ $0 (Tier 4) NDS PA XOLAIR 150MG/ML SYRINGE $0 (Tier 4) NDS PA XOLAIR 75MG/0.5ML SYRINGE $0 (Tier 4) NDS PA BRONCHODILATORS - ANTICHOLINERGICS - Drugs to treat breathing disorders ATROVENT 17MCG INH $0 (Tier 3) QL=25.80 GM/30 Days INCRUSE 62.5MCG/INH INH $0 (Tier 3) QL=30 EA/30 Days ipratropium bromide 0.2mg/ml inh soln $0 (Tier 2) B/D SPIRIVA 1.25MCG INH $0 (Tier 3) ST QL=4 GM/30 Days LEUKOTRIENE MODULATORS - Drugs to treat asthma and COPD montelukast 10mg tab $0 (Tier 1) montelukast 4mg chew tab $0 (Tier 1) montelukast 4mg granules $0 (Tier 2) montelukast 5mg chew tab $0 (Tier 1) zafirlukast 10mg tab $0 (Tier 2) zafirlukast 20mg tab $0 (Tier 2) SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - Drugs to treat asthma and COPD DALIRESP 250MCG TAB $0 (Tier 4) DALIRESP 500MCG TAB $0 (Tier 4) STEROID INHALANTS - Drugs to treat asthma and COPD ARNUITY 100MCG INH $0 (Tier 3) QL=30 EA/30 Days ARNUITY 200MCG INH $0 (Tier 3) QL=30 EA/30 Days ARNUITY 50MCG INH $0 (Tier 3) QL=30 EA/30 Days budesonide 0.125mg/ml inh susp $0 (Tier 2) B/D QL=120 ML/30 Days budesonide 0.25mg/ml inh susp $0 (Tier 2) B/D QL=120 ML/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 30 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) budesonide 0.5mg/ml inh susp $0 (Tier 2) B/D QL=120 ML/30 Days FLOVENT 100MCG/BLIST INH $0 (Tier 3) QL=60 EA/30 Days FLOVENT 110MCG INH $0 (Tier 3) QL=24 GM/30 Days FLOVENT 220MCG INH $0 (Tier 3) QL=24 GM/30 Days FLOVENT 250MCG/BLIST INH $0 (Tier 3) QL=60 EA/30 Days FLOVENT 44MCG INH $0 (Tier 3) QL=21.20 GM/30 Days FLOVENT 50MCG/BLIST INH $0 (Tier 3) QL=60 EA/30 Days SYMPATHOMIMETICS - Drugs to treat asthma and COPD ADVAIR 0.045-0.021MG INH $0 (Tier 3) QL=12 GM/30 Days ADVAIR 0.115-0.021MG INH $0 (Tier 3) QL=12 GM/30 Days ADVAIR 0.23-0.021MG INH $0 (Tier 3) QL=12 GM/30 Days albuterol 0.21mg/ml inh soln $0 (Tier 1) B/D albuterol 0.417mg/ml inh soln $0 (Tier 1) B/D albuterol 0.4mg/ml oral soln $0 (Tier 2) albuterol 0.83mg/ml inh soln $0 (Tier 2) B/D albuterol 2mg tab $0 (Tier 2) albuterol 4mg tab $0 (Tier 2) albuterol 5mg/ml inh soln $0 (Tier 2) B/D albuterol sulfate 108mcg hfa inhaler (8.5gm) $0 (Tier 1) QL=17 GM/30 Days ANORO 0.0625-0.025MG INH $0 (Tier 3) QL=60 EA/30 Days BREO 0.1-0.025MG INH $0 (Tier 3) QL=60 EA/30 Days BREO 0.2-0.025MG INH $0 (Tier 3) QL=60 EA/30 Days BREZTRI AEROSPHERE 160-9-4.8MCG/ACT INH $0 (Tier 3) QL=10.70 GM/30 Days BROVANA 15MCG/2ML INH SOLN $0 (Tier 4) B/D COMBIVENT 0.1-0.02MG INH $0 (Tier 3) QL=8 GM/30 Days DULERA 0.005-0.1MG INH $0 (Tier 3) QL=13 GM/30 Days DULERA 0.005-0.2MG INH $0 (Tier 3) QL=13 GM/30 Days DULERA INHALER 50-5MCG $0 (Tier 3) QL=13 GM/30 Days fluticasone propionate 0.1mg/salmeterol 0.05mg inh $0 (Tier 2) QL=60 EA/30 Days fluticasone propionate 0.25mg/salmeterol 0.05mg inh $0 (Tier 2) QL=60 EA/30 Days fluticasone propionate 0.5mg/salmeterol 0.05mg inh $0 (Tier 2) QL=60 EA/30 Days FLUTICASONE PROPIONATE/SALMETEROL $0 (Tier 2) QL=1 EA/30 Days XINAFOATE 113-14MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL $0 (Tier 2) QL=1 EA/30 Days XINAFOATE 232-14MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL $0 (Tier 2) QL=1 EA/30 Days XINAFOATE 55-14MCG/ACT POWDER INH ipratropium/albuterol 0.5-2.5mg/3ml inh soln $0 (Tier 2) B/D levalbuterol 0.103mg/ml inh soln $0 (Tier 2) B/D levalbuterol 0.21mg/ml inh soln $0 (Tier 2) B/D levalbuterol 0.417mg/ml inh soln $0 (Tier 2) B/D levalbuterol 2.5mg/ml inh soln $0 (Tier 2) B/D SEREVENT 50MCG/DOSE INH $0 (Tier 3) QL=180 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 31 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) STIOLTO 0.0025-0.0025MG INH $0 (Tier 3) QL=4 GM/30 Days terbutaline sulfate 2.5mg tab $0 (Tier 2) terbutaline sulfate 5mg tab $0 (Tier 2) TRELEGY ELLIPTA 100- 62.5-25MCG INHALER $0 (Tier 3) QL=60 EA/30 Days TRELEGY ELLIPTA 200-62.5-25 MCG/INH $0 (Tier 3) QL=60 EA/30 Days VENTOLIN 108MCG INH $0 (Tier 3) QL=36 GM/30 Days wixela 0.1-0.05mg inh $0 (Tier 2) QL=60 EA/30 Days wixela 0.25-0.05mg inh $0 (Tier 2) QL=60 EA/30 Days wixela 0.5-0.05mg inh $0 (Tier 2) QL=60 EA/30 Days XANTHINES - Drugs to treat asthma and COPD THEO-24 100MG ER CAP $0 (Tier 4) THEO-24 200MG ER CAP $0 (Tier 4) THEO-24 300MG ER CAP $0 (Tier 4) THEO-24 400MG ER CAP $0 (Tier 4) THEOPHYLLINE 300MG ER TAB $0 (Tier 3) theophylline 400mg er tab $0 (Tier 1) theophylline 5.33mg/ml oral soln $0 (Tier 2) theophylline 600mg er tab $0 (Tier 1) ANTICOAGULANTS - Drugs to thin the blood COUMARIN ANTICOAGULANTS - Drugs to thin the blood jantoven 10mg tab $0 (Tier 1) jantoven 1mg tab $0 (Tier 1) jantoven 2.5mg tab $0 (Tier 1) jantoven 2mg tab $0 (Tier 1) jantoven 3mg tab $0 (Tier 1) jantoven 4mg tab $0 (Tier 1) jantoven 5mg tab $0 (Tier 1) jantoven 6mg tab $0 (Tier 1) jantoven 7.5mg tab $0 (Tier 1) warfarin sodium 10mg tab $0 (Tier 1) warfarin sodium 1mg tab $0 (Tier 1) warfarin sodium 2.5mg tab $0 (Tier 1) warfarin sodium 2mg tab $0 (Tier 1) warfarin sodium 3mg tab $0 (Tier 1) warfarin sodium 4mg tab $0 (Tier 1) warfarin sodium 5mg tab $0 (Tier 1) warfarin sodium 6mg tab $0 (Tier 1) warfarin sodium 7.5mg tab $0 (Tier 1) DIRECT FACTOR XA INHIBITORS - Drugs to thin the blood ELIQUIS 2.5MG TAB $0 (Tier 3) ELIQUIS 30-DAY STARTER PACK 5MG $0 (Tier 3) ELIQUIS 5MG TAB $0 (Tier 3)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 32 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) XARELTO 10MG TAB $0 (Tier 3) XARELTO 15MG TAB $0 (Tier 3) XARELTO 2.5MG TAB $0 (Tier 3) XARELTO 20MG TAB $0 (Tier 3) XARELTO KIT PACK $0 (Tier 3) HEPARINS AND HEPARINOID-LIKE AGENTS - Drugs to thin the blood enoxaparin sodium 100mg/ml (0.3ml) syringe $0 (Tier 2) QL=18 ML/30 Days enoxaparin sodium 100mg/ml (0.4ml) syringe $0 (Tier 2) QL=24 ML/30 Days enoxaparin sodium 100mg/ml (0.6ml) syringe $0 (Tier 2) QL=36 ML/30 Days enoxaparin sodium 100mg/ml (0.8ml) syringe $0 (Tier 2) QL=48 ML/30 Days enoxaparin sodium 100mg/ml (1ml) syringe $0 (Tier 2) QL=60 ML/30 Days enoxaparin sodium 150mg/ml (0.8ml) syringe $0 (Tier 2) QL=48 ML/30 Days enoxaparin sodium 150mg/ml (1ml) syringe $0 (Tier 2) QL=60 ML/30 Days fondaparinux sodium 12.5mg/ml (0.4ml) syringe $0 (Tier 2) fondaparinux sodium 12.5mg/ml (0.6ml) syringe $0 (Tier 2) fondaparinux sodium 12.5mg/ml (0.8ml) syringe $0 (Tier 2) fondaparinux sodium 5mg/ml syringe $0 (Tier 2) FRAGMIN 10000UNIT/ML SYRINGE $0 (Tier 4) FRAGMIN 12500UNIT/0.5ML SYRINGE $0 (Tier 4) FRAGMIN 15000UNIT/0.6ML SYRINGE $0 (Tier 4) FRAGMIN 18000UNT/0.72ML SYRINGE $0 (Tier 4) FRAGMIN 2500UNIT/0.2ML SYRINGE $0 (Tier 4) FRAGMIN 5000UNIT/0.2ML SYRINGE $0 (Tier 4) FRAGMIN 7500UNIT/0.3ML SYRINGE $0 (Tier 4) FRAGMIN 95000UNIT/3.8ML INJ $0 (Tier 4) heparin sodium (porcine) lock flush iv soln 10 unit/ml $0 (Tier 5) heparin sodium (porcine) lock flush iv soln 100 unit/ml $0 (Tier 5) heparin sodium porcine 10000unit/ml inj $0 (Tier 2) heparin sodium porcine 1000unit/ml inj $0 (Tier 2) heparin sodium porcine 20000unit/ml inj $0 (Tier 2) heparin sodium porcine 5000unit/ml inj $0 (Tier 2) THROMBIN INHIBITORS - Drugs to thin the blood PRADAXA 110MG CAP $0 (Tier 3) PRADAXA 150MG CAP $0 (Tier 3) PRADAXA 75MG CAP $0 (Tier 3) ANTICONVULSANTS - Drugs to treat seizures AMPA GLUTAMATE RECEPTOR ANTAGONISTS - Drugs to treat seizures FYCOMPA 0.5MG/ML SUSP $0 (Tier 4) PA NSO FYCOMPA 10MG TAB $0 (Tier 4) PA NSO FYCOMPA 12MG TAB $0 (Tier 4) PA NSO FYCOMPA 2MG TAB $0 (Tier 4) PA NSO FYCOMPA 4MG TAB $0 (Tier 4) PA NSO

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 33 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) FYCOMPA 6MG TAB $0 (Tier 4) PA NSO FYCOMPA 8MG TAB $0 (Tier 4) PA NSO ANTICONVULSANTS - BENZODIAZEPINES - Drugs to treat seizures clobazam 10mg tab $0 (Tier 2) QL=60 EA/30 Days clobazam 2.5mg/ml susp $0 (Tier 2) clobazam 20mg tab $0 (Tier 2) QL=60 EA/30 Days clonazepam 0.125mg odt $0 (Tier 2) clonazepam 0.25mg odt $0 (Tier 2) clonazepam 0.5mg odt $0 (Tier 2) clonazepam 0.5mg tab $0 (Tier 1) clonazepam 1mg odt $0 (Tier 2) clonazepam 1mg tab $0 (Tier 1) clonazepam 2mg odt $0 (Tier 2) clonazepam 2mg tab $0 (Tier 1) DIASTAT 10MG RECTAL GEL $0 (Tier 3) DIASTAT 2.5MG RECTAL GEL $0 (Tier 3) DIASTAT 20MG RECTAL GEL $0 (Tier 3) DIAZEPAM 10MG/2ML RECTAL GEL $0 (Tier 3) DIAZEPAM 2.5MG/0.5ML RECTAL GEL $0 (Tier 3) DIAZEPAM 20MG/4ML RECTAL GEL $0 (Tier 3) NAYZILAM 5MG/0.1ML NASAL SPRAY $0 (Tier 4) SYMPAZAN 10MG ORAL FILM $0 (Tier 4) ST_NSO SYMPAZAN 20MG ORAL FILM $0 (Tier 4) ST_NSO SYMPAZAN 5MG ORAL FILM $0 (Tier 4) ST_NSO VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK $0 (Tier 4) QL=10 EA/30 Days VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK $0 (Tier 4) QL=10 EA/30 Days VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK $0 (Tier 4) QL=10 EA/30 Days VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK $0 (Tier 4) QL=10 EA/30 Days ANTICONVULSANTS - MISC. - Miscellaneous anti-convulsant drugs APTIOM 200MG TAB $0 (Tier 4) PA NSO APTIOM 400MG TAB $0 (Tier 4) PA NSO APTIOM 600MG TAB $0 (Tier 4) PA NSO APTIOM 800MG TAB $0 (Tier 4) PA NSO BANZEL 40MG/ML SUSP $0 (Tier 3) PA NSO BRIVIACT 100MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days BRIVIACT 10MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days BRIVIACT 10MG/ML ORAL SOLN $0 (Tier 4) PA NSO BRIVIACT 25MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days BRIVIACT 50MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days BRIVIACT 75MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days carbamazepine 100mg chew tab $0 (Tier 2) carbamazepine 100mg er cap $0 (Tier 2) carbamazepine 100mg er tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 34 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) carbamazepine 200mg er cap $0 (Tier 2) carbamazepine 200mg er tab $0 (Tier 2) carbamazepine 200mg tab $0 (Tier 2) carbamazepine 20mg/ml susp $0 (Tier 2) carbamazepine 300mg er cap $0 (Tier 2) carbamazepine 400mg er tab $0 (Tier 2) DIACOMIT 250MG CAP $0 (Tier 4) NDS PA NSO DIACOMIT 250MG POWDER FOR ORAL SUSP $0 (Tier 4) NDS PA NSO DIACOMIT 500MG CAP $0 (Tier 4) NDS PA NSO DIACOMIT 500MG POWDER FOR ORAL SUSP $0 (Tier 4) NDS PA NSO EPIDIOLEX 100MG/ML ORAL SOLN $0 (Tier 3) PA NSO epitol 200mg tab $0 (Tier 2) FINTEPLA 2.2MG/ML ORAL SOLN $0 (Tier 4) NDS PA NSO QL=360 ML/30 Days gabapentin 100mg cap $0 (Tier 1) gabapentin 300mg cap $0 (Tier 1) gabapentin 400mg cap $0 (Tier 1) gabapentin 50mg/ml oral soln $0 (Tier 2) gabapentin 600mg tab $0 (Tier 1) gabapentin 800mg tab $0 (Tier 1) lamotrigine 100mg er tab $0 (Tier 2) lamotrigine 100mg odt $0 (Tier 2) lamotrigine 100mg tab $0 (Tier 1) lamotrigine 150mg tab $0 (Tier 1) lamotrigine 200mg er tab $0 (Tier 2) lamotrigine 200mg odt $0 (Tier 2) lamotrigine 200mg tab $0 (Tier 1) lamotrigine 250mg er tab $0 (Tier 2) lamotrigine 25mg chew tab $0 (Tier 2) lamotrigine 25mg er tab $0 (Tier 2) lamotrigine 25mg odt $0 (Tier 2) lamotrigine 25mg pack $0 (Tier 2) lamotrigine 25mg tab $0 (Tier 1) lamotrigine 300mg er tab $0 (Tier 2) lamotrigine 50mg er tab $0 (Tier 2) lamotrigine 50mg odt $0 (Tier 2) lamotrigine 5mg chew tab $0 (Tier 2) lamotrigine ODT kit $0 (Tier 2) lamotrigine tab 25mg (42)/100mg (7) starter pack $0 (Tier 2) lamotrigine tab 25mg (84)/100mg (14) starter pack $0 (Tier 2) levetiracetam 1000mg tab $0 (Tier 1) levetiracetam 100mg/ml oral soln $0 (Tier 1) levetiracetam 250mg tab $0 (Tier 1) levetiracetam 500mg er tab $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 35 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) levetiracetam 500mg tab $0 (Tier 1) levetiracetam 750mg er tab $0 (Tier 1) levetiracetam 750mg tab $0 (Tier 2) oxcarbazepine 150mg tab $0 (Tier 1) oxcarbazepine 300mg tab $0 (Tier 1) oxcarbazepine 600mg tab $0 (Tier 1) oxcarbazepine 60mg/ml susp $0 (Tier 2) pregabalin 100mg cap $0 (Tier 1) pregabalin 150mg cap $0 (Tier 1) pregabalin 200mg cap $0 (Tier 1) pregabalin 20mg/ml oral soln $0 (Tier 2) pregabalin 225mg cap $0 (Tier 1) pregabalin 25mg cap $0 (Tier 1) pregabalin 300mg cap $0 (Tier 1) pregabalin 50mg cap $0 (Tier 1) pregabalin 75mg cap $0 (Tier 1) primidone 250mg tab $0 (Tier 1) primidone 50mg tab $0 (Tier 1) roweepra 500mg tab $0 (Tier 1) rufinamide 200mg tab $0 (Tier 3) PA NSO rufinamide 400mg tab $0 (Tier 3) PA NSO rufinamide 40mg/ml susp $0 (Tier 2) PA NSO SPRITAM 1000MG TAB FOR ORAL SUSP $0 (Tier 4) PA NSO SPRITAM 250MG TAB FOR ORAL SUSP $0 (Tier 4) PA NSO SPRITAM 500MG TAB FOR ORAL SUSP $0 (Tier 4) PA NSO SPRITAM 750MG TAB FOR ORAL SUSP $0 (Tier 4) PA NSO TOPIRAMATE 100MG ER CAP $0 (Tier 4) PA NSO topiramate 100mg tab $0 (Tier 1) TOPIRAMATE 150MG ER CAP $0 (Tier 4) PA NSO topiramate 15mg cap $0 (Tier 2) TOPIRAMATE 200MG ER CAP $0 (Tier 4) PA NSO topiramate 200mg tab $0 (Tier 1) topiramate 25mg cap $0 (Tier 2) TOPIRAMATE 25MG ER CAP $0 (Tier 4) PA NSO topiramate 25mg tab $0 (Tier 1) TOPIRAMATE 50MG ER CAP $0 (Tier 4) PA NSO topiramate 50mg tab $0 (Tier 1) VIMPAT 100MG TAB $0 (Tier 3) QL=60 EA/30 Days VIMPAT 10MG/ML ORAL SOLN $0 (Tier 3) VIMPAT 150MG TAB $0 (Tier 3) QL=60 EA/30 Days VIMPAT 200MG TAB $0 (Tier 3) QL=60 EA/30 Days VIMPAT 50MG TAB $0 (Tier 3) QL=60 EA/30 Days zonisamide 100mg cap $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 36 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) zonisamide 25mg cap $0 (Tier 1) zonisamide 50mg cap $0 (Tier 1) CARBAMATES - Drugs to treat seizures felbamate 120mg/ml susp $0 (Tier 2) felbamate 400mg tab $0 (Tier 2) felbamate 600mg tab $0 (Tier 2) XCOPRI 100MG TAB $0 (Tier 3) PA NSO XCOPRI 12.5/25MG TITRATION PACK $0 (Tier 3) PA NSO XCOPRI 150/200MG TITRATION PACK $0 (Tier 3) PA NSO XCOPRI 150MG TAB $0 (Tier 3) PA NSO XCOPRI 200MG TAB $0 (Tier 3) PA NSO XCOPRI 50/100MG TITRATION PACK $0 (Tier 3) PA NSO XCOPRI 50MG TAB $0 (Tier 3) PA NSO XCOPRI TAB 100/150MG MAINTENANCE PACK $0 (Tier 3) PA NSO XCOPRI TAB 150/200MG PACK $0 (Tier 3) PA NSO XCOPRI TAB 50/200MG PACK $0 (Tier 3) PA NSO GABA MODULATORS - Drugs to treat seizures tiagabine 12mg tab $0 (Tier 2) tiagabine 16mg tab $0 (Tier 2) tiagabine 2mg tab $0 (Tier 2) tiagabine 4mg tab $0 (Tier 2) vigabatrin 500mg powder for oral soln $0 (Tier 4) NDS PA NSO vigabatrin 500mg tab $0 (Tier 4) NDS PA NSO vigadrone 500mg powder for oral soln $0 (Tier 4) NDS PA NSO HYDANTOINS - Drugs to treat seizures DILANTIN 30MG ER CAP $0 (Tier 3) phenytoin 25mg/ml susp $0 (Tier 2) phenytoin 50mg chew tab $0 (Tier 2) phenytoin sodium 100mg er cap $0 (Tier 1) phenytoin sodium 200mg er cap $0 (Tier 2) phenytoin sodium 300mg er cap $0 (Tier 2) SUCCINIMIDES - Drugs to treat seizures CELONTIN 300MG CAP $0 (Tier 3) ethosuximide 250mg cap $0 (Tier 2) ethosuximide 50mg/ml oral soln $0 (Tier 2) VALPROIC ACID - Drugs to treat seizures divalproex sodium 125mg dr cap $0 (Tier 2) divalproex sodium 125mg dr tab $0 (Tier 1) divalproex sodium 250mg dr tab $0 (Tier 1) divalproex sodium 250mg er tab $0 (Tier 2) divalproex sodium 500mg dr tab $0 (Tier 1) divalproex sodium 500mg er tab $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 37 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) valproic acid 250mg cap $0 (Tier 2) valproic acid 50mg/ml oral soln $0 (Tier 2) ANTIDEPRESSANTS - Drugs to treat depression disorder ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) - Drugs to treat depression mirtazapine 15mg odt $0 (Tier 2) mirtazapine 15mg tab $0 (Tier 1) mirtazapine 30mg odt $0 (Tier 2) mirtazapine 30mg tab $0 (Tier 1) mirtazapine 45mg odt $0 (Tier 2) mirtazapine 45mg tab $0 (Tier 1) mirtazapine 7.5mg tab $0 (Tier 2) ANTIDEPRESSANTS - MISC. - Miscellaneous anti-depressant drugs bupropion 100mg er tab $0 (Tier 1) bupropion 100mg tab $0 (Tier 1) bupropion 150mg sr (12 hr) tab $0 (Tier 1) bupropion 150mg xl (24 hr) tab $0 (Tier 1) bupropion 200mg er tab $0 (Tier 1) bupropion 300mg er tab $0 (Tier 1) bupropion 75mg tab $0 (Tier 1) MAPROTILINE 25MG TAB $0 (Tier 2) MAPROTILINE 50MG TAB $0 (Tier 2) MAPROTILINE 75MG TAB $0 (Tier 2) MONOAMINE OXIDASE INHIBITORS (MAOIS) - Drugs to treat depression EMSAM 12MG/24HR PATCH $0 (Tier 4) EMSAM 6MG/24HR PATCH $0 (Tier 4) EMSAM 9MG/24HR PATCH $0 (Tier 4) MARPLAN 10MG TAB $0 (Tier 3) phenelzine 15mg tab $0 (Tier 2) tranylcypromine 10mg tab $0 (Tier 2) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) - Drugs to treat depression citalopram 10mg tab $0 (Tier 1) citalopram 20mg tab $0 (Tier 1) citalopram 2mg/ml oral soln $0 (Tier 2) citalopram 40mg tab $0 (Tier 1) escitalopram 10mg tab $0 (Tier 1) escitalopram 1mg/ml oral soln $0 (Tier 2) escitalopram 20mg tab $0 (Tier 1) escitalopram 5mg tab $0 (Tier 1) fluoxetine 10mg cap $0 (Tier 1) fluoxetine 10mg tab $0 (Tier 2) fluoxetine 20mg cap $0 (Tier 1) fluoxetine 40mg cap $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 38 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) fluoxetine 4mg/ml oral soln $0 (Tier 1) fluvoxamine maleate 100mg er cap $0 (Tier 2) ST_NSO fluvoxamine maleate 100mg tab $0 (Tier 1) fluvoxamine maleate 150mg er cap $0 (Tier 2) ST_NSO fluvoxamine maleate 25mg tab $0 (Tier 1) fluvoxamine maleate 50mg tab $0 (Tier 1) paroxetine 10mg tab $0 (Tier 1) paroxetine 12.5mg er tab $0 (Tier 2) paroxetine 20mg tab $0 (Tier 1) paroxetine 25mg er tab $0 (Tier 2) paroxetine 30mg tab $0 (Tier 1) paroxetine 37.5mg er tab $0 (Tier 2) paroxetine 40mg tab $0 (Tier 1) PAXIL 10MG/5ML SUSP $0 (Tier 4) sertraline 100mg tab $0 (Tier 1) sertraline 20mg/ml oral soln $0 (Tier 2) sertraline 25mg tab $0 (Tier 1) sertraline 50mg tab $0 (Tier 1) SEROTONIN MODULATORS - Drugs to treat depression NEFAZODONE 100MG TAB $0 (Tier 4) NEFAZODONE 150MG TAB $0 (Tier 4) NEFAZODONE 200MG TAB $0 (Tier 4) NEFAZODONE 250MG TAB $0 (Tier 2) NEFAZODONE 50MG TAB $0 (Tier 2) trazodone 100mg tab $0 (Tier 1) trazodone 150mg tab $0 (Tier 1) trazodone 300mg tab $0 (Tier 2) trazodone 50mg tab $0 (Tier 1) TRINTELLIX 10MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days TRINTELLIX 20MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days TRINTELLIX 5MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days VIIBRYD 10/20MG STARTER PACK $0 (Tier 4) ST_NSO QL=30 EA/30 Days VIIBRYD 10MG TAB $0 (Tier 4) ST_NSO QL=30 EA/30 Days VIIBRYD 20MG TAB $0 (Tier 4) ST_NSO QL=30 EA/30 Days VIIBRYD 40MG TAB $0 (Tier 4) ST_NSO QL=30 EA/30 Days SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) - Drugs to treat depression desvenlafaxine succinate 100mg er tab $0 (Tier 2) desvenlafaxine succinate 25mg er tab $0 (Tier 2) desvenlafaxine succinate 50mg er tab $0 (Tier 2) DRIZALMA 20MG DR CAP $0 (Tier 4) PA NSO DRIZALMA 30MG DR CAP $0 (Tier 4) PA NSO DRIZALMA 40MG DR CAP $0 (Tier 4) PA NSO DRIZALMA 60MG DR CAP $0 (Tier 4) PA NSO You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 39 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) duloxetine 20mg dr cap $0 (Tier 1) duloxetine 30mg dr cap $0 (Tier 1) duloxetine 40mg dr cap $0 (Tier 2) ST_NSO QL=30 EA/30 Days duloxetine 60mg dr cap $0 (Tier 1) FETZIMA 120MG ER CAP $0 (Tier 4) ST_NSO QL=30 EA/30 Days FETZIMA 20MG ER CAP $0 (Tier 4) ST_NSO QL=30 EA/30 Days FETZIMA 40MG ER CAP $0 (Tier 4) ST_NSO QL=30 EA/30 Days FETZIMA 80MG ER CAP $0 (Tier 4) ST_NSO QL=30 EA/30 Days FETZIMA PACK $0 (Tier 4) ST_NSO QL=30 EA/30 Days venlafaxine 100mg tab $0 (Tier 1) venlafaxine 150mg er cap $0 (Tier 1) venlafaxine 25mg tab $0 (Tier 1) venlafaxine 37.5mg er cap $0 (Tier 1) venlafaxine 37.5mg tab $0 (Tier 1) venlafaxine 50mg tab $0 (Tier 1) venlafaxine 75mg er cap $0 (Tier 1) venlafaxine 75mg tab $0 (Tier 1) TRICYCLIC AGENTS - Drugs to treat depression amitriptyline 100mg tab $0 (Tier 1) amitriptyline 10mg tab $0 (Tier 1) amitriptyline 150mg tab $0 (Tier 1) amitriptyline 25mg tab $0 (Tier 1) amitriptyline 50mg tab $0 (Tier 1) amitriptyline 75mg tab $0 (Tier 1) AMOXAPINE 100MG TAB $0 (Tier 3) AMOXAPINE 150MG TAB $0 (Tier 3) AMOXAPINE 25MG TAB $0 (Tier 3) AMOXAPINE 50MG TAB $0 (Tier 3) clomipramine 25mg cap $0 (Tier 2) clomipramine 50mg cap $0 (Tier 2) clomipramine 75mg cap $0 (Tier 2) desipramine 100mg tab $0 (Tier 2) desipramine 10mg tab $0 (Tier 2) desipramine 150mg tab $0 (Tier 2) desipramine 25mg tab $0 (Tier 2) desipramine 50mg tab $0 (Tier 2) desipramine 75mg tab $0 (Tier 2) doxepin 100mg cap $0 (Tier 2) doxepin 10mg cap $0 (Tier 2) doxepin 10mg/ml oral soln $0 (Tier 2) doxepin 150mg cap $0 (Tier 2) doxepin 25mg cap $0 (Tier 2) doxepin 50mg cap $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 40 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) doxepin 75mg cap $0 (Tier 2) imipramine 10mg tab $0 (Tier 1) imipramine 25mg tab $0 (Tier 1) imipramine 50mg tab $0 (Tier 1) imipramine pamoate 100mg cap $0 (Tier 2) imipramine pamoate 125mg cap $0 (Tier 2) imipramine pamoate 150mg cap $0 (Tier 2) imipramine pamoate 75mg cap $0 (Tier 2) nortriptyline 10mg cap $0 (Tier 1) nortriptyline 25mg cap $0 (Tier 1) NORTRIPTYLINE 2MG/ML ORAL SOLN $0 (Tier 3) nortriptyline 50mg cap $0 (Tier 1) nortriptyline 75mg cap $0 (Tier 1) protriptyline 10mg tab $0 (Tier 2) protriptyline 5mg tab $0 (Tier 2) trimipramine 100mg cap $0 (Tier 2) trimipramine 25mg cap $0 (Tier 2) trimipramine 50mg cap $0 (Tier 2) ANTIDIABETICS - Drugs to regulate blood sugar ALPHA-GLUCOSIDASE INHIBITORS - Drugs to regulate blood sugar acarbose 100mg tab $0 (Tier 2) acarbose 25mg tab $0 (Tier 2) acarbose 50mg tab $0 (Tier 2) miglitol 100mg tab $0 (Tier 2) miglitol 25mg tab $0 (Tier 2) miglitol 50mg tab $0 (Tier 2) ANTIDIABETIC COMBINATIONS - Drugs to regulate blood sugar glipizide 2.5mg/metformin 250mg tab $0 (Tier 1) glipizide 2.5mg/metformin 500mg tab $0 (Tier 1) glipizide 5mg/metformin 500mg tab $0 (Tier 1) JANUMET 1000-100MG ER TAB $0 (Tier 3) QL=30 EA/30 Days JANUMET 1000-50MG ER TAB $0 (Tier 3) QL=60 EA/30 Days JANUMET 1000-50MG TAB $0 (Tier 3) QL=60 EA/30 Days JANUMET 500-50MG ER TAB $0 (Tier 3) QL=60 EA/30 Days JANUMET 500-50MG TAB $0 (Tier 3) QL=60 EA/30 Days JENTADUETO 2.5-1000MG ER TAB $0 (Tier 3) QL=30 EA/30 Days JENTADUETO 2.5-1000MG TAB $0 (Tier 3) QL=60 EA/30 Days JENTADUETO 2.5-500MG TAB $0 (Tier 3) QL=60 EA/30 Days JENTADUETO 2.5-850MG TAB $0 (Tier 3) QL=60 EA/30 Days JENTADUETO 5-1000MG ER TAB $0 (Tier 3) QL=30 EA/30 Days SYNJARDY 10-1000MG ER TAB $0 (Tier 3) QL=30 EA/30 Days SYNJARDY 12.5-1000MG ER TAB $0 (Tier 3) QL=60 EA/30 Days SYNJARDY 12.5-1000MG TAB $0 (Tier 3) QL=60 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 41 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) SYNJARDY 12.5-500MG TAB $0 (Tier 3) QL=60 EA/30 Days SYNJARDY 25-1000MG ER TAB $0 (Tier 3) QL=30 EA/30 Days SYNJARDY 5-1000MG ER TAB $0 (Tier 3) QL=60 EA/30 Days SYNJARDY 5-1000MG TAB $0 (Tier 3) QL=60 EA/30 Days SYNJARDY 5-500MG TAB $0 (Tier 3) QL=60 EA/30 Days XIGDUO 10-1000MG ER TAB $0 (Tier 3) QL=30 EA/30 Days XIGDUO 10-500MG ER TAB $0 (Tier 3) QL=30 EA/30 Days XIGDUO 2.5-1000MG ER TAB $0 (Tier 3) QL=60 EA/30 Days XIGDUO 5-1000MG ER TAB $0 (Tier 3) QL=60 EA/30 Days XIGDUO 5-500MG ER TAB $0 (Tier 3) QL=30 EA/30 Days BIGUANIDES - Drugs to regulate blood sugar metformin 1000mg tab $0 (Tier 1) metformin 100mg/ml soln $0 (Tier 2) metformin 500mg er tab $0 (Tier 1) metformin 500mg tab $0 (Tier 1) metformin 750mg er tab $0 (Tier 1) metformin 850mg tab $0 (Tier 1) DIABETIC OTHER - Drugs to regulate blood sugar BAQSIMI 3MG/DOSE NASAL POWDER $0 (Tier 3) QL=2 EA/7 Days diazoxide 50mg/ml susp $0 (Tier 2) GLUCAGEN 1MG INJ $0 (Tier 3) QL=2 EA/7 Days GLUCAGON (RDNA) 1MG INJ $0 (Tier 3) QL=2 EA/7 Days GLUCOSE CHEW TAB 4-0.006GM $0 (Tier 5) GLUCOSE CHEW TAB 4GM $0 (Tier 5) GLUCOSE GEL 15 GM/33GM $0 (Tier 5) glucose gel 40% $0 (Tier 5) GLUCOSE ORAL LIQUID 15 GM/59ML $0 (Tier 5) KORLYM 300MG TAB $0 (Tier 4) NDS PA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS - Drugs to regulate blood sugar JANUVIA 100MG TAB $0 (Tier 3) QL=30 EA/30 Days JANUVIA 25MG TAB $0 (Tier 3) QL=30 EA/30 Days JANUVIA 50MG TAB $0 (Tier 3) QL=30 EA/30 Days TRADJENTA 5MG TAB $0 (Tier 3) QL=30 EA/30 Days INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) - Drugs to regulate blood sugar OZEMPIC 2MG/1.5ML PEN INJ $0 (Tier 3) QL=1.50 ML/28 Days OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) $0 (Tier 3) QL=3 ML/28 Days OZEMPIC 4MG/3ML PEN INJ $0 (Tier 3) QL=3 ML/28 Days RYBELSUS 14MG TAB $0 (Tier 3) QL=30 EA/30 Days RYBELSUS 3MG TAB $0 (Tier 3) QL=30 EA/30 Days RYBELSUS 7MG TAB $0 (Tier 3) QL=30 EA/30 Days TRULICITY 0.75MG/0.5ML AUTO-INJECTOR $0 (Tier 3) QL=2 ML/28 Days TRULICITY 1.5MG/0.5ML AUTO-INJECTOR $0 (Tier 3) QL=2 ML/28 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 42 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) TRULICITY 3MG/0.5ML AUTO-INJECTOR $0 (Tier 3) QL=2 ML/28 Days TRULICITY 4.5MG/0.5ML AUTO-INJECTOR $0 (Tier 3) QL=2 ML/28 Days VICTOZA 18MG/3ML PEN INJ $0 (Tier 3) QL=9 ML/30 Days INSULIN - Drugs to regulate blood sugar HUMULIN R 500UNIT/ML INJ $0 (Tier 3) B/D HUMULIN R 500UNIT/ML PEN INJ $0 (Tier 3) LANTUS 100UNIT/ML INJ $0 (Tier 3) LANTUS 100UNIT/ML PEN INJ $0 (Tier 3) LEVEMIR 100UNIT/ML INJ $0 (Tier 3) LEVEMIR 100UNIT/ML PEN INJ $0 (Tier 3) NOVOLIN MIX (70/30) 100UNIT/ML INJ $0 (Tier 3) NOVOLIN MIX (70/30) FLEXPEN 100UNIT/ML $0 (Tier 3) NOVOLIN N 100UNIT/ML INJ $0 (Tier 3) NOVOLIN N 100UNIT/ML PEN INJ $0 (Tier 3) NOVOLIN R 100UNIT/ML INJ $0 (Tier 3) NOVOLIN R 100UNIT/ML PEN INJ $0 (Tier 3) NOVOLOG 100UNIT/ML CARTRIDGE $0 (Tier 3) NOVOLOG 100UNIT/ML INJ $0 (Tier 3) B/D NOVOLOG 100UNIT/ML PEN INJ $0 (Tier 3) NOVOLOG MIX (70/30) 100UNIT/ML FLEXPEN $0 (Tier 3) NOVOLOG MIX (70/30) 100UNIT/ML INJ $0 (Tier 3) TOUJEO 300UNIT/ML PEN INJ $0 (Tier 3) TOUJEO MAX 300UNIT/ML PEN INJ (3ML) $0 (Tier 3) TRESIBA 100UNIT/ML INJ $0 (Tier 3) TRESIBA 100UNIT/ML PEN INJ $0 (Tier 3) TRESIBA 200UNIT/ML PEN INJ $0 (Tier 3) INSULIN SENSITIZING AGENTS - Drugs to regulate blood sugar pioglitazone 15mg tab $0 (Tier 1) pioglitazone 30mg tab $0 (Tier 1) pioglitazone 45mg tab $0 (Tier 1) MEGLITINIDE ANALOGUES - Drugs to regulate blood sugar nateglinide 120mg tab $0 (Tier 2) nateglinide 60mg tab $0 (Tier 2) repaglinide 0.5mg tab $0 (Tier 2) repaglinide 1mg tab $0 (Tier 2) repaglinide 2mg tab $0 (Tier 2) SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS - Drugs to regulate blood sugar FARXIGA 10MG TAB $0 (Tier 3) QL=30 EA/30 Days FARXIGA 5MG TAB $0 (Tier 3) QL=30 EA/30 Days JARDIANCE 10MG TAB $0 (Tier 3) QL=30 EA/30 Days JARDIANCE 25MG TAB $0 (Tier 3) QL=30 EA/30 Days SULFONYLUREAS - Drugs to regulate blood sugar

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 43 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) glimepiride 1mg tab $0 (Tier 1) glimepiride 2mg tab $0 (Tier 1) glimepiride 4mg tab $0 (Tier 1) glipizide 10mg er tab $0 (Tier 1) glipizide 10mg tab $0 (Tier 1) glipizide 2.5mg er tab $0 (Tier 1) glipizide 5mg er tab $0 (Tier 1) glipizide 5mg tab $0 (Tier 1) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to treat diarrhea ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. - Drugs to treat diarrhea bismuth subsalicylate susp 262mg/15ml $0 (Tier 5) bismuth subsalicylate susp 525mg/15ml $0 (Tier 5) CULTURELLE DROPS $0 (Tier 5) probiotic product - chew tab $0 (Tier 5) saccharomyces boulardii cap 250mg $0 (Tier 5) ANTIPERISTALTIC AGENTS - Drugs to treat diarrhea atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml $0 (Tier 2) oral soln atropine sulfate 0.025mg/diphenoxylate 2.5mg tab $0 (Tier 2) loperamide 2mg cap $0 (Tier 1) loperamide cap 2mg $0 (Tier 5) ANTIDIARRHEALS - Drugs to treat diarrhea ANTIDIARRHEAL AGENTS - MISC. - Miscellaneous antidiarrheal agents bismuth subsalicylate chew tab 262mg $0 (Tier 5) bismuth subsalicylate tab 262mg $0 (Tier 5) CULTURELLE 10B CELL CAPSULE $0 (Tier 5) CULTURELLE KIDS PACKET $0 (Tier 5) ANTIDIARRHEAL COMBINATIONS - Drugs to treat diarrhea CULTURELLE CHEW TAB $0 (Tier 5) CULTURELLE HLTH-WELL 15B CELL $0 (Tier 5) ANTIPERISTALTIC AGENTS - Drugs to treat diarrhea anti-diarrheal 2mg caplet $0 (Tier 5) loperamide liquid 1mg/7.5ml $0 (Tier 5) ANTIDOTES AND SPECIFIC ANTAGONISTS - Drugs to treat overdose or toxicity ANTIDOTES - CHELATING AGENTS - Drugs to treat overdose or toxicity CHEMET 100MG CAP $0 (Tier 3) deferasirox 125mg tab for oral susp $0 (Tier 2) deferasirox 180mg granules $0 (Tier 4) NDS deferasirox 180mg tab $0 (Tier 2) deferasirox 250mg tab for oral susp $0 (Tier 2) deferasirox 360mg granules $0 (Tier 4) NDS deferasirox 360mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 44 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) deferasirox 500mg tab for oral susp $0 (Tier 2) deferasirox 90mg granules $0 (Tier 4) NDS deferasirox 90mg tab $0 (Tier 2) deferiprone 500mg tab $0 (Tier 4) NDS PA FERRIPROX 1000MG TAB $0 (Tier 4) NDS PA FERRIPROX 100MG/ML ORAL SOLN $0 (Tier 4) NDS PA OPIOID ANTAGONISTS - Drugs to treat opioid overdose or toxicity NALOXONE 0.4MG/ML CARTRIDGE $0 (Tier 2) QL=2 ML/2 Days naloxone 0.4mg/ml inj $0 (Tier 2) QL=2 ML/2 Days naloxone 1mg/ml syringe $0 (Tier 1) naltrexone 50mg tab $0 (Tier 1) NARCAN 4MG/0.1ML NASAL SPRAY $0 (Tier 2) VIVITROL 380MG INJ $0 (Tier 4) NDS ANTIEMETICS - Drugs to treat nausea and vomiting 5-HT3 RECEPTOR ANTAGONISTS - Drugs to treat nausea and vomiting granisetron 1mg tab $0 (Tier 2) B/D QL=60 EA/30 Days ondansetron 0.8mg/ml oral soln $0 (Tier 2) B/D ONDANSETRON 24MG TAB $0 (Tier 2) B/D ondansetron 4mg odt $0 (Tier 1) B/D ondansetron 4mg tab $0 (Tier 1) B/D ondansetron 8mg odt $0 (Tier 1) B/D ondansetron 8mg tab $0 (Tier 1) B/D ANTIEMETICS - ANTICHOLINERGIC - Drugs to treat nausea and vomiting DIMENHYDRINATE TAB 50 MG $0 (Tier 5) meclizine 12.5mg tab $0 (Tier 5) meclizine 12.5mg tab $0 (Tier 1) meclizine 25mg tab $0 (Tier 1) meclizine chew tab 25mg $0 (Tier 5) meclizine tab 25mg $0 (Tier 5) scopolamine 0.0139mg/hr patch $0 (Tier 2) trimethobenzamide 300mg cap $0 (Tier 2) ANTIEMETICS - MISCELLANEOUS - Miscellaneous anti-emetics doxylamine succinate 10mg/pyridoxine 10mg dr tab $0 (Tier 2) QL=120 EA/30 Days dronabinol 10mg cap $0 (Tier 2) PA dronabinol 10mg cap $0 (Tier 5) PA dronabinol 2.5mg cap $0 (Tier 2) PA dronabinol 2.5mg cap $0 (Tier 5) PA dronabinol 5mg cap $0 (Tier 2) PA dronabinol 5mg cap $0 (Tier 5) PA SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS - Drugs to treat nausea and vomiting aprepitant 125mg cap $0 (Tier 2) B/D QL=3 EA/2 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 45 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) aprepitant 125mg/aprepitant 80mg pack $0 (Tier 2) B/D QL=6 EA/4 Days aprepitant 40mg cap $0 (Tier 2) B/D QL=3 EA/2 Days aprepitant 80mg cap $0 (Tier 2) B/D QL=6 EA/4 Days VARUBI 90MG TAB $0 (Tier 4) B/D QL=4 EA/28 Days ANTIFUNGALS - Drugs to treat fungal infection ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) - Drugs to treat fungal infections caspofungin acetate 50mg inj $0 (Tier 4) NDS caspofungin acetate 70mg inj $0 (Tier 4) NDS ERAXIS 100MG INJ $0 (Tier 3) ERAXIS 50MG INJ $0 (Tier 3) micafungin sodium 100mg inj $0 (Tier 2) micafungin sodium 50mg inj $0 (Tier 2) ANTIFUNGALS - Drugs to treat fungal infection ABELCET 5MG/ML INJ $0 (Tier 4) B/D AMBISOME 50MG INJ $0 (Tier 4) B/D AMPHOTERICIN B 50MG INJ $0 (Tier 4) B/D flucytosine 250mg cap $0 (Tier 2) flucytosine 500mg cap $0 (Tier 2) griseofulvin 125mg tab $0 (Tier 2) griseofulvin 250mg tab $0 (Tier 2) griseofulvin 25mg/ml susp $0 (Tier 2) griseofulvin 500mg tab $0 (Tier 2) nystatin 500000unit tab $0 (Tier 2) terbinafine 250mg tab $0 (Tier 1) IMIDAZOLE-RELATED ANTIFUNGALS - Drugs to treat fungal infections fluconazole 100mg tab $0 (Tier 2) fluconazole 10mg/ml susp $0 (Tier 2) fluconazole 150mg tab $0 (Tier 1) fluconazole 200mg tab $0 (Tier 2) fluconazole 2mg/ml (100ml) inj $0 (Tier 2) fluconazole 2mg/ml (200ml) inj $0 (Tier 2) fluconazole 40mg/ml susp $0 (Tier 2) fluconazole 50mg tab $0 (Tier 2) itraconazole 100mg cap $0 (Tier 2) PA ketoconazole 200mg tab $0 (Tier 1) NOXAFIL 40MG/ML SUSP $0 (Tier 3) PA posaconazole 100mg dr tab $0 (Tier 2) PA voriconazole 200mg inj $0 (Tier 2) PA voriconazole 200mg tab $0 (Tier 2) PA voriconazole 40mg/ml susp $0 (Tier 2) PA voriconazole 50mg tab $0 (Tier 2) PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 46 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ANTIHISTAMINES - Drugs to treat allergies ANTIHISTAMINES - ALKYLAMINES - Drugs to treat cough, cold, and allergy symptoms chlorpheniramine maleate CR tab 12mg $0 (Tier 5) chlorpheniramine maleate syrup 2 mg/5ml $0 (Tier 5) chlorpheniramine maleate tab 4mg $0 (Tier 5) ANTIHISTAMINES - ETHANOLAMINES - Drugs to treat cough, cold, and allergy symptoms diphenhydramine cap 25mg $0 (Tier 5) diphenhydramine cap 50mg $0 (Tier 5) diphenhydramine liquid 12.5mg/5ml $0 (Tier 5) diphenhydramine tab 25mg $0 (Tier 5) ANTIHISTAMINES - NON-SEDATING - Drugs to treat cough, cold, and allergy symptoms cetirizine 1mg/ml oral soln $0 (Tier 2) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) $0 (Tier 5) cetirizine tab 10mg $0 (Tier 5) cetirizine tab 5mg $0 (Tier 5) desloratadine 5mg tab $0 (Tier 2) fexofenadine 180mg tab $0 (Tier 5) fexofenadine 60mg tab $0 (Tier 5) levocetirizine 0.5mg/ml oral soln $0 (Tier 2) levocetirizine 5mg tab $0 (Tier 1) loratadine rapidly-disintegrating tab 10 mg $0 (Tier 5) loratadine syrup 5mg/5ml $0 (Tier 5) loratadine tab 10mg $0 (Tier 5) ANTIHISTAMINES - PHENOTHIAZINES - Drugs to treat cough, cold, and allergy symptoms promethazine 1.25mg/ml oral soln $0 (Tier 2) PA promethazine 12.5mg rectal supp $0 (Tier 2) promethazine 12.5mg tab $0 (Tier 1) PA promethazine 25mg rectal supp $0 (Tier 2) promethazine 25mg tab $0 (Tier 1) PA promethazine 50mg tab $0 (Tier 1) promethegan 25mg rectal supp $0 (Tier 2) PROMETHEGAN 50MG RECTAL SUPP $0 (Tier 3) ANTIHYPERLIPIDEMICS - Drugs to treat high cholesterol ANTIHYPERLIPIDEMICS - COMBINATIONS - drugs to treat high cholesterol ezetimibe 10mg/simvastatin 10mg tab $0 (Tier 2) QL=30 EA/30 Days ezetimibe 10mg/simvastatin 20mg tab $0 (Tier 2) QL=30 EA/30 Days ezetimibe 10mg/simvastatin 40mg tab $0 (Tier 2) QL=30 EA/30 Days ezetimibe 10mg/simvastatin 80mg tab $0 (Tier 2) QL=30 EA/30 Days ANTIHYPERLIPIDEMICS - MISC. - Miscellaneous anti-hyperlipidemics omega-3 acid ethyl esters (usp) 1000mg cap $0 (Tier 2) VASCEPA 0.5GM CAP $0 (Tier 3) PA QL=120 EA/30 Days VASCEPA 1GM CAP $0 (Tier 3) PA QL=120 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 47 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) BILE ACID SEQUESTRANTS - Drugs to treat high cholesterol cholestyramine resin 4gm sf powder for oral susp $0 (Tier 2) cholestyramine resin 4gm sf powder for oral susp $0 (Tier 2) (sugar free) colesevelam 3750mg powder for oral susp $0 (Tier 2) colesevelam 625mg tab $0 (Tier 2) colestipol 1000mg tab $0 (Tier 2) colestipol 5000mg granules for oral susp $0 (Tier 2) prevalite 4gm powder for oral susp $0 (Tier 2) FIBRIC ACID DERIVATIVES - Drugs to treat high cholesterol fenofibrate 134mg cap $0 (Tier 2) fenofibrate 145mg tab $0 (Tier 2) FENOFIBRATE 150MG CAP $0 (Tier 4) fenofibrate 160mg tab $0 (Tier 2) fenofibrate 200mg cap $0 (Tier 2) fenofibrate 48mg tab $0 (Tier 2) FENOFIBRATE 50MG CAP $0 (Tier 4) fenofibrate 54mg tab $0 (Tier 2) fenofibrate 67mg cap $0 (Tier 2) fenofibric acid 135mg dr cap $0 (Tier 2) fenofibric acid 45mg dr cap $0 (Tier 2) gemfibrozil 600mg tab $0 (Tier 1) HMG COA REDUCTASE INHIBITORS - Drugs to treat high cholesterol atorvastatin 10mg tab $0 (Tier 1) QL=45 EA/30 Days atorvastatin 20mg tab $0 (Tier 1) QL=45 EA/30 Days atorvastatin 40mg tab $0 (Tier 1) QL=45 EA/30 Days atorvastatin 80mg tab $0 (Tier 1) QL=30 EA/30 Days fluvastatin 20mg cap $0 (Tier 2) QL=30 EA/30 Days fluvastatin 40mg cap $0 (Tier 2) QL=30 EA/30 Days fluvastatin 80mg er tab $0 (Tier 2) QL=30 EA/30 Days lovastatin 10mg tab $0 (Tier 1) lovastatin 20mg tab $0 (Tier 1) lovastatin 40mg tab $0 (Tier 1) pravastatin sodium 10mg tab $0 (Tier 1) QL=45 EA/30 Days pravastatin sodium 20mg tab $0 (Tier 1) QL=45 EA/30 Days pravastatin sodium 40mg tab $0 (Tier 1) QL=45 EA/30 Days pravastatin sodium 80mg tab $0 (Tier 1) QL=30 EA/30 Days rosuvastatin calcium 10mg tab $0 (Tier 1) QL=45 EA/30 Days rosuvastatin calcium 20mg tab $0 (Tier 1) QL=45 EA/30 Days rosuvastatin calcium 40mg tab $0 (Tier 1) QL=30 EA/30 Days rosuvastatin calcium 5mg tab $0 (Tier 1) QL=45 EA/30 Days simvastatin 10mg tab $0 (Tier 1) QL=45 EA/30 Days simvastatin 20mg tab $0 (Tier 1) QL=45 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 48 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) simvastatin 40mg tab $0 (Tier 1) QL=45 EA/30 Days simvastatin 5mg tab $0 (Tier 1) QL=45 EA/30 Days simvastatin 80mg tab $0 (Tier 1) QL=30 EA/30 Days INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS - Drugs to treat high cholesterol ezetimibe 10mg tab $0 (Tier 2) QL=30 EA/30 Days MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS - Drugs to treat high cholesterol JUXTAPID 10MG CAP $0 (Tier 4) NDS PA JUXTAPID 20MG CAP $0 (Tier 4) NDS PA JUXTAPID 30MG CAP $0 (Tier 4) NDS PA JUXTAPID 5MG CAP $0 (Tier 4) NDS PA NICOTINIC ACID DERIVATIVES - Drugs to treat high cholesterol niacin 1000mg er tab $0 (Tier 2) niacin 500mg er tab $0 (Tier 2) niacin 750mg er tab $0 (Tier 2) PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS - Drugs to treat high cholesterol PRALUENT 150MG/ML AUTO-INJECTOR $0 (Tier 3) PA QL=2 ML/28 Days PRALUENT 75MG/ML AUTO-INJECTOR $0 (Tier 3) PA QL=2 ML/28 Days REPATHA 140MG/ML AUTO-INJECTOR $0 (Tier 3) PA QL=2 ML/28 Days REPATHA 140MG/ML SYRINGE $0 (Tier 3) PA QL=2 ML/28 Days REPATHA 420MG/3.5ML CARTRIDGE $0 (Tier 3) PA QL=3.50 ML/28 Days ANTIHYPERTENSIVES - Drugs to treat high blood pressure ACE INHIBITORS - Drugs to treat high blood pressure benazepril 10mg tab $0 (Tier 1) benazepril 20mg tab $0 (Tier 1) benazepril 40mg tab $0 (Tier 1) benazepril 5mg tab $0 (Tier 1) captopril 100mg tab $0 (Tier 2) captopril 12.5mg tab $0 (Tier 2) captopril 25mg tab $0 (Tier 2) captopril 50mg tab $0 (Tier 2) enalapril maleate 10mg tab $0 (Tier 1) enalapril maleate 2.5mg tab $0 (Tier 1) enalapril maleate 20mg tab $0 (Tier 1) enalapril maleate 5mg tab $0 (Tier 1) fosinopril sodium 10mg tab $0 (Tier 1) fosinopril sodium 20mg tab $0 (Tier 1) fosinopril sodium 40mg tab $0 (Tier 1) lisinopril 10mg tab $0 (Tier 1) lisinopril 2.5mg tab $0 (Tier 1) lisinopril 20mg tab $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 49 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) lisinopril 30mg tab $0 (Tier 1) lisinopril 40mg tab $0 (Tier 1) lisinopril 5mg tab $0 (Tier 1) moexipril 15mg tab $0 (Tier 2) moexipril 7.5mg tab $0 (Tier 2) perindopril erbumine 2mg tab $0 (Tier 2) perindopril erbumine 4mg tab $0 (Tier 2) perindopril erbumine 8mg tab $0 (Tier 2) quinapril 10mg tab $0 (Tier 1) quinapril 20mg tab $0 (Tier 1) quinapril 40mg tab $0 (Tier 1) quinapril 5mg tab $0 (Tier 1) ramipril 1.25mg cap $0 (Tier 1) ramipril 10mg cap $0 (Tier 1) ramipril 2.5mg cap $0 (Tier 1) ramipril 5mg cap $0 (Tier 1) trandolapril 1mg tab $0 (Tier 1) trandolapril 2mg tab $0 (Tier 1) trandolapril 4mg tab $0 (Tier 1) AGENTS FOR PHEOCHROMOCYTOMA - Drugs to treat high blood pressure DEMSER 250MG CAP $0 (Tier 4) NDS metyrosine 250mg cap $0 (Tier 4) NDS phenoxybenzamine 10mg cap $0 (Tier 2) ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs to treat high blood pressure candesartan cilexetil 32mg tab $0 (Tier 1) irbesartan 150mg tab $0 (Tier 1) irbesartan 300mg tab $0 (Tier 1) irbesartan 75mg tab $0 (Tier 1) losartan potassium 100mg tab $0 (Tier 1) losartan potassium 25mg tab $0 (Tier 1) losartan potassium 50mg tab $0 (Tier 1) olmesartan medoxomil 20mg tab $0 (Tier 1) olmesartan medoxomil 40mg tab $0 (Tier 1) olmesartan medoxomil 5mg tab $0 (Tier 1) telmisartan 20mg tab $0 (Tier 2) telmisartan 40mg tab $0 (Tier 2) telmisartan 80mg tab $0 (Tier 2) valsartan 160mg tab $0 (Tier 1) valsartan 320mg tab $0 (Tier 1) valsartan 40mg tab $0 (Tier 1) valsartan 80mg tab $0 (Tier 1) ANTIADRENERGIC ANTIHYPERTENSIVES - Drugs to treat high blood pressure clonidine 0.00417mg/hr weekly patch $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 50 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) clonidine 0.00833mg/hr weekly patch $0 (Tier 2) clonidine 0.0125mg/hr weekly patch $0 (Tier 2) clonidine 0.1mg tab $0 (Tier 1) clonidine 0.2mg tab $0 (Tier 1) clonidine 0.3mg tab $0 (Tier 1) doxazosin 1mg tab $0 (Tier 1) doxazosin 2mg tab $0 (Tier 1) doxazosin 4mg tab $0 (Tier 1) doxazosin 8mg tab $0 (Tier 1) prazosin 1mg cap $0 (Tier 1) prazosin 2mg cap $0 (Tier 1) prazosin 5mg cap $0 (Tier 1) terazosin 10mg cap $0 (Tier 1) terazosin 1mg cap $0 (Tier 1) terazosin 2mg cap $0 (Tier 1) terazosin 5mg cap $0 (Tier 1) ANTIHYPERTENSIVE COMBINATIONS - Drugs to treat high blood pressure amlodipine 10mg/benazepril 20mg cap $0 (Tier 2) amlodipine 10mg/benazepril 40mg cap $0 (Tier 2) amlodipine 10mg/hydrochlorothiazide $0 (Tier 2) 12.5mg/valsartan 160mg tab amlodipine 10mg/hydrochlorothiazide $0 (Tier 2) 25mg/valsartan 160mg tab amlodipine 10mg/hydrochlorothiazide $0 (Tier 2) 25mg/valsartan 320mg tab amlodipine 10mg/olmesartan medoxomil 20mg tab $0 (Tier 2) amlodipine 10mg/olmesartan medoxomil 40mg tab $0 (Tier 2) amlodipine 10mg/valsartan 160mg tab $0 (Tier 2) amlodipine 10mg/valsartan 320mg tab $0 (Tier 2) amlodipine 2.5mg/benazepril 10mg cap $0 (Tier 2) amlodipine 5mg/benazepril 10mg cap $0 (Tier 2) amlodipine 5mg/benazepril 20mg cap $0 (Tier 2) amlodipine 5mg/benazepril 40mg cap $0 (Tier 2) amlodipine 5mg/hydrochlorothiazide $0 (Tier 2) 12.5mg/valsartan 160mg tab amlodipine 5mg/hydrochlorothiazide 25mg/valsartan $0 (Tier 2) 160mg tab amlodipine 5mg/olmesartan medoxomil 20mg tab $0 (Tier 2) amlodipine 5mg/olmesartan medoxomil 40mg tab $0 (Tier 2) amlodipine 5mg/valsartan 160mg tab $0 (Tier 2) amlodipine 5mg/valsartan 320mg tab $0 (Tier 2) atenolol 100mg/chlorthalidone 25mg tab $0 (Tier 2) atenolol 50mg/chlorthalidone 25mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 51 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) benazepril 10mg/hydrochlorothiazide 12.5mg tab $0 (Tier 2) benazepril 20mg/hydrochlorothiazide 12.5mg tab $0 (Tier 2) benazepril 20mg/hydrochlorothiazide 25mg tab $0 (Tier 2) benazepril 5mg/hydrochlorothiazide 6.25mg tab $0 (Tier 2) bisoprolol fumarate 10mg/hydrochlorothiazide $0 (Tier 1) 6.25mg tab bisoprolol fumarate 2.5mg/hydrochlorothiazide $0 (Tier 1) 6.25mg tab bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg $0 (Tier 1) tab candesartan cilexetil 16mg/hydrochlorothiazide $0 (Tier 1) 12.5mg tab candesartan cilexetil 32mg/hydrochlorothiazide $0 (Tier 1) 12.5mg tab candesartan cilexetil 32mg/hydrochlorothiazide 25mg $0 (Tier 1) tab enalapril maleate 10mg/hydrochlorothiazide 25mg $0 (Tier 1) tab enalapril maleate 5mg/hydrochlorothiazide 12.5mg $0 (Tier 1) tab fosinopril sodium 10mg/hydrochlorothiazide 12.5mg $0 (Tier 2) tab fosinopril sodium 20mg/hydrochlorothiazide 12.5mg $0 (Tier 2) tab hydrochlorothiazide 12.5mg/irbesartan 150mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/irbesartan 300mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/lisinopril 10mg tab $0 (Tier 1) hydrochlorothiazide 12.5mg/lisinopril 20mg tab $0 (Tier 1) hydrochlorothiazide 12.5mg/losartan potassium $0 (Tier 2) 100mg tab hydrochlorothiazide 12.5mg/losartan potassium 50mg $0 (Tier 2) tab hydrochlorothiazide 12.5mg/olmesartan medoxomil $0 (Tier 1) 20mg tab hydrochlorothiazide 12.5mg/olmesartan medoxomil $0 (Tier 1) 40mg tab hydrochlorothiazide 12.5mg/quinapril 10mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/quinapril 20mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/telmisartan 40mg tab $0 (Tier 1) hydrochlorothiazide 12.5mg/telmisartan 80mg tab $0 (Tier 1) hydrochlorothiazide 12.5mg/valsartan 160mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/valsartan 320mg tab $0 (Tier 2) hydrochlorothiazide 12.5mg/valsartan 80mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 52 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) hydrochlorothiazide 25mg/lisinopril 20mg tab $0 (Tier 1) hydrochlorothiazide 25mg/losartan potassium 100mg $0 (Tier 2) tab hydrochlorothiazide 25mg/metoprolol tartrate 100mg $0 (Tier 2) tab hydrochlorothiazide 25mg/metoprolol tartrate 50mg $0 (Tier 2) tab hydrochlorothiazide 25mg/olmesartan medoxomil $0 (Tier 1) 40mg tab hydrochlorothiazide 25mg/propranolol 40mg tab $0 (Tier 2) hydrochlorothiazide 25mg/propranolol 80mg tab $0 (Tier 2) hydrochlorothiazide 25mg/quinapril 20mg tab $0 (Tier 2) hydrochlorothiazide 25mg/telmisartan 80mg tab $0 (Tier 1) hydrochlorothiazide 25mg/valsartan 160mg tab $0 (Tier 2) hydrochlorothiazide 25mg/valsartan 320mg tab $0 (Tier 2) hydrochlorothiazide 50mg/metoprolol tartrate 100mg $0 (Tier 2) tab TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB $0 (Tier 4) trandolapril 2mg/verapamil 180mg er tab $0 (Tier 2) trandolapril 2mg/verapamil 240mg er tab $0 (Tier 2) trandolapril 4mg/verapamil 240mg er tab $0 (Tier 2) DIRECT RENIN INHIBITORS - Drugs to treat high blood pressure aliskiren 150mg tab $0 (Tier 2) aliskiren 300mg tab $0 (Tier 2) SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) - Drugs to treat high blood pressure eplerenone 25mg tab $0 (Tier 2) eplerenone 50mg tab $0 (Tier 2) VASODILATORS - Drugs to treat high blood pressure hydralazine 100mg tab $0 (Tier 2) hydralazine 10mg tab $0 (Tier 2) hydralazine 25mg tab $0 (Tier 2) hydralazine 50mg tab $0 (Tier 2) minoxidil 10mg tab $0 (Tier 1) minoxidil 2.5mg tab $0 (Tier 1) ANTI-INFECTIVE AGENTS - MISC. - Miscellaneous anti-infective drugs ANTI-INFECTIVE AGENTS - MISC. - Miscellaneous anti-infective drugs IMPAVIDO 50MG CAP $0 (Tier 4) NDS PA QL=84 EA/28 Days metronidazole 250mg tab $0 (Tier 1) metronidazole 375mg cap $0 (Tier 2) metronidazole 500mg tab $0 (Tier 1) metronidazole 5mg/ml inj $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 53 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) pentamidine isethionate 300mg inj $0 (Tier 2) pentamidine isethionate 50mg/ml inh soln $0 (Tier 2) B/D tinidazole 250mg tab $0 (Tier 2) tinidazole 500mg tab $0 (Tier 2) trimethoprim 100mg tab $0 (Tier 1) XIFAXAN 200MG TAB $0 (Tier 4) QL=9 EA/3 Days XIFAXAN 550MG TAB $0 (Tier 4) PA QL=60 EA/30 Days ANTI-INFECTIVE MISC. - COMBINATIONS - Miscellaneous anti-infective drug combinations sulfamethoxazole 400mg/trimethoprim 80mg tab $0 (Tier 1) sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp $0 (Tier 2) sulfamethoxazole 800mg/trimethoprim 160mg tab $0 (Tier 1) ANTIPROTOZOAL AGENTS - Drugs to treat protozoan infections ALINIA 100MG/5ML SUSP $0 (Tier 3) PA QL=150 ML/3 Days ALINIA 500MG TAB $0 (Tier 3) PA QL=6 EA/3 Days atovaquone 150mg/ml susp $0 (Tier 2) LAMPIT 120MG TAB $0 (Tier 3) PA LAMPIT 30MG TAB $0 (Tier 3) PA nitazoxanide 500mg tab $0 (Tier 2) PA QL=6 EA/3 Days CARBAPENEMS - Drugs to treat bacterial infections CILASTATIN 250MG/IMIPENEM 250MG INJ $0 (Tier 2) cilastatin 500mg/imipenem 500mg inj $0 (Tier 2) ertapenem 1000mg inj $0 (Tier 2) meropenem 1000mg inj $0 (Tier 2) meropenem 500mg inj $0 (Tier 2) CYCLIC LIPOPEPTIDES - Drugs to treat bacterial infections daptomycin 500mg inj $0 (Tier 4) NDS GLYCOPEPTIDES - Drugs to treat bacterial infections DALVANCE 500MG INJ $0 (Tier 4) NDS FIRVANQ 25MG/ML ORAL SOLN $0 (Tier 2) FIRVANQ 50MG/ML ORAL SOLN $0 (Tier 2) vancomycin 1000mg inj $0 (Tier 2) vancomycin 100mg/ml inj $0 (Tier 2) vancomycin 125mg cap $0 (Tier 2) QL=120 EA/30 Days vancomycin 250mg cap $0 (Tier 2) QL=120 EA/30 Days VANCOMYCIN 250MG INJ $0 (Tier 2) vancomycin 500mg inj $0 (Tier 2) vancomycin 750mg inj $0 (Tier 2) LEPROSTATICS - Drugs to treat Leprosy (bacterial infections) dapsone 100mg tab $0 (Tier 2) dapsone 25mg tab $0 (Tier 2) LINCOSAMIDES - Drugs to treat bacterial infections clindamycin 12mg/ml inj $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 54 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) clindamycin 150mg cap $0 (Tier 1) clindamycin 150mg/ml (2ml) inj $0 (Tier 2) clindamycin 150mg/ml (4ml) inj $0 (Tier 2) clindamycin 150mg/ml (6ml) inj $0 (Tier 2) clindamycin 15mg/ml oral soln $0 (Tier 2) clindamycin 18mg/ml inj $0 (Tier 2) clindamycin 300mg cap $0 (Tier 1) clindamycin 6mg/ml inj $0 (Tier 2) clindamycin 75mg cap $0 (Tier 1) MONOBACTAMS - Drugs to treat bacterial infections aztreonam 1000mg inj $0 (Tier 2) CAYSTON 75MG INH SOLN $0 (Tier 4) NDS PA OXAZOLIDINONES - Drugs to treat bacterial infections linezolid 20mg/ml susp $0 (Tier 2) linezolid 2mg/ml inj $0 (Tier 2) linezolid 600mg tab $0 (Tier 2) SIVEXTRO 200MG INJ $0 (Tier 4) NDS PA QL=6 EA/6 Days SIVEXTRO 200MG TAB $0 (Tier 4) NDS PA QL=6 EA/6 Days PLEUROMUTILINS - drugs to treat infections XENLETA 600MG TAB $0 (Tier 3) PA QL=14 EA/7 Days POLYMYXINS - Drugs to treat bacterial infections colistin 75mg/ml inj $0 (Tier 2) polymyxin b 250000unit/ml inj $0 (Tier 2) URINARY ANTI-INFECTIVES - Drugs to treat bladder/kidney infections fosfomycin 3000mg powder for oral soln $0 (Tier 2) ANTIMALARIALS - Drugs to treat malaria (parasitic infections) ANTIMALARIAL COMBINATIONS - Drugs to treat malaria (parasitic infections) atovaquone 250mg/proguanil 100mg tab $0 (Tier 2) atovaquone 62.5mg/proguanil 25mg tab $0 (Tier 2) COARTEM 20-120MG TAB $0 (Tier 3) QL=24 EA/3 Days ANTIMALARIALS - Drugs to treat malaria (parasitic infections) CHLOROQUINE PHOSPHATE 250MG TAB $0 (Tier 3) chloroquine phosphate 500mg tab $0 (Tier 2) hydroxychloroquine sulfate 200mg tab $0 (Tier 2) KRINTAFEL 150MG TAB $0 (Tier 3) MEFLOQUINE 250MG TAB $0 (Tier 3) PRIMAQUINE PHOSPHATE 26.3MG TAB $0 (Tier 1) quinine sulfate 324mg cap $0 (Tier 2) PA ANTIMYASTHENIC/CHOLINERGIC AGENTS - Drugs to treat neurological disorders ANTIMYASTHENIC/CHOLINERGIC AGENTS - Drugs to treat neurological disorders GUANIDINE 125MG TAB $0 (Tier 3) pyridostigmine bromide 12mg/ml oral soln $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 55 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) pyridostigmine bromide 180mg er tab $0 (Tier 2) pyridostigmine bromide 60mg tab $0 (Tier 2) RUZURGI 10MG TAB $0 (Tier 4) NDS PA ANTIMYCOBACTERIAL AGENTS - Drugs to treat Tuberculosis (bacterial infections) ANTIMYCOBACTERIAL AGENTS - Drugs to treat Tuberculosis (bacterial infections) ethambutol 100mg tab $0 (Tier 2) ethambutol 400mg tab $0 (Tier 2) isoniazid 100mg tab $0 (Tier 1) ISONIAZID 10MG/ML ORAL SOLN $0 (Tier 3) isoniazid 300mg tab $0 (Tier 1) PASER D/R 4GM GRANULES $0 (Tier 3) PRETOMANID 200MG TAB $0 (Tier 3) QL=30 EA/30 Days PRIFTIN 150MG TAB $0 (Tier 4) pyrazinamide 500mg tab $0 (Tier 2) rifabutin 150mg cap $0 (Tier 2) rifampin 150mg cap $0 (Tier 2) rifampin 300mg cap $0 (Tier 2) rifampin 600mg inj $0 (Tier 2) SIRTURO 100MG TAB $0 (Tier 4) NDS PA SIRTURO 20MG TAB $0 (Tier 4) NDS PA TRECATOR 250MG TAB $0 (Tier 4) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to treat cancer ALKYLATING AGENTS - Drugs to treat cancer CYCLOPHOSPHAMIDE 25MG CAP $0 (Tier 2) B/D CYCLOPHOSPHAMIDE 25MG TAB $0 (Tier 3) CYCLOPHOSPHAMIDE 50MG CAP $0 (Tier 2) B/D CYCLOPHOSPHAMIDE 50MG TAB $0 (Tier 3) LEUKERAN 2MG TAB $0 (Tier 3) ANTIMETABOLITES - Drugs to treat cancer mercaptopurine 50mg tab $0 (Tier 2) methotrexate 2.5mg tab $0 (Tier 1) methotrexate 25mg/ml (2ml) inj $0 (Tier 1) methotrexate 25mg/ml inj $0 (Tier 1) ONUREG 200MG TAB $0 (Tier 4) NDS PA NSO QL=14 EA/28 Days ONUREG 300MG TAB $0 (Tier 4) NDS PA NSO QL=14 EA/28 Days PURIXAN 2000MG/100ML SUSP $0 (Tier 4) TABLOID 40MG TAB $0 (Tier 3) XATMEP 2.5MG/ML ORAL SOLN $0 (Tier 4) PA ANTINEOPLASTIC - BCL-2 INHIBITORS - Drugs to treat cancer VENCLEXTA 100MG TAB $0 (Tier 4) NDS PA NSO VENCLEXTA 10MG TAB $0 (Tier 3) PA NSO VENCLEXTA 50MG TAB $0 (Tier 3) PA NSO

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 56 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) VENCLEXTA STARTING PACK $0 (Tier 4) NDS PA NSO ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS - Drugs to treat cancer DAURISMO 100MG TAB $0 (Tier 4) NDS PA NSO DAURISMO 25MG TAB $0 (Tier 4) NDS PA NSO ERIVEDGE 150MG CAP $0 (Tier 4) NDS PA NSO ODOMZO 200MG CAP $0 (Tier 4) NDS PA NSO ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS - Drugs to treat cancer abiraterone acetate 250mg tab $0 (Tier 2) QL=120 EA/30 Days anastrozole 1mg tab $0 (Tier 1) bicalutamide 50mg tab $0 (Tier 1) ELIGARD 22.5MG SYRINGE $0 (Tier 4) ELIGARD 30MG SYRINGE $0 (Tier 4) ELIGARD 45MG SYRINGE $0 (Tier 4) ELIGARD 7.5MG SYRINGE $0 (Tier 4) EMCYT 140MG CAP $0 (Tier 3) ERLEADA 60MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days exemestane 25mg tab $0 (Tier 2) FIRMAGON 120MG INJ $0 (Tier 3) PA NSO FIRMAGON 80MG INJ $0 (Tier 3) PA NSO flutamide 125mg cap $0 (Tier 2) letrozole 2.5mg tab $0 (Tier 1) leuprolide acetate 5mg/ml inj $0 (Tier 2) LUPRON 11.25MG SYRINGE $0 (Tier 4) PA NSO LUPRON 22.5MG SYRINGE $0 (Tier 4) PA NSO LUPRON 3.75MG SYRINGE $0 (Tier 4) PA NSO LUPRON 30MG SYRINGE $0 (Tier 4) LUPRON 45MG SYRINGE $0 (Tier 4) PA NSO LUPRON 7.5MG SYRINGE $0 (Tier 4) PA NSO LYSODREN 500MG TAB $0 (Tier 3) megestrol acetate 20mg tab $0 (Tier 2) PA NSO megestrol acetate 40mg tab $0 (Tier 2) PA NSO megestrol acetate 40mg/ml susp $0 (Tier 2) PA megestrol acetate susp 40 mg/ml $0 (Tier 5) PA nilutamide 150mg tab $0 (Tier 4) NDS NUBEQA 300MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days ORGOVYX 120MG TAB $0 (Tier 4) NDS PA NSO QL=32 EA/30 Days SOLTAMOX 10MG/5ML ORAL SOLN $0 (Tier 4) PA NSO tamoxifen 10mg tab $0 (Tier 1) tamoxifen 20mg tab $0 (Tier 1) toremifene 60mg tab $0 (Tier 2) TRELSTAR 11.25MG INJ $0 (Tier 4) TRELSTAR 22.5MG INJ $0 (Tier 4) TRELSTAR 3.75MG INJ $0 (Tier 4) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 57 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) XTANDI 40MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days ANTINEOPLASTIC - IMMUNOMODULATORS - Drugs to treat cancer POMALYST 1MG CAP $0 (Tier 4) NDS PA NSO POMALYST 2MG CAP $0 (Tier 4) NDS PA NSO POMALYST 3MG CAP $0 (Tier 4) NDS PA NSO POMALYST 4MG CAP $0 (Tier 4) NDS PA NSO ANTINEOPLASTIC - XPO1 INHIBITORS - Drugs to treat cancer XPOVIO 100 MG ONCE WEEKLY $0 (Tier 4) NDS PA NSO QL=32 EA/28 Days XPOVIO 100MG ONCE WEEKLY CARTON (8-PACK) $0 (Tier 4) NDS PA NSO QL=8 EA/28 Days XPOVIO 40MG ONCE WEEKLY CARTON (4-PACK) $0 (Tier 4) NDS PA NSO QL=4 EA/28 Days XPOVIO 40MG ONCE WEEKLY PACK $0 (Tier 4) NDS PA NSO XPOVIO 40MG TWICE WEEKLY CARTON (8-PACK) $0 (Tier 4) NDS PA NSO QL=8 EA/28 Days XPOVIO 40MG TWICE WEEKLY PACK $0 (Tier 4) NDS PA NSO XPOVIO 60 MG ONCE WEEKLY $0 (Tier 4) NDS PA NSO QL=32 EA/28 Days XPOVIO 60MG ONCE WEEKLY CARTON (4-PACK) $0 (Tier 4) NDS PA NSO QL=4 EA/28 Days XPOVIO 60MG TWICE WEEKLY PACK $0 (Tier 4) NDS PA NSO XPOVIO 80 MG ONCE WEEKLY $0 (Tier 4) NDS PA NSO QL=32 EA/28 Days XPOVIO 80 MG TWICE WEEKLY $0 (Tier 4) NDS PA NSO QL=32 EA/28 Days XPOVIO 80MG ONCE WEEKLY CARTON (8-PACK) $0 (Tier 4) NDS PA NSO QL=8 EA/28 Days ANTINEOPLASTIC COMBINATIONS - Drugs to treat cancer INQOVI 5 TABLET PACK $0 (Tier 4) NDS PA NSO QL=5 EA/28 Days KISQALI FEMARA CO-PACK 200 PACK $0 (Tier 4) NDS PA NSO QL=49 EA/28 Days KISQALI FEMARA CO-PACK 400 PACK $0 (Tier 4) NDS PA NSO QL=70 EA/28 Days KISQALI FEMARA CO-PACK 600 PACK $0 (Tier 4) NDS PA NSO QL=91 EA/28 Days LONSURF 6.14-15MG TAB $0 (Tier 4) NDS PA NSO LONSURF 8.19-20MG TAB $0 (Tier 4) NDS PA NSO ANTINEOPLASTIC ENZYME INHIBITORS - Drugs to treat cancer AFINITOR 10MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days AFINITOR 2MG TAB FOR ORAL SUSP $0 (Tier 4) NDS PA NSO AFINITOR 3MG TAB FOR ORAL SUSP $0 (Tier 4) NDS PA NSO AFINITOR 5MG TAB FOR ORAL SUSP $0 (Tier 4) NDS PA NSO ALECENSA 150MG CAP $0 (Tier 4) NDS PA NSO QL=240 EA/30 Days ALUNBRIG 180MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days ALUNBRIG 30MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days ALUNBRIG 90MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days ALUNBRIG INITIATION PACK $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days AYVAKIT 100MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days AYVAKIT 200MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days AYVAKIT 300MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days BALVERSA 3MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days BALVERSA 4MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days BALVERSA 5MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 58 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) BOSULIF 100MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days BOSULIF 400MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days BOSULIF 500MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days BRAFTOVI 75MG CAP $0 (Tier 4) NDS PA NSO QL=180 EA/30 Days BRUKINSA 80MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days CABOMETYX 20MG TAB $0 (Tier 4) NDS PA NSO CABOMETYX 40MG TAB $0 (Tier 4) NDS PA NSO CABOMETYX 60MG TAB $0 (Tier 4) NDS PA NSO CALQUENCE 100MG CAP $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days CAPRELSA 100MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days CAPRELSA 300MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days COMETRIQ 100MG DAILY DOSE CARTON PACK $0 (Tier 4) NDS PA NSO COMETRIQ 140MG DAILY DOSE CARTON PACK $0 (Tier 4) NDS PA NSO COMETRIQ 60MG DAILY DOSE CARTON PACK $0 (Tier 4) NDS PA NSO COPIKTRA 15MG CAP $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days COPIKTRA 25MG CAP $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days COTELLIC 20MG TAB $0 (Tier 4) NDS PA NSO QL=63 EA/28 Days erlotinib 100mg tab $0 (Tier 2) PA NSO QL=90 EA/30 Days erlotinib 150mg tab $0 (Tier 2) PA NSO QL=30 EA/30 Days erlotinib 25mg tab $0 (Tier 2) PA NSO QL=30 EA/30 Days everolimus 2.5mg tab $0 (Tier 2) PA NSO QL=30 EA/30 Days everolimus 5mg tab $0 (Tier 2) PA NSO QL=30 EA/30 Days everolimus 7.5mg tab $0 (Tier 2) PA NSO QL=30 EA/30 Days FARYDAK 10MG CAP $0 (Tier 4) NDS PA NSO FARYDAK 15MG CAP $0 (Tier 4) NDS PA NSO FARYDAK 20MG CAP $0 (Tier 4) NDS PA NSO FOTIVDA 0.89MG CAP $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days FOTIVDA 1.34MG CAP $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days GAVRETO 100MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days GILOTRIF 20MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days GILOTRIF 30MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days GILOTRIF 40MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IBRANCE 100MG CAP $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days IBRANCE 100MG TAB $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG CAP $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG TAB $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG CAP $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG TAB $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days ICLUSIG 10MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days ICLUSIG 15MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days ICLUSIG 30MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days ICLUSIG 45MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IDHIFA 100MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 59 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) IDHIFA 50MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days imatinib 100mg tab $0 (Tier 1) imatinib 400mg tab $0 (Tier 1) IMBRUVICA 140MG CAP $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days IMBRUVICA 140MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IMBRUVICA 280MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IMBRUVICA 420MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IMBRUVICA 560MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days IMBRUVICA 70MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days INLYTA 1MG TAB $0 (Tier 4) NDS PA NSO INLYTA 5MG TAB $0 (Tier 4) NDS PA NSO INREBIC 100MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days IRESSA 250MG TAB $0 (Tier 4) NDS PA NSO JAKAFI 10MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days JAKAFI 15MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days JAKAFI 20MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days JAKAFI 25MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days JAKAFI 5MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days KISQALI 200MG DAILY DOSE PACK $0 (Tier 4) NDS PA NSO QL=21 EA/28 Days KISQALI 400MG DAILY DOSE PACK $0 (Tier 4) NDS PA NSO QL=42 EA/28 Days KISQALI 600MG DAILY DOSE PACK $0 (Tier 4) NDS PA NSO QL=63 EA/28 Days KOSELUGO 10MG CAP $0 (Tier 4) NDS PA NSO KOSELUGO 25MG CAP $0 (Tier 4) NDS PA NSO lapatinib 250mg tab $0 (Tier 4) NDS PA NSO LENVIMA 10 10MG PACK $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days LENVIMA 12 4MG PACK $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days LENVIMA 14 PACK $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days LENVIMA 18 PACK $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days LENVIMA 20 10MG PACK $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days LENVIMA 24 PACK $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days LENVIMA 4 4MG PACK $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days LENVIMA 8 4MG PACK $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days LORBRENA 100MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days LORBRENA 25MG TAB $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days LYNPARZA 100MG TAB $0 (Tier 3) NDS PA NSO QL=120 EA/30 Days LYNPARZA 150MG TAB $0 (Tier 3) NDS PA NSO QL=120 EA/30 Days MEKINIST 0.5MG TAB $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days MEKINIST 2MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days MEKTOVI 15MG TAB $0 (Tier 4) NDS PA NSO QL=180 EA/30 Days NERLYNX 40MG TAB $0 (Tier 4) NDS PA NSO NEXAVAR 200MG TAB $0 (Tier 4) NDS PA NSO NINLARO 2.3MG CAP $0 (Tier 4) NDS PA NSO NINLARO 3MG CAP $0 (Tier 4) NDS PA NSO You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 60 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) NINLARO 4MG CAP $0 (Tier 4) NDS PA NSO PEMAZYRE 13.5MG TAB $0 (Tier 4) NDS PA NSO QL=14 EA/21 Days PEMAZYRE 4.5MG TAB $0 (Tier 4) NDS PA NSO QL=14 EA/21 Days PEMAZYRE 9MG TAB $0 (Tier 4) NDS PA NSO QL=14 EA/21 Days PIQRAY 200MG DAILY DOSE PACK $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days PIQRAY 250MG DAILY DOSE PACK $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days PIQRAY 300MG DAILY DOSE 150MG PACK $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days QINLOCK 50MG TAB $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days RETEVMO 40MG CAP $0 (Tier 4) NDS PA NSO QL=180 EA/30 Days RETEVMO 80MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days ROZLYTREK 100MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days ROZLYTREK 200MG CAP $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days RUBRACA 200MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days RUBRACA 250MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days RUBRACA 300MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days RYDAPT 25MG CAP $0 (Tier 4) NDS PA NSO SPRYCEL 100MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days SPRYCEL 140MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days SPRYCEL 20MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days SPRYCEL 50MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days SPRYCEL 70MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days SPRYCEL 80MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days STIVARGA 40MG TAB $0 (Tier 4) NDS PA NSO QL=84 EA/28 Days SUTENT 12.5MG CAP $0 (Tier 3) NDS PA NSO SUTENT 25MG CAP $0 (Tier 3) NDS PA NSO SUTENT 37.5MG CAP $0 (Tier 3) NDS PA NSO SUTENT 50MG CAP $0 (Tier 3) NDS PA NSO TABRECTA 150MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days TABRECTA 200MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days TAFINLAR 50MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days TAFINLAR 75MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days TAGRISSO 40MG TAB $0 (Tier 4) NDS PA NSO TAGRISSO 80MG TAB $0 (Tier 4) NDS PA NSO TALZENNA 0.25MG CAP $0 (Tier 3) NDS PA NSO QL=90 EA/30 Days TALZENNA 1MG CAP $0 (Tier 3) NDS PA NSO QL=30 EA/30 Days TASIGNA 150MG CAP $0 (Tier 4) NDS PA NSO TASIGNA 200MG CAP $0 (Tier 4) NDS PA NSO TASIGNA 50MG CAP $0 (Tier 4) NDS PA NSO TAZVERIK 200MG TAB $0 (Tier 4) NDS PA NSO QL=240 EA/30 Days TEPMETKO 225MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days TIBSOVO 250MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days TUKYSA 150MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days TUKYSA 50MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 61 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) TURALIO 200MG CAP $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days UKONIQ 200MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days VERZENIO 100MG TAB $0 (Tier 4) NDS PA NSO QL=56 EA/28 Days VERZENIO 150MG TAB $0 (Tier 4) NDS PA NSO QL=56 EA/28 Days VERZENIO 200MG TAB $0 (Tier 4) NDS PA NSO QL=56 EA/28 Days VERZENIO 50MG TAB $0 (Tier 4) NDS PA NSO QL=56 EA/28 Days VITRAKVI 100MG CAP $0 (Tier 4) NDS PA NSO VITRAKVI 20MG/ML ORAL SOLN $0 (Tier 4) NDS PA NSO VITRAKVI 25MG CAP $0 (Tier 4) NDS PA NSO VIZIMPRO 15MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days VIZIMPRO 30MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days VIZIMPRO 45MG TAB $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days VOTRIENT 200MG TAB $0 (Tier 4) NDS PA NSO QL=120 EA/30 Days XALKORI 200MG CAP $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days XALKORI 250MG CAP $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days XOSPATA 40MG TAB $0 (Tier 4) NDS PA NSO ZEJULA 100MG CAP $0 (Tier 3) NDS PA NSO QL=90 EA/30 Days ZELBORAF 240MG TAB $0 (Tier 4) NDS PA NSO QL=240 EA/30 Days ZOLINZA 100MG CAP $0 (Tier 4) NDS PA NSO ZYDELIG 100MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days ZYDELIG 150MG TAB $0 (Tier 4) NDS PA NSO QL=60 EA/30 Days ZYKADIA 150MG TAB $0 (Tier 4) NDS PA NSO QL=90 EA/30 Days ANTINEOPLASTICS MISC. - Miscellaneous drugs to treat cancer ACTIMMUNE 2000000UNIT/0.5ML INJ $0 (Tier 4) NDS PA NSO bexarotene 75mg cap $0 (Tier 2) PA NSO hydroxyurea 500mg cap $0 (Tier 2) INTRON A 10MU INJ $0 (Tier 3) INTRON A 10MU/ML INJ $0 (Tier 3) INTRON A 18MU INJ $0 (Tier 4) NDS INTRON A 50MU INJ $0 (Tier 4) NDS INTRON A 6000000UNIT/ML INJ $0 (Tier 3) MATULANE 50MG CAP $0 (Tier 4) NDS SYNRIBO 3.5MG INJ $0 (Tier 4) NDS tretinoin 10mg cap $0 (Tier 1) CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS - Drugs to protect against chemotherapy drugs LEUCOVORIN 10MG TAB $0 (Tier 2) LEUCOVORIN 15MG TAB $0 (Tier 2) leucovorin 25mg tab $0 (Tier 2) leucovorin 5mg tab $0 (Tier 2) MESNEX 400MG TAB $0 (Tier 3) ANTIPARKINSON AGENTS - Drugs to treat Parkinson's disease ANTIPARKINSON ANTICHOLINERGICS - Drugs to treat parkinson's disease

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 62 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) benztropine mesylate 2mg tab $0 (Tier 1) trihexyphenidyl 2mg tab $0 (Tier 1) trihexyphenidyl 5mg tab $0 (Tier 1) ANTIPARKINSON DOPAMINERGICS - Drugs to treat parkinson's disease amantadine 10mg/ml oral soln $0 (Tier 2) bromocriptine 2.5mg tab $0 (Tier 2) bromocriptine 5mg cap $0 (Tier 2) carbidopa 10mg/levodopa 100mg odt $0 (Tier 2) carbidopa 10mg/levodopa 100mg tab $0 (Tier 1) carbidopa 25mg/levodopa 100mg er tab $0 (Tier 1) carbidopa 25mg/levodopa 100mg odt $0 (Tier 2) carbidopa 25mg/levodopa 100mg tab $0 (Tier 1) carbidopa 25mg/levodopa 250mg odt $0 (Tier 2) carbidopa 50mg/levodopa 200mg er tab $0 (Tier 1) NEUPRO 1MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days NEUPRO 2MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days NEUPRO 3MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days NEUPRO 4MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days NEUPRO 6MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days NEUPRO 8MG/24HR PATCH $0 (Tier 4) QL=30 EA/30 Days pramipexole 0.125mg tab $0 (Tier 1) pramipexole 0.25mg tab $0 (Tier 1) pramipexole 0.375mg er tab $0 (Tier 2) pramipexole 0.5mg tab $0 (Tier 1) pramipexole 0.75mg er tab $0 (Tier 2) pramipexole 0.75mg tab $0 (Tier 1) pramipexole 1.5mg er tab $0 (Tier 2) pramipexole 1.5mg tab $0 (Tier 1) pramipexole 1mg tab $0 (Tier 1) pramipexole 2.25mg er tab $0 (Tier 2) pramipexole 3.75mg er tab $0 (Tier 2) pramipexole 3mg er tab $0 (Tier 2) pramipexole 4.5mg er tab $0 (Tier 2) ropinirole 0.25mg tab $0 (Tier 1) ropinirole 0.5mg tab $0 (Tier 1) ropinirole 12mg er tab $0 (Tier 2) ropinirole 2mg er tab $0 (Tier 2) ropinirole 3mg tab $0 (Tier 1) ropinirole 4mg er tab $0 (Tier 2) ropinirole 4mg tab $0 (Tier 1) ropinirole 5mg tab $0 (Tier 1) ropinirole 6mg er tab $0 (Tier 2) ropinirole 8mg er tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 63 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to treat Parkinson's disease ANTIPARKINSON ADJUNCTIVE THERAPY - Drugs to treat parkinson's disease carbidopa 25mg tab $0 (Tier 2) NOURIANZ 20MG TAB $0 (Tier 4) PA QL=30 EA/30 Days NOURIANZ 40MG TAB $0 (Tier 4) PA QL=30 EA/30 Days ANTIPARKINSON ANTICHOLINERGICS - Drugs to treat parkinson's disease benztropine mesylate 0.5mg tab $0 (Tier 1) benztropine mesylate 1mg tab $0 (Tier 1) trihexyphenidyl 0.4mg/ml oral soln $0 (Tier 2) ANTIPARKINSON COMT INHIBITORS - Drugs to treat parkinson's disease entacapone 200mg tab $0 (Tier 2) ONGENTYS 25MG CAP $0 (Tier 4) PA QL=30 EA/30 Days ONGENTYS 50MG CAP $0 (Tier 4) PA QL=30 EA/30 Days tolcapone 100mg tab $0 (Tier 2) ANTIPARKINSON DOPAMINERGICS - Drugs to treat parkinson's disease amantadine 100mg cap $0 (Tier 2) amantadine 100mg tab $0 (Tier 2) APOKYN 30MG/3ML CARTRIDGE $0 (Tier 4) NDS CARBIDOPA 12.5MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 50MG TAB CARBIDOPA 18.75MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 75MG TAB CARBIDOPA 25MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 100MG TAB carbidopa 25mg/levodopa 250mg tab $0 (Tier 1) CARBIDOPA 31.25MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 125MG TAB CARBIDOPA 37.5MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 150MG TAB CARBIDOPA 50MG/ENTACAPONE $0 (Tier 3) 200MG/LEVODOPA 200MG TAB ropinirole 1mg tab $0 (Tier 1) ropinirole 2mg tab $0 (Tier 1) ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS - Drugs to treat parkinson's disease rasagiline 0.5mg tab $0 (Tier 2) rasagiline 1mg tab $0 (Tier 2) selegiline 5mg cap $0 (Tier 2) SELEGILINE 5MG TAB $0 (Tier 2) ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to treat mood disorders ANTIMANIC AGENTS - Drugs to treat mental and emotional conditions lithium carbonate 150mg cap $0 (Tier 1) lithium carbonate 300mg cap $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 64 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) lithium carbonate 300mg er tab $0 (Tier 1) lithium carbonate 300mg tab $0 (Tier 1) lithium carbonate 450mg er tab $0 (Tier 1) lithium carbonate 600mg cap $0 (Tier 1) lithium citrate 60mg/ml oral soln $0 (Tier 1) ANTIPSYCHOTICS - MISC. - Miscellaneous anti-psychotic drugs CAPLYTA 42MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days EQUETRO 100MG ER CAP $0 (Tier 4) EQUETRO 200MG ER CAP $0 (Tier 4) EQUETRO 300MG ER CAP $0 (Tier 4) LATUDA 120MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days LATUDA 20MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days LATUDA 40MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days LATUDA 60MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days LATUDA 80MG TAB $0 (Tier 3) ST_NSO QL=30 EA/30 Days NUPLAZID 10MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days NUPLAZID 34MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days VRAYLAR 1.5/3MG MIXED PACK $0 (Tier 4) PA NSO QL=30 EA/30 Days VRAYLAR 1.5MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days VRAYLAR 3MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days VRAYLAR 4.5MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days VRAYLAR 6MG CAP $0 (Tier 4) PA NSO QL=30 EA/30 Days ziprasidone 20mg cap $0 (Tier 1) ziprasidone 20mg inj $0 (Tier 2) ziprasidone 40mg cap $0 (Tier 1) ziprasidone 60mg cap $0 (Tier 1) ziprasidone 80mg cap $0 (Tier 1) BENZISOXAZOLES - Drugs to treat mood disorders FANAPT 10MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 12MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 1MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 2MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 4MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 6MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT 8MG TAB $0 (Tier 4) PA NSO QL=60 EA/30 Days FANAPT TITRATION PACK $0 (Tier 4) PA NSO QL=60 EA/30 Days INVEGA 117MG/0.75ML SYRINGE $0 (Tier 4) QL=.75 ML/30 Days INVEGA 156MG/ML SYRINGE $0 (Tier 4) QL=1 ML/30 Days INVEGA 234MG/1.5ML SYRINGE $0 (Tier 4) QL=1.50 ML/30 Days INVEGA 273MG/0.875ML SYRINGE $0 (Tier 4) QL=.88 ML/90 Days INVEGA 39MG/0.25ML SYRINGE $0 (Tier 4) QL=.25 ML/30 Days INVEGA 410MG/1.315ML SYRINGE $0 (Tier 4) QL=1.32 ML/90 Days INVEGA 546MG/1.75ML SYRINGE $0 (Tier 4) QL=1.75 ML/90 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 65 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) INVEGA 78MG/0.5ML SYRINGE $0 (Tier 4) QL=.50 ML/30 Days INVEGA 819MG/2.625ML SYRINGE $0 (Tier 4) QL=2.63 ML/90 Days paliperidone 1.5mg er tab $0 (Tier 2) PA NSO QL=30 EA/30 Days paliperidone 3mg er tab $0 (Tier 2) PA NSO QL=30 EA/30 Days paliperidone 6mg er tab $0 (Tier 2) PA NSO QL=60 EA/30 Days paliperidone 9mg er tab $0 (Tier 2) PA NSO QL=30 EA/30 Days PERSERIS 120MG SYRINGE $0 (Tier 4) NDS QL=1 EA/30 Days PERSERIS 90MG SYRINGE $0 (Tier 4) NDS QL=1 EA/30 Days RISPERDAL 12.5MG INJ $0 (Tier 4) QL=1 EA/14 Days RISPERDAL 25MG INJ $0 (Tier 4) QL=1 EA/14 Days RISPERDAL 37.5MG INJ $0 (Tier 4) QL=1 EA/14 Days RISPERDAL 50MG INJ $0 (Tier 4) QL=1 EA/14 Days risperidone 0.25mg odt $0 (Tier 2) risperidone 0.25mg tab $0 (Tier 1) risperidone 0.5mg odt $0 (Tier 2) risperidone 0.5mg tab $0 (Tier 1) risperidone 1mg odt $0 (Tier 2) risperidone 1mg tab $0 (Tier 1) risperidone 1mg/ml oral soln $0 (Tier 2) risperidone 2mg odt $0 (Tier 2) risperidone 2mg tab $0 (Tier 1) risperidone 3mg odt $0 (Tier 2) risperidone 3mg tab $0 (Tier 1) risperidone 4mg odt $0 (Tier 2) risperidone 4mg tab $0 (Tier 1) BUTYROPHENONES - Drugs to treat mood disorders haloperidol 0.5mg tab $0 (Tier 1) haloperidol 10mg tab $0 (Tier 1) haloperidol 1mg tab $0 (Tier 1) haloperidol 20mg tab $0 (Tier 1) haloperidol 2mg tab $0 (Tier 1) haloperidol 2mg/ml oral soln $0 (Tier 1) haloperidol 5mg tab $0 (Tier 1) haloperidol 5mg/ml inj $0 (Tier 2) haloperidol decanoate 100mg/ml (1ml) inj $0 (Tier 2) haloperidol decanoate 100mg/ml inj $0 (Tier 2) haloperidol decanoate 50mg/ml inj $0 (Tier 2) haloperidol decanoate 50mg/ml inj $0 (Tier 2) DIBENZAPINES - Drugs to treat mood disorders asenapine 10mg sl tab $0 (Tier 2) PA NSO QL=60 EA/30 Days asenapine 2.5mg sl tab $0 (Tier 2) PA NSO QL=60 EA/30 Days asenapine 5mg sl tab $0 (Tier 2) PA NSO QL=60 EA/30 Days clozapine 100mg odt $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 66 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) clozapine 100mg tab $0 (Tier 2) CLOZAPINE 12.5MG ODT $0 (Tier 2) CLOZAPINE 150MG ODT $0 (Tier 4) CLOZAPINE 200MG ODT $0 (Tier 4) clozapine 200mg tab $0 (Tier 2) clozapine 25mg odt $0 (Tier 2) clozapine 25mg tab $0 (Tier 2) clozapine 50mg tab $0 (Tier 2) loxapine 10mg cap $0 (Tier 2) loxapine 25mg cap $0 (Tier 2) loxapine 50mg cap $0 (Tier 2) loxapine 5mg cap $0 (Tier 2) olanzapine 10mg inj $0 (Tier 2) olanzapine 10mg odt $0 (Tier 2) olanzapine 10mg tab $0 (Tier 1) olanzapine 15mg odt $0 (Tier 2) olanzapine 15mg tab $0 (Tier 1) olanzapine 2.5mg tab $0 (Tier 1) olanzapine 20mg odt $0 (Tier 2) olanzapine 20mg tab $0 (Tier 1) olanzapine 5mg odt $0 (Tier 2) olanzapine 5mg tab $0 (Tier 1) olanzapine 7.5mg tab $0 (Tier 1) quetiapine 100mg tab $0 (Tier 1) quetiapine 150mg er tab $0 (Tier 1) quetiapine 200mg er tab $0 (Tier 1) quetiapine 200mg tab $0 (Tier 1) quetiapine 25mg tab $0 (Tier 1) quetiapine 300mg er tab $0 (Tier 1) quetiapine 300mg tab $0 (Tier 1) quetiapine 400mg er tab $0 (Tier 1) quetiapine 400mg tab $0 (Tier 1) quetiapine 50mg er tab $0 (Tier 1) quetiapine 50mg tab $0 (Tier 1) SECUADO 3.8MG/24HR PATCH $0 (Tier 4) PA NSO QL=30 EA/30 Days SECUADO 5.7MG/24HR PATCH $0 (Tier 4) PA NSO QL=30 EA/30 Days SECUADO 7.6MG/24HR PATCH $0 (Tier 4) PA NSO QL=30 EA/30 Days VERSACLOZ 50MG/ML SUSP $0 (Tier 4) ZYPREXA RELPREVV 210MG INJ $0 (Tier 4) QL=1 EA/14 Days DIHYDROINDOLONES - Drugs to treat mood disorders MOLINDONE 10MG TAB $0 (Tier 4) MOLINDONE 25MG TAB $0 (Tier 4) MOLINDONE 5MG TAB $0 (Tier 4) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 67 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) PHENOTHIAZINES - Drugs to treat mood disorders chlorpromazine 100mg tab $0 (Tier 2) chlorpromazine 10mg tab $0 (Tier 2) chlorpromazine 200mg tab $0 (Tier 2) chlorpromazine 25mg tab $0 (Tier 2) chlorpromazine 50mg tab $0 (Tier 2) compro 25mg rectal supp $0 (Tier 2) FLUPHENAZINE 0.5MG/ML ORAL SOLN $0 (Tier 3) fluphenazine 10mg tab $0 (Tier 3) fluphenazine 1mg tab $0 (Tier 3) fluphenazine 2.5mg tab $0 (Tier 3) FLUPHENAZINE 2.5MG/ML INJ $0 (Tier 3) fluphenazine 5mg tab $0 (Tier 3) FLUPHENAZINE 5MG/ML ORAL SOLN $0 (Tier 3) fluphenazine decanoate 25mg/ml inj $0 (Tier 2) perphenazine 16mg tab $0 (Tier 2) perphenazine 2mg tab $0 (Tier 2) perphenazine 4mg tab $0 (Tier 2) perphenazine 8mg tab $0 (Tier 2) prochlorperazine 10mg tab $0 (Tier 1) prochlorperazine 25mg rectal supp $0 (Tier 2) prochlorperazine 5mg tab $0 (Tier 1) thioridazine 100mg tab $0 (Tier 2) thioridazine 10mg tab $0 (Tier 2) thioridazine 25mg tab $0 (Tier 2) thioridazine 50mg tab $0 (Tier 2) trifluoperazine 10mg tab $0 (Tier 2) trifluoperazine 1mg tab $0 (Tier 2) trifluoperazine 2mg tab $0 (Tier 2) trifluoperazine 5mg tab $0 (Tier 2) QUINOLINONE DERIVATIVES - Drugs to treat mood disorders ABILIFY 300MG INJ $0 (Tier 4) NDS QL=1 EA/30 Days ABILIFY 300MG SYRINGE $0 (Tier 4) NDS QL=1 EA/30 Days ABILIFY 400MG INJ $0 (Tier 4) NDS QL=1 EA/30 Days ABILIFY 400MG SYRINGE $0 (Tier 4) NDS QL=1 EA/30 Days aripiprazole 10mg odt $0 (Tier 2) QL=60 EA/30 Days aripiprazole 10mg tab $0 (Tier 1) aripiprazole 15mg odt $0 (Tier 2) QL=60 EA/30 Days aripiprazole 15mg tab $0 (Tier 1) aripiprazole 1mg/ml oral soln $0 (Tier 2) aripiprazole 20mg tab $0 (Tier 1) aripiprazole 2mg tab $0 (Tier 1) aripiprazole 30mg tab $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 68 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) aripiprazole 5mg tab $0 (Tier 1) ARISTADA 1064MG/3.9ML SYRINGE $0 (Tier 4) QL=4 ML/56 Days ARISTADA 441MG/1.6ML SYRINGE $0 (Tier 4) NDS QL=1.60 ML/28 Days ARISTADA 662MG/2.4ML SYRINGE $0 (Tier 4) NDS QL=2.40 ML/28 Days ARISTADA 675MG/2.4ML SYRINGE $0 (Tier 4) NDS QL=2.40 ML/28 Days ARISTADA 882MG/3.2ML SYRINGE $0 (Tier 4) QL=3.20 ML/28 Days REXULTI 0.25MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days REXULTI 0.5MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days REXULTI 1MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days REXULTI 2MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days REXULTI 3MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days REXULTI 4MG TAB $0 (Tier 4) PA NSO QL=30 EA/30 Days THIOXANTHENES - Drugs to treat mood disorders thiothixene 10mg cap $0 (Tier 2) thiothixene 1mg cap $0 (Tier 2) thiothixene 2mg cap $0 (Tier 2) thiothixene 5mg cap $0 (Tier 2) ANTISEPTICS & DISINFECTANTS - Drugs to treat bacterial infections ANTISEPTICS & DISINFECTANTS - Drugs to treat bacterial infections HYDROGEN PEROXIDE SOLN $0 (Tier 5) hydrogen peroxide soln 3% $0 (Tier 5) CHLORINE ANTISEPTICS - Drugs to treat bacterial infections chlorhexidine gluconate 4% topical soln $0 (Tier 5) CHLORHEXIDINE GLUCONATE LIQUID 2% $0 (Tier 5) CHLORHEXIDINE GLUCONATE LIQUID 4% $0 (Tier 5) chlorhexidine gluconate liquid 4% $0 (Tier 5) DAKIN'S SOLUTION 0.5% $0 (Tier 5) IODINE ANTISEPTICS - Drugs to treat bacterial infections IODINE TINCTURE MILD 2% $0 (Tier 5) IODINE TINCTURE STRONG $0 (Tier 5) povidone-iodine soln 10% $0 (Tier 5) povidone/iodine swab $0 (Tier 5) povidone/iodine topical soln 7.5% $0 (Tier 5) ANTIVIRALS - Drugs to treat viral infection ANTIRETROVIRALS - Drugs to treat viral infections abacavir 20mg/ml oral soln $0 (Tier 2) abacavir 300mg tab $0 (Tier 2) abacavir 300mg/lamivudine 150mg/zidovudine 300mg $0 (Tier 2) tab abacavir 600mg/lamivudine 300mg tab $0 (Tier 2) APTIVUS 100MG/ML ORAL SOLN $0 (Tier 4) APTIVUS 250MG CAP $0 (Tier 4) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 69 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) atazanavir 150mg cap $0 (Tier 2) atazanavir 200mg cap $0 (Tier 2) atazanavir 300mg cap $0 (Tier 2) BIKTARVY 50-200-25MG TAB $0 (Tier 4) CIMDUO 300-300MG TAB $0 (Tier 4) COMPLERA 200-25-300MG TAB $0 (Tier 4) DELSTRIGO 100-300-300MG TAB $0 (Tier 4) DESCOVY 200-25MG TAB $0 (Tier 4) DOVATO 50-300MG TAB $0 (Tier 4) EDURANT 25MG TAB $0 (Tier 4) efavirenz 200mg cap $0 (Tier 2) efavirenz 50mg cap $0 (Tier 2) efavirenz 600mg tab $0 (Tier 2) efavirenz/emtricitabine/tenofovir disoproxil fumarate $0 (Tier 2) 600-200-300mg tab efavirenz/emtricitabine/tenofovir disoproxil fumarate $0 (Tier 4) 600-200-300mg tab efavirenz/lamivudine/tenofovir disoproxil fumarate $0 (Tier 2) 400-300-300mg tab emtricitabine 200mg cap $0 (Tier 2) emtricitabine/tenofovir disoproxil fumarate $0 (Tier 4) 100-150mg tab emtricitabine/tenofovir disoproxil fumarate $0 (Tier 4) 133-200mg tab emtricitabine/tenofovir disoproxil fumarate $0 (Tier 4) 167-250mg tab emtricitabine/tenofovir disoproxil fumarate $0 (Tier 4) 200-300mg tab EMTRIVA 10MG/ML ORAL SOLN $0 (Tier 3) EMTRIVA 200MG CAP $0 (Tier 3) etravirine 100mg tab $0 (Tier 4) etravirine 200mg tab $0 (Tier 4) EVOTAZ 300-150MG TAB $0 (Tier 4) fosamprenavir 700mg tab $0 (Tier 4) FUZEON 90MG INJ $0 (Tier 4) GENVOYA 150-150-200-10MG TAB $0 (Tier 4) INTELENCE 25MG TAB $0 (Tier 4) NDS INVIRASE 500MG TAB $0 (Tier 4) ISENTRESS 100MG CHEW TAB $0 (Tier 3) QL=180 EA/30 Days ISENTRESS 100MG GRANULES FOR ORAL SUSP $0 (Tier 3) ISENTRESS 25MG CHEW TAB $0 (Tier 3) QL=720 EA/30 Days ISENTRESS 400MG TAB $0 (Tier 3) ISENTRESS 600MG TAB $0 (Tier 3) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 70 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) JULUCA 50-25MG TAB $0 (Tier 4) lamivudine 10mg/ml oral soln $0 (Tier 2) lamivudine 150mg tab $0 (Tier 2) lamivudine 150mg/zidovudine 300mg tab $0 (Tier 2) lamivudine 300mg tab $0 (Tier 2) LEXIVA 50MG/ML SUSP $0 (Tier 3) lopinavir 80mg/ml/ritonavir 20mg/ml oral solution $0 (Tier 4) lopinavir-ritonavir 100-25mg tab $0 (Tier 3) lopinavir-ritonavir 200-50mg tab $0 (Tier 4) NEVIRAPINE 100MG ER TAB $0 (Tier 3) nevirapine 10mg/ml susp $0 (Tier 2) nevirapine 200mg tab $0 (Tier 1) nevirapine 400mg er tab $0 (Tier 2) NORVIR 100MG ORAL POWDER $0 (Tier 3) NORVIR 80MG/ML ORAL SOLN $0 (Tier 3) ODEFSEY 200-25-25MG TAB $0 (Tier 4) PIFELTRO 100MG TAB $0 (Tier 4) PREZCOBIX 150-800MG TAB $0 (Tier 4) PREZISTA 100MG/ML SUSP $0 (Tier 3) PREZISTA 150MG TAB $0 (Tier 3) PREZISTA 600MG TAB $0 (Tier 4) PREZISTA 75MG TAB $0 (Tier 3) PREZISTA 800MG TAB $0 (Tier 4) REYATAZ 50MG ORAL POWDER $0 (Tier 4) ritonavir 100mg tab $0 (Tier 2) RUKOBIA 600MG ER TAB $0 (Tier 4) SELZENTRY 150MG TAB $0 (Tier 4) QL=60 EA/30 Days SELZENTRY 20MG/ML ORAL SOLN $0 (Tier 4) SELZENTRY 25MG TAB $0 (Tier 3) QL=120 EA/30 Days SELZENTRY 300MG TAB $0 (Tier 4) QL=120 EA/30 Days SELZENTRY 75MG TAB $0 (Tier 4) QL=60 EA/30 Days STRIBILD 150-150-200-300MG TAB $0 (Tier 4) SYMFI 400-300-300MG TAB $0 (Tier 3) SYMFI 600-300-300MG TAB $0 (Tier 3) SYMTUZA 800-150-200-10MG TAB $0 (Tier 4) TEMIXYS 300-300MG TAB $0 (Tier 4) tenofovir disoproxil fumarate 300mg tab $0 (Tier 2) TIVICAY 10MG TAB $0 (Tier 4) TIVICAY 25MG TAB $0 (Tier 4) TIVICAY 50MG TAB $0 (Tier 4) TIVICAY 5MG TAB FOR ORAL SUSP $0 (Tier 3) TRIUMEQ 600-50-300MG TAB $0 (Tier 4) TYBOST 150MG TAB $0 (Tier 3) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 71 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) VIRACEPT 250MG TAB $0 (Tier 4) VIRACEPT 625MG TAB $0 (Tier 4) VIREAD 150MG TAB $0 (Tier 4) VIREAD 200MG TAB $0 (Tier 4) VIREAD 250MG TAB $0 (Tier 4) VIREAD 40MG/GM ORAL POWDER $0 (Tier 3) zidovudine 100mg cap $0 (Tier 2) zidovudine 10mg/ml oral soln $0 (Tier 2) zidovudine 300mg tab $0 (Tier 2) CMV AGENTS - Drugs to treat viral infections PREVYMIS 240MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days PREVYMIS 480MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days valganciclovir 450mg tab $0 (Tier 3) NDS valganciclovir 50mg/ml oral soln $0 (Tier 4) NDS HEPATITIS AGENTS - Drugs to treat viral infections adefovir dipivoxil 10mg tab $0 (Tier 2) entecavir 0.5mg tab $0 (Tier 2) entecavir 1mg tab $0 (Tier 2) EPIVIR HBV 5MG/ML ORAL SOLN $0 (Tier 3) lamivudine 100mg tab $0 (Tier 2) MAVYRET 100-40MG TAB $0 (Tier 3) NDS PA QL=90 EA/30 Days PEGASYS 180MCG/0.5ML SYRINGE $0 (Tier 4) NDS PEGASYS 180MCG/ML INJ $0 (Tier 4) NDS ribavirin 200mg cap $0 (Tier 1) ribavirin 200mg tab $0 (Tier 1) SOFOSBUVIR 400MG/VELPATASVIR 100MG TAB $0 (Tier 3) NDS PA QL=30 EA/30 Days VEMLIDY 25MG TAB $0 (Tier 4) NDS HERPES AGENTS - Drugs to treat viral infections acyclovir 200mg cap $0 (Tier 1) acyclovir 400mg tab $0 (Tier 1) acyclovir 40mg/ml susp $0 (Tier 2) acyclovir 50mg/ml inj $0 (Tier 2) B/D acyclovir 800mg tab $0 (Tier 1) famciclovir 125mg tab $0 (Tier 2) famciclovir 250mg tab $0 (Tier 2) famciclovir 500mg tab $0 (Tier 2) valacyclovir 1000mg tab $0 (Tier 1) valacyclovir 500mg tab $0 (Tier 1) INFLUENZA AGENTS - Drugs to treat viral infections oseltamivir 30mg cap $0 (Tier 1) QL=84 EA/180 Days oseltamivir 45mg cap $0 (Tier 1) QL=42 EA/180 Days oseltamivir 6mg/ml susp $0 (Tier 2) QL=540 ML/180 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 72 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) oseltamivir 75mg cap $0 (Tier 1) QL=42 EA/180 Days RELENZA 5MG/BLISTER INH $0 (Tier 3) QL=120 EA/30 Days RIMANTADINE 100MG TAB $0 (Tier 3) XOFLUZA 20MG THERAPY PACK $0 (Tier 4) QL=2 EA/30 Days XOFLUZA 40MG THERAPY PACK $0 (Tier 4) QL=2 EA/30 Days ASSORTED CLASSES - Drugs to treat assorted conditions IMMUNOSUPPRESSIVE AGENTS - Drugs to treat disorders of the immune system AZASAN 100MG TAB $0 (Tier 4) B/D AZASAN 75MG TAB $0 (Tier 4) B/D cyclosporine 100mg cap $0 (Tier 2) B/D cyclosporine 25mg cap $0 (Tier 2) B/D cyclosporine modified 100mg cap $0 (Tier 2) B/D cyclosporine modified 25mg cap $0 (Tier 2) B/D gengraf 100mg cap $0 (Tier 2) B/D gengraf 100mg/ml oral soln $0 (Tier 2) B/D gengraf 25mg cap $0 (Tier 2) B/D mycophenolate mofetil 200mg/ml susp $0 (Tier 2) B/D mycophenolate mofetil 250mg cap $0 (Tier 2) B/D mycophenolate mofetil 500mg tab $0 (Tier 2) B/D SANDIMMUNE 100MG/ML ORAL SOLN $0 (Tier 4) B/D sirolimus 0.5mg tab $0 (Tier 2) B/D sirolimus 1mg tab $0 (Tier 2) B/D sirolimus 2mg tab $0 (Tier 2) B/D tacrolimus 0.5mg cap $0 (Tier 1) B/D tacrolimus 1mg cap $0 (Tier 1) B/D tacrolimus 5mg cap $0 (Tier 1) B/D BETA BLOCKERS - Drugs to treat high blood pressure ALPHA-BETA BLOCKERS - Drugs to treat high blood pressure carvedilol 12.5mg tab $0 (Tier 1) carvedilol 25mg tab $0 (Tier 1) carvedilol 3.125mg tab $0 (Tier 1) carvedilol 6.25mg tab $0 (Tier 1) labetalol 100mg tab $0 (Tier 2) labetalol 200mg tab $0 (Tier 2) labetalol 300mg tab $0 (Tier 2) BETA BLOCKERS CARDIO-SELECTIVE - Drugs to treat high blood pressure acebutolol 200mg cap $0 (Tier 1) acebutolol 400mg cap $0 (Tier 1) atenolol 100mg tab $0 (Tier 1) atenolol 25mg tab $0 (Tier 1) atenolol 50mg tab $0 (Tier 1) betaxolol 10mg tab $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 73 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) betaxolol 20mg tab $0 (Tier 1) bisoprolol fumarate 10mg tab $0 (Tier 1) bisoprolol fumarate 5mg tab $0 (Tier 1) metoprolol succinate 100mg er tab $0 (Tier 1) metoprolol succinate 200mg er tab $0 (Tier 1) metoprolol succinate 25mg er tab $0 (Tier 1) metoprolol succinate 50mg er tab $0 (Tier 1) metoprolol tartrate 100mg tab $0 (Tier 1) metoprolol tartrate 25mg tab $0 (Tier 1) metoprolol tartrate 50mg tab $0 (Tier 1) BETA BLOCKERS NON-SELECTIVE - Drugs to treat high blood pressure nadolol 20mg tab $0 (Tier 2) nadolol 40mg tab $0 (Tier 2) nadolol 80mg tab $0 (Tier 2) pindolol 10mg tab $0 (Tier 2) pindolol 5mg tab $0 (Tier 2) propranolol 10mg tab $0 (Tier 1) propranolol 120mg er cap $0 (Tier 2) propranolol 160mg er cap $0 (Tier 2) propranolol 20mg tab $0 (Tier 1) propranolol 40mg tab $0 (Tier 1) PROPRANOLOL 4MG/ML ORAL SOLN $0 (Tier 2) propranolol 60mg er cap $0 (Tier 2) propranolol 60mg tab $0 (Tier 1) propranolol 80mg er cap $0 (Tier 2) propranolol 80mg tab $0 (Tier 1) PROPRANOLOL 8MG/ML ORAL SOLN $0 (Tier 2) sorine 120mg tab $0 (Tier 1) sorine 160mg tab $0 (Tier 1) sorine 240mg tab $0 (Tier 1) sorine 80mg tab $0 (Tier 1) sotalol 120mg tab $0 (Tier 1) sotalol 160mg tab $0 (Tier 1) sotalol 240mg tab $0 (Tier 1) sotalol 80mg tab $0 (Tier 1) sotalol af 120mg tab $0 (Tier 1) sotalol AF 160mg tab $0 (Tier 1) sotalol AF 80mg tab $0 (Tier 1) timolol 10mg tab $0 (Tier 2) timolol 20mg tab $0 (Tier 2) timolol 5mg tab $0 (Tier 2) CALCIUM CHANNEL BLOCKERS - Drugs to treat high blood pressure CALCIUM CHANNEL BLOCKERS - Drugs to treat heart disease You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 74 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) amlodipine 10mg tab $0 (Tier 1) amlodipine 2.5mg tab $0 (Tier 1) amlodipine 5mg tab $0 (Tier 1) cartia 120mg er cap $0 (Tier 2) cartia 180mg er cap $0 (Tier 2) cartia 240mg er cap $0 (Tier 2) cartia 300mg er cap $0 (Tier 2) DILT 120MG ER CAP $0 (Tier 2) DILT 180MG ER CAP $0 (Tier 2) DILT 240MG ER CAP $0 (Tier 2) diltiazem 120mg er (12 hr) cap $0 (Tier 2) diltiazem 120mg er (24 hr) cap $0 (Tier 2) diltiazem 120mg tab $0 (Tier 1) diltiazem 180mg er cap $0 (Tier 2) diltiazem 180mg er tab $0 (Tier 2) diltiazem 240mg er cap $0 (Tier 2) diltiazem 240mg er tab $0 (Tier 2) diltiazem 300mg er cap $0 (Tier 2) diltiazem 300mg er tab $0 (Tier 2) diltiazem 30mg tab $0 (Tier 1) diltiazem 360mg er cap $0 (Tier 2) diltiazem 360mg er tab $0 (Tier 2) diltiazem 420mg er cap $0 (Tier 2) diltiazem 60mg er cap $0 (Tier 2) diltiazem 60mg tab $0 (Tier 1) diltiazem 90mg er cap $0 (Tier 2) diltiazem 90mg tab $0 (Tier 1) felodipine 10mg er tab $0 (Tier 1) felodipine 2.5mg er tab $0 (Tier 1) felodipine 5mg er tab $0 (Tier 1) isradipine 2.5mg cap $0 (Tier 2) isradipine 5mg cap $0 (Tier 2) matzim 180mg er tab $0 (Tier 2) matzim 240mg er tab $0 (Tier 2) matzim 300mg er tab $0 (Tier 2) matzim 360mg er tab $0 (Tier 2) matzim 420mg er tab $0 (Tier 2) nicardipine 20mg cap $0 (Tier 2) nicardipine 30mg cap $0 (Tier 2) nifedipine 30mg er tab $0 (Tier 2) nifedipine 30mg osmotic er tab $0 (Tier 2) nifedipine 60mg er tab $0 (Tier 2) nifedipine 60mg osmotic er tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 75 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) nifedipine 90mg er tab $0 (Tier 2) nifedipine 90mg osmotic er tab $0 (Tier 2) nimodipine 30mg cap $0 (Tier 2) nisoldipine 17mg er tab $0 (Tier 2) nisoldipine 20mg er tab $0 (Tier 2) nisoldipine 30mg er tab $0 (Tier 2) nisoldipine 34mg er tab $0 (Tier 2) nisoldipine 40mg er tab $0 (Tier 2) nisoldipine 8.5mg er tab $0 (Tier 2) taztia 120mg er cap $0 (Tier 2) taztia 180mg er cap $0 (Tier 2) taztia 240mg er cap $0 (Tier 2) taztia 300mg er cap $0 (Tier 2) taztia 360mg er cap $0 (Tier 2) tiadylt 120mg er cap $0 (Tier 2) tiadylt 180mg er cap $0 (Tier 2) tiadylt 240mg er cap $0 (Tier 2) tiadylt 300mg er cap $0 (Tier 2) tiadylt 360mg er cap $0 (Tier 2) tiadylt 420mg er cap $0 (Tier 2) VERAPAMIL 100MG ER CAP $0 (Tier 2) verapamil 120mg er cap $0 (Tier 2) verapamil 120mg er tab $0 (Tier 2) verapamil 120mg tab $0 (Tier 1) verapamil 180mg er cap $0 (Tier 2) verapamil 180mg er tab $0 (Tier 2) VERAPAMIL 200MG ER CAP $0 (Tier 2) verapamil 240mg er cap $0 (Tier 2) verapamil 240mg er tab $0 (Tier 2) VERAPAMIL 300MG ER CAP $0 (Tier 2) VERAPAMIL 360MG ER CAP $0 (Tier 2) verapamil 40mg tab $0 (Tier 1) verapamil 80mg tab $0 (Tier 1) CARDIOTONICS - Drugs to treat heart failure and abnormal heart rhythm CARDIAC GLYCOSIDES - Drugs to treat heart failure and abnormal heart rhythm digitek 0.125mg tab $0 (Tier 2) digitek 0.25mg tab $0 (Tier 2) digox 125mcg tab $0 (Tier 2) digox 250mcg tab $0 (Tier 2) digoxin 0.05mg/ml oral soln $0 (Tier 2) digoxin 0.125mg tab $0 (Tier 2) digoxin 0.25mg tab $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 76 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) CARDIOVASCULAR AGENTS - MISC. - Drugs to treat heart and circulation conditions CARDIOVASCULAR AGENTS MISC. - COMBINATIONS - Miscellaneous cardiovascular combination drugs amlodipine 10mg/atorvastatin 10mg tab $0 (Tier 2) amlodipine 10mg/atorvastatin 20mg tab $0 (Tier 2) amlodipine 10mg/atorvastatin 40mg tab $0 (Tier 2) amlodipine 10mg/atorvastatin 80mg tab $0 (Tier 2) amlodipine 2.5mg/atorvastatin 10mg tab $0 (Tier 2) amlodipine 2.5mg/atorvastatin 20mg tab $0 (Tier 2) amlodipine 2.5mg/atorvastatin 40mg tab $0 (Tier 2) amlodipine 5mg/atorvastatin 10mg tab $0 (Tier 2) amlodipine 5mg/atorvastatin 20mg tab $0 (Tier 2) amlodipine 5mg/atorvastatin 40mg tab $0 (Tier 2) amlodipine 5mg/atorvastatin 80mg tab $0 (Tier 2) BIDIL 37.5-20MG TAB $0 (Tier 3) ENTRESTO 24-26MG TAB $0 (Tier 3) QL=60 EA/30 Days ENTRESTO 49-51MG TAB $0 (Tier 3) QL=60 EA/30 Days ENTRESTO 97-103MG TAB $0 (Tier 3) QL=60 EA/30 Days PERIPHERAL VASODILATORS - Drugs to treat heart and circulation conditions niacin cap 500mg $0 (Tier 5) PROSTAGLANDIN VASODILATORS - Drugs to treat pulmonary hypertension ORENITRAM 0.125MG ER TAB $0 (Tier 3) PA ORENITRAM 0.25MG ER TAB $0 (Tier 4) NDS PA ORENITRAM 1MG ER TAB $0 (Tier 4) NDS PA ORENITRAM 2.5MG ER TAB $0 (Tier 4) NDS PA ORENITRAM 5MG ER TAB $0 (Tier 4) NDS PA VENTAVIS 10MCG/ML INH SOLN $0 (Tier 4) NDS PA VENTAVIS 20MCG/ML INH SOLN $0 (Tier 4) NDS PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS - Drugs to treat pulmonary hypertension ambrisentan 10mg tab $0 (Tier 2) PA QL=30 EA/30 Days ambrisentan 5mg tab $0 (Tier 2) PA QL=30 EA/30 Days bosentan 125mg tab $0 (Tier 2) PA QL=60 EA/30 Days bosentan 62.5mg tab $0 (Tier 2) PA QL=60 EA/30 Days OPSUMIT 10MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days TRACLEER 32MG TAB FOR ORAL SUSP $0 (Tier 4) NDS PA QL=120 EA/30 Days PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS - Drugs to treat pulmonary hypertension alyq 20mg tab $0 (Tier 1) PA sildenafil 20mg tab $0 (Tier 1) PA tadalafil 20mg tab $0 (Tier 1) PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 77 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST - Drugs to treat pulmonary hypertension UPTRAVI 1000MCG TAB $0 (Tier 4) NDS PA UPTRAVI 1200MCG TAB $0 (Tier 4) NDS PA UPTRAVI 1400MCG TAB $0 (Tier 4) NDS PA UPTRAVI 1600MCG TAB $0 (Tier 4) NDS PA UPTRAVI 200MCG TAB $0 (Tier 4) NDS PA UPTRAVI 400MCG TAB $0 (Tier 4) NDS PA UPTRAVI 600MCG TAB $0 (Tier 4) NDS PA UPTRAVI 800MCG TAB $0 (Tier 4) NDS PA UPTRAVI TITRATION PACK $0 (Tier 4) NDS PA QL=200 EA/28 Days PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR - Drugs to treat pulmonary hypertension ADEMPAS 0.5MG TAB $0 (Tier 4) NDS PA ADEMPAS 1.5MG TAB $0 (Tier 4) NDS PA ADEMPAS 1MG TAB $0 (Tier 4) NDS PA ADEMPAS 2.5MG TAB $0 (Tier 4) NDS PA ADEMPAS 2MG TAB $0 (Tier 4) NDS PA SINUS NODE INHIBITORS - Drugs to control heart rhythm CORLANOR 5MG TAB $0 (Tier 4) PA CORLANOR 5MG/5ML ORAL SOLN $0 (Tier 4) PA CORLANOR 7.5MG TAB $0 (Tier 4) PA TRANSTHYRETIN STABILIZERS - drugs to treat heart problems due to transthyretin amyloidosis VYNDAMAX 61MG CAP $0 (Tier 4) NDS PA QL=30 EA/30 Days VYNDAQEL 20MG CAP $0 (Tier 4) NDS PA QL=120 EA/30 Days VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) - Drugs to treat heart failure VERQUVO 10MG TAB $0 (Tier 3) PA QL=30 EA/30 Days VERQUVO 2.5MG TAB $0 (Tier 3) PA QL=30 EA/30 Days VERQUVO 5MG TAB $0 (Tier 3) PA QL=30 EA/30 Days CEPHALOSPORINS - Drugs to treat bacterial infections CEPHALOSPORIN COMBINATIONS - Drugs to treat bacterial infections AVYCAZ 500-2000MG INJ $0 (Tier 4) NDS ZERBAXA 1000-500MG INJ $0 (Tier 4) NDS CEPHALOSPORINS - 1ST GENERATION - Drugs to treat bacterial infections cefadroxil 1000mg tab $0 (Tier 2) cefadroxil 100mg/ml susp $0 (Tier 2) cefadroxil 500mg cap $0 (Tier 1) cefadroxil 50mg/ml susp $0 (Tier 2) cefazolin 1000mg inj $0 (Tier 2) cefazolin 200mg/ml inj $0 (Tier 2) cefazolin 500mg inj $0 (Tier 2) cephalexin 250mg cap $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 78 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) cephalexin 25mg/ml susp $0 (Tier 1) cephalexin 500mg cap $0 (Tier 1) cephalexin 50mg/ml susp $0 (Tier 1) CEPHALOSPORINS - 2ND GENERATION - Drugs to treat bacterial infections cefaclor 250mg cap $0 (Tier 2) CEFACLOR 25MG/ML SUSP $0 (Tier 4) cefaclor 500mg cap $0 (Tier 2) CEFACLOR 50MG/ML SUSP $0 (Tier 4) CEFACLOR 75MG/ML SUSP $0 (Tier 4) cefotetan 1000mg inj $0 (Tier 2) cefotetan 2000mg inj $0 (Tier 2) cefoxitin 1000mg inj $0 (Tier 2) cefoxitin 2000mg inj $0 (Tier 2) cefoxitin 200mg/ml inj $0 (Tier 2) cefprozil 250mg tab $0 (Tier 1) cefprozil 25mg/ml susp $0 (Tier 1) cefprozil 500mg tab $0 (Tier 1) cefprozil 50mg/ml susp $0 (Tier 1) cefuroxime 1500mg inj $0 (Tier 2) cefuroxime 250mg tab $0 (Tier 2) cefuroxime 500mg tab $0 (Tier 2) cefuroxime 750mg inj $0 (Tier 2) cefuroxime 95mg/ml inj $0 (Tier 2) CEPHALOSPORINS - 3RD GENERATION - Drugs to treat bacterial infections cefdinir 25mg/ml susp $0 (Tier 1) cefdinir 300mg cap $0 (Tier 1) cefdinir 50mg/ml susp $0 (Tier 1) cefixime 20mg/ml susp $0 (Tier 2) cefixime 400mg cap $0 (Tier 2) cefixime 40mg/ml susp $0 (Tier 2) cefpodoxime 100mg tab $0 (Tier 2) cefpodoxime 10mg/ml susp $0 (Tier 2) cefpodoxime 200mg tab $0 (Tier 2) cefpodoxime 20mg/ml susp $0 (Tier 2) ceftazidime 1000mg inj $0 (Tier 2) ceftazidime 2000mg inj $0 (Tier 2) ceftazidime 200mg/ml inj $0 (Tier 2) ceftriaxone 1000mg inj $0 (Tier 2) ceftriaxone 100mg/ml inj $0 (Tier 2) ceftriaxone 2000mg inj $0 (Tier 2) ceftriaxone 250mg inj $0 (Tier 2) ceftriaxone 500mg inj $0 (Tier 2) tazicef 1gm inj $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 79 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) tazicef 2gm inj $0 (Tier 2) tazicef 6gm inj $0 (Tier 2) CEPHALOSPORINS - 4TH GENERATION - Drugs to treat bacterial infections cefepime 1000mg inj $0 (Tier 2) cefepime 2000mg inj $0 (Tier 2) CEPHALOSPORINS - 5TH GENERATION - Drugs to treat bacterial infections TEFLARO 400MG INJ $0 (Tier 4) NDS TEFLARO 600MG INJ $0 (Tier 4) NDS CHEMICALS - Miscellaneous chemicals LIQUIDS - Miscellaneous liquids GLYCERIN LIQUID $0 (Tier 5) isopropyl alcohol 70% soln $0 (Tier 5) isopropyl alcohol 91% soln $0 (Tier 5) ISOPROPYL ALCOHOL 99% $0 (Tier 5) ISOPROPYL ALCOHOL SOLN 70% $0 (Tier 5) ISOPROPYL ALCOHOL SOLN 91% $0 (Tier 5) isopropyl alcohol soln 99% $0 (Tier 5) CONTRACEPTIVES - Drugs to prevent pregnancy COMBINATION CONTRACEPTIVES - ORAL - Drugs to prevent pregnancy altavera 28 day pack $0 (Tier 2) alyacen 1/35 28 day pack $0 (Tier 2) amethia 91 day pack $0 (Tier 2) apri 28 day pack $0 (Tier 2) aranelle 28 pack $0 (Tier 2) ashlyna 91 day pack $0 (Tier 2) aubra 28 day pack $0 (Tier 2) aviane 28 pack $0 (Tier 2) balziva 28 day pack $0 (Tier 2) blisovi 21 fe 1.5/30 28 day $0 (Tier 2) blisovi 24 fe 1/20 28 day pack $0 (Tier 2) briellyn 28 day pack $0 (Tier 2) camreselo 91 day pack $0 (Tier 2) caziant 28 day pack $0 (Tier 2) cryselle 28 pack $0 (Tier 2) cyclafem 1/35 28 day pack $0 (Tier 2) cyclafem 7/7/7 28 day pack $0 (Tier 2) cyred 28 day pack $0 (Tier 2) desogestrel /ethinyl estradiol 0.15mg-30mcg tab $0 (Tier 2) desogestrel/ethinyl estradiol pack $0 (Tier 2) drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg $0 (Tier 2) pack

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 80 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) drospirenone 3mg/ethinyl estradiol 0.03mg/inert $0 (Tier 2) ingredients 1mg pack emoquette pack $0 (Tier 2) enpresse 28 day pack $0 (Tier 2) enskyce 28 day pack $0 (Tier 2) estarylla 28 day pack $0 (Tier 2) ethinyl estradiol 0.01mg/ethinyl estradiol $0 (Tier 2) 0.02mg/levonorgestrel 0.1mg 91 day pack ethinyl estradiol 0.01mg/ethinyl estradiol $0 (Tier 2) 0.03mg/levonorgestrel 0.15mg pack ethinyl estradiol 0.025mg/ferrous fumarate $0 (Tier 2) 75mg/norethindrone 0.8mg pack ethinyl estradiol 0.025mg/inert/norgestimate $0 (Tier 2) 0.18mg/0.215mg/0.25mg pack ethinyl estradiol 0.02mg/inert ingredients $0 (Tier 2) 1mg/levonorgestrel 0.1mg pack ethinyl estradiol 0.02mg/norethindrone acetate 1mg $0 (Tier 2) pack ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack $0 (Tier 2) ethinyl estradiol 0.035mg/ferrous fumarate $0 (Tier 2) 75mg/norethindrone 0.4mg pack ethinyl estradiol 0.035mg/inert/norgestimate $0 (Tier 2) 0.18mg/0.215mg/0.25mg pack ethinyl estradiol 0.035mg/norgestimate 0.25mg pack $0 (Tier 2) ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel $0 (Tier 2) 0.05mg/ 0.075mg pack ethinyl estradiol 0.03mg/inert ingredients $0 (Tier 2) 1mg/levonorgestrel 0.15mg pack ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 $0 (Tier 2) day pack ethinyl estradiol 0.05mg/ethynodiol 1mg/inert $0 (Tier 2) ingredients 1mg 28 day pack ethinyl estradiol/levonorgestrel 91 day pack $0 (Tier 2) falmina 28 day pack $0 (Tier 2) fayosim 91 day pack $0 (Tier 2) femynor 28 day pack $0 (Tier 2) hailey 24 fe 28 day pack $0 (Tier 2) iclevia 91 day pack $0 (Tier 2) introvale 91 day pack $0 (Tier 2) isibloom 28 day pack $0 (Tier 2) jasmiel 28 day pack $0 (Tier 2) juleber 28 day pack $0 (Tier 2) junel 1.5/30 21 day pack $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 81 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) junel 1/20 21 day pack $0 (Tier 2) junel fe 1.5/30 28 day pack $0 (Tier 2) junel fe 1/20 28 day pack $0 (Tier 2) junel fe 24 1/20 28 day pack $0 (Tier 2) kaitlib fe 28 day pack $0 (Tier 2) kariva 28 day pack $0 (Tier 2) kelnor 1/35 28 day pack $0 (Tier 2) kelnor 1/50 28 day pack $0 (Tier 2) kurvelo pack $0 (Tier 2) larin 1.5/30 pack $0 (Tier 2) larin 1/20 pack $0 (Tier 2) larin fe 1.5/30 pack $0 (Tier 2) larin fe 1/20 pack $0 (Tier 2) larissia 28 day pack $0 (Tier 2) layolis fe 28 pack $0 (Tier 2) leena 28 day pack $0 (Tier 2) lessina 28 day pack $0 (Tier 2) levonest 28 day pack $0 (Tier 2) levora 0.15/30 28 day pack $0 (Tier 2) loryna 28 day pack $0 (Tier 2) low-ogestrel 28 day pack $0 (Tier 2) lutera 28 day pack $0 (Tier 2) marlissa 28 day pack $0 (Tier 2) microgestin 1.5/30 21 day pack $0 (Tier 2) microgestin 1/20 21 day pack $0 (Tier 2) microgestin fe 1.5/30 28 day pack $0 (Tier 2) microgestin fe 1/20 28 day pack $0 (Tier 2) mili 28 day pack $0 (Tier 2) NATAZIA 28 DAY PACK $0 (Tier 4) necon 0.5/35 28 day pack $0 (Tier 2) nikki 28 day pack $0 (Tier 2) nortrel 0.5/35 28 day pack $0 (Tier 2) nortrel 1/35 21 day pack $0 (Tier 2) nortrel 1/35 28 day pack $0 (Tier 2) nortrel 7/7/7 28 day pack $0 (Tier 2) nylia 7/7/7 28 day pack $0 (Tier 2) nymyo 28 day pack $0 (Tier 2) ocella 28 day pack $0 (Tier 2) orsythia 28 day pack $0 (Tier 2) pimtrea pack $0 (Tier 2) pirmella 1/35 28 day pack $0 (Tier 2) portia 28 day pack $0 (Tier 2) previfem 28 day pack $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 82 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) reclipsen 28 day pack $0 (Tier 2) rivelsa 91 day pack $0 (Tier 2) setlakin 91 day pack $0 (Tier 2) sprintec 28 day pack $0 (Tier 2) sronyx 28 day pack $0 (Tier 2) syeda 28 day pack $0 (Tier 2) tarina 24 fe 1/20 28 day pack $0 (Tier 2) tarina fe 1/20 28 day pack $0 (Tier 2) tilia fe pack $0 (Tier 2) tri-estarylla 28 day pack $0 (Tier 2) tri-legest 28 day pack $0 (Tier 2) tri-lo-estarylla 28 day pack $0 (Tier 2) tri-lo-sprintec 28 day pack $0 (Tier 2) tri-mili 28 day pack $0 (Tier 2) tri-nymyo 28 day pack $0 (Tier 2) tri-previfem 28 day pack $0 (Tier 2) tri-sprintec 28 day pack $0 (Tier 2) tri-vylibra 28 day pack $0 (Tier 2) tri-vylibra lo 28 day pack $0 (Tier 2) trivora 28 day pack $0 (Tier 2) velivet 28 day pack $0 (Tier 2) vestura 3-0.02mg pack $0 (Tier 2) vienva 28 day pack $0 (Tier 2) vyfemla 28 day pack $0 (Tier 2) vylibra 28 day pack $0 (Tier 2) wymzya fe 28 day pack $0 (Tier 2) zarah pack $0 (Tier 2) zovia 1/35e 28 day pack $0 (Tier 2) COMBINATION CONTRACEPTIVES - TRANSDERMAL - Drugs to prevent pregnancy xulane 150-35mcg/24hr patch $0 (Tier 2) zafemy 150-35mcg/24hr patch $0 (Tier 2) COMBINATION CONTRACEPTIVES - VAGINAL - Drugs to prevent pregnancy eluryng 0.000625-0.005mg/hr vaginal system $0 (Tier 2) etonogestrel-ethinyl estradiol 0.120-0.015mg/24hr $0 (Tier 2) vaginal ring NUVARING 0.000625-0.005MG/HR VAGINAL $0 (Tier 4) SYSTEM EMERGENCY CONTRACEPTIVES - Drugs to prevent pregnancy levonorgestrel 1.5mg tab $0 (Tier 5) LEVONORGESTREL TAB 1.5 MG $0 (Tier 5) PROGESTIN CONTRACEPTIVES - INJECTABLE - Drugs to replace female hormones medroxyprogesterone acetate 150mg/ml inj $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 83 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) medroxyprogesterone acetate 150mg/ml syringe $0 (Tier 2) PROGESTIN CONTRACEPTIVES - ORAL - Drugs to replace female hormones camila 28 day 0.35mg pack $0 (Tier 2) deblitane 28 day 0.35mg pack $0 (Tier 2) errin 28 day 0.35mg pack $0 (Tier 2) incassia 28 day 0.35mg pack $0 (Tier 2) lyleq 28 day 0.35mg pack $0 (Tier 2) lyza 0.35mg pack $0 (Tier 2) nora-be 28 day 0.35mg pack $0 (Tier 2) norethindrone 0.35mg pack $0 (Tier 2) sharobel 28 day 0.35mg pack $0 (Tier 2) SLYND 4MG PACK $0 (Tier 4) CORTICOSTEROIDS - Drugs to treat systemic swelling conditions GLUCOCORTICOSTEROIDS - Drugs to treat systemic swelling conditions budesonide 3mg dr cap $0 (Tier 2) budesonide 9mg er tab $0 (Tier 2) PA QL=30 EA/30 Days dexamethasone 0.1mg/ml oral soln $0 (Tier 2) dexamethasone 0.5mg tab $0 (Tier 1) dexamethasone 0.75mg tab $0 (Tier 1) dexamethasone 1.5mg tab $0 (Tier 1) DEXAMETHASONE 1MG TAB $0 (Tier 2) DEXAMETHASONE 2MG TAB $0 (Tier 2) dexamethasone 4mg tab $0 (Tier 1) dexamethasone 6mg tab $0 (Tier 1) hydrocortisone 10mg tab $0 (Tier 1) hydrocortisone 20mg tab $0 (Tier 1) hydrocortisone 5mg tab $0 (Tier 1) MEDROL 2MG TAB $0 (Tier 3) B/D methylprednisolone 16mg tab $0 (Tier 2) B/D methylprednisolone 32mg tab $0 (Tier 2) B/D methylprednisolone 4mg pack $0 (Tier 2) methylprednisolone 4mg tab $0 (Tier 2) B/D methylprednisolone 8mg tab $0 (Tier 2) B/D prednisolone 10mg odt $0 (Tier 2) B/D prednisolone 15mg odt $0 (Tier 2) B/D prednisolone 1mg/ml oral soln $0 (Tier 2) B/D prednisolone 2mg/ml oral soln $0 (Tier 2) B/D prednisolone 30mg odt $0 (Tier 2) B/D PREDNISOLONE 3MG/ML ORAL SOLN $0 (Tier 2) B/D prednisolone 4mg/ml oral soln $0 (Tier 2) B/D prednisone 10mg tab $0 (Tier 1) B/D prednisone 1mg tab $0 (Tier 1) B/D PREDNISONE 1MG/ML ORAL SOLN $0 (Tier 2) B/D You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 84 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) prednisone 2.5mg tab $0 (Tier 1) B/D prednisone 20mg tab $0 (Tier 1) B/D prednisone 50mg tab $0 (Tier 1) B/D prednisone 5mg tab $0 (Tier 1) B/D PREDNISONE 5MG/ML ORAL SOLN $0 (Tier 3) B/D MINERALOCORTICOIDS - Drugs to treat systemic swelling conditions fludrocortisone 0.1mg tab $0 (Tier 2) COUGH/COLD/ALLERGY - Drugs to treat cough, cold, and allergy symptoms COUGH/COLD/ALLERGY COMBINATIONS - Drugs to treat cough, cold, and allergy symptoms cetirizine-pseudoephedrine tab sr 12hr 5-120 mg $0 (Tier 5) CLARINEX-D 2.5-120MG ER TAB $0 (Tier 4) dextromethorphan-guaifenesin tab 20-400 mg $0 (Tier 5) loratadine & pseudoephedrine tab er 12hr 5-120 mg $0 (Tier 5) loratadine/pseudoephedrine SR tab (24hr) 10-240mg $0 (Tier 5) PHENYLEPHRINE 1MG/ML/PROMETHAZINE $0 (Tier 2) 1.25MG/ML ORAL SOLN MISC. RESPIRATORY INHALANTS - Miscellaneous respiratory inhalants sodium chloride soln nebu 3% $0 (Tier 5) sodium chloride solution for inhalation $0 (Tier 5) PA MUCOLYTICS - Drugs to treat cough, cold, and allergy symptoms acetylcysteine 100mg/ml inh soln $0 (Tier 2) B/D acetylcysteine 200mg/ml inh soln $0 (Tier 2) B/D DERMATOLOGICALS - Drugs to treat skin conditions ACNE PRODUCTS - Drugs to treat skin conditions accutane 20mg cap $0 (Tier 2) accutane 30mg cap $0 (Tier 2) accutane 40mg cap $0 (Tier 2) adapalene 0.1% cream $0 (Tier 2) PA adapalene 0.1% gel $0 (Tier 2) PA adapalene 0.3% gel $0 (Tier 2) PA adapalene/benzoyl peroxide 0.1-2.5% gel $0 (Tier 2) PA amnesteem 10mg cap $0 (Tier 2) amnesteem 20mg cap $0 (Tier 2) amnesteem 40mg cap $0 (Tier 2) avita 0.025% cream $0 (Tier 2) PA avita 0.025% gel $0 (Tier 2) PA benzoyl peroxide 10% bar $0 (Tier 5) PA benzoyl peroxide 5%/clindamycin phosphate 1.2% $0 (Tier 2) QL=90 GM/30 Days topical gel benzoyl peroxide gel 10% $0 (Tier 5) PA benzoyl peroxide gel 2.5% $0 (Tier 5) PA benzoyl peroxide gel 5% $0 (Tier 5) PA You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 85 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) benzoyl peroxide liq 2.5% $0 (Tier 5) PA BENZOYL PEROXIDE LIQ 6% $0 (Tier 5) PA BENZOYL PEROXIDE LOTION 10% $0 (Tier 5) PA BENZOYL PEROXIDE LOTION 5% $0 (Tier 5) PA BENZOYL PEROXIDE LOTION 9% $0 (Tier 5) PA claravis 10mg cap $0 (Tier 2) claravis 20mg cap $0 (Tier 2) claravis 30mg cap $0 (Tier 2) claravis 40mg cap $0 (Tier 2) clindamycin 1% gel $0 (Tier 2) QL=180 GM/30 Days clindamycin 1% lotion $0 (Tier 2) QL=180 ML/30 Days clindamycin 1% pad $0 (Tier 2) QL=120 EA/30 Days clindamycin 1% topical soln $0 (Tier 2) QL=300 ML/30 Days clindamycin/benzoyl peroxide 1-5% gel $0 (Tier 2) QL=100 GM/30 Days clindamycin/benzoyl peroxide 1.2-2.5% gel $0 (Tier 2) QL=100 GM/30 Days ERY 2% PAD $0 (Tier 2) erythromycin 2% gel $0 (Tier 2) erythromycin 2% topical soln $0 (Tier 2) erythromycin/benzoyl peroxide 5-3% gel $0 (Tier 2) isotretinoin 10mg cap $0 (Tier 2) isotretinoin 20mg cap $0 (Tier 2) isotretinoin 30mg cap $0 (Tier 2) isotretinoin 40mg cap $0 (Tier 2) myorisan 10mg cap $0 (Tier 2) myorisan 20mg cap $0 (Tier 2) myorisan 30mg cap $0 (Tier 2) myorisan 40mg cap $0 (Tier 2) neuac 5-1.2% gel $0 (Tier 2) QL=90 GM/30 Days sulfacetamide sodium 10% lotion $0 (Tier 2) tretinoin 0.01% gel $0 (Tier 2) PA tretinoin 0.025% cream $0 (Tier 2) PA tretinoin 0.025% gel $0 (Tier 2) PA tretinoin 0.04% gel $0 (Tier 2) PA tretinoin 0.05% cream $0 (Tier 2) PA tretinoin 0.05% gel $0 (Tier 2) PA tretinoin 0.1% cream $0 (Tier 2) PA tretinoin 0.1% gel $0 (Tier 2) PA zenatane 10mg cap $0 (Tier 2) zenatane 20mg cap $0 (Tier 2) zenatane 30mg cap $0 (Tier 2) zenatane 40mg cap $0 (Tier 2) ANTIBIOTICS - TOPICAL - Drugs to treat bacterial infections bacitracin ointment 500unit/gm $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 86 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) bacitracin zinc oint 500 unit/gm $0 (Tier 5) bacitracin-polymyxin b oint $0 (Tier 5) gentamicin 0.1% cream $0 (Tier 2) QL=120 GM/30 Days gentamicin 0.1% ointment $0 (Tier 2) QL=120 GM/30 Days mupirocin 2% ointment $0 (Tier 2) QL=220 GM/30 Days neomycin-bacitracin-polymyxin oint $0 (Tier 5) neomycin-polymyxin w/ pramoxine cream 1% $0 (Tier 5) neomycin/bacitracin/polymyxin/pramoxine ointment $0 (Tier 5) 1% NEOSPORIN ORIGINAL OINTMENT $0 (Tier 5) ANTIFUNGALS - TOPICAL - Drugs to treat fungal infections betamethasone/clotrimazole 1-0.05% cream $0 (Tier 2) QL=270 GM/30 Days betamethasone/clotrimazole 1-0.05% lotion $0 (Tier 2) QL=180 ML/30 Days ciclopirox 0.77% cream $0 (Tier 2) QL=270 GM/30 Days ciclopirox 0.77% gel $0 (Tier 2) QL=300 GM/30 Days ciclopirox 0.77% lotion $0 (Tier 2) QL=240 ML/30 Days ciclopirox 1% shampoo $0 (Tier 2) QL=240 ML/30 Days ciclopirox 8% topical soln $0 (Tier 2) QL=13.20 ML/30 Days clotrimazole 1% cream $0 (Tier 5) clotrimazole 1% cream $0 (Tier 2) QL=180 GM/30 Days clotrimazole 1% topical soln $0 (Tier 2) QL=240 ML/30 Days clotrimazole 1% topical soln $0 (Tier 5) CLOVERINE OINTMENT $0 (Tier 5) econazole nitrate 1% cream $0 (Tier 1) QL=255 GM/30 Days ketoconazole 2% cream $0 (Tier 2) QL=240 GM/30 Days ketoconazole 2% shampoo $0 (Tier 1) QL=360 ML/30 Days miconazole nitrate 2% ointment $0 (Tier 5) miconazole nitrate aerosol pow 2% $0 (Tier 5) miconazole nitrate cream 2% $0 (Tier 5) MICONAZOLE NITRATE OINTMENT 2% $0 (Tier 5) miconazole nitrate powder 2% $0 (Tier 5) naftifine 1% cream $0 (Tier 2) QL=270 GM/30 Days naftifine 2% cream $0 (Tier 2) QL=240 GM/30 Days nyamyc 100000unit/gm topical powder $0 (Tier 2) QL=480 GM/30 Days nystatin 100000unit/ml cream $0 (Tier 2) QL=240 GM/30 Days nystatin 100unit/mg ointment $0 (Tier 2) QL=240 GM/30 Days nystatin 100unit/mg topical powder $0 (Tier 2) QL=480 GM/30 Days nystop 100000unit/gm topical powder $0 (Tier 2) QL=480 GM/30 Days oxiconazole 1% cream $0 (Tier 2) QL=270 GM/30 Days tolnaftate aerosol powder 1% $0 (Tier 5) tolnaftate cream 1% $0 (Tier 5) tolnaftate powder 1% $0 (Tier 5) tolnaftate soln 1% $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 87 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ANTIHISTAMINES-TOPICAL - Drugs to treat allergies diphenhydramine hcl soln 2% $0 (Tier 5) ANTI-INFLAMMATORY AGENTS - TOPICAL - Drugs to treat pain and inflammation diclofenac sodium 1% gel $0 (Tier 2) QL=1000 GM/30 Days diclofenac sodium 1.5% topical soln $0 (Tier 2) QL=450 ML/30 Days ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL - Drugs to treat cancer diclofenac sodium 3% gel $0 (Tier 2) PA QL=300 GM/30 Days FLUOROURACIL 2% TOPICAL SOLN $0 (Tier 3) fluorouracil 5% cream $0 (Tier 1) FLUOROURACIL 5% TOPICAL SOLN $0 (Tier 3) PICATO 0.015% GEL $0 (Tier 4) QL=3 EA/10 Days PICATO 0.05% GEL $0 (Tier 4) QL=2 EA/10 Days TARGRETIN 1% GEL $0 (Tier 4) NDS PA NSO VALCHLOR 0.016% GEL $0 (Tier 4) NDS PA NSO QL=240 GM/30 Days ANTIPSORIATICS - Drugs to treat psoriasis acitretin 10mg cap $0 (Tier 2) acitretin 17.5mg cap $0 (Tier 2) acitretin 25mg cap $0 (Tier 2) calcipotriene 0.005% cream $0 (Tier 2) PA QL=240 GM/30 Days calcipotriene 0.005% ointment $0 (Tier 2) PA QL=240 GM/30 Days calcipotriene 0.005% topical soln $0 (Tier 2) PA QL=120 ML/30 Days methoxsalen 10mg cap $0 (Tier 2) SKYRIZI 150MG DOSE PACK 75MG/0.83ML $0 (Tier 3) PA STELARA 45MG/0.5ML INJ $0 (Tier 3) PA STELARA 45MG/0.5ML SYRINGE $0 (Tier 3) PA STELARA 90MG/ML SYRINGE $0 (Tier 3) PA TALTZ 80MG/ML AUTO-INJECTOR $0 (Tier 3) PA TALTZ 80MG/ML SYRINGE $0 (Tier 3) PA tazarotene 0.1% cream $0 (Tier 2) PA TAZORAC 0.05% CREAM $0 (Tier 4) PA TAZORAC 0.05% GEL $0 (Tier 4) PA TAZORAC 0.1% GEL $0 (Tier 4) PA TREMFYA 100MG/ML AUTO-INJECTOR $0 (Tier 3) PA TREMFYA 100MG/ML SYRINGE $0 (Tier 3) PA ANTISEBORRHEIC PRODUCTS - Drugs to treat skin conditions PYRITHIONE ZINC LIQUID 0.25% $0 (Tier 5) selenium sulfide 2.5% shampoo $0 (Tier 1) selenium sulfide lotion 1% $0 (Tier 5) ANTIVIRALS - TOPICAL - Drugs to treat viral infections acyclovir 5% ointment $0 (Tier 2) QL=60 GM/30 Days DENAVIR 1% CREAM $0 (Tier 4) QL=5 GM/7 Days BATH PRODUCTS - Drugs to treat skin conditions

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 88 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) mapo bath oil $0 (Tier 5) BURN PRODUCTS - Drugs to treat burns silver sulfadiazine 1% cream $0 (Tier 2) ssd 1% cream $0 (Tier 2) SULFAMYLON 85MG/GM CREAM $0 (Tier 3) CORTICOSTEROIDS - TOPICAL - Drugs to treat itching and inflammation ala-cort 1% cream $0 (Tier 2) ala-cort 2.5% cream $0 (Tier 2) alclometasone dipropionate 0.05% cream $0 (Tier 2) alclometasone dipropionate 0.05% ointment $0 (Tier 2) betamethasone 0.05% aug cream $0 (Tier 2) betamethasone 0.05% aug lotion $0 (Tier 2) betamethasone 0.05% aug ointment $0 (Tier 2) betamethasone 0.05% cream $0 (Tier 2) BETAMETHASONE 0.05% GEL $0 (Tier 2) betamethasone 0.05% lotion $0 (Tier 2) betamethasone 0.05% ointment $0 (Tier 2) betamethasone 0.1% cream $0 (Tier 2) betamethasone 0.1% lotion $0 (Tier 2) betamethasone 0.1% ointment $0 (Tier 2) calcipotriene/betamethasone 0.005-0.064% ointment $0 (Tier 2) PA QL=420 GM/30 Days clobetasol propionate 0.05% cream $0 (Tier 2) QL=120 GM/30 Days clobetasol propionate 0.05% e cream $0 (Tier 2) QL=120 GM/30 Days clobetasol propionate 0.05% foam $0 (Tier 2) QL=120 GM/30 Days clobetasol propionate 0.05% gel $0 (Tier 2) QL=120 GM/30 Days clobetasol propionate 0.05% lotion $0 (Tier 2) QL=120 ML/30 Days clobetasol propionate 0.05% ointment $0 (Tier 2) QL=120 GM/30 Days clobetasol propionate 0.05% shampoo $0 (Tier 2) QL=120 ML/30 Days clobetasol propionate 0.05% spray $0 (Tier 2) QL=120 ML/30 Days clobetasol propionate 0.05% topical soln $0 (Tier 2) QL=450 ML/30 Days clodan 0.05% shampoo $0 (Tier 2) desonide 0.05% ointment $0 (Tier 2) desoximetasone 0.05% cream $0 (Tier 2) QL=300 GM/30 Days desoximetasone 0.05% gel $0 (Tier 2) QL=240 GM/30 Days desoximetasone 0.25% cream $0 (Tier 2) QL=300 GM/30 Days desoximetasone 0.25% ointment $0 (Tier 2) QL=300 GM/30 Days fluocinolone acetonide 0.01% cream $0 (Tier 2) fluocinolone acetonide 0.01% topical soln $0 (Tier 2) fluocinolone acetonide 0.025% cream $0 (Tier 2) fluocinolone acetonide 0.025% ointment $0 (Tier 2) fluocinolone acetonide 0.1mg/ml oil $0 (Tier 2) fluocinonide 0.05% cream $0 (Tier 1) fluocinonide 0.05% e cream $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 89 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) fluocinonide 0.05% gel $0 (Tier 2) fluocinonide 0.05% ointment $0 (Tier 2) fluocinonide 0.05% topical soln $0 (Tier 2) fluocinonide 0.1% cream $0 (Tier 1) fluticasone propionate 0.005% ointment $0 (Tier 2) fluticasone propionate 0.05% cream $0 (Tier 2) halobetasol propionate 0.05% cream $0 (Tier 2) halobetasol propionate 0.05% ointment $0 (Tier 2) hydrocortisone 1% cream $0 (Tier 2) hydrocortisone 1% lotion(OTC) $0 (Tier 5) hydrocortisone 1% ointment $0 (Tier 5) hydrocortisone 2.5% cream $0 (Tier 2) hydrocortisone 2.5% lotion $0 (Tier 2) hydrocortisone 2.5% ointment $0 (Tier 2) hydrocortisone cream 0.5% $0 (Tier 5) HYDROCORTISONE CREAM 1% $0 (Tier 5) hydrocortisone cream 1% $0 (Tier 5) hydrocortisone ointment 0.5% $0 (Tier 5) hydrocortisone soln 1% $0 (Tier 5) hydrocortisone-aloe vera cream 1% $0 (Tier 5) hydrocortisone/aloe vera cream 0.5% $0 (Tier 5) mometasone furoate 0.1% cream $0 (Tier 2) mometasone furoate 0.1% lotion $0 (Tier 2) mometasone furoate 0.1% ointment $0 (Tier 2) PREDNICARBATE 0.1% OINTMENT $0 (Tier 3) triamcinolone acetonide 0.0147% spray $0 (Tier 2) triamcinolone acetonide 0.025% cream $0 (Tier 2) triamcinolone acetonide 0.025% lotion $0 (Tier 2) triamcinolone acetonide 0.025% ointment $0 (Tier 2) triamcinolone acetonide 0.1% cream $0 (Tier 2) triamcinolone acetonide 0.1% lotion $0 (Tier 2) triamcinolone acetonide 0.1% ointment $0 (Tier 2) triamcinolone acetonide 0.5% cream $0 (Tier 2) triamcinolone acetonide 0.5% ointment $0 (Tier 2) triderm 0.1% cream $0 (Tier 2) triderm 0.5% cream $0 (Tier 2) ECZEMA AGENTS - Drugs to treat eczema DUPIXENT 200MG/1.14ML SYRINGE $0 (Tier 4) NDS PA DUPIXENT 300MG/2ML AUTO-INJECTOR $0 (Tier 4) NDS PA DUPIXENT 300MG/2ML SYRINGE $0 (Tier 4) NDS PA EMOLLIENTS - Drugs to treat skin conditions A+D (topical) ointment $0 (Tier 5) ammonium lactate 12% cream $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 90 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ammonium lactate 12% lotion $0 (Tier 2) emollient ointment $0 (Tier 5) glycerin topical liquid $0 (Tier 5) lactic acid (ammonium lactate) cream 12% $0 (Tier 5) lactic acid (ammonium lactate) lotion 12% $0 (Tier 5) lactic acid lotion 5% $0 (Tier 5) PETROLATUM OINTMENT $0 (Tier 5) thera-derm lotion $0 (Tier 5) VITAMIN A+D CREAM $0 (Tier 5) vitamin E oil $0 (Tier 5) ENZYMES - TOPICAL - Drugs to treat skin conditions SANTYL 250UNIT/GM OINTMENT $0 (Tier 3) QL=90 GM/30 Days IMMUNOMODULATING AGENTS - TOPICAL - Drugs to treat disorders of the immune system imiquimod 5% cream $0 (Tier 2) ZYCLARA 2.5% CREAM $0 (Tier 4) IMMUNOSUPPRESSIVE AGENTS - TOPICAL - Drugs to treat disorders of the immune system pimecrolimus 1% cream $0 (Tier 2) PA tacrolimus 0.03% ointment $0 (Tier 2) PA QL=100 GM/30 Days tacrolimus 0.1% ointment $0 (Tier 2) PA QL=100 GM/30 Days KERATOLYTIC/ANTIMITOTIC AGENTS - Drugs to treat skin conditions podofilox 0.5% topical soln $0 (Tier 2) LOCAL ANESTHETICS - TOPICAL - Drugs for numbing CAPSAICIN CREAM 0.025% $0 (Tier 5) capsaicin cream 0.025% $0 (Tier 5) CAPSAICIN CREAM 0.033% $0 (Tier 5) CAPSAICIN CREAM 0.075% $0 (Tier 5) capsaicin cream 0.1% $0 (Tier 5) lidocaine 4% topical soln $0 (Tier 2) lidocaine 5% ointment $0 (Tier 1) QL=107 GM/30 Days lidocaine 5% patch $0 (Tier 2) PA QL=90 EA/30 Days lidocaine/prilocaine 2.5-2.5% cream $0 (Tier 2) QL=60 GM/30 Days MISC. TOPICAL - Miscellaneous topical products AMERIDERM PERISHIELD OINTMENT $0 (Tier 5) CALAMINE LOTION $0 (Tier 5) CALAMINE/ZINC OXIDE CREAM 2-12% $0 (Tier 5) CALAMINE/ZINC OXIDE LOTION 8-8% $0 (Tier 5) INSTACLEAN LIQUID $0 (Tier 5) lanolin cream $0 (Tier 5) lanolin ointment $0 (Tier 5) MINERAL OIL LIGHT $0 (Tier 5) REMEDY CALAZIME PROTECT PASTE $0 (Tier 5) skin protectants misc - cream $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 91 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) skin protectants ointment $0 (Tier 5) skin protectants, misc. lotion $0 (Tier 5) witch hazel liquid $0 (Tier 5) ZINC OXIDE CREAM 12% $0 (Tier 5) zinc oxide ointment 10% $0 (Tier 5) zinc oxide ointment 20% $0 (Tier 5) ZINC OXIDE PASTE 25% $0 (Tier 5) PIGMENTING-DEPIGMENTING AGENTS - drugs to treat skin discoloration DIHYDROXYACETONE SOLN 6.55% $0 (Tier 5) ROSACEA AGENTS - Drugs to treat skin conditions azelaic acid 15% gel $0 (Tier 2) FINACEA 15% FOAM $0 (Tier 3) metronidazole 0.75% cream $0 (Tier 2) metronidazole 0.75% gel $0 (Tier 2) metronidazole 0.75% lotion $0 (Tier 2) metronidazole 1% gel $0 (Tier 2) SCABICIDES & PEDICULICIDES - Drugs to treat skin conditions lindane 1% shampoo $0 (Tier 2) malathion 0.5% lotion $0 (Tier 2) NIX COMPLETE LICE TREATMENT $0 (Tier 5) permethrin 5% cream $0 (Tier 2) PERMETHRIN CREME RINSE 1% $0 (Tier 5) permethrin creme rinse 1% $0 (Tier 5) permethrin lotion 1% $0 (Tier 5) pyreth-piperonyl butox sham-permeth aero-nit $0 (Tier 5) remover gel kit PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4% $0 (Tier 5) pyrethrins-piperonyl butoxide shampoo 0.3-3% $0 (Tier 5) pyrethrins/piperonyl butoxide shampoo 0.33-4% $0 (Tier 5) WOUND CARE PRODUCTS - Drugs to treat diabetic ulcers REGRANEX 0.01% GEL $0 (Tier 3) QL=30 GM/15 Days DIAGNOSTIC PRODUCTS - Miscellaneous diagnostic test products DIAGNOSTIC TESTS - Miscellaneous diagnostic test products CHEMSTRIP URINE TEST STRIP $0 (Tier 5) DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS - Drugs to treat nutrition condition DIETARY MANAGEMENT PRODUCTS - Drugs to treat nutritional deficiency FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN $0 (Tier 5) TAB 2.2-25-1.3 MG folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg $0 (Tier 5) FOLIC ACID-PYRIDOXINE-CYANOCOBALAMIN $0 (Tier 5) TAB 2.5-25-2MG

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 92 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) L-METHYLFOLATE W/ VIT B6-VIT B12 TAB $0 (Tier 5) 1.13-25-2 MG L-METHYLFOLATE W/ VIT B6-VIT B12 TAB 3-35-2 $0 (Tier 5) MG METAFOLBIC TAB $0 (Tier 5) NUTRITIONAL SUPPLEMENTS - Drugs to treat nutrition deficiency NUTRITIONAL SUPPLEMENT LIQUID $0 (Tier 5) DIGESTIVE AIDS - Drugs to treat low digestive enzymes DIGESTIVE ENZYMES - Drugs to treat low digestive enzymes CREON 120000-76000-24000UNIT DR CAP $0 (Tier 3) CREON 15000-9500-3000UNIT DR CAP $0 (Tier 3) CREON 30000-19000-6000UNIT DR CAP $0 (Tier 3) CREON 36000-114000-180000UNIT DR CAP $0 (Tier 3) CREON 60000-38000-12000UNIT DR CAP $0 (Tier 3) lactase tab 3000 unit $0 (Tier 5) lactase tab 9000 unit $0 (Tier 5) SUCRAID 8500UNIT/ML ORAL SOLN $0 (Tier 4) NDS PA ZENPEP 105000-79000-25000UNIT DR CAP $0 (Tier 4) ST ZENPEP 14000-10000-3000UNIT DR CAP $0 (Tier 4) ST ZENPEP 24000-17000-5000UNIT DR CAP $0 (Tier 4) ST ZENPEP 40000-126000-168000UNIT DR CAP $0 (Tier 4) ST ZENPEP 42000-32000-10000UNIT DR CAP $0 (Tier 4) ST ZENPEP 63000-47000-15000UNIT DR CAP $0 (Tier 4) ST ZENPEP 84000-63000-20000UNIT DR CAP $0 (Tier 4) ST DIURETICS - Drugs to treat heart, circulation conditions, and blood pressure CARBONIC ANHYDRASE INHIBITORS - Drugs to treat high blood pressure acetazolamide 125mg tab $0 (Tier 2) acetazolamide 250mg tab $0 (Tier 2) acetazolamide 500mg er cap $0 (Tier 2) methazolamide 25mg tab $0 (Tier 2) methazolamide 50mg tab $0 (Tier 2) DIURETIC COMBINATIONS - Drugs to treat heart, circulation conditions, and blood pressure amiloride 5mg/hydrochlorothiazide 50mg tab $0 (Tier 1) hydrochlorothiazide 25mg/spironolactone 25mg tab $0 (Tier 2) hydrochlorothiazide 25mg/triamterene 37.5mg cap $0 (Tier 1) hydrochlorothiazide 25mg/triamterene 37.5mg tab $0 (Tier 1) hydrochlorothiazide 50mg/triamterene 75mg tab $0 (Tier 1) LOOP DIURETICS - Drugs to treat heart, circulation conditions, and blood pressure bumetanide 0.25mg/ml inj $0 (Tier 2) bumetanide 0.5mg tab $0 (Tier 2) bumetanide 1mg tab $0 (Tier 2) bumetanide 2mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 93 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ethacrynic acid 25mg tab $0 (Tier 2) furosemide 10mg/ml inj $0 (Tier 2) furosemide 10mg/ml oral soln $0 (Tier 2) furosemide 10mg/ml syringe $0 (Tier 2) furosemide 20mg tab $0 (Tier 1) furosemide 40mg tab $0 (Tier 1) furosemide 80mg tab $0 (Tier 1) FUROSEMIDE 8MG/ML ORAL SOLN $0 (Tier 2) torsemide 100mg tab $0 (Tier 1) torsemide 10mg tab $0 (Tier 1) torsemide 20mg tab $0 (Tier 1) torsemide 5mg tab $0 (Tier 1) POTASSIUM SPARING DIURETICS - Drugs to treat heart, circulation conditions, and blood pressure amiloride 5mg tab $0 (Tier 1) spironolactone 100mg tab $0 (Tier 1) spironolactone 25mg tab $0 (Tier 1) spironolactone 50mg tab $0 (Tier 1) triamterene 100mg cap $0 (Tier 2) triamterene 50mg cap $0 (Tier 2) THIAZIDES AND THIAZIDE-LIKE DIURETICS - Drugs to treat heart, circulation conditions, and blood pressure chlorthalidone 25mg tab $0 (Tier 2) chlorthalidone 50mg tab $0 (Tier 2) DIURIL 250MG/5ML SUSP $0 (Tier 3) hydrochlorothiazide 12.5mg cap $0 (Tier 1) hydrochlorothiazide 12.5mg tab $0 (Tier 1) hydrochlorothiazide 25mg tab $0 (Tier 1) hydrochlorothiazide 50mg tab $0 (Tier 1) indapamide 1.25mg tab $0 (Tier 1) indapamide 2.5mg tab $0 (Tier 1) metolazone 10mg tab $0 (Tier 2) metolazone 2.5mg tab $0 (Tier 2) metolazone 5mg tab $0 (Tier 2) ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to treat bone disease and regulate hormones ADRENAL STEROID INHIBITORS - Drugs to treat Cushing disease ISTURISA 10MG TAB $0 (Tier 4) NDS PA QL=180 EA/30 Days ISTURISA 1MG TAB $0 (Tier 4) NDS PA QL=240 EA/30 Days ISTURISA 5MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days BONE DENSITY REGULATORS - Drugs to treat bone disease ALENDRONIC ACID 0.933MG/ML ORAL SOLN $0 (Tier 4) alendronic acid 10mg tab $0 (Tier 1) QL=30 EA/30 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 94 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) alendronic acid 35mg tab $0 (Tier 1) QL=4 EA/28 Days alendronic acid 70mg tab $0 (Tier 1) QL=4 EA/28 Days FORTEO 600MCG/2.4ML PEN INJ $0 (Tier 4) NDS PA ibandronic acid 150mg tab $0 (Tier 1) QL=1 EA/30 Days NATPARA 100MCG CARTRIDGE $0 (Tier 4) NDS PA NATPARA 25MCG CARTRIDGE $0 (Tier 4) NDS PA NATPARA 50MCG CARTRIDGE $0 (Tier 4) NDS PA NATPARA 75MCG CARTRIDGE $0 (Tier 4) NDS PA PROLIA 60MG/ML SYRINGE $0 (Tier 4) PA risedronate sodium 150mg tab $0 (Tier 2) QL=1 EA/30 Days risedronate sodium 30mg tab $0 (Tier 2) QL=30 EA/30 Days risedronate sodium 35mg (12) pack $0 (Tier 2) QL=4 EA/28 Days risedronate sodium 35mg (4) pack $0 (Tier 2) QL=4 EA/28 Days risedronate sodium 35mg tab $0 (Tier 2) QL=4 EA/28 Days risedronate sodium 5mg tab $0 (Tier 2) QL=30 EA/30 Days salmon calcitonin 200unit/act nasal spray $0 (Tier 2) TYMLOS 3120MCG/1.56ML PEN INJ $0 (Tier 4) NDS PA XGEVA 120MG/1.7ML INJ $0 (Tier 4) NDS PA GNRH/LHRH ANTAGONISTS - Drugs to treat endometriosis ORILISSA 150MG TAB $0 (Tier 3) PA QL=30 EA/30 Days ORILISSA 200MG TAB $0 (Tier 3) PA QL=60 EA/30 Days GROWTH HORMONE RECEPTOR ANTAGONISTS - Drugs to regulate hormones SOMAVERT 10MG INJ $0 (Tier 4) NDS PA SOMAVERT 15MG INJ $0 (Tier 4) NDS PA SOMAVERT 20MG INJ $0 (Tier 4) NDS PA SOMAVERT 25MG INJ $0 (Tier 4) NDS PA SOMAVERT 30MG INJ $0 (Tier 4) NDS PA GROWTH HORMONES - Drugs to regulate hormones GENOTROPIN 0.2MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 0.4MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 0.6MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 0.8MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 1.2MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 1.4MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 1.6MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 1.8MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 12MG CARTRIDGE $0 (Tier 4) NDS PA GENOTROPIN 1MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 2MG SYRINGE $0 (Tier 4) NDS PA GENOTROPIN 5MG CARTRIDGE $0 (Tier 4) NDS PA HORMONE RECEPTOR MODULATORS - Drugs to regulate hormones OSPHENA 60MG TAB $0 (Tier 4) PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 95 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) raloxifene 60mg tab $0 (Tier 2) INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) - Drugs to regulate hormones INCRELEX 40MG/4ML INJ $0 (Tier 4) NDS PA LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS - Drugs to regulate hormones LUPANETA PACK 1-MONTH PACK $0 (Tier 4) NDS LUPANETA PACK 3-MONTH PACK $0 (Tier 4) SYNAREL 2MG/ML NASAL INHALER $0 (Tier 4) NDS METABOLIC MODIFIERS - Drugs to regulate metabolism or hormones calcitriol 0.00025mg cap $0 (Tier 2) calcitriol 0.0005mg cap $0 (Tier 2) calcitriol 0.001mg/ml oral soln $0 (Tier 2) CARBAGLU 200MG TAB FOR ORAL SUSP $0 (Tier 4) PA cinacalcet 30mg tab $0 (Tier 2) cinacalcet 60mg tab $0 (Tier 2) cinacalcet 90mg tab $0 (Tier 2) doxercalciferol 0.0005mg cap $0 (Tier 2) doxercalciferol 0.001mg cap $0 (Tier 2) doxercalciferol 0.0025mg cap $0 (Tier 2) GALAFOLD 28 DAY WALLET 123MG PACK $0 (Tier 4) NDS PA QL=15 EA/30 Days KUVAN 100MG POWDER FOR ORAL SOLN $0 (Tier 4) NDS PA KUVAN 500MG POWDER FOR ORAL SOLN $0 (Tier 4) NDS PA levocarnitine 100mg/ml oral soln $0 (Tier 2) levocarnitine 330mg tab $0 (Tier 2) nitisinone 10mg cap $0 (Tier 4) NDS PA nitisinone 2mg cap $0 (Tier 4) NDS PA nitisinone 5mg cap $0 (Tier 4) NDS PA ORFADIN 20MG CAP $0 (Tier 4) NDS PA ORFADIN 4MG/ML SUSP $0 (Tier 4) NDS PA PALYNZIQ 10MG/0.5ML SYRINGE $0 (Tier 4) NDS PA PALYNZIQ 2.5MG/0.5ML SYRINGE $0 (Tier 4) NDS PA PALYNZIQ 20MG/ML SYRINGE $0 (Tier 4) NDS PA paricalcitol 0.001mg cap $0 (Tier 2) paricalcitol 0.002mg cap $0 (Tier 2) paricalcitol 0.004mg cap $0 (Tier 2) RAVICTI 1.1GM/ML ORAL SOLN $0 (Tier 4) NDS PA sapropterin 100mg powder for oral soln $0 (Tier 4) NDS PA sapropterin 100mg tab $0 (Tier 4) NDS PA sapropterin 500mg powder for oral soln $0 (Tier 4) NDS PA sodium phenylbutyrate 0.94mg/mg oral powder $0 (Tier 2) POSTERIOR PITUITARY HORMONES - Drugs to regulate hormones desmopressin acetate 0.01mg/act nasal spray $0 (Tier 2) desmopressin acetate 0.1mg tab $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 96 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) desmopressin acetate 0.2mg tab $0 (Tier 2) PROLACTIN INHIBITORS - Drugs to regulate hormones cabergoline 0.5mg tab $0 (Tier 2) SOMATOSTATIC AGENTS - Drugs to regulate hormones octreotide 0.05mg/ml inj $0 (Tier 1) octreotide 0.1mg/ml inj $0 (Tier 1) octreotide 0.2mg/ml inj $0 (Tier 1) octreotide 0.5mg/ml inj $0 (Tier 1) octreotide 1mg/ml inj $0 (Tier 1) SIGNIFOR 0.3MG/ML INJ $0 (Tier 4) NDS PA QL=60 ML/30 Days SIGNIFOR 0.6MG/ML INJ $0 (Tier 4) NDS PA QL=60 ML/30 Days SIGNIFOR 0.9MG/ML INJ $0 (Tier 4) NDS PA QL=60 ML/30 Days VASOPRESSIN RECEPTOR ANTAGONISTS - Drugs to regulate hormones JYNARQUE 15MG TAB $0 (Tier 4) NDS PA QL=120 EA/30 Days JYNARQUE 30MG TAB $0 (Tier 4) NDS PA QL=120 EA/30 Days JYNARQUE 45/15 THERAPY PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days JYNARQUE 60/30 THERAPY PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days JYNARQUE 90/30 THERAPY PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days JYNARQUE TAB 15/15MG THERAPY PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days JYNARQUE TAB 30/15MG THERAPY PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days ESTROGENS - Drugs to replace female hormones ESTROGEN COMBINATIONS - Drugs to replace female hormones amabelz 0.5/0.1mg 28 day pack $0 (Tier 2) amabelz 1/0.5mg 28 day pack $0 (Tier 2) COMBIPATCH 0.00208-0.00583MG/HR PATCH $0 (Tier 4) COMBIPATCH 0.00208-0.0104MG/HR PATCH $0 (Tier 4) estradiol 0.5mg/norethindrone acetate 0.1mg pack $0 (Tier 2) estradiol 1mg/norethindrone acetate 0.5mg pack $0 (Tier 2) ethinyl estradiol 0.0025mg/norethindrone acetate $0 (Tier 2) 0.5mg pack ethinyl estradiol 0.005mg/norethindrone acetate 1mg $0 (Tier 2) pack fyavolv 0.0025-0.5mg tab $0 (Tier 2) fyavolv 0.005-1mg tab $0 (Tier 2) jinteli 0.005-1mg tab $0 (Tier 2) mimvey pack $0 (Tier 2) ORIAHNN 28 DAY KIT PACK $0 (Tier 3) PA QL=56 EA/28 Days PREMPHASE 28 DAY PACK $0 (Tier 3) PREMPRO 0.3/1.5MG 28 DAY PACK $0 (Tier 3) PREMPRO 0.45/1.5 28 DAY PACK $0 (Tier 3) PREMPRO 0.625/2.5MG 28 DAY PACK $0 (Tier 3) PREMPRO 0.625/5MG 28 DAY PACK $0 (Tier 3)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 97 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ESTROGENS - Drugs used for contraception dotti 0.025mg/24hr patch $0 (Tier 2) dotti 0.0375mg/24hr patch $0 (Tier 2) dotti 0.05mg/24hr patch $0 (Tier 2) dotti 0.075mg/24hr patch $0 (Tier 2) dotti 0.1mg/24hr patch $0 (Tier 2) estradiol 0.00104mg/hr twice weekly patch $0 (Tier 2) estradiol 0.00104mg/hr weekly patch $0 (Tier 2) estradiol 0.00156mg/hr twice weekly patch $0 (Tier 2) estradiol 0.00156mg/hr weekly patch $0 (Tier 2) estradiol 0.00208mg/hr twice weekly patch $0 (Tier 2) estradiol 0.00208mg/hr weekly patch $0 (Tier 2) estradiol 0.0025mg/hr weekly patch $0 (Tier 2) estradiol 0.00312mg/hr weekly patch $0 (Tier 2) estradiol 0.00313mg/hr twice weekly patch $0 (Tier 2) estradiol 0.00417mg/hr twice weekly patch $0 (Tier 2) estradiol 0.00417mg/hr weekly patch $0 (Tier 2) estradiol 0.5mg tab $0 (Tier 1) estradiol 1mg tab $0 (Tier 1) estradiol 2mg tab $0 (Tier 1) estradiol valerate 20mg/ml inj $0 (Tier 2) estradiol valerate 40mg/ml inj $0 (Tier 2) lyllana 0.025mg/24hr patch $0 (Tier 2) lyllana 0.0375mg/24hr patch $0 (Tier 2) lyllana 0.05mg/24hr patch $0 (Tier 2) lyllana 0.075mg/24hr patch $0 (Tier 2) lyllana 0.1mg/24hr patch $0 (Tier 2) PREMARIN 0.3MG TAB $0 (Tier 3) PREMARIN 0.45MG TAB $0 (Tier 3) PREMARIN 0.625MG TAB $0 (Tier 3) PREMARIN 0.9MG TAB $0 (Tier 3) PREMARIN 1.25MG TAB $0 (Tier 3) FLUOROQUINOLONES - Drugs to treat bacterial infections FLUOROQUINOLONES - Drugs to treat bacterial infections BAXDELA 450MG TAB $0 (Tier 3) PA QL=60 EA/30 Days ciprofloxacin 250mg tab $0 (Tier 1) ciprofloxacin 2mg/ml inj $0 (Tier 2) ciprofloxacin 500mg tab $0 (Tier 1) ciprofloxacin 750mg tab $0 (Tier 1) levofloxacin 250mg tab $0 (Tier 1) levofloxacin 25mg/ml inj $0 (Tier 2) levofloxacin 25mg/ml oral soln $0 (Tier 2) levofloxacin 500mg tab $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 98 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) levofloxacin 5mg/ml (100ml) inj $0 (Tier 2) levofloxacin 5mg/ml (150ml) inj $0 (Tier 2) levofloxacin 750mg tab $0 (Tier 1) moxifloxacin 1.6mg/ml inj $0 (Tier 2) moxifloxacin 400mg tab $0 (Tier 2) ofloxacin 400mg tab $0 (Tier 2) GASTROINTESTINAL AGENTS - MISC. - Miscellaneous gastrointestinal drugs AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) - drugs to treat constipation TRULANCE 3MG TAB $0 (Tier 3) PA QL=30 EA/30 Days ANTIFLATULENTS - Drugs to treat excessive gas simethicone cap 125mg $0 (Tier 5) simethicone cap 180mg $0 (Tier 5) simethicone chew tab 125 mg $0 (Tier 5) simethicone chew tab 80 mg $0 (Tier 5) simethicone liquid 40mg/0.6ml $0 (Tier 5) simethicone susp 40mg/0.6ml $0 (Tier 5) BILE ACID SYNTHESIS DISORDER AGENTS - Drugs to treat bile acid disorders CHOLBAM 250MG CAP $0 (Tier 4) NDS PA CHOLBAM 50MG CAP $0 (Tier 4) NDS PA FARNESOID X RECEPTOR (FXR) AGONISTS - Drugs to treat primary biliary cholangitis OCALIVA 10MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days OCALIVA 5MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days GALLSTONE SOLUBILIZING AGENTS - Drugs to treat bowel, intestine, and stomach conditions CHENODAL 250MG TAB $0 (Tier 4) NDS ursodiol 250mg tab $0 (Tier 1) ursodiol 300mg cap $0 (Tier 2) ursodiol 500mg tab $0 (Tier 1) GASTROINTESTINAL ANTIALLERGY AGENTS - Drugs to treat bowel, intestine, and stomach conditions cromolyn sodium 20mg/ml oral soln $0 (Tier 2) GASTROINTESTINAL STIMULANTS - Drugs to treat bowel, intestine, and stomach conditions metoclopramide 10mg tab $0 (Tier 1) metoclopramide 1mg/ml oral soln $0 (Tier 2) metoclopramide 5mg tab $0 (Tier 1) INFLAMMATORY BOWEL AGENTS - Drugs to treat disorders of the immune system balsalazide disodium 750mg cap $0 (Tier 2) CIMZIA 200MG INJ $0 (Tier 3) PA QL=1 EA/28 Days CIMZIA 200MG/ML SYRINGE $0 (Tier 3) PA QL=1 EA/28 Days DIPENTUM 250MG CAP $0 (Tier 4) mesalamine 1000mg rectal supp $0 (Tier 2) mesalamine 1200mg dr tab $0 (Tier 2) mesalamine 375mg er cap $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 99 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) mesalamine 400mg dr cap $0 (Tier 2) mesalamine 66.7mg/ml enema $0 (Tier 2) mesalamine 800mg dr tab $0 (Tier 2) sulfasalazine 500mg dr tab $0 (Tier 1) sulfasalazine 500mg tab $0 (Tier 1) INTESTINAL ACIDIFIERS - Drugs to treat bowel, intestine, and stomach conditions enulose 10gm/15ml oral soln $0 (Tier 1) generlac 10gm/15ml oral soln $0 (Tier 1) IRRITABLE BOWEL SYNDROME (IBS) AGENTS - Drugs to treat disorders of the immune system alosetron 0.5mg tab $0 (Tier 2) alosetron 1mg tab $0 (Tier 2) VIBERZI 100MG TAB $0 (Tier 4) PA VIBERZI 75MG TAB $0 (Tier 4) PA PERIPHERAL OPIOID RECEPTOR ANTAGONISTS - Drugs to treat overdose or toxicity MOVANTIK 12.5MG TAB $0 (Tier 3) PA MOVANTIK 25MG TAB $0 (Tier 3) PA RELISTOR 12MG/0.6ML INJ $0 (Tier 4) PA RELISTOR 12MG/0.6ML SYRINGE $0 (Tier 4) PA RELISTOR 8MG/0.4ML SYRINGE $0 (Tier 4) PA SYMPROIC 0.2MG TAB $0 (Tier 3) PA PHOSPHATE BINDER AGENTS - Drugs to regulate calcium and phosphorus levels calcium acetate 667mg cap $0 (Tier 2) calcium acetate 667mg tab $0 (Tier 2) lanthanum carbonate 1000mg chew tab $0 (Tier 2) lanthanum carbonate 500mg chew tab $0 (Tier 2) lanthanum carbonate 750mg chew tab $0 (Tier 2) PHOSLYRA 667MG/5ML ORAL SOLN $0 (Tier 3) SEVELAMER 400MG TAB $0 (Tier 3) sevelamer 800mg tab $0 (Tier 3) sevelamer carbonate 2400mg powder for oral susp $0 (Tier 2) sevelamer carbonate 800mg powder for oral susp $0 (Tier 2) sevelamer carbonate 800mg tab $0 (Tier 2) VELPHORO 500MG CHEW TAB $0 (Tier 4) SHORT BOWEL SYNDROME (SBS) AGENTS - Drugs to treat nutrient absorption disorders GATTEX 5MG INJ $0 (Tier 4) NDS PA GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous genitourinary drugs ALKALINIZERS - Drugs to treat low pH potassium and sodium citrates w/citric acid soln $0 (Tier 5) 550-500-334 mg/5ml potassium citrate 10meq er tab $0 (Tier 2) potassium citrate 15meq er tab $0 (Tier 2) potassium citrate 5meq er tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 100 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) CYSTINOSIS AGENTS - Drugs to treat enzyme deficiencies CYSTAGON 150MG CAP $0 (Tier 3) CYSTAGON 50MG CAP $0 (Tier 3) GENITOURINARY IRRIGANTS - Drugs to treat the urinary system sodium chloride 0.154meq/ml soln $0 (Tier 2) INTERSTITIAL CYSTITIS AGENTS - Drugs to treat urinary incontinence ELMIRON 100MG CAP $0 (Tier 3) PROSTATIC HYPERTROPHY AGENTS - Drugs to treat enlarged prostate alfuzosin 10mg er tab $0 (Tier 1) dutasteride 0.5mg cap $0 (Tier 1) dutasteride 0.5mg/tamsulosin 0.4mg cap $0 (Tier 2) finasteride 5mg tab $0 (Tier 1) silodosin 4mg cap $0 (Tier 2) silodosin 8mg cap $0 (Tier 2) tamsulosin 0.4mg cap $0 (Tier 1) URINARY ANALGESICS - Drugs to treat urinary pain phenazopyridine hcl tab 95 mg $0 (Tier 5) URINARY STONE AGENTS - Drugs to prevent kidney stones LITHOSTAT 250MG TAB $0 (Tier 4) THIOLA 100MG DR TAB $0 (Tier 4) THIOLA 300MG DR TAB $0 (Tier 4) tiopronin 100mg tab $0 (Tier 2) GOUT AGENTS - Drugs to treat gout GOUT AGENT COMBINATIONS - Drugs to treat gout colchicine 0.5mg/probenecid 500mg tab $0 (Tier 2) GOUT AGENTS - Drugs to treat gout allopurinol 100mg tab $0 (Tier 1) allopurinol 300mg tab $0 (Tier 1) COLCHICINE 0.6MG CAP $0 (Tier 2) febuxostat 40mg tab $0 (Tier 2) ST febuxostat 80mg tab $0 (Tier 2) ST MITIGARE 0.6MG CAP $0 (Tier 3) URICOSURICS - Drugs to treat gout probenecid 500mg tab $0 (Tier 2) HEMATOLOGICAL AGENTS - MISC. - Drugs to treat blood disorders BRADYKININ B2 RECEPTOR ANTAGONISTS - Drugs to treat systemic swelling conditions icatibant 10mg/ml syringe $0 (Tier 3) NDS PA COMPLEMENT INHIBITORS - Drugs to treat blood disorders BERINERT 500UNIT INJ $0 (Tier 4) NDS PA CINRYZE 500UNIT INJ $0 (Tier 4) NDS PA HAEGARDA 2000UNIT INJ $0 (Tier 4) NDS PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 101 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) HAEGARDA 3000UNIT INJ $0 (Tier 4) NDS PA RUCONEST 2100UNIT INJ $0 (Tier 4) NDS PA HEMATAOLOGIC - TYROSINE KINASE INHIBITORS - Drugs to treat blood disorders TAVALISSE 100MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days TAVALISSE 150MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days HEMATORHEOLOGIC AGENTS - Drugs to treat circulation disorders pentoxifylline 400mg er tab $0 (Tier 1) PLASMA KALLIKREIN INHIBITORS - Drugs to treat systemic swelling conditions TAKHZYRO 300MG/2ML INJ $0 (Tier 4) NDS PA QL=4 ML/28 Days PLATELET AGGREGATION INHIBITORS - Drugs to thin the blood anagrelide 0.5mg cap $0 (Tier 2) anagrelide 1mg cap $0 (Tier 2) aspirin 25mg/dipyridamole 200mg er cap $0 (Tier 2) BRILINTA 60MG TAB $0 (Tier 4) BRILINTA 90MG TAB $0 (Tier 4) cilostazol 100mg tab $0 (Tier 1) cilostazol 50mg tab $0 (Tier 1) clopidogrel 75mg tab $0 (Tier 1) prasugrel 10mg tab $0 (Tier 1) prasugrel 5mg tab $0 (Tier 1) HEMATOPOIETIC AGENTS - Drugs to treat blood disorders AGENTS FOR GAUCHER DISEASE - Drugs to treat blood disorders CERDELGA 84MG CAP $0 (Tier 4) NDS PA QL=60 EA/30 Days miglustat 100mg cap $0 (Tier 4) NDS PA AGENTS FOR SICKLE CELL ANEMIA - Drugs to treat blood disorders DROXIA 200MG CAP $0 (Tier 3) DROXIA 300MG CAP $0 (Tier 3) DROXIA 400MG CAP $0 (Tier 3) ENDARI 5GM POWDER FOR ORAL SOLN $0 (Tier 4) NDS PA QL=180 EA/30 Days OXBRYTA 500MG TAB $0 (Tier 4) NDS PA QL=90 EA/30 Days COBALAMINS - Drugs to treat vitamin deficiency cyanocobalamin inj 1000mcg/ml $0 (Tier 5) CYANOCOBALAMIN LOZENGE 50 MCG $0 (Tier 5) CYANOCOBALAMIN SUBLINGUAL LIQUID 3000 $0 (Tier 5) MCG/ML cyanocobalamin tab 100 mcg $0 (Tier 5) cyanocobalamin tab 500 mcg $0 (Tier 5) CYANOCOBALAMIN TAB ER 5000 MCG $0 (Tier 5) docusate sodium enema 283mg $0 (Tier 5) HYDROXOCOBALAMIN ACETATE INJ 1000 $0 (Tier 5) MCG/ML (BASE EQUIVALENT)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 102 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) METHYLCOBALAMIN ORALLY DISINTEGRATING $0 (Tier 5) TAB 1000 MCG methylcobalamin sl tab 1000 mcg $0 (Tier 5) vitamin B-12 CR tab 1000mg $0 (Tier 5) VITAMIN B-12 LOZENGE 250MCG $0 (Tier 5) vitamin B-12 lozenge 500mcg $0 (Tier 5) vitamin b-12 odt 5000mcg $0 (Tier 5) vitamin B-12 SL tab 2500mcg $0 (Tier 5) vitamin B-12 SL tab 5000mcg $0 (Tier 5) vitamin B-12 SL tab 500mcg $0 (Tier 5) VITAMIN B-12 SUPER STRENGTH LIQUID $0 (Tier 5) 5000MCG/ML vitamin B-12 tab 1000mcg $0 (Tier 5) vitamin B-12 tab 250mcg $0 (Tier 5) FOLIC ACID/FOLATES - Drugs to treat vitamin deficiency FOLIC ACID CAP 20MG $0 (Tier 5) folic acid cap 800mcg $0 (Tier 5) folic acid inj 5mg/ml $0 (Tier 5) folic acid tab 1mg $0 (Tier 5) folic acid tab 400mcg $0 (Tier 5) folic acid tab 800mcg $0 (Tier 5) HEMATOPOIETIC GROWTH FACTORS - Drugs to treat blood disorders DOPTELET 20MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days DOPTELET 40MG DAILY DOSE PACK $0 (Tier 4) NDS PA QL=10 EA/5 Days DOPTELET 60MG DAILY DOSE PACK $0 (Tier 4) NDS PA QL=15 EA/5 Days FULPHILA 6MG/0.6ML SYRINGE $0 (Tier 4) NDS NIVESTYM 300MCG/0.5ML SYRINGE $0 (Tier 4) NDS NIVESTYM 300MCG/ML INJ $0 (Tier 4) NDS NIVESTYM 480MCG/0.8ML SYRINGE $0 (Tier 4) NDS NIVESTYM 480MCG/1.6ML INJ $0 (Tier 4) NDS PROMACTA 12.5MG POWDER FOR ORAL SUSP $0 (Tier 4) NDS PA QL=360 EA/30 Days PROMACTA 12.5MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days PROMACTA 25MG POWDER FOR ORAL SUSP $0 (Tier 4) NDS PA PROMACTA 25MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days PROMACTA 50MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days PROMACTA 75MG TAB $0 (Tier 4) NDS PA QL=30 EA/30 Days RETACRIT 10000UNIT/ML INJ $0 (Tier 3) B/D RETACRIT 20000UNIT/2ML INJ $0 (Tier 3) B/D RETACRIT 20000UNIT/ML INJ $0 (Tier 3) B/D RETACRIT 2000UNIT/ML INJ $0 (Tier 3) B/D RETACRIT 3000UNIT/ML INJ $0 (Tier 3) B/D RETACRIT 40000UNIT/ML INJ $0 (Tier 3) B/D RETACRIT 4000UNIT/ML INJ $0 (Tier 3) B/D You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 103 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ZARXIO 300MCG/0.5ML SYRINGE $0 (Tier 4) NDS ZARXIO 480MCG/0.8ML SYRINGE $0 (Tier 4) NDS ZIEXTENZO 6MG/0.6ML SYRINGE $0 (Tier 4) NDS HEMATOPOIETIC MIXTURES - Drugs to treat blood disorders ABATRON LIQUID $0 (Tier 5) CYANOCOBALAMIN-METHYLCOBALAMIN SL TAB $0 (Tier 5) 600-600 MCG cyanocobalamin-methylcobalamin sl tab 600-600 mcg $0 (Tier 5) FE FUM-FE POLY-FA-C-B3 CAP $0 (Tier 5) 62.5-62.5-1-40-3MG(125 MG FE) FE FUM-FE POLYSAC-C-B3 CAP 62.5-62.5-40-3 MG $0 (Tier 5) (125 MG FE) FE FUM-IRON POLYSACCH COMPLEX-FA-B $0 (Tier 5) COMPLEX-C-BIOTIN CAP FERROUS FUMARATE-FA-B $0 (Tier 5) COMPLEX-C-ZN-MG-MN-CU CAP 106-1 MG ferrous fumarate-folic acid tab 324-1 mg $0 (Tier 5) FERROUS FUMARATE-VIT C TAB ER 65-25 MG $0 (Tier 5) (ELEMENTAL FE) FOLIC + B12 TAB $0 (Tier 5) folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg $0 (Tier 5) folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg $0 (Tier 5) folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg $0 (Tier 5) FOLITAB 500MG $0 (Tier 5) FUSION CAP $0 (Tier 5) FUSION PLUS CAP $0 (Tier 5) HEMOCYTE-F ELIXIR $0 (Tier 5) IRO-PLEX LIQUID $0 (Tier 5) IRO-PLEX TAB $0 (Tier 5) IRON HEME POLYPEPTIDE-FOLIC ACID TAB 12-1 $0 (Tier 5) MG (FE EQUIV) IRON-VITAMIN C TAB 100-250 MG $0 (Tier 5) iron/vitamin C tab 100-250mg $0 (Tier 5) iron/vitamin C/vitamin B12/folic acid tab $0 (Tier 5) IROSPAN TAB $0 (Tier 5) NEPHRON FATAB $0 (Tier 5) POLYSACCH FE COMPLEX-CHOLECALCIFEROL $0 (Tier 5) LIQ 125-100 MG-UNIT/5ML TARON FORTE CAP $0 (Tier 5) vitamin B-12 sl tab $0 (Tier 5) IRON - Drugs to treat iron deficiency CARBONYL IRON CHEW TAB 15 MG (ELEMENTAL $0 (Tier 5) IRON) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 104 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) CARBONYL IRON SUSP 15 MG/1.25ML $0 (Tier 5) (ELEMENTAL IRON) CARBONYL IRON TAB 25 MG (ELEMENTAL IRON) $0 (Tier 5) FERRIMIN TAB 150MG $0 (Tier 5) FERROUS FUMARATE TAB 29MG $0 (Tier 5) ferrous fumarate tab 324 mg (106 mg elemental fe) $0 (Tier 5) FERROUS FUMARTE TAB 325 MG $0 (Tier 5) ferrous gluconate tab 240mg $0 (Tier 5) ferrous gluconate tab 324mg $0 (Tier 5) FERROUS GLUCONATE TAB 324MG $0 (Tier 5) ferrous sulfate CR tab 142mg $0 (Tier 5) ferrous sulfate CR tab 160mg $0 (Tier 5) ferrous sulfate CR tab 45mg $0 (Tier 5) ferrous sulfate dried tab 200 mg (65 mg elemental fe) $0 (Tier 5) FERROUS SULFATE EC TAB 324MG $0 (Tier 5) ferrous sulfate EC tab 325mg $0 (Tier 5) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml $0 (Tier 5) elemental fe) FERROUS SULFATE LIQUID 220 MG/5ML (44 $0 (Tier 5) MG/5ML ELEMENTAL FE) ferrous sulfate oral soln 75mg/ml $0 (Tier 5) FERROUS SULFATE SYRUP 300MG/5ML $0 (Tier 5) ferrous sulfate tab 325mg $0 (Tier 5) HEMOCYTE TAB 324MG $0 (Tier 5) IRON HEME POLYPEPTIDE TAB 12 MG $0 (Tier 5) (ELEMENTAL FE EQUIV) IRON SUCCINYL-PROTEIN COMPLEX SOLN $0 (Tier 5) 40MG/15ML (ELEMENT FE EQ) IRON TAB 256MG $0 (Tier 5) polysaccharide iron complex 150mg cap $0 (Tier 5) POLYSACCHARIDE IRON COMPLEX CAP 391.3 MG $0 (Tier 5) (180 MG ELEM FE) POLYSACCHARIDE IRON COMPLEX CAP 434.8 MG $0 (Tier 5) (200 MG ELEM FE) POLYSACCHARIDE IRON COMPLEX CAP 50 MG $0 (Tier 5) (IRON EQUIVALENT) POLYSACCHARIDE IRON COMPLEX LIQUID 15 $0 (Tier 5) MG/ML (FE EQUIV) HEMOSTATICS - Drugs to stop bleeding/treat blood disorders HEMOSTATICS - SYSTEMIC - Drugs to thin the blood tranexamic acid 650mg tab $0 (Tier 2) HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS - Drugs to treat insomnia

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 105 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ANTIHISTAMINE HYPNOTICS - Drugs to treat insomnia diphenhydramine hcl (sleep) cap 50 mg $0 (Tier 5) diphenhydramine hcl (sleep) liquid 50 mg/30ml $0 (Tier 5) diphenhydramine tab 25mg $0 (Tier 5) diphenhydramine/acetaminophen tab 25-500mg $0 (Tier 5) doxylamine succinate tab 25mg $0 (Tier 5) sleep aid 25mg cap $0 (Tier 5) BARBITURATE HYPNOTICS - Drugs to treat insomnia phenobarbital 100mg tab $0 (Tier 2) phenobarbital 15mg tab $0 (Tier 2) phenobarbital 16.2mg tab $0 (Tier 2) phenobarbital 30mg tab $0 (Tier 2) phenobarbital 32.4mg tab $0 (Tier 2) phenobarbital 4mg/ml oral soln $0 (Tier 2) phenobarbital 60mg tab $0 (Tier 2) phenobarbital 64.8mg tab $0 (Tier 2) phenobarbital 97.2mg tab $0 (Tier 2) NON-BARBITURATE HYPNOTICS - Drugs to treat insomnia estazolam 1mg tab $0 (Tier 2) estazolam 2mg tab $0 (Tier 2) eszopiclone 1mg tab $0 (Tier 1) QL=30 EA/30 Days eszopiclone 2mg tab $0 (Tier 1) QL=30 EA/30 Days eszopiclone 3mg tab $0 (Tier 1) QL=30 EA/30 Days FLURAZEPAM 15MG CAP $0 (Tier 3) FLURAZEPAM 30MG CAP $0 (Tier 3) temazepam 15mg cap $0 (Tier 1) temazepam 22.5mg cap $0 (Tier 2) temazepam 30mg cap $0 (Tier 1) temazepam 7.5mg cap $0 (Tier 2) triazolam 0.125mg tab $0 (Tier 2) triazolam 0.25mg tab $0 (Tier 2) zaleplon 10mg cap $0 (Tier 1) QL=30 EA/30 Days zaleplon 5mg cap $0 (Tier 1) QL=30 EA/30 Days zolpidem tartrate 10mg tab $0 (Tier 1) QL=30 EA/30 Days zolpidem tartrate 5mg tab $0 (Tier 1) QL=60 EA/30 Days SELECTIVE MELATONIN RECEPTOR AGONISTS - Drugs to treat insomnia HETLIOZ 20MG CAP $0 (Tier 4) NDS PA QL=30 EA/30 Days ramelteon 8mg tab $0 (Tier 2) QL=30 EA/30 Days LAXATIVES - Drugs to treat constipation BULK LAXATIVES - Drugs to treat constipation fiber therapy tab 500mg $0 (Tier 5) psyllium cap 0.52gm $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 106 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) psyllium cap 400 mg $0 (Tier 5) psyllium powder 25% $0 (Tier 5) psyllium powder 28% $0 (Tier 5) psyllium powder 28.3% $0 (Tier 5) psyllium powder 30.9% $0 (Tier 5) psyllium powder 43% $0 (Tier 5) psyllium powder 48.57% $0 (Tier 5) psyllium powder 51.7% $0 (Tier 5) psyllium powder 58.6% $0 (Tier 5) psyllium powder 68% $0 (Tier 5) psyllium powder 95% $0 (Tier 5) wheat dextrin oral powder $0 (Tier 5) LAXATIVE COMBINATIONS - Drugs to treat constipation CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN $0 (Tier 3) GAVILYTE-C ORAL SOLN $0 (Tier 1) gavilyte-g powder for oral soln $0 (Tier 1) gavilyte-n powder for oral soln $0 (Tier 1) peg 3350/electrolyte oral soln $0 (Tier 1) peg 3350/kcl/sodium bicarbonate/sodium chloride $0 (Tier 1) powder for oral soln sennosides-docusate sodium tab 8.6-50 mg $0 (Tier 5) trilyte powder for oral soln $0 (Tier 1) LAXATIVES - MISCELLANEOUS - Drugs to treat constipation constulose 10gm/15ml oral soln $0 (Tier 1) glycerin supp 1 gm $0 (Tier 5) glycerin supp 1.2gm $0 (Tier 5) glycerin supp 2.1gm $0 (Tier 5) glycerin suppos 2 gm $0 (Tier 5) KRISTALOSE 10GM POWDER FOR ORAL SOLN $0 (Tier 4) KRISTALOSE 20GM POWDER FOR ORAL SOLN $0 (Tier 4) lactulose 667mg/ml oral soln $0 (Tier 1) polyethylene glycol 3350 powder (OTC) $0 (Tier 5) polyethylene glycol 3350 powder packet (OTC) $0 (Tier 5) LUBRICANT LAXATIVES - Drugs to treat constipation mineral oil $0 (Tier 5) MINERAL OIL (BULK) $0 (Tier 5) mineral oil enema $0 (Tier 5) SALINE LAXATIVES - Drugs to treat constipation magnesium citrate soln $0 (Tier 5) magnesium hydroxide susp 400mg/5ml $0 (Tier 5) magnesium hydroxide susp concentrate 2400 mg/10ml $0 (Tier 5) magnesium sulfate oral granules $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 107 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) sodium phosphates enema $0 (Tier 5) STIMULANT LAXATIVES - Drugs to treat constipation bisacodyl suppos 10 mg $0 (Tier 5) bisacodyl tab delayed release 5mg $0 (Tier 5) SENNA SYRUP 176MG/5ML $0 (Tier 5) sennosides syrup 8.8 mg/5ml $0 (Tier 5) sennosides tab 15 mg $0 (Tier 5) sennosides tab 25 mg $0 (Tier 5) sennosides tab 8.6mg $0 (Tier 5) SURFACTANT LAXATIVES - Drugs to treat constipation docusate calcium cap 240mg $0 (Tier 5) docusate sodium cap 100mg $0 (Tier 5) docusate sodium cap 250mg $0 (Tier 5) docusate sodium enema 283 mg/5ml $0 (Tier 5) docusate sodium liquid 150mg/15ml $0 (Tier 5) docusate sodium syrup 60mg/15ml $0 (Tier 5) docusate sodium tab 100mg $0 (Tier 5) MACROLIDES - Drugs to treat bacterial infections AZITHROMYCIN - Drugs to treat bacterial infections azithromycin 20mg/ml susp $0 (Tier 1) azithromycin 250mg pack $0 (Tier 1) azithromycin 250mg tab $0 (Tier 1) azithromycin 40mg/ml susp $0 (Tier 1) azithromycin 500mg inj $0 (Tier 2) azithromycin 500mg pack $0 (Tier 1) azithromycin 500mg tab $0 (Tier 1) azithromycin 600mg tab $0 (Tier 2) CLARITHROMYCIN - Drugs to treat bacterial infections clarithromycin 250mg tab $0 (Tier 1) CLARITHROMYCIN 25MG/ML SUSP $0 (Tier 3) clarithromycin 500mg er tab $0 (Tier 2) clarithromycin 500mg tab $0 (Tier 1) CLARITHROMYCIN 50MG/ML SUSP $0 (Tier 3) ERYTHROMYCINS - Drugs to treat bacterial infections ery-tab 500mg dr tab $0 (Tier 2) ERYTHROCIN 500MG INJ $0 (Tier 4) erythromycin 250mg dr cap $0 (Tier 2) erythromycin 250mg tab $0 (Tier 2) erythromycin 500mg dr tab $0 (Tier 2) erythromycin 500mg tab $0 (Tier 2) erythromycin ethylsuccinate 40mg/ml susp $0 (Tier 2) erythromycin ethylsuccinate 80mg/ml susp $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 108 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) FIDAXOMICIN - drugs to treat infections DIFICID 200MG TAB $0 (Tier 3) PA QL=20 EA/10 Days DIFICID 40MG/ML SUSP $0 (Tier 3) PA QL=136 ML/10 Days MEDICAL DEVICES - Drugs for miscellaneous use PARENTERAL THERAPY SUPPLIES - Miscellaneous supplies INSULIN SYRINGE (DISP) U-100 1/2ML $0 (Tier 2) MEDICAL DEVICES AND SUPPLIES - Drugs for miscellaneous use BANDAGES-DRESSINGS-TAPE - Miscellaneous products GAUZE PADS & DRESSINGS - PADS 2 X 2 $0 (Tier 2) MISC. DEVICES - Drugs for miscellaneous use ISOPROPYL ALCOHOL 0.7ML/ML PAD $0 (Tier 2) PARENTERAL THERAPY SUPPLIES - Miscellaneous supplies INSULIN PEN NEEDLE $0 (Tier 2) INSULIN SYRINGE (DISP) U-100 0.3ML $0 (Tier 2) INSULIN SYRINGE (DISP) U-100 1ML $0 (Tier 2) NEEDLES INSULIN DISP. SAFETY $0 (Tier 2) MIGRAINE PRODUCTS - Drugs to treat migraine headaches CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG - Drugs to treat migraine or other types of headache AIMOVIG 140MG/ML AUTO-INJECTOR $0 (Tier 3) PA AIMOVIG 70MG/ML AUTO-INJECTOR $0 (Tier 3) PA EMGALITY 100MG/ML SYRINGE $0 (Tier 3) PA EMGALITY 120MG/ML AUTO-INJECTOR $0 (Tier 3) PA EMGALITY 120MG/ML SYRINGE $0 (Tier 3) PA NURTEC 75MG ODT $0 (Tier 3) PA QL=16 EA/30 Days MIGRAINE PRODUCTS - Drugs to treat migraine headaches dihydroergotamine mesylate 0.5mg/act nasal inhaler $0 (Tier 3) QL=16 ML/30 Days MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES - Drugs to treat migraine headaches UBRELVY 100MG TAB $0 (Tier 3) PA QL=16 EA/30 Days UBRELVY 50MG TAB $0 (Tier 3) PA QL=16 EA/30 Days SEROTONIN AGONISTS - Drugs to treat migraine headaches eletriptan 20mg tab $0 (Tier 2) QL=18 EA/30 Days eletriptan 40mg tab $0 (Tier 2) QL=18 EA/30 Days naratriptan 1mg tab $0 (Tier 2) QL=18 EA/30 Days naratriptan 2.5mg tab $0 (Tier 2) QL=18 EA/30 Days REYVOW 100MG TAB $0 (Tier 3) PA QL=8 EA/30 Days REYVOW 50MG TAB $0 (Tier 3) PA QL=8 EA/30 Days rizatriptan 10mg odt $0 (Tier 2) QL=36 EA/60 Days rizatriptan 10mg tab $0 (Tier 2) QL=36 EA/60 Days rizatriptan 5mg odt $0 (Tier 2) QL=36 EA/60 Days rizatriptan 5mg tab $0 (Tier 2) QL=36 EA/60 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 109 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) sumatriptan 100mg tab $0 (Tier 1) QL=18 EA/30 Days sumatriptan 12mg/ml auto-injector $0 (Tier 2) QL=5 ML/30 Days sumatriptan 12mg/ml cartridge $0 (Tier 2) QL=5 ML/30 Days sumatriptan 12mg/ml inj $0 (Tier 2) QL=5 ML/30 Days sumatriptan 20mg/act nasal spray $0 (Tier 2) QL=12 EA/30 Days sumatriptan 25mg tab $0 (Tier 1) QL=18 EA/30 Days sumatriptan 50mg tab $0 (Tier 1) QL=18 EA/30 Days sumatriptan 5mg/act nasal spray $0 (Tier 2) QL=12 EA/30 Days sumatriptan 8mg/ml auto-injector $0 (Tier 2) QL=5 ML/30 Days sumatriptan 8mg/ml cartridge $0 (Tier 2) QL=5 ML/30 Days zolmitriptan 2.5mg odt $0 (Tier 2) QL=18 EA/30 Days zolmitriptan 2.5mg tab $0 (Tier 2) QL=18 EA/30 Days zolmitriptan 5mg odt $0 (Tier 2) QL=18 EA/30 Days zolmitriptan 5mg tab $0 (Tier 2) QL=18 EA/30 Days ZOMIG 2.5MG NASAL SPRAY $0 (Tier 4) QL=16 EA/30 Days ZOMIG 5MG NASAL SPRAY $0 (Tier 4) QL=12 EA/30 Days MINERALS & ELECTROLYTES - Drugs to treat electrolyte disorders CALCIUM - Drugs to treat calcium deficiency ADVANCED CALCIUM FORMULA TAB $0 (Tier 5) CAL-CITRATE + VITAMIN D TAB 250MG-100UNIT $0 (Tier 5) CAL/MAG CHEW TAB 200-100MG $0 (Tier 5) CALC-PHOSPHORUS-VIT D-MAG TAB 600 MG-280 $0 (Tier 5) MG-500 UNIT-50 MG calcium + D tab 600mg-200unit $0 (Tier 5) CALCIUM 1000MG + D TAB $0 (Tier 5) calcium carb-vit d w/ minerals chew tab 600 mg-800 $0 (Tier 5) unit CALCIUM CARBONATE 260MG CHEW $0 (Tier 5) CALCIUM CARBONATE CAP 1250MG $0 (Tier 5) CALCIUM CARBONATE CHEW TAB 1250 MG (500 $0 (Tier 5) MG ELEMENTAL CA) CALCIUM CARBONATE POWDER $0 (Tier 5) calcium carbonate tab 1250 mg (500 mg elemental ca) $0 (Tier 5) calcium carbonate tab 1500mg $0 (Tier 5) calcium carbonate tab 600mg $0 (Tier 5) CALCIUM CARBONATE-CHOLECALCIFEROL CAP $0 (Tier 5) 600 MG-2500 UNIT calcium carbonate-cholecalciferol cap 600 mg-500 $0 (Tier 5) unit calcium carbonate-cholecalciferol chew tab 500 $0 (Tier 5) mg-400 unit CALCIUM CARBONATE-CHOLECALCIFEROL $0 (Tier 5) POWD PACK 500 MG-200 UNIT You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 110 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) calcium carbonate-cholecalciferol tab 600 mg-800 $0 (Tier 5) unit calcium carbonate-vitamin d tab 500 mg-125 unit $0 (Tier 5) calcium carbonate/vitamin D cap 600mg-200unit $0 (Tier 5) calcium carbonate/vitamin D chew tab 500mg-100unit $0 (Tier 5) calcium carbonate/vitamin D chew tab 600mg-400unit $0 (Tier 5) calcium carbonate/vitamin D tab 200mg-250unit $0 (Tier 5) calcium carbonate/vitamin D tab 250mg-125unit $0 (Tier 5) calcium carbonate/vitamin D tab 315mg-200unit $0 (Tier 5) calcium carbonate/vitamin D tab 315mg-250unit $0 (Tier 5) calcium carbonate/vitamin D tab 500mg-200unit $0 (Tier 5) calcium carbonate/vitamin D tab 500mg-400unit $0 (Tier 5) calcium carbonate/vitamin D tab 500mg-600unit $0 (Tier 5) calcium carbonate/vitamin D tab 600mg-200unit $0 (Tier 5) calcium carbonate/vitamin D tab 600mg-400unit $0 (Tier 5) calcium carbonate/vitamin D w/ minerals tab $0 (Tier 5) calcium carbonate/vitamin d w/ minerals tab $0 (Tier 5) CALCIUM CITRATE 760MG/3.5GM GRANULES $0 (Tier 5) CALCIUM CITRATE TAB 250MG $0 (Tier 5) calcium citrate tab 950 mg (200 mg elemental ca) $0 (Tier 5) CALCIUM CITRATE-VIT D LIQD 1000 MG/30ML-400 $0 (Tier 5) UNIT/30ML CALCIUM CITRATE-VITAMIN D TAB 200 MG-125 $0 (Tier 5) UNIT (ELEMENTAL CA) CALCIUM GLUCONATE TAB 50MG $0 (Tier 5) CALCIUM LACTATE TAB 100MG $0 (Tier 5) calcium w/ magnesium tab $0 (Tier 5) CALCIUM W/ MAGNESIUM TAB 250-155 MG $0 (Tier 5) CALCIUM W/ VITAMIN D AND K CHEW TAB 500 $0 (Tier 5) MG-500 UNIT-40 MCG CALCIUM-MAGNESIUM W/ VITAMIN D TAB 300 $0 (Tier 5) MG-150 MG-400 UNIT calcium-magnesium-zinc tab 333-133-8.3mg $0 (Tier 5) CALCIUM/C/D CHEW $0 (Tier 5) CALCIUM/MAGNESIUM/VITAMIN D TAB $0 (Tier 5) calcium/magnesium/zinc tab 333-133-5mg $0 (Tier 5) calcium/magnesium/zinc tab 334-134-5mg $0 (Tier 5) CALCIUM/VITAMIN D3 CHEW TAB $0 (Tier 5) 200MG-200UNIT CHELATED CALCIUM 200MG TAB $0 (Tier 5) CORAL CALCIUM CAP $0 (Tier 5) DISNEY CALCIUM + VITAMIN CHEW TAB $0 (Tier 5) LOCALNESIUM TAB 166.67-83.3MG $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 111 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) LOCALNESIUM-C TAB $0 (Tier 5) oyster shell calcium tab 500mg $0 (Tier 5) PARVA-CAL TAB 250MG-100UNIT $0 (Tier 5) PARVA-CAL TAB 500MG-200UNIT $0 (Tier 5) RISCAL-D TAB $0 (Tier 5) UPCAL D POWDER 500MG-500UNIT $0 (Tier 5) UPCAL D POWDER PACKET 500MG-500UNIT $0 (Tier 5) ELECTROLYTE MIXTURES - Drugs to treat electrolyte disorders GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342 $0 (Tier 3) B/D MEQ/ML INJ GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769 $0 (Tier 3) B/D MEQ/ML INJ GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 $0 (Tier 2) MEQ/ML INJ glucose 50 mg/ml/potassium chloride $0 (Tier 2) 0.04meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.01 $0 (Tier 2) meq/ml/sodium chloride 0.0769 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 meq/ml inj $0 (Tier 2) glucose 50mg/ml/potassium chloride 0.02 $0 (Tier 2) meq/ml/sodium chloride 0.0342 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 $0 (Tier 2) meq/ml/sodium chloride 0.154 meq/ml inj glucose 50mg/ml/potassium chloride $0 (Tier 2) 0.02meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.03 $0 (Tier 2) meq/ml/sodium chloride 0.0769 meq/ml inj GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 $0 (Tier 3) MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj $0 (Tier 2) glucose 50mg/ml/sodium chloride 4.5mg/ml inj $0 (Tier 2) glucose 50mg/ml/sodium chloride 9mg/ml inj $0 (Tier 2) ISOLYTE P INJ $0 (Tier 3) ISOLYTE S INJ $0 (Tier 3) KCL/D5W/LR INJ 0.15% $0 (Tier 3) ORAL ELECTROLYTE - PACKET $0 (Tier 5) oral electrolyte solution $0 (Tier 5) PEDIALYTE FREEZER POPS $0 (Tier 5) PLASMA-LYTE 148 INJ $0 (Tier 3) PLASMALYTE A INJ $0 (Tier 3) potassium chloride 0.02 meq/ml/sodium chloride $0 (Tier 2) 0.0769 meq/ml inj

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 112 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) potassium chloride 0.02 meq/ml/sodium chloride $0 (Tier 2) 0.154 meq/ml inj POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM $0 (Tier 2) CHLORIDE 0.154 MEQ/ML INJ REPLACE SR TAB $0 (Tier 5) TPN ELECTROLYTES INJ $0 (Tier 2) B/D FLUORIDE - Drugs to treat mineral deficiency sodium fluoride 0.25 (0.55) mg $0 (Tier 5) sodium fluoride 0.5 mg(1.1 mg) $0 (Tier 5) sodium fluoride 0.5 mg/ml drop $0 (Tier 5) sodium fluoride 1 mg (2.2 mg) $0 (Tier 5) IODINE PRODUCTS - Drugs to treat iodine deficiency iodine tab 150mcg $0 (Tier 5) MAGNESIUM - Drugs to treat electrolyte disorders MAGINEX TAB 615MG $0 (Tier 5) MAGNESIUM CAP 300 MG $0 (Tier 5) MAGNESIUM CHLORIDE TAB DR 64 MG $0 (Tier 5) (ELEMENTAL MG) magnesium chloride tab dr 64 mg (elemental mg) $0 (Tier 5) MAGNESIUM CITRATE 100MG TAB $0 (Tier 5) MAGNESIUM GLUCONATE 500MG TAB $0 (Tier 5) magnesium gluconate tab 500 mg $0 (Tier 5) magnesium gluconate tab 500 mg (27 mg elemental $0 (Tier 5) mg) magnesium gluconate tab 500mg $0 (Tier 5) magnesium lactate tab er 84 mg (elemental mg) (7 $0 (Tier 5) meq) magnesium oxide cap 500mg $0 (Tier 5) MAGNESIUM OXIDE POWDER PACK 240 MG $0 (Tier 5) (ELEMENTAL MG) magnesium oxide tab 200mg $0 (Tier 5) magnesium oxide tab 250mg $0 (Tier 5) magnesium oxide tab 400 mg (240 mg elemental mg) $0 (Tier 5) MAGNESIUM OXIDE TAB 400 MG (241.3 MG $0 (Tier 5) ELEMENTAL MG) magnesium oxide tab 400mg $0 (Tier 5) magnesium oxide tab 500mg $0 (Tier 5) magnesium sulfate 500mg/ml inj $0 (Tier 2) magnesium sulfate 500mg/ml syringe $0 (Tier 2) MAGNESIUM SULFATE 70MG CAP $0 (Tier 5) magnesium tab 100mg $0 (Tier 5) magnesium tab 200mg $0 (Tier 5) magnesium tab 250mg $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 113 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) magnesium/calcium carbonate DR tab $0 (Tier 5) MAGONATE LIQUID 1000MG/5ML LIQUID $0 (Tier 5) SLOW-MAG TAB $0 (Tier 5) MINERAL COMBINATIONS - Drugs to treat mineral deficiency BONE ESSENTIALS CAP $0 (Tier 5) multiple minerals w/ vitamins tab $0 (Tier 5) THERACAL TAB D4000 $0 (Tier 5) PHOSPHATE - Drugs to treat electrolyte deficiency PHOS-NAK POWDER CONCENTRA PACK $0 (Tier 5) pot phos monobasic w/sod phos di & monobas tab $0 (Tier 5) 155-852-130mg potassium and sodium phosphates powder pack $0 (Tier 5) 280-160-250 mg POTASSIUM - Drugs to treat electrolyte disorders K-TAB 8MEQ ER TAB $0 (Tier 2) klor-con 10meq er tab $0 (Tier 1) klor-con 10meq micro er tab $0 (Tier 1) KLOR-CON 15MEQ MICRO ER TAB $0 (Tier 2) klor-con 20meq micro er tab $0 (Tier 1) klor-con 8meq er tab $0 (Tier 1) POTASSIUM CHLORIDE 0.1MEQ/ML INJ $0 (Tier 2) POTASSIUM CHLORIDE 0.2MEQ/ML INJ $0 (Tier 2) POTASSIUM CHLORIDE 0.4MEQ/ML INJ $0 (Tier 2) potassium chloride 1.33meq/ml oral soln $0 (Tier 2) potassium chloride 10meq er cap $0 (Tier 1) potassium chloride 10meq er tab $0 (Tier 1) potassium chloride 10meq micro er tab $0 (Tier 1) potassium chloride 2.67meq/ml oral soln $0 (Tier 2) potassium chloride 20meq er tab $0 (Tier 2) potassium chloride 20meq micro er tab $0 (Tier 1) potassium chloride 20meq powder for oral soln $0 (Tier 2) potassium chloride 2meq/ml (20ml) inj $0 (Tier 2) potassium chloride 2meq/ml inj $0 (Tier 2) potassium chloride 8meq er cap $0 (Tier 1) potassium chloride 8meq er tab $0 (Tier 1) SODIUM - Drugs to treat electrolyte disorders sodium chloride 30mg/ml inj $0 (Tier 2) sodium chloride 4.5mg/ml inj $0 (Tier 2) sodium chloride 50mg/ml inj $0 (Tier 2) sodium chloride 9mg/ml inj $0 (Tier 2) sodium chloride flush iv soln 0.9% $0 (Tier 5) sodium chloride tab 1gm $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 114 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ZINC - Drugs to treat mineral deficiency zinc sulfate cap 220mg $0 (Tier 5) MISCELLANEOUS THERAPEUTIC CLASSES - Drugs to treat assorted conditions CHELATING AGENTS - Drugs to treat overdose or toxicity clovique 250mg cap $0 (Tier 2) PA penicillamine 250mg tab $0 (Tier 2) trientine 250mg cap $0 (Tier 2) PA IMMUNOMODULATORS - Drugs to treat rheumatoid arthritis, multiple sclerosis, etc. REVLIMID 10MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days REVLIMID 15MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days REVLIMID 2.5MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days REVLIMID 20MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days REVLIMID 25MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days REVLIMID 5MG CAP $0 (Tier 4) NDS PA NSO QL=30 EA/30 Days THALOMID 100MG CAP $0 (Tier 3) NDS PA NSO THALOMID 150MG CAP $0 (Tier 3) NDS PA NSO THALOMID 200MG CAP $0 (Tier 3) NDS PA NSO THALOMID 50MG CAP $0 (Tier 3) NDS PA NSO IMMUNOSUPPRESSIVE AGENTS - Drugs to treat disorders of the immune system ASTAGRAF 0.5MG ER CAP $0 (Tier 4) B/D ASTAGRAF 1MG ER CAP $0 (Tier 4) B/D ASTAGRAF 5MG ER CAP $0 (Tier 4) B/D azathioprine 50mg tab $0 (Tier 2) B/D cyclosporine modified 100mg/ml oral soln $0 (Tier 2) B/D cyclosporine modified 50mg cap $0 (Tier 2) B/D ENSPRYNG 120MG/ML SYRINGE $0 (Tier 4) NDS PA QL=1 ML/28 Days ENVARSUS 0.75MG ER TAB $0 (Tier 4) B/D ENVARSUS 1MG ER TAB $0 (Tier 4) B/D ENVARSUS 4MG ER TAB $0 (Tier 4) B/D everolimus 0.25mg tab $0 (Tier 2) B/D everolimus 0.5mg tab $0 (Tier 2) B/D everolimus 0.75mg tab $0 (Tier 2) B/D LUPKYNIS 7.9MG CAP $0 (Tier 4) NDS PA QL=180 EA/30 Days mycophenolic acid 180mg dr tab $0 (Tier 2) B/D mycophenolic acid 360mg dr tab $0 (Tier 2) B/D PROGRAF 0.2MG GRANULES FOR ORAL SUSP $0 (Tier 4) B/D PROGRAF 1MG GRANULES FOR ORAL SUSP $0 (Tier 4) B/D sirolimus 1mg/ml oral soln $0 (Tier 2) B/D ZORTRESS 1MG TAB $0 (Tier 4) B/D POTASSIUM REMOVING AGENTS - Drugs to manage potassium levels LOKELMA 10GM POWDER FOR ORAL SUSP $0 (Tier 3) PA LOKELMA 5GM POWDER FOR ORAL SUSP $0 (Tier 3) PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 115 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) sodium polystyrene sulfonate 15000mg powder for $0 (Tier 2) oral susp sps 15gm/60ml susp $0 (Tier 2) VELTASSA 16.8GM POWDER FOR ORAL SUSP $0 (Tier 3) PA VELTASSA 25.2GM POWDER FOR ORAL SUSP $0 (Tier 3) PA VELTASSA 8.4GM POWDER FOR ORAL SUSP $0 (Tier 3) PA SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS - Drugs to treat disorders of the immune system BENLYSTA 200MG/ML AUTO-INJECTOR $0 (Tier 4) NDS PA QL=4 ML/28 Days BENLYSTA 200MG/ML SYRINGE $0 (Tier 4) NDS PA QL=4 ML/28 Days MOUTH/THROAT/DENTAL AGENTS - Drugs to treat problems related to mouth/throat/teeth ANESTHETICS TOPICAL ORAL - Drugs for numbing lidocaine 2% topical soln $0 (Tier 2) ANTI-INFECTIVES - THROAT - Drugs to treat throat infections carbamide peroxide soln 10% $0 (Tier 5) clotrimazole 10mg lozenge $0 (Tier 2) nystatin 100000unit/ml susp $0 (Tier 2) ANTISEPTICS - MOUTH/THROAT - Drugs to treat bacterial infections in the mouth and throat chlorhexidine gluconate 0.12% mouthwash $0 (Tier 1) periogard 0.12% mouthwash $0 (Tier 1) DENTAL PRODUCTS - Drugs to prevent cavities sodium fluoride 1.1% gel $0 (Tier 5) sodium fluoride 5000 plus crm $0 (Tier 5) SODIUM FLUORIDE RINSE 0.044% $0 (Tier 5) LOZENGES - Miscellaneous drugs to treat the throat ZINC W/A AND C LOZENGE $0 (Tier 5) MOUTHWASHES - Drugs to treat bacterial infections in the mouth and throat gnp dry mouth mouthwash $0 (Tier 5) STEROIDS - MOUTH/THROAT/DENTAL - Drugs to treat oral sores triamcinolone acetonide 0.1% oral paste $0 (Tier 2) THROAT PRODUCTS - MISC. - Miscellaneous drugs to treat the throat BIOTENE SPRAY $0 (Tier 5) cevimeline 30mg cap $0 (Tier 2) LEMON-GLYCERIN SWABSTICKS $0 (Tier 5) pilocarpine 5mg tab $0 (Tier 2) pilocarpine 7.5mg tab $0 (Tier 2) MULTIVITAMINS - Drugs to treat vitamin deficiency B-COMPLEX VITAMINS - Drugs to treat vitamin deficiency APETIGEN ELIXIR $0 (Tier 5) B-complex vitamin cap $0 (Tier 5) B-COMPLEX VITAMIN ELIXIR $0 (Tier 5) B-complex vitamin SL liquid $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 116 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) B-complex vitamin tab $0 (Tier 5) B-COMPLEX W/ C - Drugs to treat vitamin deficiency b-complex w/ c cap $0 (Tier 5) B-complex w/vitamin C and calcium tab $0 (Tier 5) B-complex w/vitamin C tab $0 (Tier 5) B-complex w/vitamin C/E + zinc tab $0 (Tier 5) B-COMPLEX W/ FOLIC ACID - Drugs to treat vitamin deficiency B-COMPLEX W/ C AND FOLIC ACID ER TAB $0 (Tier 5) B-COMPLEX W/ C-ZN & FOLIC ACID TAB 1 MG $0 (Tier 5) b-complex w/biotin & folic acid tab $0 (Tier 5) B-complex w/biotin and folic acid tab $0 (Tier 5) B-complex w/folic acid tab $0 (Tier 5) B-complex w/vitamin C and folic acid tab $0 (Tier 5) DIALYVITE PLUS VITAMIN D WAFER $0 (Tier 5) DIALYVITE W/IRON TAB $0 (Tier 5) DIALYVITE WAFER $0 (Tier 5) FOLBEE PLUS TAB $0 (Tier 5) NEPHRO-VITE TAB $0 (Tier 5) rena-vite tab $0 (Tier 5) reno cap $0 (Tier 5) VITAL-D RX TAB $0 (Tier 5) B-COMPLEX W/ IRON - Drugs to treat vitamin deficiency B-COMPLEX W/IRON SOLN $0 (Tier 5) B-COMPLEX W/ MINERALS - Drugs to treat vitamin deficiency APETIGEN PLUS TAB $0 (Tier 5) b-complex w/minerals liquid $0 (Tier 5) BIOFLAVONOID PRODUCTS - Drugs to treat vitamin deficiency BIOFLAVONOID PRODUCTS CHEW TAB $0 (Tier 5) VITAMIN C LIQUID $0 (Tier 5) vitamin c tab $0 (Tier 5) MULTIPLE VITAMINS W/ CALCIUM - Drugs to treat vitamin and electrolyte deficiency CALCI-MAX CAP $0 (Tier 5) multi-vitamin w/calcium tab $0 (Tier 5) MULTIPLE VITAMINS W/ IRON - Drugs to treat vitamin and iron deficiency once daily w/iron multivitamin tab $0 (Tier 5) MULTIPLE VITAMINS W/ MINERALS - Drugs to treat vitamin and mineral deficiency DEKAS PLUS SOFTGEL? $0 (Tier 5) ENDUR-VM TAB $0 (Tier 5) MULTIPLE VITAMINS W/ MINERALS & FA TAB 1.25 $0 (Tier 5) MG MULTIPLE VITAMINS W/ MINERALS & FA TAB 3 $0 (Tier 5) MG You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 117 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) MULTIPLE VITAMINS W/ MINERALS CHEW TAB $0 (Tier 5) MULTIPLE VITAMINS W/ MINERALS COMBO PACK $0 (Tier 5) multiple vitamins w/ minerals liquid $0 (Tier 5) MULTIPLE VITAMINS W/ MINERALS LOZENGE $0 (Tier 5) MULTIPLE VITAMINS W/MINERALS LIQUID $0 (Tier 5) MULTIPLE VITAMINS W/MINERALS TAB $0 (Tier 5) multiple vitamins w/minerals tab $0 (Tier 5) multivitamins with minerals cap $0 (Tier 5) MULTIVITAMINS WITH MINERALS POWDER $0 (Tier 5) DRINK THRIVITE 19 TAB $0 (Tier 5) MULTIVITAMINS - Drugs to treat vitamin deficiency DEKAS ESSENTIAL LIQUID $0 (Tier 5) multiple vitamin tab $0 (Tier 5) MULTIVITAMIN CAP $0 (Tier 5) ONE-DAILY MULTI-VITAMIN PACK $0 (Tier 5) THERA/BETA-CAROTENE TAB $0 (Tier 5) PED MULTIPLE VITAMINS W/ MINERALS - Drugs to treat vitamin and mineral deficiency abdek pediatric drops $0 (Tier 5) PED MV W/ FLUORIDE - Drugs to treat vitamin deficiency MULTIVIT-FLUOR 0.25 MG TAB CHW $0 (Tier 5) multivit-fluor 0.25 mg/ml drop $0 (Tier 5) MULTIVIT-FLUOR 0.5 MG TAB CHEW $0 (Tier 5) multivit-fluor 0.5 mg/ml drop $0 (Tier 5) MULTIVIT-FLUORIDE 1 MG TAB CHW $0 (Tier 5) tri-vite-fluoride 0.25 mg/ml $0 (Tier 5) tri-vite-fluoride 0.5 mg/ml $0 (Tier 5) PED MV W/ IRON - Drugs to treat vitamin and iron deficiency MULTI-DELYN/IRON LIQUID $0 (Tier 5) PRENATAL VITAMINS - Drugs to treat and prevent vitamin deficiency GNP DAILY PRENATAL TAB (OTC) $0 (Tier 5) PRENATAL DHA MULTI-PACK (OTC) $0 (Tier 5) PRENATAL MULTIVITAMINS & MINERALS W/IRON $0 (Tier 5) & FA TAB 0.1 MG PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG $0 (Tier 5) PRENATAL VITAMIN (OTC) $0 (Tier 5) PRENATAL VITAMINS W/IRON (OTC) $0 (Tier 5) SPECIALTY VITAMINS PRODUCTS - Drugs to treat vitamin deficiency SPECIALITY VITAMIN PRODUCT TAB $0 (Tier 5) VITAMIN MIXTURES - Drugs to treat vitamin deficiency APATATE LIQUID $0 (Tier 5) COD LIVER OIL $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 118 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) cod liver oil cap $0 (Tier 5) DOSOQUIN TAB $0 (Tier 5) niacin cap 400mg $0 (Tier 5) vitamins a/d tab $0 (Tier 5) VITAMINS W/ LIPOTROPICS - Drugs to treat vitamin and lipotropic nutrients deficiency vitamins w/ lipotropics tab $0 (Tier 5) vitamins w/lipotropics cap $0 (Tier 5) MUSCULOSKELETAL THERAPY AGENTS - Drugs to treat spasms CENTRAL MUSCLE RELAXANTS - Drugs to treat muscle spasms baclofen 10mg tab $0 (Tier 1) baclofen 20mg tab $0 (Tier 1) cyclobenzaprine 10mg tab $0 (Tier 1) cyclobenzaprine 5mg tab $0 (Tier 1) methocarbamol 500mg tab $0 (Tier 1) methocarbamol 750mg tab $0 (Tier 1) tizanidine 2mg cap $0 (Tier 2) tizanidine 2mg tab $0 (Tier 2) tizanidine 4mg cap $0 (Tier 2) tizanidine 4mg tab $0 (Tier 2) tizanidine 6mg cap $0 (Tier 2) DIRECT MUSCLE RELAXANTS - Drugs to treat muscle spasms dantrolene sodium 100mg cap $0 (Tier 2) dantrolene sodium 25mg cap $0 (Tier 2) dantrolene sodium 50mg cap $0 (Tier 2) NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the nose or sinus NASAL AGENTS - MISC. - Miscellaneous nasal agents SALINE NASAL SOLN 0.65% $0 (Tier 5) SALINE NASAL SOLN 0.9% $0 (Tier 5) SALINE NASAL SOLN 2.65% $0 (Tier 5) saline nasal spray 0.65% $0 (Tier 5) NASAL ANTIALLERGY - Drugs to treat cough, cold, and allergy symptoms azelastine 0.137mg/act nasal inhaler $0 (Tier 1) QL=40 ML/30 Days azelastine 0.206mg/act nasal inhaler $0 (Tier 2) QL=40 ML/30 Days olopatadine 0.665mg/act nasal inhaler $0 (Tier 2) QL=30.50 GM/30 Days NASAL ANTICHOLINERGICS - Drugs to treat cough, cold, and allergy symptoms ipratropium bromide 0.021mg/act nasal inhaler $0 (Tier 2) QL=60 ML/30 Days ipratropium bromide 0.042mg/act nasal inhaler $0 (Tier 2) QL=30 ML/30 Days NASAL STEROIDS - Drugs to treat cough, cold, and allergy symptoms budesonide nasal susp 32 mcg/act $0 (Tier 5) QL=8.60 GM/30 Days FLUNISOLIDE 0.025MG/ACT NASAL INHALER $0 (Tier 4) QL=50 ML/30 Days fluticasone propionate 0.05mg/act nasal inhaler $0 (Tier 1) QL=32 GM/30 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 119 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) TRIAMCINOLONE ACETONIDE NASAL AEROSOL $0 (Tier 5) QL=16.90 GM/30 Days SUSP 55MCG (OTC) triamcinolone acetonide nasal aerosol suspension 55 $0 (Tier 5) QL=16.90 GM/30 Days mcg/act SYMPATHOMIMETIC DECONGESTANTS - Drugs to treat sinus congestion pseudoephedrine liquid 15mg/5ml $0 (Tier 5) pseudoephedrine SR tab (12hr) 120mg $0 (Tier 5) pseudoephedrine tab 30mg $0 (Tier 5) pseudoephedrine tab 60mg $0 (Tier 5) NEUROMUSCULAR AGENTS - Drugs to relax/paralyze muscles ALS AGENTS - Drugs to treat ALS riluzole 50mg tab $0 (Tier 2) SPINAL MUSCULAR ATROPHY AGENTS (SMA) - Drugs to treat spinal muscular atrophy EVRYSDI 0.75MG/ML ORAL SOLN $0 (Tier 4) NDS PA QL=200 ML/30 Days NUTRIENTS - Drugs to treat nutrient disorders CARBOHYDRATES - Drugs to treat nutrient disorders glucose 100mg/ml inj $0 (Tier 2) B/D glucose 50mg/ml inj $0 (Tier 2) LIPIDS - Drugs to treat nutrient disorders INTRALIPID 20GM/100ML INJ $0 (Tier 2) B/D INTRALIPID 30GM/100ML INJ $0 (Tier 4) B/D NUTRILIPID 20GM/100ML INJ $0 (Tier 2) B/D PROTEINS - Drugs to treat nutrient disorders acetylcysteine cap 600 mg $0 (Tier 5) AMINOSYN-PF 7% INJ $0 (Tier 4) B/D ARGININE TAB 500 MG $0 (Tier 5) CLINIMIX 4.25/10 INJ $0 (Tier 3) B/D CLINIMIX 4.25/5 INJ $0 (Tier 3) B/D CLINIMIX 5/15 INJ $0 (Tier 3) B/D CLINIMIX 5/20 INJ $0 (Tier 3) B/D CLINIMIX E 2.75/5 INJ $0 (Tier 3) B/D CLINIMIX E 4.25/10 INJ $0 (Tier 3) B/D CLINIMIX E 4.25/5 INJ $0 (Tier 3) B/D CLINIMIX E 5/15 INJ $0 (Tier 3) B/D CLINIMIX E 5/20 INJ $0 (Tier 3) B/D clinisol 15% inj $0 (Tier 2) B/D HEPATAMINE 8% INJ $0 (Tier 2) B/D plenamine 15% inj $0 (Tier 2) B/D PREMASOL 10% INJ $0 (Tier 4) B/D PROCALAMINE 3% INJ $0 (Tier 4) B/D PROSOL 20% INJ $0 (Tier 4) B/D TRAVASOL 10% INJ $0 (Tier 4) B/D You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 120 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) TROPHAMINE 10% INJ $0 (Tier 4) B/D TRYPTOPHAN TAB 500 MG $0 (Tier 5) OPHTHALMIC AGENTS - Drugs to treat eye conditions ARTIFICIAL TEARS AND LUBRICANTS - Drugs to treat dry eyes artificial tear ointment $0 (Tier 5) artificial tears ophth soln 5-6mg/ml $0 (Tier 5) carboxymethylcellulose sodium (pf) ophth soln 0.5% $0 (Tier 5) carboxymethylcellulose sodium ophth soln 0.5% $0 (Tier 5) genteal tear moderate soln $0 (Tier 5) glycerin/hypromellose/PEG 400 ophth soln $0 (Tier 5) hypromellose ophth soln 0.3% $0 (Tier 5) MINERAL OIL OPHTH EMULSION 0.5-0.5% $0 (Tier 5) polyethylene glycol-propylene glycol ophth soln $0 (Tier 5) 0.4-0.3% polyvinyl alcohol ophth soln 1.4% $0 (Tier 5) propylene glycol-glycerin ophth soln 1-0.3% $0 (Tier 5) STERILE LUBRICANT OPHTH LIQUID 0.7% $0 (Tier 5) white petrolatum-mineral oil ophth ointment $0 (Tier 5) BETA-BLOCKERS - OPHTHALMIC - Drugs to treat glaucoma betaxolol 0.5% ophth soln $0 (Tier 2) BETOPTIC S 0.25% OPHTH SUSP $0 (Tier 4) CARTEOLOL 1% OPHTH SOLN $0 (Tier 2) COMBIGAN 2-5MG/ML OPHTH SOLN $0 (Tier 3) dorzolamide/timolol 22.3-6.8mg/ml ophth soln $0 (Tier 1) dorzolamide/timolol 22.3-6.8mg/ml ophth soln $0 (Tier 2) (preservative-free) LEVOBUNOLOL 0.5% OPHTH SOLN $0 (Tier 2) timolol 0.25% ophth gel $0 (Tier 2) timolol 0.25% ophth soln $0 (Tier 1) timolol 0.5% ophth gel $0 (Tier 2) timolol 0.5% ophth soln $0 (Tier 1) timolol 5mg/ml ophth 24hr ophth soln $0 (Tier 2) CYCLOPLEGIC MYDRIATICS - Drugs to treat eye conditions ATROPINE SULFATE 1% OPHTH SOLN $0 (Tier 2) MIOTICS - Drugs to treat eye conditions pilocarpine 1% ophth soln $0 (Tier 2) pilocarpine 2% ophth soln $0 (Tier 2) pilocarpine 4% ophth soln $0 (Tier 2) OPHTHALMIC ADRENERGIC AGENTS - Drugs to treat eye conditions ALPHAGAN 0.1% OPHTH SOLN $0 (Tier 4) apraclonidine 0.5% ophth soln $0 (Tier 2) brimonidine tartrate 0.15% ophth soln $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 121 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) brimonidine tartrate 0.2% ophth soln $0 (Tier 2) IOPIDINE 1% OPHTH SOLN $0 (Tier 4) SIMBRINZA 0.2-1% OPHTH SUSP $0 (Tier 3) OPHTHALMIC ANTI-INFECTIVES - Drugs to treat eye infections AZASITE 1% OPHTH SOLN $0 (Tier 3) BACITRACIN 0.5UNIT/MG OPHTH OINTMENT $0 (Tier 2) bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth $0 (Tier 2) QL=7 GM/7 Days ointment ciprofloxacin 0.3% ophth soln $0 (Tier 2) QL=60 ML/30 Days erythromycin 0.5% ophth ointment $0 (Tier 2) QL=7 GM/7 Days gatifloxacin 0.5% ophth soln $0 (Tier 2) QL=5 ML/7 Days GENTAK 0.3% OPHTH OINTMENT $0 (Tier 2) QL=7 GM/7 Days gentamicin 0.3% ophth soln $0 (Tier 2) QL=10 ML/7 Days GRAMICIDIN 0.025MG/ML/NEOMYCIN $0 (Tier 2) QL=10 ML/7 Days 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN levofloxacin 0.5% ophth soln $0 (Tier 1) QL=60 ML/30 Days moxifloxacin 0.5% ophth soln $0 (Tier 1) QL=6 ML/7 Days NATACYN 5% OPHTH SUSP $0 (Tier 3) QL=15 ML/7 Days neomycin/bacitracin/polymyxin ophth ointment $0 (Tier 2) QL=7 GM/7 Days 5(3.5)mg-400unit-10000unit ofloxacin 0.3% ophth soln $0 (Tier 2) QL=60 ML/30 Days polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth $0 (Tier 1) QL=10 ML/7 Days soln SULFACETAMIDE SODIUM 10% OPHTH OINTMENT $0 (Tier 2) QL=7 GM/7 Days sulfacetamide sodium 10% ophth soln $0 (Tier 2) QL=15 ML/7 Days tobramycin 0.3% ophth soln $0 (Tier 2) QL=60 ML/30 Days TRIFLURIDINE 1% OPHTH SOLN $0 (Tier 2) QL=15 ML/7 Days ZIRGAN 0.15% OPHTH GEL $0 (Tier 3) QL=10 GM/7 Days OPHTHALMIC DECONGESTANTS - Drugs to treat eye conditions NAPHCON-A OPHTH SOLN 0.025-0.3% $0 (Tier 5) OPCON-A OPHTH SOLN 0.027-0.315% $0 (Tier 5) tetrahydroz-dextran-peg-povidone ophth soln $0 (Tier 5) 0.05-0.1-1-1% tetrahydrozoline ophthsoln 0.05% $0 (Tier 5) OPHTHALMIC IMMUNOMODULATORS - Drugs to treat dry eyes RESTASIS 0.05% OPHTH SUSP $0 (Tier 3) OPHTHALMIC KINASE INHIBITORS - Drugs to treat glaucoma RHOPRESSA 0.02% OPHTH SOLN $0 (Tier 3) QL=5 ML/30 Days ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN $0 (Tier 3) QL=5 ML/30 Days OPHTHALMIC LOCAL ANESTHETICS - Drugs for numbing proparacaine 0.5% ophth soln $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 122 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) OPHTHALMIC STEROIDS - Drugs to treat inflammation ALREX 0.2% OPHTH SUSP $0 (Tier 3) BLEPHAMIDE 0.2-10% OPHTH OINTMENT $0 (Tier 4) BLEPHAMIDE 0.2-10% OPHTH SUSP $0 (Tier 4) DEXAMETHASONE PHOSPHATE 0.1% OPHTH $0 (Tier 2) SOLN dexamethasone/neomycin/polymyxin b 0.1% ophth $0 (Tier 2) ointment dexamethasone/neomycin/polymyxin b 0.1% ophth $0 (Tier 2) susp dexamethasone/tobramycin 0.3-0.1% ophth susp $0 (Tier 2) DUREZOL 0.05% OPHTH SUSP $0 (Tier 3) fluorometholone 0.1% ophth susp $0 (Tier 2) FML 0.1% OPHTH OINTMENT $0 (Tier 4) FML FORTE LIQUIFILM 0.25% OPHTH SUSP $0 (Tier 4) hydrocortisone 10mg/ml/neomycin $0 (Tier 2) 3.5mg/ml/polymyxin b 10000unit/ml ophth susp LOTEMAX 0.5% OPHTH OINTMENT $0 (Tier 3) loteprednol etabonate 0.5% ophth gel $0 (Tier 2) loteprednol etabonate 0.5% ophth susp $0 (Tier 1) MAXIDEX 0.1% OPHTH SUSP $0 (Tier 3) neomycin/polymyxin/bacitracin/hydrocortisone ophth $0 (Tier 2) ointmentment 1% PRED FORTE 1% OPHTH SUSP $0 (Tier 4) PRED MILD 0.12% OPHTH SUSP $0 (Tier 3) PRED-G 0.3-1% OPHTH SUSP $0 (Tier 3) PREDNISOLONE 1% OPHTH SOLN $0 (Tier 2) PREDNISOLONE ACETATE 1% OPHTH SUSP $0 (Tier 2) PREDNISOLONE SODIUM PHOSPHATE $0 (Tier 2) 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN TOBRADEX 0.1-0.3% OPHTH OINTMENT $0 (Tier 3) ZYLET 0.5-0.3% OPHTH SUSP $0 (Tier 3) OPHTHALMICS - MISC. - Miscellaneous eye agents ALOCRIL 2% OPHTH SOLN $0 (Tier 3) ALOMIDE 0.1% OPHTH SOLN $0 (Tier 3) azelastine 0.05% ophth soln $0 (Tier 2) AZOPT 1% OPHTH SUSP $0 (Tier 3) brinzolamide 1% ophth susp $0 (Tier 2) bromfenac 0.09% ophth soln $0 (Tier 2) cromolyn sodium 4% ophth soln $0 (Tier 2) CYSTADROPS 0.37% OPHTH SOLN $0 (Tier 4) NDS PA QL=20 ML/28 Days CYSTARAN 0.44% OPHTH SOLN $0 (Tier 4) NDS PA QL=60 ML/30 Days You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 123 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) diclofenac sodium 0.1% ophth soln $0 (Tier 1) dorzolamide 2% ophth soln $0 (Tier 1) epinastine 0.05% ophth soln $0 (Tier 2) FLURBIPROFEN SODIUM 0.03% OPHTH SOLN $0 (Tier 1) ILEVRO 0.3% OPHTH SUSP $0 (Tier 3) ketorolac tromethamine 0.4% ophth soln $0 (Tier 2) ketorolac tromethamine 0.5% ophth soln $0 (Tier 1) ketotifen fumarate ophth soln 0.025% (base equiv) $0 (Tier 5) olopatadine 0.1% ophth soln $0 (Tier 1) olopatadine 0.2% ophth soln $0 (Tier 1) PROSTAGLANDINS - OPHTHALMIC - Drugs to treat glaucoma bimatoprost 0.03% ophth soln $0 (Tier 2) QL=5 ML/30 Days latanoprost 0.005% ophth soln $0 (Tier 1) QL=5 ML/30 Days LUMIGAN 0.01% OPHTH SOLN $0 (Tier 3) QL=5 ML/30 Days travoprost 0.004% ophth soln $0 (Tier 2) QL=5 ML/30 Days OTIC AGENTS - Drugs to treat ear infection OTIC AGENTS - MISCELLANEOUS - Miscellaneous ear agents acetic acid 2% otic soln $0 (Tier 2) carbamide peroxide 6.5% otic soln $0 (Tier 5) OTIC ANTI-INFECTIVES - Drugs to treat ear infections CIPROFLOXACIN 0.2% OTIC SOLN $0 (Tier 3) ofloxacin 0.3% otic soln $0 (Tier 1) OTIC COMBINATIONS - Drugs to treat ear conditions CIPRO HC 0.2-1% OTIC SUSP $0 (Tier 4) ciprofloxacin/dexamethasone 0.3-0.1% otic susp $0 (Tier 2) hydrocortisone 10mg/ml/neomycin $0 (Tier 2) 3.5mg/ml/polymyxin b 10000unit/ml otic soln hydrocortisone 10mg/ml/neomycin $0 (Tier 2) 3.5mg/ml/polymyxin b 10000unit/ml otic susp OTIC STEROIDS - Drugs to treat ear swelling acetic acid/hydrocortisone 1-2% otic soln $0 (Tier 2) flac 0.01% otic soln $0 (Tier 2) fluocinolone acetonide 0.01% otic soln $0 (Tier 2) PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody drugs to treat low immune system IMMUNE SERUMS - Antibody drugs to treat low immune system BIVIGAM 5GM/50ML INJ $0 (Tier 4) NDS PA FLEBOGAMMA 5GM/50ML INJ $0 (Tier 4) NDS PA GAMMAGARD 10GM INJ $0 (Tier 4) NDS PA GAMMAGARD 2.5GM/25ML INJ $0 (Tier 4) NDS PA GAMMAGARD 5GM INJ $0 (Tier 4) NDS PA GAMMAKED 1GM/10ML INJ $0 (Tier 4) NDS PA GAMMAPLEX 10GM/100ML INJ $0 (Tier 4) NDS PA You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 124 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) GAMMAPLEX 10GM/200ML INJ $0 (Tier 4) NDS PA GAMMAPLEX 20GM/200ML INJ $0 (Tier 4) NDS PA GAMMAPLEX 5GM/50ML INJ $0 (Tier 4) NDS PA GAMUNEX 1GM/10ML INJ $0 (Tier 3) NDS PA OCTAGAM 1GM/20ML INJ $0 (Tier 4) NDS PA OCTAGAM 2GM/20ML INJ $0 (Tier 4) NDS PA PANZYGA 10GM/100ML INJ $0 (Tier 4) NDS PA PANZYGA 1GM/10ML INJ $0 (Tier 4) NDS PA PANZYGA 2.5GM/25ML INJ $0 (Tier 4) NDS PA PANZYGA 20GM/200ML INJ $0 (Tier 4) NDS PA PANZYGA 30GM/300ML INJ $0 (Tier 4) NDS PA PANZYGA 5GM/50ML INJ $0 (Tier 4) NDS PA PRIVIGEN 20GM/200ML INJ $0 (Tier 4) NDS PA VARIZIG 125UNIT/1.2ML INJ $0 (Tier 4) NDS PENICILLINS - Drugs to treat bacterial infections AMINOPENICILLINS - Drugs to treat infections amoxicillin 125mg chew tab $0 (Tier 1) amoxicillin 250mg cap $0 (Tier 1) AMOXICILLIN 250MG CHEW TAB $0 (Tier 2) amoxicillin 25mg/ml susp $0 (Tier 1) amoxicillin 40mg/ml susp $0 (Tier 1) amoxicillin 500mg cap $0 (Tier 1) amoxicillin 500mg tab $0 (Tier 1) amoxicillin 50mg/ml susp $0 (Tier 1) amoxicillin 80mg/ml susp $0 (Tier 1) amoxicillin 875mg tab $0 (Tier 1) ampicillin 1000mg inj $0 (Tier 2) ampicillin 100mg/ml inj $0 (Tier 2) AMPICILLIN 125MG INJ $0 (Tier 3) AMPICILLIN 500MG CAP $0 (Tier 1) NATURAL PENICILLINS - Drugs to treat bacterial infections BICILLIN L-A 1200000UNIT/2ML SYRINGE $0 (Tier 3) BICILLIN L-A 2400000UNIT/4ML SYRINGE $0 (Tier 3) BICILLIN L-A 600000UNIT/ML SYRINGE $0 (Tier 3) penicillin g potassium 1000000unit/ml inj $0 (Tier 2) PENICILLIN G POTASSIUM 40000UNIT/ML INJ $0 (Tier 2) PENICILLIN G POTASSIUM 60000UNIT/ML INJ $0 (Tier 2) PENICILLIN G PROCAINE 600000UNIT/ML $0 (Tier 3) SYRINGE PENICILLIN G SODIUM 100000UNIT/ML INJ $0 (Tier 3) penicillin v potassium 250mg tab $0 (Tier 1) PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN $0 (Tier 1) penicillin v potassium 500mg tab $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 125 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN $0 (Tier 1) PENICILLIN COMBINATIONS - Drugs to treat bacterial infections AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER $0 (Tier 4) TAB amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp $0 (Tier 2) AMOXICILLIN 200MG/CLAVULANATE 28.5MG $0 (Tier 3) CHEW TAB amoxicillin 250mg/clavulanate 125mg tab $0 (Tier 2) AMOXICILLIN 400MG/CLAVULANATE 57MG $0 (Tier 3) CHEW TAB amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp $0 (Tier 2) amoxicillin 500mg/clavulanate 125mg tab $0 (Tier 1) amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp $0 (Tier 2) amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp $0 (Tier 2) amoxicillin 875mg/clavulanate 125mg tab $0 (Tier 1) ampicillin 1000mg/sulbactam 500mg inj $0 (Tier 2) ampicillin 100mg/ml/sulbactam 50mg/ml inj $0 (Tier 2) ampicillin 2000mg/sulbactam 1000mg inj $0 (Tier 2) BICILLIN 300000-300000UNIT/ML SYRINGE $0 (Tier 3) BICILLIN 450000-150000UNIT/ML SYRINGE $0 (Tier 3) piperacillin 2000mg/tazobactam 250mg inj $0 (Tier 2) piperacillin 200mg/ml/tazobactam 25mg/ml inj $0 (Tier 2) piperacillin 3000mg/tazobactam 375mg inj $0 (Tier 2) piperacillin 4000mg/tazobactam 500mg inj $0 (Tier 2) ZOSYN 2000-250MG INJ $0 (Tier 4) ZOSYN 3000-375MG INJ $0 (Tier 4) PENICILLINASE-RESISTANT PENICILLINS - Drugs to treat bacterial infections dicloxacillin 250mg cap $0 (Tier 2) dicloxacillin 500mg cap $0 (Tier 2) nafcillin 1000mg inj $0 (Tier 2) nafcillin 100mg/ml inj $0 (Tier 2) nafcillin 2000mg inj $0 (Tier 2) oxacillin 1000mg inj $0 (Tier 2) oxacillin 100mg/ml inj $0 (Tier 2) oxacillin 2000mg inj $0 (Tier 2) OXACILLIN 20MG/ML INJ $0 (Tier 3) OXACILLIN 40MG/ML INJ $0 (Tier 3) PHARMACEUTICAL ADJUVANTS - Drugs to enhance primary drug effects LIQUID VEHICLES - Miscellaneous compounding ingredients CHERRY SYRUP $0 (Tier 5) ORA-BLEND SUSP $0 (Tier 5) ORA-PLUS LIQUID $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 126 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) ORAL VEHICLES - SYRUP $0 (Tier 5) RASPBERRY SYRUP $0 (Tier 5) SIMPLE - SYRUP $0 (Tier 5) SEMI SOLID VEHICLES - Miscellaneous compounding ingredients HYDROPHILIC OINTMENT $0 (Tier 5) LANOLIN ANHYDROUS $0 (Tier 5) lanolin ointment $0 (Tier 5) PETROLATUM OINTMENT $0 (Tier 5) PETROLATUM, HYDROPHILIC OINTMENT $0 (Tier 5) WHITE PETROLATUM GEL $0 (Tier 5) white petrolatum gel $0 (Tier 5) white petrolatum topical gel $0 (Tier 5) PROGESTINS - Drugs to replace female hormones PROGESTINS - Drugs used for contraception medroxyprogesterone acetate 10mg tab $0 (Tier 1) medroxyprogesterone acetate 2.5mg tab $0 (Tier 1) medroxyprogesterone acetate 5mg tab $0 (Tier 1) megestrol acetate 125mg/ml susp $0 (Tier 5) PA megestrol acetate 125mg/ml susp $0 (Tier 2) PA norethindrone acetate 5mg tab $0 (Tier 2) progesterone 100mg cap $0 (Tier 2) progesterone 200mg cap $0 (Tier 2) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to treat mental and emotional conditions AGENTS FOR CHEMICAL DEPENDENCY - Drugs to treat chemical dependency acamprosate calcium 333mg dr tab $0 (Tier 2) disulfiram 250mg tab $0 (Tier 2) disulfiram 500mg tab $0 (Tier 2) ANTI-CATAPLECTIC AGENTS - Drugs to treat sleep disorders XYREM 500MG/ML ORAL SOLN $0 (Tier 4) NDS PA QL=540 ML/30 Days ANTIDEMENTIA AGENTS - Drugs to treat dementia and memory loss donepezil 10mg odt $0 (Tier 2) QL=30 EA/30 Days donepezil 10mg tab $0 (Tier 1) donepezil 23mg tab $0 (Tier 2) QL=30 EA/30 Days donepezil 5mg odt $0 (Tier 2) QL=30 EA/30 Days donepezil 5mg tab $0 (Tier 1) galantamine 12mg tab $0 (Tier 2) galantamine 4mg tab $0 (Tier 2) galantamine 8mg tab $0 (Tier 2) galantamine hydrobromide 16mg er cap $0 (Tier 2) galantamine hydrobromide 24mg er cap $0 (Tier 2)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 127 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) GALANTAMINE HYDROBROMIDE 4MG/ML ORAL $0 (Tier 4) SOLN galantamine hydrobromide 8mg er cap $0 (Tier 2) memantine 10mg tab $0 (Tier 1) memantine 10mg/memantine 5mg pack $0 (Tier 1) memantine 14mg er cap $0 (Tier 2) QL=30 EA/30 Days memantine 21mg er cap $0 (Tier 2) QL=30 EA/30 Days memantine 28mg er cap $0 (Tier 2) QL=30 EA/30 Days memantine 2mg/ml oral soln $0 (Tier 2) memantine 5mg tab $0 (Tier 1) memantine 7mg er cap $0 (Tier 2) QL=30 EA/30 Days rivastigmine 0.192mg/hr patch $0 (Tier 2) rivastigmine 0.396mg/hr patch $0 (Tier 2) rivastigmine 0.554mg/hr patch $0 (Tier 2) rivastigmine 1.5mg cap $0 (Tier 2) rivastigmine 3mg cap $0 (Tier 2) rivastigmine 4.5mg cap $0 (Tier 2) rivastigmine 6mg cap $0 (Tier 2) COMBINATION PSYCHOTHERAPEUTICS - Drugs to treat psychoses AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB $0 (Tier 2) AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB $0 (Tier 2) amitriptyline 12.5mg/chlordiazepoxide 5mg tab $0 (Tier 2) amitriptyline 25mg/chlordiazepoxide 10mg tab $0 (Tier 2) AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB $0 (Tier 2) AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB $0 (Tier 2) AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB $0 (Tier 2) fluoxetine 25mg/olanzapine 12mg cap $0 (Tier 2) fluoxetine 25mg/olanzapine 3mg cap $0 (Tier 2) fluoxetine 25mg/olanzapine 6mg cap $0 (Tier 2) fluoxetine 50mg/olanzapine 12mg cap $0 (Tier 2) fluoxetine 50mg/olanzapine 6mg cap $0 (Tier 2) FIBROMYALGIA AGENTS - Drugs to treat widespread muscle pain SAVELLA 100MG TAB $0 (Tier 3) PA QL=60 EA/30 Days SAVELLA 12.5MG TAB $0 (Tier 3) PA QL=60 EA/30 Days SAVELLA 25MG TAB $0 (Tier 3) PA QL=60 EA/30 Days SAVELLA 4-WEEK TITRATION PACK $0 (Tier 3) PA SAVELLA 50MG TAB $0 (Tier 3) PA QL=60 EA/30 Days MOVEMENT DISORDER DRUG THERAPY - Drugs to treat movement disorders AUSTEDO 12MG TAB $0 (Tier 4) NDS PA AUSTEDO 6MG TAB $0 (Tier 4) NDS PA AUSTEDO 9MG TAB $0 (Tier 4) NDS PA tetrabenazine 12.5mg tab $0 (Tier 2) PA tetrabenazine 25mg tab $0 (Tier 2) PA You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 128 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) MULTIPLE SCLEROSIS AGENTS - Drugs to treat multiple sclerosis (MS) AUBAGIO 14MG TAB $0 (Tier 4) NDS AUBAGIO 7MG TAB $0 (Tier 4) NDS AVONEX 30MCG/0.5ML AUTO-INJECTOR $0 (Tier 4) NDS AVONEX 30MCG/0.5ML SYRINGE $0 (Tier 4) NDS dalfampridine 10mg er tab $0 (Tier 1) QL=60 EA/30 Days dimethyl fumarate 120mg dr cap $0 (Tier 4) NDS QL=60 EA/30 Days dimethyl fumarate 120mg/dimethyl fumarate 240mg $0 (Tier 4) NDS pack dimethyl fumarate 240mg dr cap $0 (Tier 4) NDS EXTAVIA 0.3MG INJ $0 (Tier 4) NDS GILENYA 0.5MG CAP $0 (Tier 4) NDS QL=30 EA/30 Days glatiramer acetate 20mg/ml syringe $0 (Tier 2) glatiramer acetate 40mg/ml syringe $0 (Tier 2) glatopa 20mg/ml syringe $0 (Tier 2) glatopa 40mg/ml syringe $0 (Tier 2) MAYZENT 0.25MG STARTER PACK $0 (Tier 4) NDS MAYZENT 0.25MG TAB $0 (Tier 4) NDS MAYZENT 2MG TAB $0 (Tier 4) NDS PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR $0 (Tier 4) NDS PLEGRIDY 125MCG/0.5ML SYRINGE $0 (Tier 4) NDS REBIF 22MCG/0.5ML AUTO-INJECTOR $0 (Tier 4) NDS REBIF 22MCG/0.5ML SYRINGE $0 (Tier 4) NDS REBIF 44MCG/0.5ML AUTO-INJECTOR $0 (Tier 4) NDS REBIF 44MCG/0.5ML SYRINGE $0 (Tier 4) NDS REBIF REBIDOSE PACK $0 (Tier 4) NDS REBIF TITRATION PACK $0 (Tier 4) NDS PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - Drugs to treat premenstrual dysphoric disorder FLUOXETINE 10MG TAB $0 (Tier 2) PSEUDOBULBAR AFFECT (PBA) AGENTS - Drugs to treat nervous system disorders NUEDEXTA 20-10MG CAP $0 (Tier 3) PA QL=60 EA/30 Days PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Miscellaneous psyotherapeutic and neurological drugs ERGOLOID MESYLATES USP 1MG TAB $0 (Tier 4) PIMOZIDE 1MG TAB $0 (Tier 3) PIMOZIDE 2MG TAB $0 (Tier 3) SMOKING DETERRENTS - Drugs to treat smoking urges bupropion 150mg sr tab $0 (Tier 1) CHANTIX 0.5MG TAB $0 (Tier 3) CHANTIX 1MG TAB $0 (Tier 3)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 129 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) CHANTIX CONTINUING MONTHS OF THERAPY $0 (Tier 3) 1MG PACK CHANTIX FIRST MONTH OF THERAPY PACK $0 (Tier 3) nicotine 4 mg mini lozenge $0 (Tier 5) nicotine patch 14mg/24hr $0 (Tier 5) nicotine patch 21mg/24hr $0 (Tier 5) nicotine patch 7mg/24hr $0 (Tier 5) NICOTINE PATCH KIT $0 (Tier 5) nicotine polacrilex gum 2 mg $0 (Tier 5) nicotine polacrilex gum 4mg $0 (Tier 5) nicotine polacrilex lozenge 2 mg $0 (Tier 5) nicotine polacrilex lozenge 4mg $0 (Tier 5) NICOTROL 10MG INH SOLN $0 (Tier 3) NICOTROL 10MG/ML NASAL INHALER $0 (Tier 3) sm nicotine 2 mg lozenge $0 (Tier 5) TRANSTHYRETIN AMYLOIDOSIS AGENTS - Drugs to treat nerve problems associated with transthyretin amyloidosis TEGSEDI 284MG/1.5ML SYRINGE $0 (Tier 4) NDS PA QL=6 ML/28 Days RESPIRATORY AGENTS - MISC. - Drugs to treat lung conditions ALPHA-PROTEINASE INHIBITOR (HUMAN) - Drugs to treat difficulty breathing ARALAST 1000MG INJ $0 (Tier 4) NDS PA GLASSIA 1000MG/50ML INJ $0 (Tier 4) NDS PA PROLASTIN 1000MG INJ $0 (Tier 4) NDS PA ZEMAIRA 1000MG INJ $0 (Tier 4) NDS PA CYSTIC FIBROSIS AGENTS - Drugs to treat cystic fibrosis conditions KALYDECO 150MG TAB $0 (Tier 4) NDS PA QL=60 EA/30 Days KALYDECO 25MG GRANULES $0 (Tier 4) NDS PA QL=60 EA/30 Days KALYDECO 50MG GRANULES $0 (Tier 4) NDS PA QL=60 EA/30 Days KALYDECO 75MG GRANULES $0 (Tier 4) NDS PA QL=60 EA/30 Days ORKAMBI 125-100MG GRANULES $0 (Tier 4) NDS PA QL=60 EA/30 Days ORKAMBI 125-100MG TAB $0 (Tier 4) NDS PA QL=120 EA/30 Days ORKAMBI 125-200MG TAB $0 (Tier 4) NDS PA QL=120 EA/30 Days ORKAMBI 188-150MG GRANULES $0 (Tier 4) NDS PA QL=60 EA/30 Days PULMOZYME 1MG/ML INH SOLN $0 (Tier 4) NDS B/D SYMDEKO 50-75MG/75MG PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days SYMDEKO TAB 4-WEEK PACK $0 (Tier 4) NDS PA QL=60 EA/30 Days TRIKAFTA 100-50-75MG/150MG PACK $0 (Tier 3) NDS PA QL=90 EA/30 Days PULMONARY FIBROSIS AGENTS - Drugs to treat pulmonary fibrosis ESBRIET 267MG CAP $0 (Tier 3) NDS PA QL=270 EA/30 Days ESBRIET 267MG TAB $0 (Tier 3) NDS PA QL=270 EA/30 Days ESBRIET 801MG TAB $0 (Tier 3) NDS PA QL=90 EA/30 Days OFEV 100MG CAP $0 (Tier 3) NDS PA QL=90 EA/30 Days

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 130 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) OFEV 150MG CAP $0 (Tier 3) NDS PA QL=60 EA/30 Days SULFONAMIDES - Drugs to treat bacterial infections SULFONAMIDES - Drugs to treat infection SULFADIAZINE 500MG TAB $0 (Tier 3) TETRACYCLINES - Drugs to treat bacterial infections AMINOMETHYLCYCLINES - Drugs to treat infection NUZYRA 150MG TAB $0 (Tier 4) NDS PA QL=30 EA/14 Days GLYCYLCYCLINES - Drugs to treat bacterial infections TIGECYCLINE 50MG INJ $0 (Tier 4) NDS TETRACYCLINES - Drugs to treat infections demeclocycline 150mg tab $0 (Tier 2) demeclocycline 300mg tab $0 (Tier 2) doxy 100mg inj $0 (Tier 2) doxycycline hyclate 100mg cap $0 (Tier 1) doxycycline hyclate 100mg tab $0 (Tier 1) doxycycline hyclate 20mg tab $0 (Tier 1) doxycycline hyclate 50mg cap $0 (Tier 1) doxycycline monohydrate 100mg cap $0 (Tier 1) doxycycline monohydrate 100mg tab $0 (Tier 1) doxycycline monohydrate 50mg cap $0 (Tier 1) doxycycline monohydrate 50mg tab $0 (Tier 1) doxycycline monohydrate 5mg/ml susp $0 (Tier 2) minocycline 100mg cap $0 (Tier 1) minocycline 100mg tab $0 (Tier 2) minocycline 50mg cap $0 (Tier 1) minocycline 50mg tab $0 (Tier 2) minocycline 75mg cap $0 (Tier 1) minocycline 75mg tab $0 (Tier 2) mondoxyne 100mg cap $0 (Tier 1) tetracycline 250mg cap $0 (Tier 2) tetracycline 500mg cap $0 (Tier 2) THYROID AGENTS - Drugs to regulate thyroid hormones ANTITHYROID AGENTS - Drugs to treat high thyroid level methimazole 10mg tab $0 (Tier 1) methimazole 5mg tab $0 (Tier 1) propylthiouracil 50mg tab $0 (Tier 2) THYROID HORMONES - Drugs to regulate thyroid hormones euthyrox 100mcg tab $0 (Tier 2) euthyrox 112mcg tab $0 (Tier 2) euthyrox 125mcg tab $0 (Tier 2) euthyrox 137mcg tab $0 (Tier 2) euthyrox 150mcg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 131 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) euthyrox 175mcg tab $0 (Tier 2) euthyrox 200mcg tab $0 (Tier 2) euthyrox 25mcg tab $0 (Tier 2) euthyrox 50mcg tab $0 (Tier 2) euthyrox 75mcg tab $0 (Tier 2) euthyrox 88mcg tab $0 (Tier 2) levo-t 100mcg tab $0 (Tier 2) levo-t 112mcg tab $0 (Tier 2) levo-t 125mcg tab $0 (Tier 2) levo-t 137mcg tab $0 (Tier 2) levo-t 150mcg tab $0 (Tier 2) levo-t 175mcg tab $0 (Tier 2) levo-t 200mcg tab $0 (Tier 2) levo-t 25mcg tab $0 (Tier 2) levo-t 300mcg tab $0 (Tier 2) levo-t 50mcg tab $0 (Tier 2) levo-t 75mcg tab $0 (Tier 2) levo-t 88mcg tab $0 (Tier 2) levothyroxine sodium 0.025mg tab $0 (Tier 2) levothyroxine sodium 0.05mg tab $0 (Tier 2) levothyroxine sodium 0.075mg tab $0 (Tier 2) levothyroxine sodium 0.088mg tab $0 (Tier 2) levothyroxine sodium 0.112mg tab $0 (Tier 2) levothyroxine sodium 0.125mg tab $0 (Tier 2) levothyroxine sodium 0.137mg tab $0 (Tier 2) levothyroxine sodium 0.15mg tab $0 (Tier 2) levothyroxine sodium 0.175mg tab $0 (Tier 2) levothyroxine sodium 0.1mg tab $0 (Tier 2) levothyroxine sodium 0.2mg tab $0 (Tier 2) levothyroxine sodium 0.3mg tab $0 (Tier 2) levoxyl 100mcg tab $0 (Tier 2) levoxyl 112mcg tab $0 (Tier 2) levoxyl 125mcg tab $0 (Tier 2) levoxyl 137mcg tab $0 (Tier 2) levoxyl 150mcg tab $0 (Tier 2) levoxyl 175mcg tab $0 (Tier 2) levoxyl 200mcg tab $0 (Tier 2) levoxyl 25mcg tab $0 (Tier 2) levoxyl 50mcg tab $0 (Tier 2) levoxyl 75mcg tab $0 (Tier 2) levoxyl 88mcg tab $0 (Tier 2) liothyronine sodium 0.005mg tab $0 (Tier 2) liothyronine sodium 0.025mg tab $0 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 132 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) liothyronine sodium 0.05mg tab $0 (Tier 2) SYNTHROID 100MCG TAB $0 (Tier 4) SYNTHROID 112MCG TAB $0 (Tier 4) SYNTHROID 125MCG TAB $0 (Tier 4) SYNTHROID 137MCG TAB $0 (Tier 4) SYNTHROID 150MCG TAB $0 (Tier 4) SYNTHROID 175MCG TAB $0 (Tier 4) SYNTHROID 200MCG TAB $0 (Tier 4) SYNTHROID 25MCG TAB $0 (Tier 4) SYNTHROID 300MCG TAB $0 (Tier 4) SYNTHROID 50MCG TAB $0 (Tier 4) SYNTHROID 75MCG TAB $0 (Tier 4) SYNTHROID 88MCG TAB $0 (Tier 4) unithroid 100mcg tab $0 (Tier 2) unithroid 112mcg tab $0 (Tier 2) unithroid 125mcg tab $0 (Tier 2) unithroid 137mcg tab $0 (Tier 2) unithroid 150mcg tab $0 (Tier 2) unithroid 175mcg tab $0 (Tier 2) unithroid 200mcg tab $0 (Tier 2) unithroid 25mcg tab $0 (Tier 2) unithroid 300mcg tab $0 (Tier 2) unithroid 50mcg tab $0 (Tier 2) unithroid 75mcg tab $0 (Tier 2) unithroid 88mcg tab $0 (Tier 2) TOXOIDS - Drugs to prevent infection TOXOID COMBINATIONS - Drugs to prevent infection ADACEL INJ $0 (Tier 3) ADACEL SYRINGE $0 (Tier 3) BOOSTRIX INJ $0 (Tier 3) BOOSTRIX SYRINGE $0 (Tier 3) DAPTACEL INJ $0 (Tier 3) DIPHTHERIA/TETANUS TOXOID INJ $0 (Tier 3) B/D INFANRIX INJ $0 (Tier 3) KINRIX INJ $0 (Tier 3) KINRIX PF INJ $0 (Tier 3) PEDIARIX INJ $0 (Tier 3) QUADRACEL INJ $0 (Tier 3) TDVAX 4-4UNIT/ML INJ $0 (Tier 3) B/D TENIVAC 4-10UNIT/ML SYRINGE $0 (Tier 3) B/D ULCER DRUGS - Drugs to treat bowel, intestine, and stomach conditions ANTISPASMODICS - Drugs to treat diarrhea

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 133 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) dicyclomine 10mg cap $0 (Tier 1) dicyclomine 20mg tab $0 (Tier 1) glycopyrrolate 1mg tab $0 (Tier 2) glycopyrrolate 2mg tab $0 (Tier 2) H-2 ANTAGONISTS - Drugs to treat bowel, intestine, and stomach conditions cimetidine 200mg tab $0 (Tier 2) cimetidine 300mg tab $0 (Tier 2) cimetidine 400mg tab $0 (Tier 2) cimetidine 800mg tab $0 (Tier 2) CIMETIDINE TAB 200 MG $0 (Tier 5) cimetidine tab 200mg $0 (Tier 5) famotidine 20mg tab $0 (Tier 1) famotidine 8mg/ml susp $0 (Tier 2) famotidine tab 10mg $0 (Tier 5) famotidine tab 20mg $0 (Tier 5) MISC. ANTI-ULCER - Miscellaneous anti-ulcer drugs sucralfate 1000mg tab $0 (Tier 1) PROTON PUMP INHIBITORS - Drugs to treat acid reflux esomeprazole 20mg dr cap $0 (Tier 2) lansoprazole 15mg dr cap $0 (Tier 2) lansoprazole 30mg dr cap $0 (Tier 2) omeprazole 20mg dr cap $0 (Tier 1) pantoprazole 20mg dr tab $0 (Tier 1) rabeprazole sodium 20mg dr tab $0 (Tier 2) ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS - Drugs to treat ulcers ANTISPASMODICS - Drugs to treat diarrhea dicyclomine 2mg/ml oral soln $0 (Tier 2) METHSCOPOLAMINE BROMIDE 2.5MG TAB $0 (Tier 2) METHSCOPOLAMINE BROMIDE 5MG TAB $0 (Tier 2) H-2 ANTAGONISTS - Drugs to treat bowel, intestine, and stomach conditions CIMETIDINE 60MG/ML ORAL SOLN $0 (Tier 2) famotidine 40mg tab $0 (Tier 1) nizatidine 150mg cap $0 (Tier 2) nizatidine 300mg cap $0 (Tier 2) ranitidine tab 150mg $0 (Tier 5) ranitidine tab 75mg $0 (Tier 5) MISC. ANTI-ULCER - Miscellaneous anti-ulcer drugs sucralfate 100mg/ml susp $0 (Tier 2) PROTON PUMP INHIBITORS - Drugs to treat acid reflux esomeprazole 40mg dr cap $0 (Tier 2) omeprazole 10mg dr cap $0 (Tier 1) omeprazole 40mg dr cap $0 (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 134 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) pantoprazole 40mg dr tab $0 (Tier 1) ULCER DRUGS - PROSTAGLANDINS - Drugs to treat bowel, intestine, and stomach conditions misoprostol 0.1mg tab $0 (Tier 2) misoprostol 0.2mg tab $0 (Tier 2) ULCER THERAPY COMBINATIONS - Drugs to treat bowel, intestine, and stomach conditions amoxicillin 500mg/clarithromycin $0 (Tier 2) 500mg/lansoprazole 30mg pack PYLERA 140-125-125MG CAP $0 (Tier 4) URINARY ANTI-INFECTIVES - Drugs to treat bladder/kidney infections URINARY ANTI-INFECTIVES - Drugs to treat bladder/kidney infections methenamine hippurate 1000mg tab $0 (Tier 2) MONUROL 5.631GM POWDER FOR ORAL SOLN $0 (Tier 4) nitrofurantoin macro 25mg/nitrofurantoin mono 75mg $0 (Tier 2) cap nitrofurantoin macrocrystals 100mg cap $0 (Tier 2) QL=90 EA/365 Days nitrofurantoin macrocrystals 50mg cap $0 (Tier 2) URINARY ANTISPASMODICS - Drugs to treat miscellaneous bladder spasms URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) - Drugs to treat miscellaneous bladder spasms oxybutynin chloride 10mg er tab $0 (Tier 1) oxybutynin chloride 15mg er tab $0 (Tier 1) oxybutynin chloride 1mg/ml oral soln $0 (Tier 1) oxybutynin chloride 5mg er tab $0 (Tier 1) oxybutynin chloride 5mg tab $0 (Tier 1) solifenacin succinate 10mg tab $0 (Tier 1) solifenacin succinate 5mg tab $0 (Tier 1) tolterodine tartrate 1mg tab $0 (Tier 2) tolterodine tartrate 2mg er cap $0 (Tier 2) tolterodine tartrate 2mg tab $0 (Tier 2) tolterodine tartrate 4mg er cap $0 (Tier 2) trospium chloride 20mg tab $0 (Tier 2) trospium chloride 60mg er cap $0 (Tier 2) URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS - Drugs to treat miscellaneous bladder spasms MYRBETRIQ 25MG ER TAB $0 (Tier 3) QL=30 EA/30 Days MYRBETRIQ 50MG ER TAB $0 (Tier 3) QL=30 EA/30 Days URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS - Drugs to treat urinary retention bethanechol chloride 10mg tab $0 (Tier 1) bethanechol chloride 25mg tab $0 (Tier 1) bethanechol chloride 50mg tab $0 (Tier 1) bethanechol chloride 5mg tab $0 (Tier 1)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 135 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS - Drugs to treat miscellaneous bladder spasms flavoxate 100mg tab $0 (Tier 2) VACCINES - Drugs to prevent infection BACTERIAL VACCINES - Drugs to prevent infection ACTHIB INJ $0 (Tier 3) BCG LIVE TICE STRAIN 50MG INJ $0 (Tier 3) BEXSERO SYRINGE $0 (Tier 3) HIBERIX 10MCG INJ $0 (Tier 3) MENACTRA INJ $0 (Tier 3) MENQUADFI INJ $0 (Tier 3) MENVEO INJ $0 (Tier 3) PEDVAXHIB 7.5MCG/0.5ML INJ $0 (Tier 3) TRUMENBA SYRINGE $0 (Tier 3) TYPHIM VI 25MCG/0.5ML INJ $0 (Tier 3) TYPHIM VI 25MCG/0.5ML SYRINGE $0 (Tier 3) VIRAL VACCINES - Drugs to prevent infection ENGERIX-B 10MCG/0.5ML SYRINGE $0 (Tier 3) B/D ENGERIX-B 20MCG/ML SYRINGE $0 (Tier 3) B/D GARDASIL 9 INJ $0 (Tier 3) GARDASIL 9 SYRINGE $0 (Tier 3) HAVRIX 1440ELU/ML SYRINGE $0 (Tier 3) HAVRIX 720ELU/0.5ML SYRINGE $0 (Tier 3) IMOVAX 2.5UNIT/ML INJ $0 (Tier 3) B/D IPOL INJ $0 (Tier 3) IXIARO 0.012MG/ML SYRINGE $0 (Tier 3) M-M-R II INJ $0 (Tier 3) PROQUAD INJ $0 (Tier 3) RABAVERT 2.5UNIT/ML INJ $0 (Tier 3) B/D RECOMBIVAX 10MCG/ML INJ $0 (Tier 3) B/D RECOMBIVAX 10MCG/ML SYRINGE $0 (Tier 3) B/D RECOMBIVAX 40MCG/ML INJ $0 (Tier 3) B/D RECOMBIVAX 5MCG/0.5ML SYRINGE $0 (Tier 3) B/D ROTARIX SUSP $0 (Tier 3) ROTATEQ SUSP $0 (Tier 3) SHINGRIX 50MCG/0.5ML INJ $0 (Tier 3) TWINRIX 720UNIT SYRINGE $0 (Tier 3) VAQTA 25UNIT/0.5ML INJ $0 (Tier 3) VAQTA 25UNIT/0.5ML SYRINGE $0 (Tier 3) VAQTA 50UNIT/ML INJ $0 (Tier 3) VAQTA 50UNIT/ML SYRINGE $0 (Tier 3) VARIVAX 1350PFU/0.5ML INJ $0 (Tier 3)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 136 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) YF-VAX 4000UNIT/ML INJ $0 (Tier 3) VAGINAL AND RELATED PRODUCTS - Drugs to treat vaginal infections VAGINAL ANTI-INFECTIVES - Drugs to treat vaginal infections clindamycin 2% vaginal cream $0 (Tier 2) metronidazole 0.75% vaginal gel $0 (Tier 2) miconazole nitrate vaginal kit $0 (Tier 5) terconazole 0.4% vaginal cream $0 (Tier 2) TERCONAZOLE 0.8% VAGINAL CREAM $0 (Tier 2) terconazole 80mg vaginal insert $0 (Tier 2) vandazole 0.75% vaginal gel $0 (Tier 2) VAGINAL ESTROGENS - Drugs to treat low hormones estradiol 0.01% vaginal cream $0 (Tier 2) estradiol 0.01mg vaginal insert $0 (Tier 2) ESTRING 2MG VAGINAL SYSTEM $0 (Tier 4) ST PREMARIN 0.625MG/GM VAGINAL CREAM $0 (Tier 3) yuvafem 10mcg vaginal insert $0 (Tier 2) VAGINAL PROGESTINS - Drugs to treat low hormones CRINONE 4% VAGINAL GEL $0 (Tier 3) PA CRINONE 8% VAGINAL GEL $0 (Tier 3) PA VAGINAL PRODUCTS - Drugs to treat vaginal infections and low hormones SPERMICIDES - Drugs to prevent pregnancy NONOXYNOL-9 FILM 28% $0 (Tier 5) NONOXYNOL-9 FOAM 12.5% $0 (Tier 5) VAGINAL ANTI-INFECTIVES - Drugs to treat vaginal infections clotrimazole vaginal cream 1% $0 (Tier 5) clotrimazole vaginal cream 2% $0 (Tier 5) miconazole nitrate vaginal cream 2% $0 (Tier 5) miconazole nitrate vaginal cream 4% $0 (Tier 5) miconazole nitrate vaginal supp 100mg $0 (Tier 5) miconazole nitrate vaginal supp 200mg/2% cream $0 (Tier 5) 9gm kit VASOPRESSORS - Drugs to treat heart and circulation conditions ANAPHYLAXIS THERAPY AGENTS - Drugs to treat systemic swelling conditions epinephrine 0.5mg/ml auto-injector $0 (Tier 2) QL=2 EA/15 Days epinephrine 1mg/ml auto-injector $0 (Tier 2) QL=2 EA/15 Days SYMJEPI 0.15MG/0.3ML SYRINGE $0 (Tier 3) QL=2 EA/15 Days SYMJEPI 0.3MG/0.3ML SYRINGE $0 (Tier 3) QL=2 EA/15 Days NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS - Drugs to prevent fainting droxidopa 100mg cap $0 (Tier 2) PA droxidopa 200mg cap $0 (Tier 2) PA droxidopa 300mg cap $0 (Tier 2) PA

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 137 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) VIRAL VACCINES - Drugs to prevent infection midodrine 10mg tab $0 (Tier 2) midodrine 2.5mg tab $0 (Tier 2) midodrine 5mg tab $0 (Tier 2) VITAMINS - Drugs to treat vitamin deficiency OIL SOLUBLE VITAMINS - Drugs to treat vitamin deficiency beta carotene cap 25000 unit $0 (Tier 5) cholecalciferol cap 125 mcg (5000 unit) $0 (Tier 5) CHOLECALCIFEROL CAP 14000 UNIT $0 (Tier 5) cholecalciferol cap 25 mcg (1000 unit) $0 (Tier 5) cholecalciferol cap 50 mcg (2000 unit) $0 (Tier 5) cholecalciferol chew tab 2000 unit $0 (Tier 5) CHOLECALCIFEROL DROPS 1000 UNIT/0.028ML $0 (Tier 5) (PER DROP) CHOLECALCIFEROL DROPS 2000 UNIT/0.028ML $0 (Tier 5) (PER DROP) CHOLECALCIFEROL DROPS 400 UNIT/0.025ML $0 (Tier 5) (PER DROP) CHOLECALCIFEROL ORAL LIQUID 1000 $0 (Tier 5) UNIT/10ML CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML $0 (Tier 5) CHOLECALCIFEROL ORALLY DISINTEGRATING $0 (Tier 5) TAB 5000 UNIT CHOLECALCIFEROL TAB 10000 UNIT $0 (Tier 5) cholecalciferol tab 2000unit $0 (Tier 5) ergocalciferol cap 50000unit $0 (Tier 5) ergocalciferol soln 200 mcg/ml (8000 unit/ml) $0 (Tier 5) ERGOCALCIFEROL TAB 2000UNIT $0 (Tier 5) ERGOCALCIFEROL TAB 400UNIT $0 (Tier 5) phytonadione soln 1mg/0.5ml $0 (Tier 5) phytonadione tab 5 mg $0 (Tier 5) vitamin A cap 10000unit $0 (Tier 5) vitamin a cap 2400 mcg (8000 unit) $0 (Tier 5) VITAMIN A PALMITATE 15000UNIT TAB $0 (Tier 5) vitamin A tab 10000unit $0 (Tier 5) VITAMIN A/BETA CAROTEN TAB $0 (Tier 5) vitamin D3 cap 10000unit $0 (Tier 5) VITAMIN D3 CAP 4000UNIT $0 (Tier 5) vitamin D3 cap 50000unit $0 (Tier 5) vitamin D3 chew tab 1000unit $0 (Tier 5) vitamin D3 chew tab 400unit $0 (Tier 5) vitamin D3 drops 5000unit/ml $0 (Tier 5) vitamin D3 oral liquid 400unit/ml $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 138 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) vitamin D3 tab 1000unit $0 (Tier 5) VITAMIN D3 TAB 3000UNIT $0 (Tier 5) vitamin D3 tab 400unit $0 (Tier 5) vitamin D3 tab 50000unit $0 (Tier 5) vitamin D3 tab 5000unit $0 (Tier 5) VITAMIN E 100UNIT TAB $0 (Tier 5) vitamin e cap 100 unit $0 (Tier 5) vitamin E cap 1000unit $0 (Tier 5) vitamin e cap 200 unit $0 (Tier 5) vitamin E cap 400unit $0 (Tier 5) vitamin e soln 15 unit/0.3ml (50 unit/ml) $0 (Tier 5) vitamin k1 10mg/ml inj $0 (Tier 5) WATER SOLUBLE VITAMINS - Drugs to treat vitamin deficiency ascorbic acid chew tab 100 mg $0 (Tier 5) ascorbic acid chew tab 125 mg $0 (Tier 5) ascorbic acid chew tab 250 mg $0 (Tier 5) ascorbic acid chew tab 500 mg $0 (Tier 5) ascorbic acid liquid 500 mg/5ml $0 (Tier 5) ASCORBIC ACID POWDER $0 (Tier 5) ASCORBIC ACID POWDER PACK 500 MG $0 (Tier 5) ASCORBIC ACID TAB 100 MG $0 (Tier 5) ascorbic acid tab er 1500 mg $0 (Tier 5) calcium ascorbate tab 500 mg $0 (Tier 5) niacin CR cap 250mg $0 (Tier 5) niacin CR cap 500mg $0 (Tier 5) NIACIN CR TAB 1000MG $0 (Tier 5) niacin CR tab 750mg $0 (Tier 5) niacin tab 100mg $0 (Tier 5) niacin tab 250mg $0 (Tier 5) niacin tab 50 mg $0 (Tier 5) niacin tab 500mg $0 (Tier 5) niacin tab er 250 mg $0 (Tier 5) niacin tab er 500 mg $0 (Tier 5) niacinamide er tab 500mg $0 (Tier 5) niacinamide tab 500mg $0 (Tier 5) niacinamide tab er 750 mg $0 (Tier 5) pyridoxine hcl tab 50 mg $0 (Tier 5) RIBOFLAVIN POWDER 343 MG/GM $0 (Tier 5) RIBOFLAVIN TAB 400 MG $0 (Tier 5) riboflavin tab 50 mg $0 (Tier 5) thiamine hcl tab 100 mg $0 (Tier 5) thiamine hcl tab 50 mg $0 (Tier 5) thiamine tab 250mg $0 (Tier 5) You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 139 Name of drug What the drug Necessary actions, will cost you (tier restrictions, or limits on use level) vitamin B-1 tab 100mg $0 (Tier 5) vitamin B-2 tab 100mg $0 (Tier 5) vitamin B-2 tab 25mg $0 (Tier 5) vitamin B-6 tab 100mg $0 (Tier 5) vitamin B-6 tab 250mg $0 (Tier 5) vitamin B-6 tab 25mg $0 (Tier 5) vitamin C cap 500mg $0 (Tier 5) vitamin C drops 60mg $0 (Tier 5) VITAMIN C ORAL CRYSTALS $0 (Tier 5) VITAMIN C POWDER FOR SOLUTION $0 (Tier 5) vitamin C tab 1000mg $0 (Tier 5) vitamin C tab 250mg $0 (Tier 5) vitamin C tab 500mg $0 (Tier 5)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 140 ALPHABETICAL LISTING OF DRUGS

A acetaminophen 24 acetaminophen CR tab 22 300mg/codeine 650mg A+D (topical) ointment 90 phosphate 30mg tab acetaminophen 22 abacavir 20mg/ml oral 69 acetaminophen 24 disintegrating tab 80 mg soln 300mg/codeine acetaminophen 22 abacavir 300mg tab 69 phosphate 60mg tab dispersible tab 160mg abacavir 69 acetaminophen 24 acetaminophen 22 300mg/lamivudine 300mg/hydrocodone dispersible tab 80mg 150mg/zidovudine 300mg bitartrate 10mg tab acetaminophen elixir 160 22 tab acetaminophen 24 mg/5ml abacavir 69 300mg/hydrocodone acetaminophen liquid 22 600mg/lamivudine 300mg bitartrate 5mg tab 160mg/5ml tab acetaminophen 24 acetaminophen liquid 167 22 ABATRON LIQUID 104 300mg/hydrocodone mg/5ml abdek pediatric drops 118 bitartrate 7.5mg tab acetaminophen soln 22 ABELCET 5MG/ML INJ 46 acetaminophen 25 160mg/5ml ABILIFY 300MG INJ 68 325mg/hydrocodone acetaminophen suppos 22 ABILIFY 300MG 68 bitartrate 10mg tab 120 mg SYRINGE acetaminophen 25 ACETAMINOPHEN 22 ABILIFY 400MG INJ 68 325mg/hydrocodone SUPPOS 325 MG ABILIFY 400MG 68 bitartrate 5mg tab acetaminophen suppos 22 SYRINGE acetaminophen 25 650 mg abiraterone acetate 57 325mg/hydrocodone ACETAMINOPHEN 22 250mg tab bitartrate 7.5mg tab SUPPOS 80 MG acamprosate calcium 127 acetaminophen 25 acetaminophen susp 22 333mg dr tab 325mg/oxycodone 10mg 160mg/5ml acarbose 100mg tab 41 tab ACETAMINOPHEN SUSP 22 acarbose 25mg tab 41 acetaminophen 25 80 MG/0.8ML acarbose 50mg tab 41 325mg/oxycodone 2.5mg acetaminophen susp 80 22 accutane 20mg cap 85 tab mg/0.8ml accutane 30mg cap 85 acetaminophen 25 acetaminophen tab 325 22 accutane 40mg cap 85 325mg/oxycodone 5mg mg acebutolol 200mg cap 73 tab acetaminophen tab 22 acebutolol 400mg cap 73 acetaminophen 25 500mg acetaminophen 24 325mg/oxycodone 7.5mg ACETAMINOPHEN W/ 22 21.7mg/ml/hydrocodone tab PAMABROM TAB bitartrate 0.5mg/ml oral acetaminophen 25 325-25 MG soln 325mg/tramadol 37.5mg ACETAMINOPHEN-MAG 22 acetaminophen 24 tab NESIUM 24mg/ml/codeine acetaminophen cap 22 SALICYLATE-CAFF TAB phosphate 2.4mg/ml oral 500mg 250-290-50 MG soln acetaminophen chew tab 22 acetaminophen-pamabro 22 acetaminophen 24 160mg m-pyrilamine tab 300mg/codeine 500-25-15 mg phosphate 15mg tab You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 141 ALPHABETICAL LISTING OF DRUGS acetazolamide 125mg tab 93 ADVAIR 0.045-0.021MG 31 ALENDRONIC ACID 94 acetazolamide 250mg tab 93 INH 0.933MG/ML ORAL acetazolamide 500mg er 93 ADVAIR 0.115-0.021MG 31 SOLN cap INH alendronic acid 10mg tab 94 acetic acid 2% otic soln 124 ADVAIR 0.23-0.021MG 31 alendronic acid 35mg tab 95 acetic 124 INH alendronic acid 70mg tab 95 acid/hydrocortisone 1-2% ADVANCED CALCIUM 110 alfuzosin 10mg er tab 101 otic soln FORMULA TAB ALINIA 100MG/5ML 54 acetylcysteine 100mg/ml 85 AFINITOR 10MG TAB 58 SUSP inh soln AFINITOR 2MG TAB FOR 58 ALINIA 500MG TAB 54 acetylcysteine 200mg/ml 85 ORAL SUSP aliskiren 150mg tab 53 inh soln AFINITOR 3MG TAB FOR 58 aliskiren 300mg tab 53 acetylcysteine cap 600 mg 120 ORAL SUSP allopurinol 100mg tab 101 acitretin 10mg cap 88 AFINITOR 5MG TAB FOR 58 allopurinol 300mg tab 101 acitretin 17.5mg cap 88 ORAL SUSP ALOCRIL 2% OPHTH 123 acitretin 25mg cap 88 AIMOVIG 140MG/ML 109 SOLN ACTEMRA 20 AUTO-INJECTOR ALOMIDE 0.1% OPHTH 123 162MG/0.9ML AIMOVIG 70MG/ML 109 SOLN AUTO-INJECTOR AUTO-INJECTOR alosetron 0.5mg tab 100 ACTEMRA 20 ala-cort 1% cream 89 alosetron 1mg tab 100 162MG/0.9ML SYRINGE ala-cort 2.5% cream 89 ALPHAGAN 0.1% 121 ACTHIB INJ 136 albendazole 200mg tab 27 OPHTH SOLN ACTIMMUNE 62 albuterol 0.21mg/ml inh 31 alpha-lipoic acid (thioctic 18 2000000UNIT/0.5ML INJ soln acid) cap 600 mg acyclovir 200mg cap 72 albuterol 0.417mg/ml inh 31 alprazolam 0.25mg odt 28 acyclovir 400mg tab 72 soln alprazolam 0.25mg tab 28 acyclovir 40mg/ml susp 72 albuterol 0.4mg/ml oral 31 alprazolam 0.5mg er tab 28 acyclovir 5% ointment 88 soln alprazolam 0.5mg odt 28 acyclovir 50mg/ml inj 72 albuterol 0.83mg/ml inh 31 alprazolam 0.5mg tab 28 acyclovir 800mg tab 72 soln alprazolam 1mg er tab 28 ADACEL INJ 133 albuterol 2mg tab 31 alprazolam 1mg odt 28 ADACEL SYRINGE 133 albuterol 4mg tab 31 alprazolam 1mg tab 29 adapalene 0.1% cream 85 albuterol 5mg/ml inh soln 31 alprazolam 2mg er tab 29 adapalene 0.1% gel 85 albuterol sulfate 108mcg 31 alprazolam 2mg odt 29 adapalene 0.3% gel 85 hfa inhaler (8.5gm) alprazolam 2mg tab 29 adapalene/benzoyl 85 alclometasone 89 alprazolam 3mg er tab 29 peroxide 0.1-2.5% gel dipropionate 0.05% ALREX 0.2% OPHTH 123 adefovir dipivoxil 10mg 72 cream SUSP tab alclometasone 89 altavera 28 day pack 80 ADEMPAS 0.5MG TAB 78 dipropionate 0.05% alum/mag 26 ADEMPAS 1.5MG TAB 78 ointment hydroxide-simethicone ADEMPAS 1MG TAB 78 ALECENSA 150MG CAP 58 chew tab 200-200-25 mg ADEMPAS 2.5MG TAB 78 ADEMPAS 2MG TAB 78

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

ALUMINUM 27 amiodarone 200mg tab 30 amlodipine 51 HYDROXIDE GEL SUSP amiodarone 400mg tab 30 10mg/benazepril 20mg 320MG/5ML amitriptyline 100mg tab 40 cap aluminum 26 amitriptyline 10mg tab 40 amlodipine 51 hydroxide/magnesium AMITRIPTYLINE 128 10mg/benazepril 40mg carbonate chew tab 10MG/PERPHENAZINE cap 160-105mg 2MG TAB amlodipine 51 aluminum 26 AMITRIPTYLINE 128 10mg/hydrochlorothiazid hydroxide/magnesium 10MG/PERPHENAZINE e 12.5mg/valsartan carbonate susp 4MG TAB 160mg tab 95-358mg/15ml amitriptyline 128 amlodipine 51 aluminum/magnesium 27 12.5mg/chlordiazepoxide 10mg/hydrochlorothiazid hydroxide/simethicone 5mg tab e 25mg/valsartan 160mg susp 200-200-20mg/5ml amitriptyline 150mg tab 40 tab aluminum/magnesium 27 amitriptyline 25mg tab 40 amlodipine 51 hydroxide/simethicone amitriptyline 128 10mg/hydrochlorothiazid susp 400-400-40mg/5ml 25mg/chlordiazepoxide e 25mg/valsartan 320mg ALUNBRIG 180MG TAB 58 10mg tab tab ALUNBRIG 30MG TAB 58 AMITRIPTYLINE 128 amlodipine 51 ALUNBRIG 90MG TAB 58 25MG/PERPHENAZINE 10mg/olmesartan ALUNBRIG INITIATION 58 2MG TAB medoxomil 20mg tab PACK AMITRIPTYLINE 128 amlodipine 51 alyacen 1/35 28 day pack 80 25MG/PERPHENAZINE 10mg/olmesartan alyq 20mg tab 77 4MG TAB medoxomil 40mg tab amabelz 0.5/0.1mg 28 day 97 amitriptyline 50mg tab 40 amlodipine 51 pack AMITRIPTYLINE 128 10mg/valsartan 160mg amabelz 1/0.5mg 28 day 97 50MG/PERPHENAZINE tab pack 4MG TAB amlodipine 51 amantadine 100mg cap 64 amitriptyline 75mg tab 40 10mg/valsartan 320mg amantadine 100mg tab 64 amlodipine 10mg tab 75 tab amantadine 10mg/ml oral 63 amlodipine 77 amlodipine 2.5mg tab 75 soln 10mg/atorvastatin 10mg amlodipine 77 AMBISOME 50MG INJ 46 tab 2.5mg/atorvastatin 10mg ambrisentan 10mg tab 77 amlodipine 77 tab ambrisentan 5mg tab 77 10mg/atorvastatin 20mg amlodipine 77 AMERIDERM 91 tab 2.5mg/atorvastatin 20mg PERISHIELD OINTMENT amlodipine 77 tab amethia 91 day pack 80 10mg/atorvastatin 40mg amlodipine 77 amikacin 250mg/ml inj 19 tab 2.5mg/atorvastatin 40mg amiloride 5mg tab 94 amlodipine 77 tab amiloride 93 10mg/atorvastatin 80mg amlodipine 51 5mg/hydrochlorothiazide tab 2.5mg/benazepril 10mg 50mg tab cap AMINOSYN-PF 7% INJ 120 amlodipine 5mg tab 75

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 143 ALPHABETICAL LISTING OF DRUGS amlodipine 77 AMOXAPINE 100MG 40 amoxicillin 80mg/ml susp 125 5mg/atorvastatin 10mg TAB amoxicillin 126 tab AMOXAPINE 150MG 40 80mg/ml/clavulanate amlodipine 77 TAB 11.4mg/ml susp 5mg/atorvastatin 20mg AMOXAPINE 25MG TAB 40 amoxicillin 875mg tab 125 tab AMOXAPINE 50MG TAB 40 amoxicillin 126 amlodipine 77 AMOXICILLIN 126 875mg/clavulanate 5mg/atorvastatin 40mg 1000MG/CLAVULANAT 125mg tab tab E 62.5MG ER TAB amphetamine-dextroamp 16 amlodipine 77 amoxicillin 126 hetamine 10mg ER cap 5mg/atorvastatin 80mg 120mg/ml/clavulanate amphetamine-dextroamp 16 tab 8.58mg/ml susp hetamine 10mg tab amlodipine 51 amoxicillin 125mg chew 125 amphetamine-dextroamp 16 5mg/benazepril 10mg cap tab hetamine 12.5mg tab amlodipine 51 AMOXICILLIN 126 amphetamine-dextroamp 16 5mg/benazepril 20mg cap 200MG/CLAVULANATE hetamine 15mg ER cap amlodipine 51 28.5MG CHEW TAB amphetamine-dextroamp 16 5mg/benazepril 40mg cap amoxicillin 250mg cap 125 hetamine 15mg tab amlodipine 51 AMOXICILLIN 250MG 125 amphetamine-dextroamp 16 5mg/hydrochlorothiazide CHEW TAB hetamine 20mg ER cap 12.5mg/valsartan 160mg amoxicillin 126 amphetamine-dextroamp 16 tab 250mg/clavulanate hetamine 20mg tab amlodipine 51 125mg tab amphetamine-dextroamp 16 5mg/hydrochlorothiazide amoxicillin 25mg/ml susp 125 hetamine 25mg ER cap 25mg/valsartan 160mg AMOXICILLIN 126 amphetamine-dextroamp 16 tab 400MG/CLAVULANATE hetamine 30mg ER cap amlodipine 51 57MG CHEW TAB amphetamine-dextroamp 16 5mg/olmesartan amoxicillin 40mg/ml susp 125 hetamine 30mg tab medoxomil 20mg tab amoxicillin 126 amphetamine-dextroamp 16 amlodipine 51 40mg/ml/clavulanate hetamine 5mg ER cap 5mg/olmesartan 5.7mg/ml susp amphetamine-dextroamp 16 medoxomil 40mg tab amoxicillin 500mg cap 125 hetamine 5mg tab amlodipine 51 amoxicillin 500mg tab 125 amphetamine-dextroamp 16 5mg/valsartan 160mg tab amoxicillin 135 hetamine 7.5mg tab amlodipine 51 500mg/clarithromycin AMPHOTERICIN B 46 5mg/valsartan 320mg tab 500mg/lansoprazole 50MG INJ ammonium lactate 12% 90 30mg pack ampicillin 1000mg inj 125 cream amoxicillin 126 ampicillin 126 ammonium lactate 12% 91 500mg/clavulanate 1000mg/sulbactam lotion 125mg tab 500mg inj amnesteem 10mg cap 85 amoxicillin 50mg/ml susp 125 ampicillin 100mg/ml inj 125 amnesteem 20mg cap 85 amoxicillin 126 ampicillin 126 amnesteem 40mg cap 85 50mg/ml/clavulanate 100mg/ml/sulbactam 12.5mg/ml susp 50mg/ml inj

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 144 ALPHABETICAL LISTING OF DRUGS

AMPICILLIN 125MG INJ 125 aripiprazole 15mg tab 68 ascorbic acid tab er 1500 139 ampicillin 126 aripiprazole 1mg/ml oral 68 mg 2000mg/sulbactam soln asenapine 10mg sl tab 66 1000mg inj aripiprazole 20mg tab 68 asenapine 2.5mg sl tab 66 AMPICILLIN 500MG 125 aripiprazole 2mg tab 68 asenapine 5mg sl tab 66 CAP aripiprazole 30mg tab 68 ashlyna 91 day pack 80 anagrelide 0.5mg cap 102 aripiprazole 5mg tab 69 aspirin 102 anagrelide 1mg cap 102 ARISTADA 69 25mg/dipyridamole anastrozole 1mg tab 57 1064MG/3.9ML 200mg er cap ANDRODERM 26 SYRINGE ASPIRIN 25 2MG/24HR PATCH ARISTADA 69 325MG/OXYCODONE ANDRODERM 26 441MG/1.6ML SYRINGE 4.84MG TAB 4MG/24HR PATCH ARISTADA 69 ASPIRIN BUFFERED (CA 23 ANORO 0.0625-0.025MG 31 662MG/2.4ML SYRINGE CARB-MG CARB-MG INH ARISTADA 69 OX) TAB 325 MG anti-diarrheal 2mg caplet 44 675MG/2.4ML SYRINGE aspirin buffered tab 23 APATATE LIQUID 118 ARISTADA 69 325mg APETIGEN ELIXIR 116 882MG/3.2ML SYRINGE aspirin chew tab 81mg 23 APETIGEN PLUS TAB 117 armodafinil 150mg tab 17 aspirin effervescent tab 23 APOKYN 30MG/3ML 64 armodafinil 200mg tab 17 ASPIRIN SUPP 300MG 23 CARTRIDGE armodafinil 250mg tab 17 ASPIRIN SUPP 600MG 23 apraclonidine 0.5% ophth 121 armodafinil 50mg tab 17 aspirin tab 325mg 23 soln ARNUITY 100MCG INH 30 ASPIRIN TAB DELAYED 23 aprepitant 125mg cap 45 ARNUITY 200MCG INH 30 RELEASE 325 MG aprepitant 46 ARNUITY 50MCG INH 30 aspirin tab delayed 23 125mg/aprepitant 80mg artificial tear ointment 121 release 325 mg pack artificial tears ophth soln 121 aspirin tab delayed 23 aprepitant 40mg cap 46 5-6mg/ml release 500 mg aprepitant 80mg cap 46 ascorbic acid chew tab 139 aspirin tab delayed 23 apri 28 day pack 80 100 mg release 81 mg APTIOM 200MG TAB 34 ascorbic acid chew tab 139 aspirin/acetaminophen/ca 22 APTIOM 400MG TAB 34 125 mg ffeine tab 250-250-65mg APTIOM 600MG TAB 34 ascorbic acid chew tab 139 ASPIRIN-ACETAMINOP 22 APTIOM 800MG TAB 34 250 mg HEN-CAFFEINE POWD APTIVUS 100MG/ML 69 ascorbic acid chew tab 139 PACK 500-325-65 MG ORAL SOLN 500 mg ASPIRIN-ACETAMINOP 22 APTIVUS 250MG CAP 69 ascorbic acid liquid 500 139 HEN-CAFFEINE POWD ARALAST 1000MG INJ 130 mg/5ml PACK 520-260-32.5 MG aranelle 28 pack 80 ASCORBIC ACID 139 ASPIRIN-APAP-SALICYL 22 ARCALYST 220MG INJ 20 POWDER AMIDE-CAFFEINE TAB ARGININE TAB 500 MG 120 ASCORBIC ACID 139 162-110-152-32.4 MG aripiprazole 10mg odt 68 POWDER PACK 500 MG ASPIRIN-CAFFEINE 22 aripiprazole 10mg tab 68 ASCORBIC ACID TAB 139 POWDER PACKET aripiprazole 15mg odt 68 100 MG 1000-65 MG

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

ASPIRIN-CAFFEINE 22 atropine sulfate 44 azithromycin 500mg tab 108 POWDER PACKET 0.025mg/diphenoxylate azithromycin 600mg tab 108 845-65 MG 2.5mg tab AZOPT 1% OPHTH SUSP 123 ASPIRIN-CAFFEINE TAB 22 ATROPINE SULFATE 1% 121 aztreonam 1000mg inj 55 400-32 MG OPHTH SOLN B ASTAGRAF 0.5MG ER 115 ATROVENT 17MCG INH 30 BACITRACIN 122 CAP AUBAGIO 14MG TAB 129 0.5UNIT/MG OPHTH ASTAGRAF 1MG ER CAP 115 AUBAGIO 7MG TAB 129 OINTMENT ASTAGRAF 5MG ER CAP 115 aubra 28 day pack 80 bacitracin 122 atazanavir 150mg cap 70 AUSTEDO 12MG TAB 128 0.5unit/mg/polymyxin b atazanavir 200mg cap 70 AUSTEDO 6MG TAB 128 10unit/mg ophth ointment atazanavir 300mg cap 70 AUSTEDO 9MG TAB 128 bacitracin ointment 86 atenolol 100mg tab 73 aviane 28 pack 80 500unit/gm atenolol 51 avita 0.025% cream 85 bacitracin zinc oint 500 87 100mg/chlorthalidone avita 0.025% gel 85 unit/gm 25mg tab AVONEX 30MCG/0.5ML 129 bacitracin-polymyxin b 87 atenolol 25mg tab 73 AUTO-INJECTOR oint atenolol 50mg tab 73 AVONEX 30MCG/0.5ML 129 baclofen 10mg tab 119 atenolol 51 SYRINGE baclofen 20mg tab 119 50mg/chlorthalidone AVYCAZ 500-2000MG 78 balsalazide disodium 99 25mg tab INJ 750mg cap atomoxetine 100mg cap 16 AYVAKIT 100MG TAB 58 BALVERSA 3MG TAB 58 atomoxetine 10mg cap 16 AYVAKIT 200MG TAB 58 BALVERSA 4MG TAB 58 atomoxetine 18mg cap 16 AYVAKIT 300MG TAB 58 BALVERSA 5MG TAB 58 atomoxetine 25mg cap 16 AZASAN 100MG TAB 73 balziva 28 day pack 80 atomoxetine 40mg cap 16 AZASAN 75MG TAB 73 BANZEL 40MG/ML 34 atomoxetine 60mg cap 16 AZASITE 1% OPHTH 122 SUSP atomoxetine 80mg cap 16 SOLN BAQSIMI 3MG/DOSE 42 atorvastatin 10mg tab 48 azathioprine 50mg tab 115 NASAL POWDER atorvastatin 20mg tab 48 azelaic acid 15% gel 92 BAXDELA 450MG TAB 98 atorvastatin 40mg tab 48 azelastine 0.05% ophth 123 BCG LIVE TICE STRAIN 136 atorvastatin 80mg tab 48 soln 50MG INJ atovaquone 150mg/ml 54 azelastine 0.137mg/act 119 B-complex vitamin cap 116 susp nasal inhaler B-COMPLEX VITAMIN 116 atovaquone 55 azelastine 0.206mg/act 119 ELIXIR 250mg/proguanil 100mg nasal inhaler B-complex vitamin SL 116 tab azithromycin 20mg/ml 108 liquid atovaquone 55 susp B-complex vitamin tab 117 62.5mg/proguanil 25mg azithromycin 250mg pack 108 B-COMPLEX W/ C AND 117 tab azithromycin 250mg tab 108 FOLIC ACID ER TAB atropine sulfate 44 azithromycin 40mg/ml 108 b-complex w/ c cap 117 0.005mg/ml/diphenoxylat susp B-COMPLEX W/ C-ZN & 117 e 0.5mg/ml oral soln azithromycin 500mg inj 108 FOLIC ACID TAB 1 MG azithromycin 500mg pack 108

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 146 ALPHABETICAL LISTING OF DRUGS b-complex w/biotin & 117 benzoyl peroxide 85 betamethasone 0.1% 89 folic acid tab 5%/clindamycin ointment B-complex w/biotin and 117 phosphate 1.2% topical betamethasone/clotrimaz 87 folic acid tab gel ole 1-0.05% cream B-complex w/folic acid 117 benzoyl peroxide gel 10% 85 betamethasone/clotrimaz 87 tab benzoyl peroxide gel 85 ole 1-0.05% lotion B-COMPLEX W/IRON 117 2.5% betaxolol 0.5% ophth 121 SOLN benzoyl peroxide gel 5% 85 soln b-complex w/minerals 117 benzoyl peroxide liq 2.5% 86 betaxolol 10mg tab 73 liquid BENZOYL PEROXIDE 86 betaxolol 20mg tab 74 B-complex w/vitamin C 117 LIQ 6% bethanechol chloride 135 and calcium tab BENZOYL PEROXIDE 86 10mg tab B-complex w/vitamin C 117 LOTION 10% bethanechol chloride 135 and folic acid tab BENZOYL PEROXIDE 86 25mg tab B-complex w/vitamin C 117 LOTION 5% bethanechol chloride 135 tab BENZOYL PEROXIDE 86 50mg tab B-complex w/vitamin C/E 117 LOTION 9% bethanechol chloride 5mg 135 + zinc tab benztropine mesylate 64 tab benazepril 10mg tab 49 0.5mg tab BETOPTIC S 0.25% 121 benazepril 52 benztropine mesylate 1mg 64 OPHTH SUSP 10mg/hydrochlorothiazid tab bexarotene 75mg cap 62 e 12.5mg tab benztropine mesylate 2mg 63 BEXSERO SYRINGE 136 benazepril 20mg tab 49 tab bicalutamide 50mg tab 57 benazepril 52 BERINERT 500UNIT INJ 101 BICILLIN 126 20mg/hydrochlorothiazid beta carotene cap 25000 138 300000-300000UNIT/ML e 12.5mg tab unit SYRINGE benazepril 52 betamethasone 0.05% 89 BICILLIN 126 20mg/hydrochlorothiazid aug cream 450000-150000UNIT/ML e 25mg tab betamethasone 0.05% 89 SYRINGE benazepril 40mg tab 49 aug lotion BICILLIN L-A 125 benazepril 5mg tab 49 betamethasone 0.05% 89 1200000UNIT/2ML benazepril 52 aug ointment SYRINGE 5mg/hydrochlorothiazide betamethasone 0.05% 89 BICILLIN L-A 125 6.25mg tab cream 2400000UNIT/4ML BENLYSTA 200MG/ML 116 BETAMETHASONE 89 SYRINGE AUTO-INJECTOR 0.05% GEL BICILLIN L-A 125 BENLYSTA 200MG/ML 116 betamethasone 0.05% 89 600000UNIT/ML SYRINGE lotion SYRINGE BENZNIDAZOLE 100MG 27 betamethasone 0.05% 89 BIDIL 37.5-20MG TAB 77 TAB ointment BIKTARVY 70 BENZNIDAZOLE 27 betamethasone 0.1% 89 50-200-25MG TAB 12.5MG TAB cream bimatoprost 0.03% ophth 124 benzoyl peroxide 10% 85 betamethasone 0.1% 89 soln bar lotion

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 147 ALPHABETICAL LISTING OF DRUGS

BIOFLAVONOID 117 BOSULIF 500MG TAB 59 buprenorphine 25 PRODUCTS CHEW TAB BRAFTOVI 75MG CAP 59 0.005mg/hr weekly patch BIOTENE SPRAY 116 BREO 0.1-0.025MG INH 31 buprenorphine 25 bisacodyl suppos 10 mg 108 BREO 0.2-0.025MG INH 31 0.0075mg/hr weekly bisacodyl tab delayed 108 BREZTRI AEROSPHERE 31 patch release 5mg 160-9-4.8MCG/ACT INH buprenorphine 25 bismuth subsalicylate 44 briellyn 28 day pack 80 0.015mg/hr weekly patch chew tab 262mg BRILINTA 60MG TAB 102 buprenorphine 0.01mg/hr 25 bismuth subsalicylate 44 BRILINTA 90MG TAB 102 weekly patch susp 262mg/15ml brimonidine tartrate 121 buprenorphine 0.02mg/hr 25 bismuth subsalicylate 44 0.15% ophth soln weekly patch susp 525mg/15ml brimonidine tartrate 122 buprenorphine 25 bismuth subsalicylate tab 44 0.2% ophth soln 12mg/naloxone 3mg 262mg brinzolamide 1% ophth 123 sublingual film bisoprolol fumarate 10mg 74 susp buprenorphine 2mg sl tab 25 tab BRIVIACT 100MG TAB 34 buprenorphine 25 bisoprolol fumarate 52 BRIVIACT 10MG TAB 34 2mg/naloxone 0.5mg sl 10mg/hydrochlorothiazid BRIVIACT 10MG/ML 34 tab e 6.25mg tab ORAL SOLN buprenorphine 25 bisoprolol fumarate 52 BRIVIACT 25MG TAB 34 2mg/naloxone 0.5mg 2.5mg/hydrochlorothiazid BRIVIACT 50MG TAB 34 sublingual film e 6.25mg tab BRIVIACT 75MG TAB 34 buprenorphine 25 bisoprolol fumarate 5mg 74 bromfenac 0.09% ophth 123 4mg/naloxone 1mg tab soln sublingual film bisoprolol fumarate 52 bromocriptine 2.5mg tab 63 buprenorphine 8mg sl tab 25 5mg/hydrochlorothiazide bromocriptine 5mg cap 63 buprenorphine 25 6.25mg tab BROVANA 15MCG/2ML 31 8mg/naloxone 2mg sl tab BIVIGAM 5GM/50ML 124 INH SOLN buprenorphine 25 INJ BRUKINSA 80MG CAP 59 8mg/naloxone 2mg BLEPHAMIDE 0.2-10% 123 budesonide 0.125mg/ml 30 sublingual film OPHTH OINTMENT inh susp bupropion 100mg er tab 38 BLEPHAMIDE 0.2-10% 123 budesonide 0.25mg/ml 30 bupropion 100mg tab 38 OPHTH SUSP inh susp bupropion 150mg sr (12 38 blisovi 21 fe 1.5/30 28 80 budesonide 0.5mg/ml inh 31 hr) tab day susp bupropion 150mg sr tab 129 blisovi 24 fe 1/20 28 day 80 budesonide 3mg dr cap 84 bupropion 150mg xl (24 38 pack budesonide 9mg er tab 84 hr) tab BONE ESSENTIALS CAP 114 budesonide nasal susp 32 119 bupropion 200mg er tab 38 BOOSTRIX INJ 133 mcg/act bupropion 300mg er tab 38 BOOSTRIX SYRINGE 133 bumetanide 0.25mg/ml inj 93 bupropion 75mg tab 38 bosentan 125mg tab 77 bumetanide 0.5mg tab 93 buspirone 10mg tab 28 bosentan 62.5mg tab 77 bumetanide 1mg tab 93 buspirone 15mg tab 28 BOSULIF 100MG TAB 59 bumetanide 2mg tab 93 buspirone 30mg tab 28 BOSULIF 400MG TAB 59 buspirone 5mg tab 28

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 148 ALPHABETICAL LISTING OF DRUGS buspirone 7.5mg tab 28 calcium ascorbate tab 139 calcium 111 butorphanol tartrate 25 500 mg carbonate/vitamin D tab 1mg/act nasal inhaler calcium carbonate 27 200mg-250unit C (antacid) chew tab calcium 111 1000mg carbonate/vitamin D tab cabergoline 0.5mg tab 97 calcium carbonate 27 250mg-125unit CABOMETYX 20MG 59 (antacid) chew tab 420 mg calcium 111 TAB calcium carbonate 27 carbonate/vitamin D tab CABOMETYX 40MG 59 (antacid) chew tab 500mg 315mg-200unit TAB calcium carbonate 27 calcium 111 CABOMETYX 60MG 59 (antacid) chew tab 750mg carbonate/vitamin D tab TAB CALCIUM CARBONATE 27 315mg-250unit CAL/MAG CHEW TAB 110 (ANTACID) TAB 648 MG calcium 111 200-100MG CALCIUM CARBONATE 110 carbonate/vitamin D tab CALAMINE LOTION 91 260MG CHEW 500mg-200unit CALAMINE/ZINC OXIDE 91 CALCIUM CARBONATE 110 calcium 111 CREAM 2-12% CAP 1250MG carbonate/vitamin D tab CALAMINE/ZINC OXIDE 91 calcium carbonate chew 27 500mg-400unit LOTION 8-8% tab 1000-60mg calcium 111 CALCI-MAX CAP 117 CALCIUM CARBONATE 110 carbonate/vitamin D tab calcipotriene 0.005% 88 CHEW TAB 1250 MG 500mg-600unit cream (500 MG ELEMENTAL calcium 111 calcipotriene 0.005% 88 CA) carbonate/vitamin D tab ointment CALCIUM CARBONATE 110 600mg-200unit calcipotriene 0.005% 88 POWDER calcium 111 topical soln calcium carbonate susp 27 carbonate/vitamin D tab calcipotriene/betamethas 89 1250mg/5ml 600mg-400unit one 0.005-0.064% calcium carbonate tab 110 calcium 111 ointment 1250 mg (500 mg carbonate/vitamin D w/ CAL-CITRATE + 110 elemental ca) minerals tab VITAMIN D TAB calcium carbonate tab 110 calcium 111 250MG-100UNIT 1500mg carbonate/vitamin d w/ calcitriol 0.00025mg cap 96 calcium carbonate tab 110 minerals tab calcitriol 0.0005mg cap 96 600mg CALCIUM 110 calcitriol 0.001mg/ml oral 96 calcium 111 CARBONATE-CHOLECA soln carbonate/vitamin D cap LCIFEROL CAP 600 calcium + D tab 110 600mg-200unit MG-2500 UNIT 600mg-200unit calcium 111 calcium 110 CALCIUM 1000MG + D 110 carbonate/vitamin D chew carbonate-cholecalciferol TAB tab 500mg-100unit cap 600 mg-500 unit calcium acetate 667mg 100 calcium 111 calcium 110 cap carbonate/vitamin D chew carbonate-cholecalciferol calcium acetate 667mg 100 tab 600mg-400unit chew tab 500 mg-400 unit tab

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 149 ALPHABETICAL LISTING OF DRUGS

CALCIUM 110 calcium/magnesium/zinc 111 captopril 12.5mg tab 49 CARBONATE-CHOLECA tab 333-133-5mg captopril 25mg tab 49 LCIFEROL POWD PACK calcium/magnesium/zinc 111 captopril 50mg tab 49 500 MG-200 UNIT tab 334-134-5mg CARBAGLU 200MG TAB 96 calcium 111 CALCIUM/VITAMIN D3 111 FOR ORAL SUSP carbonate-cholecalciferol CHEW TAB carbamazepine 100mg 34 tab 600 mg-800 unit 200MG-200UNIT chew tab calcium 111 CALCIUM-MAGNESIUM 111 carbamazepine 100mg er 34 carbonate-vitamin d tab W/ VITAMIN D TAB 300 cap 500 mg-125 unit MG-150 MG-400 UNIT carbamazepine 100mg er 34 calcium carb-vit d w/ 110 calcium-magnesium-zinc 111 tab minerals chew tab 600 tab 333-133-8.3mg carbamazepine 200mg er 35 mg-800 unit CALC-PHOSPHORUS-VI 110 cap CALCIUM CITRATE 111 T D-MAG TAB 600 carbamazepine 200mg er 35 760MG/3.5GM MG-280 MG-500 tab GRANULES UNIT-50 MG carbamazepine 200mg 35 CALCIUM CITRATE TAB 111 CALQUENCE 100MG 59 tab 250MG CAP carbamazepine 20mg/ml 35 calcium citrate tab 950 111 camila 28 day 0.35mg 84 susp mg (200 mg elemental ca) pack carbamazepine 300mg er 35 CALCIUM CITRATE-VIT 111 camreselo 91 day pack 80 cap D LIQD 1000 candesartan cilexetil 52 carbamazepine 400mg er 35 MG/30ML-400 16mg/hydrochlorothiazid tab UNIT/30ML e 12.5mg tab carbamide peroxide 6.5% 124 CALCIUM 111 candesartan cilexetil 50 otic soln CITRATE-VITAMIN D 32mg tab carbamide peroxide soln 116 TAB 200 MG-125 UNIT candesartan cilexetil 52 10% (ELEMENTAL CA) 32mg/hydrochlorothiazid carbidopa 63 CALCIUM GLUCONATE 111 e 12.5mg tab 10mg/levodopa 100mg TAB 50MG candesartan cilexetil 52 odt CALCIUM LACTATE TAB 111 32mg/hydrochlorothiazid carbidopa 63 100MG e 25mg tab 10mg/levodopa 100mg calcium w/ magnesium tab 111 CAPLYTA 42MG CAP 65 tab CALCIUM W/ 111 CAPRELSA 100MG TAB 59 CARBIDOPA 64 MAGNESIUM TAB CAPRELSA 300MG TAB 59 12.5MG/ENTACAPONE 250-155 MG CAPSAICIN CREAM 91 200MG/LEVODOPA CALCIUM W/ VITAMIN 111 0.025% 50MG TAB D AND K CHEW TAB capsaicin cream 0.025% 91 CARBIDOPA 64 500 MG-500 UNIT-40 CAPSAICIN CREAM 91 18.75MG/ENTACAPONE MCG 0.033% 200MG/LEVODOPA CALCIUM/C/D CHEW 111 CAPSAICIN CREAM 91 75MG TAB CALCIUM/MAGNESIUM 111 0.075% carbidopa 25mg tab 64 /VITAMIN D TAB capsaicin cream 0.1% 91 captopril 100mg tab 49

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 150 ALPHABETICAL LISTING OF DRUGS

CARBIDOPA 64 carboxymethylcellulose 121 cefixime 40mg/ml susp 79 25MG/ENTACAPONE sodium (pf) ophth soln cefotetan 1000mg inj 79 200MG/LEVODOPA 0.5% cefotetan 2000mg inj 79 100MG TAB carboxymethylcellulose 121 cefoxitin 1000mg inj 79 carbidopa 63 sodium ophth soln 0.5% cefoxitin 2000mg inj 79 25mg/levodopa 100mg er CARTEOLOL 1% OPHTH 121 cefoxitin 200mg/ml inj 79 tab SOLN cefpodoxime 100mg tab 79 carbidopa 63 cartia 120mg er cap 75 cefpodoxime 10mg/ml 79 25mg/levodopa 100mg cartia 180mg er cap 75 susp odt cartia 240mg er cap 75 cefpodoxime 200mg tab 79 carbidopa 63 cartia 300mg er cap 75 cefpodoxime 20mg/ml 79 25mg/levodopa 100mg carvedilol 12.5mg tab 73 susp tab carvedilol 25mg tab 73 cefprozil 250mg tab 79 carbidopa 63 carvedilol 3.125mg tab 73 cefprozil 25mg/ml susp 79 25mg/levodopa 250mg carvedilol 6.25mg tab 73 cefprozil 500mg tab 79 odt caspofungin acetate 50mg 46 cefprozil 50mg/ml susp 79 carbidopa 64 inj ceftazidime 1000mg inj 79 25mg/levodopa 250mg caspofungin acetate 70mg 46 ceftazidime 2000mg inj 79 tab inj ceftazidime 200mg/ml inj 79 CARBIDOPA 64 CAYSTON 75MG INH 55 ceftriaxone 1000mg inj 79 31.25MG/ENTACAPONE SOLN ceftriaxone 100mg/ml inj 79 200MG/LEVODOPA caziant 28 day pack 80 ceftriaxone 2000mg inj 79 125MG TAB cefaclor 250mg cap 79 ceftriaxone 250mg inj 79 CARBIDOPA 64 CEFACLOR 25MG/ML 79 ceftriaxone 500mg inj 79 37.5MG/ENTACAPONE SUSP cefuroxime 1500mg inj 79 200MG/LEVODOPA cefaclor 500mg cap 79 cefuroxime 250mg tab 79 150MG TAB CEFACLOR 50MG/ML 79 cefuroxime 500mg tab 79 CARBIDOPA 64 SUSP cefuroxime 750mg inj 79 50MG/ENTACAPONE CEFACLOR 75MG/ML 79 cefuroxime 95mg/ml inj 79 200MG/LEVODOPA SUSP celecoxib 100mg cap 20 200MG TAB cefadroxil 1000mg tab 78 celecoxib 200mg cap 20 carbidopa 63 cefadroxil 100mg/ml susp 78 celecoxib 400mg cap 20 50mg/levodopa 200mg er cefadroxil 500mg cap 78 celecoxib 50mg cap 20 tab cefadroxil 50mg/ml susp 78 CELONTIN 300MG CAP 37 CARBONYL IRON 104 cefazolin 1000mg inj 78 cephalexin 250mg cap 78 CHEW TAB 15 MG cefazolin 200mg/ml inj 78 cephalexin 25mg/ml susp 79 (ELEMENTAL IRON) cefazolin 500mg inj 78 cephalexin 500mg cap 79 CARBONYL IRON SUSP 105 cefdinir 25mg/ml susp 79 cephalexin 50mg/ml susp 79 15 MG/1.25ML cefdinir 300mg cap 79 CERDELGA 84MG CAP 102 (ELEMENTAL IRON) cefdinir 50mg/ml susp 79 cetirizine 1mg/ml oral 47 CARBONYL IRON TAB 105 cefepime 1000mg inj 80 soln 25 MG (ELEMENTAL cefepime 2000mg inj 80 cetirizine hcl oral soln 1 47 IRON) cefixime 20mg/ml susp 79 mg/ml (5 mg/5ml) cefixime 400mg cap 79 cetirizine tab 10mg 47

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 151 ALPHABETICAL LISTING OF DRUGS cetirizine tab 5mg 47 chlorpheniramine 47 CHOLECALCIFEROL 138 cetirizine-pseudoephedri 85 maleate syrup 2 mg/5ml ORALLY ne tab sr 12hr 5-120 mg chlorpheniramine 47 DISINTEGRATING TAB cevimeline 30mg cap 116 maleate tab 4mg 5000 UNIT CHANTIX 0.5MG TAB 129 chlorpromazine 100mg 68 CHOLECALCIFEROL 138 CHANTIX 1MG TAB 129 tab TAB 10000 UNIT CHANTIX CONTINUING 130 chlorpromazine 10mg tab 68 cholecalciferol tab 138 MONTHS OF THERAPY chlorpromazine 200mg 68 2000unit 1MG PACK tab cholestyramine resin 4gm 48 CHANTIX FIRST MONTH 130 chlorpromazine 25mg tab 68 sf powder for oral susp OF THERAPY PACK chlorpromazine 50mg tab 68 cholestyramine resin 4gm 48 CHELATED CALCIUM 111 chlorthalidone 25mg tab 94 sf powder for oral susp 200MG TAB chlorthalidone 50mg tab 94 (sugar free) CHEMET 100MG CAP 44 CHOLBAM 250MG CAP 99 ciclopirox 0.77% cream 87 CHEMSTRIP URINE 92 CHOLBAM 50MG CAP 99 ciclopirox 0.77% gel 87 TEST STRIP cholecalciferol cap 125 138 ciclopirox 0.77% lotion 87 CHENODAL 250MG TAB 99 mcg (5000 unit) ciclopirox 1% shampoo 87 CHERRY SYRUP 126 CHOLECALCIFEROL 138 ciclopirox 8% topical soln 87 chlordiazepoxide 10mg 29 CAP 14000 UNIT CILASTATIN 54 cap cholecalciferol cap 25 138 250MG/IMIPENEM chlordiazepoxide 25mg 29 mcg (1000 unit) 250MG INJ cap cholecalciferol cap 50 138 cilastatin 54 chlordiazepoxide 5mg 29 mcg (2000 unit) 500mg/imipenem 500mg cap cholecalciferol chew tab 138 inj chlorhexidine gluconate 116 2000 unit cilostazol 100mg tab 102 0.12% mouthwash CHOLECALCIFEROL 138 cilostazol 50mg tab 102 chlorhexidine gluconate 69 DROPS 1000 CIMDUO 300-300MG 70 4% topical soln UNIT/0.028ML (PER TAB CHLORHEXIDINE 69 DROP) cimetidine 200mg tab 134 GLUCONATE LIQUID CHOLECALCIFEROL 138 cimetidine 300mg tab 134 2% DROPS 2000 cimetidine 400mg tab 134 CHLORHEXIDINE 69 UNIT/0.028ML (PER CIMETIDINE 60MG/ML 134 GLUCONATE LIQUID DROP) ORAL SOLN 4% CHOLECALCIFEROL 138 cimetidine 800mg tab 134 chlorhexidine gluconate 69 DROPS 400 CIMETIDINE TAB 200 134 liquid 4% UNIT/0.025ML (PER MG CHLOROQUINE 55 DROP) cimetidine tab 200mg 134 PHOSPHATE 250MG CHOLECALCIFEROL 138 CIMZIA 200MG INJ 99 TAB ORAL LIQUID 1000 CIMZIA 200MG/ML 99 chloroquine phosphate 55 UNIT/10ML SYRINGE 500mg tab CHOLECALCIFEROL 138 cinacalcet 30mg tab 96 chlorpheniramine 47 ORAL LIQUID 400 cinacalcet 60mg tab 96 maleate CR tab 12mg UNIT/ML cinacalcet 90mg tab 96 CINRYZE 500UNIT INJ 101

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 152 ALPHABETICAL LISTING OF DRUGS

CIPRO HC 0.2-1% OTIC 124 clindamycin 150mg/ml 55 clobetasol propionate 89 SUSP (4ml) inj 0.05% spray CIPROFLOXACIN 0.2% 124 clindamycin 150mg/ml 55 clobetasol propionate 89 OTIC SOLN (6ml) inj 0.05% topical soln ciprofloxacin 0.3% ophth 122 clindamycin 15mg/ml oral 55 clodan 0.05% shampoo 89 soln soln clomipramine 25mg cap 40 ciprofloxacin 250mg tab 98 clindamycin 18mg/ml inj 55 clomipramine 50mg cap 40 ciprofloxacin 2mg/ml inj 98 clindamycin 2% vaginal 137 clomipramine 75mg cap 40 ciprofloxacin 500mg tab 98 cream clonazepam 0.125mg odt 34 ciprofloxacin 750mg tab 98 clindamycin 300mg cap 55 clonazepam 0.25mg odt 34 ciprofloxacin/dexamethas 124 clindamycin 6mg/ml inj 55 clonazepam 0.5mg odt 34 one 0.3-0.1% otic susp clindamycin 75mg cap 55 clonazepam 0.5mg tab 34 citalopram 10mg tab 38 clindamycin/benzoyl 86 clonazepam 1mg odt 34 citalopram 20mg tab 38 peroxide 1.2-2.5% gel clonazepam 1mg tab 34 citalopram 2mg/ml oral 38 clindamycin/benzoyl 86 clonazepam 2mg odt 34 soln peroxide 1-5% gel clonazepam 2mg tab 34 citalopram 40mg tab 38 CLINIMIX 4.25/10 INJ 120 clonidine 0.00417mg/hr 50 claravis 10mg cap 86 CLINIMIX 4.25/5 INJ 120 weekly patch claravis 20mg cap 86 CLINIMIX 5/15 INJ 120 clonidine 0.00833mg/hr 51 claravis 30mg cap 86 CLINIMIX 5/20 INJ 120 weekly patch claravis 40mg cap 86 CLINIMIX E 2.75/5 INJ 120 clonidine 0.0125mg/hr 51 CLARINEX-D 85 CLINIMIX E 4.25/10 INJ 120 weekly patch 2.5-120MG ER TAB CLINIMIX E 4.25/5 INJ 120 clonidine 0.1mg er tab 16 clarithromycin 250mg tab 108 CLINIMIX E 5/15 INJ 120 clonidine 0.1mg tab 51 CLARITHROMYCIN 108 CLINIMIX E 5/20 INJ 120 clonidine 0.2mg tab 51 25MG/ML SUSP clinisol 15% inj 120 clonidine 0.3mg tab 51 clarithromycin 500mg er 108 clobazam 10mg tab 34 clopidogrel 75mg tab 102 tab clobazam 2.5mg/ml susp 34 clorazepate dipotassium 29 clarithromycin 500mg tab 108 clobazam 20mg tab 34 15mg tab CLARITHROMYCIN 108 clobetasol propionate 89 clorazepate dipotassium 29 50MG/ML SUSP 0.05% cream 3.75mg tab CLENPIQ 107 clobetasol propionate 89 clorazepate dipotassium 29 75-21.9-0.0625MG/ML 0.05% e cream 7.5mg tab ORAL SOLN clobetasol propionate 89 clotrimazole 1% cream 87 clindamycin 1% gel 86 0.05% foam clotrimazole 1% cream 87 clindamycin 1% lotion 86 clobetasol propionate 89 clotrimazole 1% topical 87 clindamycin 1% pad 86 0.05% gel soln clindamycin 1% topical 86 clobetasol propionate 89 clotrimazole 1% topical 87 soln 0.05% lotion soln clindamycin 12mg/ml inj 54 clobetasol propionate 89 clotrimazole 10mg 116 clindamycin 150mg cap 55 0.05% ointment lozenge clindamycin 150mg/ml 55 clobetasol propionate 89 clotrimazole vaginal 137 (2ml) inj 0.05% shampoo cream 1%

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 153 ALPHABETICAL LISTING OF DRUGS clotrimazole vaginal 137 colchicine 101 CREON 93 cream 2% 0.5mg/probenecid 500mg 120000-76000-24000UNI CLOVERINE OINTMENT 87 tab T DR CAP clovique 250mg cap 115 COLCHICINE 0.6MG 101 CREON 93 clozapine 100mg odt 66 CAP 15000-9500-3000UNIT clozapine 100mg tab 67 colesevelam 3750mg 48 DR CAP CLOZAPINE 12.5MG 67 powder for oral susp CREON 93 ODT colesevelam 625mg tab 48 30000-19000-6000UNIT CLOZAPINE 150MG 67 colestipol 1000mg tab 48 DR CAP ODT colestipol 5000mg 48 CREON 93 CLOZAPINE 200MG 67 granules for oral susp 36000-114000-180000U ODT colistin 75mg/ml inj 55 NIT DR CAP clozapine 200mg tab 67 COMBIGAN 2-5MG/ML 121 CREON 93 clozapine 25mg odt 67 OPHTH SOLN 60000-38000-12000UNIT clozapine 25mg tab 67 COMBIPATCH 97 DR CAP clozapine 50mg tab 67 0.00208-0.00583MG/HR CRINONE 4% VAGINAL 137 COARTEM 20-120MG 55 PATCH GEL TAB COMBIPATCH 97 CRINONE 8% VAGINAL 137 COD LIVER OIL 118 0.00208-0.0104MG/HR GEL cod liver oil cap 119 PATCH cromolyn sodium 99 CODEINE SULFATE 23 COMBIVENT 31 20mg/ml oral soln 15MG TAB 0.1-0.02MG INH cromolyn sodium 4% 123 codeine sulfate 30mg tab 23 COMETRIQ 100MG 59 ophth soln codeine sulfate 60mg tab 23 DAILY DOSE CARTON cryselle 28 pack 80 coenzyme Q10 10mg cap 18 PACK CULTURELLE 10B CELL 44 coenzyme Q10 150mg cap 18 COMETRIQ 140MG 59 CAPSULE coenzyme Q10 30mg cap 18 DAILY DOSE CARTON CULTURELLE CHEW 44 coenzyme Q10 50mg cap 18 PACK TAB coenzyme Q10 60mg cap 18 COMETRIQ 60MG 59 CULTURELLE DROPS 44 coenzyme Q10 cap 100mg 18 DAILY DOSE CARTON CULTURELLE 44 coenzyme q10 cap 200 mg 18 PACK HLTH-WELL 15B CELL coenzyme Q10 cap 75mg 18 COMPLERA 70 CULTURELLE KIDS 44 COENZYME Q10 CHEW 18 200-25-300MG TAB PACKET TAB 100MG compro 25mg rectal supp 68 cyanocobalamin inj 102 COENZYME Q10 CHEW 18 constulose 10gm/15ml 107 1000mcg/ml TAB 30MG oral soln CYANOCOBALAMIN 102 COENZYME Q10 CHEW 18 COPIKTRA 15MG CAP 59 LOZENGE 50 MCG TAB 600MG COPIKTRA 25MG CAP 59 CYANOCOBALAMIN 102 COENZYME Q-10 ER 18 CORAL CALCIUM CAP 111 SUBLINGUAL LIQUID CAP 100MG CORLANOR 5MG TAB 78 3000 MCG/ML COENZYME Q10 TAB 18 CORLANOR 5MG/5ML 78 cyanocobalamin tab 100 102 100MG ORAL SOLN mcg COENZYME Q10 TAB 18 CORLANOR 7.5MG TAB 78 cyanocobalamin tab 500 102 50MG COTELLIC 20MG TAB 59 mcg

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 154 ALPHABETICAL LISTING OF DRUGS

CYANOCOBALAMIN 102 dalfampridine 10mg er 129 demeclocycline 150mg 131 TAB ER 5000 MCG tab tab CYANOCOBALAMIN-M 104 DALIRESP 250MCG TAB 30 demeclocycline 300mg 131 ETHYLCOBALAMIN SL DALIRESP 500MCG TAB 30 tab TAB 600-600 MCG DALVANCE 500MG INJ 54 DEMSER 250MG CAP 50 cyanocobalamin-methylco 104 danazol 100mg cap 26 DENAVIR 1% CREAM 88 balamin sl tab 600-600 danazol 200mg cap 26 DESCOVY 200-25MG 70 mcg danazol 50mg cap 26 TAB cyclafem 1/35 28 day 80 dantrolene sodium 100mg 119 desipramine 100mg tab 40 pack cap desipramine 10mg tab 40 cyclafem 7/7/7 28 day 80 dantrolene sodium 25mg 119 desipramine 150mg tab 40 pack cap desipramine 25mg tab 40 cyclobenzaprine 10mg 119 dantrolene sodium 50mg 119 desipramine 50mg tab 40 tab cap desipramine 75mg tab 40 cyclobenzaprine 5mg tab 119 dapsone 100mg tab 54 desloratadine 5mg tab 47 CYCLOPHOSPHAMIDE 56 dapsone 25mg tab 54 desmopressin acetate 96 25MG CAP DAPTACEL INJ 133 0.01mg/act nasal spray CYCLOPHOSPHAMIDE 56 daptomycin 500mg inj 54 desmopressin acetate 96 25MG TAB DAURISMO 100MG TAB 57 0.1mg tab CYCLOPHOSPHAMIDE 56 DAURISMO 25MG TAB 57 desmopressin acetate 97 50MG CAP deblitane 28 day 0.35mg 84 0.2mg tab CYCLOPHOSPHAMIDE 56 pack desogestrel /ethinyl 80 50MG TAB deferasirox 125mg tab 44 estradiol 0.15mg-30mcg cyclosporine 100mg cap 73 for oral susp tab cyclosporine 25mg cap 73 deferasirox 180mg 44 desogestrel/ethinyl 80 cyclosporine modified 73 granules estradiol pack 100mg cap deferasirox 180mg tab 44 desonide 0.05% ointment 89 cyclosporine modified 115 deferasirox 250mg tab 44 desoximetasone 0.05% 89 100mg/ml oral soln for oral susp cream cyclosporine modified 73 deferasirox 360mg 44 desoximetasone 0.05% 89 25mg cap granules gel cyclosporine modified 115 deferasirox 360mg tab 44 desoximetasone 0.25% 89 50mg cap deferasirox 500mg tab 45 cream cyred 28 day pack 80 for oral susp desoximetasone 0.25% 89 CYSTADROPS 0.37% 123 deferasirox 90mg 45 ointment OPHTH SOLN granules desvenlafaxine succinate 39 CYSTAGON 150MG CAP 101 deferasirox 90mg tab 45 100mg er tab CYSTAGON 50MG CAP 101 deferiprone 500mg tab 45 desvenlafaxine succinate 39 CYSTARAN 0.44% 123 DEKAS ESSENTIAL 118 25mg er tab OPHTH SOLN LIQUID desvenlafaxine succinate 39 D DEKAS PLUS SOFTGEL? 117 50mg er tab DELSTRIGO 70 dexamethasone 0.1mg/ml 84 DAKIN'S SOLUTION 69 100-300-300MG TAB oral soln 0.5% dexamethasone 0.5mg tab 84

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 155 ALPHABETICAL LISTING OF DRUGS dexamethasone 0.75mg 84 dextroamphetamine 16 diazoxide 50mg/ml susp 42 tab sulfate 10mg tab diclofenac potassium 20 dexamethasone 1.5mg tab 84 dextroamphetamine 16 50mg tab DEXAMETHASONE 1MG 84 sulfate 15mg er cap diclofenac sodium 0.1% 124 TAB dextroamphetamine 16 ophth soln DEXAMETHASONE 2MG 84 sulfate 1mg/ml oral soln diclofenac sodium 1% gel 88 TAB dextroamphetamine 16 diclofenac sodium 1.5% 88 dexamethasone 4mg tab 84 sulfate 5mg er cap topical soln dexamethasone 6mg tab 84 dextroamphetamine 16 diclofenac sodium 100mg 20 DEXAMETHASONE 123 sulfate 5mg tab er tab PHOSPHATE 0.1% dextromethorphan-guaife 85 diclofenac sodium 25mg 20 OPHTH SOLN nesin tab 20-400 mg dr tab dexamethasone/neomycin 123 DIACOMIT 250MG CAP 35 diclofenac sodium 3% gel 88 /polymyxin b 0.1% ophth DIACOMIT 250MG 35 diclofenac sodium 50mg 20 ointment POWDER FOR ORAL dr tab dexamethasone/neomycin 123 SUSP diclofenac sodium 20 /polymyxin b 0.1% ophth DIACOMIT 500MG CAP 35 50mg/misoprostol 0.2mg susp DIACOMIT 500MG 35 dr tab dexamethasone/tobramyc 123 POWDER FOR ORAL diclofenac sodium 75mg 20 in 0.3-0.1% ophth susp SUSP dr tab dexmethylphenidate 17 DIALYVITE PLUS 117 diclofenac sodium 20 10mg er cap VITAMIN D WAFER 75mg/misoprostol 0.2mg dexmethylphenidate 17 DIALYVITE W/IRON TAB 117 dr tab 10mg tab DIALYVITE WAFER 117 dicloxacillin 250mg cap 126 dexmethylphenidate 17 DIASTAT 10MG RECTAL 34 dicloxacillin 500mg cap 126 15mg er cap GEL dicyclomine 10mg cap 134 dexmethylphenidate 17 DIASTAT 2.5MG RECTAL 34 dicyclomine 20mg tab 134 2.5mg tab GEL dicyclomine 2mg/ml oral 134 dexmethylphenidate 17 DIASTAT 20MG RECTAL 34 soln 20mg er cap GEL DIFICID 200MG TAB 109 dexmethylphenidate 17 diazepam 10mg tab 29 DIFICID 40MG/ML SUSP 109 25mg er cap DIAZEPAM 10MG/2ML 34 diflunisal 500mg tab 23 dexmethylphenidate 17 RECTAL GEL digitek 0.125mg tab 76 30mg er cap DIAZEPAM 1MG/ML 29 digitek 0.25mg tab 76 dexmethylphenidate 17 ORAL SOLN digox 125mcg tab 76 35mg er cap DIAZEPAM 34 digox 250mcg tab 76 dexmethylphenidate 17 2.5MG/0.5ML RECTAL digoxin 0.05mg/ml oral 76 40mg er cap GEL soln dexmethylphenidate 5mg 17 DIAZEPAM 20MG/4ML 34 digoxin 0.125mg tab 76 er cap RECTAL GEL digoxin 0.25mg tab 76 dexmethylphenidate 5mg 17 diazepam 2mg tab 29 dihydroergotamine 109 tab diazepam 5mg tab 29 mesylate 0.5mg/act nasal dextroamphetamine 16 diazepam 5mg/ml oral 29 inhaler sulfate 10mg er cap soln

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 156 ALPHABETICAL LISTING OF DRUGS

DIHYDROXYACETONE 92 diphenhydramine hcl soln 88 docusate sodium syrup 108 SOLN 6.55% 2% 60mg/15ml DILANTIN 30MG ER 37 diphenhydramine liquid 47 docusate sodium tab 108 CAP 12.5mg/5ml 100mg DILT 120MG ER CAP 75 diphenhydramine tab 47 dofetilide 0.125mg cap 30 DILT 180MG ER CAP 75 25mg dofetilide 0.25mg cap 30 DILT 240MG ER CAP 75 diphenhydramine tab 47 dofetilide 0.5mg cap 30 diltiazem 120mg er (12 75 25mg donepezil 10mg odt 127 hr) cap diphenhydramine/acetami 106 donepezil 10mg tab 127 diltiazem 120mg er (24 75 nophen tab 25-500mg donepezil 23mg tab 127 hr) cap DIPHTHERIA/TETANUS 133 donepezil 5mg odt 127 diltiazem 120mg tab 75 TOXOID INJ donepezil 5mg tab 127 diltiazem 180mg er cap 75 DISNEY CALCIUM + 111 DOPTELET 20MG TAB 103 diltiazem 180mg er tab 75 VITAMIN CHEW TAB DOPTELET 40MG DAILY 103 diltiazem 240mg er cap 75 disopyramide 100mg cap 29 DOSE PACK diltiazem 240mg er tab 75 disopyramide 150mg cap 29 DOPTELET 60MG DAILY 103 diltiazem 300mg er cap 75 disulfiram 250mg tab 127 DOSE PACK diltiazem 300mg er tab 75 disulfiram 500mg tab 127 dorzolamide 2% ophth 124 diltiazem 30mg tab 75 DIURIL 250MG/5ML 94 soln diltiazem 360mg er cap 75 SUSP dorzolamide/timolol 121 diltiazem 360mg er tab 75 divalproex sodium 125mg 37 22.3-6.8mg/ml ophth soln diltiazem 420mg er cap 75 dr cap dorzolamide/timolol 121 diltiazem 60mg er cap 75 divalproex sodium 125mg 37 22.3-6.8mg/ml ophth soln diltiazem 60mg tab 75 dr tab (preservative-free) diltiazem 90mg er cap 75 divalproex sodium 250mg 37 DOSOQUIN TAB 119 diltiazem 90mg tab 75 dr tab dotti 0.025mg/24hr patch 98 DIMENHYDRINATE TAB 45 divalproex sodium 250mg 37 dotti 0.0375mg/24hr 98 50 MG er tab patch dimethyl fumarate 120mg 129 divalproex sodium 500mg 37 dotti 0.05mg/24hr patch 98 dr cap dr tab dotti 0.075mg/24hr patch 98 dimethyl fumarate 129 divalproex sodium 500mg 37 dotti 0.1mg/24hr patch 98 120mg/dimethyl fumarate er tab DOVATO 50-300MG TAB 70 240mg pack docusate calcium cap 108 doxazosin 1mg tab 51 dimethyl fumarate 240mg 129 240mg doxazosin 2mg tab 51 dr cap docusate sodium cap 108 doxazosin 4mg tab 51 DIPENTUM 250MG CAP 99 100mg doxazosin 8mg tab 51 diphenhydramine cap 47 docusate sodium cap 108 doxepin 100mg cap 40 25mg 250mg doxepin 10mg cap 40 diphenhydramine cap 47 docusate sodium enema 108 doxepin 10mg/ml oral 40 50mg 283 mg/5ml soln diphenhydramine hcl 106 docusate sodium enema 102 doxepin 150mg cap 40 (sleep) cap 50 mg 283mg doxepin 25mg cap 40 diphenhydramine hcl 106 docusate sodium liquid 108 doxepin 50mg cap 40 (sleep) liquid 50 mg/30ml 150mg/15ml doxepin 75mg cap 41

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 157 ALPHABETICAL LISTING OF DRUGS doxercalciferol 0.0005mg 96 drospirenone 3mg/ethinyl 80 efavirenz/emtricitabine/te 70 cap estradiol 0.02mg/inert 1 nofovir disoproxil doxercalciferol 0.001mg 96 mg pack fumarate 600-200-300mg cap drospirenone 3mg/ethinyl 81 tab doxercalciferol 0.0025mg 96 estradiol 0.03mg/inert efavirenz/emtricitabine/te 70 cap ingredients 1mg pack nofovir disoproxil doxy 100mg inj 131 DROXIA 200MG CAP 102 fumarate 600-200-300mg doxycycline hyclate 131 DROXIA 300MG CAP 102 tab 100mg cap DROXIA 400MG CAP 102 efavirenz/lamivudine/ten 70 doxycycline hyclate 131 droxidopa 100mg cap 137 ofovir disoproxil 100mg tab droxidopa 200mg cap 137 fumarate 400-300-300mg doxycycline hyclate 20mg 131 droxidopa 300mg cap 137 tab tab DULERA 0.005-0.1MG 31 eletriptan 20mg tab 109 doxycycline hyclate 50mg 131 INH eletriptan 40mg tab 109 cap DULERA 0.005-0.2MG 31 ELIGARD 22.5MG 57 doxycycline monohydrate 131 INH SYRINGE 100mg cap DULERA INHALER 31 ELIGARD 30MG 57 doxycycline monohydrate 131 50-5MCG SYRINGE 100mg tab duloxetine 20mg dr cap 40 ELIGARD 45MG 57 doxycycline monohydrate 131 duloxetine 30mg dr cap 40 SYRINGE 50mg cap duloxetine 40mg dr cap 40 ELIGARD 7.5MG 57 doxycycline monohydrate 131 duloxetine 60mg dr cap 40 SYRINGE 50mg tab DUPIXENT 90 ELIQUIS 2.5MG TAB 32 doxycycline monohydrate 131 200MG/1.14ML ELIQUIS 30-DAY 32 5mg/ml susp SYRINGE STARTER PACK 5MG doxylamine succinate 45 DUPIXENT 300MG/2ML 90 ELIQUIS 5MG TAB 32 10mg/pyridoxine 10mg dr AUTO-INJECTOR ELMIRON 100MG CAP 101 tab DUPIXENT 300MG/2ML 90 eluryng 83 doxylamine succinate tab 106 SYRINGE 0.000625-0.005mg/hr 25mg DUREZOL 0.05% OPHTH 123 vaginal system DRIZALMA 20MG DR 39 SUSP EMCYT 140MG CAP 57 CAP dutasteride 0.5mg cap 101 EMGALITY 100MG/ML 109 DRIZALMA 30MG DR 39 dutasteride 101 SYRINGE CAP 0.5mg/tamsulosin 0.4mg EMGALITY 120MG/ML 109 DRIZALMA 40MG DR 39 cap AUTO-INJECTOR CAP E EMGALITY 120MG/ML 109 DRIZALMA 60MG DR 39 SYRINGE econazole nitrate 1% 87 CAP emollient ointment 91 cream dronabinol 10mg cap 45 emoquette pack 81 EDURANT 25MG TAB 70 dronabinol 10mg cap 45 EMSAM 12MG/24HR 38 efavirenz 200mg cap 70 dronabinol 2.5mg cap 45 PATCH efavirenz 50mg cap 70 dronabinol 2.5mg cap 45 EMSAM 6MG/24HR 38 efavirenz 600mg tab 70 dronabinol 5mg cap 45 PATCH dronabinol 5mg cap 45

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 158 ALPHABETICAL LISTING OF DRUGS

EMSAM 9MG/24HR 38 ENDARI 5GM POWDER 102 EPIDIOLEX 100MG/ML 35 PATCH FOR ORAL SOLN ORAL SOLN emtricitabine 200mg cap 70 endocet 325-10mg tab 25 epinastine 0.05% ophth 124 emtricitabine/tenofovir 70 endocet 325-5mg tab 25 soln disoproxil fumarate endocet 325-7.5mg tab 25 epinephrine 0.5mg/ml 137 100-150mg tab ENDUR-VM TAB 117 auto-injector emtricitabine/tenofovir 70 ENGERIX-B 136 epinephrine 1mg/ml 137 disoproxil fumarate 10MCG/0.5ML SYRINGE auto-injector 133-200mg tab ENGERIX-B 20MCG/ML 136 epitol 200mg tab 35 emtricitabine/tenofovir 70 SYRINGE EPIVIR HBV 5MG/ML 72 disoproxil fumarate enoxaparin sodium 33 ORAL SOLN 167-250mg tab 100mg/ml (0.3ml) syringe eplerenone 25mg tab 53 emtricitabine/tenofovir 70 enoxaparin sodium 33 eplerenone 50mg tab 53 disoproxil fumarate 100mg/ml (0.4ml) syringe EQUETRO 100MG ER 65 200-300mg tab enoxaparin sodium 33 CAP EMTRIVA 10MG/ML 70 100mg/ml (0.6ml) syringe EQUETRO 200MG ER 65 ORAL SOLN enoxaparin sodium 33 CAP EMTRIVA 200MG CAP 70 100mg/ml (0.8ml) syringe EQUETRO 300MG ER 65 enalapril maleate 10mg 49 enoxaparin sodium 33 CAP tab 100mg/ml (1ml) syringe ERAXIS 100MG INJ 46 enalapril maleate 52 enoxaparin sodium 33 ERAXIS 50MG INJ 46 10mg/hydrochlorothiazid 150mg/ml (0.8ml) syringe ergocalciferol cap 138 e 25mg tab enoxaparin sodium 33 50000unit enalapril maleate 2.5mg 49 150mg/ml (1ml) syringe ergocalciferol soln 200 138 tab enpresse 28 day pack 81 mcg/ml (8000 unit/ml) enalapril maleate 20mg 49 enskyce 28 day pack 81 ERGOCALCIFEROL TAB 138 tab ENSPRYNG 120MG/ML 115 2000UNIT enalapril maleate 5mg 49 SYRINGE ERGOCALCIFEROL TAB 138 tab entacapone 200mg tab 64 400UNIT enalapril maleate 52 entecavir 0.5mg tab 72 ERGOLOID MESYLATES 129 5mg/hydrochlorothiazide entecavir 1mg tab 72 USP 1MG TAB 12.5mg tab ENTRESTO 24-26MG 77 ERIVEDGE 150MG CAP 57 ENBREL 25MG INJ 21 TAB ERLEADA 60MG TAB 57 ENBREL 25MG/0.5ML 22 ENTRESTO 49-51MG 77 erlotinib 100mg tab 59 INJ TAB erlotinib 150mg tab 59 ENBREL 25MG/0.5ML 22 ENTRESTO 97-103MG 77 erlotinib 25mg tab 59 SYRINGE TAB errin 28 day 0.35mg pack 84 ENBREL 50MG/ML 22 enulose 10gm/15ml oral 100 ertapenem 1000mg inj 54 AUTO-INJECTOR soln ERY 2% PAD 86 ENBREL 50MG/ML 22 ENVARSUS 0.75MG ER 115 ery-tab 500mg dr tab 108 CARTRIDGE TAB ERYTHROCIN 500MG 108 ENBREL 50MG/ML 22 ENVARSUS 1MG ER TAB 115 INJ SYRINGE ENVARSUS 4MG ER TAB 115 erythromycin 0.5% ophth 122 ointment

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 159 ALPHABETICAL LISTING OF DRUGS erythromycin 2% gel 86 estradiol 0.0025mg/hr 98 ethinyl estradiol 81 erythromycin 2% topical 86 weekly patch 0.01mg/ethinyl estradiol soln estradiol 0.00312mg/hr 98 0.02mg/levonorgestrel erythromycin 250mg dr 108 weekly patch 0.1mg 91 day pack cap estradiol 0.00313mg/hr 98 ethinyl estradiol 81 erythromycin 250mg tab 108 twice weekly patch 0.01mg/ethinyl estradiol erythromycin 500mg dr 108 estradiol 0.00417mg/hr 98 0.03mg/levonorgestrel tab twice weekly patch 0.15mg pack erythromycin 500mg tab 108 estradiol 0.00417mg/hr 98 ethinyl estradiol 81 erythromycin 108 weekly patch 0.025mg/ferrous ethylsuccinate 40mg/ml estradiol 0.01% vaginal 137 fumarate susp cream 75mg/norethindrone erythromycin 108 estradiol 0.01mg vaginal 137 0.8mg pack ethylsuccinate 80mg/ml insert ethinyl estradiol 81 susp estradiol 0.5mg tab 98 0.025mg/inert/norgestima erythromycin/benzoyl 86 estradiol 97 te peroxide 5-3% gel 0.5mg/norethindrone 0.18mg/0.215mg/0.25mg ESBRIET 267MG CAP 130 acetate 0.1mg pack pack ESBRIET 267MG TAB 130 estradiol 1mg tab 98 ethinyl estradiol 81 ESBRIET 801MG TAB 130 estradiol 97 0.02mg/inert ingredients escitalopram 10mg tab 38 1mg/norethindrone 1mg/levonorgestrel escitalopram 1mg/ml oral 38 acetate 0.5mg pack 0.1mg pack soln estradiol 2mg tab 98 ethinyl estradiol 81 escitalopram 20mg tab 38 estradiol valerate 98 0.02mg/norethindrone escitalopram 5mg tab 38 20mg/ml inj acetate 1mg pack esomeprazole 20mg dr 134 estradiol valerate 98 ethinyl estradiol 81 cap 40mg/ml inj 0.035mg/ethynodiol 1mg esomeprazole 40mg dr 134 ESTRING 2MG VAGINAL 137 28 day pack cap SYSTEM ethinyl estradiol 81 estarylla 28 day pack 81 eszopiclone 1mg tab 106 0.035mg/ferrous estazolam 1mg tab 106 eszopiclone 2mg tab 106 fumarate estazolam 2mg tab 106 eszopiclone 3mg tab 106 75mg/norethindrone estradiol 0.00104mg/hr 98 ethacrynic acid 25mg tab 94 0.4mg pack twice weekly patch ethambutol 100mg tab 56 ethinyl estradiol 81 estradiol 0.00104mg/hr 98 ethambutol 400mg tab 56 0.035mg/inert/norgestima weekly patch ethinyl estradiol 97 te estradiol 0.00156mg/hr 98 0.0025mg/norethindrone 0.18mg/0.215mg/0.25mg twice weekly patch acetate 0.5mg pack pack estradiol 0.00156mg/hr 98 ethinyl estradiol 97 ethinyl estradiol 81 weekly patch 0.005mg/norethindrone 0.035mg/norgestimate estradiol 0.00208mg/hr 98 acetate 1mg pack 0.25mg pack twice weekly patch estradiol 0.00208mg/hr 98 weekly patch

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 160 ALPHABETICAL LISTING OF DRUGS ethinyl estradiol 81 euthyrox 88mcg tab 132 FANAPT TITRATION 65 0.03mg/0.04mg everolimus 0.25mg tab 115 PACK /inert/levonorgestrel everolimus 0.5mg tab 115 FARXIGA 10MG TAB 43 0.05mg/ 0.075mg pack everolimus 0.75mg tab 115 FARXIGA 5MG TAB 43 ethinyl estradiol 81 everolimus 2.5mg tab 59 FARYDAK 10MG CAP 59 0.03mg/inert ingredients everolimus 5mg tab 59 FARYDAK 15MG CAP 59 1mg/levonorgestrel everolimus 7.5mg tab 59 FARYDAK 20MG CAP 59 0.15mg pack EVOTAZ 300-150MG 70 fayosim 91 day pack 81 ethinyl estradiol 81 TAB FE FUM-FE 104 0.03mg/levonorgestrel EVRYSDI 0.75MG/ML 120 POLY-FA-C-B3 CAP 0.15mg tab 28 day pack ORAL SOLN 62.5-62.5-1-40-3MG(125 ethinyl estradiol 81 exemestane 25mg tab 57 MG FE) 0.05mg/ethynodiol EXTAVIA 0.3MG INJ 129 FE FUM-FE 104 1mg/inert ingredients ezetimibe 10mg tab 49 POLYSAC-C-B3 CAP 1mg 28 day pack ezetimibe 47 62.5-62.5-40-3 MG (125 ethinyl 81 10mg/simvastatin 10mg MG FE) estradiol/levonorgestrel tab FE FUM-IRON 104 91 day pack ezetimibe 47 POLYSACCH ethosuximide 250mg cap 37 10mg/simvastatin 20mg COMPLEX-FA-B ethosuximide 50mg/ml 37 tab COMPLEX-C-BIOTIN oral soln ezetimibe 47 CAP etodolac 200mg cap 20 10mg/simvastatin 40mg febuxostat 40mg tab 101 etodolac 300mg cap 20 tab febuxostat 80mg tab 101 etodolac 400mg er tab 20 ezetimibe 47 felbamate 120mg/ml susp 37 etodolac 400mg tab 20 10mg/simvastatin 80mg felbamate 400mg tab 37 etodolac 500mg er tab 20 tab felbamate 600mg tab 37 etodolac 500mg tab 20 F felodipine 10mg er tab 75 etodolac 600mg er tab 20 felodipine 2.5mg er tab 75 falmina 28 day pack 81 etonogestrel-ethinyl 83 felodipine 5mg er tab 75 famciclovir 125mg tab 72 estradiol femynor 28 day pack 81 famciclovir 250mg tab 72 0.120-0.015mg/24hr fenofibrate 134mg cap 48 famciclovir 500mg tab 72 vaginal ring fenofibrate 145mg tab 48 famotidine 20mg tab 134 etravirine 100mg tab 70 FENOFIBRATE 150MG 48 famotidine 40mg tab 134 etravirine 200mg tab 70 CAP famotidine 8mg/ml susp 134 euthyrox 100mcg tab 131 fenofibrate 160mg tab 48 famotidine tab 10mg 134 euthyrox 112mcg tab 131 fenofibrate 200mg cap 48 famotidine tab 20mg 134 euthyrox 125mcg tab 131 fenofibrate 48mg tab 48 FANAPT 10MG TAB 65 euthyrox 137mcg tab 131 FENOFIBRATE 50MG 48 FANAPT 12MG TAB 65 euthyrox 150mcg tab 131 CAP FANAPT 1MG TAB 65 euthyrox 175mcg tab 132 fenofibrate 54mg tab 48 FANAPT 2MG TAB 65 euthyrox 200mcg tab 132 fenofibrate 67mg cap 48 FANAPT 4MG TAB 65 euthyrox 25mcg tab 132 fenofibric acid 135mg dr 48 FANAPT 6MG TAB 65 euthyrox 50mcg tab 132 cap FANAPT 8MG TAB 65 euthyrox 75mcg tab 132

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 161 ALPHABETICAL LISTING OF DRUGS fenofibric acid 45mg dr 48 ferrous sulfate CR tab 105 flac 0.01% otic soln 124 cap 142mg flavoxate 100mg tab 136 fentanyl 0.012mg/hr 23 ferrous sulfate CR tab 105 FLEBOGAMMA 124 patch 160mg 5GM/50ML INJ fentanyl 0.025mg/hr 23 ferrous sulfate CR tab 105 flecainide acetate 100mg 29 patch 45mg tab fentanyl 0.05mg/hr patch 23 ferrous sulfate dried tab 105 flecainide acetate 150mg 29 fentanyl 0.075mg/hr 23 200 mg (65 mg elemental tab patch fe) flecainide acetate 50mg 29 fentanyl 0.1mg/hr patch 23 FERROUS SULFATE EC 105 tab fentanyl 0.2mg lozenge 23 TAB 324MG FLOVENT 31 fentanyl 0.4mg lozenge 23 ferrous sulfate EC tab 105 100MCG/BLIST INH fentanyl 0.6mg lozenge 23 325mg FLOVENT 110MCG INH 31 fentanyl 0.8mg lozenge 23 ferrous sulfate elixir 220 105 FLOVENT 220MCG INH 31 fentanyl 1.2mg lozenge 23 mg/5ml (44 mg/5ml FLOVENT 31 fentanyl 1.6mg lozenge 23 elemental fe) 250MCG/BLIST INH FERRIMIN TAB 150MG 105 FERROUS SULFATE 105 FLOVENT 44MCG INH 31 FERRIPROX 1000MG 45 LIQUID 220 MG/5ML (44 FLOVENT 50MCG/BLIST 31 TAB MG/5ML ELEMENTAL INH FERRIPROX 100MG/ML 45 FE) fluconazole 100mg tab 46 ORAL SOLN ferrous sulfate oral soln 105 fluconazole 10mg/ml susp 46 FERROUS FUMARATE 105 75mg/ml fluconazole 150mg tab 46 TAB 29MG FERROUS SULFATE 105 fluconazole 200mg tab 46 ferrous fumarate tab 324 105 SYRUP 300MG/5ML fluconazole 2mg/ml 46 mg (106 mg elemental fe) ferrous sulfate tab 325mg 105 (100ml) inj FERROUS 104 FETZIMA 120MG ER 40 fluconazole 2mg/ml 46 FUMARATE-FA-B CAP (200ml) inj COMPLEX-C-ZN-MG-M FETZIMA 20MG ER CAP 40 fluconazole 40mg/ml susp 46 N-CU CAP 106-1 MG FETZIMA 40MG ER CAP 40 fluconazole 50mg tab 46 ferrous fumarate-folic 104 FETZIMA 80MG ER CAP 40 flucytosine 250mg cap 46 acid tab 324-1 mg FETZIMA PACK 40 flucytosine 500mg cap 46 FERROUS 104 fexofenadine 180mg tab 47 fludrocortisone 0.1mg tab 85 FUMARATE-VIT C TAB fexofenadine 60mg tab 47 FLUNISOLIDE 119 ER 65-25 MG fiber therapy tab 500mg 106 0.025MG/ACT NASAL (ELEMENTAL FE) FINACEA 15% FOAM 92 INHALER FERROUS FUMARTE 105 finasteride 5mg tab 101 fluocinolone acetonide 89 TAB 325 MG FINTEPLA 2.2MG/ML 35 0.01% cream ferrous gluconate tab 105 ORAL SOLN fluocinolone acetonide 124 240mg FIRMAGON 120MG INJ 57 0.01% otic soln ferrous gluconate tab 105 FIRMAGON 80MG INJ 57 fluocinolone acetonide 89 324mg FIRVANQ 25MG/ML 54 0.01% topical soln FERROUS GLUCONATE 105 ORAL SOLN fluocinolone acetonide 89 TAB 324MG FIRVANQ 50MG/ML 54 0.025% cream ORAL SOLN

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 162 ALPHABETICAL LISTING OF DRUGS fluocinolone acetonide 89 fluphenazine 10mg tab 68 FLUTICASONE 31 0.025% ointment fluphenazine 1mg tab 68 PROPIONATE/SALMETE fluocinolone acetonide 89 fluphenazine 2.5mg tab 68 ROL XINAFOATE 0.1mg/ml oil FLUPHENAZINE 68 55-14MCG/ACT fluocinonide 0.05% cream 89 2.5MG/ML INJ POWDER INH fluocinonide 0.05% e 89 fluphenazine 5mg tab 68 fluvastatin 20mg cap 48 cream FLUPHENAZINE 68 fluvastatin 40mg cap 48 fluocinonide 0.05% gel 90 5MG/ML ORAL SOLN fluvastatin 80mg er tab 48 fluocinonide 0.05% 90 fluphenazine decanoate 68 fluvoxamine maleate 39 ointment 25mg/ml inj 100mg er cap fluocinonide 0.05% 90 FLURAZEPAM 15MG 106 fluvoxamine maleate 39 topical soln CAP 100mg tab fluocinonide 0.1% cream 90 FLURAZEPAM 30MG 106 fluvoxamine maleate 39 fluorometholone 0.1% 123 CAP 150mg er cap ophth susp flurbiprofen 100mg tab 20 fluvoxamine maleate 39 FLUOROURACIL 2% 88 FLURBIPROFEN 124 25mg tab TOPICAL SOLN SODIUM 0.03% OPHTH fluvoxamine maleate 39 fluorouracil 5% cream 88 SOLN 50mg tab FLUOROURACIL 5% 88 flutamide 125mg cap 57 FML 0.1% OPHTH 123 TOPICAL SOLN fluticasone propionate 90 OINTMENT fluoxetine 10mg cap 38 0.005% ointment FML FORTE LIQUIFILM 123 fluoxetine 10mg tab 38 fluticasone propionate 90 0.25% OPHTH SUSP FLUOXETINE 10MG TAB 38 0.05% cream FOLBEE PLUS TAB 117 fluoxetine 20mg cap 38 fluticasone propionate 119 FOLIC + B12 TAB 104 fluoxetine 128 0.05mg/act nasal inhaler FOLIC ACID CAP 20MG 103 25mg/olanzapine 12mg fluticasone propionate 31 folic acid cap 800mcg 103 cap 0.1mg/salmeterol 0.05mg folic acid inj 5mg/ml 103 fluoxetine 128 inh folic acid tab 1mg 103 25mg/olanzapine 3mg fluticasone propionate 31 folic acid tab 400mcg 103 cap 0.25mg/salmeterol folic acid tab 800mcg 103 fluoxetine 128 0.05mg inh FOLIC 92 25mg/olanzapine 6mg fluticasone propionate 31 ACID-PYRIDOXINE-CYA cap 0.5mg/salmeterol 0.05mg NOCOBALAMIN TAB fluoxetine 40mg cap 38 inh 2.2-25-1.3 MG fluoxetine 4mg/ml oral 39 FLUTICASONE 31 folic 92 soln PROPIONATE/SALMETE acid-pyridoxine-cyanoco fluoxetine 128 ROL XINAFOATE balamin tab 2.5-25-2 mg 50mg/olanzapine 12mg 113-14MCG/ACT FOLIC 92 cap POWDER INH ACID-PYRIDOXINE-CYA fluoxetine 128 FLUTICASONE 31 NOCOBALAMIN TAB 50mg/olanzapine 6mg PROPIONATE/SALMETE 2.5-25-2MG cap ROL XINAFOATE folic acid-vitamin 104 FLUPHENAZINE 68 232-14MCG/ACT b6-vitamin b12 tab 0.5MG/ML ORAL SOLN POWDER INH 2.2-25-0.5 mg

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 163 ALPHABETICAL LISTING OF DRUGS folic acid-vitamin 104 FRAGMIN 33 gabapentin 50mg/ml oral 35 b6-vitamin b12 tab 18000UNT/0.72ML soln 2.2-25-1 mg SYRINGE gabapentin 600mg tab 35 folic acid-vitamin 104 FRAGMIN 33 gabapentin 800mg tab 35 b6-vitamin b12 tab 2500UNIT/0.2ML GALAFOLD 28 DAY 96 2.5-25-1 mg SYRINGE WALLET 123MG PACK FOLITAB 500MG 104 FRAGMIN 33 galantamine 12mg tab 127 fondaparinux sodium 33 5000UNIT/0.2ML galantamine 4mg tab 127 12.5mg/ml (0.4ml) syringe SYRINGE galantamine 8mg tab 127 fondaparinux sodium 33 FRAGMIN 33 galantamine 127 12.5mg/ml (0.6ml) syringe 7500UNIT/0.3ML hydrobromide 16mg er fondaparinux sodium 33 SYRINGE cap 12.5mg/ml (0.8ml) syringe FRAGMIN 33 galantamine 127 fondaparinux sodium 33 95000UNIT/3.8ML INJ hydrobromide 24mg er 5mg/ml syringe FULPHILA 6MG/0.6ML 103 cap FORTEO 600MCG/2.4ML 95 SYRINGE GALANTAMINE 128 PEN INJ furosemide 10mg/ml inj 94 HYDROBROMIDE fosamprenavir 700mg tab 70 furosemide 10mg/ml oral 94 4MG/ML ORAL SOLN fosfomycin 3000mg 55 soln galantamine 128 powder for oral soln furosemide 10mg/ml 94 hydrobromide 8mg er cap fosinopril sodium 10mg 49 syringe GAMMAGARD 10GM 124 tab furosemide 20mg tab 94 INJ fosinopril sodium 52 furosemide 40mg tab 94 GAMMAGARD 124 10mg/hydrochlorothiazid furosemide 80mg tab 94 2.5GM/25ML INJ e 12.5mg tab FUROSEMIDE 8MG/ML 94 GAMMAGARD 5GM INJ 124 fosinopril sodium 20mg 49 ORAL SOLN GAMMAKED 124 tab FUSION CAP 104 1GM/10ML INJ fosinopril sodium 52 FUSION PLUS CAP 104 GAMMAPLEX 124 20mg/hydrochlorothiazid FUZEON 90MG INJ 70 10GM/100ML INJ e 12.5mg tab fyavolv 0.0025-0.5mg tab 97 GAMMAPLEX 125 fosinopril sodium 40mg 49 fyavolv 0.005-1mg tab 97 10GM/200ML INJ tab FYCOMPA 0.5MG/ML 33 GAMMAPLEX 125 FOTIVDA 0.89MG CAP 59 SUSP 20GM/200ML INJ FOTIVDA 1.34MG CAP 59 FYCOMPA 10MG TAB 33 GAMMAPLEX 125 FRAGMIN 33 FYCOMPA 12MG TAB 33 5GM/50ML INJ 10000UNIT/ML FYCOMPA 2MG TAB 33 GAMUNEX 1GM/10ML 125 SYRINGE FYCOMPA 4MG TAB 33 INJ FRAGMIN 33 FYCOMPA 6MG TAB 34 GARDASIL 9 INJ 136 12500UNIT/0.5ML FYCOMPA 8MG TAB 34 GARDASIL 9 SYRINGE 136 SYRINGE G gatifloxacin 0.5% ophth 122 FRAGMIN 33 soln gabapentin 100mg cap 35 15000UNIT/0.6ML GATTEX 5MG INJ 100 gabapentin 300mg cap 35 SYRINGE gabapentin 400mg cap 35

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 164 ALPHABETICAL LISTING OF DRUGS

GAUZE PADS & 109 gentamicin 0.1% ointment 87 GLUCAGON (RDNA) 42 DRESSINGS - PADS 2 X gentamicin 0.3% ophth 122 1MG INJ 2 soln glucose 100mg/ml inj 120 GAVILYTE-C ORAL 107 GENTAMICIN 0.8MG/ML 19 GLUCOSE 112 SOLN INJ 100MG/ML/SODIUM gavilyte-g powder for 107 gentamicin 1.2mg/ml inj 19 CHLORIDE 0.0342 oral soln GENTAMICIN 1.6MG/ML 19 MEQ/ML INJ gavilyte-n powder for 107 INJ GLUCOSE 112 oral soln GENTAMICIN 1MG/ML 19 100MG/ML/SODIUM GAVRETO 100MG CAP 59 INJ CHLORIDE 0.0769 gemfibrozil 600mg tab 48 gentamicin 40mg/ml inj 19 MEQ/ML INJ generlac 10gm/15ml oral 100 genteal tear moderate 121 GLUCOSE 112 soln soln 25MG/ML/SODIUM gengraf 100mg cap 73 GENVOYA 70 CHLORIDE 0.0769 gengraf 100mg/ml oral 73 150-150-200-10MG TAB MEQ/ML INJ soln GILENYA 0.5MG CAP 129 glucose 50 112 gengraf 25mg cap 73 GILOTRIF 20MG TAB 59 mg/ml/potassium chloride GENOTROPIN 0.2MG 95 GILOTRIF 30MG TAB 59 0.04meq/ml/sodium SYRINGE GILOTRIF 40MG TAB 59 chloride 4.5mg/ml inj GENOTROPIN 0.4MG 95 GLASSIA 1000MG/50ML 130 glucose 50mg/ml inj 120 SYRINGE INJ glucose 112 GENOTROPIN 0.6MG 95 glatiramer acetate 129 50mg/ml/potassium SYRINGE 20mg/ml syringe chloride 0.01 GENOTROPIN 0.8MG 95 glatiramer acetate 129 meq/ml/sodium chloride SYRINGE 40mg/ml syringe 0.0769 meq/ml inj GENOTROPIN 1.2MG 95 glatopa 20mg/ml syringe 129 glucose 112 SYRINGE glatopa 40mg/ml syringe 129 50mg/ml/potassium GENOTROPIN 1.4MG 95 glimepiride 1mg tab 44 chloride 0.02 meq/ml inj SYRINGE glimepiride 2mg tab 44 glucose 112 GENOTROPIN 1.6MG 95 glimepiride 4mg tab 44 50mg/ml/potassium SYRINGE glipizide 10mg er tab 44 chloride 0.02 GENOTROPIN 1.8MG 95 glipizide 10mg tab 44 meq/ml/sodium chloride SYRINGE glipizide 2.5mg er tab 44 0.0342 meq/ml inj GENOTROPIN 12MG 95 glipizide 41 glucose 112 CARTRIDGE 2.5mg/metformin 250mg 50mg/ml/potassium GENOTROPIN 1MG 95 tab chloride 0.02 SYRINGE glipizide 41 meq/ml/sodium chloride GENOTROPIN 2MG 95 2.5mg/metformin 500mg 0.154 meq/ml inj SYRINGE tab glucose 112 GENOTROPIN 5MG 95 glipizide 5mg er tab 44 50mg/ml/potassium CARTRIDGE glipizide 5mg tab 44 chloride GENTAK 0.3% OPHTH 122 glipizide 5mg/metformin 41 0.02meq/ml/sodium OINTMENT 500mg tab chloride 4.5mg/ml inj gentamicin 0.1% cream 87 GLUCAGEN 1MG INJ 42

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 165 ALPHABETICAL LISTING OF DRUGS glucose 112 GRAMICIDIN 122 HAVRIX 1440ELU/ML 136 50mg/ml/potassium 0.025MG/ML/NEOMYCI SYRINGE chloride 0.03 N HAVRIX 720ELU/0.5ML 136 meq/ml/sodium chloride 1.75MG/ML/POLYMYXI SYRINGE 0.0769 meq/ml inj N B 10000UNIT/ML HEMOCYTE TAB 324MG 105 GLUCOSE 112 OPHTH SOLN HEMOCYTE-F ELIXIR 104 50MG/ML/POTASSIUM granisetron 1mg tab 45 heparin sodium (porcine) 33 CHLORIDE 0.04 griseofulvin 125mg tab 46 lock flush iv soln 10 MEQ/ML/SODIUM griseofulvin 250mg tab 46 unit/ml CHLORIDE 0.154 griseofulvin 25mg/ml 46 heparin sodium (porcine) 33 MEQ/ML INJ susp lock flush iv soln 100 glucose 50mg/ml/sodium 112 griseofulvin 500mg tab 46 unit/ml chloride 0.0342 meq/ml guanfacine 1mg er tab 16 heparin sodium porcine 33 inj guanfacine 2mg er tab 16 10000unit/ml inj glucose 50mg/ml/sodium 112 guanfacine 3mg er tab 16 heparin sodium porcine 33 chloride 4.5mg/ml inj guanfacine 4mg er tab 16 1000unit/ml inj glucose 50mg/ml/sodium 112 GUANIDINE 125MG TAB 55 heparin sodium porcine 33 chloride 9mg/ml inj H 20000unit/ml inj GLUCOSE CHEW TAB 42 heparin sodium porcine 33 HAEGARDA 2000UNIT 101 4-0.006GM 5000unit/ml inj INJ GLUCOSE CHEW TAB 42 HEPATAMINE 8% INJ 120 HAEGARDA 3000UNIT 102 4GM HETLIOZ 20MG CAP 106 INJ GLUCOSE GEL 15 42 HIBERIX 10MCG INJ 136 hailey 24 fe 28 day pack 81 GM/33GM HUMIRA 10MG/0.1ML 19 halobetasol propionate 90 glucose gel 40% 42 SYRINGE 0.05% cream GLUCOSE ORAL LIQUID 42 HUMIRA 20MG/0.2ML 19 halobetasol propionate 90 15 GM/59ML SYRINGE 0.05% ointment GLYCERIN LIQUID 80 HUMIRA 40MG/0.4ML 19 haloperidol 0.5mg tab 66 glycerin supp 1 gm 107 AUTO-INJECTOR haloperidol 10mg tab 66 glycerin supp 1.2gm 107 HUMIRA 40MG/0.4ML 19 haloperidol 1mg tab 66 glycerin supp 2.1gm 107 SYRINGE haloperidol 20mg tab 66 glycerin suppos 2 gm 107 HUMIRA 40MG/0.8ML 19 haloperidol 2mg tab 66 glycerin topical liquid 91 AUTO-INJECTOR haloperidol 2mg/ml oral 66 glycerin/hypromellose/PE 121 HUMIRA 40MG/0.8ML 19 soln G 400 ophth soln SYRINGE haloperidol 5mg tab 66 glycopyrrolate 1mg tab 134 HUMIRA 80MG/0.8ML 19 haloperidol 5mg/ml inj 66 glycopyrrolate 2mg tab 134 AUTO-INJECTOR haloperidol decanoate 66 GNP DAILY PRENATAL 118 HUMIRA PEDIATRIC 19 100mg/ml (1ml) inj TAB (OTC) CROHN'S STARTER haloperidol decanoate 66 gnp dry mouth 116 PACK (3) 80MG/0.8ML 100mg/ml inj mouthwash INJ haloperidol decanoate 66 50mg/ml inj haloperidol decanoate 66 50mg/ml inj You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 166 ALPHABETICAL LISTING OF DRUGS

HUMIRA PEDIATRIC 19 hydrochlorothiazide 52 hydrochlorothiazide 53 CROHN'S STARTER 12.5mg/losartan 25mg/metoprolol tartrate PACK SYRINGE (2) potassium 100mg tab 50mg tab 40MG/0.4ML hydrochlorothiazide 52 hydrochlorothiazide 53 HUMIRA PEN - 19 12.5mg/losartan 25mg/olmesartan CROHN'S STARTER potassium 50mg tab medoxomil 40mg tab PACK 40MG/0.8ML INJ hydrochlorothiazide 52 hydrochlorothiazide 53 HUMIRA PEN - 19 12.5mg/olmesartan 25mg/propranolol 40mg CROHN'S STARTER medoxomil 20mg tab tab PACK 80MG/0.8ML INJ hydrochlorothiazide 52 hydrochlorothiazide 53 HUMIRA PEN - 20 12.5mg/olmesartan 25mg/propranolol 80mg PEDIATRIC UC STARTER medoxomil 40mg tab tab PACK 80MG/0.8ML INJ hydrochlorothiazide 52 hydrochlorothiazide 53 HUMIRA PEN - 20 12.5mg/quinapril 10mg 25mg/quinapril 20mg tab PSORIASIS STARTER tab hydrochlorothiazide 93 PACK 40MG/0.8ML INJ hydrochlorothiazide 52 25mg/spironolactone HUMIRA PEN - 20 12.5mg/quinapril 20mg 25mg tab PSORIASIS STARTER tab hydrochlorothiazide 53 PACK 80MG/0.8ML INJ hydrochlorothiazide 52 25mg/telmisartan 80mg HUMULIN R 43 12.5mg/telmisartan 40mg tab 500UNIT/ML INJ tab hydrochlorothiazide 93 HUMULIN R 43 hydrochlorothiazide 52 25mg/triamterene 37.5mg 500UNIT/ML PEN INJ 12.5mg/telmisartan 80mg cap hydralazine 100mg tab 53 tab hydrochlorothiazide 93 hydralazine 10mg tab 53 hydrochlorothiazide 52 25mg/triamterene 37.5mg hydralazine 25mg tab 53 12.5mg/valsartan 160mg tab hydralazine 50mg tab 53 tab hydrochlorothiazide 53 hydrochlorothiazide 94 hydrochlorothiazide 52 25mg/valsartan 160mg 12.5mg cap 12.5mg/valsartan 320mg tab hydrochlorothiazide 94 tab hydrochlorothiazide 53 12.5mg tab hydrochlorothiazide 52 25mg/valsartan 320mg hydrochlorothiazide 52 12.5mg/valsartan 80mg tab 12.5mg/irbesartan 150mg tab hydrochlorothiazide 94 tab hydrochlorothiazide 94 50mg tab hydrochlorothiazide 52 25mg tab hydrochlorothiazide 53 12.5mg/irbesartan 300mg hydrochlorothiazide 53 50mg/metoprolol tartrate tab 25mg/lisinopril 20mg tab 100mg tab hydrochlorothiazide 52 hydrochlorothiazide 53 hydrochlorothiazide 93 12.5mg/lisinopril 10mg 25mg/losartan potassium 50mg/triamterene 75mg tab 100mg tab tab hydrochlorothiazide 52 hydrochlorothiazide 53 hydrocodone bitartrate 25 12.5mg/lisinopril 20mg 25mg/metoprolol tartrate 10mg/ibuprofen 200mg tab 100mg tab tab

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 167 ALPHABETICAL LISTING OF DRUGS hydrocodone bitartrate 25 hydrocortisone/pramoxin 26 IBRANCE 125MG CAP 59 5mg/ibuprofen 200mg tab e 1-1% rectal cream IBRANCE 125MG TAB 59 hydrocodone bitartrate 25 hydrocortisone-aloe vera 90 IBRANCE 75MG CAP 59 7.5mg/ibuprofen 200mg cream 1% IBRANCE 75MG TAB 59 tab HYDROGEN PEROXIDE 69 ibu 600mg tab 20 hydrocortisone 1% cream 90 SOLN ibu 800mg tab 21 hydrocortisone 1% 90 hydrogen peroxide soln 69 ibuprofen 20mg/ml susp 21 lotion(OTC) 3% ibuprofen 400mg tab 21 hydrocortisone 1% 90 hydromorphone 10mg/ml 23 ibuprofen 600mg tab 21 ointment (1ml) inj ibuprofen 800mg tab 21 hydrocortisone 26 hydromorphone 10mg/ml 23 ibuprofen cap 200mg 21 1.67mg/ml enema (5ml) inj ibuprofen chew tab 21 hydrocortisone 10mg tab 84 hydromorphone 1mg/ml 23 100mg hydrocortisone 123 oral soln ibuprofen susp 20mg/ml 21 10mg/ml/neomycin hydromorphone 2mg tab 23 ibuprofen susp 40mg/ml 21 3.5mg/ml/polymyxin b hydromorphone 4mg tab 23 ibuprofen tab 200mg 21 10000unit/ml ophth susp hydromorphone 8mg tab 23 icatibant 10mg/ml syringe 101 hydrocortisone 124 HYDROPHILIC 127 iclevia 91 day pack 81 10mg/ml/neomycin OINTMENT ICLUSIG 10MG TAB 59 3.5mg/ml/polymyxin b HYDROXOCOBALAMIN 102 ICLUSIG 15MG TAB 59 10000unit/ml otic soln ACETATE INJ 1000 ICLUSIG 30MG TAB 59 hydrocortisone 124 MCG/ML (BASE ICLUSIG 45MG TAB 59 10mg/ml/neomycin EQUIVALENT) IDHIFA 100MG TAB 59 3.5mg/ml/polymyxin b hydroxychloroquine 55 IDHIFA 50MG TAB 60 10000unit/ml otic susp sulfate 200mg tab ILEVRO 0.3% OPHTH 124 hydrocortisone 2.5% 90 hydroxyurea 500mg cap 62 SUSP cream hydroxyzine 10mg tab 28 imatinib 100mg tab 60 hydrocortisone 2.5% 90 hydroxyzine 25mg tab 28 imatinib 400mg tab 60 lotion hydroxyzine 2mg/ml oral 28 IMBRUVICA 140MG 60 hydrocortisone 2.5% 90 soln CAP ointment hydroxyzine 50mg tab 28 IMBRUVICA 140MG TAB 60 hydrocortisone 20mg tab 84 HYDROXYZINE 28 IMBRUVICA 280MG TAB 60 hydrocortisone 5mg tab 84 PAMOATE 100MG CAP IMBRUVICA 420MG TAB 60 hydrocortisone cream 90 hydroxyzine pamoate 28 IMBRUVICA 560MG TAB 60 0.5% 25mg cap IMBRUVICA 70MG CAP 60 HYDROCORTISONE 90 hydroxyzine pamoate 28 imipramine 10mg tab 41 CREAM 1% 50mg cap imipramine 25mg tab 41 hydrocortisone cream 1% 90 hypromellose ophth soln 121 imipramine 50mg tab 41 hydrocortisone ointment 90 0.3% imipramine pamoate 41 0.5% I 100mg cap hydrocortisone soln 1% 90 imipramine pamoate 41 ibandronic acid 150mg 95 hydrocortisone/aloe vera 90 125mg cap tab cream 0.5% imipramine pamoate 41 IBRANCE 100MG CAP 59 150mg cap IBRANCE 100MG TAB 59 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 168 ALPHABETICAL LISTING OF DRUGS imipramine pamoate 41 INVEGA 234MG/1.5ML 65 IRON HEME 104 75mg cap SYRINGE POLYPEPTIDE-FOLIC imiquimod 5% cream 91 INVEGA 65 ACID TAB 12-1 MG (FE IMOVAX 2.5UNIT/ML 136 273MG/0.875ML EQUIV) INJ SYRINGE IRON 105 IMPAVIDO 50MG CAP 53 INVEGA 39MG/0.25ML 65 SUCCINYL-PROTEIN incassia 28 day 0.35mg 84 SYRINGE COMPLEX SOLN pack INVEGA 65 40MG/15ML (ELEMENT INCRELEX 40MG/4ML 96 410MG/1.315ML FE EQ) INJ SYRINGE IRON TAB 256MG 105 INCRUSE 62.5MCG/INH 30 INVEGA 546MG/1.75ML 65 iron/vitamin C tab 104 INH SYRINGE 100-250mg indapamide 1.25mg tab 94 INVEGA 78MG/0.5ML 66 iron/vitamin C/vitamin 104 indapamide 2.5mg tab 94 SYRINGE B12/folic acid tab INFANRIX INJ 133 INVEGA 66 IRON-VITAMIN C TAB 104 INLYTA 1MG TAB 60 819MG/2.625ML 100-250 MG INLYTA 5MG TAB 60 SYRINGE IRO-PLEX LIQUID 104 INQOVI 5 TABLET PACK 58 INVIRASE 500MG TAB 70 IRO-PLEX TAB 104 INREBIC 100MG CAP 60 iodine tab 150mcg 113 IROSPAN TAB 104 INSTACLEAN LIQUID 91 IODINE TINCTURE MILD 69 ISENTRESS 100MG 70 INSULIN PEN NEEDLE 109 2% CHEW TAB INSULIN SYRINGE 109 IODINE TINCTURE 69 ISENTRESS 100MG 70 (DISP) U-100 0.3ML STRONG GRANULES FOR ORAL INSULIN SYRINGE 109 IOPIDINE 1% OPHTH 122 SUSP (DISP) U-100 1/2ML SOLN ISENTRESS 25MG 70 INSULIN SYRINGE 109 IPOL INJ 136 CHEW TAB (DISP) U-100 1ML ipratropium bromide 119 ISENTRESS 400MG TAB 70 INTELENCE 25MG TAB 70 0.021mg/act nasal ISENTRESS 600MG TAB 70 INTRALIPID 120 inhaler isibloom 28 day pack 81 20GM/100ML INJ ipratropium bromide 119 ISOLYTE P INJ 112 INTRALIPID 120 0.042mg/act nasal ISOLYTE S INJ 112 30GM/100ML INJ inhaler isoniazid 100mg tab 56 INTRON A 10MU INJ 62 ipratropium bromide 30 ISONIAZID 10MG/ML 56 INTRON A 10MU/ML INJ 62 0.2mg/ml inh soln ORAL SOLN INTRON A 18MU INJ 62 ipratropium/albuterol 31 isoniazid 300mg tab 56 INTRON A 50MU INJ 62 0.5-2.5mg/3ml inh soln ISOPROPYL ALCOHOL 109 INTRON A 62 irbesartan 150mg tab 50 0.7ML/ML PAD 6000000UNIT/ML INJ irbesartan 300mg tab 50 isopropyl alcohol 70% 80 introvale 91 day pack 81 irbesartan 75mg tab 50 soln INVEGA 117MG/0.75ML 65 IRESSA 250MG TAB 60 isopropyl alcohol 91% 80 SYRINGE IRON HEME 105 soln INVEGA 156MG/ML 65 POLYPEPTIDE TAB 12 ISOPROPYL ALCOHOL 80 SYRINGE MG (ELEMENTAL FE 99% EQUIV)

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 169 ALPHABETICAL LISTING OF DRUGS

ISOPROPYL ALCOHOL 80 JAKAFI 5MG TAB 60 junel fe 24 1/20 28 day 82 SOLN 70% jantoven 10mg tab 32 pack ISOPROPYL ALCOHOL 80 jantoven 1mg tab 32 JUXTAPID 10MG CAP 49 SOLN 91% jantoven 2.5mg tab 32 JUXTAPID 20MG CAP 49 isopropyl alcohol soln 80 jantoven 2mg tab 32 JUXTAPID 30MG CAP 49 99% jantoven 3mg tab 32 JUXTAPID 5MG CAP 49 isosorbide dinitrate 10mg 27 jantoven 4mg tab 32 JYNARQUE 15MG TAB 97 tab jantoven 5mg tab 32 JYNARQUE 30MG TAB 97 isosorbide dinitrate 20mg 27 jantoven 6mg tab 32 JYNARQUE 45/15 97 tab jantoven 7.5mg tab 32 THERAPY PACK isosorbide dinitrate 30mg 27 JANUMET 1000-100MG 41 JYNARQUE 60/30 97 tab ER TAB THERAPY PACK isosorbide dinitrate 40mg 27 JANUMET 1000-50MG 41 JYNARQUE 90/30 97 tab ER TAB THERAPY PACK isosorbide dinitrate 5mg 28 JANUMET 1000-50MG 41 JYNARQUE TAB 97 tab TAB 15/15MG THERAPY isosorbide mononitrate 28 JANUMET 500-50MG ER 41 PACK 10mg tab TAB JYNARQUE TAB 97 isosorbide mononitrate 28 JANUMET 500-50MG 41 30/15MG THERAPY 120mg er tab TAB PACK isosorbide mononitrate 28 JANUVIA 100MG TAB 42 K 20mg tab JANUVIA 25MG TAB 42 kaitlib fe 28 day pack 82 isosorbide mononitrate 28 JANUVIA 50MG TAB 42 KALYDECO 150MG TAB 130 30mg er tab JARDIANCE 10MG TAB 43 KALYDECO 25MG 130 isosorbide mononitrate 28 JARDIANCE 25MG TAB 43 GRANULES 60mg er tab jasmiel 28 day pack 81 KALYDECO 50MG 130 isotretinoin 10mg cap 86 JENTADUETO 41 GRANULES isotretinoin 20mg cap 86 2.5-1000MG ER TAB KALYDECO 75MG 130 isotretinoin 30mg cap 86 JENTADUETO 41 GRANULES isotretinoin 40mg cap 86 2.5-1000MG TAB kariva 28 day pack 82 isradipine 2.5mg cap 75 JENTADUETO 41 KCL/D5W/LR INJ 0.15% 112 isradipine 5mg cap 75 2.5-500MG TAB kelnor 1/35 28 day pack 82 ISTURISA 10MG TAB 94 JENTADUETO 41 kelnor 1/50 28 day pack 82 ISTURISA 1MG TAB 94 2.5-850MG TAB ketoconazole 2% cream 87 ISTURISA 5MG TAB 94 JENTADUETO 41 ketoconazole 2% 87 itraconazole 100mg cap 46 5-1000MG ER TAB shampoo ivermectin 3mg tab 27 jinteli 0.005-1mg tab 97 ketoconazole 200mg tab 46 IXIARO 0.012MG/ML 136 juleber 28 day pack 81 ketorolac tromethamine 124 SYRINGE JULUCA 50-25MG TAB 71 0.4% ophth soln junel 1.5/30 21 day pack 81 J ketorolac tromethamine 124 junel 1/20 21 day pack 82 JAKAFI 10MG TAB 60 0.5% ophth soln junel fe 1.5/30 28 day 82 JAKAFI 15MG TAB 60 ketotifen fumarate ophth 124 pack JAKAFI 20MG TAB 60 soln 0.025% (base equiv) junel fe 1/20 28 day pack 82 JAKAFI 25MG TAB 60 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 170 ALPHABETICAL LISTING OF DRUGS

KEVZARA 20 K-TAB 8MEQ ER TAB 114 lamotrigine 50mg er tab 35 150MG/1.14ML kurvelo pack 82 lamotrigine 50mg odt 35 AUTO-INJECTOR KUVAN 100MG 96 lamotrigine 5mg chew tab 35 KEVZARA 20 POWDER FOR ORAL lamotrigine ODT kit 35 150MG/1.14ML SOLN lamotrigine tab 25mg 35 SYRINGE KUVAN 500MG 96 (42)/100mg (7) starter KEVZARA 20 POWDER FOR ORAL pack 200MG/1.14ML SOLN lamotrigine tab 25mg 35 AUTO-INJECTOR L (84)/100mg (14) starter KEVZARA 20 pack labetalol 100mg tab 73 200MG/1.14ML LAMPIT 120MG TAB 54 labetalol 200mg tab 73 SYRINGE LAMPIT 30MG TAB 54 labetalol 300mg tab 73 KINRIX INJ 133 LANOLIN ANHYDROUS 127 lactase tab 3000 unit 93 KINRIX PF INJ 133 lanolin cream 91 lactase tab 9000 unit 93 KISQALI 200MG DAILY 60 lanolin ointment 91 lactic acid (ammonium 91 DOSE PACK lanolin ointment 91 lactate) cream 12% KISQALI 400MG DAILY 60 lansoprazole 15mg dr cap 134 lactic acid (ammonium 91 DOSE PACK lansoprazole 30mg dr cap 134 lactate) lotion 12% KISQALI 600MG DAILY 60 lanthanum carbonate 100 lactic acid lotion 5% 91 DOSE PACK 1000mg chew tab lactulose 667mg/ml oral 107 KISQALI FEMARA 58 lanthanum carbonate 100 soln CO-PACK 200 PACK 500mg chew tab lamivudine 100mg tab 72 KISQALI FEMARA 58 lanthanum carbonate 100 lamivudine 10mg/ml oral 71 CO-PACK 400 PACK 750mg chew tab soln KISQALI FEMARA 58 LANTUS 100UNIT/ML 43 lamivudine 150mg tab 71 CO-PACK 600 PACK INJ lamivudine 71 klor-con 10meq er tab 114 LANTUS 100UNIT/ML 43 150mg/zidovudine 300mg klor-con 10meq micro er 114 PEN INJ tab tab lapatinib 250mg tab 60 lamivudine 300mg tab 71 KLOR-CON 15MEQ 114 larin 1.5/30 pack 82 lamotrigine 100mg er tab 35 MICRO ER TAB larin 1/20 pack 82 lamotrigine 100mg odt 35 klor-con 20meq micro er 114 larin fe 1.5/30 pack 82 lamotrigine 100mg tab 35 tab larin fe 1/20 pack 82 lamotrigine 150mg tab 35 klor-con 8meq er tab 114 larissia 28 day pack 82 lamotrigine 200mg er tab 35 KORLYM 300MG TAB 42 latanoprost 0.005% 124 lamotrigine 200mg odt 35 KOSELUGO 10MG CAP 60 ophth soln lamotrigine 200mg tab 35 KOSELUGO 25MG CAP 60 LATUDA 120MG TAB 65 lamotrigine 250mg er tab 35 KRINTAFEL 150MG TAB 55 LATUDA 20MG TAB 65 lamotrigine 25mg chew 35 KRISTALOSE 10GM 107 LATUDA 40MG TAB 65 tab POWDER FOR ORAL LATUDA 60MG TAB 65 lamotrigine 25mg er tab 35 SOLN LATUDA 80MG TAB 65 lamotrigine 25mg odt 35 KRISTALOSE 20GM 107 layolis fe 28 pack 82 lamotrigine 25mg pack 35 POWDER FOR ORAL leena 28 day pack 82 lamotrigine 25mg tab 35 SOLN leflunomide 10mg tab 21 lamotrigine 300mg er tab 35 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 171 ALPHABETICAL LISTING OF DRUGS leflunomide 20mg tab 21 levetiracetam 750mg er 36 levothyroxine sodium 132 LEMON-GLYCERIN 116 tab 0.05mg tab SWABSTICKS levetiracetam 750mg tab 36 levothyroxine sodium 132 LENVIMA 10 10MG 60 LEVOBUNOLOL 0.5% 121 0.075mg tab PACK OPHTH SOLN levothyroxine sodium 132 LENVIMA 12 4MG PACK 60 levocarnitine 100mg/ml 96 0.088mg tab LENVIMA 14 PACK 60 oral soln levothyroxine sodium 132 LENVIMA 18 PACK 60 levocarnitine 330mg tab 96 0.112mg tab LENVIMA 20 10MG 60 levocetirizine 0.5mg/ml 47 levothyroxine sodium 132 PACK oral soln 0.125mg tab LENVIMA 24 PACK 60 levocetirizine 5mg tab 47 levothyroxine sodium 132 LENVIMA 4 4MG PACK 60 levofloxacin 0.5% ophth 122 0.137mg tab LENVIMA 8 4MG PACK 60 soln levothyroxine sodium 132 lessina 28 day pack 82 levofloxacin 250mg tab 98 0.15mg tab letrozole 2.5mg tab 57 levofloxacin 25mg/ml inj 98 levothyroxine sodium 132 LEUCOVORIN 10MG 62 levofloxacin 25mg/ml 98 0.175mg tab TAB oral soln levothyroxine sodium 132 LEUCOVORIN 15MG 62 levofloxacin 500mg tab 98 0.1mg tab TAB levofloxacin 5mg/ml 99 levothyroxine sodium 132 leucovorin 25mg tab 62 (100ml) inj 0.2mg tab leucovorin 5mg tab 62 levofloxacin 5mg/ml 99 levothyroxine sodium 132 LEUKERAN 2MG TAB 56 (150ml) inj 0.3mg tab leuprolide acetate 5mg/ml 57 levofloxacin 750mg tab 99 levoxyl 100mcg tab 132 inj levonest 28 day pack 82 levoxyl 112mcg tab 132 levalbuterol 0.103mg/ml 31 levonorgestrel 1.5mg tab 83 levoxyl 125mcg tab 132 inh soln LEVONORGESTREL TAB 83 levoxyl 137mcg tab 132 levalbuterol 0.21mg/ml 31 1.5 MG levoxyl 150mcg tab 132 inh soln levora 0.15/30 28 day 82 levoxyl 175mcg tab 132 levalbuterol 0.417mg/ml 31 pack levoxyl 200mcg tab 132 inh soln levo-t 100mcg tab 132 levoxyl 25mcg tab 132 levalbuterol 2.5mg/ml inh 31 levo-t 112mcg tab 132 levoxyl 50mcg tab 132 soln levo-t 125mcg tab 132 levoxyl 75mcg tab 132 LEVEMIR 100UNIT/ML 43 levo-t 137mcg tab 132 levoxyl 88mcg tab 132 INJ levo-t 150mcg tab 132 LEXIVA 50MG/ML SUSP 71 LEVEMIR 100UNIT/ML 43 levo-t 175mcg tab 132 lidocaine 2% topical soln 116 PEN INJ levo-t 200mcg tab 132 lidocaine 4% topical soln 91 levetiracetam 1000mg tab 35 levo-t 25mcg tab 132 lidocaine 5% ointment 91 levetiracetam 100mg/ml 35 levo-t 300mcg tab 132 lidocaine 5% patch 91 oral soln levo-t 50mcg tab 132 lidocaine/prilocaine 91 levetiracetam 250mg tab 35 levo-t 75mcg tab 132 2.5-2.5% cream levetiracetam 500mg er 35 levo-t 88mcg tab 132 lindane 1% shampoo 92 tab levothyroxine sodium 132 linezolid 20mg/ml susp 55 levetiracetam 500mg tab 36 0.025mg tab linezolid 2mg/ml inj 55 linezolid 600mg tab 55

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 172 ALPHABETICAL LISTING OF DRUGS liothyronine sodium 132 LONSURF 6.14-15MG 58 loteprednol etabonate 123 0.005mg tab TAB 0.5% ophth susp liothyronine sodium 132 LONSURF 8.19-20MG 58 lovastatin 10mg tab 48 0.025mg tab TAB lovastatin 20mg tab 48 liothyronine sodium 133 loperamide 2mg cap 44 lovastatin 40mg tab 48 0.05mg tab loperamide cap 2mg 44 low-ogestrel 28 day pack 82 LIQSORB LIQUID 18 loperamide liquid 44 loxapine 10mg cap 67 100MG/ML 1mg/7.5ml loxapine 25mg cap 67 lisinopril 10mg tab 49 lopinavir 71 loxapine 50mg cap 67 lisinopril 2.5mg tab 49 80mg/ml/ritonavir loxapine 5mg cap 67 lisinopril 20mg tab 49 20mg/ml oral solution LUMIGAN 0.01% OPHTH 124 lisinopril 30mg tab 50 lopinavir-ritonavir 71 SOLN lisinopril 40mg tab 50 100-25mg tab LUPANETA PACK 96 lisinopril 5mg tab 50 lopinavir-ritonavir 71 1-MONTH PACK lithium carbonate 150mg 64 200-50mg tab LUPANETA PACK 96 cap loratadine & 85 3-MONTH PACK lithium carbonate 300mg 64 pseudoephedrine tab er LUPKYNIS 7.9MG CAP 115 cap 12hr 5-120 mg LUPRON 11.25MG 57 lithium carbonate 300mg 65 loratadine 47 SYRINGE er tab rapidly-disintegrating LUPRON 22.5MG 57 lithium carbonate 300mg 65 tab 10 mg SYRINGE tab loratadine syrup 5mg/5ml 47 LUPRON 3.75MG 57 lithium carbonate 450mg 65 loratadine tab 10mg 47 SYRINGE er tab loratadine/pseudoephedr 85 LUPRON 30MG 57 lithium carbonate 600mg 65 ine SR tab (24hr) SYRINGE cap 10-240mg LUPRON 45MG 57 lithium citrate 60mg/ml 65 lorazepam 0.5mg tab 29 SYRINGE oral soln lorazepam 1mg tab 29 LUPRON 7.5MG 57 LITHOSTAT 250MG TAB 101 lorazepam 2mg tab 29 SYRINGE L-METHYLFOLATE W/ 93 lorazepam 2mg/ml oral 29 lutera 28 day pack 82 VIT B6-VIT B12 TAB soln lyleq 28 day 0.35mg pack 84 1.13-25-2 MG LORBRENA 100MG TAB 60 lyllana 0.025mg/24hr 98 L-METHYLFOLATE W/ 93 LORBRENA 25MG TAB 60 patch VIT B6-VIT B12 TAB loryna 28 day pack 82 lyllana 0.0375mg/24hr 98 3-35-2 MG losartan potassium 50 patch LOCALNESIUM TAB 111 100mg tab lyllana 0.05mg/24hr 98 166.67-83.3MG losartan potassium 25mg 50 patch LOCALNESIUM-C TAB 112 tab lyllana 0.075mg/24hr 98 LOKELMA 10GM 115 losartan potassium 50mg 50 patch POWDER FOR ORAL tab lyllana 0.1mg/24hr patch 98 SUSP LOTEMAX 0.5% OPHTH 123 LYNPARZA 100MG TAB 60 LOKELMA 5GM 115 OINTMENT LYNPARZA 150MG TAB 60 POWDER FOR ORAL loteprednol etabonate 123 LYSODREN 500MG TAB 57 SUSP 0.5% ophth gel lyza 0.35mg pack 84

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 173 ALPHABETICAL LISTING OF DRUGS

M magnesium oxide tab 400 113 matzim 240mg er tab 75 MAG-AL LIQUID 27 mg (240 mg elemental mg) matzim 300mg er tab 75 MAGINEX TAB 615MG 113 MAGNESIUM OXIDE 113 matzim 360mg er tab 75 MAGNESIUM CAP 300 113 TAB 400 MG (241.3 MG matzim 420mg er tab 75 MG ELEMENTAL MG) MAVYRET 100-40MG 72 MAGNESIUM 113 magnesium oxide tab 27 TAB CHLORIDE TAB DR 64 400mg MAXIDEX 0.1% OPHTH 123 MG (ELEMENTAL MG) magnesium oxide tab 27 SUSP magnesium chloride tab 113 400mg MAYZENT 0.25MG 129 dr 64 mg (elemental mg) magnesium oxide tab 420 27 STARTER PACK MAGNESIUM CITRATE 113 mg MAYZENT 0.25MG TAB 129 100MG TAB magnesium oxide tab 113 MAYZENT 2MG TAB 129 magnesium citrate soln 107 500mg meclizine 12.5mg tab 45 MAGNESIUM 113 MAGNESIUM 27 meclizine 12.5mg tab 45 GLUCONATE 500MG OXIDE-ASAFOETIDA meclizine 25mg tab 45 TAB LIQD 250 MG-6 meclizine chew tab 25mg 45 magnesium gluconate tab 113 MIN/5ML meclizine tab 25mg 45 500 mg magnesium sulfate 113 MEDROL 2MG TAB 84 magnesium gluconate tab 113 500mg/ml inj medroxyprogesterone 127 500 mg (27 mg elemental magnesium sulfate 113 acetate 10mg tab mg) 500mg/ml syringe medroxyprogesterone 83 magnesium gluconate tab 113 MAGNESIUM SULFATE 113 acetate 150mg/ml inj 500mg 70MG CAP medroxyprogesterone 84 magnesium hydroxide 107 magnesium sulfate oral 107 acetate 150mg/ml syringe susp 400mg/5ml granules medroxyprogesterone 127 magnesium hydroxide 107 magnesium tab 100mg 113 acetate 2.5mg tab susp concentrate 2400 magnesium tab 200mg 113 medroxyprogesterone 127 mg/10ml magnesium tab 250mg 113 acetate 5mg tab magnesium lactate tab er 113 magnesium/calcium 114 MEFLOQUINE 250MG 55 84 mg (elemental mg) (7 carbonate DR tab TAB meq) MAGONATE LIQUID 114 megestrol acetate 127 MAGNESIUM OXIDE 27 1000MG/5ML LIQUID 125mg/ml susp 400MG CAP malathion 0.5% lotion 92 megestrol acetate 127 magnesium oxide cap 113 mapo bath oil 89 125mg/ml susp 500mg MAPROTILINE 25MG 38 megestrol acetate 20mg 57 MAGNESIUM OXIDE 113 TAB tab POWDER PACK 240 MG MAPROTILINE 50MG 38 megestrol acetate 40mg 57 (ELEMENTAL MG) TAB tab magnesium oxide tab 113 MAPROTILINE 75MG 38 megestrol acetate 57 200mg TAB 40mg/ml susp magnesium oxide tab 27 marlissa 28 day pack 82 megestrol acetate susp 40 57 250mg MARPLAN 10MG TAB 38 mg/ml magnesium oxide tab 27 MATULANE 50MG CAP 62 MEKINIST 0.5MG TAB 60 250mg matzim 180mg er tab 75 MEKINIST 2MG TAB 60

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 174 ALPHABETICAL LISTING OF DRUGS

MEKTOVI 15MG TAB 60 mesalamine 800mg dr tab 100 methylphenidate 10mg 17 melatonin 300mcg tab 18 MESNEX 400MG TAB 62 tab melatonin 3mg tab 18 METAFOLBIC TAB 93 METHYLPHENIDATE 17 melatonin 5mg odt 18 metformin 1000mg tab 42 18MG ER TAB melatonin chew tab 2.5 18 metformin 100mg/ml soln 42 methylphenidate 18mg er 17 mg metformin 500mg er tab 42 tab melatonin liquid 18 metformin 500mg tab 42 methylphenidate 1mg/ml 17 MELATONIN LIQUID 18 metformin 750mg er tab 42 oral soln 1MG/4ML metformin 850mg tab 42 methylphenidate 2.5mg 17 melatonin tab 1 mg 18 methadone 10mg tab 23 chew tab melatonin tab 5 mg 18 methadone 5mg tab 23 methylphenidate 20mg cr 17 melatonin/pyridoxine 18 methazolamide 25mg tab 93 cap 5-10mg tab methazolamide 50mg tab 93 methylphenidate 20mg er 17 MELATONIN/PYRIDOXI 18 methenamine hippurate 135 tab NE TAB 1-10MG 1000mg tab methylphenidate 20mg la 17 MELATONIN/PYRIDOXI 19 methimazole 10mg tab 131 cap NE TAB 3-10MG methimazole 5mg tab 131 methylphenidate 20mg 17 meloxicam 15mg tab 21 methocarbamol 500mg 119 tab meloxicam 7.5mg tab 21 tab methylphenidate 27mg sr 17 memantine 10mg tab 128 methocarbamol 750mg 119 tab memantine 128 tab methylphenidate 2mg/ml 17 10mg/memantine 5mg methotrexate 2.5mg tab 56 oral soln pack methotrexate 25mg/ml 56 methylphenidate 30mg cr 17 memantine 14mg er cap 128 (2ml) inj cap memantine 21mg er cap 128 methotrexate 25mg/ml inj 56 methylphenidate 30mg la 17 memantine 28mg er cap 128 methoxsalen 10mg cap 88 cap memantine 2mg/ml oral 128 METHSCOPOLAMINE 134 methylphenidate 36mg sr 17 soln BROMIDE 2.5MG TAB tab memantine 5mg tab 128 METHSCOPOLAMINE 134 methylphenidate 40mg cr 17 memantine 7mg er cap 128 BROMIDE 5MG TAB cap MENACTRA INJ 136 METHYLCOBALAMIN 103 methylphenidate 40mg la 17 MENQUADFI INJ 136 ORALLY cap MENVEO INJ 136 DISINTEGRATING TAB methylphenidate 50mg cr 18 mercaptopurine 50mg tab 56 1000 MCG cap meropenem 1000mg inj 54 methylcobalamin sl tab 103 methylphenidate 54mg sr 18 meropenem 500mg inj 54 1000 mcg tab mesalamine 1000mg 99 methylphenidate 10mg 17 methylphenidate 5mg 18 rectal supp chew tab chew tab mesalamine 1200mg dr 99 methylphenidate 10mg cr 17 methylphenidate 5mg tab 18 tab cap methylphenidate 60mg cr 18 mesalamine 375mg er cap 99 methylphenidate 10mg er 17 cap mesalamine 400mg dr cap 100 tab methylphenidate 60mg la 18 mesalamine 66.7mg/ml 100 methylphenidate 10mg la 17 cap enema cap

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 175 ALPHABETICAL LISTING OF DRUGS methylprednisolone 16mg 84 mexiletine 150mg cap 29 mimvey pack 97 tab mexiletine 200mg cap 29 mineral oil 107 methylprednisolone 32mg 84 mexiletine 250mg cap 29 MINERAL OIL (BULK) 107 tab micafungin sodium 46 mineral oil enema 107 methylprednisolone 4mg 84 100mg inj MINERAL OIL LIGHT 91 pack micafungin sodium 50mg 46 MINERAL OIL OPHTH 121 methylprednisolone 4mg 84 inj EMULSION 0.5-0.5% tab miconazole nitrate 2% 87 minitran 0.1mg/hr patch 28 methylprednisolone 8mg 84 ointment minitran 0.2mg/hr patch 28 tab miconazole nitrate 87 minitran 0.4mg/hr patch 28 metoclopramide 10mg tab 99 aerosol pow 2% minitran 0.6mg/hr patch 28 metoclopramide 1mg/ml 99 miconazole nitrate cream 87 minocycline 100mg cap 131 oral soln 2% minocycline 100mg tab 131 metoclopramide 5mg tab 99 MICONAZOLE NITRATE 87 minocycline 50mg cap 131 metolazone 10mg tab 94 OINTMENT 2% minocycline 50mg tab 131 metolazone 2.5mg tab 94 miconazole nitrate 87 minocycline 75mg cap 131 metolazone 5mg tab 94 powder 2% minocycline 75mg tab 131 metoprolol succinate 74 miconazole nitrate 137 minoxidil 10mg tab 53 100mg er tab vaginal cream 2% minoxidil 2.5mg tab 53 metoprolol succinate 74 miconazole nitrate 137 mirtazapine 15mg odt 38 200mg er tab vaginal cream 4% mirtazapine 15mg tab 38 metoprolol succinate 74 miconazole nitrate 137 mirtazapine 30mg odt 38 25mg er tab vaginal kit mirtazapine 30mg tab 38 metoprolol succinate 74 miconazole nitrate 137 mirtazapine 45mg odt 38 50mg er tab vaginal supp 100mg mirtazapine 45mg tab 38 metoprolol tartrate 74 miconazole nitrate 137 mirtazapine 7.5mg tab 38 100mg tab vaginal supp 200mg/2% misoprostol 0.1mg tab 135 metoprolol tartrate 25mg 74 cream 9gm kit misoprostol 0.2mg tab 135 tab microgestin 1.5/30 21 day 82 MITIGARE 0.6MG CAP 101 metoprolol tartrate 50mg 74 pack M-M-R II INJ 136 tab microgestin 1/20 21 day 82 modafinil 100mg tab 18 metronidazole 0.75% 92 pack modafinil 200mg tab 18 cream microgestin fe 1.5/30 28 82 moexipril 15mg tab 50 metronidazole 0.75% gel 92 day pack moexipril 7.5mg tab 50 metronidazole 0.75% 92 microgestin fe 1/20 28 82 MOLINDONE 10MG TAB 67 lotion day pack MOLINDONE 25MG TAB 67 metronidazole 0.75% 137 midodrine 10mg tab 138 MOLINDONE 5MG TAB 67 vaginal gel midodrine 2.5mg tab 138 mometasone furoate 0.1% 90 metronidazole 1% gel 92 midodrine 5mg tab 138 cream metronidazole 250mg tab 53 miglitol 100mg tab 41 mometasone furoate 0.1% 90 metronidazole 375mg cap 53 miglitol 25mg tab 41 lotion metronidazole 500mg tab 53 miglitol 50mg tab 41 mometasone furoate 0.1% 90 metronidazole 5mg/ml inj 53 miglustat 100mg cap 102 ointment metyrosine 250mg cap 50 mili 28 day pack 82 mondoxyne 100mg cap 131

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 176 ALPHABETICAL LISTING OF DRUGS montelukast 10mg tab 30 MULTIPLE VITAMINS 117 mycophenolate mofetil 73 montelukast 4mg chew 30 W/ MINERALS & FA TAB 250mg cap tab 1.25 MG mycophenolate mofetil 73 montelukast 4mg 30 MULTIPLE VITAMINS 117 500mg tab granules W/ MINERALS & FA TAB mycophenolic acid 180mg 115 montelukast 5mg chew 30 3 MG dr tab tab MULTIPLE VITAMINS 118 mycophenolic acid 360mg 115 MONUROL 5.631GM 135 W/ MINERALS CHEW dr tab POWDER FOR ORAL TAB myorisan 10mg cap 86 SOLN MULTIPLE VITAMINS 118 myorisan 20mg cap 86 morphine sulfate 100mg 23 W/ MINERALS COMBO myorisan 30mg cap 86 er tab PACK myorisan 40mg cap 86 morphine sulfate 15mg er 23 multiple vitamins w/ 118 MYRBETRIQ 25MG ER 135 tab minerals liquid TAB morphine sulfate 15mg 23 MULTIPLE VITAMINS 118 MYRBETRIQ 50MG ER 135 tab W/ MINERALS TAB morphine sulfate 200mg 23 LOZENGE N er tab MULTIPLE VITAMINS 118 nabumetone 500mg tab 21 morphine sulfate 20mg/ml 23 W/MINERALS LIQUID nabumetone 750mg tab 21 oral soln MULTIPLE VITAMINS 118 nadolol 20mg tab 74 morphine sulfate 2mg/ml 24 W/MINERALS TAB nadolol 40mg tab 74 oral soln multiple vitamins 118 nadolol 80mg tab 74 morphine sulfate 30mg er 24 w/minerals tab nafcillin 1000mg inj 126 tab MULTIVITAMIN CAP 118 nafcillin 100mg/ml inj 126 morphine sulfate 30mg 24 multi-vitamin w/calcium 117 nafcillin 2000mg inj 126 tab tab naftifine 1% cream 87 morphine sulfate 4mg/ml 24 multivitamins with 118 naftifine 2% cream 87 oral soln minerals cap NALOXONE 0.4MG/ML 45 morphine sulfate 60mg er 24 MULTIVITAMINS WITH 118 CARTRIDGE tab MINERALS POWDER naloxone 0.4mg/ml inj 45 MOVANTIK 12.5MG TAB 100 DRINK naloxone 1mg/ml syringe 45 MOVANTIK 25MG TAB 100 MULTIVIT-FLUOR 0.25 118 naltrexone 50mg tab 45 moxifloxacin 0.5% ophth 122 MG TAB CHW NAPHCON-A OPHTH 122 soln multivit-fluor 0.25 mg/ml 118 SOLN 0.025-0.3% moxifloxacin 1.6mg/ml inj 99 drop naproxen 250mg tab 21 moxifloxacin 400mg tab 99 MULTIVIT-FLUOR 0.5 118 naproxen 375mg dr tab 21 MULTAQ 400MG TAB 30 MG TAB CHEW naproxen 375mg tab 21 MULTI-DELYN/IRON 118 multivit-fluor 0.5 mg/ml 118 naproxen 500mg dr tab 21 LIQUID drop naproxen 500mg tab 21 multiple minerals w/ 114 MULTIVIT-FLUORIDE 1 118 naproxen sodium 275mg 21 vitamins tab MG TAB CHW tab multiple vitamin tab 118 mupirocin 2% ointment 87 naproxen sodium 550mg 21 mycophenolate mofetil 73 tab 200mg/ml susp

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 177 ALPHABETICAL LISTING OF DRUGS naproxen sodium cap 21 neomycin/bacitracin/poly 87 niacin tab 250mg 139 220mg myxin/pramoxine niacin tab 50 mg 139 naproxen sodium tab 21 ointment 1% niacin tab 500mg 139 220mg neomycin/polymyxin/bacit 123 niacin tab er 250 mg 139 naratriptan 1mg tab 109 racin/hydrocortisone niacin tab er 500 mg 139 naratriptan 2.5mg tab 109 ophth ointmentment 1% niacinamide er tab 500mg 139 NARCAN 4MG/0.1ML 45 neomycin-bacitracin-poly 87 niacinamide tab 500mg 139 NASAL SPRAY myxin oint niacinamide tab er 750 139 NATACYN 5% OPHTH 122 neomycin-polymyxin w/ 87 mg SUSP pramoxine cream 1% NIACIN-PANTETHINE 19 NATAZIA 28 DAY PACK 82 NEOSPORIN ORIGINAL 87 TAB ER 500-200 MG nateglinide 120mg tab 43 OINTMENT nicardipine 20mg cap 75 nateglinide 60mg tab 43 NEPHRON FATAB 104 nicardipine 30mg cap 75 NATPARA 100MCG 95 NEPHRO-VITE TAB 117 nicotine 4 mg mini 130 CARTRIDGE NERLYNX 40MG TAB 60 lozenge NATPARA 25MCG 95 neuac 5-1.2% gel 86 nicotine patch 14mg/24hr 130 CARTRIDGE NEUPRO 1MG/24HR 63 nicotine patch 21mg/24hr 130 NATPARA 50MCG 95 PATCH nicotine patch 7mg/24hr 130 CARTRIDGE NEUPRO 2MG/24HR 63 NICOTINE PATCH KIT 130 NATPARA 75MCG 95 PATCH nicotine polacrilex gum 2 130 CARTRIDGE NEUPRO 3MG/24HR 63 mg NAYZILAM 5MG/0.1ML 34 PATCH nicotine polacrilex gum 130 NASAL SPRAY NEUPRO 4MG/24HR 63 4mg necon 0.5/35 28 day pack 82 PATCH nicotine polacrilex 130 NEEDLES INSULIN 109 NEUPRO 6MG/24HR 63 lozenge 2 mg DISP. SAFETY PATCH nicotine polacrilex 130 NEFAZODONE 100MG 39 NEUPRO 8MG/24HR 63 lozenge 4mg TAB PATCH NICOTROL 10MG INH 130 NEFAZODONE 150MG 39 NEVIRAPINE 100MG ER 71 SOLN TAB TAB NICOTROL 10MG/ML 130 NEFAZODONE 200MG 39 nevirapine 10mg/ml susp 71 NASAL INHALER TAB nevirapine 200mg tab 71 nifedipine 30mg er tab 75 NEFAZODONE 250MG 39 nevirapine 400mg er tab 71 nifedipine 30mg osmotic 75 TAB NEXAVAR 200MG TAB 60 er tab NEFAZODONE 50MG 39 niacin 1000mg er tab 49 nifedipine 60mg er tab 75 TAB niacin 500mg er tab 49 nifedipine 60mg osmotic 75 neomycin sulfate 500mg 19 niacin 750mg er tab 49 er tab tab niacin cap 400mg 119 nifedipine 90mg er tab 76 neomycin/bacitracin/poly 122 niacin cap 500mg 77 nifedipine 90mg osmotic 76 myxin ophth ointment niacin CR cap 250mg 139 er tab 5(3.5)mg-400unit-10000u niacin CR cap 500mg 139 nikki 28 day pack 82 nit NIACIN CR TAB 1000MG 139 nilutamide 150mg tab 57 niacin CR tab 750mg 139 nimodipine 30mg cap 76 niacin tab 100mg 139 NINLARO 2.3MG CAP 60

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 178 ALPHABETICAL LISTING OF DRUGS

NINLARO 3MG CAP 60 NIVESTYM 103 NOVOLIN N 43 NINLARO 4MG CAP 61 480MCG/0.8ML 100UNIT/ML INJ nisoldipine 17mg er tab 76 SYRINGE NOVOLIN N 43 nisoldipine 20mg er tab 76 NIVESTYM 103 100UNIT/ML PEN INJ nisoldipine 30mg er tab 76 480MCG/1.6ML INJ NOVOLIN R 43 nisoldipine 34mg er tab 76 NIX COMPLETE LICE 92 100UNIT/ML INJ nisoldipine 40mg er tab 76 TREATMENT NOVOLIN R 43 nisoldipine 8.5mg er tab 76 nizatidine 150mg cap 134 100UNIT/ML PEN INJ nitazoxanide 500mg tab 54 nizatidine 300mg cap 134 NOVOLOG 100UNIT/ML 43 nitisinone 10mg cap 96 NONOXYNOL-9 FILM 137 CARTRIDGE nitisinone 2mg cap 96 28% NOVOLOG 100UNIT/ML 43 nitisinone 5mg cap 96 NONOXYNOL-9 FOAM 137 INJ NITRO-BID 2% 28 12.5% NOVOLOG 100UNIT/ML 43 OINTMENT nora-be 28 day 0.35mg 84 PEN INJ NITRO-DUR 0.3MG/HR 28 pack NOVOLOG MIX (70/30) 43 PATCH norethindrone 0.35mg 84 100UNIT/ML FLEXPEN NITRO-DUR 0.8MG/HR 28 pack NOVOLOG MIX (70/30) 43 PATCH norethindrone acetate 127 100UNIT/ML INJ nitrofurantoin macro 135 5mg tab NOXAFIL 40MG/ML 46 25mg/nitrofurantoin NORPACE 100MG ER 29 SUSP mono 75mg cap CAP NUBEQA 300MG TAB 57 nitrofurantoin 135 NORPACE 150MG ER 29 NUCALA 100MG INJ 30 macrocrystals 100mg cap CAP NUCALA 100MG/ML 30 nitrofurantoin 135 nortrel 0.5/35 28 day 82 AUTO-INJECTOR macrocrystals 50mg cap pack NUCALA 100MG/ML 30 nitroglycerin 0.1mg/hr 28 nortrel 1/35 21 day pack 82 SYRINGE patch nortrel 1/35 28 day pack 82 NUEDEXTA 20-10MG 129 nitroglycerin 0.2mg/hr 28 nortrel 7/7/7 28 day pack 82 CAP patch nortriptyline 10mg cap 41 NUPLAZID 10MG TAB 65 nitroglycerin 0.3mg sl tab 28 nortriptyline 25mg cap 41 NUPLAZID 34MG CAP 65 nitroglycerin 0.4mg sl tab 28 NORTRIPTYLINE 41 NURTEC 75MG ODT 109 nitroglycerin 0.4mg/act 28 2MG/ML ORAL SOLN NUTRILIPID 120 spray nortriptyline 50mg cap 41 20GM/100ML INJ nitroglycerin 0.4mg/hr 28 nortriptyline 75mg cap 41 NUTRITIONAL 93 patch NORVIR 100MG ORAL 71 SUPPLEMENT LIQUID nitroglycerin 0.6mg sl tab 28 POWDER NUVARING 83 nitroglycerin 0.6mg/hr 28 NORVIR 80MG/ML 71 0.000625-0.005MG/HR patch ORAL SOLN VAGINAL SYSTEM NIVESTYM 103 NOURIANZ 20MG TAB 64 NUZYRA 150MG TAB 131 300MCG/0.5ML NOURIANZ 40MG TAB 64 nyamyc 100000unit/gm 87 SYRINGE NOVOLIN MIX (70/30) 43 topical powder NIVESTYM 300MCG/ML 103 100UNIT/ML INJ nylia 7/7/7 28 day pack 82 INJ NOVOLIN MIX (70/30) 43 nymyo 28 day pack 82 FLEXPEN 100UNIT/ML

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 179 ALPHABETICAL LISTING OF DRUGS nystatin 100000unit/ml 87 olmesartan medoxomil 50 ORA-PLUS LIQUID 126 cream 20mg tab ORENCIA 125MG/ML 21 nystatin 100000unit/ml 116 olmesartan medoxomil 50 AUTO-INJECTOR susp 40mg tab ORENCIA 125MG/ML 21 nystatin 100unit/mg 87 olmesartan medoxomil 50 SYRINGE ointment 5mg tab ORENCIA 50MG/0.4ML 21 nystatin 100unit/mg 87 olopatadine 0.1% ophth 124 SYRINGE topical powder soln ORENCIA 21 nystatin 500000unit tab 46 olopatadine 0.2% ophth 124 87.5MG/0.7ML SYRINGE nystop 100000unit/gm 87 soln ORENITRAM 0.125MG 77 topical powder olopatadine 0.665mg/act 119 ER TAB O nasal inhaler ORENITRAM 0.25MG ER 77 OLUMIANT 1MG TAB 19 TAB OCALIVA 10MG TAB 99 OLUMIANT 2MG TAB 19 ORENITRAM 1MG ER 77 OCALIVA 5MG TAB 99 omega-3 acid ethyl esters 47 TAB ocella 28 day pack 82 (usp) 1000mg cap ORENITRAM 2.5MG ER 77 OCTAGAM 1GM/20ML 125 omeprazole 10mg dr cap 134 TAB INJ omeprazole 20mg dr cap 134 ORENITRAM 5MG ER 77 OCTAGAM 2GM/20ML 125 omeprazole 40mg dr cap 134 TAB INJ once daily w/iron 117 ORFADIN 20MG CAP 96 octreotide 0.05mg/ml inj 97 multivitamin tab ORFADIN 4MG/ML 96 octreotide 0.1mg/ml inj 97 ondansetron 0.8mg/ml 45 SUSP octreotide 0.2mg/ml inj 97 oral soln ORGOVYX 120MG TAB 57 octreotide 0.5mg/ml inj 97 ONDANSETRON 24MG 45 ORIAHNN 28 DAY KIT 97 octreotide 1mg/ml inj 97 TAB PACK ODEFSEY 200-25-25MG 71 ondansetron 4mg odt 45 ORILISSA 150MG TAB 95 TAB ondansetron 4mg tab 45 ORILISSA 200MG TAB 95 ODOMZO 200MG CAP 57 ondansetron 8mg odt 45 ORKAMBI 125-100MG 130 OFEV 100MG CAP 130 ondansetron 8mg tab 45 GRANULES OFEV 150MG CAP 131 ONE-DAILY 118 ORKAMBI 125-100MG 130 ofloxacin 0.3% ophth soln 122 MULTI-VITAMIN PACK TAB ofloxacin 0.3% otic soln 124 ONGENTYS 25MG CAP 64 ORKAMBI 125-200MG 130 ofloxacin 400mg tab 99 ONGENTYS 50MG CAP 64 TAB olanzapine 10mg inj 67 ONUREG 200MG TAB 56 ORKAMBI 188-150MG 130 olanzapine 10mg odt 67 ONUREG 300MG TAB 56 GRANULES olanzapine 10mg tab 67 OPCON-A OPHTH SOLN 122 orsythia 28 day pack 82 olanzapine 15mg odt 67 0.027-0.315% oseltamivir 30mg cap 72 olanzapine 15mg tab 67 OPSUMIT 10MG TAB 77 oseltamivir 45mg cap 72 olanzapine 2.5mg tab 67 ORA-BLEND SUSP 126 oseltamivir 6mg/ml susp 72 olanzapine 20mg odt 67 ORAL ELECTROLYTE - 112 oseltamivir 75mg cap 73 olanzapine 20mg tab 67 PACKET OSPHENA 60MG TAB 95 olanzapine 5mg odt 67 oral electrolyte solution 112 OTEZLA 28-DAY 21 olanzapine 5mg tab 67 ORAL VEHICLES - 127 STARTER PACK olanzapine 7.5mg tab 67 SYRUP OTEZLA 30MG TAB 21

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 180 ALPHABETICAL LISTING OF DRUGS oxacillin 1000mg inj 126 OXYCONTIN 15MG ER 24 PANZYGA 20GM/200ML 125 oxacillin 100mg/ml inj 126 TAB INJ oxacillin 2000mg inj 126 OXYCONTIN 20MG ER 24 PANZYGA 30GM/300ML 125 OXACILLIN 20MG/ML 126 TAB INJ INJ OXYCONTIN 30MG ER 24 PANZYGA 5GM/50ML 125 OXACILLIN 40MG/ML 126 TAB INJ INJ OXYCONTIN 40MG ER 24 paricalcitol 0.001mg cap 96 oxandrolone 10mg tab 25 TAB paricalcitol 0.002mg cap 96 oxandrolone 10mg tab 25 OXYCONTIN 60MG ER 24 paricalcitol 0.004mg cap 96 oxandrolone 2.5mg tab 26 TAB paromomycin 250mg cap 19 oxandrolone 2.5mg tab 26 OXYCONTIN 80MG ER 24 paroxetine 10mg tab 39 oxaprozin 600mg tab 21 TAB paroxetine 12.5mg er tab 39 OXAZEPAM 10MG CAP 29 oxymorphone 10mg tab 24 paroxetine 20mg tab 39 OXAZEPAM 15MG CAP 29 oxymorphone 5mg tab 24 paroxetine 25mg er tab 39 OXAZEPAM 30MG CAP 29 oyster shell calcium tab 112 paroxetine 30mg tab 39 OXBRYTA 500MG TAB 102 500mg paroxetine 37.5mg er tab 39 oxcarbazepine 150mg tab 36 OZEMPIC 2MG/1.5ML 42 paroxetine 40mg tab 39 oxcarbazepine 300mg tab 36 PEN INJ PARVA-CAL TAB 112 oxcarbazepine 600mg tab 36 OZEMPIC 2MG/1.5ML 42 250MG-100UNIT oxcarbazepine 60mg/ml 36 PEN INJ (1MG DOSE) PARVA-CAL TAB 112 susp OZEMPIC 4MG/3ML 42 500MG-200UNIT oxiconazole 1% cream 87 PEN INJ PASER D/R 4GM 56 oxybutynin chloride 10mg 135 P GRANULES er tab PAXIL 10MG/5ML SUSP 39 pacerone 200mg tab 30 oxybutynin chloride 15mg 135 PEDIALYTE FREEZER 112 pacerone 400mg tab 30 er tab POPS paliperidone 1.5mg er tab 66 oxybutynin chloride 135 PEDIARIX INJ 133 paliperidone 3mg er tab 66 1mg/ml oral soln PEDVAXHIB 136 paliperidone 6mg er tab 66 oxybutynin chloride 5mg 135 7.5MCG/0.5ML INJ paliperidone 9mg er tab 66 er tab peg 3350/electrolyte oral 107 PALYNZIQ 10MG/0.5ML 96 oxybutynin chloride 5mg 135 soln SYRINGE tab peg 3350/kcl/sodium 107 PALYNZIQ 96 oxycodone 10mg tab 24 bicarbonate/sodium 2.5MG/0.5ML SYRINGE oxycodone 15mg tab 24 chloride powder for oral PALYNZIQ 20MG/ML 96 oxycodone 1mg/ml oral 24 soln SYRINGE soln PEGASYS 72 pantoprazole 20mg dr tab 134 oxycodone 20mg tab 24 180MCG/0.5ML pantoprazole 40mg dr tab 135 oxycodone 20mg/ml oral 24 SYRINGE PANZYGA 10GM/100ML 125 soln PEGASYS 180MCG/ML 72 INJ oxycodone 30mg tab 24 INJ PANZYGA 1GM/10ML 125 oxycodone 5mg cap 24 PEMAZYRE 13.5MG TAB 61 INJ oxycodone 5mg tab 24 PEMAZYRE 4.5MG TAB 61 PANZYGA 2.5GM/25ML 125 OXYCONTIN 10MG ER 24 PEMAZYRE 9MG TAB 61 INJ TAB penicillamine 250mg tab 115

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 181 ALPHABETICAL LISTING OF DRUGS penicillin g potassium 125 perphenazine 16mg tab 68 PHOS-NAK POWDER 114 1000000unit/ml inj perphenazine 2mg tab 68 CONCENTRA PACK PENICILLIN G 125 perphenazine 4mg tab 68 phytonadione soln 138 POTASSIUM perphenazine 8mg tab 68 1mg/0.5ml 40000UNIT/ML INJ PERSERIS 120MG 66 phytonadione tab 5 mg 138 PENICILLIN G 125 SYRINGE PICATO 0.015% GEL 88 POTASSIUM PERSERIS 90MG 66 PICATO 0.05% GEL 88 60000UNIT/ML INJ SYRINGE PIFELTRO 100MG TAB 71 PENICILLIN G 125 PETROLATUM 91 pilocarpine 1% ophth 121 PROCAINE OINTMENT soln 600000UNIT/ML PETROLATUM 91 pilocarpine 2% ophth 121 SYRINGE OINTMENT soln PENICILLIN G SODIUM 125 PETROLATUM, 127 pilocarpine 4% ophth 121 100000UNIT/ML INJ HYDROPHILIC soln penicillin v potassium 125 OINTMENT pilocarpine 5mg tab 116 250mg tab phenazopyridine hcl tab 101 pilocarpine 7.5mg tab 116 PENICILLIN V 125 95 mg pimecrolimus 1% cream 91 POTASSIUM 25MG/ML phenelzine 15mg tab 38 PIMOZIDE 1MG TAB 129 ORAL SOLN phenobarbital 100mg tab 106 PIMOZIDE 2MG TAB 129 penicillin v potassium 125 phenobarbital 15mg tab 106 pimtrea pack 82 500mg tab phenobarbital 16.2mg tab 106 pindolol 10mg tab 74 PENICILLIN V 126 phenobarbital 30mg tab 106 pindolol 5mg tab 74 POTASSIUM 50MG/ML phenobarbital 32.4mg tab 106 pioglitazone 15mg tab 43 ORAL SOLN phenobarbital 4mg/ml 106 pioglitazone 30mg tab 43 pentamidine isethionate 54 oral soln pioglitazone 45mg tab 43 300mg inj phenobarbital 60mg tab 106 piperacillin 126 pentamidine isethionate 54 phenobarbital 64.8mg tab 106 2000mg/tazobactam 50mg/ml inh soln phenobarbital 97.2mg tab 106 250mg inj pentoxifylline 400mg er 102 phenoxybenzamine 10mg 50 piperacillin 126 tab cap 200mg/ml/tazobactam perindopril erbumine 50 PHENYLEPHRINE 85 25mg/ml inj 2mg tab 1MG/ML/PROMETHAZI piperacillin 126 perindopril erbumine 50 NE 1.25MG/ML ORAL 3000mg/tazobactam 4mg tab SOLN 375mg inj perindopril erbumine 50 phenytoin 25mg/ml susp 37 piperacillin 126 8mg tab phenytoin 50mg chew tab 37 4000mg/tazobactam periogard 0.12% 116 phenytoin sodium 100mg 37 500mg inj mouthwash er cap PIQRAY 200MG DAILY 61 permethrin 5% cream 92 phenytoin sodium 200mg 37 DOSE PACK PERMETHRIN CREME 92 er cap PIQRAY 250MG DAILY 61 RINSE 1% phenytoin sodium 300mg 37 DOSE PACK permethrin creme rinse 92 er cap PIQRAY 300MG DAILY 61 1% PHOSLYRA 667MG/5ML 100 DOSE 150MG PACK permethrin lotion 1% 92 ORAL SOLN pirmella 1/35 28 day pack 82

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 182 ALPHABETICAL LISTING OF DRUGS piroxicam 10mg cap 21 POLYSACCHARIDE 105 potassium chloride 114 piroxicam 20mg cap 21 IRON COMPLEX LIQUID 10meq micro er tab PLASMA-LYTE 148 INJ 112 15 MG/ML (FE EQUIV) potassium chloride 114 PLASMALYTE A INJ 112 polyvinyl alcohol ophth 121 2.67meq/ml oral soln PLEGRIDY 129 soln 1.4% potassium chloride 114 125MCG/0.5ML POMALYST 1MG CAP 58 20meq er tab AUTO-INJECTOR POMALYST 2MG CAP 58 potassium chloride 114 PLEGRIDY 129 POMALYST 3MG CAP 58 20meq micro er tab 125MCG/0.5ML POMALYST 4MG CAP 58 potassium chloride 114 SYRINGE portia 28 day pack 82 20meq powder for oral plenamine 15% inj 120 posaconazole 100mg dr 46 soln podofilox 0.5% topical 91 tab potassium chloride 114 soln pot phos monobasic 114 2meq/ml (20ml) inj polyethylene glycol 3350 107 w/sod phos di & monobas potassium chloride 114 powder (OTC) tab 155-852-130mg 2meq/ml inj polyethylene glycol 3350 107 potassium and sodium 100 potassium chloride 8meq 114 powder packet (OTC) citrates w/citric acid soln er cap polyethylene 121 550-500-334 mg/5ml potassium chloride 8meq 114 glycol-propylene glycol potassium and sodium 114 er tab ophth soln 0.4-0.3% phosphates powder pack potassium citrate 10meq 100 polymyxin b 122 280-160-250 mg er tab 10000unit/ml/trimethopri potassium chloride 0.02 112 potassium citrate 15meq 100 m 1mg/ml ophth soln meq/ml/sodium chloride er tab polymyxin b 55 0.0769 meq/ml inj potassium citrate 5meq er 100 250000unit/ml inj potassium chloride 0.02 113 tab POLYSACCH FE 104 meq/ml/sodium chloride povidone/iodine swab 69 COMPLEX-CHOLECALC 0.154 meq/ml inj povidone/iodine topical 69 IFEROL LIQ 125-100 POTASSIUM CHLORIDE 113 soln 7.5% MG-UNIT/5ML 0.04 MEQ/ML/SODIUM povidone-iodine soln 69 polysaccharide iron 105 CHLORIDE 0.154 10% complex 150mg cap MEQ/ML INJ PRADAXA 110MG CAP 33 POLYSACCHARIDE 105 POTASSIUM CHLORIDE 114 PRADAXA 150MG CAP 33 IRON COMPLEX CAP 0.1MEQ/ML INJ PRADAXA 75MG CAP 33 391.3 MG (180 MG POTASSIUM CHLORIDE 114 PRALUENT 150MG/ML 49 ELEM FE) 0.2MEQ/ML INJ AUTO-INJECTOR POLYSACCHARIDE 105 POTASSIUM CHLORIDE 114 PRALUENT 75MG/ML 49 IRON COMPLEX CAP 0.4MEQ/ML INJ AUTO-INJECTOR 434.8 MG (200 MG potassium chloride 114 pramipexole 0.125mg tab 63 ELEM FE) 1.33meq/ml oral soln pramipexole 0.25mg tab 63 POLYSACCHARIDE 105 potassium chloride 114 pramipexole 0.375mg er 63 IRON COMPLEX CAP 50 10meq er cap tab MG (IRON potassium chloride 114 pramipexole 0.5mg tab 63 EQUIVALENT) 10meq er tab pramipexole 0.75mg er 63 tab

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 183 ALPHABETICAL LISTING OF DRUGS pramipexole 0.75mg tab 63 PREDNISOLONE 123 PREMPRO 0.45/1.5 28 97 pramipexole 1.5mg er tab 63 ACETATE 1% OPHTH DAY PACK pramipexole 1.5mg tab 63 SUSP PREMPRO 0.625/2.5MG 97 pramipexole 1mg tab 63 PREDNISOLONE 123 28 DAY PACK pramipexole 2.25mg er 63 SODIUM PHOSPHATE PREMPRO 0.625/5MG 97 tab 2.5MG/ML/SULFACETA 28 DAY PACK pramipexole 3.75mg er 63 MIDE SODIUM PRENATAL DHA 118 tab 100MG/ML OPHTH MULTI-PACK (OTC) pramipexole 3mg er tab 63 SOLN PRENATAL 118 pramipexole 4.5mg er tab 63 prednisone 10mg tab 84 MULTIVITAMINS & prasugrel 10mg tab 102 prednisone 1mg tab 84 MINERALS W/IRON & prasugrel 5mg tab 102 PREDNISONE 1MG/ML 84 FA TAB 0.1 MG pravastatin sodium 10mg 48 ORAL SOLN PRENATAL VIT W/ FE 118 tab prednisone 2.5mg tab 85 FUMARATE-FA TAB pravastatin sodium 20mg 48 prednisone 20mg tab 85 27-1 MG tab prednisone 50mg tab 85 PRENATAL VITAMIN 118 pravastatin sodium 40mg 48 prednisone 5mg tab 85 (OTC) tab PREDNISONE 5MG/ML 85 PRENATAL VITAMINS 118 pravastatin sodium 80mg 48 ORAL SOLN W/IRON (OTC) tab pregabalin 100mg cap 36 PRETOMANID 200MG 56 prazosin 1mg cap 51 pregabalin 150mg cap 36 TAB prazosin 2mg cap 51 pregabalin 200mg cap 36 prevalite 4gm powder for 48 prazosin 5mg cap 51 pregabalin 20mg/ml oral 36 oral susp PRED FORTE 1% OPHTH 123 soln previfem 28 day pack 82 SUSP pregabalin 225mg cap 36 PREVYMIS 240MG TAB 72 PRED MILD 0.12% 123 pregabalin 25mg cap 36 PREVYMIS 480MG TAB 72 OPHTH SUSP pregabalin 300mg cap 36 PREZCOBIX 150-800MG 71 PRED-G 0.3-1% OPHTH 123 pregabalin 50mg cap 36 TAB SUSP pregabalin 75mg cap 36 PREZISTA 100MG/ML 71 PREDNICARBATE 0.1% 90 PREMARIN 0.3MG TAB 98 SUSP OINTMENT PREMARIN 0.45MG TAB 98 PREZISTA 150MG TAB 71 PREDNISOLONE 1% 123 PREMARIN 0.625MG 98 PREZISTA 600MG TAB 71 OPHTH SOLN TAB PREZISTA 75MG TAB 71 prednisolone 10mg odt 84 PREMARIN 137 PREZISTA 800MG TAB 71 prednisolone 15mg odt 84 0.625MG/GM VAGINAL PRIFTIN 150MG TAB 56 prednisolone 1mg/ml oral 84 CREAM PRIMAQUINE 55 soln PREMARIN 0.9MG TAB 98 PHOSPHATE 26.3MG prednisolone 2mg/ml oral 84 PREMARIN 1.25MG TAB 98 TAB soln PREMASOL 10% INJ 120 primidone 250mg tab 36 prednisolone 30mg odt 84 PREMPHASE 28 DAY 97 primidone 50mg tab 36 PREDNISOLONE 84 PACK PRIVIGEN 20GM/200ML 125 3MG/ML ORAL SOLN PREMPRO 0.3/1.5MG 28 97 INJ prednisolone 4mg/ml oral 84 DAY PACK probenecid 500mg tab 101 soln

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 184 ALPHABETICAL LISTING OF DRUGS probiotic product - chew 44 promethazine 25mg rectal 47 pseudoephedrine SR tab 120 tab supp (12hr) 120mg PROCALAMINE 3% INJ 120 promethazine 25mg tab 47 pseudoephedrine tab 120 procentra 5mg/5ml oral 16 promethazine 50mg tab 47 30mg soln promethegan 25mg rectal 47 pseudoephedrine tab 120 prochlorperazine 10mg 68 supp 60mg tab PROMETHEGAN 50MG 47 psyllium cap 0.52gm 106 prochlorperazine 25mg 68 RECTAL SUPP psyllium cap 400 mg 107 rectal supp propafenone 150mg tab 29 psyllium powder 25% 107 prochlorperazine 5mg tab 68 propafenone 225mg er 29 psyllium powder 28% 107 procto-med 2.5% cream 26 cap psyllium powder 28.3% 107 procto-pak 1% rectal 26 propafenone 225mg tab 30 psyllium powder 30.9% 107 cream propafenone 300mg tab 30 psyllium powder 43% 107 proctosol 2.5% cream 26 propafenone 325mg er 30 psyllium powder 48.57% 107 proctozone hc 2.5% 26 cap psyllium powder 51.7% 107 cream propafenone 425mg er 30 psyllium powder 58.6% 107 progesterone 100mg cap 127 cap psyllium powder 68% 107 progesterone 200mg cap 127 proparacaine 0.5% ophth 122 psyllium powder 95% 107 PROGRAF 0.2MG 115 soln PULMOZYME 1MG/ML 130 GRANULES FOR ORAL propranolol 10mg tab 74 INH SOLN SUSP propranolol 120mg er 74 PURIXAN 56 PROGRAF 1MG 115 cap 2000MG/100ML SUSP GRANULES FOR ORAL propranolol 160mg er 74 PYLERA 135 SUSP cap 140-125-125MG CAP PROLASTIN 1000MG INJ 130 propranolol 20mg tab 74 pyrantel pamoate susp 27 PROLIA 60MG/ML 95 propranolol 40mg tab 74 144mg/ml SYRINGE PROPRANOLOL 74 pyrazinamide 500mg tab 56 PROMACTA 12.5MG 103 4MG/ML ORAL SOLN pyreth-piperonyl butox 92 POWDER FOR ORAL propranolol 60mg er cap 74 sham-permeth aero-nit SUSP propranolol 60mg tab 74 remover gel kit PROMACTA 12.5MG 103 propranolol 80mg er cap 74 pyrethrins/piperonyl 92 TAB propranolol 80mg tab 74 butoxide shampoo PROMACTA 25MG 103 PROPRANOLOL 74 0.33-4% POWDER FOR ORAL 8MG/ML ORAL SOLN PYRETHRINS-PIPERON 92 SUSP propylene glycol-glycerin 121 YL BUTOXIDE LIQ PROMACTA 25MG TAB 103 ophth soln 1-0.3% 0.33-4% PROMACTA 50MG TAB 103 propylthiouracil 50mg 131 pyrethrins-piperonyl 92 PROMACTA 75MG TAB 103 tab butoxide shampoo 0.3-3% promethazine 1.25mg/ml 47 PROQUAD INJ 136 pyridostigmine bromide 55 oral soln PROSOL 20% INJ 120 12mg/ml oral soln promethazine 12.5mg 47 protriptyline 10mg tab 41 pyridostigmine bromide 56 rectal supp protriptyline 5mg tab 41 180mg er tab promethazine 12.5mg tab 47 pseudoephedrine liquid 120 pyridostigmine bromide 56 15mg/5ml 60mg tab

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 185 ALPHABETICAL LISTING OF DRUGS pyridoxine hcl tab 50 mg 139 rasagiline 0.5mg tab 64 REPATHA 140MG/ML 49 PYRITHIONE ZINC 88 rasagiline 1mg tab 64 SYRINGE LIQUID 0.25% RASPBERRY SYRUP 127 REPATHA 420MG/3.5ML 49 Q RAVICTI 1.1GM/ML 96 CARTRIDGE ORAL SOLN REPLACE SR TAB 113 QINLOCK 50MG TAB 61 REBIF 22MCG/0.5ML 129 RESTASIS 0.05% OPHTH 122 QUADRACEL INJ 133 AUTO-INJECTOR SUSP quetiapine 100mg tab 67 REBIF 22MCG/0.5ML 129 RETACRIT 103 quetiapine 150mg er tab 67 SYRINGE 10000UNIT/ML INJ quetiapine 200mg er tab 67 REBIF 44MCG/0.5ML 129 RETACRIT 103 quetiapine 200mg tab 67 AUTO-INJECTOR 20000UNIT/2ML INJ quetiapine 25mg tab 67 REBIF 44MCG/0.5ML 129 RETACRIT 103 quetiapine 300mg er tab 67 SYRINGE 20000UNIT/ML INJ quetiapine 300mg tab 67 REBIF REBIDOSE PACK 129 RETACRIT 2000UNIT/ML 103 quetiapine 400mg er tab 67 REBIF TITRATION PACK 129 INJ quetiapine 400mg tab 67 reclipsen 28 day pack 83 RETACRIT 3000UNIT/ML 103 quetiapine 50mg er tab 67 RECOMBIVAX 136 INJ quetiapine 50mg tab 67 10MCG/ML INJ RETACRIT 103 quinapril 10mg tab 50 RECOMBIVAX 136 40000UNIT/ML INJ quinapril 20mg tab 50 10MCG/ML SYRINGE RETACRIT 4000UNIT/ML 103 quinapril 40mg tab 50 RECOMBIVAX 136 INJ quinapril 5mg tab 50 40MCG/ML INJ RETEVMO 40MG CAP 61 quinidine gluconate 29 RECOMBIVAX 136 RETEVMO 80MG CAP 61 324mg er tab 5MCG/0.5ML SYRINGE REVLIMID 10MG CAP 115 QUINIDINE SULFATE 29 RECTIV 0.4% RECTAL 26 REVLIMID 15MG CAP 115 200MG TAB OINTMENT REVLIMID 2.5MG CAP 115 QUINIDINE SULFATE 29 REGRANEX 0.01% GEL 92 REVLIMID 20MG CAP 115 300MG TAB RELENZA 5MG/BLISTER 73 REVLIMID 25MG CAP 115 quinine sulfate 324mg 55 INH REVLIMID 5MG CAP 115 cap RELISTOR 12MG/0.6ML 100 REXULTI 0.25MG TAB 69 R INJ REXULTI 0.5MG TAB 69 RABAVERT 2.5UNIT/ML 136 RELISTOR 12MG/0.6ML 100 REXULTI 1MG TAB 69 INJ SYRINGE REXULTI 2MG TAB 69 rabeprazole sodium 20mg 134 RELISTOR 8MG/0.4ML 100 REXULTI 3MG TAB 69 dr tab SYRINGE REXULTI 4MG TAB 69 raloxifene 60mg tab 96 REMEDY CALAZIME 91 REYATAZ 50MG ORAL 71 ramelteon 8mg tab 106 PROTECT PASTE POWDER ramipril 1.25mg cap 50 rena-vite tab 117 REYVOW 100MG TAB 109 ramipril 10mg cap 50 reno cap 117 REYVOW 50MG TAB 109 ramipril 2.5mg cap 50 repaglinide 0.5mg tab 43 RHOPRESSA 0.02% 122 ramipril 5mg cap 50 repaglinide 1mg tab 43 OPHTH SOLN ranitidine tab 150mg 134 repaglinide 2mg tab 43 ribavirin 200mg cap 72 ranitidine tab 75mg 134 REPATHA 140MG/ML 49 ribavirin 200mg tab 72 ranolazine 1000mg er tab 27 AUTO-INJECTOR ranolazine 500mg er tab 27 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 186 ALPHABETICAL LISTING OF DRUGS

RIBOFLAVIN POWDER 139 risperidone 4mg tab 66 ROZLYTREK 100MG 61 343 MG/GM ritonavir 100mg tab 71 CAP RIBOFLAVIN TAB 400 139 rivastigmine 0.192mg/hr 128 ROZLYTREK 200MG 61 MG patch CAP riboflavin tab 50 mg 139 rivastigmine 0.396mg/hr 128 RUBRACA 200MG TAB 61 RIDAURA 3MG CAP 20 patch RUBRACA 250MG TAB 61 rifabutin 150mg cap 56 rivastigmine 0.554mg/hr 128 RUBRACA 300MG TAB 61 rifampin 150mg cap 56 patch RUCONEST 2100UNIT 102 rifampin 300mg cap 56 rivastigmine 1.5mg cap 128 INJ rifampin 600mg inj 56 rivastigmine 3mg cap 128 rufinamide 200mg tab 36 riluzole 50mg tab 120 rivastigmine 4.5mg cap 128 rufinamide 400mg tab 36 RIMANTADINE 100MG 73 rivastigmine 6mg cap 128 rufinamide 40mg/ml susp 36 TAB rivelsa 91 day pack 83 RUKOBIA 600MG ER 71 RINVOQ 15MG ER TAB 19 rizatriptan 10mg odt 109 TAB RISCAL-D TAB 112 rizatriptan 10mg tab 109 RUZURGI 10MG TAB 56 risedronate sodium 95 rizatriptan 5mg odt 109 RYBELSUS 14MG TAB 42 150mg tab rizatriptan 5mg tab 109 RYBELSUS 3MG TAB 42 risedronate sodium 30mg 95 ROCKLATAN 122 RYBELSUS 7MG TAB 42 tab 0.05-0.2MG/ML OPHTH RYDAPT 25MG CAP 61 risedronate sodium 35mg 95 SOLN S (12) pack ropinirole 0.25mg tab 63 saccharomyces boulardii 44 risedronate sodium 35mg 95 ropinirole 0.5mg tab 63 cap 250mg (4) pack ropinirole 12mg er tab 63 SALINE NASAL SOLN 119 risedronate sodium 35mg 95 ropinirole 1mg tab 64 0.65% tab ropinirole 2mg er tab 63 SALINE NASAL SOLN 119 risedronate sodium 5mg 95 ropinirole 2mg tab 64 0.9% tab ropinirole 3mg tab 63 SALINE NASAL SOLN 119 RISPERDAL 12.5MG INJ 66 ropinirole 4mg er tab 63 2.65% RISPERDAL 25MG INJ 66 ropinirole 4mg tab 63 saline nasal spray 0.65% 119 RISPERDAL 37.5MG INJ 66 ropinirole 5mg tab 63 salmon calcitonin 95 RISPERDAL 50MG INJ 66 ropinirole 6mg er tab 63 200unit/act nasal spray risperidone 0.25mg odt 66 ropinirole 8mg er tab 63 SANDIMMUNE 73 risperidone 0.25mg tab 66 rosuvastatin calcium 48 100MG/ML ORAL SOLN risperidone 0.5mg odt 66 10mg tab SANTYL 250UNIT/GM 91 risperidone 0.5mg tab 66 rosuvastatin calcium 48 OINTMENT risperidone 1mg odt 66 20mg tab sapropterin 100mg 96 risperidone 1mg tab 66 rosuvastatin calcium 48 powder for oral soln risperidone 1mg/ml oral 66 40mg tab sapropterin 100mg tab 96 soln rosuvastatin calcium 5mg 48 sapropterin 500mg 96 risperidone 2mg odt 66 tab powder for oral soln risperidone 2mg tab 66 ROTARIX SUSP 136 SAVELLA 100MG TAB 128 risperidone 3mg odt 66 ROTATEQ SUSP 136 SAVELLA 12.5MG TAB 128 risperidone 3mg tab 66 roweepra 500mg tab 36 SAVELLA 25MG TAB 128 risperidone 4mg odt 66

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 187 ALPHABETICAL LISTING OF DRUGS

SAVELLA 4-WEEK 128 sevelamer carbonate 100 simvastatin 10mg tab 48 TITRATION PACK 2400mg powder for oral simvastatin 20mg tab 48 SAVELLA 50MG TAB 128 susp simvastatin 40mg tab 49 scopolamine 0.0139mg/hr 45 sevelamer carbonate 100 simvastatin 5mg tab 49 patch 800mg powder for oral simvastatin 80mg tab 49 SECUADO 3.8MG/24HR 67 susp sirolimus 0.5mg tab 73 PATCH sevelamer carbonate 100 sirolimus 1mg tab 73 SECUADO 5.7MG/24HR 67 800mg tab sirolimus 1mg/ml oral 115 PATCH sharobel 28 day 0.35mg 84 soln SECUADO 7.6MG/24HR 67 pack sirolimus 2mg tab 73 PATCH SHINGRIX 136 SIRTURO 100MG TAB 56 selegiline 5mg cap 64 50MCG/0.5ML INJ SIRTURO 20MG TAB 56 SELEGILINE 5MG TAB 64 SIGNIFOR 0.3MG/ML 97 SIVEXTRO 200MG INJ 55 selenium sulfide 2.5% 88 INJ SIVEXTRO 200MG TAB 55 shampoo SIGNIFOR 0.6MG/ML 97 skin protectants misc - 91 selenium sulfide lotion 88 INJ cream 1% SIGNIFOR 0.9MG/ML 97 skin protectants ointment 92 SELZENTRY 150MG TAB 71 INJ skin protectants, misc. 92 SELZENTRY 20MG/ML 71 sildenafil 20mg tab 77 lotion ORAL SOLN silodosin 4mg cap 101 SKYRIZI 150MG DOSE 88 SELZENTRY 25MG TAB 71 silodosin 8mg cap 101 PACK 75MG/0.83ML SELZENTRY 300MG TAB 71 silver sulfadiazine 1% 89 sleep aid 25mg cap 106 SELZENTRY 75MG TAB 71 cream SLOW-MAG TAB 114 SENNA SYRUP 108 SIMBRINZA 0.2-1% 122 SLYND 4MG PACK 84 176MG/5ML OPHTH SUSP sm nicotine 2 mg lozenge 130 sennosides syrup 8.8 108 simethicone cap 125mg 99 sodium bicarbonate tab 27 mg/5ml simethicone cap 180mg 99 325mg sennosides tab 15 mg 108 simethicone chew tab 125 99 sodium bicarbonate tab 27 sennosides tab 25 mg 108 mg 650mg sennosides tab 8.6mg 108 simethicone chew tab 80 99 sodium chloride 101 sennosides-docusate 107 mg 0.154meq/ml soln sodium tab 8.6-50 mg simethicone liquid 99 sodium chloride 30mg/ml 114 SEREVENT 31 40mg/0.6ml inj 50MCG/DOSE INH simethicone susp 99 sodium chloride 4.5mg/ml 114 sertraline 100mg tab 39 40mg/0.6ml inj sertraline 20mg/ml oral 39 SIMPLE - SYRUP 127 sodium chloride 50mg/ml 114 soln SIMPONI 100MG/ML 20 inj sertraline 25mg tab 39 AUTO-INJECTOR sodium chloride 9mg/ml 114 sertraline 50mg tab 39 SIMPONI 100MG/ML 20 inj setlakin 91 day pack 83 SYRINGE sodium chloride flush iv 114 SEVELAMER 400MG 100 SIMPONI 50MG/0.5ML 20 soln 0.9% TAB AUTO-INJECTOR sodium chloride soln 85 sevelamer 800mg tab 100 SIMPONI 50MG/0.5ML 20 nebu 3% SYRINGE

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 188 ALPHABETICAL LISTING OF DRUGS sodium chloride solution 85 sotalol 80mg tab 74 STRIBILD 71 for inhalation sotalol af 120mg tab 74 150-150-200-300MG sodium chloride tab 1gm 114 sotalol AF 160mg tab 74 TAB sodium fluoride 0.25 113 sotalol AF 80mg tab 74 SUCRAID 8500UNIT/ML 93 (0.55) mg SPECIALITY VITAMIN 118 ORAL SOLN sodium fluoride 0.5 113 PRODUCT TAB sucralfate 1000mg tab 134 mg(1.1 mg) SPIRIVA 1.25MCG INH 30 sucralfate 100mg/ml susp 134 sodium fluoride 0.5 mg/ml 113 spironolactone 100mg 94 sulfacetamide sodium 86 drop tab 10% lotion sodium fluoride 1 mg (2.2 113 spironolactone 25mg tab 94 SULFACETAMIDE 122 mg) spironolactone 50mg tab 94 SODIUM 10% OPHTH sodium fluoride 1.1% gel 116 sprintec 28 day pack 83 OINTMENT sodium fluoride 5000 116 SPRITAM 1000MG TAB 36 sulfacetamide sodium 122 plus crm FOR ORAL SUSP 10% ophth soln SODIUM FLUORIDE 116 SPRITAM 250MG TAB 36 SULFADIAZINE 500MG 131 RINSE 0.044% FOR ORAL SUSP TAB sodium phenylbutyrate 96 SPRITAM 500MG TAB 36 sulfamethoxazole 54 0.94mg/mg oral powder FOR ORAL SUSP 400mg/trimethoprim sodium phosphates 108 SPRITAM 750MG TAB 36 80mg tab enema FOR ORAL SUSP sulfamethoxazole 54 sodium polystyrene 116 SPRYCEL 100MG TAB 61 40mg/ml/trimethoprim sulfonate 15000mg SPRYCEL 140MG TAB 61 8mg/ml susp powder for oral susp SPRYCEL 20MG TAB 61 sulfamethoxazole 54 SOFOSBUVIR 72 SPRYCEL 50MG TAB 61 800mg/trimethoprim 400MG/VELPATASVIR SPRYCEL 70MG TAB 61 160mg tab 100MG TAB SPRYCEL 80MG TAB 61 SULFAMYLON 89 solifenacin succinate 135 sps 15gm/60ml susp 116 85MG/GM CREAM 10mg tab sronyx 28 day pack 83 sulfasalazine 500mg dr 100 solifenacin succinate 5mg 135 ssd 1% cream 89 tab tab STELARA 45MG/0.5ML 88 sulfasalazine 500mg tab 100 SOLTAMOX 10MG/5ML 57 INJ sulindac 150mg tab 21 ORAL SOLN STELARA 45MG/0.5ML 88 sulindac 200mg tab 21 SOMAVERT 10MG INJ 95 SYRINGE sumatriptan 100mg tab 110 SOMAVERT 15MG INJ 95 STELARA 90MG/ML 88 sumatriptan 12mg/ml 110 SOMAVERT 20MG INJ 95 SYRINGE auto-injector SOMAVERT 25MG INJ 95 STERILE LUBRICANT 121 sumatriptan 12mg/ml 110 SOMAVERT 30MG INJ 95 OPHTH LIQUID 0.7% cartridge sorine 120mg tab 74 STIOLTO 32 sumatriptan 12mg/ml inj 110 sorine 160mg tab 74 0.0025-0.0025MG INH sumatriptan 20mg/act 110 sorine 240mg tab 74 STIVARGA 40MG TAB 61 nasal spray sorine 80mg tab 74 STREPTOMYCIN 19 sumatriptan 25mg tab 110 sotalol 120mg tab 74 1000MG INJ sumatriptan 50mg tab 110 sotalol 160mg tab 74 sumatriptan 5mg/act 110 sotalol 240mg tab 74 nasal spray

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 189 ALPHABETICAL LISTING OF DRUGS sumatriptan 8mg/ml 110 SYNJARDY 5-1000MG 42 TAGRISSO 40MG TAB 61 auto-injector ER TAB TAGRISSO 80MG TAB 61 sumatriptan 8mg/ml 110 SYNJARDY 5-1000MG 42 TAKHZYRO 300MG/2ML 102 cartridge TAB INJ SUNOSI 150MG TAB 17 SYNJARDY 5-500MG 42 TALTZ 80MG/ML 88 SUNOSI 75MG TAB 17 TAB AUTO-INJECTOR SUTENT 12.5MG CAP 61 SYNRIBO 3.5MG INJ 62 TALTZ 80MG/ML 88 SUTENT 25MG CAP 61 SYNTHROID 100MCG 133 SYRINGE SUTENT 37.5MG CAP 61 TAB TALZENNA 0.25MG CAP 61 SUTENT 50MG CAP 61 SYNTHROID 112MCG 133 TALZENNA 1MG CAP 61 syeda 28 day pack 83 TAB tamoxifen 10mg tab 57 SYMDEKO 130 SYNTHROID 125MCG 133 tamoxifen 20mg tab 57 50-75MG/75MG PACK TAB tamsulosin 0.4mg cap 101 SYMDEKO TAB 4-WEEK 130 SYNTHROID 137MCG 133 TARGRETIN 1% GEL 88 PACK TAB tarina 24 fe 1/20 28 day 83 SYMFI 400-300-300MG 71 SYNTHROID 150MCG 133 pack TAB TAB tarina fe 1/20 28 day 83 SYMFI 600-300-300MG 71 SYNTHROID 175MCG 133 pack TAB TAB TARON FORTE CAP 104 SYMJEPI 0.15MG/0.3ML 137 SYNTHROID 200MCG 133 TASIGNA 150MG CAP 61 SYRINGE TAB TASIGNA 200MG CAP 61 SYMJEPI 0.3MG/0.3ML 137 SYNTHROID 25MCG 133 TASIGNA 50MG CAP 61 SYRINGE TAB TAVALISSE 100MG TAB 102 SYMPAZAN 10MG 34 SYNTHROID 300MCG 133 TAVALISSE 150MG TAB 102 ORAL FILM TAB tazarotene 0.1% cream 88 SYMPAZAN 20MG 34 SYNTHROID 50MCG 133 tazicef 1gm inj 79 ORAL FILM TAB tazicef 2gm inj 80 SYMPAZAN 5MG ORAL 34 SYNTHROID 75MCG 133 tazicef 6gm inj 80 FILM TAB TAZORAC 0.05% 88 SYMPROIC 0.2MG TAB 100 SYNTHROID 88MCG 133 CREAM SYMTUZA 71 TAB TAZORAC 0.05% GEL 88 800-150-200-10MG TAB T TAZORAC 0.1% GEL 88 SYNAREL 2MG/ML 96 taztia 120mg er cap 76 TABLOID 40MG TAB 56 NASAL INHALER taztia 180mg er cap 76 TABRECTA 150MG TAB 61 SYNJARDY 10-1000MG 41 taztia 240mg er cap 76 TABRECTA 200MG TAB 61 ER TAB taztia 300mg er cap 76 tacrolimus 0.03% 91 SYNJARDY 41 taztia 360mg er cap 76 ointment 12.5-1000MG ER TAB TAZVERIK 200MG TAB 61 tacrolimus 0.1% ointment 91 SYNJARDY 41 TDVAX 4-4UNIT/ML INJ 133 tacrolimus 0.5mg cap 73 12.5-1000MG TAB TEFLARO 400MG INJ 80 tacrolimus 1mg cap 73 SYNJARDY 12.5-500MG 42 TEFLARO 600MG INJ 80 tacrolimus 5mg cap 73 TAB TEGSEDI 284MG/1.5ML 130 tadalafil 20mg tab 77 SYNJARDY 25-1000MG 42 SYRINGE TAFINLAR 50MG CAP 61 ER TAB telmisartan 20mg tab 50 TAFINLAR 75MG CAP 61 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 190 ALPHABETICAL LISTING OF DRUGS telmisartan 40mg tab 50 testosterone cypionate 26 THIOLA 300MG DR TAB 101 telmisartan 80mg tab 50 200mg/ml (1ml) inj thioridazine 100mg tab 68 temazepam 15mg cap 106 testosterone cypionate 26 thioridazine 10mg tab 68 temazepam 22.5mg cap 106 200mg/ml inj thioridazine 25mg tab 68 temazepam 30mg cap 106 TESTOSTERONE 26 thioridazine 50mg tab 68 temazepam 7.5mg cap 106 ENANTHATE 200MG/ML thiothixene 10mg cap 69 TEMIXYS 300-300MG 71 INJ thiothixene 1mg cap 69 TAB tetrabenazine 12.5mg tab 128 thiothixene 2mg cap 69 TENIVAC 4-10UNIT/ML 133 tetrabenazine 25mg tab 128 thiothixene 5mg cap 69 SYRINGE tetracycline 250mg cap 131 THRIVITE 19 TAB 118 tenofovir disoproxil 71 tetracycline 500mg cap 131 tiadylt 120mg er cap 76 fumarate 300mg tab tetrahydroz-dextran-peg- 122 tiadylt 180mg er cap 76 TEPMETKO 225MG TAB 61 povidone ophth soln tiadylt 240mg er cap 76 terazosin 10mg cap 51 0.05-0.1-1-1% tiadylt 300mg er cap 76 terazosin 1mg cap 51 tetrahydrozoline 122 tiadylt 360mg er cap 76 terazosin 2mg cap 51 ophthsoln 0.05% tiadylt 420mg er cap 76 terazosin 5mg cap 51 THALOMID 100MG CAP 115 tiagabine 12mg tab 37 terbinafine 250mg tab 46 THALOMID 150MG CAP 115 tiagabine 16mg tab 37 terbutaline sulfate 2.5mg 32 THALOMID 200MG CAP 115 tiagabine 2mg tab 37 tab THALOMID 50MG CAP 115 tiagabine 4mg tab 37 terbutaline sulfate 5mg 32 THEO-24 100MG ER 32 TIBSOVO 250MG TAB 61 tab CAP TIGECYCLINE 50MG INJ 131 terconazole 0.4% vaginal 137 THEO-24 200MG ER 32 tilia fe pack 83 cream CAP timolol 0.25% ophth gel 121 TERCONAZOLE 0.8% 137 THEO-24 300MG ER 32 timolol 0.25% ophth soln 121 VAGINAL CREAM CAP timolol 0.5% ophth gel 121 terconazole 80mg vaginal 137 THEO-24 400MG ER 32 timolol 0.5% ophth soln 121 insert CAP timolol 10mg tab 74 testosterone 1% (25mg) 26 THEOPHYLLINE 300MG 32 timolol 20mg tab 74 gel packet ER TAB timolol 5mg tab 74 testosterone 1% (50mg) 26 theophylline 400mg er 32 timolol 5mg/ml ophth 121 gel packet tab 24hr ophth soln testosterone 1.62% 26 theophylline 5.33mg/ml 32 tinidazole 250mg tab 54 (1.25gm) gel packet oral soln tinidazole 500mg tab 54 testosterone 1.62% 26 theophylline 600mg er 32 tiopronin 100mg tab 101 (2.5gm) gel packet tab TIVICAY 10MG TAB 71 TESTOSTERONE 26 THERA/BETA-CAROTEN 118 TIVICAY 25MG TAB 71 12.5MG/ACT GEL PUMP E TAB TIVICAY 50MG TAB 71 testosterone 20.25mg/act 26 THERACAL TAB D4000 114 TIVICAY 5MG TAB FOR 71 gel pump thera-derm lotion 91 ORAL SUSP testosterone 30mg/act 26 thiamine hcl tab 100 mg 139 tizanidine 2mg cap 119 topical soln thiamine hcl tab 50 mg 139 tizanidine 2mg tab 119 testosterone cypionate 26 thiamine tab 250mg 139 tizanidine 4mg cap 119 100mg/ml inj THIOLA 100MG DR TAB 101 tizanidine 4mg tab 119

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 191 ALPHABETICAL LISTING OF DRUGS tizanidine 6mg cap 119 torsemide 5mg tab 94 trazodone 300mg tab 39 TOBRADEX 0.1-0.3% 123 TOUJEO 300UNIT/ML 43 trazodone 50mg tab 39 OPHTH OINTMENT PEN INJ TRECATOR 250MG TAB 56 tobramycin 0.3% ophth 122 TOUJEO MAX 43 TRELEGY ELLIPTA 100- 32 soln 300UNIT/ML PEN INJ 62.5-25MCG INHALER TOBRAMYCIN 19 (3ML) TRELEGY ELLIPTA 32 10MG/ML INJ TPN ELECTROLYTES INJ 113 200-62.5-25 MCG/INH tobramycin 40mg/ml inj 19 TRACLEER 32MG TAB 77 TRELSTAR 11.25MG INJ 57 tobramycin 60mg/ml inh 19 FOR ORAL SUSP TRELSTAR 22.5MG INJ 57 soln TRADJENTA 5MG TAB 42 TRELSTAR 3.75MG INJ 57 tolcapone 100mg tab 64 tramadol 100mg er tab 24 TREMFYA 100MG/ML 88 tolnaftate aerosol powder 87 tramadol 100mg er tab 24 AUTO-INJECTOR 1% (matrix delivery) TREMFYA 100MG/ML 88 tolnaftate cream 1% 87 tramadol 200mg er tab 24 SYRINGE tolnaftate powder 1% 87 tramadol 200mg er tab 24 TRESIBA 100UNIT/ML 43 tolnaftate soln 1% 87 (matrix delivery) INJ tolterodine tartrate 1mg 135 tramadol 300mg er tab 24 TRESIBA 100UNIT/ML 43 tab tramadol 300mg er tab 24 PEN INJ tolterodine tartrate 2mg 135 (matrix delivery) TRESIBA 200UNIT/ML 43 er cap tramadol 50mg tab 24 PEN INJ tolterodine tartrate 2mg 135 trandolapril 1mg tab 50 tretinoin 0.01% gel 86 tab TRANDOLAPRIL 53 tretinoin 0.025% cream 86 tolterodine tartrate 4mg 135 1MG/VERAPAMIL tretinoin 0.025% gel 86 er cap 240MG ER TAB tretinoin 0.04% gel 86 TOPIRAMATE 100MG 36 trandolapril 2mg tab 50 tretinoin 0.05% cream 86 ER CAP trandolapril 53 tretinoin 0.05% gel 86 topiramate 100mg tab 36 2mg/verapamil 180mg er tretinoin 0.1% cream 86 TOPIRAMATE 150MG 36 tab tretinoin 0.1% gel 86 ER CAP trandolapril 53 tretinoin 10mg cap 62 topiramate 15mg cap 36 2mg/verapamil 240mg er triamcinolone acetonide 90 TOPIRAMATE 200MG 36 tab 0.0147% spray ER CAP trandolapril 4mg tab 50 triamcinolone acetonide 90 topiramate 200mg tab 36 trandolapril 53 0.025% cream topiramate 25mg cap 36 4mg/verapamil 240mg er triamcinolone acetonide 90 TOPIRAMATE 25MG ER 36 tab 0.025% lotion CAP tranexamic acid 650mg 105 triamcinolone acetonide 90 topiramate 25mg tab 36 tab 0.025% ointment TOPIRAMATE 50MG ER 36 tranylcypromine 10mg 38 triamcinolone acetonide 90 CAP tab 0.1% cream topiramate 50mg tab 36 TRAVASOL 10% INJ 120 triamcinolone acetonide 90 toremifene 60mg tab 57 travoprost 0.004% ophth 124 0.1% lotion torsemide 100mg tab 94 soln triamcinolone acetonide 90 torsemide 10mg tab 94 trazodone 100mg tab 39 0.1% ointment torsemide 20mg tab 94 trazodone 150mg tab 39

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 192 ALPHABETICAL LISTING OF DRUGS triamcinolone acetonide 116 tri-mili 28 day pack 83 TYMLOS 95 0.1% oral paste trimipramine 100mg cap 41 3120MCG/1.56ML PEN triamcinolone acetonide 90 trimipramine 25mg cap 41 INJ 0.5% cream trimipramine 50mg cap 41 TYPHIM VI 136 triamcinolone acetonide 90 TRINTELLIX 10MG TAB 39 25MCG/0.5ML INJ 0.5% ointment TRINTELLIX 20MG TAB 39 TYPHIM VI 136 TRIAMCINOLONE 120 TRINTELLIX 5MG TAB 39 25MCG/0.5ML SYRINGE ACETONIDE NASAL tri-nymyo 28 day pack 83 U AEROSOL SUSP 55MCG tri-previfem 28 day pack 83 ubiquinol cap 100 mg 18 (OTC) tri-sprintec 28 day pack 83 UBIQUINONE CAP 75 18 triamcinolone acetonide 120 TRIUMEQ 71 MG nasal aerosol suspension 600-50-300MG TAB UBRELVY 100MG TAB 109 55 mcg/act tri-vite-fluoride 0.25 118 UBRELVY 50MG TAB 109 triamterene 100mg cap 94 mg/ml UCERIS 2MG/ACT 26 triamterene 50mg cap 94 tri-vite-fluoride 0.5 mg/ml 118 RECTAL FOAM triazolam 0.125mg tab 106 trivora 28 day pack 83 UKONIQ 200MG TAB 62 triazolam 0.25mg tab 106 tri-vylibra 28 day pack 83 unithroid 100mcg tab 133 triderm 0.1% cream 90 tri-vylibra lo 28 day pack 83 unithroid 112mcg tab 133 triderm 0.5% cream 90 TROPHAMINE 10% INJ 121 unithroid 125mcg tab 133 trientine 250mg cap 115 trospium chloride 20mg 135 unithroid 137mcg tab 133 tri-estarylla 28 day pack 83 tab unithroid 150mcg tab 133 trifluoperazine 10mg tab 68 trospium chloride 60mg 135 unithroid 175mcg tab 133 trifluoperazine 1mg tab 68 er cap unithroid 200mcg tab 133 trifluoperazine 2mg tab 68 TRULANCE 3MG TAB 99 unithroid 25mcg tab 133 trifluoperazine 5mg tab 68 TRULICITY 42 unithroid 300mcg tab 133 TRIFLURIDINE 1% 122 0.75MG/0.5ML unithroid 50mcg tab 133 OPHTH SOLN AUTO-INJECTOR unithroid 75mcg tab 133 trihexyphenidyl 0.4mg/ml 64 TRULICITY 42 unithroid 88mcg tab 133 oral soln 1.5MG/0.5ML UPCAL D POWDER 112 trihexyphenidyl 2mg tab 63 AUTO-INJECTOR 500MG-500UNIT trihexyphenidyl 5mg tab 63 TRULICITY 3MG/0.5ML 43 UPCAL D POWDER 112 TRIKAFTA 130 AUTO-INJECTOR PACKET 100-50-75MG/150MG TRULICITY 43 500MG-500UNIT PACK 4.5MG/0.5ML UPTRAVI 1000MCG TAB 78 tri-legest 28 day pack 83 AUTO-INJECTOR UPTRAVI 1200MCG TAB 78 tri-lo-estarylla 28 day 83 TRUMENBA SYRINGE 136 UPTRAVI 1400MCG TAB 78 pack TRYPTOPHAN TAB 500 121 UPTRAVI 1600MCG TAB 78 tri-lo-sprintec 28 day 83 MG UPTRAVI 200MCG TAB 78 pack TUKYSA 150MG TAB 61 UPTRAVI 400MCG TAB 78 trilyte powder for oral 107 TUKYSA 50MG TAB 61 UPTRAVI 600MCG TAB 78 soln TURALIO 200MG CAP 62 UPTRAVI 800MCG TAB 78 trimethobenzamide 45 TWINRIX 720UNIT 136 UPTRAVI TITRATION 78 300mg cap SYRINGE PACK trimethoprim 100mg tab 54 TYBOST 150MG TAB 71 URO-MAG 140MG CAP 27 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 193 ALPHABETICAL LISTING OF DRUGS ursodiol 250mg tab 99 VARIZIG 125 verapamil 180mg er tab 76 ursodiol 300mg cap 99 125UNIT/1.2ML INJ VERAPAMIL 200MG ER 76 ursodiol 500mg tab 99 VARUBI 90MG TAB 46 CAP V VASCEPA 0.5GM CAP 47 verapamil 240mg er cap 76 VASCEPA 1GM CAP 47 verapamil 240mg er tab 76 valacyclovir 1000mg tab 72 velivet 28 day pack 83 VERAPAMIL 300MG ER 76 valacyclovir 500mg tab 72 VELPHORO 500MG 100 CAP VALCHLOR 0.016% GEL 88 CHEW TAB VERAPAMIL 360MG ER 76 valganciclovir 450mg tab 72 VELTASSA 16.8GM 116 CAP valganciclovir 50mg/ml 72 POWDER FOR ORAL verapamil 40mg tab 76 oral soln SUSP verapamil 80mg tab 76 valproic acid 250mg cap 38 VELTASSA 25.2GM 116 VERQUVO 10MG TAB 78 valproic acid 50mg/ml 38 POWDER FOR ORAL VERQUVO 2.5MG TAB 78 oral soln SUSP VERQUVO 5MG TAB 78 valsartan 160mg tab 50 VELTASSA 8.4GM 116 VERSACLOZ 50MG/ML 67 valsartan 320mg tab 50 POWDER FOR ORAL SUSP valsartan 40mg tab 50 SUSP VERZENIO 100MG TAB 62 valsartan 80mg tab 50 VEMLIDY 25MG TAB 72 VERZENIO 150MG TAB 62 VALTOCO 10MG DOSE 34 VENCLEXTA 100MG 56 VERZENIO 200MG TAB 62 KIT 10MG/0.1ML PACK TAB VERZENIO 50MG TAB 62 VALTOCO 15MG DOSE 34 VENCLEXTA 10MG TAB 56 vestura 3-0.02mg pack 83 KIT 7.5MG/0.1ML PACK VENCLEXTA 50MG TAB 56 VIBERZI 100MG TAB 100 VALTOCO 20MG DOSE 34 VENCLEXTA STARTING 57 VIBERZI 75MG TAB 100 KIT 10MG/0.1ML PACK PACK VICTOZA 18MG/3ML 43 VALTOCO 5MG DOSE 34 venlafaxine 100mg tab 40 PEN INJ KIT 5MG/0.1ML PACK venlafaxine 150mg er cap 40 vienva 28 day pack 83 vancomycin 1000mg inj 54 venlafaxine 25mg tab 40 vigabatrin 500mg powder 37 vancomycin 100mg/ml inj 54 venlafaxine 37.5mg er 40 for oral soln vancomycin 125mg cap 54 cap vigabatrin 500mg tab 37 vancomycin 250mg cap 54 venlafaxine 37.5mg tab 40 vigadrone 500mg powder 37 VANCOMYCIN 250MG 54 venlafaxine 50mg tab 40 for oral soln INJ venlafaxine 75mg er cap 40 VIIBRYD 10/20MG 39 vancomycin 500mg inj 54 venlafaxine 75mg tab 40 STARTER PACK vancomycin 750mg inj 54 VENTAVIS 10MCG/ML 77 VIIBRYD 10MG TAB 39 vandazole 0.75% vaginal 137 INH SOLN VIIBRYD 20MG TAB 39 gel VENTAVIS 20MCG/ML 77 VIIBRYD 40MG TAB 39 VAQTA 25UNIT/0.5ML 136 INH SOLN VIMPAT 100MG TAB 36 INJ VENTOLIN 108MCG INH 32 VIMPAT 10MG/ML 36 VAQTA 25UNIT/0.5ML 136 VERAPAMIL 100MG ER 76 ORAL SOLN SYRINGE CAP VIMPAT 150MG TAB 36 VAQTA 50UNIT/ML INJ 136 verapamil 120mg er cap 76 VIMPAT 200MG TAB 36 VAQTA 50UNIT/ML 136 verapamil 120mg er tab 76 VIMPAT 50MG TAB 36 SYRINGE verapamil 120mg tab 76 VIRACEPT 250MG TAB 72 VARIVAX 136 verapamil 180mg er cap 76 VIRACEPT 625MG TAB 72 1350PFU/0.5ML INJ You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 194 ALPHABETICAL LISTING OF DRUGS

VIREAD 150MG TAB 72 VITAMIN C ORAL 140 VITRAKVI 25MG CAP 62 VIREAD 200MG TAB 72 CRYSTALS VIVITROL 380MG INJ 45 VIREAD 250MG TAB 72 VITAMIN C POWDER 140 VIZIMPRO 15MG TAB 62 VIREAD 40MG/GM 72 FOR SOLUTION VIZIMPRO 30MG TAB 62 ORAL POWDER vitamin c tab 117 VIZIMPRO 45MG TAB 62 VITAL-D RX TAB 117 vitamin C tab 1000mg 140 voriconazole 200mg inj 46 vitamin A cap 10000unit 138 vitamin C tab 250mg 140 voriconazole 200mg tab 46 vitamin a cap 2400 mcg 138 vitamin C tab 500mg 140 voriconazole 40mg/ml 46 (8000 unit) vitamin D3 cap 10000unit 138 susp VITAMIN A PALMITATE 138 VITAMIN D3 CAP 138 voriconazole 50mg tab 46 15000UNIT TAB 4000UNIT VOTRIENT 200MG TAB 62 vitamin A tab 10000unit 138 vitamin D3 cap 50000unit 138 VRAYLAR 1.5/3MG 65 VITAMIN A/BETA 138 vitamin D3 chew tab 138 MIXED PACK CAROTEN TAB 1000unit VRAYLAR 1.5MG CAP 65 VITAMIN A+D CREAM 91 vitamin D3 chew tab 138 VRAYLAR 3MG CAP 65 vitamin B-1 tab 100mg 140 400unit VRAYLAR 4.5MG CAP 65 vitamin B-12 CR tab 103 vitamin D3 drops 138 VRAYLAR 6MG CAP 65 1000mg 5000unit/ml vyfemla 28 day pack 83 VITAMIN B-12 103 vitamin D3 oral liquid 138 vylibra 28 day pack 83 LOZENGE 250MCG 400unit/ml VYNDAMAX 61MG CAP 78 vitamin B-12 lozenge 103 vitamin D3 tab 1000unit 139 VYNDAQEL 20MG CAP 78 500mcg VITAMIN D3 TAB 139 W vitamin b-12 odt 5000mcg 103 3000UNIT WAKIX 17.8MG TAB 17 vitamin B-12 sl tab 104 vitamin D3 tab 400unit 139 WAKIX 4.45MG TAB 17 vitamin B-12 SL tab 103 vitamin D3 tab 50000unit 139 warfarin sodium 10mg 32 2500mcg vitamin D3 tab 5000unit 139 tab vitamin B-12 SL tab 103 VITAMIN E 100UNIT 139 warfarin sodium 1mg tab 32 5000mcg TAB warfarin sodium 2.5mg 32 vitamin B-12 SL tab 103 vitamin e cap 100 unit 139 tab 500mcg vitamin E cap 1000unit 139 warfarin sodium 2mg tab 32 VITAMIN B-12 SUPER 103 vitamin e cap 200 unit 139 warfarin sodium 3mg tab 32 STRENGTH LIQUID vitamin E cap 400unit 139 warfarin sodium 4mg tab 32 5000MCG/ML vitamin E oil 91 warfarin sodium 5mg tab 32 vitamin B-12 tab 103 vitamin e soln 15 139 warfarin sodium 6mg tab 32 1000mcg unit/0.3ml (50 unit/ml) warfarin sodium 7.5mg 32 vitamin B-12 tab 250mcg 103 vitamin k1 10mg/ml inj 139 tab vitamin B-2 tab 100mg 140 vitamins a/d tab 119 wheat dextrin oral 107 vitamin B-2 tab 25mg 140 vitamins w/ lipotropics 119 powder vitamin B-6 tab 100mg 140 tab WHITE PETROLATUM 127 vitamin B-6 tab 250mg 140 vitamins w/lipotropics 119 GEL vitamin B-6 tab 25mg 140 cap white petrolatum gel 127 vitamin C cap 500mg 140 VITRAKVI 100MG CAP 62 white petrolatum topical 127 vitamin C drops 60mg 140 VITRAKVI 20MG/ML 62 gel VITAMIN C LIQUID 117 ORAL SOLN

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 195 ALPHABETICAL LISTING OF DRUGS white petrolatum-mineral 121 XIFAXAN 550MG TAB 54 XPOVIO 80 MG ONCE 58 oil ophth ointment XIGDUO 10-1000MG ER 42 WEEKLY witch hazel liquid 92 TAB XPOVIO 80 MG TWICE 58 wixela 0.1-0.05mg inh 32 XIGDUO 10-500MG ER 42 WEEKLY wixela 0.25-0.05mg inh 32 TAB XPOVIO 80MG ONCE 58 wixela 0.5-0.05mg inh 32 XIGDUO 2.5-1000MG ER 42 WEEKLY CARTON wymzya fe 28 day pack 83 TAB (8-PACK) X XIGDUO 5-1000MG ER 42 XTANDI 40MG CAP 58 TAB xulane 150-35mcg/24hr 83 XALKORI 200MG CAP 62 XIGDUO 5-500MG ER 42 patch XALKORI 250MG CAP 62 TAB XYREM 500MG/ML 127 XARELTO 10MG TAB 33 XOFLUZA 20MG 73 ORAL SOLN XARELTO 15MG TAB 33 THERAPY PACK XARELTO 2.5MG TAB 33 Y XOFLUZA 40MG 73 XARELTO 20MG TAB 33 YF-VAX 4000UNIT/ML 137 THERAPY PACK XARELTO KIT PACK 33 INJ XOLAIR 150MG INJ 30 XATMEP 2.5MG/ML 56 yuvafem 10mcg vaginal 137 XOLAIR 150MG/ML 30 ORAL SOLN insert SYRINGE XCOPRI 100MG TAB 37 XOLAIR 75MG/0.5ML 30 Z XCOPRI 12.5/25MG 37 SYRINGE zafemy 150-35mcg/24hr 83 TITRATION PACK XOSPATA 40MG TAB 62 patch XCOPRI 150/200MG 37 XPOVIO 100 MG ONCE 58 zafirlukast 10mg tab 30 TITRATION PACK WEEKLY zafirlukast 20mg tab 30 XCOPRI 150MG TAB 37 XPOVIO 100MG ONCE 58 zaleplon 10mg cap 106 XCOPRI 200MG TAB 37 WEEKLY CARTON zaleplon 5mg cap 106 XCOPRI 50/100MG 37 (8-PACK) zarah pack 83 TITRATION PACK XPOVIO 40MG ONCE 58 ZARXIO 300MCG/0.5ML 104 XCOPRI 50MG TAB 37 WEEKLY CARTON SYRINGE XCOPRI TAB 37 (4-PACK) ZARXIO 480MCG/0.8ML 104 100/150MG XPOVIO 40MG ONCE 58 SYRINGE MAINTENANCE PACK WEEKLY PACK ZEJULA 100MG CAP 62 XCOPRI TAB 37 XPOVIO 40MG TWICE 58 ZELBORAF 240MG TAB 62 150/200MG PACK WEEKLY CARTON ZEMAIRA 1000MG INJ 130 XCOPRI TAB 50/200MG 37 (8-PACK) zenatane 10mg cap 86 PACK XPOVIO 40MG TWICE 58 zenatane 20mg cap 86 XELJANZ 10MG TAB 19 WEEKLY PACK zenatane 30mg cap 86 XELJANZ 11MG ER TAB 19 XPOVIO 60 MG ONCE 58 zenatane 40mg cap 86 XELJANZ 1MG/ML 19 WEEKLY ZENPEP 93 ORAL SOLN XPOVIO 60MG ONCE 58 105000-79000-25000UNI XELJANZ 22MG ER TAB 19 WEEKLY CARTON T DR CAP XELJANZ 5MG TAB 19 (4-PACK) ZENPEP 93 XENLETA 600MG TAB 55 XPOVIO 60MG TWICE 58 14000-10000-3000UNIT XGEVA 120MG/1.7ML 95 WEEKLY PACK DR CAP INJ XIFAXAN 200MG TAB 54 You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 196 ALPHABETICAL LISTING OF DRUGS

ZENPEP 93 zolpidem tartrate 10mg 106 24000-17000-5000UNIT tab DR CAP zolpidem tartrate 5mg tab 106 ZENPEP 93 ZOMIG 2.5MG NASAL 110 40000-126000-168000U SPRAY NIT DR CAP ZOMIG 5MG NASAL 110 ZENPEP 93 SPRAY 42000-32000-10000UNIT zonisamide 100mg cap 36 DR CAP zonisamide 25mg cap 37 ZENPEP 93 zonisamide 50mg cap 37 63000-47000-15000UNIT ZORTRESS 1MG TAB 115 DR CAP ZOSYN 2000-250MG INJ 126 ZENPEP 93 ZOSYN 3000-375MG INJ 126 84000-63000-20000UNIT zovia 1/35e 28 day pack 83 DR CAP ZUBSOLV 0.7-0.18MG 25 ZERBAXA 1000-500MG 78 SL TAB INJ ZUBSOLV 1.4-0.36MG 25 zidovudine 100mg cap 72 SL TAB zidovudine 10mg/ml oral 72 ZUBSOLV 11.4-2.9MG 25 soln SL TAB zidovudine 300mg tab 72 ZUBSOLV 2.9-0.71MG 25 ZIEXTENZO 6MG/0.6ML 104 SL TAB SYRINGE ZUBSOLV 5.7-1.4MG SL 25 ZINC OXIDE CREAM 92 TAB 12% ZUBSOLV 8.6-2.1MG SL 25 zinc oxide ointment 10% 92 TAB zinc oxide ointment 20% 92 ZYCLARA 2.5% CREAM 91 ZINC OXIDE PASTE 25% 92 ZYDELIG 100MG TAB 62 zinc sulfate cap 220mg 115 ZYDELIG 150MG TAB 62 ZINC W/A AND C 116 ZYKADIA 150MG TAB 62 LOZENGE ZYLET 0.5-0.3% OPHTH 123 ziprasidone 20mg cap 65 SUSP ziprasidone 20mg inj 65 ZYPREXA RELPREVV 67 ziprasidone 40mg cap 65 210MG INJ ziprasidone 60mg cap 65 ziprasidone 80mg cap 65 ZIRGAN 0.15% OPHTH 122 GEL ZOLINZA 100MG CAP 62 zolmitriptan 2.5mg odt 110 zolmitriptan 2.5mg tab 110 zolmitriptan 5mg odt 110 zolmitriptan 5mg tab 110

You can find information on what the symbols and abbreviations in this table mean by going to the beginning of this table. 197 Notice of Nondiscrimination Commonwealth Care Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Commonwealth Care Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Commonwealth Care Alliance: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Civil Rights Coordinator. If you believe that Commonwealth Care Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of General Counsel 30 Winter Street Boston, MA 02108 Phone: 1-617-960-0474, ext. 3932, (TTY: 711) Fax: 1-617-249-0709 E-mail: [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Multi-language Interpreter Services English: ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-866-610-2273 (TTY: 711). Spanish (Español): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-610-2273 (TTY: 711). 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Звоните 1-866-610-2273 (телетайп: 711). .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم :(ةيبرعل) Arabic .(117 :مكبلاو مصلا فتاه مقر) 1-668-016-3722 مقرب لصتا Hindi (�हंद�): 鵍यान द�: य�द आप �हंद� बोलते ह� तो आ प के �लए मु굍त म� भाषा सहायता सेवाएं उपल녍ध ह�। 1-866-610-2273 (TTY: 711) पर कॉल कर� । Italian (Italiano): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-610-2273 (TTY: 711). Portuguese (Português): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-610-2273 (TTY: 711). French Creole (Kreyòl Ayisyen): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-610-2273 (TTY: 711). Polish (Polski): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-866-610-2273 (TTY: 711). 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1-866-610-2273 (TTY: callMassRelay at 711), 8 a.m. – 8 p.m., 7 days a week, or visit www.commonwealthonecare.org