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2020 Pharmacy Benefits

1

Table of Contents

Prescription Drug Program...... ii Generic ...... ii Step Therapy...... ii Prior Authorization Drugs...... iii Once-Daily Medications...... iii Quantity Limits...... iii Affordable Care Act...... iii Medications Not Covered...... iii Participating Pharmacies...... iv Copayments...... iv Specialty and Injectable Drugs...... iv 90-Day Supply for Maintenance Medications...... iv Pharmacy Benefit Questions...... iv Drug Formulary List...... 1 Anti-Infectives...... 3 Antineoplastic & Immunosuppressant Drugs...... 11 Autonomic & CNS Drugs, Neurology & Psychiatric Drugs...... 16 Cardiovascular, Hypertension & Lipids...... 32 Dermatologicals/Topical Therapy...... 39 Diagnostics & Miscellaneous Agents...... 46 Ear, Nose & Throat Medications...... 48 Endocrine/...... 49 Gastroenterology...... 56 Immunology, Vaccines & Biotechnology...... 62 Musculoskeletal & Rheumatology...... 65 Obstetrics & Gynecology...... 67 Ophthalmology...... 75 Respiratory, Allergy, Cough & Cold...... 79 Urologicals...... 90 Vitamins, Hematinics & Electrolytes...... 91 Drug Formulary Index...... 106

i Prescription Drug Program For maximum coverage, your child’s provider The UPMC for Kids formulary is developed by the should prescribe medications from the formulary UPMC Health Plan Pharmacy and Therapeutics (preferred medications). A nonformulary (P&T) Committee. The formulary is composed (nonpreferred) is one that is not on of medications approved by the Food and Drug the list of medications covered by UPMC for Administration (FDA). Kids. To have a prescription for a nonformulary (nonpreferred) medicine covered, your child’s The P&T Committee makes decisions about provider must contact our Health Care Concierge which medications to include in the UPMC for team toll-free at 1-800-650-8762 (TTY: 711) to Kids Pharmacy Benefit program. The committee, ask for a medical exception. The provider should made up of physicians and pharmacists from call our Health Care Concierge team before you communities throughout the UPMC Health Plan go to the pharmacy. service area, decides which medications to cover based on a drug’s safety, effectiveness, and cost. Your child can get covered over-the-counter medications when the provider writes a prescription The P&T Committee’s job is to make sure that for them. Over-the-counter medications appear on the UPMC for Kids Pharmacy Benefit program the formulary with OTC following their name. provides children with high-quality, cost-effective prescription medications. The P&T Committee If you have questions about the formulary, its reviews and updates the UPMC for Kids Pharmacy use, or specific medications, call our Health Care Benefit program regularly during the year. You Concierge team toll-free at 1-800-650-8762. TTY can find information about these updates in the users should call 711. UPMC for Kids member newsletters and pharmacy mailings. Generic Medications UPMC for Kids requires that generic medications Medications on the formulary (drug list) are be used when available. Generic drugs have the covered (paid for) by UPMC for Kids. This booklet same active ingredients as their brand-name provides lists of covered prescription and over- versions and are just as safe and effective. Health the-counter medications. Please note that there care providers are encouraged to prescribe generic are other drugs that UPMC for Kids covers in medications whenever clinically appropriate. If your addition to the ones listed in this booklet. The child’s provider prescribes a drug by brand name, drugs on the formulary were selected because Pennsylvania law permits the pharmacist to give they are safe, work well, and cost less than other you a generic version of that drug. If the provider drugs with the same level of effectiveness. For a thinks your child needs the brand-name version of complete list of covered medications, visit the drug, the provider must call our Health Care www.upmchealthplan.com/forkids. Concierge team to request a medical exception. UPMC for Kids allows the brand-name drug at the The amount of medication your child may receive generic cost-sharing rate if the provider establishes through the UPMC for Kids pharmacy program is that the brand-name drug is medically necessary based on the type of medication ordered. Specialty and the medical exception request is approved. medications and controlled substances are limited to a 30-day supply. You may receive a 30-day Step Therapy or 90-day supply of medications filled at a retail Step therapy is a process that encourages the use of pharmacy. See the 90-day Supply for Maintenance medications preferred by UPMC for Kids as the first Medications section on page iv of this booklet course of treatment. If the preferred medication is for more information on getting a 90-day supply. not clinically effective or if the member suffers side Prescription refills will be allowed for a maximum effects, another medication may be approved as the period of one year from the date of the original second course of treatment. prescription. Medications that require step therapy appear on the formulary with ST following their name. ii Prior Authorization Drugs Affordable Care Act Certain drugs require prior authorization, which You will see the abbreviation ACA next to some means that the provider must consult with UPMC drugs on the formulary tables in this booklet. ACA for Kids before prescribing them to your child for stands for Affordable Care Act. In accordance the first time. These may be newer drugs on which with the Patient Protection and Affordable UPMC for Kids wants to track usage, drugs not Care Act of 2010 (PPACA), select preventive used as a standard first option in treating a medical medications are covered at no cost to you when condition, or drugs with potential side effects filled at a participating pharmacy and with a valid that UPMC for Kids wants to monitor for patient prescription. These medications include, but are safety. The UPMC Health Plan Pharmacy Services not limited to, contraceptives, sodium fluoride, folic Department must authorize the use of these drugs acid supplements, aspirin, smoking deterrents, before UPMC for Kids will cover them. tamoxifen, and raloxifene.

Medications that require prior authorization appear Medications Not Covered on the formulary with PA following their name. Medications considered standard benefit exclusions by the Pennsylvania Children’s Health Once-Daily Medications Insurance Program (CHIP) will not be covered. This The FDA has approved some drugs to be taken includes the following medications: once daily in a larger dose instead of several times • Drug Efficacy Study Implementation (DESI) a day in smaller doses. For these drugs, UPMC for drugs. DESI drugs are classified by the FDA Kids covers only one larger dose per day. as being safe but not effective because these drugs did not have the appropriate studies done For example: The provider writes a prescription for to prove they are effective. your child to take two 10-milligram (mg) doses of • Drugs from manufacturers not participating in medicine each day, one in the morning and one in the Federal Drug Rebate Program agreement the evening. If the medication also comes in 20 mg with the Centers for Medicare and Medicaid strength, your child’s doctor may have to prescribe Services (CMS) one 20 mg dose per day instead of two 10 mg • Erectile dysfunction medications doses per day for medications that are labeled to • Experimental/Investigational medications be taken once a day. If a medical reason prevents • Drugs used for cosmetic purposes your child from taking medications once daily in • Drugs used for fertility purposes the larger dose, the provider should call our Health • Weight-loss drugs Care Concierge team at 1-800-650-8762 • Over-the-counter drugs in the form of troches, (TTY: 711) to request a medical exception. lozenges, throat tablets, cough drops, , , and similar items (except Quantity Limits nicotine replacement products) • Over-the-counter and prescription soaps, The UPMC for Kids Pharmacy and Therapeutics cleansing agents, dentifrices, mouthwashes, Committee has established quantity limits on , diluents, ear wax removal certain drugs to encourage the appropriate use of agents, deodorants, , antiseptics, these drugs. irrigants, and other personal care items

Medications with quantity limits appear on the There is no coverage for lost, stolen, or destroyed formulary with QL following their name. Quantity medications or for prescriptions that are over- limits are drug-specific and limit the number of refilled or dispensed more than one year after the certain drugs that can be dispensed in a specified date the prescription was written. For a complete period of time. These limits are based on the list of exclusions, you can call our Health Care FDA’s recommended dosing, clinical literature, and Concierge team at 1-800-650-8762 (TTY: 711) manufacturer’s instructions. for a copy or view it online at www.upmchealthplan.com/forkids.

iii Participating Pharmacies with SP following their name. Please call our Health The UPMC for Kids network includes many Care Concierge team at 1-800-650-8762 (TTY: participating pharmacies across the service area 711) to request additional information. that can fill your child’s prescription. You can call our Health Care Concierge team at 1-800-650-8762 90-Day Supply for Maintenance Medications (TTY: 711) or visit www.upmchealthplan.com/find If your child takes a medication on a routine to find a participating pharmacy close to you. basis, they can get a 90-day supply from a UPMC for Kids participating retail pharmacy. Eligible Copayments medications are those used to treat chronic or A copayment may be required for each medication. ongoing conditions. If the member is responsible Copayments apply to covered prescription and for copayments (noted in the table below), they over-the-counter medications. The copayment will only have to pay two copayments for a 90- amount is determined by the CHIP coverage level in day supply instead of the usual three. Specialty which your child is enrolled. medications and controlled substances cannot be ordered in 90-day supplies. If a 90-day supply of the medication is ordered, you will only have to pay two copayments instead Tips for Ordering a 90-Day Supply of three. Please see the 90-Day Supply for For a first-time prescription or a new medication, Maintenance Medications section of this booklet UPMC for Kids recommends that your child try a for more information. 30-day supply before requesting a 90-day supply. This gives your child’s provider a chance to ensure Your child’s UPMC for Kids member identification that the dose is correct and that the medication (ID) card will have copayment information printed is not causing any side effects. This will help you on the front. You are responsible for copayments avoid unnecessary copayments if your child’s when the prescription is picked up at the pharmacy. doctor needs to change the medication. To take advantage of this option, ask your child’s Specialty and Injectable Drugs provider to write prescriptions for 90-day supplies The UPMC for Kids pharmacy program covers of any routine medications taken by your child. prescriptions for specialty drugs and injectable medications through a preferred specialty vendor. Pharmacy Benefit Questions Specialty medications are used to treat complex If you have questions about your child’s pharmacy clinical conditions, and they usually require close benefit, please call our Health Care Concierge management by a physician because of their team at 1-800-650-8762 Monday through Friday potential side effects and the frequent need from 7 a.m. to 7 p.m. and Saturday from 8 a.m. to for dosage adjustments. Medications that are 3 p.m. TTY users should call 711. considered specialty drugs appear on the formulary

The copayments for each of the CHIP coverage levels are listed below: Free CHIP Low-cost CHIP Full-cost CHIP Retail pharmacy 30-day supply: Generic drug $0 $6 $10 Brand-name drug $0 $9 $18 Select preventive drugs $0 $0 $0 Retail pharmacy 90-day supply: Generic drug $0 $12 $20 Brand-name drug $0 $18 $36 Select preventive drugs $0 $0 $0

iv Drug Formulary List The formulary that begins on page 3 provides information about the drugs covered by UPMC for Kids. If you have trouble finding a drug in the list, turn to the index on page 106.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ELIQUIS ORAL ) and generic drugs are listed in lowercase italics (e.g., ibuprofen oral tablet).

The information in the Requirements/Limits column tells you if UPMC for Kids has any special requirements for coverage of a drug. Below is a list of abbreviations that may appear in this column.

List of Abbreviations

1: Generic

2: Brand

ACA: Affordable Care Act.

OTC: Over-the-Counter. An OTC drug is a nonprescription drug.

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

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

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

SP: Specialty Drug. Specialty drugs may only be obtained through a preferred specialty vendor. In some cases, specialty drugs may be limited to a 30-day supply.

1 2 Drug Name Drug Tier Requirements / Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS clotrimazole mucous membrane troche 1 CRESEMBA ORAL 2 QL; SP fluconazole oral for reconstitution 1 fluconazole oral tablet 1 QL flucytosine oral capsule 1 SP griseofulvin microsize oral suspension 1 griseofulvin microsize oral tablet 1 griseofulvin ultramicrosize oral tablet 1 itraconazole oral capsule 1 PA; QL ketoconazole oral tablet 1 nystatin oral suspension 1 nystatin oral tablet 1 ONMEL ORAL TABLET 2 PA; QL posaconazole oral tablet,delayed release (dr/ec) 1 PA; QL terbinafine hcl oral tablet 1 QL voriconazole oral suspension for reconstitution 1 QL; SP voriconazole oral tablet 1 QL; SP ANTIVIRALS abacavir oral 1 QL abacavir oral tablet 1 QL abacavir-lamivudine oral tablet 1 QL abacavir-lamivudine-zidovudine oral tablet 1 QL acyclovir oral capsule 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 1 adefovir oral tablet 1 SP amantadine hcl oral capsule 1 amantadine hcl oral solution 1 amantadine hcl oral tablet 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Tier Requirements / Limits APTIVUS ORAL CAPSULE 2 QL APTIVUS ORAL SOLUTION 2 QL atazanavir oral capsule 150 mg 1 atazanavir oral capsule 200 mg, 300 mg 1 QL ATRIPLA ORAL TABLET 2 QL BARACLUDE ORAL SOLUTION 2 PA BIKTARVY ORAL TABLET 2 QL CIMDUO ORAL TABLET 2 QL COMPLERA ORAL TABLET 2 QL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL DELSTRIGO ORAL TABLET 2 QL; SP DESCOVY ORAL TABLET 2 QL didanosine oral capsule,delayed release(dr/ec) 1 QL EDURANT ORAL TABLET 2 QL efavirenz oral capsule 1 QL efavirenz oral tablet 1 QL EMTRIVA ORAL CAPSULE 2 QL EMTRIVA ORAL SOLUTION 2 QL entecavir oral tablet 1 PA; SP EPIVIR HBV ORAL SOLUTION 2 PA EVOTAZ ORAL TABLET 2 QL famciclovir oral tablet 1 QL fosamprenavir oral tablet 1 QL FUZEON SUBCUTANEOUS RECON SOLN 2 QL; SP GENVOYA ORAL TABLET 2 QL INTELENCE ORAL TABLET 2 QL INVIRASE ORAL TABLET 2 QL ISENTRESS HD ORAL TABLET 2 QL ISENTRESS ORAL IN PACKET 2 QL ISENTRESS ORAL TABLET 2 QL ISENTRESS ORAL TABLET,CHEWABLE 2 QL JULUCA ORAL TABLET 2 QL; SP You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Tier Requirements / Limits KALETRA ORAL TABLET 2 QL lamivudine oral solution 1 QL lamivudine oral tablet 100 mg 1 PA lamivudine oral tablet 150 mg, 300 mg 1 QL lamivudine-zidovudine oral tablet 1 QL LEDIPASVIR-SOFOSBUVIR ORAL TABLET 2 PA; QL; SP LEXIVA ORAL SUSPENSION 2 QL lopinavir-ritonavir oral solution 1 QL MAVYRET ORAL TABLET 2 PA; QL; SP nevirapine oral suspension 1 QL nevirapine oral tablet 1 QL nevirapine oral tablet extended release 24 hr 100 1 mg nevirapine oral tablet extended release 24 hr 400 1 QL mg NORVIR ORAL POWDER IN PACKET 2 QL NORVIR ORAL SOLUTION 2 QL ODEFSEY ORAL TABLET 2 QL oseltamivir oral capsule 1 QL oseltamivir oral suspension for reconstitution 1 QL PIFELTRO ORAL TABLET 2 QL; SP PREVYMIS ORAL TABLET 2 PA; QL; SP PREZCOBIX ORAL TABLET 2 QL PREZISTA ORAL SUSPENSION 2 QL PREZISTA ORAL TABLET 150 MG, 600 MG, 2 QL 75 MG, 800 MG RELENZA DISKHALER INHALATION 2 QL BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET 2 QL REYATAZ ORAL POWDER IN PACKET 2 QL rimantadine oral tablet 1 ritonavir oral tablet 1 QL SELZENTRY ORAL SOLUTION 2 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Tier Requirements / Limits SELZENTRY ORAL TABLET 2 QL SOFOSBUVIR-VELPATASVIR ORAL TABLET 2 PA; QL; SP SOVALDI ORAL TABLET 2 PA; QL; SP stavudine oral capsule 1 QL STRIBILD ORAL TABLET 2 QL SYMFI LO ORAL TABLET 2 QL SYMFI ORAL TABLET 2 QL SYMTUZA ORAL TABLET 2 QL SYNAGIS INTRAMUSCULAR SOLUTION 2 PA; QL; SP tenofovir disoproxil fumarate oral tablet 1 QL TIVICAY ORAL TABLET 2 QL

TRIUMEQ ORAL TABLET 2 QL TROGARZO INTRAVENOUS SOLUTION 2 PA; SP TRUVADA ORAL TABLET 2 QL TYBOST ORAL TABLET 2 QL valacyclovir oral tablet 1 QL valganciclovir oral recon soln 1 SP valganciclovir oral tablet 1 SP VEMLIDY ORAL TABLET 2 PA; QL; SP VIDEX 2 GRAM PEDIATRIC ORAL RECON 2 QL SOLN VIEKIRA PAK ORAL TABLETS,DOSE PACK 2 PA; QL; SP VIRACEPT ORAL TABLET 2 QL VIREAD ORAL POWDER 2 QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 2 QL MG VOSEVI ORAL TABLET 2 PA; QL; SP zidovudine oral capsule 1 QL zidovudine oral 1 QL zidovudine oral tablet 1 QL CEPHALOSPORINS cefaclor oral capsule 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6 Drug Name Drug Tier Requirements / Limits cefaclor oral tablet extended release 12 hr 1 cefadroxil oral capsule 1 cefadroxil oral suspension for reconstitution 250 1 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 cefdinir oral capsule 1 cefdinir oral suspension for reconstitution 1 cefixime oral suspension for reconstitution 1 cefpodoxime oral suspension for reconstitution 1 cefpodoxime oral tablet 1 cefprozil oral suspension for reconstitution 1 cefprozil oral tablet 1 cefuroxime axetil oral tablet 1 cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral suspension for reconstitution 1 cephalexin oral tablet 1 ERYTHROMYCINS & OTHER MACROLIDES azithromycin oral packet 1 azithromycin oral suspension for reconstitution 1 azithromycin oral tablet 1 clarithromycin oral suspension for reconstitution 1 clarithromycin oral tablet 1 clarithromycin oral tablet extended release 24 hr 1 DIFICID ORAL TABLET 2 ST; QL; SP ery-tab oral tablet,delayed release (dr/ec) 250 mg, 1 333 mg erythrocin (as stearate) oral tablet 250 mg 1 erythromycin ethylsuccinate oral suspension for 1 reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 1 erythromycin oral capsule,delayed release(dr/ec) 1 erythromycin oral tablet 1 MISCELLANEOUS ANTIINFECTIVES You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7 Drug Name Drug Tier Requirements / Limits AEMCOLO ORAL TABLET,DELAYED 2 QL RELEASE (DR/EC) albendazole oral tablet 1 ALINIA ORAL SUSPENSION FOR 2 RECONSTITUTION ALINIA ORAL TABLET 2 ARIKAYCE INHALATION SUSPENSION FOR 2 PA; SP NEBULIZATION atovaquone oral suspension 1 SP BENZNIDAZOLE ORAL TABLET 2 QL CAYSTON INHALATION SOLUTION FOR 2 QL; SP NEBULIZATION chloroquine phosphate oral tablet 1 clindamycin hcl oral capsule 1 clindamycin palmitate hcl oral recon soln 1 clindamycin pediatric oral recon soln 1 dapsone oral tablet 1 ethambutol oral tablet 1 hydroxychloroquine oral tablet 1 isoniazid oral solution 1 isoniazid oral tablet 1 ivermectin oral tablet 1 linezolid oral suspension for reconstitution 1 QL; SP linezolid oral tablet 1 QL; SP metronidazole oral capsule 1 metronidazole oral tablet 1 NEBUPENT INHALATION RECON SOLN 2 neomycin oral tablet 1 paromomycin oral capsule 1 PASER ORAL GRANULES DR FOR SUSP IN 2 PACKET praziquantel oral tablet 1 PRIFTIN ORAL TABLET 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8 Drug Name Drug Tier Requirements / Limits pyrazinamide oral tablet 1 rifabutin oral capsule 1 rifampin oral capsule 1 RIFATER ORAL TABLET 2 SP SIRTURO ORAL TABLET 2 PA SIVEXTRO INTRAVENOUS RECON SOLN 2 QL; SP SIVEXTRO ORAL TABLET 2 QL; SP tinidazole oral tablet 1 TOBI PODHALER INHALATION CAPSULE, 2 QL; SP W/INHALATION DEVICE tobramycin in 0.225 % nacl inhalation solution for 1 QL; SP nebulization TRECATOR ORAL TABLET 2 XIFAXAN ORAL TABLET 200 MG 2 QL XIFAXAN ORAL TABLET 550 MG 2 PA; QL; SP PENICILLINS amoxicillin oral capsule 1 amoxicillin oral suspension for reconstitution 1 amoxicillin oral tablet 1 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for 1 reconstitution amoxicillin-pot clavulanate oral tablet 1 amoxicillin-pot clavulanate oral tablet extended 1 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable 1 ampicillin oral capsule 1 AUGMENTIN ORAL SUSPENSION FOR 2 RECONSTITUTION 125-31.25 MG/5 ML dicloxacillin oral capsule 1 penicillin v potassium oral recon soln 1 penicillin v potassium oral tablet 1 QUINOLONES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9 Drug Name Drug Tier Requirements / Limits ciprofloxacin hcl oral tablet 1 levofloxacin oral solution 1 levofloxacin oral tablet 1 moxifloxacin oral tablet 1 ofloxacin oral tablet 300 mg, 400 mg 1 SULFA'S & RELATED AGENTS sulfadiazine oral tablet 1 sulfamethoxazole-trimethoprim oral suspension 1 sulfamethoxazole-trimethoprim oral tablet 400-80 1 mg sulfatrim oral suspension 1 TETRACYCLINES doxycycline hyclate oral capsule 1 doxycycline monohydrate oral capsule 100 mg, 50 1 mg doxycycline monohydrate oral suspension for 1 reconstitution minocycline oral capsule 1 ORACEA ORAL CAPSULE,IR - DELAY 2 QL REL,BIPHASE tetracycline oral capsule 1 URINARY TRACT AGENTS methenamine hippurate oral tablet 1 methenamine mandelate oral tablet 1 MONUROL ORAL PACKET 2 nitrofurantoin macrocrystal oral capsule 100 mg, 1 50 mg nitrofurantoin monohyd/m-cryst oral capsule 1 PRIMSOL ORAL SOLUTION 2 trimethoprim oral tablet 1 VANCOMYCIN FIRVANQ ORAL RECON SOLN 2 vancomycin oral capsule 1 SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10 Drug Name Drug Tier Requirements / Limits ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln 1 leucovorin calcium oral tablet 1 SP MESNEX ORAL TABLET 2 SP XGEVA SUBCUTANEOUS SOLUTION 2 PA; QL; SP ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS abiraterone oral tablet 1 PA; QL; SP AFINITOR DISPERZ ORAL TABLET FOR 2 PA; QL; SP SUSPENSION AFINITOR ORAL TABLET 2 PA; QL; SP ALECENSA ORAL CAPSULE 2 PA; QL; SP ALIMTA INTRAVENOUS RECON SOLN 500 2 SP MG ALUNBRIG ORAL TABLET 2 PA; QL; SP ALUNBRIG ORAL TABLETS,DOSE PACK 2 PA; QL; SP anastrozole oral tablet 1 azathioprine oral tablet 1 BALVERSA ORAL TABLET 2 PA; QL; SP bexarotene oral capsule 1 PA; SP bicalutamide oral tablet 1 BOSULIF ORAL TABLET 2 PA; QL; SP BRAFTOVI ORAL CAPSULE 2 PA; QL; SP CABOMETYX ORAL TABLET 2 PA; QL; SP CALQUENCE ORAL CAPSULE 2 PA; QL; SP capecitabine oral tablet 1 PA; SP CAPRELSA ORAL TABLET 2 PA; QL; SP COMETRIQ ORAL CAPSULE 2 PA; QL; SP COPIKTRA ORAL CAPSULE 2 PA; QL; SP COTELLIC ORAL TABLET 2 PA; QL; SP cyclophosphamide oral capsule 1 SP cyclosporine modified oral capsule 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11 Drug Name Drug Tier Requirements / Limits cyclosporine modified oral solution 1 cyclosporine oral capsule 1 DAURISMO ORAL TABLET 2 PA; QL; SP ELIGARD (3 MONTH) SUBCUTANEOUS 2 PA; QL; SP ELIGARD (4 MONTH) SUBCUTANEOUS 2 PA; QL; SP SYRINGE ELIGARD (6 MONTH) SUBCUTANEOUS 2 PA; QL; SP SYRINGE ELIGARD SUBCUTANEOUS SYRINGE 2 PA; QL; SP EMCYT ORAL CAPSULE 2 PA; SP ERIVEDGE ORAL CAPSULE 2 PA; QL; SP ERLEADA ORAL TABLET 2 PA; QL; SP erlotinib oral tablet 100 mg, 150 mg 1 PA; QL; SP erlotinib oral tablet 25 mg 1 PA; SP etoposide oral capsule 1 SP exemestane oral tablet 1 FARYDAK ORAL CAPSULE 2 PA; QL; SP FASLODEX INTRAMUSCULAR SYRINGE 2 SP FIRMAGON KIT W DILUENT SYRINGE 2 PA; QL; SP SUBCUTANEOUS RECON SOLN flutamide oral capsule 1 fulvestrant intramuscular syringe 1 GAMIFANT INTRAVENOUS SOLUTION 2 PA; SP gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 1 GILOTRIF ORAL TABLET 2 PA; QL; SP GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 2 PA; SP 40 MG HYCAMTIN ORAL CAPSULE 2 PA; SP hydroxyurea oral capsule 1 IBRANCE ORAL CAPSULE 2 PA; QL; SP ICLUSIG ORAL TABLET 2 PA; QL; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12 Drug Name Drug Tier Requirements / Limits IDHIFA ORAL TABLET 2 PA; QL; SP imatinib oral tablet 1 PA; QL; SP IMBRUVICA ORAL CAPSULE 2 PA; QL; SP IMBRUVICA ORAL TABLET 2 PA; QL; SP INLYTA ORAL TABLET 2 PA; QL; SP INREBIC ORAL CAPSULE 2 PA; QL; SP IRESSA ORAL TABLET 2 PA; QL; SP JAKAFI ORAL TABLET 2 PA; QL; SP KISQALI FEMARA CO-PACK ORAL TABLET 2 PA; QL; SP KISQALI ORAL TABLET 2 PA; QL; SP LENVIMA ORAL CAPSULE 10 MG/DAY (10 2 PA; QL; SP MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 12 MG/DAY (4 2 PA; QL; SP MG X 3), 4 MG letrozole oral tablet 1 LEUKERAN ORAL TABLET 2 SP leuprolide subcutaneous kit 1 PA; QL; SP LONSURF ORAL TABLET 2 PA; SP LORBRENA ORAL TABLET 2 PA; QL; SP LUPRON DEPOT (3 MONTH) 2 PA; QL; SP INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) 2 PA; QL; SP INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) 2 PA; QL; SP INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR 2 PA; QL; SP SYRINGE KIT LUPRON DEPOT-PED (3 MONTH) 2 PA; QL; SP INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED INTRAMUSCULAR KIT 2 PA; QL; SP LYNPARZA ORAL TABLET 2 PA; QL; SP LYSODREN ORAL TABLET 2 SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13 Drug Name Drug Tier Requirements / Limits MATULANE ORAL CAPSULE 2 SP megestrol oral suspension 400 mg/10 ml (40 1 mg/ml) megestrol oral tablet 1 MEKINIST ORAL TABLET 2 PA; QL; SP MEKTOVI ORAL TABLET 2 PA; QL; SP melphalan oral tablet 1 mercaptopurine oral tablet 1 methotrexate sodium (pf) recon soln 1 methotrexate sodium (pf) injection solution 1 methotrexate sodium injection solution 1 methotrexate sodium oral tablet 1 mycophenolate mofetil oral capsule 1 mycophenolate mofetil oral suspension for 1 reconstitution mycophenolate mofetil oral tablet 1 mycophenolate sodium oral tablet,delayed release 1 (dr/ec) MYLERAN ORAL TABLET 2 SP NERLYNX ORAL TABLET 2 PA; QL; SP NEXAVAR ORAL TABLET 2 PA; QL; SP nilutamide oral tablet 1 PA; SP NINLARO ORAL CAPSULE 2 PA; QL; SP NULOJIX INTRAVENOUS RECON SOLN 2 PA; SP octreotide acetate injection solution 1 SP octreotide acetate injection syringe 1 SP ODOMZO ORAL CAPSULE 2 PA; QL; SP RITUXAN INTRAVENOUS CONCENTRATE 2 PA; SP ROZLYTREK ORAL CAPSULE 2 PA; QL; SP RUBRACA ORAL TABLET 2 PA; QL; SP RYDAPT ORAL CAPSULE 2 PA; QL; SP SANDIMMUNE ORAL SOLUTION 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations14 on this table mean by going to the beginning of this table. 14 Drug Name Drug Tier Requirements / Limits SANDOSTATIN LAR DEPOT 2 PA; QL; SP INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR LAR INTRAMUSCULAR 2 PA; QL; SP SUSPENSION FOR RECONSTITUTION SIGNIFOR SUBCUTANEOUS SOLUTION 2 PA; QL; SP SIMULECT INTRAVENOUS RECON SOLN 2 SP sirolimus oral solution 1 PA sirolimus oral tablet 1 SOLTAMOX ORAL SOLUTION 2 ACA SOMATULINE DEPOT SUBCUTANEOUS 2 PA; QL; SP SYRINGE SPRYCEL ORAL TABLET 2 PA; QL; SP STIVARGA ORAL TABLET 2 PA; QL; SP SUPPRELIN LA IMPLANT KIT 2 PA; QL; SP SUTENT ORAL CAPSULE 2 PA; QL; SP SYLVANT INTRAVENOUS RECON SOLN 2 PA; SP TABLOID ORAL TABLET 2 PA; SP tacrolimus oral capsule 1 TAFINLAR ORAL CAPSULE 2 PA; QL; SP TAGRISSO ORAL TABLET 2 PA; QL; SP TALZENNA ORAL CAPSULE 2 PA; QL; SP tamoxifen oral tablet 1 ACA TARGRETIN TOPICAL GEL 2 PA; SP TASIGNA ORAL CAPSULE 2 PA; QL; SP temozolomide oral capsule 1 PA; SP THALOMID ORAL CAPSULE 100 MG, 50 MG 2 PA; SP THALOMID ORAL CAPSULE 150 MG, 200 MG 2 PA; QL; SP TIBSOVO ORAL TABLET 2 PA; QL; SP toremifene oral tablet 1 PA; QL; SP TRELSTAR INTRAMUSCULAR SUSPENSION 2 PA; QL; SP FOR RECONSTITUTION tretinoin (chemotherapy) oral capsule 1 SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations15 on this table mean by going to the beginning of this table. 15 Drug Name Drug Tier Requirements / Limits TRIPTODUR INTRAMUSCULAR 2 PA; QL; SP SUSPENSION FOR RECONSTITUTION TURALIO ORAL CAPSULE 2 PA; QL TYKERB ORAL TABLET 2 PA; QL; SP VANTAS IMPLANT KIT 2 PA; QL; SP VENCLEXTA ORAL TABLET 2 PA; QL; SP VENCLEXTA STARTING PACK ORAL 2 PA; QL; SP TABLETS,DOSE PACK VERZENIO ORAL TABLET 2 PA; QL; SP VITRAKVI ORAL CAPSULE 2 PA; QL; SP VITRAKVI ORAL SOLUTION 2 PA; QL; SP VIZIMPRO ORAL TABLET 2 PA; QL; SP VOTRIENT ORAL TABLET 2 PA; QL; SP XALKORI ORAL CAPSULE 2 PA; QL; SP XERMELO ORAL TABLET 2 PA; QL; SP XOSPATA ORAL TABLET 2 PA; QL; SP XPOVIO ORAL TABLET 2 PA; QL; SP XTANDI ORAL CAPSULE 2 PA; QL; SP YONSA ORAL TABLET 2 PA; QL; SP ZEJULA ORAL CAPSULE 2 PA; QL; SP ZELBORAF ORAL TABLET 2 PA; QL; SP ZOLADEX SUBCUTANEOUS IMPLANT 2 PA; QL; SP ZOLINZA ORAL CAPSULE 2 PA; QL; SP ZORTRESS ORAL TABLET 2 SP ZYDELIG ORAL TABLET 2 PA; QL; SP ZYKADIA ORAL TABLET 2 PA; QL; SP ZYTIGA ORAL TABLET 500 MG 2 PA; QL; SP AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 2 PA; QL; SP BANZEL ORAL SUSPENSION 2 PA; SP BANZEL ORAL TABLET 2 PA; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations16 on this table mean by going to the beginning of this table. 16 Drug Name Drug Tier Requirements / Limits BRIVIACT ORAL SOLUTION 2 PA; QL; SP BRIVIACT ORAL TABLET 2 PA; QL; SP carbamazepine oral capsule, er multiphase 12 hr 1 carbamazepine oral suspension 100 mg/5 ml 1 carbamazepine oral tablet 1 carbamazepine oral tablet extended release 12 hr 1 carbamazepine oral tablet,chewable 1 CELONTIN ORAL CAPSULE 300 MG 2 clobazam oral suspension 1 PA; QL clobazam oral tablet 1 PA; QL clonazepam oral tablet 1 clonazepam oral tablet,disintegrating 1 ST DIACOMIT ORAL CAPSULE 2 PA; SP DIACOMIT ORAL POWDER IN PACKET 2 PA; SP DIASTAT RECTAL KIT 2 rectal kit 1 divalproex oral capsule, delayed rel sprinkle 1 divalproex oral tablet extended release 24 hr 1 divalproex oral tablet,delayed release (dr/ec) 1 EPIDIOLEX ORAL SOLUTION 2 PA; SP epitol oral tablet 1 ethosuximide oral capsule 1 ethosuximide oral solution 1 felbamate oral suspension 1 SP felbamate oral tablet 1 SP FYCOMPA ORAL SUSPENSION 2 PA; QL; SP FYCOMPA ORAL TABLET 2 PA; QL; SP gabapentin oral capsule 1 QL gabapentin oral solution 250 mg/5 ml 1 QL gabapentin oral solution 300 mg/6 ml (6 ml) 1 QL gabapentin oral tablet 600 mg, 800 mg 1 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations17 on this table mean by going to the beginning of this table. 17 Drug Name Drug Tier Requirements / Limits GRALISE 30-DAY STARTER PACK ORAL 2 PA; QL TABLET EXTENDED RELEASE 24 HR GRALISE ORAL TABLET EXTENDED 2 PA; QL RELEASE 24 HR lamotrigine oral tablet 1 lamotrigine oral tablet, chewable dispersible 1 QL levetiracetam oral solution 1 levetiracetam oral tablet 1 levetiracetam oral tablet extended release 24 hr 1 QL oxcarbazepine oral suspension 1 oxcarbazepine oral tablet 1 PEGANONE ORAL TABLET 2 PA; SP phenobarbital oral 1 phenobarbital oral tablet 1 phenytoin oral suspension 1 phenytoin oral tablet,chewable 1 phenytoin sodium extended oral capsule 1 pregabalin oral capsule 1 PA; QL pregabalin oral solution 1 PA; QL primidone oral tablet 1 roweepra oral tablet 1 roweepra xr oral tablet extended release 24 hr 1 QL subvenite oral tablet 1 tiagabine oral tablet 1 topiramate oral capsule, sprinkle 1 QL topiramate oral tablet 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml, 500 mg/10 ml (10 ml) valproic acid oral capsule 1 vigabatrin oral powder in packet 1 PA; QL; SP vigabatrin oral tablet 1 PA; QL; SP vigadrone oral powder in packet 1 PA; QL; SP zonisamide oral capsule 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations18 on this table mean by going to the beginning of this table. 18 Drug Name Drug Tier Requirements / Limits ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 2 PA; QL; SP benztropine oral tablet 1 bromocriptine oral capsule 1 bromocriptine oral tablet 1 carbidopa oral tablet 1 carbidopa-levodopa oral tablet 1 carbidopa-levodopa oral tablet extended release 1 carbidopa-levodopa oral tablet,disintegrating 1 carbidopa-levodopa-entacapone oral tablet 1 entacapone oral tablet 1 INBRIJA INHALATION CAPSULE, 2 PA; QL; SP W/INHALATION DEVICE pramipexole oral tablet 1 ropinirole oral tablet 1 selegiline hcl oral capsule 1 selegiline hcl oral tablet 1 trihexyphenidyl oral elixir 1 trihexyphenidyl oral tablet 1 MIGRAINE & CLUSTER HEADACHE THERAPY AIMOVIG AUTOINJECTOR SUBCUTANEOUS 2 PA; QL AUTO-INJECTOR dihydroergotamine injection solution 1 SP dihydroergotamine ,non-aerosol 1 QL; SP ergotamine-caffeine oral tablet 1 migergot rectal 1 naratriptan oral tablet 1 QL rizatriptan oral tablet 1 QL rizatriptan oral tablet,disintegrating 1 QL nasal spray,non-aerosol 1 QL sumatriptan succinate oral tablet 1 QL sumatriptan succinate subcutaneous cartridge 1 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations19 on this table mean by going to the beginning of this table. 19 Drug Name Drug Tier Requirements / Limits sumatriptan succinate subcutaneous pen injector 1 QL sumatriptan succinate subcutaneous solution 1 QL sumatriptan succinate subcutaneous syringe 6 1 QL mg/0.5 ml MISCELLANEOUS NEUROLOGICAL THERAPY AUSTEDO ORAL TABLET 2 PA; QL; SP dalfampridine oral tablet extended release 12 hr 1 PA; QL; SP donepezil oral tablet 10 mg, 5 mg 1 PA donepezil oral tablet,disintegrating 1 PA EXONDYS 51 INTRAVENOUS SOLUTION 2 PA; SP galantamine oral capsule,ext rel. pellets 24 hr 1 PA galantamine oral solution 1 PA galantamine oral tablet 1 PA HORIZANT ORAL TABLET EXTENDED 2 PA; QL RELEASE INGREZZA ORAL CAPSULE 2 PA; QL; SP KEVEYIS ORAL TABLET 2 PA; SP memantine oral solution 1 PA memantine oral tablet 1 PA MEMANTINE ORAL TABLETS,DOSE PACK 2 PA NUEDEXTA ORAL CAPSULE 2 PA; QL; SP rivastigmine tartrate oral capsule 1 PA RUZURGI ORAL TABLET 2 PA; QL; SP TEGSEDI SUBCUTANEOUS SYRINGE 2 PA; QL; SP tetrabenazine oral tablet 1 PA; QL; SP TYSABRI INTRAVENOUS SOLUTION 2 PA; QL; SP MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 20 mg 1 carisoprodol oral tablet 350 mg 1 carisoprodol-aspirin oral tablet 1 carisoprodol-aspirin-codeine oral tablet 1 PA; QL chlorzoxazone oral tablet 500 mg 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations20 on this table mean by going to the beginning of this table. 20 Drug Name Drug Tier Requirements / Limits cyclobenzaprine oral tablet 10 mg, 5 mg 1 dantrolene oral capsule 1 meprobamate oral tablet 1 methocarbamol oral tablet 1 orphenadrine citrate oral tablet extended release 1 pyridostigmine bromide oral syrup 1 SP pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide oral tablet extended 1 PA; QL; SP release tizanidine oral tablet 1 NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET 2 PA; QL; SP acetaminophen-codeine oral solution 120-12 mg/5 1 PA; QL ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 1 PA; QL buprenorphine hcl sublingual tablet 1 PA; QL buprenorphine weekly 10 1 PA; QL mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour BUPRENORPHINE TRANSDERMAL PATCH 2 PA; QL WEEKLY 7.5 MCG/HOUR butalbital-acetaminop-caf-cod oral capsule 50- 1 PA; QL 325-40-30 mg butalbital-acetaminophen-caff oral tablet 50-325- 1 40 mg butalbital-aspirin-caffeine oral capsule 1 codeine sulfate oral tablet 1 PA; QL endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 1 PA; QL mg, 7.5-325 mg fentanyl citrate buccal lozenge on a handle 1 PA; QL; SP fentanyl transdermal patch 72 hour 100 mcg/hr, 1 PA; QL 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, 2 PA; QL; SP EFFERVESCENT hydrocodone-acetaminophen oral solution 10-325 1 PA; QL mg/15 ml(15 ml), 7.5-325 mg/15 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations21 on this table mean by going to the beginning of this table. 21 Drug Name Drug Tier Requirements / Limits hydrocodone-acetaminophen oral tablet 10-325 1 PA; QL mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 PA; QL hydromorphone oral tablet 1 PA; QL hydromorphone rectal suppository 1 PA; QL LAZANDA NASAL SPRAY,NON-AEROSOL 2 PA; QL; SP levorphanol tartrate oral tablet 2 mg 1 PA; QL lorcet (hydrocodone) oral tablet 1 PA; QL lorcet hd oral tablet 1 PA; QL lorcet plus oral tablet 7.5-325 mg 1 PA; QL meperidine oral solution 1 PA; QL meperidine oral tablet 1 PA; QL methadone oral concentrate 1 PA; QL methadone oral solution 1 PA; QL methadone oral tablet 1 PA; QL methadose oral concentrate 1 PA; QL morphine concentrate oral solution 1 PA; QL morphine oral solution 1 PA; QL morphine oral tablet 1 PA; QL morphine oral tablet extended release 1 PA; QL morphine rectal suppository 1 PA; QL oxycodone oral concentrate 1 PA; QL oxycodone oral solution 1 PA; QL oxycodone oral tablet 1 PA; QL OXYCODONE ORAL TABLET,ORAL 2 PA; QL ONLY,EXT.REL.12 HR oxycodone-acetaminophen oral tablet 10-325 mg, 1 PA; QL 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 1 PA; QL OXYCONTIN ORAL TABLET,ORAL 2 PA; QL ONLY,EXT.REL.12 HR oxymorphone oral tablet 1 PA; QL oxymorphone oral tablet extended release 12 hr 1 PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations22 on this table mean by going to the beginning of this table. 22 Drug Name Drug Tier Requirements / Limits PROBUPHINE SUBDERMAL IMPLANT 2 PA; QL; SP SUBLOCADE SUBCUTANEOUS SOLUTION, 2 PA; QL; SP EXTENDED REL SYRINGE XTAMPZA ER ORAL 2 PA; QL CAP,SPRINKL,ER12HR(DONT CRUSH) NON-NARCOTIC ANALGESICS acetadryl oral tablet 1 OTC acetaminophen oral elixir 1 OTC acetaminophen oral 160 mg/5 ml 1 OTC acetaminophen oral solution 1 OTC acetaminophen oral suspension 160 mg/5 ml 1 OTC acetaminophen oral tablet 1 OTC acetaminophen oral tablet extended release 1 OTC acetaminophen pm oral tablet 1 OTC acetaminophen rectal suppository 1 OTC adult aspirin regimen oral tablet,delayed release 1 ACA; OTC (dr/ec) all day pain relief oral tablet 1 OTC all day relief oral tablet 1 OTC arthritis pain relief (acetam) oral tablet extended 1 OTC release aspir-81 oral tablet,delayed release (dr/ec) 1 ACA; OTC aspirin low dose oral tablet,delayed release 1 ACA; OTC (dr/ec) aspirin oral tablet,chewable 1 ACA; OTC aspirin oral tablet,delayed release (dr/ec) 325 mg, 1 ACA; OTC 81 mg aspirin rectal suppository 1 OTC aspirin,buffd-calcium carb-mag oral tablet 1 OTC aspir-low oral tablet,delayed release (dr/ec) 1 ACA; OTC aspir-trin oral tablet,delayed release (dr/ec) 1 ACA; OTC back and body pain reliever oral tablet 1 OTC bayer aspirin oral tablet 1 ACA; OTC bufferin oral tablet 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations23 on this table mean by going to the beginning of this table. 23 Drug Name Drug Tier Requirements / Limits buprenorphine-naloxone sublingual tablet 1 QL celecoxib oral capsule 100 mg, 200 mg, 50 mg 1 ST; QL children's acetaminophen oral suspension 160 1 OTC mg/5 ml, 160 mg/5 ml (5 ml) children's acetaminophen oral tablet,chewable 1 OTC children's aspirin oral tablet,chewable 1 ACA; OTC children's pain relief oral suspension 1 OTC children's pain reliever oral suspension 1 OTC children's pain-fever relief oral suspension 1 OTC children's silapap oral liquid 1 OTC children's tactinal oral tablet,chewable 1 OTC choline,magnesium salicylate oral liquid 1 diclofenac potassium oral tablet 1 diclofenac sodium oral tablet extended release 24 1 hr diclofenac sodium oral tablet,delayed release 1 (dr/ec) diclofenac sodium topical gel 1 % 1 QL diflunisal oral tablet 1 e.c. prin oral tablet,delayed release (dr/ec) 1 ACA; OTC ecotrin low strength oral tablet,delayed release 1 ACA; OTC (dr/ec) ecotrin oral tablet,delayed release (dr/ec) 1 ACA; OTC efferves pain relief antacid oral tablet, effervescent 1 OTC effervescent pain relief oral tablet, effervescent 1 OTC 324 mg etodolac oral tablet 1 EUFLEXXA INTRA-ARTICULAR SYRINGE 2 QL; SP feverall rectal suppository 650 mg 1 OTC FEVERALL RECTAL SUPPOSITORY 80 MG 2 OTC flanax (naproxen) oral tablet 1 OTC flurbiprofen oral tablet 100 mg 1 ibu oral tablet 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations24 on this table mean by going to the beginning of this table. 24 Drug Name Drug Tier Requirements / Limits ibu-200 oral tablet 1 OTC ibuprofen ib oral tablet 1 OTC ibuprofen ib oral tablet,chewable 1 OTC ibuprofen jr strength oral tablet,chewable 1 OTC ibuprofen oral capsule 1 OTC ibuprofen oral suspension 1 ibuprofen oral tablet 200 mg 1 OTC ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 indomethacin oral capsule 1 indomethacin oral capsule, extended release 1 infant pain reliever oral suspension 1 OTC infant's ibuprofen oral drops,suspension 1 OTC infants' pain and fever oral suspension 1 OTC infant's pain relief oral drops,suspension 80 1 OTC mg/0.8 ml infants' pain relief oral suspension 1 OTC ketoprofen oral capsule 50 mg, 75 mg 1 ketoprofen oral capsule,ext rel. pellets 24 hr 200 1 mg ketorolac oral tablet 1 QL little remedies fever and pain oral liquid 1 OTC LUCEMYRA ORAL TABLET 2 PA; QL; SP mapap (acetaminophen) oral capsule 1 OTC mapap (acetaminophen) oral liquid 1 OTC mapap (acetaminophen) oral tablet 1 OTC mapap arthritis pain oral tablet extended release 1 OTC mapap extra strength oral tablet 1 OTC mapap pm oral tablet 1 OTC meclofenamate oral capsule 1 meloxicam oral tablet 1 nabumetone oral tablet 1 NALFON ORAL CAPSULE 400 MG 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations25 on this table mean by going to the beginning of this table. 25 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits naloxone injection solution 1 pentazocine-naloxone oral tablet 1 PA; QL naloxone injection syringe 1 piroxicam oral capsule 1 naltrexone oral tablet 1 salsalate oral tablet 1 naproxen oral suspension 1 st joseph aspirin oral tablet,chewable 1 ACA; OTC naproxen oral tablet 1 SUBOXONE SUBLINGUAL FILM 2 QL naproxen oral tablet,delayed release (dr/ec) 1 sulindac oral tablet 1 naproxen sodium oral capsule 1 OTC tolmetin oral capsule 1 naproxen sodium oral tablet 220 mg 1 OTC tolmetin oral tablet 1 naproxen sodium oral tablet 275 mg, 550 mg 1 tramadol oral tablet 1 PA; QL NARCAN NASAL SPRAY,NON-AEROSOL 4 2 tramadol-acetaminophen oral tablet 1 PA; QL MG/ACTUATION tri-buffered aspirin oral tablet 1 OTC non-aspirin extra strength oral tablet 1 OTC VIVITROL INTRAMUSCULAR 2 QL; SP non-aspirin oral elixir 1 OTC SUSPENSION,EXTENDED REL RECON non-aspirin oral tablet 1 OTC ZUBSOLV SUBLINGUAL TABLET 2 QL non-aspirin pain relief oral tablet 500 mg 1 OTC PSYCHOTHERAPEUTIC DRUGS non-aspirin pm oral tablet 1 OTC ABILIFY MAINTENA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP pain and fever oral tablet 325 mg 1 OTC SUSPENSION,EXTENDED REL RECON pain relief extra strength oral tablet 1 OTC ABILIFY MAINTENA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL SYRING pain relief oral liquid 1 OTC ADDERALL XR ORAL CAPSULE,EXTENDED 2 PA < 4 and ≥ 18 years of age; QL pain relief oral tablet 1 OTC RELEASE 24HR pain relief oral tablet extended release 1 OTC alprazolam intensol oral concentrate 1 pain relief pm oral tablet 1 OTC alprazolam oral tablet 1 pain relief pm rapid release oral tablet 1 OTC alprazolam oral tablet extended release 24 hr 1 pain relief regular strength oral tablet 1 OTC alprazolam oral tablet,disintegrating 1 ST pain reliever (acetam-aspirin) oral tablet 1 OTC amitriptyline oral tablet 1 pain reliever extra strength oral tablet 1 OTC amitriptyline-chlordiazepoxide oral tablet 1 pain reliever oral tablet 325 mg 1 OTC amoxapine oral tablet 1 pain reliever plus oral tablet 1 OTC aripiprazole oral solution 1 PA < 12 years of age; QL pain reliever pm ex-strength oral tablet 1 OTC aripiprazole oral tablet 1 PA < 12 years of age; QL pain reliever pm oral tablet 25-500 mg 1 OTC ARISTADA INITIO INTRAMUSCULAR 2 ST < 12 years of age; QL; SP pain-off oral tablet 1 OTC SUSPENSION,EXTENDED REL SYRING pediacare fever reducer oral suspension 1 OTC ARISTADA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL SYRING You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations26 on this table mean by going to the beginning of this table. 27 26 Drug Name Drug Tier Requirements / Limits pentazocine-naloxone oral tablet 1 PA; QL piroxicam oral capsule 1 salsalate oral tablet 1 st joseph aspirin oral tablet,chewable 1 ACA; OTC SUBOXONE SUBLINGUAL FILM 2 QL sulindac oral tablet 1 tolmetin oral capsule 1 tolmetin oral tablet 1 tramadol oral tablet 1 PA; QL tramadol-acetaminophen oral tablet 1 PA; QL tri-buffered aspirin oral tablet 1 OTC VIVITROL INTRAMUSCULAR 2 QL; SP SUSPENSION,EXTENDED REL RECON ZUBSOLV SUBLINGUAL TABLET 2 QL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL SYRING ADDERALL XR ORAL CAPSULE,EXTENDED 2 PA < 4 and ≥ 18 years of age; QL RELEASE 24HR alprazolam intensol oral concentrate 1 alprazolam oral tablet 1 alprazolam oral tablet extended release 24 hr 1 alprazolam oral tablet,disintegrating 1 ST amitriptyline oral tablet 1 amitriptyline-chlordiazepoxide oral tablet 1 amoxapine oral tablet 1 aripiprazole oral solution 1 PA < 12 years of age; QL aripiprazole oral tablet 1 PA < 12 years of age; QL ARISTADA INITIO INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL SYRING ARISTADA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SUSPENSION,EXTENDED REL SYRING You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations27 on this table mean by going to the beginning of this table. 27 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits armodafinil oral tablet 1 PA; QL escitalopram oxalate oral solution 1 QL atomoxetine oral capsule 1 QL escitalopram oxalate oral tablet 1 QL bupropion hcl oral tablet 1 estazolam oral tablet 1 bupropion hcl oral tablet extended release 24 hr 1 FANAPT ORAL TABLET 2 PA; QL; SP 150 mg, 300 mg fluoxetine oral capsule (generic Prozac) 1 bupropion hcl oral tablet sustained-release 12 hr 1 fluoxetine oral solution 1 buspirone oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg 1 fluoxetine oral tablet 20 mg 1 chlordiazepoxide hcl oral capsule 1 fluphenazine decanoate injection solution 1 PA < 12 years of age chlorpromazine injection solution 1 PA < 12 years of age fluphenazine hcl injection solution 1 PA < 12 years of age chlorpromazine oral tablet 1 PA < 12 years of age fluphenazine hcl oral concentrate 1 PA < 12 years of age citalopram oral solution 1 fluphenazine hcl oral elixir 1 PA < 12 years of age citalopram oral tablet 1 QL fluphenazine hcl oral tablet 1 PA < 12 years of age clorazepate dipotassium oral tablet 1 flurazepam oral capsule 1 clozapine oral tablet 1 PA < 12 years of age fluvoxamine oral tablet 1 clozapine oral tablet,disintegrating 100 mg, 12.5 1 PA < 12 years of age; ST; QL guanfacine oral tablet extended release 24 hr 1 QL mg, 25 mg guanidine oral tablet 1 CLOZAPINE ORAL 2 PA < 12 years of age; ST; QL TABLET,DISINTEGRATING 150 MG, 200 MG haloperidol decanoate intramuscular solution 1 PA < 12 years of age desipramine oral tablet 1 haloperidol lactate injection solution 1 PA < 12 years of age dexmethylphenidate oral capsule,er biphasic 50- 1 PA < 4 and ≥ 18 years of age; QL haloperidol lactate oral concentrate 1 PA < 12 years of age 50 haloperidol oral tablet 1 PA < 12 years of age dexmethylphenidate oral tablet 1 QL HETLIOZ ORAL CAPSULE 2 PA; QL; SP dextroamphetamine oral capsule, extended release 1 PA < 4 and ≥ 18 years of age; QL imipramine hcl oral tablet 1 dextroamphetamine oral tablet 1 PA < 4 and ≥ 18 years of age; QL imipramine pamoate oral capsule 1 dextroamphetamine-amphetamine oral tablet 1 QL INVEGA SUSTENNA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP diazepam intensol oral concentrate 1 SYRINGE diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 INVEGA TRINZA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SYRINGE diazepam oral tablet 1 LATUDA ORAL TABLET 2 PA; QL; SP doxepin oral capsule 1 lithium carbonate oral capsule 1 doxepin oral concentrate 1 lithium carbonate oral tablet 1 duloxetine oral capsule,delayed release(dr/ec) 20 1 QL mg, 30 mg, 60 mg lithium carbonate oral tablet extended release 1 ergoloid oral tablet 1 lithium citrate oral solution 8 meq/5 ml 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations28 on this table mean by going to the beginning of this table. 29 28 Drug Name Drug Tier Requirements / Limits escitalopram oxalate oral solution 1 QL escitalopram oxalate oral tablet 1 QL estazolam oral tablet 1 FANAPT ORAL TABLET 2 PA; QL; SP fluoxetine oral capsule (generic Prozac) 1 fluoxetine oral solution 1 fluoxetine oral tablet 20 mg 1 fluphenazine decanoate injection solution 1 PA < 12 years of age fluphenazine hcl injection solution 1 PA < 12 years of age fluphenazine hcl oral concentrate 1 PA < 12 years of age fluphenazine hcl oral elixir 1 PA < 12 years of age fluphenazine hcl oral tablet 1 PA < 12 years of age flurazepam oral capsule 1 fluvoxamine oral tablet 1 guanfacine oral tablet extended release 24 hr 1 QL guanidine oral tablet 1 haloperidol decanoate intramuscular solution 1 PA < 12 years of age haloperidol lactate injection solution 1 PA < 12 years of age haloperidol lactate oral concentrate 1 PA < 12 years of age haloperidol oral tablet 1 PA < 12 years of age HETLIOZ ORAL CAPSULE 2 PA; QL; SP imipramine hcl oral tablet 1 imipramine pamoate oral capsule 1 INVEGA SUSTENNA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SYRINGE INVEGA TRINZA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SYRINGE LATUDA ORAL TABLET 2 PA; QL; SP lithium carbonate oral capsule 1 lithium carbonate oral tablet 1 lithium carbonate oral tablet extended release 1 lithium citrate oral solution 8 meq/5 ml 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations29 on this table mean by going to the beginning of this table. 29 Drug Name Drug Tier Requirements / Limits lorazepam intensol oral concentrate 1 lorazepam oral concentrate 1 lorazepam oral tablet 1 loxapine succinate oral capsule 1 PA < 12 years of age maprotiline oral tablet 1 MARPLAN ORAL TABLET 2 metadate er oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL methylphenidate hcl oral capsule, er biphasic 30- 1 PA < 4 and ≥ 18 years of age; QL 70 methylphenidate hcl oral capsule,er biphasic 50- 1 PA < 4 and ≥ 18 years of age; QL 50 methylphenidate hcl oral solution 1 PA < 4 and ≥ 18 years of age; QL methylphenidate hcl oral tablet 1 QL methylphenidate hcl oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL methylphenidate hcl oral tablet extended release 1 PA < 4 and ≥ 18 years of age; QL 24hr 18 mg, 27 mg, 36 mg, 54 mg midazolam oral syrup 2 mg/ml 1 mirtazapine oral tablet 1 mirtazapine oral tablet,disintegrating 1 modafinil oral tablet 1 PA; QL MYDAYIS ORAL CAPSULE, ER TRIPHASIC 2 PA < 4 and ≥ 18 years of age; QL 24 HR nefazodone oral tablet 1 nortriptyline oral capsule 1 nortriptyline oral solution 1 NUPLAZID ORAL CAPSULE 2 PA; QL; SP NUPLAZID ORAL TABLET 10 MG 2 PA; QL; SP olanzapine intramuscular recon soln 1 PA < 12 years of age olanzapine oral tablet 1 PA < 12 years of age; QL olanzapine oral tablet,disintegrating 1 PA < 12 years of age; ST; QL olanzapine-fluoxetine oral capsule 1 PA < 12 years of age; ST; QL oxazepam oral capsule 1 paroxetine hcl oral tablet 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations30 on this table mean by going to the beginning of this table. 30 Drug Name Drug Tier Requirements / Limits perphenazine oral tablet 1 PA < 12 years of age perphenazine-amitriptyline oral tablet 1 phenelzine oral tablet 1 pimozide oral tablet 1 PA < 12 years of age protriptyline oral tablet 1 quetiapine oral tablet 1 PA < 12 years of age; QL quetiapine oral tablet extended release 24 hr 150 1 PA; QL mg, 200 mg, 300 mg, 50 mg REXULTI ORAL TABLET 2 PA; QL; SP RISPERDAL CONSTA INTRAMUSCULAR 2 ST < 12 years of age; QL; SP SYRINGE risperidone oral solution 1 PA < 12 years of age; ST risperidone oral tablet 1 PA < 12 years of age; QL risperidone oral tablet,disintegrating 1 PA < 12 years of age; ST; QL SAPHRIS SUBLINGUAL TABLET 2 PA; QL; SP sertraline oral concentrate 1 sertraline oral tablet 1 SPRAVATO NASAL SPRAY,NON-AEROSOL 2 PA; QL; SP 56 MG (28 MG X 2), 84 MG (28 MG X 3) temazepam oral capsule 15 mg, 30 mg 1 thioridazine oral tablet 1 PA < 12 years of age thiothixene oral capsule 1 PA < 12 years of age tranylcypromine oral tablet 1 trazodone oral tablet 1 triazolam oral tablet 1 trifluoperazine oral tablet 1 PA < 12 years of age trimipramine oral capsule 1 venlafaxine oral capsule,extended release 24hr 1 QL venlafaxine oral tablet 1 VRAYLAR ORAL CAPSULE 2 PA; QL; SP VRAYLAR ORAL CAPSULE,DOSE PACK 2 PA; QL; SP VYVANSE ORAL CAPSULE 2 PA < 4 and ≥ 18 years of age; QL VYVANSE ORAL TABLET,CHEWABLE 2 PA < 4 and ≥ 18 years of age; QL You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations31 on this table mean by going to the beginning of this table. 31 Drug Name Drug Tier Requirements / Limits zaleplon oral capsule 1 zenzedi oral tablet 10 mg, 5 mg 1 PA < 4 and ≥ 18 years of age; QL ziprasidone hcl oral capsule 1 PA < 12 years of age; QL zolpidem oral tablet 1 QL CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 200 mg, 400 mg 1 disopyramide phosphate oral capsule 1 dofetilide oral capsule 1 flecainide oral tablet 1 mexiletine oral capsule 1 MULTAQ ORAL TABLET 2 pacerone oral tablet 200 mg 1 propafenone oral capsule,extended release 12 hr 1 propafenone oral tablet 1 quinidine gluconate oral tablet extended release 1 quinidine sulfate oral tablet 1 sotalol af oral tablet 1 sotalol oral tablet 1 ANTIHYPERTENSIVE THERAPY acebutolol oral capsule 1 amiloride oral tablet 1 amiloride-hydrochlorothiazide oral tablet 1 amlodipine oral tablet 1 amlodipine-benazepril oral capsule 1 atenolol oral tablet 1 atenolol-chlorthalidone oral tablet 1 benazepril oral tablet 1 benazepril-hydrochlorothiazide oral tablet 1 betaxolol oral tablet 1 bisoprolol fumarate oral tablet 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations32 on this table mean by going to the beginning of this table. 32 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits zaleplon oral capsule 1 bisoprolol-hydrochlorothiazide oral tablet 1 zenzedi oral tablet 10 mg, 5 mg 1 PA < 4 and ≥ 18 years of age; QL bumetanide oral tablet 1 ziprasidone hcl oral capsule 1 PA < 12 years of age; QL captopril-hydrochlorothiazide oral tablet 1 zolpidem oral tablet 1 QL cartia xt oral capsule,extended release 24hr 1 CARDIOVASCULAR, HYPERTENSION & LIPIDS carvedilol oral tablet 1 ANTIARRHYTHMIC AGENTS chlorothiazide oral tablet 500 mg 1 amiodarone oral tablet 200 mg, 400 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 disopyramide phosphate oral capsule 1 clonidine hcl oral tablet 1 dofetilide oral capsule 1 clonidine transdermal patch weekly 1 flecainide oral tablet 1 DEMSER ORAL CAPSULE 2 PA; SP mexiletine oral capsule 1 diltiazem hcl oral capsule,ext.rel 24h degradable 1 MULTAQ ORAL TABLET 2 diltiazem hcl oral capsule,extended release 12 hr 1 pacerone oral tablet 200 mg 1 diltiazem hcl oral capsule,extended release 24 hr 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg propafenone oral capsule,extended release 12 hr 1 diltiazem hcl oral capsule,extended release 24hr 1 propafenone oral tablet 1 diltiazem hcl oral tablet 1 quinidine gluconate oral tablet extended release 1 diltiazem hcl oral tablet extended release 24 hr 1 quinidine sulfate oral tablet 1 dilt-xr oral capsule,ext.rel 24h degradable 1 sotalol af oral tablet 1 DIURIL ORAL SUSPENSION 2 sotalol oral tablet 1 doxazosin oral tablet 1 ANTIHYPERTENSIVE THERAPY enalapril maleate oral tablet 1 acebutolol oral capsule 1 enalapril-hydrochlorothiazide oral tablet 1 amiloride oral tablet 1 eplerenone oral tablet 1 amiloride-hydrochlorothiazide oral tablet 1 felodipine oral tablet extended release 24 hr 1 amlodipine oral tablet 1 FLOLAN INTRAVENOUS RECON SOLN 2 PA; SP amlodipine-benazepril oral capsule 1 fosinopril oral tablet 1 atenolol oral tablet 1 fosinopril-hydrochlorothiazide oral tablet 1 atenolol-chlorthalidone oral tablet 1 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 benazepril oral tablet 1 mg/ml) benazepril-hydrochlorothiazide oral tablet 1 furosemide oral tablet 1 betaxolol oral tablet 1 guanfacine oral tablet 1 bisoprolol fumarate oral tablet 1 hydralazine oral tablet 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. 32 You can find information on what the symbols and abbreviations33 on this table mean by going to the beginning of this table. 33 Drug Name Drug Tier Requirements / Limits hydrochlorothiazide oral capsule 1 hydrochlorothiazide oral tablet 1 indapamide oral tablet 1 irbesartan oral tablet 1 irbesartan-hydrochlorothiazide oral tablet 1 isradipine oral capsule 1 labetalol oral tablet 1 lisinopril oral tablet 1 lisinopril-hydrochlorothiazide oral tablet 1 losartan oral tablet 1 losartan-hydrochlorothiazide oral tablet 1 matzim la oral tablet extended release 24 hr 1 methyldopa oral tablet 1 methyldopa-hydrochlorothiazide oral tablet 1 metolazone oral tablet 1 metoprolol succinate oral tablet extended release 1 24 hr metoprolol ta-hydrochlorothiaz oral tablet 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 1 mg minoxidil oral tablet 1 moexipril oral tablet 1 nadolol oral tablet 1 nadolol-bendroflumethiazide oral tablet 80-5 mg 1 nicardipine oral capsule 1 nifedipine oral capsule 1 nifedipine oral tablet extended release 1 nifedipine oral tablet extended release 24hr 1 nimodipine oral capsule 1 SP nisoldipine oral tablet extended release 24 hr 20 1 mg, 30 mg, 40 mg ORENITRAM ORAL TABLET EXTENDED 2 PA; SP RELEASE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations34 on this table mean by going to the beginning of this table. 34 Drug Name Drug Tier Requirements / Limits perindopril erbumine oral tablet 1 phenoxybenzamine oral capsule 1 PA; SP pindolol oral tablet 1 prazosin oral capsule 1 propranolol oral solution 1 propranolol oral tablet 1 propranolol-hydrochlorothiazid oral tablet 1 quinapril oral tablet 1 quinapril-hydrochlorothiazide oral tablet 1 ramipril oral capsule 1 spironolactone oral tablet 1 spironolacton-hydrochlorothiaz oral tablet 1 taztia xt oral capsule,extended release 24 hr 1 telmisartan oral tablet 1 telmisartan-amlodipine oral tablet 1 telmisartan-hydrochlorothiazid oral tablet 1 terazosin oral capsule 1 timolol maleate oral tablet 1 torsemide oral tablet 1 trandolapril oral tablet 1 triamterene-hydrochlorothiazid oral capsule 37.5- 1 25 mg triamterene-hydrochlorothiazid oral tablet 1 UPTRAVI ORAL TABLET 2 PA; QL; SP UPTRAVI ORAL TABLETS,DOSE PACK 2 PA; QL; SP valsartan oral tablet 1 valsartan-hydrochlorothiazide oral tablet 1 veletri intravenous recon soln 1 PA; SP verapamil oral capsule, 24 hr er pellet ct 1 verapamil oral capsule,ext rel. pellets 24 hr 1 verapamil oral tablet 1 verapamil oral tablet extended release 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations35 on this table mean by going to the beginning of this table. 35 Drug Name Drug Tier Requirements / Limits CARDIAC GLYCOSIDES digox oral tablet 1 digoxin oral solution 50 mcg/ml (0.05 mg/ml) 1 digoxin oral tablet 1 COAGULATION THERAPY aminocaproic acid intravenous solution 1 SP cilostazol oral tablet 1 clopidogrel oral tablet 1 dipyridamole oral tablet 1 DOPTELET (15 TAB PACK) ORAL TABLET 2 PA; QL; SP ELIQUIS DVT-PE TREAT 30D START ORAL 2 QL TABLETS,DOSE PACK ELIQUIS ORAL TABLET 2 QL enoxaparin subcutaneous solution 1 QL enoxaparin subcutaneous syringe 1 QL fondaparinux subcutaneous syringe 1 QL; SP FRAGMIN SUBCUTANEOUS SOLUTION 2 QL; SP FRAGMIN SUBCUTANEOUS SYRINGE 2 QL; SP heparin (porcine) injection cartridge 1 heparin (porcine) injection solution 1 heparin (porcine) injection syringe 5,000 unit/ml 1 heparin, porcine (pf) injection solution 1 heparin, porcine (pf) injection syringe 5,000 1 unit/0.5 ml jantoven oral tablet 1 MULPLETA ORAL TABLET 2 PA; QL; LA; SP NPLATE SUBCUTANEOUS RECON SOLN 250 2 PA; SP MCG, 500 MCG pentoxifylline oral tablet extended release 1 phytonadione (vitamin k1) oral tablet 5 mg 1 prasugrel oral tablet 1 QL PROMACTA ORAL POWDER IN PACKET 2 PA; QL; SP PROMACTA ORAL TABLET 2 PA; QL; SP You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations36 on this table mean by going to the beginning of this table. 36 Drug Name Drug Tier Requirements / Limits TAVALISSE ORAL TABLET 2 PA; QL; SP warfarin oral tablet 1 XARELTO ORAL TABLET 2 QL XARELTO ORAL TABLETS,DOSE PACK 2 QL ZONTIVITY ORAL TABLET 2 PA; QL LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin oral tablet 1 cholestyramine (with sugar) oral powder 1 cholestyramine (with sugar) oral powder in packet 1 cholestyramine light oral powder 1 cholestyramine light oral powder in packet 1 colestipol oral granules 1 colestipol oral packet 1 colestipol oral tablet 1 ezetimibe oral tablet 1 fenofibrate micronized oral capsule 134 mg, 200 1 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 1 mg fenofibrate oral tablet 160 mg, 54 mg 1 fish oil concentrate oral capsule 1 OTC fluvastatin oral capsule 1 fluvastatin oral tablet extended release 24 hr 1 gemfibrozil oral tablet 1 JUXTAPID ORAL CAPSULE 2 PA; QL; SP lovastatin oral tablet 1 niacin oral capsule, extended release 250 mg, 500 1 OTC mg niacin oral tablet 1 OTC NIACIN ORAL TABLET EXTENDED 2 OTC RELEASE 1,000 MG niacin oral tablet extended release 250 mg, 500 1 OTC mg, 750 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations37 on this table mean by going to the beginning of this table. 37 Drug Name Drug Tier Requirements / Limits omega-3 fatty acids oral capsule 1 OTC PRALUENT PEN SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR pravastatin oral tablet 1 prevalite oral powder 1 prevalite oral powder in packet 1 REPATHA PUSHTRONEX SUBCUTANEOUS 2 PA; QL WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS 2 PA; QL PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS 2 PA; QL SYRINGE rosuvastatin oral tablet 1 simvastatin oral tablet 1 slo-niacin oral tablet extended release 500 mg 1 OTC super omega-3 oral capsule 1,000 mg 1 OTC MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL SOLUTION 2 PA; QL CORLANOR ORAL TABLET 2 PA; QL ENTRESTO ORAL TABLET 2 QL ranolazine oral tablet extended release 12 hr 1 VYNDAMAX ORAL CAPSULE 2 PA; QL; SP VYNDAQEL ORAL CAPSULE 2 PA; QL; SP NITRATES DILATRATE-SR ORAL CAPSULE, 2 EXTENDED RELEASE isosorbide dinitrate oral tablet 1 isosorbide dinitrate oral tablet extended release 1 isosorbide mononitrate oral tablet 1 isosorbide mononitrate oral tablet extended 1 release 24 hr nitro-bid transdermal ointment 1 NITRO-DUR TRANSDERMAL PATCH 24 2 HOUR 0.3 MG/HR, 0.8 MG/HR You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations38 on this table mean by going to the beginning of this table. 38 Drug Name Drug Tier Requirements / Limits nitroglycerin sublingual tablet 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual spray,non-aerosol 1 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 1 PA; SP calcipotriene scalp solution 1 calcipotriene topical 1 calcipotriene topical ointment 1 calcipotriene-betamethasone topical ointment 1 calcitriol topical ointment 1 QL COSENTYX (2 ) SUBCUTANEOUS 2 PA; QL; SP SYRINGE COSENTYX PEN (2 PENS) SUBCUTANEOUS 2 PA; QL; SP PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR COSENTYX SUBCUTANEOUS SYRINGE 2 PA; QL; SP drithocreme hp topical cream 1 selenium sulfide topical 1 selenium sulfide topical 2.25 % 1 SILIQ SUBCUTANEOUS SYRINGE 2 PA; QL; SP SKYRIZI SUBCUTANEOUS SYRINGE KIT 2 PA; QL; SP STELARA SUBCUTANEOUS SOLUTION 2 PA; QL; SP STELARA SUBCUTANEOUS SYRINGE 2 PA; QL; SP TALTZ AUTOINJECTOR (2 PACK) 2 PA; QL; SP SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR (3 PACK) 2 PA; QL; SP SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR SUBCUTANEOUS 2 PA; QL; SP AUTO-INJECTOR TALTZ SYRINGE SUBCUTANEOUS 2 PA; QL; SP SYRINGE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations39 on this table mean by going to the beginning of this table. 39 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits TREMFYA SUBCUTANEOUS AUTO- 2 PA; QL; SP urea topical cream 40 %, 50 % 1 INJECTOR ure-k topical cream 1 TREMFYA SUBCUTANEOUS SYRINGE 2 PA; QL; SP VALCHLOR TOPICAL GEL 2 PA; SP BURN THERAPY XERAC AC TOPICAL SOLUTION 2 OTC silver sulfadiazine topical cream 1 zinc oxide topical ointment 20 % 1 OTC ssd topical cream 1 THERAPY FOR ACNE KERATOLYTICS amnesteem oral capsule 1 PODOCON TOPICAL LIQUID 2 benzoyl peroxide topical cleanser 10 %, 5 %, 6 % 1 OTC rapid clear treatment pads topical pads, medicated 1 OTC benzoyl peroxide topical gel 10 %, 2.5 %, 5 % 1 OTC salicylic acid topical gel 1 bp topical gel 1 OTC salicylic acid topical lotion 1 bpo-10 topical cleanser 1 OTC salicylic acid topical lotion,extended release 1 bpo-5 topical cleanser 1 OTC salicylic acid topical shampoo 1 claravis oral capsule 1 wart remover topical liquid 1 OTC clindacin p topical swab 1 MISCELLANEOUS DERMATOLOGICALS clindamycin phosphate topical foam 1 ammonium lactate topical cream 1 clindamycin phosphate topical gel 1 ammonium lactate topical lotion 1 clindamycin phosphate topical lotion 1 CONDYLOX TOPICAL GEL 2 clindamycin phosphate topical solution 1 DUPIXENT SUBCUTANEOUS SYRINGE 2 PA; QL; SP clindamycin phosphate topical swab 1 EUCRISA TOPICAL OINTMENT 2 PA; QL ery pads topical swab 1 fluorouracil topical cream 5 % 1 erygel topical gel 1 fluorouracil topical solution 1 erythromycin with ethanol topical gel 1 methoxsalen oral capsule,liqd-filled,rapid rel 1 PA; SP erythromycin with ethanol topical solution 1 PANRETIN TOPICAL GEL 2 PA; SP erythromycin-benzoyl peroxide topical gel 1 pimecrolimus topical cream 1 PA; QL isotretinoin oral capsule 1 podofilox topical solution 1 metronidazole topical cream 1 pruclair topical cream 1 metronidazole topical gel 0.75 % 1 REGRANEX TOPICAL GEL 2 PA; QL; SP metronidazole topical lotion 1 silver nitrate applicators topical stick 1 myorisan oral capsule 1 silver nitrate topical solution 1 panoxyl topical cleanser 1 OTC tacrolimus topical ointment 1 PA sulfacetamide sodium-sulfur topical cleanser 10-5 1 urea nail stick topical solution 1 % (w/w) You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations40 on this table mean by going to the beginning of this table. 41 40 Drug Name Drug Tier Requirements / Limits urea topical cream 40 %, 50 % 1 ure-k topical cream 1 VALCHLOR TOPICAL GEL 2 PA; SP XERAC AC TOPICAL SOLUTION 2 OTC zinc oxide topical ointment 20 % 1 OTC THERAPY FOR ACNE amnesteem oral capsule 1 benzoyl peroxide topical cleanser 10 %, 5 %, 6 % 1 OTC benzoyl peroxide topical gel 10 %, 2.5 %, 5 % 1 OTC bp topical gel 1 OTC bpo-10 topical cleanser 1 OTC bpo-5 topical cleanser 1 OTC claravis oral capsule 1 clindacin p topical swab 1 clindamycin phosphate topical foam 1 clindamycin phosphate topical gel 1 clindamycin phosphate topical lotion 1 clindamycin phosphate topical solution 1 clindamycin phosphate topical swab 1 ery pads topical swab 1 erygel topical gel 1 erythromycin with ethanol topical gel 1 erythromycin with ethanol topical solution 1 erythromycin-benzoyl peroxide topical gel 1 isotretinoin oral capsule 1 metronidazole topical cream 1 metronidazole topical gel 0.75 % 1 metronidazole topical lotion 1 myorisan oral capsule 1 panoxyl topical cleanser 1 OTC sulfacetamide sodium-sulfur topical cleanser 10-5 1 % (w/w)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations41 on this table mean by going to the beginning of this table. 41 Drug Name Drug Tier Requirements / Limits tretinoin topical cream 1 tretinoin topical gel 0.01 %, 0.025 % 1 zenatane oral capsule 1 TOPICAL ANESTHETICS ASPERCREME (LIDOCAINE) TOPICAL 2 OTC; QL ADHESIVE PATCH,MEDICATED ASPERCREME (LIDOCAINE) TOPICAL 2 OTC; QL CREAM glydo mucous membrane jelly in applicator 1 lc-4 topical cream 1 OTC; QL lc-5 topical cream 1 OTC lidocaine hcl mucous membrane jelly 1 lidocaine hcl mucous membrane jelly in applicator 1 lidocaine hcl mucous membrane solution 4 % (40 1 mg/ml) lidocaine hcl topical cream 3 % 1 LIDOCAINE HCL TOPICAL CREAM 4 % 2 OTC; QL lidocaine hcl-hydrocortison ac topical cream 1 lidocaine topical adhesive patch,medicated 5 % 1 PA; QL LIDOCAINE TOPICAL CREAM 4 % 2 OTC; QL lidocaine viscous mucous membrane solution 1 lidocaine-prilocaine topical cream 1 lidocaine-prilocaine topical kit 1 LIDOCARE TOPICAL ADHESIVE 2 OTC; QL PATCH,MEDICATED lido-k topical lotion 1 LMX 4 TOPICAL CREAM 2 OTC; QL LMX 5 TOPICAL CREAM 2 OTC RECTICARE TOPICAL CREAM 2 OTC XOLIDO XP TOPICAL CREAM 2 OTC; QL TOPICAL ANTIBACTERIALS antibiotic (bacitracin zinc) topical ointment 1 OTC bacitracin topical ointment 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations42 on this table mean by going to the beginning of this table. 42 Drug Name Drug Tier Requirements / Limits gentamicin topical cream 1 gentamicin topical ointment 1 mafenide acetate topical packet 1 mupirocin topical ointment 1 sulfacetamide sodium (acne) topical suspension 1 TOPICAL ANTIFUNGALS antifungal (tolnaftate) topical aerosol,spray 1 OTC antifungal (tolnaftate) topical cream 1 OTC antifungal (tolnaftate) topical powder 1 OTC antifungal cream (miconazole) topical cream 1 OTC antifungal spray topical aerosol powder 1 OTC anti-fungal topical powder 1 OTC ciclodan topical cream 1 ciclopirox topical cream 1 ciclopirox topical gel 1 ciclopirox topical solution 1 ciclopirox topical suspension 1 clotrimazole topical cream 1 clotrimazole topical solution 1 clotrimazole-betamethasone topical cream 1 clotrimazole-betamethasone topical lotion 1 econazole topical cream 1 ketoconazole topical cream 1 ketoconazole topical shampoo 1 lamisil af topical aerosol powder 1 OTC lamisil at topical cream 1 OTC miconazole nitrate topical aerosol powder 1 OTC miconazole nitrate topical cream 1 OTC NIZORAL A-D TOPICAL SHAMPOO 2 OTC nyamyc topical powder 1 nystatin topical cream 1 nystatin topical ointment 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations43 on this table mean by going to the beginning of this table. 43 Drug Name Drug Tier Requirements / Limits nystatin topical powder 1 nystatin-triamcinolone topical cream 1 nystatin-triamcinolone topical ointment 1 nystop topical powder 1 terbinafine hcl topical cream 1 OTC tolnaftate topical cream 1 OTC tolnaftate topical powder 1 OTC TOPICAL ANTIVIRALS acyclovir topical ointment 1 TOPICAL CORTICOSTEROIDS alclometasone topical cream 1 alclometasone topical ointment 1 amcinonide topical cream 1 amcinonide topical lotion 1 amcinonide topical ointment 1 betamethasone dipropionate topical cream 1 betamethasone dipropionate topical lotion 1 betamethasone dipropionate topical ointment 1 betamethasone valerate topical cream 1 betamethasone valerate topical lotion 1 betamethasone valerate topical ointment 1 betamethasone, augmented topical cream 1 betamethasone, augmented topical gel 1 betamethasone, augmented topical lotion 1 betamethasone, augmented topical ointment 1 clobetasol scalp solution 1 clobetasol topical cream 1 clobetasol topical gel 1 clobetasol topical ointment 1 clobetasol-emollient topical cream 1 cormax scalp solution 1 desonide topical cream 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations44 on this table mean by going to the beginning of this table. 44 Drug Name Drug Tier Requirements / Limits desonide topical lotion 1 desonide topical ointment 1 desoximetasone topical cream 1 desoximetasone topical gel 1 desoximetasone topical ointment 0.25 % 1 diflorasone topical cream 1 diflorasone topical ointment 1 fluocinolone and shower cap scalp oil 1 fluocinolone topical cream 1 fluocinolone topical oil 1 fluocinolone topical ointment 1 fluocinolone topical solution 1 fluocinonide topical cream 0.05 % 1 fluocinonide topical gel 1 fluocinonide topical ointment 1 fluocinonide topical solution 1 fluocinonide-e topical cream 1 fluticasone propionate topical cream 1 fluticasone propionate topical ointment 1 halobetasol propionate topical cream 1 halobetasol propionate topical ointment 1 hydrocortisone acetate topical cream 1 OTC hydrocortisone acetate topical ointment 1 OTC hydrocortisone butyrate topical cream 1 hydrocortisone butyrate topical ointment 1 hydrocortisone butyrate topical solution 1 hydrocortisone plus topical cream 1 OTC hydrocortisone topical cream 0.5 % 1 OTC hydrocortisone topical cream 1 %, 2.5 % 1 hydrocortisone topical lotion 1 % 1 OTC hydrocortisone topical lotion 2.5 % 1 hydrocortisone topical ointment 0.5 % 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations45 on this table mean by going to the beginning of this table. 45 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits hydrocortisone topical ointment 1 %, 2.5 % 1 MISCELLANEOUS AGENTS hydrocortisone valerate topical cream 1 acamprosate oral tablet,delayed release (dr/ec) 1 hydrocortisone valerate topical ointment 1 anagrelide oral capsule 1 hydrocortisone-aloe vera topical cream 1 % 1 OTC ARALAST NP INTRAVENOUS RECON SOLN 2 PA; SP mometasone topical cream 1 CARBAGLU ORAL TABLET, DISPERSIBLE 2 PA; SP mometasone topical ointment 1 cevimeline oral capsule 1 mometasone topical solution 1 CHEMET ORAL CAPSULE 2 SP prednicarbate topical cream 1 deferasirox oral tablet, dispersible 1 PA; SP prednicarbate topical ointment 1 disulfiram oral tablet 1 scalacort topical lotion 1 ENDARI ORAL POWDER IN PACKET 2 PA; QL; SP triamcinolone acetonide topical aerosol 1 etidronate disodium oral tablet 200 mg 1 triamcinolone acetonide topical cream 1 GLASSIA INTRAVENOUS SOLUTION 2 PA; SP triamcinolone acetonide topical lotion 1 glucose oral tablet,chewable 4 gram 1 OTC triamcinolone acetonide topical ointment 0.025 %, 1 INCRELEX SUBCUTANEOUS SOLUTION 2 PA; SP 0.1 %, 0.5 % JADENU ORAL TABLET 2 PA; SP triderm topical cream 1 JADENU SPRINKLE ORAL GRANULES IN 2 PA; SP TOPICAL ENZYMES PACKET SANTYL TOPICAL OINTMENT 2 PA levocarnitine (with sugar) oral solution 1 TOPICAL SCABICIDES / PEDICULICIDES levocarnitine oral tablet 1 EURAX TOPICAL CREAM 2 little remedies nasal aerosol,spray 1 OTC EURAX TOPICAL LOTION 2 MELATONIN ORAL 2 OTC TABLET,DISINTEGRATING 5 MG lice killing topical shampoo 1 OTC midodrine oral tablet 1 lice solution topical kit 1 OTC NITYR ORAL TABLET 2 PA; SP lice treatment (permethrin) topical liquid 1 OTC NORTHERA ORAL CAPSULE 2 PA; QL; SP lice treatment topical liquid 1 % 1 OTC ORFADIN ORAL CAPSULE 20 MG 2 PA; SP lice treatment topical shampoo 1 OTC ORFADIN ORAL SUSPENSION 2 PA; SP lindane topical shampoo 1 pilocarpine hcl oral tablet 5 mg 1 malathion topical lotion 1 PROLASTIN-C INTRAVENOUS RECON SOLN 2 PA; SP permethrin topical cream 1 PROLASTIN-C INTRAVENOUS SOLUTION 2 PA; SP rid complete lice elim kit topical kit 1 OTC RAVICTI ORAL LIQUID 2 PA; QL; SP spinosad topical suspension 1 REVCOVI INTRAMUSCULAR SOLUTION 2 PA; SP DIAGNOSTICS & MISCELLANEOUS AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations46 on this table mean by going to the beginning of this table. 47 46 Drug Name Drug Tier Requirements / Limits MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 1 anagrelide oral capsule 1 ARALAST NP INTRAVENOUS RECON SOLN 2 PA; SP CARBAGLU ORAL TABLET, DISPERSIBLE 2 PA; SP cevimeline oral capsule 1 CHEMET ORAL CAPSULE 2 SP deferasirox oral tablet, dispersible 1 PA; SP disulfiram oral tablet 1 ENDARI ORAL POWDER IN PACKET 2 PA; QL; SP etidronate disodium oral tablet 200 mg 1 GLASSIA INTRAVENOUS SOLUTION 2 PA; SP glucose oral tablet,chewable 4 gram 1 OTC INCRELEX SUBCUTANEOUS SOLUTION 2 PA; SP JADENU ORAL TABLET 2 PA; SP JADENU SPRINKLE ORAL GRANULES IN 2 PA; SP PACKET levocarnitine (with sugar) oral solution 1 levocarnitine oral tablet 1 little remedies nasal aerosol,spray 1 OTC MELATONIN ORAL 2 OTC TABLET,DISINTEGRATING 5 MG midodrine oral tablet 1 NITYR ORAL TABLET 2 PA; SP NORTHERA ORAL CAPSULE 2 PA; QL; SP ORFADIN ORAL CAPSULE 20 MG 2 PA; SP ORFADIN ORAL SUSPENSION 2 PA; SP pilocarpine hcl oral tablet 5 mg 1 PROLASTIN-C INTRAVENOUS RECON SOLN 2 PA; SP PROLASTIN-C INTRAVENOUS SOLUTION 2 PA; SP RAVICTI ORAL LIQUID 2 PA; QL; SP REVCOVI INTRAMUSCULAR SOLUTION 2 PA; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations47 on this table mean by going to the beginning of this table. 47 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits riluzole oral tablet 1 PA; QL denta 5000 plus dental cream 1 sodium ferric gluconat-sucrose intravenous 1 dentagel dental gel 1 solution ipratropium bromide nasal spray,non-aerosol 1 sodium phenylbutyrate oral powder 1 PA; SP oralone dental 1 sodium phenylbutyrate oral tablet 1 PA; SP paroex oral rinse mucous membrane 1 SOLIRIS INTRAVENOUS SOLUTION 2 PA; SP pilocarpine hcl oral tablet 7.5 mg 1 THIOLA ORAL TABLET 2 PA; SP sf 5000 plus dental cream 1 trientine oral capsule 1 PA; SP sf dental gel 1 ZEMAIRA INTRAVENOUS RECON SOLN 2 PA; SP triamcinolone acetonide dental paste 1 zoledronic acid-mannitol-water intravenous 1 QL piggyback 5 mg/100 ml MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 1 SMOKING DETERRENTS ciprofloxacin hcl otic (ear) dropperette 1 bupropion hcl (smoking deter) oral tablet extended 1 ACA; QL release 12 hr fluocinolone acetonide oil otic (ear) drops 1 CHANTIX CONTINUING MONTH BOX ORAL 2 ACA; QL hydrocortisone-acetic acid otic (ear) drops 1 TABLET ofloxacin otic (ear) drops 1 CHANTIX ORAL TABLET 2 ACA; QL OTIC STEROID / ANTIBIOTIC CHANTIX STARTING MONTH BOX ORAL 2 ACA; QL CIPRO HC OTIC (EAR) DROPS,SUSPENSION 2 TABLETS,DOSE PACK CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2 nicorelief buccal gum 1 ACA; OTC; QL COLY-MYCIN S OTIC (EAR) 2 nicorette buccal gum 4 mg 1 ACA; OTC; QL DROPS,SUSPENSION nicotine (polacrilex) buccal mini lozenge 1 ACA; OTC; QL CORTISPORIN-TC OTIC (EAR) 2 nicotine transdermal patch, td daily, sequential 1 ACA; OTC; QL DROPS,SUSPENSION NICOTROL INHALATION CARTRIDGE 2 ACA; QL neomycin-polymyxin-hc otic (ear) 1 NICOTROL NS NASAL SPRAY,NON- 2 ACA; QL drops,suspension AEROSOL neomycin-polymyxin-hc otic (ear) solution 1 quit 2 buccal gum 1 ACA; OTC; QL ENDOCRINE/DIABETES quit 4 buccal gum 1 ACA; OTC; QL ADRENAL HORMONES EAR, NOSE & THROAT MEDICATIONS ACTHAR INJECTION GEL 2 PA; QL; SP MISCELLANEOUS AGENTS cortisone oral tablet 1 azelastine nasal aerosol,spray 1 decadron oral tablet 1 azelastine nasal spray,non-aerosol 1 dexamethasone intensol oral drops 1 chlorhexidine gluconate mucous membrane 1 dexamethasone oral elixir 1 mouthwash You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations48 on this table mean by going to the beginning of this table. 49 48 Drug Name Drug Tier Requirements / Limits denta 5000 plus dental cream 1 dentagel dental gel 1 ipratropium bromide nasal spray,non-aerosol 1 oralone dental paste 1 paroex oral rinse mucous membrane mouthwash 1 pilocarpine hcl oral tablet 7.5 mg 1 sf 5000 plus dental cream 1 sf dental gel 1 triamcinolone acetonide dental paste 1 MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 1 ciprofloxacin hcl otic (ear) dropperette 1 fluocinolone acetonide oil otic (ear) drops 1 hydrocortisone-acetic acid otic (ear) drops 1 ofloxacin otic (ear) drops 1 OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC (EAR) DROPS,SUSPENSION 2 CIPRODEX OTIC (EAR) DROPS,SUSPENSION 2 COLY-MYCIN S OTIC (EAR) 2 DROPS,SUSPENSION CORTISPORIN-TC OTIC (EAR) 2 DROPS,SUSPENSION neomycin-polymyxin-hc otic (ear) 1 drops,suspension neomycin-polymyxin-hc otic (ear) solution 1 ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR INJECTION GEL 2 PA; QL; SP cortisone oral tablet 1 decadron oral tablet 1 dexamethasone intensol oral drops 1 dexamethasone oral elixir 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations49 on this table mean by going to the beginning of this table. 49 Drug Name Drug Tier Requirements / Limits dexamethasone oral solution 1 dexamethasone oral tablet 1 dexamethasone sodium phos (pf) injection solution 1 dexamethasone sodium phosphate injection 1 solution EMFLAZA ORAL SUSPENSION 2 PA; SP EMFLAZA ORAL TABLET 2 PA; SP fludrocortisone oral tablet 1 hydrocortisone oral tablet 1 KENALOG INJECTION SUSPENSION 10 2 MG/ML methylprednisolone acetate injection suspension 1 methylprednisolone oral tablet 1 methylprednisolone oral tablets,dose pack 1 prednisolone oral solution 15 mg/5 ml 1 prednisolone sodium phosphate oral solution 15 1 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone intensol oral concentrate 1 prednisone oral solution 1 prednisone oral tablet 1 prednisone oral tablets,dose pack 1 triamcinolone acetonide injection suspension 1 ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 1 SSKI ORAL SOLUTION 2 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ONETOUCH ULTRA BLUE TEST STRIP 2 OTC; QL ONETOUCH VERIO STRIP 2 OTC; QL DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT SYRINGE-NEEDLE U-100 SYRINGE 2 0.5 ML 29 GAUGE X 1/2"

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations50 on this table mean by going to the beginning of this table. 50 Drug Name Drug Tier Requirements / Limits senna oral tablet 1 OTC senna plus oral tablet 1 OTC senna-s oral tablet 1 OTC senno oral tablet 1 OTC sennosides-docusate sodium oral tablet 1 OTC sevelamer carbonate oral powder in packet 1 sevelamer carbonate oral tablet 1 sodium bicarbonate oral tablet 1 OTC sodium polystyrene sulfonate oral powder 1 sodium polystyrene sulfonate oral suspension 1 sps (with sorbitol) oral suspension 1 SUCRAID ORAL SOLUTION 2 PA; SP sulfasalazine oral tablet 1 sulfasalazine oral tablet,delayed release (dr/ec) 1 trilyte with flavor packets oral recon soln 1 trimethobenzamide oral capsule 1 ursodiol oral capsule 1 ursodiol oral tablet 1 VELTASSA ORAL POWDER IN PACKET 2 PA; QL; SP VIBERZI ORAL TABLET 2 PA; QL; SP ZELNORM ORAL TABLET 2 PA; QL ULCER THERAPY CARAFATE ORAL SUSPENSION 2 cimetidine hcl oral solution 1 cimetidine oral tablet 1 famotidine oral suspension 1 famotidine oral tablet 10 mg 1 OTC famotidine oral tablet 20 mg, 40 mg 1 heartburn relief (famotidine) oral tablet 10 mg 1 OTC heartburn relief (ranitidine) oral tablet 75 mg 1 OTC lansoprazole oral capsule,delayed release(dr/ec) 1 QL misoprostol oral tablet 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations61 on this table mean by going to the beginning of this table. 51 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits HUMALOG U-100 INSULIN SUBCUTANEOUS 2 QL danazol oral capsule 1 PA CARTRIDGE DEPO-TESTOSTERONE INTRAMUSCULAR 2 PA HUMALOG U-100 INSULIN SUBCUTANEOUS 2 QL OIL 100 MG/ML SOLUTION desmopressin nasal spray,non-aerosol 1 HUMULIN 70/30 U-100 INSULIN 2 QL desmopressin oral tablet 1 SUBCUTANEOUS SUSPENSION doxercalciferol oral capsule 1 HUMULIN 70/30 U-100 KWIKPEN 2 QL SUBCUTANEOUS INSULIN PEN ELAPRASE INTRAVENOUS SOLUTION 2 PA; SP HUMULIN N NPH INSULIN KWIKPEN 2 QL ELELYSO INTRAVENOUS RECON SOLN 2 PA; SP SUBCUTANEOUS INSULIN PEN FABRAZYME INTRAVENOUS RECON SOLN 2 PA; SP HUMULIN N NPH U-100 INSULIN 2 QL GALAFOLD ORAL CAPSULE 2 PA; QL; SP SUBCUTANEOUS SUSPENSION JYNARQUE ORAL TABLETS, SEQUENTIAL 2 PA; QL; SP HUMULIN R REGULAR U-100 INSULN 2 QL INJECTION SOLUTION KANUMA INTRAVENOUS SOLUTION 2 PA; SP HUMULIN R U-500 (CONC) INSULIN 2 QL KORLYM ORAL TABLET 2 PA; QL; SP SUBCUTANEOUS SOLUTION KUVAN ORAL POWDER IN PACKET 2 PA; SP HUMULIN R U-500 (CONC) KWIKPEN 2 QL KUVAN ORAL TABLET,SOLUBLE 2 PA; SP SUBCUTANEOUS INSULIN PEN LUMIZYME INTRAVENOUS RECON SOLN 2 PA; SP LANTUS SOLOSTAR U-100 INSULIN 2 QL SUBCUTANEOUS INSULIN PEN MEPSEVII INTRAVENOUS SOLUTION 2 PA; SP LANTUS U-100 INSULIN SUBCUTANEOUS 2 QL METHITEST ORAL TABLET 2 PA; SP SOLUTION miglustat oral capsule 1 PA; SP XULTOPHY 100/3.6 SUBCUTANEOUS 2 QL MYALEPT SUBCUTANEOUS RECON SOLN 2 PA; QL; SP INSULIN PEN NAGLAZYME INTRAVENOUS SOLUTION 2 PA; SP MISCELLANEOUS HORMONES NATPARA SUBCUTANEOUS CARTRIDGE 2 PA; QL; SP ALDURAZYME INTRAVENOUS SOLUTION 2 PA; SP NOCDURNA SUBLINGUAL 2 PA BRINEURA INTRAVENTRICULAR KIT 2 PA TABLET,DISINTEGRATING cabergoline oral tablet 1 NOCTIVA NASAL SPRAY,NON-AEROSOL 2 PA; QL calcitonin (salmon) nasal spray,non-aerosol 1 ORILISSA ORAL TABLET 2 PA; QL; SP calcitriol oral capsule 1 PALYNZIQ SUBCUTANEOUS SYRINGE 2 PA; QL; SP calcitriol oral solution 1 SAMSCA ORAL TABLET 2 PA; QL; SP CERDELGA ORAL CAPSULE 2 PA; SP SOMAVERT SUBCUTANEOUS RECON SOLN 2 PA; QL; SP CEREZYME INTRAVENOUS RECON SOLN 2 PA; SP STIMATE NASAL SPRAY,NON-AEROSOL 2 SP 400 UNIT STRENSIQ SUBCUTANEOUS SOLUTION 2 PA; SP cinacalcet oral tablet 1 SP SYNAREL NASAL SPRAY,NON-AEROSOL 2 PA; QL; SP CRYSVITA SUBCUTANEOUS SOLUTION 2 PA; QL; SP You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations52 on this table mean by going to the beginning of this table. 53 52 Drug Name Drug Tier Requirements / Limits danazol oral capsule 1 PA DEPO-TESTOSTERONE INTRAMUSCULAR 2 PA OIL 100 MG/ML desmopressin nasal spray,non-aerosol 1 desmopressin oral tablet 1 doxercalciferol oral capsule 1 ELAPRASE INTRAVENOUS SOLUTION 2 PA; SP ELELYSO INTRAVENOUS RECON SOLN 2 PA; SP FABRAZYME INTRAVENOUS RECON SOLN 2 PA; SP GALAFOLD ORAL CAPSULE 2 PA; QL; SP JYNARQUE ORAL TABLETS, SEQUENTIAL 2 PA; QL; SP KANUMA INTRAVENOUS SOLUTION 2 PA; SP KORLYM ORAL TABLET 2 PA; QL; SP KUVAN ORAL POWDER IN PACKET 2 PA; SP KUVAN ORAL TABLET,SOLUBLE 2 PA; SP LUMIZYME INTRAVENOUS RECON SOLN 2 PA; SP MEPSEVII INTRAVENOUS SOLUTION 2 PA; SP METHITEST ORAL TABLET 2 PA; SP miglustat oral capsule 1 PA; SP MYALEPT SUBCUTANEOUS RECON SOLN 2 PA; QL; SP NAGLAZYME INTRAVENOUS SOLUTION 2 PA; SP NATPARA SUBCUTANEOUS CARTRIDGE 2 PA; QL; SP NOCDURNA SUBLINGUAL 2 PA TABLET,DISINTEGRATING NOCTIVA NASAL SPRAY,NON-AEROSOL 2 PA; QL ORILISSA ORAL TABLET 2 PA; QL; SP PALYNZIQ SUBCUTANEOUS SYRINGE 2 PA; QL; SP SAMSCA ORAL TABLET 2 PA; QL; SP SOMAVERT SUBCUTANEOUS RECON SOLN 2 PA; QL; SP STIMATE NASAL SPRAY,NON-AEROSOL 2 SP STRENSIQ SUBCUTANEOUS SOLUTION 2 PA; SP SYNAREL NASAL SPRAY,NON-AEROSOL 2 PA; QL; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations53 on this table mean by going to the beginning of this table. 53 Drug Name Drug Tier Requirements / Limits testosterone cypionate intramuscular oil 100 1 PA mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 1 PA testosterone transdermal gel 1 PA testosterone transdermal gel in metered-dose 1 PA pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 1 PA mg/2.5gram), 1 % (50 mg/5 gram) VIMIZIM INTRAVENOUS SOLUTION 2 PA; SP VPRIV INTRAVENOUS RECON SOLN 2 PA; SP zoledronic acid intravenous recon soln 1 SP zoledronic acid intravenous solution 1 SP zoledronic acid-mannitol-water intravenous 1 SP piggyback 4 mg/100 ml NON-INSULIN HYPOGLYCEMIC AGENTS acarbose oral tablet 1 ALOGLIPTIN ORAL TABLET 2 ST; QL ALOGLIPTIN-METFORMIN ORAL TABLET 2 QL ALOGLIPTIN-PIOGLITAZONE ORAL 2 ST; QL TABLET AVANDIA ORAL TABLET 2 MG, 4 MG 2 ST glimepiride oral tablet 1 glipizide oral tablet 1 glipizide oral tablet extended release 24hr 1 glipizide-metformin oral tablet 1 glyburide micronized oral tablet 1 glyburide oral tablet 1 glyburide-metformin oral tablet 1 metformin oral tablet 1 metformin oral tablet extended release 24 hr 1 (generic Glucophage XR) nateglinide oral tablet 1 OZEMPIC SUBCUTANEOUS PEN INJECTOR 2 QL pioglitazone oral tablet 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations54 on this table mean by going to the beginning of this table. 54 Drug Name Drug Tier Requirements / Limits pioglitazone-glimepiride oral tablet 1 pioglitazone-metformin oral tablet 1 repaglinide oral tablet 1 RIOMET ORAL SOLUTION 2 SEGLUROMET ORAL TABLET 2 QL STEGLATRO ORAL TABLET 2 ST; QL SYMLINPEN 120 SUBCUTANEOUS PEN 2 ST; QL INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN 2 ST; QL INJECTOR TRULICITY SUBCUTANEOUS PEN 2 QL INJECTOR VICTOZA 2-PAK SUBCUTANEOUS PEN 2 QL INJECTOR VICTOZA 3-PAK SUBCUTANEOUS PEN 2 QL INJECTOR THYROID HORMONES ARMOUR THYROID ORAL TABLET 2 levothyroxine oral tablet 1 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 1 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 1 nature-throid oral tablet 1 np thyroid oral tablet 1 thyroid (pork) oral tablet 1 THYROLAR-1 ORAL TABLET 2 THYROLAR-1/2 ORAL TABLET 2 THYROLAR-1/4 ORAL TABLET 2 THYROLAR-2 ORAL TABLET 2 THYROLAR-3 ORAL TABLET 2 unithroid oral tablet 1 westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 1 mg, 97.5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations55 on this table mean by going to the beginning of this table. 55 Drug Name Drug Tier Requirements / Limits GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS belladonna alkaloids-opium rectal suppository 1 PA dicyclomine oral capsule 1 dicyclomine oral solution 1 dicyclomine oral tablet 1 diphenoxylate- oral liquid 1 diphenoxylate-atropine oral tablet 1 ed-spaz oral tablet,disintegrating 1 glycopyrrolate oral tablet 1 mg, 2 mg 1 loperamide oral capsule 1 QL methscopolamine oral tablet 1 MYTESI ORAL TABLET,DELAYED RELEASE 2 PA; QL; SP (DR/EC) paregoric oral liquid 1 peptic relief oral tablet,chewable 1 OTC propantheline oral tablet 1 MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO (FOSNETUPITANT) 2 INTRAVENOUS RECON SOLN AKYNZEO (NETUPITANT) ORAL CAPSULE 2 QL alosetron oral tablet 1 PA; QL; SP antacid (calcium carb-mag hyd) oral 1 OTC tablet,chewable 550-110 mg antacid anti-gas oral suspension 1 OTC antacid exst (mag carb-al hyd) oral 1 OTC tablet,chewable antacid extra-strength oral suspension 200-200-20 1 OTC mg/5 ml antacid maximum strength oral suspension 1 OTC antacid oral suspension 1 OTC antacid plus anti-gas oral suspension 1 OTC antacid regular strength oral suspension 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations56 on this table mean by going to the beginning of this table. 56 Drug Name Drug Tier Requirements / Limits antacid-antigas oral suspension 1 OTC antacid-simethicone oral suspension 1 OTC aprepitant oral capsule 1 QL aprepitant oral capsule,dose pack 1 QL balsalazide oral capsule 1 bisacodyl oral tablet,delayed release (dr/ec) 1 OTC bisacodyl rectal suppository 1 OTC bisa-lax oral tablet,delayed release (dr/ec) 1 OTC budesonide oral capsule,delayed,extend.release 1 budesonide oral tablet,delayed and ext.release 1 PA calcium acetate oral capsule 1 calcium acetate oral tablet 667 mg 1 children's pepto oral tablet,chewable 1 OTC CIMZIA SUBCUTANEOUS SYRINGE KIT 2 PA; QL; SP citrate of magnesia oral solution 1 OTC citroma oral solution 1 OTC citrucel oral tablet 1 OTC CITRUCEL SUGAR FREE ORAL POWDER 2 OTC clearlax oral powder in packet 1 OTC col-rite oral capsule 250 mg 1 OTC compro rectal suppository 1 constulose oral solution 1 CREON ORAL CAPSULE,DELAYED 2 RELEASE(DR/EC) cromolyn oral concentrate 1 SP CYSTADANE ORAL POWDER 2 PA; SP dairy relief oral tablet 3,000 unit 1 OTC dimenhydrinate oral tablet 1 OTC docusate calcium oral capsule 1 OTC docusate sodium oral capsule 1 OTC docusate sodium oral liquid 1 OTC docusate sodium oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations57 on this table mean by going to the beginning of this table. 57 Drug Name Drug Tier Requirements / Limits docusil oral capsule 1 OTC DOCUSOL RECTAL 2 OTC dronabinol oral capsule 1 droperidol injection solution 1 ducodyl oral tablet,delayed release (dr/ec) 1 OTC dulcoease oral capsule 1 OTC dulcolax stool softener (dss) oral capsule 1 OTC enulose oral solution 1 fiber (calcium polycarbophil) oral tablet 1 OTC fiber (dextrin) oral powder 1 OTC fiber (psyllium husk/sugar) oral powder 1 OTC fiber (with aspartame) oral powder 3.4 gram/5.8 1 OTC gram fiber laxative (ca polycarbo) oral tablet 1 OTC fiber laxative (methylcellulo) oral tablet 1 OTC fiber oral powder 1 OTC fiber smooth (sucrose) oral powder 1 OTC fiber smooth oral powder 1 OTC fiber therapy (m-cell/sugar) oral powder 2 1 OTC gram/19 gram fiber therapy (m-cellulose) oral tablet 1 OTC fiber-lax oral tablet 1 OTC fiber-tabs oral tablet 1 OTC FLEET BISACODYL RECTAL ENEMA 2 OTC fleet enema rectal enema 1 OTC fleet glycerin (adult) rectal suppository 1 OTC fleet laxative oral tablet,delayed release (dr/ec) 1 OTC gas relief 80 oral tablet,chewable 1 OTC gas relief extra strength oral capsule 1 OTC gas relief extra strength oral tablet,chewable 1 OTC gas relief oral capsule 125 mg 1 OTC gas relief oral drops,suspension 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations58 on this table mean by going to the beginning of this table. 58 Drug Name Drug Tier Requirements / Limits gas relief oral tablet,chewable 80 mg 1 OTC GATTEX 30-VIAL SUBCUTANEOUS KIT 2 PA; QL; SP gavilax oral powder 1 OTC gavilyte-c oral recon soln 1 gavilyte-g oral recon soln 1 gavilyte-n oral recon soln 1 generlac oral solution 1 glycolax oral powder 1 OTC granisetron hcl oral tablet 1 QL hemorrhoid rectal ointment 1 OTC hemorrhoidal rectal ointment 1 OTC hydrocortisone rectal enema 1 hydrocortisone topical cream with perineal 1 applicator 2.5 % infants gas relief oral drops,suspension 1 OTC konsyl fiber oral tablet 1 OTC konsyl formula-d oral powder 1 OTC konsyl sugar-free oral powder in packet 1 OTC lactulose oral solution 10 gram/15 ml, 20 gram/30 1 ml lidocaine hcl-hydrocortison ac rectal cream 3-0.5 1 % lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 1 3-1 % (7 gram) lidocaine-hydrocortisone-aloe rectal gel 1 lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 1 gram) magnesium oral tablet 250 mg 1 OTC meclizine oral tablet 12.5 mg, 25 mg 1 meclizine oral tablet,chewable 1 OTC mesalamine oral tablet,delayed release (dr/ec) 1 mesalamine rectal enema 1 mesalamine rectal suppository 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations59 on this table mean by going to the beginning of this table. 59 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits metoclopramide hcl oral solution 1 senna oral tablet 1 OTC metoclopramide hcl oral tablet 1 senna plus oral tablet 1 OTC miralax oral powder in packet 1 OTC senna-s oral tablet 1 OTC MOVANTIK ORAL TABLET 2 PA; QL senno oral tablet 1 OTC OCALIVA ORAL TABLET 2 PA; QL; SP sennosides-docusate sodium oral tablet 1 OTC ondansetron hcl oral solution 1 sevelamer carbonate oral powder in packet 1 ondansetron hcl oral tablet 1 QL sevelamer carbonate oral tablet 1 ondansetron oral tablet,disintegrating 1 QL sodium bicarbonate oral tablet 1 OTC OSMOPREP ORAL TABLET 2 sodium polystyrene sulfonate oral powder 1 peg 3350-electrolytes oral recon soln 236-22.74- 1 sodium polystyrene sulfonate oral suspension 1 6.74 -5.86 gram sps (with sorbitol) oral suspension 1 peg-electrolyte soln oral recon soln 1 SUCRAID ORAL SOLUTION 2 PA; SP peg-prep oral kit 1 sulfasalazine oral tablet 1 phosphate laxative oral liquid 1 OTC sulfasalazine oral tablet,delayed release (dr/ec) 1 polyethylene glycol 3350 oral powder 1 OTC trilyte with flavor packets oral recon soln 1 polyethylene glycol 3350 oral powder in packet 1 OTC trimethobenzamide oral capsule 1 powderlax oral powder 1 OTC ursodiol oral capsule 1 powderlax oral powder in packet 1 OTC ursodiol oral tablet 1 prochlorperazine maleate oral tablet 1 VELTASSA ORAL POWDER IN PACKET 2 PA; QL; SP prochlorperazine rectal suppository 1 VIBERZI ORAL TABLET 2 PA; QL; SP procto-med hc topical cream with perineal 1 ZELNORM ORAL TABLET 2 PA; QL applicator procto-pak topical cream with perineal applicator 1 ULCER THERAPY proctozone-hc topical cream with perineal 1 CARAFATE ORAL SUSPENSION 2 applicator cimetidine hcl oral solution 1 RELISTOR ORAL TABLET 2 PA; QL; SP cimetidine oral tablet 1 RELISTOR SUBCUTANEOUS SOLUTION 2 PA; QL; SP famotidine oral suspension 1 RELISTOR SUBCUTANEOUS SYRINGE 2 PA; QL; SP famotidine oral tablet 10 mg 1 OTC REMICADE INTRAVENOUS RECON SOLN 2 PA; SP famotidine oral tablet 20 mg, 40 mg 1 senexon-s oral tablet 1 OTC heartburn relief (famotidine) oral tablet 10 mg 1 OTC senna lax oral tablet 1 OTC heartburn relief (ranitidine) oral tablet 75 mg 1 OTC senna laxative oral tablet 8.6 mg 1 OTC lansoprazole oral capsule,delayed release(dr/ec) 1 QL senna oral syrup 8.8 mg/5 ml 1 OTC misoprostol oral tablet 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations60 on this table mean by going to the beginning of this table. 61 60 Drug Name Drug Tier Requirements / Limits senna oral tablet 1 OTC senna plus oral tablet 1 OTC senna-s oral tablet 1 OTC senno oral tablet 1 OTC sennosides-docusate sodium oral tablet 1 OTC sevelamer carbonate oral powder in packet 1 sevelamer carbonate oral tablet 1 sodium bicarbonate oral tablet 1 OTC sodium polystyrene sulfonate oral powder 1 sodium polystyrene sulfonate oral suspension 1 sps (with sorbitol) oral suspension 1 SUCRAID ORAL SOLUTION 2 PA; SP sulfasalazine oral tablet 1 sulfasalazine oral tablet,delayed release (dr/ec) 1 trilyte with flavor packets oral recon soln 1 trimethobenzamide oral capsule 1 ursodiol oral capsule 1 ursodiol oral tablet 1 VELTASSA ORAL POWDER IN PACKET 2 PA; QL; SP VIBERZI ORAL TABLET 2 PA; QL; SP ZELNORM ORAL TABLET 2 PA; QL ULCER THERAPY CARAFATE ORAL SUSPENSION 2 cimetidine hcl oral solution 1 cimetidine oral tablet 1 famotidine oral suspension 1 famotidine oral tablet 10 mg 1 OTC famotidine oral tablet 20 mg, 40 mg 1 heartburn relief (famotidine) oral tablet 10 mg 1 OTC heartburn relief (ranitidine) oral tablet 75 mg 1 OTC lansoprazole oral capsule,delayed release(dr/ec) 1 QL misoprostol oral tablet 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations61 on this table mean by going to the beginning of this table. 61 Drug Name Drug Tier Requirements / Limits nizatidine oral capsule 1 nizatidine oral solution 1 omeprazole oral capsule,delayed release(dr/ec) 1 omeprazole oral tablet,delayed release (dr/ec) 1 OTC pantoprazole oral tablet,delayed release (dr/ec) 1 rabeprazole oral tablet,delayed release (dr/ec) 1 QL ranitidine hcl oral syrup 1 ranitidine hcl oral tablet 150 mg, 300 mg 1 ranitidine hcl oral tablet 75 mg 1 OTC sucralfate oral tablet 1 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ARANESP (IN POLYSORBATE) INJECTION 2 PA; SP SOLUTION ARANESP (IN POLYSORBATE) INJECTION 2 PA; SP SYRINGE EPOGEN INJECTION SOLUTION 10,000 2 PA; SP UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SOLUTION 2 PA; SP GRANIX SUBCUTANEOUS SYRINGE 2 PA; SP MOZOBIL SUBCUTANEOUS SOLUTION 2 PA; QL; SP NEULASTA SUBCUTANEOUS SYRINGE 2 PA; SP NEULASTA SUBCUTANEOUS SYRINGE, W/ 2 PA; SP WEARABLE INJECTOR NEUPOGEN INJECTION SOLUTION 2 PA; SP NEUPOGEN INJECTION SYRINGE 2 PA; SP PROCRIT INJECTION SOLUTION 10,000 2 PA; SP UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML RETACRIT INJECTION SOLUTION 2 PA; SP UDENYCA SUBCUTANEOUS SYRINGE 2 PA; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations62 on this table mean by going to the beginning of this table. 62 Drug Name Drug Tier Requirements / Limits ZARXIO INJECTION SYRINGE 2 PA; SP GROWTH HORMONES EGRIFTA SUBCUTANEOUS RECON SOLN 1 2 PA; QL; SP MG NORDITROPIN FLEXPRO SUBCUTANEOUS 2 PA; SP PEN INJECTOR OMNITROPE SUBCUTANEOUS RECON 2 PA; SP SOLN SEROSTIM SUBCUTANEOUS RECON SOLN 4 2 PA; SP MG, 5 MG, 6 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 2 PA; SP INTERFERONS AUBAGIO ORAL TABLET 2 PA; QL; SP AVONEX (WITH ALBUMIN) 2 QL; SP INTRAMUSCULAR KIT AVONEX INTRAMUSCULAR PEN INJECTOR 2 QL; SP KIT AVONEX INTRAMUSCULAR SYRINGE KIT 2 QL; SP GILENYA ORAL CAPSULE 0.5 MG 2 PA; QL; SP glatiramer subcutaneous syringe 1 QL; SP glatopa subcutaneous syringe 1 QL; SP LEMTRADA INTRAVENOUS SOLUTION 2 PA; SP OCREVUS INTRAVENOUS SOLUTION 2 PA; SP PEGINTRON SUBCUTANEOUS KIT 50 2 QL; SP MCG/0.5 ML POMALYST ORAL CAPSULE 2 PA; QL; SP REVLIMID ORAL CAPSULE 2 PA; QL; SP ribasphere oral capsule 1 QL; SP ribasphere oral tablet 600 mg 1 QL; SP ribasphere ribapak oral tablets,dose pack 600 mg 1 QL; SP (7)- 400 mg (7), 600 mg (7)- 600 mg (7), 600-400 mg (28)-mg (28), 600-600 mg (28)-mg (28) ribavirin oral capsule 1 QL; SP ribavirin oral tablet 200 mg 1 QL; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations63 on this table mean by going to the beginning of this table. 63 Drug Name Drug Tier Requirements / Limits SYLATRON SUBCUTANEOUS KIT 2 SP TECFIDERA ORAL CAPSULE,DELAYED 2 PA; QL; SP RELEASE(DR/EC) INTERLEUKINS ACTIMMUNE SUBCUTANEOUS SOLUTION 2 PA; SP ARCALYST SUBCUTANEOUS RECON SOLN 2 PA; QL; SP ILARIS (PF) SUBCUTANEOUS SOLUTION 2 PA; QL; SP imiquimod topical cream in packet 1 INTRON A INJECTION RECON SOLN 2 SP INTRON A INJECTION SOLUTION 2 SP KINERET SUBCUTANEOUS SYRINGE 2 PA; SP VACCINES & MISCELLANEOUS IMMUNOLOGICALS BIVIGAM INTRAVENOUS SOLUTION 2 PA; SP BOTOX INJECTION RECON SOLN 2 PA; QL; SP DYSPORT INTRAMUSCULAR RECON SOLN 2 PA; QL; SP FLEBOGAMMA DIF INTRAVENOUS 2 PA; SP SOLUTION GAMMAGARD LIQUID INJECTION 2 PA; SP SOLUTION GAMMAGARD S-D (IGA < 1 MCG/ML) 2 PA; SP INTRAVENOUS RECON SOLN GAMMAKED INJECTION SOLUTION 1 2 PA; SP GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) GAMMAPLEX (WITH SORBITOL) 2 PA; SP INTRAVENOUS SOLUTION GAMUNEX-C INJECTION SOLUTION 1 2 PA; SP GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) HIZENTRA SUBCUTANEOUS SOLUTION 2 PA; SP MYOBLOC INTRAMUSCULAR SOLUTION 2 PA; QL; SP OCTAGAM INTRAVENOUS SOLUTION 2 PA; SP PRIVIGEN INTRAVENOUS SOLUTION 2 PA; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations64 on this table mean by going to the beginning of this table. 64 Drug Name Drug Tier Requirements / Limits XEOMIN INTRAMUSCULAR RECON SOLN 2 PA; QL; SP ZINPLAVA INTRAVENOUS SOLUTION 2 PA; QL; SP MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet 1 COLCHICINE ORAL CAPSULE 2 COLCHICINE ORAL TABLET 2 DUZALLO ORAL TABLET 2 PA; QL febuxostat oral tablet 1 PA; QL KRYSTEXXA INTRAVENOUS SOLUTION 2 PA; QL; SP probenecid oral tablet 1 probenecid-colchicine oral tablet 1 OSTEOPOROSIS THERAPY alendronate oral solution 1 QL alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 EVENITY SUBCUTANEOUS SYRINGE 2 PA; QL; SP FORTEO SUBCUTANEOUS PEN INJECTOR 2 PA; QL; SP ibandronate oral tablet 1 QL PROLIA SUBCUTANEOUS SYRINGE 2 PA; QL; SP raloxifene oral tablet 1 ACA TYMLOS SUBCUTANEOUS PEN INJECTOR 2 PA; QL; SP OTHER RHEUMATOLOGICALS ACTEMRA ACTPEN SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR ACTEMRA INTRAVENOUS SOLUTION 2 PA; QL; SP ACTEMRA SUBCUTANEOUS SYRINGE 2 PA; QL; SP BENLYSTA INTRAVENOUS RECON SOLN 2 PA; SP BENLYSTA SUBCUTANEOUS AUTO- 2 PA; QL; SP INJECTOR BENLYSTA SUBCUTANEOUS SYRINGE 2 PA; QL; SP DEPEN TITRATABS ORAL TABLET 2 PA; SP D-PENAMINE ORAL TABLET 2 PA; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations65 on this table mean by going to the beginning of this table. 65 Drug Name Drug Tier Requirements / Limits ENBREL MINI SUBCUTANEOUS 2 PA; QL; SP CARTRIDGE ENBREL SUBCUTANEOUS RECON SOLN 2 PA; QL; SP ENBREL SUBCUTANEOUS SYRINGE 2 PA; QL; SP ENBREL SURECLICK SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR HUMIRA PEDIATRIC CROHNS START 2 PA; QL; SP SUBCUTANEOUS SYRINGE KIT HUMIRA PEN CROHNS-UC-HS START 2 PA; QL; SP SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN PSOR-UVEITS-ADOL HS 2 PA; QL; SP SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 2 PA; QL; SP HUMIRA(CF) PEDI CROHNS STARTER 2 PA; QL; SP SUBCUTANEOUS SYRINGE KIT HUMIRA(CF) PEN CROHNS-UC-HS 2 PA; QL; SP SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN PSOR-UV-ADOL HS 2 PA; QL; SP SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN SUBCUTANEOUS PEN 2 PA; QL; SP INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE 2 PA; QL; SP KIT KEVZARA SUBCUTANEOUS PEN INJECTOR 2 PA; QL; SP KEVZARA SUBCUTANEOUS SYRINGE 2 PA; QL; SP leflunomide oral tablet 1 OLUMIANT ORAL TABLET 2 MG 2 PA; QL; SP ORENCIA (WITH MALTOSE) INTRAVENOUS 2 PA; SP RECON SOLN ORENCIA CLICKJECT SUBCUTANEOUS 2 PA; QL; SP AUTO-INJECTOR ORENCIA SUBCUTANEOUS SYRINGE 2 PA; QL; SP OTEZLA ORAL TABLET 2 PA; QL; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations66 on this table mean by going to the beginning of this table. 66 Drug Name Drug Tier Requirements / Limits OTEZLA STARTER ORAL TABLETS,DOSE 2 PA; QL; SP PACK OTREXUP (PF) SUBCUTANEOUS AUTO- 2 PA; QL; SP INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML penicillamine oral capsule 1 PA; SP RASUVO (PF) SUBCUTANEOUS AUTO- 2 PA; QL; SP INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE 2 RINVOQ ER ORAL TABLET EXTENDED 2 PA; QL; SP RELEASE 24 HR SAVELLA ORAL TABLET 2 PA; QL SAVELLA ORAL TABLETS,DOSE PACK 2 PA; QL SIMPONI ARIA INTRAVENOUS SOLUTION 2 PA; SP SIMPONI SUBCUTANEOUS PEN INJECTOR 2 PA; QL; SP SIMPONI SUBCUTANEOUS SYRINGE 2 PA; QL; SP XELJANZ ORAL TABLET 2 PA; QL; SP XELJANZ XR ORAL TABLET EXTENDED 2 PA; QL; SP RELEASE 24 HR OBSTETRICS & GYNECOLOGY DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES CAYA CONTOURED VAGINAL DIAPHRAGM 2 ACA FC2 FEMALE CONDOM 2 ACA; OTC FEMCAP VAGINAL DEVICE 22 MM 2 ACA WIDE-SEAL DIAPHRAGM 2 ACA ESTROGENS & PROGESTINS amabelz oral tablet 1 camila oral tablet 1 ACA CRINONE VAGINAL GEL 4 % 2 deblitane oral tablet 1 ACA DEPO-ESTRADIOL INTRAMUSCULAR OIL 2 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations67 on this table mean by going to the beginning of this table. 67 Drug Name Drug Tier Requirements / Limits DEPO-PROVERA INTRAMUSCULAR 2 SUSPENSION 400 MG/ML DEPO-SUBQ PROVERA 104 2 QL SUBCUTANEOUS SYRINGE errin oral tablet 1 ACA estradiol oral tablet 1 estradiol transdermal patch weekly 1 QL estradiol vaginal cream 1 estradiol valerate intramuscular oil 20 mg/ml, 40 1 mg/ml estradiol-norethindrone acet oral tablet 1 ESTRING VAGINAL RING 2 QL FEMRING VAGINAL RING 2 QL fyavolv oral tablet 1 heather oral tablet 1 ACA hydroxyprogest(pf)(preg presv) intramuscular oil 1 PA; QL; SP incassia oral tablet 1 ACA jencycla oral tablet 1 ACA jinteli oral tablet 1 lyza oral tablet 1 ACA MAKENA (PF) SUBCUTANEOUS AUTO- 2 PA; QL; SP INJECTOR medroxyprogesterone intramuscular suspension 1 ACA; QL medroxyprogesterone intramuscular syringe 1 ACA; QL medroxyprogesterone oral tablet 1 mimvey oral tablet 1 nora-be oral tablet 1 ACA norethindrone (contraceptive) oral tablet 1 ACA norethindrone acetate oral tablet 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 1 mg-mcg, 1-5 mg-mcg norlyda oral tablet 1 ACA PREMARIN ORAL TABLET 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations68 on this table mean by going to the beginning of this table. 68 Drug Name Drug Tier Requirements / Limits PREMPHASE ORAL TABLET 2 PREMPRO ORAL TABLET 2 progesterone micronized oral capsule 1 sharobel oral tablet 1 ACA tulana oral tablet 1 ACA MISCELLANEOUS OB/GYN 1-DAY VAGINAL OINTMENT 2 OTC 3-day vaginal vaginal cream 1 OTC CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin phosphate vaginal cream 1 CLINDESSE VAGINAL CREAM,EXTENDED 2 RELEASE clotrimazole vaginal cream 1 OTC clotrimazole-3 vaginal cream 1 OTC fem ph vaginal gel 1 gynol ii vaginal gel 1 ACA; OTC LUPANETA PACK (1 MONTH) KIT. SYRINGE 2 PA; QL; SP AND TABLET LUPANETA PACK (3 MONTH) KIT. SYRINGE 2 PA; QL; SP AND TABLET metronidazole vaginal gel 1 miconazole 7 vaginal cream 1 OTC miconazole 7 vaginal suppository 1 OTC miconazole nitrate vaginal comb pack,prefill appl, 1 OTC cream miconazole nitrate vaginal cream 1 OTC miconazole-3 vaginal kit 1 OTC miconazole-3 vaginal suppository 1 NUVARING VAGINAL RING 2 ACA; QL terconazole vaginal cream 1 terconazole vaginal suppository 1 tioconazole vaginal ointment 1 OTC tioconazole-1 vaginal ointment 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations69 on this table mean by going to the beginning of this table. 69 Drug Name Drug Tier Requirements / Limits TODAY CONTRACEPTIVE SPONGE 2 ACA; OTC VAGINAL CONTRACEPTIVE SPONGE tranexamic acid oral tablet 1 PA; QL vaginal contraceptive foam vaginal foam 1 ACA; OTC vandazole vaginal gel 1 VCF CONTRACEPTIVE FILM VAGINAL 2 ACA; OTC FILM VCF CONTRACEPTIVE GEL VAGINAL GEL 2 ACA; OTC xulane transdermal patch weekly 1 ACA; QL ORAL CONTRACEPTIVES & RELATED AGENTS altavera (28) oral tablet 1 ACA alyacen 1/35 (28) oral tablet 1 ACA alyacen 7/7/7 (28) oral tablet 1 ACA amethia lo oral tablets,dose pack,3 month 1 ACA; QL amethia oral tablets,dose pack,3 month 1 ACA; QL amethyst (28) oral tablet 1 ACA apri oral tablet 1 ACA aranelle (28) oral tablet 1 ACA ashlyna oral tablets,dose pack,3 month 1 ACA; QL aubra eq oral tablet 1 ACA aubra oral tablet 1 ACA aviane oral tablet 1 ACA azurette (28) oral tablet 1 ACA balziva (28) oral tablet 1 ACA bekyree (28) oral tablet 1 ACA blisovi fe 1.5/30 (28) oral tablet 1 ACA blisovi fe 1/20 (28) oral tablet 1 ACA briellyn oral tablet 1 ACA camrese lo oral tablets,dose pack,3 month 1 ACA; QL camrese oral tablets,dose pack,3 month 1 ACA; QL caziant (28) oral tablet 1 ACA chateal eq (28) oral tablet 1 ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations70 on this table mean by going to the beginning of this table. 70 Drug Name Drug Tier Requirements / Limits cryselle (28) oral tablet 1 ACA cyclafem 1/35 (28) oral tablet 1 ACA cyclafem 7/7/7 (28) oral tablet 1 ACA cyred eq oral tablet 1 ACA cyred oral tablet 1 ACA dasetta 1/35 (28) oral tablet 1 ACA dasetta 7/7/7 (28) oral tablet 1 ACA daysee oral tablets,dose pack,3 month 1 ACA; QL desog-e.estradiol/e.estradiol oral tablet 1 ACA desogestrel-ethinyl estradiol oral tablet 1 ACA drospirenone-e.estradiol-lm.fa oral tablet 1 ACA drospirenone-ethinyl estradiol oral tablet 1 ACA econtra ez oral tablet 1 ACA; OTC econtra one-step oral tablet 1 ACA; OTC elinest oral tablet 1 ACA ELLA ORAL TABLET 2 ACA emoquette oral tablet 1 ACA enpresse oral tablet 1 ACA enskyce oral tablet 1 ACA estarylla oral tablet 1 ACA ethynodiol diac-eth estradiol oral tablet 1 ACA falmina (28) oral tablet 1 ACA femynor oral tablet 1 ACA gianvi (28) oral tablet 1 ACA hailey 24 fe oral tablet 1 ACA hailey oral tablet 1 ACA introvale oral tablets,dose pack,3 month 1 ACA; QL isibloom oral tablet 1 ACA jasmiel (28) oral tablet 1 ACA jolessa oral tablets,dose pack,3 month 1 ACA; QL juleber oral tablet 1 ACA junel 1.5/30 (21) oral tablet 1 ACA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations71 on this table mean by going to the beginning of this table. 71 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits junel 1/20 (21) oral tablet 1 ACA marlissa (28) oral tablet 1 ACA junel fe 1.5/30 (28) oral tablet 1 ACA microgestin 1.5/30 (21) oral tablet 1 ACA junel fe 1/20 (28) oral tablet 1 ACA microgestin 1/20 (21) oral tablet 1 ACA junel fe 24 oral tablet 1 ACA microgestin fe 1.5/30 (28) oral tablet 1 ACA kaitlib fe oral tablet,chewable 1 ACA microgestin fe 1/20 (28) oral tablet 1 ACA kalliga oral tablet 1 ACA mili oral tablet 1 ACA kariva (28) oral tablet 1 ACA mono-linyah oral tablet 1 ACA kelnor 1/35 (28) oral tablet 1 ACA my choice oral tablet 1 ACA; OTC kelnor 1-50 oral tablet 1 ACA my way oral tablet 1 ACA; OTC kurvelo (28) oral tablet 1 ACA necon 0.5/35 (28) oral tablet 1 ACA l norgest/e.estradiol-e.estrad oral tablets,dose 1 ACA; QL new day oral tablet 1 ACA; OTC pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), nikki (28) oral tablet 1 ACA 0.15 mg-30 mcg (84)/10 mcg (7) noreth-ethinyl estradiol-iron oral tablet,chewable 1 ACA larin 1.5/30 (21) oral tablet 1 ACA norethindrone ac-eth estradiol oral tablet 1-20 1 ACA larin 1/20 (21) oral tablet 1 ACA mg-mcg larin 24 fe oral tablet 1 ACA norethindrone-e.estradiol-iron oral tablet 1 mg-20 1 ACA larin fe 1.5/30 (28) oral tablet 1 ACA mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 ACA norgestimate-ethinyl estradiol oral tablet 1 ACA larissia oral tablet 1 ACA nortrel 0.5/35 (28) oral tablet 1 ACA layolis fe oral tablet,chewable 1 ACA nortrel 1/35 (21) oral tablet 1 ACA leena 28 oral tablet 1 ACA nortrel 1/35 (28) oral tablet 1 ACA lessina oral tablet 1 ACA nortrel 7/7/7 (28) oral tablet 1 ACA levonest (28) oral tablet 1 ACA ocella oral tablet 1 ACA levonorgestrel oral tablet 1.5 mg 1 ACA; OTC ogestrel (28) oral tablet 1 ACA levonorgestrel-ethinyl estrad oral tablet 1 ACA opcicon one-step oral tablet 1 ACA; OTC levonorgestrel-ethinyl estrad oral tablets,dose 1 ACA; QL option-2 oral tablet 1 ACA; OTC pack,3 month orsythia oral tablet 1 ACA levonorg-eth estrad triphasic oral tablet 1 ACA philith oral tablet 1 ACA levora-28 oral tablet 1 ACA pimtrea (28) oral tablet 1 ACA lillow (28) oral tablet 1 ACA pirmella oral tablet 1 ACA loryna (28) oral tablet 1 ACA portia 28 oral tablet 1 ACA low-ogestrel (28) oral tablet 1 ACA previfem oral tablet 1 ACA lutera (28) oral tablet 1 ACA You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations72 on this table mean by going to the beginning of this table. 73 72 Drug Name Drug Tier Requirements / Limits marlissa (28) oral tablet 1 ACA microgestin 1.5/30 (21) oral tablet 1 ACA microgestin 1/20 (21) oral tablet 1 ACA microgestin fe 1.5/30 (28) oral tablet 1 ACA microgestin fe 1/20 (28) oral tablet 1 ACA mili oral tablet 1 ACA mono-linyah oral tablet 1 ACA my choice oral tablet 1 ACA; OTC my way oral tablet 1 ACA; OTC necon 0.5/35 (28) oral tablet 1 ACA new day oral tablet 1 ACA; OTC nikki (28) oral tablet 1 ACA noreth-ethinyl estradiol-iron oral tablet,chewable 1 ACA norethindrone ac-eth estradiol oral tablet 1-20 1 ACA mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 1 ACA mcg (21)/75 mg (7) norgestimate-ethinyl estradiol oral tablet 1 ACA nortrel 0.5/35 (28) oral tablet 1 ACA nortrel 1/35 (21) oral tablet 1 ACA nortrel 1/35 (28) oral tablet 1 ACA nortrel 7/7/7 (28) oral tablet 1 ACA ocella oral tablet 1 ACA ogestrel (28) oral tablet 1 ACA opcicon one-step oral tablet 1 ACA; OTC option-2 oral tablet 1 ACA; OTC orsythia oral tablet 1 ACA philith oral tablet 1 ACA pimtrea (28) oral tablet 1 ACA pirmella oral tablet 1 ACA portia 28 oral tablet 1 ACA previfem oral tablet 1 ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations73 on this table mean by going to the beginning of this table. 73 Drug Name Drug Tier Requirements / Limits reclipsen (28) oral tablet 1 ACA setlakin oral tablets,dose pack,3 month 1 ACA; QL sprintec (28) oral tablet 1 ACA sronyx oral tablet 1 ACA syeda oral tablet 1 ACA tarina 24 fe oral tablet 1 ACA tarina fe 1/20 (28) oral tablet 1 ACA tilia fe oral tablet 1 ACA tri femynor oral tablet 1 ACA tri-estarylla oral tablet 1 ACA tri-legest fe oral tablet 1 ACA tri-linyah oral tablet 1 ACA tri-lo-estarylla oral tablet 1 ACA tri-lo-marzia oral tablet 1 ACA tri-lo-mili oral tablet 1 ACA tri-lo-sprintec oral tablet 1 ACA tri-mili oral tablet 1 ACA tri-previfem (28) oral tablet 1 ACA tri-sprintec (28) oral tablet 1 ACA trivora (28) oral tablet 1 ACA tri-vylibra lo oral tablet 1 ACA tri-vylibra oral tablet 1 ACA tydemy oral tablet 1 ACA velivet triphasic regimen (28) oral tablet 1 ACA vienva oral tablet 1 ACA viorele (28) oral tablet 1 ACA vyfemla (28) oral tablet 1 ACA vylibra oral tablet 1 ACA wera (28) oral tablet 1 ACA wymzya fe oral tablet,chewable 1 ACA zarah oral tablet 1 ACA zovia 1/35e (28) oral tablet 1 ACA You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations74 on this table mean by going to the beginning of this table. 74 Drug Name Drug Tier Requirements / Limits OXYTOCICS methergine oral tablet 1 SP methylergonovine oral tablet 1 SP OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac ophthalmic (eye) ointment 1 bacitracin ophthalmic (eye) ointment 1 bacitracin-polymyxin b ophthalmic (eye) ointment 1 BETADINE OPHTHALMIC PREP 2 OPHTHALMIC (EYE) SOLUTION CILOXAN OPHTHALMIC (EYE) OINTMENT 2 ciprofloxacin hcl ophthalmic (eye) drops 1 erythromycin ophthalmic (eye) ointment 1 gatifloxacin ophthalmic (eye) drops 1 gentak ophthalmic (eye) ointment 1 gentamicin ophthalmic (eye) drops 1 levofloxacin ophthalmic (eye) drops 1 NATACYN OPHTHALMIC (EYE) 2 DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic (eye) 1 ointment neomycin-polymyxin-gramicidin ophthalmic (eye) 1 drops neo-polycin ophthalmic (eye) ointment 1 ofloxacin ophthalmic (eye) drops 1 polycin ophthalmic (eye) ointment 1 tobramycin ophthalmic (eye) drops 1 TOBREX OPHTHALMIC (EYE) OINTMENT 2 ANTIVIRALS trifluridine ophthalmic (eye) drops 1 ZIRGAN OPHTHALMIC (EYE) GEL 2 BETA-BLOCKERS betaxolol ophthalmic (eye) drops 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations75 on this table mean by going to the beginning of this table. 75 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits carteolol ophthalmic (eye) drops 1 EYLEA INTRAVITREAL SOLUTION 2 SP levobunolol ophthalmic (eye) drops 0.5 % 1 flucaine ophthalmic (eye) drops 1 metipranolol ophthalmic (eye) drops 1 fluorescein-proparacaine ophthalmic (eye) drops 1 timolol maleate ophthalmic (eye) drops 1 GENTEAL TEARS SEVERE GEL 2 OTC OPHTHALMIC (EYE) GEL timolol maleate ophthalmic (eye) gel forming 1 solution JETREA (PF) INTRAVITREAL SOLUTION 2 PA; QL; SP 0.125 MG/0.1 ML (1.25 MG/ML) CHOLINESTERASE INHIBITOR MIOTICS ketotifen fumarate ophthalmic (eye) drops 1 OTC PHOSPHOLINE IODIDE OPHTHALMIC (EYE) 2 DROPS lubricant (p-glycol-glycerin) ophthalmic (eye) 1 OTC drops CYCLOPLEGIC MYDRIATICS lubricating plus ophthalmic (eye) dropperette 1 OTC atropine ophthalmic (eye) drops 1 lubrifresh pm ophthalmic (eye) ointment 1 OTC atropine ophthalmic (eye) ointment 1 LUCENTIS INTRAVITREAL SOLUTION 2 SP cyclopentolate ophthalmic (eye) drops 1 LUCENTIS INTRAVITREAL SYRINGE 2 SP homatropaire ophthalmic (eye) drops 1 LUXTURNA SUBRETINAL SUSPENSION 2 PA homatropine hbr ophthalmic (eye) drops 1 MACUGEN INTRAVITREAL SYRINGE 2 SP tropicamide ophthalmic (eye) drops 1 OXERVATE OPHTHALMIC (EYE) DROPS 2 PA; QL; SP DIRECT ACTING MIOTICS proparacaine ophthalmic (eye) drops 1 pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 1 4 % REFRESH CELLUVISC OPHTHALMIC (EYE) 2 OTC DROPPERETTE,GEL MISCELLANEOUS OPHTHALMOLOGICS sodium chloride ophthalmic (eye) drops 1 OTC alaway ophthalmic (eye) drops 1 OTC sodium chloride ophthalmic (eye) ointment 1 OTC ALOMIDE OPHTHALMIC (EYE) DROPS 2 SYSTANE GEL OPHTHALMIC (EYE) GEL 2 OTC artificial tears (polyvin alc) ophthalmic (eye) 1 OTC drops tetcaine ophthalmic (eye) drops 1 artificial tears(pvalch-povid) ophthalmic (eye) 1 OTC tetracaine hcl ophthalmic (eye) drops 1 drops THERATEARS OPHTHALMIC (EYE) 2 OTC azelastine ophthalmic (eye) drops 1 DROPPERETTE BEVACIZUMAB INTRAVITREAL SYRINGE 2 PA NON-STEROIDAL ANTI-INFLAMMATORY AGENTS 2.5 MG/0.1 ML, 3.25 MG/0.13 ML bromfenac ophthalmic (eye) drops 1 children's alaway ophthalmic (eye) drops 1 OTC diclofenac sodium ophthalmic (eye) drops 1 cromolyn ophthalmic (eye) drops 1 flurbiprofen sodium ophthalmic (eye) drops 1 CYSTARAN OPHTHALMIC (EYE) DROPS 2 PA; QL; SP ketorolac ophthalmic (eye) drops 1 epinastine ophthalmic (eye) drops 1 ORAL DRUGS FOR GLAUCOMA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations76 on this table mean by going to the beginning of this table. 77 76 Drug Name Drug Tier Requirements / Limits EYLEA INTRAVITREAL SOLUTION 2 SP flucaine ophthalmic (eye) drops 1 fluorescein-proparacaine ophthalmic (eye) drops 1 GENTEAL TEARS SEVERE GEL 2 OTC OPHTHALMIC (EYE) GEL JETREA (PF) INTRAVITREAL SOLUTION 2 PA; QL; SP 0.125 MG/0.1 ML (1.25 MG/ML) ketotifen fumarate ophthalmic (eye) drops 1 OTC lubricant (p-glycol-glycerin) ophthalmic (eye) 1 OTC drops lubricating plus ophthalmic (eye) dropperette 1 OTC lubrifresh pm ophthalmic (eye) ointment 1 OTC LUCENTIS INTRAVITREAL SOLUTION 2 SP LUCENTIS INTRAVITREAL SYRINGE 2 SP LUXTURNA SUBRETINAL SUSPENSION 2 PA MACUGEN INTRAVITREAL SYRINGE 2 SP OXERVATE OPHTHALMIC (EYE) DROPS 2 PA; QL; SP proparacaine ophthalmic (eye) drops 1 REFRESH CELLUVISC OPHTHALMIC (EYE) 2 OTC DROPPERETTE,GEL sodium chloride ophthalmic (eye) drops 1 OTC sodium chloride ophthalmic (eye) ointment 1 OTC SYSTANE GEL OPHTHALMIC (EYE) GEL 2 OTC tetcaine ophthalmic (eye) drops 1 tetracaine hcl ophthalmic (eye) drops 1 THERATEARS OPHTHALMIC (EYE) 2 OTC DROPPERETTE NON-STEROIDAL ANTI-INFLAMMATORY AGENTS bromfenac ophthalmic (eye) drops 1 diclofenac sodium ophthalmic (eye) drops 1 flurbiprofen sodium ophthalmic (eye) drops 1 ketorolac ophthalmic (eye) drops 1 ORAL DRUGS FOR GLAUCOMA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations77 on this table mean by going to the beginning of this table. 77 Drug Name Drug Tier Requirements / Limits acetazolamide oral capsule, extended release 1 acetazolamide oral tablet 1 methazolamide oral tablet 1 OTHER GLAUCOMA DRUGS dorzolamide ophthalmic (eye) drops 1 dorzolamide-timolol ophthalmic (eye) drops 1 latanoprost ophthalmic (eye) drops 1 STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic (eye) 1 ointment neomycin-polymyxin b-dexameth ophthalmic (eye) 1 drops,suspension neomycin-polymyxin b-dexameth ophthalmic (eye) 1 ointment neomycin-polymyxin-hc ophthalmic (eye) 1 drops,suspension neo-polycin hc ophthalmic (eye) ointment 1 TOBRADEX OPHTHALMIC (EYE) 2 OINTMENT tobramycin-dexamethasone ophthalmic (eye) 1 drops,suspension STEROIDS dexamethasone sodium phosphate ophthalmic 1 (eye) drops fluorometholone ophthalmic (eye) 1 drops,suspension FML S.O.P. OPHTHALMIC (EYE) OINTMENT 2 ILUVIEN INTRAVITREAL IMPLANT 2 QL; SP OZURDEX INTRAVITREAL IMPLANT 2 PRED MILD OPHTHALMIC (EYE) 2 DROPS,SUSPENSION prednisolone acetate ophthalmic (eye) 1 drops,suspension prednisolone sodium phosphate ophthalmic (eye) 1 drops

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations78 on this table mean by going to the beginning of this table. 78 Drug Name Drug Tier Requirements / Limits STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC (EYE) 2 DROPS,SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 2 OINTMENT sulfacetamide-prednisolone ophthalmic (eye) 1 drops SULFONAMIDES sulfacetamide sodium ophthalmic (eye) drops 1 sulfacetamide sodium ophthalmic (eye) ointment 1 SYMPATHOMIMETICS apraclonidine ophthalmic (eye) drops 1 brimonidine ophthalmic (eye) drops 1 VASOCONSTRICTOR DECONGESTANTS CYCLOMYDRIL OPHTHALMIC (EYE) DROPS 2 eye drops (tetrahydrozoline) ophthalmic (eye) 1 OTC drops eye drops (with povidone) ophthalmic (eye) drops 1 OTC eye drops advanced relief ophthalmic (eye) drops 1 OTC phenylephrine hcl ophthalmic (eye) drops 1 redness reliever lubricant ophthalmic (eye) drops 1 OTC RESPIRATORY, ALLERGY, COUGH & COLD ANTIHISTAMINE & ANTIALLERGENIC AGENTS all day allergy (cetirizine) oral tablet 1 OTC ALLEGRA ALLERGY ORAL TABLET 2 OTC aller-chlor oral tablet 1 OTC allerclear oral tablet 1 OTC aller-ease oral tablet 1 OTC aller-fex oral tablet 1 OTC allergy (chlorpheniramine) oral tablet 1 OTC allergy (diphenhydramine) oral capsule 1 OTC allergy (diphenhydramine) oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations79 on this table mean by going to the beginning of this table. 79 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits allergy 4-hour oral tablet 1 OTC cyproheptadine oral syrup 1 allergy medicine oral tablet 1 OTC cyproheptadine oral tablet 1 allergy relief (cetirizine) oral tablet 1 OTC dayhist allergy oral tablet 1 OTC allergy relief (clemastine) oral tablet 1 OTC diphedryl oral capsule 1 OTC allergy relief (fexofenadine) oral tablet 180 mg 1 OTC diphedryl oral liquid 1 OTC allergy relief (loratadine) oral solution 1 OTC diphedryl oral tablet 1 OTC allergy relief (loratadine) oral tablet 1 OTC diphenhist oral capsule 1 OTC allergy relief (loratadine) oral 1 OTC diphenhydramine hcl oral capsule 1 OTC tablet,disintegrating diphenhydramine hcl oral elixir 1 allergy relief(chlorpheniramn) oral tablet 1 OTC diphenhydramine hcl oral tablet 25 mg 1 OTC allergy relief(diphenhydramin) oral capsule 1 OTC epinephrine injection auto-injector 0.15 mg/0.3 ml, 1 QL allergy relief(diphenhydramin) oral liquid 1 OTC 0.3 mg/0.3 ml (generic EpiPen) allergy relief(diphenhydramin) oral tablet 1 OTC fexofenadine oral tablet 180 mg, 60 mg 1 OTC allergy-time oral tablet 1 OTC hydroxyzine hcl intramuscular solution 1 aller-tec oral tablet 1 OTC hydroxyzine hcl oral solution 10 mg/5 ml 1 banophen oral capsule 1 OTC hydroxyzine hcl oral tablet 1 banophen oral tablet 1 OTC hydroxyzine pamoate oral capsule 1 carbinoxamine maleate oral liquid 1 levocetirizine oral solution 1 carbinoxamine maleate oral tablet 4 mg 1 levocetirizine oral tablet 1 cetirizine oral solution 5 mg/5 ml 1 OTC loradamed oral tablet 1 OTC cetirizine oral tablet 1 OTC loratadine oral solution 1 OTC cetirizine oral tablet,chewable 1 OTC loratadine oral tablet 1 OTC children's allegra allergy oral suspension 1 OTC loratadine oral tablet,disintegrating 1 OTC children's allegra allergy oral tablet,disintegrating 1 OTC nighttime sleep aid (diphen) oral tablet 1 OTC children's allergy (diphenhyd) oral liquid 1 OTC phenadoz rectal suppository 1 children's allergy relief(lor) oral solution 1 OTC promethazine oral syrup 1 children's cetirizine oral tablet,chewable 1 OTC promethazine oral tablet 1 chlorhist oral tablet 1 OTC promethazine rectal suppository 1 chlorpheniramine maleate oral tablet 1 OTC promethegan rectal suppository 1 clemastine oral tablet 2.68 mg 1 siladryl sa oral liquid 1 OTC complete allergy medicine oral capsule 1 OTC sleep aid (diphenhydramine) oral capsule 50 mg 1 OTC complete allergy oral tablet 1 OTC sleep aid (diphenhydramine) oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations80 on this table mean by going to the beginning of this table. 81 80 Drug Name Drug Tier Requirements / Limits cyproheptadine oral syrup 1 cyproheptadine oral tablet 1 dayhist allergy oral tablet 1 OTC diphedryl oral capsule 1 OTC diphedryl oral liquid 1 OTC diphedryl oral tablet 1 OTC diphenhist oral capsule 1 OTC diphenhydramine hcl oral capsule 1 OTC diphenhydramine hcl oral elixir 1 diphenhydramine hcl oral tablet 25 mg 1 OTC epinephrine injection auto-injector 0.15 mg/0.3 ml, 1 QL 0.3 mg/0.3 ml (generic EpiPen) fexofenadine oral tablet 180 mg, 60 mg 1 OTC hydroxyzine hcl intramuscular solution 1 hydroxyzine hcl oral solution 10 mg/5 ml 1 hydroxyzine hcl oral tablet 1 hydroxyzine pamoate oral capsule 1 levocetirizine oral solution 1 levocetirizine oral tablet 1 loradamed oral tablet 1 OTC loratadine oral solution 1 OTC loratadine oral tablet 1 OTC loratadine oral tablet,disintegrating 1 OTC nighttime sleep aid (diphen) oral tablet 1 OTC phenadoz rectal suppository 1 promethazine oral syrup 1 promethazine oral tablet 1 promethazine rectal suppository 1 promethegan rectal suppository 1 siladryl sa oral liquid 1 OTC sleep aid (diphenhydramine) oral capsule 50 mg 1 OTC sleep aid (diphenhydramine) oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations81 on this table mean by going to the beginning of this table. 81 Drug Name Drug Tier Requirements / Limits sleep aid max str (diphenhydr) oral capsule 1 OTC sleep-tabs oral tablet 1 OTC unisom sleepgels oral capsule 1 OTC COUGH & COLD THERAPY 12 hour decongestant oral tablet extended release 1 OTC 12 hour nasal decongest (pse) oral tablet extended 1 OTC release adult tussin chest congestion oral liquid 1 OTC adult tussin cough congest dm oral liquid 1 OTC adult tussin dm oral syrup 1 OTC all day allergy-d oral tablet extended release 12 hr 1 OTC allerclear d-12hr oral tablet extended release 12 1 OTC hr allerclear d-24hr oral tablet extended release 24 1 OTC hr allergy and congestion relief oral tablet extended 1 OTC release 12 hr allergy and congestion relief oral tablet extended 1 OTC release 24 hr allergy complete-d oral tablet extended release 12 1 OTC hr allergy multi-symptom oral tablet 1 OTC allergy plus severe sinus ha oral tablet 1 OTC allergy relief d-24hr oral tablet extended release 1 OTC 24 hr allergy relief,nasal decongest oral tablet extended 1 OTC release 24 hr allergy relief-d (cetirizine) oral tablet extended 1 OTC release 12 hr allergy relief-d (loratadine) oral tablet extended 1 OTC release 12 hr aller-tec d oral tablet extended release 12 hr 1 OTC benzonatate oral capsule 100 mg, 200 mg 1 brompheniramine-pseudoeph-dm oral syrup 1 brotapp dm oral elixir 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations82 on this table mean by going to the beginning of this table. 82 Drug Name Drug Tier Requirements / Limits CITRACAL + D PETITES ORAL TABLET 2 OTC CITRACAL REGULAR ORAL TABLET 2 OTC effer-k oral tablet, effervescent 25 meq 1 electrolytes-dextrose oral solution 1 OTC FLORICAL ORAL CAPSULE 2 OTC GALZIN ORAL CAPSULE 2 PA klor-con 10 oral tablet extended release 1 klor-con 8 oral tablet extended release 1 klor-con m10 oral tablet,er particles/crystals 1 klor-con m15 oral tablet,er particles/crystals 1 klor-con m20 oral tablet,er particles/crystals 1 klor-con oral packet 1 klor-con/ef oral tablet, effervescent 1 k-phos-neutral oral tablet 1 OTC k-tab oral tablet extended release 8 meq 1 LIQUID CALCIUM WITH VITAMIN D ORAL 2 OTC CAPSULE mag 64 oral tablet,delayed release (dr/ec) 1 OTC mag-g oral tablet 1 OTC MAGNESIUM AMINO ACID CHELATE ORAL 2 OTC TABLET 100 MG magnesium gluconate oral tablet 27 mg 1 OTC magnesium (500 mg), 27.5 mg magne- sium (500 mg) magnesium oral tablet 200 mg 1 OTC magnesium oxide oral capsule 500 mg 1 OTC magnesium oxide oral tablet 200 mg magnesium, 1 OTC 250 mg magnesium, 400 mg (241.3 mg magnesium), 400 mg magnesium, 500 mg oysco-500 oral tablet 1 OTC oyster shell + d3 oral tablet 1 OTC oyster shell calcium 500 oral tablet 1 OTC oyster shell calcium oral tablet 1 OTC pediatric electrolyte oral solution 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations93 on this table mean by going to the beginning of this table. 83 Drug Name Drug Tier Requirements / Limits DELSYM 12 HOUR ORAL 2 OTC SUSPENSION,EXTENDED REL 12 HR dextromethorphan polistirex oral 1 OTC suspension,extended rel 12 hr dextromethorphan-guaifenesin oral syrup 1 OTC dextromethorphan-guaifenesin oral tablet 1 OTC diabetic siltussin-dm max str oral liquid 1 OTC diabetic tussin dm oral liquid 10-100 mg/5 ml 1 OTC diabetic tussin ex oral liquid 1 OTC dimaphen (pe) oral solution 1 OTC dimaphen dm oral solution 1 OTC fenesin ir oral tablet 1 OTC geri-tussin oral liquid 1 OTC guaiatussin ac oral liquid 1 PA; QL guaifenesin ac oral liquid 1 PA; QL guaifenesin dac oral syrup 1 PA; QL guaifenesin oral liquid 1 OTC guaifenesin oral tablet 1 OTC G-ZYNCOF ORAL LIQUID 2 OTC hydrocodone-chlorpheniramine oral 1 PA; QL suspension,extended rel 12 hr hydrocodone-homatropine oral syrup 5-1.5 mg/5 1 PA; QL ml hydrocodone-homatropine oral tablet 1 PA hydromet oral syrup 1 PA; QL ibuprofen cold-sinus(with pse) oral tablet 1 OTC lohist - d oral liquid 1 OTC lorata-dine d oral tablet extended release 24 hr 1 OTC loratadine-d oral tablet extended release 12 hr 1 OTC loratadine-d oral tablet extended release 24 hr 1 OTC mucinex d maximum strength oral tablet extended 1 OTC release 12 hr mucinex d oral tablet extended release 12 hr 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations84 on this table mean by going to the beginning of this table. 84 Drug Name Drug Tier Requirements / Limits mucinex dm oral tablet extended release 12 hr 30- 1 OTC 600 mg MUCINEX DM ORAL TABLET EXTENDED 2 OTC RELEASE 12 HR 60-1,200 MG mucosa dm oral tablet 1 OTC mucosa oral tablet 1 OTC mucus relief chest oral tablet 1 OTC mucus relief dm cough oral tablet 1 OTC mucus relief dm oral tablet 1 OTC mucus relief oral tablet 400 mg 1 OTC nasal decongestant (pseudoeph) oral tablet 1 OTC nasal decongestant (pseudoeph) oral tablet 1 OTC extended release neo-tuss oral liquid 1 OTC NEOTUSS PLUS ORAL SOLUTION 2 OTC night time cold-flu oral capsule 1 OTC nighttime cough oral solution 1 OTC nohist-dm oral liquid 1 OTC nohist-lq oral liquid 1 OTC NOREL AD ORAL TABLET 2 OTC pain relief allergy sinus oral tablet 1 OTC pediatric cough and cold oral liquid 1-15-5 mg/5 1 OTC ml promethazine-codeine oral syrup 1 PA; QL promethazine-dm oral syrup 1 promethazine-phenyleph-codeine oral syrup 1 PA; QL promethazine-phenylephrine oral syrup 1 pseudoephedrine hcl oral tablet 1 OTC refenesen dm oral tablet 1 OTC RESCON-DM ORAL LIQUID 2 OTC rescon-gg oral liquid 1 OTC robafen dm cough oral liquid 1 OTC robafen dm cough-chest congest oral syrup 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations85 on this table mean by going to the beginning of this table. 85 Drug Name Drug Tier Requirements / Limits robafen oral liquid 1 OTC rynex dm oral solution 1 OTC rynex pe oral solution 1 OTC rynex pse oral liquid 1 OTC scot-tussin dm oral liquid 1 OTC siltussin dm das oral liquid 1 OTC siltussin sa oral liquid 1 OTC siltussin-dm oral syrup 1 OTC sinus 12 hour oral tablet extended release 1 OTC sinus and allergy pe oral tablet 1 OTC sinus congestion-pain(chlorph) oral tablet 1 OTC sinus congest-pain day-night oral tablets, 1 OTC sequential sinus decongestant (pe) oral tablet 1 OTC sudogest 12-hour oral tablet extended release 1 OTC sudogest cold and allergy oral tablet 1 OTC sudogest oral tablet 1 OTC sudogest sinus and allergy oral tablet 1 OTC suphedrin oral liquid 1 OTC suphedrin oral tablet 1 OTC suphedrine 12 hour oral tablet extended release 1 OTC suphedrine oral tablet 1 OTC supress dx oral drops 1 OTC TUSNEL DM PEDIATRIC(PSEUDOEPH) 2 OTC ORAL DROPS tusnel pediatric oral drops 1 OTC TUSNEL PEDIATRIC ORAL LIQUID 2 tussi pres-b oral liquid 4-10-20 mg/5 ml 1 OTC tussin chest congestion oral liquid 1 OTC tussin dm clear oral syrup 1 OTC tussin dm cough and chest oral syrup 1 OTC tussin dm max oral liquid 10-200 mg/5 ml 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations86 on this table mean by going to the beginning of this table. 86 Drug Name Drug Tier Requirements / Limits tussin dm oral liquid 1 OTC tussin dm oral syrup 10-100 mg/5 ml 1 OTC tussin dm oral tablet 1 OTC tussin expectorant oral liquid 1 OTC tussin maximum strength cough oral syrup 1 OTC tussin mucus-chest congestion oral liquid 1 OTC tussin oral tablet 1 OTC TUSSI-PRES PEDIATRIC ORAL LIQUID 2 OTC virtussin ac oral liquid 1 PA; QL ZODRYL DEC 30 ORAL SUSPENSION 2 PA; QL ZYNCOF ORAL LIQUID 2 OTC PULMONARY AGENTS ADEMPAS ORAL TABLET 2 PA; QL; SP albuterol sulfate inhalation solution for 1 nebulization albuterol sulfate oral syrup 1 albuterol sulfate oral tablet 1 albuterol sulfate oral tablet extended release 12 hr 1 alyq oral tablet 1 PA; QL; SP ambrisentan oral tablet 1 PA; QL; SP ANORO ELLIPTA INHALATION BLISTER 2 WITH DEVICE ARNUITY ELLIPTA INHALATION BLISTER 2 WITH DEVICE ASMANEX HFA INHALATION HFA 2 AEROSOL INHALER ASMANEX TWISTHALER INHALATION 2 AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) BERINERT INTRAVENOUS KIT 2 PA; SP bosentan oral tablet 1 PA; QL; SP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations87 on this table mean by going to the beginning of this table. 87 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits budesonide inhalation suspension for nebulization 1 LEVALBUTEROL TARTRATE INHALATION 2 ST; QL HFA AEROSOL INHALER CINQAIR INTRAVENOUS SOLUTION 2 PA; SP metaproterenol oral syrup 1 CINRYZE INTRAVENOUS RECON SOLN 2 PA; QL; SP montelukast oral granules in packet 1 QL COMBIVENT RESPIMAT INHALATION MIST 2 montelukast oral tablet 1 QL cromolyn inhalation solution for nebulization 1 montelukast oral tablet,chewable 1 QL cromolyn nasal spray,non-aerosol 1 OTC NASACORT NASAL AEROSOL,SPRAY 2 OTC DALIRESP ORAL TABLET 2 PA nasal allergy symptom control nasal spray,non- 1 OTC ESBRIET ORAL CAPSULE 2 PA; QL; SP aerosol ESBRIET ORAL TABLET 2 PA; QL; SP NUCALA SUBCUTANEOUS AUTO-INJECTOR 2 PA; QL; SP FASENRA SUBCUTANEOUS SYRINGE 2 PA; QL; SP NUCALA SUBCUTANEOUS RECON SOLN 2 PA; QL; SP FLOVENT DISKUS INHALATION BLISTER 2 NUCALA SUBCUTANEOUS SYRINGE 2 PA; QL; SP WITH DEVICE OFEV ORAL CAPSULE 2 PA; QL; SP FLOVENT HFA INHALATION HFA AEROSOL 2 INHALER OPSUMIT ORAL TABLET 2 PA; QL; SP flunisolide nasal spray,non-aerosol 25 mcg (0.025 1 ORKAMBI ORAL GRANULES IN PACKET 2 PA; QL; SP %) ORKAMBI ORAL TABLET 2 PA; QL; SP fluticasone propionate nasal spray,suspension 1 PULMOZYME INHALATION SOLUTION 2 PA; QL; SP FLUTICASONE PROPION-SALMETEROL 2 RUCONEST INTRAVENOUS RECON SOLN 2 PA; SP INHALATION AEROSOL POWDR BREATH ACTIVATED (generic AirDuo) SEREVENT DISKUS INHALATION BLISTER 2 WITH DEVICE fluticasone propion-salmeterol inhalation blister 1 PA with device sildenafil (pulm.hypertension) oral tablet 1 PA; QL; SP HAEGARDA SUBCUTANEOUS RECON SOLN 2 PA; SP SPIRIVA RESPIMAT INHALATION MIST 2 icatibant subcutaneous syringe 1 PA; QL STIOLTO RESPIMAT INHALATION MIST 2 INCRUSE ELLIPTA INHALATION BLISTER 2 STRIVERDI RESPIMAT INHALATION MIST 2 WITH DEVICE SYMDEKO ORAL TABLETS, SEQUENTIAL 2 PA; QL; SP ipratropium bromide inhalation solution 1 tadalafil (pulm. hypertension) oral tablet 1 PA; QL; SP ipratropium-albuterol inhalation solution for 1 TAKHZYRO SUBCUTANEOUS SOLUTION 2 PA; QL; SP nebulization terbutaline oral tablet 1 KALBITOR SUBCUTANEOUS SOLUTION 2 PA; SP terbutaline subcutaneous solution 1 KALYDECO ORAL GRANULES IN PACKET 2 PA; QL; SP theochron oral tablet extended release 12 hr 300 1 KALYDECO ORAL TABLET 2 PA; QL; SP mg levalbuterol hcl inhalation solution for 1 ST theophylline oral tablet extended release 12 hr 1 nebulization theophylline oral tablet extended release 24 hr 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations88 on this table mean by going to the beginning of this table. 89 88 Drug Name Drug Tier Requirements / Limits LEVALBUTEROL TARTRATE INHALATION 2 ST; QL HFA AEROSOL INHALER metaproterenol oral syrup 1 montelukast oral granules in packet 1 QL montelukast oral tablet 1 QL montelukast oral tablet,chewable 1 QL NASACORT NASAL AEROSOL,SPRAY 2 OTC nasal allergy symptom control nasal spray,non- 1 OTC aerosol NUCALA SUBCUTANEOUS AUTO-INJECTOR 2 PA; QL; SP NUCALA SUBCUTANEOUS RECON SOLN 2 PA; QL; SP NUCALA SUBCUTANEOUS SYRINGE 2 PA; QL; SP OFEV ORAL CAPSULE 2 PA; QL; SP OPSUMIT ORAL TABLET 2 PA; QL; SP ORKAMBI ORAL GRANULES IN PACKET 2 PA; QL; SP ORKAMBI ORAL TABLET 2 PA; QL; SP PULMOZYME INHALATION SOLUTION 2 PA; QL; SP RUCONEST INTRAVENOUS RECON SOLN 2 PA; SP SEREVENT DISKUS INHALATION BLISTER 2 WITH DEVICE sildenafil (pulm.hypertension) oral tablet 1 PA; QL; SP SPIRIVA RESPIMAT INHALATION MIST 2 STIOLTO RESPIMAT INHALATION MIST 2 STRIVERDI RESPIMAT INHALATION MIST 2 SYMDEKO ORAL TABLETS, SEQUENTIAL 2 PA; QL; SP tadalafil (pulm. hypertension) oral tablet 1 PA; QL; SP TAKHZYRO SUBCUTANEOUS SOLUTION 2 PA; QL; SP terbutaline oral tablet 1 terbutaline subcutaneous solution 1 theochron oral tablet extended release 12 hr 300 1 mg theophylline oral tablet extended release 12 hr 1 theophylline oral tablet extended release 24 hr 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations89 on this table mean by going to the beginning of this table. 89 Drug Name Drug Tier Requirements / Limits TRACLEER ORAL TABLET FOR 2 PA; QL; SP SUSPENSION TYVASO INHALATION SOLUTION FOR 2 PA; SP NEBULIZATION TYVASO REFILL KIT INHALATION 2 PA; SP SOLUTION FOR NEBULIZATION TYVASO STARTER KIT INHALATION 2 PA; SP SOLUTION FOR NEBULIZATION VENTAVIS INHALATION SOLUTION FOR 2 PA; SP NEBULIZATION VENTOLIN HFA INHALATION HFA 2 QL AEROSOL INHALER wixela inhub inhalation blister with device 1 PA XOLAIR SUBCUTANEOUS RECON SOLN 2 PA; QL; SP XOLAIR SUBCUTANEOUS SYRINGE 150 2 PA; QL; SP MG/ML XOLAIR SUBCUTANEOUS SYRINGE 75 2 PA; QL; SP MG/0.5 ML zafirlukast oral tablet 1 UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS flavoxate oral tablet 1 oxybutynin chloride oral tablet 1 oxybutynin chloride oral tablet extended release 1 24hr tolterodine oral capsule,extended release 24hr 1 ST tolterodine oral tablet 1 ST trospium oral capsule,extended release 24hr 1 ST trospium oral tablet 1 ST BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin oral tablet extended release 24 hr 1 dutasteride oral capsule 1 finasteride oral tablet 5 mg 1 tamsulosin oral capsule 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations90 on this table mean by going to the beginning of this table. 90 Drug Name Drug Tier Requirements / Limits CHOLINERGIC STIMULANTS bethanechol chloride oral tablet 1 MISCELLANEOUS UROLOGICALS CYSTAGON ORAL CAPSULE 2 PA cytra k crystals oral packet 1 cytra-2 oral solution 1 OTC cytra-3 oral solution 1 OTC cytra-k oral solution 1 OTC ELMIRON ORAL CAPSULE 2 hyophen oral tablet 1 ORACIT ORAL SOLUTION 2 phosphasal oral tablet 1 potassium citrate oral tablet extended release 1 PROCYSBI ORAL CAPSULE, DELAYED REL 2 PA; QL; SP SPRINKLE sodium citrate-citric acid oral solution 1 OTC tricitrates oral solution 1 OTC uretron d-s oral tablet 81.6-10.8-40.8 mg 1 urimar-t oral tablet 1 urin ds oral tablet 1 urogesic-blue oral tablet 1 uryl oral tablet 1 utira-c oral tablet 1 virtrate-2 oral solution 1 OTC virtrate-3 oral solution 1 OTC virtrate-k oral solution 1 OTC URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg 1 VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES antacid (calcium carbonate) oral tablet,chewable 1 OTC 200 mg calcium (500 mg)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations91 on this table mean by going to the beginning of this table. 91 Drug Name Drug Tier Requirements / Limits antacid ext str (calcium carb) oral tablet,chewable 1 OTC antacid extra-strength oral tablet,chewable 168 1 OTC mg calcium (420 mg), 300 mg (750 mg) antacid ultra strength oral tablet,chewable 400 mg 1 OTC calcium (1,000 mg) calci-chew oral tablet,chewable 1 OTC CALCI-MIX ORAL CAPSULE 2 OTC calcitrate oral tablet 1 OTC calcium 500 + d oral tablet,chewable 1 OTC calcium 500 oral tablet,chewable 1 OTC calcium 600 + d(3) oral capsule 1 OTC calcium 600 + d(3) oral tablet 600 mg(1,500mg) - 1 OTC 200 unit calcium 600 oral tablet 1 OTC calcium 600 with vitamin d3 oral tablet,chewable 1 OTC calcium antacid oral tablet,chewable 200 mg 1 OTC calcium (500 mg), 300 mg (750 mg), 320 mg calcium (750 mg), 400 mg calcium (1,000 mg) calcium antacid ultra max st oral tablet,chewable 1 OTC calcium carbonate oral suspension 1 OTC calcium carbonate oral tablet 500 mg calcium 1 OTC (1,250 mg), 600 mg calcium (1,500 mg) calcium carbonate oral tablet,chewable 200 mg 1 OTC calcium (500 mg), 320 mg calcium (750 mg), 500 mg calcium (1,250 mg) calcium carbonate-vitamin d3 oral capsule 600 1 OTC mg(1,500mg) -400 unit calcium citrate oral tablet 200 mg (950 mg) 1 OTC calcium citrate-vitamin d3 oral tablet 200-125 mg- 1 OTC unit, 315 mg- 250 unit, 315-200 mg-unit calcium gluconate oral tablet 45 mg (500 mg) 1 OTC calcium lactate oral tablet 84 mg (648 mg) 1 OTC cal-gest antacid oral tablet,chewable 1 OTC CERALYTE 90 ORAL PACKET 2 OTC CERALYTE-70 ORAL PACKET 2 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations92 on this table mean by going to the beginning of this table. 92 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits antacid ext str (calcium carb) oral tablet,chewable 1 OTC CITRACAL + D PETITES ORAL TABLET 2 OTC antacid extra-strength oral tablet,chewable 168 1 OTC CITRACAL REGULAR ORAL TABLET 2 OTC mg calcium (420 mg), 300 mg (750 mg) effer-k oral tablet, effervescent 25 meq 1 antacid ultra strength oral tablet,chewable 400 mg 1 OTC electrolytes-dextrose oral solution 1 OTC calcium (1,000 mg) FLORICAL ORAL CAPSULE 2 OTC calci-chew oral tablet,chewable 1 OTC GALZIN ORAL CAPSULE 2 PA CALCI-MIX ORAL CAPSULE 2 OTC klor-con 10 oral tablet extended release 1 calcitrate oral tablet 1 OTC klor-con 8 oral tablet extended release 1 calcium 500 + d oral tablet,chewable 1 OTC klor-con m10 oral tablet,er particles/crystals 1 calcium 500 oral tablet,chewable 1 OTC klor-con m15 oral tablet,er particles/crystals 1 calcium 600 + d(3) oral capsule 1 OTC klor-con m20 oral tablet,er particles/crystals 1 calcium 600 + d(3) oral tablet 600 mg(1,500mg) - 1 OTC 200 unit klor-con oral packet 1 calcium 600 oral tablet 1 OTC klor-con/ef oral tablet, effervescent 1 calcium 600 with vitamin d3 oral tablet,chewable 1 OTC k-phos-neutral oral tablet 1 OTC calcium antacid oral tablet,chewable 200 mg 1 OTC k-tab oral tablet extended release 8 meq 1 calcium (500 mg), 300 mg (750 mg), 320 mg LIQUID CALCIUM WITH VITAMIN D ORAL 2 OTC calcium (750 mg), 400 mg calcium (1,000 mg) CAPSULE calcium antacid ultra max st oral tablet,chewable 1 OTC mag 64 oral tablet,delayed release (dr/ec) 1 OTC calcium carbonate oral suspension 1 OTC mag-g oral tablet 1 OTC calcium carbonate oral tablet 500 mg calcium 1 OTC MAGNESIUM AMINO ACID CHELATE ORAL 2 OTC (1,250 mg), 600 mg calcium (1,500 mg) TABLET 100 MG calcium carbonate oral tablet,chewable 200 mg 1 OTC magnesium gluconate oral tablet 27 mg 1 OTC calcium (500 mg), 320 mg calcium (750 mg), 500 magnesium (500 mg), 27.5 mg magne- sium (500 mg calcium (1,250 mg) mg) calcium carbonate-vitamin d3 oral capsule 600 1 OTC magnesium oral tablet 200 mg 1 OTC mg(1,500mg) -400 unit magnesium oxide oral capsule 500 mg 1 OTC calcium citrate oral tablet 200 mg (950 mg) 1 OTC magnesium oxide oral tablet 200 mg magnesium, 1 OTC calcium citrate-vitamin d3 oral tablet 200-125 mg- 1 OTC 250 mg magnesium, 400 mg (241.3 mg unit, 315 mg- 250 unit, 315-200 mg-unit magnesium), 400 mg magnesium, 500 mg calcium gluconate oral tablet 45 mg (500 mg) 1 OTC oysco-500 oral tablet 1 OTC calcium lactate oral tablet 84 mg (648 mg) 1 OTC oyster shell + d3 oral tablet 1 OTC cal-gest antacid oral tablet,chewable 1 OTC oyster shell calcium 500 oral tablet 1 OTC CERALYTE 90 ORAL PACKET 2 OTC oyster shell calcium oral tablet 1 OTC CERALYTE-70 ORAL PACKET 2 OTC pediatric electrolyte oral solution 1 OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. 92 You can find information on what the symbols and abbreviations93 on this table mean by going to the beginning of this table. 93 Drug Name Drug Tier Requirements / Limits phospha 250 neutral oral tablet 1 OTC potassium chloride oral liquid 1 potassium chloride oral packet 1 potassium chloride oral tablet extended release 1 potassium chloride oral tablet,er particles/crystals 1 potassium gluconate oral tablet 500 mg (83 mg), 1 OTC 595 mg (99 mg) selenium oral tablet 50 mcg 1 OTC ultra strength antacid oral tablet,chewable 1 OTC ultra strength calcium antacid oral 1 OTC tablet,chewable virt-phos 250 neutral oral tablet 1 OTC zinc gluconate oral tablet 100 mg 1 OTC zinc sulfate oral tablet 1 OTC MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES FISH OIL ORAL CAPSULE 1,000 MG (120 MG- 2 OTC 180 MG) l-methyl-mc nac oral tablet 1 OTC lysine oral tablet 500 mg 1 OTC omega 3-dha-epa-fish oil oral capsule 1,000 mg 1 OTC (120 mg-180 mg) VITAMINS & HEMATINICS abc plus oral tablet 1 OTC animal shapes complete oral tablet,chewable 1 OTC ANTIOXIDANT VITAMINS ORAL TABLET 2 OTC 1,000 UNIT-200 MG-60 UNIT-2 MG AQUADEKS ORAL TABLET,CHEWABLE 2 OTC AQUADEKS PEDIATRIC ORAL DROPS 2 OTC ascorbate calcium (vitamin c) oral tablet 1 OTC ascorbic acid (vitamin c) oral capsule, extended 1 OTC release ascorbic acid (vitamin c) oral tablet 1 OTC ascorbic acid (vitamin c) oral tablet extended 1 OTC release 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations94 on this table mean by going to the beginning of this table. 94 Drug Name Drug Tier Requirements / Limits ascorbic acid (vitamin c) oral tablet,chewable 500 1 OTC mg b complex-vitamin b12 oral tablet 1 ACA; OTC b complex-vitamin c-folic acid oral tablet 1 ACA; OTC B COMPLEX-VITAMIN C-FOLIC ACID ORAL 2 OTC TABLET EXTENDED RELEASE b-12 dots oral tablet 1 OTC BACMIN ORAL TABLET 2 OTC balance b-100 (folic acid) oral tablet 1 ACA; OTC balanced b-100 complex oral tablet extended 1 ACA; OTC release 100 mg bal-care dha oral combo pack,tablet and cap,dr 1 b-complex with vitamin c oral capsule 1 OTC b-complex with vitamin c oral tablet 1 ACA; OTC beta carotene oral capsule 25,000 unit 1 OTC c complex oral tablet extended release 1 OTC c-1000 oral tablet 1 OTC c-1000 with rose hips oral tablet 1 OTC c-500 oral tablet 1 OTC c-500 oral tablet,chewable 1 OTC CALCET PETITES ORAL TABLET 2 OTC calcium for women oral tablet,chewable 1 OTC calcium-folic acid-vitamin d oral wafer 1 OTC centamin oral liquid 1 OTC centravites 50 plus oral tablet 1 OTC centravites oral tablet 1 OTC cerovite advanced formula oral tablet 1 OTC cerovite jr oral tablet,chewable 18 mg iron- 10 1 OTC mcg cerovite senior oral tablet 1 OTC certa plus oral tablet 1 OTC certavite senior-antioxidant oral tablet 1 OTC chewable-vite oral tablet,chewable 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations95 on this table mean by going to the beginning of this table. 95 Drug Name Drug Tier Requirements / Limits chewable-vite with iron oral tablet,chewable 1 OTC children's chewable vitamin oral tablet,chewable 1 OTC childs chew vite oral tablet,chewable 1 OTC child's chewable vitamins/iron oral 1 OTC tablet,chewable childs/iron oral tablet,chewable 1 OTC cholecalciferol (vitamin d3) oral capsule 1,250 1 OTC mcg (50,000 unit), 125 mcg (5,000 unit), 25 mcg (1,000 unit) cholecalciferol (vitamin d3) oral drops 10 mcg/ml 1 OTC (400 unit/ml), 125 mcg/ml (5,000 unit/ml) cholecalciferol (vitamin d3) oral tablet 125 mcg 1 OTC (5,000 unit), 25 mcg (1,000 unit) CHOLECALCIFEROL (VITAMIN D3) ORAL 2 OTC TABLET,CHEWABLE 400 UNIT classic prenatal oral tablet 1 ACA; OTC c-nate dha oral capsule 1 cod liver oil oral capsule 1 OTC complete 50+ oral tablet 1 OTC complete multi 50+ oral tablet 1 OTC complete multi oral tablet 1 OTC complete multivitamin oral tablet 1 OTC complete multivitamin-mineral oral tablet 1 OTC complete natal dha oral combo pack 1 complete oral tablet 18-500-300-250 mg-mcg- 1 OTC mcg-mcg complete senior oral tablet 1 OTC completenate oral tablet,chewable 1 complex b-100 oral tablet extended release 1 ACA; OTC CORAL CALCIUM ORAL CAPSULE 250-125- 2 OTC 100 MG-MG-UNIT CORVITE ORAL TABLET 2 OTC cyanocobalamin (vitamin b-12) injection solution 1 cyanocobalamin (vitamin b-12) oral tablet 1,000 1 OTC mcg, 100 mcg, 500 mcg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations96 on this table mean by going to the beginning of this table. 96 Drug Name Drug Tier Requirements / Limits cyanocobalamin (vitamin b-12) oral tablet 1 OTC extended release 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 1 OTC 1,000 mcg, 2,500 mcg D3-50 CHOLECALCIFEROL ORAL CAPSULE 2 OTC daily multiple oral tablet , 18-400 mg-mcg 1 OTC daily multiple vitamins/iron oral tablet 1 OTC daily multi-vitamin oral tablet 1 OTC daily multivitamin with iron oral tablet 1 OTC daily multivitamin-minerals oral tablet 1 OTC daily value oral tablet 1 OTC daily vitamin formula oral tablet 1 OTC daily vitamin formula-iron oral tablet 1 OTC daily vitamin formula-minerals oral tablet 1 OTC daily vitamin with iron oral tablet 1 OTC daily vites/iron oral tablet 1 OTC daily-vite oral tablet 1 OTC DIALYVITE 3000 ORAL TABLET 2 OTC dialyvite 800 oral tablet 1 ACA; OTC DIALYVITE 800 WITH IRON ORAL TABLET 2 OTC dialyvite oral tablet 1 OTC dino-life oral tablet,chewable 1 OTC dino-life with extra c oral tablet,chewable 1 OTC dino-life with iron-zinc oral tablet,chewable 1 OTC elite-ob oral tablet 1 ergocalciferol (vitamin d2) oral capsule 1,250 mcg 1 (50,000 unit) ERGOCALCIFEROL (VITAMIN D2) ORAL 2 OTC TABLET 2,000 UNIT ergocalciferol (vitamin d2) oral tablet 400 unit 1 OTC eye health plus lutein oral tablet 1 OTC ezfe 200 oral capsule 1 OTC ferocon oral capsule 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations97 on this table mean by going to the beginning of this table. 97 Drug Name Drug Tier Requirements / Limits ferosul oral tablet 1 OTC ferretts oral tablet 1 OTC ferrex 150 forte oral capsule 1 OTC ferrex 28 oral tablet 1 OTC ferrocite plus oral tablet 1 OTC ferrous gluconate oral tablet 256 mg (28 mg iron), 1 OTC 324 mg (37.5 mg iron), 324 mg (38 mg iron) ferrous sulfate oral liquid 1 OTC ferrous sulfate oral solution 1 OTC ferrous sulfate oral tablet,delayed release (dr/ec) 1 OTC FLINTSTONES MULTI-VIT GUMMIES ORAL 2 OTC TABLET,CHEWABLE FLINTSTONES TAB CHEW ORAL 2 OTC TABLET,CHEWABLE fluoride (sodium) oral drops 1 ACA; OTC fluoride (sodium) oral tablet,chewable 1 ACA; OTC fluoritab oral tablet,chewable 1 ACA; OTC folbee oral tablet 1 OTC folbee plus oral tablet 5-1.5-25 mg 1 OTC folbic oral tablet 1 OTC FOLGARD OS ORAL TABLET 2 OTC folic acid oral tablet 1 mg 1 folic acid oral tablet 400 mcg, 800 mcg 1 ACA; OTC folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg 1 OTC folivane-f oral capsule 1 OTC folivane-ob oral capsule 1 folivane-plus oral capsule 1 OTC folplex 2.2 oral tablet 1 OTC foltabs 800 oral tablet 1 ACA; OTC FOLTRATE ORAL TABLET 2 OTC fosfree oral tablet 1 OTC fruit c-500 oral tablet,chewable 1 OTC full spectrum b-vitamin c oral tablet 1 ACA; OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations98 on this table mean by going to the beginning of this table. 98 Drug Name Drug Tier Requirements / Limits hematinic plus vit/minerals oral tablet 1 OTC hematinic/folic acid oral tablet 1 OTC hematogen fa oral capsule 1 OTC hematogen forte oral capsule 1 OTC hematogen oral capsule 1 OTC HEMATRON-AF ORAL TABLET EXTENDED 2 OTC RELEASE 24 HR HEMAX ORAL TABLET 2 OTC hydroxocobalamin intramuscular solution 1 iferex 150 forte oral capsule 1 OTC infed injection solution 1 kobee oral tablet 1 ACA; OTC kpn oral tablet 1 ACA; OTC KPN ORAL TABLET 9 MG IRON- 267 MCG 2 OTC levomefolate calcium oral tablet 7.5 mg 1 OTC l-methylfolate oral tablet 7.5 mg 1 OTC l-methyl-mc oral tablet 1 OTC ludent fluoride oral tablet,chewable 1 ACA; OTC lutein oral capsule 20 mg 1 OTC LUTEIN ORAL TABLET 10 MG 2 OTC men's one daily oral tablet 1 OTC milltrium senior oral tablet 1 OTC multi complete with iron oral tablet 1 OTC multi for her oral tablet 1 OTC multi-day with iron oral tablet 1 OTC multi-delyn with iron oral liquid 1 OTC multigen folic oral tablet 1 OTC multigen oral tablet 1 OTC multigen plus oral tablet 1 OTC multilex oral tablet 1 OTC multilex-t and m oral tablet 1 OTC multiple vitamin-minerals oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations99 on this table mean by going to the beginning of this table. 99 Drug Name Drug Tier Requirements / Limits multi-vit with fluoride-iron oral drops 1 OTC multivitamin oral capsule 1 OTC multivitamin oral tablet 1 OTC multi-vitamin with fluoride oral drops 1 ACA; OTC multi-vitamin with fluoride oral tablet,chewable 1 ACA; OTC multivitamin with iron oral tablet 1 OTC multivitamin with minerals oral liquid 1 OTC multivitamin with minerals oral tablet 1 OTC multivitamins with fluoride oral tablet,chewable 1 ACA; OTC mvc-fluoride oral tablet,chewable 1 ACA; OTC myferon 150 forte oral capsule 1 OTC mynatal advance oral tablet 1 mynatal oral capsule 1 mynatal oral tablet 1 mynatal plus oral tablet 1 mynatal-z oral tablet 1 mynate 90 plus oral tablet extended release 1 my-vitalife oral capsule 1 OTC nephplex rx oral tablet 1 OTC nephronex oral liquid 1 OTC nephro-vite rx oral tablet 1 OTC newgen oral tablet 1 norwegian cod liver oil oral capsule 1 OTC NUTRIVIT ORAL LIQUID 2 OTC OBSTETRIX EC ORAL TABLET,DELAYED 2 RELEASE (DR/EC) O-CAL F.A. ORAL TABLET 2 OTC omnicap oral tablet 1 OTC once daily oral tablet 1 OTC one daily calcium/iron oral tablet 1 OTC one daily complete oral tablet 1 OTC one daily essential oral tablet 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations100 on this table mean by going to the beginning of this table. 100 Drug Name Drug Tier Requirements / Limits one daily maximum oral tablet 1 OTC one daily men's 50 plus memory oral tablet 1 OTC one daily multi-vit w-mineral oral tablet 1 OTC one daily multivitamin oral tablet 1 OTC one daily plus iron oral tablet 18-400 mg-mcg 1 OTC one daily plus minerals oral tablet 1 OTC one daily with iron oral tablet 1 OTC one-a-day teen advantage oral tablet 1 OTC opti-vitamins oral tablet 1 OTC perry prenatal oral capsule 1 ACA; OTC pnv 29-1 oral tablet 1 pnv-dha + docusate oral capsule 1 pnv-dha oral capsule 1 pnv-omega oral capsule 1 pnv-select oral tablet 1 poly-iron 150 forte oral capsule 1 OTC polyvitamin with iron oral tablet,chewable 1 OTC poly-vitamins oral tablet,chewable 1 OTC pr natal 400 ec oral combo pack,tablet and cap,dr 1 pr natal 400 oral combo pack 1 pr natal 430 ec oral combo pack,tablet and cap,dr 1 pr natal 430 oral combo pack 1 prenaissance oral capsule 1 prenaissance plus oral capsule 1 prenatabs fa oral tablet 1 prenatabs rx oral tablet 1 prenatal 19 (with docusate) oral tablet 1 OTC prenatal 19 oral tablet,chewable 1 OTC prenatal complete oral tablet 1 ACA; OTC prenatal formula oral tablet 28 mg iron- 800 mcg 1 ACA; OTC PRENATAL FORMULA ORAL TABLET 9 MG 2 OTC IRON- 267 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations101 on this table mean by going to the beginning of this table. 101 Drug Name Drug Tier Requirements / Limits Drug Name Drug Tier Requirements / Limits prenatal multi-dha (algal oil) oral capsule 1 ACA; OTC taron-c dha oral capsule 1 prenatal one daily oral tablet 1 ACA; OTC taron-prex prenatal-dha oral capsule 1 prenatal oral tablet 28 mg iron- 800 mcg 1 ACA; OTC thiamine hcl (vitamin b1) oral tablet 100 mg, 50 1 OTC mg prenatal plus oral tablet 1 thiamine mononitrate (vit b1) oral tablet 1 OTC prenatal vitamin oral tablet 27 mg iron- 0.8 mg 1 ACA; OTC thrivite-19 oral tablet 1 OTC prenatal vitamin with minerals oral tablet 1 ACA; OTC total b/c oral tablet 1 ACA; OTC prenatal vits96-iron fum-folic oral tablet 1 ACA; OTC tricon oral capsule 1 OTC prenatal-u oral capsule 1 trigels-f forte oral capsule 1 OTC pretab oral tablet 1 trinatal rx 1 oral tablet 1 pyridoxine (vitamin b6) oral tablet 100 mg, 50 mg 1 OTC trinate oral tablet 1 quintabs-m iron free oral tablet 1 OTC triveen-duo dha oral combo pack 1 rena-vite oral tablet 1 ACA; OTC tri-vitamin with fluoride oral drops 1 ACA; OTC rena-vite rx oral tablet 1 OTC UDAMIN SP ORAL TABLET 2 OTC reno caps oral capsule 1 OTC unicomplex-m oral tablet 1 OTC se-natal 19 chewable oral tablet,chewable 1 v-c forte oral capsule 1 OTC se-natal-19 oral tablet 1 VENOFER INTRAVENOUS SOLUTION 2 sentry senior oral tablet 1 OTC vic-forte oral capsule 1 OTC SIDEROL ORAL TABLET 2 OTC vinate care oral tablet,chewable 1 slow release iron oral tablet extended release 142 1 OTC mg (45 mg iron), 250 mg (50 mg iron) vinate m oral tablet 1 SLOW RELEASE IRON ORAL TABLET 2 OTC vinate one oral tablet 1 EXTENDED RELEASE 159 MG (45 MG IRON) virt-c dha oral capsule 1 STROVITE ONE ORAL TABLET 2 OTC virt-nate dha oral capsule 1 super b maxi complex oral tablet 1 ACA; OTC virt-pn dha oral capsule 1 super b/c oral capsule 1 OTC virt-pn plus oral capsule 1 super quints b-50 oral tablet 1 ACA; OTC vision formula (with lutein) oral tablet 1 OTC super quints oral tablet 1 ACA; OTC vit 3 oral capsule 1 OTC super thera vite m oral tablet 1 OTC vit a and d3 in cod liver oil oral capsule 1 OTC superplex-t oral tablet 1 ACA; OTC vitacel (with lutein) oral tablet 1 OTC tab-a-vite oral tablet 1 OTC VITAFOL-OB ORAL TABLET 2 tab-a-vite/iron oral tablet 1 OTC vitalee oral tablet 1 OTC taron forte oral capsule 1 OTC vitalets oral tablet,chewable 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. of this table. You can find information on what the symbols and abbreviations102 on this table mean by going to the beginning of this table. 103 102 Drug Name Drug Tier Requirements / Limits taron-c dha oral capsule 1 taron-prex prenatal-dha oral capsule 1 thiamine hcl (vitamin b1) oral tablet 100 mg, 50 1 OTC mg thiamine mononitrate (vit b1) oral tablet 1 OTC thrivite-19 oral tablet 1 OTC total b/c oral tablet 1 ACA; OTC tricon oral capsule 1 OTC trigels-f forte oral capsule 1 OTC trinatal rx 1 oral tablet 1 trinate oral tablet 1 triveen-duo dha oral combo pack 1 tri-vitamin with fluoride oral drops 1 ACA; OTC UDAMIN SP ORAL TABLET 2 OTC unicomplex-m oral tablet 1 OTC v-c forte oral capsule 1 OTC VENOFER INTRAVENOUS SOLUTION 2 vic-forte oral capsule 1 OTC vinate care oral tablet,chewable 1 vinate m oral tablet 1 vinate one oral tablet 1 virt-c dha oral capsule 1 virt-nate dha oral capsule 1 virt-pn dha oral capsule 1 virt-pn plus oral capsule 1 vision formula (with lutein) oral tablet 1 OTC vit 3 oral capsule 1 OTC vit a and d3 in cod liver oil oral capsule 1 OTC vitacel (with lutein) oral tablet 1 OTC VITAFOL-OB ORAL TABLET 2 vitalee oral tablet 1 OTC vitalets oral tablet,chewable 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations103 on this table mean by going to the beginning of this table. 103 Drug Name Drug Tier Requirements / Limits vitamin a oral capsule 10,000 unit, 8,000 unit 1 OTC vitamin b complex oral capsule 1 OTC vitamin b complex-folic acid oral tablet 1 ACA; OTC vitamin b-1 (mononitrate) oral tablet 1 OTC vitamin b-1 oral tablet 1 OTC VITAMIN B-12 ORAL LOZENGE 500 MCG 2 OTC vitamin b-12 oral tablet 1,000 mcg, 100 mcg, 250 1 OTC mcg, 500 mcg vitamin b-12 oral tablet extended release 1,000 1 OTC mcg, 2,000 mcg vitamin b-12 sublingual tablet 2,500 mcg 1 OTC VITAMIN B-12 SUBLINGUAL TABLET 5,000 2 OTC MCG vitamin b-2 oral tablet 100 mg, 25 mg 1 OTC vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg 1 OTC vitamin c drops oral lozenge 1 OTC vitamin c oral capsule, extended release 1 OTC vitamin c oral tablet 1 OTC vitamin c oral tablet extended release 1 OTC vitamin c oral tablet,chewable 250 mg, 500 mg 1 OTC vitamin c with rose hips oral tablet 1 OTC vitamin c with rose hips oral tablet extended 1 OTC release 1,000 mg vitamin d3 oral capsule 400 unit, 50 mcg (2,000 1 OTC unit) vitamin d3 oral tablet 10 mcg (400 unit), 2,000 1 OTC unit vitamin d3 oral tablet,chewable 1 OTC vitamin e (dl, acetate) oral capsule 400 unit 1 OTC vitamin e (dl, acetate) oral drops 22.5 mg (50 1 OTC unit)/ml vitamin e acetate oral capsule 1 OTC vitamin e mixed oral capsule 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations104 on this table mean by going to the beginning of this table. 104 Drug Name Drug Tier Requirements / Limits vitamin e oral capsule 1,000 unit, 100 unit, 200 1 OTC unit, 400 unit vitamins a,c,d and fluoride oral drops 1 ACA; OTC vitamins and minerals oral tablet 1 OTC vitamins b complex oral capsule 1 OTC vitatrum oral tablet 1 OTC vp-ch-pnv oral capsule 1 vp-vite rx oral tablet 1 OTC zatean-pn dha oral capsule 1 zatean-pn plus oral capsule 1 zingiber oral tablet 1 zoo chews oral tablet,chewable 1 OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. You can find information on what the symbols and abbreviations105 on this table mean by going to the beginning of this table. 105 Index antacid ...... 56 ASMANEX HFA ...... 87 balziva (28) ...... 70 antacid (calcium carb-mag ASMANEX TWISTHALER 87 banophen ...... 80 hyd) ...... 56 ASPERCREME BANZEL ...... 16 antacid (calcium carbonate) . 91 (LIDOCAINE) ...... 42 BARACLUDE ...... 4 1 AIMOVIG AUTOINJECTOR allergy relief-d (loratadine) ... 82 antacid anti-gas ...... 56 aspir-81 ...... 23 BASAGLAR KWIKPEN U- 12 hour decongestant ...... 82 ...... 19 allergy-time ...... 80 antacid exst (mag carb-al hyd) aspirin ...... 23 100 INSULIN ...... 51 12 hour nasal decongest (pse) ak-poly-bac ...... 75 aller-tec ...... 80 ...... 56 aspirin low dose ...... 23 bayer aspirin ...... 23 ...... 82 AKYNZEO aller-tec d ...... 82 antacid ext str (calcium carb) 92 aspirin,buffd-calcium carb-mag b-complex with vitamin c ..... 95 1-DAY ...... 69 (FOSNETUPITANT) ...... 56 allopurinol ...... 65 antacid extra-strength ..... 56, 92 ...... 23 bekyree (28) ...... 70 3 AKYNZEO (NETUPITANT) ALOGLIPTIN ...... 54 antacid maximum strength ... 56 aspir-low ...... 23 belladonna alkaloids-opium .. 56 3-day vaginal ...... 69 ...... 56 ALOGLIPTIN-METFORMIN antacid plus anti-gas ...... 56 aspir-trin ...... 23 benazepril ...... 32 A alaway ...... 76 ...... 54 antacid regular strength ...... 56 atazanavir ...... 4 benazepril-hydrochlorothiazide abacavir ...... 3 albendazole ...... 8 ALOGLIPTIN- antacid ultra strength ...... 92 atenolol ...... 32 ...... 32 abacavir-lamivudine ...... 3 albuterol sulfate ...... 87 PIOGLITAZONE ...... 54 antacid-antigas ...... 57 atenolol-chlorthalidone ...... 32 BENLYSTA ...... 65 abacavir-lamivudine- alclometasone ...... 44 ALOMIDE ...... 76 antacid-simethicone ...... 57 atomoxetine ...... 28 BENZNIDAZOLE ...... 8 zidovudine ...... 3 ALDURAZYME ...... 52 alosetron ...... 56 antibiotic (bacitracin zinc) .... 42 atorvastatin ...... 37 benzonatate ...... 82 abc plus ...... 94 ALECENSA ...... 11 alprazolam ...... 27 anti-fungal ...... 43 atovaquone ...... 8 benzoyl peroxide ...... 41 ABILIFY MAINTENA ...... 27 alendronate ...... 65 alprazolam intensol ...... 27 antifungal (tolnaftate) ...... 43 ATRIPLA ...... 4 benztropine ...... 19 abiraterone ...... 11 alfuzosin ...... 90 altavera (28) ...... 70 antifungal cream (miconazole) atropine ...... 76 BERINERT ...... 87 ABSTRAL ...... 21 ALIMTA ...... 11 ALUNBRIG ...... 11 ...... 43 AUBAGIO ...... 63 beta carotene ...... 95 acamprosate ...... 47 ALINIA ...... 8 alyacen 1/35 (28) ...... 70 antifungal spray ...... 43 aubra ...... 70 BETADINE OPHTHALMIC acarbose ...... 54 all day allergy (cetirizine) ..... 79 alyacen 7/7/7 (28) ...... 70 ANTIOXIDANT VITAMINS aubra eq ...... 70 PREP ...... 75 acebutolol ...... 32 all day allergy-d ...... 82 alyq ...... 87 ...... 94 AUGMENTIN ...... 9 betamethasone dipropionate . 44 acetadryl ...... 23 all day pain relief ...... 23 amabelz ...... 67 APOKYN ...... 19 AUSTEDO ...... 20 betamethasone valerate ...... 44 acetaminophen ...... 23 all day relief ...... 23 amantadine hcl ...... 3 apraclonidine ...... 79 AVANDIA ...... 54 betamethasone, augmented ... 44 acetaminophen pm ...... 23 ALLEGRA ALLERGY ...... 79 ambrisentan ...... 87 aprepitant ...... 57 aviane ...... 70 betaxolol ...... 32, 75 acetaminophen-codeine ...... 21 aller-chlor ...... 79 amcinonide ...... 44 apri ...... 70 AVONEX ...... 63 bethanechol chloride ...... 91 acetazolamide ...... 78 allerclear ...... 79 amethia ...... 70 APTIOM ...... 16 AVONEX (WITH ALBUMIN) BEVACIZUMAB ...... 76 acetic acid ...... 49 allerclear d-12hr ...... 82 amethia lo ...... 70 APTIVUS ...... 4 ...... 63 bexarotene ...... 11 acitretin ...... 39 allerclear d-24hr ...... 82 amethyst (28) ...... 70 AQUADEKS ...... 94 azathioprine ...... 11 bicalutamide ...... 11 ACTEMRA ...... 65 aller-ease ...... 79 amifostine crystalline ...... 11 AQUADEKS PEDIATRIC .. 94 azelastine ...... 48, 76 BIKTARVY ...... 4 ACTEMRA ACTPEN ...... 65 aller-fex ...... 79 amiloride ...... 32 ARALAST NP ...... 47 azithromycin ...... 7 bisacodyl ...... 57 ACTHAR ...... 49 allergy (chlorpheniramine) ... 79 amiloride-hydrochlorothiazide aranelle (28) ...... 70 azurette (28) ...... 70 bisa-lax ...... 57 ACTIMMUNE ...... 64 allergy (diphenhydramine) ... 79 ...... 32 ARANESP (IN B bisoprolol fumarate ...... 32 acyclovir ...... 3, 44 allergy 4-hour ...... 80 aminocaproic acid ...... 36 POLYSORBATE) ...... 62 b complex-vitamin b12 ...... 95 bisoprolol-hydrochlorothiazide ADDERALL XR ...... 27 allergy and congestion relief 82 amiodarone ...... 32 ARCALYST ...... 64 b complex-vitamin c-folic acid ...... 33 adefovir ...... 3 allergy complete-d ...... 82 amitriptyline ...... 27 ARIKAYCE ...... 8 ...... 95 BIVIGAM ...... 64 ADEMPAS ...... 87 allergy medicine ...... 80 amitriptyline-chlordiazepoxide aripiprazole ...... 27 B COMPLEX-VITAMIN C- BLEPHAMIDE ...... 79 ADMELOG SOLOSTAR U- allergy multi-symptom ...... 82 ...... 27 ARISTADA ...... 27 FOLIC ACID ...... 95 BLEPHAMIDE S.O.P...... 79 100 INSULIN ...... 51 allergy plus severe sinus ha .. 82 amlodipine ...... 32 ARISTADA INITIO ...... 27 b-12 dots ...... 95 blisovi fe 1.5/30 (28) ...... 70 ADMELOG U-100 INSULIN allergy relief (cetirizine) ...... 80 amlodipine-benazepril ...... 32 armodafinil ...... 28 bacitracin ...... 42, 75 blisovi fe 1/20 (28) ...... 70 LISPRO ...... 51 allergy relief (clemastine) ..... 80 ammonium lactate ...... 40 ARMOUR THYROID ...... 55 bacitracin-polymyxin b ...... 75 bosentan ...... 87 adult aspirin regimen ...... 23 allergy relief (fexofenadine) . 80 amnesteem ...... 41 ARNUITY ELLIPTA ...... 87 back and body pain reliever .. 23 BOSULIF ...... 11 adult tussin chest congestion 82 allergy relief (loratadine) ...... 80 amoxapine ...... 27 arthritis pain relief (acetam) . 23 baclofen ...... 20 BOTOX ...... 64 adult tussin cough congest dm allergy relief d-24hr ...... 82 amoxicillin ...... 9 artificial tears (polyvin alc) .. 76 BACMIN ...... 95 bp ...... 41 ...... 82 allergy relief(chlorpheniramn) amoxicillin-pot clavulanate .... 9 artificial tears(pvalch-povid) 76 balance b-100 (folic acid) ..... 95 bpo-10 ...... 41 adult tussin dm ...... 82 ...... 80 ampicillin ...... 9 ascorbate calcium (vitamin c) balanced b-100 complex ...... 95 bpo-5 ...... 41 AEMCOLO ...... 8 allergy relief(diphenhydramin) anagrelide ...... 47 ...... 94 bal-care dha ...... 95 BRAFTOVI ...... 11 AFINITOR ...... 11 ...... 80 anastrozole ...... 11 ascorbic acid (vitamin c) 94, 95 balsalazide ...... 57 briellyn ...... 70 AFINITOR DISPERZ ...... 11 allergy relief,nasal decongest82 animal shapes complete ...... 94 ashlyna ...... 70 BALVERSA ...... 11 brimonidine ...... 79 AFREZZA ...... 51 allergy relief-d (cetirizine) .... 82 ANORO ELLIPTA ...... 87 106 107 106 antacid ...... 56 ASMANEX HFA ...... 87 balziva (28) ...... 70 antacid (calcium carb-mag ASMANEX TWISTHALER 87 banophen ...... 80 hyd) ...... 56 ASPERCREME BANZEL ...... 16 antacid (calcium carbonate) . 91 (LIDOCAINE) ...... 42 BARACLUDE ...... 4 antacid anti-gas ...... 56 aspir-81 ...... 23 BASAGLAR KWIKPEN U- antacid exst (mag carb-al hyd) aspirin ...... 23 100 INSULIN ...... 51 ...... 56 aspirin low dose ...... 23 bayer aspirin ...... 23 antacid ext str (calcium carb) 92 aspirin,buffd-calcium carb-mag b-complex with vitamin c ..... 95 antacid extra-strength ..... 56, 92 ...... 23 bekyree (28) ...... 70 antacid maximum strength ... 56 aspir-low ...... 23 belladonna alkaloids-opium .. 56 antacid plus anti-gas ...... 56 aspir-trin ...... 23 benazepril ...... 32 antacid regular strength ...... 56 atazanavir ...... 4 benazepril-hydrochlorothiazide antacid ultra strength ...... 92 atenolol ...... 32 ...... 32 antacid-antigas ...... 57 atenolol-chlorthalidone ...... 32 BENLYSTA ...... 65 antacid-simethicone ...... 57 atomoxetine ...... 28 BENZNIDAZOLE ...... 8 antibiotic (bacitracin zinc) .... 42 atorvastatin ...... 37 benzonatate ...... 82 anti-fungal ...... 43 atovaquone ...... 8 benzoyl peroxide ...... 41 antifungal (tolnaftate) ...... 43 ATRIPLA ...... 4 benztropine ...... 19 antifungal cream (miconazole) atropine ...... 76 BERINERT ...... 87 ...... 43 AUBAGIO ...... 63 beta carotene ...... 95 antifungal spray ...... 43 aubra ...... 70 BETADINE OPHTHALMIC ANTIOXIDANT VITAMINS aubra eq ...... 70 PREP ...... 75 ...... 94 AUGMENTIN ...... 9 betamethasone dipropionate . 44 APOKYN ...... 19 AUSTEDO ...... 20 betamethasone valerate ...... 44 apraclonidine ...... 79 AVANDIA ...... 54 betamethasone, augmented ... 44 aprepitant ...... 57 aviane ...... 70 betaxolol ...... 32, 75 apri ...... 70 AVONEX ...... 63 bethanechol chloride ...... 91 APTIOM ...... 16 AVONEX (WITH ALBUMIN) BEVACIZUMAB ...... 76 APTIVUS ...... 4 ...... 63 bexarotene ...... 11 AQUADEKS ...... 94 azathioprine ...... 11 bicalutamide ...... 11 AQUADEKS PEDIATRIC .. 94 azelastine ...... 48, 76 BIKTARVY ...... 4 ARALAST NP ...... 47 azithromycin ...... 7 bisacodyl ...... 57 aranelle (28) ...... 70 azurette (28) ...... 70 bisa-lax ...... 57 ARANESP (IN B bisoprolol fumarate ...... 32 POLYSORBATE) ...... 62 b complex-vitamin b12 ...... 95 bisoprolol-hydrochlorothiazide ARCALYST ...... 64 b complex-vitamin c-folic acid ...... 33 ARIKAYCE ...... 8 ...... 95 BIVIGAM ...... 64 aripiprazole ...... 27 B COMPLEX-VITAMIN C- BLEPHAMIDE ...... 79 ARISTADA ...... 27 FOLIC ACID ...... 95 BLEPHAMIDE S.O.P...... 79 ARISTADA INITIO ...... 27 b-12 dots ...... 95 blisovi fe 1.5/30 (28) ...... 70 armodafinil ...... 28 bacitracin ...... 42, 75 blisovi fe 1/20 (28) ...... 70 ARMOUR THYROID ...... 55 bacitracin-polymyxin b ...... 75 bosentan ...... 87 ARNUITY ELLIPTA ...... 87 back and body pain reliever .. 23 BOSULIF ...... 11 arthritis pain relief (acetam) . 23 baclofen ...... 20 BOTOX ...... 64 artificial tears (polyvin alc) .. 76 BACMIN ...... 95 bp ...... 41 artificial tears(pvalch-povid) 76 balance b-100 (folic acid) ..... 95 bpo-10 ...... 41 ascorbate calcium (vitamin c) balanced b-100 complex ...... 95 bpo-5 ...... 41 ...... 94 bal-care dha ...... 95 BRAFTOVI ...... 11 ascorbic acid (vitamin c) 94, 95 balsalazide ...... 57 briellyn ...... 70 ashlyna ...... 70 BALVERSA ...... 11 brimonidine ...... 79

107 107 BRINEURA ...... 52 calcium citrate-vitamin d3 .... 92 cerovite jr ...... 95 child's chewable vitamins/iron clindamycin pediatric ...... 8 complete multivitamin-mineral BRIVIACT ...... 17 calcium for women ...... 95 cerovite senior ...... 95 ...... 96 clindamycin phosphate ... 41, 69 ...... 96 bromfenac ...... 77 calcium gluconate ...... 92 certa plus ...... 95 childs triacting cold-cough ... 83 CLINDESSE ...... 69 complete natal dha ...... 96 bromocriptine ...... 19 calcium lactate ...... 92 certavite senior-antioxidant .. 95 childs/iron ...... 96 clobazam ...... 17 complete senior ...... 96 brompheniramine-pseudoeph- calcium-folic acid-vitamin d 95 cetirizine ...... 80 chlordiazepoxide hcl ...... 28 clobetasol ...... 44 completenate ...... 96 dm ...... 82 cal-gest antacid ...... 92 cetirizine-pseudoephedrine ... 83 chlorhexidine gluconate ...... 48 clobetasol-emollient ...... 44 complex b-100 ...... 96 brotapp dm ...... 82 CALQUENCE ...... 11 cevimeline ...... 47 chlorhist ...... 80 clonazepam ...... 17 compro ...... 57 budesonide ...... 57, 88 camila ...... 67 CHANTIX ...... 48 chloroquine phosphate ...... 8 clonidine ...... 33 CONDYLOX ...... 40 bufferin ...... 23 camrese ...... 70 CHANTIX CONTINUING chlorothiazide ...... 33 clonidine hcl ...... 33 constulose ...... 57 bumetanide ...... 33 camrese lo ...... 70 MONTH BOX ...... 48 chlorpheniramine maleate .... 80 clopidogrel ...... 36 COPIKTRA ...... 11 buprenorphine ...... 21 capecitabine ...... 11 CHANTIX STARTING chlorpromazine ...... 28 clorazepate dipotassium ...... 28 CORAL CALCIUM ...... 96 BUPRENORPHINE ...... 21 CAPRELSA ...... 11 MONTH BOX ...... 48 chlorthalidone ...... 33 clotrimazole ...... 3, 43, 69 CORLANOR ...... 38 buprenorphine hcl ...... 21 captopril-hydrochlorothiazide chateal eq (28) ...... 70 chlorzoxazone ...... 20 clotrimazole-3 ...... 69 cormax ...... 44 buprenorphine-naloxone ...... 24 ...... 33 CHEMET ...... 47 cholecalciferol (vitamin d3) . 96 clotrimazole-betamethasone . 43 cortisone ...... 49 bupropion hcl ...... 28 CARAFATE ...... 61 chest congestion relief ...... 83 CHOLECALCIFEROL clozapine ...... 28 CORTISPORIN-TC ...... 49 bupropion hcl (smoking deter) CARBAGLU ...... 47 chest congestion relief dm .... 83 (VITAMIN D3) ...... 96 CLOZAPINE ...... 28 CORVITE ...... 96 ...... 48 carbamazepine ...... 17 chest congestion-cough relief cholestyramine (with sugar) . 37 c-nate dha ...... 96 COSENTYX ...... 39 buspirone ...... 28 carbidopa ...... 19 ...... 83 cholestyramine light ...... 37 cod liver oil ...... 96 COSENTYX (2 SYRINGES) butalbital-acetaminop-caf-cod carbidopa-levodopa ...... 19 chewable-vite ...... 95 choline,magnesium salicylate codeine sulfate ...... 21 ...... 39 ...... 21 carbidopa-levodopa- chewable-vite with iron ...... 96 ...... 24 codeine-guaifenesin ...... 83 COSENTYX PEN ...... 39 butalbital-acetaminophen-caff entacapone ...... 19 child benadryl plus congestion ciclodan ...... 43 COLCHICINE ...... 65 COSENTYX PEN (2 PENS) 39 ...... 21 carbinoxamine maleate ...... 80 ...... 83 ciclopirox ...... 43 cold and allergy ...... 83 COTELLIC ...... 11 butalbital-aspirin-caffeine .... 21 carisoprodol ...... 20 CHILD MUCINEX COUGH cilostazol ...... 36 cold and allergy (bromphen-pe) cough dm er ...... 83 C carisoprodol-aspirin ...... 20 MINI-MELTS ...... 83 CILOXAN ...... 75 ...... 83 CREON ...... 57 c complex ...... 95 carisoprodol-aspirin-codeine 20 child mucus relief expectorant CIMDUO ...... 4 cold and allergy pe ...... 83 CRESEMBA ...... 3 c-1000 ...... 95 carteolol ...... 76 ...... 83 cimetidine ...... 61 cold and cough dm ...... 83 CRINONE ...... 67 c-1000 with rose hips ...... 95 cartia xt ...... 33 children's acetaminophen ..... 24 cimetidine hcl ...... 61 cold and cough elixir ...... 83 CRIXIVAN ...... 4 c-500 ...... 95 carvedilol ...... 33 children's alaway ...... 76 CIMZIA ...... 57 COLD HEAD CONGESTION cromolyn ...... 57, 76, 88 cabergoline ...... 52 CAYA CONTOURED ...... 67 children's allegra allergy ...... 80 cinacalcet ...... 52 DAY/NITE ...... 83 cryselle (28) ...... 71 CABOMETYX ...... 11 CAYSTON ...... 8 children's allergy (diphenhyd) CINQAIR ...... 88 cold head congestion nighttime CRYSVITA ...... 52 CALCET PETITES ...... 95 caziant (28) ...... 70 ...... 80 CINRYZE ...... 88 ...... 83 cyanocobalamin (vitamin b-12) calci-chew ...... 92 cefaclor ...... 6, 7 children's allergy relief(lor) .. 80 CIPRO HC ...... 49 cold multi-symptom ...... 96, 97 CALCI-MIX ...... 92 cefadroxil ...... 7 children's aspirin ...... 24 CIPRODEX ...... 49 (chlorphen) ...... 83 cyclafem 1/35 (28) ...... 71 calcipotriene ...... 39 cefdinir ...... 7 children's cetirizine ...... 80 ciprofloxacin hcl ...... 10, 49, 75 COLD MULTI-SYMPTOM cyclafem 7/7/7 (28) ...... 71 calcipotriene-betamethasone 39 cefixime ...... 7 children's chewable vitamin . 96 citalopram ...... 28 DAY/NIGHT ...... 83 cyclobenzaprine ...... 21 calcitonin (salmon) ...... 52 cefpodoxime ...... 7 children's cold and cough (pe) CITRACAL + D PETITES .. 93 cold relief plus ...... 83 CYCLOMYDRIL ...... 79 calcitrate ...... 92 cefprozil ...... 7 ...... 83 CITRACAL REGULAR ...... 93 cold-sinus relief ...... 83 cyclopentolate ...... 76 calcitriol ...... 39, 52 cefuroxime axetil ...... 7 children's cold-allergy (pe) ... 83 citrate of magnesia ...... 57 colestipol ...... 37 cyclophosphamide ...... 11 calcium 500 ...... 92 celecoxib ...... 24 children's pain relief ...... 24 citroma ...... 57 col-rite ...... 57 cyclosporine ...... 12 calcium 500 + d ...... 92 CELONTIN ...... 17 children's pain reliever ...... 24 citrucel ...... 57 COLY-MYCIN S ...... 49 cyclosporine modified .... 11, 12 calcium 600 ...... 92 centamin ...... 95 children's pain-fever relief .... 24 CITRUCEL SUGAR FREE . 57 COMBIVENT RESPIMAT . 88 cyproheptadine ...... 81 calcium 600 + d(3) ...... 92 centergy ...... 83 children's pepto ...... 57 claravis ...... 41 COMETRIQ ...... 11 cyred ...... 71 calcium 600 with vitamin d3 92 centravites ...... 95 childrens plus multi-symp cold clarithromycin ...... 7 COMPLERA ...... 4 cyred eq ...... 71 calcium acetate ...... 57 centravites 50 plus ...... 95 ...... 83 classic prenatal ...... 96 complete ...... 96 CYSTADANE ...... 57 calcium antacid ...... 92 cephalexin ...... 7 children's silapap ...... 24 clearlax ...... 57 complete 50+ ...... 96 CYSTAGON ...... 91 calcium antacid ultra max st . 92 CERALYTE 90 ...... 92 children's silfedrine ...... 83 clemastine ...... 80 complete allergy ...... 80 CYSTARAN ...... 76 calcium carbonate ...... 92 CERALYTE-70 ...... 92 CHILDREN'S SUDAFED ... 83 CLEOCIN ...... 69 complete allergy medicine .... 80 cytra k crystals ...... 91 calcium carbonate-vitamin d3 CERDELGA ...... 52 children's tactinal ...... 24 clindacin p ...... 41 complete multi ...... 96 cytra-2 ...... 91 ...... 92 CEREZYME ...... 52 childs chew vite ...... 96 clindamycin hcl ...... 8 complete multi 50+ ...... 96 cytra-3 ...... 91 calcium citrate ...... 92 cerovite advanced formula ... 95 clindamycin palmitate hcl ...... 8 complete multivitamin ...... 96 cytra-k ...... 91

108 109 108 child's chewable vitamins/iron clindamycin pediatric ...... 8 complete multivitamin-mineral ...... 96 clindamycin phosphate ... 41, 69 ...... 96 childs triacting cold-cough ... 83 CLINDESSE ...... 69 complete natal dha ...... 96 childs/iron ...... 96 clobazam ...... 17 complete senior ...... 96 chlordiazepoxide hcl ...... 28 clobetasol ...... 44 completenate ...... 96 chlorhexidine gluconate ...... 48 clobetasol-emollient ...... 44 complex b-100 ...... 96 chlorhist ...... 80 clonazepam ...... 17 compro ...... 57 chloroquine phosphate ...... 8 clonidine ...... 33 CONDYLOX ...... 40 chlorothiazide ...... 33 clonidine hcl ...... 33 constulose ...... 57 chlorpheniramine maleate .... 80 clopidogrel ...... 36 COPIKTRA ...... 11 chlorpromazine ...... 28 clorazepate dipotassium ...... 28 CORAL CALCIUM ...... 96 chlorthalidone ...... 33 clotrimazole ...... 3, 43, 69 CORLANOR ...... 38 chlorzoxazone ...... 20 clotrimazole-3 ...... 69 cormax ...... 44 cholecalciferol (vitamin d3) . 96 clotrimazole-betamethasone . 43 cortisone ...... 49 CHOLECALCIFEROL clozapine ...... 28 CORTISPORIN-TC ...... 49 (VITAMIN D3) ...... 96 CLOZAPINE ...... 28 CORVITE ...... 96 cholestyramine (with sugar) . 37 c-nate dha ...... 96 COSENTYX ...... 39 cholestyramine light ...... 37 cod liver oil ...... 96 COSENTYX (2 SYRINGES) choline,magnesium salicylate codeine sulfate ...... 21 ...... 39 ...... 24 codeine-guaifenesin ...... 83 COSENTYX PEN ...... 39 ciclodan ...... 43 COLCHICINE ...... 65 COSENTYX PEN (2 PENS) 39 ciclopirox ...... 43 cold and allergy ...... 83 COTELLIC ...... 11 cilostazol ...... 36 cold and allergy (bromphen-pe) cough dm er ...... 83 CILOXAN ...... 75 ...... 83 CREON ...... 57 CIMDUO ...... 4 cold and allergy pe ...... 83 CRESEMBA ...... 3 cimetidine ...... 61 cold and cough dm ...... 83 CRINONE ...... 67 cimetidine hcl ...... 61 cold and cough elixir ...... 83 CRIXIVAN ...... 4 CIMZIA ...... 57 COLD HEAD CONGESTION cromolyn ...... 57, 76, 88 cinacalcet ...... 52 DAY/NITE ...... 83 cryselle (28) ...... 71 CINQAIR ...... 88 cold head congestion nighttime CRYSVITA ...... 52 CINRYZE ...... 88 ...... 83 cyanocobalamin (vitamin b-12) CIPRO HC ...... 49 cold multi-symptom ...... 96, 97 CIPRODEX ...... 49 (chlorphen) ...... 83 cyclafem 1/35 (28) ...... 71 ciprofloxacin hcl ...... 10, 49, 75 COLD MULTI-SYMPTOM cyclafem 7/7/7 (28) ...... 71 citalopram ...... 28 DAY/NIGHT ...... 83 cyclobenzaprine ...... 21 CITRACAL + D PETITES .. 93 cold relief plus ...... 83 CYCLOMYDRIL ...... 79 CITRACAL REGULAR ...... 93 cold-sinus relief ...... 83 cyclopentolate ...... 76 citrate of magnesia ...... 57 colestipol ...... 37 cyclophosphamide ...... 11 citroma ...... 57 col-rite ...... 57 cyclosporine ...... 12 citrucel ...... 57 COLY-MYCIN S ...... 49 cyclosporine modified .... 11, 12 CITRUCEL SUGAR FREE . 57 COMBIVENT RESPIMAT . 88 cyproheptadine ...... 81 claravis ...... 41 COMETRIQ ...... 11 cyred ...... 71 clarithromycin ...... 7 COMPLERA ...... 4 cyred eq ...... 71 classic prenatal ...... 96 complete ...... 96 CYSTADANE ...... 57 clearlax ...... 57 complete 50+ ...... 96 CYSTAGON ...... 91 clemastine ...... 80 complete allergy ...... 80 CYSTARAN ...... 76 CLEOCIN ...... 69 complete allergy medicine .... 80 cytra k crystals ...... 91 clindacin p ...... 41 complete multi ...... 96 cytra-2 ...... 91 clindamycin hcl ...... 8 complete multi 50+ ...... 96 cytra-3 ...... 91 clindamycin palmitate hcl ...... 8 complete multivitamin ...... 96 cytra-k ...... 91

109 109 D dexamethasone ...... 49, 50 disopyramide phosphate ...... 32 D3-50 CHOLECALCIFEROL dexamethasone intensol ...... 49 disulfiram ...... 47 ...... 97 dexamethasone sodium phos DIURIL ...... 33 daily multiple ...... 97 (pf) ...... 50 divalproex ...... 17 daily multiple vitamins/iron . 97 dexamethasone sodium docusate calcium ...... 57 daily multi-vitamin ...... 97 phosphate ...... 50, 78 docusate sodium ...... 57 daily multivitamin with iron . 97 dexmethylphenidate ...... 28 docusil ...... 58 daily multivitamin-minerals . 97 dextroamphetamine ...... 28 DOCUSOL ...... 58 daily value ...... 97 dextroamphetamine- dofetilide ...... 32 daily vitamin formula ...... 97 amphetamine ...... 28 donepezil ...... 20 daily vitamin formula-iron ... 97 dextromethorphan polistirex . 84 DOPTELET (15 TAB PACK) daily vitamin formula-minerals dextromethorphan-guaifenesin ...... 36 ...... 97 ...... 84 dorzolamide ...... 78 daily vitamin with iron ...... 97 diabetic siltussin-dm max str 84 dorzolamide-timolol ...... 78 daily vites/iron ...... 97 diabetic tussin dm ...... 84 doxazosin ...... 33 daily-vite ...... 97 diabetic tussin ex ...... 84 doxepin ...... 28 dairy relief ...... 57 DIACOMIT ...... 17 doxercalciferol ...... 53 dalfampridine ...... 20 dialyvite ...... 97 doxycycline hyclate ...... 10 DALIRESP ...... 88 DIALYVITE 3000 ...... 97 doxycycline monohydrate .... 10 danazol ...... 53 dialyvite 800 ...... 97 D-PENAMINE ...... 65 dantrolene ...... 21 DIALYVITE 800 WITH IRON drithocreme hp ...... 39 dapsone ...... 8 ...... 97 dronabinol ...... 58 dasetta 1/35 (28) ...... 71 DIASTAT ...... 17 droperidol ...... 58 dasetta 7/7/7 (28) ...... 71 diazepam ...... 17, 28 drospirenone-e.estradiol-lm.fa DAURISMO ...... 12 diazepam intensol ...... 28 ...... 71 dayhist allergy ...... 81 diclofenac potassium ...... 24 drospirenone-ethinyl estradiol daysee ...... 71 diclofenac sodium ...... 24, 77 ...... 71 DAYTIME AND dicloxacillin ...... 9 ducodyl ...... 58 NIGHTTIME COLD ...... 83 dicyclomine ...... 56 dulcoease ...... 58 deblitane ...... 67 didanosine ...... 4 dulcolax stool softener (dss) . 58 decadron ...... 49 DIFICID ...... 7 duloxetine ...... 28 deferasirox ...... 47 diflorasone ...... 45 DUPIXENT ...... 40 DELSTRIGO ...... 4 diflunisal ...... 24 dutasteride ...... 90 DELSYM 12 HOUR ...... 84 digox ...... 36 DUZALLO ...... 65 DEMSER ...... 33 digoxin ...... 36 DYSPORT ...... 64 denta 5000 plus ...... 49 dihydroergotamine ...... 19 E dentagel ...... 49 DILATRATE-SR ...... 38 e.c. prin ...... 24 DEPEN TITRATABS ...... 65 diltiazem ...... 33 econazole ...... 43 DEPO-ESTRADIOL ...... 67 dilt-xr ...... 33 econtra ez ...... 71 DEPO-PROVERA ...... 68 dimaphen (pe) ...... 84 econtra one-step ...... 71 DEPO-SUBQ PROVERA 104 dimaphen dm ...... 84 ecotrin ...... 24 ...... 68 dimenhydrinate ...... 57 ecotrin low strength ...... 24 DEPO-TESTOSTERONE .... 53 dino-life ...... 97 ed-spaz ...... 56 DESCOVY ...... 4 dino-life with extra c ...... 97 EDURANT ...... 4 desipramine ...... 28 dino-life with iron-zinc ...... 97 efavirenz ...... 4 desmopressin ...... 53 diphedryl ...... 81 effer-k ...... 93 desog-e.estradiol/e.estradiol . 71 diphenhist ...... 81 efferves pain relief antacid ... 24 desogestrel-ethinyl estradiol . 71 diphenhydramine hcl ...... 81 effervescent pain relief ...... 24 desonide ...... 44, 45 diphenoxylate-atropine ...... 56 EGRIFTA ...... 63 desoximetasone ...... 45 dipyridamole ...... 36 ELAPRASE ...... 53

110 110 electrolytes-dextrose...... 93 ery-tab ...... 7 FEMRING ...... 68 ELELYSO ...... 53 erythrocin (as stearate) ...... 7 femynor ...... 71 ELIGARD ...... 12 erythromycin ...... 7, 75 fenesin ir ...... 84 ELIGARD (3 MONTH) ...... 12 erythromycin ethylsuccinate ... 7 fenofibrate ...... 37 ELIGARD (4 MONTH) ...... 12 erythromycin with ethanol .... 41 fenofibrate micronized ...... 37 ELIGARD (6 MONTH) ...... 12 erythromycin-benzoyl peroxide fenofibrate nanocrystallized . 37 elinest ...... 71 ...... 41 fentanyl ...... 21 ELIQUIS ...... 36 ESBRIET ...... 88 fentanyl citrate ...... 21 ELIQUIS DVT-PE TREAT escitalopram oxalate ...... 29 FENTORA ...... 21 30D START ...... 36 estarylla ...... 71 ferocon ...... 97 elite-ob ...... 97 estazolam ...... 29 ferosul ...... 98 ELLA ...... 71 estradiol ...... 68 ferretts ...... 98 ELMIRON ...... 91 estradiol valerate ...... 68 ferrex 150 forte ...... 98 EMCYT ...... 12 estradiol-norethindrone acet . 68 ferrex 28 ...... 98 EMFLAZA ...... 50 ESTRING ...... 68 ferrocite plus ...... 98 emoquette ...... 71 ethambutol ...... 8 ferrous gluconate ...... 98 EMTRIVA ...... 4 ethosuximide ...... 17 ferrous sulfate ...... 98 enalapril maleate ...... 33 ethynodiol diac-eth estradiol 71 feverall ...... 24 enalapril-hydrochlorothiazide etidronate disodium ...... 47 FEVERALL ...... 24 ...... 33 etodolac ...... 24 fexofenadine ...... 81 ENBREL ...... 66 etoposide ...... 12 fiber ...... 58 ENBREL MINI ...... 66 EUCRISA ...... 40 fiber (calcium polycarbophil) ENBREL SURECLICK ...... 66 EUFLEXXA ...... 24 ...... 58 ENDARI ...... 47 EURAX ...... 46 fiber (dextrin) ...... 58 endocet ...... 21 EVENITY ...... 65 fiber (psyllium husk/sugar) ... 58 enoxaparin ...... 36 EVOTAZ ...... 4 fiber (with aspartame) ...... 58 enpresse ...... 71 exemestane ...... 12 fiber laxative (ca polycarbo) . 58 enskyce ...... 71 EXONDYS 51 ...... 20 fiber laxative (methylcellulo) entacapone ...... 19 eye drops (tetrahydrozoline) . 79 ...... 58 entecavir ...... 4 eye drops (with povidone) .... 79 fiber smooth ...... 58 ENTRESTO ...... 38 eye drops advanced relief ..... 79 fiber smooth (sucrose) ...... 58 enulose ...... 58 eye health plus lutein ...... 97 fiber therapy (m-cell/sugar) .. 58 EPIDIOLEX ...... 17 EYLEA ...... 77 fiber therapy (m-cellulose) ... 58 epinastine ...... 76 ezetimibe ...... 37 fiber-lax ...... 58 epinephrine ...... 81 ezfe 200 ...... 97 fiber-tabs ...... 58 epitol ...... 17 F finasteride ...... 90 EPIVIR HBV ...... 4 FABRAZYME ...... 53 FIRMAGON KIT W eplerenone ...... 33 falmina (28) ...... 71 DILUENT SYRINGE ...... 12 EPOGEN ...... 62 famciclovir ...... 4 FIRVANQ ...... 10 ergocalciferol (vitamin d2) ... 97 famotidine ...... 61 FISH OIL ...... 94 ERGOCALCIFEROL FANAPT ...... 29 fish oil concentrate ...... 37 (VITAMIN D2) ...... 97 FARYDAK ...... 12 flanax (naproxen) ...... 24 ergoloid ...... 28 FASENRA ...... 88 flavoxate ...... 90 ergotamine-caffeine ...... 19 FASLODEX ...... 12 FLEBOGAMMA DIF ...... 64 ERIVEDGE ...... 12 FC2 FEMALE CONDOM ... 67 flecainide ...... 32 ERLEADA ...... 12 febuxostat ...... 65 FLEET BISACODYL ...... 58 erlotinib ...... 12 felbamate ...... 17 fleet enema ...... 58 errin ...... 68 felodipine ...... 33 fleet glycerin (adult) ...... 58 ery pads ...... 41 fem ph ...... 69 fleet laxative ...... 58 erygel ...... 41 FEMCAP ...... 67

111 111 FLINTSTONES MULTI-VIT fondaparinux ...... 36 glatiramer ...... 63 GUMMIES ...... 98 FORTEO ...... 65 glatopa ...... 63 FLINTSTONES TAB CHEW fosamprenavir ...... 4 GLEOSTINE ...... 12 ...... 98 fosfree ...... 98 glimepiride ...... 54 FLOLAN ...... 33 fosinopril ...... 33 glipizide ...... 54 FLORICAL ...... 93 fosinopril-hydrochlorothiazide glipizide-metformin ...... 54 FLOVENT DISKUS ...... 88 ...... 33 GLUCAGON EMERGENCY FLOVENT HFA ...... 88 FRAGMIN ...... 36 KIT (HUMAN) ...... 51 flucaine ...... 77 fruit c-500 ...... 98 glucose ...... 47 fluconazole ...... 3 full spectrum b-vitamin c ..... 98 glyburide ...... 54 flucytosine ...... 3 fulvestrant ...... 12 glyburide micronized ...... 54 fludrocortisone ...... 50 furosemide ...... 33 glyburide-metformin ...... 54 flunisolide ...... 88 FUZEON ...... 4 glycolax ...... 59 fluocinolone ...... 45 fyavolv ...... 68 glycopyrrolate ...... 56 fluocinolone acetonide oil .... 49 FYCOMPA ...... 17 glydo ...... 42 fluocinolone and shower cap 45 G GRALISE ...... 18 fluocinonide ...... 45 gabapentin ...... 17 GRALISE 30-DAY STARTER fluocinonide-e ...... 45 GALAFOLD ...... 53 PACK ...... 18 fluorescein-proparacaine ...... 77 galantamine ...... 20 granisetron hcl ...... 59 fluoride (sodium) ...... 98 GALZIN ...... 93 GRANIX ...... 62 fluoritab ...... 98 GAMIFANT ...... 12 griseofulvin microsize ...... 3 fluorometholone ...... 78 GAMMAGARD LIQUID .... 64 griseofulvin ultramicrosize ..... 3 fluorouracil ...... 40 GAMMAGARD S-D (IGA < 1 guaiatussin ac ...... 84 fluoxetine ...... 29 MCG/ML) ...... 64 guaifenesin ...... 84 fluphenazine decanoate ...... 29 GAMMAKED ...... 64 guaifenesin ac ...... 84 fluphenazine hcl ...... 29 GAMMAPLEX (WITH guaifenesin dac ...... 84 flurazepam ...... 29 SORBITOL) ...... 64 guanfacine ...... 29, 33 flurbiprofen ...... 24 GAMUNEX-C ...... 64 guanidine ...... 29 flurbiprofen sodium ...... 77 gas relief ...... 58, 59 gynol ii ...... 69 flutamide ...... 12 gas relief 80 ...... 58 G-ZYNCOF ...... 84 fluticasone propionate .... 45, 88 gas relief extra strength ...... 58 H fluticasone propion-salmeterol gatifloxacin ...... 75 HAEGARDA ...... 88 ...... 88 GATTEX 30-VIAL ...... 59 hailey ...... 71 FLUTICASONE PROPION- gavilax ...... 59 hailey 24 fe ...... 71 SALMETEROL ...... 88 gavilyte-c ...... 59 halobetasol propionate ...... 45 fluvastatin ...... 37 gavilyte-g ...... 59 haloperidol ...... 29 fluvoxamine ...... 29 gavilyte-n ...... 59 haloperidol decanoate ...... 29 FML S.O.P...... 78 gemfibrozil ...... 37 haloperidol lactate ...... 29 folbee ...... 98 generlac ...... 59 heartburn relief (famotidine) 61 folbee plus ...... 98 gengraf ...... 12 heartburn relief (ranitidine) .. 61 folbic ...... 98 gentak ...... 75 heather ...... 68 FOLGARD OS ...... 98 gentamicin ...... 43, 75 hematinic plus vit/minerals ... 99 folic acid ...... 98 GENTEAL TEARS SEVERE hematinic/folic acid ...... 99 folic acid-vit b6-vit b12 ...... 98 GEL ...... 77 hematogen ...... 99 folivane-f ...... 98 GENVOYA ...... 4 hematogen fa ...... 99 folivane-ob ...... 98 geri-tussin ...... 84 hematogen forte ...... 99 folivane-plus ...... 98 gianvi (28) ...... 71 HEMATRON-AF ...... 99 folplex 2.2 ...... 98 GILENYA ...... 63 HEMAX ...... 99 foltabs 800 ...... 98 GILOTRIF ...... 12 hemorrhoid ...... 59 FOLTRATE ...... 98 GLASSIA ...... 47 hemorrhoidal ...... 59

112 112 heparin (porcine) ...... 36 HUMULIN R U-500 (CONC) incassia ...... 68 heparin, porcine (pf) ...... 36 KWIKPEN ...... 52 INCRELEX ...... 47 HETLIOZ ...... 29 HYCAMTIN ...... 12 INCRUSE ELLIPTA ...... 88 HIZENTRA ...... 64 hydralazine ...... 33 indapamide ...... 34 homatropaire ...... 76 hydrochlorothiazide ...... 34 indomethacin ...... 25 homatropine hbr ...... 76 hydrocodone-acetaminophen infant pain reliever ...... 25 HORIZANT ...... 20 ...... 21, 22 infants gas relief ...... 59 HUMALOG JUNIOR hydrocodone-chlorpheniramine infant's ibuprofen ...... 25 KWIKPEN U-100 ...... 51 ...... 84 infants' pain and fever ...... 25 HUMALOG KWIKPEN hydrocodone-homatropine .... 84 infants' pain relief ...... 25 INSULIN ...... 51 hydrocodone-ibuprofen ...... 22 infant's pain relief ...... 25 HUMALOG MIX 50-50 hydrocortisone .... 45, 46, 50, 59 infed ...... 99 INSULN U-100 ...... 51 hydrocortisone acetate ...... 45 INGREZZA ...... 20 HUMALOG MIX 50-50 hydrocortisone butyrate ...... 45 INLYTA ...... 13 KWIKPEN ...... 51 hydrocortisone plus ...... 45 INREBIC ...... 13 HUMALOG MIX 75-25 hydrocortisone valerate ...... 46 INSULIN SYRINGE- KWIKPEN ...... 51 hydrocortisone-acetic acid .... 49 NEEDLE U-100 ...... 50 HUMALOG MIX 75-25(U- hydrocortisone-aloe vera ...... 46 INTELENCE ...... 4 100)INSULN ...... 51 hydromet ...... 84 INTRON A ...... 64 HUMALOG U-100 INSULIN hydromorphone ...... 22 introvale ...... 71 ...... 52 hydroxocobalamin ...... 99 INVEGA SUSTENNA ...... 29 HUMIRA ...... 66 hydroxychloroquine ...... 8 INVEGA TRINZA ...... 29 HUMIRA PEDIATRIC hydroxyprogest(pf)(preg presv) INVIRASE ...... 4 CROHNS START ...... 66 ...... 68 ipratropium bromide ...... 49, 88 HUMIRA PEN ...... 66 hydroxyurea ...... 12 ipratropium-albuterol ...... 88 HUMIRA PEN CROHNS-UC- hydroxyzine hcl ...... 81 irbesartan ...... 34 HS START ...... 66 hydroxyzine pamoate ...... 81 irbesartan-hydrochlorothiazide HUMIRA PEN PSOR- hyophen ...... 91 ...... 34 UVEITS-ADOL HS ...... 66 I IRESSA ...... 13 HUMIRA(CF) ...... 66 ibandronate ...... 65 ISENTRESS ...... 4 HUMIRA(CF) PEDI IBRANCE ...... 12 ISENTRESS HD ...... 4 CROHNS STARTER ...... 66 ibu ...... 24 isibloom ...... 71 HUMIRA(CF) PEN ...... 66 ibu-200 ...... 25 isoniazid ...... 8 HUMIRA(CF) PEN ibuprofen ...... 25 isosorbide dinitrate ...... 38 CROHNS-UC-HS ...... 66 ibuprofen cold-sinus(with pse) isosorbide mononitrate ...... 38 HUMIRA(CF) PEN PSOR- ...... 84 isotretinoin ...... 41 UV-ADOL HS ...... 66 ibuprofen ib ...... 25 isradipine ...... 34 HUMULIN 70/30 U-100 ibuprofen jr strength ...... 25 itraconazole ...... 3 INSULIN ...... 52 icatibant ...... 88 ivermectin ...... 8 HUMULIN 70/30 U-100 ICLUSIG ...... 12 J KWIKPEN ...... 52 IDHIFA ...... 13 JADENU ...... 47 HUMULIN N NPH INSULIN iferex 150 forte ...... 99 JADENU SPRINKLE ...... 47 KWIKPEN ...... 52 ILARIS (PF) ...... 64 JAKAFI ...... 13 HUMULIN N NPH U-100 ILUVIEN ...... 78 jantoven ...... 36 INSULIN ...... 52 imatinib ...... 13 jasmiel (28) ...... 71 HUMULIN R REGULAR U- IMBRUVICA ...... 13 jencycla ...... 68 100 INSULN ...... 52 imipramine hcl ...... 29 JETREA (PF) ...... 77 HUMULIN R U-500 (CONC) imipramine pamoate ...... 29 jinteli ...... 68 INSULIN ...... 52 imiquimod ...... 64 jolessa ...... 71 INBRIJA ...... 19 juleber ...... 71

113 113 JULUCA ...... 4 labetalol ...... 34 levothyroxine ...... 55 junel 1.5/30 (21) ...... 71 lactulose ...... 59 levoxyl ...... 55 junel 1/20 (21) ...... 72 lamisil af ...... 43 LEXIVA ...... 5 junel fe 1.5/30 (28) ...... 72 lamisil at ...... 43 lice killing ...... 46 junel fe 1/20 (28) ...... 72 lamivudine ...... 5 lice solution ...... 46 junel fe 24 ...... 72 lamivudine-zidovudine ...... 5 lice treatment ...... 46 JUXTAPID ...... 37 lamotrigine...... 18 lice treatment (permethrin) ... 46 JYNARQUE ...... 53 lansoprazole ...... 61 lidocaine ...... 42 K LANTUS SOLOSTAR U-100 LIDOCAINE ...... 42 kaitlib fe ...... 72 INSULIN ...... 52 lidocaine hcl ...... 42 KALBITOR ...... 88 LANTUS U-100 INSULIN .. 52 LIDOCAINE HCL ...... 42 KALETRA ...... 5 larin 1.5/30 (21) ...... 72 lidocaine hcl-hydrocortison ac kalliga ...... 72 larin 1/20 (21) ...... 72 ...... 42, 59 KALYDECO ...... 88 larin 24 fe ...... 72 lidocaine viscous ...... 42 KANUMA ...... 53 larin fe 1.5/30 (28) ...... 72 lidocaine-hydrocortisone-aloe kariva (28) ...... 72 larin fe 1/20 (28) ...... 72 ...... 59 kelnor 1/35 (28) ...... 72 larissia ...... 72 lidocaine-prilocaine ...... 42 kelnor 1-50 ...... 72 latanoprost ...... 78 LIDOCARE ...... 42 KENALOG ...... 50 LATUDA ...... 29 lido-k ...... 42 ketoconazole ...... 3, 43 layolis fe ...... 72 lillow (28) ...... 72 ketoprofen ...... 25 LAZANDA ...... 22 lindane ...... 46 ketorolac ...... 25, 77 lc-4 ...... 42 linezolid ...... 8 ketotifen fumarate ...... 77 lc-5 ...... 42 liothyronine ...... 55 KEVEYIS ...... 20 LEDIPASVIR-SOFOSBUVIR LIQUID CALCIUM WITH KEVZARA ...... 66 ...... 5 VITAMIN D ...... 93 KINERET ...... 64 leena 28 ...... 72 lisinopril ...... 34 KISQALI ...... 13 leflunomide ...... 66 lisinopril-hydrochlorothiazide KISQALI FEMARA CO- LEMTRADA ...... 63 ...... 34 PACK ...... 13 LENVIMA ...... 13 lithium carbonate ...... 29 klor-con ...... 93 lessina ...... 72 lithium citrate ...... 29 klor-con 10 ...... 93 letrozole ...... 13 little remedies ...... 47 klor-con 8 ...... 93 leucovorin calcium ...... 11 little remedies fever and pain 25 klor-con m10 ...... 93 LEUKERAN ...... 13 l-methylfolate ...... 99 klor-con m15 ...... 93 leuprolide ...... 13 l-methyl-mc ...... 99 klor-con m20 ...... 93 levalbuterol hcl ...... 88 l-methyl-mc nac ...... 94 klor-con/ef ...... 93 LEVALBUTEROL LMX 4 ...... 42 kobee ...... 99 TARTRATE ...... 89 LMX 5 ...... 42 konsyl fiber ...... 59 levetiracetam ...... 18 lohist - d ...... 84 konsyl formula-d ...... 59 levobunolol ...... 76 LONSURF ...... 13 konsyl sugar-free ...... 59 levocarnitine ...... 47 loperamide ...... 56 KORLYM ...... 53 levocarnitine (with sugar) ..... 47 lopinavir-ritonavir ...... 5 k-phos-neutral ...... 93 levocetirizine ...... 81 loradamed ...... 81 kpn ...... 99 levofloxacin ...... 10, 75 loratadine ...... 81 KPN ...... 99 levomefolate calcium ...... 99 lorata-dine d ...... 84 KRYSTEXXA ...... 65 levonest (28) ...... 72 loratadine-d ...... 84 k-tab ...... 93 levonorgestrel ...... 72 lorazepam ...... 30 kurvelo (28) ...... 72 levonorgestrel-ethinyl estrad 72 lorazepam intensol ...... 30 KUVAN ...... 53 levonorg-eth estrad triphasic 72 LORBRENA ...... 13 L levora-28 ...... 72 lorcet (hydrocodone) ...... 22 l norgest/e.estradiol-e.estrad . 72 levorphanol tartrate ...... 22 lorcet hd ...... 22

114 114 lorcet plus ...... 22 mapap extra strength ...... 25 metoclopramide hcl ...... 60 loryna (28) ...... 72 mapap pm ...... 25 metolazone ...... 34 losartan ...... 34 maprotiline...... 30 metoprolol succinate ...... 34 losartan-hydrochlorothiazide 34 marlissa (28) ...... 73 metoprolol ta-hydrochlorothiaz lovastatin ...... 37 MARPLAN ...... 30 ...... 34 low-ogestrel (28) ...... 72 MATULANE ...... 14 metoprolol tartrate ...... 34 loxapine succinate ...... 30 matzim la ...... 34 metronidazole ...... 8, 41, 69 lubricant (p-glycol-glycerin) 77 MAVYRET ...... 5 mexiletine ...... 32 lubricating plus ...... 77 meclizine ...... 59 miconazole 7 ...... 69 lubrifresh pm ...... 77 meclofenamate ...... 25 miconazole nitrate ...... 43, 69 LUCEMYRA ...... 25 medroxyprogesterone ...... 68 miconazole-3 ...... 69 LUCENTIS ...... 77 megestrol ...... 14 microgestin 1.5/30 (21) ...... 73 ludent fluoride ...... 99 MEKINIST ...... 14 microgestin 1/20 (21) ...... 73 LUMIZYME ...... 53 MEKTOVI ...... 14 microgestin fe 1.5/30 (28) .... 73 LUPANETA PACK (1 MELATONIN ...... 47 microgestin fe 1/20 (28) ...... 73 MONTH) ...... 69 meloxicam ...... 25 midazolam ...... 30 LUPANETA PACK (3 melphalan ...... 14 midodrine ...... 47 MONTH) ...... 69 memantine ...... 20 migergot ...... 19 LUPRON DEPOT ...... 13 MEMANTINE ...... 20 miglustat ...... 53 LUPRON DEPOT (3 men's one daily ...... 99 mili ...... 73 MONTH) ...... 13 meperidine ...... 22 milltrium senior ...... 99 LUPRON DEPOT (4 meprobamate ...... 21 mimvey ...... 68 MONTH) ...... 13 MEPSEVII ...... 53 minocycline ...... 10 LUPRON DEPOT (6 mercaptopurine ...... 14 minoxidil ...... 34 MONTH) ...... 13 mesalamine ...... 59 miralax ...... 60 LUPRON DEPOT-PED ...... 13 MESNEX ...... 11 mirtazapine ...... 30 LUPRON DEPOT-PED (3 metadate er ...... 30 misoprostol ...... 61 MONTH) ...... 13 metaproterenol ...... 89 modafinil ...... 30 lutein ...... 99 metformin ...... 54 moexipril ...... 34 LUTEIN ...... 99 methadone ...... 22 mometasone ...... 46 lutera (28) ...... 72 methadose ...... 22 mono-linyah ...... 73 LUXTURNA ...... 77 methazolamide ...... 78 montelukast ...... 89 LYNPARZA ...... 13 methenamine hippurate ...... 10 MONUROL ...... 10 lysine ...... 94 methenamine mandelate ...... 10 morphine ...... 22 LYSODREN ...... 13 methergine ...... 75 morphine concentrate ...... 22 lyza ...... 68 methimazole ...... 50 MOVANTIK ...... 60 M METHITEST ...... 53 moxifloxacin ...... 10 MACUGEN ...... 77 methocarbamol ...... 21 MOZOBIL ...... 62 mafenide acetate ...... 43 methotrexate sodium ...... 14 mucinex d ...... 84 mag 64 ...... 93 methotrexate sodium (pf) ..... 14 mucinex d maximum strength mag-g ...... 93 methoxsalen ...... 40 ...... 84 magnesium ...... 59, 93 methscopolamine ...... 56 mucinex dm ...... 85 MAGNESIUM AMINO ACID methyldopa ...... 34 MUCINEX DM ...... 85 CHELATE ...... 93 methyldopa- mucosa ...... 85 magnesium gluconate ...... 93 hydrochlorothiazide ...... 34 mucosa dm ...... 85 magnesium oxide ...... 93 methylergonovine ...... 75 mucus relief ...... 85 MAKENA (PF) ...... 68 methylphenidate hcl ...... 30 mucus relief chest ...... 85 malathion ...... 46 methylprednisolone ...... 50 mucus relief dm ...... 85 mapap (acetaminophen) ...... 25 methylprednisolone acetate .. 50 mucus relief dm cough ...... 85 mapap arthritis pain ...... 25 metipranolol...... 76 MULPLETA ...... 36

115 115 MULTAQ ...... 32 nasal allergy symptom control NINLARO ...... 14 nystatin ...... 3, 43, 44 ONETOUCH VERIO IQ pain relief pm rapid release .. 26 multi complete with iron ...... 99 ...... 89 nisoldipine ...... 34 nystatin-triamcinolone ...... 44 METER ...... 51 pain relief regular strength .... 26 multi for her ...... 99 nasal decongestant nitro-bid ...... 38 nystop ...... 44 ONETOUCH VERIO pain reliever ...... 26 multi-day with iron ...... 99 (pseudoeph) ...... 85 NITRO-DUR ...... 38 O SYSTEM ...... 51 pain reliever (acetam-aspirin) multi-delyn with iron ...... 99 NATACYN ...... 75 nitrofurantoin macrocrystal .. 10 OBSTETRIX EC ...... 100 ONMEL ...... 3 ...... 26 multigen ...... 99 nateglinide ...... 54 nitrofurantoin monohyd/m- O-CAL F.A...... 100 opcicon one-step ...... 73 pain reliever extra strength ... 26 multigen folic ...... 99 NATPARA ...... 53 cryst ...... 10 OCALIVA ...... 60 OPSUMIT ...... 89 pain reliever plus ...... 26 multigen plus ...... 99 nature-throid ...... 55 nitroglycerin ...... 39 ocella ...... 73 option-2 ...... 73 pain reliever pm ...... 26 multilex ...... 99 NEBUPENT ...... 8 NITYR ...... 47 OCREVUS ...... 63 opti-vitamins ...... 101 pain reliever pm ex-strength . 26 multilex-t and m ...... 99 necon 0.5/35 (28) ...... 73 nizatidine ...... 62 OCTAGAM ...... 64 ORACEA ...... 10 pain-off ...... 26 multiple vitamin-minerals .... 99 nefazodone ...... 30 NIZORAL A-D ...... 43 octreotide acetate ...... 14 ORACIT ...... 91 PALYNZIQ ...... 53 multi-vit with fluoride-iron 100 neomycin ...... 8 NOCDURNA ...... 53 ODEFSEY ...... 5 oralone ...... 49 panoxyl ...... 41 multivitamin ...... 100 neomycin-bacitracin-poly-hc 78 NOCTIVA ...... 53 ODOMZO ...... 14 ORENCIA ...... 66 PANRETIN ...... 40 multi-vitamin with fluoride 100 neomycin-bacitracin- nohist-dm ...... 85 OFEV ...... 89 ORENCIA (WITH pantoprazole ...... 62 multivitamin with iron ...... 100 polymyxin ...... 75 nohist-lq ...... 85 ofloxacin ...... 10, 49, 75 MALTOSE) ...... 66 paregoric ...... 56 multivitamin with minerals 100 neomycin-polymyxin b- non-aspirin ...... 26 ogestrel (28) ...... 73 ORENCIA CLICKJECT ...... 66 paroex oral rinse ...... 49 multivitamins with fluoride 100 dexameth ...... 78 non-aspirin extra strength ..... 26 olanzapine ...... 30 ORENITRAM ...... 34 paromomycin ...... 8 mupirocin ...... 43 neomycin-polymyxin- non-aspirin pain relief ...... 26 olanzapine-fluoxetine ...... 30 ORFADIN ...... 47 paroxetine hcl ...... 30 mvc-fluoride ...... 100 gramicidin ...... 75 non-aspirin pm ...... 26 OLUMIANT ...... 66 ORILISSA ...... 53 PASER ...... 8 my choice ...... 73 neomycin-polymyxin-hc 49, 78 nora-be ...... 68 omega 3-dha-epa-fish oil ...... 94 ORKAMBI ...... 89 pediacare fever reducer ...... 26 my way ...... 73 neo-polycin ...... 75 NORDITROPIN FLEXPRO 63 omega-3 fatty acids ...... 38 orphenadrine citrate ...... 21 pediatric cough and cold ...... 85 MYALEPT ...... 53 neo-polycin hc ...... 78 NOREL AD ...... 85 omeprazole ...... 62 orsythia ...... 73 pediatric electrolyte ...... 93 mycophenolate mofetil ...... 14 neo-tuss ...... 85 noreth-ethinyl estradiol-iron . 73 omnicap ...... 100 oseltamivir ...... 5 peg 3350-electrolytes ...... 60 mycophenolate sodium ...... 14 NEOTUSS PLUS ...... 85 norethindrone (contraceptive) OMNIPOD DASH INSULIN OSMOPREP ...... 60 PEGANONE ...... 18 MYDAYIS ...... 30 nephplex rx ...... 100 ...... 68 POD ...... 51 OTEZLA ...... 66 peg-electrolyte soln ...... 60 myferon 150 forte ...... 100 nephronex ...... 100 norethindrone acetate ...... 68 OMNITROPE ...... 63 OTEZLA STARTER ...... 67 PEGINTRON ...... 63 MYLERAN ...... 14 nephro-vite rx ...... 100 norethindrone ac-eth estradiol once daily ...... 100 OTREXUP (PF) ...... 67 peg-prep ...... 60 mynatal ...... 100 NERLYNX ...... 14 ...... 68, 73 ondansetron ...... 60 oxazepam ...... 30 penicillamine ...... 67 mynatal advance ...... 100 NEULASTA ...... 62 norethindrone-e.estradiol-iron ondansetron hcl ...... 60 oxcarbazepine ...... 18 penicillin v potassium ...... 9 mynatal plus ...... 100 NEUPOGEN ...... 62 ...... 73 one daily calcium/iron ...... 100 OXERVATE ...... 77 pentazocine-naloxone ...... 27 mynatal-z ...... 100 nevirapine ...... 5 norgestimate-ethinyl estradiol one daily complete ...... 100 oxybutynin chloride ...... 90 pentoxifylline ...... 36 mynate 90 plus ...... 100 new day ...... 73 ...... 73 one daily essential ...... 100 oxycodone ...... 22 peptic relief ...... 56 MYOBLOC ...... 64 newgen ...... 100 norlyda ...... 68 one daily maximum ...... 101 OXYCODONE ...... 22 perindopril erbumine ...... 35 myorisan ...... 41 NEXAVAR ...... 14 NORTHERA ...... 47 one daily men's 50 plus oxycodone-acetaminophen ... 22 permethrin ...... 46 MYTESI ...... 56 niacin ...... 37 nortrel 0.5/35 (28) ...... 73 memory ...... 101 oxycodone-aspirin ...... 22 perphenazine ...... 31 my-vitalife ...... 100 NIACIN ...... 37 nortrel 1/35 (21) ...... 73 one daily multi-vit w-mineral OXYCONTIN ...... 22 perphenazine-amitriptyline ... 31 N nicardipine ...... 34 nortrel 1/35 (28) ...... 73 ...... 101 oxymorphone ...... 22 perry prenatal ...... 101 nabumetone ...... 25 nicorelief ...... 48 nortrel 7/7/7 (28) ...... 73 one daily multivitamin ...... 101 oysco-500 ...... 93 phenadoz ...... 81 nadolol ...... 34 nicorette ...... 48 nortriptyline ...... 30 one daily plus iron ...... 101 oyster shell + d3 ...... 93 phenazopyridine ...... 91 nadolol-bendroflumethiazide 34 nicotine ...... 48 NORVIR ...... 5 one daily plus minerals ...... 101 oyster shell calcium ...... 93 phenelzine ...... 31 NAGLAZYME ...... 53 nicotine (polacrilex) ...... 48 norwegian cod liver oil ...... 100 one daily with iron ...... 101 oyster shell calcium 500 ...... 93 phenobarbital ...... 18 NALFON ...... 25 NICOTROL ...... 48 np thyroid ...... 55 one-a-day teen advantage ... 101 OZEMPIC ...... 54 phenoxybenzamine ...... 35 naloxone ...... 26 NICOTROL NS ...... 48 NPLATE ...... 36 ONETOUCH ULTRA BLUE OZURDEX ...... 78 phenylephrine hcl ...... 79 naltrexone ...... 26 nifedipine ...... 34 NUCALA ...... 89 TEST STRIP ...... 50 P phenytoin ...... 18 naproxen ...... 26 night time cold-flu ...... 85 NUEDEXTA ...... 20 ONETOUCH ULTRA2 pacerone ...... 32 phenytoin sodium extended .. 18 naproxen sodium ...... 26 nighttime cough ...... 85 NULOJIX ...... 14 METER ...... 51 pain and fever ...... 26 philith ...... 73 naratriptan ...... 19 nighttime sleep aid (diphen) . 81 NUPLAZID ...... 30 ONETOUCH ULTRAMINI 51 pain relief ...... 26 phospha 250 neutral ...... 94 NARCAN ...... 26 nikki (28) ...... 73 NUTRIVIT ...... 100 ONETOUCH VERIO ...... 50 pain relief allergy sinus ...... 85 phosphasal ...... 91 NASACORT ...... 89 nilutamide ...... 14 NUVARING ...... 69 ONETOUCH VERIO FLEX 51 pain relief extra strength ...... 26 phosphate laxative ...... 60 nimodipine ...... 34 nyamyc ...... 43 pain relief pm ...... 26 PHOSPHOLINE IODIDE .... 76

116 117 116 nystatin ...... 3, 43, 44 ONETOUCH VERIO IQ pain relief pm rapid release .. 26 nystatin-triamcinolone ...... 44 METER ...... 51 pain relief regular strength .... 26 nystop ...... 44 ONETOUCH VERIO pain reliever ...... 26 O SYSTEM ...... 51 pain reliever (acetam-aspirin) OBSTETRIX EC ...... 100 ONMEL ...... 3 ...... 26 O-CAL F.A...... 100 opcicon one-step ...... 73 pain reliever extra strength ... 26 OCALIVA ...... 60 OPSUMIT ...... 89 pain reliever plus ...... 26 ocella ...... 73 option-2 ...... 73 pain reliever pm ...... 26 OCREVUS ...... 63 opti-vitamins ...... 101 pain reliever pm ex-strength . 26 OCTAGAM ...... 64 ORACEA ...... 10 pain-off ...... 26 octreotide acetate ...... 14 ORACIT ...... 91 PALYNZIQ ...... 53 ODEFSEY ...... 5 oralone ...... 49 panoxyl ...... 41 ODOMZO ...... 14 ORENCIA ...... 66 PANRETIN ...... 40 OFEV ...... 89 ORENCIA (WITH pantoprazole ...... 62 ofloxacin ...... 10, 49, 75 MALTOSE) ...... 66 paregoric ...... 56 ogestrel (28) ...... 73 ORENCIA CLICKJECT ...... 66 paroex oral rinse ...... 49 olanzapine ...... 30 ORENITRAM ...... 34 paromomycin ...... 8 olanzapine-fluoxetine ...... 30 ORFADIN ...... 47 paroxetine hcl ...... 30 OLUMIANT ...... 66 ORILISSA ...... 53 PASER ...... 8 omega 3-dha-epa-fish oil ...... 94 ORKAMBI ...... 89 pediacare fever reducer ...... 26 omega-3 fatty acids ...... 38 orphenadrine citrate ...... 21 pediatric cough and cold ...... 85 omeprazole ...... 62 orsythia ...... 73 pediatric electrolyte ...... 93 omnicap ...... 100 oseltamivir ...... 5 peg 3350-electrolytes ...... 60 OMNIPOD DASH INSULIN OSMOPREP ...... 60 PEGANONE ...... 18 POD ...... 51 OTEZLA ...... 66 peg-electrolyte soln ...... 60 OMNITROPE ...... 63 OTEZLA STARTER ...... 67 PEGINTRON ...... 63 once daily ...... 100 OTREXUP (PF) ...... 67 peg-prep ...... 60 ondansetron ...... 60 oxazepam ...... 30 penicillamine ...... 67 ondansetron hcl ...... 60 oxcarbazepine ...... 18 penicillin v potassium ...... 9 one daily calcium/iron ...... 100 OXERVATE ...... 77 pentazocine-naloxone ...... 27 one daily complete ...... 100 oxybutynin chloride ...... 90 pentoxifylline ...... 36 one daily essential ...... 100 oxycodone ...... 22 peptic relief ...... 56 one daily maximum ...... 101 OXYCODONE ...... 22 perindopril erbumine ...... 35 one daily men's 50 plus oxycodone-acetaminophen ... 22 permethrin ...... 46 memory ...... 101 oxycodone-aspirin ...... 22 perphenazine ...... 31 one daily multi-vit w-mineral OXYCONTIN ...... 22 perphenazine-amitriptyline ... 31 ...... 101 oxymorphone ...... 22 perry prenatal ...... 101 one daily multivitamin ...... 101 oysco-500 ...... 93 phenadoz ...... 81 one daily plus iron ...... 101 oyster shell + d3 ...... 93 phenazopyridine ...... 91 one daily plus minerals ...... 101 oyster shell calcium ...... 93 phenelzine ...... 31 one daily with iron ...... 101 oyster shell calcium 500 ...... 93 phenobarbital ...... 18 one-a-day teen advantage ... 101 OZEMPIC ...... 54 phenoxybenzamine ...... 35 ONETOUCH ULTRA BLUE OZURDEX ...... 78 phenylephrine hcl ...... 79 TEST STRIP ...... 50 P phenytoin ...... 18 ONETOUCH ULTRA2 pacerone ...... 32 phenytoin sodium extended .. 18 METER ...... 51 pain and fever ...... 26 philith ...... 73 ONETOUCH ULTRAMINI 51 pain relief ...... 26 phospha 250 neutral ...... 94 ONETOUCH VERIO ...... 50 pain relief allergy sinus ...... 85 phosphasal ...... 91 ONETOUCH VERIO FLEX 51 pain relief extra strength ...... 26 phosphate laxative ...... 60 pain relief pm ...... 26 PHOSPHOLINE IODIDE .... 76

117 117 phytonadione (vitamin k1) ... 36 PREMARIN ...... 68 promethazine-dm ...... 85 PIFELTRO ...... 5 PREMPHASE ...... 69 promethazine-phenyleph- pilocarpine hcl ...... 47, 49, 76 PREMPRO ...... 69 codeine ...... 85 pimecrolimus ...... 40 prenaissance ...... 101 promethazine-phenylephrine 85 pimozide ...... 31 prenaissance plus ...... 101 promethegan ...... 81 pimtrea (28) ...... 73 prenatabs fa ...... 101 propafenone ...... 32 pindolol ...... 35 prenatabs rx ...... 101 propantheline ...... 56 pioglitazone ...... 54 prenatal ...... 102 proparacaine ...... 77 pioglitazone-glimepiride ...... 55 prenatal 19 ...... 101 propranolol ...... 35 pioglitazone-metformin ...... 55 prenatal 19 (with docusate) 101 propranolol-hydrochlorothiazid pirmella ...... 73 prenatal complete ...... 101 ...... 35 piroxicam ...... 27 prenatal formula ...... 101 propylthiouracil ...... 50 pnv 29-1 ...... 101 PRENATAL FORMULA .. 101 protriptyline ...... 31 pnv-dha ...... 101 prenatal multi-dha (algal oil) pruclair ...... 40 pnv-dha + docusate ...... 101 ...... 102 pseudoephedrine hcl ...... 85 pnv-omega ...... 101 prenatal one daily ...... 102 PULMOZYME ...... 89 pnv-select ...... 101 prenatal plus ...... 102 pyrazinamide ...... 9 PODOCON ...... 40 prenatal vitamin ...... 102 pyridostigmine bromide ...... 21 podofilox ...... 40 prenatal vitamin with minerals pyridoxine (vitamin b6) ...... 102 polycin ...... 75 ...... 102 Q polyethylene glycol 3350 ..... 60 prenatal vits96-iron fum-folic quetiapine ...... 31 poly-iron 150 forte ...... 101 ...... 102 quinapril ...... 35 polyvitamin with iron ...... 101 prenatal-u ...... 102 quinapril-hydrochlorothiazide poly-vitamins ...... 101 pretab ...... 102 ...... 35 POMALYST ...... 63 prevalite ...... 38 quinidine gluconate ...... 32 portia 28 ...... 73 previfem ...... 73 quinidine sulfate ...... 32 posaconazole ...... 3 PREVYMIS ...... 5 quintabs-m iron free ...... 102 potassium chloride ...... 94 PREZCOBIX ...... 5 quit 2 ...... 48 potassium citrate ...... 91 PREZISTA ...... 5 quit 4 ...... 48 potassium gluconate ...... 94 PRIFTIN ...... 8 R powderlax ...... 60 primidone ...... 18 rabeprazole ...... 62 pr natal 400 ...... 101 PRIMSOL ...... 10 raloxifene ...... 65 pr natal 400 ec ...... 101 PRIVIGEN ...... 64 ramipril ...... 35 pr natal 430 ...... 101 probenecid ...... 65 ranitidine hcl ...... 62 pr natal 430 ec ...... 101 probenecid-colchicine ...... 65 ranolazine ...... 38 PRALUENT PEN ...... 38 PROBUPHINE ...... 23 rapid clear treatment pads ..... 40 pramipexole ...... 19 prochlorperazine ...... 60 RASUVO (PF) ...... 67 prasugrel ...... 36 prochlorperazine maleate ..... 60 RAVICTI ...... 47 pravastatin ...... 38 PROCRIT ...... 62 reclipsen (28) ...... 74 praziquantel ...... 8 procto-med hc ...... 60 RECTICARE ...... 42 prazosin ...... 35 procto-pak ...... 60 redness reliever lubricant ...... 79 PRED MILD ...... 78 proctozone-hc ...... 60 refenesen dm ...... 85 prednicarbate ...... 46 PROCYSBI ...... 91 REFRESH CELLUVISC ..... 77 prednisolone ...... 50 progesterone micronized ...... 69 REGRANEX ...... 40 prednisolone acetate ...... 78 PROGLYCEM ...... 51 RELENZA DISKHALER ...... 5 prednisolone sodium phosphate PROLASTIN-C ...... 47 RELISTOR ...... 60 ...... 50, 78 PROLIA ...... 65 REMICADE ...... 60 prednisone ...... 50 PROMACTA ...... 36 rena-vite ...... 102 prednisone intensol ...... 50 promethazine ...... 81 rena-vite rx ...... 102 pregabalin ...... 18 promethazine-codeine ...... 85 reno caps ...... 102

118 118 repaglinide ...... 55 SANDIMMUNE ...... 14 sinus and allergy pe ...... 86 REPATHA PUSHTRONEX 38 SANDOSTATIN LAR sinus congestion-pain(chlorph) REPATHA SURECLICK .... 38 DEPOT ...... 15 ...... 86 REPATHA SYRINGE ...... 38 SANTYL ...... 46 sinus congest-pain day-night 86 RESCON-DM ...... 85 SAPHRIS ...... 31 sinus decongestant (pe) ...... 86 rescon-gg ...... 85 SAVELLA ...... 67 sirolimus ...... 15 RESCRIPTOR ...... 5 scalacort ...... 46 SIRTURO ...... 9 RETACRIT ...... 62 scot-tussin dm ...... 86 SIVEXTRO ...... 9 REVCOVI ...... 47 SEGLUROMET ...... 55 SKYRIZI ...... 39 REVLIMID ...... 63 selegiline hcl ...... 19 sleep aid (diphenhydramine) 81 REXULTI ...... 31 selenium ...... 94 sleep aid max str (diphenhydr) REYATAZ ...... 5 selenium sulfide ...... 39 ...... 82 ribasphere ...... 63 SELZENTRY ...... 5, 6 sleep-tabs ...... 82 ribasphere ribapak ...... 63 se-natal 19 chewable ...... 102 slo-niacin ...... 38 ribavirin ...... 63 se-natal-19 ...... 102 slow release iron ...... 102 rid complete lice elim kit ...... 46 senexon-s ...... 60 SLOW RELEASE IRON ... 102 RIDAURA ...... 67 senna ...... 60, 61 sodium bicarbonate ...... 61 rifabutin ...... 9 senna lax ...... 60 sodium chloride ...... 77 rifampin ...... 9 senna laxative ...... 60 sodium citrate-citric acid ...... 91 RIFATER ...... 9 senna plus ...... 61 sodium ferric gluconat-sucrose riluzole ...... 48 senna-s ...... 61 ...... 48 rimantadine ...... 5 senno ...... 61 sodium phenylbutyrate ...... 48 RINVOQ ER ...... 67 sennosides-docusate sodium . 61 sodium polystyrene sulfonate RIOMET ...... 55 sentry senior ...... 102 ...... 61 RISPERDAL CONSTA ...... 31 SEREVENT DISKUS ...... 89 SOFOSBUVIR- risperidone ...... 31 SEROSTIM ...... 63 VELPATASVIR ...... 6 ritonavir ...... 5 sertraline ...... 31 SOLIRIS ...... 48 RITUXAN ...... 14 setlakin ...... 74 SOLTAMOX ...... 15 rivastigmine tartrate ...... 20 sevelamer carbonate ...... 61 SOMATULINE DEPOT ...... 15 rizatriptan ...... 19 sf 49 SOMAVERT ...... 53 robafen ...... 86 sf 5000 plus ...... 49 sotalol ...... 32 robafen dm cough ...... 85 sharobel ...... 69 sotalol af ...... 32 robafen dm cough-chest SIDEROL ...... 102 SOVALDI ...... 6 congest ...... 85 SIGNIFOR ...... 15 spinosad ...... 46 ropinirole ...... 19 SIGNIFOR LAR ...... 15 SPIRIVA RESPIMAT ...... 89 rosuvastatin ...... 38 siladryl sa ...... 81 spironolactone ...... 35 roweepra ...... 18 sildenafil (pulm.hypertension) spironolacton-hydrochlorothiaz roweepra xr ...... 18 ...... 89 ...... 35 ROZLYTREK ...... 14 SILIQ ...... 39 SPRAVATO ...... 31 RUBRACA ...... 14 siltussin dm das ...... 86 sprintec (28) ...... 74 RUCONEST ...... 89 siltussin sa ...... 86 SPRYCEL ...... 15 RUZURGI ...... 20 siltussin-dm ...... 86 sps (with sorbitol) ...... 61 RYDAPT ...... 14 silver nitrate ...... 40 sronyx ...... 74 rynex dm ...... 86 silver nitrate applicators ...... 40 ssd ...... 40 rynex pe ...... 86 silver sulfadiazine ...... 40 SSKI ...... 50 rynex pse ...... 86 SIMPONI ...... 67 st joseph aspirin ...... 27 S SIMPONI ARIA ...... 67 stavudine ...... 6 salicylic acid ...... 40 SIMULECT ...... 15 STEGLATRO ...... 55 salsalate ...... 27 simvastatin ...... 38 STELARA ...... 39 SAMSCA ...... 53 sinus 12 hour ...... 86 STIMATE ...... 53

119 119 STIOLTO RESPIMAT ...... 89 SYNAREL ...... 53 THALOMID ...... 15 TREMFYA ...... 40 TUSNEL DM valganciclovir ...... 6 STIVARGA ...... 15 SYSTANE GEL ...... 77 theochron ...... 89 tretinoin ...... 42 PEDIATRIC(PSEUDOEPH) valproic acid ...... 18 STRENSIQ ...... 53 T theophylline ...... 89 tretinoin (chemotherapy) ...... 15 ...... 86 valproic acid (as sodium salt) STRIBILD ...... 6 tab-a-vite ...... 102 THERATEARS ...... 77 tri femynor ...... 74 tusnel pediatric ...... 86 ...... 18 STRIVERDI RESPIMAT .... 89 tab-a-vite/iron ...... 102 thiamine hcl (vitamin b1) ... 103 triamcinolone acetonide 46, 49, TUSNEL PEDIATRIC ...... 86 valsartan ...... 35 STROVITE ONE ...... 102 TABLOID ...... 15 thiamine mononitrate (vit b1) 50 tussi pres-b ...... 86 valsartan-hydrochlorothiazide SUBLOCADE ...... 23 tacrolimus ...... 15, 40 ...... 103 triamterene-hydrochlorothiazid tussin ...... 87 ...... 35 SUBOXONE ...... 27 tadalafil (pulm. hypertension) THIOLA ...... 48 ...... 35 tussin chest congestion ...... 86 vancomycin ...... 10 subvenite ...... 18 ...... 89 thioridazine ...... 31 triazolam ...... 31 tussin dm ...... 87 vandazole ...... 70 SUCRAID ...... 61 TAFINLAR ...... 15 thiothixene ...... 31 tri-buffered aspirin ...... 27 tussin dm clear ...... 86 VANTAS ...... 16 sucralfate ...... 62 TAGRISSO ...... 15 thrivite-19 ...... 103 tricitrates ...... 91 tussin dm cough and chest .... 86 v-c forte ...... 103 sudogest ...... 86 TAKHZYRO ...... 89 thyroid (pork) ...... 55 tricon ...... 103 tussin dm max ...... 86 VCF CONTRACEPTIVE sudogest 12-hour ...... 86 TALTZ AUTOINJECTOR .. 39 THYROLAR-1 ...... 55 triderm ...... 46 tussin expectorant ...... 87 FILM ...... 70 sudogest cold and allergy ..... 86 TALTZ AUTOINJECTOR (2 THYROLAR-1/2 ...... 55 trientine ...... 48 tussin maximum strength VCF CONTRACEPTIVE GEL sudogest sinus and allergy .... 86 PACK) ...... 39 THYROLAR-1/4 ...... 55 tri-estarylla ...... 74 cough ...... 87 ...... 70 sulfacetamide sodium ...... 79 TALTZ AUTOINJECTOR (3 THYROLAR-2 ...... 55 trifluoperazine ...... 31 tussin mucus-chest congestion veletri ...... 35 sulfacetamide sodium (acne) 43 PACK) ...... 39 THYROLAR-3 ...... 55 trifluridine ...... 75 ...... 87 velivet triphasic regimen (28) sulfacetamide sodium-sulfur 41 TALTZ SYRINGE ...... 39 tiagabine ...... 18 trigels-f forte ...... 103 TUSSI-PRES PEDIATRIC .. 87 ...... 74 sulfacetamide-prednisolone .. 79 TALZENNA ...... 15 TIBSOVO ...... 15 trihexyphenidyl ...... 19 TYBOST ...... 6 VELTASSA ...... 61 sulfadiazine ...... 10 tamoxifen ...... 15 tilia fe ...... 74 tri-legest fe ...... 74 tydemy ...... 74 VEMLIDY ...... 6 sulfamethoxazole-trimethoprim tamsulosin ...... 90 timolol maleate ...... 35, 76 tri-linyah ...... 74 TYKERB ...... 16 VENCLEXTA ...... 16 ...... 10 TARGRETIN ...... 15 tinidazole ...... 9 tri-lo-estarylla ...... 74 TYMLOS ...... 65 VENCLEXTA STARTING sulfasalazine ...... 61 tarina 24 fe ...... 74 tioconazole ...... 69 tri-lo-marzia ...... 74 TYSABRI ...... 20 PACK ...... 16 sulfatrim ...... 10 tarina fe 1/20 (28) ...... 74 tioconazole-1 ...... 69 tri-lo-mili ...... 74 TYVASO ...... 90 venlafaxine ...... 31 sulindac ...... 27 taron forte ...... 102 TIVICAY ...... 6 tri-lo-sprintec ...... 74 TYVASO REFILL KIT ...... 90 VENOFER ...... 103 sumatriptan ...... 19 taron-c dha ...... 103 tizanidine ...... 21 trilyte with flavor packets ..... 61 TYVASO STARTER KIT ... 90 VENTAVIS ...... 90 sumatriptan succinate ..... 19, 20 taron-prex prenatal-dha ...... 103 TOBI PODHALER ...... 9 trimethobenzamide ...... 61 U VENTOLIN HFA ...... 90 super b maxi complex ...... 102 TASIGNA ...... 15 TOBRADEX ...... 78 trimethoprim ...... 10 UDAMIN SP ...... 103 verapamil ...... 35 super b/c ...... 102 TAVALISSE ...... 37 tobramycin ...... 75 tri-mili ...... 74 UDENYCA ...... 62 VERZENIO ...... 16 super omega-3 ...... 38 taztia xt ...... 35 tobramycin in 0.225 % nacl .... 9 trimipramine ...... 31 ultra strength antacid ...... 94 VIBERZI ...... 61 super quints ...... 102 TECFIDERA ...... 64 tobramycin-dexamethasone .. 78 trinatal rx 1 ...... 103 ultra strength calcium antacid vic-forte ...... 103 super quints b-50 ...... 102 TEGSEDI ...... 20 TOBREX ...... 75 trinate ...... 103 ...... 94 VICTOZA 2-PAK ...... 55 super thera vite m ...... 102 telmisartan ...... 35 TODAY CONTRACEPTIVE tri-previfem (28) ...... 74 unicomplex-m ...... 103 VICTOZA 3-PAK ...... 55 superplex-t ...... 102 telmisartan-amlodipine ...... 35 SPONGE ...... 70 TRIPTODUR ...... 16 unisom sleepgels ...... 82 VIDEX 2 GRAM PEDIATRIC suphedrin ...... 86 telmisartan-hydrochlorothiazid tolmetin ...... 27 tri-sprintec (28) ...... 74 unithroid ...... 55 ...... 6 suphedrine ...... 86 ...... 35 tolnaftate ...... 44 TRIUMEQ ...... 6 UPTRAVI ...... 35 VIEKIRA PAK ...... 6 suphedrine 12 hour ...... 86 temazepam ...... 31 tolterodine ...... 90 triveen-duo dha ...... 103 urea ...... 41 vienva ...... 74 SUPPRELIN LA ...... 15 temozolomide ...... 15 topiramate ...... 18 tri-vitamin with fluoride ..... 103 urea nail stick ...... 40 vigabatrin ...... 18 supress dx ...... 86 tenofovir disoproxil fumarate . 6 toremifene ...... 15 trivora (28) ...... 74 ure-k ...... 41 vigadrone ...... 18 SUTENT ...... 15 terazosin ...... 35 torsemide ...... 35 tri-vylibra ...... 74 uretron d-s ...... 91 VIMIZIM ...... 54 syeda ...... 74 terbinafine hcl ...... 3, 44 total b/c ...... 103 tri-vylibra lo ...... 74 urimar-t ...... 91 vinate care ...... 103 SYLATRON ...... 64 terbutaline ...... 89 TRACLEER ...... 90 TROGARZO ...... 6 urin ds ...... 91 vinate m ...... 103 SYLVANT ...... 15 terconazole ...... 69 tramadol ...... 27 tropicamide ...... 76 urogesic-blue ...... 91 vinate one ...... 103 SYMDEKO ...... 89 testosterone ...... 54 tramadol-acetaminophen ...... 27 trospium ...... 90 ursodiol ...... 61 viorele (28) ...... 74 SYMFI ...... 6 testosterone cypionate ...... 54 trandolapril ...... 35 TRULICITY ...... 55 uryl ...... 91 VIRACEPT ...... 6 SYMFI LO ...... 6 testosterone enanthate ...... 54 tranexamic acid ...... 70 TRUVADA ...... 6 utira-c ...... 91 VIREAD ...... 6 SYMLINPEN 120 ...... 55 tetcaine ...... 77 tranylcypromine ...... 31 tulana ...... 69 V virt-c dha ...... 103 SYMLINPEN 60 ...... 55 tetrabenazine ...... 20 trazodone ...... 31 TURALIO ...... 16 vaginal contraceptive foam .. 70 virt-nate dha ...... 103 SYMTUZA ...... 6 tetracaine hcl ...... 77 TRECATOR ...... 9 valacyclovir ...... 6 virt-phos 250 neutral ...... 94 SYNAGIS ...... 6 tetracycline ...... 10 TRELSTAR ...... 15 VALCHLOR ...... 41 virt-pn dha ...... 103

120 121 120 TREMFYA ...... 40 TUSNEL DM valganciclovir ...... 6 tretinoin ...... 42 PEDIATRIC(PSEUDOEPH) valproic acid ...... 18 tretinoin (chemotherapy) ...... 15 ...... 86 valproic acid (as sodium salt) tri femynor ...... 74 tusnel pediatric ...... 86 ...... 18 triamcinolone acetonide 46, 49, TUSNEL PEDIATRIC ...... 86 valsartan ...... 35 50 tussi pres-b ...... 86 valsartan-hydrochlorothiazide triamterene-hydrochlorothiazid tussin ...... 87 ...... 35 ...... 35 tussin chest congestion ...... 86 vancomycin ...... 10 triazolam ...... 31 tussin dm ...... 87 vandazole ...... 70 tri-buffered aspirin ...... 27 tussin dm clear ...... 86 VANTAS ...... 16 tricitrates ...... 91 tussin dm cough and chest .... 86 v-c forte ...... 103 tricon ...... 103 tussin dm max ...... 86 VCF CONTRACEPTIVE triderm ...... 46 tussin expectorant ...... 87 FILM ...... 70 trientine ...... 48 tussin maximum strength VCF CONTRACEPTIVE GEL tri-estarylla ...... 74 cough ...... 87 ...... 70 trifluoperazine ...... 31 tussin mucus-chest congestion veletri ...... 35 trifluridine ...... 75 ...... 87 velivet triphasic regimen (28) trigels-f forte ...... 103 TUSSI-PRES PEDIATRIC .. 87 ...... 74 trihexyphenidyl ...... 19 TYBOST ...... 6 VELTASSA ...... 61 tri-legest fe ...... 74 tydemy ...... 74 VEMLIDY ...... 6 tri-linyah ...... 74 TYKERB ...... 16 VENCLEXTA ...... 16 tri-lo-estarylla ...... 74 TYMLOS ...... 65 VENCLEXTA STARTING tri-lo-marzia ...... 74 TYSABRI ...... 20 PACK ...... 16 tri-lo-mili ...... 74 TYVASO ...... 90 venlafaxine ...... 31 tri-lo-sprintec ...... 74 TYVASO REFILL KIT ...... 90 VENOFER ...... 103 trilyte with flavor packets ..... 61 TYVASO STARTER KIT ... 90 VENTAVIS ...... 90 trimethobenzamide ...... 61 U VENTOLIN HFA ...... 90 trimethoprim ...... 10 UDAMIN SP ...... 103 verapamil ...... 35 tri-mili ...... 74 UDENYCA ...... 62 VERZENIO ...... 16 trimipramine ...... 31 ultra strength antacid ...... 94 VIBERZI ...... 61 trinatal rx 1 ...... 103 ultra strength calcium antacid vic-forte ...... 103 trinate ...... 103 ...... 94 VICTOZA 2-PAK ...... 55 tri-previfem (28) ...... 74 unicomplex-m ...... 103 VICTOZA 3-PAK ...... 55 TRIPTODUR ...... 16 unisom sleepgels ...... 82 VIDEX 2 GRAM PEDIATRIC tri-sprintec (28) ...... 74 unithroid ...... 55 ...... 6 TRIUMEQ ...... 6 UPTRAVI ...... 35 VIEKIRA PAK ...... 6 triveen-duo dha ...... 103 urea ...... 41 vienva ...... 74 tri-vitamin with fluoride ..... 103 urea nail stick ...... 40 vigabatrin ...... 18 trivora (28) ...... 74 ure-k ...... 41 vigadrone ...... 18 tri-vylibra ...... 74 uretron d-s ...... 91 VIMIZIM ...... 54 tri-vylibra lo ...... 74 urimar-t ...... 91 vinate care ...... 103 TROGARZO ...... 6 urin ds ...... 91 vinate m ...... 103 tropicamide ...... 76 urogesic-blue ...... 91 vinate one ...... 103 trospium ...... 90 ursodiol ...... 61 viorele (28) ...... 74 TRULICITY ...... 55 uryl ...... 91 VIRACEPT ...... 6 TRUVADA ...... 6 utira-c ...... 91 VIREAD ...... 6 tulana ...... 69 V virt-c dha ...... 103 TURALIO ...... 16 vaginal contraceptive foam .. 70 virt-nate dha ...... 103 valacyclovir ...... 6 virt-phos 250 neutral ...... 94 VALCHLOR ...... 41 virt-pn dha ...... 103

121 121 virt-pn plus ...... 103 VOTRIENT ...... 16 Z virtrate-2 ...... 91 vp-ch-pnv ...... 105 zafirlukast ...... 90 virtrate-3 ...... 91 VPRIV ...... 54 zaleplon ...... 32 virtrate-k ...... 91 vp-vite rx ...... 105 zarah ...... 74 virtussin ac ...... 87 VRAYLAR ...... 31 ZARXIO ...... 63 vision formula (with lutein) 103 vyfemla (28) ...... 74 zatean-pn dha ...... 105 vit 3 ...... 103 vylibra ...... 74 zatean-pn plus ...... 105 vit a and d3 in cod liver oil . 103 VYNDAMAX ...... 38 ZEJULA ...... 16 vitacel (with lutein) ...... 103 VYNDAQEL ...... 38 ZELBORAF ...... 16 VITAFOL-OB ...... 103 VYVANSE ...... 31 ZELNORM ...... 61 vitalee ...... 103 W ZEMAIRA ...... 48 vitalets ...... 103 warfarin ...... 37 zenatane ...... 42 vitamin a ...... 104 wart remover ...... 40 zenzedi ...... 32 vitamin b complex ...... 104 wera (28) ...... 74 zidovudine ...... 6 vitamin b complex-folic acid westhroid ...... 55 zinc gluconate ...... 94 ...... 104 WIDE-SEAL DIAPHRAGM zinc oxide ...... 41 vitamin b-1 ...... 104 ...... 67 zinc sulfate ...... 94 vitamin b-1 (mononitrate) .. 104 wixela inhub ...... 90 zingiber ...... 105 vitamin b-12 ...... 104 wymzya fe ...... 74 ZINPLAVA ...... 65 VITAMIN B-12 ...... 104 X ziprasidone hcl ...... 32 vitamin b-2 ...... 104 XALKORI ...... 16 ZIRGAN ...... 75 vitamin b-6 ...... 104 XARELTO ...... 37 ZODRYL DEC 30 ...... 87 vitamin c ...... 104 XELJANZ ...... 67 ZOLADEX ...... 16 vitamin c drops ...... 104 XELJANZ XR ...... 67 zoledronic acid ...... 54 vitamin c with rose hips ..... 104 XEOMIN ...... 65 zoledronic acid-mannitol-water vitamin d3 ...... 104 XERAC AC ...... 41 ...... 48, 54 vitamin e ...... 105 XERMELO ...... 16 ZOLINZA ...... 16 vitamin e (dl, acetate) ...... 104 XGEVA ...... 11 zolpidem ...... 32 vitamin e acetate ...... 104 XIFAXAN ...... 9 zonisamide ...... 18 vitamin e mixed ...... 104 XOLAIR ...... 90 ZONTIVITY ...... 37 vitamins a,c,d and fluoride . 105 XOLIDO XP ...... 42 zoo chews ...... 105 vitamins and minerals ...... 105 XOSPATA ...... 16 ZORBTIVE ...... 63 vitamins b complex ...... 105 XPOVIO ...... 16 ZORTRESS ...... 16 vitatrum ...... 105 XTAMPZA ER ...... 23 zovia 1/35e (28) ...... 74 VITRAKVI ...... 16 XTANDI ...... 16 ZUBSOLV ...... 27 VIVITROL ...... 27 xulane ...... 70 ZYDELIG ...... 16 VIZIMPRO ...... 16 XULTOPHY 100/3.6 ...... 52 ZYKADIA ...... 16 voriconazole ...... 3 Y ZYNCOF ...... 87 VOSEVI ...... 6 YONSA ...... 16 ZYTIGA ...... 16

122 122 Nondiscrimination Notice UPMC for Kids complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender, gender identity or expression, or sexual orientation. UPMC for Kids does not exclude people or treat them differently because of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender, gender identity or expression, or sexual orientation. UPMC for Kids provides to people with disabilities to communicate effectively with us free aids and services, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) UPMC for Kids provides to people whose primary language is not English free language services, such as: • Qualified interpreters • Information written in other languages If you need these services, contact UPMC for Kids at 1-800-650-8762. If you believe that UPMC for Kids has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender, gender identity or expression, or sexual orientation, you can file a grievance with: Bureau of Equal Opportunity Room 223, Health and Welfare Building PO Box 2675 Harrisburg, PA 17105-2675 Phone: (717) 787-1127; TTY: 1-800-654-5484; Fax: (717) 772-4366 Email: [email protected] You can file a complaint in person or by mail, fax, or email. If you need help filing a grievance, the Bureau of Equal Opportunity are 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, DC 20201 1-800-368-1019, 1-800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Translation Services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call: 1-800-650-8762 (TTY: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-650-8762 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-650-8762 (телетайп: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-650-8762 (TTY：711)。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-650-8762 (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-650-8762 (رقم هاتف الصم والبكم: 711).

ध्봾न दिनुहोस:् तप봾셍ᴂले नेप봾ली बोलनुहुन㔛 भने तप봾셍ᴂको ननम्त भ봾ष봾 सह봾्त봾 सेव봾ह셂 ननःशुलक 셂पम봾 उपलब㔧 㔛 । फोन गनुꅁहोस ्1-800-650-8762 (दिदिव봾셍: 711) । 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-650-8762 (TTY: 711) 번으로 전화해 주십시오.

ស插ஶល់៖ ប䮚សិនប䮚ើអ䮓កនិ架យ徶羶ខ្揂រ បយើង插នផ䮊ល់បស玶ជំនួយខផ䮓ក徶羶បោយមិនគិ តថ្濃។ សូមទូរស័ព䮑បៅបល្ 1-800-650-8762 (TTY: 711)។ ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposes gratuitement. Appelez le 1-800-650-8762 (ATS: 711).

သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-800-650-8762 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-650-8762 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-650-8762 (TTY: 711). ল嗍ষ্য ক쇁নঃ যদি আপদন বাংলা, কথা বলতে পাতেন, োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে। ফ�ান ক쇁ন 1-800-650-8762 (TTY: 711)। KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-650-8762 (TTY: 711).

સચના:ુ જો તમે ગજરાતીુ બોલતા હો, તો નન:શલ㚕ુ ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ㚧 છે. ફોન 㚕રો 1-800-650-8762 (TTY: 711).

This managed care plan may not cover all your child’s health care expenses. Read all UPMC for Kids materials carefully to determine which health care services are covered. Call UPMC for Kids Health Care Concierge team at 1-800-650-8762 (TTY: 711) for more information.

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