Centene Employee

Home , Androstenedione, Bile acid, Chrysin, Demecarium bromide, Diclazuril, Fenbendazole

Centene Employee

PREFERRED DRUG LIST

The Centene Employee Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website at https://pharmacy.envolvehealth.com/members/formulary.html or call us at 1-844-262-6337. Updated: December 1, 2020

Table of Contents

What is the Centene Employee Formulary?...... ii

How are the drugs listed in the categorical list?...... ii

How much will I pay for my drugs?...... ii

How do I find a drug on the Drug List?...... iii

Are there any limits on my drug coverage?...... iv

Can I go to any pharmacy?...... iv

Can I use a mail order pharmacy?...... v

How can I get prior authorization or an exception to the rules for drug coverage?...... v

How can I save money on my prescription drugs?...... v

How often does the Drug List change?...... v

What drugs are under my medical benefit?...... v

Definitions...... vi

Categorical list of prescription drugs...... 1

Alphabetical index of prescription drugs...... Index 1

What is the Centene Employee Formulary? The Centene Employee Formulary is a list of covered drugs used to treat common diseases or health problems. The formulary is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class. Example:

The generic drug name for a brand drug is included after the brand name in parentheses and all lowercase italicized letters. Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase italicized letters. Generic Drug Example: terbutaline sulfate tabs

If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand drug will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Generic Drug Marketed Under A Brand Name Example: levothyroxine sodium (Levoxyl) TABS

How much will I pay for my drugs? To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on the formulary. The copayment or coinsurance for each tier is defined in your Summary of Benefits or other plan documents. After any deductible has been satisfied, the maximum cost share is $100 per 30-day prescription for any oral cancer drug or $100 for all other drugs for a 30-day supply.

Benefit Phase Maximum Cost Share Days Supply Drug Class/Plan Deductible met $100 30 days Oral Cancer Drugs Only Deductible met $100 30 days All Other (non-oral cancer) Drugs

Below is a description for each tier:

Abbreviation Description 1 Value generic drugs

2 Preferred generic drugs

3 Value brand drugs 4 Preferred brand drugs 5 Non-preferred brand or generic drugs

6 Prevention Drug $0 (ACA regulated)

NC Drugs listed as NC are drugs that are not covered on the Centene Employee Preferred Drug List.

How do I find a drug in the Drug List? You can search for a drug by using the search tool, alphabetical index or by medical condition. There are three ways to find out if your drug is covered.

Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.

Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.

Medical Condition: The drugs are grouped into categories by type of medical condition that they are used to treat. For example, “Cardiovascular Agents – Drugs to Treat Heart and Circulation Conditions." If you know what your drug is used for look through the list to find the category. Then look under the category for your drug.

If a generic equivalent for a brand name drug is not available in the market or not covered, the generic drug will not be listed separately. The presence of a drug on the drug list does not guarantee that your doctor will prescribe the drug for a particular medical condition.

iii

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the formulary:

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations.

PA Prior Authorization These drugs require prior authorization for coverage, effectiveness, or safety reasons. This means that your doctor must request approval from the plan before the drug will be covered.

PV Preventive Drugs Preventive benefit drugs covered at no cost to members under the Affordable Care Act. A deductible does not apply. To get a brand drug that has a generic available, your doctor must request prior authorization to show medical necessity. You will be responsible for the difference in cost between the brand and the generic drug.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug.

RX/OTC Prescription & Over- Certain drugs are available both in a prescription form and in an OTC the-Counter (OTC) form. Only prescription drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs.

SP Specialty Drugs Specialty drugs are used to treat complex, chronic conditions that may require special handling, storage or clinical management. Specialty drugs are limited to a 30 day supply and in most cases must be obtained from one of the plan’s Specialty Pharmacies. ST Step Therapy Step Therapy is when you are required to use one drug before another, in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy.

Can I go to any pharmacy? You must use pharmacies that are in the network. These pharmacies have a contract with Envolve Pharmacy Solutions. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at https://pharmacy.envolvehealth.com or call us at the telephone number on your member ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy will not be able to bill us online so you will have to pay the full cost of your drug.

Some injectable and high cost drugs may be considered “specialty drugs”. Specialty drugs are limited to a 30 day supply and in most cases must be must be obtained from one of the plan’s Specialty Pharmacies.

iv Can I use a mail order pharmacy? You can use the HomescriptsTM Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those that you take daily and are needed for a long term condition.

To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. For more information about Homescripts Mail Order Pharmacy go to www.homescripts.envolvehealth.com.

How can I get prior authorization or an exception to the rules for drug coverage? Requests for prior authorization, step therapy exception or other exceptions to the rules for drug coverage may be submitted electronically, by phone at the phone number shown on your Centene ID card or by fax at 1-844-262-7239. Expedited/exigent requests will be processed and the prescriber notified, within 24 hours after receipt of the request. Non-urgent requests will be processed and the prescriber notified, within 72 hours after receipt of request.

If you are suffering from a condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a drug that is not on the Centene Employee Preferred Drug List, then you, your designee or your doctor can request an expedited/exigent circumstances review. Expedited requests for authorizations are processed, and providers notified of coverage determination within 24 hours after receipt of request and 72 hours for non-urgent requests.

How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at network pharmacies. • Be sure your doctor prescribes drugs on the formulary. • Fill your maintenance drugs through our mail order pharmacy.

How often does the Drug List change? The formulary will be updated with changes on a monthly basis. The types of changes may include the following:

• Removal of a drug or dosage form of a drug from the formulary; • Any change in tier placement of a drug that results in an increase in cost sharing; • Adding or changing utilization management procedures applicable to a drug.

If these changes occur, you will be notified at least 60 days in advance of the change, unless the drug is removed for safety reasons.

What drugs are under my medical benefit? Drugs that are not considered self-injectable and are administered by your doctor will be covered under you medical benefit. If your doctor does not have the drug, your doctor will give you instructions on where you can receive the drug. Certain drugs that are self-administered are covered under your

v pharmacy benefit. Refer to your coverage information and exceptions.

Contacting Envolve Pharmacy Solutions Call Envolve Pharmacy Solutions Customer Service Center at 1-844-262-6337 To access TTY service for hearing impaired members, call 1-866-492-9674

Definitions

Brand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters. Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible: Is the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If the plan has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. The plan pay the rest. Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug. Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or your doctor submits a request for coverage of a non-formulary drug, the plan must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances: Is when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or prescription drug list: Is the list of drugs that is covered by the plan under the prescription drug benefit of the policy. Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list in italicized lowercase letters. Medically Necessary: Is health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary. Non-formulary drug: Is a prescription drug that is not listed on the drug list. Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan. Out- of-pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered paid by the Member. Prescribing provider: This is a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug: Is a drug that by law requires a prescription. vi Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug.

vii Nondiscrimination Notice

Envolve Pharmacy Solutions, Inc. on behalf of itself and its affiliates does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Email: [email protected]

Mail: Civil Rights Coordinator Envolve Pharmacy Solutions 1850 W. Rio Salado Parkway, Suite 211

Tempe, AZ 85281 Phone: 800-460-8988 or (800) 413-7721 Fax: 888-246-1422 TTY: 866-492-9674

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, or TTY 711.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, (TDD 1-800-537-7697 Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Language Assistance Notices

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 1-844-262-6337, or TTY 711. We have free services to help you communicate with us. Such as, letters in other languages or large print. ENGLISH Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number on your ID card or TTY 711. Brindamos servicios gratuitos para ayudarle a comunicarse con nosotros. Ofrecemos cartas en otros SPANISH idiomas o en letra grande. Puede pedir un intérprete. Para obtener ayuda, llame al nmero telefnico gratuito de su tarjeta de identificacin o TTY 711. Nous avons des services gratuits pour nous aider à communiquer avec vous, comme des lettres écrites FRENCH dans d’autres langues ou imprimées en gros caractères. Vous pouvez également solliciter un interprète. Pour toute demande d’assistance, veuillez appeler le numéro gratuit figurant sur votre carte d’identification ou bien TTY 711 Wir bieten kostenlose Services an, um Ihnen dabei zu helfen, mit uns Verbindung aufzunehmen, GERMAN beispielsweise durch Briefe in anderen Sprachen oder Großdruck. Sie knnen auch einen Dolmetscher anfordern. Wenn Sie Hilfe bentigen, rufen Sie bitte die gebhrenfreie Nummer auf Ihrem Ausweis oder TTY 711 an. Offriamo servizi gratuiti per aiutarla a comunicare con noi, come lettere in altre lingue o a caratteri pi ITALIAN grandi, oppure il servizio di interpretariato. Per chiedere aiuto, chiami il numero verde sulla sua tessera ID o TTY 711. Temos serviços gratuitos para ajudar a se comunicar conosco – tais como, cartas em outros idiomas ou PORTUGUESE impressão em letras grandes. Ou você pode obter a ajuda de um intérprete. Para pedir ajuda, por favor ligue para o nmero de telefone gratuito em seu cartão de identidade ou TTY 711. Nou gen sèvis ki gratis pou sa ede w kominike avè n. Tankou lèt nan lt lang oubyen eki ak lèt laj. FR CREOLE Oubyen, ou kapab mande pou yon entèprèt. Pou w mande pou n sa ede w, sonnen nimewo telefn gratis la ki sou kat idantifikasyon ou an oubyen TTY ka sonnen 711. 我们有有费有务有有帮有您与有们有有，例如提供其他语有有有有有有号有有有有有有有。或者您有有 CHINESE 有有有有有有译员。有有帮有，请有电您 ID 卡上的免费电话号码有有 TTY 711。言語サービスは無料でご提供いたします。通訳を依頼できます。 JAPANESE また文書の代読および、ご希望の言語による文書の郵送が可能です。支援が必要な場合は、ID カードの裏側に記載されている[ 電話番号を記入 ]までお電話ください。 귀하께서 저희와 소통하시는 데 도움이 되는 무료 서비스를 제공해드립니 다다. 른 언어로 또는 대형 활자본으로 서신을 KOREAN 제공하는 것이 그러한 예입니다통. 역사 를 요청하실 수도 있습니다도. 움이 필요하시면 귀하의ID 카드에 안내된 수신자 부담 전화 번호로 또는T TY 의 경우71 1번으 로 연락해 주십시오. Oferujemy bezpłatne usługi ułatwiające komunikowanie się z nami, na przykład pisma w innym języku POLISH lub duża czcionka. Można również poprosić o pomoc tłumacza. Aby poprosić o pomoc, proszę zadzwonić pod bezpłatny numer znajdujący się na karcie identyfikacyjnej lub numer TTY 711. Мы предоставляем бесплатные услуги, которые помогут вам поддерживать с нами связь. Такие как, например, отправка писем на различных языках или писем, выполненных RUSSIAN крупным шрифтом. Вы также можете обратиться за помощью переводчика. Чтобы получить соответствующую помощь, позвоните нам, пожалуйста, по бесплатному номеру телефона, указанному в вашем членском удостоверении, или наберите номер 771 на телекоммуникационном аппарате (телетайпе) для слабослышащих. Mayroon kaming mga libreng serbisyo upang tulungan kang makipagkomunika sa amin. Halimbawa, mga TAGALOG letra sa mga ibang wika o large print. O kaya’y maaari kang humingi ng interpreter. Upang humingi ng tulong, mangyaring tawagan ang toll-free na numero na nakasulat sa iyong ID card o tawagan ang TTY 711. Chng ti c các dịch vụ miễn phí để gip qu vị liên lạc với chng tôi. Như, thư từ bằng các ngn ngữ VIETNAMESE khác hoặc chữ in khổ lớn. Hoặc, qu vị c thể yêu cầu một thng dịch viên. Để yêu cầu gip đỡ, xin gọi số điện thoại miễn phí c ghi trên thẻ ID của qu vị hoặc TTY 711.

ﺪﺎﻣ ﺧ ﻟﺪﺎﻨﯾ ت ﻲﻓ ﻚﺗﺪﻋﺎﺴﻤﻟ ﺔﯿﻧﺎ ﻣﺠ اﻮﺘﻟا ﻞﯿﺒﺳ ﻰﻠﻋ ﻨﻌﻣﺎ. ﻞﺻاﺎﺜﻤﻟل، ر ﻠﺑﻐﺎ ﻞﺋﺎﺳت أﺮﺧى أوﺮ ﺄﺑﺣ ف ﻛﺮﯿﺒ ة . ،أو ﻤﯾﻜﻚﻨ أن ARABIC ﻢ ﻣﺮﺘﺟ ﻄﺗﻠﺐ در ﻮﺧاﻠﻄﻟ ﮏﻤﮐ ﺖﺳﻟ، ﺎ ﺪﺧﻣ ًﺎﻣ أ ﺎﺑ ﺎ ﻄﻔ ﻟ ت ﻞ را ﻲﻧ ﺎ ﮕﯾ را ﻟﺮﺑ ای ﺮﺑﻟ ﺷﺎﻤﻚ ﮫﺑ ﺔ ﻄﮏﻤﮐ ايﻠ ﺮ ﻗأ ﺮﺑ ر ﻂاي ارﻄﺔ ﺎﺒﺗ ط ﺎﻣ ﺎﺑ، ﮫﺑ ﺎﻧﮫﻣ ﺎﻣﺪﻨﻧ زﺎﺑن یﺎھ د ﺮﮕﯾ ﺎﭼو ﺎﺑ ﮫﻣ ﺎﻧ ﺎﯾ پ ﺰﺑرگ اﺖﺳ در د ﺮﺘﺳس دا ر ﻢﯾو ﺎﯾ اﻮﺗ ﯽﻣ ﺷﻤﺎ ﮑﻨﯾﮫ اﺎ ﺿ ﻘﺗﺎ ﺪﯿﻧی . ﯿﻨﮐﺪ ﺟﻢ ﺮﺘﻣ PERSIAN ﺮﺑای

Disclaimer:

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New- to-market products and new variations of products already in the marketplace may not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by an independent Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Please contact Envolve Pharmacy Solutions Customer Service at 1- 844-262-6337 to check coverage and copay information for a specific medicine.

The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

Member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, please contact an Envolve Pharmacy Solutions Customer Service representative at 1-844-262-6337.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- dextroamphetamine sulfate 2 QL(60 ml daily) OBESITY/ANOREXIANTS - Drugs to Treat soln 5 mg/5ml ADHD, Sleep and Eating Disorders dextroamphetamine sulfate 2 QL(2 ea daily) tabs 10 mg Amphetamines ADDERALL TABS QL(2 ea daily) dextroamphetamine sulfate (amphetamine- 5 tabs 15 mg, 2.5 mg, 20 mg, 2 dextroamphetamine) 30 mg, 7.5 mg, 5 mg ADDERALL XR CP24 QL(2 ea daily) DYANAVEL XR SUER 5 QL(8 ml daily) (amphetamine- 2 dextroamphetamine) EVEKEO ODT TBDP NC ADZENYS ER SUER 5 EVEKEO TABS 10 MG NC QL(6 ea daily) (amphetamine) (amphetamine sulfate) ADZENYS XR-ODT TBED 5 QL(1 ea daily) EVEKEO TABS 5 MG NC QL(12 ea daily) (amphetamine sulfate) amphetamine suer 2 methamphetamine hcl tabs 2 QL(2 ea daily) amphetamine sulfate tabs 2 QL(6 ea daily) 10 mg MYDAYIS CP24 4 amphetamine sulfate tabs 2 QL(12 ea daily) 5 mg VYVANSE CAPS 10 MG 4 amphetamine- VYVANSE CAPS 20 MG, QL(1 ea daily) dextroamphetamine cp24 30 MG, 40 MG, 50 MG, 60 4 1.25 mg-1.25 mg-1.25 mg- MG, 70 MG 1.25 mg, 2.5 mg-2.5 mg- VYVANSE CHEW 10 MG, QL(1 ea daily) 2.5 mg-2.5 mg, 3.75 mg- NC 4 3.75 mg-3.75 mg-3.75 mg, 20 MG, 30 MG, 40 MG, 50 5 mg-5 mg-5 mg-5 mg, MG, 60 MG 6.25 mg-6.25 mg-6.25 mg- Analeptics 6.25 mg, 7.5 mg-7.5 mg- CAFCIT SOLN (caffeine 5 7.5 mg-7.5 mg citrate) amphetamine- QL(2 ea daily) caffeine & sodium 2 dextroamphetamine tabs benzoate soln 1.875 mg-1.875 mg-1.875 mg-1.875 mg, 3.125 mg- CAFFEINE ANHYDROUS 5 RX/OTC 3.125 mg-3.125 mg-3.125 POWD mg, 3.75 mg-3.75 mg-3.75 2 caffeine citrate soln 2 mg-3.75 mg, 1.25 mg-1.25 mg-1.25 mg-1.25 mg, 2.5 CAFFEINE CITRATED 5 mg-2.5 mg-2.5 mg-2.5 mg, POWD 5 mg-5 mg-5 mg-5 mg, 7.5 mg-7.5 mg-7.5 mg-7.5 mg DOPRAM SOLN 5 DESOXYN TABS 5 QL(2 ea daily) Attention-Deficit/Hyperactivity Disorder (ADHD) (methamphetamine hcl) atomoxetine hcl caps 10 2 PA; QL(2 ea DEXEDRINE CP24 QL(2 ea daily) mg, 18 mg, 25 mg, 40 mg daily) (dextroamphetamine 5 atomoxetine hcl caps 100 2 PA; QL(1 ea sulfate) mg, 60 mg, 80 mg daily) dextroamphetamine sulfate QL(2 ea daily) PA; QL(4 ea 2 clonidine hcl (adhd) tb12 2 cp24 10 mg, 15 mg, 5 mg daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea guanfacine hcl (adhd) tb24 2 FOCALIN TABS 5 QL(2 ea daily) daily) (dexmethylphenidate hcl) INTUNIV TB24 (guanfacine NC PA; QL(1 ea FOCALIN XR CP24 25 hcl (adhd)) daily) MG, 35 MG 5 (dexmethylphenidate hcl) KAPVAY TB12 (clonidine 5 PA; QL(4 ea hcl (adhd)) daily) FOCALIN XR CP24 40 QL(1 ea daily) STRATTERA CAPS 10 PA; QL(2 ea MG, 10 MG, 15 MG, 20 5 MG, 18 MG, 25 MG, 40 MG 5 daily) MG, 30 MG, 5 MG (atomoxetine hcl) (dexmethylphenidate hcl) STRATTERA CAPS 100 PA; QL(1 ea JORNAY PM CP24 NC MG, 60 MG, 80 MG 5 daily) (atomoxetine hcl) METHYLIN SOLN 5 (methylphenidate hcl) Dopamine and Norepinephrine Reuptake methylphenidate hcl chew 2 SUNOSI TABS 4 PA or 10 mg, 2.5 mg, 5 mg methylphenidate hcl cp24 QL(1 ea daily) Histamine H3-Receptor Antagonist/Inverse or 10 mg, 15 mg, 20 mg, 30 2 WAKIX TABS NC mg, 40 mg, 50 mg, 60 mg methylphenidate hcl cp24 2 QL(2 ea daily) Stimulants - Misc. or 10 mg, 20 mg, 30 mg ADHANSIA XR CP24 NC methylphenidate hcl cpcr or 2 QL(2 ea daily) 20 mg, 30 mg APTENSIO XR CP24 5 QL(1 ea daily) methylphenidate hcl cpcr or (methylphenidate hcl) 40 mg, 10 mg, 50 mg, 60 2 mg armodafinil tabs 150 mg, 2 QL(1 ea daily) 250 mg, 50 mg methylphenidate hcl soln or 2 10 mg/5ml, 5 mg/5ml armodafinil tabs 200 mg 2 methylphenidate hcl tabs or 2 QL(2 ea daily) CONCERTA TBCR 18 MG, QL(1 ea daily) 20 mg, 10 mg, 5 mg 27 MG, 54 MG 2 methylphenidate hcl tb24 or 2 QL(1 ea daily) (methylphenidate hcl) 18 mg, 27 mg, 54 mg CONCERTA TBCR 36 MG QL(2 ea daily) 2 methylphenidate hcl tb24 or 2 QL(2 ea daily) (methylphenidate hcl) 36 mg COTEMPLA XR-ODT QL(2 ea daily) NC methylphenidate hcl tbcr or 2 QL(1 ea daily) TBED 17.3 MG, 25.9 MG 10 mg, 20 mg COTEMPLA XR-ODT NC QL(3 ea daily) methylphenidate hcl tbcr or TBED 8.6 MG 18 mg, 27 mg, 36 mg, 54 NC DAYTRANA PTCH 5 QL(1 ea daily) mg METHYLPHENIDATE dexmethylphenidate hcl 2 HYDROCHLORIDE ER 4 cp24 25 mg, 35 mg TBCR dexmethylphenidate hcl QL(1 ea daily) QL(1 ea daily) cp24 40 mg, 10 mg, 15 mg, 2 modafinil tabs 2 20 mg, 30 mg, 5 mg NUVIGIL TABS 150 MG, QL(1 ea daily) dexmethylphenidate hcl 2 QL(2 ea daily) 250 MG, 50 MG NC tabs 10 mg, 2.5 mg, 5 mg (armodafinil)

1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUVIGIL TABS 200 MG NC Alternative Medicine Combinations (armodafinil) CO-VERATROL CAPS NC PROVIGIL TABS 5 QL(1 ea daily) (modafinil) AMEBICIDES QUILLICHEW ER CHER 5 PA; QL(1 ea 20 MG, 40 MG daily) Amebicides QUILLICHEW ER CHER 5 PA; QL(2 ea 30 MG daily) IODOQUINOL POWD 5 PA; QL(12 ml QUILLIVANT XR SRER 5 daily) SOLOSEC PACK NC RELEXXII TBCR NC AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections RITALIN LA CP24 10 MG, QL(2 ea daily) 20 MG, 30 MG 5 Aminoglycosides (methylphenidate hcl) AMIKACIN SULFATE 5 POWD XX RITALIN LA CP24 40 MG 5 QL(1 ea daily) (methylphenidate hcl) amikacin sulfate soln ij 1 2 gm/4ml, 500 mg/2ml RITALIN TABS 5 QL(2 ea daily) (methylphenidate hcl) ARIKAYCE SUSP 5 PA; SP ALLERGENIC EXTRACTS/BIOLOGICALS MISC BETHKIS NEBU NC PA; SP (tobramycin) Biologicals Misc gentamicin in saline soln 2 ADAGEN SOLN 5 gentamicin sulfate soln ij 10 2 ALTERNATIVE MEDICINES mg/ml, 40 mg/ml KITABIS PAK NEBU 5 PA; SP Alternative Medicine - A's (tobramycin) ALPHA-LIPOIC ACID NC SOLN neomycin sulfate tabs or 2 RX/OTC CYTO RALA POWD NC paromomycin sulfate caps 2 or RX/OTC NEOKE RA LIPOIC POWD NC STREPTOMYCIN 5 SULFATE POWD XX Alternative Medicine - P's streptomycin sulfate solr im 2 EC- RX DHEA 4% CREA NC TOBI NEBU (tobramycin) NC PA; SP EC-RX DHEA 10% CREA NC TOBI PODHALER CAPS NC Alternative Medicine - R's tobramycin nebu in 300 2 PA; SP RESERVAPAK KIT SYRP NC mg/4ml, 300 mg/5ml TOBRAMYCIN SULFATE RESERVAPAK PLUS KIT NC 5 SYRP POWD XX Alternative Medicine - U tobramycin sulfate soln ij 10 mg/ml, 40 mg/ml, 1.2 2 COENZYME Q-10 SOLN IJ NC gm/30ml, 80 mg/2ml

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tobramycin sulfate solr ij 2 Gold Compounds 1.2 gm RIDAURA CAPS 5 ZEMDRI SOLN 5 Interleukin-1 Blockers ANALGESICS - ANTI-INFLAMMATORY - Drugs PA; SP to Treat Pain, Swelling, Muscle and Joint ARCALYST SOLR 5 Conditions Interleukin-1 Receptor Antagonist (IL-1Ra) Analgesics - Anti-inflammatory Combinations KINERET SOSY NC SP EQUAPAX/IBUPROFEN/M NC INREX THPK Interleukin-1beta Blockers PRASTERA KIT 5 ILARIS SOLN 4 PA; SP Anti-TNF-alpha - Monoclonal Antibodies Interleukin-6 Receptor Inhibitors HUMIRA PEDIATRIC PA; SP CROHNS DISEASE 4 ACTEMRA ACTPEN SOAJ NC STARTER PACK PSKT ACTEMRA SOLN IV 200 NC HUMIRA PEN PNKT 4 PA; SP MG/10ML ACTEMRA SOLN IV 400 SP HUMIRA PEN-CD/UC/HS 4 PA; SP NC STARTER PNKT MG/20ML, 80 MG/4ML ACTEMRA SOSY SC 162 HUMIRA PEN-PS/UV 4 PA; SP NC STARTER PNKT MG/0.9ML PA; SP HUMIRA PSKT 4 PA; SP KEVZARA SOAJ 4 PA; SP SIMPONI ARIA SOLN 4 PA; SP KEVZARA SOSY 4 Nonsteroidal Anti-inflammatory Agents (NSAIDs) SIMPONI SOAJ NC SP ACTIVE INJECTION KIT 5 SIMPONI SOSY NC SP KET-L KIT ACTIVE INJECTION KIT 5 Antirheumatic - Enzyme Inhibitors KETMARC-L KIT OLUMIANT TABS NC ANAPROX DS TABS 4 (naproxen sodium) PA; SP RINVOQ TB24 4 ANJESO INJ NC PA; SP XELJANZ TABS 4 ARTHROTEC 50 TBEC NC (diclofenac w/ misoprostol) PA; SP XELJANZ XR TB24 4 ARTHROTEC 75 TBEC NC (diclofenac w/ misoprostol) Antirheumatic Antimetabolites BASE FIVE COMPONENT METHOTREXATE TABS NC NAPROXEN SODIUM 5 OR MULTI-PHASIC COMPOUND POWD OTREXUP SOAJ 5 PA; SP CALDOLOR SOLN 5 RASUVO SOAJ 4 PA; SP CELEBREX CAPS 5 QL(2 ea daily) (celecoxib) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits celecoxib caps or 100 mg, 2 QL(2 ea daily) fenoprofen calcium tabs or 2 200 mg, 400 mg, 50 mg 600 mg CHILDRENS ADVIL SUSP NC RX/OTC fenoprofen calcium tabs or NC (ibuprofen) 600 mg CHILDRENS MOTRIN NC RX/OTC FENORTHO CAPS NC SUSP (ibuprofen) FLEXIZOL COMBIPAK DAYPRO TABS 5 NC (oxaprozin) THPK DERMACINRX FLURBIPROFEN POWD 5 ANALGESIC COMBOPAK NC XX KIT FLURBIPROFEN TABS 4 DERMACINRX OR 50 MG INFLAMMATRAL PAK NC flurbiprofen tabs or 50 mg, 2 THPK 100 mg DFS DR/MS/MENTH/CAP NC IBU 600-EZS KIT NC PAK KIT DICLOFENAC CAPS NC QL(3 ea daily) IBUPAK KIT NC IBUPROFEN COMFORT 2 5 diclofenac potassium tabs PAC KIT diclofenac sodium tb24 or 2 ibuprofen lysine soln 2 100 mg diclofenac sodium tbec or 2 IBUPROFEN POWD XX 5 25 mg, 50 mg, 75 mg ibuprofen susp or 100 RX/OTC diclofenac sodium- NC 2 capsaicin thpk mg/5ml ibuprofen tabs or 400 mg, diclofenac w/ misoprostol 2 2 tbec 600 mg, 800 mg DUEXIS TABS 5 PA INDOCIN SUPP NC

EC-NAPROSYN TBEC 5 QL(2 ea daily) INDOCIN SUSP NC (naproxen) indomethacin caps or 20 etodolac caps 200 mg, 300 2 NC mg mg indomethacin caps or 25 etodolac tabs 400 mg, 500 2 2 mg mg, 50 mg indomethacin cpcr or 75 etodolac tb24 400 mg, 500 2 QL(2 ea daily) 2 mg, 600 mg mg INDOMETHACIN POWD FELDENE CAPS 5 5 (piroxicam) XX indomethacin sodium solr 2 FENOPROFEN CALCIUM NC CAPS OR 200 MG INFLAMMATION NC fenoprofen calcium caps or NC REDUCTION PACK THPK 200 mg, 400 mg INFLATHERM KIT NC FENOPROFEN CALCIUM 5 POWD XX

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INFLATHERM THPK NC mefenamic acid caps or 2

KETAMINE mefenamic acid caps or NC HYDROCHLORIDE/ROPIV ACAINE NC MEFENAMIC ACID POWD 5 HYDROCHLORIDE/KETO XX ROLAC T SOSY meloxicam tabs or 15 mg, 2 QL(1 ea daily) ketoprofen caps or 25 mg NC 7.5 mg MOBIC TABS (meloxicam) 5 QL(1 ea daily) ketoprofen caps or 50 mg, 2 75 mg nabumetone tabs or 500 2 ketoprofen cp24 or 200 mg NC mg, 750 mg NALFON CAPS 400 MG NC KETOROCAINE-L KIT 5 NALFON TABS 600 MG 2 KETOROCAINE-LM KIT 5 (fenoprofen calcium) NAPRELAN TB24 500 MG, NC ketorolac tromethamine 2 375 MG (naproxen sodium) soln ij 15 mg/ml, 30 mg/ml KETOROLAC NAPRELAN TB24 750 MG NC TROMETHAMINE SOLN IJ 4 30 MG/ML NAPROSYN SUSP 5 (naproxen) ketorolac tromethamine soln im 30 mg/ml, 60 2 NAPROSYN TABS 5 mg/2ml (naproxen) KETOROLAC QL(1 ea daily) NAPROXEN COMFORT 5 TROMETHAMINE SOLN NC PAC KIT NA 15.75 MG/SPRAY NAPROXEN POWD XX 5 KETOROLAC TROMETHAMINE SOSY IJ NC NAPROXEN SODIUM 5 60 MG/20ML POWD XX QL(20 ea per naproxen sodium tabs or 2 275 mg, 550 mg ketorolac tromethamine 2 fill retail,20 ea tabs or 10 mg per 30 days naproxen sodium tb24 or NC retail) 500 mg, 375 mg KETOROLAC naproxen susp or 125 5 TROMETHAMINE/BUPIVA mg/5ml CAINE NC naproxen tabs or 250 mg, 2 HYDROCHLORIDE/KETA 375 mg, 500 mg MINE HY SOSY naproxen tbec or 375 mg, 2 QL(2 ea daily) LIDOVIX KIT NC 500 mg naproxen-esomeprazole NC PA LODINE TABS (etodolac) NC magnesium tbec NEOPROFEN SOLN meclofenamate sodium 2 5 caps or 100 mg, 50 mg (ibuprofen lysine) NUDROXIPAK DSDR-50 MECLOFENAMATE 5 NC SODIUM POWD XX KIT

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUDROXIPAK DSDR-75 NC VIMOVO TBEC (naproxen- 5 PA KIT esomeprazole magnesium) NUDROXIPAK E-400 KIT NC VIVLODEX CAPS NC

NUDROXIPAK I-800 KIT NC YBUPHEN TBPK NC

NUDROXIPAK M-15 KIT NC ZIPSOR CAPS 5 ST

NUDROXIPAK N-500 KIT NC ZORVOLEX CAPS 18 MG, NC QL(3 ea daily) 35 MG NUDROXIPAK THPK NC Phosphodiesterase 4 (PDE4) Inhibitors PA; SP oxaprozin tabs 2 OTEZLA TABS 4 PA; SP PHENYLBUTAZONE 5 OTEZLA TBPK 4 POWD Pyrimidine Synthesis Inhibitors piroxicam caps or 10 mg, 2 20 mg ARAVA TABS 10 MG 4 QL(2 ea daily) (leflunomide) PIROXICAM POWD XX 5 ARAVA TABS 20 MG 4 QL(1 ea daily) (leflunomide) PREVIDOLRX NC ANALGESIC PAK THPK leflunomide tabs or 10 mg 2 QL(2 ea daily) QMIIZ ODT TBDP NC leflunomide tabs or 20 mg 2 QL(1 ea daily) READYSHARP ANESTHETICS NC Selective Costimulation Modulators +KETOROLAC KIT ORENCIA CLICKJECT NC SP READYSHARP NC SOAJ KETOROLAC KIT ORENCIA SOLR NC SP RELAFEN DS TABS NC ORENCIA SOSY NC SP SPRIX SOLN NC QL(1 ea daily) Soluble Tumor Necrosis Factor Receptor Agents SULINDAC POWD XX 5 ENBREL MINI SOCT 4 PA; SP sulindac tabs or 150 mg, 2 200 mg ENBREL SOLR 25 MG 4 PA; SP TIVORBEX CAPS 20 MG NC ENBREL SOSY 25 4 PA; SP MG/0.5ML, 50 MG/ML TIVORBEX CAPS 40 MG NC QL(3 ea daily) ENBREL SURECLICK 4 PA; SP SOAJ tolmetin sodium caps 2 ANALGESICS - NonNarcotic - Drugs to Treat tolmetin sodium tabs 2 Pain, Muscle and Joint Conditions Analgesic Combinations TORONOVA II SUIK KIT NC acetaminophen- salicylamide- 2 TORONOVA SUIK KIT NC phenyltoloxamine caps 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALLZITAL TABS NC QL(8 ea daily) OFIRMEV SOLN 5 (acetaminophen) butalbital-acetaminophen 2 Analgesics-Peptide Channel Blockers caps 300 mg-50 mg PRIALT SOLN 5 PA; SP butalbital-acetaminophen 2 QL(8 ea daily) tabs 25 mg-325 mg Salicylates butalbital-acetaminophen NC tabs 300 mg-50 mg ACETYL SALICYLIC ACID 5 RX/OTC POWD butalbital-acetaminophen QL(6 ea daily) 2 AL(Up to 79 yrs tabs 325 mg-50 mg aspirin chew or 81 mg 5 old ) butalbital-acetaminophen- QL(6 ea daily) RX/OTC caffeine caps 300 mg-40 NC ASPIRIN POWD XX 5 mg-50 mg, 325 mg-40 mg- 50 mg AL(At least 45 butalbital-acetaminophen- QL(90 ml daily) aspirin tabs or 325 mg 2 yrs old - Up to caffeine soln 325 mg/15ml- 2 79 yrs old) 40 mg/15ml-50 mg/15ml AL(At least 45 aspirin tbec or 324 mg, 325 2 yrs old - Up to butalbital-acetaminophen- QL(90 ml daily) mg caffeine soln 325 mg/15ml- NC 79 yrs old) AL(Up to 79 yrs 40 mg/15ml-50 mg/15ml aspirin tbec or 81 mg 5 butalbital-acetaminophen- QL(6 ea daily) old ) caffeine tabs 325 mg-40 2 DIFLUNISAL POWD XX 5 mg-50 mg butalbital-aspirin-caffeine 2 QL(6 ea daily) diflunisal tabs or 2 caps ECOTRIN REGULAR AL(At least 45 BUTALBITAL/ACETAMINO STRENGTH TBEC 5 yrs old - Up to PHEN CAPS (butalbital- NC (aspirin) 79 yrs old) acetaminophen) AL(At least 45 BUTALBITAL/ASPIRIN/CA NC ECOTRIN TBEC (aspirin) 5 yrs old - Up to FFEINE TABS 79 yrs old) ESGIC TABS (butalbital- QL(6 ea daily) 5 salsalate tabs or 500 mg, 2 acetaminophen-caffeine) 750 mg FIORICET CAPS QL(6 ea daily) SODIUM SALICYLATE 5 (butalbital-acetaminophen- NC CRYS caffeine) SODIUM SALICYLATE 5 FIORINAL CAPS 5 QL(6 ea daily) POWD (butalbital-aspirin-caffeine) ANALGESICS - OPIOID - Drugs to Treat Pain, Analgesics Other Muscle and Joint Conditions 7T GUMMY ES CHEW NC Opioid Agonists ABSTRAL SUBL 100 MCG, 5 PA; QL(4 ea acetaminophen soln iv 5 800 MCG daily) clonidine hcl (analgesia) 2 ABSTRAL SUBL 200 MCG, soln 300 MCG, 400 MCG, 600 5 MCG DURACLON SOLN 5 (clonidine hcl (analgesia)) ACTIQ LPOP (fentanyl 5 PA; QL(4 ea citrate) daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits alfentanil hcl soln 2 EXALGO TB24 12 MG, 16 QL(4 ea daily) MG, 8 MG (hydromorphone 5 hcl) ALFENTANIL 5 HYDROCHLORIDE SOLN EXALGO TB24 32 MG 5 QL(2 ea daily) ARYMO ER TBEA NC QL(3 ea daily) (hydromorphone hcl) fentanyl citrate lpop bu PA; QL(4 ea CODEINE PHOSPHATE 5 1200 mcg, 1600 mcg, 200 2 daily) POWD mcg, 400 mcg, 600 mcg, 800 mcg CODEINE SULFATE TABS 2 15 MG FENTANYL CITRATE 5 POWD XX CODEINE SULFATE TABS 5 QL(6 ea daily) 30 MG (codeine sulfate) fentanyl citrate soct ij 100 2 mcg/2ml codeine sulfate tabs 30 mg, 2 QL(6 ea daily) 60 mg fentanyl citrate soln ij 1000 mcg/20ml, 250 mcg/5ml, CODEINE SULFATE TABS 5 QL(6 ea daily) 2 60 MG 2500 mcg/50ml, 500 mcg/10ml, 100 mcg/2ml CONZIP CP24 (tramadol 5 QL(1 ea daily) hcl) FENTANYL CITRATE DEMEROL SOLN 100 SOLN IJ 1500 MCG/30ML, NC MG/2ML, 25 MG/0.5ML, 75 5 50 MCG/ML MG/1.5ML, 75 MG/ML FENTANYL CITRATE DEMEROL SOLN 100 SOLN IJ 250 MCG/5ML, 5 MG/ML, 25 MG/ML, 50 5 100 MCG/2ML (fentanyl MG/ML (meperidine hcl) citrate) DILAUDID LIQD OR 1 FENTANYL CITRATE MG/ML (hydromorphone 5 SOLN IV 2500 MCG/50ML, NC hcl) 5000 MCG/100ML FENTANYL CITRATE DILAUDID SOLN IJ 0.2 NC MG/ML SOSY IJ 50 MCG/5ML, 50 NC MCG/ML DILAUDID SOLN IJ 1 MG/ML, 2 MG/ML NC FENTANYL CITRATE (hydromorphone hcl) SOSY IV 100 MCG/2ML, 1500 MCG/30ML, 250 NC DILAUDID TABS OR 2 MG 5 QL(8 ea daily) MCG/5ML, 2750 (hydromorphone hcl) MCG/55ML DILAUDID TABS OR 4 fentanyl citrate tabs bu 100 PA; QL(3 ea MG, 8 MG (hydromorphone 5 mcg, 200 mcg, 400 mcg, 2 daily) hcl) 600 mcg, 800 mcg DOLOPHINE TABS QL(12 ea daily) 5 FENTANYL NC (methadone hcl) CITRATE/NACL SOSY DSUVIA SUBL 5 FENTANYL CITRATE/SODIUM NC DURAGESIC PT72 5 QL(0.5 ea CHLORIDE SOLN (fentanyl) daily) FENTANYL EMBEDA CPCR 4 CITRATE/SODIUM NC CHLORIDE SOSY QL(0.5 ea fentanyl pt72 2 daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENTORA TABS (fentanyl 5 PA; QL(3 ea HYDROMORPHONE citrate) daily) HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN IJ 0.9 hydromorphone hcl liqd or 2 1 mg/ml %-20 MG/100ML HYDROMORPHONE HYDROMORPHONE HCL 5 POWD XX HYDROCHLORIDE/SODIU M CHLORIDE SOLN IV 0.9 hydromorphone hcl soln ij 1 %-10 MG/100ML, 0.9 %-10 mg/ml, 2 mg/ml, 10 mg/ml, 2 MG/50ML, 0.9 %-100 110 mg/55ml, 2 mg/ml, 50 MG/50ML, 0.9 %-12 mg/5ml, 500 mg/50ml MG/30ML, 0.9 %-15 hydromorphone hcl soln ij 4 NC MG/30ML, 0.9 %-150 mg/ml MG/150ML, 0.9 %-18 MG/30ML, 0.9 %-2 HYDROMORPHONE HCL 5 SUPP RE 3 MG MG/50ML, 0.9 %-20 MG/100ML, 0.9 %-200 hydromorphone hcl tabs or 2 QL(8 ea daily) 2 mg MG/100ML, 0.9 %-24 MG/30ML, 0.9 %-25 hydromorphone hcl tabs or 2 MG/250ML, 0.9 %-25 NC 4 mg, 8 mg MG/50ML, 0.9 %-250 hydromorphone hcl tb24 or 2 QL(4 ea daily) MG/250ML, 0.9 %-3 12 mg, 16 mg, 8 mg MG/30ML, 0.9 %-30 MG/150ML, 0.9 %-30 hydromorphone hcl tb24 or 2 QL(2 ea daily) 32 mg MG/30ML, 0.9 %-36 HYDROMORPHONE MG/30ML, 0.9 %-40 HCL/SODIUMCHLORIDE NC MG/100ML, 0.9 %-5 SOLN MG/50ML, 0.9 %-50 MG/100ML, 0.9 %-50 HYDROMORPHONE MG/250ML, 0.9 %-50 HCL/SODIUMCHLORIDE NC MG/50ML, 0.9 %-6 SOSY MG/30ML, 0.9 %-60 HYDROMORPHONE MG/30ML, 0.9 %-9 HYDROCHLORIDE SOLN NC MG/30ML IJ 0.2 MG/ML, 1 MG/ML, 4 MG/ML HYDROMORPHONE HYDROCHLORIDE SOLN 2 IJ 1 MG/ML HYDROMORPHONE HYDROCHLORIDE SOLN 5 IJ 10 MG/ML (hydromorphone hcl) HYDROMORPHONE HYDROCHLORIDE SOLN NC IJ 2 MG/ML (hydromorphone hcl) HYDROMORPHONE HYDROCHLORIDE/ NC SODIUM CHLORIDE SOLN

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROMORPHONE MEPERIDINE HCL POWD 5 HYDROCHLORIDE/SODIU XX M CHLORIDE SOSY IV 0.2 meperidine hcl soln ij 100 2 MG/0.2ML-0.9 %, 0.4 mg/ml, 25 mg/ml, 50 mg/ml MG/2ML-0.9 %, 0.5 MG/0.5ML-0.9 %, 0.5 meperidine hcl soln or 50 2 QL(500 ml per MG/ML-0.9 %, 0.9 %-1 mg/5ml fill retail) MG/5ML, 0.9 %-1 MG/ML, meperidine hcl tabs or 100 2 QL(6 ea daily) 0.9 %-10 MG/25ML, 0.9 %- mg, 50 mg 10 MG/50ML, 0.9 %-12 MEPERIDINE MG/30ML, 0.9 %-12 HYDROCHLORIDE/SODIU NC MG/60ML, 0.9 %-12.5 M CHLORIDE SOLN MG/25ML, 0.9 %-15 NC methadone hcl conc or 10 2 QL(10 ml daily) MG/30ML, 0.9 %-15 mg/ml MG/50ML, 0.9 %-2 MG/10ML, 0.9 %-2 MG/ML, METHADONE HCL POWD 5 0.9 %-2.5 MG/25ML, 0.9 XX %-20 MG/50ML, 0.9 %-25 methadone hcl soln ij 10 2 MG/25ML, 0.9 %-25 mg/ml MG/50ML, 0.9 %-3 METHADONE HCL SOLN MG/30ML, 0.9 %-30 IJ 10 MG/ML (methadone 5 MG/30ML, 0.9 %-5 hcl) MG/25ML, 0.9 %-50 methadone hcl soln or 10 2 QL(50 ml daily) MG/50ML, 0.9 %-6 mg/5ml MG/30ML methadone hcl soln or 5 2 QL(100 ml HYDROMORPHONE/SODI NC mg/5ml daily) UM CHLORIDE SOLN methadone hcl tabs or 5 2 QL(12 ea daily) HYSINGLA ER T24A NC mg, 10 mg INFUMORPH 200 SOLN methadone hcl tbso or 40 2 QL(2 ea daily) (morphine sulfate for 5 mg continuous microinfusion) METHADOSE CONC 5 QL(10 ml daily) INFUMORPH 500 SOLN (methadone hcl) (morphine sulfate for 5 METHADOSE SUGAR- QL(10 ml daily) continuous microinfusion) FREE CONC (methadone 5 hcl) IONSYS PTCH NC MORPHABOND ER T12A NC QL(2 ea daily) KADIAN CP24 10 MG, 100 QL(2 ea daily) morphine sulfate beads QL(1 ea daily) MG, 20 MG, 30 MG, 40 5 2 MG, 50 MG, 60 MG, 80 MG cp24 (morphine sulfate) morphine sulfate cp24 or QL(2 ea daily) KADIAN CP24 200 MG 5 10 mg, 100 mg, 20 mg, 30 2 mg, 40 mg, 50 mg, 60 mg, 80 mg LAZANDA SOLN 100 NC MCG/ACT, 400 MCG/ACT MORPHINE SULFATE 5 DEVI IM 10 MG/0.7ML LAZANDA SOLN 300 NC PA MCG/ACT morphine sulfate for continuous microinfusion 2 levorphanol tartrate tabs or NC 2 mg, 3 mg soln

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MORPHINE SULFATE 5 MORPHINE POWD XX SULFATE/DEXTROSE NC MORPHINE SULFATE SOSY SOLN IJ 1 MG/ML, 2 5 MORPHINE MG/ML, 4 MG/ML, 5 SULFATE/SODIUM NC MG/ML CHLORIDE SOLN MORPHINE SULFATE MORPHINE SOLN IJ 10 MG/ML, 2 NC SULFATE/SODIUM NC MG/ML, 4 MG/ML, 5 CHLORIDE SOSY MG/ML, 8 MG/ML MS CONTIN TBCR 5 QL(3 ea daily) morphine sulfate soln ij 10 (morphine sulfate) mg/ml, 8 mg/ml, 0.5 mg/ml, 2 QL(2 ea daily) 1 mg/ml NUCYNTA ER TB12 4 MORPHINE SULFATE NC NUCYNTA TABS 4 QL(6 ea daily) SOLN IV 0.5 MG/ML OPANA TABS 10 MG QL(12 ea daily) MORPHINE SULFATE 2 5 SOLN IV 1 MG/ML (oxymorphone hcl) MORPHINE SULFATE OPANA TABS 5 MG 5 QL(6 ea daily) SOLN IV 150 MG/30ML, 2 5 (oxymorphone hcl) MG/ML OXAYDO TABS 5 QL(6 ea daily) morphine sulfate soln iv 25 oxycodone hcl caps or 5 mg/ml, 4 mg/ml, 50 mg/ml, 2 2 8 mg/ml, 1 mg/ml, 10 mg mg/ml oxycodone hcl conc or 100 2 QL(6 ml daily) MORPHINE SULFATE mg/5ml SOLN IV 4 MG/ML, 8 5 OXYCODONE HCL POWD 5 MG/ML, 10 MG/ML XX (morphine sulfate) oxycodone hcl soln or 5 2 morphine sulfate soln or 10 2 QL(100 ml mg/5ml mg/5ml daily) oxycodone hcl t12a or 15 QL(3 ea daily) morphine sulfate soln or 20 mg, 30 mg, 60 mg, 10 mg, 2 mg/5ml, 100 mg/5ml, 20 2 20 mg, 80 mg, 40 mg mg/ml oxycodone hcl tabs or 10 QL(6 ea daily) morphine sulfate supp re 2 QL(24 ea per mg, 20 mg, 15 mg, 30 mg, 2 10 mg, 20 mg, 5 mg fill retail) 5 mg morphine sulfate supp re 2 30 mg OXYCONTIN T12A NC morphine sulfate tabs or 15 QL(6 ea daily) 2 oxymorphone hcl tabs 10 2 QL(12 ea daily) mg, 30 mg mg morphine sulfate tbcr or QL(3 ea daily) oxymorphone hcl tabs 5 mg 2 QL(6 ea daily) 100 mg, 15 mg, 200 mg, 30 2 mg, 60 mg oxymorphone hcl tb12 10 QL(2 ea daily) MORPHINE mg, 15 mg, 20 mg, 30 mg, 2 SULFATE/DEXTROSE NC 40 mg, 5 mg, 7.5 mg SOLN remifentanil hcl solr 2

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REMIFENTANIL acetaminophen-caff- HYDROCHLORIDE/SODIU NC dihydrocod tabs 16 mg-30 2 M CHLORIDE SOSY mg-325 mg ROXICODONE TABS 5 QL(6 ea daily) APADAZ TABS NC (oxycodone hcl) BENZHYDROCODONE/A ROXYBOND TABA 15 MG, NC NC 30 MG CETAMINOPHEN TABS butalbital-acetaminophen- ROXYBOND TABA 5 MG NC QL(4 ea daily) caffeine w/ codeine caps 2 30 mg-300 mg-40 mg-50 SUBSYS LIQD 100 MCG 4 PA; QL(4 ea daily) mg SUBSYS LIQD 1200 MCG, PA; QL(8 ea butalbital-acetaminophen- QL(6 ea daily) 1600 MCG, 200 MCG, 400 4 daily) caffeine w/ codeine caps 2 MCG, 600 MCG, 800 MCG 30 mg-325 mg-40 mg-50 mg SUFENTANIL CITRATE butalbital-aspirin-caffeine QL(6 ea daily) SOLN IV 50 MCG/ML, 100 5 2 MCG/2ML, 250 MCG/5ML w/cod caps (sufentanil citrate) FENTANYL sufentanil citrate soln iv 50 CITRATE/BUPIVACAINE NC mcg/ml, 100 mcg/2ml, 250 2 HCL/SODIUM CHLORIDE mcg/5ml, 50 mcg/ml SOLN FENTANYL SYNAPRYN FUSEPAQ 5 SUSR CITRATE/BUPIVACAINE NC HYDROCHLORIDE SOLN tramadol hcl cp24 or 100 2 QL(1 ea daily) mg, 200 mg, 300 mg FENTANYL CITRATE/BUPIVACAINE NC tramadol hcl cp24 or 150 2 HYDROCHLORIDE/SODIU mg M CHLORIDE SOLN tramadol hcl tabs or 100 NC FENTANYL mg CITRATE/BUPIVICAINE NC tramadol hcl tabs or 50 mg 2 QL(8 ea daily) HCL/SODIUM CHLORIDE SOLN tramadol hcl tb24 or 100 2 QL(1 ea daily) FENTANYL mg, 200 mg, 300 mg CITRATE/BUPIVICAINE NC ULTIVA SOLR 5 HYDROCHLORIDE/SODIU (remifentanil hcl) M CHLORIDE SOLN ULTRAM TABS (tramadol 5 QL(8 ea daily) FENTANYL hcl) CITRATE/ROPIVACAINE NC HYDROCHLORIDE SOLN XTAMPZA ER C12A 4 QL(2 ea daily) FENTANYL Opioid Combinations CITRATE/ROPIVACAINE NC HYDROCHLORIDE/SODIU acetaminophen w/ codeine 2 soln M CHLORIDE SOLN FENTANYL acetaminophen w/ codeine 2 tabs CITRATE/ROPIVACAINE NC HYDROCHLORIDE/SODIU acetaminophen-caff- QL(12 ea daily) M CHLORIDE SOSY dihydrocod caps 16 mg-30 2 mg-320.5 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENTANYL/BUPIVACAINE NC LORTAB ELIX 5 /NACL SOLN FIORICET/CODEINE NALOCET TABS NC CAPS (butalbital- 5 acetaminophen-caffeine w/ NORCO TABS QL(12 ea codeine) (hydrocodone- 5 daily,240 ea FIORINAL/CODEINE #3 QL(6 ea daily) acetaminophen) per fill retail) CAPS (butalbital-aspirin- 5 oxycodone w/ 2 QL(12 ea daily) caffeine w/cod) acetaminophen tabs HYDROCODONE oxycodone-aspirin tabs 2 BITARTRATE/ACETAMIN NC OPHEN SOLN oxycodone-ibuprofen tabs 2 QL(4 ea daily) hydrocodone- QL(180 ml acetaminophen soln 108 daily) OXYCODONE/ACETAMIN NC mg/5ml-2.5 mg/5ml, 217 2 OPHEN TABS mg/10ml-5 mg/10ml, 325 PERCOCET TABS QL(12 ea daily) mg/15ml-7.5 mg/15ml (oxycodone w/ NC hydrocodone- QL(13 ea daily) acetaminophen) acetaminophen tabs 10 2 PRIMLEV TABS NC mg-300 mg, 300 mg-7.5 mg PROLATE TABS NC hydrocodone- QL(12 ea acetaminophen tabs 10 2 daily,240 ea ROXICET SOLN 2 mg-325 mg, 325 mg-5 mg, per fill retail) 325 mg-7.5 mg tramadol-acetaminophen 2 QL(8 ea daily) hydrocodone- tabs acetaminophen tabs 300 2 TYLENOL/CODEINE #3 mg-5 mg TABS (acetaminophen w/ 5 codeine) hydrocodone-ibuprofen 2 QL(5 ea daily) tabs TYLENOL/CODEINE #4 HYDROMORPHONE TABS (acetaminophen w/ 5 codeine) HYDROCHLORIDE/BUPIV NC ACAINE ULTRACET TABS 5 QL(8 ea daily) HYDROCHLORIDE SOLN (tramadol-acetaminophen) HYDROMORPHONE Opioid Partial Agonists HYDROCHLORIDE/BUPIV ACAINE NC BELBUCA FILM 4 QL(2 ea daily) HYDROCHLORIDE/SODIU M SOLN BUNAVAIL FILM 5 PA; QL(3 ea daily) HYDROMORPHONE BUPRENEX SOLN HYDROCHLORIDE/ROPIV NC 5 ACAINE (buprenorphine hcl) HYDROCHLORIDE SOLN buprenorphine hcl soln ij 2 HYDROMORPHONE 0.3 mg/ml buprenorphine hcl subl sl 2 PA; QL(3 ea HYDROCHLORIDE/ROPIV NC 2 ACAINE/SODIUM mg daily) CHLORIDE SOLN buprenorphine hcl subl sl 8 2 PA; QL(4 ea mg daily)

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits buprenorphine hcl- QL(3 ea daily) ANDRODERM PT24 4 QL(1 ea daily) naloxone hcl dihydrate film 2 0.5 mg-2 mg, 1 mg-4 mg, 2 ANDROGEL GEL 20.25 QL(10 gm mg-8 mg MG/1.25GM, 40.5 5 daily) buprenorphine hcl- QL(2 ea daily) MG/2.5GM (testosterone) naloxone hcl dihydrate film 2 ANDROGEL GEL 25 NC QL(10 gm 12 mg-3 mg MG/2.5GM (testosterone) daily) buprenorphine hcl- QL(3 ea daily) ANDROGEL GEL 50 NC naloxone hcl dihydrate subl 2 MG/5GM (testosterone) 0.5 mg-2 mg, 2 mg-8 mg ANDROGEL PUMP GEL 5 QL(10 gm buprenorphine ptwk td 10 (testosterone) daily) mcg/hr, 15 mcg/hr, 20 2 PA; SP mcg/hr, 5 mcg/hr, 7.5 AVEED SOLN 5 mcg/hr danazol caps or 100 mg, 2 butorphanol tartrate soln ij 2 200 mg, 50 mg 1 mg/ml, 2 mg/ml BUTORPHANOL DANAZOL POWD XX 5 TARTRATE SOLN IJ 2 4 DEPO-TESTOSTERONE PA; QL(0.334 MG/ML SOLN (testosterone 5 ml daily) cypionate) butorphanol tartrate soln na 2 QL(0.25 ml 10 mg/ml daily) EC-RX TESTOSTERONE NC 0.2% CREA BUTRANS PTWK NC (buprenorphine) EC-RX TESTOSTERONE NC 0.4% CREA nalbuphine hcl soln ij 10 2 QL(8 ml daily) mg/ml, 20 mg/ml EC-RX TESTOSTERONE NC 10% CREA pentazocine w/ naloxone 2 QL(12 ea daily) tabs EC-RX TESTOSTERONE NC 20% CREA PROBUPHINE IMPLANT NC SP KIT IMPL FORTESTA GEL NC PA; QL(3.5 gm SUBLOCADE SOSY 5 PA; SP (testosterone) daily) SUBOXONE FILM 0.5 MG- QL(3 ea daily) JATENZO CAPS NC 2 MG, 1 MG-4 MG, 2 MG-8 NC MG (buprenorphine hcl- METHITEST TABS 5 naloxone hcl dihydrate) methyltestosterone caps or 2 SUBOXONE FILM 12 MG- QL(2 ea daily) 3 MG (buprenorphine hcl- NC METHYLTESTOSTERONE 5 naloxone hcl dihydrate) POWD XX ZUBSOLV SUBL 0.18 MG- PA; QL(3 ea NANDROLONE 0.7 MG, 0.36 MG-1.4 MG, 4 daily) DECANOATE/TESTOSTE 0.71 MG-2.9 MG, 1.4 MG- RONE NC 5.7 MG CYPIONATE/TESTOSTER ONE ENA OIL ZUBSOLV SUBL 11.4 MG- 4 PA; QL(2 ea 2.9 MG, 2.1 MG-8.6 MG daily) QL(0.78 gm NATESTO GEL NC ANDROGENS-ANABOLIC - Drugs to Regulate daily) Hormones STRIANT MISC 5 QL(2 ea daily) Androgens 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TESTIM GEL NC ANORECTAL AND RELATED PRODUCTS - (testosterone) Rectal Drugs to Treat Pain, Swelling and Itching TESTONE CIK KIT NC Intrarectal Steroids PA; SP CORTENEMA ENEM QL(420 ml per TESTOPEL PLLT 5 (hydrocortisone 5 fill retail) TESTOSTERONE (intrarectal)) COMPOUNDINGKIT NC CORTIFOAM FOAM 4 CREA TESTOSTERONE hydrocortisone (intrarectal) 2 QL(420 ml per enem fill retail) CYPIONATE SOLN IJ 100 NC MG/ML, 150 MG/ML, 50 UCERIS FOAM RE 2 5 MG/ML, 200 MG/ML MG/ACT testosterone cypionate soln 2 Rectal Combinations ij 200 mg/ml LIDOCAINE HCL- testosterone cypionate soln PA; QL(0.334 2 HYDROCORTISONE 5 im 100 mg/ml, 200 mg/ml ml daily) ACETATE WITH ALOE TESTOSTERONE GEL CYPIONATE/TESTOSTER NC lidocaine-hydrocortisone 2 ONE PROPIONATE SOLN acetate (rectal) crea TESTOSTERONE NC lidocaine-hydrocortisone 2 ENANTHATE SOLN IJ acetate (rectal) kit testosterone enanthate 2 PA soln im PROCTOFOAM HC FOAM 4 testosterone gel td 1 % NC Rectal Steroids ANUSOL-HC CREA 4 testosterone gel td 1 %, 50 2 PA; QL(10 gm (hydrocortisone (rectal)) mg/5gm daily) testosterone gel td 1.62 %, QL(10 gm hydrocortisone (rectal) crea 2 20.25 mg/1.25gm, 25 daily) 2 PROCTOCORT CREA 5 mg/2.5gm, 40.5 mg/2.5gm, (hydrocortisone (rectal)) 1 % Vasodilating Agents testosterone gel td 10 2 PA; QL(3.5 gm mg/act daily) RECTIV OINT 5 TESTOSTERONE PLLT IL 100 MG, 200 MG, 25 MG, NC ANTACIDS 50 MG Antacids - Bicarbonate TESTOSTERONE NC PROPIONATE SOLN IJ SODIUM BICARBONATE 5 RX/OTC POWD OR testosterone soln td 30 2 PA; QL(6 ml mg/act daily) Antacids - Magnesium Salts VOGELXO GEL NC MAGNESIUM OXIDE 5 RX/OTC (testosterone) HEAVY POWD VOGELXO PUMP GEL QL(10 gm NC MAGNESIUM OXIDE 5 RX/OTC (testosterone) daily) LIGHT POWD XYOSTED SOAJ NC

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGNESIUM IMPAVIDO CAPS 5 TRISILICATE HYDRATE 5 POWD METRONIDAZOLE BENZOATE/SYRSPEND NC MAGNESIUM 5 TRISILICATE POWD SF PH4 SUSR ANTHELMINTICS - Drugs to Treat Worm metronidazole caps or 375 2 Infections mg Anthelmintics metronidazole in nacl soln 2 albendazole tabs or 2 METRONIDAZOLE SOLN IV 0.74 %-500 MG/100ML 5 ALBENZA TABS 5 (metronidazole in nacl) (albendazole) METRONIDAZOLE SOLN 5 BENZNIDAZOLE TABS 5 PA; SP IV 5 MG/ML metronidazole tabs or 250 2 BILTRICIDE TABS 5 mg, 500 mg (praziquantel) NEBUPENT SOLR 5 EMVERM CHEW 4 QL(6 ea per fill (pentamidine isethionate) retail) PENTAM 300 SOLR 5 ivermectin tabs or 3 mg 2 (pentamidine isethionate) pentamidine isethionate 2 MEBENDAZOLE POWD 5 solr

PIPERAZINE CITRATE 5 PRIMSOL SOLN 5 POWD TINDAMAX TABS 4 praziquantel tabs or 2 (tinidazole) tinidazole tabs or 250 mg, STROMECTOL TABS 5 2 (ivermectin) 500 mg TRIMETHOPRIM POWD 5 THIABENDAZOLE POWD 5 XX ANTI-INFECTIVE AGENTS - MISC. - Drugs to trimethoprim tabs or 2 Treat Bacterial Infections XIFAXAN TABS 200 MG 5 PA; QL(9 ea Anti-infective Agents - Misc. per fill retail) PA; QL(2 ea AEMCOLO TBEC 5 XIFAXAN TABS 550 MG 4 daily) bacitracin solr im 2 Anti-infective Misc. - Combinations BACTRIM DS TABS FIRST-METRONIDAZOLE NC 100 SUSR (sulfamethoxazole- 4 trimethoprim) FIRST-METRONIDAZOLE NC 50 SUSR BACTRIM TABS (sulfamethoxazole- 4 FLAGYL CAPS 5 trimethoprim) (metronidazole) HYOPHEN TABS 2 FLAGYL TABS 5 (metronidazole)

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methenamine-hyosc- PRIMAXIN IV SOLR 5 methylene blue-sod phos- 2 (imipenem-cilastatin) phenyl sal caps RECARBRIO SOLR 5 methenamine-hyosc- 2 methylene blue-sod phos- VABOMERE SOLR 5 phenyl sal tabs methenamine-hyoscamine- Chloramphenicols methylene blue-sodium 2 chloramphenicol sodium 2 phosphate tabs succinate solr sulfamethoxazole- 2 trimethoprim soln Cyclic Lipopeptides CUBICIN RF SOLR sulfamethoxazole- 2 5 trimethoprim susp (daptomycin) CUBICIN SOLR sulfamethoxazole- 2 5 trimethoprim tabs (daptomycin) DAPTOMYCIN SOLR 350 5 URIMAR-T TABS 2 MG (daptomycin) UROGESIC-BLUE TABS DAPTOMYCIN SOLR 350 NF MG (daptomycin) (methenamine- 5 hyoscamine-methylene daptomycin solr 500 mg, 2 blue-sodium phosphate) 350 mg UTA CAPS 2 Glycopeptides Antiprotozoal Agents DALVANCE SOLR 5 ALINIA SUSR 5 FIRST-VANCOMYCIN 25 5 SOLN ALINIA TABS 5 FIRST-VANCOMYCIN 50 5 SOLN atovaquone susp or 2 FIRVANQ SOLR NC MEPRON SUSP 5 (atovaquone) ORBACTIV SOLR 5 Carbapenems VANCOCIN CAPS 4 (vancomycin hcl) doripenem solr 2 VANCOCIN HCL CAPS 4 ertapenem sodium solr 2 (vancomycin hcl) VANCOMYCIN HCL + NC imipenem-cilastatin solr 2 SYRSPENDSF PH4 SUSP vancomycin hcl caps or 2 INVANZ SOLR (ertapenem 5 125 mg, 250 mg sodium) VANCOMYCIN HCL SOLN 5 meropenem solr 2 IV 0.9 %-1 GM/200ML vancomycin hcl solr iv 1 QL(14 ea per MEROPENEM/SODIUM NC 2 CHLORIDE SOLR gm, 1000 mg fill retail) vancomycin hcl solr iv 100 MERREM SOLR 5 2 (meropenem) gm, 5 gm, 10 gm, 750 mg

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits vancomycin hcl solr iv 500 2 QL(0.4667 ea CLEOCIN PHOSPHATE mg daily) SOLN IV 300 MG/2ML, 600 5 VANCOMYCIN MG/4ML, 900 MG/6ML HYDROCHLORIDE SOLN CLIN SINGLE USE KIT KIT NC IV 1000 MG/10ML, 1000 MG/200ML, 1250 clindamycin hcl caps or 75 2 MG/12.5ML, 1500 mg, 150 mg, 300 mg MG/15ML, 1500 5 clindamycin palmitate 2 MG/300ML, 1750 hydrochloride solr MG/17.5ML, 1750 MG/350ML, 2000 clindamycin phosphate in 2 MG/20ML, 500 MG/100ML, d5w soln 750 MG/7.5ML clindamycin phosphate soln VANCOMYCIN ij 300 mg/2ml, 600 mg/4ml, 2 900 mg/6ml, 9 gm/60ml, HYDROCHLORIDE SOLR 5 IV 1.25 GM, 1.5 GM, 250 9000 mg/60ml MG clindamycin phosphate soln VANCOMYCIN iv 300 mg/2ml, 600 mg/4ml, 2 HYDROCHLORIDE SOLR NC 900 mg/6ml OR 250 MG/5ML CLINDAMYCIN/SODIUM NC VANCOMYCIN CHLORIDE SOLN HYDROCHLORIDE/DEXT 5 LINCOCIN SOLN 5 ROSE SOLN (lincomycin hcl) VANCOMYCIN lincomycin hcl soln ij 2 HYDROCHLORIDE/SODIU 5 M CHLORIDE SOLN Monobactams VANCOMYCIN SOLN 5 AZACTAM SOLR 5 (aztreonam) VANCOSOL PACK KIT 5 AZACTAMIN ISO- OSMOTIC DEXTROSE 5 VIBATIV SOLR 5 SOLN Leprostatics aztreonam solr 2 dapsone tabs or 100 mg, 2 CAYSTON SOLR 5 PA; SP 25 mg Lincosamides Oxazolidinones CLEOCIN CAPS OR 75 linezolid in sodium chloride 2 MG, 150 MG, 300 MG 4 soln (clindamycin hcl) linezolid soln iv 600 2 CLEOCIN PEDIATRIC mg/300ml GRANULES SOLR 4 linezolid susr or 100 2 QL(210 ml per (clindamycin palmitate mg/5ml 90 days retail) hydrochloride) QL(20 ea per linezolid tabs or 600 mg 2 CLEOCIN PHOSPHATE 90 days retail) SOLN IJ 300 MG/2ML, 600 MG/4ML, 900 MG/6ML, 9 5 SIVEXTRO SOLR IV 5 GM/60ML (clindamycin phosphate)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitrofurantoin monohyd SIVEXTRO TABS OR 5 QL(6 ea per 90 2 days retail) macro caps ZYVOX SOLN IV 200 5 nitrofurantoin susp or 2 QL(40 ml daily) MG/100ML ZYVOX SOLN IV 600 5 ANTIANGINAL AGENTS - Drugs to Treat Chest MG/300ML (linezolid) Pain ZYVOX SUSR OR 100 5 QL(210 ml per Antianginals-Other MG/5ML (linezolid) 90 days retail) RANEXA TB12 1000 MG 5 QL(2 ea daily) ZYVOX TABS OR 600 MG 5 QL(20 ea per (ranolazine) (linezolid) 90 days retail) RANEXA TB12 500 MG 5 QL(4 ea daily) Pleuromutilins (ranolazine) XENLETA SOLN IV 150 5 ranolazine tb12 1000 mg 2 QL(2 ea daily) MG/15ML QL(4 ea daily) XENLETA TABS OR 600 5 PA; SP ranolazine tb12 500 mg 2 MG Polymyxins Nitrates colistimethate sodium solr ij 2 DILATRATE SR CPCR 5

COLY-MYCIN M SOLR 5 GONITRO PACK NC (colistimethate sodium) ISORDIL TITRADOSE 5 POLYMYXIN B SULFATE 5 TABS (isosorbide dinitrate) POWD XX 100 MU, isosorbide dinitrate tabs 30 polymyxin b sulfate solr ij 2 mg, 40 mg, 10 mg, 5 mg, 2 500000 unit 20 mg Streptogramins isosorbide dinitrate tbcr 40 2 SYNERCID SOLR 5 mg isosorbide mononitrate tabs 2 QL(2 ea daily) Urinary Anti-infectives 10 mg, 20 mg isosorbide mononitrate QL(1 ea daily) FURADANTIN SUSP 5 QL(40 ml daily) 2 (nitrofurantoin) tb24 120 mg, 30 mg, 60 mg HIPREX TABS 5 NITRO-BID OINT 5 (methenamine hippurate) MACROBID CAPS NITRO-DUR PT24 0.1 (nitrofurantoin monohyd 4 MG/HR, 0.2 MG/HR, 0.4 4 macro) MG/HR, 0.6 MG/HR (nitroglycerin) MACRODANTIN CAPS (nitrofurantoin NC NITRO-DUR PT24 0.3 4 macrocrystal) MG/HR, 0.8 MG/HR nitroglycerin cpcr or 2.5 methenamine hippurate 2 2 tabs mg, 6.5 mg, 9 mg methenamine mandelate nitroglycerin in d5w soln 2 tabs or 1 gm, 0.5 gm, 500 2 mg nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 2 nitrofurantoin macrocrystal 2 caps mg/hr, 0.6 mg/hr

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITROGLYCERIN SOLN 5 ATIVAN SOLN IJ 4 IV 5 MG/ML MG/ML, 2 MG/ML 5 (lorazepam) nitroglycerin soln tl 0.4 2 mg/spray ATIVAN TABS OR 0.5 MG, 4 QL(4 ea daily) 1 MG, 2 MG (lorazepam) nitroglycerin subl sl 0.3 mg, 2 0.4 mg, 0.6 mg chlordiazepoxide hcl caps 2 QL(4 ea daily) NITROLINGUAL PUMPSPRAY SOLN 5 clorazepate dipotassium 2 QL(4 ea daily) (nitroglycerin) tabs NITROMIST AERS 5 diazepam conc or 5 mg/ml 2 DIAZEPAM SOAJ IM 10 NITROSTAT SUBL 5 5 (nitroglycerin) MG/2ML DIAZEPAM SOLN IJ 5 2 ANTIANXIETY AGENTS - Drugs to Treat Anxiety MG/ML Antianxiety Agents - Misc. diazepam soln ij 5 mg/ml, 2 50 mg/10ml buspirone hcl tabs or 10 QL(3 ea daily) mg, 30 mg, 5 mg, 15 mg, 2 diazepam soln or 5 mg/5ml 2 7.5 mg diazepam tabs or 10 mg, 2 2 QL(4 ea daily) DROPERIDOL POWD XX 5 mg, 5 mg QL(5 ml daily) DROPERIDOL SOLN IJ 4 lorazepam conc or 2 mg/ml 2 lorazepam soln ij 4 mg/ml, hydroxyzine hcl soln im 25 2 2 mg/ml, 50 mg/ml 2 mg/ml, 20 mg/10ml lorazepam tabs or 0.5 mg, QL(4 ea daily) hydroxyzine hcl syrp or 10 2 2 mg/5ml 1 mg, 2 mg LORAZEPAM/DEXTROSE hydroxyzine hcl tabs or 10 2 NC mg, 25 mg, 50 mg SOLN LORAZEPAM/SODIUM hydroxyzine pamoate caps 2 NC or 100 mg, 25 mg, 50 mg CHLORIDE SOLN QL(4 ea daily) HYDROXYZINE 5 oxazepam caps 2 PAMOATE POWD XX TRANXENE T TABS 5 QL(4 ea daily) meprobamate tabs 2 (clorazepate dipotassium) QL(4 ea daily) VISTARIL CAPS 5 VALIUM TABS (diazepam) 4 (hydroxyzine pamoate) QL(4 ea daily) Benzodiazepines XANAX TABS (alprazolam) NC ALPRAZOLAM INTENSOL 5 XANAX XR TB24 NC CONC (alprazolam) alprazolam tabs or 0.25 2 QL(4 ea daily) ANTIARRHYTHMICS - Drugs to treat abnormal mg, 0.5 mg, 1 mg, 2 mg heart rhythms alprazolam tb24 or 0.5 mg, 2 1 mg, 2 mg, 3 mg Antiarrhythmics - Misc. ADENOCARD SOLN alprazolam tbdp or 0.25 2 5 mg, 0.5 mg, 1 mg, 2 mg (adenosine)

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits adenosine soln iv 12 2 amiodarone hcl tabs 2 mg/4ml, 3 mg/ml, 6 mg/2ml AMIODARONE ADENOSINE SOSY IV 60 NC MG/20ML, 90 MG/30ML HYDROCHLORIDE/DEXT NC ROSE SOLN Antiarrhythmics Type I-A BRETYLIUM TOSYLATE NC disopyramide phosphate 2 SOLN caps 100 mg, 150 mg CORDARONE TABS NC NORPACE CAPS 4 (amiodarone hcl) (disopyramide phosphate) CORVERT SOLN (ibutilide 5 NORPACE CR CP12 4 fumarate) dofetilide caps 125 mcg, 2 SP PROCAINAMIDE HCL 5 250 mcg, 500 mcg POWD XX ibutilide fumarate soln 2 procainamide hcl soln ij 2 500 mg/ml, 100 mg/ml MULTAQ TABS 4 QUINIDINE GLUCONATE 5 SOLN IJ 80 MG/ML NEXTERONE SOLN 5 quinidine gluconate tbcr or 2 324 mg TIKOSYN CAPS 125 MCG, SP 250 MCG, 500 MCG 4 quinidine sulfate tabs or 2 200 mg, 300 mg (dofetilide) Antiarrhythmics Type I-B TIKOSYN CAPS 250 MCG NF SP (dofetilide) lidocaine hcl (cardiac) sosy 2 ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions LIDOCAINE HCL SOLN IV NC 100 MG/5ML Anti-Inflammatory Agents LIDOCAINE QL(8 ml daily) HYDROCHLORIDE/DEXT NC cromolyn sodium nebu in 2 ROSE SOLN CROMOLYN SODIUM 4 QL(8 ml daily) lidocaine in d5w soln 2 NEBU IN CROMOLYN SODIUM 5 mexiletine hcl caps 2 POWD XX Antiarrhythmics Type I-C Antiasthmatic - Monoclonal Antibodies SP flecainide acetate tabs 2 CINQAIR SOLN NC FASENRA PEN SOAJ 4 PA; SP propafenone hcl cp12 225 2 mg, 325 mg, 425 mg FASENRA SOSY 4 PA; SP propafenone hcl tabs 150 2 mg, 225 mg, 300 mg NUCALA SOAJ 4 PA; SP RYTHMOL SR CP12 4 (propafenone hcl) NUCALA SOLR 4 PA; SP Antiarrhythmics Type III PA; SP amiodarone hcl soln 2 NUCALA SOSY 4

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOLAIR SOLR 4 PA; SP SINGULAIR PACK NC QL(1 ea daily) (montelukast sodium) PA; SP XOLAIR SOSY 4 SINGULAIR TABS NC QL(1 ea daily) (montelukast sodium) Asthma and Bronchodilator Agent Combinations zafirlukast tabs 2 QL(2 ea daily) DIFIL-G FORTE LIQD 4 zileuton tb12 2 dyphylline-guaifenesin liqd 2 ZYFLO CR TB12 (zileuton) 5 Bronchodilators - Anticholinergics ZYFLO TABS 5 ATROVENT HFA AERS 3 QL(0.86 gm daily) Selective Phosphodiesterase 4 (PDE4) Inhibitors INCRUSE ELLIPTA AEPB 4 QL(1 ea daily) DALIRESP TABS 3 QL(1 ea daily) IPRATROPIUM BROMIDE 5 MONOHYDRATE POWD Steroid Inhalants IPRATROPIUM BROMIDE QL(0.41 gm 5 ALVESCO AERS NC POWD XX daily) QL(12.5 ml ipratropium bromide soln in 1 ARMONAIR RESPICLICK NC QL(0.04 ea daily) 113 AEPB daily) LONHALA MAGNAIR NC QL(2 ml daily) ARMONAIR RESPICLICK NC QL(0.04 ea REFILL KIT SOLN 232 AEPB daily) LONHALA MAGNAIR NC QL(2 ml daily) ARMONAIR RESPICLICK NC QL(0.04 ea STARTER KIT SOLN 55 AEPB daily) SEEBRI NEOHALER NC QL(2 ea daily) ARNUITY ELLIPTA AEPB QL(1 ea daily) CAPS 100 MCG/ACT, 200 4 MCG/ACT SPIRIVA HANDIHALER 3 QL(1 ea daily) CAPS ARNUITY ELLIPTA AEPB 4 50 MCG/ACT SPIRIVA RESPIMAT 4 QL(0.14 gm AERS daily) ASMANEX HFA AERO NC TUDORZA PRESSAIR NC QL(0.04 ea AEPB daily) ASMANEX TWISTHALER 120 METERED DOSES NC YUPELRI SOLN 4 AEPB ASMANEX TWISTHALER Leukotriene Modulators 14 METERED DOSES NC ACCOLATE TABS 5 QL(2 ea daily) AEPB (zafirlukast) ASMANEX TWISTHALER montelukast sodium chew 1 QL(1 ea daily) 30 METERED DOSES NC or 4 mg, 5 mg AEPB montelukast sodium pack 1 QL(1 ea daily) ASMANEX TWISTHALER or 4 mg 60 METERED DOSES NC AEPB montelukast sodium tabs or 1 QL(1 ea daily) 10 mg ASMANEX TWISTHALER 7 METERED DOSES NC SINGULAIR CHEW NC QL(1 ea daily) (montelukast sodium) AEPB

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits budesonide (inhalation) 1 QL(8 ml daily) AIRDUO RESPICLICK QL(0.04 ea susp 0.25 mg/2ml 55/14 AEPB (fluticasone- NC daily) salmeterol) budesonide (inhalation) 1 QL(4 ml daily) susp 0.5 mg/2ml albuterol sulfate aers in 108 1 QL(1.2 gm mcg/act daily) budesonide (inhalation) 1 QL(2 ml daily) susp 1 mg/2ml albuterol sulfate nebu in QL(12.5 ml 0.083 %, 0.63 mg/3ml, 1.25 1 daily) FLOVENT DISKUS AEPB 3 QL(20 ea daily) 100 MCG/BLIST mg/3ml ALBUTEROL SULFATE QL(2 ml daily) FLOVENT DISKUS AEPB 3 QL(8 ea daily) 3 250 MCG/BLIST NEBU IN 0.5 % albuterol sulfate nebu in 0.5 QL(2 ml daily) FLOVENT DISKUS AEPB 3 QL(40 ea daily) 1 50 MCG/BLIST %, 2.5 mg/0.5ml ALBUTEROL SULFATE FLOVENT HFA AERO 110 3 QL(0.8 gm 5 MCG/ACT, 220 MCG/ACT daily) POWD XX albuterol sulfate syrp or 2 FLOVENT HFA AERO 44 3 QL(0.36 gm 1 MCG/ACT daily) mg/5ml albuterol sulfate tabs or 2 FLUNISOLIDE 5 1 ANHYDROUS POWD mg, 4 mg albuterol sulfate tb12 or 4 PULMICORT FLEXHALER 3 QL(0.07 ea 1 AEPB 180 MCG/ACT daily) mg, 8 mg QL(2 ea daily) PULMICORT FLEXHALER 3 QL(0.27 ea ANORO ELLIPTA AEPB 4 AEPB 90 MCG/ACT daily) PULMICORT SUSP 0.25 QL(8 ml daily) ARCAPTA NEOHALER 5 QL(1 ea daily) MG/2ML (budesonide 5 CAPS (inhalation)) BEVESPI AEROSPHERE 4 QL(0.36 gm PULMICORT SUSP 0.5 QL(4 ml daily) AERO daily) MG/2ML (budesonide 5 BREO ELLIPTA AEPB 100 3 QL(2 ea daily) (inhalation)) MCG/INH-25 MCG/INH PULMICORT SUSP 1 QL(2 ml daily) BREO ELLIPTA AEPB 200 4 QL(2 ea daily) MG/2ML (budesonide 5 MCG/INH-25 MCG/INH )) (inhalation BROVANA NEBU 5 QL(4 ml daily) QVAR REDIHALER AERB 3 QL(0.36 gm 40 MCG/ACT daily) budesonide-formoterol NC fumarate dihydrate aero QVAR REDIHALER AERB 3 QL(0.72 gm 80 MCG/ACT daily) COMBIVENT RESPIMAT 3 AERS Sympathomimetics DUAKLIR PRESSAIR NC ADVAIR DISKUS AEPB 1 QL(2 ea daily) AEPB (fluticasone-salmeterol) DULERA AERO 100 QL(0.45 gm QL(0.4 gm ADVAIR HFA AERO 3 MCG/ACT-5 MCG/ACT, NC daily) daily) 200 MCG/ACT-5 AIRDUO RESPICLICK QL(0.04 ea MCG/ACT 113/14 AEPB (fluticasone- NC daily) DULERA AERO 5 NC salmeterol) MCG/ACT-50 MCG/ACT AIRDUO RESPICLICK QL(0.04 ea 232/14 AEPB (fluticasone- NC daily) EPHEDRINE HCL POWD 5 salmeterol)

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPHEDRINE SULFATE 5 SYMBICORT AERO QL(0.34 gm POWD XX (budesonide-formoterol 3 daily) fluticasone-salmeterol aepb QL(2 ea daily) fumarate dihydrate) 100 mcg/dose-50 TERBUTALINE SULFATE 5 mcg/dose, 250 mcg/dose- NC POWD XX 50 mcg/dose, 50 terbutaline sulfate soln ij 1 1 mcg/dose-500 mcg/dose mg/ml fluticasone-salmeterol aepb QL(0.04 ea terbutaline sulfate tabs or 1 113 mcg/act-14 mcg/act, NC daily) 2.5 mg, 5 mg 14 mcg/act-232 mcg/act, 14 mcg/act-55 mcg/act TRELEGY ELLIPTA AEPB QL(2 ea daily) 100 MCG/INH-25 4 ipratropium-albuterol soln 1 QL(18 ml daily) MCG/INH-62.5 MCG/INH UTIBRON NEOHALER NC QL(2 ea daily) isoproterenol hcl soln ij 2 CAPS VENTOLIN HFA AERS QL(1.2 gm ISUPREL SOLN 5 NC (isoproterenol hcl) (albuterol sulfate) daily) levalbuterol hcl nebu in QL(9.6 ml XOPENEX QL(2 ea daily) 0.31 mg/3ml, 0.63 mg/3ml, 1 daily) CONCENTRATE NEBU 5 1.25 mg/3ml (levalbuterol hcl) XOPENEX HFA AERO QL(0.6 gm levalbuterol hcl nebu in 2 QL(2 ea daily) NC 1.25 mg/0.5ml (levalbuterol tartrate) daily) QL(0.6 gm XOPENEX NEBU QL(9.6 ml levalbuterol tartrate aero 1 NC daily) (levalbuterol hcl) daily) Xanthines METAPROTERENOL 5 SULFATE POWD XX AMINOPHYLLINE 5 ANHYDROUS POWD metaproterenol sulfate syrp 2 QL(30 ml daily) or 10 mg/5ml AMINOPHYLLINE POWD 5 XX metaproterenol sulfate tabs 2 or 10 mg, 20 mg aminophylline soln iv 2 PERFOROMIST NEBU 4 QL(4 ml daily) ELIXOPHYLLIN ELIX 5 PROAIR DIGIHALER NC AEPB THEO-24 CP24 5 PROAIR HFA AERS NC QL(1.2 gm (albuterol sulfate) daily) THEOPHYLLINE ETHYLENEDIAMINE EP 5 PROAIR RESPICLICK NC POWD AEPB theophylline soln 2 PROVENTIL HFA AERS NC QL(1.2 gm (albuterol sulfate) daily) theophylline tb12 2 SEREVENT DISKUS 3 QL(2 ea daily) AEPB theophylline tb24 2 STIOLTO RESPIMAT 4 QL(0.14 gm AERS daily) THEOPHYLLINE/D5W 5 SOLN STRIVERDI RESPIMAT 4 QL(0.14 gm AERS daily) ANTICOAGULANTS - Blood Thinners

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anticoagulants - Misc. heparin (porcine) in sodium 2 chloride soln ANTICOAGULANT SODIUM CITRATE SOSY NC HEPARIN LOCK FLUSH 4 % SOLN (heparin sodium 2 (porcine) lock flush) SODIUM CITRATE LOCK NC FLUSH SOSY heparin sod (porcine) in NC d5w soln 100 unit/ml-5 % SODIUM CITRATE SOSY NC IV heparin sod (porcine) in SP d5w soln 25000 unit/500ml- 2 Coumarin Anticoagulants 5 % COUMADIN TABS NC heparin sod (porcine) in 2 (warfarin sodium) d5w soln 40 unit/ml-5 % WARFARIN SODIUM 5 heparin sodium (porcine) CLATHRATEFORM POWD lock flush & nacl lock flush 2 warfarin sodium tabs 1 mg, kit 10 mg, 3 mg, 4 mg, 5 mg, 6 2 heparin sodium (porcine) 2 mg, 7.5 mg, 2 mg, 2.5 mg lock flush soln Direct Factor Xa Inhibitors heparin sodium (porcine) 2 soln BEVYXXA CAPS NC QL(43 ea per 42 days retail) HEPARIN SODIUM SOLN NC IJ 5000 UNIT/ML ELIQUIS STARTER PACK 4 TBPK HEPARIN SODIUM SOSY NC IJ 5000 UNIT/0.5ML ELIQUIS TABS 4 HEPARIN SODIUM SOSY SAVAYSA TABS NC IV 10000 UNIT/10ML, 15000 UNIT/3ML, 3000 NC UNIT/3ML, 5000 XARELTO STARTER 4 PACK TBPK UNIT/5ML, 6000 UNIT/6ML, 7000 UNIT/7ML XARELTO TABS 10 MG 4 QL(1 ea daily) HEPARIN SODIUM/D5W 5 SOLN XARELTO TABS 15 MG, 4 2.5 MG, 20 MG HEPARIN Heparins And Heparinoid-Like Agents SODIUM/DEXTROSE SOLN 10000 UNIT/100ML- NC ARIXTRA SOLN 4 PA; SP 5 %, 25000 UNIT/250ML-5 (fondaparinux sodium) % enoxaparin sodium soln ij 2 SP HEPARIN SP 300 mg/3ml SODIUM/DEXTROSE 5 enoxaparin sodium soln sc SP SOLN 25000 UNIT/500ML- 100 mg/ml, 120 mg/0.8ml, 2 5 % 150 mg/ml, 30 mg/0.3ml, HEPARIN 80 mg/0.8ml, 60 mg/0.6ml SODIUM/DEXTROSE NC enoxaparin sodium soln sc 2 PA; SP SOSY 10 %-50 UNIT/50ML 60 mg/0.6ml HEPARIN SODIUM/NACL fondaparinux sodium soln 2 PA; SP 0.45% SOLN 0.45 %- 5 12500 UNIT/250ML FRAGMIN SOLN 4 PA; SP

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEPARIN SODIUM/NACL HEPARIN 0.45% SOLN 0.45 %- NC SODIUM/SODIUM 25000 UNIT/250ML, 0.45 CHLORIDE SOLN 0.45 %- %-25000 UNIT/500ML 100 UNIT/100ML, 0.45 %- HEPARIN 150 UNIT/150ML, 0.45 %- 250 UNIT/250ML, 0.45 %- SODIUM/SODIUM 5 CHLORIDE 0.9% SOLN IJ 25000 UNIT/250ML, 0.45 0.9 %-2 UNIT/ML %-25000 UNIT/500ML, 0.45 %-40000 UNIT/L, 0.45 HEPARIN %-500 UNIT/250ML, 0.45 SODIUM/SODIUM %-500 UNIT/500ML, 0.45 CHLORIDE 0.9% SOLN IV NF %-5000 UNIT/L, 0.9 %-100 0.9 %-1000 UNIT/500ML UNIT/100ML, 0.9 %-1000 (heparin (porcine) in UNIT/100ML, 0.9 %-1000 sodium chloride) UNIT/250ML, 0.9 %-1000 UNIT/L, 0.9 %-10000 UNIT/100ML, 0.9 %-10000 UNIT/500ML, 0.9 %-10000 UNIT/L, 0.9 %-1250 NC UNIT/250ML, 0.9 %-1500 UNIT/150ML, 0.9 %-1500 UNIT/250ML, 0.9 %-15000 UNIT/500ML, 0.9 %-2000 UNIT/500ML, 0.9 %-20000 UNIT/L, 0.9 %-250 UNIT/250ML, 0.9 %-2500 UNIT/250ML, 0.9 %-2500 UNIT/500ML, 0.9 %-25000 UNIT/250ML, 0.9 %-25000 UNIT/500ML, 0.9 %-3000 UNIT/500ML, 0.9 %-3000 UNIT/L, 0.9 %-30000 UNIT/L, 0.9 %-4000 UNIT/500ML, 0.9 %-4000 UNIT/L, 0.9 %-500 UNIT/500ML, 0.9 %-5000 UNIT/500ML, 0.9 %-6000 UNIT/L, 0.9 %-8000 UNIT/L HEPARIN SODIUM/SODIUM 5 CHLORIDE SOLN 0.9 %- 2000 UNIT/L HEPARIN SODIUM/SODIUM CHLORIDE SOSY 0.45 %- 20 UNIT/20ML, 0.45 %-50 UNIT/50ML, 0.9 %-100 NC UNIT/50ML, 0.9 %-20 UNIT/20ML, 0.9 %-4 UNIT/2ML, 0.9 %-50 UNIT/50ML

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEPARIN/SODIUM NC AMPA Glutamate Receptor Antagonists CHLORIDE SOLN FYCOMPA SUSP 4 HEPMED KIT NC FYCOMPA TABS 4 LOVENOX SOLN 5 SP (enoxaparin sodium) Anticonvulsants - Benzodiazepines SOLU-PREF KIT NC clobazam susp 2 In Vitro/Lock Anticoagulants clobazam tabs 2 ACD FORMULA A SOLN 5 clonazepam tabs or 0.5 2 QL(4 ea daily) ACD-A NOCLOT-50 SOLN 5 mg, 1 mg, 2 mg clonazepam tbdp or 0.125 QL(4 ea daily) ANTICOAGULANT mg, 0.25 mg, 0.5 mg, 1 mg, 2 CITRATE DEXTROSE 5 2 mg SOLUTION A SOLN DIASTAT ACUDIAL GEL QL(1 ea per fill ANTICOAGULANT (diazepam 5 retail,4 ea per SODIUM CITRATE SOLN 5 (anticonvulsant)) 30 days retail) 4 GM/100ML DIASTAT PEDIATRIC GEL QL(1 ea per fill SODIUM (diazepam 5 retail,4 ea per CITRATE/GENTAMICIN NC (anticonvulsant)) 30 days retail) SOLN QL(1 ea per fill diazepam (anticonvulsant) 2 retail,4 ea per TRICITRASOL CONC 5 gel 30 days retail) Thrombin Inhibitors KLONOPIN TABS 5 QL(4 ea daily) (clonazepam) ANGIOMAX SOLR 5 (bivalirudin trifluoroacetate) NAYZILAM SOLN NC ARGATROBAN SOLN 0.9 5 %-125 MG/125ML ONFI SUSP (clobazam) NC argatroban soln 250 2 mg/2.5ml ONFI TABS (clobazam) NC ARGATROBAN SOLN 250 5 MG/2.5ML (argatroban) SYMPAZAN FILM NC ARGATROBAN SOLN 50 5 MG/50ML, 250 MG/2.5ML VALTOCO LIQD NC ARGATROBAN/SODIUM NC CHLORIDE SOLN VALTOCO LQPK NC bivalirudin trifluoroacetate 2 Anticonvulsants - Misc. solr APTIOM TABS 200 MG, 5 QL(2 ea daily) BIVALIRUDIN/SODIUM NC 400 MG, 600 MG CHLORIDE SOLN APTIOM TABS 800 MG 5 QL(1 ea daily) PRADAXA CAPS 110 MG, NC 75 MG BANZEL SUSP 40 MG/ML 5 PA; SP PRADAXA CAPS 150 MG NC QL(2 ea daily) (rufinamide) BANZEL TABS 200 MG, 5 PA; SP ANTICONVULSANTS - Drugs to Treat Seizures 400 MG 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRIVIACT SOLN IV 50 5 PA; SP gabapentin soln or 250 2 QL(60 ml daily) MG/5ML mg/5ml, 300 mg/6ml BRIVIACT SOLN OR 10 5 gabapentin tabs or 600 mg, 2 QL(4 ea daily) MG/ML 800 mg BRIVIACT TABS OR 10 KEPPRA SOLN IV 500 5 MG, 100 MG, 25 MG, 50 5 MG/5ML (levetiracetam) MG, 75 MG KEPPRA SOLN OR 100 5 QL(30 ml daily) carbamazepine chew or 2 MG/ML (levetiracetam) 100 mg KEPPRA TABS OR 1000 5 QL(3 ea daily) carbamazepine cp12 or 2 MG (levetiracetam) 100 mg KEPPRA TABS OR 250 QL(4 ea daily) carbamazepine cp12 or 2 QL(6 ea daily) MG, 500 MG, 750 MG 5 200 mg (levetiracetam) carbamazepine cp12 or 2 QL(4 ea daily) KEPPRA XR TB24 5 QL(4 ea daily) 300 mg (levetiracetam) CARBAMAZEPINE POWD 5 LAMICTAL CHEWABLE XX DISPERSIBLE CHEW NC (lamotrigine) carbamazepine susp or 2 100 mg/5ml LAMICTAL ODT KIT NC carbamazepine tabs or 200 2 mg LAMICTAL ODT KIT NC (lamotrigine) carbamazepine tb12 or 100 2 mg LAMICTAL ODT TBDP 100 MG, 200 MG, 25 MG, 50 NC carbamazepine tb12 or 200 2 QL(6 ea daily) mg MG (lamotrigine) LAMICTAL STARTER/NOT carbamazepine tb12 or 400 2 QL(4 ea daily) mg TAKING NC CARBAMAZEPINE KIT CARBATROL CP12 100 5 (lamotrigine) MG (carbamazepine) LAMICTAL CARBATROL CP12 200 5 QL(6 ea daily) STARTER/TAKING MG (carbamazepine) CARBAMAZEPINE/NOT NC CARBATROL CP12 300 5 QL(4 ea daily) TAKING VALPROATE KIT MG (carbamazepine) (lamotrigine) DIACOMIT CAPS 5 LAMICTAL STARTER/TAKING NC DIACOMIT PACK 5 VALPROATE KIT (lamotrigine) PA; SP EPIDIOLEX SOLN 5 LAMICTAL TABS NC (lamotrigine) FANATREX FUSEPAQ NC SUSP LAMICTAL XR KIT NC FINTEPLA SOLN NC LAMICTAL XR TB24 250 MG, 300 MG, 100 MG, 200 NC gabapentin caps or 100 2 QL(4 ea daily) MG, 25 MG, 50 MG mg, 300 mg, 400 mg (lamotrigine)

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lamotrigine chew or 25 mg, 2 NEURONTIN CAPS 100 QL(4 ea daily) 5 mg MG, 300 MG, 400 MG 5 (gabapentin) lamotrigine kit or NC NEURONTIN SOLN 250 5 QL(60 ml daily) lamotrigine kit or 25 mg 2 MG/5ML (gabapentin) NEURONTIN TABS 600 5 QL(4 ea daily) lamotrigine tabs or 100 mg, 2 MG, 800 MG (gabapentin) 150 mg, 200 mg, 25 mg oxcarbazepine susp 300 2 QL(40 ml daily) lamotrigine tb24 or 250 mg 2 QL(2 ea daily) mg/5ml, 60 mg/ml oxcarbazepine tabs 150 2 QL(4 ea daily) lamotrigine tb24 or 300 mg, QL(1 ea daily) mg, 300 mg, 600 mg 100 mg, 200 mg, 25 mg, 50 2 mg OXTELLAR XR TB24 4 ST lamotrigine tbdp or 100 mg, 2 pregabalin caps or 100 mg, PA; QL(3 ea 200 mg, 25 mg, 50 mg 200 mg, 25 mg, 50 mg, 75 2 daily) levetiracetam in sodium 2 mg chloride soln pregabalin caps or 150 mg, 2 PA; QL(2 ea LEVETIRACETAM SOLN 225 mg, 300 mg daily) IV 1000 MG/100ML-750 pregabalin soln or 20 2 PA; QL(30 ml MG/100ML, 1500 mg/ml daily) MG/100ML-540 5 MG/100ML, 500 primidone tabs or 250 mg, 2 MG/100ML-820 MG/100ML 50 mg (levetiracetam in sodium QUDEXY XR CS24 5 chloride) (topiramate) PA; SP levetiracetam soln iv 500 2 rufinamide susp 5 mg/5ml levetiracetam soln or 100 2 QL(30 ml daily) SPRITAM TB3D NC mg/ml, 500 mg/5ml TEGRETOL SUSP levetiracetam soln or 500 2 5 mg/5ml (carbamazepine) TEGRETOL TABS levetiracetam tabs or 1000 2 QL(3 ea daily) 5 mg (carbamazepine) TEGRETOL-XR TB12 100 levetiracetam tabs or 250 2 QL(4 ea daily) 5 mg, 500 mg, 750 mg MG (carbamazepine) TEGRETOL-XR TB12 200 QL(6 ea daily) levetiracetam tb24 or 500 2 QL(4 ea daily) 5 mg, 750 mg MG (carbamazepine) LYRICA CAPS 100 MG, PA; QL(3 ea TEGRETOL-XR TB12 400 5 QL(4 ea daily) 200 MG, 25 MG, 50 MG, 5 daily) MG (carbamazepine) 75 MG (pregabalin) TOPAMAX SPRINKLE 5 QL(6 ea daily) LYRICA CAPS 150 MG, PA; QL(2 ea CPSP 15 MG (topiramate) 225 MG, 300 MG 5 daily) TOPAMAX SPRINKLE 5 QL(8 ea daily) (pregabalin) CPSP 25 MG (topiramate) TOPAMAX TABS 100 MG QL(3 ea daily) LYRICA SOLN 20 MG/ML 5 PA; QL(30 ml 5 (pregabalin) daily) (topiramate) TOPAMAX TABS 200 MG QL(8 ea daily) MYSOLINE TABS 5 5 (primidone) (topiramate)

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPAMAX TABS 25 MG, 5 QL(4 ea daily) XCOPRI TABS NC 50 MG (topiramate) topiramate cpsp or 15 mg 2 QL(6 ea daily) XCOPRI TBPK NC topiramate cpsp or 25 mg 2 QL(8 ea daily) GABA Modulators GABITRIL TABS (tiagabine 5 topiramate cs24 or 100 mg, hcl) 150 mg, 200 mg, 25 mg, 50 2 PA; SP mg SABRIL PACK (vigabatrin) NC QL(3 ea daily) topiramate tabs or 100 mg 2 SABRIL TABS (vigabatrin) NC PA; SP QL(8 ea daily) topiramate tabs or 200 mg 2 tiagabine hcl tabs 2 topiramate tabs or 25 mg, 2 QL(4 ea daily) PA; SP 50 mg vigabatrin pack 2 TRILEPTAL SUSP 300 5 QL(40 ml daily) PA; SP MG/5ML (oxcarbazepine) vigabatrin tabs 2 TRILEPTAL TABS 150 QL(4 ea daily) Hydantoins MG, 300 MG, 600 MG 5 CEREBYX SOLN 5 (oxcarbazepine) (fosphenytoin sodium) TROKENDI XR CP24 4 DILANTIN CAPS 100 MG (phenytoin sodium 5 VIMPAT SOLN IV 200 4 extended) MG/20ML DILANTIN CAPS 30 MG 5 VIMPAT SOLN OR 10 4 QL(40 ml daily) MG/ML DILANTIN INFATABS 5 VIMPAT TABS OR 100 QL(2 ea daily) CHEW (phenytoin) MG, 150 MG, 200 MG, 50 4 DILANTIN-125 SUSP 5 MG (phenytoin) ZONEGRAN CAPS NC (zonisamide) fosphenytoin sodium soln 2 zonisamide caps or 100 2 QL(6 ea daily) mg, 50 mg, 25 mg PEGANONE TABS 5 Carbamates PHENYTEK CAPS (phenytoin sodium 5 felbamate susp 600 2 QL(120 ml mg/5ml daily) extended) felbamate tabs 400 mg 2 QL(9 ea daily) phenytoin chew or 50 mg 2 QL(6 ea daily) phenytoin sodium extended 2 felbamate tabs 600 mg 2 caps PHENYTOIN SODIUM FELBATOL SUSP 600 5 QL(120 ml 5 MG/5ML (felbamate) daily) POWD XX FELBATOL TABS 400 MG 5 QL(9 ea daily) phenytoin sodium soln ij 2 (felbamate) phenytoin susp or 100 FELBATOL TABS 600 MG 5 QL(6 ea daily) 2 (felbamate) mg/4ml, 125 mg/5ml Succinimides

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELONTIN CAPS 5 REMERON TABS 5 (mirtazapine) ethosuximide caps or 250 2 Antidepressants - Misc. mg APLENZIN TB24 NC ethosuximide soln or 250 2 QL(30 ml daily) mg/5ml bupropion hcl tabs or 100 2 ZARONTIN CAPS 250 MG 5 mg, 75 mg (ethosuximide) bupropion hcl tb12 or 200 2 ZARONTIN SOLN 250 5 QL(30 ml daily) mg, 100 mg, 150 mg MG/5ML (ethosuximide) bupropion hcl tb24 or 150 2 QL(1 ea daily) Valproic Acid mg, 300 mg DEPACON SOLN 5 bupropion hcl tb24 or 450 NC (valproate sodium) mg DEPAKENE CAPS 5 FORFIVO XL TB24 5 (valproic acid) (bupropion hcl) DEPAKENE SOLN 5 maprotiline hcl tabs 2 (valproate sodium) WELLBUTRIN SR TB12 DEPAKOTE ER TB24 5 5 (divalproex sodium) (bupropion hcl) WELLBUTRIN XL TB24 QL(1 ea daily) DEPAKOTE SPRINKLES 5 5 CSDR (divalproex sodium) (bupropion hcl) DEPAKOTE TBEC 5 GABA Receptor Modulator - Neuroactive Steroid (divalproex sodium) ZULRESSO SOLN NC divalproex sodium csdr or 2 125 mg Monoamine Oxidase Inhibitors (MAOIs) divalproex sodium tb24 or 2 QL(1 ea daily) 250 mg, 500 mg EMSAM PT24 5 divalproex sodium tbec or 2 125 mg, 250 mg, 500 mg MARPLAN TABS 5 NARDIL TABS (phenelzine valproate sodium soln iv 2 4 100 mg/ml, 500 mg/5ml sulfate) PARNATE TABS valproate sodium soln or 2 4 250 mg/5ml (tranylcypromine sulfate) valproic acid caps or 2 phenelzine sulfate tabs or 2

ANTIDEPRESSANTS - Drugs to Treat tranylcypromine sulfate 2 Depression tabs Alpha-2 Receptor Antagonists (Tetracyclics) N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE PA; SP mirtazapine tabs or 7.5 mg, 2 5 15 mg, 30 mg, 45 mg SOPK SPRAVATO 84MG DOSE PA; SP mirtazapine tbdp or 15 mg, 2 5 30 mg, 45 mg SOPK Selective Serotonin Reuptake Inhibitors (SSRIs) REMERON SOLTAB TBDP 5 (mirtazapine) CELEXA TABS 10 MG 5 QL(4 ea daily) (citalopram hydrobromide)

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEXA TABS 20 MG 5 QL(2 ea daily) PAXIL TABS 30 MG, 40 (citalopram hydrobromide) MG, 10 MG, 20 MG 5 (paroxetine hcl) CELEXA TABS 40 MG 5 QL(1 ea daily) (citalopram hydrobromide) PEXEVA TABS 5 ST citalopram hydrobromide 2 QL(20 ml daily) soln 10 mg/5ml PROZAC CAPS (fluoxetine NC hcl) citalopram hydrobromide 2 QL(4 ea daily) tabs 10 mg sertraline hcl conc or 20 2 mg/ml citalopram hydrobromide 2 QL(2 ea daily) tabs 20 mg sertraline hcl tabs or 100 2 mg, 25 mg, 50 mg citalopram hydrobromide 2 QL(1 ea daily) tabs 40 mg ZOLOFT CONC (sertraline 5 hcl) escitalopram oxalate soln 5 2 mg/5ml ZOLOFT TABS (sertraline 5 hcl) escitalopram oxalate tabs 2 10 mg, 20 mg, 5 mg Serotonin Modulators fluoxetine hcl caps or 10 2 nefazodone hcl tabs 2 mg, 40 mg, 20 mg TRAZODONE HCL POWD fluoxetine hcl cpdr or 90 2 5 mg XX trazodone hcl tabs or 300 fluoxetine hcl soln or 20 2 mg/5ml mg, 100 mg, 150 mg, 50 2 fluoxetine hcl tabs or 10 mg 2 ST; QL(1 ea mg, 20 mg TRINTELLIX TABS 4 PA; QL(1 ea daily) fluoxetine hcl tabs or 60 mg NC daily) VIIBRYD STARTER PACK 4 ST KIT fluoxetine hcl tabs or 60 mg NC VIIBRYD TABS 4 ST fluoxetine hcl tabs or 60 mg NC QL(1 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors FLUOXETINE PA; QL(1 ea CYMBALTA CPEP NC HYDROCHLORIDE TABS 5 daily) (duloxetine hcl) (fluoxetine hcl) DESVENLAFAXINE ER 5 QL(1 ea daily) fluvoxamine maleate cp24 2 TB24 100 mg, 150 mg desvenlafaxine succinate 2 QL(1 ea daily) fluvoxamine maleate tabs 2 ST tb24 100 mg, 25 mg, 50 mg desvenlafaxine tb24 2 QL(1 ea daily) LEXAPRO TABS NC (escitalopram oxalate) DRIZALMA SPRINKLE NC paroxetine hcl tabs 2 CSDR duloxetine hcl cpep or 20 2 QL(2 ea daily) paroxetine hcl tb24 2 mg, 60 mg, 30 mg duloxetine hcl cpep or 40 2 PAXIL CR TB24 5 mg (paroxetine hcl) EFFEXOR XR CP24 NC PAXIL SUSP 10 MG/5ML 5 (venlafaxine hcl)

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FETZIMA CP24 120 MG, 5 ST; QL(1 ea IMIPRAMINE HCL POWD 5 40 MG, 80 MG daily) XX imipramine hcl tabs or 10 FETZIMA CP24 20 MG 5 ST; QL(2 ea 2 daily) mg, 25 mg, 50 mg FETZIMA TITRATION 5 ST imipramine pamoate caps 2 PACK C4PK NORPRAMIN TABS KHEDEZLA TB24 5 QL(1 ea daily) 4 (desvenlafaxine) (desipramine hcl) nortriptyline hcl caps or 10 PRISTIQ TB24 NC 2 (desvenlafaxine succinate) mg, 50 mg, 75 mg, 25 mg NORTRIPTYLINE HCL venlafaxine hcl cp24 150 2 QL(2 ea daily) 5 mg POWD XX nortriptyline hcl soln or 10 venlafaxine hcl cp24 37.5 2 QL(1 ea daily) 2 mg, 75 mg mg/5ml PAMELOR CAPS venlafaxine hcl cp24 37.5 2 4 mg, 75 mg, 150 mg (nortriptyline hcl) venlafaxine hcl tabs 100 protriptyline hcl tabs 2 mg, 25 mg, 37.5 mg, 50 2 mg, 75 mg SURMONTIL CAPS 5 (trimipramine maleate) venlafaxine hcl tb24 150 NC mg, 37.5 mg TOFRANIL TABS 10 MG NF (imipramine hcl) venlafaxine hcl tb24 225 2 mg TOFRANIL TABS 10 MG, QL(1 ea daily) 25 MG, 50 MG (imipramine 4 venlafaxine hcl tb24 75 mg NC hcl) Tricyclic Agents trimipramine maleate caps 2 or 100 mg, 25 mg, 50 mg amitriptyline hcl tabs or 10 mg, 50 mg, 150 mg, 25 mg, 2 TRIMIPRAMINE MALEATE 5 100 mg, 75 mg POWD XX ANTIDIABETICS - Drugs to Regulate Blood amoxapine tabs 2 Sugar ANAFRANIL CAPS 4 Alpha-Glucosidase Inhibitors (clomipramine hcl) acarbose tabs or 100 mg, 2 QL(3 ea daily) clomipramine hcl caps or 2 25 mg, 50 mg 25 mg, 50 mg, 75 mg GLYSET TABS (miglitol) 5 QL(3 ea daily) DESIPRAMINE HCL 5 POWD XX miglitol tabs 2 QL(3 ea daily) desipramine hcl tabs or 10 mg, 100 mg, 150 mg, 25 2 PRECOSE TABS 4 QL(3 ea daily) mg, 50 mg, 75 mg (acarbose) doxepin hcl caps or 100 Antidiabetic - Amylin Analogs mg, 150 mg, 25 mg, 10 mg, 2 50 mg, 75 mg SYMLINPEN 120 SOPN 4 QL(0.36 ml daily) doxepin hcl conc or 10 2 mg/ml SYMLINPEN 60 SOPN 3 QL(0.2 ml daily)

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antidiabetic Combinations pioglitazone hcl-glimepiride 2 QL(1 ea daily) tabs ACTOPLUS MET TABS (pioglitazone hcl-metformin 5 pioglitazone hcl-metformin 1 hcl) hcl tabs ACTOPLUS MET XR TB24 5 QTERN TABS NC repaglinide-metformin hcl QL(2 ea daily) alogliptin-metformin hcl NC 2 tabs tabs alogliptin-pioglitazone tabs NC SEGLUROMET TABS NC

D-CARE DM2 KIT NC SOLIQUA 100/33 SOPN 4 DUETACT TABS QL(1 ea daily) STEGLUJAN TABS NC QL(1 ea daily) (pioglitazone hcl- 5 glimepiride) SYNJARDY TABS 3 glipizide-metformin hcl tabs QL(2 ea daily) 2.5 mg-250 mg, 2.5 mg- 2 SYNJARDY XR TB24 3 500 mg TRIJARDY XR TB24 4 glipizide-metformin hcl tabs 2 QL(4 ea daily) 5 mg-500 mg glyburide-metformin tabs QL(2 ea daily) XIGDUO XR TB24 4 1.25 mg-250 mg, 2.5 mg- 1 500 mg XULTOPHY 100/3.6 SOPN 3 glyburide-metformin tabs 5 1 QL(4 ea daily) Biguanides mg-500 mg FORTAMET TB24 1000 NC PA; QL(2 ea GLYXAMBI TABS 4 MG (metformin hcl) daily) FORTAMET TB24 500 MG NC PA; QL(4 ea INVOKAMET TABS NC (metformin hcl) daily) GLUCOPHAGE TABS NC QL(2 ea daily) INVOKAMET XR TB24 NC 1000 MG (metformin hcl) JANUMET TABS 3 QL(2 ea daily) GLUCOPHAGE TABS 500 NC QL(5 ea daily) MG (metformin hcl) JANUMET XR TB24 100 QL(1 ea daily) GLUCOPHAGE TABS 850 5 QL(3 ea daily) MG-1000 MG, 50 MG-500 3 MG (metformin hcl) MG GLUCOPHAGE XR TB24 NC QL(4 ea daily) JANUMET XR TB24 1000 3 QL(2 ea daily) 500 MG (metformin hcl) MG-50 MG GLUCOPHAGE XR TB24 5 QL(3 ea daily) JENTADUETO TABS NC QL(2 ea daily) 750 MG (metformin hcl) GLUMETZA TB24 1000 NC PA; QL(2 ea JENTADUETO XR TB24 NC MG (metformin hcl) daily) GLUMETZA TB24 500 MG PA; QL(4 ea KAZANO TABS (alogliptin- NC NC metformin hcl) (metformin hcl) daily) metformin hcl soln or 500 2 KOMBIGLYZE XR TB24 NC mg/5ml metformin hcl tabs or 1000 QL(2 ea daily) OSENI TABS (alogliptin- NC 1 pioglitazone) mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metformin hcl tabs or 500 1 QL(5 ea daily) NESINA TABS (alogliptin NC mg benzoate) metformin hcl tabs or 850 1 QL(3 ea daily) ONGLYZA TABS NC mg QL(1 ea daily) metformin hcl tb24 or 1000 NC PA; QL(2 ea TRADJENTA TABS NC mg daily) Dopamine Receptor Agonists - Antidiabetic metformin hcl tb24 or 500 NC PA; QL(4 ea mg daily) CYCLOSET TABS 5 metformin hcl tb24 or 500 1 QL(4 ea daily) mg Incretin Mimetic Agents (GLP-1 Receptor metformin hcl tb24 or 750 1 QL(3 ea daily) mg ADLYXIN SOPN NC RIOMET ER SRER NC ADLYXIN STARTER PACK NC PNKT RIOMET SOLN (metformin NC hcl) BYDUREON BCISE AUIJ NC Diabetic Other BYDUREON PEN PEN NC BAQSIMI ONE PACK 4 POWD BYDUREON SRER NC BAQSIMI TWO PACK 4 POWD BYETTA SOPN NC diazoxide susp or 2 OZEMPIC SOPN 4 GLUCAGEN HYPOKIT 4 QL(1 ea per fill SOLR retail) RYBELSUS TABS 4 GLUCAGON TANZEUM PEN NC EMERGENCY KIT FOR NC LOW BLOOD SUGAR TRULICITY SOPN 0.75 4 SOLR MG/0.5ML, 1.5 MG/0.5ML GLUCAGON QL(1 ea per fill 4 VICTOZA SOPN 3 QL(0.3 ml EMERGENCY KIT KIT retail) daily) GVOKE HYPOPEN 1- 4 Insulin Sensitizing Agents PACK SOAJ ACTOS TABS 15 MG, 30 NC QL(1 ea daily) GVOKE HYPOPEN 2- 4 MG (pioglitazone hcl) PACK SOAJ ACTOS TABS 45 MG NC GVOKE PFS SOSY 4 (pioglitazone hcl) AVANDIA TABS 5 KORLYM TABS 5 PA; SP pioglitazone hcl tabs 15 1 QL(1 ea daily) PROGLYCEM SUSP 5 mg, 30 mg (diazoxide) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors pioglitazone hcl tabs 45 mg 1 alogliptin benzoate tabs NC Insulin ADMELOG SOLN NC QL(1.5 ml JANUVIA TABS 3 QL(1 ea daily) daily)

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADMELOG SOLOSTAR NC HUMULIN R U-500 3 QL(1.34 ml SOPN (CONCENTRATED) SOLN daily) AFREZZA POWD NC HUMULIN R U-500 3 QL(1.5 ml KWIKPEN SOPN daily) AFREZZA POWD 12 UNIT, NC QL(3 ea daily) INSULIN ASPART 4 UNIT, 8 UNIT, PROTAMINE/INSULIN NC QL(1.34 ml ASPART FLEXPEN SUPN APIDRA SOLN NC daily) INSULIN ASPART PROTAMINE/INSULIN NC APIDRA SOLOSTAR NC QL(1.5 ml SOPN daily) ASPART SUSP INSULIN LISPRO JUNIOR QL(1.5 ml BASAGLAR KWIKPEN 3 QL(1.5 ml NC SOPN daily) KWIKPEN SOPN daily) INSULIN LISPRO FIASP FLEXTOUCH 3 NC SOPN KWIKPEN SOPN FIASP PENFILL SOCT 3 INSULIN LISPRO QL(1.5 ml PROTAMINE/INSULIN NC daily) LISPRO KWIKPEN SUPN FIASP SOLN 3 QL(1.5 ml INSULIN LISPRO SOLN NC HUMALOG JUNIOR NC QL(1.5 ml daily) KWIKPEN SOPN daily) LANTUS SOLN NC HUMALOG KWIKPEN NC SOPN 100 UNIT/ML LANTUS SOLOSTAR NC QL(1.5 ml SOPN daily) HUMALOG KWIKPEN NC QL(0.8 ml SOPN 200 UNIT/ML daily) LANTUS SOLOSTAR NC SOPN HUMALOG MIX 50/50 NC QL(1.5 ml KWIKPEN SUPN daily) LEVEMIR FLEXTOUCH 3 QL(1.5 ml SOPN daily) HUMALOG MIX 50/50 NC QL(1.5 ml SUSP daily) LEVEMIR SOLN 3 QL(1.5 ml daily) HUMALOG MIX 75/25 NC QL(1.5 ml KWIKPEN SUPN daily) LYUMJEV KWIKPEN NC SOPN HUMALOG MIX 75/25 NC QL(1.34 ml SUSP daily) LYUMJEV SOLN NC QL(1.5 ml HUMALOG SOCT NC daily) MYXREDLIN SOLN NC QL(1.5 ml HUMALOG SOLN NC daily) NOVOLIN 70/30 FLEXPEN NC QL(1.5 ml RELION SUPN daily) HUMULIN 70/30 KWIKPEN NC QL(1.5 ml SUPN daily) NOVOLIN 70/30 FLEXPEN 3 QL(1.5 ml SUPN daily) QL(1.34 ml HUMULIN 70/30 SUSP NC daily) NOVOLIN 70/30 RELION NC QL(1.34 ml SUSP daily) HUMULIN N KWIKPEN NC QL(1.5 ml SUPN daily) NOVOLIN 70/30 SUSP NC QL(1.34 ml daily) HUMULIN N SUSP NC NOVOLIN N FLEXPEN NC QL(1.5 ml RELION SUPN daily) HUMULIN R SOLN NC NOVOLIN N FLEXPEN 3 QL(1.5 ml SUPN daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLIN N RELION NC PRANDIN TABS 2 MG 5 QL(8 ea daily) SUSP (repaglinide) QL(4 ea daily) NOVOLIN N SUSP 3 QL(1.34 ml repaglinide tabs 0.5 mg, 1 2 daily) mg NOVOLIN R FLEXPEN NC repaglinide tabs 2 mg 2 QL(8 ea daily) RELION SOPN STARLIX TABS QL(3 ea daily) NOVOLIN R FLEXPEN 4 5 SOPN (nateglinide) NOVOLIN R RELION NC Sodium-Glucose Co-Transporter 2 (SGLT2) SOLN FARXIGA TABS 3 NOVOLIN R SOLN 3 QL(1.34 ml daily) INVOKANA TABS NC NOVOLOG FLEXPEN 3 QL (1.5 ml SOPN daily) JARDIANCE TABS 4 NOVOLOG MIX 70/30 QL (1.5 ml PREFILLED FLEXPEN 3 daily) STEGLATRO TABS NC QL(1 ea daily) SUPN NOVOLOG MIX 70/30 QL(1.5 ml Sulfonylureas PREFILLED FLEXPEN 3 daily) AMARYL TABS 5 QL(2 ea daily) SUPN (glimepiride) NOVOLOG MIX 70/30 3 QL (1.34 ml chlorpropamide tabs 2 SUSP daily) QL(2 ea daily) NOVOLOG MIX 70/30 3 glimepiride tabs 1 SUSP NOVOLOG PENFILL 3 QL (1.5 ml GLIPIZIDE POWD XX 5 SOCT daily) glipizide tabs or 10 mg, 5 1 NOVOLOG SOLN 3 QL(1.67 ml mg daily glipizide tb24 or 10 mg, 2.5 1 SEMGLEE SOLN NC mg, 5 mg GLUCOTROL TABS TOUJEO MAX SOLOSTAR NC QL(0.5 ml 5 SOPN daily) (glipizide) GLUCOTROL XL TB24 TOUJEO SOLOSTAR NC QL(0.5 ml 5 SOPN daily) (glipizide) TRESIBA FLEXTOUCH 3 QL(1.5 ml glyburide micronized tabs 2 SOPN 100 UNIT/ML daily) GLYBURIDE POWD XX 5 TRESIBA FLEXTOUCH 3 QL(0.9 ml SOPN 200 UNIT/ML daily) glyburide tabs or 5 mg, 1 TRESIBA SOLN 3 1.25 mg, 2.5 mg GLYNASE TABS (glyburide 5 Meglitinide Analogues micronized) QL(3 ea daily) nateglinide tabs 1 tolazamide tabs 2 PRANDIN TABS 1 MG 5 QL(4 ea daily) (repaglinide) tolbutamide tabs 2

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs diphenoxylate w/ atropine 2 to Treat Diarrhea tabs IMODIUM A-D CAPS NC RX/OTC Antidiarrheal - Chloride Channel Antagonists (loperamide hcl) MYTESI TBEC NC LOMOTIL TABS 4 (diphenoxylate w/ atropine) Antidiarrheal/Probiotic Agents - Misc. loperamide hcl caps or 2 RX/OTC BISMUTH SUBGALLATE 5 RX/OTC POWD LOPERAMIDE HCL POWD 5 CULTURELLE DIGESTIVE RX/OTC XX HEALTH WOMENS 4 LOPERAMIDE NC HEALTHY BALANCE HYDROCHLORIDE SOLN CAPS MOTOFEN TABS NC FLORAJEN ACIDOPHILUS 4 RX/OTC CAPS opium tincture tinc 2 FLORAJEN WOMEN 4 RX/OTC CAPS paregoric tinc 2 lactobacillus caps 2 RX/OTC Gastrointestinal Adsorbents PROBIOTIC CAPS 4 RX/OTC KAOLIN COLLOIDAL 5 RX/OTC POWD PROBIOTIC GOLD EXTRA 4 RX/OTC STRENGTH CAPS KAOLIN POWD 5 RX/OTC RX/OTC PRODIGEN CAPS NC PECTIN POWD 5 RX/OTC PROMELLA IN NC RX/OTC PREBIOTIC CAPS ANTIDOTES AND SPECIFIC ANTAGONISTS PROVAD CAPS NC RX/OTC Antidote Combinations

REPHRESH PRO-B CAPS 4 RX/OTC DUODOTE SOAJ 5

VISBIOME PACK 5 RX/OTC NITHIODOTE KIT 5 Antidotes - Chelating Agents VSL#3 DS PACK 5 RX/OTC CHEMET CAPS 5 ZELAC CAPS NC RX/OTC deferasirox pack 180 mg, 5 PA; SP Antidiarrheal/Probiotic Combinations 360 mg, 90 mg RX/OTC deferasirox tabs 360 mg, 2 PA; SP PROBICHEW CHEW NC 90 mg, 180 mg RESTORA RX CAPS 5 deferasirox tbso 125 mg, 2 PA; SP 250 mg, 500 mg RESTORA SPRINKLES NC PA; SP PACK deferiprone tabs 5 Antiperistaltic Agents DIMERCAPTOPROPANE NC SULFONATE DMPS SOLN diphenoxylate w/ atropine 2 liqd EXJADE TBSO 5 PA; SP (deferasirox) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERRIPROX SOLN 100 NC methylene blue (antidote) 2 MG/ML soln FERRIPROX TABS 1000 5 PA; SP PHYSOSTIGMINE 5 MG SALICYLATE SOLN FERRIPROX TABS 500 5 PA; SP PRALIDOXIME CHLORIDE 5 MG (deferiprone) SOAJ FERRIPROX TWICE-A- 5 PA; SP PRAXBIND SOLN 5 DAY TABS PROTOPAM CHLORIDE JADENU SPRINKLE PACK 5 PA; SP 5 (deferasirox) SOLR JADENU TABS 5 PA; SP PROVAYBLUE SOLN NC (deferasirox) PENTETATE CALCIUM NC RADIOGARDASE CAPS 5 TRISODIUM SOLN SODIUM NITRITE SOLN 5 PENTETATE ZINC NC IV TRISODIUM SOLN SODIUM THIOSULFATE 2 Antidotes and Specific Antagonists SOLN IV ACETADOTE SOLN 5 (acetylcysteine (antidote)) sodium thiosulfate soln iv 2 acetylcysteine (antidote) 2 VISTOGARD PACK 4 soln ANDEXXA SOLR 5 PA; SP Benzodiazepine Antagonists flumazenil soln iv 0.5 2 BAL IN OIL SOLN 5 mg/5ml, 1 mg/10ml Opioid Antagonists BRIDION SOLN NC EVZIO SOAJ NC QL(1.6 ml per 30 days retail) CALCIUM DISODIUM 5 VERSENATE SOLN naloxone hcl soaj ij 2 NC QL(1.6 ml per mg/0.4ml 30 days retail) CETYLEV TBEF NC naloxone hcl soct ij 0.4 2 CHARCOAL ACTIVATED 5 RX/OTC mg/ml POWD naloxone hcl soln ij 0.4 2 CHARCOAL POWD 5 RX/OTC mg/ml, 4 mg/10ml naloxone hcl sosy ij 2 2 CYANOKIT SOLR 5 mg/2ml naltrexone hcl tabs or 2 deferoxamine mesylate solr 2 PA; SP NALTREXONE IMPL SC NC DESFERAL SOLR 5 PA; SP ( ) deferoxamine mesylate QL(4 ea per 30 NARCAN LIQD 4 DIGIFAB SOLR 5 days retail) VIVITROL SUSR 5 PA; SP EDETATE CALCIUM 5 DISODIUM POWD ANTIEMETICS - Drugs to Treat Nausea and fomepizole soln 2 Vomiting

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 5-HT3 Receptor Antagonists Antiemetics - Anticholinergic ALOXI SOLN 5 DIMENHYDRINATE SOLN 5 (palonosetron hcl) MECLIZINE HCL ANZEMET TABS 5 QL(2 ea per fill 5 retail) MONOHYDRATE POWD granisetron hcl soln iv 0.1 MECLIZINE HCL POWD 5 mg/ml, 1 mg/ml, 1 mg/ml, 4 2 XX mg/4ml meclizine hcl tabs or 12.5 2 RX/OTC Limit 10 per mg, 25 mg granisetron hcl tabs or 1 2 month;QL(2 ea mg scopolamine pt72 2 daily) TIGAN CAPS OR 300 MG ondansetron hcl soln ij 40 2 5 mg/20ml, 4 mg/2ml (trimethobenzamide hcl) TIGAN SOLN IM 100 ondansetron hcl soln or 4 2 QL(50 ml per 5 mg/5ml fill retail) MG/ML TRANSDERM SCOP PT72 ondansetron hcl tabs or 24 2 QL(0.143 ea NC mg daily) (scopolamine) QL(2 ea TRANSDERM-SCOP PT72 NC ondansetron hcl tabs or 4 2 daily,30 ea per (scopolamine) mg, 8 mg fill retail) trimethobenzamide hcl 2 ONDANSETRON caps or HYDROCHLORIDE/DEXT NC Antiemetics - Miscellaneous ROSE SOLN AKYNZEO CAPS OR 0.5 5 QL(2 ea per 28 ONDANSETRON MG-300 MG days retail) HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN AKYNZEO SOLN IV 0.25 5 MG/20ML-235 MG/20ML QL(2 ea ondansetron tbdp 2 daily,30 ea per AKYNZEO SOLR IV 0.25 NC fill retail) MG-235 MG QL(2 ea daily) palonosetron hcl soln 2 BONJESTA TBCR NC CESAMET CAPS 5 PA; QL(2 ea palonosetron hcl sosy 2 daily) DICLEGIS TBEC QL(4 ea daily) PALONOSETRON 5 5 HYDROCHLORIDE SOLN (doxylamine-pyridoxine) QL(0.0667 ea doxylamine-pyridoxine tbec 2 QL(4 ea daily) SANCUSO PTCH 4 daily,1 ea per 21 days retail) dronabinol caps 2 PA SUSTOL PRSY NC MARINOL CAPS 5 PA (dronabinol) ZOFRAN SOLN 4 MG/5ML 5 QL(50 ml per (ondansetron hcl) fill retail) SYNDROS SOLN NC QL(2 ea ZOFRAN TABS 4 MG, 8 5 daily,30 ea per Substance P/Neurokinin 1 (NK1) Receptor MG (ondansetron hcl) fill retail) QL(3 ea per 30 aprepitant caps 2 days retail) ZUPLENZ FILM NC QL(30 ea per fill retail) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aprepitant caps 125 mg, 80 2 QL(1 ea per 30 BIO-STATIN CAPS 5 mg days retail) QL(2 ea per 30 aprepitant caps 40 mg 2 flucytosine caps or 250 mg 2 days retail) CINVANTI EMUL NC flucytosine caps or 500 mg NC

EMEND CAPS OR 125 5 QL(1 ea per 30 griseofulvin microsize susp 2 MG, 80 MG (aprepitant) days retail) griseofulvin microsize tabs 2 EMEND CAPS OR 40 MG 5 QL(2 ea per 30 (aprepitant) days retail) griseofulvin ultramicrosize 2 EMEND SOLR IV 150 MG tabs (fosaprepitant 5 dimeglumine) nystatin powd or 2 EMEND SUSR OR 125 5 QL(1 ea per 30 QL(6 ea daily) MG/5ML days retail) nystatin tabs or 2 EMEND TRIPACK CAPS 5 QL(3 ea per 30 QL(1 ea daily) (aprepitant) days retail) terbinafine hcl tabs or 2 fosaprepitant dimeglumine 2 Imidazole-Related Antifungals solr CRESEMBA CAPS 5 VARUBI TBPK 4 QL(4 ea per fill retail) CRESEMBA SOLR 5 ANTIFUNGALS - Drugs to Treat Fungal Infections DIFLUCAN SUSR 10 QL(70 ml per Antifungal - Glucan Synthesis Inhibitors MG/ML, 40 MG/ML 5 fill retail) (fluconazole) CANCIDAS SOLR 5 (caspofungin acetate) DIFLUCAN TABS 100 MG 5 QL(1 ea daily) (fluconazole) caspofungin acetate solr 50 2 mg, 70 mg DIFLUCAN TABS 150 MG 5 QL(2 ea per fill (fluconazole) retail) CASPOFUNGIN ACETATE 5 SOLR 50 MG, 70 MG DIFLUCAN TABS 200 MG 5 QL(2 ea daily) (fluconazole) ERAXIS SOLR 5 DIFLUCAN TABS 50 MG 5 QL(7 ea per fill (fluconazole) retail) micafungin sodium solr 2 fluconazole in nacl soln 2 MYCAMINE SOLR 5 (micafungin sodium) fluconazole susr or 10 2 QL(70 ml per mg/ml, 40 mg/ml fill retail) Antifungals fluconazole tabs or 100 mg 2 QL(1 ea daily) ABELCET SUSP 5 QL(2 ea per fill fluconazole tabs or 150 mg 2 AMBISOME SUSR 5 retail) QL(2 ea daily) amphotericin b solr iv 50 2 fluconazole tabs or 200 mg 2 mg QL(7 ea per fill fluconazole tabs or 50 mg 2 ANCOBON CAPS 5 retail) (flucytosine) itraconazole caps or 100 2 PA; QL(1 ea mg daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits itraconazole soln or 10 2 carbinoxamine maleate 2 mg/ml soln 4 mg/5ml ketoconazole tabs or 2 QL(2 ea daily) carbinoxamine maleate 2 tabs 4 mg MICONAZOLE POWD 5 CARBINOXAMINE NC MALEATE TABS 6 MG NOXAFIL SOLN IV 300 5 CLEMASTINE FUMARATE 5 MG/16.7ML POWD XX NOXAFIL SUSP OR 40 5 clemastine fumarate tabs 2 MG/ML or NOXAFIL TBEC OR 100 5 DICOPANOL FUSEPAQ 5 MG (posaconazole) SUSR posaconazole tbec NC DICOPANOL RAPIDPAQ 5 SUSR SPORANOX CAPS 100 5 PA; QL(1 ea MG (itraconazole) daily) QL(240 ml per diphenhydramine hcl elix or 2 fill retail); 12.5 mg/5ml SPORANOX PULSEPAK 5 PA; QL(1 ea RX/OTC CAPS (itraconazole) daily) QL(240 ml per SPORANOX SOLN 10 diphenhydramine hcl elix or NC fill retail); 5 12.5 mg/5ml MG/ML (itraconazole) RX/OTC TOLSURA CAPS NC DIPHENHYDRAMINE HCL 5 POWD XX VFEND IV SOLR 5 diphenhydramine hcl soln ij 2 (voriconazole) 50 mg/ml VFEND SUSR 40 MG/ML 4 DOXYLAMINE 5 RX/OTC (voriconazole) SUCCINATE POWD VFEND TABS 200 MG, 50 4 QL(2 ea daily) MG (voriconazole) KARBINAL ER SUER 5 voriconazole solr iv 200 mg 2 RYVENT TABS NC voriconazole susr or 40 2 mg/ml Antihistamines - Ethylenediamines PYRILAMINE MALEATE voriconazole tabs or 200 2 QL(2 ea daily) 5 mg, 50 mg CRYS PYRILAMINE MALEATE 5 ANTIHISTAMINES - Drugs to Treat Allergies POWD TRIPELENNAMINE HCL 5 Antihistamines - Alkylamines POWD BROMPHENIRAMINE 5 MALEATE POWD Antihistamines - Non-Sedating QL(240 ml per BROMPHENIRAMINE NC SOLN cetirizine hcl soln 2 fill retail); RX/OTC CHLORPHENIRAMINE 5 MALEATE POWD CLARINEX SYRP 0.5 5 MG/ML dexchlorpheniramine NC maleate soln or CLARINEX TABS 5 MG 5 QL(1 ea daily) (desloratadine) Antihistamines - Ethanolamines

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desloratadine tabs 2 QL(1 ea daily) OMEGA-3/D-3 WELLNESS NC PACK KIT QL(1 ea daily) desloratadine tbdp 2 SURE RESULT O3D3 NC SYSTEM KIT levocetirizine QL(10 ml VYTORIN TABS 5 PA; ST; QL(1 dihydrochloride soln or 2.5 2 daily); RX/OTC (ezetimibe-simvastatin) ea daily) mg/5ml levocetirizine QL(1 ea daily); Antihyperlipidemics - Misc. dihydrochloride tabs or 5 2 RX/OTC icosapent ethyl caps 2 ST mg LOVAZA CAPS (omega-3- 5 QL(4 ea daily) QUZYTTIR SOLN NC acid ethyl esters) XYZAL ALLERGY 24HR QL(10 ml omega-3-acid ethyl esters 2 QL(4 ea daily) caps CHILDRENS SOLN NC daily); RX/OTC (levocetirizine ST dihydrochloride) VASCEPA CAPS 4 Antihistamines - Phenothiazines Bile Acid Sequestrants cholestyramine light pack 4 QL(6 ea daily) PHENERGAN SOLN 5 2 (promethazine hcl) gm cholestyramine light powd QL(6 gm daily) promethazine hcl soln ij 50 2 2 mg/ml, 25 mg/ml 4 gm/dose cholestyramine pack or 4 QL(6 ea daily) promethazine hcl soln or 2 QL(240 ml per 2 6.25 mg/5ml fill retail) gm cholestyramine powd or 4 QL(6 gm daily) promethazine hcl supp re 2 QL(12 ea per 2 50 mg, 12.5 mg, 25 mg fill retail) gm/dose colesevelam hcl pack 3.75 QL(1 ea daily) promethazine hcl syrp or 2 QL(240 ml per 2 6.25 mg/5ml fill retail) gm colesevelam hcl tabs 625 QL(7 ea daily) promethazine hcl tabs or 2 2 12.5 mg, 25 mg, 50 mg mg Antihistamines - Piperidines COLESTID FLAVORED 5 QL(6 gm daily) GRAN 5 GM (colestipol hcl) cyproheptadine hcl syrp or 2 2 mg/5ml COLESTID FLAVORED QL(6 ea daily) PACK 5 GM/7.5GM 5 cyproheptadine hcl tabs or 2 (colestipol hcl) 4 mg COLESTID GRAN 5 GM 5 QL(6 gm daily) ANTIHYPERLIPIDEMICS - Drugs to Treat High (colestipol hcl) Cholesterol COLESTID PACK 5 GM 5 QL(6 ea daily) Adenosine Triphosphate-Citrate Lyase (ACL) (colestipol hcl) NEXLETOL TABS NC COLESTID TABS 1 GM 5 QL(16 ea daily) (colestipol hcl) Antihyperlipidemics - Combinations colestipol hcl gran 5 gm 2 QL(6 gm daily) PA; ST; QL(1 ezetimibe-simvastatin tabs 2 ea daily) colestipol hcl pack 5 gm 2 QL(6 ea daily) NEXLIZET TABS NC colestipol hcl tabs 1 gm 2 QL(16 ea daily) OMEGA-3 RX COMPLETE NC THPK 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUESTRAN LIGHT POWD 5 QL(6 gm daily) LOPID TABS (gemfibrozil) 5 QL(2 ea daily) (cholestyramine light) TRICOR TABS QUESTRAN PACK 4 GM 5 QL(6 ea daily) NC (cholestyramine) (fenofibrate) QUESTRAN POWD 4 QL(6 gm daily) TRIGLIDE TABS 5 QL(1 ea daily) GM/DOSE 5 (cholestyramine) TRILIPIX CPDR (choline 5 QL(1 ea daily) fenofibrate) WELCHOL PACK 3.75 GM 5 QL(1 ea daily) (colesevelam hcl) HMG CoA Reductase Inhibitors WELCHOL TABS 625 MG 5 QL(7 ea daily) (colesevelam hcl) ALTOPREV TB24 NC Fibric Acid Derivatives $0 copay for Generic only, ANTARA CAPS 5 atorvastatin calcium tabs or 2 age 40 to 10 mg, 20 mg 76;QL(1 ea choline fenofibrate cpdr 2 QL(1 ea daily) daily) atorvastatin calcium tabs or QL(1 ea daily) fenofibrate caps or 150 mg, 2 QL(1 ea daily) 2 50 mg 40 mg, 80 mg QL(1 ea daily) $0 copay for fenofibrate micronized caps 2 CRESTOR TABS 10 MG, 5 NC MG (rosuvastatin calcium) Generic only, age 40 to 76 fenofibrate tabs or 120 mg NC CRESTOR TABS 40 MG, 20 MG (rosuvastatin NC fenofibrate tabs or 160 mg 2 calcium) EQUAPAX/ATORVASTATI FENOFIBRATE TABS OR NC NC 160 MG N CALCIUM/COQ10 THPK fenofibrate tabs or 40 mg, QL(1 ea daily) EZALLOR SPRINKLE NC 54 mg, 145 mg, 48 mg, 160 2 CPSP mg FLOLIPID SUSP NC FENOFIBRIC ACID TABS NC 105 MG $0 copay for Generic only, fenofibric acid tabs 105 mg, 2 QL(1 ea daily) 35 mg fluvastatin sodium caps 2 age 40 to 76;QL(1 ea FENOGLIDE TABS 120 NC daily) MG (fenofibrate) $0 copay for FENOGLIDE TABS 40 MG 5 QL(1 ea daily) Generic only, (fenofibrate) fluvastatin sodium tb24 2 age 40 to FIBRICOR TABS 105 MG, 5 76;QL(1 ea 35 MG daily) FIBRICOR TABS 105 MG, 5 QL(1 ea daily) $0 copay for 35 MG (fenofibric acid) LESCOL XL TB24 NC (fluvastatin sodium) Generic only, age 40 to 76 GEMFIBROZIL POWD XX 5 $0 copay for QL(2 ea daily) LIPITOR TABS 10 MG NF Generic only, gemfibrozil tabs or 2 (atorvastatin calcium) age 40 to 76 LIPOFEN CAPS 5 QL(1 ea daily) (fenofibrate) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits $0 copay for $0 copay for LIPITOR TABS 10 MG, 20 NC Generic only, Generic only, MG (atorvastatin calcium) rosuvastatin calcium tabs age 40 to 76 2 age 40 to 10 mg, 5 mg 76;QL(1 ea LIPITOR TABS 40 MG, 80 NC MG (atorvastatin calcium) daily) rosuvastatin calcium tabs QL(1 ea daily) LIPITOR TABS 80 MG NF 2 (atorvastatin calcium) 40 mg, 20 mg QL(1 ea daily) SIMVASTATIN SUSP OR NC LIVALO TABS NC 20 MG/5ML $0 copay for PA; ST; $0 Generic only, copay for lovastatin tabs 10 mg, 20 2 age 40 to simvastatin tabs or 10 mg, 2 Generic only, mg 76;QL(1 ea 20 mg, 40 mg, 5 mg age 40 to daily) 76;QL(1 ea ST; $0 copay daily) PA; ST; QL(1 for Generic simvastatin tabs or 80 mg 2 lovastatin tabs 40 mg 2 only, age 40 to ea daily) 76;QL(2 ea PA; ST; $0 daily) copay for ZOCOR TABS 10 MG, 20 Generic only, PA; ST; $0 MG, 40 MG, 5 MG 5 copay for (simvastatin) age 40 to PRAVACHOL TABS 20 Generic only, 76;QL(1 ea MG, 80 MG (pravastatin 5 daily) ) age 40 to sodium 76;QL(1 ea ZOCOR TABS 80 MG 5 PA; ST; QL(1 daily) (simvastatin) ea daily) PA; ST; $0 QL(1 ea daily) copay for ZYPITAMAG TABS NC PRAVACHOL TABS 40 5 Generic only, MG (pravastatin sodium) age 40 to Intestinal Cholesterol Absorption Inhibitors 76;QL(2 ea ezetimibe tabs 2 QL(1 ea daily) daily) $0 copay for ZETIA TABS (ezetimibe) NC Generic only, pravastatin sodium tabs 10 2 age 40 to Microsomal Triglyceride Transfer Protein (MTP) mg 76;QL(1 ea PA; SP daily) JUXTAPID CAPS 5 PA; ST; $0 Nicotinic Acid Derivatives copay for niacin (antihyperlipidemic) NC pravastatin sodium tabs 20 2 Generic only, tabs 500 mg mg, 80 mg age 40 to 76;QL(1 ea niacin (antihyperlipidemic) 2 QL(2 ea daily) daily) tbcr 1000 mg, 750 mg PA; ST; $0 niacin (antihyperlipidemic) 2 QL(1 ea daily) copay for tbcr 500 mg pravastatin sodium tabs 40 2 Generic only, NIASPAN TBCR 1000 MG, QL(2 ea daily) mg age 40 to 750 MG (niacin 5 76;QL(2 ea (antihyperlipidemic)) daily) NIASPAN TBCR 500 MG 5 QL(1 ea daily) (niacin (antihyperlipidemic))

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Proprotein Convertase Subtilisin/Kexin Type 9 quinapril hcl tabs 2 QL(2 ea daily) PRALUENT SOAJ 4 PA; SP ramipril caps 2 QL(2 ea daily) REPATHA PUSHTRONEX NC PA; SP SYSTEM SOCT trandolapril tabs 1 mg, 2 2 QL(1 ea daily) mg REPATHA SOSY NC SP trandolapril tabs 4 mg 2 QL(2 ea daily) REPATHA SURECLICK NC SP SOAJ VASOTEC TABS (enalapril 5 QL(2 ea daily) maleate) ANTIHYPERTENSIVES - Drugs to Treat High ZESTRIL TABS 10 MG, 20 QL(2 ea daily) Blood Pressure MG, 30 MG, 40 MG, 5 MG 5 ACE Inhibitors (lisinopril) ZESTRIL TABS 2.5 MG QL(1 ea daily) ACCUPRIL TABS 5 QL(2 ea daily) 5 (quinapril hcl) (lisinopril) ALTACE CAPS (ramipril) 5 QL(2 ea daily) Agents for Pheochromocytoma DEMSER CAPS 5 PA; SP benazepril hcl tabs or 10 2 QL(2 ea daily) (metyrosine) mg, 40 mg, 20 mg DIBENZYLINE CAPS 5 benazepril hcl tabs or 5 mg 2 QL(1 ea daily) (phenoxybenzamine hcl) metyrosine caps 5 PA; SP captopril tabs or 100 mg, 2 QL(3 ea daily) 12.5 mg, 25 mg, 50 mg phenoxybenzamine hcl 2 enalapril maleate tabs or QL(2 ea daily) caps or 10 mg, 2.5 mg, 20 mg, 5 2 mg phentolamine mesylate solr 2 ij enalaprilat inj 2 Angiotensin II Receptor Antagonists EPANED SOLN 5 QL(5 ml daily) ATACAND TABS NC (candesartan cilexetil) fosinopril sodium tabs 10 QL(1 ea daily) 2 AVAPRO TABS 5 QL(1 ea daily) mg, 20 mg (irbesartan) fosinopril sodium tabs 40 QL(2 ea daily) 2 BENICAR TABS NC mg (olmesartan medoxomil) lisinopril tabs or 10 mg, 20 QL(2 ea daily) 2 candesartan cilexetil tabs 2 QL(2 ea daily) mg, 30 mg, 40 mg, 5 mg 16 mg, 4 mg, 8 mg QL(1 ea daily) lisinopril tabs or 2.5 mg 2 candesartan cilexetil tabs 2 QL(1 ea daily) 32 mg LOTENSIN TABS QL(2 ea daily) 5 candesartan cilexetil tabs 2 (benazepril hcl) 32 mg QL(2 ea daily) moexipril hcl tabs 2 COZAAR TABS 100 MG 5 QL(1 ea daily) (losartan potassium) perindopril erbumine tabs 2 QL(2 ea daily) COZAAR TABS 25 MG, 50 5 QL(2 ea daily) MG (losartan potassium) PRINIVIL TABS (lisinopril) 5 QL(2 ea daily) DIOVAN TABS (valsartan) NC QBRELIS SOLN 5 QL(5 ml daily)

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDARBI TABS NC guanfacine hcl tabs 2 eprosartan mesylate tabs 2 QL(1 ea daily) methyldopa tabs 2 irbesartan tabs 2 QL(1 ea daily) MINIPRESS CAPS 5 (prazosin hcl) losartan potassium tabs or 2 QL(1 ea daily) 100 mg prazosin hcl caps 2 losartan potassium tabs or 2 QL(2 ea daily) PRAZOSIN 5 25 mg, 50 mg HYDROCHLORIDE POWD MICARDIS TABS 5 QL(1 ea daily) RESERPINE POWD 5 (telmisartan) olmesartan medoxomil tabs 2 QL(1 ea daily) terazosin hcl caps 2 or 20 mg, 40 mg Antihypertensive Combinations olmesartan medoxomil tabs 2 QL(2 ea daily) or 5 mg ACCURETIC TABS 10 QL(1 ea daily) QL(1 ea daily) MG-12.5 MG, 20 MG-25 5 telmisartan tabs 2 MG (quinapril- hydrochlorothiazide) valsartan tabs 160 mg, 80 2 QL(2 ea daily) mg ACCURETIC TABS 12.5 QL(2 ea daily) MG-20 MG (quinapril- 5 valsartan tabs 320 mg, 40 2 QL(1 ea daily) mg hydrochlorothiazide) amlodipine besylate- QL(1 ea daily) valsartan tabs 320 mg, 40 2 2 mg benazepril hcl caps Antiadrenergic Antihypertensives amlodipine besylate- 2 QL(1 ea daily) olmesartan medoxomil tabs CARDURA TABS 5 (doxazosin mesylate) amlodipine besylate- QL(1 ea daily) valsartan tabs 10 mg-160 2 CATAPRES TABS 4 mg, 10 mg-320 mg, 160 (clonidine hcl) mg-5 mg, 320 mg-5 mg CATAPRES-TTS-1 PTWK 4 amlodipine-valsartan- 2 QL(1 ea daily) (clonidine) hydrochlorothiazide tabs CATAPRES-TTS-2 PTWK 4 ATACAND HCT TABS (clonidine) (candesartan cilexetil- NC ) CATAPRES-TTS-3 PTWK 4 hydrochlorothiazide (clonidine) atenolol & chlorthalidone 2 QL(1 ea daily) CLONIDINE HCL POWD 5 tabs XX AVALIDE TABS QL(1 ea daily) 5 clonidine hcl tabs or 0.1 2 (irbesartan- mg, 0.2 mg, 0.3 mg hydrochlorothiazide) CLONIDINE 5 AZOR TABS (amlodipine QL(1 ea daily) HYDROCHLORIDE POWD besylate-olmesartan 5 medoxomil) clonidine ptwk 2 benazepril & 2 QL(1 ea daily) hydrochlorothiazide tabs doxazosin mesylate tabs or 2 1 mg, 2 mg, 4 mg, 8 mg

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENICAR HCT TABS HYZAAR TABS (losartan QL(1 ea daily) (olmesartan medoxomil- NC potassium & 5 hydrochlorothiazide) hydrochlorothiazide) bisoprolol & QL(2 ea daily) irbesartan- 2 QL(1 ea daily) hydrochlorothiazide tabs 10 2 hydrochlorothiazide tabs mg-6.25 mg lisinopril & QL(1 ea daily) bisoprolol & QL(1 ea daily) hydrochlorothiazide tabs 10 2 hydrochlorothiazide tabs 2 mg-12.5 mg 2.5 mg-6.25 mg, 5 mg-6.25 lisinopril & QL(4 ea daily) mg hydrochlorothiazide tabs 2 BYVALSON TABS NC 12.5 mg-20 mg lisinopril & QL(2 ea daily) candesartan cilexetil- 2 QL(1 ea daily) hydrochlorothiazide tabs 20 2 hydrochlorothiazide tabs mg-25 mg captopril & QL(3 ea daily) LOPRESSOR HCT TABS QL(2 ea daily) hydrochlorothiazide tabs 15 2 (metoprolol & 4 mg-25 mg, 15 mg-50 mg hydrochlorothiazide) captopril & QL(2 ea daily) losartan potassium & 2 QL(1 ea daily) hydrochlorothiazide tabs 25 2 hydrochlorothiazide tabs mg-25 mg, 25 mg-50 mg LOTENSIN HCT TABS QL(1 ea daily) CORZIDE TABS 40 MG-5 QL(1 ea daily) (benazepril & 5 MG (nadolol & 5 hydrochlorothiazide) bendroflumethiazide) LOTREL CAPS QL(1 ea daily) CORZIDE TABS 5 MG-80 5 QL(1 ea daily) (amlodipine besylate- 4 MG benazepril hcl) DIOVAN HCT TABS methyldopa & QL(3 ea daily) (valsartan- NC hydrochlorothiazide tabs 15 2 hydrochlorothiazide) mg-250 mg DUTOPROL TB24 NC methyldopa & QL(2 ea daily) hydrochlorothiazide tabs 25 2 EDARBYCLOR TABS NC mg-250 mg metoprolol & 2 QL(2 ea daily) enalapril maleate & 2 QL(2 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs METOPROLOL EXFORGE HCT TABS SUCCINATE NC (amlodipine-valsartan- NC ER/HYDROCHLOROTHIA hydrochlorothiazide) ZIDE TB24 EXFORGE TABS MICARDIS HCT TABS QL(1 ea daily) (amlodipine besylate- NC 12.5 MG-40 MG, 25 MG-80 5 valsartan) MG (telmisartan- fosinopril sodium & QL(1 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 10 2 MICARDIS HCT TABS QL(2 ea daily) mg-12.5 mg 12.5 MG-80 MG 5 fosinopril sodium & QL(4 ea daily) (telmisartan- hydrochlorothiazide tabs 2 hydrochlorothiazide) 12.5 mg-20 mg nadolol & 2 QL(1 ea daily) bendroflumethiazide tabs

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olmesartan medoxomil- QL(1 ea daily) VASERETIC TABS QL(2 ea daily) amlodipine- 2 (enalapril maleate & 5 hydrochlorothiazide tabs hydrochlorothiazide) olmesartan medoxomil- QL(1 ea daily) ZESTORETIC TABS 10 QL(1 ea daily) hydrochlorothiazide tabs 2 MG-12.5 MG (lisinopril & 5 12.5 mg-20 mg, 12.5 mg- hydrochlorothiazide) 40 mg, 25 mg-40 mg ZESTORETIC TABS 12.5 QL(4 ea daily) olmesartan medoxomil- MG-20 MG (lisinopril & 5 hydrochlorothiazide tabs 2 hydrochlorothiazide) 12.5 mg-20 mg, 25 mg-40 ZESTORETIC TABS 20 QL(2 ea daily) mg MG-25 MG (lisinopril & 5 PRESTALIA TABS NC hydrochlorothiazide) ZIAC TABS 10 MG-6.25 QL(2 ea daily) propranolol & 2 QL(2 ea daily) MG (bisoprolol & 4 hydrochlorothiazide tabs hydrochlorothiazide) quinapril- QL(1 ea daily) ZIAC TABS 2.5 MG-6.25 QL(1 ea daily) hydrochlorothiazide tabs 10 2 MG, 5 MG-6.25 MG 4 mg-12.5 mg, 20 mg-25 mg (bisoprolol & quinapril- QL(2 ea daily) hydrochlorothiazide) hydrochlorothiazide tabs 2 Antihypertensives - Misc. 12.5 mg-20 mg VECAMYL TABS 5 PA; SP TARKA TBCR (trandolapril- 4 QL(1 ea daily) verapamil hcl) Direct Renin Inhibitors TEKTURNA HCT TABS 4 aliskiren fumarate tabs 150 2 QL(2 ea daily) mg telmisartan-amlodipine tabs 2 QL(1 ea daily) aliskiren fumarate tabs 300 2 QL(1 ea daily) telmisartan- QL(1 ea daily) mg hydrochlorothiazide tabs 2 TEKTURNA TABS 150 MG 5 QL(2 ea daily) 12.5 mg-40 mg, 25 mg-80 (aliskiren fumarate) mg TEKTURNA TABS 300 MG 5 QL(1 ea daily) telmisartan- QL(2 ea daily) (aliskiren fumarate) hydrochlorothiazide tabs 2 12.5 mg-80 mg Selective Aldosterone Receptor Antagonists QL(2 ea daily) TENORETIC 100 TABS 5 QL(1 ea daily) eplerenone tabs 2 (atenolol & chlorthalidone) INSPRA TABS 4 QL(2 ea daily) TENORETIC 50 TABS 5 QL(1 ea daily) (eplerenone) (atenolol & chlorthalidone) Vasodilators trandolapril-verapamil hcl 2 QL(1 ea daily) tbcr CORLOPAM SOLN 5 TRIBENZOR TABS QL(1 ea daily) hydralazine hcl soln ij 20 (olmesartan medoxomil- 5 2 amlodipine- mg/ml hydrochlorothiazide) hydralazine hcl tabs or 10 2 mg, 100 mg, 50 mg, 25 mg TWYNSTA TABS 5 QL(1 ea daily) (telmisartan-amlodipine) minoxidil tabs or 10 mg, 2.5 2 mg valsartan- 2 QL(1 ea daily) hydrochlorothiazide tabs 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIPRIDE RTU SOLN NC QUINACRINE DIHYDROCHLORIDE 5 DIHYDRATE POWD NITROPRESS SOLN 5 (nitroprusside sodium) QUINACRINE 5 nitroprusside sodium soln 2 DIHYDROCHLORIDE POWD ANTIMALARIALS - Drugs to Treat Malaria QUINACRINE HCL POWD 5 (Parasitic Infections) QL(2 ea Antimalarial Combinations quinine sulfate caps or 2 daily,84 ea per atovaquone-proguanil hcl 2 fill retail) tabs QUININE SULFATE 5 COARTEM TABS 5 QL(24 ea per DIHYDRATE POWD fill retail) QUININE SULFATE 5 MALARONE TABS 4 POWD XX (atovaquone-proguanil hcl) ANTIMYASTHENIC/CHOLINERGIC AGENTS PYRIMETHAMINE/LEUCO NC VORIN CAPS Antimyasthenic/Cholinergic Agents Antimalarials BLOXIVERZ SOLN 5 ARAKODA TABS NC (neostigmine methylsulfate) FIRDAPSE TABS 5 PA; SP CHLOROQUINE 5 PHOSPHATE POWD XX GUANIDINE HCL TABS 5 chloroquine phosphate 2 tabs or 250 mg, 500 mg MESTINON SOLN 5 (pyridostigmine bromide) DARAPRIM TABS 5 PA; SP MESTINON TABS 5 (pyridostigmine bromide) hydroxychloroquine sulfate 2 tabs or MESTINON TIMESPAN KRINTAFEL TABS NC TBCR (pyridostigmine 5 bromide) QL(6 ea per fill mefloquine hcl tabs 2 neostigmine methylsulfate retail) soln iv 10 mg/10ml, 5 2 PLAQUENIL TABS mg/10ml (hydroxychloroquine 4 NEOSTIGMINE sulfate) METHYLSULFATE SOLN 5 IV 10 MG/10ML, 5 2 primaquine phosphate tabs MG/10ML PRIMAQUINE NEOSTIGMINE PHOSPHATE TABS 5 METHYLSULFATE SOLN NC (primaquine phosphate) IV 3 MG/3ML, 5 MG/5ML pyrimethamine tabs or 2 PA; SP NEOSTIGMINE METHYLSULFATE SOSY NC QL(2 ea IV 2 MG/2ML, 3 MG/3ML, 4 QUALAQUIN CAPS 5 (quinine sulfate) daily,84 ea per MG/4ML, 5 MG/5ML fill retail) pyridostigmine bromide 2 soln or 60 mg/5ml

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyridostigmine bromide NC PRIFTIN TABS 5 tabs or 30 mg pyridostigmine bromide 2 pyrazinamide tabs or 2 tabs or 60 mg pyridostigmine bromide 2 PYRAZINAMIDE TABS OR 4 tbcr or 180 mg rifabutin caps 2 REGONOL SOLN 5 RIFADIN CAPS OR 150 4 RUZURGI TABS 5 PA; SP MG, 300 MG (rifampin) RIFADIN SOLR IV 600 MG 5 ANTIMYCOBACTERIAL AGENTS - Drugs to (rifampin) Treat Tuberculosis (Bacterial Infections) rifampin caps or 150 mg, 2 Anti TB Combinations 300 mg RIFAMATE CAPS 5 rifampin solr iv 600 mg 2

RIFATER TABS 5 RIFAMPIN/SYRSPEND SF NC PH4 SUSP Antimycobacterial Agents SIRTURO TABS 100 MG 5 AMINOSALICYLIC ACID 5 POWD TRECATOR TABS 5 CAPASTAT SULFATE 5 SOLR ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer cycloserine caps or 2 Alkylating Agents ETHAMBUTOL HCL 5 ALKERAN SOLR IV 50 MG 5 SP POWD XX (melphalan hcl) ethambutol hcl tabs or 100 2 ALKERAN TABS OR 2 MG 4 mg, 400 mg (melphalan) ISONIAZID POWD XX 5 BELRAPZO SOLN NC SP isoniazid soln ij 100 mg/ml 2 BENDAMUSTINE 5 PA; SP HYDROCHLORIDE SOLN isoniazid syrp or 50 mg/5ml 2 BENDEKA SOLN 5 PA; SP ISONIAZID TABS OR 100 2 MG BICNU SOLR (carmustine) 5 isoniazid tabs or 100 mg, 2 300 mg busulfan soln 2 MYAMBUTOL TABS 4 BUSULFEX SOLN 5 (ethambutol hcl) (busulfan) MYCOBUTIN CAPS 5 carboplatin soln 450 (rifabutin) mg/45ml, 50 mg/5ml, 600 2 PASER PACK 5 mg/60ml, 150 mg/15ml, 50 mg/5ml PRETOMANID TABS 5 carmustine solr 2

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cisplatin soln iv 200 TEPADINA SOLR 100 MG 5 PA; SP mg/200ml, 100 mg/100ml, 2 (thiotepa) 50 mg/50ml TEPADINA SOLR 15 MG 5 CISPLATIN SOLR IV 50 NC (thiotepa) MG thiotepa solr ij 100 mg 2 PA; SP cyclophosphamide caps or 2 25 mg, 50 mg thiotepa solr ij 15 mg 2 cyclophosphamide solr ij 1 2 gm, 2 gm, 500 mg TREANDA SOLR 5 PA; SP EVOMELA SOLR NC SP YONDELIS SOLR 5 PA; SP GLEOSTINE CAPS 5 ZANOSAR SOLR 5 GLIADEL WAFER WAFR 5 ZEPZELCA SOLR NC IFEX SOLR 1 GM 5 (ifosfamide) Antimetabolites IFEX SOLR 3 GM 5 ALIMTA SOLR 5 PA; SP ifosfamide soln 1 gm/20ml, 2 ARRANON SOLN 5 3 gm/60ml SP ifosfamide solr 1 gm 2 azacitidine susr 2 PA; SP IFOSFAMIDE SOLR 3 GM 5 capecitabine tabs 2

LEUKERAN TABS 4 cladribine soln 2 melphalan hcl solr 2 SP clofarabine soln 2 CLOLAR SOLN 5 melphalan tabs 2 (clofarabine) MUSTARGEN SOLR 5 cytarabine soln 2

MYLERAN TABS 4 DACOGEN SOLR 5 SP (decitabine) oxaliplatin soln 2 decitabine solr 2 SP oxaliplatin solr 2 floxuridine solr ij 2 TEMODAR CAPS OR 100 PA; SP fludarabine phosphate soln 2 MG, 140 MG, 180 MG, 20 4 MG, 250 MG, 5 MG (temozolomide) fludarabine phosphate solr 2 TEMODAR SOLR IV 100 5 PA; SP fluorouracil soln iv 1 MG gm/20ml, 2.5 gm/50ml, 5 2 gm/100ml, 500 mg/10ml temozolomide caps 2 PA; SP FOLOTYN SOLN 5 PA; SP

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gemcitabine hcl soln 2 ZALTRAP SOLN 5 PA; SP gemcitabine hcl solr 2 ZIRABEV SOLN NC GEMCITABINE Antineoplastic - Antibodies HYDROCHLORIDE SOLN 1 GM/10ML, 2 GM/20ML, 5 ADCETRIS SOLR 5 PA; SP 200 MG/2ML (gemcitabine hcl) ARZERRA CONC 5 PA; SP GEMCITABINE PA; SP HYDROCHLORIDE SOLN 5 BAVENCIO SOLN 5 1.5 GM/15ML BESPONSA SOLR 5 PA; SP GEMCITABINE SOLN 5 (gemcitabine hcl) BLINCYTO SOLR 5 PA; SP GEMZAR SOLR 5 (gemcitabine hcl) CAMPATH SOLN 5 INFUGEM SOLN NC DARZALEX SOLN 5 PA; SP mercaptopurine tabs or 2 EMPLICITI SOLR 5 PA; SP METHOTREXATE POWD 5 XX ENHERTU SOLR NC methotrexate sodium soln 2 ERBITUX SOLN 5 PA; SP methotrexate sodium solr 2 GAZYVA SOLN 5 PA; SP methotrexate sodium tabs 2 HERCEPTIN SOLR 150 5 PA; SP MG PURIXAN SUSP 5 HERCEPTIN SOLR 440 5 SP MG TABLOID TABS 4 PA; SP HERZUMA SOLR NC TREXALL TABS 4 IMFINZI SOLN 5 PA; SP VIDAZA SUSR 5 SP (azacitidine) KADCYLA SOLR 5 PA; SP XATMEP SOLN 5 KANJINTI SOLR NC XELODA TABS 4 PA; SP (capecitabine) KEYTRUDA SOLN 5 PA; SP Antineoplastic - Angiogenesis Inhibitors LARTRUVO SOLN 5 PA; SP AVASTIN SOLN 5 PA; SP LIBTAYO SOLN 5 PA; SP CYRAMZA SOLN 5 PA; SP LUMOXITI SOLR 5 PA; SP MVASI SOLN NC MYLOTARG SOLR 5 PA; SP

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OGIVRI SOLR NC YESCARTA SUSP 5 PA; SP

ONTRUZANT SOLR NC Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS NC OPDIVO SOLN 5 PA; SP ERIVEDGE CAPS 5 PA; SP PADCEV SOLR NC ODOMZO CAPS 4 PA; SP PERJETA SOLN 5 PA; SP Antineoplastic - Hormonal and Related Agents POLIVY SOLR 140 MG NC abiraterone acetate tabs 2 PA; SP PORTRAZZA SOLN 5 PA; SP anastrozole tabs or 2 POTELIGEO SOLN 5 PA; SP ARIMIDEX TABS 4 (anastrozole) RITUXAN SOLN 5 PA; SP AROMASIN TABS 4 SP RUXIENCE SOLN NC (exemestane) bicalutamide tabs 2 SARCLISA SOLN NC CASODEX TABS 5 TECENTRIQ SOLN 5 PA; SP (bicalutamide) DEPO-PROVERA SUSP 5 TRAZIMERA SOLR NC ELIGARD KIT 4 PA; SP TRODELVY SOLR 5 PA; SP EMCYT CAPS 4 PA; SP TRUXIMA SOLN NC PA; QL(4 ea ERLEADA TABS 4 UNITUXIN SOLN 5 PA; SP daily); SP SP VECTIBIX SOLN 5 PA; SP exemestane tabs 2 PA; SP FARESTON TABS 5 YERVOY SOLN 5 (toremifene citrate) PA; SP FASLODEX SOLN 5 ZEVALIN Y-90 KIT 5 (fulvestrant) Antineoplastic - BCL-2 Inhibitors FEMARA TABS (letrozole) 4 VENCLEXTA STARTING 5 PA; SP PACK TBPK FIRMAGON SOLR 5 PA; SP PA; SP VENCLEXTA TABS 5 flutamide caps 2 Antineoplastic - Cellular Immunotherapy fulvestrant soln 2 KYMRIAH SUSP 5 PA; SP hydroxyprogesterone PA; SP caproate (antineoplastic) 2 PROVENGE SUSP 5 soln

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits letrozole tabs or 2 ZYTIGA TABS 500 MG NC SP leuprolide acetate kit ij 2 SP Antineoplastic - Immunomodulators LEUPROLIDE LEVAMISOLE HCL POWD 5 ACETATE/BUPIVACAINE NC PA; SP HYDROCHLORIDE SOLN POMALYST CAPS 4 LUPRON DEPOT (1- 4 PA; SP MONTH) KIT Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE LUPRON DEPOT (3- 4 PA; SP NC MONTH) KIT WEEKLY TBPK XPOVIO 40 MG ONCE LUPRON DEPOT (4- 4 PA; SP NC MONTH) KIT WEEKLY TBPK XPOVIO 40 MG TWICE LUPRON DEPOT (6- 4 PA; SP NC MONTH) KIT WEEKLY TBPK PA; SP XPOVIO 60 MG ONCE NC LYSODREN TABS 4 WEEKLY TBPK XPOVIO 60 MG TWICE MEGESTROL ACETATE 5 NC POWD XX WEEKLY TBPK XPOVIO 80 MG ONCE megestrol acetate susp or 2 NC 40 mg/ml, 400 mg/10ml WEEKLY TBPK XPOVIO 80 MG TWICE megestrol acetate tabs or 2 NC 20 mg, 40 mg WEEKLY TBPK Antineoplastic Antibiotics NILANDRON TABS NC (nilutamide) bleomycin sulfate solr 2 nilutamide tabs 2 COSMEGEN SOLR 5 NUBEQA TABS 4 PA; SP (dactinomycin) dactinomycin solr 2 SOLTAMOX SOLN 5 daunorubicin hcl soln 2 PA; SP tamoxifen citrate tabs or 10 6 AL(At least 40 mg, 20 mg yrs old) DAUNORUBICIN PA; SP toremifene citrate tabs 2 HYDROCHLORIDE SOLN 5 20 MG/4ML (daunorubicin hcl) TRELSTAR MIXJECT 5 PA; SP SUSR DAUNORUBICIN PA; SP PA; SP HYDROCHLORIDE SOLN 5 VANTAS KIT 5 50 MG/10ML PA; SP XTANDI CAPS 4 DOXIL INJ (doxorubicin hcl 5 liposomal) PA; SP YONSA TABS 4 doxorubicin hcl liposomal 2 inj PA; SP ZOLADEX IMPL 5 doxorubicin hcl soln 2 ZYTIGA TABS 250 MG NC PA; SP (abiraterone acetate) doxorubicin hcl solr 2

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELLENCE SOLN 5 ALECENSA CAPS 5 PA; SP (epirubicin hcl) epirubicin hcl soln 2 ALIQOPA SOLR NC PA; SP IDAMYCIN PFS SOLN 5 ALUNBRIG TABS 5 (idarubicin hcl) PA; SP idarubicin hcl soln 2 ALUNBRIG TBPK 5

JELMYTO SOLR NC AYVAKIT TABS NC mitomycin solr iv 20 mg, 40 2 BALVERSA TABS NC mg, 5 mg BELEODAQ SOLR 5 PA; SP MITOMYCIN SOSY IS 20 5 MG/40ML BORTEZOMIB SOLR 5 PA; SP mitoxantrone hcl conc 2 SP BOSULIF TABS 4 PA; SP valrubicin soln 2 PA; SP BRAFTOVI CAPS 50 MG 5 VALSTAR SOLN 5 PA; SP (valrubicin) BRAFTOVI CAPS 75 MG 5 PA; SP Antineoplastic Combinations DARZALEX FASPRO NC BRUKINSA CAPS NC SOLN CABOMETYX TABS 4 PA; SP HERCEPTIN HYLECTA NC SOLN CALQUENCE CAPS 5 PA; SP KISQALI FEMARA 200 4 PA; SP DOSE TBPK CAPRELSA TABS 5 PA; SP KISQALI FEMARA 400 4 PA; SP DOSE TBPK COMETRIQ KIT 5 PA; SP KISQALI FEMARA 600 4 PA; SP DOSE TBPK COPIKTRA CAPS 4 PA; SP LONSURF TABS 5 PA; SP COTELLIC TABS 5 PA; SP PHESGO SOLN NC erlotinib hcl tabs 2 PA; SP RITUXAN HYCELA SOLN 5 PA; SP everolimus tabs 2 PA; SP VYXEOS SUSR 5 PA; SP FARYDAK CAPS NC SP Antineoplastic Enzyme Inhibitors GILOTRIF TABS 5 PA; SP AFINITOR DISPERZ TBSO 4 PA; SP GLEEVEC TABS (imatinib NC PA; SP AFINITOR TABS 10 MG 4 PA; SP mesylate) IBRANCE CAPS 4 PA; SP AFINITOR TABS 2.5 MG, 5 4 PA; SP MG, 7.5 MG (everolimus) IBRANCE TABS 4 PA; SP

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ICLUSIG TABS 15 MG, 45 5 PA; SP LORBRENA TABS 5 PA; SP MG PA; SP IDHIFA TABS 5 PA; SP LYNPARZA TABS 4 PA; SP imatinib mesylate tabs 2 PA; SP MEKINIST TABS 5 PA; SP IMBRUVICA CAPS 140 5 PA; SP MEKTOVI TABS 5 MG PA; SP IMBRUVICA CAPS 70 MG 5 PA; QL(1 ea NERLYNX TABS 5 daily); SP PA; SP IMBRUVICA TABS 140 PA; QL(1 ea NEXAVAR TABS 5 MG, 280 MG, 420 MG, 560 5 daily); SP MG NINLARO CAPS 5 PA; SP PA; SP INLYTA TABS 5 PEMAZYRE TABS NC

INREBIC CAPS NC PIQRAY 200MG DAILY NC DOSE TBPK IRESSA TABS 4 PA; SP PIQRAY 250MG DAILY NC DOSE TBPK ISTODAX (OVERFILL) 5 PA; SP SOLR PIQRAY 300MG DAILY NC DOSE TBPK JAKAFI TABS 5 PA; SP QINLOCK TABS NC KISQALI TBPK 4 PA; SP RETEVMO CAPS NC KOSELUGO CAPS 5 PA; SP ROMIDEPSIN SOLN 27.5 5 PA; SP MG/5.5ML KYPROLIS SOLR 5 PA; SP ROMIDEPSIN SOLR 10 5 PA; SP MG lapatinib ditosylate tabs 2 PA; SP ROZLYTREK CAPS NC LENVIMA 10 MG DAILY 5 PA; SP DOSE CPPK RUBRACA TABS 4 PA; SP LENVIMA 12MG DAILY 5 PA; SP DOSE CPPK RYDAPT CAPS 4 PA; SP LENVIMA 14 MG DAILY 5 PA; SP DOSE CPPK SPRYCEL TABS 4 PA; SP LENVIMA 18 MG DAILY 5 PA; SP DOSE CPPK STIVARGA TABS 5 PA; SP LENVIMA 20 MG DAILY 5 PA; SP PA; SP DOSE CPPK SUTENT CAPS 4 LENVIMA 24 MG DAILY 5 PA; SP DOSE CPPK TABRECTA TABS NC PA; SP LENVIMA 4 MG DAILY 5 PA; SP TAFINLAR CAPS 5 DOSE CPPK PA; SP LENVIMA 8 MG DAILY 5 PA; SP TAGRISSO TABS 5 DOSE CPPK

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TALZENNA CAPS NC ZYKADIA TABS 5 PA; SP

TARCEVA TABS (erlotinib 5 PA; SP Antineoplastic Enzymes hcl) ASPARLAS SOLN 5 PA; SP TASIGNA CAPS 150 MG, NC SP 50 MG ERWINAZE SOLR 5 PA; SP TASIGNA CAPS 200 MG NC ONCASPAR SOLN 5 PA; SP TAZVERIK TABS NC Antineoplastic Radiopharmaceuticals temsirolimus soln 2 SP AZEDRA DOSIMETRIC 5 PA; SP SOLN TIBSOVO TABS 5 PA; SP AZEDRA THERAPEUTIC 5 PA; SP SOLN TORISEL SOLN 5 SP (temsirolimus) LUTATHERA SOLN 5 PA; SP TUKYSA TABS 5 PA; SP METASTRON SOLN 5 TURALIO CAPS NC QUADRAMET SOLN 5 TYKERB TABS (lapatinib NC PA; SP ditosylate) STRONTIUM CHLORIDE NC SR-89 SOLN VELCADE SOLR 5 PA; SP XOFIGO SOLN NC VERZENIO TABS 5 PA; SP Antineoplastics Misc. PA; SP VITRAKVI CAPS 5 ACTIMMUNE SOLN 5 PA; SP PA; SP VITRAKVI SOLN 5 ALFERON N SOLN 5 PA; SP

VIZIMPRO TABS NC arsenic trioxide soln iv 10 2 mg/10ml PA; SP VOTRIENT TABS 4 arsenic trioxide soln iv 12 2 PA; SP mg/6ml XALKORI CAPS 5 PA; SP bexarotene caps 2 PA; SP XOSPATA TABS NC dacarbazine solr 2 ZEJULA CAPS 4 PA; SP ELZONRIS SOLN 5 ZELBORAF TABS 5 PA; SP HYDREA CAPS 4 (hydroxyurea) ZOLINZA CAPS 4 PA; SP hydroxyurea caps or 2 ZYDELIG TABS NC INTRON A SOLN 4 PA; SP ZYKADIA CAPS 5 PA; INTRON A SOLR 4 PA; SP

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MATULANE CAPS 4 PA; SP mesna soln 2 SP

NIPENT SOLR 5 MESNEX SOLN IV 100 5 SP MG/ML (mesna) PA; SP PHOTOFRIN SOLR 5 MESNEX TABS OR 400 5 PA; SP MG PA; SP PROLEUKIN SOLR 5 TOTECT SOLR NC PA; SP SYLATRON KIT 4 VORAXAZE SOLR 5 PA; SP PA; SP SYNRIBO SOLR 5 ZINECARD SOLR 5 (dexrazoxane hcl) TARGRETIN CAPS OR 75 4 PA; SP MG (bexarotene) Mitotic Inhibitors PA; SP TICE BCG SUSR 5 ABRAXANE SUSR 5 DOCETAXEL (NON- tretinoin (chemotherapy) 2 SP caps ALCOHOL FORMULA) 5 SOLN TRISENOX SOLN (arsenic 5 PA; SP trioxide) DOCETAXEL CONC 160 5 PA; SP MG/8ML Chemotherapy Adjuncts DOCETAXEL CONC 160 5 PA; SP ELITEK SOLR 5 MG/8ML (docetaxel) docetaxel conc 160 PA; SP KEPIVANCE SOLR 5 PA; SP mg/8ml, 20 mg/ml, 80 2 mg/4ml Chemotherapy Rescue/Antidote Agents DOCETAXEL CONC 20 2 PA; SP dexrazoxane hcl solr 2 MG/ML, 80 MG/4ML DOCETAXEL CONC 200 NC SP ETHYOL SOLR 5 MG/10ML docetaxel soln 160 FUSILEV SOLR 5 SP (levoleucovorin calcium) mg/16ml, 20 mg/2ml, 80 2 mg/8ml KHAPZORY SOLR NC DOCETAXEL SOLN 160 MG/16ML, 20 MG/2ML, 80 5 leucovorin calcium soln ij 2 MG/8ML 100 mg/10ml, 500 mg/50ml DOCETAXEL SOLN 160 leucovorin calcium solr ij MG/16ML, 20 MG/2ML, 80 5 100 mg, 200 mg, 350 mg, 2 MG/8ML (docetaxel) 50 mg, 500 mg ETOPOPHOS SOLR 5 leucovorin calcium tabs or 2 10 mg, 15 mg, 25 mg, 5 mg etoposide caps or 50 mg 2 PA; SP levoleucovorin calcium soln 2 SP etoposide soln iv 1 2 levoleucovorin calcium solr 2 SP gm/50ml, 500 mg/25ml etoposide soln iv 100 2 SP LEVOLEUCOVORIN SOLR NC mg/5ml

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALAVEN SOLN 5 PA; SP topotecan hcl soln 4 2 SP mg/4ml PA; SP IXEMPRA KIT SOLR 5 TOPOTECAN HCL SOLN 5 SP 4 MG/4ML PA; SP JEVTANA SOLN 5 TOPOTECAN HCL SOLN 5 SP 4 MG/4ML (topotecan hcl) MARQIBO SUSP 5 PA; SP topotecan hcl solr 4 mg 2 SP NAVELBINE SOLN 5 (vinorelbine tartrate) ANTIPARKINSON AND RELATED THERAPY paclitaxel conc 150 AGENTS - Drugs to Treat Parkinson's Disease mg/25ml, 100 mg/16.7ml, 2 Antiparkinson Adjunctive Therapy 30 mg/5ml, 300 mg/50ml, 6 mg/ml carbidopa tabs or 2 TAXOL CONC (paclitaxel) NC LODOSYN TABS 5 (carbidopa) TAXOTERE CONC 2 PA; SP (docetaxel) NOURIANZ TABS NC TENIPOSIDE SOLN 5 Antiparkinson Anticholinergics vinblastine sulfate soln 2 benztropine mesylate soln 2 vincristine sulfate soln 2 PA; SP benztropine mesylate tabs 2 COGENTIN SOLN 5 vinorelbine tartrate soln 2 (benztropine mesylate) trihexyphenidyl hcl soln 0.4 2 QL(16.67 ml Oncolytic Viral Agents mg/ml daily) IMLYGIC SUSP 5 PA; SP trihexyphenidyl hcl tabs 2 2 mg, 5 mg Topoisomerase I Inhibitors Antiparkinson COMT Inhibitors CAMPTOSAR SOLN 300 5 PA; SP MG/15ML (irinotecan hcl) COMTAN TABS 5 (entacapone) CAMPTOSAR SOLN 40 MG/2ML, 100 MG/5ML 5 entacapone tabs 2 (irinotecan hcl) HYCAMTIN CAPS OR 0.25 PA; SP TASMAR TABS 5 4 (tolcapone) MG, 1 MG tolcapone tabs 2 HYCAMTIN SOLR IV 4 MG 5 SP (topotecan hcl) Antiparkinson Dopaminergics irinotecan hcl soln 300 2 PA; SP mg/15ml amantadine hcl caps or 100 2 irinotecan hcl soln 500 mg mg/25ml, 40 mg/2ml, 100 2 amantadine hcl syrp or 50 2 mg/5ml mg/5ml amantadine hcl tabs or 100 2 ONIVYDE INJ 5 mg APOKYN SOCT 5 PA; SP

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bromocriptine mesylate 2 REQUIP TABS 0.5 MG, 1 QL(3 ea daily) caps or 5 mg MG, 2 MG, 5 MG 5 (ropinirole hydrochloride) BROMOCRIPTINE 5 MESYLATE POWD XX REQUIP XL TB24 12 MG, QL(2 ea daily) 8 MG (ropinirole 5 bromocriptine mesylate 2 tabs or 2.5 mg hydrochloride) REQUIP XL TB24 2 MG, 4 QL(1 ea daily) carbidopa-levodopa tabs 2 MG, 6 MG (ropinirole 5 hydrochloride) carbidopa-levodopa tbcr 2 ropinirole hydrochloride 2 QL(6 ea daily) tabs 0.25 mg, 3 mg, 4 mg carbidopa-levodopa tbdp 2 ropinirole hydrochloride QL(3 ea daily) carbidopa-levodopa- 2 tabs 0.5 mg, 1 mg, 2 mg, 5 2 entacapone tabs mg DUOPA SUSP 5 ropinirole hydrochloride 2 QL(2 ea daily) tb24 12 mg, 8 mg GOCOVRI CP24 NC ropinirole hydrochloride 2 QL(1 ea daily) tb24 2 mg, 4 mg, 6 mg INBRIJA CAPS NC RYTARY CPCR 5

KYNMOBI FILM NC SINEMET CR TBCR 5 (carbidopa-levodopa) LEVODOPA POWD 5 SINEMET TABS 5 (carbidopa-levodopa) MIRAPEX ER TB24 (pramipexole 5 STALEVO 100 TABS dihydrochloride) (carbidopa-levodopa- 5 entacapone) MIRAPEX TABS (pramipexole 5 STALEVO 100 TABS dihydrochloride) (carbidopa-levodopa- NF entacapone) QL(1 ea daily) NEUPRO PT24 4 STALEVO 125 TABS (carbidopa-levodopa- 5 OSMOLEX ER T4PK NC entacapone) STALEVO 150 TABS OSMOLEX ER TB24 NC (carbidopa-levodopa- 5 entacapone) PARLODEL CAPS 5 (bromocriptine mesylate) STALEVO 200 TABS (carbidopa-levodopa- 5 PARLODEL TABS 5 (bromocriptine mesylate) entacapone) STALEVO 50 TABS pramipexole 2 dihydrochloride tabs (carbidopa-levodopa- 5 entacapone) pramipexole 2 dihydrochloride tb24 STALEVO 75 TABS REQUIP TABS 0.25 MG, 4 QL(6 ea daily) (carbidopa-levodopa- 5 MG (ropinirole 5 entacapone) hydrochloride) Antiparkinson Monoamine Oxidase Inhibitors

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZILECT TABS (rasagiline 5 QL(1 ea daily) VRAYLAR CPPK 4 ST mesylate) rasagiline mesylate tabs or 2 QL(1 ea daily) ziprasidone hcl caps 2 0.5 mg, 1 mg selegiline hcl caps or 2 ziprasidone mesylate solr 2 Benzisoxazoles SELEGILINE HCL POWD 5 XX FANAPT TABS NC selegiline hcl tabs or 2 FANAPT TITRATION NC PACK TABS XADAGO TABS NC INVEGA SUSTENNA PA; QL(0.034 ZELAPAR TBDP 5 SUSY 117 MG/0.75ML, 5 ml daily); SP 156 MG/ML, 39 ANTIPSYCHOTICS/ANTIMANIC AGENTS - MG/0.25ML, 78 MG/0.5ML Drugs to Treat Mood Disorders INVEGA SUSTENNA 5 PA; SP SUSY 234 MG/1.5ML Antimanic Agents INVEGA TB24 5 lithium carbonate caps or 2 (paliperidone) 300 mg, 150 mg, 600 mg INVEGA TRINZA SUSY NC PA; LITHIUM CARBONATE 5 POWD XX paliperidone tb24 2 lithium carbonate tabs or 2 300 mg PERSERIS PRSY NC lithium carbonate tbcr or 2 300 mg, 450 mg RISPERDAL CONSTA 4 PA; SP SRER LITHIUM SOLN 5 RISPERDAL SOLN 5 LITHOBID TBCR (lithium 4 (risperidone) carbonate) RISPERDAL TABS 5 Antipsychotics - Misc. (risperidone) CAPLYTA CAPS NC risperidone soln 2

EQUETRO CP12 5 risperidone tabs 2

GEODON CAPS 5 risperidone tbdp 2 (ziprasidone hcl) Butyrophenones GEODON SOLR 5 (ziprasidone mesylate) HALDOL DECANOATE LATUDA TABS 4 100 SOLN (haloperidol 5 decanoate) NUPLAZID CAPS 5 HALDOL DECANOATE 50 SOLN (haloperidol 5 NUPLAZID TABS 5 decanoate) HALDOL SOLN 5 VRAYLAR CAPS 4 ST (haloperidol lactate)

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol decanoate soln 2 ZYPREXA ZYDIS TBDP 5 im 100 mg/ml, 50 mg/ml (olanzapine) haloperidol lactate conc 2 Dihydroindolones molindone hcl tabs 2 haloperidol lactate soln 2 haloperidol tabs or 20 mg, Phenothiazines 0.5 mg, 1 mg, 10 mg, 2 mg, 2 chlorpromazine hcl soln ij 5 5 mg 25 mg/ml, 50 mg/2ml Dibenzapines chlorpromazine hcl tabs or 10 mg, 200 mg, 25 mg, 100 2 ADASUVE AEPB 5 mg, 50 mg fluphenazine decanoate 2 clozapine tabs 2 soln ij clozapine tbdp 2 fluphenazine hcl conc 2

CLOZARIL TABS 5 fluphenazine hcl elix 2 (clozapine) FAZACLO TBDP 5 fluphenazine hcl soln 2 (clozapine) fluphenazine hcl tabs 2 loxapine succinate caps 2 perphenazine tabs or 16 2 olanzapine solr 2 mg, 2 mg, 4 mg, 8 mg prochlorperazine edisylate olanzapine tabs 2 soln ij 10 mg/2ml, 50 2 mg/10ml olanzapine tbdp 2 PROCHLORPERAZINE 5 MALEATE POWD XX quetiapine fumarate tabs 2 prochlorperazine maleate 2 tabs or 10 mg, 5 mg quetiapine fumarate tb24 2 prochlorperazine supp 2 SAPHRIS SUBL 5 ST thioridazine hcl tabs or 10 2 SECUADO PT24 NC mg, 100 mg, 25 mg, 50 mg trifluoperazine hcl tabs 2 SEROQUEL TABS 5 (quetiapine fumarate) Quinolinone Derivatives SEROQUEL XR TB24 NC (quetiapine fumarate) ABILIFY MAINTENA PRSY 4 PA; SP QL(18 ml daily) VERSACLOZ SUSP 5 ABILIFY MAINTENA SRER 4 PA; SP ZYPREXA RELPREVV 5 PA; SP SUSR ABILIFY MYCITE TABS NC ZYPREXA SOLR 5 ABILIFY TABS NC (olanzapine) (aripiprazole) ZYPREXA TABS 5 (olanzapine) aripiprazole soln 1 mg/ml 2 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aripiprazole tabs 10 mg, 15 CVS IODINE TINCTURE 5 RX/OTC mg, 2 mg, 20 mg, 30 mg, 5 2 TINC mg DECOLORIZED IODINE 5 RX/OTC aripiprazole tbdp 10 mg, 15 2 TINC mg GNP IODIDES TINCTURE 5 RX/OTC ARISTADA INITIO PRSY 4 PA; SP TINC GNP IODINE TINCTURE 5 RX/OTC ARISTADA PRSY 4 PA; SP TINC GOODSENSE IODINE 5 RX/OTC REXULTI TABS 5 ST TINC HM IODIDES TINCTURE 5 RX/OTC Thioxanthenes TINC thiothixene caps 2 HM IODINE TINCTURE 5 RX/OTC TINC ANTISEPTICS & DISINFECTANTS IODIDES TINCTURE TINC 5 RX/OTC Antiseptic Combinations IODINE TINCTURE MILD 5 RX/OTC BUCALSEP LIQD 5 TINC IODINE TINCTURE TINC 5 RX/OTC BUCALSEP SOLN 5 LUGOLS STRONG 5 Antiseptics & Disinfectants IODINE SOLN CETYLCIDE-G CONC 5 QC IODIDES TINCTURE 5 RX/OTC TINC QL(90 ml per formaldehyde soln 10 % 2 QC IODINE TINCTURE 5 RX/OTC fill retail) TINC formaldehyde soln 20 % 2 RA FIRST AID IODINE 5 RX/OTC TINC FORMALDEHYDE SOLN RX/OTC 5 SM IODIDES TINCTURE 5 RX/OTC 37 % TINC GLUTARALDEHYDE 5 SM IODINE TINCTURE 5 RX/OTC SOLN EX 25 % TINC hydrogen peroxide soln 2 Mercury Antiseptics PHENOL CRYS XX 5 THIMEROSAL POWD 5

PHENOL LIQD XX 89 %, 5 Silver Antiseptics SILVER PROTEIN MILD 5 Chlorine Antiseptics POWD BENZALKONIUM RX/OTC 5 ANTIVIRALS - Drugs to Treat Viral Infections CHLORIDE SOLN BENZALKONIUM 5 Antiretrovirals CHLORIDE SOLN abacavir sulfate soln 20 2 CHLORHEXIDINE 5 mg/ml GLUCONATE SOLN abacavir sulfate tabs 300 2 QL(2 ea daily) Iodine Antiseptics mg

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits abacavir sulfate-lamivudine 2 QL(1 ea daily) efavirenz-lamivudine- tabs tenofovir disoproxil 2 fumarate tabs abacavir sulfate- 2 QL(2 ea daily) lamivudine-zidovudine tabs emtricitabine caps 2 QL(1 ea daily) APTIVUS CAPS 5 emtricitabine-tenofovir 2 QL(1 ea daily) disoproxil fumarate tabs APTIVUS SOLN 5 EMTRIVA CAPS 200 MG NC QL(1 ea daily) (emtricitabine) atazanavir sulfate caps 150 2 QL(2 ea daily) mg, 200 mg EMTRIVA SOLN 10 4 QL(24 ml daily) MG/ML atazanavir sulfate caps 300 2 QL(1 ea daily) mg EPIVIR SOLN 10 MG/ML 5 QL(30 ml daily) ATRIPLA TABS (efavirenz- QL(1 ea daily) (lamivudine) emtricitabine-tenofovir NC EPIVIR TABS 150 MG 5 QL(2 ea daily) disoproxil fumarate) (lamivudine) QL(1 ea daily) BIKTARVY TABS 4 EPIVIR TABS 300 MG 5 QL(1 ea daily) (lamivudine) CIMDUO TABS 4 EPZICOM TABS (abacavir 5 QL(1 ea daily) sulfate-lamivudine) COMBIVIR TABS 5 QL(2 ea daily) (lamivudine-zidovudine) EVOTAZ TABS 4 QL(1 ea daily) COMPLERA TABS 4 fosamprenavir calcium tabs 2

CRIXIVAN CAPS 5 FUZEON SOLR 4 PA; SP

DELSTRIGO TABS NC GENVOYA TABS 4 QL(1 ea daily) QL(1 ea daily) DESCOVY TABS 4 INTELENCE TABS 100 4 QL(4 ea daily) MG didanosine cpdr 200 mg 2 QL(2 ea daily) INTELENCE TABS 200 4 QL(2 ea daily) MG didanosine cpdr 250 mg, 2 QL(1 ea daily) 400 mg INTELENCE TABS 25 MG 4 QL(8 ea daily) DOVATO TABS 4 PA; SP INVIRASE CAPS 5 EDURANT TABS 4 QL(1 ea daily) INVIRASE TABS 5 efavirenz caps 200 mg 2 QL(2 ea daily) ISENTRESS CHEW 100 4 MG, 25 MG efavirenz caps 50 mg 2 QL(3 ea daily) ISENTRESS HD TABS 4 QL(2 ea daily) efavirenz tabs 600 mg 2 QL(1 ea daily) ISENTRESS PACK 100 4 efavirenz-emtricitabine- QL(1 ea daily) MG tenofovir disoproxil 2 ISENTRESS TABS 400 4 QL(2 ea daily) fumarate tabs MG JULUCA TABS 5

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KALETRA SOLN 100 QL(12.5 ml RETROVIR CAPS 100 MG 4 QL(6 ea daily) MG/5ML-400 MG/5ML 4 daily) (zidovudine) (lopinavir-ritonavir) RETROVIR IV INFUSION 5 KALETRA TABS 100 MG- 4 QL(4 ea daily) SOLN 25 MG, 200 MG-50 MG RETROVIR SYRP 50 4 QL(60 ml daily) lamivudine soln 10 mg/ml 2 QL(30 ml daily) MG/5ML (zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) lamivudine tabs 150 mg 2 QL(2 ea daily) 200 MG (atazanavir 5 sulfate) QL(1 ea daily) lamivudine tabs 300 mg 2 REYATAZ CAPS 300 MG 5 QL(1 ea daily) (atazanavir sulfate) lamivudine-zidovudine tabs 2 QL(2 ea daily) REYATAZ PACK 50 MG 5 LEXIVA SUSP 50 MG/ML 5 ritonavir tabs 2 QL(12 ea daily) LEXIVA TABS 700 MG 5 (fosamprenavir calcium) SELZENTRY SOLN 5 QL(12.5 ml lopinavir-ritonavir soln 2 daily) SELZENTRY TABS 5 QL(40 ml daily) nevirapine susp 50 mg/5ml 2 stavudine caps 2 QL(2 ea daily) QL(2 ea daily) nevirapine tabs 200 mg 2 STRIBILD TABS 4 nevirapine tb24 100 mg 2 SUSTIVA CAPS 200 MG 5 QL(2 ea daily) (efavirenz) QL(1 ea daily) nevirapine tb24 400 mg 2 SUSTIVA CAPS 50 MG 5 QL(3 ea daily) (efavirenz) NORVIR PACK 100 MG 4 QL(12 ea daily) SUSTIVA TABS 600 MG 5 QL(1 ea daily) (efavirenz) QL(15 ml daily) NORVIR SOLN 80 MG/ML 4 SYMFI LO TABS (efavirenz-lamivudine- NORVIR TABS 100 MG 4 QL(12 ea daily) NC (ritonavir) tenofovir disoproxil fumarate) QL(1 ea daily) ODEFSEY TABS 4 SYMFI TABS (efavirenz- lamivudine-tenofovir NC PIFELTRO TABS NC disoproxil fumarate) PREZCOBIX TABS 4 SYMTUZA TABS 4

PREZISTA SUSP 100 4 TEMIXYS TABS 4 MG/ML tenofovir disoproxil QL(1 ea daily) PREZISTA TABS 150 MG, 4 SL(2 ea daily) 2 600 MG, 75 MG fumarate tabs PREZISTA TABS 800 MG 4 QL(1 ea daily) TIVICAY PD TBSO 4

RESCRIPTOR TABS 5 TIVICAY TABS 4 TRIUMEQ TABS 4 QL(1 ea daily)

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIZIVIR TABS (abacavir QL(2 ea daily) zidovudine syrp 50 mg/5ml 2 QL(60 ml daily) sulfate-lamivudine- 5 zidovudine) zidovudine tabs 300 mg 2 QL(2 ea daily) TROGARZO SOLN 5 PA; SP CMV Agents TRUVADA TABS 100 MG- QL(1 ea daily) 150 MG, 133 MG-200 MG, 4 cidofovir soln 2 167 MG-250 MG CYTOVENE SOLR 5 TRUVADA TABS 200 MG- QL(1 ea daily) (ganciclovir sodium) 300 MG (emtricitabine- NC tenofovir disoproxil FOSCAVIR SOLN 5 fumarate) ganciclovir sodium solr 2 TYBOST TABS 5 GANCICLOVIR SOLN NC VIDEX EC CPDR 125 MG 4 QL(2 ea daily) PREVYMIS SOLN 5 PA; SP VIDEX EC CPDR 200 MG 4 QL(2 ea daily) (didanosine) PREVYMIS TABS 5 PA; SP VIDEX EC CPDR 250 MG, 4 QL(1 ea daily) 400 MG (didanosine) VALCYTE SOLR 50 NC QL(21 ml daily) MG/ML (valganciclovir hcl) VIDEXPEDIATRIC SOLR 5 VALCYTE TABS 450 MG NC QL(4 ea daily) VIRACEPT TABS 5 (valganciclovir hcl) valganciclovir hcl solr 50 2 QL(21 ml daily) VIRAMUNE SUSP 50 5 QL(40 ml daily) mg/ml MG/5ML (nevirapine) valganciclovir hcl tabs 450 2 QL(4 ea daily) VIRAMUNE TABS 200 MG 5 QL(2 ea daily) mg (nevirapine) Hepatitis Agents VIRAMUNE XR TB24 100 5 PA; QL(1 ea MG (nevirapine) adefovir dipivoxil tabs 2 daily); SP VIRAMUNE XR TB24 400 5 QL(1 ea daily) MG (nevirapine) BARACLUDE SOLN 0.05 4 QL(20 ml daily) MG/ML VIREAD POWD 40 MG/GM 4 BARACLUDE TABS 0.5 NC QL(1 ea daily) MG, 1 MG (entecavir) VIREAD TABS 150 MG, 4 200 MG, 250 MG DAKLINZA TABS NC PA; VIREAD TABS 300 MG QL(1 ea daily) (tenofovir disoproxil 4 entecavir tabs 2 QL(1 ea daily) fumarate) QL(2 ea daily) EPCLUSA TABS 100 MG- NC PA; SP ZERIT CAPS (stavudine) 4 400 MG EPIVIR HBV SOLN 5 QL(60 ml daily) ZIAGEN SOLN 20 MG/ML 5 4 (abacavir sulfate) MG/ML EPIVIR HBV TABS 100 QL(3 ea daily) ZIAGEN TABS 300 MG 5 QL(2 ea daily) 5 (abacavir sulfate) MG (lamivudine (hbv)) QL(6 ea daily) HARVONI PACK 150 MG- 4 PA; SP zidovudine caps 100 mg 2 33.75 MG, 200 MG-45 MG

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HARVONI TABS 200 MG- 4 PA; SP VIEKIRA PAK TBPK NC SP 45 MG, 400 MG-90 MG PA; SP HEPSERA TABS (adefovir 5 PA; QL(1 ea VOSEVI TABS 4 dipivoxil) daily); SP SP lamivudine (hbv) tabs 2 QL(3 ea daily) ZEPATIER TABS NC Herpes Agents LEDIPASVIR/SOFOSBUVI NC R TABS acyclovir caps or 200 mg 2 MAVYRET TABS NC SP acyclovir sodium soln 2 MODERIBA 1200 DOSE 5 PA; SP PACK TBPK acyclovir susp or 200 2 mg/5ml PEGASYS PROCLICK 4 QL(0.0714 ml SOLN 135 MCG/0.5ML daily); SP acyclovir tabs or 400 mg, 2 800 mg PEGASYS PROCLICK 4 PA; QL(0.0714 SOLN 180 MCG/0.5ML ml daily); SP famciclovir tabs or 125 mg, 2 250 mg, 500 mg PEGASYS SOLN 180 4 PA; QL(0.0714 MCG/0.5ML ml daily); SP SITAVIG TABS 5 PEGASYS SOLN 180 4 PA; QL(0.143 MCG/ML ml daily); SP valacyclovir hcl tabs or 1 2 gm, 1000 mg, 500 mg PEGINTRON KIT 5 PA; SP VALTREX TABS NC (valacyclovir hcl) REBETOL CAPS 200 MG 5 PA; QL(7 ea (ribavirin (hepatitis c)) daily); SP ZOVIRAX CAPS OR 200 5 MG (acyclovir) REBETOL SOLN 40 4 QL(35 ml MG/ML daily); SP ZOVIRAX SUSP OR 200 5 MG/5ML (acyclovir) RIBASPHERE RIBAPAK 5 TBPK ZOVIRAX TABS OR 400 5 MG, 800 MG (acyclovir) RIBASPHERE RIBAPAK 5 PA; SP TBPK 400 MG, 600 MG Influenza Agents SP RIBASPHERE TABS NC FLUMADINE TABS 5 QL(2 ea daily) (rimantadine hydrochloride) ribavirin (hepatitis c) caps 2 PA; QL(7 ea QL(20 ea per 200 mg daily); SP oseltamivir phosphate caps 2 fill retail,20 ea ribavirin (hepatitis c) tabs 2 PA; QL(7 ea or 30 mg per 30 days 200 mg daily); SP retail) ribavirin (hepatitis c) tabs 2 PA; QL(2 ea QL(10 ea per 600 mg daily); SP oseltamivir phosphate caps 2 fill retail,10 ea or 45 mg, 75 mg per 30 days SOFOSBUVIR/VELPATAS NC PA; SP VIR TABS retail) QL(120 ml per SOVALDI PACK 5 PA; SP oseltamivir phosphate susr 2 fill retail,120 ml PA; SP or 6 mg/ml per 30 days SOVALDI TABS 5 retail) VEMLIDY TABS 4 PA; SP RAPIVAB SOLN 5

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.6667 ea COREG CR CP24 20 MG, RELENZA DISKHALER 4 carvedilol NF AEPB daily,20 ea per 40 MG ( 30 days retail) phosphate) rimantadine hydrochloride 2 QL(2 ea daily) COREG TABS 12.5 MG, QL(3 ea daily) tabs 3.125 MG, 6.25 MG 5 QL(20 ea per (carvedilol) TAMIFLU CAPS 30 MG 5 fill retail,20 ea COREG TABS 25 MG 5 QL(4 ea daily) (oseltamivir phosphate) per 30 days (carvedilol) retail) labetalol hcl soln iv 5 mg/ml 2 QL(10 ea per TAMIFLU CAPS 45 MG, 75 fill retail,10 ea MG (oseltamivir 5 labetalol hcl tabs or 100 mg 2 QL(3 ea daily) phosphate) per 30 days retail) labetalol hcl tabs or 200 mg 2 QL(6 ea daily) QL(120 ml per QL(8 ea daily) TAMIFLU SUSR 6 MG/ML 5 fill retail,120 ml labetalol hcl tabs or 300 mg 2 (oseltamivir phosphate) per 30 days retail) LABETALOL NC HYDROCHLORIDE SOLN XOFLUZA TBPK NC LABETALOL NC Misc. Antivirals HYDROCHLORIDE SOSY LABETALOL FAVIPIRAVIR TABS 5 HYDROCHLORIDE/DEXT NC ROSE SOLN REMDESIVIR SOLR 5 LABETALOL HYDROCHLORIDE/SODIU NC VEKLURY SOLN 5 M CHLORIDE SOLN VEKLURY SOLR 5 Beta Blockers Cardio-Selective acebutolol hcl caps or 400 2 Respiratory Syncytial Virus (RSV) Agents mg, 200 mg ribavirin solr in 2 ACEBUTOLOL HCL 5 POWD XX VIRAZOLE SOLR 5 (ribavirin) ATENOLOL POWD XX 5 BETA BLOCKERS - Drugs to Treat High Blood atenolol tabs or 100 mg, 25 2 QL(2 ea daily) Pressure mg, 50 mg Alpha-Beta Blockers ATENOLOL/SYRSPEND NC SF PH4 SUSP carvedilol phosphate cp24 2 QL(1 ea daily) betaxolol hcl tabs 2 carvedilol tabs 12.5 mg, 2 QL(3 ea daily) 3.125 mg, 6.25 mg bisoprolol fumarate tabs 2 QL(1 ea daily) QL(4 ea daily) carvedilol tabs 25 mg 2 BREVIBLOC PREMIXED DOUBLESTRENGTH 5 COREG CR CP24 10 MG, QL(1 ea daily) SOLN (esmolol hcl-sodium 20 MG, 40 MG, 80 MG 5 chloride) (carvedilol phosphate)

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREVIBLOC PREMIXED metoprolol tartrate tabs or 2 QL(2 ea daily) SOLN (esmolol hcl-sodium 5 100 mg, 25 mg chloride) metoprolol tartrate tabs or 2 BREVIBLOC SOLN 5 37.5 mg, 75 mg (esmolol hcl) metoprolol tartrate tabs or 2 QL(3 ea daily) BREVIBLOC SOLN 50 mg (esmolol hcl-sodium 5 TENORMIN TABS 5 QL(2 ea daily) chloride) (atenolol) BYSTOLIC TABS 4 TOPROL XL TB24 NC (metoprolol succinate) esmolol hcl soln 2 Beta Blockers Non-Selective BETAPACE AF TABS esmolol hcl-sodium 2 NC chloride soln (sotalol hcl (afib/afl)) ESMOLOL BETAPACE TABS 120 NC MG, 80 MG (sotalol hcl) HYDROCHLORIDE 5 INWATER DOUBLE BETAPACE TABS 160 MG NC QL(2 ea daily) STRENGTH SOLN (sotalol hcl) ESMOLOL QL(2 ea daily) HYDROCHLORIDE 5 CORGARD TABS (nadolol) 5 INWATER SOLN PA; QL(1 ml HEMANGEOL SOLN 5 per fill retail); ESMOLOL NC HYDROCHLORIDE SOSY SP INDERAL LA CP24 QL(2 ea daily) FIRST - METOPROLOL NC NC SOLN (propranolol hcl) FIRST-ATENOLOL SOLN NC INDERAL XL CP24 NC

KAPSPARGO SPRINKLE NC INNOPRAN XL CP24 NC CS24 LOPRESSOR TABS 100 5 QL(2 ea daily) NADOLOL POWD XX 5 MG (metoprolol tartrate) nadolol tabs or 80 mg, 20 QL(2 ea daily) LOPRESSOR TABS 50 5 QL(3 ea daily) 2 MG (metoprolol tartrate) mg, 40 mg nadolol tabs or 80 mg, 20 metoprolol succinate tb24 2 QL(2 ea daily) 2 200 mg mg, 40 mg pindolol tabs 2 metoprolol succinate tb24 2 QL(1 ea daily) 25 mg, 100 mg, 50 mg propranolol hcl cp24 or 120 2 QL(2 ea daily) METOPROLOL 5 mg, 160 mg, 60 mg, 80 mg TARTRATE POWD XX PROPRANOLOL HCL 5 metoprolol tartrate soct iv 5 2 POWD XX mg/5ml propranolol hcl soln iv 1 2 metoprolol tartrate soln iv 5 2 mg/ml mg/5ml propranolol hcl soln or 20 2 METOPROLOL mg/5ml, 40 mg/5ml TARTRATE SOSY IV 5 NC MG/5ML

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propranolol hcl tabs or 10 CARDIZEM LA TB24 420 2 mg, 80 mg, 20 mg, 40 mg, MG, 180 MG, 240 MG, 300 NC 60 mg MG, 360 MG (diltiazem hcl coated beads) sotalol hcl (afib/afl) tabs 2 QL(2 ea daily) 120 mg, 80 mg, 160 mg CARDIZEM TABS NC (diltiazem hcl) sotalol hcl tabs 120 mg, 2 QL(2 ea daily) 160 mg, 80 mg CLEVIPREX EMUL 5 sotalol hcl tabs 240 mg 2 diltiazem hcl coated beads 2 QL(2 ea daily) cp24 240 mg SOTALOL 5 HYDROCHLORIDE SOLN diltiazem hcl coated beads QL(1 ea daily) cp24 300 mg, 120 mg, 180 2 SOTYLIZE SOLN 5 mg diltiazem hcl coated beads TIMOLOL MALEATE 5 POWD XX cp24 300 mg, 360 mg, 120 2 mg, 180 mg, 240 mg timolol maleate tabs or 10 2 mg, 20 mg, 5 mg diltiazem hcl coated beads tb24 420 mg, 180 mg, 240 NC CALCIUM CHANNEL BLOCKERS - Drugs to mg, 300 mg, 360 mg Treat High Blood Pressure diltiazem hcl cp12 or 120 2 QL(2 ea daily) Calcium Channel Blocker Combinations mg, 60 mg, 90 mg CONSENSI TABS NC diltiazem hcl cp24 or 120 2 QL(1 ea daily) mg, 180 mg Calcium Channel Blockers diltiazem hcl cp24 or 240 2 QL(2 ea daily) mg ADALAT CC TB24 30 MG, 5 QL(1 ea daily) 90 MG (nifedipine) diltiazem hcl extended 2 QL(1 ea daily) release beads cp24 ADALAT CC TB24 60 MG 5 QL(2 ea daily) (nifedipine) diltiazem hcl soln iv 25 mg/5ml, 125 mg/25ml, 50 2 amlodipine besylate tabs or 2 10 mg mg/10ml DILTIAZEM HCL SOLR IV amlodipine besylate tabs or 2 QL(1 ea daily) 5 2.5 mg, 5 mg, 10 mg 100 MG AMLODIPINE diltiazem hcl tabs or 120 2 QL(3 ea daily) BESYLATE/SYRSPEND NC mg, 60 mg, 30 mg, 90 mg SF PH4 SUSP DILTIAZEM 5 HYDROCHLORIDE SOSY CALAN SR TBCR 5 QL(2 ea daily) (verapamil hcl) DILTIAZEM HYDROCHLORIDE/DEXT NC CALAN TABS (verapamil 5 QL(3 ea daily) hcl) ROSE SOLN DILTIAZEM CARDENE IV SOLN 5 HYDROCHLORIDE/SODIU NC CARDIZEM CD CP24 M CHLORIDE SOLN (diltiazem hcl coated NC felodipine tb24 2 QL(1 ea daily) beads) CARDIZEM LA TB24 120 NC isradipine caps 2 MG

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KATERZIA SUSP NC VERAPAMIL HCL POWD 5 XX nicardipine hcl caps 2 verapamil hcl soln iv 2.5 2 mg/ml nicardipine hcl soln 2 verapamil hcl tabs or 40 2 QL(3 ea daily) mg, 120 mg, 80 mg NICARDIPINE NC HYDROCHLORIDE SOLN verapamil hcl tbcr or 120 2 QL(2 ea daily) mg, 180 mg, 240 mg NICARDIPINE HYDROCHLORIDE/DEXT NC VERELAN CP24 120 MG, QL(2 ea daily) ROSE SOLN 180 MG, 240 MG 5 (verapamil hcl) NICARDIPINE HYDROCHLORIDE/SODIU NC VERELAN CP24 360 MG 5 QL(1 ea daily) M CHLORIDE SOLN (verapamil hcl) NICARDIPINE VERELAN PM CP24 5 HYDROCHLORIDE/SODIU NC (verapamil hcl) M CHLORIDE SOSY CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm nifedipine caps 10 mg, 20 2 QL(4 ea daily) mg Cardiac Glycosides nifedipine tb24 30 mg, 90 2 QL(1 ea daily) mg digoxin soln ij 0.25 mg/ml 2 QL(2 ea daily) nifedipine tb24 60 mg 2 digoxin soln or 0.05 mg/ml 2 nimodipine caps or 2 digoxin tabs or 0.25 mg, 250 mcg, 0.125 mg, 125 2 nisoldipine tb24 2 mcg LANOXIN PEDIATRIC 5 NORVASC TABS NC SOLN (amlodipine besylate) LANOXIN SOLN IJ 0.25 5 NYMALIZE SOLN 5 MG/ML (digoxin) LANOXIN TABS OR 250 NC PROCARDIA CAPS 5 QL(4 ea daily) MCG, 125 MCG (digoxin) (nifedipine) LANOXIN TABS OR 62.5 4 PROCARDIA XL TB24 30 5 QL(1 ea daily) MCG MG, 90 MG (nifedipine) Phosphodiesterase Inhibitors PROCARDIA XL TB24 60 5 QL(2 ea daily) MG (nifedipine) milrinone lactate in 2 dextrose soln SULAR TB24 (nisoldipine) 5 milrinone lactate soln 2 TIAZAC CP24 (diltiazem QL(1 ea daily) hcl extended release 5 CARDIOVASCULAR AGENTS - MISC. - Drugs to beads) Treat Heart and Circulation Conditions verapamil hcl cp24 or 100 2 Cardioplegic Solutions mg, 200 mg, 300 mg CARDIOPLEGIA DEL 2 verapamil hcl cp24 or 120 2 QL(2 ea daily) NIDO FORMULA SOLN mg, 180 mg, 240 mg verapamil hcl cp24 or 360 2 QL(1 ea daily) mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIOPLEGIA amlodipine besylate- 2 QL(1 ea daily) INDUCTION HIGH 2 atorvastatin calcium tabs POTASSIUM SOLN BIDIL TABS 4 CARDIOPLEGIA INDUCTION HIGH 2 CADUET TABS QL(1 ea daily) POTASSIUM/LOW (amlodipine besylate- 5 DEXTROSE SOLN atorvastatin calcium) CARDIOPLEGIA ENTRESTO TABS 4 INDUCTION HIGH 2 POTASSIUM/NON- Impotence Agents ENRICHED SOLN CIALIS TABS (tadalafil) NC PA; QL(1 ea CARDIOPLEGIA daily) INDUCTION 2 PLASMALYTE/HIGH tadalafil tabs or 2.5 mg, 5 2 PA; QL(1 ea POTASSIUM SOLN mg daily) CARDIOPLEGIA Peripheral Vasodilators INDUCTION NYLIDRIN 5 PLASMALYTE/TROMETH 2 HYDROCHLORIDE POWD AMINE HIGH POTASSIU PAPAVERINE HCL POWD 5 SOLN XX CARDIOPLEGIA papaverine hcl soln ij 2 MAINTENANCELOW 2 DEXTROSE/LOW POTASSIUM SOLN PAPAVERINE 5 HYDROCHLORIDE POWD CARDIOPLEGIA MAINTENANCELOW 2 Prostaglandin Vasodilators POTASSIUM SOLN epoprostenol sodium solr 2 PA; SP CARDIOPLEGIA FLOLAN SOLR PA; SP MAINTENANCELOW 2 4 TROMETHAMINE/LOW (epoprostenol sodium) POTASSIUM SOLN ORENITRAM TBCR 4 PA; SP CARDIOPLEGIA PA; SP MAINTENANCEPLASMAL 2 REMODULIN SOLN 5 YTE/TROMETHAMINE LOW POTASSI SOLN treprostinil soln 2 PA; SP CARDIOPLEGIA REPERFUSATE/LOW 2 TYVASO REFILL SOLN 5 PA; SP POTASSIUM SOLN PA; SP CARDIOPLEGIC SOLN 2 TYVASO SOLN 5 PA; SP cardioplegic soln soln 2 TYVASO STARTER SOLN 5 PA; SP MICROPLEGIA MSA/MSG 2 VELETRI SOLR 5 SOLN VENTAVIS SOLN 5 PA; SP PLEGISOL SOLN 5 (cardioplegic soln) Pulmonary Hypertension - Endothelin Receptor Cardiovascular Agents Misc. - Combinations PA; QL(1 ea ambrisentan tabs 2 daily); SP 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bosentan tabs 2 PA; SP Transthyretin Stabilizers VYNDAMAX CAPS 5 PA; SP LETAIRIS TABS NC PA; QL(1 ea (ambrisentan) daily); SP VYNDAQEL CAPS NC OPSUMIT TABS 4 PA; SP Vasoactive Natriuretic Peptides TRACLEER TABS 125 5 PA; SP MG, 62.5 MG (bosentan) NATRECOR SOLR 5 PA; SP TRACLEER TBSO 32 MG 5 CEPHALOSPORINS - Drugs to Treat Bacterial Infections Pulmonary Hypertension - Phosphodiesterase Cephalosporin Combinations ADCIRCA TABS (tadalafil 5 PA; SP (pulmonary hypertension)) AVYCAZ SOLR 5 REVATIO SOLN (sildenafil PA; SP citrate (pulmonary 5 ZERBAXA SOLR 5 hypertension)) REVATIO SUSR (sildenafil PA; SP Cephalosporins - 1st Generation citrate (pulmonary 5 hypertension)) cefadroxil caps 2 REVATIO TABS (sildenafil PA; SP cefadroxil susr 2 citrate (pulmonary 5 hypertension)) cefadroxil tabs 2 sildenafil citrate (pulmonary 2 PA; SP hypertension) soln CEFAZOLIN SODIUM 5 SOLN IV 1 GM/50ML-4 % sildenafil citrate (pulmonary 2 PA; SP hypertension) susr CEFAZOLIN SODIUM 5 SOLR IJ 100 GM, 300 GM sildenafil citrate (pulmonary 2 PA; SP hypertension) tabs cefazolin sodium solr ij 20 2 gm, 500 mg, 1 gm, 10 gm tadalafil (pulmonary 2 PA; SP hypertension) tabs cefazolin sodium solr iv 1 2 gm Pulmonary Hypertension - Prostacyclin Receptor CEFAZOLIN SODIUM UPTRAVI TABS 4 PA; SP SOSY IV 1 GM/10ML, 2 NC GM/20ML, 3 GM/20ML PA; SP UPTRAVI TBPK 4 CEFAZOLIN SODIUM/DEXTROSE Pulmonary Hypertension - Sol Guanylate Cyclase SOLN 2 GM/100ML-5 %, 2 NC ADEMPAS TABS 4 PA; SP GM/50ML-5 %, 3 GM/100ML-5 % Septal Agents CEFAZOLIN SODIUM/DEXTROSE 5 ABLYSINOL SOLN NC SOLR 1 GM-4 %, 2 GM-3 % Sinus Node Inhibitors CEFAZOLIN CORLANOR SOLN 5 5 SODIUM/SODIUM NC MG/5ML CHLORIDE SOLN CORLANOR TABS 5 MG, 4 7.5 MG 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEFAZOLIN cefdinir susr 125 mg/5ml, 2 SODIUM/SODIUM NC 250 mg/5ml CHLORIDE SOSY cefditoren pivoxil tabs 2 CEFAZOLIN SOLN NC cefixime caps 2 CEFAZOLIN/SODIUM NC CHLORIDE SOLN cefixime susr 2 cephalexin caps 2 cefotaxime sodium solr 2 cephalexin susr 2 cefpodoxime proxetil susr 2 cephalexin tabs 2 cefpodoxime proxetil tabs 2 KEFLEX CAPS 5 (cephalexin) ceftazidime solr ij 2 gm, 1 2 gm, 6 gm Cephalosporins - 2nd Generation ceftazidime solr iv 1 gm, 2 2 cefaclor caps 2 gm CEFTAZIDIME/DEXTROS 5 CEFACLOR ER TB12 5 E SOLR cefaclor susr 2 CEFTRI-IM KIT 5 ceftriaxone sodium in CEFOTAN SOLR 5 2 (cefotetan disodium) dextrose soln ceftriaxone sodium solr ij 1 2 QL(0.1 ea cefotetan disodium solr 2 gm, 250 mg, 500 mg daily) CEFTRIAXONE SODIUM CEFOTETAN/DEXTROSE 5 5 SOLR SOLR IJ 100 GM ceftriaxone sodium solr ij 2 cefoxitin sodium solr ij 10 2 2 gm gm ceftriaxone sodium solr iv 1 cefoxitin sodium solr iv 1 2 2 gm, 2 gm gm, 2 gm, 10 gm CEFOXITIN SODIUM CEFTRIAXONE/DEXTROS 5 SOLR IV 1 GM-4 %, 2 GM- 5 E SOLR 2.2 % CEFTRISOL PLUS KIT 5 cefprozil susr 125 mg/5ml, 2 250 mg/5ml CLAFORAN SOLR NC (cefotaxime sodium) cefprozil tabs 250 mg, 500 2 QL(20 ea per mg fill retail) FORTAZ SOLR IJ 1 GM NC QL(20 ea per (ceftazidime) cefuroxime axetil tabs 2 fill retail) FORTAZ SOLR IJ 500 MG 5 cefuroxime sodium solr 2 FORTAZ SOLR IV 2 GM 2 Cephalosporins - 3rd Generation SUPRAX CAPS 400 MG QL(20 ea per 4 cefdinir caps 300 mg 2 (cefixime) fill retail)

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPRAX CHEW 100 MG, 4 LACTIC ACID RACEMIC 5 RX/OTC 200 MG SOLN SUPRAX SUSR 100 LACTIC ACID SOLN 5 RX/OTC MG/5ML, 200 MG/5ML 4 (cefixime) NITRIC ACID LIQD 5 SUPRAX SUSR 500 4 MG/5ML OXALIC ACID 5 DIHYDRATE POWD TAZICEF SOLN 5 PHOSPHORIC ACID 5 Cephalosporins - 4th Generation SOLN POTASSIUM HYDROXIDE 5 RX/OTC cefepime hcl solr 2 PLLT XX POTASSIUM HYDROXIDE 5 CEFEPIME SOLN 5 SOLN EX 5 % POTASSIUM HYDROXIDE CEFEPIME/DEXTROSE 5 5 SOLR SOLN XX 45 % SODIUM BORATE RX/OTC MAXIPIME SOLR IJ 1 GM, 5 5 2 GM (cefepime hcl) DECAHYDRATE POWD RX/OTC MAXIPIME SOLR IV 1 GM, 5 SODIUM BORATE POWD 5 2 GM Cephalosporins - 5th Generation SODIUM CARBONATE 5 ANHYDROUS POWD TEFLARO SOLR 5 SODIUM CARBONATE 5 MONOHYDRATE POWD Cephalosporins - Siderophores SODIUM HYDROXIDE 5 RX/OTC FETROJA SOLR 5 PLLT XX SODIUM HYDROXIDE 5 CHEMICALS SOLN EX Acids, Bases, & Buffers SULFURIC ACID SOLN 5 ACETIC ACID GLACIAL 5 RX/OTC RX/OTC SOLN TARTARIC ACID GRAN 5 ACETIC ACID SOLN XX 5 5 TARTARIC ACID POWD 5 % AMMONIUM HYDROXIDE 5 RX/OTC Bulk Chemicals - A's SOLN 6-AMINOCAPROIC ACID 5 FUMARIC ACID POWD 5 POWD 9-AMINOACRIDINE HCL 5 GLYCOLIC ACID CRYS 5 RX/OTC POWD A-LIPOIC ACID (DL- 5 RX/OTC GLYCOLIC ACID GRAN 5 THIOCTIC ACID) POWD

HYDROCHLORIC ACID 5 ACARBOSE POWD XX 5 LIQD 10 %, ACEPROMAZINE 5 HYDROCHLORIC ACID 5 RX/OTC MALEATE POWD LIQD 37 % ACESULFAME 5 RX/OTC POTASSIUM POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACETAMINOPHEN 5 ALOE VERA FREEZE 5 RX/OTC CRYSTAL 60MESH CRYS DRIED POWD ACETAMINOPHEN GRAN 5 ALOE VERA LEAF POWD 5 RX/OTC XX ACETAMINOPHEN POWD 5 RX/OTC ALOE VERA OIL 5 XX RX/OTC ACETARSONE POWD 5 ALOE VERA POWD 5 ALPHA LIPOIC ACID RX/OTC ACETAZOLAMIDE POWD 5 5 XX POWD ALPHA-KETOGLUTARIC ACETYL DIPEPTIDE-1 5 5 CETYLESTER SOLN ACID CRYS ALPHA-KETOGLUTARIC ACETYL HEXAPEPTIDE-8 5 5 POWD ACID POWD ACETYL HEXAPEPTIDE-8 5 ALPRAZOLAM POWD XX 5 SOLN ALTRENOGEST POWD 5 ACETYL-D- 5 GLUCOSAMINE POWD ALUMINUM ACETATE 5 ACETYL-L-CARNITINE 5 RX/OTC BASIC POWD HYDROCHLORIDE POWD ALUMINUM RX/OTC ACETYLCHOLINE 5 CHLOROHYDRATE 5 CHLORIDE POWD POWD ACTIPHYTE OF ALGAE 5 AMANTADINE HCL POWD 5 GL LIQD XX ACYCLOVIR POWD XX 5 AMINOCAPROIC ACID 5 POWD XX ADEMETIONINE AMINOLEVULINIC ACID 5 DISULFATE TOSYLATE 5 HCL POWD POWD AMINOLEVULINIC ACID 5 ADENOSINE POWD XX 5 HYDROCHLORIDE POWD AMINOLEVULINIC ACID 5 AGAR GRAN 5 HYDROCHOLRIDE POWD AMINOPROPYL AGAR POWD 5 MENTHYL PHOSPHATE 5 POWD ALASKAN RED ALGAE 5 POWD AMITRIPTYLINE HCL 5 POWD XX ALBENDAZOLE POWD XX 5 AMITRIPTYLINE 5 ALDOSTERONE POWD 5 HYDROCHLORIDE POWD AMLODIPINE BESYLATE 5 ALGINIC ACID POWD 5 POWD XX AMMONIUM LAURYL 5 ALKYL BENZOATE C12- 5 SULFATE LIQD 15 LIQD AMMONIUM MOLYBDATE 5 ALLOPURINOL POWD XX 5 TETRAHYDRATE POWD

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMMONIUM ATORVASTATIN 5 TETRATHIOMOLYBDATE 5 CALCIUM POWD XX POWD ATOVAQUONE POWD XX 5 AMOXICILLIN/CLAVULAN ATE POTASSIUM 4:1 5 ATTAPULGITE POWD ACTIVATED COLLODIAL 5 POWD ANASTROZOLE POWD 5 XX AVIPTADIL ACETATE 5 POWD ANDROSTENEDIONE 5 POWD AVOCADO OIL OIL 5 ANISINDIONE POWD 5 AZELAIC ACID FLAK XX 5 RX/OTC ANTIMONY POTASSIUM 5 TARTRATE POWD AZELASTINE HCL POWD 5 XX ANTIMONY 5 TRICHLORIDE CRYS AZITHROMYCIN 5 DIHYDRATE POWD ANTIMONY TRISULFIDE 5 POWD AZITHROMYCIN POWD 5 XX ANTIPYRINE CRYS 5 BLUE AGAVE ORGANIC 5 LIQD ANTIPYRINE POWD 5 DL-ALPHA LIPOIC ACID 5 RX/OTC APOMORPHINE HCL 5 POWD HEMIHYDRATE POWD ENOVARX- 5 APOMORPHINE HCL 5 AMITRIPTYLINE KIT POWD GINSENG (AMERICAN) 5 APOMORPHINE 5 POWD HYDROCHLORIDE POWD L-ARGININE HCL POWD 5 RX/OTC ARBUTIN ALPHA POWD 5 LIPOIC ACID POWD 5 RX/OTC ARGININE HCL POWD 5 RX/OTC LIPOIC ACID/DL-ALPHA RX/OTC ARNICA LG LIQD 5 (DL-THIOCTIC ACID) 5 POWD ARSENIC TRIOXIDE 5 POWD XX MAGNASWEET 110 LIQD 5 MAGNASWEET 135 ASCORBIC ACID 5 RX/OTC 5 CASSAVE POWD POWD SODIUM 4- ASCORBIC ACID GRAN 5 RX/OTC XX AMINOSALICYLATEDIHY 5 DRATE POWD ASCORBIC ACID POWD 5 RX/OTC XX Bulk Chemicals - B's ASCORBYL PALMITATE RX/OTC 5 BACITRACIN 5 POWD MICRONIZED POWD ASPARAGINE 5 BASIC FUCHSIN HCL 5 RX/OTC MONOHYDRATE POWD POWD

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BECLOMETHASONE BETAMETHASONE 5 DIPROPIONATE 5 POWD ANYDROUS POWD BETANAPHTHOL POWD 5 BECLOMETHASONE 5 DIPROPIONATE POWD BETHANECHOL 5 CHLORIDE POWD XX belladonna (bulk) tinc 2 BHA FLAK 5 BELLADONNA EXTRACT 5 POWD BIMATOPROST POWD XX 5 BELLADONNA TINC 5 BIOTIN POWD 5 RX/OTC BENACTYZINE 5 HYDROCHLORIDE POWD BIOTIN-D POWD 5 RX/OTC BENAZEPRIL HCL POWD 5 XX BISABOLOL ALPHA-L 5 LIQD BENAZEPRIL 5 HYDROCHLORIDE POWD BISMUTH CITRATE 5 RX/OTC POWD BENFOTIAMINE POWD 5 BITTER ORANGE POWD 5 BENZETHONIUM 5 CHLORIDE POWD BORON AMORPHOUS 5 FINE POWD BENZOCAINE POWD 5 RX/OTC BORON CITRATE POWD 5 BENZOIN GUM POWD 5 BOSWELLIA SERRATA 5 EXTRACT POWD BENZOQUINONE (PARA) 5 CRYS BOSWELLIA SERRATA 5 EXTRACT65% POWD BETA CAROTENE BEAD 5 BOSWELLIA SERRATA 5 EXTRACT70% POWD BETA CYCLODEXTRIN 5 POWD BRILLIANT GREEN POWD 5 RX/OTC BETA GLUCAN POWD 5 BRIMONIDINE TARTRATE 5 BETAHISTINE POWD XX DIHYDROCHLORIDE 5 BROMFENAC SODIUM 5 POWD MISC BETAHISTINE HCL POWD 5 BROMFENAC SODIUM 5 POWD BETAINE ANHYDROUS RX/OTC 5 BUDESONIDE 5 POWD MICRONIZED POWD BETAINE HCL POWD 5 BUDESONIDE POWD XX 5 BETAMETHASONE ACETATE MICRONIZED 5 BUFLOMEDIL HCL POWD 5 POWD BUPRENORPHINE HCL 5 BETAMETHASONE 5 POWD XX ACETATE POWD

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUPRENORPHINE POWD 5 CALCITRIOL IN ALMOND 5 XX OIL OIL BUPROPION HCL POWD 5 CALCITRIOL POWD XX 5 XX CALCIUM ACETATE BUPROPION 5 5 HYDROCHLORIDE POWD POWD CALCIUM ALGINATE BUSPIRONE HCL POWD 5 5 XX POWD CALCIUM AMINO ACID BUSPIRONE 5 5 HYDROCHLORIDE POWD CHELATE 30% GRAN CALCIUM CHLORIDE 5 BUTALBITAL POWD 5 ANHYDROUS POWD BUTORPHANOL 5 CALCIUM CITRATE 5 RX/OTC TARTRATE POWD XX POWD BUTYL ALCOHOL LIQD 5 CALCIUM CITRATE 5 RX/OTC TETRAHYDRATE POWD BUTYLATED CALCIUM 5 HYDROXYANISOLE 5 FRUCTOBORATE POWD POWD CALCIUM GLUBIONATE 5 BUTYLENE GLYCOL LIQD 5 MONOHYDRATE POWD CALCIUM GLUBIONATE 5 TINOGARD TL LIQD 5 POWD CALCIUM Bulk Chemicals - C's GLYCEROPHOSPHATE 5 ACTIPHYTE OF 5 POWD CUCUMBER LIQD CALCIUM LEVULINATE 5 ADENOSYLCOBALAMIN 5 RX/OTC DIHYDRATE POWD POWD CALCIUM OXIDE POWD 5 ADRENOCHROME 5 SEMICARBAZONE POWD CALCIUM PROPIONATE 5 POWD ADRENOCORTICOTROP 5 HIC HORMONE POWD CALCIUM PYRUVATE 5 AVICEL PH 101 RX/OTC POWD MICROCRYSTALLINE 5 CALCIUM STEARATE 5 CELLULOSE POWD POWD AVICEL PH 105 RX/OTC CALCIUM MICROCRYSTALLINE 5 THIOGLYCOLATE 5 CELLULOSE POWD TRIHYDRATE POWD C INDICUM EXTRACT/C RX/OTC SINESIS LEAF EXTRACT 5 CANADIAN BALSAM LIQD 5 LIQD CANNABIDIOL POWD 5 CALCIPOTRIENE 5 MONOHYDRATE POWD CAPRYLIC ACID LIQD 5 CALCIPOTRIENE POWD 5 XX CAPRYLIC/CAPRIC 5 TRIGLYCERIDE LIQD CALCIPOTRIOL POWD 5

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPRYLIC/CAPRIC 5 CELLULOSE RX/OTC TRIGLYCERIDES LIQD MICROCRYSTALLINE 5 POWD CAPSAICIN PALMITATE 5 POWD CELLULOSE PARTIALLY 5 RX/OTC DEPOLYMERIZED POWD CAPTOPRIL POWD XX 5 CELLULOSE/CMC NA 5 CARBACHOL POWD 5 MICROCRYSTALLINE POWD CARBAMIDE PEROXIDE RX/OTC 5 5 POWD CERESIN WAX FLAK CESIUM CHLORIDE CARBAZOCHROME 5 5 POWD POWD CARBIMAZOLE POWD 5 CETEARYL ALCOHOL/CETEARETH- 5 20 POWD CARBOMER 934P POWD 5 RX/OTC CETOSTEARYL 5 CARBOMER 934P RESIN 5 RX/OTC ALCOHOL MISC POWD CETYL MYRISTOLEATE 5 CARBOMER 940 POWD 5 RX/OTC OIL CETYL MYRISTOLEATE 5 CARBOMER 941 POWD 5 RX/OTC POWD CETYL MYRISTOLEATE 5 CARBOMER RX/OTC WAX HOMOPOLYMER TYPE C 5 POWD CETYLPYRIDINIUM 5 CHLORIDE CRYS CARBOPOL 940 NF 5 RX/OTC POWD CETYLPYRIDINIUM CHLORIDEMONOHYDRA 5 CARBOPOL 940 POWD 5 RX/OTC TE CRYS CHICKEN PROTEIN 5 CARMINE POWD 5 POWD CARNAUBA WAX FLAK 5 CHLORAMBUCIL POWD 5 CHLORAMPHENICOL 5 CARNOSINE L POWD 5 CRYS CEFTAZIDIME POWD XX 5 CHLORAMPHENICOL 5 PALMITATE POWD CEFTAZIDIME/SODIUM 5 CHLORAMPHENICOL 5 CARBONATE POWD POWD CEFTRIAXONE SODIUM 5 CHLORHEXIDINE POWD XX DIACETATE HYDRATE 5 POWD CELECOXIB POWD XX 5 CHLOROPHYLLIN 5 CELLULASE POWD 5 RX/OTC SODIUM COPPER POWD CHLOROTHIAZIDE POWD 5 CELLULOSE RX/OTC XX MICROCRYSTALLINE 5 CRYS CHLOROXINE POWD 5

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHLOROXYLENOL POWD 5 CIDOFOVIR DIHYDRATE 5 POWD CHLORPROMAZINE HCL 5 CINNAMON BARK 5 POWD XX CASSIA POWD CHOLECALCIFEROL 5 CIPROFLOXACIN HCL 5 CRYS XX POWD XX CHOLECALCIFEROL RX/OTC 5 CIPROFLOXACIN POWD 5 POWD XX XX CHOLESTEROL FLAK 5 CISAPRIDE 5 MONOHYDRATE POWD RX/OTC CHOLESTEROL POWD 5 CISPLATIN POWD XX 5 CHOLESTYRAMINE 5 RX/OTC POWD XX CITRULLINE(L) POWD 5 CHOLESTYRAMINE 5 CITRUS BIOFLAVONOIDS 5 RESIN POWD POWD CHOLINE CHLORIDE 5 CLARITHROMYCIN 5 POWD POWD XX CHOLINE MAGNESIUM 5 TRISALICYLATE POWD CLEMIZOLE HCL POWD 5 CHONDROITIN SULFATE 5 RX/OTC CLIDINIUM BROMIDE 5 SODIUM POWD POWD CHORIONIC CLINDAMYCIN HCL 5 GONADOTROPIN POWD 5 MONOHYDRATE POWD XX CLINDAMYCIN HCL 5 CHORIONIC POWD XX GONADOTROPIN(HUMAN 5 CLINDAMYCIN 5 ) POWD PHOSPHATE POWD XX CHROMIC CHLORIDE 5 RX/OTC CRYS XX CLOFAZIMINE POWD 5 CHROMIUM CHLORIDE RX/OTC CLOMIPRAMINE HCL 5 HEXAHYDRATE 5 POWD XX REAGENT CRYS CLONAZEPAM POWD XX 5 CHROMIUM CHLORIDE 5 POWD CLOPIDOGREL 5 BISULFATE POWD XX CHROMIUM PICOLINATE 5 RX/OTC POWD CLORSULON POWD 5 CHROMIUM 5 POLYNICOTINATE POWD COBALT GLUCONATE 5 CHROMIUM POTASSIUM POWD SULFATE 5 COBAMAMIDE POWD 5 RX/OTC DODECAHYDRATE CRYS CHRYSIN POWD 5 RX/OTC COCAMIDE DEA LIQD 5

CIDOFOVIR ANHYDROUS 5 COLHIBIN SOLN 5 POWD

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COLISTIMETHATE 5 CYCLOBENZAPRINE 5 SODIUM POWD XX POWD COLLAGEN 5 CYCLOMETHICONE LIQD 5 HYDROLYSATE POWD CYCLOPENTASILOXANE/ COPPER GLUCONATE 5 POWD PEG/PPG-18/18 5 DIMETHICONE LIQD COPPER GLYCINATE 5 POWD CYCLOPENTOLATE HCL 5 POWD XX COPPER PEPTIDE POWD 5 CYCLOPHOSPHAMIDE 5 MONOHYDRATE POWD CORAL CALCIUM POWD 5 CYCLOPHOSPHAMIDE 5 CORN OIL OIL 5 RX/OTC POWD XX CYCLOSERINE POWD XX 5 COUMARIN POWD 5 CYCLOSPORINE A POWD 5 CRANBERRY POWD 5 CYCLOSPORINE POWD 5 CREATINE ANHYDROUS 5 XX POWD CYPROHEPTADINE HCL 5 CREATINE 5 RX/OTC POWD XX MONOHYDRATE POWD CYSTEAMINE HCL POWD 5 CREATINE POWD 5 DERMACINRX ETHOXY 5 RX/OTC CREATININE POWD 5 RX/OTC DIGLYCOL LIQD DIETHYLENE GLYCOL RX/OTC CRESOL LIQD 5 MONOETHYL ETHER 5 LIQD CROSCARMELLOSE 5 DIETHYLENE GLYCOL RX/OTC SODIUM POWD MONOETHYL ETHER NF 5 CROTAMITON LIQD XX 5 LIQD ETHOXY DIGLYCOL LIQD 5 RX/OTC CROTON OIL OIL 5 RX/OTC ETHOXY ETHOXY RX/OTC CUPRIC CHLORIDE 5 ETHANOL REAGENT 5 DIHYDRATE CRYS LIQD CUPUACU BUTTER MISC 5 FREEDOM ESTERDERM 5 LIQD CYANOCOBALAMIN 5 RX/OTC CRYS XX HUMAN CHORIONIC 5 GONADOTROPIN POWD CYANOCOBALAMIN 5 POWD XX L-CARNOSINE POWD 5

CYCLANDELATE POWD 5 L-CITRULLINE POWD 5 RX/OTC CYCLOBENZAPRINE HCL 5 POWD XX L-CYSTEINE CRYS 5 CYCLOBENZAPRINE 5 L-CYSTEINE HCL 5 RX/OTC HYDROCHLORIDE POWD MONOHYDRATE POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits L-CYSTEINE POWD 5 DEOXYCHOLIC ACID 5 POWD LOCUST BEAN GUM 5 DESICCATED BEEF 5 POWD LIVER POWD MICROCRYSTALLINE RX/OTC DESMOPRESSIN 5 CELLULOSE NF 101 5 ACETATE POWD XX POWD DESOXIMETASONE 5 MICROCRYSTALLINE RX/OTC POWD XX CELLULOSE NF 105 5 DESOXYCORTICOSTERO 5 POWD NE ACETATE POWD RX/OTC UREA PEROXIDE POWD 5 DEVILS CLAW POWD 5 VITAMIN D3 LIQD XX DEXAMETHASONE 1000000 UNIT/GM, 2400 5 ACETATE ANHYDROUS 5 UNIT/ML, POWD VITAMIN D3 POWD XX 5 RX/OTC DEXAMETHASONE 5 ACETATE POWD VITAMIN D3 POWD XX 5 100000 UNIT/GM DEXAMETHASONE BASE 5 POWD YLANG-YLANG OIL 5 FRAGRANCE OIL DEXAMETHASONE 5 ISONICOTINATE POWD Bulk Chemicals - D's DEXAMETHASONE 5 2-DEOXY-D-GLUCOSE 5 RX/OTC POWD XX POWD DEXAMETHASONE 2-DEOXY-D-GLUCOSE 5 RX/OTC SODIUM PHOSPHATE 5 REAGANTGRADE POWD POWD XX CALCIUM DEXCHLORPHENIRAMIN 5 HYDROXYAPATITE 5 E MALEATE POWD XX POWD DEXPANTHENOL LIQD 5 RX/OTC D-MANNOSE POWD 5 XX DEXPANTHENOL POWD 5 D-RIBOSE POWD 5 XX DEXTRAN 40000 POWD 5 D-RIBOSE REAGENT 5 POWD DEXTRAN 75000 POWD 5 DANTROLENE SODIUM 5 POWD XX DEXTROMETHORPHAN 5 DAPIPRAZOLE HCL 5 POWD POWD DIAMINOPYRIDINE 5 DAPSONE POWD XX 5 POWD DIAZEPAM POWD XX 5 DEHYDROCHOLIC ACID 5 POWD DIAZOXIDE POWD XX 5 DEMECARIUM BROMIDE 5 POWD DIBUCAINE HCL POWD 5 DENATONIUM 5 BENZOATE GRAN

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIBUCAINE POWD 5 DIMETHYLACETAMIDE 5 LIQD DICHLORALPHENAZONE 5 DIMETHYLAMINOETHAN 5 POWD OL (DEANOL) LIQD DICHLOROACETIC ACID 5 DIMETHYLGLYCINE HCL 5 RX/OTC LIQD POWD DICLAZURIL POWD 5 DIOSGENIN POWD 5 DICLOFENAC SODIUM 5 POWD XX DIOSMIN POWD 5 DICUMAROL POWD 5 DIOXYBENZONE POWD 5

DICYCLOMINE 5 DIPHENIDOL 5 HYDROCHLORIDE POWD HYDROCHLORIDE POWD DIETHANOLAMINE LIQD 5 DIPHENYLCYCLOPROPE 5 NONE POWD DIETHYL PHTHALATE 5 DIPYRIDAMOLE POWD 5 LIQD XX DIETHYL-M-TOLUAMIDE 5 LIQD DISOPHENOL POWD 5 DIETHYLCARBAMAZINE 5 DISULFIRAM POWD XX 5 CITRATE POWD DIETHYLPROPION DIVALPROEX SODIUM 5 HYDROCHLORIDE/TART 5 POWD XX ARIC ACID POWD DMAE BITARTRATE 5 POWD DIETHYLSTILBESTROL 5 POWD DOCOSANOL POWD 5 DIGOXIN MICRONIZED 5 POWD DOPAMINE 5 HYDROCHLORIDE POWD DIGOXIN POWD XX 5 DORZOLAMIDE 5 HYDROCHLORIDE POWD DIHYDROCODEINE 5 BITARTRATE POWD DOW CORNING 1501 5 FLUID LIQD DIHYDROXYACETONE 5 (1,3) DIMER POWD DOXAZOSIN MESYLATE 5 POWD XX DIINDOLYLMETHANE 5 POWD DOXEPIN HCL POWD XX 5 DIIODO-L-THYRONINE 5 3,5 POWD DOXEPIN 5 HYDROCHLORIDE POWD DILTIAZEM HCL POWD 5 XX DOXYCYCLINE 5 MONOHYDRATE POWD DIMETHYL FUMARATE 5 POWD XX DULOXETINE HCL POWD 5 DIMETHYL SILOXANE XX HYDROXYALKYL- 5 DULOXETINE 5 TERMINATED LIQD HYDROCHLORIDE POWD

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUTASTERIDE POWD XX 5 ESTRADIOL VALERATE 5 CRYS XX DYCLONINE HCL POWD 5 ESTRADIOL VALERATE 5 POWD XX DYCLONINE 5 ESTRIOL CONCENTRATE 5 HYDROCHLORIDE CRYS CREA DYPHYLLINE POWD 5 ESTRIOL MICRONIZED 5 POWD GERMALL PLUS LIQD 5 ESTRIOL POWD 5 PCCA DMAE COMPLEX 5 LIQD ESTRIOL ULTRA 5 MICRONIZED POWD PROSTAGLANDIN E2 5 POWD ESTRONE 5 CONCENTRATE CREA RIBOSE (D) POWD 5 ESTRONE CRYS 5 SYN-AKE LIQD 5 ESTRONE POWD 5 Bulk Chemicals - E's ETHOSUXIMIDE POWD 5 ECONAZOLE NITRATE 5 XX POWD XX ETHYL OLEATE LIQD 5 RX/OTC EDROPHONIUM 5 CHLORIDE POWD ETHYL VANILLIN FLAK 5 EMU OIL OIL 5 ETHYLCELLULOSE 5 POWD ENALAPRIL MALEATE 5 POWD XX ETHYLENEDIAMINE LIQD 5 ENROFLOXACIN POWD 5 ETOMIDATE POWD XX 5 EPINEPHRINE 5 BITARTRATE POWD ETOPOSIDE POWD XX 5 ERGOLOID MESYLATES 5 POWD XX EUCALYPTOL LIQD 5 RX/OTC ERYTHROMYCIN 5 ESTOLATE POWD GREEN TEA POWD 5 ESTRADIOL BENZOATE 5 POWD Bulk Chemicals - F's ESTRADIOL 5 4-AMINOPYRIDINE POWD 5 CONCENTRATE CREA 4-METHYLPYRAZOLE 5 ESTRADIOL CYPIONATE 5 LIQD POWD 5-FLUOROURACIL POWD 5 ESTRADIOL 5 HEMIHYDRATE POWD DALFAMPRIDINE POWD 5 ESTRADIOL MICRONIZED 5 XX POWD FAMCICLOVIR POWD XX 5 ESTRADIOL POWD XX 5

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FAMOTIDINE POWD XX 5 FLUOROURACIL POWD 5 XX FENBENDAZOLE POWD 5 FLUOXETINE HCL POWD 5 XX FENOFIBRATE POWD XX 5 FLUPHENAZINE 5 DECANOATE LIQD XX FERRIC AMMONIUM 5 CITRATE POWD FLUPHENAZINE 5 DECANOATE POWD XX FERRIC CHLORIDE 5 HEXAHYDRATE MISC FLUTICASONE 5 PROPIONATE POWD XX FERRIC SUBSULFATE 5 RX/OTC SOLN FORMOTEROL 5 FUMARATE POWD FERRIC SULFATE 5 HYDRATE POWD FORSKOLIN POWD 5 FERROUS BISGLYCINATE CHELATE 5 FURAZOLIDONE POWD 5 POWD Bulk Chemicals - G's FERROUS FUMARATE 5 POWD 4-AMINOBUTYRIC ACID 5 CRYS FERROUS GLUCONATE 5 DIHYDRATE GRAN ALPHA-GPC 50% POWD 5 FERROUS GLUCONATE 5 DIHYDRATE POWD ARLACEL 165 POWD 5 FERROUS GLUCONATE 5 BASE FOUR POWD COMPONENT FERULIC ACID POWD 5 GABAPENTIN MULTI- 5 PHASIC COMPOUND FEVERFEW POWD 5 POWD EGCG POWD 5 RX/OTC FEXOFENADINE HCL 5 POWD GABAPENTIN POWD XX 5 FINASTERIDE CRYS XX 5 GALACTOSE POWD 5 FINASTERIDE POWD XX 5 GAMMA-AMINOBUTYRIC 5 FLIBANSERIN POWD 5 ACID CRYS GARDENIA FRAGRANCE 5 FLOXURIDINE POWD XX 5 OIL GATIFLOXACIN 5 FLUCONAZOLE POWD 5 SESQUIHYDRATE POWD XX GENISTEIN POWD 5 FLUCYTOSINE POWD XX 5 GINGER OIL 5 FLUMAZENIL POWD XX 5 GINSENG ROOT POWD 5 FLUNIXIN MEGLUMINE 5 POWD

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCONOLACTONE 5 GUANETHIDINE 5 POWD HEMISULFATE POWD GLUCOSAMINE 5 RX/OTC GUANIDINEACETIC ACID 5 HYDROCHLORIDE POWD POWD GLUCOSAMINE SULFATE GUAR GUM POWD 5 POTASSIUM CHLORIDE 5 POWD GUARANA SEED 5 EXTRACT POWD GLUCOSAMINE SULFATE 5 RX/OTC POWD GYMNEMA SYLVESTRIS 5 GLUCOSAMINE SULFATE LEAF POWD SODIUM CHLORIDE 5 Bulk Chemicals - H's POWD ACTIPHYTE OF IVY LIQD 5 GLUTARALDEHYDE IN 5 WATER LIQD HALOPERIDOL 5 GLYCEROL 5 DECANOATE POWD XX MONOOLEATE POWD HALOPERIDOL POWD XX 5 GLYCERYL 5 RX/OTC MONOSTEARATE FLAK HAWTHORN BERRY 5 GLYCOFUROL LIQD 5 POWD HEMATOXYLIN POWD 5 GLYCOPYRROLATE 5 POWD XX HEPARIN SODIUM POWD 5 XX GLYCOSAMINOGLYCANS 5 LIQD HEPES POWD 5 GLYCYRRHIZIC ACID 5 POWD HEPTAMINOL POWD 5 GOLD SODIUM 5 THIOMALATE POWD HISTAMINE PHOSPHATE 5 CRYS GRAMICIDIN D POWD 5 HONEY ALMOND 5 FRAGRANCE LIQD GRAPE SEED OIL 5 RX/OTC HUPERZINE SERRATE A 5 GRAPESEED OIL 5 RX/OTC POWD HYALURONATE SODIUM 5 GREEN SOAP EMUL 5 POWD HYALURONIC ACID 5 GREEN TEA OIL 5 HYDROLYZED POWD FRAGRANCE OIL HYALURONIC ACID 5 GREEN TEA POWD 5 RX/OTC SODIUM POWD GRISEOFULVIN HYALURONIC ACID 5 5 SODIUM SALT POWD MICRONIZED POWD HYALURONIDASE POWD 5 GRISEOFULVIN POWD 5 XX HYDRALAZINE HCL GUANABENZ ACETATE 5 5 POWD POWD XX

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDRAZINE SULFATE 5 HYDROXYPROPYL RX/OTC CRYS CELLULOSE 75-100 CPS 5 POWD HYDROCODONE 5 BITARTRATE CRYS HYDROXYPROPYL 5 RX/OTC CELLULOSE POWD HYDROCODONE 5 BITARTRATE POWD HYDROXYPROPYL RX/OTC HYDROCORTISONE METHYLCELLULOSE 5 HEMISUCCINATE 5 POWD MONOHYDRATE POWD HYDROXYPROPYL-BETA- 5 CYCLODEXTRIN POWD HYDROFLUORIC ACID 5 LIQD HYDROXYUREA POWD 5 XX HYDROXOCOBALAMIN 5 HYDROCHLORIDE POWD HYDROXYZINE HCL 5 POWD XX HYDROXOCOBALAMIN 5 RX/OTC POWD HYPROMELLOSE 5 RX/OTC 100000CPS POWD HYDROXYAMPHETAMINE 5 HYDROBROMIDE POWD HYPROMELLOSE 4000 5 RX/OTC MPA-S POWD HYDROXYCHLOROQUIN 5 E SULFATE POWD XX HYPROMELLOSE 5 RX/OTC HYDROXYETHYL 4000CPS POWD CELLULOSE 100 CPS 5 HYPROMELLOSE RX/OTC POWD METHOCEL K100M 5 HYDROXYETHYL POWD 5 CELLULOSE 4500-6500 HYPROMELLOSE TYPE 5 RX/OTC CPS POWD 2910 POWD HYDROXYETHYL METHOCEL E4M POWD 5 RX/OTC CELLULOSE 5000 CPS 5 POWD METHOCEL E4M 5 RX/OTC PREMIUM CR POWD HYDROXYETHYL 5 CELLULOSE POWD METHOCEL E4M 5 RX/OTC PREMIUM POWD HYDROXYETHYL 5 METHACRYLATE POWD METHOCEL K100 5 RX/OTC PREMIUM POWD HYDROXYPROGESTERO 5 NE CAPROATE POWD XX METHOCEL K100M 5 RX/OTC HYDROXYPROPYL RX/OTC PREMIUM POWD CELLULOSE 150-400 CPS 5 SODIUM HYALURONATE POWD (INJECTION GRADE) 5 HYDROXYPROPYL RX/OTC POWD CELLULOSE 1500 CPS 5 SODIUM HYALURONATE 5 POWD POWD HYDROXYPROPYL RX/OTC WITCH HAZEL EXTR 5 CELLULOSE 1500-3000 5 CPS POWD Bulk Chemicals - I's HYDROXYPROPYL RX/OTC CELLULOSE 4000-6500 5 CERAPHYL SLK LIQD 5 CPS POWD IDEBENONE POWD 5

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IDOXURIDINE POWD 5 Bulk Chemicals - K's 7-KETO DHEA POWD 5 RX/OTC IMIDUREA POWD 5 ACTIPHYTE OF SEA 5 IMIQUIMOD POWD XX 5 KELP LIQD ACTIPHYTE OF SUGAR INDOCYANINE GREEN 5 5 POWD KELP LIQD KANAMYCIN SULFATE INDOLE-3-CARBINOL 5 RX/OTC 5 POWD POWD KETAMINE HCL POWD INOSITOL 5 RX/OTC 5 HEXANICOTINATE POWD XX KETOPROFEN 5 INOSITOL POWD 5 MICRONIZED POWD IODINE FLAK 5 KETOPROFEN POWD XX 5 KETOPROFEN ULTRA IODINE RESUBLIMED 5 5 GRAN MICRONIZED POWD KETOROLAC iodine strong (lugol's) (bulk) 2 RX/OTC soln TROMETHAMINE POWD 5 XX IODINE STRONG SOLN 5 RX/OTC KETOTIFEN FUMARATE 5 POWD IOPANOIC ACID POWD 5 KETOTIFEN HYDROGEN 5 FUMARATE POWD ISOMETHEPTENE 5 MUCATE POWD KINETIN POWD 5 ISOPROPYL MYRISTATE 5 SOLN KIWI FRAGRANCE LIQD 5 ISOPROTERENOL HCL 5 POWD XX KUDZU ROOT POWD 5 ISOSORBIDE POWD 5 Bulk Chemicals - L's ISOTRETINOIN POWD XX 5 5- METHYLTETRAHYDROF OLIC 5 ISOXSUPRINE HCL 5 POWD ACID/GLUCOSAMINE SALT POWD ITRACONAZOLE POWD 5 XX ACIDOPHILUS 5 LACTOBACILLUS POWD IVERMECTIN POWD XX 5 CALCIUM FOLINATE 5 POWD LIPACTIVE INCA INCHI 5 WO LIQD CARNITINE (L) POWD 5 RX/OTC Bulk Chemicals - J's L-5- JASMINE FRAGRANCE 5 METHYLTETRAHYDROF 5 LIQD OLICACID CALCIUM JOJOBA OIL OIL 5 POWD

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits L-CARNITINE POWD XX 5 RX/OTC LEVOFLOXACIN 5 HEMIHYDRATE POWD RX/OTC L-LYSINE HCL POWD 5 LEVOMEFOLATE 5 CALCIUM POWD L-LYSINE RX/OTC LEVORPHANOL 5 MONOHYDROCHLORIDE 5 TARTRATE POWD XX POWD LEVOTHYROXINE 5 L-METHYLFOLATE 5 SODIUM (T4) POWD CALCIUM POWD LEVOTHYROXINE 5 L-SELENOMETHIONINE 5 SODIUM POWD XX BLEND POWD LICORICE L-SELENOMETHIONINE 5 DEGLYCYRRHIZINATED 5 POWD POWD LABETALOL HCL POWD 5 XX LIDOCAINE BASE POWD 5 LACTASE 5000 POWD 5 LIDOCAINE CRYS XX 5

LAMOTRIGINE POWD XX 5 LIDOCAINE HCL 5 MONOHYDRATE POWD LANSOPRAZOLE POWD RX/OTC 5 LIDOCAINE HCL POWD 5 XX XX LATANOPROST POWD 5 LIDOCAINE XX HYDROCHLORIDE POWD 5 LAURETH-9 5 XX POLIDOCANOL LIQD LIDOCAINE POWD XX 5 LAURIC ACID POWD 5 LIMONENE LIQD 5 LEAD TETROXIDE POWD 5 LINCOMYCIN HCL POWD 5 LEFLUNOMIDE POWD XX 5 XX LINOLEIC ACID LIQD 5 LETROZOLE POWD XX 5 LIOTHYRONINE POWD 5 LEUCOVORIN CALCIUM 5 POWD XX LIOTHYRONINE SODIUM 5 LEUPROLIDE ACETATE 5 (T3) POWD POWD XX LIOTHYRONINE SODIUM 5 LEVALBUTEROL HCL 5 POWD XX POWD XX LISINOPRIL POWD XX 5 LEVETIRACETAM POWD 5 XX LITHIUM CITRATE 5 LEVOCARNITINE POWD 5 RX/OTC TETRAHYDRATE POWD 5 RX/OTC LEVOCETIRIZINE LORATADINE POWD DIHYDROCHLORIDE 5 POWD XX LORAZEPAM POWD XX 5 LUTEIN BEAD 5

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LUTEIN POWD 5 MAGNESIUM CITRATE 5 RX/OTC TRIBASIC POWD LYSINE HCL GRAN 5 MAGNESIUM 5 GLUCONATE POWD PCCA T3 SODIUM 5 MAGNESIUM GLYCINATE 5 DILUTION POWD POWD PCCA T4 SODIUM 5 MAGNESIUM 5 DILUTION POWD HYDROXIDE POWD PINENE (L-ALPHA) POWD 5 MAGNESIUM MALATE 5 POWD Bulk Chemicals - M's MAGNESIUM 2-METHOXYESTRADIOL 5 PHOSPHATE DIBASIC 5 POWD TRIHYDRATE POWD 5- RX/OTC MAGNESIUM 5 METHYLTETRAHYDROF 5 SALICYLATE POWD OLATE POWD MALEIC ACID POWD 5 5- RX/OTC METHYLTETRAHYDROF 5 RX/OTC OLATECALCIUM POWD MALIC ACID POWD 5 CALCIUM L-5 RX/OTC MALTODEXTRIN POWD 5 METHYLTETRAHYDROF 5 OLATE POWD MANDELIC ACID POWD 5 DIMETHYL SULFONE 5 POWD MANGANESE CHLORIDE 5 TETRAHYDRATE POWD DL-MALIC ACID POWD 5 RX/OTC MANGANESE 5 GLUCONATE POWD L-GLUTAMIC ACID 5 MONOSODIUM POWD MANGANESE SULFATE 5 POWD XX MACA ROOT POWD 5 MECAMYLAMINE HCL 5 POWD MAFENIDE ACETATE 5 POWD XX MECHLORETHAMINE 5 HCL POWD MAGNESIUM ALUMINUM 5 SILICATE POWD MECLOFENOXATE 5 MAGNESIUM AMINO HYDROCHLORIDE POWD ACID CHELLATE 20% 5 MEDIUM CHAIN 5 POWD TRIGLYCERIDES LIQD MAGNESIUM 5 MEDROXYPROGESTERO ASCORBATE POWD NE ACETATE 5 MAGNESIUM MICRONIZED POWD BISGLYCINATE CHELATE 5 MEDROXYPROGESTERO 5 POWD NE ACETATE POWD XX MAGNESIUM MEDROXYPROGESTERO 5 BISGLYCINATE 5 NE ACETATE YAM POWD DIHYDRATE POWD MEDROXYPROGESTERO 5 MAGNESIUM CITRATE 5 RX/OTC NE MICRONIZED POWD POWD

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEGLUMINE POWD 5 METHYLENE CHLORIDE 5 LIQD MELOXICAM POWD XX 5 METHYLMETHACRYLATE CROSSPOLYMER (310) 5 MEMANTINE 5 POWD HYDROCHLORIDE POWD METHYLPHENIDATE HCL 5 MENADIONE POWD 5 POWD XX METHYLSULFONYLMETH 5 MEQUINOL POWD 5 ANE POWD METHYLTETRAHYDROF 5 RX/OTC MERCAPTOPURINE 5 OLATE CALCIUM POWD MONOHYDRATE POWD METHYSERGIDE 5 MERCAPTOPURINE 5 MALEATE POWD POWD XX METRONIDAZOLE 5 METACRESOL ACETATE 5 BENZOATE POWD LIQD METRONIDAZOLE POWD 5 METFORMIN HCL POWD 5 XX XX MEXILETINE 5 METHACHOLINE 5 HYDROCHLORIDE POWD CHLORIDE CRYS XX MIDAZOLAM POWD XX 5 METHACHOLINE 5 CHLORIDE POWD XX METHACRYLIC ACID MILK THISTLE POWD 5 COPOLYMER TYPE A 5 POWD MIRTAZAPINE POWD XX 5 METHANESULFONIC 5 MISOPROSTOL POWD 5 ACID LIQD XX 1 % METHOCARBAMOL 5 MISOPROSTOL-HPMC 5 POWD XX POWD METHOXYAMINE 5 HYDROCHLORIDE POWD MITOMYCIN POWD XX 5 METHOXYETHANOL LIQD 5 MITOTANE POWD 5

METHSCOPOLAMINE 5 MOLYBDENUM POWD 5 BROMIDE POWD XX MOMETASONE FUROATE METHSCOPOLAMINE 5 5 NITRATE POWD POWD XX METHYL FOLATE POWD 5 MONOBENZONE POWD 5 METHYL MONOETHANOLAMINE 5 METHACRYLATE 5 LIQD CROSSPOLYMER POWD MONTELUKAST SODIUM 5 POWD XX METHYL SULFONE CRYS 5 RX/OTC MORANTEL TARTRATE 5 METHYLCOBALAMIN 5 RX/OTC POWD POWD XX MOXIFLOXACIN HCL 5 POWD XX

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOXISYLYTE HCL POWD 5 NICOTINE POLACRILEX 5 RX/OTC POWD XX MUPIROCIN POWD XX 5 NICOTINE TARTRATE 5 POWD VITAMIN K2 POWD 5 NIMODIPINE POWD XX 5 Bulk Chemicals - N's NITROFURANTOIN 5 ANHYDROUS POWD N-ACETYL-L-CARNOSINE 5 POWD NITROFURANTOIN 5 POWD XX NABUMETONE POWD XX 5 NOREPINEPHRINE 5 NADH POWD 5 BITARTRATE POWD XX NORETHINDRONE POWD 5 NALBUPHINE HCL POWD 5 XX NYSTATIN FOREIGN 5 NALOXONE HCL 5 POWD DIHYDRATE POWD NYSTATIN POWD XX 5 NALOXONE HCL POWD 5 XX Bulk Chemicals - O's NALOXONE HYDROXYQUINOLINE 5 HYDROCHLORIDE 5 SULFATE POWD DIHYDRATE POWD L-ORNITHINE 5 RX/OTC NALTREXONE HCL 5 HYDROCHLORIDE POWD POWD XX OCTINOXATE LIQD 5 NALTREXONE 5 HYDROCHLORIDE POWD OCTYL STEARATE LIQD 5 NALTREXONE POWD XX 5 OLMESARTAN 5 NANDROLONE 5 MEDOXOMIL POWD XX DECANOATE POWD OMEPRAZOLE POWD XX 5 NAPHAZOLINE HCL 5 POWD ONDANSETRON HCL 5 NEOSTIGMINE DIHYDRATE POWD METHYLSULFATE POWD 5 ONDANSETRON HCL 5 XX POWD XX NEPAFENAC POWD 5 ORIGANUM OIL 5

NETTLE LEAF POWD 5 ORLISTAT POWD 5

NICLOSAMIDE POWD 5 ORNITHINE 5 RX/OTC HYDROCHLORIDE POWD NICOTINAMIDE ADENINE RX/OTC OSELTAMIVIR 5 DINUCLEOTIDE (NAD) 5 PHOSPHATE POWD XX POWD OXANDROLONE POWD 5 NICOTINAMIDE ADENINE 5 RX/OTC DINUCLEOTIDE POWD OXYBUTININ CHLORIDE 5 POWD

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYBUTYNIN CHLORIDE 5 PEG-40 CASTOR OIL OIL 5 POWD XX PENICILLAMINE POWD OXYMETAZOLINE HCL 5 5 POWD XX OXYTETRACYCLINE 5 PENNYROYAL OIL OIL 5 DIHYDRATE POWD PENTOSAN OXYTOCIN POWD XX 5 POLYSULFATE SODIUM 5 POWD TRITON X-100 LIQD 5 PENTOXIFYLLINE POWD 5 XX Bulk Chemicals - P's PENTYLENE GLYCOL 5 BRIJ 35 WAX 5 LIQD PENTYLENETETRAZOLE 5 BRIJ 700 WAX 5 CRYS PERFLUORODECALIN 5 BRIJ 93 LIQD 5 LIQD COSMOCIL CQ LIQD 5 PERGOLIDE MESYLATE 5 POWD DL-PANTHENOL 5 PERMETHRIN 5 ALCOHOL POWD TECHNICAL LIQD DL-PANTHENOL POWD 5 PERPHENAZINE POWD 5 XX PALMAROSA OIL OIL 5 PEUCEDANUM OSTRUTHIUM EXTRACT 5 PALMITAMIDE MEA 5 SOLN (PMEA) POWD PHENELZINE SULFATE 5 PALMITOYL 5 POWD XX PENTAPEPTIDE-3 GEL PHENINDIONE POWD 5 PALMITOYL TRIPEPTIDE- 5 3 SOLN PHENIRAMINE MALEATE 5 PANCREATIN POWD 5 POWD PHENOLSULFONIC ACID 5 PANTHENOL POWD 5 LIQD PHENOXYBENZAMINE PANTOPRAZOLE 5 5 SODIUM POWD XX HCL POWD XX PAPAIN POWD 5 PHENOXYETHANOL LIQD 5 PHENTERMINE PARACHLOROPHENOL 5 5 POWD HYDROCHLORIDE POWD PHENTOLAMINE PARAFORMALDEHYDE 5 5 POWD MESYLATE POWD XX PHENYL SALICYLATE PAROMOMYCIN 5 5 SULFATE POWD XX CRYS PHENYLETHYL ALCOHOL PEG 400 5 5 MONOSTEARATE POWD LIQD

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHENYLETHYLAMINE 5 POTASSIUM AZELAOYL 5 HCL POWD DIGLYCINATE LIQD PHENYLTOLOXAMINE POTASSIUM BENZOATE 5 DIHYDROGEN CITRATE 5 POWD POWD POTASSIUM IODIDE 5 RX/OTC PHENYTOIN POWD XX 5 CRYS POTASSIUM IODIDE 5 PHOSPHATIDYLCHOLINE 5 RX/OTC GRAN POWD POTASSIUM IODIDE 5 PHYTIC ACID IN WATER 5 POWD LIQD POTASSIUM 5 PHYTONADIONE CRYS 5 METABISULFITE CRYS XX POTASSIUM 5 PHYTONADIONE LIQD XX 5 RX/OTC METABISULFITE POWD POTASSIUM 5 RX/OTC PIMOBENDAN POWD 5 PERMANGANATE GRAN POTASSIUM PINE BARK EXTRACT 5 POWD PHOSPHATE DIBASIC 5 ANHYDROUS GRAN PINE NEEDLE OIL OIL 5 POTASSIUM PHOSPHATE DIBASIC 5 PINEAPPLE EXTRACT 5 GRAN LIQD POTASSIUM PIPERINE POWD 5 PHOSPHATE 5 MONOBASIC CRYS PIRACETAM POWD 5 POTASSIUM SODIUM 5 TARTRATE GRAN PODOFILOX POWD XX 5 POTASSIUM SULFATE 5 POWD POLYHEXAMETHYLENE 5 BIGUANIDE SOLN POVIDONE K-30 POWD 5 POLYVINYL ALCOHOL 5 POWD POVIDONE POWD 5 POLYVINYLPYRROLIDON 5 E K-30 POWD POVIDONE-IODINE FLAK 5 POLYVINYLPYRROLIDON 5 POVIDONE-IODINE 5 E K-90 POWD POWD POMEGRANATE SEED 5 POWDER SCENT 5 OIL FRAGRANCE LIQD PONAZURIL POWD 5 PRALIDOXIME CHLORIDE 5 POWD POTASSIUM ACETATE 5 RX/OTC CRYS XX PRAZIQUANTEL POWD 5 XX POTASSIUM ACETATE 5 POWD XX PREGABALIN POWD XX 5 POTASSIUM ASPARTATE 5 POWD PRILOCAINE HCL POWD 5

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRILOCAINE HCLUSP 5 PROPYL GALLATE POWD 5 POWD PROPYLENE GLYCOL RX/OTC PRILOCAINE 5 5 HYDROCHLORIDE POWD LIQD XX PROPYLENE GLYCOL 5 PRILOCAINE POWD 5 MONOSTEARATE BEAD PRIMIDONE POWD XX 5 PROPYLTHIOURACIL 5 POWD XX PROCARBAZINE HCL 5 PROTAMINE SULFATE 5 POWD POWD PROCHLORPERAZINE 5 EDISYLATE POWD XX PSYLLIUM HUSK POWD 5 PROFLAVINE 5 PULLULAN POWD 5 HEMISULFATE POWD PYRANTEL PAMOATE PROGESTERONE 5 5 CONCENTRATE CREA POWD PROGESTERONE PYRAZINAMIDE POWD 5 MICRONIZED (SOY) 5 XX POWD PYRIDOSTIGMINE 5 PROGESTERONE BROMIDE POWD XX MICRONIZED (YAM) 5 PYRIDOXAL-5- RX/OTC POWD PHOSPHATE 5 MONOHYDRATE POWD PROGESTERONE 5 MICRONIZED POWD XX PYRIMETHAMINE POWD 5 PROGESTERONE XX MICRONIZED PREMIUM 5 ZINC PYRITHIONE LIQD 5 POWD PROGESTERONE 5 Bulk Chemicals - Q's MILLED POWD QUATERNIUM-15 POWD 5 PROGESTERONE POWD 5 XX QUERCETIN DIHYDRATE 5 POWD PROGESTERONE ULTRA 5 MICRONIZED POWD QUININE HCL CRYS 5 PROGESTERONE 5 WETTABLE (YAM) POWD Bulk Chemicals - R's PROGESTERONE 5 RACEPINEPHRINE HCL 5 RX/OTC WETTABLE POWD POWD PROMAZINE HCL POWD 5 RANITIDINE HCL POWD 5 XX PROMETHAZINE HCL 5 RANITIDINE 5 POWD XX HYDROCHLORIDE POWD PROPANEDIOL LIQD 5 RAPESEED OIL OIL 5 PROPARACAINE HCL 5 RASAGILINE MESYLATE 5 POWD XX POWD XX PROPIONIC ACID LIQD 5

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RAUWOLFIA 5 CALCIUM SACCHARIN 5 SERPENTINA POWD CRYS RED YEAST RICE 5 RX/OTC CETYL ESTERS WAX 5 EXTRACT POWD WAX RED YEAST RICE POWD 5 RX/OTC COPASIL GEL XX 5

RESVERATROL 98% 5 DEOXYCHOLIC ACID 5 POWD SODIUM POWD RESVERATROL 98+% 5 DIBUTYL SQUARATE 5 RX/OTC POWD LIQD RESVERATROL POWD 5 DIMERCAPTOSUCCINIC 5 ACID CRYS RETINALDEHYDE POWD 5 DIMERCAPTOSUCCINIC 5 ACID POWD RIBAVIRIN POWD XX 5 DL-3-HYDROXYBUTYRIC 5 ACIDSODIUM POWD RIBOFLAVIN POWD 5 RX/OTC DOW CORNING 200 LIQD 5 RX/OTC RIBOFLAVIN-5- RX/OTC PHOSPHATE SODIUM 5 L-ASPARTIC ACID RX/OTC ANHYDROUS POWD SODIUM MONOHYDRATE 5 POWD RIBOFLAVIN-5- RX/OTC PHOSPHATE SODIUM 5 L-ASPARTIC ACID 5 POWD SODIUM SALT POWD RX/OTC RIFAMPIN POWD XX 5 L-SERINE POWD 5

RIFAXIMIN POWD 5 LECITHIN GRAN XX 5 LECITHIN SOYA GRAN 5 ROCURONIUM BROMIDE 5 POWD XX LECITHIN SOYA POWD 5 RONIDAZOLE POWD 5 NICE PURE BAKING 5 RX/OTC ROPIVACAINE SODA POWD HYDROCHLORIDE POWD 5 XX NOURISIL GEL 5 ROSE BENGAL B POWD 5 PHOSPHATIDYLSERINE 5 POWD RUBIDIUM CHLORIDE 5 POWD PMX-1184 SILICONE LIQD 5 RX/OTC RUTIN POWD 5 SACCHARIN CALCIUM 5 CRYS Bulk Chemicals - S's 2,3- SAGE LEAF POWD 5 DIMERCAPTOSUCCINIC 5 SALICYLIC ACID CRYS 5 ACID(DMSA) POWD XX AC DERMAPEPTIDE LIQD 5 SALICYLIC ACID POWD 5 RX/OTC XX

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SALICYLIC ACID SOLN 5 SODIUM ACETATE 5 XX 50 % TRIHYDRATE POWD SALSALATE POWD XX 5 SODIUM ALGINATE 5 POWD SAW PALMETTO BERRY 5 SODIUM BICARBONATE 5 RX/OTC POWD POWD XX SCARLET RED POWD 5 SODIUM BISULFITE 5 RX/OTC GRAN SECRETIN-MANNITOL 5 SODIUM BITARTRATE 5 POWD MONOHYDRATE POWD SELENIUM SULFIDE 5 SODIUM CAPRATE 5 POWD XX POWD SELENIUM YEAST POWD 5 SODIUM CAPYRLATE 5 FOOD GRADE POWD SENNA EXTR 5 SODIUM CHLORITE FLAK 5 SERMORELIN ACETATE 5 POWD SODIUM CITRATE 5 DIHYDRATE POWD SEROTONIN HCL POWD 5 SODIUM COCOYL 5 GLUTAMATE LIQD SERTRALINE HCL POWD 5 XX SODIUM DEHYDROACETATE 5 SHARK CARTILAGE 5 POWD POWD SODIUM 5 SHOWER FRESH 5 DEOXYCHOLATE POWD FRAGRANCE LIQD SODIUM DIACETATE 5 SIBERIAN GINSENG 5 POWD POWD SODIUM SILDENAFIL CITRATE 5 DICHLOROACETATE 5 POWD POWD SILICONE BLEND 5 SODIUM FLUORIDE 5 CUSTOM PSTE POWD XX SILICONE ELASTOMER 5 SODIUM BLEND GEL FLUOROPHOSPHATE 5 SILICONE ELASTOMER 5 RX/OTC POWD BLEND LIQD SODIUM GLUCONATE 5 SILICONE FLUID 556 5 RX/OTC POWD LIQD SODIUM IODIDE CRYS 5 SILVER SULFADIAZINE 5 POWD XX SODIUM IODIDE GRAN 5 SIMVASTATIN POWD XX 5 SODIUM L-ASPARTATE 5 RX/OTC SINCALIDE IN MANNITOL 5 POWD POWD SODIUM LACTATE SOLN 5 SIROLIMUS POWD XX 5 SODIUM LAURETH 5 SULFATE LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM METABISULFITE 5 RX/OTC SODIUM SELENITE 5 ANHYDROUS GRAN POWD SODIUM METABISULFITE 5 RX/OTC SODIUM STEARATE 5 GRAN POWD SODIUM METABISULFITE 5 SODIUM STEARYL 5 POWD FUMARATE POWD SODIUM MOLYBDATE 5 SODIUM SUCCINATE 5 POWD POWD SODIUM SODIUM TARTRATE 5 MONOFLUOROPHOSPHA 5 DIHYDRATE POWD TE POWD SODIUM TETRADECYL 5 SODIUM NITRATE ACS 5 SULFATE POWD XX POWD SODIUM TETRADECYL 5 SODIUM OLEATE POWD 5 SULFATE SOLN XX 27 % SODIUM-L-ASCORBYL-2- SODIUM PHOSPHATE DIHYDRATE 5 PHENYLBUTYRATE 5 POWD POWD XX SORBITAN 5 SODIUM PHOSPHATE 5 MONOLAURATE LIQD DIBASIC CRYS SORBITAN 5 SODIUM PHOSPHATE 5 MONOOLEATE LIQD DIBASIC POWD SORBITAN SODIUM PHOSPHATE MONOPALMITATE BASE I 5 DIBASICANHYDROUS 5 POWD POWD SORBITAN 5 SODIUM PHOSPHATE MONOPALMITATE POWD DIBASICDIHYDRATE 5 SORBITAN 5 POWD MONOSTEARATE PLLT SODIUM PHOSPHATE RX/OTC 5 SOYABEAN CASEIN 5 DIBASICDRIED GRAN DIGEST MEDIUM POWD SODIUM PHOSPHATE DIBASICHEPTAHYDRATE 5 SPAN 80 LIQD 5 CRYS SODIUM PHOSPHATE SPIRULINA POWD 5 DIBASICHEPTAHYDRATE 5 POWD SQUALANE LIQD 5 SODIUM PHOSPHATE RX/OTC MONOBASIC 5 SQUALANE OIL 5 ANHYDROUS POWD SQUARIC ACID IN 5 RX/OTC BUTANOL LIQD SODIUM PHOSPHATE 5 MONOBASIC GRAN SQUARIC ACID POWD 5 SODIUM PHOSPHATE 5 TRIBASIC CRYS ST JOHNS WORT POWD 5 SODIUM PROPIONATE 5 RX/OTC POWD STANNOUS CHLORIDE 5 DIHYDRATE CRYS SODIUM PYRROLIDONE 5 CARBOXYLATE LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STANOZOLOL POWD 5 SUMATRIPTAN 5 SUCCINATE POWD XX RX/OTC STEVIA EXTRACT POWD 5 SUPEROXIDE 5 DISMUTASE POWD STEVIA EXTRACT POWD 5 SUPEROXIDE 5 DISMUTASE SOLN STEVIA POWDER 5 RX/OTC EXTRACT POWD THIOSALICYLIC ACID 5 SODIUMSALT POWD STEVIOL GLYCOSIDES 5 POWD Bulk Chemicals - T's CURCUMIN EXTRACT 5 STEVIOSIDE EXTR 5 POWD STRONTIUM CHLORIDE 5 CURCUMIN POWD 5 CRYS NATURAL MIXED STRONTIUM CHLORIDE 5 POWD TOCOPHEROLS30% 5 POWD SUCCIMER DMSA POWD 5 RENOVAGE LIQD 5 SUCCINIC ACID CRYS 5 TACROLIMUS MONOHYDRATE POWD 5 SUCCINYLCHOLINE 5 CHLORIDE POWD XX XX SUCCINYLCHOLINE TACROLIMUS POWD XX 5 CHLORIDEDIHYDRATE 5 POWD TADALAFIL POWD XX 5 SUCROSE 5 OCTAACETATE CRYS TAMOXIFEN CITRATE 5 POWD XX SUFENTANIL CITRATE 5 POWD XX TAZAROTENE POWD XX 5 SULFACETAMIDE POWD 5 TEA COCOYL 5 GLUTAMINE SOLN SULFADIMETHOXINE 5 POWD TEA TREE OIL OIL 5 RX/OTC SULFAMERAZINE POWD 5 TERBINAFINE HCL POWD 5 XX SULFOSALICYLIC ACID 5 DIHYDRATE POWD TESTOSTERONE 5 CONCENTRATE CREA SULFUR POWD 5 RX/OTC TESTOSTERONE 5 CYPIONATE POWD XX SULFUR PRECIPITATED 5 RX/OTC POWD TESTOSTERONE 5 ENANTHATE POWD XX SULFUR SUBLIMED 5 RX/OTC POWD TESTOSTERONE MICRONIZED (SOY) 5 SULPIRIDE POWD 5 POWD TESTOSTERONE SUMATRIPTAN POWD XX 5 MICRONIZED (YAM) 5 POWD

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TESTOSTERONE 5 TITANIUM DIOXIDE LIQD 5 MICRONIZED POWD TITANIUM DIOXIDE TESTOSTERONE 5 5 MICRONIZED SOY POWD POWD TIZANIDINE HCL POWD TESTOSTERONE 5 5 MICRONIZED YAM CRYS XX TESTOSTERONE NON- 5 TOBRAMYCIN POWD XX 5 MICRONIZED SOY POWD TESTOSTERONE POWD 5 TOCOTRIENOLS SUSP 5 XX TOLAZOLINE 5 TESTOSTERONE 5 HYDROCHLORIDE POWD PROPIONATE POWD XX TOLTRAZURIL POWD 5 TETRACAINE HCL POWD 5 XX TOLU BALSAM MISC 5 TETRACAINE POWD 5 TOLUIDINE BLUE O 5 TETRAHYDRO-L- POWD BIOPTERIN 5 DIHYDROCHLORIDE TOPIRAMATE POWD XX 5 POWD TRAMADOL HCL POWD 5 TETRAHYDROBIOPTERIN XX DIHYDROCHLORIDE 5 POWD TRAMADOL 5 HYDROCHLORIDE POWD TETRAHYDROBIOPTERIN 5 HYDROCHLORIDE POWD TRANEXAMIC ACID 5 RX/OTC POWD XX TETRAHYDROCURCUMI 5 NOIDS (THC) POWD TRANILAST POWD 5 TETRAHYDROZOLINE 5 HCL POWD TRIACETIN LIQD 5 THEANINE POWD 5 TRIAMCINOLONE 5 HEXACETONIDE POWD THEOBROMINE POWD 5 TRIAMCINOLONE POWD 5 THIOGUANINE POWD 5 TRIAMCINOLONEUSP, 5 MICRONIZED POWD THIORIDAZINE HCL 5 POWD XX TRICHLORMETHIAZIDE 5 POWD THIOTEPA POWD XX 5 TRICHLOROACETIC ACID 5 RX/OTC CRYS THYMUS POWD XX 5 TRICHLOROACETIC ACID 5 POWD THYROID POWD XX 5 TRICLOSAN POWD 5 TICARCILLIN DISODIUM/CLAVULANAT 5 TRIETHANOLAMINE 5 E POTASSIUM POWD LAURYL SULFATE LIQD TIOPRONIN POWD 5 TRIETHYL CITRATE LIQD 5

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRILOSTANE POWD 5 VALACYCLOVIR 5 HYDROCHLORIDE POWD TRIMEPRAZINE 5 TARTRATE POWD VALERIAN ROOT POWD 5 TRIMETHOBENZAMIDE 5 VALPROATE SODIUM 5 HCL POWD XX POWD XX TRIOXSALEN POWD 5 VANADIUM POWD 5

TRIPROLIDINE HCL 5 VANADYL SULFATE 5 RX/OTC CRYS HYDRATE CRYS TROMETHAMINE POWD 5 VANCOMYCIN HCL 5 POWD XX TROPOLONE POWD 5 VANCOMYCIN HYDROCHLORIDE POWD 5 TRYPSIN POWD 5 XX VANILLIN CRYS 5 TURMERIC POWD 5 VANILLIN POWD 5 TURMERIC ROOT POWD 5 VARDENAFIL 5 TYLOSIN TARTRATE 5 HYDROCHLORIDE POWD POWD VECURONIUM BROMIDE 5 TYLOXAPOL LIQD 5 POWD XX Bulk Chemicals - U's VIDARABINE POWD 5 UBIQUINOL POWD 5 VINPOCETINE POWD 5 RX/OTC UREA POWD XX 5 VITAMIN A ACETATE 5 BEAD URIDINE POWD 5 VITAMIN A PALMITATE 5 RX/OTC LIQD URSODIOL POWD XX 5 VITAMIN A POWD 5 Bulk Chemicals - V's VITAMIN E ACETATE RX/OTC LIQD 1 UNIT/MG, 125 5 ALPHA-TOCOPHEROL 5 LIQD UNIT/ML, D-VITAMIN E SUCCINATE 5 RX/OTC VITAMIN E LIQD 5 POWD VITAMIN E SUCCINATE RX/OTC RETINOL MOLECULAR 5 5 FILM OIL POWD VORICONAZOLE POWD SODIUM VALPROATE 5 5 POWD XX TOCOPHERYL ACID RX/OTC Bulk Chemicals - W's SUCCINATED-ALPHA 5 POWD SEPICALM VG LIQD 5 VALACYCLOVIR HCL 5 WHEY PROTEIN ISOLATE 5 POWD XX INSTANIZED POWD

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WHITE KIDNEY BEAN 5 BAY RUM LIQD 5 RX/OTC EXTRACT POWD BIORE HYDRATING WHITE WILLOW BARK 5 5 POWD MOISTURIZER LIQD Bulk Chemicals - X CUCUMBER MELON LIQD 5 XYLAZINE 5 HYDROCHLORIDE POWD DRAKKAR NOIR LIQD 5 RX/OTC XYLITOL NF POWD 5 ETHYLPARABEN POWD 5 XYLITOL POWD 5 RX/OTC FERRIC PYROPHOSPHATE 5 XYLOMETAZOLINE HCL 5 POWD POWD FRESH LINEN 5 XYLOMETAZOLINE 5 FRAGRANCE LIQD HYDROCHLORIDE POWD L-ASPARAGINE 5 Bulk Chemicals - Y's MONOHYDRATE POWD RX/OTC YEAST EXTRACT LIQD 5 NATAPRES LIQD 5 POLYETHYLENE GLYCOL RX/OTC 5 5 YOHIMBINE HCL POWD 600 LIQD Bulk Chemicals - Z's POLYOX WSR-301 POWD 5 ZEAXANTHIN POWD 5 SODIUM RX/OTC PYROPHOSPHATE 5 ZINC ACETATE POWD 5 ANHYDROUS POWD VICTORIAS SECRET ZINC CHLORIDE GRAN 5 RX/OTC 5 XX VANILLALACE LIQD ZINC CITRATE 5 Liquids DIHYDRATE POWD ACETONE SOLN 5 RX/OTC ZINC GLUCONATE POWD 5 XX ACTIPHYTE OF 5 LEMONGRASS LIQD ZINC MONOMETHIONINE 5 POWD ALCOHOL SOLN XX 95 % 5 RX/OTC ZINC OXIDE POWD 5 RX/OTC ALMOND OIL OIL 5 RX/OTC ZINC PICOLINATE POWD 5 ALMOND OIL SWEET OIL 5 RX/OTC ZINC UNDECYLENATE 5 POWD AMMONIUM LACTATE 5 SOLN ZIRCONIUM OXIDE 5 POWD BASE G ALMOND OIL 5 RX/OTC SWEET OIL ZOLMITRIPTAN POWD 5 XX BAY OIL OIL 5 ZONISAMIDE POWD XX 5 BENZYL BENZOATE LIQD 5 RX/OTC Bulk Chemicals

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CASTOR OIL OIL 5 RX/OTC GLYCEROL FORMAL 5 RX/OTC LIQD CEDAR LEAF OIL OIL 5 GLYCINE SOYA PROTEIN 5 SOLN CHLORHEXIDINE 5 GNP EUCALYPTUS OIL 5 RX/OTC GLUCONATE SOLN OIL RX/OTC CHLOROFORM SOLN 5 GNP ISOPROPYL 5 RX/OTC ALCOHOL SOLN RX/OTC CITRONELLA OIL OIL 5 GOODSENSE RX/OTC ISOPROPYL ALCOHOL 5 CLOVE OIL OIL 5 RX/OTC SOLN

COCONUT OIL OIL 5 RX/OTC GUAIACOL SOLN 5 RX/OTC COTTONSEED OIL OIL 5 RX/OTC HM CASTOR OIL OIL 5 RX/OTC HM ISOPROPYL RX/OTC CRYOSERV SOLN 5 RUBBING ALCOHOL 5 SOLN CVS ISOPROPYL 5 RX/OTC ALCOHOL SOLN HM ISOPRPYL RUBBING 5 RX/OTC CVS ISOPROPYL RX/OTC ALCOHOL SOLN RUBBING ALCOHOL 5 ISOPROPANOL SOLN 5 RX/OTC SOLN ISOPROPYL ALCOHOL RX/OTC DIMETHYL SULFOXIDE 5 RX/OTC 5 SOLN SOLN 100 %, 70 % RX/OTC ETHER SOLN 5 isopropyl alcohol soln 99 % 2 ISOPROPYL PALMITATE RX/OTC ETHYL ALCOHOL 190 5 RX/OTC 5 PROOF SOLN LIQD ETHYL ALCOHOL SDA- 5 RX/OTC JUNIPER TAR OIL 5 40B 190 PROOF SOLN LAVENDER OIL 5 RX/OTC ETHYL ALCOHOL SOLN 5 RX/OTC FRAGRANCE OIL RX/OTC LAVENDER OIL NATURAL 5 RX/OTC EUCALYPTUS OIL OIL 5 OIL RX/OTC EUGENOL SOLN 5 RX/OTC LAVENDER OIL OIL 5 RX/OTC GERANIUM NATURAL OIL 5 RX/OTC LIME OIL OIL 5

GERANIUM OIL OIL 5 RX/OTC LINSEED OIL RAW OIL 5

GLYCERIN LIQD 99 %, 5 RX/OTC MACADAMIA NUT OIL OIL 5 99.5 %, RX/OTC GLYCERIN SOLN 5 METHANOL SOLN 5 RX/OTC GLYCERINE LIQD 5 RX/OTC METHYL ALCOHOL SOLN 5 NIAOULI OIL 5

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OIL-ALMOND SWEET OIL 5 RX/OTC SPEARMINT OIL OIL 5 RX/OTC

OIL-COCONUT OIL 5 RX/OTC SWEET OIL OIL 5 RX/OTC

OLIVE OIL OIL 5 RX/OTC UNDECYLENIC ACID 5 RX/OTC LIQD ORGANIC COCONUT OIL RX/OTC 5 WA-001 EXPERIMENTAL 5 OIL SOILSURFACTANT OIL PEANUT OIL OIL 5 RX/OTC Semi-Solids RX/OTC PEPPERMINT OIL OIL 5 RX/OTC COAL TAR SOLN 5

PINE OIL OIL 5 COAL TAR TAR 5

PINE TAR LIQD 5 PERUVIAN BALSAM MISC 5 RX/OTC PERUVIAN BALSAM 5 POLYSORBATE 20 SOLN 5 POWD POLYSORBATE 40 SOLN 5 Solids 5-HYDROXY-L- 5 POLYSORBATE 60 LIQD 5 TRYPTOPHAN POWD ALLANTOIN POWD 5 RX/OTC POLYSORBATE 80 LIQD 5 RX/OTC ALPROSTADIL POWD XX 5 QC CASTOR OIL OIL 5 RX/OTC ALUMINUM HYDROXIDE 5 RX/OTC QC SWEET OIL OIL 5 RX/OTC DRIEDGEL POWD RX/OTC ALUMINUM POTASSIUM 5 RX/OTC ROSE OIL OIL 5 SULFATE POWD RX/OTC ALUMINUM SULFATE 5 ROSEMARY OIL OIL 5 HYDRATE GRAN SAFFLOWER OIL OIL 5 RX/OTC AMMONIUM BROMIDE 5 ACS POWD SASSAFRAS OIL OIL 5 AMMONIUM BROMIDE 5 GRAN RX/OTC SESAME OIL OIL 5 AMMONIUM CHLORIDE 5 RX/OTC GRAN SM ISOPROPYL RX/OTC ALCOHOL RUBBING 5 AMMONIUM PHOSPHATE 5 SOLN DIBASIC GRAN AMMONIUM SULFATE SM ISOPROPYL 5 RX/OTC 5 ALCOHOL SOLN GRAN SM SWEET OIL OIL 5 RX/OTC BHT GRAN 5 RX/OTC BISMUTH 5 RX/OTC SOYBEAN OIL OIL 5 SUBCARBONATE POWD RX/OTC BISMUTH SUBNITRATE 5 RX/OTC SPEARMINT OIL 5 POWD

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BISMUTH 5 RX/OTC CITRIC ACID 5 RX/OTC SUBSALICYLATE POWD MONOHYDRATE GRAN BORIC ACID CRYS XX 5 CITRIC ACID 5 MONOHYDRATE POWD RX/OTC BORIC ACID NF POWD 5 CITRIC ACID POWD 5 RX/OTC RX/OTC BORIC ACID POWD XX 5 CO-ENZYME Q 10 POWD 5 RX/OTC BUTYLATED COENZYME Q-10 POWD 5 RX/OTC HYDROXYTOLUENE 5 XX GRAN RX/OTC BUTYLATED COENZYME Q10 POWD 5 HYDROXYTOLUENE 5 RX/OTC POWD CORN STARCH POWD 5 CALCIUM HYDROXIDE RX/OTC 5 CROSCARMELLOSE 5 RX/OTC POWD SODIUM POWD CALCIUM SULFATE 5 RX/OTC DEHYDROEPIANDROSTE ANHYDROUS POWD RONE MICRONIZED 5 POWD CALCIUM SULFATE 5 RX/OTC HEMIHYDRATE POWD DEHYDROEPIANDROSTE 5 RX/OTC RONE POWD CALCIUM SULFATE 5 RX/OTC POWD DHEA MICRONIZED 5 POWD CAPSICUM OLEORESIN 5 LIQD DHEA POWD 5 RX/OTC CARBIDOPA 5 ANHYDROUS POWD DIMENHYDRINATE 5 POWD CARBIDOPA POWD XX 5 DIMERCAPTO-1- CARBOXYMETHYLCELLU RX/OTC PROPANESULFONIC 5 LOSE SODIUM HIGH 5 ACID (DMPS) POWD VISCOSITY POWD DIMERCAPTO-1- CARBOXYMETHYLCELLU RX/OTC PROPANESULFONIC 5 LOSE SODIUM LOW 5 ACID SODIUM SALT VISCOSITY POWD POWD CARBOXYMETHYLCELLU DIMERCAPTOPROPANE- LOSE SODIUM MEDIUM 5 SULFONATE (2,3) 5 VISCOSITY GRAN SODIUM POWD CARBOXYMETHYLCELLU RX/OTC DINITROCHLOROBENZE 5 LOSE SODIUM MEDIUM 5 NE CRYS VISCOSITY POWD DOCUSATE SODIUM/SODIUM 5 CARBOXYMETHYLCELLU 5 RX/OTC LOSE SODIUM POWD BENZOATE POWD CITRIC ACID 5 RX/OTC EDETATE ACID POWD 5 ANHYDROUS GRAN EDETATE DISODIUM RX/OTC CITRIC ACID 5 RX/OTC 5 ANHYDROUS POWD DIHYDRATE POWD

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDETATE DISODIUM 5 RX/OTC MENTHOL CRYS 5 RX/OTC POWD RX/OTC EDETATE TETRASODIUM 5 MENTHOL-L CRYS 5 TETRAHYDRATE POWD METHENAMINE EPINEPHRINE BASE 5 5 POWD MANDELATE POWD XX EPINEPHRINE POWD XX 5 METHENAMINE POWD 5 METHYLENE BLUE 5 FLUORESCEIN POWD 5 POWD METHYLENE BLUE FLUORESCEIN SODIUM 5 5 POWD TRIHYDRATE POWD FULLERS EARTH POWD 5 RX/OTC MINOXIDIL POWD XX 5

GERMANIUM 5 OXYBENZONE POWD 5 SESQUIOXIDE POWD PHENYLMERCURIC 5 GINGER ROOT POWD 5 ACETATE POWD RX/OTC PHENYLMERCURIC 5 GNP BORIC ACID POWD 5 NITRATE POWD HM BORIC ACID POWD 5 RX/OTC PILOCARPINE HCL 5 POWD XX HOMATROPINE 5 PILOCARPINE NITRATE 5 METHYLBROMIDE POWD CRYS HYDROXYTRYPTOPHAN 5 PILOCARPINE NITRATE 5 L-5 POWD POWD HYDROXYTRYPTOPHAN 5 POTASH SULFURATED 5 POWD LUMP MISC RX/OTC IODOFORM POWD 5 POTASSIUM ALUM 5 RX/OTC POWD KETOCONAZOLE POWD 5 POTASSIUM 5 RX/OTC XX BITARTRATE POWD RX/OTC KOJIC ACID POWD 5 POTASSIUM BROMIDE 5 RX/OTC CRYS L-ASPARTIC ACID POWD 5 RX/OTC POTASSIUM BROMIDE 5 GRAN L-MENTHOL CRYS 5 RX/OTC POTASSIUM BROMIDE 5 POWD LEAD ACETATE 5 TRIHYDRATE POWD POTASSIUM 5 CARBONATE GRAN LICORICE ROOT POWD 5 POTASSIUM RX/OTC RX/OTC GLUCONATE 5 MANNITOL POWD XX 5 ANHYDROUS POWD RX/OTC MELATONIN POWD 5 POTASSIUM NITRATE 5 CRYS MENADIONE SODIUM 5 POTASSIUM NITRATE 5 BISULFITE CRYS POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM 5 SODIUM RX/OTC PERCHLORATE CRYS CARBOXYMETHYLCELLU 5 LOSE MEDIUM prasterone micronized 2 powd VISCOSITY POWD SODIUM PREGNENOLONE 5 MICRONIZED POWD CHLORIDE/SODIUM 5 BICARBONATE POWD PREGNENOLONE POWD 5 SODIUM NITRITE GRAN 5 RX/OTC XX PROSTAGLANDIN E1 5 POWD SODIUM PERBORATE 5 RX/OTC MONOHYDRATE POWD PUMICE (FLOUR) POWD 5 SODIUM PERBORATE 5 RX/OTC TETRAHYDRATE POWD PYROGALLOL CRYS 5 SODIUM SULFATE POWD 5 PYRUVIC ACID LIQD 5 RX/OTC SODIUM SULFITE 5 RX/OTC PYRUVIC ACID POWD 5 ANHYDROUS POWD SODIUM SULFITE POWD 5 RX/OTC QC BORIC ACID POWD 5 RX/OTC SORBITOL POWD XX 5 QUINIDINE SULFATE 5 DIHYDRATE CRYS STANNOUS FLUORIDE 5 QUINIDINE SULFATE 5 POWD POWD XX STARCH POWD 5 RX/OTC RA BORIC ACID POWD 5 RX/OTC STRONTIUM NITRATE 5 RESORCINOL CRYS 5 RX/OTC CRYS SUCROSE 5 RESORCINOL POWD 5 RX/OTC CONFECTIONERS POWD SUCROSE POWD 5 ROSIN LUMP MISC 5 SUCROSE POWDERED 5 SILICA GEL GEL 5 RX/OTC CONFECTIONERS POWD SULFANILAMIDE POWD 5 SILICA GEL 5 RX/OTC ULTRAMICRONIZED GEL TALC POWD 5 RX/OTC SILICON DIOXIDE 5 (SYLOID 244 FP) POWD THEOPHYLLINE 5 RX/OTC SILICON DIOXIDE POWD 5 ANHYDROUS POWD THYMOL CRYS 5 RX/OTC SM BORIC ACID POWD 5 RX/OTC THYMOL IODIDE POWD 5 SODIUM BROMIDE GRAN 5 RX/OTC TINIDAZOLE POWD XX 5 SODIUM BUTYRATE 5 RX/OTC POWD UBIDECARENONE POWD 5 RX/OTC SODIUM CACODYLATE 5 POWD

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONTRACEPTIVES - Drugs to Prevent LOSEASONIQUE TABS QL(1 ea Pregnancy (levonorgestrel-ethinyl 5 daily,91 day(s) estradiol (91-day)) limit) Combination Contraceptives - Oral MINASTRIN 24 FE CHEW 6 BALCOLTRA TABS 6 MINASTRIN 24 FE CHEW NC BEYAZ TABS (norethin acet & estrad-fe) (drospirenone-ethinyl NC estradiol-levomefolate MIRCETTE TABS calcium) (desogestrel-ethinyl 5 estradiol (biphasic)) desogestrel & ethinyl 6 QL(1 ea daily) estradiol tabs NATAZIA TABS NC desogestrel-ethinyl 6 norethin acet & estrad-fe NC estradiol (biphasic) tabs caps 1 mg-20 mcg-75 mg desogestrel-ethinyl QL(1 ea daily) 6 norethin acet & estrad-fe 6 estradiol (triphasic) tabs chew 1 mg-20 mcg-75 mg drospirenone-ethinyl norethin acet & estrad-fe 6 estradiol tabs 0.02 mg-3 6 tabs 1 mg-20 mcg-75 mg mg norethin acet & estrad-fe QL(1 ea daily) drospirenone-ethinyl QL(1 ea daily) tabs 1.5 mg-30 mcg-75 mg, 6 estradiol tabs 0.03 mg-3 6 1 mg-20 mcg-75 mg mg norethindrone & eth 6 QL(1 ea daily) drospirenone-ethinyl estradiol tabs estradiol-levomefolate 6 calcium tabs norethindrone & ethinyl 6 estradiol-fe chew ESTROSTEP FE TABS (norethindrone acetate- 5 norethindrone acet & eth 6 QL(1 ea daily) ethinyl estradiol-fe) estra tabs norethindrone acetate- ethynodiol diacet & eth 6 QL(1 ea daily) 6 estrad tabs 1 mg-35 mcg, ethinyl estradiol-fe tabs norethindrone-eth estradiol QL(1 ea daily) ethynodiol diacet & eth 6 6 estrad tabs 1 mg-50 mcg (triphasic) tabs norgestimate-ethinyl 6 FALESSA KIT 6 estradiol (triphasic) tabs GENERESS FE CHEW norgestimate-ethinyl 6 QL(1 ea daily) (norethindrone & ethinyl 5 estradiol (triphasic) tabs estradiol-fe) norgestimate-ethinyl 6 QL(1 ea daily) estradiol tabs levonorgestrel & eth 6 QL(1 ea daily) estradiol tabs norgestrel & ethinyl QL(2 ea daily) estradiol tabs 0.3 mg-30 6 levonorgestrel-eth estradiol 6 QL(1 ea daily) (triphasic) tabs mcg QL(1 ea norgestrel & ethinyl QL(1 ea daily) levonorgestrel-ethinyl 6 daily,91 day(s) estradiol tabs 0.5 mg-50 6 estradiol (91-day) tabs limit) mcg ORTHO TRI-CYCLEN LO levonorgestrel-ethinyl 6 estradiol (continuous) tabs TABS (norgestimate-ethinyl NC estradiol (triphasic)) LO LOESTRIN FE TABS 6 QL(1 ea daily)

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHO TRI-CYCLEN LO NUVARING RING QL(0.04 ea TABS (norgestimate-ethinyl NF (etonogestrel-ethinyl 5 daily) estradiol (triphasic)) estradiol) ORTHO TRI-CYCLEN QL(1 ea daily) Copper Contraceptives - IUD TABS (norgestimate-ethinyl 5 estradiol (triphasic)) PARAGARD PV INTRAUTERINE COPPER 6 ORTHO-CYCLEN TABS QL(1 ea daily) CONTRACEPTIVE T380A (norgestimate-ethinyl 5 IUD estradiol) Emergency Contraceptives ORTHO-NOVUM 1/35 QL(1 ea daily) TABS (norethindrone & eth 5 ELLA TABS 6 estradiol) ORTHO-NOVUM 7/7/7 QL(1 ea daily) levonorgestrel (emergency 6 TABS (norethindrone-eth 5 oc) tabs estradiol (triphasic)) PLAN B ONE-STEP TABS QUARTETTE TABS QL(1 ea (levonorgestrel (emergency 5 (levonorgestrel-ethinyl 5 daily,91 day(s) oc)) estradiol (91-day)) limit) Progestin Contraceptives - IUD SAFYRAL TABS KYLEENA IUD 6 SP (drospirenone-ethinyl 5 estradiol-levomefolate SP calcium) LILETTA IUD 6 SEASONIQUE TABS QL(1 ea QL(1 ea per (levonorgestrel-ethinyl 5 daily,91 day(s) 365 days estradiol (91-day)) limit) MIRENA IUD 6 retail,1 ea per 365 days mail); TAYTULLA CAPS NC (norethin acet & estrad-fe) SP TRI-NORINYL 28 TABS QL(1 ea daily) SKYLA IUD 6 SP (norethindrone-eth 5 estradiol (triphasic)) Progestin Contraceptives - Implants TYBLUME TABS 6 QL(1 ea daily) NEXPLANON IMPL 6 PA; SP YASMIN 28 TABS QL(1 ea daily) Progestin Contraceptives - Injectable (drospirenone-ethinyl 5 DEPO-PROVERA estradiol) CONTRACEPTIVE SUSP 5 YAZ TABS (drospirenone- NC (medroxyprogesterone ethinyl estradiol) acetate (contraceptive)) Combination Contraceptives - Transdermal DEPO-PROVERA CONTRACEPTIVE SUSY norelgestromin-ethinyl 6 QL(0.1071 ea 5 estradiol ptwk daily) (medroxyprogesterone acetate (contraceptive)) TWIRLA PTWK 6 DEPO-SUBQ PROVERA 6 104 SUSY Combination Contraceptives - Vaginal medroxyprogesterone ANNOVERA RING NC acetate (contraceptive) 6 susp etonogestrel-ethinyl 6 QL(0.04 ea estradiol ring daily)

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits medroxyprogesterone BETAMETHASONE acetate (contraceptive) 6 ACETATE/BETAMETHAS NC susy ONE SUSP Progestin Contraceptives - Oral BETAMETHASONE NC COMBO SUSP norethindrone 6 QL(1 ea daily) (contraceptive) tabs betamethasone sod 2 phosphate & acetate susp ORTHO MICRONOR QL(1 ea daily) TABS (norethindrone 5 BETAMETHASONE (contraceptive)) SODIUM PHOSPHATE 5 POWD SLYND TABS NC BETAMETHASONE SODIUM PHOSPHATE 5 CORTICOSTEROIDS - Steroid Hormone Drugs to SOLN Treat Systemic Swelling Conditions Glucocorticosteroids BSP 0820 KIT NC ACTIVE INJECTION KIT 5 BT INJECTION KIT KIT 5 BLM-1 KIT ACTIVE INJECTION KIT 5 budesonide cpep or 3 mg 1 BM KIT ACTIVE INJECTION KIT D 5 budesonide tb24 or 9 mg 2 KIT BUPIVILOG KIT KIT 5 ACTIVE INJECTION KIT 5 DL KIT CELESTONE-SOLUSPAN ACTIVE INJECTION KIT 5 SUSP (betamethasone sod NC DLM KIT phosphate & acetate) ACTIVE INJECTION KIT 5 CONTRAST ALLERGY NC KL-3 KIT PREMED PACK KIT ACTIVE INJECTION KIT 5 CORTEF TABS 5 KM KIT (hydrocortisone) ACTIVE INJECTION KIT L 5 CORTISONE ACETATE 5 KIT POWD XX ACTIVE INJECTION KIT 5 LM-DEP-1 KIT cortisone acetate tabs or 2 ACTIVE INJECTION KIT 5 DEPO-MEDROL SUSP 20 5 LM-DEP-2 KIT MG/ML ACTIVE INJECTION KIT 5 DEPO-MEDROL SUSP 80 M-1 KIT MG/ML, 40 MG/ML 5 (methylprednisolone BETA 1 KIT KIT NC acetate) BETA INJECT KIT KIT 5 DERMACINRX CINLONE-I NC CPI KIT BETALIDO KIT 5 DEXABLISS TBPK NC

BETALOAN SUIK KIT 5 DEXAMETHASONE (LA) 5 SUSP 16 MG/ML DEXAMETHASONE (LA) NC SUSP 8 MG/ML 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXAMETHASONE 10- 2 DEXAMETHASONE/SODI NC DAY DOSE PACK TBPK UM PHOSPHATE SOSY DEXAMETHASONE 13- 2 DEXLIDO KIT 5 DAY DOSE PACK TBPK DEXAMETHASONE DEXLIDO-M KIT 5 ACETATE/DEXAMETHAS 5 ONE PHOSPHATE SUSP DEXONTO 0.4% SOLN NC dexamethasone elix or 0.5 2 mg/5ml DEXOPIN KIT NC DEXAMETHASONE 5 INTENSOL CONC DMT SUIK KIT NC DEXAMETHASONE SODIUM PHOSPHATE 2 DOUBLEDEX KIT 5 SOLN IJ 10 MG/ML dexamethasone sodium DXEVO 11-DAY TBPK NC phosphate soln ij 10 mg/ml, 100 mg/10ml, 120 2 DYURAL-40 KIT 5 mg/30ml, 20 mg/5ml, 4 mg/ml, 10 mg/ml DYURAL-80 KIT 5 DEXAMETHASONE SODIUM PHOSPHATE 4 DYURAL-L KIT 5 SOLN IJ 4 MG/ML DYURAL-LM KIT 5 DEXAMETHASONE SODIUM PHOSPHATE NC EMFLAZA SUSP NC SP SOSY IJ 10 MG/ML DEXAMETHASONE EMFLAZA TABS NC SP SODIUM PHOSPHATE NC SOSY IV 10 MG/2.5ML, 4 ENTOCORT EC CPEP NC MG/ML, 8 MG/2ML (budesonide) DEXAMETHASONE hydrocortisone tabs or 10 2 mg, 20 mg, 5 mg SODIUM NC PHOSPHATE/DEXTROSE SOLN JTT PHYSICIANS KIT KIT 5 DEXAMETHASONE KENALOG-10 SUSP 5 SODIUM NC PHOSPHATE/SODIUM KENALOG-40 SUSP 5 CHLORIDE SOLN (triamcinolone acetonide) dexamethasone soln or 0.5 2 KENALOG-80 SUSP 5 mg/5ml dexamethasone tabs or 1 LIDOCIDEX I SOLN NC mg, 1.5 mg, 2 mg, 0.5 mg, 2 0.75 mg, 4 mg, 6 mg LIDOCILONE I SUSP NC dexamethasone tbpk or 1.5 2 mg LIDOLOG KIT KIT 5 dexamethasone tbpk or 1.5 NC mg, 1.5 mg LT INJECTION KIT KIT 5

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MARBETA-25 KIT 5 MILLIPRED TABS 5 MG NC

MARBETA-L KIT 5 MLK F1 KIT KIT 5

MARDEX-25 KIT 5 MLK F2 KIT KIT 5

MAS CARE-PAK KIT 5 MLK F3 KIT KIT 5

MEDROL DOSEPAK TBPK 5 MLK F4 KIT KIT 5 (methylprednisolone) MEDROL TABS 16 MG, 32 MLP A-1 KIT 5 MG, 8 MG, 4 MG 5 (methylprednisolone) MULTI-SPECIALTY KIT 5 KIT 5 MEDROL TABS 2 MG ORAPRED ODT TBDP (prednisolone sodium 4 MEDROLOAN II SUIK KIT NC phosphate) MEDROLOAN SUIK KIT NC P-CARE D40 KIT NC

METHYLPREDNISOLONE 5 P-CARE D40G KIT NC ACETATE POWD XX METHYLPREDNISOLONE P-CARE D40MX KIT NC ACETATE SUSP IJ 50 NC MG/ML P-CARE D80 KIT NC METHYLPREDNISOLONE ACETATE SUSP IJ 80 5 P-CARE D80G KIT NC MG/ML P-CARE D80MX KIT NC methylprednisolone acetate 2 susp ij 80 mg/ml, 40 mg/ml METHYLPREDNISOLONE P-CARE K40 KIT 5 ACETATE/BUPIVACAINE NC HYDROCHLORIDE SUSP P-CARE K40G KIT 5 METHYLPREDNISOLONE 5 POWD XX P-CARE K40MX KIT 5 methylprednisolone sod 2 P-CARE K80 KIT 5 succ solr methylprednisolone tabs or 2 P-CARE K80G KIT 5 16 mg, 32 mg, 8 mg, 4 mg methylprednisolone tbpk or 2 P-CARE K80MX KIT 5 4 mg PEDIAPRED SOLN METHYLPREDNISOLONE/ NC (prednisolone sodium 5 LIDOCAINE SUSP phosphate) MILLIPRED DP TBPK NC PHYSICIANS EZ USE JOINT TUNNEL AND 5 MILLIPRED SOLN 10 TRIGGER KIT MG/5ML (prednisolone NC sodium phosphate) PHYSICIANS EZ USE M- 5 PRED KIT

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POD-CARE 100C KIT NC PREDNISONE POWD XX 5

POD-CARE 100CG KIT 5 prednisone soln or 5 2 mg/5ml POD-CARE 100CMX KIT 5 prednisone tabs or 1 mg, 10 mg, 2.5 mg, 50 mg, 20 2 POD-CARE 100K KIT 5 mg, 5 mg prednisone tbpk or 10 mg, 2 POD-CARE 100KG KIT 5 5 mg PRO-C-DURE 1 KIT KIT 5 POD-CARE 100KMX KIT 5 PRO-C-DURE 2 KIT KIT 5 POINT OF CARE KM KIT 5 PRO-C-DURE 3 KIT KIT 5 POINT OF CARE L.2 KIT 5 PRO-C-DURE 4 KIT KIT 5 POINT OF CARE L.5 KIT 5 PRO-C-DURE 5 KIT KIT 5 POINT OF CARE LM DEP 5 2 KIT PRO-C-DURE 6 KIT KIT NC PREDNISOLONE 5 ACETATE POWD RAYOS TBEC NC PREDNISOLONE 5 ANHYDROUS POWD READYSHARP ANESTHETICS 5 PREDNISOLONE POWD 5 XX +BETAMETHASONE KIT READYSHARP PREDNISOLONE SODIUM 5 PHOSPHATE POWD XX ANESTHETICS NC prednisolone sodium +DEXAMETHASONE KIT READYSHARP phosphate soln or 10 2 mg/5ml, 20 mg/5ml, 25 ANESTHETICS NC mg/5ml, 5 mg/5ml +METHYLPREDNISOLON prednisolone sodium QL(240 ml per E 80 KIT phosphate soln or 15 2 fill retail) READYSHARP NC mg/5ml BETAMETHASONE KIT prednisolone sodium READYSHARP NC phosphate tbdp or 10 mg, 2 DEXAMETHASONE KIT 15 mg, 30 mg READYSHARP-K KIT 5 PREDNISOLONE SODIUM 5 PHOSPHATE, USP POWD ROPIDEX KIT NC prednisolone soln or 2 SOLU-CORTEF SOLR 5 PREDNISOLONEUSP, MICRONIZED 5 SOLU-MEDROL SOLR 2 5 ANHYDROUS POWD GM PREDNISONE INTENSOL 5 CONC

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOLU-MEDROL SOLR FLUDROCORTISONE 5 500 MG, 125 MG, 40 MG, ACETATE POWD XX 1000 MG 5 fludrocortisone acetate tabs 2 (methylprednisolone sod or succ) COUGH/COLD/ALLERGY - Drugs to Treat TOPIDEX KIT 5 Cough, Cold and Allergy Symptoms Antitussives TRIAMCINOLONE 5 ACETONIDE PF SUSP benzonatate caps 100 mg, 2 TRIAMCINOLONE 200 mg, 150 mg ACETONIDE SUSP IJ 40 2 MG/ML benzonatate caps 150 mg NC triamcinolone acetonide DEXTROMETHORPHAN susp ij 40 mg/ml, 400 2 HBR MONOHYDRATE 5 mg/10ml CRYS TRIAMCINOLONE DEXTROMETHORPHAN ACETONIDE SUSP IJ 50 5 HBR MONOHYDRATE 5 MG/ML POWD TRIAMCINOLONE DEXTROMETHORPHAN 5 ACETONIDE/BUPIVACAIN NC HBR POWD E HYDROCHLORIDE hydrocodone w/ 2 SUSP homatropine syrp TRIAMCINOLONE hydrocodone w/ 2 DIACETATE MICRONIZED 5 homatropine tabs POWD TESSALON PERLES 4 TRIAMCINOLONE 5 CAPS (benzonatate) DIACETATE POWD XX TRIAMCINOLONE Cough/Cold/Allergy Combinations DIACETATE SUSP IJ 40 5 CARBAPHEN 12 LIQD 5 MG/ML TRIAMCINOLONE CARBAPHEN 12 PED 5 DIACETATE SUSP IJ 80 NC SUSP MG/ML CLARINEX-D 12 HOUR 5 TB12 TRIAMCINOLONE SUSP 5 CODAR AR LIQD 5 TRILOAN II SUIK KIT 5 GILPHEX TR TABS 5 RX/OTC TRILOAN SUIK KIT 5 GILTUSS TR TABS 5 RX/OTC UCERIS TB24 OR 9 MG 5 (budesonide) guaifenesin-codeine liqd 10 2 VERIPRED 20 SOLN mg/5ml-100 mg/5ml (prednisolone sodium 5 guaifenesin-codeine soln 2 phosphate) 10 mg/5ml-100 mg/5ml SP guaifenesin-codeine syrp 2 ZILRETTA SRER NC 10 mg/5ml-100 mg/5ml Mineralocorticoids

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCODONE BROMHEXINE HCL 5 BITARTRATE/GUAIFENES NC POWD IN SOLN GUAIFENESIN POWD 5 hydrocodone polistirex- QL(10 ml daily) 2 chlorpheniramine polistirex SSKI SOLN 5 suer TERPIN HYDRATE 5 5 NEOTUSS PLUS LIQD MONOHYDRATE POWD phenylephrine w/ dm-gg 2 RX/OTC TERPIN HYDRATE POWD 5 liqd promethazine & 2 QL(240 ml per Misc. Respiratory Inhalants phenylephrine syrp fill retail) HYPER-SAL NEBU 5 promethazine w/codeine 2 (sodium chloride (inhalant)) soln HYPERSAL NEBU 3.5 % 5 promethazine w/codeine 2 syrp HYPERSAL NEBU 7 % 5 promethazine-dm soln 2 (sodium chloride (inhalant)) NEBUSAL NEBU 5 promethazine-dm syrp 2 sodium chloride (inhalant) 2 promethazine- nebu phenylephrine-codeine 2 syrp Mucolytics ACETYLCYSTEINE POWD PROMETHAZINE/PHENYL 2 QL(240 ml per 5 EPHRINE SYRP fill retail) XX acetylcysteine soln in 10 %, pseudoephed-bromphen- 2 2 dm syrp 20 % N-ACETYL-L-CYSTEINE pseudoephed-cpm w/ 2 5 hydrocod soln POWD DERMATOLOGICALS - Drugs to Treat Skin SEMPREX-D CAPS 5 Conditions TUSSICAPS CP12 5 Acne Products QL(4 ea daily) TUSSIONEX QL(10 ml daily) ABSORICA CAPS 10 MG 5 PENNKINETIC ABSORICA CAPS 20 MG 5 QL(5 ea daily) EXTENDED RELEASE 5 SUER (hydrocodone polistirex-chlorpheniramine ABSORICA CAPS 25 MG, 5 polistirex) 35 MG ABSORICA CAPS 30 MG, QL(2 ea daily) TUSSLIN PEDIATRIC 4 RX/OTC 5 LIQD 40 MG TUXARIN ER TB12 NC ABSORICA LD CAPS NC ACANYA GEL (clindamycin TUZISTRA XR SUER 5 phosphate-benzoyl 4 peroxide) Expectorants ACZONE GEL 5 % 5 (dapsone (topical))

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACZONE GEL 7.5 % 5 QL(2 gm daily) AVAR-E LS CREA (sulfacetamide sodium w/ 5 sulfur) ACZONE GEL 7.5 % 5 QL(2 gm daily) (dapsone (topical)) AZELAIC NC adapalene crea 0.1 % 2 ACID/NIACINAMIDE CREA AZELEX CREA 5 ST adapalene gel 0.1 % 2 RX/OTC BENZAC AC WASH LIQD 5 RX/OTC adapalene gel 0.3 % 2 (benzoyl peroxide) BENZACLIN GEL QL(1.97 ml adapalene lotn 0.1 % 2 (clindamycin phosphate- NC daily) benzoyl peroxide) adapalene pads 0.1 % NC BENZACLIN WITH PUMP GEL (clindamycin NC ADAPALENE SOLN 0.1 % NC phosphate-benzoyl peroxide) adapalene-benzoyl 2 QL(1.5 gm BENZAMYCIN GEL QL(2 gm daily) peroxide gel daily) (benzoyl peroxide- 5 ADAPALENE/BENZOYL erythromycin) PEROXIDE/CLINDAMYCI NC BENZEFOAM FOAM 5 RX/OTC N GEL (benzoyl peroxide) ADAPALENE/BENZOYL BENZEFOAM ULTRA 5 PEROXIDE/NIACINAMIDE NC FOAM (benzoyl peroxide) GEL BENZEPRO FOAM NC AKLIEF CREA NC BENZEPRO LIQD NC AKTIPAK PACK NC QL(2 ea daily) BENZEPRO MISC NC ALTRENO LOTN NC BENZOLYL PEROXIDE NC AMZEEQ FOAM NC FORTE-HC LOTN benzoyl peroxide foam ex 2 RX/OTC ARAZLO LOTN NC 5.3 % benzoyl peroxide foam ex ATRALIN GEL (tretinoin) 5 QL(1.5 gm 2 daily) 9.8 % BENZOYL PEROXIDE NC AVAR FOAM NC GEL EX 6.5 % AVAR LS CLEANSER BENZOYL PEROXIDE 5 LIQD (sulfacetamide 5 HYDROUS POWD sodium w/ sulfur) benzoyl peroxide liqd ex 5 5 RX/OTC AVAR LS FOAM NC % benzoyl peroxide liqd ex 7 2 AVAR LS PADS 5 % benzoyl peroxide misc ex 6 2 RX/OTC AVAR PADS 5 % BENZOYL PEROXIDE 5 POWD XX 70 %

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzoyl peroxide- 2 QL(2 gm daily) clindamycin phosphate- NC QL(1 gm daily) erythromycin gel tretinoin gel benzoyl peroxide- NC CLINDAMYCIN hydrocortisone lotn PHOSPHATE/NIACINAMI NC BENZOYL DE GEL PEROXIDE/CLINDAMYCI NC CLINDAMYCIN N/NIACINAMIDE GEL PHOSPHATE/NIACINAMI NC BENZOYL DE LOTN PEROXIDE/CLINDAMYCI NC CLINDAMYCIN N/NIACINAMIDE/TRETINO PHOSPHATE/NIACINAMI NC IN GEL DE/TRETINOIN CREA CLEOCIN-T GEL CLINDAMYCIN/NIACINAM (clindamycin phosphate 5 IDE/SPIRONOLACTONE/T NC (topical)) RETINOIN GEL CLEOCIN-T LOTN CLINOIN CREA 5 (clindamycin phosphate 5 (topical)) dapsone (topical) gel 5 % 2 CLEOCIN-T SOLN (clindamycin phosphate 5 dapsone (topical) gel 7.5 % 2 QL(2 gm daily) (topical)) CLEOCIN-T SWAB DAPSONE GEL EX 7.5 % 5 QL(2 gm daily) (clindamycin phosphate 5 (topical)) DAPSONE/NIACINAMIDE NC GEL CLINDACIN ETZ KIT 5 DAPSONE/NIACINAMIDE/ NC SPIRONOLACTONE GEL CLINDACIN PAC KIT 5 DEOXIA GEL NC CLINDAGEL GEL (clindamycin phosphate 5 DEOXIA LOTN NC (topical)) clindamycin phosphate 2 DIADIMAXIA GEL NC (topical) foam clindamycin phosphate 2 DIAOXIA GEL NC (topical) gel DIASDIMAXIA GEL NC clindamycin phosphate NC (topical) gel DIASOXIA GEL NC clindamycin phosphate 2 (topical) lotn DIFFERIN CREA 0.1 % 5 clindamycin phosphate 2 (adapalene) (topical) soln DIFFERIN GEL 0.1 % 5 RX/OTC clindamycin phosphate 2 (adapalene) (topical) swab DIFFERIN GEL 0.3 % 5 clindamycin phosphate- (adapalene) benzoyl peroxide 2 DIFFERIN LOTN 0.1 % 5 QL(1.97 ml (refrigerate) gel daily) clindamycin phosphate- 2 benzoyl peroxide gel DIMOXIA GEL NC

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRAXACE LOTION NC KLARON LOTN QL(120 ml per CLEANSER SUSP (sulfacetamide sodium 5 fill retail) (acne)) DRAXACE SUSP NC NEUAC KIT KIT 5 DRIXECE SUSP NC NIACINAMIDE/SPIRONOL NC DUAC GEL (clindamycin ACTONE GEL phosphate-benzoyl 5 NIACINAMIDE/SPIRONOL NC peroxide (refrigerate)) ACTONE/TRETINOIN GEL ECEOXIA CREA NC NIACINAMIDE/SULFACET AMIDE SODIUM NC EPIDUO FORTE GEL 4 QL(1.5 gm MONOHYDRATE CREA daily) NIACINAMIDE/TAZAROTE NC EPIDUO GEL (adapalene- 4 QL(1.5 gm NE CREA benzoyl peroxide) daily) NIACINAMIDE/TRETINOIN NC ERYGEL GEL 5 CREA (erythromycin (acne aid)) NIACINAMIDE/TRETINOIN NC erythromycin (acne aid) gel 2 GEL NUCARACLINPAK KIT NC erythromycin (acne aid) 2 pads NUCARARXPAK KIT NC erythromycin (acne aid) 2 soln ONEXTON GEL 4 ETHOXIA CREA NC PLEXION CLEANSER EVOCLIN FOAM LIQD (sulfacetamide 5 (clindamycin phosphate 5 sodium w/ sulfur) (topical)) PLEXION CLEANSING 5 ST; QL(1.67 CLOTHS PADS FABIOR FOAM 5 gm daily) PLEXION CREA HYALURONIC ACID (sulfacetamide sodium w/ 5 SODIUM/NIACINAMIDE/T NC sulfur) RETINOIN CREA PLEXION LOTN (sulfacetamide sodium w/ 5 INOVA 4/1 ACNE 5 CONTROL THERAPY KIT sulfur) INOVA 8/2 ACNE 5 PLIXDA PADS NC CONTROL THERAPY KIT PR BENZOYL PEROXIDE NC INOVA KIT 5 LIQD isotretinoin caps or 10 mg 2 QL(4 ea daily) resorcinol-sulfur lotn 2 RX/OTC isotretinoin caps or 20 mg 2 QL(5 ea daily) RETIN-A CREA (tretinoin) 5 isotretinoin caps or 30 mg, 2 QL(2 ea daily) RETIN-A GEL (tretinoin) 5 40 mg RETIN-A MICRO GEL 0.04 QL(1.7 gm ITHOXIA CREA NC %, 0.1 % (tretinoin 5 daily) microsphere) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETIN-A MICRO GEL 0.06 5 QL(1.7 gm sulfacetamide sodium w/ % daily) sulfur pads 10 %-10 %-4 2 RETIN-A MICRO PUMP QL(1.7 gm %-4 %, 10 %-4 % GEL 0.04 %, 0.1 % 5 daily) sulfacetamide sodium w/ 2 (tretinoin microsphere) sulfur susp 4 %-8 % RETIN-A MICRO PUMP 5 PA; QL(1.7 gm sulfacetamide sodium- 2 GEL 0.08 % daily) sulfur in urea vehicle emul RETINOIC ACID POWD 5 sulfacetamide sodium- 2 sulfur w/ skin cleanser kit RETINOIC ACID-ALL 5 sulfacetamide sodium- 2 TRANS POWD sulfur-sunscreen kit REZAMID LOTN NC RX/OTC SUMADAN KIT KIT (resorcinol-sulfur) (sulfacetamide sodium- 5 REZESOL LOTN NC sulfur w/ skin cleanser) SUMADAN WASH LIQD RIAX FOAM 5 ST (sulfacetamide sodium w/ 5 sulfur) SALICYLIC SUMADAN XLT KIT 5 ACID/SULFACETAMIDE NC SODIUM MONOHYDRATE SUSP SUMAXIN CP KIT KIT 5 SODIUM SUMAXIN PADS SULFACETAMIDE/SULFU 5 (sulfacetamide sodium w/ 5 R CLEANSER IN UREA sulfur) EMUL SUMAXIN WASH LIQD SODIUM (sulfacetamide sodium w/ 5 SULFACETAMIDE/SULFU 5 sulfur) R SUSP TARDEOXIA CREA NC sulfacetamide sodium 2 QL(120 ml per (acne) lotn fill retail) TARDIMAXIA GEL NC sulfacetamide sodium w/ 2 sulfur crea 10 %-2 %, 4.8 TAROXIA CREA NC %-9.8 %, 10 %-5 % sulfacetamide sodium w/ TRETINOIN (ALL-TRANS 5 sulfur emul 1 %-10 %, 10 2 RETINOIC ACID) POWD %-5 % tretinoin crea ex 0.05 %, 2 0.1 %, 0.025 % sulfacetamide sodium w/ 2 sulfur foam 10 %-5 % tretinoin gel ex 0.01 %, 2 sulfacetamide sodium w/ 0.025 % sulfur liqd 10 %-2 %, 4 %-9 2 QL(1.5 gm tretinoin gel ex 0.05 % 2 %, 4.5 %-9 %, 4.8 %-9.8 % daily) sulfacetamide sodium w/ QL(30 gm per QL(1.7 gm 2 tretinoin microsphere gel 2 sulfur lotn 10 %-5 % fill retail) daily) sulfacetamide sodium w/ 2 sulfur lotn 4.8 %-9.8 % TRETINOIN POWD XX 5 VARDIMAXIA GEL NC

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VAROXIA CREA NC BIIFENAC 1000 THPK NC

VAROXIA GEL NC BIIFENAC 500 THPK NC

VELTIN GEL NC QL(1 gm daily) DERMACINRX LEXITRAL PHARMAPAK THPK NC ZACARE 4% KIT KIT 5 (diclofenac sodium- capsaicin (topical)) ZACARE 8% KIT KIT 5 DFS/MS/MENTH/CAP PAK NC KIT ZACLIR CLEANSING 5 LOTN DICLO GEL PAK KIT NC ZIANA GEL (clindamycin QL(1 gm daily) NC DICLO GEL/XRYLIX NC phosphate-tretinoin) SHEETS THPK Agents for External Genital and Perianal Warts diclofenac epolamine ptch 2 QL(30 gm per VEREGEN OINT NC fill retail) diclofenac sodium (topical) 2 RX/OTC gel 1 % Analgesics - Topical diclofenac sodium (topical) 2 QL(5 ml daily) A.A.G.C. KIT IN 5 soln 1.5 % TERODERM CREA diclofenac sodium- NC ACTIVE-PREP KIT IV 5 capsaicin (topical) thpk CREA DICLOFONO GEL NC ACTIVE-TRAMADOL KIT 5 CREA DICLOPR KIT NC BACLOFEN CREA EX 2 % 5 DICLOSTREAM THPK NC ENOVARX-BACLOFEN 5 CREA DICLOVIX KIT NC ENOVARX-TRAMADOL 5 CREA DICLOVIX M THPK NC NEURAPTINE CREA NC DICLOZOR THPK NC Anti-inflammatory Agents - Topical DIMENTHO THPK NC ACTIVE-KETOPROFEN NC KIT CREA DITHOL THPK NC ACTIVE-PREP KIT I CREA 5 DS PREP PAK THPK NC ACTIVE-PREP KIT II 5 CREA DST PLUS PAK KIT NC ACTIVE-PREP KIT III 5 CREA DUAL COMPLEX 5 FORMULA 1 KIT CREA AIF #2 DRUG 5 PREPARATIONKIT CREA DYNABAC 5.0 THPK NC AIF #3 DRUG 5 PREPARATION KIT CREA ENOVARX-DICLOFENAC NC SODIUM CREA

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENOVARX-IBUPROFEN 5 VOPAC GB CREA NC CREA ENOVARX-NAPROXEN 5 VOPAC KT CREA NC CREA FBL KIT CREA 5 VP FC KIT CREA 5

FLECTOR PTCH 5 VP GKL KIT CREA NC

FLECTOR PTCH 5 XRYLIX THPK NC (diclofenac epolamine) Antibiotics - Topical FROTEK CREA NC ALTABAX OINT 5 GABAPENTIN/NAPROXE N SOD MULTI-PHASIC NC BACITRACIN POWD XX 5 TRANSDERMAL CMPD KIT CREA BACITRACIN ZINC POWD 5 INFLAMMA-K KIT KIT NC BACTROBAN CREA (mupirocin calcium 4 K.B.G.L. IN TERODERM 5 CREAM CREA (topical)) KETOPHENE RAPIDPAQ NC CENTANY AT KIT 5 CREA CENTANY OINT 5 KETOROLAC 2% GEL 5 GEL CORTISPORIN CREA 5 LEXIXRYL THPK NC CORTISPORIN OINT 5 LICART PT24 NC gentamicin sulfate (topical) 2 LIDOPROFEN CREA NC crea NAPRO 15% gentamicin sulfate (topical) 2 COMPOUNDING KIT 5 oint CREA GENTAMICIN SULFATE 5 POWD XX NP #2 DRUG 5 PREPARATION KIT CREA mupirocin calcium (topical) NC crea PENNSAID SOLN NC QL(4 gm daily) mupirocin oint ex 2 REXAPHENAC CREA 5 NEO-SYNALAR CREA 5 TRIPLE COMPLEX NC FORMULA 3KIT CREA NEO-SYNALAR KIT KIT 5 TRIXYLITRAL THPK NC NEOMYCIN SULFATE 5 POWD XX VAROPHEN KIT NC TETRACYCLINE HCL 5 VOLTAREN GEL RX/OTC POWD XX (diclofenac sodium 5 TETRACYCLINE 5 (topical)) HYDROCHLORIDE POWD

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XEPI CREA NC ECOZA FOAM 5 QL(2.5 gm daily) Antifungals - Topical ERTACZO CREA 5 ACTIVE-PREP KIT V 5 CREA EXELDERM CREA 5 (sulconazole nitrate) BENZOIC ACID CRYS 5 RX/OTC EXELDERM SOLN 5 BENZOIC ACID POWD 5 EXODERM LOTN 5 CICLODAN SOLUTION 5 KIT KIT (ciclopirox) EXTINA FOAM 5 (ketoconazole (topical)) ciclopirox gel ex 0.77 % 2 EXTINA FOAM NC (ketoconazole (topical)) ciclopirox kit ex 8 % 2 FLUCONAZOLE/IBUPROF EN/ITRACONAZOLE/TER NC ciclopirox olamine crea ex 2 BINAFINE HYDROCHLORIDE SOLN CICLOPIROX OLAMINE 5 POWD XX FUNGIMEZ SOLN NC RX/OTC ciclopirox olamine susp ex 2 G-MYCO NAIL SOLN NC RX/OTC ciclopirox sham ex 1 % 2 GENTIAN VIOLET POWD 5 ciclopirox soln ex 8 % 2 HYDROCORTISONE/IOD RX/OTC OQUINOL/KETOCONAZO NC CLIOQUINOL POWD 5 LE CREA clotrimazole (topical) soln 2 RX/OTC HYDROCORTISONE/KET NC OCONAZOLE CREA CLOTRIMAZOLE CRYS 5 XX IMIOXIA CREA NC PA CLOTRIMAZOLE POWD 5 JUBLIA SOLN 5 XX KERYDIN SOLN QL(10 ml per clotrimazole w/ 2 5 betamethasone crea (tavaborole) fill retail) clotrimazole w/ 2 ketoconazole (topical) crea 2 betamethasone lotn DERMACINRX NC ketoconazole (topical) foam NC THERAZOLE PAK THPK ketoconazole (topical) 2 QL(120 ml per DIFMETIOXRIME SOLN NC sham fill retail)

ECONASIL KIT NC KETODAN KIT KIT 5 LOPROX CREA (ciclopirox NC econazole nitrate crea ex 2 olamine) ECONAZOLE LOPROX KIT 5 NITRATE/NIACINAMIDE NC CREA 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPROX KIT KIT NC OXISTAT CREA 5 (oxiconazole nitrate) LOPROX SHAMPOO 5 SHAM (ciclopirox) OXISTAT LOTN 5 LOPROX SUSP (ciclopirox NC PEDIZOLPAK THPK NC olamine) LOTRISONE CREA PENLAC NAIL LACQUER 5 (clotrimazole w/ 5 SOLN (ciclopirox) betamethasone) PHEODOYO CREA NC luliconazole crea 2 PHEYO CREA NC LUZU CREA (luliconazole) NC RECURA CREA NC MICONAZOLE NITRATE 5 POWD sulconazole nitrate crea 2 miconazole-zinc oxide- 5 white petrolatum oint sulconazole nitrate soln 2 RX/OTC MYCO NAIL SOLN NC QL(10 ml per tavaborole soln 5 fill retail) MYCO-NAIL SOLN NC RX/OTC TOLNAFTATE POWD 5 naftifine hcl crea 2 VUSION OINT (miconazole-zinc oxide- 5 naftifine hcl gel 2 white petrolatum) NAFTIN CREA 2 % 4 XOLEGEL COREPAK KIT 5 (naftifine hcl) XOLEGEL DUO/HEAD & NAFTIN GEL 1 % (naftifine 4 5 hcl) SHOULDERS KIT XOLEGEL DUO/XOLEX 5 NAFTIN GEL 2 % 4 KIT NIZORAL SHAM 5 QL(120 ml per XOLEGEL GEL NC (ketoconazole (topical)) fill retail) Antineoplastic or Premalignant Lesion Agents - nystatin (topical) crea 2 AMELUZ GEL NC nystatin (topical) oint 2 CARAC CREA (fluorouracil NC QL(1 gm daily) nystatin (topical) powd 2 (topical)) diclofenac sodium (actinic 2 nystatin-triamcinolone crea 2 keratoses) gel DICLOFENAC nystatin-triamcinolone oint 2 SODIUM/HYALURONIC NC ACID SODIUM ONYCHO-MED KIT NC SALT/NIACINAMIDE GEL EFUDEX CREA 5 QL(40 gm per oxiconazole nitrate crea 2 (fluorouracil (topical)) fill retail) FLUOROPLEX CREA 5

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluorouracil (topical) crea NC QL(1 gm daily) ANTHRALIN POWD 5 0.5 % QL(5 gm fluorouracil (topical) crea 5 2 QL(40 gm per % fill retail) calcipotriene crea ex NC daily,60 gm per fill retail) fluorouracil (topical) soln 2 2 QL(10 ml per %, 5 % fill retail) CALCIPOTRIENE FOAM NC QL(4 gm daily) EX HYALUCIL-4 CREA NC calcipotriene foam ex NC QL(4 gm daily) IMIQUIMOD/LEVOCETIRI ZINEDIHYDROCHLORIDE NC calcipotriene oint ex 2 QL(5 gm daily) /NIACINAMIDE GEL QL(60 ml per IMIQUIMOD/LEVOCETIRI calcipotriene soln ex 2 ZINEDIHYDROCHLORIDE NC fill retail) QL(3.4 gm /TRETINOIN GEL calcitriol (topical) oint NC daily) LEVULAN KERASTICK 5 PA; SP SOLR COSENTYX 4 PA; SP SENSOREADY PEN SOAJ ORMECA KIT NC COSENTYX SOSY 4 PA; SP PANRETIN GEL 5 QL(5 gm DOVONEX CREA 5 (calcipotriene) daily,60 gm per PICATO GEL 4 fill retail) SOLARAVIX THPK NC DRITHO-CREME HP 5 CREA PA; SP TARGRETIN GEL EX 1 % 5 ILUMYA SOSY NC

TOLAK CREA 4 methoxsalen rapid caps 2 QL(4 ea daily) PA; SP VALCHLOR GEL 5 NUDERMRXPAK 120 NC THPK Antipruritics - Topical NUDERMRXPAK 60 THPK NC CAMPHOR CRYS 5 RX/OTC OXSORALEN ULTRA 5 QL(4 ea daily) CAPS (methoxsalen rapid) CAMPHOR GRAN 5 RX/OTC SILIQ SOSY NC PA doxepin hcl (antipruritic) NC crea SKYRIZI PSKT 4 PA; SP PRUDOXIN CREA NC (doxepin hcl (antipruritic)) SORIATANE CAPS 10 MG 5 QL(1 ea daily) (acitretin) ZONALON CREA (doxepin NC hcl (antipruritic)) SORIATANE CAPS 25 MG 5 QL(2 ea daily) (acitretin) Antipsoriatics SORILUX FOAM NC QL(4 gm daily) acitretin caps 10 mg, 17.5 2 QL(1 ea daily) mg STELARA SOLN 4 PA; SP acitretin caps 25 mg 2 QL(2 ea daily) STELARA SOSY 4 PA; SP

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TALTZ SOAJ NC OVACE PLUS WASH GEL 5 (sulfacetamide sodium) TALTZ SOSY NC OVACE PLUS WASH LIQD 5 (sulfacetamide sodium) QL(1 gm daily) tazarotene crea ex 2 OVACE WASH LIQD 5 (sulfacetamide sodium) TAZORAC CREA 0.05 % 4 QL(1 gm daily) PROMISEB COMPLETE 5 KIT TAZORAC CREA 0.1 % 4 QL(1 gm daily) (tazarotene) PROMISEB CREA 5 RX/OTC TAZORAC GEL 0.05 %, 4 QL(1 gm daily) 0.1 % selenium sulfide lotn ex 2.5 2 QL(120 ml per % fill retail) TREMFYA SOPN 4 PA; SP selenium sulfide sham ex 2 2.3 %, 2.25 % TREMFYA SOSY 4 PA; SP SELRX SHAM (selenium 5 sulfide) VECTICAL OINT (calcitriol NC QL(3.4 gm (topical)) daily) SODIUM SULFACETAMIDE WASH 5 ZITHRANOL SHAM 5 LIQD Antiseborrheic Products sulfacetamide sodium gel 2 ex CICLOPIROX sulfacetamide sodium liqd OLAMINE/CLOBETASOL NC 2 PROPIONATE/SALICYLIC ex ACID SHAM SULFACETAMIDE 5 CICLOPIROX SODIUM POWD XX OLAMINE/CLOBETASOL NC sulfacetamide sodium 2 SHAM sham ex CICLOPIROX/SALICYLIC NC Antivirals - Topical ACID SHAM QL(0.17 gm acyclovir topical crea NC DERMAZINC CREAM 5 RX/OTC daily) CREA acyclovir topical oint 2 QL(1 gm daily) ESKATA SOLN NC QL(0.17 gm DENAVIR CREA 5 GLYCOLIC ACID 70% 5 RX/OTC daily) HIGH PURITY SOLN QL(0.17 gm XERESE CREA 5 GLYCOLIC ACID SOLN 5 RX/OTC daily) ZOVIRAX CREA EX 5 % 5 QL(0.17 gm NUTRASEB CREA 5 RX/OTC (acyclovir topical) daily) ZOVIRAX OINT EX 5 % 5 QL(1 gm daily) OVACE PLUS CREA 10 % 5 (acyclovir topical) Burn Products OVACE PLUS FOAM 9.8 NC % mafenide acetate pack ex 2 OVACE PLUS LOTN 9.8 % 5 NITROFURAZONE POWD 5 OVACE PLUS SHAM 10 % 5 (sulfacetamide sodium) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SILVADENE CREA (silver 4 betamethasone 2 sulfadiazine) dipropionate (topical) oint silver sulfadiazine crea ex 2 betamethasone dipropionate augmented 2 crea SULFAMYLON CREA 85 5 MG/GM betamethasone dipropionate augmented 2 SULFAMYLON PACK 5 % 5 (mafenide acetate) gel Cauterizing Agents betamethasone dipropionate augmented 2 CHLOROACETIC ACID 5 lotn POWD betamethasone SILVER NITRATE CRYS 5 RX/OTC dipropionate augmented 2 XX oint SILVER NITRATE OINT 5 BETAMETHASONE 5 EX 10 % DIPROPIONATE POWD SILVER NITRATE SOLN betamethasone valerate 2 EX 0.5 %, 10 %, 25 %, 50 5 crea ex 0.1 % % betamethasone valerate 2 silver nitrate-potassium 2 foam ex 0.12 % nitrate misc betamethasone valerate 2 QL(60 ml per TRI-CHLOR LIQD 5 lotn ex 0.1 % fill retail) betamethasone valerate 2 Corticosteroids - Topical oint ex 0.1 % ADVANCED ALLERGY NC BETAMETHASONE 5 COLLECTION KIT KIT VALERATE POWD XX ALA SCALP LOTN 5 BRYHALI LOTN 4 ALA-SCALP LOTN 5 CALCIPOTRIENE ANHYDROUS/CLOBETAS NC alclometasone dipropionate 2 OL PROPIONATE SOLN crea calcipotriene- QL(2 gm daily) alclometasone dipropionate 2 betamethasone 2 oint dipropionate oint amcinonide crea 2 calcipotriene- ST; QL(2 gm betamethasone 2 daily) amcinonide lotn 2 dipropionate susp calcipotriene- ST; QL(2 gm AMCINONIDE OINT 5 betamethasone NC daily) dipropionate susp APEXICON E CREA NC CAPEX SHAM 4 BESER KIT NC CHLOOXIA CREA NC betamethasone 2 dipropionate (topical) crea CHLOOXIA OINT NC betamethasone 2 QL(60 ml per dipropionate (topical) lotn fill retail) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHLOOXIA SOLN NC CLOBEX SHAM 4 (clobetasol propionate) CLOBETASOL 17 5 PROPIONATE POWD clocortolone pivalate crea 2 clobetasol propionate crea 2 CLODAN KIT KIT 5 ex clobetasol propionate 2 CLODERM CREA 5 emollient base crea CLODERM CREA clobetasol propionate 2 5 emulsion foam (clocortolone pivalate) CLODERM CREA clobetasol propionate foam 2 NF ex (clocortolone pivalate) clobetasol propionate gel 2 CLODERM PUMP CREA 5 ex CORDRAN CREA 0.025 % 5 clobetasol propionate liqd NC ex CORDRAN CREA 0.05 % 5 clobetasol propionate lotn 2 (flurandrenolide) ex CORDRAN LOTN 0.05 % 5 CLOBETASOL (flurandrenolide) PROPIONATE 5 MICRONIZED USP POWD CORDRAN OINT 0.05 % NC (flurandrenolide) clobetasol propionate oint 2 ex CORDRAN TAPE 4 5 MCG/SQCM CLOBETASOL 5 PROPIONATE POWD XX CUTIVATE LOTN 5 (fluticasone propionate) clobetasol propionate sham 2 ex DERMA-SMOOTHE/FS BODY OIL (fluocinolone 4 clobetasol propionate soln 2 acetonide) ex DERMA-SMOOTHE/FS CLOBETASOL SCALP OIL (fluocinolone 4 PROPIONATE/LEVOCETI acetonide) RIZINE NC DIHYDROCHLORIDE DERMASORB HC KIT 5 SHAM CLOBETASOL DERMASORB TA KIT 5 PROPIONATE/NIACINAMI NC DE CREA DESONATE GEL 5 CLOBETASOL DESONATE GEL 5 PROPIONATE/NIACINAMI NC (desonide) DE OINT CLOBETASOL desonide crea ex 2 PROPIONATE/NIACINAMI NC DE SOLN desonide gel ex NC CLOBEX LIQD (clobetasol NC propionate) desonide lotn ex 2 CLOBEX LOTN (clobetasol 4 desonide oint ex 2 propionate) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DESONIDE POWD XX 5 fluocinolone acetonide soln 2 ex 0.01 % DESOWEN CREA 4 FLUOCINOLONE (desonide) ACETONIDE/NIACINAMID NC E CREA DESOWEN LOTN 4 (desonide) fluocinonide crea ex 0.05 % 2 DESOXIMETASONE 5 CREA EX 0.05 % fluocinonide crea ex 0.1 % NC desoximetasone crea ex 2 0.05 %, 0.25 % fluocinonide emulsified 2 base crea desoximetasone gel ex 2 0.05 % fluocinonide gel ex 0.05 % 2 desoximetasone liqd ex 2 0.25 % fluocinonide oint ex 0.05 % 2 desoximetasone oint ex 2 FLUOCINONIDE POWD 5 0.05 %, 0.25 % XX diflorasone diacetate crea NC fluocinonide soln ex 0.05 % 2 diflorasone diacetate oint NC FLUOPAR KIT NC DIPROLENE AF CREA (betamethasone 5 FLUOVIX PLUS THPK NC dipropionate augmented) DIPROLENE OINT FLUOVIX THPK NC (betamethasone 4 dipropionate augmented) flurandrenolide crea 2 DUOBRII LOTN 5 flurandrenolide lotn 2

ELLZIA PAK THPK NC flurandrenolide lotn NC

ELOCON CREA 5 (mometasone furoate) flurandrenolide oint NC fluticasone propionate crea ELOCON OINT 4 2 (mometasone furoate) ex 0.05 % ENSTILAR FOAM 5 fluticasone propionate lotn 2 ex 0.05 % EPIFOAM FOAM 5 fluticasone propionate oint 2 ex 0.005 % fluocinolone acetonide crea 2 ex 0.01 %, 0.025 % halcinonide crea 2 fluocinolone acetonide oil 2 halobetasol propionate 2 ex 0.01 % crea fluocinolone acetonide oint 2 HALOBETASOL NC ex 0.025 % PROPIONATE FOAM FLUOCINOLONE 5 ACETONIDE POWD XX halobetasol propionate oint 2

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALOG CREA 5 hydrocortisone valerate oint 2 (halcinonide) HALOG OINT 5 IMPOYZ CREA NC KENALOG AERS HALOG SOLN 5 (triamcinolone acetonide 5 (topical)) hydrocortisone (topical) 2 RX/OTC crea 1 % LEXETTE FOAM NC hydrocortisone (topical) 2 crea 2.5 % lidocaine-hydrocortisone 2 acetate crea hydrocortisone (topical) 2 lotn 2.5 % LIDOSOL-HC CREA NC hydrocortisone (topical) 2 RX/OTC oint 1 % LOCOID CREA 5 (hydrocortisone butyrate) hydrocortisone (topical) NC RX/OTC oint 1 % LOCOID LIPOCREAM CREA (hydrocortisone 5 hydrocortisone (topical) 2 butyrate hydrophilic lipo oint 2.5 % base) HYDROCORTISONE LOCOID LOTN 5 ACETATE MICRONIZED 5 (hydrocortisone butyrate) POWD LOCOID SOLN 5 HYDROCORTISONE 5 (hydrocortisone butyrate) ACETATE POWD LUXIQ FOAM 5 HYDROCORTISONE (betamethasone valerate) ACETATE/LIDOCAINE HYDROCHLORIDE CREA NC MICORT-HC CREA NC (lidocaine-hydrocortisone acetate) mometasone furoate crea 2 ex hydrocortisone butyrate 2 crea mometasone furoate oint 2 ex hydrocortisone butyrate NC hydrophilic lipo base crea mometasone furoate soln 2 ex hydrocortisone butyrate 2 lotn MONISTAT SOOTHING RX/OTC CARE ITCH RELIEF CREA NC hydrocortisone butyrate 2 (hydrocortisone (topical)) oint NIACINAMIDE/TRIAMCIN HYDROCORTISONE 5 OLONE ACETONIDE NC BUTYRATE SOLN CREA hydrocortisone butyrate 2 soln NOXIPAK THPK NC HYDROCORTISONE 5 MICRONIZED POWD NUCORT LOTN 5 HYDROCORTISONE 5 OLUX FOAM (clobetasol 5 POWD XX propionate) hydrocortisone valerate 2 OLUX-E FOAM (clobetasol NC crea propionate emulsion)

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PANDEL CREA 5 TEMOVATE CREA 4 (clobetasol propionate) prednicarbate crea 2 TEMOVATE OINT 4 (clobetasol propionate) prednicarbate oint 2 TEXACORT SOLN 4

PSORCON CREA NC TOPICORT CREA 5 (desoximetasone) QUINIXIL THPK NC TOPICORT GEL 5 (desoximetasone) QUINOSONE KIT NC TOPICORT LIQD 5 (desoximetasone) RRB PAK THPK NC TOPICORT OINT 5 (desoximetasone) SCALACORT DK KIT 5 TOVET KIT KIT NC SCARZEN SKIN REPAIR NC KIT triamcinolone acetonide NC (topical) aers 0.147 mg/gm SERNIVO EMUL 5 triamcinolone acetonide SILA III THPK NC (topical) crea 0.025 %, 0.1 2 % SILALITE PAK THPK NC triamcinolone acetonide 2 QL(15 gm per (topical) crea 0.5 % fill retail) SYNALAR CREA 5 triamcinolone acetonide QL(60 ml per (fluocinolone acetonide) (topical) lotn 0.025 %, 0.1 2 fill retail) SYNALAR CREAM KIT KIT 5 % triamcinolone acetonide SYNALAR OINT 5 (topical) oint 0.025 %, 0.1 2 (fluocinolone acetonide) % SYNALAR OINTMENT KIT 5 triamcinolone acetonide 2 ST; QL(2 gm KIT (topical) oint 0.05 % daily) SYNALAR SOLN 5 triamcinolone acetonide 2 QL(15 gm per (fluocinolone acetonide) (topical) oint 0.5 % fill retail) SYNALAR TS KIT 5 TRIAMCINOLONE 5 ACETONIDE POWD XX TACLONEX OINT QL(2 gm daily) triamcinolone acetonide- (calcipotriene- 5 2 betamethasone dimethicone-silicone kit dipropionate) TRIAMCINOLONE TACLONEX SUSP ST; QL(2 gm ACETONIDEUSP, 5 MICRONIZED POWD (calcipotriene- 5 daily) betamethasone TRIAMSIL COMBIPAK NC dipropionate) THPK TACLONEX SUSP ST TRIAMSIL MULTIPAK NC THPK (calcipotriene- NF betamethasone ST; QL(2 gm TRIANEX OINT 5 dipropionate) daily)

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIDESILON CREA 4 urea crea ex 45 %, 41 %, 2 (desonide) 47 %, 39 % ULTRAVATE CREA 4 UREA FOAM EX 35 % NC (halobetasol propionate) ULTRAVATE LOTN 5 urea foam ex 40 % 2

ULTRAVATE OINT 4 urea gel ex 45 % 2 (halobetasol propionate) urea in lactic acid vehicle VANOS CREA 5 2 (fluocinonide) foam VERDESO FOAM 5 urea lotn ex 40 % 2

XILAPAK KIT NC urea susp ex 40 %, 50 % 2 Eczema Agents URESOL CREA NC DUPIXENT SOPN 300 NC MG/2ML UTOPIC CREA (urea) 5 DUPIXENT SOSY 200 4 PA; SP Emollients MG/1.14ML, 300 MG/2ML HPR PLUS/MB 5 Emollient/Keratolytic Agents HYDROGEL KIT CEM-UREA SOLN 5 hyaluronate sodium 2 (emollient) gel DERMASORB XM KIT 5 HYLINATE LOTN NC

GORDONS UREA OINT 5 LAC-HYDRIN CREA (lactic 4 RX/OTC acid (ammonium lactate)) HYDRO 35 FOAM (urea in 5 lactic acid (ammonium 2 RX/OTC lactic acid vehicle) lactate) crea 12 % HYDRO 40 FOAM FOAM 5 lactic acid (ammonium 2 (urea) lactate) lotn 10 % KERALAC CREA (urea) 5 lactic acid w/ vitamin e crea 2 LATRIX XM EMUL 5 Enzymes - Topical PROTEXA CREA NC COLLAGENASE POWD 5

RYNODERM CREA NC SANTYL OINT 5

URALISS CREA NC Immunomodulating Agents - Topical ALDARA CREA 5 QL(0.2667 ea URAMAXIN GEL (urea) 5 (imiquimod) daily) imiquimod crea ex 3.75 % 2 QL(1 gm daily) URE-K CREA 5 QL(0.2667 ea imiquimod crea ex 5 % 2 urea crea ex 40 % 2 RX/OTC daily) ZYCLARA CREA 4 QL(1 ea daily) (imiquimod) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZYCLARA PUMP CREA 4 QL(0.6 gm PYROGALLIC ACID OINT 5 2.5 % daily) SALEX CREAM KIT ZYCLARA PUMP CREA 4 QL(1 gm daily) 5 3.75 % (imiquimod) (salicylic acid w/ cleanser) Immunosuppressive Agents - Topical SALEX LOTION KIT 5 QL(1 gm SALEX SHAM (salicylic ELIDEL CREA 5 daily,60 gm per 5 (pimecrolimus) acid) fill retail) HYALURONIC ACID salicylic acid crea ex 6 % 2 SODIUM/NIACINAMIDE/T NC ACROLIMUS CREA salicylic acid foam ex 6 % 2 NIACINAMIDE/TACROLIM NC US MONOHYDRATE OINT salicylic acid gel ex 6 % 2 QL(1 gm salicylic acid liqd ex 27.5 % 2 pimecrolimus crea 2 daily,60 gm per fill retail) salicylic acid lotn ex 6 % 2 PROTOPIC OINT 5 QL(2 gm daily) (tacrolimus (topical)) salicylic acid sham ex 6 % 2 tacrolimus (topical) oint 2 QL(2 gm daily) salicylic acid soln ex 28.5 2 TACROLIMUS %, 26 % MONOHYDRATE CREA NC salicylic acid w/ cleanser kit 2 EX Keratolytic/Antimitotic Agents SALIMEZ FORTE CREA 5

BENSAL HP OINT NC SALISOL SOLN NC

CANTHARIDIN POWD XX 5 SALITECH LOTN NC

CANTHARIDIN SOLN EX NC SALVAX DUO PLUS KIT 5 CIMETIDINE/LIDOCAINE/ NC SALVAX FOAM (salicylic 5 SALICYLIC ACID CREA acid) CONDYLOX GEL 4 ULTRASAL-ER SOLN 5 (salicylic acid) GORDOFILM SOLN 5 VIRASAL LIQD (salicylic 5 acid) KERALYT GEL (salicylic 5 acid) XALIX SOLN NC KERALYT SCALP KIT 5 Liniments PODOCON 25 IN MEDI-DERM CREA 5 RX/OTC BENZOIN TINCTURE 5 SOLN MEDI-DERM-RX CREA 5 RX/OTC QL(4 ml per fill podofilox soln ex 2 retail) MEDROX-RX OINT 5 PODOPHYLLUM RESIN 5 RX/OTC POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYL SALICYLATE 5 RX/OTC DERMACINRX ZRM PAK NC LIQD THPK TURPENTINE SPIRITS 5 DERMAZYL THPK NC SPRT Local Anesthetics - Topical DOLOTRANZ KIT NC 1ST MEDX- 5 RX/OTC PATCH/LIDOCAINE PTCH EHA LOTION 4% LOTN 5 ACCUCAINE KIT NC EHA LOTION LOTN 5 RX/OTC RX/OTC ALIVIO PATCH PTCH NC EMPRICAINE II KIT NC ALOCANE EMERGENCY QL(1 ml daily); ENOVARX-LIDOCAINE 5 BURN MAXIMUM NC RX/OTC HCL CREA STRENGTH GEL ethyl chloride aero 2 ANACAINE OINT 5 ETHYL CHLORIDE/FINE 5 ANASTIA LOTN NC STREAM AERO ETHYL APRIZIO PAK II KIT NC CHLORIDE/MEDIUM 5 STREAM AERO APRIZIO PAK KIT NC FLEXIN PTCH NC RX/OTC QL(1 ml daily); ASTERO GEL NC RX/OTC GEBAUERS INSTANT ICE 5 RX/OTC AERO AVADERM CREA 5 RX/OTC GEBAUERS PAIN EASE 5 RX/OTC AERO BENZOCAINE/LIDOCAINE NC /TETRACAINE OINT GEBAUERS SPRAY AND 5 RX/OTC STRETCH AERO CADIRAMD KIT NC GEN7T LOTN NC CAPSAICIN POWD 5 RX/OTC GEN7T PLUS LOTN NC CBD4 FREEZE PUMP RX/OTC MAXIMUMSTRENGTH 5 GEN7T PLUS PTCH NC CREA COCAINE HCL POWD XX 5 GEN7T PTCH NC ICY HOT LIDOCAINE 5 RX/OTC cocaine hcl soln ex 2 PLUS MENTHOL CREA DERMACINRX IV NOVICE PACK KIT NC DUOPATCH PHARMAPAK NC THPK L.E.T. GEL NC DERMACINRX QL(1 ml daily); NEUROTRAL NC LDO PLUS GEL NC PHARMAPAK THPK RX/OTC LENZAPATCH PTCH RX/OTC DERMACINRX PHN PAK NC NC THPK (lidocaine-menthol)

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVATIO PATCH PTCH NC RX/OTC LIDOPIN CREA 5

LEVIGOLT CREA 5 RX/OTC LIDOPURE PATCH KIT NC

LIDOCAINE AND LIDORX GEL 5 RX/OTC TETRACAINECREAM NC CREA LIDOSTREAM KIT NC lidocaine hcl crea ex 3 % 2 RX/OTC LIDOTHOL GEL NC lidocaine hcl crea ex 3.88 2 % LIDOTHOL PTCH NC lidocaine hcl gel ex 2 % 2 RX/OTC LIDOTRAL CREA NC lidocaine hcl gel ex 2 % 2 LIDOTRANS 5 PAK KIT NC lidocaine hcl lotn ex 3 % 2 LIDOTREX GEL NC lidocaine hcl prsy ex 2 % 2 LIDOVEX CREA NC lidocaine hcl soln ex 4 % 2 LIDTOPIC MAX CREA 5 LIDOCAINE HYDROCHLORIDE CREA NC LMR PLUS KIT NC EX 4.12 % LIDOCAINE LYDEXA CREA NC HYDROCHLORIDE/EPINE NC PHRINE/TETRACAINE MEDI-DERM/L CREA 5 RX/OTC HYDROCHLORIDE SOLN MEDI-DERM/L-RX CREA 5 RX/OTC lidocaine oint ex 5 % 2 RX/OTC PA; QL(3 ea MEDI-PATCH RX PTCH 5 lidocaine ptch ex 5 % 2 daily) MEDI-PATCH/LIDOCAINE 5 RX/OTC lidocaine-menthol ptch 2 RX/OTC PTCH MENTHO-CAINE KIT KIT NC lidocaine-prilocaine crea 2 MICROVIX LP THPK NC lidocaine-prilocaine kit 2 NEURCAINE THPK NC lidocaine-transparent NC dressing kit NUMBONEX LOTN NC LIDOCAINE/TETRACAINE NC CREA 23 %-7 %, 7 %-7 % NUVAKAAN II KIT NC LIDODERM PTCH 4 PA; QL(3 ea (lidocaine) daily) PAINGO KFT KIT NC LIDODOSE GEL 5 RX/OTC PLIAGLIS CREA NC LIDODOSE PEDIATRIC 5 RX/OTC BULK PACK GEL PRAMOX GEL GEL 4

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRAMOXINE HCL POWD 5 ZTLIDO PTCH NC

PREMIUM SCAR PATCH NC Misc. Dermatological Products PTCH 7TOPIC EMUL NC PREPIV SUPPLY KIT NC ALEVAMAX CREA 5 RX/OTC PRILO PATCH KIT NC ALEVICYN ANTIPRURITIC NC RX/OTC PRILOVIXIL KIT NC GEL GEL ALEVICYN ANTIPRURITIC NC RX/OTC PRIZOPAK II KIT NC SG GEL RX/OTC PRIZOTRAL II KIT NC ALEVICYN PLUS KIT NC RX/OTC PRIZOTRAL KIT NC ATOPADERM CREA NC RX/OTC QUTENZA KIT 5 ATOPICLAIR CREA 5

RENOVO PTCH 5 RX/OTC CERACADE EMUL 5

SOLUPAK THPK NC CERACADE EMUL NC RX/OTC SOOTHEE PTCH NC CERAMAX CREA NC RX/OTC SUN BURNT PLUS PAIN NC QL(1 ml daily); CERAMAX LOTN NC RELIEF GEL RX/OTC dermatological products, 5 RX/OTC SX1 MEDICATED POST- NC misc. liqd 0.2 % OPERATIVE SYSTEM KIT DEXERYL CREA 5 RX/OTC SYNERA PTCH 5 ELETONE CREA 5 RX/OTC SYNVEXIA TC CREA 5 RX/OTC ELETONE TWINPACK 5 RX/OTC TRANZAREL GEL NC QL(1 ml daily); CREA RX/OTC VEINPUNCTURE PX1 EMULSION SB EMUL 5 PHLEBOTOMY SYSTEM NC KIT ENTTY SPRAY EMUL 5 VENIPUNCTURE CPI KIT NC EPICERAM EMUL NC WPR PLUS WOUND NC HEALING SYSTEM THPK GENADUR KIT KIT 5 XRYLIDERM KIT NC GENADUR LIQD 5 RX/OTC

ZENEVIX THPK NC HALUCORT GEL NC RX/OTC

ZEYOCAINE KIT NC HPR FOAM 5

ZILACAINE PATCH THPK NC HPR PLUS CREA 5 RX/OTC

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HPR PLUS FOAM 5 PRESERA FOAM 5

HPR PLUS HYDROGEL 5 RX/OTC PRUCLAIR CREA 5 RX/OTC KIT KIT RX/OTC HYLAGUARD CREA NC RX/OTC PRUMYX CREA 5 RX/OTC HYLAMIX CREA NC RX/OTC REMIGEN CREAM CREA 5 RX/OTC HYLATOPIC PLUS CREA 5 RX/OTC SEBUDERM GEL 5 RX/OTC HYLATOPIC PLUS FOAM 5 STRATA CTX GEL NC RX/OTC HYLATOPIC PLUS LOTN 5 RX/OTC STRATA XRT GEL NC

HYLATOPIC PLUS LOTN NC RX/OTC SUVICORT EMUL NC

ILIDERM EMUL NC SYNERDERM EMUL NC RX/OTC KAMDOY EMUL NC TETRIX CREA 5 RX/OTC KIVIK EMUL NC XERALUX CREA 5

LEVICYN GEL NC RX/OTC Misc. Topical ACUICYN RX/OTC LOYON SOLN 5 ANTIMICROBIAL EYELID NC & EYELASH HYGIENE MB HYDROGEL KIT 5 RX/OTC SOLN ACUICYN DAILY EYELID RX/OTC MIMYX CREA 5 RX/OTC & EYELASH CLEANSER NC SOLN NEOCERA CREA 5 RX/OTC ALCOHOL WIPES MISC 5 RX/OTC NEOSALUS CP CREA 5 RX/OTC ALUMINUM CHLORIDE 5 RX/OTC ANHYDROUS POWD NEOSALUS CREA 5 RX/OTC ALUMINUM CHLORIDE 5 RX/OTC CRYS NEOSALUS FOAM 5 ALUMINUM CHLORIDE 5 RX/OTC HEXAHYDRATE CRYS NEOSALUS LOTN 5 RX/OTC ALUMINUM CHLORIDE 5 RX/OTC NIVATOPIC PLUS CREA 5 RX/OTC HEXAHYDRATE POWD ARNICA FLOWER TINC 5 NUVAIL SOLN 5 AVENOVA SOLN NC RX/OTC PENLEN EMUL NC benzoin compound tinc 2 RX/OTC PHLAG SPRAY EMUL 5 BENZOIN TINCTURE 5 RX/OTC PR CREAM KIT 5 RX/OTC PLAIN TINC

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENZOIN TINCTURE 5 RX/OTC TANNIC ACID POWD 5 RX/OTC TINC BORIC ACID GRAN EX 5 RX/OTC XERAC AC SOLN 5

CALAMINE POWD 5 RX/OTC Phosphodiesterase 4 (PDE4) Inhibitors - Topical PA; QL(2 gm EUCRISA OINT 4 CVS ISOPROPYL 5 RX/OTC daily) ALCOHOL WIPES MISC Pigmenting-Depigmenting Agents DERMACINRX NC CLORHEXACIN KIT HYDROQUINONE POWD 5 DERMACINRX SURGICAL NC COMBOPAK KIT LACTIC NC ACID/NIACINAMIDE CREA DERMACINRX SURGICAL NC PHARMAPAK KIT METHOXSALEN POWD 5 DRYSOL SOLN 5 Protectives Against UV Radiation EPICYN SOLN NC SCENESSE IMPL 5 ESSENTRA WIPES 9X9" RX/OTC Rosacea Agents CLEANROOM 5 SUPPLIES/PRESATURAT AVEIDAOXIA GEL NC ED MISC azelaic acid gel ex 2 GNP ISOPROPYL 5 RX/OTC ALCOHOL WIPES MISC doxycycline (rosacea) cpdr 2 HYCLODEX SOLN NC FINACEA FOAM 4 HYPOCYN SOLN 5 RX/OTC FINACEA GEL (azelaic NC acid) ICHTHAMMOL POWD 5 QL(1.5 gm ivermectin (rosacea) crea 2 ISOPROPYL ALCOHOL 5 RX/OTC daily) WIPES MISC IVERMECTIN CREA EX 1 4 QL(1.5 gm MEDPURA ALCOHOL 5 RX/OTC % daily) PADS MISC IVERMECTIN/METRONID NUSRUGEPAK AZOLE/NIACINAMIDE NC SURGICAL NC GEL PREP/CAREPAK KIT METROCREAM CREA 5 QL(45 gm per NUSURGEPAK (metronidazole (topical)) fill retail) SURGICAL NC METROGEL GEL 5 PREP/CAREPAK KIT (metronidazole (topical)) PRE & POST SX POUCH NC METROLOTION LOTN 5 THPK (metronidazole (topical)) QBREXZA PADS NC metronidazole (topical) 2 QL(45 gm per crea 0.75 % fill retail) RA ISOPROPYL 5 RX/OTC ALCOHOL WIPES MISC metronidazole (topical) gel 2 QL(45 gm per 0.75 % fill retail) SM BENZOIN TINCTURE 5 RX/OTC TINC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metronidazole (topical) gel 2 COPASIL GEL EX 5 RX/OTC 1 % RX/OTC metronidazole (topical) lotn 2 KELARX GEL NC 0.75 % PALMERS COCOA RX/OTC MIRVASO GEL 5 BUTTER FORMULA SCAR NC SERUM LIQD NORITATE CREA NC RECEDO GEL NC RX/OTC ORACEA CPDR 5 (doxycycline (rosacea)) scar treatment products gel 2 RX/OTC RHOFADE CREA 5 SCARCIN GEL GEL 5 RX/OTC ROSADAN KIT KIT 5 SCARCIN ROLL-ON LIQD NC RX/OTC QL(1.5 gm SOOLANTRA CREA 4 daily) SCARSILK GEL GEL NC RX/OTC

ZILXI FOAM NC SILIPAC KIT NC Scabicides & Pediculicides Tar Products crotamiton lotn ex 2 coal tar extract soln 2 ELIMITE CREA 4 (permethrin) Wound Care Products ACTICOAT FLEX 3 RX/OTC EURAX CREA 5 BARRIER DRESSING 5 4"'X4" PADS EURAX LOTN (crotamiton) 5 ACTIMARIS ALL- RX/OTC NATURAL WOUND NC lindane sham 2 RINSE/ENERGIZED QL(59 ml per SINGLET OXYGEN SOLN malathion lotn 2 fill retail) ACTIMARIS WOUND GEL NC RX/OTC GEL NATROBA SUSP 5 (spinosad) ALEVICYN DERMAL NC RX/OTC SPRAY SOLN OVIDE LOTN (malathion) 4 QL(59 ml per fill retail) ALLEVYN GENTLE PADS 5 RX/OTC permethrin crea 2 AMERIGEL WOUND NC RX/OTC DRESSING GEL SKLICE LOTN 5 AMERIGEL WOUND NC RX/OTC WASH SOLN spinosad susp 2 AQUACEL AG BURN NC RX/OTC SULFURATED LIME SOLN 5 PADS ATRAPRO ANTIPRURITIC NC RX/OTC ULESFIA LOTN 5 HYDROGEL GEL RX/OTC Scar Treatment Products ATRAPRO CP KIT NC BEAU RX GEL NC RX/OTC

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BALSAM PERU & NC DIAB DAILY CARE GEL NC RX/OTC CASTOR OIL OINT DIAB F.D.G. FREEZE- NC RX/OTC BPCO OINT NC DRIED GEL CARRAKLENZ SOLN NC RX/OTC DIAB GEL NC RX/OTC

CARRASMART GEL EX NC RX/OTC EXCEL-GEL GEL NC RX/OTC

CARRASYN HYDROGEL NC RX/OTC EXU-DRY NON- RX/OTC WOUND DRESSING GEL PERMEABLE SHEET 5 CARRASYN V RX/OTC 36"X72" SHEE NC HYDROGEL EXU-DRY PERMEABLE 5 RX/OTC WOUNDDRESSING GEL QUILTED 36"X72" SHEE CELACYN POST- 5 RX/OTC GRX WOUND GEL NC RX/OTC PROCEDURE PACK KIT RX/OTC HYDROFERA BLUE RX/OTC CICA-CARE SHEE 5 FOAM DRESSING 2"X2" 5 PADS COOLMAGIC SHEE 5 RX/OTC HYDROFERA BLUE RX/OTC FOAM DRESSING 4"X4" 5 COOLMAGIC TUBE SITE 5 RX/OTC DRESSING SHEE PADS HYDROFERA BLUE RX/OTC CURAFIL GEL WOUND NC RX/OTC DRESSING GEL FOAM DRESSING 6"X6" 5 CURITY HYPERTONIC RX/OTC PADS HYDROFERA BLUE RX/OTC SODIUMCHLORIDE 5 PACKING STRIP 1/2"X15' FOAM MISC DRESSING/MOISTURE 5 CURITY SODIUM RX/OTC RETENTIVE FILM/2-1/4X8 CHLORIDE DRESSING 5 PADS 6"X6-3/4" PADS HYDROFERA BLUE RX/OTC FOAM CVS MANUKA HONEY NC RX/OTC WOUND GEL GEL DRESSING/MOISTURE 5 RETENTIVE FILM/4"X4" DELUO ANTIMICROBIAL RX/OTC PADS WOUND& SKIN NC CLEANSER SOLN HYDROFERA BLUE RX/OTC FOAM DERMAGRAN RX/OTC DRESSING/MOISTURE 5 HYDROGEL NC RETENTIVE FILM/ISLAND WOUNDDRESSING GEL PADS DERMAGRAN-B RX/OTC HYDROFERA BLUE RX/OTC HYDROPHILIC WOUND NC FOAM DRESSING GEL DRESSING/MOISTURE 5 DERMASYN GEL NC RX/OTC RETENTIVE/OSTOMY/2.5" PADS DERMULCERA OINT NC HYDROFERA BLUE RX/OTC FOAM 5 DIAB CREA 5 RX/OTC DRESSING/TUNNELING/9 MM PADS

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROFERA BLUE RX/OTC KENDALL ZINC CALCIUM RX/OTC HEAVY DRAINAGE 4"X4" 5 ALGINATE DRESSING 5 PADS ROPE 12" MISC HYDROFERA BLUE RX/OTC KERAGEL GEL NC RX/OTC HEAVY DRAINAGE 6"X6" 5 PADS KERAGELT GEL NC RX/OTC HYDROFERA BLUE RX/OTC READY FOAMDRESSING 5 KERAMATRIX REPLICINE 5 RX/OTC 2.5"X2.5" PADS 10CMX10CM SHEE HYDROFERA BLUE RX/OTC KERAMATRIX REPLICINE 5 RX/OTC READY FOAMDRESSING 5 5CMX5CM SHEE 4"X5" PADS LAVARE WOUND WASH 5 HYDROFERA BLUE RX/OTC GEL READY FOAMDRESSING 5 LEVICYN DERMAL NC RX/OTC 8"X8" PADS SPRAY SOLN RX/OTC HYDROGEL GEL EX NC LIDOTREX GEL NC INTRASITE GEL NC RX/OTC RX/OTC APPLIPAK GEL LUXAMEND CREA 5 KENDALL AMORPHOUS RX/OTC MEDIHONEY RX/OTC HYDROGEL WOUND NC WOUND/BURNDRESSING NC DRESSING GEL GEL KENDALL HYDROGEL RX/OTC MICROCYN GEL 0.002 %- IMPREGNATED GAUZE 5 0.008 %-0.066 %-0.4 %-3 5 2"X2" PADS % KENDALL HYDROGEL RX/OTC MICROCYN LIQD 0.023 % 5 RX/OTC IMPREGNATED GAUZE 5 4"X4" PADS MICROCYN SKIN AND 5 KENDALL HYDROGEL RX/OTC WOUND HYDROGEL GEL IMPREGNATED GAUZE 5 NU-GEL COLLAGEN NC RX/OTC 4"X8" PADS WOUND DRESSING GEL KENDALL HYDROGEL RX/OTC PICO SINGLE USE RX/OTC WOUND DRESSING 3" 5 NEGATIVEPRESSURE 5 DISK MISC WOUND THERAPY KENDALL HYDROGEL RX/OTC SYSTEM KIT WOUND DRESSING 4- 5 RADIACARE POST 5 RX/OTC 3/4" DISK MISC HEALING CREA KENDALL ZINC CALCIUM RX/OTC RADIADRES GEL SHEET 5 RX/OTC ALGINATE DRESSING 5 SHEE 2"X2" PADS RADIAGEL GEL NC RX/OTC KENDALL ZINC CALCIUM RX/OTC ALGINATE DRESSING 5 RX/OTC 4"X4" PADS RADIAPLEXRX GEL NC KENDALL ZINC CALCIUM RX/OTC REGENECARE GEL NC ALGINATE DRESSING 5 4"X8" PADS REGRANEX GEL 5 QL(15 gm per fill retail)

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTORE HYDROGEL NC RX/OTC VEXASYN GEL NC RX/OTC DRESSING GEL WOUND DEBRIDEMENT RX/OTC REVITADERM WOUND NC RX/OTC 5 CARE GEL KIT REXASIL PATCH/VITAMIN WOUND GEL GEL NC RX/OTC E KIT KIT (silicone-vitamin NC e) WOUND GEL SPRAY GEL NC RX/OTC RTD WOUND CARE 5 RX/OTC DRESSING2" X 2" PADS XEROFORM NON- OCCLUSIVE OIL 5 RTD WOUND CARE 5 RX/OTC EMULSION GAUZE STRIP DRESSING4" X 4" PADS 5"X9" PADS RTD WOUND CARE 5 RX/OTC XEROFORM NON- DRESSING4" X 5" PADS OCCLUSIVE OIL 5 SIL-K PAD/LARGE MISC NC RX/OTC EMULSION PATCH 2"X2" PADS SIL-K PAD/MEDIUM MISC NC RX/OTC XEROFORM NON- OCCLUSIVE OIL SIL-K PAD/SMALL MISC NC RX/OTC EMULSION 5 STRIP/OVERWRAP 1"X8" silicone-vitamin e kit 2 MISC XEROFORM NON- 5 SKINTEGRITY NC RX/OTC OCCLUSIVE ROLL MISC HYDROGEL GEL XEROFORM OCCLUSIVE SOLOSITE GEL NC RX/OTC PETROLATUM GAUZE 5 ROLL 4"X9' MISC RX/OTC STIMULEN GEL NC XEROFORM OCCLUSIVE PETROLATUM GAUZE 5 STRATA GRT GEL NC RX/OTC STRIP 1"X8" MISC XEROFORM OCCLUSIVE TEGADERM HYDROGEL NC RX/OTC WOUND FILLER GEL PETROLATUM GAUZE 5 STRIP 5"X9" MISC RX/OTC THERAHONEY GEL NC XEROFORM OCCLUSIVE RX/OTC PETROLATUM GAUZE 5 THERAHONEY SHEE 5 STRIP/OVERWRAP 1"X8" MISC RX/OTC VACUSTIM BLACK KIT 5 XEROFORM OCCLUSIVE RX/OTC PETROLATUM GAUZE 5 VACUSTIM SILVER KIT 5 STRIP/OVERWRAP 5"X9" MISC VASCUDERM HYDROGEL NC RX/OTC WOUNDDRESSING GEL XEROFORM OCCLUSIVE VASHE RX/OTC PETROLTUM GAUZE 5 SKIN/WOUND/BURN NC PATCH 2"X2" PADS CLEANSING SOLN XEROFORM OCCLUSIVE PETROLTUM GAUZE 5 VASHE WOUND NC RX/OTC THERAPY SOLN PATCH 4"X4" PADS ZANABIN ANTIPRURITIC NC RX/OTC VENELEX OINT NC HYDROGEL GEL

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASSURE PLATINUM TEST NC QL(5 ea daily); DIAGNOSTIC PRODUCTS STRIPS STRP RX/OTC Diagnostic Tests ASSURE PLATINUM TEST NC RX/OTC STRIPS STRP ACCU-CHEK AVIVA PLUS 3 QL(5 ea daily); STRP VI RX/OTC ASSURE PRISM MULTI 5 QL(5 ea daily); TEST STRIPS STRP RX/OTC ACCU-CHEK COMPACT 3 QL(5 ea daily); PLUS STRP RX/OTC ASSURE PRISM MULTI NC QL(5 ea daily); TEST STRIPS STRP RX/OTC ACCU-CHEK GUIDE 3 QL(5 ea daily); STRP VI RX/OTC ASSURE PRO TEST NC QL(5 ea daily); STRIPS STRP RX/OTC ACCU-CHEK GUIDE 5 QL(5 ea daily); STRP VI RX/OTC BIOSCANNER GLUCOSE NC QL(5 ea daily); TEST STRIPS STRP RX/OTC ACCU-CHEK SMARTVIEW 3 QL(5 ea daily); STRIPS STRP RX/OTC BLOOD GLUCOSE TEST NC QL(5 ea daily); STRIPS PREMIUM STRP RX/OTC ACCUTREND GLUCOSE NC QL(5 ea daily); STRP RX/OTC BLOOD GLUCOSE TEST NC QL(5 ea daily); STRIPS STRP RX/OTC ADVANCE INTUITION NC QL(5 ea daily); TEST STRIPS STRP RX/OTC BLOOD GLUCOSE TEST NC RX/OTC STRIPS STRP ADVANCE MICRO-DRAW NC QL(5 ea daily); TEST STRIPS STRP RX/OTC CAREONE BLOOD QL(5 ea daily); GLUCOSE TEST NC RX/OTC ADVOCATE REDI-CODE NC QL(5 ea daily); STRP RX/OTC STRIPS/PREMIUM STRP CAREONE BLOOD QL(5 ea daily); ADVOCATE REDI-CODE+ NC QL(5 ea daily); TESTSTRIPS STRP RX/OTC GLUCOSE TEST NC RX/OTC STRIPS/VALUE STRP ADVOCATE TEST STRIPS NC QL(5 ea daily); STRP RX/OTC CARESENS N BLOOD QL(5 ea daily); GLUCOSETEST STRIPS NC RX/OTC AGAMATRIX AMP NO QL(5 ea daily); STRP CODE TEST STRIPS NC RX/OTC STRP CARETOUCH BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC AGAMATRIX JAZZ TEST NC QL(5 ea daily); STRP STRIPS STRP RX/OTC CARETOUCH BLOOD RX/OTC AGAMATRIX KEYNOTE NC QL(5 ea daily); GLUCOSE TEST STRIPS NC TEST STRIPS STRP RX/OTC STRP AGAMATRIX PRESTO QL(5 ea daily); NC CHEMSTRIP-K STRP 5 QL(100 ea per TEST STRIPS STRP RX/OTC fill retail) AGAMATRIX PRESTO NC RX/OTC CLEVER CHEK AUTO- QL(5 ea daily); TEST STRIPS STRP CODE TEST STRIPS NC RX/OTC ASSURE 3 TEST STRIPS NC QL(5 ea daily); STRP STRP RX/OTC CLEVER CHEK AUTO- QL(5 ea daily); ASSURE 4 TEST STRIPS NC QL(5 ea daily); CODE VOICE TEST NC RX/OTC STRP RX/OTC STRIPS STRP ASSURE II CHECK STRIP QL(5 ea daily); NC CLEVER CHEK TEST NC QL(5 ea daily); STRP RX/OTC STRIPS STRP RX/OTC QL(5 ea daily); ASSURE II STRP NC CLEVER CHOICE AUTO- QL(5 ea daily); RX/OTC CODE PRO TEST STRIPS NC RX/OTC STRP ASSURE II TEST STRIPS NC QL(5 ea daily); STRP RX/OTC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE MICRO NC QL(5 ea daily); EASY TRAK II BLOOD RX/OTC TESTSTRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC CLEVER CHOICE NO QL(5 ea daily); STRP CODING TEST STRIPS NC RX/OTC EASYGLUCO PLUS STRP NC QL(5 ea daily); STRP RX/OTC CLEVER CHOICE TALK QL(5 ea daily); EASYGLUCO STRP VI NC QL(5 ea daily); NO CODING TEST NC RX/OTC RX/OTC STRIPS STRP EASYMAX 15 TEST NC QL(5 ea daily); CONTOUR BLOOD QL(5 ea daily); STRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC EASYMAX TEST STRIPS NC QL(5 ea daily); STRP STRP RX/OTC CONTOUR NEXT BLOOD NC QL(5 ea daily); EASYPRO BLOOD QL(5 ea daily); GLUCOSE TEST STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC CONTOUR NEXT BLOOD NC RX/OTC STRP GLUCOSE TEST STRP QL(5 ea daily); EASYPRO PLUS STRP VI NC COOL BLOOD GLUCOSE NC QL(5 ea daily); RX/OTC TEST STRIPS STRP RX/OTC ELEMENT COMPACT NC QL(5 ea daily); CVS ADVANCED QL(5 ea daily); TEST STRIPS STRP RX/OTC GLUCOSE METER TEST NC RX/OTC ELEMENT TEST STRIPS NC QL(5 ea daily); STRIPS STRP STRP RX/OTC CVS GLUCOSE METER NC RX/OTC EMBRACE BLOOD QL(5 ea daily); TEST STRIPS STRP GLUCOSE TEST STRIPS NC RX/OTC D-CARE BLOOD NC QL(5 ea daily); STRP GLUCOSE STRP RX/OTC EMBRACE EVO BLOOD QL(5 ea daily); DIASTIX STRP 5 GLUCOSETEST STRIPS NC RX/OTC STRP DIATHRIVE BLOOD RX/OTC EMBRACE PRO BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC GLUCOSETEST STRIPS NC RX/OTC STRP STRP DIATRUE PLUS BLOOD QL(5 ea daily); EMBRACE TALK BLOOD RX/OTC GLUCOSE TEST STRIPS NC RX/OTC GLUCOSE TEST STRIPS NC STRP STRP DUO-CARE TEST STRIPS QL(5 ea daily); NC EQ BLOOD GLUCOSE NC QL(5 ea daily); STRP RX/OTC TEST STRIPS STRP RX/OTC EASY PLUS II BLOOD QL(5 ea daily); NC EQ BLOOD GLUCOSE NC RX/OTC GLUCOSE TEST STRP RX/OTC TEST STRIPS STRP EASY STEP TEST STRIPS NC QL(5 ea daily); EVENCARE + BLOOD QL(5 ea daily); STRP RX/OTC GLUCOSETEST STRIP NC RX/OTC EASY TALK BLOOD QL(5 ea daily); STRP GLUCOSE TEST STRIPS NC RX/OTC EVENCARE BLOOD QL(5 ea daily); STRP GLUCOSE TEST STRIP NC RX/OTC STRP EASY TOUCH GLUCOSE NC QL(5 ea daily); TEST STRIPS STRP RX/OTC EVENCARE G2 TEST NC QL(5 ea daily); EASY TRAK BLOOD QL(5 ea daily); STRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC EVENCARE G3 TEST NC QL(5 ea daily); STRP STRIPS STRP RX/OTC

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVENCARE MINI BLOOD QL(5 ea daily); FORA TN'G/TN'G VOICE QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC BLOOD GLUCOSE TEST NC RX/OTC STRP STRIPS STRP EVENCARE PROVIEW RX/OTC FORA V10 BLOOD QL(5 ea daily); BLOOD GLUCOSE TEST NC GLUCOSE TEST STRIPS NC RX/OTC STRIPS STRP STRP EVOLUTION AUTOCODE NC QL(5 ea daily); FORA V12 BLOOD QL(5 ea daily); STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP EXACTECH R-S-G TEST NC QL(5 ea daily); STRIPS STRP RX/OTC FORA V20 BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC EXACTECH TEST STRIPS NC QL(5 ea daily); STRP RX/OTC STRP EZ SMART BLOOD QL(5 ea daily); FORA V30A BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP STRP QL(5 ea daily); EZ SMART PLUS BLOOD QL(5 ea daily); FORACARE GD40 STRP NC GLUCOSE TEST STRIPS NC RX/OTC RX/OTC STRP FORACARE PREMIUM NC QL(5 ea daily); V10 TESTSTRIPS STRP RX/OTC FIFTY50 GLUCOSE TEST NC QL(5 ea daily); STRIP 2.0 STRP RX/OTC FORACARE TEST N GO NC QL(5 ea daily); TEST STRIPS STRP RX/OTC FORA BLOOD GLUCOSE NC QL(5 ea daily); TEST STRIPS STRP RX/OTC FORTISCARE BLOOD QL(5 ea daily); FORA D15G BLOOD QL(5 ea daily); GLUCOSETEST STRIP NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP STRP FREESTYLE INSULINX QL(5 ea daily); FORA D20 BLOOD QL(5 ea daily); BLOODGLUCOSE TEST NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRIPS STRP STRP FREESTYLE INSULINX QL(5 ea daily); FORA D40/G31 BLOOD QL(5 ea daily); BLOODGLUCOSE TEST NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP STRP FREESTYLE LITE TEST NC QL(5 ea daily); FORA G20 BLOOD QL(5 ea daily); STRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC FREESTYLE PRECISION QL(5 ea daily); STRP NEO BLOOD GLUCOSE NC RX/OTC FORA G30/PREMIUM V10 QL(5 ea daily); TEST STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC FREESTYLE TEST NC QL(5 ea daily); STRIPS STRP STRIPS STRP RX/OTC FORA GD20 TEST QL(5 ea daily); NC GE100 BLOOD GLUCOSE NC QL(5 ea daily); STRIPS STRP RX/OTC TESTSTRIPS STRP RX/OTC FORA GD50 BLOOD QL(5 ea daily); GENULTIMATE TEST 5 QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC STRIPS STRP RX/OTC STRP GHT TEST STRIPS STRP NC QL(5 ea daily); FORA GTEL BLOOD RX/OTC RX/OTC GLUCOSE TEST STRIPS NC GLUCO PERFECT 3 TEST NC QL(5 ea daily); STRP STRIPS STRP RX/OTC GLUCOCARD 01 SENSOR NC QL(5 ea daily); PLUS STRP RX/OTC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOCARD 01 QL(5 ea daily); IN TOUCH BLOOD QL(5 ea daily); SENSOR PLUSTEST NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRIPS STRP STRP GLUCOCARD QL(5 ea daily); INFINITY BLOOD QL(5 ea daily); EXPRESSION BLOOD NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC GLUCOSE TEST STRIPS STRP STRP INFINITY BLOOD RX/OTC GLUCOCARD SHINE 5 QL(5 ea daily); GLUCOSE TEST STRIPS NC TEST STRIPS STRP RX/OTC STRP GLUCOCARD VITAL TEST QL(5 ea daily); NC INFINITY VOICE STRP VI NC QL(5 ea daily); STRIPS STRP RX/OTC RX/OTC GLUCOCARD X-SENSOR QL(5 ea daily); QL(100 ea per NC KETONE STRP 5 STRP RX/OTC fill retail) GLUCOCOM TEST NC QL(5 ea daily); KETONE TEST STRIPS 5 QL(100 ea per STRIPS STRP RX/OTC STRP fill retail) GLUCONAVII BLOOD QL(5 ea daily); KETOSTIX STRP 5 QL(100 ea per GLUCOSETEST STRIPS NC RX/OTC fill retail) STRP KROGER BLOOD QL(5 ea daily); GLUCOSE METER TEST QL(5 ea daily); GLUCOSE TESTSTRIPS NC RX/OTC STRIPS ADVANCED NC RX/OTC STRP STRP KROGER HEALTHPRO QL(5 ea daily); GNP EASY TOUCH QL(5 ea daily); GLUCOSETEST STRIPS NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP STRP KROGER HEALTHPRO RX/OTC GOJJI BLOOD GLUCOSE NC RX/OTC GLUCOSETEST STRIPS NC TESTSTRIPS STRP STRP GOJJI BLOOD GLUCOSE RX/OTC KROGER PREMIUM QL(5 ea daily); TESTSTRIPS/GOJJI NC BLOOD GLUCOSE TEST NC RX/OTC STERILE LANCETS 30G STRIPS STRP STRP KROGER TEST STRIPS NC QL(5 ea daily); GOODSENSE PREMIUM QL(5 ea daily); STRP RX/OTC BLOOD GLUCOSE TEST NC RX/OTC LIBERTY NEXT QL(5 ea daily); STRIPS STRP GENERATION BLOOD NC RX/OTC HARMONY BLOOD RX/OTC GLUCOSE TEST STRIPS GLUCOSE TEST STRIPS NC STRP STRP LIBERTY TEST STRIPS NC QL(5 ea daily); HW EMBRACE PRO RX/OTC STRP RX/OTC BLOOD GLUCOSE TEST NC MEIJER BLOOD QL(5 ea daily); STRIPS STRP GLUCOSE TESTSTRIPS NC RX/OTC HW EMBRACE TALK QL(5 ea daily); STRP BLOOD GLUCOSE TEST NC RX/OTC MEIJER ESSENTIAL QL(5 ea daily); STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC IGLUCOSE BLOOD QL(5 ea daily); STRIPS STRP GLUCOSE TEST STRIPS NC RX/OTC MEIJER PREMIUM QL(5 ea daily); STRP BLOOD GLUCOSE TEST NC RX/OTC STRIPS STRP

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEIJER TRUETEST QL(5 ea daily); PHARMACIST CHOICE QL(5 ea daily); NC BLOOD GLUCOSE TEST RX/OTC NO CODING BLOOD NC RX/OTC STRIPS STRP GLUCOSE TEST STRIPS MEIJER TRUETRACK QL(5 ea daily); STRP BLOOD GLUCOSE TEST NC RX/OTC POCKETCHEM EZ QL(5 ea daily); STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC STRIPS STRP MICRODOT TEST STRIPS NC QL(5 ea daily); STRP RX/OTC PRECISION PCX PLUS NC QL(5 ea daily); TEST STRIPS STRP RX/OTC MICRODOT XTRA TEST NC RX/OTC STRIPS STRP QL(5 ea daily); PRECISION PCX STRP NC MM EASY TOUCH QL(5 ea daily); RX/OTC GLUCOSE TEST STRIPS NC RX/OTC PRECISION POINT OF QL(5 ea daily); STRP CARE TEST STRIPS NC RX/OTC MYGLUCOHEALTH QL(5 ea daily); STRP NC BLOOD GLUCOSE TEST RX/OTC PRECISION QID TEST NC QL(5 ea daily); STRP STRIPS STRP RX/OTC NEUTEK 2TEK TEST NC QL(5 ea daily); PRECISION SOF-TACT NC QL(5 ea daily); STRIPS STRP RX/OTC TEST STRIPS STRP RX/OTC NOVA MAX GLUCOSE NC QL(5 ea daily); PRECISION XTRA BLOOD QL(5 ea daily); TEST STRIPS STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC ON CALL EXPRESS QL(5 ea daily); STRP BLOOD GLUCOSE TEST NC RX/OTC PREMIUM BLOOD QL(5 ea daily); STRIPS STRP GLUCOSE TEST STRIPS NC RX/OTC STRP ON CALL PLUS BLOOD NC QL(5 ea daily); GLUCOSE TEST STRP RX/OTC PRO VOICE V8/V9 QL(5 ea daily); ON CALL VIVID BLOOD QL(5 ea daily); BLOOD GLUCOSE TEST NC RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRIPS STRP STRP PRODIGY NO CODING QL(5 ea daily); BLOOD GLUCOSE TEST NC RX/OTC ON CALL VIVID BLOOD NC QL(5 ea daily); GLUCOSE TEST STRP RX/OTC STRIPS STRP ONE DROP BLOOD QL(5 ea daily); PTS PANELS GLUCOSE NC QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC TEST STRP RX/OTC STRP QUICKTEK TEST STRIPS NC QL(5 ea daily); QL(5 ea daily); STRP RX/OTC ONETOUCH ULTRA STRP NC RX/OTC QUINTET AC BLOOD QL(5 ea daily); GLUCOSETEST STRIPS NC RX/OTC ONETOUCH VERIO TEST NC QL(5 ea daily); STRIPS STRP RX/OTC STRP QUINTET BLOOD QL(5 ea daily); OPTIUM TEST STRIPS NC QL(5 ea daily); STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC STRP OPTIUMEZ TEST STRIPS NC QL(5 ea daily); STRP RX/OTC RA TRUETEST STRIPS NC QL(5 ea daily); STRP RX/OTC OPTUMRX BLOOD NC QL(5 ea daily); GLUCOSE TEST STRP RX/OTC REFUAH PLUS BLOOD QL(5 ea daily); GLUCOSETEST STRIPS NC RX/OTC PHARMACIST CHOICE QL(5 ea daily); STRP AUTOCODE BLOOD NC RX/OTC GLUCOSE TEST STRIPS STRP 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION BLOOD QL(5 ea daily); SOLUS V2 AUDIBLE TEST NC QL(5 ea daily); GLUCOSE TESTSTRIPS NC RX/OTC STRP RX/OTC STRP SUPREME TEST STRIPS NC QL(5 ea daily); RELION CONFIRM/MICRO NC QL(5 ea daily); STRP RX/OTC TEST STRIPS STRP RX/OTC SURE EDGE BLOOD QL(5 ea daily); QL(100 ea per GLUCOSE TEST STRIPS NC RX/OTC RELION KETONE STRP 5 fill retail) STRP RELION KETONE TEST 5 QL(100 ea per SURE-TEST EASYPLUS QL(5 ea daily); STRIPS STRP fill retail) MINI BLOOD GLUCOSE NC RX/OTC RELION PREMIER QL(5 ea daily); TEST STRIPS STRP BLOOD GLUCOSE TEST NC RX/OTC SURECHEK BLOOD QL(5 ea daily); STRIPS STRP GLUCOSE TEST STRIPS NC RX/OTC RELION PREMIER RX/OTC STRP BLOOD GLUCOSE TEST NC TELCARE BLOOD QL(5 ea daily); STRIPS STRP GLUCOSE TEST STRIPS NC RX/OTC RELION PRIME BLOOD QL(5 ea daily); STRP GLUCOSE TEST STRIPS NC RX/OTC TGT BLOOD GLUCOSE QL(5 ea daily); STRP TEST STRIPS PREMIUM NC RX/OTC RELION ULTIMA BLOOD QL(5 ea daily); STRP NC GLUCOSE TEST STRIPS RX/OTC TGT BLOOD GLUCOSE NC QL(5 ea daily); STRP TEST STRIPS STRP RX/OTC RELION ULTIMA TEST NC QL(5 ea daily); TRUE FOCUS SELF QL(5 ea daily); STRIPS STRP RX/OTC MONITORING BLOOD NC RX/OTC GLUCOSE TEST STRIPS REVEAL BLOOD NC QL(5 ea daily); GLUCOSE TEST STRP RX/OTC STRP REXALL BLOOD QL(5 ea daily); TRUE METRIX BLOOD QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC GLUCOSETEST STRIPS NC RX/OTC STRP STRP RIGHTEST GS100 BLOOD QL(5 ea daily); TRUE METRIX SELF QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC MONITORING BLOOD NC RX/OTC STRP GLUCOSE STRIPS STRP QL(5 ea daily); RIGHTEST GS300 BLOOD QL(5 ea daily); TRUETEST STRIPS STRP NC GLUCOSE TEST STRIPS NC RX/OTC RX/OTC STRP TRUETRACK BLOOD NC QL(5 ea daily); RIGHTEST GS550 BLOOD QL(5 ea daily); GLUCOSE TEST STRP RX/OTC GLUCOSE TEST STRIPS NC RX/OTC TRUETRACK TEST STRP NC QL(5 ea daily); STRP RX/OTC SMART SENSE PREMIUM QL(5 ea daily); ULTIMA TEST STRIPS NC QL(5 ea daily); BLOODGLUCOSE STRIPS NC RX/OTC STRP RX/OTC STRP ULTRATRAK PRO TEST NC QL(5 ea daily); SMART SENSE VALUE QL(5 ea daily); STRIPS STRP RX/OTC BLOOD GLUCOSE NC RX/OTC ULTRATRAK ULTIMATE NC QL(5 ea daily); STRIPS STRP TEST STRIPS STRP RX/OTC SMARTEST BLOOD QL(5 ea daily); UNISTRIP1 GENERIC NC QL(5 ea daily); GLUCOSE TEST STRIPS NC RX/OTC STRP RX/OTC STRP

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VERASENS BLOOD QL(5 ea daily); methazolamide tabs or 25 2 GLUCOSE TEST STRIPS NC RX/OTC mg, 50 mg STRP Diuretic Combinations VIVAGUARD INO BLOOD RX/OTC NC ALDACTAZIDE TABS 25 GLUCOSE TEST STRIPS MG-25 MG (spironolactone 5 STRP & hydrochlorothiazide) VOCAL POINT BLOOD QL(5 ea daily); ALDACTAZIDE TABS 50 GLUCOSE TEST STRIPS NC RX/OTC 5 MG-50 MG STRP amiloride & WAVESENSE PRESTO QL(5 ea daily); 2 NC hydrochlorothiazide tabs TEST STRIPS STRP RX/OTC DYAZIDE CAPS QL(1 ea daily) DIGESTIVE AIDS - Drugs to Treat Low Digestive (triamterene & 5 Enzymes hydrochlorothiazide) Digestive Enzymes MAXZIDE TABS QL(1 ea daily) (triamterene & 5 CREON CPEP 4 hydrochlorothiazide) ENZADYNE CAPS NC RX/OTC MAXZIDE-25 TABS QL(1 ea daily) (triamterene & 5 hydrochlorothiazide) PANCREAZE CPEP 5 spironolactone & 2 PEPSIN POWD 5 hydrochlorothiazide tabs triamterene & 2 QL(1 ea daily) PERTZYE CPEP 5 hydrochlorothiazide caps triamterene & 2 QL(1 ea daily) SUCRAID SOLN 5 PA; SP hydrochlorothiazide tabs Loop Diuretics VIOKACE TABS 4 bumetanide soln 2 ZENPEP CPEP 4 bumetanide tabs 2 Gastric Acidifiers BUMEX TABS L-GLUTAMIC ACID HCL 5 5 POWD (bumetanide) DEMADEX TABS 10 MG 5 QL(1 ea daily) DIURETICS - Drugs to Treat Heart, Circulation (torsemide) Conditions and Blood Pressure DEMADEX TABS 20 MG 5 QL(4 ea daily) Carbonic Anhydrase Inhibitors (torsemide) acetazolamide cp12 or 500 2 EDECRIN TABS 5 mg (ethacrynic acid) acetazolamide sodium solr 2 ethacrynate sodium solr 2 acetazolamide tabs or 125 2 mg, 250 mg ethacrynic acid tabs 2 KEVEYIS TABS 5 FUROSEMIDE POWD XX 5

METHAZOLAMIDE POWD 5 furosemide soln ij 10 mg/ml 2 XX

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits furosemide soln or 10 2 DIURIL SUSP 5 mg/ml, 8 mg/ml hydrochlorothiazide caps or furosemide tabs or 20 mg, 2 2 40 mg, 80 mg 12.5 mg HYDROCHLOROTHIAZID FUROSEMIDE/SODIUM NC 5 CHLORIDE SOLN E POWD XX hydrochlorothiazide tabs or 2 LASIX TABS (furosemide) 5 12.5 mg, 25 mg, 50 mg SODIUM EDECRIN SOLR 5 indapamide tabs 2 (ethacrynate sodium) torsemide tabs 10 mg, 100 2 QL(1 ea daily) methyclothiazide tabs 2 mg, 5 mg torsemide tabs 20 mg 2 QL(4 ea daily) metolazone tabs 2 MICROZIDE CAPS 5 Osmotic Diuretics (hydrochlorothiazide) mannitol soln iv 10 %, 15 2 SODIUM DIURIL SOLR 5 %, 5 %, 25 %, 20 % (chlorothiazide sodium) Potassium Sparing Diuretics ENDOCRINE AND METABOLIC AGENTS - ALDACTONE TABS 4 MISC. - Drugs to Treat Bone Disease and (spironolactone) Regulate Hormones AMILORIDE HCL POWD 5 Adrenal Steroid Inhibitors XX ISTURISA TABS NC amiloride hcl tabs or 2 QL(4 ea daily) Bone Density Regulators CAROSPIR SUSP NC ACTONEL TABS 150 MG 5 QL(0.04 ea (risedronate sodium) daily) DYRENIUM CAPS NC (triamterene) ACTONEL TABS 35 MG 5 QL(0.15 ea (risedronate sodium) daily) SPIRONOLACTONE 5 POWD XX ACTONEL TABS 5 MG 5 QL(1 ea daily) (risedronate sodium) spironolactone tabs or 50 2 mg, 100 mg, 25 mg alendronate sodium soln 70 2 QL(10.8 ml mg/75ml daily) triamterene caps or 100 2 mg, 50 mg alendronate sodium tabs 2 QL(0.15 ea 35 mg, 70 mg daily) TRIAMTERENE POWD XX 5 alendronate sodium tabs 2 QL(1 ea daily) Thiazides and Thiazide-Like Diuretics 40 mg, 10 mg, 5 mg ATELVIA TBEC 5 QL(0.15 ea chlorothiazide sodium solr 2 (risedronate sodium) daily) ST; QL(0.15 ea chlorothiazide tabs or 250 2 QL(2 ea daily) BINOSTO TBEF 5 mg daily) BONIVA SOLN IV 3 SP chlorothiazide tabs or 500 2 QL(4 ea daily) mg MG/3ML (ibandronate 5 sodium) chlorthalidone tabs 2 BONIVA TABS OR 150 MG 5 QL(0.04 ea (ibandronate sodium) daily)

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.1233 ml ZOLEDRONIC ACID SOLN calcitonin (salmon) soln 2 5 daily) 4 MG/100ML etidronate disodium tabs 2 zoledronic acid soln 4 2 PA; SP mg/100ml, 5 mg/100ml EVENITY SOSY NC ZOLEDRONIC ACID SOLR 5 PA; 4 MG PA; SP FORTEO SOPN 4 ZOMETA CONC 4 5 PA; SP MG/5ML (zoledronic acid) ST; QL(0.15 ea FOSAMAX PLUS D TABS 5 daily) ZOMETA SOLN 4 5 MG/100ML FOSAMAX TABS 5 QL(0.15 ea (alendronate sodium) daily) Corticotropin PA; SP ibandronate sodium soln iv 2 PA; SP ACTHAR GEL 5 3 mg/3ml Fertility Regulators ibandronate sodium tabs or 2 QL(0.04 ea 150 mg daily) BRAVELLE SOLR 5 PA; MIACALCIN SOLN NC QL(0.0667 ml daily) CHORIONIC PA; SP PA; SP GONADOTROPIN SOLR 5 NATPARA CART 5 IM CLOMIPHENE CITRATE pamidronate disodium soln 2 SP 5 30 mg/10ml, 90 mg/10ml POWD XX QL(15 ea per PAMIDRONATE PA; SP clomiphene citrate tabs or 2 DISODIUM SOLN 6 5 30 days retail) MG/ML FOLLISTIM AQ SOLN NC SP pamidronate disodium solr 2 SP 30 mg, 90 mg GONAL-F RFF REDIJECT 4 PA; SP SOLN PROLIA SOSY 4 PA; SP GONAL-F RFF SOLR 4 PA; SP RECLAST SOLN 5 PA; SP (zoledronic acid) GONAL-F SOLR 4 PA; SP risedronate sodium tabs 2 QL(0.04 ea 150 mg daily) HCG SOLR NC risedronate sodium tabs 30 2 QL(1 ea daily) mg, 5 mg MENOPUR SOLR 5 PA; SP risedronate sodium tabs 35 2 QL(0.15 ea PA; SP mg daily) NOVAREL SOLR 5 risedronate sodium tbec 35 2 QL(0.15 ea PA; SP mg daily) OVIDREL INJ 4 TERIPARATIDE SOPN NC PREGNYL W/DILUENT PA; SP BENZYLALCOHOL/NACL 5 SOLR TYMLOS SOPN 4 PA; SP GnRH/LHRH Antagonists XGEVA SOLN 5 PA; SP CETROTIDE KIT 4 PA; SP zoledronic acid conc 4 2 PA; SP mg/5ml ganirelix acetate sosy 2 SP

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GANIRELIX ACETATE 5 SP ZOMACTON SOLR NC SOSY (ganirelix acetate) PA; SP ORILISSA TABS 4 PA; SP ZORBTIVE SOLR 5 Growth Hormone Receptor Antagonists Hormone Receptor Modulators PA; SP QL(1 ea daily); SOMAVERT SOLR 4 EVISTA TABS (raloxifene 5 hcl) AL(At least 40 yrs old) Growth Hormone Releasing Hormones (GHRH) OSPHENA TABS 4 EGRIFTA SOLR 5 PA; SP QL(1 ea daily); PA; SP EGRIFTA SV SOLR 5 raloxifene hcl tabs 6 AL(At least 40 yrs old) GHRP-2/GHRP- 6/SERMORELINACETATE NC Insulin-Like Growth Factor Receptor Inhibitors SOLR TEPEZZA SOLR 5 PA; SP GHRP-2/SERMORELIN NC ACETATE SOLR Insulin-Like Growth Factors (Somatomedins) IPAMORELIN ACETATE NC PA; SP SOLR INCRELEX SOLN 5 Growth Hormones LHRH/GnRH Agonist Analog Pituitary GENOTROPIN MINIQUICK 4 PA; SP FENSOLVI KIT NC SP SOLR PA; SP GENOTROPIN SOLR 12 4 PA; SP LUPANETA PACK KIT 5 MG LUPRON DEPOT-PED (1- PA; SP GENOTROPIN SOLR 5 4 PA; 5 MG MONTH) KIT LUPRON DEPOT-PED (3- PA; SP HUMATROPE COMBO 4 PA; SP 5 PACK SOLR MONTH) KIT PA; SP HUMATROPE SOLR 4 PA; SP SUPPRELIN LA KIT 5 PA; SP NORDITROPIN FLEXPRO NC SP SYNAREL SOLN 5 SOPN TRIPTODUR SRER NC SP OMNITROPE SOCT 10 NC SP MG/1.5ML, 5 MG/1.5ML Metabolic Modifiers OMNITROPE SOLR 5.8 NC MG ALDURAZYME SOLN 5 PA; SP SP SAIZEN SOLR 5 MG NC AMMONUL SOLN (sod benzoate & sod 5 SAIZEN SOLR 8.8 MG NC phenylacetate) SAIZENPREP BRINEURA KIT 5 PA; SP RECONSTITUTIONKIT NC SOLR BUPHENYL POWD 3 PA; SP PA; SP GM/TSP (sodium 5 SEROSTIM SOLR 5 phenylbutyrate) BUPHENYL TABS 500 MG 5 SP (sodium phenylbutyrate) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcitriol caps or 0.25 mcg, 2 levocarnitine (metabolic 2 QL(30 ml daily) 0.5 mcg modifiers) soln 1 gm/10ml calcitriol soln iv 1 mcg/ml 2 levocarnitine (metabolic 2 QL(3 ea daily) modifiers) tabs 330 mg calcitriol soln or 1 mcg/ml 2 LUMIZYME SOLR 5 PA; SP PA; SP CARBAGLU TABS 5 MEPSEVII SOLN 5 PA; SP CARNITOR SF SOLN QL(30 ml daily) PA; SP (levocarnitine (metabolic NC MYALEPT SOLR 5 modifiers)) NAGLAZYME SOLN 5 PA; SP CARNITOR SOLN IV 200 5 MG/ML nitisinone caps 2 PA; SP CARNITOR SOLN OR 1 QL(30 ml daily) GM/10ML (levocarnitine NC NITYR TABS 5 PA; SP (metabolic modifiers)) CARNITOR TABS OR 330 QL(3 ea daily) ORFADIN CAPS 10 MG, 2 4 PA; SP MG (levocarnitine NC MG, 5 MG (nitisinone) (metabolic modifiers)) ORFADIN CAPS 20 MG 4 PA; SP cinacalcet hcl tabs 2 PA; SP ORFADIN SUSP 4 MG/ML 4 PA; SP CRYSVITA SOLN 5 PA; SP PALYNZIQ SOSY NC CYSTADANE POWD 5 PA; SP paricalcitol caps or 1 mcg, 2 2 mcg, 4 mcg doxercalciferol caps 2 paricalcitol soln iv 2 2 SP mcg/ml, 5 mcg/ml doxercalciferol soln 2 PARSABIV SOLN NC SP ELAPRASE SOLN 5 PA; SP RAVICTI LIQD 5 PA; SP FABRAZYME SOLR 5 PA; SP RAYALDEE CPCR 5 GALAFOLD CAPS 5 PA; SP REVCOVI SOLN 5 PA; SP HECTOROL SOLN 2 5 MCG/ML ROCALTROL CAPS 4 (calcitriol) HECTOROL SOLN 4 5 MCG/2ML (doxercalciferol) ROCALTROL SOLN 4 (calcitriol) KANUMA SOLN 5 PA; SP sapropterin dihydrochloride 2 PA; SP KUVAN PACK (sapropterin NC PA; SP pack dihydrochloride) sapropterin dihydrochloride 2 PA; SP KUVAN TBSO (sapropterin NC PA; SP tbso dihydrochloride) SENSIPAR TABS 5 PA; SP L-CARNITINE SOLN IJ NC (cinacalcet hcl) sod benzoate & sod 2 phenylacetate soln

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium phenylbutyrate 2 PA; SP VASOPRESSIN/SODIUM NC powd or 3 gm/tsp CHLORIDE SOLN sodium phenylbutyrate tabs 2 SP VASOSTRICT SOLN 5 or 500 mg STRENSIQ SOLN 5 PA; SP Prolactin Inhibitors cabergoline tabs 2 VIMIZIM SOLN 5 PA; SP Somatostatic Agents XURIDEN PACK 5 BYNFEZIA PEN SOPN NC ZEMPLAR CAPS OR 1 4 MCG, 2 MCG (paricalcitol) octreotide acetate soln 2 PA; SP ZEMPLAR SOLN IV 2 SP MCG/ML, 5 MCG/ML 5 SANDOSTATIN LAR 5 PA; SP (paricalcitol) DEPOT KIT SANDOSTATIN SOLN 5 PA; SP Posterior Pituitary Hormones (octreotide acetate) DDAVP SOLN IJ 4 SP PA; SP MCG/ML (desmopressin 5 SIGNIFOR LAR SRER 5 acetate) SIGNIFOR SOLN 5 PA; SP DDAVP SOLN NA 0.01 % 4 QL(5 ml per fill retail) SOMATULINE DEPOT 4 PA; SP DDAVP SOLN NA 0.01 % QL(5 ml per fill SOLN (desmopressin acetate 4 retail); SP Vasopressin Receptor Antagonists spray) JYNARQUE TABS 5 PA; SP DDAVP TABS OR 0.1 MG 4 QL(6 ea daily) (desmopressin acetate) JYNARQUE TBPK 5 PA; SP DDAVP TABS OR 0.2 MG 4 QL(8 ea daily) (desmopressin acetate) SAMSCA TABS (tolvaptan) 5 PA; SP desmopressin acetate soln 2 SP ij 4 mcg/ml tolvaptan tabs 15 mg 5 PA; SP desmopressin acetate 2 QL(5 ml per fill spray refrigerated soln retail) tolvaptan tabs 30 mg 2 PA; SP desmopressin acetate 2 QL(5 ml per fill spray soln retail); SP VAPRISOL SOLN 5 desmopressin acetate tabs 2 QL(6 ea daily) or 0.1 mg ESTROGENS - Hormone Replacement/Modifying Drugs desmopressin acetate tabs 2 QL(8 ea daily) or 0.2 mg Estrogen Combinations NOCDURNA SUBL NC ACTIVELLA TABS 0.1 MG- 0.5 MG (estradiol & 5 NOCTIVA EMUL NC norethindrone acetate) ACTIVELLA TABS 0.5 MG- QL(1 ea daily) STIMATE SOLN 5 PA; SP 1 MG (estradiol & 5 norethindrone acetate) VASOPRESSIN/DEXTROS NC E SOLN ANGELIQ TABS 5

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BI-EST 50:50 ALORA PTTW 0.025 QL(0.29 ea COMPOUNDINGKIT NC MG/24HR, 0.075 5 daily) CREA MG/24HR, 0.1 MG/24HR, BI-EST 50:50 0.05 MG/24HR PROGESTERONE- ALORA PTTW 0.075 TESTOSTERONE NC MG/24HR, 0.1 MG/24HR, 5 COMPOUNDING KIT 0.05 MG/24HR CREA CLIMARA PTWK 5 QL(0.15 ea BI-EST 80:20 (estradiol) daily) PROGESTERONE NC DELESTROGEN OIL 10 5 COMPOUNDING KIT MG/ML CREA DELESTROGEN OIL 20 BIEST/PROGESTERONE NC MG/ML, 40 MG/ML 5 CREA (estradiol valerate) BIJUVA CAPS 5 DEPO-ESTRADIOL OIL 5 QL(0.15 ea CLIMARA PRO PTWK 4 daily) DIVIGEL GEL 4 Limit 8 patches EC-RX ESTRADIOL 0.4% NC COMBIPATCH PTTW 0.05 4 per CREA MG/DAY-0.14 MG/DAY month;QL(0.29 EC-RX ESTRADIOL 0.6% NC ea daily) CREA COMBIPATCH PTTW 0.05 4 MG/DAY-0.25 MG/DAY ELESTRIN GEL 5 DUAVEE TABS 4 ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG 5 estradiol & norethindrone 2 (estradiol) acetate tabs 0.1 mg-0.5 mg estradiol pttw td 0.025 QL(0.29 ea estradiol & norethindrone QL(1 ea daily) 2 mg/24hr, 0.0375 mg/24hr, 2 daily) acetate tabs 0.5 mg-1 mg 0.075 mg/24hr, 0.1 ESTRIOL- mg/24hr, 0.05 mg/24hr PROGESTERONE NC estradiol pttw td 0.1 5 QL(0.29 ea COMPOUNDING KIT mg/24hr, 0.05 mg/24hr daily) CREA estradiol ptwk td 0.05 QL(0.15 ea FEMHRT LOW DOSE mg/24hr, 0.06 mg/24hr, daily) TABS (norethindrone 5 0.075 mg/24hr, 0.1 2 acetate-ethinyl estradiol) mg/24hr, 37.5 mcg/24hr, 0.025 mg/24hr norethindrone acetate- 2 ethinyl estradiol tabs estradiol tabs or 0.5 mg, 1 2 mg, 2 mg ORIAHNN CPPK 4 estradiol valerate oil im 20 2 PREFEST TABS 5 mg/ml, 40 mg/ml QL(1.67 gm ESTROGEL GEL 5 PREMPHASE TABS 4 QL(1 ea daily) daily) ETHINYL ESTRADIOL 5 PREMPRO TABS 4 QL(1 ea daily) POWD Estrogens 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVAMIST SOLN 4 QL(0.27 ml ciprofloxacin susr or 2 daily) ciprofloxacin-ciprofloxacin 2 MENEST TABS 5 hcl tb24 QL(0.15 ea QL(1 ea MENOSTAR PTWK 5 LEVAQUIN TABS 5 daily) (levofloxacin) daily,14 ea per MINIVELLE PTTW 0.025 fill retail) MG/24HR, 0.075 NC levofloxacin in d5w soln 2 MG/24HR, 0.1 MG/24HR, 0.05 MG/24HR (estradiol) levofloxacin soln iv 25 2 mg/ml MINIVELLE PTTW 0.0375 NC QL(0.29 ea MG/24HR (estradiol) daily) levofloxacin soln or 25 2 mg/ml PREMARIN SOLR IJ 25 5 MG QL(1 ea levofloxacin tabs or 250 2 daily,14 ea per PREMARIN TABS OR 0.3 QL(1 ea daily) mg, 500 mg, 750 mg MG, 0.45 MG, 0.625 MG, 4 fill retail) 0.9 MG, 1.25 MG MOXIFLOXACIN VIVELLE-DOT PTTW HYDROCHLORIDE/SODIU 2 M HYDROCHLORIDE 0.025 MG/24HR, 0.075 NC MG/24HR, 0.1 MG/24HR, SOLN 0.05 MG/24HR (estradiol) moxifloxacin hcl tabs or 2 VIVELLE-DOT PTTW QL(0.29 ea 0.0375 MG/24HR NC daily) MOXIFLOXACIN NC (estradiol) HYDROCHLORIDE SOLN FLUOROQUINOLONES - Drugs to Treat Bacterial ofloxacin tabs 300 mg 2 Infections QL(56 ea per ofloxacin tabs 400 mg 2 Fluoroquinolones fill retail) AVELOX SOLN 5 GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs AVELOX TABS 5 (moxifloxacin hcl) 5-HT4 Receptor Agonists BAXDELA SOLR 5 MOTEGRITY TABS NC

BAXDELA TABS 5 Agents for Chronic Idiopathic Constipation (CIC) TRULANCE TABS 5 CIPRO I.V.-IN D5W SOLN 5 (ciprofloxacin in d5w) Antiflatulents CIPRO SUSR 5 5 GM/100ML, 500 MG/5ML SIMETHICONE LIQD 5 RX/OTC CIPRO TABS 250 MG, 500 5 MG (ciprofloxacin hcl) Bile Acid Synthesis Disorder Agents PA; SP ciprofloxacin hcl tabs or 2 QL(6 ea per fill CHOLBAM CAPS 5 100 mg retail) Farnesoid X Receptor (FXR) Agonists ciprofloxacin hcl tabs or 2 750 mg, 250 mg, 500 mg OCALIVA TABS 5 PA; SP ciprofloxacin in d5w soln 2 Gallstone Solubilizing Agents 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTIGALL CAPS 4 QL(3 ea daily) REGLAN TABS 5 (ursodiol) (metoclopramide hcl) CHENODAL TABS 5 PA; SP Inflammatory Bowel Agents 5-AMINOSALICYLIC ACID 5 RX/OTC URSO 250 TABS (ursodiol) 4 QL(7 ea daily) POWD APRISO CP24 URSO FORTE TABS 4 5 (ursodiol) (mesalamine) QL(3 ea daily) ASACOL HD TBEC NC ursodiol caps or 300 mg 2 (mesalamine) ursodiol tabs or 250 mg 2 QL(7 ea daily) AVSOLA SOLR NC AZULFIDINE EN-TABS 5 ursodiol tabs or 500 mg 2 TBEC (sulfasalazine) AZULFIDINE TABS URSODIOL/SYRSPEND NC 5 SF PH4 SUSP (sulfasalazine) Gastrointestinal Antiallergy Agents balsalazide disodium caps 2 QL(9 ea daily) cromolyn sodium 2 (mastocytosis) conc CANASA SUPP 5 (mesalamine) GASTROCROM CONC (cromolyn sodium 5 CIMZIA KIT 200 MG NC (mastocytosis)) SP Gastrointestinal Chloride Channel Activators CIMZIA KIT 200 MG/ML NC AMITIZA CAPS 4 CIMZIA STARTER KIT KIT NC

Gastrointestinal Stimulants COLAZAL CAPS NC QL(9 ea daily) (balsalazide disodium) DEXPANTHENOL SOLN IJ NC DELZICOL CPDR NC QL(12 ea daily) (mesalamine) METOCLOPRAMIDE HCL 5 MONOHYDRATE POWD DIPENTUM CAPS 5 METOCLOPRAMIDE HCL 5 POWD XX ENTYVIO SOLR NC SP metoclopramide hcl soln ij 2 5 mg/ml INFLECTRA SOLR NC SP metoclopramide hcl soln or 2 LIALDA TBEC NC 10 mg/10ml, 5 mg/5ml (mesalamine) metoclopramide hcl tabs or 2 mesalamine cp24 or 0.375 2 5 mg, 10 mg gm metoclopramide hcl tbdp or 2 mesalamine cpdr or 400 2 QL(12 ea daily) 5 mg mg METOCLOPRAMIDE 5 QL(60 ml daily) HYDROCHLORIDE POWD mesalamine enem re 4 gm 2 METOCLOPRAMIDE ODT 5 RX/OTC TBDP MESALAMINE POWD XX 5 mesalamine supp re 1000 METOCLOPRAMIDE ODT NC 2 TBDP mg

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mesalamine tbec or 1.2 2 Phosphate Binder Agents gm, 800 mg AURYXIA TABS 5 mesalamine w/ cleanser kit 2 calcium acetate (phosphate 2 PENTASA CPCR 4 QL(8 ea daily) binder) caps FOSRENOL CHEW 1000 REMICADE SOLR 4 PA; SP MG, 500 MG, 750 MG NC (lanthanum carbonate) RENFLEXIS SOLR NC SP FOSRENOL PACK 1000 NC MG, 750 MG ROWASA KIT (mesalamine 5 w/ cleanser) lanthanum carbonate chew NC SFROWASA ENEM 5 PHOSLYRA SOLN 4 STELARA SOLN 4 PA; SP RENAGEL TABS 5 (sevelamer hcl) SULFASALAZINE POWD 5 XX RENVELA PACK 5 (sevelamer carbonate) sulfasalazine tabs or 2 RENVELA TABS 5 (sevelamer carbonate) sulfasalazine tbec or 2 sevelamer carbonate pack 2 Intestinal Acidifiers sevelamer carbonate tabs 2 lactulose (encephalopathy) 2 soln sevelamer hcl tabs 2 Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs 2 QL(2 ea daily) VELPHORO CHEW 4

LINZESS CAPS 4 Short Bowel Syndrome (SBS) Agents GATTEX KIT 5 PA; SP LOTRONEX TABS 5 QL(2 ea daily) (alosetron hcl) Tryptophan Hydroxylase Inhibitors VIBERZI TABS 4 XERMELO TABS 5 PA; SP ZELNORM TABS NC GENERAL ANESTHETICS Peripheral Opioid Receptor Antagonists Anesthetics - Misc. ENTEREG CAPS 5 AMIDATE SOLN 5 (etomidate) MOVANTIK TABS 4 ANESTHESIA S/I-40 KIT NC RELISTOR SOLN NC ANESTHESIA S/I-40A KIT NC RELISTOR TABS NC ANESTHESIA S/I-40H KIT NC SYMPROIC TABS 4 ANESTHESIA S/I-40S KIT NC

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANESTHESIA S/I-60 KIT NC Volatile Anesthetics desflurane soln 2 DIPRIVAN EMUL 100 5 MG/10ML FORANE SOLN 5 DIPRIVAN EMUL 1000 (isoflurane) MG/100ML, 200 MG/20ML, 5 500 MG/50ML (propofol) isoflurane soln 2 etomidate soln iv 2 sevoflurane soln 2 FRESENIUS PROPOVEN NC SUPRANE SOLN 5 2% EMUL (desflurane) KETALAR SOLN (ketamine 5 ULTANE SOLN 5 hcl) (sevoflurane) ketamine hcl soln ij 10 mg/ml, 100 mg/ml, 50 2 GENITOURINARY AGENTS - MISCELLANEOUS mg/ml - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System KETAMINE HYDROCHLORIDE SOLN NC Acidifiers IJ 0.6 MG/ML, 1 MG/ML K-PHOS NO 2 TABS 5 KETAMINE HYDROCHLORIDE SOSY Alkalinizers IJ 30 MG/3ML, 50 NC MG/5ML, 50 MG/ML, 60 ORACIT SOLN 5 MG/20ML pot & sod citrates w/citric 2 KETAMINE ac soln HYDROCHLORIDE SOSY NC potassium citrate 2 IV 100 MG/2ML, 50 MG/ML (alkalinizer) tbcr KETAMINE POTASSIUM CITRATE 5 RX/OTC HYDROCHLORIDE TROC NC GRAN SL 100 MG POTASSIUM CITRATE 5 RX/OTC KETAMINE MONOHYDRATE GRAN HYDROCHLORIDE/SODIU M CHLORIDE SOSY IV 0.9 POTASSIUM CITRATE 5 %-10 MG/ML, 0.9 %-100 NC POWD MG/10ML, 0.9 %-20 potassium citrate-citric acid 2 MG/2ML, 0.9 %-50 pack MG/5ML SODIUM CITRATE 5 RX/OTC propofol emul 1000 ANHYDROUS GRAN mg/100ml, 200 mg/20ml, 2 SODIUM CITRATE 5 500 mg/50ml ANHYDROUS POWD PROPOFOL PRSY 100 SODIUM CITRATE CRYS 5 MG/10ML, 150 MG/15ML, NC XX 200 MG/20ML, 50 MG/5ML UROCIT-K 10 TBCR Barbiturate Anesthetics (potassium citrate 4 (alkalinizer)) BREVITAL SODIUM SOLR 5 UROCIT-K 15 TBCR (potassium citrate 4 METHOHEXITAL SODIUM NC SOSY (alkalinizer)) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UROCIT-K 5 TBCR CARDURA XL TB24 5 ST (potassium citrate 4 (alkalinizer)) dutasteride caps or 2 QL(1 ea daily) Cystinosis Agents dutasteride-tamsulosin hcl 2 QL(1 ea daily) CYSTAGON CAPS 5 PA; SP caps QL(1 ea daily) PROCYSBI CPDR 25 MG 5 PA; SP finasteride tabs or 2 FLOMAX CAPS QL(2 ea daily) PROCYSBI CPDR 75 MG 5 PA; QL(0.034 5 ea daily); SP (tamsulosin hcl) JALYN CAPS (dutasteride- QL(1 ea daily) PROCYSBI PACK 300 MG, NC NC 75 MG tamsulosin hcl) PROSCAR TABS 5 QL(1 ea daily) Genitourinary Irrigants (finasteride) acetic acid soln ir 0.25 % 2 RAPAFLO CAPS NC (silodosin) glycine (gu irrigant) soln 2 silodosin caps 8 mg, 4 mg 2 GLYCINE (L) POWD 5 RX/OTC tamsulosin hcl caps 2 QL(2 ea daily) GLYCINE POWD XX 5 RX/OTC UROXATRAL TB24 NC QL(1 ea daily) (alfuzosin hcl) neomycin/polymyxin b gu 2 soln Urinary Analgesics RENACIDIN SOLN 5 PHENAZOPYRIDINE HCL 5 POWD XX sodium chloride (gu 2 phenazopyridine hcl tabs or 2 irrigant) soln 100 mg, 200 mg SORBITOL SOLN IR 3 %, 5 PYRIDIUM TABS 5 3.3 % (phenazopyridine hcl) SORBITOL-MANNITOL 5 Urinary Stone Agents SOLN LITHOSTAT TABS 5 SORBITOL/MANNITOL 5 IRRIGATION SOLN THIOLA EC TBEC 5 PA; SP Interstitial Cystitis Agents PA; SP ELMIRON CAPS 5 QL(3 ea daily) THIOLA TABS 5 PENTOSAN GOUT AGENTS - Drugs to Treat Gout POLYSULFATE SODIUM NC DR CPDR Gout Agent Combinations RIMSO-50 SOLN NC colchicine w/ probenecid 2 tabs Prostatic Hypertrophy Agents DUZALLO TABS NC alfuzosin hcl tb24 2 QL(1 ea daily) Gout Agents AVODART CAPS 5 QL(1 ea daily) (dutasteride) allopurinol sodium solr 2

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits allopurinol tabs or 100 mg, 2 COAGADEX SOLR 5 PA; SP 300 mg PA; SP ALOPRIM SOLR 5 CORIFACT KIT 5 (allopurinol sodium) colchicine caps or 2 ELOCTATE SOLR NC PA; SP COLCHICINE POWD XX 5 FEIBA SOLR 5 PA; SP colchicine tabs or 2 FIBRYGA SOLR 5 PA; SP COLCRYS TABS NC HELIXATE FS KIT NC (colchicine) HEMOFIL M SOLR 5 PA; SP febuxostat tabs 2 QL(1 ea daily) HUMATE-P SOLR 5 PA; SP GLOPERBA SOLN NC IDELVION SOLR 5 PA; SP KRYSTEXXA SOLN 5 PA; SP IXINITY SOLR 5 PA; SP MITIGARE CAPS 2 (colchicine) JIVI SOLR 4 PA; SP ULORIC TABS (febuxostat) 5 QL(1 ea daily) KOATE SOLR 5 PA; SP ZURAMPIC TABS NC KOATE-DVI SOLR 5 PA; SP ZYLOPRIM TABS 5 (allopurinol) KOGENATE FS KIT NC PA; SP Uricosurics PA; SP probenecid tabs 2 KOVALTRY SOLR 4 PA; SP HEMATOLOGICAL AGENTS - MISC. - Drugs to MONOCLATE-P KIT 5 Treat Blood Disorders MONONINE SOLR 5 PA; SP Antihemophilic Products PA; SP ADVATE SOLR 5 PA; SP NOVOSEVEN RT SOLR 5 PA; SP ADYNOVATE SOLR 4 PA; SP NUWIQ KIT 4 PA; SP AFSTYLA KIT 5 PA; SP NUWIQ SOLR 4 ALPHANATE/VON PA; SP OBIZUR SOLR 5 PA; SP WILLEBRANDFACTOR 5 COMPLEX/HUMAN SOLR PROFILNINE SD SOLR 5 PA; SP ALPHANINE SD SOLR 5 PA; SP PROFILNINE SOLR 5 PA; SP ALPROLIX SOLR NC RECOMBINATE SOLR 5 PA; SP BENEFIX KIT 5 PA; SP RIASTAP SOLR 5 PA; SP

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIXUBIS SOLR 5 PA; SP cilostazol tabs 2

TRETTEN SOLR 5 PA; SP clopidogrel bisulfate tabs or 2 300 mg, 75 mg PA; SP WILATE KIT 5 CLOPIDOGREL KIT THPK NC PA; SP XYNTHA KIT 5 dipyridamole tabs or 25 2 mg, 50 mg, 75 mg PA; SP XYNTHA SOLOFUSE KIT 5 DURLAZA CP24 NC Bradykinin B2 Receptor Antagonists EFFIENT TABS 10 MG 5 QL(1 ea daily) (prasugrel hcl) FIRAZYR SOLN (icatibant 4 PA; SP acetate) EFFIENT TABS 5 MG 5 QL(2 ea daily) (prasugrel hcl) icatibant acetate soln 2 PA; SP PLAVIX TABS (clopidogrel NC Complement Inhibitors bisulfate) QL(1 ea daily) BERINERT KIT NC prasugrel hcl tabs 10 mg 2 QL(2 ea daily) CINRYZE SOLR 5 PA; SP prasugrel hcl tabs 5 mg 2

HAEGARDA SOLR 5 PA; SP YOSPRALA TBEC NC

SOLIRIS SOLN 4 PA; SP ZONTIVITY TABS NC Hematorheologic Agents HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders pentoxifylline tbcr or 2 Agents for Gaucher Disease Plasma Kallikrein Inhibitors CERDELGA CAPS 4 PA; SP KALBITOR SOLN 5 PA; SP CEREZYME SOLR 4 PA; SP TAKHZYRO SOLN 4 PA; SP ELELYSO SOLR NC SP Platelet Aggregation Inhibitors miglustat caps 2 PA; SP AGGRENOX CP12 5 (aspirin-dipyridamole) VPRIV SOLR 5 PA; SP AGRYLIN CAPS 4 (anagrelide hcl) ZAVESCA CAPS 5 PA; SP anagrelide hcl caps 2 (miglustat) Agents for Sickle Cell Disease aspirin-dipyridamole cp12 2 ADAKVEO SOLN 5 PA; SP ASPIRIN/OMEPRAZOLE NC ER TBEC DROXIA CAPS 5 ASPIRIN/OMEPRAZOLE NC PA; SP TBEC ENDARI PACK 5 BRILINTA TABS 4

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXBRYTA TABS NC EPOGEN SOLN NC SP

SIKLOS TABS 5 FULPHILA SOSY NC

Cobalamins GRANIX SOLN 300 NC MCG/ML, 480 MCG/1.6ML B-12 COMPLIANCE 5 INJECTIONKIT KIT GRANIX SOSY 300 SP MCG/0.5ML, 480 NC cyanocobalamin soln ij 2 MCG/0.8ML 1000 mcg/ml LEUKINE SOLR 5 PA; SP CYANOCOBALAMIN NC SOLN IJ 2000 MCG/ML MIRCERA SOSY 100 SP hydroxocobalamin acetate 2 MCG/0.3ML, 150 soln MCG/0.3ML, 200 NC METHYLCOBALAMIN MCG/0.3ML, 30 SOLN IJ 150 MG/30ML, 30 NC MCG/0.3ML MG/30ML, 300 MG/30ML MIRCERA SOSY 50 METHYLCOBALAMIN MCG/0.3ML, 75 NC SOLR IJ 10000 MCG, NC MCG/0.3ML 50000 MCG MULPLETA TABS 4 PA; SP NASCOBAL SOLN 5 NEULASTA ONPRO KIT 4 PA; SP PHYSICIANS EZ USE B- 5 PSKT 12 COMPLIANCE KIT KIT NEULASTA SOSY 4 PA; SP VITAMIN DEFICIENCY INJECTABLE SYSTEM- 5 SP B12 KIT NEUPOGEN SOLN NC Folic Acid/Folates NEUPOGEN SOSY NC SP folic acid caps or 0.8 mg, 5 800 mcg NIVESTYM SOLN 4 PA; SP RX/OTC FOLIC ACID POWD XX 5 NIVESTYM SOSY 4 PA; SP folic acid soln ij 5 mg/ml 2 NPLATE SOLR 125 MCG NC AL(At least 11 NPLATE SOLR 250 MCG, 5 PA; SP 2 yrs old - Up to 500 MCG folic acid tabs or 1 mg 50 yrs old); RX/OTC PROCRIT SOLN 10000 SP UNIT/ML, 2000 UNIT/ML, folic acid tabs or 800 mcg, 5 20000 UNIT/ML, 3000 NC 400 mcg UNIT/ML, 4000 UNIT/ML, Hematopoietic Growth Factors 40000 UNIT/ML PA; SP ARANESP ALBUMIN 4 PA; SP PROMACTA PACK 4 FREE SOLN PA; SP ARANESP ALBUMIN 4 PA; SP PROMACTA TABS 4 FREE SOSY REBLOZYL SOLR NC DOPTELET TABS NC

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETACRIT SOLN 10000 PA; SP cyanocobalamin- 2 UNIT/ML, 2000 UNIT/ML, methylcobalamin subl 20000 UNIT/2ML, 3000 4 DERMACINRX 5 UNIT/ML, 4000 UNIT/ML, PUREFOLIX TABS 40000 UNIT/ML DIVISTA CAPS 5 UDENYCA SOSY 4 PA; SP DURACHOL CAPS 5 ZARXIO SOSY 300 NC SP MCG/0.5ML fe fum-iron polysacch ZARXIO SOSY 480 NC complex-fa-b complex-c- 2 MCG/0.8ML zn-mn-cu caps ZIEXTENZO SOSY NC fe fumarate-vitamin c- 2 RX/OTC vitamin b12-folic acid caps Hematopoietic Mixtures FERIVA 21/7 TABS NC ACTIVE FE TABS 5 FERIVAFA CAPS 5 ANIMI-3 CAPS 5 FERRALET 90 TABS 5 ANIMI-3/VITAMIN D CAPS 5 FERRAPLUS 90 TABS 5 AXIFOL CAPS NC FERRO-PLEX HEMATINIC 5 TABS B-6 FOLIC ACID CAPS 5 FERROTRIN CAPS 5 BP VIT 3 CAPS 5 ferrous fumarate w/ b12-vit 2 CENFOL TABS 5 c-fa-ifc caps ferrous fumarate-fa-b CENTRATEX CAPS 5 complex-c-zn-mg-mn-cu 2 tabs CHOLECAL DF TABS NC ferrous fumarate-folic acid 2 tabs CIFEREX CAPS 5 FOLGARD RX TABS (folic acid-vitamin b6-vitamin 5 CIFRAZOL CAPS 5 b12) CORVITE 150 TABS 1.25 FOLI-D TABS NC MG-10 MG-120 MG-15 MCG-150 MG-25 MG (iron- 5 FOLIC + B12 TABS 5 RX/OTC folic acid-vitamin c-vitamin b6-vitamin b12-zinc) folic acid-cholecalciferol NC CORVITE 150 TABS 10 tabs MG-10 MG-100 MCG-120 folic acid-vitamin b6-vitamin 2 MG-150 MG-20 MCG-25 5 b12 tabs MG-300 MCG-5 MG-700 FOLIC D3 CAPS NC MCG CORVITE FE TABS 5 FOLIKA-D TABS NC

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLITE TABS NC iron-vitamin c-vitamin b12- NC RX/OTC folic acid tabs FOLIVANE-F CAPS 5 IROSPAN 24/6 MISC 5

FOLIVANE-PLUS CAPS NC IS 24/6 MISC 5

FOLIXAPURE TABS 5 LIPO-B SOLN NC

FOLIXAPURE TABS NC MAXFE TABS 5 FOLTRATE TABS 5 RX/OTC METHIONINE/INOSITOL/C HOLINE/CYANOCOBALA NC FOLVITE FE TABS NC MIN SOLN MTX SUPPORT TABS 5 RX/OTC FUSION PLUS CAPS 5 MULTIGEN FOLIC TABS 5 FUSION SPRINKLES NC PACK MULTIGEN PLUS TABS 5 GENICIN VITA-D TABS NC (folic acid-cholecalciferol) MULTIGEN TABS 5 HEMATOGEN FA CAPS 5 NEPHRON FA TABS 5 HEMATRON-AF TABS RX/OTC (iron-docusate-b12-folic 5 NEURIN-SL SUBL acid-vit c-vit e-copper- (cyanocobalamin- 5 biotin) methylcobalamin) HEMETAB TABS 5 NIFEREX TABS 5

HEMOCYTE PLUS CAPS 5 NOXIFOL-D TABS NC

ICAR-C PLUS TABS (iron- RX/OTC NUFERA TABS 5 vitamin c-vitamin b12-folic NC acid) OPURITY B12/FOLIC 5 RX/OTC ACID TABS INTEGRA F CAPS 5 ORTHO DF CAPS NC INTEGRA PLUS CAPS NC ORTHO-FOLIC CAPS NC iron combinations caps 2 RX/OTC OVEEZA CAPS NC iron polysaccharide 2 complex-vit b12-folic acid PUREFE PLUS CAPS 5 caps iron-docusate-b12-folic RX/OTC REVESTA CAPS NC acid-vit c-vit e-copper-biotin 2 tabs ROXIFOL-D TABS NC iron-folic acid-vitamin c- vitamin b6-vitamin b12-zinc 2 TALIVA CAPS NC tabs

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TANDEM F CAPS 5 MOZOBIL SOLN 4 PA; SP TANDEM PLUS CAPS (fe HEMOSTATICS - Drugs to Stop Bleeding/Treat fum-iron polysacch 5 Blood Disorders complex-fa-b complex-c- zn-mn-cu) Hemostatics - Systemic AMICAR SOLN 0.25 NC PA; SP TARON FORTE CAPS 5 GM/ML (aminocaproic acid) VIRT-FEFA PLUS CAPS NC AMICAR TABS 1000 MG, 500 MG (aminocaproic 5 acid) VITAMEZ CAPS 5 aminocaproic acid soln iv 2 PA; SP VITAMIN B12/FOLIC ACID 5 RX/OTC 250 mg/ml TABS aminocaproic acid soln or 2 PA; SP ZAVARA CAPS NC 0.25 gm/ml aminocaproic acid tabs or 2 Iron 1000 mg, 500 mg FER-IN-SOL SOLN 5 CYKLOKAPRON SOLN 5 (ferrous sulfate) (tranexamic acid) FERAHEME SOLN 5 LYSTEDA TABS 5 QL(6 ea daily) (tranexamic acid) FERRLECIT SOLN tranexamic acid soln iv 2 (sodium ferric gluconate 5 1000 mg/10ml complex in sucrose) tranexamic acid tabs or 650 2 QL(6 ea daily) FERROUS SULFATE 5 RX/OTC mg ANHYDROUS POWD TRANEXAMIC FERROUS SULFATE 5 RX/OTC ACID/SODIUM CHLORIDE NC GRAN XX SOLN FERROUS SULFATE 5 RX/OTC Hemostatics - Topical HEPTAHYDRATE GRAN ARTISS SOLN 5 FERROUS SULFATE 5 RX/OTC POWD XX ASTRINGYN SOLN 5 ferrous sulfate soln or 6 GEL-FLOW KIT NC INFED SOLN 5 GELFOAM-JMI POWDER NC INJECTAFER SOLN 5 KIT KIT GELFOAM-JMI SPONGE NC sodium ferric gluconate 2 KIT KIT complex in sucrose soln MONSELS FERRIC 5 TRIFERIC PACK NC SUBSULFATE SOLN

TRIFERIC SOLN NC RECOTHROM SOLR 5 RECOTHROM SPRAY KIT 5 VENOFER SOLN 5 SOLR Stem Cell Mobilizers RECOTHROM/SPRAY 5 APPLICATOR KIT SOLR

168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TACHOSIL PTCH 5 phenobarbital tabs or 100 mg, 15 mg, 30 mg, 60 mg, 2 64.8 mg, 97.2 mg, 16.2 mg, THROMBIN-JMI DILUENT 5 SOLR 32.4 mg THROMBIN-JMI 5 SECONAL SODIUM CAPS 5 EPISTAXIS KIT Hypnotic Combinations THROMBIN-JMI SYRINGE 5 SPRAY KIT KIT MIDAZOLAM/KETAMINE THROMBIN-JMI W/DIL HYDROCHLORIDE/ONDA NC SPRAYPUMP ACTUATOR 5 NSETRON KIT HYDROCHLORIDE TROC THROMBOGEN KIT 5 MKO MELT DOSE PACK NC TROC THROMBOGEN SOLR 5 Hypnotics - Tricyclic Agents QL(1 ea daily) TISSEEL KIT 5 doxepin hcl (sleep) tabs 2 SILENOR TABS (doxepin 5 QL(1 ea daily) TISSEEL SOLN 5 hcl (sleep)) TISSEEL VH KIT 5 Non-Barbiturate Hypnotics AMBIEN CR TBCR 5 QL(1 ea daily) HYPNOTICS/SEDATIVES/SLEEP DISORDER (zolpidem tartrate) AGENTS AMBIEN TABS (zolpidem 5 QL(1 ea daily) Barbiturate Hypnotics tartrate) CHLORAL HYDRATE 5 AMYTAL SODIUM SOLR 5 CRYS dexmedetomidine hcl in 2 BUTISOL SODIUM TABS 5 sodium chloride soln NEMBUTAL SODIUM DEXMEDETOMIDINE HCL SOLN (pentobarbital 5 SOLN 1000 MCG/10ML, NC sodium) 400 MCG/4ML PENTOBARBITAL 5 dexmedetomidine hcl soln 2 SODIUM POWD XX 200 mcg/2ml pentobarbital sodium soln ij 2 DEXMEDETOMIDINE HYDROCHLORIDE/DEXT NC ROSE MONOHYDRATE phenobarbital elix or 20 2 mg/5ml SOLN QL(1 ea daily) PHENOBARBITAL POWD 5 DORAL TABS (quazepam) 5 XX ST; QL(1 ea PHENOBARBITAL 5 EDLUAR SUBL 5 SODIUM POWD XX daily) phenobarbital sodium soln 2 estazolam tabs 2 ij 130 mg/ml, 65 mg/ml QL(1 ea daily) phenobarbital soln or 20 2 eszopiclone tabs 2 mg/5ml flurazepam hcl caps 2 QL(1 ea daily)

169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALCION TABS 5 QL(1 ea daily) zaleplon caps 2 QL(1 ea daily) (triazolam) QL(1 ea daily) INTERMEZZO SUBL NC QL(1 ea daily) zolpidem tartrate subl 2 (zolpidem tartrate) QL(1 ea daily) LUNESTA TABS NC QL(1 ea daily) zolpidem tartrate tabs 2 (eszopiclone) zolpidem tartrate tbcr 2 QL(1 ea daily) MIDAZOLAM HCL SOLN IJ 2 5 MG/5ML ZOLPIMIST SOLN NC QL(0.26 ml midazolam hcl soln ij 5 daily) mg/5ml, 10 mg/2ml, 2 mg/2ml, 5 mg/5ml, 5 2 Orexin Receptor Antagonists mg/ml, 10 mg/10ml, 50 BELSOMRA TABS 4 ST; QL(1 ea mg/10ml, 25 mg/5ml daily) midazolam hcl syrp or 2 2 DAYVIGO TABS NC mg/ml MIDAZOLAM NC Selective Melatonin Receptor Agonists HYDROCHLORIDE SOLN HETLIOZ CAPS 5 PA; SP MIDAZOLAM HYDROCHLORIDE/DEXT NC QL(1 ea daily) ROSE SOLN ramelteon tabs 2 MIDAZOLAM ROZEREM TABS NC QL(1 ea daily) HYDROCHLORIDE/SODIU NC (ramelteon) M CHLORIDE SOLN LAXATIVES - Bowel Treatment Drugs MIDAZOLAM HYDROCHLORIDE/SODIU NC Laxative Combinations M CHLORIDE SOSY bisacodyl-peg 3350-pot QL(1 ea per fill MIDAZOLAM/SODIUM NC chloride-sod bicarb-sod 2 retail) CHLORIDE SOLN chloride kit MIDAZOLAM/SYRSPEND NC SF PH4 SUSP CLENPIQ SOLN 5 PRECEDEX SOLN 0.9 %- COLYTE-FLAVOR PACKS QL(4000 ml per 80 MCG/20ML, 0.9 %-200 SOLR (peg 3350-kcl-sod 5 fill retail) MCG/50ML, 0.9 %-400 5 bicarb-sod chloride-sod MCG/100ML sulfate) (dexmedetomidine hcl in QL(4000 ea per sodium chloride) GOLYTELY SOLR 2.82 fill retail); AL(At PRECEDEX SOLN 200 GM-21.5 GM-227.1 GM- 5 least 50 yrs old MCG/2ML 5 5.53 GM-6.36 GM - Up to 75 yrs (dexmedetomidine hcl) old) quazepam tabs NC GOLYTELY SOLR 2.97 QL(4000 ml per GM-22.74 GM-236 GM- fill retail); AL(At 5.86 GM-6.74 GM (peg 5 least 50 yrs old RESTORIL CAPS 5 QL(1 ea daily) (temazepam) 3350-kcl-sod bicarb-sod - Up to 75 yrs chloride-sod sulfate) old) temazepam caps 2 QL(1 ea daily) MOVIPREP SOLR (peg 6 triazolam tabs 2 QL(1 ea daily) 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid)

170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOVIPREP SOLR (peg polyethylene glycol 3350 NC 3350-kcl-nacl-na sulfate-na NC pack or ascorbate-ascorbic acid) Lubricant Laxatives NULYTELY SOLR (peg MINERAL OIL HEAVY OIL 5 RX/OTC 3350-potassium chloride- 5 sod bicarbonate-sod chloride) MINERAL OIL LIGHT OIL 5 RX/OTC NULYTELY/FLAVOR MINERAL OIL OIL OR 4 RX/OTC PACKS SOLR (peg 3350- 5 potassium chloride-sod mineral oil oil or 100 %, 2 RX/OTC bicarbonate-sod chloride) 99.9 %, PCP 100 KIT NC MINERAL OIL OIL XX 5 RX/OTC QL(4000 ml per RX/OTC peg 3350-kcl-sod bicarb- fill retail); AL(At MURI-LUBE OIL 5 sod chloride-sod sulfate 2 least 50 yrs old solr 2.97 gm-22.74 gm-236 - Up to 75 yrs Saline Laxatives gm-5.86 gm-6.74 gm old) EPSOM SALT POWD 5 RX/OTC peg 3350-kcl-sod bicarb- QL(4000 ml per MAGNESIUM SULFATE RX/OTC sod chloride-sod sulfate 2 fill retail) 5 solr 2.98 gm-22.72 gm-240 HEPTAHYDRATE POWD gm-5.84 gm-6.72 gm MAGNESIUM SULFATE 5 RX/OTC peg 3350-potassium POWD XX chloride-sod bicarbonate- 2 sod chloride solr OSMOPREP TABS NC PLENVU SOLR 6 Stimulant Laxatives BISACODYL POWD 5 PLENVU SOLR NC CASCARA SAGRADA 5 POLY-PREP KIT NC EXTR Surfactant Laxatives PREPOPIK PACK 5 DOCUSATE SODIUM 5 AL(At least 50 POWD SUPREP BOWEL PREP 6 yrs old - Up to KIT SOLN 75 yrs old) LOCAL ANESTHETICS-Parenteral - Drugs for Numbing Laxatives - Miscellaneous Local Anesthetic Combinations GIALAX KIT NC ACTIVE INJECTION KIT 5 LM-2 KIT KRISTALOSE PACK 10 5 GM, 20 GM articaine-epinephrine soct 2 LACTULOSE PACK 10 GM NC BUFFERED LIDOCAINE HYDROCHLORIDE/SODIU NC lactulose soln 10 gm/15ml, 2 M BICARBONATE SOSY 20 gm/30ml BUFFERED MIRALAX MIX-IN PAX LIDOCAINE/SODIUM NC PACK (polyethylene glycol NF BICARBONATE SOSY 3350)

171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUFFERED RECK SOSY NC LIDOCAINE/SODIUMBICA NC RBONATE SOSY ROPIVACAINE HYDROCHLORIDE/CLONI bupivacaine w/ epinephrine 2 soln DINE NC BUPIVICAINE HYDROCHLORIDE/KETO HYDROCHLORIDE/EPINE NC ROLAC SOSY PHRINE SOSY SENSORCAINE- 5 MPF/EPINEPHRINE SOLN CITANEST FORTE 5 DENTAL SOLN XYLOCAINE- MPF/EPINEPHRINE SOLN 5 D-CARE 100X KIT NC 1 %-1 :200000 XYLOCAINE- LETS KIT KIT 5 MPF/EPINEPHRINE SOLN LIDOCAINE 1 :200000-1.5 %, 1 5 HYDROCHLORIDE/SODIU NC :200000-2 % (lidocaine w/ M BICARBONATE SOSY epinephrine) LIDOCAINE XYLOCAINE/EPINEPHRIN HYDROCHLORIDE/SODIU NC E SOLN (lidocaine w/ 5 M CHLORIDE SOLN epinephrine) LIDOCAINE Local Anesthetics - Amides HYDROCHLORIDE/SODIU NC BD PUDENDAL/LOCAL M CHLORIDE SOSY BLOCKTRAY 1% 5 LIDOCAINE KIT lidocaine w/ epinephrine 2 soln BUPIVACAINE 5 FISIOPHARMA SOLN LIDOMAR SOLN NC BUPIVACAINE HCL 5 MARCAINE/EPINEPHRIN MONOHYDRATE POWD E SOLN (bupivacaine w/ 5 BUPIVACAINE HCL 5 epinephrine) POWD XX MARLIDO KIT KIT 5 bupivacaine hcl soln ij 0.25 NC % MARLIDO-25 KIT 5 bupivacaine hcl soln ij 0.25 2 %, 0.5 %, 0.75 %, 0.25 % MARVONA SUIK KIT 5 BUPIVACAINE HYDROCHLORIDE SOLN 5 ORABLOC SOCT 5 (articaine-epinephrine) 312.5 MG/10ML BUPIVACAINE P-CARE 100MX KIT NC HYDROCHLORIDE SOSY 0.125 %, 0.25 %, 0.5 %, NC P-CARE MG KIT 5 125 MG/4ML, 250 MG/8ML, 312.5 MG/10ML, POINT OF CARE LM-2.2 5 625 MG/20ML KIT BUPIVACAINE POINT OF CARE LM-2.5 5 HYDROCHLORIDE/DEXT NC KIT ROSE SOSY READYSHARP-A KIT NC

172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUPIVACAINE DURASAFE HYDROCHLORIDE/SODIU SPINAL/EPIDURALTRAY/ M CHLORIDE SOLN EP 1% 5 0.063 %-0.9 %, 0.1 %-0.9 NC XYLOCAINE/19GX36"OPE %, 0.125 %-0.9 %, 0.15 %- N CATH KIT 0.9 %, 0.2 %-0.9 %, 0.25 DURASAFE %-0.9 % SPINAL/EPIDURALTRAY/ BUPIVACAINE 1% 5 HYDROCHLORIDE/SODIU XYLOCAINE/20GX36"CLO M CHLORIDE SOLN IJ SE CATH KIT 0.03 %-0.9 %, 0.1 %-0.9 NC DURASAFE %, 0.125 %-0.9 %, 0.2 %- SPINAL/EPIDURALTRAY/ 0.9 %, 0.25 %-0.9 %, 0.375 1% 5 %-0.9 %, 0.5 %-0.9 % XYLOCAINE/20GX36"OPE BUPIVACAINE N CATH KIT HYDROCHLORIDE/SODIU 5 M CHLORIDE SOLN IJ EXPAREL SUSP 5 0.063 %-0.9 % lidocaine hcl (local anesth.) 2 BUPIVACAINE jtaj id 0.5 mg HYDROCHLORIDE/SODIU NC lidocaine hcl (local anesth.) M CHLORIDE SOSY EP soln ij 0.5 %, 1 %, 1.5 %, 2 2 0.25 %-0.9 %, 0.5 %-0.9 % %, 4 %, 1 % BUPIVACAINE lidocaine hcl (local anesth.) NC HYDROCHLORIDE/SODIU soln ij 1 % M CHLORIDE SOSY IJ NC 0.063 %-0.9 %, 0.1 %-0.9 LIDOCAINE 5 %, 0.125 %-0.9 %, 0.25 %- HCL/DEXTROSE SOLN 0.9 %, 0.375 %-0.9 % LIDOCAINE BUPIVACAINE HYDROCHLORIDE SOLN 5 HYDROCHLORIDE/SODU NC IJ 1 %, 2 % M CHLORIDE SOSY LIDOCAINE BUPIVACAINE HYDROCHLORIDE SOSY NC HYDROCHLORIDEMONO 5 EP 400 MG/20ML HYDRATE POWD LIDOCAINE HYDROCHLORIDE SOSY bupivacaine in dextrose 2 soln IJ 10 MG/ML, 100 NC MG/5ML, 200 MG/10ML, CARBOCAINE SOLN 5 40 MG/2ML, 400 (mepivacaine hcl) MG/20ML, 60 MG/3ML CITANEST PLAIN 5 DENTAL SOLN LIDOMARK 1/5 KIT 5 DURASAFE MARCAINE SOLN 5 SPINAL/EPIDURALTRAY/ (bupivacaine hcl) 1% 5 MARCAINE SPINAL SOLN 5 XYLOCAINE/19GX36"CLO (bupivacaine in dextrose) SE CATH KIT MEPIVACAINE HCL 5 POWD XX mepivacaine hcl soln ij 1 %, 2 1.5 %, 2 %

173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT BONE XYLOCAINE-MPF SOLN 5 MARROW BIOPSY 5 (lidocaine hcl (local TRAY/BIOP ASPIR anesth.)) NEEDLE 11GX4" KIT ZINGO JTAJ (lidocaine hcl 5 MONOJECT BONE (local anesth.)) MARROW BIOPSY 5 TRAY/BIOP ASPIR Local Anesthetics - Esters NEEDLE 8GX4" KIT chloroprocaine hcl soln 2 MONOJECT BONE CLOROTEKAL SOLN NC MARROW BIOPSY 5 TRAY/STERNAL-ILIAC NEEDLE 16G KIT NESACAINE SOLN 5 NAROPIN SOLN 5 NESACAINE-MPF SOLN 2 5 (ropivacaine hcl) %, 3 % (chloroprocaine hcl) P-CARE M KIT NC PROCAINE HCL CRYS 5

P-CARE X KIT 5 tetracaine hcl soln ij 2 PF-LIDOCAINE NC HYDROCHLORIDE SOSY MACROLIDES - Drugs to Treat Bacterial Infections READYSHARP 5 LIDOCAINE KIT Azithromycin QL(2 ea per fill ropivacaine hcl soln 2 azithromycin pack or 1 gm 2 retail) ROPIVACAINE HYDROCHLORIDE SOLN NC azithromycin solr iv 500 mg 2 EP 0.5 % azithromycin susr or 100 2 ROPIVACAINE mg/5ml, 200 mg/5ml HYDROCHLORIDE SOLN 2 azithromycin tabs or 250 2 QL(6 ea per fill IJ 2 MG/ML mg retail) ROPIVACAINE azithromycin tabs or 500 2 QL(3 ea daily) HYDROCHLORIDE SOLN NC mg IJ 33.4 MG/ML QL(1 ea ROPIVACAINE azithromycin tabs or 600 2 daily,10 ea per mg HYDROCHLORIDE SOSY NC fill retail) EP 0.5 % ZITHROMAX PACK OR 1 5 QL(2 ea per fill ROPIVACAINE GM (azithromycin) retail) HYDROCHLORIDE SOSY NC ZITHROMAX SOLR IV 500 5 IJ 0.2 %, 0.5 % MG (azithromycin) ROPIVACAINE NC ZITHROMAX SUSR OR HYDROCHLORIDE/SODIU 100 MG/5ML, 200 MG/5ML 5 M CHLORIDE SOLN (azithromycin) ROPIVACAINE NC ZITHROMAX TABS OR 5 QL(6 ea per fill HYDROCHLORIDE/SODIU 250 MG (azithromycin) retail) M CHLORIDE SOSY ZITHROMAX TABS OR 5 QL(3 ea daily) XYLOCAINE SOLN ) (lidocaine hcl (local 5 500 MG (azithromycin anesth.))

174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea DIFICID TABS 4 ZITHROMAX TABS OR 5 daily,10 ea per 600 MG (azithromycin) fill retail) MEDICAL DEVICES AND SUPPLIES ZITHROMAX TRI-PAK 5 QL(3 ea daily) TABS (azithromycin) Bandages-Dressings-Tape ZITHROMAX Z-PAK TABS QL(6 ea per fill 5 2ND SKIN BLISTER KIT 5 RX/OTC (azithromycin) retail) MISC Clarithromycin 2ND SKIN BLISTER PADS 5 RX/OTC MISC clarithromycin susr or 125 2 mg/5ml, 250 mg/5ml 2ND SKIN QUIKSTIK RX/OTC ADHESIVE BANDAGES 5 clarithromycin tabs or 250 2 QL(28 ea per mg, 500 mg fill retail) MISC 2ND SKIN QUIKSTIK RX/OTC clarithromycin tb24 or 500 2 QL(14 ea per mg fill retail) ADHESIVE BANDAGES 5 SPORT PACK MISC Erythromycins 2ND SKIN SELF SEALING RX/OTC E.E.S. GRANULES SUSR CUT CLOSURE 5 (erythromycin NC BANDAGE MISC ethylsuccinate) ADHESIVE BANDAGES 5 RX/OTC ERYPED 200 SUSR ANTIBACTERIAL MISC (erythromycin NC ADHESIVE BANDAGES 5 RX/OTC ethylsuccinate) CLEAR MISC ERYPED 400 SUSR ADHESIVE BANDAGES 5 RX/OTC (erythromycin NC FLEXIBLE FABRIC MISC ethylsuccinate) ADHESIVE BANDAGES 5 RX/OTC ERYTHROCIN 5 FOAM MISC LACTOBIONATE SOLR ADHESIVE BANDAGES RX/OTC erythromycin base cpep 2 HEALTHAWARENESS 5 MISC erythromycin base tabs 2 ADHESIVE BANDAGES 5 RX/OTC HYPO-ALLERGENIC MISC erythromycin base tbec 2 adhesive bandages misc 5 RX/OTC ERYTHROMYCIN ETHYLSUCCINATE 5 ADHESIVE BANDAGES 5 RX/OTC POWD XX PLASTIC MISC erythromycin ADHESIVE BANDAGES 5 RX/OTC ethylsuccinate susr or 200 2 SHEER MISC mg/5ml, 400 mg/5ml ADHESIVE BANDAGES 5 RX/OTC erythromycin STRONGSTRIPS MISC ethylsuccinate tabs or 400 2 ADHESIVE BANDAGES 5 RX/OTC mg WATER SHIELD MISC ERYTHROMYCIN POWD 5 ADHESIVE 5 PADS/LARGE/3"X4" PADS erythromycin stearate tabs 2 ADHESIVE PADS/MEDIUM/2"X3" 5 Fidaxomicin PADS

175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVANCED CURAD 5 RX/OTC BAND-AID BUTTERFLY RX/OTC AQUA-PROTECT MISC CLOSURE LARGE 2-3/4" 5 X 1/2" MISC ADVANCED CURAD 5 RX/OTC BLISTER-CARE MISC BAND-AID CLEAR SPOTS 5 RX/OTC 7/8" MISC ADVANCED CURAD 5 RX/OTC COOL-WRAP MISC BAND-AID CLEAR STRIPS 5 RX/OTC MISC ADVANCED CURAD SOF- 5 RX/OTC GEL MISC BAND-AID DISNEY 5 RX/OTC PRINCESS MISC ALLEVYN PLUS CAVITY 5 RX/OTC PADS BAND-AID EMOJI MISC 5 RX/OTC ALLEVYN THIN PADS 5 RX/OTC BAND-AID FLEXIBLE 5 RX/OTC AMD ANTIMICROBIAL FABRIC MISC 5 FENESTRATED FOAM BAND-AID FLEXIBLE 5 RX/OTC DRESSING 3.5"X3" PADS FABRIC1" X 3" MISC AMD FOAM DRESSING 5 RX/OTC BAND-AID FLEXIBLE 5 RX/OTC 4"X4" PADS FABRICASSORTED MISC AMD FOAM DRESSING 5 RX/OTC BAND-AID FLEXIBLE RX/OTC 6"X6" PADS FABRICEXTRA LARGE 5 AMD FOAM RX/OTC MISC 5 DRESSING/TOPSHEET BAND-AID FLEXIBLE 5 RX/OTC 4"X4" PADS FABRICFINGERTIP MISC ANTIBACTERIAL RX/OTC BAND-AID FLEXIBLE RX/OTC BANDAGES/EXTRA 5 FABRICKNUCKLE & 5 LARGE MISC FINGERTIP MISC ANTIBACTERIAL CLEAR RX/OTC BAND-AID FLEXIBLE 5 RX/OTC ADVANCED BANDAGES 5 FABRICKNUCKLE MISC MISC BAND-AID FLEXIBLE RX/OTC ANTIBACTERIAL CLEAR RX/OTC FABRICTRAVEL PACK 5 BANDAGES 7/8"/SPOT 5 MISC MISC BAND-AID FLEXIBLE 5 RX/OTC ANTIBACTERIAL PLASTIC 5 RX/OTC MISC BANDAGES 3/4"X3" MISC BAND-AID FROZEN MISC 5 RX/OTC BAND AID BUTTERFLY 5 RX/OTC CLOSURE MEDIUM MISC BAND-AID GAUZE PADS 5 RX/OTC LARGE4" X 4" PADS BAND-AID 1" MISC 5 RX/OTC BAND-AID GAUZE PADS 5 RX/OTC BAND-AID ALL-IN-ONE SMALL2" X 2" PADS ADHESIVE GAUZE 5 BAND-AID GLOW IN THE 5 RX/OTC PAD/LARGE PADS DARK3/4" X 3" MISC BAND-AID ALL-IN-ONE BAND-AID HOT COLORS 5 RX/OTC ADHESIVE GAUZE 5 3/4"X 3" MISC PAD/MEDIUM PADS BAND-AID HURT-FREE BAND-AID BABY SHARK 5 RX/OTC NON-STICK PADS LARGE 5 MISC 3" X 4" PADS

176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BAND-AID HURT-FREE BAND-AID MIRASORB RX/OTC NON-STICK PADS 5 GAUZE SPONGES 5 MEDIUM 2" X 3" PADS LARGE 4" X 4" PADS BAND-AID HYDRO SEAL 5 RX/OTC BAND-AID MISC 5 RX/OTC ALL-PURPOSE MISC BAND-AID HYDRO SEAL RX/OTC BAND-AID RX/OTC BLISTER CUSHIONS 5 NICKELODEON 5 MEDIUM EXTREME MISC PAWPATROL MISC BAND-AID HYDRO SEAL RX/OTC BAND-AID PLASTIC MISC 5 RX/OTC BLISTER CUSHIONS 5 SMALL MISC BAND-AID PLASTIC 5 RX/OTC BAND-AID HYDRO SEAL RX/OTC SHEER MISC BLISTER CUSHIONS 5 BAND-AID PLASTIC 5 RX/OTC VARIETY MISC STRIPS MISC BAND-AID QUILTVENT BAND-AID HYDRO SEAL 5 RX/OTC EXTRA LARGE MISC WATERPROOF PAD 5 LARGE 2.875" X 4" PADS BAND-AID HYDRO SEAL 5 RX/OTC FINGERS MISC BAND-AID SHEER 5 RX/OTC COMFORT-FLEX MISC BAND-AID HYDRO SEAL 5 RX/OTC LARGE MISC BAND-AID SHEER 5 RX/OTC STRIPS 3/4" X 3" MISC BAND-AID INSIDE OUT 5 RX/OTC MISC BAND-AID SHEER 5 RX/OTC BAND-AID ISLAND RX/OTC STRIPS MISC SURGICALDRESSING 4" 5 BAND-AID SKIN-FLEX 5 RX/OTC X 10" PADS MISC BAND-AID ISLAND RX/OTC BAND-AID SPORT 5 RX/OTC SURGICALDRESSING 4" 5 STRIP/EXTRA WIDE MISC X 14" PADS BAND-AID STAR WARS 5 RX/OTC BAND-AID KLING RX/OTC MISC ROLLED GAUZE LARGE 5 BAND-AID SUPER 5 RX/OTC 4" X 2.1 YDS MISC STRIPS MISC BAND-AID KLING RX/OTC BAND-AID TOUGH 5 RX/OTC ROLLED GAUZE LARGE 5 STRIPS MISC 4" X 2.5 YDS MISC BAND-AID TOUGH- RX/OTC BAND-AID KLING RX/OTC STRIPS EXTRA LARGE 1- 5 ROLLED GAUZE MEDIUM 5 3/4" X 4" MISC 3" X 2.1 YDS MISC BAND-AID TOUGH- 5 RX/OTC BAND-AID KLING RX/OTC STRIPS MISC ROLLED GAUZE MEDIUM 5 BAND-AID TOUGH- RX/OTC 3" X 2.5 YDS MISC STRIPS WATERPROOF 5 BAND-AID KLING RX/OTC MISC ROLLED GAUZE SMALL 5 BAND-AID TOUGH- RX/OTC 2" X 2.5 YDS MISC STRIPS 5 BAND-AID MEDICATED 5 RX/OTC WATERPROOF/EXTRA STRIPS3/4" X 3" MISC LARGE MISC BAND-AID MICKEY RX/OTC 5 BAND-AID VARIETY 5 RX/OTC MOUSE MISC PACK MISC

177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BAND-AID WATER RX/OTC 5 CARPALAID EMPLOYEE 5 RX/OTC BLOCK PLUS MISC SURVIVAL/LARGE MISC BAND-AID WATER RX/OTC CARPALAID EMPLOYEE 5 RX/OTC BLOCK PLUSFINGER 5 SURVIVAL/SMALL MISC CARE MISC CARPALAID RX/OTC BAND-AID WATER RX/OTC PRACTIONER 5 BLOCK PLUSLARGE 5 PACK/LARGE MISC MISC CARPALAID RX/OTC BAND-AID/EXTRA LARGE 5 RX/OTC PRACTIONER 5 MISC PACK/SMALL MISC BAND-AID/HELLO KITTY 5 RX/OTC CARPALAID/LARGE MISC 5 RX/OTC MISC RX/OTC BAND-AID/MICKEY 5 RX/OTC CARPALAID/SMALL MISC 5 MOUSE MISC CARRASMART FOAM RX/OTC BAND-AID/PRINCESS 5 RX/OTC 5 MISC PADS RX/OTC BANDAGES FABRIC 5 RX/OTC CARRASMART PADS XX 5 KNUCKLE/FINGER MISC CLEAR BANDAGES MISC 5 RX/OTC BANDAGES FABRIC 5 RX/OTC STRIPS 3/4" MISC COMPEED SKIN RX/OTC BIOGUARD BARRIER RX/OTC PROTECTOR 5 DRESSING/LARGE ROLL 5 DRESSING/MEDIUM/OVA MISC L MISC BIOGUARD GAUZE RX/OTC COMPEED SKIN RX/OTC SPONGE 2"X2" 8 PLY 5 PROTECTOR 5 PADS DRESSING/SMALL/STRIP BIOGUARD GAUZE RX/OTC MISC SPONGES 4"X4" 12 PLY 5 COPA ISLAND RX/OTC PADS BORDERED FOAM 5 DRESSING 4"X4" PADS BIOGUARD ISLAND 5 RX/OTC DRESSINGS4"X10" PADS COPA ISLAND RX/OTC BORDERED FOAM 5 BIOGUARD ISLAND 5 RX/OTC DRESSINGS4"X14" PADS DRESSING 6"X6" PADS COPA PLUS RX/OTC BIOGUARD ISLAND 5 RX/OTC DRESSINGS4"X5" PADS HYDROPHILIC FOAM 5 BIOGUARD NON- RX/OTC DRESSING 4"X4" PADS ADHERENT DRESSINGS 5 COPA PLUS RX/OTC 3"X4" PADS HYDROPHILIC FOAM 5 BIOGUARD NON- RX/OTC DRESSING 4"X8" PADS ADHERENT DRESSINGS 5 COPA PLUS RX/OTC 3"X8" PADS HYDROPHILIC FOAM 5 DRESSING 6"X6" PADS BLISTER RELIEF 5 RX/OTC BANDAGE MISC COVERLET STRIPS MISC 5 RX/OTC BORDERED GAUZE 5 RX/OTC PADS COVRSITE COVER 5 RX/OTC DRESSING PADS BUTTERFLY CLOSURES 5 RX/OTC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COVRSITE PLUS RX/OTC CURAD WILD STYLES 5 RX/OTC COMPOSITE DRESSING 5 TATTOO-U MISC PADS CURITY #10 BURN RX/OTC CRAYON BANDAGES 5 RX/OTC DRESSING/READY CUT 5 STRIPS MISC GAUZE/12"X12" MISC CRUAD GAUZE PADS 4" 5 RX/OTC CURITY #10 BURN RX/OTC X 4" PADS DRESSING/READY CUT 5 GAUZE/18"X18" MISC CURAD ACTI-FLEX FOAM 5 RX/OTC 7/8" MISC CURITY #10 BURN RX/OTC DRESSING/READY CUT 5 CURAD ACTI-FLEX FOAM 5 RX/OTC ASSORTED MISC GAUZE/36"X36" MISC CURAD ADHESIVE RX/OTC CURITY #10 GAUZE RX/OTC BANDAGES FLEX 5 BOLT/OVAL 5 ASSORTED MISC FOLD/36"X300' MISC CURAD ADHESIVE RX/OTC CURITY ADHESIVE RX/OTC BANDAGES FLEX FAMILY 5 WOUND CLOSURE 5 ASSORTED MISC STRIPS 1/2"X4" MISC CURITY ADHESIVE RX/OTC CURAD COMFORT 5 RX/OTC FABRIC MISC WOUND CLOSURE 5 STRIPS 1/4"X1-1/2" MISC RX/OTC CURAD GODZILLA MISC 5 CURITY ADHESIVE RX/OTC CURAD HOLD TITE RX/OTC WOUND CLOSURE 5 STRIPS 1/4"X3" MISC TUBULAR STRETCH 5 BANDAGE/LARGE/5YDS CURITY ADHESIVE RX/OTC MISC WOUND CLOSURE 5 STRIPS 1/4"X4" MISC CURAD JURASSIC PARK 5 RX/OTC MISC CURITY ADHESIVE RX/OTC CURAD KID SIZE RX/OTC WOUND CLOSURE 5 DINOSAUR BANDAGES 5 STRIPS 1/8"X3" MISC MISC CURITY ALL PURPOSE RX/OTC SPONGES 2"X2" 4PLY 5 CURAD NON-STICK 5 RX/OTC PADS 3"X4" PADS PADS CURAD NON-STICK CURITY ALL PURPOSE 5 RX/OTC PADS WITHADHESIVE 5 SPONGES 2"X2" PADS TABS 3"X4" PADS CURITY ALL PURPOSE 5 RX/OTC SPONGES 4 PLY PADS CURAD SENSITIVE SKIN 5 RX/OTC 3/4" MISC CURITY ALL PURPOSE RX/OTC CURAD SENSITIVE SKIN RX/OTC SPONGES 4"X3" 4PLY 5 ASSORTED FAMILY 5 PADS PACK MISC CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 4PLY 5 CURAD SENSITIVE SKIN 5 RX/OTC EXTRA LARGE MISC PADS CURITY ALL PURPOSE RX/OTC CURAD SENSITIVE SKIN 5 RX/OTC SPOTS MISC SPONGES 4"X4" 5 4PLY/SOFT POUCH PADS CURAD WILD STYLES 5 RX/OTC DESIGN-ITS MISC CURITY ALL PURPOSE 5 RX/OTC SPONGES 4"X4" PADS

179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY AMD RX/OTC CURITY CURAD NEON RX/OTC ANTIMICROBIALGAUZE 5 STRIPSBANDAGES/3/4"/A 5 SPONGES 2"X2" 8 PLY SSORTED COLORS MISC PADS CURITY DRESSING RX/OTC CURITY AMD RX/OTC SPONGES 4"X3" 6 PLY 5 ANTIMICROBIALGAUZE 5 PADS SPONGES 4"X4" 12 PLY CURITY DRESSING RX/OTC PADS SPONGES 4"X4" 6 PLY 5 CURITY AMD RX/OTC PADS ANTIMICROBIALPACKING 5 CURITY GAUZE PADS 5 RX/OTC STRIPS 1"X3' MISC 2"X2" 12 PLY PADS CURITY AMD RX/OTC CURITY GAUZE PADS 5 RX/OTC ANTIMICROBIALPACKING 5 2"X2" PADS STRIPS 1/2"X3' MISC CURITY GAUZE PADS 5 RX/OTC CURITY AMD RX/OTC 4"X4" 12 PLY PADS ANTIMICROBIALPACKING 5 STRIPS 1/4"X3' MISC CURITY GAUZE SPONGE 5 RX/OTC 2"X2" 8 PLY PADS CURITY COVER SPONGE 5 RX/OTC 4"X4" PADS CURITY GAUZE SPONGE 5 RX/OTC 2"X2"12 PLY PADS CURITY COVER 5 RX/OTC SPONGES 3"X4" PADS CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 12 PLY PADS CURITY COVER 5 RX/OTC SPONGES 4"X3" PADS CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 16 PLY PADS CURITY COVER 5 RX/OTC SPONGES 4"X4" PADS CURITY GAUZE SPONGE 5 RX/OTC 4"X4" 8 PLY PADS CURITY CURAD RX/OTC CURITY GAUZE SPONGE RX/OTC ADHESIVE 5 5 BANDAGES/3/4" PLASTIC 4"X4"16 PLY PADS MISC CURITY GAUZE SPONGE 5 RX/OTC CURITY CURAD RX/OTC 8"X4" 12 PLY PADS CURITY GAUZE SPONGE RX/OTC ADHESIVE 5 5 BANDAGES/3/4" SHEER 8"X4"12 PLY PADS MISC CURITY GAUZE RX/OTC CURITY CURAD RX/OTC SPONGES 4"X3"16 PLY 5 PADS ADHESIVE 5 BANDAGES/PLASTIC CURITY GAUZE RX/OTC MISC SPONGES 4"X4" 12 PLY 5 CURITY CURAD RX/OTC PADS ADHESIVE 5 CURITY GAUZE RX/OTC BANDAGES/SHEER MISC SPONGES 4"X4" 8 PLY 5 CURITY CURAD RX/OTC PADS FLEXIBLE FABRIC 5 CURITY IODOFORM RX/OTC BANDAGES/3/4" MISC PACKING STRIP 1"X15' 5 CURITY CURAD RX/OTC MISC FLEXIBLE FABRIC 5 CURITY IODOFORM RX/OTC BANDAGES/ASSORTED PACKING STRIP 1/2"X15' 5 MISC MISC

180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY IODOFORM RX/OTC CURITY STRETCH RX/OTC PACKING STRIP 1/4"X15' 5 GAUZE 5 MISC BANDAGE/2"X4.1YD MISC CURITY IODOFORM RX/OTC CURITY STRETCH RX/OTC PACKING STRIP 2"X15' 5 GAUZE 5 MISC BANDAGE/3"X4.1YD MISC CURITY IODOFORM 5 RX/OTC CURITY STRETCH RX/OTC PACKING STRIP MISC GAUZE 5 CURITY KERLIX RX/OTC BANDAGE/4"X4.1YD MISC BANDAGE ROLL/2- 5 CURITY TELFA STERILE RX/OTC 1/4"X108" MISC ADHESIVE PADS/3"X4" 5 CURITY KERLIX RX/OTC PADS BANDAGE ROLL/4- 5 CURITY TELFA STERILE RX/OTC 1/2"X144" MISC NON-STICK PADS/3"X4" 5 PADS CURITY KERLIX ROLL 5 RX/OTC 4.5X4.1 YARDS MISC CURITY TRIANGULAR RX/OTC CURITY MESH GAUZE RX/OTC BANDAGE 40"X40"X56" 5 BANDAGEROLL 1"X30' 5 MISC MISC CURITY WET DRESSING 5 RX/OTC CURITY MESH GAUZE RX/OTC 8"X4" PADS BANDAGEROLL 2"X30' 5 CVS ADHESIVE RX/OTC MISC BANDAGES FOAM TOE 5 CURITY MESH GAUZE RX/OTC SIZE MISC BANDAGEROLL 3"X30' 5 CVS ADHESIVE GAUZE RX/OTC MISC PAD PREMIUM 4"X8" 5 CURITY MESH GAUZE RX/OTC PADS BANDAGEROLL 4"X30' 5 CVS ADHESIVE PAD 5 MISC 4"X4" PADS CURITY NON-ADHERENT 5 RX/OTC CVS ADHESIVE PAD 5 STRIPS 1/2"X12' MISC 6"X6" PADS CURITY NON-ADHERENT 5 RX/OTC CVS ADHESIVE PADS 5 STRIPS 3"X8" PADS 2.25"X3" PADS CURITY NON-ADHERING 5 RX/OTC CVS ADVANCED RX/OTC DRESSINGS 3"X8" PADS HEALING PREMIUM 5 BANDAGES/SMALL MISC CURITY PLAIN PACKING 5 RX/OTC STRIP MISC CVS ANTI-BACTERIAL RX/OTC CURITY RX/OTC BANDAGES CHILDRENS 5 SPONGES/CELLULOSEFI 5 MISC LLED/2"X2" PADS CVS ANTI-BACTERIAL 5 RX/OTC CURITY RX/OTC BANDAGES MISC SPONGES/CELLULOSEFI 5 CVS ANTI-BACTERIAL RX/OTC LLED/4"X4" PADS BANDAGES 5 CURITY STRETCH RX/OTC WATERPROOF MISC GAUZE 5 CVS ANTIBACTERIAL RX/OTC BANDAGE/1"X4.1YD BANDAGES/HEAVY DUTY 5 MISC FABRIC MISC

181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS BUTTERFLY 5 RX/OTC DERMACEA GAUZE RX/OTC CLOSURES MISC FLUFF ROLL 4.5"X4.1 YD 5 6 PLY MISC CVS CLEAR BANDAGES 5 RX/OTC MISC DERMACEA GAUZE ROLL 5 RX/OTC CVS FLEXIBLE FABRIC RX/OTC 2"X4-1/8YD MISC ANTI-BACTERIAL 5 DERMACEA GAUZE ROLL 5 RX/OTC BANDAGES MISC 3"X4-1/8YD MISC CVS GAUZE PAD 8"X4" RX/OTC 5 DERMACEA GAUZE ROLL 5 RX/OTC PADS 4"X4-1/8YD MISC CVS GAUZE PADS 2"X2" RX/OTC 5 DERMACEA GAUZE ROLL 5 RX/OTC 12-PLY PADS 6"X4-1/8YD MISC CVS GAUZE PADS 4"X4" 5 RX/OTC DERMACEA GAUZE RX/OTC 12-PLY PADS SPONGE 2"X2" 12 PLY 5 CVS GAUZE PADS RX/OTC PADS STERILE 4"X4" 12-PLY 5 DERMACEA GAUZE RX/OTC PADS SPONGE 2"X2" 8 PLY 5 PADS CVS NON-STICK PADS 5 RX/OTC 3"X4" PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 12 PLY 5 CVS NON-STICK PADS 5 RX/OTC 3"X8" PADS PADS DERMACEA GAUZE RX/OTC CVS PLASTIC 5 RX/OTC BANDAGES MISC SPONGE 4"X4" 16 PLY 5 PADS CVS SHEER BANDAGES 5 RX/OTC EXTRALARGE MISC DERMACEA GAUZE RX/OTC SPONGE 4"X4" 8 PLY 5 CVS SHEER BANDAGES 5 RX/OTC PADS MISC DERMACEA I.V. DRAIN 5 RX/OTC CVS SPOT BANDAGE 5 RX/OTC SPONGES 2"X2" PADS SHEER MISC DERMACEA I.V. DRAIN 5 RX/OTC CVS TUBULAR GAUZE 5 RX/OTC SPONGES 4"X4" PADS MISC DERMACEA I.V. 5 RX/OTC DERMACEA DRAIN 5 RX/OTC SPONGES 2"X2" PADS SPONGES 4"X4" PADS DERMACEA NON- RX/OTC DERMACEA GAUZE RX/OTC ADHERENT DRESSING 5 FLUFF ROLL 2"X3YD 5 3"X4" PADS MISC DERMACEA NON-WOVEN RX/OTC DERMACEA GAUZE RX/OTC SPONGES 2"X2" 4 PLY 5 FLUFF ROLL 2.25"X3 YD 5 PADS 6 PLY MISC DERMACEA NON-WOVEN RX/OTC DERMACEA GAUZE RX/OTC SPONGES 3"X4" 4 PLY 5 FLUFF ROLL 3.4"X3- 5 PADS 1/2YD 6PLY MISC DERMACEA NON-WOVEN RX/OTC DERMACEA GAUZE RX/OTC SPONGES 3"X4" 6 PLY 5 FLUFF ROLL 3.4"X3.6 YD 5 PADS 6 PLY MISC DERMACEA NON-WOVEN RX/OTC DERMACEA GAUZE RX/OTC SPONGES 4"X4" 4 PLY 5 FLUFF ROLL 4-1/2"X4- 5 PADS 1/8YD 6PLY MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA NON-WOVEN RX/OTC DERMACEA TYPE VII RX/OTC SPONGES 4"X4" 6 PLY 5 GAUZE 4"X4" 12 PLY 5 PADS PADS DERMACEA STRETCH RX/OTC DERMACEA TYPE VII RX/OTC BANDAGE ROLL 2"X12' 5 GAUZE 4"X4" 16 PLY 5 MISC PADS DERMACEA STRETCH RX/OTC DERMACEA TYPE VII 5 RX/OTC BANDAGE ROLL 3"X12' 5 GAUZE 4"X4" 8 PLY PADS MISC DERMACEA X-RAY RX/OTC DERMACEA STRETCH RX/OTC SPONGES 4"X4" 16 PLY 5 BANDAGE ROLL 4"X12' 5 PADS MISC DERMACEA X-RAY RX/OTC DERMACEA STRETCH RX/OTC SPONGES 4"X8" 12 PLY 5 BANDAGE ROLL 6"X12' 5 PADS MISC DERMACEA X-RAY RX/OTC DERMACEA STRETCH RX/OTC SPONGES 4"X8" 12PLY 5 BANDAGE2"X4-1/8YD 5 PADS MISC DERMACEA X-RAY RX/OTC DERMACEA STRETCH RX/OTC SPONGES 4"X8" 16 PLY 5 BANDAGE3"X4-1/8YD 5 PADS MISC DERMACEA X-RAY RX/OTC DERMACEA STRETCH RX/OTC SPONGES 4"X8" 24 PLY 5 BANDAGE4"X4-1/8YD 5 PADS MISC DERMADRESS RX/OTC DERMACEA STRETCH RX/OTC 5 WATERPROOF 5 BANDAGE6"X12.3' MISC COMPOSITE DRESSING DERMACEA STRETCH RX/OTC MISC BANDAGE6"X4-1/8YD 5 DERMALEVIN ADHESIVE RX/OTC MISC FOAMDRESSING 4"X4" 5 DERMACEA STRETCH RX/OTC PADS BANDAGEROLL 3"X12' 5 DERMALEVIN ADHESIVE RX/OTC MISC FOAMDRESSING 6"X6" 5 DERMACEA STRETCH RX/OTC PADS BANDAGEROLL 4"X12' 5 DRYMAX EXTRA PADS 5 RX/OTC MISC DERMACEA STRETCH RX/OTC EQ FLEXIBLE FABRIC RX/OTC BANDAGEROLL 6"X12' 5 BANDAGES/ANTIBACTER 5 MISC IAL MISC EQ STRONG STRIPS RX/OTC DERMACEA SUPER 5 RX/OTC SPONGE 6"X6.75" PADS BANDAGES/ANTIBACTER 5 DERMACEA TYPE VII RX/OTC IAL MISC GAUZE 2"X2" 12 PLY 5 EQL ADHESIVE PADS 5 RX/OTC PADS LARGE MISC EQL ADHESIVE PADS RX/OTC DERMACEA TYPE VII 5 RX/OTC 5 GAUZE 2"X2" 8 PLY PADS MEDIUM MISC EQL ADVANCED RX/OTC HEALING ADHESIVE 5 BANDAGES MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL ANIMAL PRINT RX/OTC 5 EQL SHEER STRIPS 5 RX/OTC STRIPS MISC MULTI-PURPOSE MISC EQL ANTIBACTERIAL RX/OTC 5 EQL STERILE NON-STICK 5 RX/OTC FABRICSTRIPS MISC PADS 3"X4"/LARGE PADS EQL BUTTERFLY 5 RX/OTC EQL STRIPS MISC 5 RX/OTC CLOSURES MISC EQL FIRST AID RX/OTC EQL STRONG STRIPS 5 RX/OTC ANTISEPTICBANDAGES 5 WATERPROOF MISC MISC EQL VARIETY PACK RX/OTC ADHESIVEBANDAGES 5 EQL FLEXIBLE FABRIC 5 RX/OTC BANDAGES MISC MISC EQL FLEXIBLE FABRIC RX/OTC EXCILON AMD RX/OTC BANDAGES MULTI- 5 ANTIMICROBIALDRAIN 5 PURPOSE MISC SPONGES 4"X4" 6 PLY EQL FLEXIBLE FABRIC RX/OTC PADS BANDAGES/EXTRA 5 EXCILON AMD RX/OTC LARGE MISC ANTIMICROBIALNON- 5 EQL FLEXIBLE FABRIC RX/OTC WOVEN SPONGES 4"X4" BANDAGES/KNUCKLE & 5 6 PLY PADS FINGERTIP MISC EXCILON DRAIN 5 RX/OTC SPONGE 4"X4" PADS EQL FLEXIBLE FOAM 5 RX/OTC STRIPS MISC EXCILON DRAIN RX/OTC SPONGES 4"X4" 6 PLY 5 EQL GAUZE PADS 5 RX/OTC 2"X2"/SMALL PADS PADS EXCILON I.V. SPONGES RX/OTC EQL GAUZE PADS 5 RX/OTC 5 4"X4"/LARGE PADS 2"X2" 6 PLY PADS FABRIC RX/OTC EQL GENTLE STRIPS 5 RX/OTC MISC BANDAGES/ASSORTED 5 MISC EQL HEAVY DUTY RX/OTC BANDAGES EXTRA LONG 5 FLEXIBLE FABRIC 5 RX/OTC 3/4"X4-3/4" MISC BANDAGES MISC EQL HEAVY DUTY RX/OTC FLEXIBLE FABRIC RX/OTC FABRIC STRIPS MULTI- 5 BANDAGESASSORTED 5 PURPOSE MISC MISC EQL HEAVY DUTY RX/OTC FLEXZAN 4 X 8 PADS 5 RX/OTC FABRIC STRIPS/EXTRA 5 LARGE MISC GAUZE BANDAGE 3" 5 RX/OTC MISC EQL PLASTIC STRIPS 5 RX/OTC MISC GAUZE BANDAGE/2" X 5 RX/OTC 4YDS MISC EQL PLASTIC STRIPS 5 RX/OTC MULTI-PURPOSE MISC GAUZE DRESSING 4"X4" 5 RX/OTC PADS EQL SHEER SPOTS 5 RX/OTC SMALL MISC GAUZE PADS 2"X2" PADS 5 RX/OTC EQL SHEER STRIPS RX/OTC 5 GAUZE PADS 4"X4" 12 5 RX/OTC EXTRA LARGE MISC PLY PADS EQL SHEER STRIPS 5 RX/OTC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAUZE PADS 4"X4" PADS 5 RX/OTC HM STERILE PADS 2"X2" 5 RX/OTC PADS GAUZE SPONGE TYPE RX/OTC RX/OTC VII MEDI-PAK 2"X2" 8PLY 5 HM STERILE PADS PADS 5 PADS HYDROCELL ADHESIVE 5 RX/OTC GAUZE SPONGES 4"X4" 5 RX/OTC DRESSING 4"X4" PADS 12 PLY PADS HYDROCELL ADHESIVE 5 RX/OTC GAUZE STRETCH RX/OTC DRESSING 6"X6" PADS BANDAGE 3"X2.5YD 5 HYDROCELL DRESSING 5 RX/OTC MISC 4"X4" PADS GENTLE ADHESIVE RX/OTC HYDROCELL DRESSING 5 RX/OTC BANDAGES/EXTRA 5 6"X6" PADS LARGE MISC J & J ADHESIVE LARGE 5 GNP ADHESIVE PADS 3" 5 PADS X 4" PADS J & J GAUZE 2"X2" 8 PLY 5 RX/OTC GNP CLEAR STRIPS 5 RX/OTC PADS MISC J & J GAUZE 4"X4" 12 PLY 5 RX/OTC GNP PLASTIC STRIPS 5 RX/OTC PADS 3/4" MISC J & J GAUZE 4"X4" 8 PLY 5 RX/OTC GNP SHEER STRIPS 5 RX/OTC PADS ASSORTED MISC J & J GAUZE SPONGES 5 RX/OTC GNP SHEER STRIPS 5 RX/OTC 12-PLY 4" X 4" MISC MISC J & J GAUZE SPONGES 5 RX/OTC GNP SUPER STRIP RX/OTC 16-PLY 4" X 4" MISC WATERSEALBANDAGES 5 MISC J & J GAUZE SPONGES 5 RX/OTC 8-PLY4" X 4" MISC HM ADHESIVE RX/OTC BANDAGES 5 J & J NON-STICK PADS 5 ANTIBACTERIAL MISC 100LARGE PADS HM ADHESIVE RX/OTC KENDALL HYDROPHILIC RX/OTC FOAM DRESSING 4"X8" 5 BANDAGES 5 ANTIBACTERIAL/SHEER PADS MISC KENDALL HYDROPHILIC RX/OTC HM ADHESIVE RX/OTC FOAMDRESSING 2"X2" 5 PADS BANDAGES 5 ANTIBACTERIAL/SHEER/ KENDALL HYDROPHILIC RX/OTC XL MISC FOAMDRESSING 4"X4" 5 HM ADHESIVE PADS PADS ANTIBACTERIAL/SHEER 5 KENDALL HYDROPHILIC RX/OTC PADS FOAMDRESSING 6"X6" 5 PADS HM BUTTERFLY 5 RX/OTC CLOSURES MISC KENDALL HYDROPHILIC RX/OTC HM FABRIC ADHESIVE RX/OTC FOAMPLUS DRESSING 5 BANDAGES ADVANCED 5 2"X2" PADS ANTIBACTERIAL MISC KERLIX AMD RX/OTC ANTIMICROBIALBANDAG HM NON-STICK PADS 3" 5 RX/OTC 5 X 4" PADS E ROLL 4-1/2"X12.3YD 6 PLY MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERLIX AMD RX/OTC LEUKOSTRIP 1/2"X4" 5 RX/OTC ANTIMICROBIALSUPER 5 MISC SPONGES PADS LEUKOSTRIP 1/4"X3" 5 RX/OTC KERLIX BANDAGE ROLL 5 RX/OTC MISC 2-1/4"X9' 6PLY MISC LEUKOSTRIP 1/4"X4" 5 RX/OTC KERLIX BANDAGE ROLL RX/OTC MISC 3-7/16"X3-3/16' 6PLY 5 LEUKOSTRIP 1/8"X1-1/2" 5 RX/OTC MISC MISC KERLIX BANDAGE ROLL RX/OTC MEDIPORE + PAD SOFT RX/OTC 4-1/2"X4-1/8YD 6PLY 5 CLOTH ADHESIVE 5 MISC WOUND DRESSING 6"X6" KERLIX BANDAGE ROLL 5 RX/OTC PADS 4-1/2"X9.3' 8PLY MISC MIRASORB SPONGES 2" 5 RX/OTC KERLIX BANDAGE RX/OTC X 2" MISC ROLL/6 PLY/MEDIUM 5 MIRASORB SPONGES 4" 5 RX/OTC MISC X 4" MISC KERLIX GAUZE ROLL RX/OTC MOLESKIN FOAM 5 LARGE 4.5"X 4.1YD 6 PLY 5 PADDING PADS MISC NEXCARE ABSOLUTE KERLIX GAUZE ROLL RX/OTC WATERPROOF PAD 5 MEDIUM3.4"X3.6YD 6 PLY 5 PADS MISC NEXCARE ABSOLUTE RX/OTC KERLIX GAUZE ROLL RX/OTC WATERPROOF PREMIUM 5 SMALL 2.25"X 3YD 6 PLY 5 ADHESIVE PAD 2- MISC 3/8"X45" MISC KERLIX SPONGES 4" X 4" 5 RX/OTC NEXCARE ACTIVE RX/OTC 12 PLY PADS BRIGHTS BANDAGES 5 KERLIX SPONGES 4" X 4" 5 RX/OTC ASSORTED MISC 16 PLY PADS NEXCARE ACTIVE RX/OTC KERLIX SUPER RX/OTC SPORT FOAM 5 SPONGES MEDIUM 6"X6- 5 BANDAGES 1-1/8" X 3" 3/4" PADS MISC KERLIX SUPER RX/OTC NEXCARE ACTIVE RX/OTC SPONGES MEDIUM 5 SPORT FOAM 5 6"X6.75" PADS BANDAGES ASSORTED KERLIX X-RAY RX/OTC MISC DETECTABLE PACKING 5 NEXCARE ACTIVE RX/OTC SPONGE 4-1/2"X22" MISC SPORT FOAM 5 KERLIX X-RAY RX/OTC BANDAGES KNEE/ELBOW MISC DETECTABLE SPONGES 5 EXTRA LARGE 1-5/8" NEXCARE ADHESIVE RX/OTC MISC DRESSING/PAD 5 RX/OTC WATERPROOF 6" X 6" KLING FLUFF MISC 5 PADS NEXCARE COMFORT RX/OTC KLING FLUFF SPONGE 5 RX/OTC 6X6.75 MISC FABRIC BANDAGES 3/4" 5 X 3" MISC

186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXCARE COMFORT RX/OTC NEXCARE TATTOO RX/OTC 5 FABRIC BANDAGES WATERPROOF 5 ASSORTED MISC BANDAGES/POOH 1-1/16" NEXCARE COMFORT RX/OTC X 2-1/4" MISC FABRIC BANDAGES 5 NEXCARE TATTOO RX/OTC KNEE/ELBOW MISC WATERPROOF 5 NEXCARE HEAVY DUTY RX/OTC BANDAGES/PRINCESS 1- 1/16" X 2-1/4" MISC CLEAR& TOUGH 5 BANDAGES ASSORTED NEXCARE WATERPROOF RX/OTC MISC BANDAGES 1-1/16" X 2- 5 NEXCARE HEAVY DUTY RX/OTC 1/4" MISC CLEAR& TOUGH 5 NEXCARE WATERPROOF RX/OTC BANDAGES BANDAGES ASSORTED 5 KNEE/ELBOW MISC MISC NEXCARE HEAVY DUTY RX/OTC NEXCARE WATERPROOF RX/OTC FLEXIBLE FABRIC 5 BANDAGES 5 BANDAGES 1-1/8"X3" KNEE/ELBOW MISC MISC NEXCARE WATERPROOF 5 RX/OTC NEXCARE HEAVY DUTY RX/OTC BANDAGES MISC FLEXIBLE FABRIC 5 NON-STICK PADS 3"X4" 5 RX/OTC BANDAGES ASSORTED PADS MISC NU GAUZE 4PLY 4"X4" 5 RX/OTC NEXCARE HEAVY DUTY RX/OTC PADS FLEXIBLE FABRIC 5 BANDAGES NU GAUZE GENERAL- RX/OTC KNEE/ELBOW MISC USE SPONGES 4"X4" 4 5 PLY MISC NEXCARE NON-STICK 5 RX/OTC PADS 3"X 4" PADS NU GAUZE PACKING RX/OTC STRIPS PLAIN 1/2" X 5 5 NEXCARE PREMIUM RX/OTC YDS MISC ADHESIVEGAUZE PAD 6" 5 X 6" PADS NU GAUZE UTERINE RX/OTC PACKINGSTRIPS 5 NEXCARE SOFT 'N FLEX 5 RX/OTC IODOFORM 8" X 10 YDS BANDAGES MISC MISC NEXCARE TATTOO RX/OTC OPTIFOAM PADS 5 RX/OTC WATERPROOF 5 BANDAGES 1-1/16" X 2- PEANUTS BANDAGES 5 RX/OTC 1/4" MISC MISC NEXCARE TATTOO RX/OTC PLASTIC ADHESIVE 5 RX/OTC WATERPROOF 5 BANDAGES 3/4" MISC BANDAGES/EINSTEINS 1- 1/16"X2-1/4" MISC PLASTIC BANDAGES 3/4" 5 RX/OTC MISC NEXCARE TATTOO RX/OTC POLYMEM FILM DOT WATERPROOF 5 5 BANDAGES/NEMO 1- PADS 1/16" X 2-1/4" MISC POLYMEM NON- 5 RX/OTC ADHESIVE PAD PADS PRIMAPORE 11-3/4"X4" 5 RX/OTC MISC

187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRIMAPORE 13-3/4"X4" 5 RX/OTC RA BANDAGES FLEXIBLE RX/OTC MISC FABRIC ASSORTED 5 SIZES MISC PRIMAPORE 2-7/8"X2" 5 RX/OTC MISC RA BANDAGES FLEXIBLE RX/OTC FABRIC EXTRA LARGE 5 PRIMAPORE 4"X3-1/8" 5 RX/OTC MISC MISC RA BANDAGES FLEXIBLE RX/OTC PRIMAPORE 6"X3-1/8" 5 RX/OTC MISC FABRIC HEAVY DUTY 5 MISC RX/OTC PRIMAPORE 8"X4" MISC 5 RA BANDAGES FLEXIBLE RX/OTC FABRIC NON STICK 5 PROXI-STRIP 1/4" X 4" 5 RX/OTC MISC 3/4"X3" MISC RA BANDAGES FLEXIBLE RX/OTC PROXI-STRIPS 1/2"X4" 5 RX/OTC MISC FABRIC NON STICK 5 EXTRA LARGE MISC PX SUPERSTRIP 1" X 3" 5 RX/OTC MISC RA BANDAGES FLEXIBLE 5 RX/OTC FOAM MISC QC ALL PURPOSE 5 RX/OTC DRESSINGS4"X4" PADS RA RX/OTC BANDAGES/CLEAR/ASSO 5 QC BORDER ISLAND 5 RX/OTC RTED MISC GAUZE PAD 2"X2" PADS RA BANDAGES/EXTRA RX/OTC QC NON-ADHERENT 5 RX/OTC LONG FABRIC/HEAVY 5 PADS 3"X4" PADS DUTY MISC QC STERILE PADS PADS 5 RX/OTC RA BANDAGES/STRONG- RX/OTC STRIPS/EXTRA LARGE 5 RA ADHESIVE RX/OTC MISC BANDAGES FLEXIBLE 5 FOAM MISC RA BUTTERFLY RX/OTC BANDAGES/MEDIUM 5 RA ADHESIVE RX/OTC MISC BANDAGES FLEXIBLE 5 MISC RA CONFORMED 5 RX/OTC BANDAGE MISC RA ADHESIVE 5 RX/OTC BANDAGES MISC RA DRESSING SPONGES 5 RX/OTC 4"X4" PADS RA ADHESIVE RX/OTC BANDAGES PLASTIC 5 RA FIRST AID RX/OTC MISC ADVANCED ANTIBACTERIAL 5 RA ADHESIVE 5 RX/OTC WATERPROOF STRONG BANDAGES SHEER MISC STRIPS MISC RA ADHESIVE PADS 2- RX/OTC 5 RA FIRST AID CLEAR 5 RX/OTC 1/4"X3" MISC SPOT 7/8" MISC RA ADHESIVE PADS 5 RX/OTC RA FIRST AID FLEXIBLE RX/OTC 3"X4" MISC FABRIC ADHESIVE 5 RA ALL PURPOSE 5 RX/OTC BANDAGE MISC DRESSINGS4"X4" PADS RA FIRST AID NON-STICK 5 RA BANDAGES CLEAR 5 RX/OTC PADS PADS MISC

188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA FIRST AID SHEER RX/OTC RESTORE FOAM RX/OTC ADHESIVE BANDAGE 5 DRESSING BORDERED 5 MISC 6"X6" PADS RA GAUZE BANDAGE 5 RX/OTC RESTORE FOAM RX/OTC MISC DRESSING NON- 5 BORDERED 4"X4" PADS RA GAUZE SPONGES 5 RX/OTC 4"X4" PADS RESTORE FOAM RX/OTC DRESSING NON- 5 RA SHEER ADHESIVE 5 LARGE PADS BORDERED 6"X6" PADS RESTORE LITE FOAM RX/OTC RA STERILE PADS 2"X2" 5 RX/OTC PADS DRESSING NON- 5 BORDERED 4"X5" PADS RA STERILE PADS 4"X4" 5 RX/OTC PADS RESTORE LITE FOAM RX/OTC DRESSING NON- 5 RA STRONG STRIPS 5 RX/OTC BORDERED 6"X6" PADS BANDAGES MISC RESTORE ODOR RX/OTC RA STRONG STRIPS RX/OTC ABSORBING DRESSING 5 BANDAGES NON-STICK 5 4"X4" PADS MISC RESTORE TRIO RX/OTC RA SUPER STRIP 1"X3" 5 RX/OTC ABSORBENT DRESSING 5 MISC 4"X5" PADS RA TUBULAR 5 RX/OTC SHEER ADHESIVE RX/OTC GAUZE/FINGER MISC BANDAGES 3/4" X 3" 5 RAY-TEC X-RAY RX/OTC MISC DETECTABLESPONGES 5 SHEER ADHESIVE 5 RX/OTC 4" X 4" 16 PLY MISC BANDAGES MISC RAY-TEC X-RAY RX/OTC SHEER BANDAGES 3/4" 5 RX/OTC DETECTABLESPONGES 5 MISC 8" X 4" 12 PLY MISC RX/OTC RAY-TEC X-RAY RX/OTC SHEER BANDAGES MISC 5 DETECTABLESPONGES 5 8" X 4" 16 PLY MISC SHEER RX/OTC BANDAGES/ASSORTED 5 RELEASE NON- RX/OTC MISC ADHERING DRESSING 4" 5 X 3" PADS SHEER BANDAGES/EX- 5 RX/OTC LARGE MISC RELIAMED SELF- RX/OTC ADHESIVE DRESSING 5 SM ADHESIVE PADS 5 RETENTION SHEET MISC 2"X3" PADS RESTORE CONTACT RX/OTC SM ADHESIVE PADS 5 LAYER/NON-ADHERENT 5 3"X4" PADS 2"X2" PADS SM BANDAGE ROLL 5 RX/OTC RESTORE DUO RX/OTC 4.5"X144" MISC ABSORBENT DRESSING 5 SM BANDAGES CLEAR 5 RX/OTC 4"X5" PADS SPOTS MISC RESTORE FOAM RX/OTC SM BANDAGES FABRIC 5 RX/OTC DRESSING BORDERED 5 3/4" MISC 4"X4" PADS SM BANDAGES FABRIC 5 RX/OTC EXTRALARGE MISC

189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM BANDAGES FABRIC RX/OTC SOF-SET ADHESIVE 5 KNUCKLE/FINGERTIP 5 PATCH PADS MISC SOF-WICK 4"X4" PADS 5 RX/OTC SM BANDAGES FOAM 5 RX/OTC EXTRA LARGE MISC SOF-WIK MISC 5 RX/OTC SM BANDAGES FOAM 5 RX/OTC MISC SORESPOT BLISTER & RX/OTC SKIN PROTECTION 5 SM BANDAGES PLASTIC 5 RX/OTC MISC BANDAGES MISC SPENCO ADHESIVE KNIT RX/OTC SM BANDAGES SHEER 5 RX/OTC 5 EXTRA LARGE MISC 3"X5" MISC STERI-STRIP 1 7/8" X RX/OTC SM BANDAGES SHEER 5 RX/OTC MISC 1/2"/DRESSING 2 3/8" X 1 5 7/8" MISC SM BANDAGES STRONG 5 RX/OTC STRIPS 1" MISC STERI-STRIP 1" X 5" MISC 5 RX/OTC SM BANDAGES RX/OTC 5 STERI-STRIP 1/2" X 2" 5 RX/OTC WATERSHIELD MISC MISC SM RX/OTC STERI-STRIP 1/2" X 4 " 5 RX/OTC BANDAGES/ANTIBACTER 5 MISC IAL MISC STERI-STRIP 1/4" X 1 1/2" 5 RX/OTC SM RX/OTC MISC BANDAGES/CLEAR/ASSO 5 RTED MISC STERI-STRIP 1/4" X 3" 5 RX/OTC MISC SM RX/OTC BANDAGES/FLEXIBLE/AS 5 STERI-STRIP 1/4" X 4" 5 RX/OTC SORTED MISC MISC STERI-STRIP 1/8" X 3" RX/OTC SM GAUZE PADS 2"X2" 5 RX/OTC 5 PADS MISC STERILE BANDAGE ROLL RX/OTC SM GAUZE PADS 4"X4" 5 RX/OTC 5 PADS 2.25"X3YD MISC STERILE GAUZE PADS RX/OTC SM HYPO-ALLERGENIC 5 RX/OTC 5 BANDAGES MISC 2"X2" PADS SM ROLLED GAUZE RX/OTC STERILE PADS 2"X2" 5 RX/OTC BANDAGE 2"X4.1YD 5 PADS MISC STERILE PADS 4"X4" 5 RX/OTC SM ROLLED GAUZE RX/OTC PADS BANDAGE 3"X4.1YD 5 STRETCH GAUZE 5 RX/OTC MISC BANDAGE MISC SURESEAL EXTRA RX/OTC SM STERILE PADS 2"X2" 5 RX/OTC 5 PADS LARGE MISC SM STERILE PADS PADS 5 RX/OTC SURESEAL LARGE MISC 5 RX/OTC RX/OTC SM STRONG STRIPS 5 RX/OTC SURESEAL MISC 5 MISC SM STURDY STRIP RX/OTC SURGICAL GAUZE 5 RX/OTC FABRIC BANDAGES 1"X3" 5 SPONGE PADS MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGADERM CONTACT RX/OTC TELFA NON-ADHERENT RX/OTC LAYER/NON-ADHERENT 5 PAD PREPACK 8"X3" 5 3"X4" PADS PADS TEGADERM CONTACT RX/OTC TELFA NON-ADHERENT RX/OTC LAYER/NON-ADHERENT 5 PADS PREPACK 3"X4" 5 3"X8" PADS PADS TEGADERM FILM RX/OTC TENDEROL UNDERCAST 5 RX/OTC TRANSPARENT 5 PADDING 2"X4 YD MISC DRESS/FRAME STYLE 1- TENDEROL UNDERCAST 5 RX/OTC 3/4"X1-3/4" MISC PADDING 3"X4 YD MISC TEGADERM FOAM RX/OTC 5 TENDEROL UNDERCAST 5 RX/OTC DRESSING 2"X2" PADS PADDING 4"X4 YD MISC TEGADERM FOAM RX/OTC 5 TENDEROL UNDERCAST 5 RX/OTC DRESSING 4"X4" PADS PADDING 6"X4 YD MISC TEGADERM FOAM 5 RX/OTC RX/OTC DRESSING 4"X8" PADS THERAGAUZE PADS 5 TEGADERM FOAM RX/OTC TOPPER DRESSING 5 RX/OTC DRESSING ROLL 4"X24" 5 SPONGES 4"X4" MISC MISC TOPPER DRESSING 5 RX/OTC TELFA ADHESIVE 5 RX/OTC SPONGES MISC DRESSING 3"X4" PADS WATERSHIELD WATER- RX/OTC TELFA AMD ADHESIVE 5 RX/OTC RESISTANT BANDAGES 5 BANDAGE 2"X3.75" MISC MISC TELFA AMD RX/OTC WOUND TREATMENT KIT 5 ANTIMICROBIAL ISLAND 5 KIT DRESSING 4"X5" PADS Contraceptives TELFA AMD RX/OTC ANTIMICROBIAL ISLAND 5 FC FEMALE CONDOM 6 DRESSING4"X8" PADS MISC TELFA AMD RX/OTC FC2 FEMALE CONDOM 6 MISC ANTIMICROBIAL NON- 5 ADHERENT PAD 3"X8" Diabetic Supplies PADS 1ST TIER UNILET QL(6.67 ea TELFA ISLAND 5 RX/OTC COMFORTOUCH 3 daily) DRESSING 4"X10" PADS LANCETS 28G MISC TELFA ISLAND 5 RX/OTC 1ST TIER UNILET QL(6.67 ea DRESSING 4"X14" PADS COMFORTOUCH 3 daily) LANCETS 30G MISC TELFA ISLAND 5 RX/OTC DRESSING 4"X5" PADS ACCU-CHEK AVIVA SOLN 5 TELFA ISLAND 5 RX/OTC DRESSING 4"X8" PADS ACCU-CHEK COMPACT PLUS CLEAR CONTROL TELFA NON-ADHERENT 5 RX/OTC 5 DRESSING 3"X4" PADS SOLUTION (2 LEVELS) SOLN TELFA NON-ADHERENT 5 RX/OTC PAD 3"X8" PADS ACCU-CHEK FASTCLIX 3 QL(6.67 ea LANCETS MISC daily)

191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCU-CHEK GUIDE ADVOCATE SAFETY 3 QL(6.67 ea CONTROL 5 LANCETS 26G MISC daily) LEVEL1/LEVEL2 LIQD ADVOCATE SAFETY 3 QL(6.67 ea ACCU-CHEK MULTICLIX 3 QL(6.67 ea LANCETS MISC daily) LANCETS MISC daily) AGAMATRIX CONTROL 5 ACCU-CHEK SAFE-T-PRO 3 QL(6.67 ea NORMAL& HIGH SOLN LANCETS MISC daily) AGAMATRIX CONTROL 5 ACCU-CHEK SAFE-T-PRO 3 QL(6.67 ea SOLUTION LEVEL 2 PLUSLANCETS MISC daily) SOLN ACCU-CHEK SMARTVIEW 5 AGAMATRIX CONTROL CONTROL LIQD SOLUTION LEVEL 4 5 SOLN ACCU-CHEK SOFTCLIX 3 QL(6.67 ea LANCETS MISC daily) AGAMATRIX ULTRA-THIN 3 QL(6.67 ea LANCETS 33G MISC daily) ACCUTREND GLUCOSE 5 CONTROL SOLN ALTERNATE SITE 5 LANCING DEVICE MISC ACTI-LANCE LANCETS 3 QL(6.67 ea 28G MISC daily) AQUA LANCE ACTI-LANCE LITE QL(6.67 ea ADJUSTABLE LANCING 5 SAFETY LANCETS 28G 3 daily) DEVICE DEVI MISC AQUALANCE LANCETS 3 QL(6.67 ea ACTI-LANCE SPECIAL QL(6.67 ea ULTRA THIN 30G MISC daily) SAFETY LANCETS 17G 3 daily) ASSURE 3 CONTROL 5 MISC LEVEL 1/2 LIQD ACTI-LANCE SPECIAL QL(6.67 ea ASSURE 4 CONTROL 5 SAFETYLANCETS 17G 3 daily) LEVEL 1/2 LIQD MISC ASSURE COMFORT QL(6.67 ea ACTI-LANCE UNIVERSAL QL(6.67 ea LANCETS ULTRA THIN 3 daily) SAFETY LANCETS 23G 3 daily) 28G MISC MISC ASSURE DOSE 5 ADJUSTABLE LANCING 5 NORMAL/HIGH CONTROL DEVICE MISC SOLN ADVANCE MICRO-DRAW ASSURE HAEMOLANCE QL(6.67 ea CONTROL LEVEL 1-2 5 PLUS HIGH FLOW 18G 3 daily) LIQD MISC ADVANCE MICRO-DRAW 5 ASSURE HAEMOLANCE QL(6.67 ea NORMAL CONTROL LIQD PLUS LOW FLOW 25G 3 daily) MISC ADVANCED MOBILE 3 QL(6.67 ea LANCET 30G MISC daily) ASSURE HAEMOLANCE QL(6.67 ea PLUS MICRO FLOW 28G 3 daily) ADVOCATE LANCETS 3 QL(6.67 ea 30G MISC daily) MISC ASSURE HAEMOLANCE QL(6.67 ea ADVOCATE LANCETS 3 QL(6.67 ea MISC daily) PLUS NORMAL FLOW 3 daily) 21G MISC ADVOCATE LANCING 5 DEVICE MISC ASSURE HAEMOLANCE QL(6.67 ea PLUS PEDIATRIC BLADE 3 daily) ADVOCATE RAPID-SAFE 5 MISC LANCING DEVICE MISC

192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASSURE II CONTROL 5 CARDIOCOM LANCING 5 LEVEL 1 LIQD DEVICE MISC ASSURE II CONTROL 5 CAREONE ADVANCED 5 LEVEL 1/2 LIQD LANCINGDEVICE MISC ASSURE LANCE 3 QL(6.67 ea CAREONE LANCET THIN 3 QL(6.67 ea LANCETS 21G MISC daily) MISC daily) ASSURE LANCE 3 QL(6.67 ea CAREONE LANCET 3 QL(6.67 ea LANCETS MISC daily) ULTRA THIN MISC daily) ASSURE LANCE PLUS QL(6.67 ea CARESENS CONTROL A 5 SAFETYLANCETS 25G 3 daily) SOLUTION SOLN MISC CARETOUCH CONTROL 5 ASSURE LANCE PLUS QL(6.67 ea SOLUTION LEVEL 2 LIQD SAFETYLANCETS 30G 3 daily) CARETOUCH LANCING MISC DEVICEWITH EJECTOR 5 MISC ASSURE LANCETS MISC 3 QL(6.67 ea daily) CARETOUCH TWIST 3 QL(6.67 ea ASSURE PRISM LANCETS 28G MISC daily) CONTROL LEVEL 1/2 5 CARETOUCH TWIST 3 QL(6.67 ea SOLN LANCETS 30G MISC daily) ASSURE PRO CONTROL 5 CARETOUCH TWIST 3 QL(6.67 ea LEVEL1/2 LIQD LANCETS 33G MISC daily) AURORA LANCET SUPER QL(6.67 ea 3 CLEANLET LANCETS 28G 3 QL(6.67 ea THIN30G MISC daily) MISC daily) AURORA LANCET THIN QL(6.67 ea 3 CLEVER CHEK LANCETS 3 QL(6.67 ea 23G MISC daily) ULTRATHIN 30G MISC daily) AUTO-LANCET MINI MISC 5 CLEVER CHEK LANCETS 3 QL(6.67 ea ULTRATHIN MISC daily) AUTO-LANCET MISC 5 CLEVER CHOICE QL(6.67 ea COMFORT EZLANCETS 3 daily) AUTOLET IMPRESSION 5 21G MISC LANCING DEVICE MISC CLEVER CHOICE QL(6.67 ea AUTOLET LANCING 5 COMFORT EZLANCETS 3 daily) DEVICE MISC 23G MISC AUTOLET MINI MISC 5 CLEVER CHOICE QL(6.67 ea COMFORT EZLANCETS 3 daily) AUTOLET PLUS MISC 5 28G MISC COAGUCHEK LANCETS 3 QL(6.67 ea BD LANCET ULTRAFINE 3 QL(6.67 ea MISC daily) 30G MISC daily) COMFORT ASSURED QL(6.67 ea BD LANCET ULTRAFINE 3 QL(6.67 ea LANCETS MICRO THIN 3 daily) 33G MISC daily) 33G MISC BD MICROTAINER 3 QL(6.67 ea COMFORT ASSURED QL(6.67 ea LANCETS MISC daily) LANCETS SUPER THIN 3 daily) BULLSEYE MINI SAFETY 3 QL(6.67 ea 28G MISC LANCETS MISC daily) COMFORT LANCETS 3 QL(6.67 ea BULLSEYE SAFETY 3 QL(6.67 ea MISC daily) LANCETS MISC daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COOL CONTROL 5 DRUG MART UNILET QL(6.67 ea SOLUTION A SOLN MICRO THIN LANCETS 3 daily) 33G MISC COOL CONTROL 5 SOLUTION B SOLN DUO-CARE CONTROL 5 QL(6.67 ea SOLUTION LIQD CVS LANCETS 21G MISC 3 daily) E-Z JECT LANCETS 21G 3 QL(6.67 ea MISC daily) CVS LANCETS MICRO 3 QL(6.67 ea THIN 33G MISC daily) E-Z JECT LANCETS 3 QL(6.67 ea COLOR MISC daily) CVS LANCETS MICRO- 3 QL(6.67 ea QL(6.67 ea THIN 33G MISC daily) E-Z JECT LANCETS MISC 3 daily) CVS LANCETS ORIGINAL 3 QL(6.67 ea MISC daily) E-Z JECT LANCETS 3 QL(6.67 ea SUPER THIN 30G MISC daily) CVS LANCETS THIN 26G 3 QL(6.67 ea MISC daily) E-Z JECT LANCETS THIN 3 QL(6.67 ea 26G MISC daily) CVS LANCETS ULTRA 3 QL(6.67 ea THIN 30G MISC daily) E-ZJECT LANCETS 3 QL(6.67 ea MICRO-THIN 33G MISC daily) CVS LANCETS ULTRA- 3 QL(6.67 ea THIN 30G MISC daily) EASY COMFORT QL(6.67 ea LANCETS 30G/PULL TOP 3 daily) CVS LANCING DEVICE 5 MISC MISC EASY COMFORT QL(6.67 ea CVS ULTRA THIN 3 QL(6.67 ea LANCETS MISC daily) LANCETS 30G/THIN TOP 3 daily) MISC DIATHRIVE GLUCOSE CONTROL SOLUTION 5 EASY COMFORT 3 QL(6.67 ea LIQD LANCETS MISC daily) EASY MINI EJECT DIATHRIVE LANCING 5 5 DEVICE MISC LANCING DEVICE MISC EASY MINI LANCING DROPLET LANCETS 3 QL(6.67 ea 5 ULTRA THIN 30G MISC daily) DEVICE MISC EASY TOUCH CONTROL DROPLET LANCING 5 DEVICE MISC SOLUTION/HIGH & LOW 5 SOLN DRUG MART ADJUSTABLE LANCING 5 EASY TOUCH LANCETS QL(6.67 ea DEVICE MISC 21G/PRESSURE 3 daily) ACTIVATED MISC DRUG MART LANCETS 3 QL(6.67 ea THIN MISC daily) EASY TOUCH LANCETS QL(6.67 ea 23G/PRESSURE 3 daily) DRUG MART ON-THE-GO QL(6.67 ea ACTIVATED MISC LANCETS GENTLE 30G 3 daily) MISC EASY TOUCH LANCETS QL(6.67 ea 26G/PRESSURE 3 daily) DRUG MART UNILET QL(6.67 ea ACTIVATED MISC LANCETSSUPER THIN 3 daily) 30G MISC EASY TOUCH LANCETS 3 QL(6.67 ea 26G/PULL-TOP MISC daily) DRUG MART UNILET QL(6.67 ea LANCETSULTRA THIN 3 daily) EASY TOUCH LANCETS QL(6.67 ea 28G MISC 28G/PRESSURE 3 daily) ACTIVATED MISC

194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 3 QL(6.67 ea EASYGLUCO PLUS 28G/PULL-TOP MISC daily) CONTROL SOLUTION 5 LEVEL 1 SOLN EASY TOUCH LANCETS 3 QL(6.67 ea 28G/TWIST MISC daily) EASYMAX 15 GLUCOSE EASY TOUCH LANCETS QL(6.67 ea CONTROL SOLUTION 5 30G/BUTTON-ACTIVATED 3 daily) LEVEL 1/LEVEL 2 SOLN MISC EASYMAX 15 GLUCOSE EASY TOUCH LANCETS QL(6.67 ea CONTROL 5 30G/PRESSURE 3 daily) SOLUTION/LEVEL ACTIVATED MISC 2/LEVEL 3 LIQD EASYMAX 15 LEVEL 2 EASY TOUCH LANCETS 3 QL(6.67 ea 30G/PULL-TOP MISC daily) GLUCOSE CONTROL 5 SOLUTION SOLN EASY TOUCH LANCETS 3 QL(6.67 ea 30G/TWIST MISC daily) EASYMAX GLUCOSE CONTROL SOLUTION 5 EASY TOUCH LANCETS QL(6.67 ea NORMAL/LOW SOLN 32G/PRESSURE 3 daily) ACTIVATED MISC EASYMAX GLUCOSE CONTROL 5 EASY TOUCH LANCETS 3 QL(6.67 ea SOLUTION/NORMAL- 32G/PULL-TOP MISC daily) HIGH LIQD EASY TOUCH LANCETS 3 QL(6.67 ea ELEMENT COMPACT 32G/TWIST MISC daily) CONTROL SOLUTION 5 EASY TOUCH LANCETS 3 QL(6.67 ea LEVEL 2 SOLN 33G/TWIST MISC daily) ELEMENT COMPACT EASY TOUCH LANCING 5 CONTROL SOLUTION 5 DEVICE/EJECTOR MISC LEVEL 3 SOLN EASY TOUCH SAFETY QL(6.67 ea EMBRACE LANCETS 3 QL(6.67 ea LANCETS21G/PRESSURE 3 daily) ULTRA THIN 30G MISC daily) ACTIVATED MISC EMBRACE LANCING EASY TOUCH SAFETY QL(6.67 ea DEVICE WITH EJECTOR 5 LANCETS23G/PRESSURE 3 daily) MISC ACTIVATED MISC EMBRACE PRO EASY TOUCH SAFETY QL(6.67 ea GLUCOSE CONTROL 5 LANCETS26G/BUTTON 3 daily) SOLUTION LIQD ACTIVATED MISC EQL COLOR LANCETS 3 QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea 21G MISC daily) LANCETS26G/PRESSURE 3 daily) EQL COLOR LANCETS 3 QL(6.67 ea ACTIVATED MISC MICRO THIN 33G MISC daily) EASY TOUCH SAFETY QL(6.67 ea EQL SUPER THIN 3 QL(6.67 ea LANCETS28G/BUTTON 3 daily) LANCETS 30G MISC daily) ACTIVATED MISC EQL THIN LANCETS 26G 3 QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea MISC daily) LANCETS28G/PRESSURE 3 daily) ACTIVATED MISC EVENCARE CONTROL 5 SOLUTION LIQD EASY TWIST & CAP 3 QL(6.67 ea LANCETS MISC daily)

195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVENCARE G2 GLUCOSE FREESTYLE CONTROL 5 CONTROL 5 SOLUTION LIQD SOLUTION/LOW-HIGH FREESTYLE LANCETS 3 QL(6.67 ea SOLN MISC daily) EVENCARE G3 GLUCOSE FREESTYLE UNISTICK II 3 QL(6.67 ea CONTROL 5 LANCETS MISC daily) SOLUTION/LOW-HIGH SOLN GENTEEL BUTTERFLY 3 QL(6.67 ea TOUCH LANCETS MISC daily) EZ SMART BLOOD QL(6.67 ea GLUCOSE LANCETS 3 daily) GENTEEL LANCING MISC DEVICE/BUFF BLACK 5 MISC EZ-LETS LANCETS 21G 3 QL(6.67 ea MISC daily) GENTEEL LANCING DEVICE/BUTTERFLY 5 EZ-LETS LANCETS 26G 3 QL(6.67 ea BLUE MISC SUPER-SOFT MISC daily) GENTEEL LANCING EZ-LETS LANCETS 28G 3 QL(6.67 ea DEVICE/GLORIOUS 5 ULTRA-SOFT MISC daily) GOLD MISC EZ-LETS LANCETS 30G 3 QL(6.67 ea GENTEEL LANCING MISC daily) DEVICE/PLAYFUL 5 FIFTY50 SAFETY SEAL 3 QL(6.67 ea PURPLE MISC LANCETS 30G MISC daily) GENTEEL LANCING 5 FIFTY50 SAFETY SEAL 3 QL(6.67 ea DEVICE/PRECIOUS LANCETS 32G MISC daily) PLATINUM MISC FIFTY50 UNILET 3 QL(6.67 ea GENTEEL LANCING LANCETS 33G MISC daily) DEVICE/PRINCESS PINK 5 MISC FINE 30 MISC 3 QL(6.67 ea daily) GENTEEL LANCING DEVICE/STATELY SILVER 5 FINGERSTIX LANCETS 3 QL(6.67 ea MISC daily) MISC GENTEEL LANCING FORA LANCETS MISC 3 QL(6.67 ea daily) DEVICE/WILLOWY WHITE 5 MISC FORA LANCING DEVICE 5 MISC GENTLE-LET GP 3 QL(6.67 ea LANCETS MISC daily) FORA LANCING 5 DEVICE/CLEARCAP MISC GENTLE-LET LANCETS QL(6.67 ea GENERAL PURPOSE 3 daily) FREDS PHARMACY STYLE/FINE POINT MISC AUTOLET LANCING 5 DEVICE MISC GENTLE-LET LANCETS QL(6.67 ea GENERAL PURPOSE 3 daily) FREDS PHARMACY QL(6.67 ea STYLE/MEDIUM POINT UNILET LANCETS SUPER 3 daily) MISC THIN 30G MISC GENTLE-LET LANCETS QL(6.67 ea FREDS PHARMACY QL(6.67 ea SAFETY STYLE/FINE 3 daily) UNILET LANCETS ULTRA 3 daily) POINT MISC THIN 28G MISC GENTLE-LET LANCETS QL(6.67 ea FREESTYLE CONTROL SAFETY STYLE/MEDIUM 3 daily) SOLUTION HIGH/LOW 5 POINT MISC LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE 3 QL(6.67 ea GOODSENSE COLOR QL(6.67 ea LANCETS 28G MISC daily) LANCETS MICRO-THIN 3 daily) 33G UNIVERSAL MISC GLOBAL INJECT EASE 3 QL(6.67 ea LANCETS 30G MISC daily) GOODSENSE LANCETS 5 QL(6.67 ea MICRO-THIN 33G MISC daily) GLOBAL LANCING 5 DEVICE MISC GOODSENSE LANCETS QL(6.67 ea GLUCOCARD 01 MICRO-THIN 33G 3 daily) CONTROL SOLUTION 5 UNIVERSAL MISC NORMAL/HIGH LIQD GOODSENSE LANCETS QL(6.67 ea GLUCOCARD ULTRA-THIN 26G 3 daily) UNIVERSAL MISC EXPRESSION CONTROL 5 SOLUTION LEVEL 1 GOODSENSE LANCETS 3 QL(6.67 ea SOLN ULTRA-THIN 30G MISC daily) GLUCOCARD SHINE GOODSENSE LANCETS QL(6.67 ea CONTROL SOLUTION 5 ULTRA-THIN 30G 3 daily) LEVEL 1 SOLN UNIVERSAL MISC GLUCOCOM LANCETS 3 QL(6.67 ea GOODSENSE LANCING 5 28G MISC daily) DEVICE MISC GLUCOCOM LANCETS 3 QL(6.67 ea H-E-B INCONTROL 30G MISC daily) ADVANCEDLANCING 5 DEVICE MISC GLUCOCOM LANCETS 3 QL(6.67 ea 33G MISC daily) H-E-B INCONTROL QL(6.67 ea LANCETS MICRO THIN 3 daily) GLUCOSE CONTROL 5 SOLUTION SOLN 33G MISC GNP EASY TOUCH H-E-B INCONTROL QL(6.67 ea CONTROL SOLUTION 5 LANCETS SUPER THIN 3 daily) HIGH/LOW SOLN 30G MISC H-E-B INCONTROL QL(6.67 ea GNP LANCETS 21G MISC 3 QL(6.67 ea daily) LANCETS ULTRA THIN 3 daily) 28G MISC GNP LANCETS MICRO 3 QL(6.67 ea THIN 33G MISC daily) HAEMOLANCE LOW 3 QL(6.67 ea FLOW LANCETS MISC daily) QL(6.67 ea GNP LANCETS MISC 3 daily) HAEMOLANCE MISC 3 QL(6.67 ea daily) GNP LANCETS SUPER 3 QL(6.67 ea THIN 30G MISC daily) HAEMOLANCE PLUS 3 QL(6.67 ea HIGH FLOW MISC daily) GNP LANCETS THIN 26G 3 QL(6.67 ea MISC daily) HAEMOLANCE PLUS 3 QL(6.67 ea LOW FLOW MISC daily) GNP LANCETS THIN 3 QL(6.67 ea MISC daily) HAEMOLANCE PLUS 3 QL(6.67 ea MAX FLOW MISC daily) GNP MICRO THIN 3 QL(6.67 ea LANCETS 33G MISC daily) HAEMOLANCE PLUS 3 QL(6.67 ea MISC daily) GNP SUPER THIN 3 QL(6.67 ea LANCETS/30G MISC daily) HAEMOLANCE PLUS 3 QL(6.67 ea PEDIATRIC FLOW MISC daily) GOJJI LANCING DEVICE/CLEAR CAP 5 HEALTH CARE LANCING 5 MISC DEVICE MISC

197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHY ACCENTS LANCET DEVICE 5 AUTOLET IMPRESSION 5 ADJUSTABLE MISC LANCING DEVICE MISC LANCET DEVICE WITH 5 HEALTHY ACCENTS QL(6.67 ea EJECTOR MISC UNILET LANCETS SUPER 3 daily) LANCETS 26G TWIST 3 QL(6.67 ea THIN 30G MISC TOP MISC daily) QL(6.67 ea HY-VEE LANCETS MISC 3 LANCETS 28G MISC 3 QL(6.67 ea daily) daily) HY-VEE THIN LANCETS QL(6.67 ea QL(6.67 ea 3 LANCETS 30G MISC 3 MISC daily) daily) IN TOUCH GLUCOSE LANCETS 30G TWIST 3 QL(6.67 ea CONTROLSOLUTION 5 TOP MISC daily) SOLN LANCETS 30G/TWIST 3 QL(6.67 ea IN TOUCH LANCING 5 TOP MISC daily) DEVICE MISC LANCETS 31G TWIST 3 QL(6.67 ea IN TOUCH STERILE 3 QL(6.67 ea TOP MISC daily) LANCETS30G MISC daily) LANCETS 33G QL(6.67 ea QL(6.67 ea KINNEY LANCETS MISC 3 UNIVERSAL DESIGN 3 daily) daily) MISC KINNEY THIN LANCETS QL(6.67 ea 3 LANCETS MICRO THIN 3 QL(6.67 ea MISC daily) 33G MISC daily) KROGER AUTOLET 5 LANCETS MISC 3 QL(6.67 ea LANCING DEVICE MISC daily) KROGER HEALTHPRO LANCETS SAFETY SEAL 3 QL(6.67 ea GLUCOSECONTROL 5 21G MISC daily) SOLUTION/HIGH/LOW LIQD LANCETS SAFETY SEAL 3 QL(6.67 ea 26G MISC daily) KROGER HEALTHPRO QL(6.67 ea TWIST LANCETS/26G 3 daily) LANCETS SAFETY SEAL 3 QL(6.67 ea MISC 28G MISC daily) LANCETS SAFETY SEAL QL(6.67 ea KROGER LANCETS 21G 3 QL(6.67 ea 3 MISC daily) 30G MISC daily) LANCETS SUPER THIN QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 MICRO THIN33G MISC daily) 28G MISC daily) QL(6.67 ea QL(6.67 ea KROGER LANCETS MISC 3 LANCETS THIN MISC 3 daily) daily) LANCETS TWIST TOP QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 SUPER THIN MISC daily) MISC daily) LANCETS ULTRA FINE QL(6.67 ea KROGER LANCETS THIN 3 QL(6.67 ea 3 26G MISC daily) MISC daily) LANCETS ULTRA THIN QL(6.67 ea KROGER LANCETS THIN 3 QL(6.67 ea 3 MISC daily) 30G MISC daily) LANCETS ULTRA THIN QL(6.67 ea KROGER LANCETS 3 QL(6.67 ea 3 ULTRATHIN30G MISC daily) MISC daily) LANCETSBULLSEYE QL(6.67 ea KROGER LANCING 5 3 DEVICE MISC SAFETY MISC daily)

198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCING DEVICE 5 MEDICHOICE PRE-SET QL(6.67 ea ADJUSTABLE MISC SAFETY LANCET 3 daily) MODERATE FLOW MISC LANCING DEVICE MISC 5 MEDICHOICE SAFETY 3 QL(6.67 ea LANZO MISC 5 LANCETEXTRA MISC daily) MEDICHOICE SAFETY 3 QL(6.67 ea LEADER ADVANCED 5 LANCETNORMAL MISC daily) LANCING DEVICE MISC MEDISENSE GLUCOSE LIBERTY GLUCOSE 5 KETONECONTROL 5 CONTROL MID SOLN SOLUTION 1-LOW,1- MED,1 HIGH LIQD LIBERTY MEDICAL 3 QL(6.67 ea LANCETS 30G MISC daily) MEDISENSE GLUCOSE KETONECONTROL LIBERTY MINI LANCING 5 5 DEVICE MISC SOLUTION 1-NORMAL LIFESCAN UNISTIK 2 QL(6.67 ea LIQD DEEP PENETRATION 3 daily) MEDISENSE HIGH/LOW MISC CONTROL SOLUTION 5 LIQD LIFESCAN UNISTIK II 3 QL(6.67 ea LANCETS MISC daily) MEDISENSE HIGH/MID/LOW LITE TOUCH LANCETS 3 QL(6.67 ea 5 MISC daily) CONTROL SOLUTION LIQD LITE TOUCH LANCING 5 PEN MISC MEDISENSE MID CONTROL SOLUTION 5 LITETOUCH LANCETS 3 QL(6.67 ea LIQD MICRO THIN 33G MISC daily) MEDISENSE THIN 3 QL(6.67 ea LIVE BETTER ADVANCED 5 LANCETS MISC daily) LANCING DEVICE MISC MEDLANCE PLUS EXTRA 3 QL(6.67 ea LIVE BETTER LANCET 3 QL(6.67 ea LANCETS 21G MISC daily) SUPERTHIN 30G MISC daily) MEDLANCE PLUS 3 QL(6.67 ea LIVE BETTER LANCET 3 QL(6.67 ea LANCETS LITE 25G MISC daily) ULTRATHIN 28G MISC daily) MEDLANCE PLUS 3 QL(6.67 ea LONGS LANCETS 3 QL(6.67 ea LANCETS MISC daily) STANDARD MISC daily) MEDLANCE PLUS LITE 3 QL(6.67 ea LONGS LANCETS THIN 3 QL(6.67 ea LANCETS 25G MISC daily) MISC daily) MEDLANCE PLUS QL(6.67 ea LONGS LANCETS ULTRA 3 QL(6.67 ea SPECIAL LANCETS 3 daily) THIN MISC daily) 0.8MM MISC MEDICHOICE PRE-SET QL(6.67 ea MEDLANCE PLUS 3 QL(6.67 ea SAFETY LANCET DUAL 3 daily) SUPERLITE 30G MISC daily) USE MISC MEDLANCE PLUS QL(6.67 ea MEDICHOICE PRE-SET QL(6.67 ea SUPERLITE 3 daily) SAFETY LANCET LOW 3 daily) 30G/COMFORT MAX FLOW MISC MISC MEDICHOICE PRE-SET QL(6.67 ea MEDLANCE PLUS QL(6.67 ea SAFETY LANCET 3 daily) UNIVERSAL LANCETS 3 daily) MEDIUM FLOW MISC 21G MISC

199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDLANCE PLUS/LITE 3 QL(6.67 ea MPD SAFETY LANCET 3 QL(6.67 ea 25G MISC daily) 21G/1.8MM MISC daily) QL(6.67 ea MPD SAFETY LANCET QL(6.67 ea MEDLANCE/EXTRA MISC 3 3 daily) 28G/1.8MM MISC daily) QL(6.67 ea MPD SAFETY LANCET QL(6.67 ea MEDLANCE/LITE MISC 3 3 daily) 30G/1.8MM MISC daily) MEDLANCE/UNIVERSAL 3 QL(6.67 ea MPD SAFETY LANCETS 3 QL(6.67 ea MISC daily) 23G/1.8MM MISC daily) MEIJER COLOR QL(6.67 ea MULTI-LANCET DEVICE 5 LANCETS UNIVERSAL 3 daily) MISC 33G MISC MYGLUCOHEALTH CONTROL MEIJER LANCETS MISC 3 QL(6.67 ea 5 daily) LOW/NORMAL/HIGH SOLN MEIJER LANCETS THIN 3 QL(6.67 ea MISC daily) MYGLUCOHEALTH MGH QL(6.67 ea SOFTLANCE LANCETS 3 daily) MEIJER LANCETS 3 QL(6.67 ea UNIVERSAL21G MISC daily) 30G MISC NEUTEK 2TEK CONTROL MEIJER LANCETS 3 QL(6.67 ea 5 UNIVERSAL30G MISC daily) SOLUTIONS SOLN NOVA MAX PLUS MEIJER LANCETS 3 QL(6.67 ea UNIVERSAL33G MISC daily) GLU/KET CONTROL 5 SOLUTION-MID LIQD MEIJER SUPER THIN 3 QL(6.67 ea LANCETS MISC daily) NOVA SAFETY LANCETS 3 QL(6.67 ea 23G MISC daily) MICRODOT CONTROL SOLUTIONHIGH/LOW 5 NOVA SAFETY LANCETS 3 QL(6.67 ea SOLN 28G MISC daily) NOVA SUREFLEX QL(6.67 ea MICROLET LANCETS 3 QL(6.67 ea 3 MISC daily) LANCETS MISC daily) NOVA SUREFLEX 5 MICROLET NEXT MISC 5 LANCING DEVICE MISC MICROTAINER SAFETY QL(6.67 ea ON CALL EXPRESS GLUCOSE CONTROL 5 FLOW 3 daily) LANCET/STERILE/SINGL SOLUTION SOLN E-USE MISC ON CALL LANCETS MISC 3 QL(6.67 ea daily) MINI LANCING DEVICE 5 MISC ON CALL LANCING 5 DEVICE MISC MM LANCING DEVICE 5 MISC ON CALL PLUS GLUCOSE CONTROL 5 MM TWIST LANCETS 3 QL(6.67 ea MISC daily) LEVEL 1/2 SOLN ON CALL PLUS LANCETS QL(6.67 ea MONOLET LANCETS 3 QL(6.67 ea 3 MISC daily) MISC daily) ON CALL PLUS LANCING MONOLET OPD LANCETS 3 QL(6.67 ea 5 MISC daily) DEVICE MISC ON CALL VIVID MONOLETTOR SAFETY 3 QL(6.67 ea LANCETS MISC daily) GLUCOSE CONTROL 5 LEVEL 1/2 SOLN 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONETOUCH CLUB QL(6.67 ea PHARMACY COUNTER 3 QL(6.67 ea LANCETS FINE POINT 3 daily) LANCETS MISC daily) MISC POCKETCHEM EZ 5 ONETOUCH DELICA QL(6.67 ea CONTROL LEVEL 1 SOLN LANCETS EXTRA FINE 3 daily) PRECISION GLUCOSE 5 33G MISC CONTROL LIQD ONETOUCH DELICA 3 QL(6.67 ea PRECISION GLUCOSE LANCETS FINE 30G MISC daily) CONTROLSOLUTION 5 ONETOUCH DELICA 5 (TRI- LANCING DEVICE MISC LEVEL/HI/LO/NORMAL) ONETOUCH DELICA SOLN PLUS LANCING DEVICE 5 PRECISION GLUCOSE MISC KETONECONTROL 5 SOLUTION 1-LOW, 1- ONETOUCH FINEPOINT 3 QL(6.67 ea LANCETS MISC daily) HIGH LIQD PRECISION ONETOUCH ULTRA 5 CONTROL SOLN GLUCOSE/KETONECONT 5 ROL SOLUTIONS 1-HI 1- ONETOUCH ULTRASOFT 3 QL(6.67 ea LO LIQD LANCETS MISC daily) PRECISION THINS GP 3 QL(6.67 ea ONETOUCH VERIO MID LANCET MISC daily) CONTROL SOLUTION 5 SOLN PREFERRED PLUS QL(6.67 ea LANCETS COLORED 21G 3 daily) OPTUMRX GLUCOSE MISC CONTROL LEVEL 1/2 5 SOLN PREFERRED PLUS QL(6.67 ea LANCETS SUPER THIN 3 daily) PC LANCETS SUPER 3 QL(6.67 ea 30G MISC THIN 30G MISC daily) PREFERRED PLUS 3 QL(6.67 ea PERFECT LANCETS 30G 3 QL(6.67 ea LANCETS THIN 26G MISC daily) MISC daily) PRESSURE ACTIVATED QL(6.67 ea PERFECT PRESSURE QL(6.67 ea SAFETYLANCET 21G 3 daily) ACTIVATED SAFETY 3 daily) MISC LANCETS 28G MISC PRO COMFORT 3 QL(6.67 ea PHARMACIST CHOICE QL(6.67 ea LANCETS 30G MISC daily) ULTRA THIN LANCETS 3 daily) 28G MISC PRO COMFORT 3 QL(6.67 ea LANCETS 31G MISC daily) PHARMACIST CHOICE QL(6.67 ea ULTRA THIN LANCETS 3 daily) PRODIGY LANCING 5 30G MISC DEVICE MISC PHARMACIST CHOICE QL(6.67 ea PRODIGY PRESSURE QL(6.67 ea ULTRA THIN LANCETS 3 daily) ACTIVATED SAFETY 3 daily) 31G MISC LANCETS MISC PHARMACIST CHOICE QL(6.67 ea PRODIGY SAFETY 3 QL(6.67 ea ULTRA THIN LANCETS 3 daily) LANCETS MISC daily) 33G MISC PRODIGY TWIST TOP 3 QL(6.67 ea PHARMACIST CHOICE QL(6.67 ea LANCETS MISC daily) ULTRA THIN LANCETS 3 daily) PSS SELECT GP 3 QL(6.67 ea MISC LANCETS MISC daily)

201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PSS SELECT SAFETY 3 QL(6.67 ea READYLANCE SAFETY QL(6.67 ea LANCETS MISC daily) LANCETS/23G/1.8MM 3 daily) MISC PUSH BUTTON SAFETY 3 QL(6.67 ea LANCETS 21G MISC daily) READYLANCE SAFETY QL(6.67 ea LANCETS/26G/1.8MM 3 daily) PUSH BUTTON SAFETY 3 QL(6.67 ea LANCETS 28G MISC daily) MISC READYLANCE SAFETY QL(6.67 ea PX ADVANCED LANCING 5 DEVICE MISC LANCETS/28G/1.8MM 3 daily) MISC PX LANCET AUTO 5 INJECTOR MISC READYLANCE SAFETY QL(6.67 ea LANCETS/30G/1.6MM 3 daily) PX LANCETS ULTRA 3 QL(6.67 ea MISC THIN 28G MISC daily) QL(6.67 ea REALITY LANCETS MISC 3 PX LANCETS ULTRA 3 QL(6.67 ea daily) THIN MISC daily) REALITY TRIGGER 3 QL(6.67 ea QC ADVANCED LANCING 5 LANCETS MISC daily) DEVICE MISC REFUAH PLUS GLUCOSE QC LANCETS SUPER 3 QL(6.67 ea CONTROL SOLUTION 5 THIN MISC daily) SOLN QC LANCETS ULTRA QL(6.67 ea 3 RELION 2-IN-1 LANCET 5 THIN MISC daily) DEVICES 30G MISC QC UNILET LANCETS QL(6.67 ea 3 RELION 2-IN-1 LANCING 5 28G/ULTRA THIN MISC daily) DEVICE 25G MISC QC UNILET LANCETS QL(6.67 ea 3 RELION 2-IN-1 LANCING 5 33G/MICRO THIN MISC daily) DEVICE 30G MISC QUICKTEK CONTROL 5 RELION ALL-IN-ONE SOLUTION LIQD COMPACTBLOOD NC QUINTET GLUCOSE GLUCOSE TESTING CONTROL/HIGH/NORMAL 5 SYSTEM DEVI SOLN RELION LANCETS 3 QL(6.67 ea RA E-ZJECT COLOR QL(6.67 ea MICRO-THIN33G MISC daily) LANCETSMICRO-THIN 3 daily) RELION LANCETS 3 QL(6.67 ea 33G MISC STANDARD 21G MISC daily) RA E-ZJECT LANCETS QL(6.67 ea 3 RELION LANCETS THIN 3 QL(6.67 ea 28G MISC daily) 26G MISC daily) RA E-ZJECT LANCETS QL(6.67 ea 3 RELION LANCETS 3 QL(6.67 ea THIN 26G MISC daily) ULTRA-THIN30G MISC daily) RA E-ZJECT LANCETS QL(6.67 ea 3 RELION LANCING 5 THIN 28G MISC daily) DEVICE MISC RA E-ZJECT LANCETS QL(6.67 ea 3 RELION ULTRA THIN 3 QL(6.67 ea ULTRATHIN 30G MISC daily) LANCETS30G MISC daily) RA LANCING DEVICE 5 RELION ULTRA THIN QL(6.67 ea MISC PLUS LANCETS 32G 3 daily) READYLANCE SAFETY QL(6.67 ea MISC LANCETS/21G/2.2MM 3 daily) RELION ULTRA THIN QL(6.67 ea MISC PLUS LANCETS 33G 3 daily) MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REXALL LANCETS ULTRA 3 QL(6.67 ea SELECT-LITE LANCING 5 THIN MISC daily) DEVICE MISC RIGHTEST GD500 5 SHOPKO AUTOLET 5 LANCING DEVICE MISC LANCING DEVICE MISC RIGHTEST GL300 3 QL(6.67 ea SHOPKO ON-THE-GO QL(6.67 ea LANCETS MISC daily) COMFORTLANCETS 30G 3 daily) MISC SAFE-T-LANCE LOW 3 QL(6.67 ea FLOW 25G MISC daily) SHOPKO UNILET QL(6.67 ea LANCETS SUPER THIN 3 daily) SAFE-T-LANCE NORMAL 3 QL(6.67 ea FLOW21G MISC daily) 30G MISC SAFE-T-LANCE PLUS QL(6.67 ea SHOPKO UNILET QL(6.67 ea SAFETYLANCET HIGH 3 daily) LANCETS ULTRA THIN 3 daily) FLOW MISC 28G MISC SAFE-T-LANCE PLUS QL(6.67 ea SIDE BUTTON SAFETY 3 QL(6.67 ea SAFETYLANCET LOW 3 daily) LANCET21G MISC daily) FLOW MISC SIDEKICK BLOOD 5 SAFE-T-LANCE PLUS QL(6.67 ea GLUCOSE SYSTEM DEVI SAFETYLANCET 3 daily) SIMPLE DIAGNOSTICS 5 NORMAL FLOW MISC LANCING DEVICE MISC SAFETY LANCET QL(6.67 ea QL(6.67 ea SINGLE-LET MISC 3 21G/PRESSURE 3 daily) daily) ACTIVATED MISC SM MICRO THIN 3 QL(6.67 ea SAFETY LANCET QL(6.67 ea LANCETS 33G MISC daily) 28G/PRESSURE 3 daily) SM TRUEDRAW LANCING 5 ACTIVATED MISC DEVICE MISC SAFETY LANCETS 21G 3 QL(6.67 ea SMART DIABETES MISC daily) VANTAGE LANCING 5 SAFETY LANCETS 28G 3 QL(6.67 ea DEVICE MISC MISC daily) SMART SENSE COLOR QL(6.67 ea LANCETS UNIVERSAL 3 daily) SAFETY LANCETS MISC 3 QL(6.67 ea daily) 33G MISC SAFETY LET LANCETS 3 QL(6.67 ea SMART SENSE QL(6.67 ea MISC daily) STANDARD LANCETS 3 daily) UNIVERSAL 21G MISC SAFETY SEAL LANCETS 3 QL(6.67 ea 28G MISC daily) SMART SENSE SUPER QL(6.67 ea THIN LANCETS 3 daily) SAFETY SEAL LANCETS 3 QL(6.67 ea 30G MISC daily) UNIVERSAL 30G MISC SMART SENSE THIN QL(6.67 ea SAPS HEALTH TWIST 5 QL(6.67 ea TOP LANCETS 30G MISC daily) LANCETSUNIVERSAL 3 daily) 26G MISC SAPSCARE TWIST TOP 3 QL(6.67 ea LANCETS 30G MISC daily) SMARTEST CONTROL 5 SOLUTIONMEDIUM SOLN QL(6.67 ea SB LANCETS THIN MISC 3 daily) SMARTEST LANCETS 3 QL(6.67 ea 28G MISC daily) SB LANCETS ULTRA 3 QL(6.67 ea THIN MISC daily) SOLARTEK GLUCOSE CONTROLSOLUTIONS 5 LIQD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOLUS V2 LANCING 5 SURESTEP GLUCOSE DEVICE MISC CONTROLSOLUTION 5 SOLUS V2 PRESSURE QL(6.67 ea SOLN ACTIVATED SAFETY 3 daily) TECHLITE AST LANCETS 3 QL(6.67 ea LANCETS 28G MISC MISC daily) SOLUS V2 TWIST 3 QL(6.67 ea TECHLITE LANCETS 30G 3 QL(6.67 ea LANCETS 30G MISC daily) MISC daily) STERILANCE TL MISC 3 QL(6.67 ea TECHLITE LANCETS 3 QL(6.67 ea daily) MISC daily) SUPER THIN LANCETS 3 QL(6.67 ea TELCARE GLUCOSE MISC daily) CONTROL SOLUTION 5 SUPREME II HIGH/LOW LEVEL 1/2 SOLN CONTROL SOLUTION 5 TGT LANCET MICRO 3 QL(6.67 ea LIQD THIN 33G MISC daily) SURE COMFORT 5 QL(6.67 ea TGT LANCET THIN 26G 3 QL(6.67 ea LANCETS 18G MISC daily) MISC daily) SURE COMFORT 5 QL(6.67 ea TGT LANCET ULTRA 3 QL(6.67 ea LANCETS 21G MISC daily) THIN 30G MISC daily) SURE COMFORT 5 QL(6.67 ea TGT LANCING DEVICE 5 LANCETS 23G MISC daily) MISC SURE COMFORT 3 QL(6.67 ea THINLETS GP LANCETS 3 QL(6.67 ea LANCETS 28G MISC daily) MISC daily) SURE COMFORT 3 QL(6.67 ea TODAYS HEALTH LANCETS 30G MISC daily) ADVANCED LANCING 5 DEVICE MISC SURE COMFORT 5 QL(6.67 ea LANCETS 30G MISC daily) TODAYS HEALTH SUPER 3 QL(6.67 ea THINLANCETS 30G MISC daily) SURE COMFORT 5 LANCING PEN MISC TODAYS HEALTH ULTRA 3 QL(6.67 ea THINLANCETS 28G MISC daily) SURE-LANCE FLAT 3 QL(6.67 ea LANCETS MISC daily) TOPCARE LANCETS 3 QL(6.67 ea MICRO-THIN 33G MISC daily) SURE-LANCE LANCETS 3 QL(6.67 ea 26G MISC daily) TRAVEL LANCETS 30G 3 QL(6.67 ea MISC daily) SURE-LANCE THIN 3 QL(6.67 ea LANCETS 28G MISC daily) TRAVEL LANCETS 3 QL(6.67 ea ADVANCED 28G MISC daily) SURE-LANCE ULTRA 3 QL(6.67 ea THIN LANCETS MISC daily) TRUE COMFORT TWIST 5 QL(6.67 ea TOP LANCETS 30G MISC daily) SURE-PEN MISC 5 TRUECONTROL GLUCOSE CONTROL 5 SURE-TOUCH LANCETS 3 QL(6.67 ea UNIVERSAL MISC daily) LEVEL 0 LIQD TRUECONTROL SURELITE LANCETS 3 QL(6.67 ea MISC daily) GLUCOSE CONTROL 5 LEVEL 1 LIQD SURESTEP GLUCOSE 5 CONTROL SOLN TRUEDRAW LANCING 5 DEVICE MISC

204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS LANCETS QL(6.67 ea 3 UNILET EXCELITE II MISC 3 QL(6.67 ea 26G MISC daily) daily) TRUEPLUS LANCETS QL(6.67 ea 3 UNILET EXCELITE MISC 3 QL(6.67 ea 28G MISC daily) daily) TRUEPLUS LANCETS 3 QL(6.67 ea UNILET G.P. LANCET 3 QL(6.67 ea 28G SUPER THIN MISC daily) MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea UNILET G.P. SUPERLITE 3 QL(6.67 ea 30G MISC daily) LANCET MISC daily) TRUEPLUS LANCETS 3 QL(6.67 ea UNILET GP 28 ULTRA 3 QL(6.67 ea 30G ULTRA THIN MISC daily) THIN MISC daily) TRUEPLUS LANCETS QL(6.67 ea 3 UNILET LANCET MISC 3 QL(6.67 ea 33G MICRO THIN MISC daily) daily) TRUEPLUS LANCETS 3 QL(6.67 ea UNILET LANCETS 3 QL(6.67 ea 33G MISC daily) MICRO-THIN33G MISC daily) TRUEPLUS SAFETY 3 QL(6.67 ea UNILET LANCETS 3 QL(6.67 ea LANCETS 28G MISC daily) SUPER-THIN30G MISC daily) ULTI-LANCE AUTOMATIC/ 5 UNILET LANCETS 3 QL(6.67 ea CLEAR TIP MISC ULTRA-THIN 28G MISC daily) ULTILET CLASSIC 3 QL(6.67 ea UNILET SUPERLITE 3 QL(6.67 ea LANCETS MISC daily) LANCET MISC daily) ULTILET LANCETS 33G QL(6.67 ea 3 UNISTIK 3 GENTLE MISC 3 QL(6.67 ea MISC daily) daily) QL(6.67 ea UNISTIK PRO SAFETY QL(6.67 ea ULTILET LANCETS MISC 3 3 daily) LANCET 21G MISC daily) ULTILET SAFETY QL(6.67 ea UNISTIK PRO SAFETY 3 QL(6.67 ea LANCETS 21G X 2.2MM 3 daily) LANCET 25G MISC daily) MISC UNISTIK PRO SAFETY 3 QL(6.67 ea ULTILET SAFETY 3 QL(6.67 ea LANCET 28G MISC daily) LANCETS 23G MISC daily) UNISTIK SAFETY 3 QL(6.67 ea ULTRA-CARE LANCETS 3 QL(6.67 ea LANCETS 28G MISC daily) 30G MISC daily) UNISTIK SAFETY 3 QL(6.67 ea ULTRA-THIN II AUTO 3 QL(6.67 ea LANCETS 30G MISC daily) LANCET MISC daily) UNISTIK TOUCH SAFETY 3 QL(6.67 ea ULTRA-THIN II LANCETS 3 QL(6.67 ea LANCETS 21G MISC daily) 28G MISC daily) UNISTIK TOUCH SAFETY 3 QL(6.67 ea ULTRA-THIN II LANCETS 3 QL(6.67 ea LANCETS 23G MISC daily) 30G MISC daily) UNISTIK TOUCH SAFETY 3 QL(6.67 ea ULTRATRAK PRO LANCETS 28G MISC daily) CONTROL SOLUTION 2 5 UNISTIK TOUCH SAFETY 3 QL(6.67 ea LEVELS SOLN LANCETS 30G MISC daily) ULTRATRAK ULTIMATE UNIVERSAL 1 LANCETS 3 QL(6.67 ea CONTROL SOLUTION 2 5 THIN26G MISC daily) LEVELS SOLN UNIVERSAL 1 LANCETS 3 QL(6.67 ea UNILET COMFORTOUCH 3 QL(6.67 ea ULTRA THIN 30G MISC daily) LANCET MISC daily)

205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIVERSAL 1 QL(6.67 ea WALGREENS ULTRA 3 QL(6.67 ea LANCETS/33G/MICRO- 3 daily) THIN LANCETS MISC daily) THIN MISC Foot Care Products VALUE PLUS LANCETS QL(6.67 ea 3 AIR FOAM INSOLES RX/OTC STANDARD 21G MISC daily) 5 MENS MISC VALUE PLUS LANCETS QL(6.67 ea 3 AIR FOAM INSOLES RX/OTC SUPERTHIN 30G MISC daily) 5 WOMENS MISC VALUE PLUS LANCETS QL(6.67 ea 3 ALL GEL BUNION TOE RX/OTC THIN 26G MISC daily) 5 SPREADER MISC VALUE PLUS LANCING 5 BIOFREQUENCY RX/OTC DEVICE MISC 5 INSOLES MISC VALUMARK LANCET QL(6.67 ea 3 RX/OTC SUPER THIN 30G MISC daily) CALLUS REMOVER MISC 5 VALUMARK LANCET QL(6.67 ea 3 CALLUS/CORN SHAVER 5 RX/OTC ULTRA THIN 28G MISC daily) BLADES MISC VERASENS GLUCOSE 5 CALLUS/CORN SHAVER 5 RX/OTC CONTROLLEVEL 1 LIQD MISC VIDA MIA AUTOLET 5 CVS ADVANCED GEL 5 RX/OTC LANCINGDEVICE MISC ORTHOTICS/MENS MISC VIDA MIA UNILET QL(6.67 ea DOUBLE AIR FOAM 5 RX/OTC LANCETS SUPER THIN 3 daily) INSOLES MENS MISC 30G MISC DOUBLE AIR FOAM 5 RX/OTC VIDA MIA UNILET QL(6.67 ea INSOLES WOMENS MISC LANCETS ULTRA THIN 3 daily) 28G MISC EASY GRIP CALLUS 5 RX/OTC REMOVER MISC VITALET PRO LANCETS 3 QL(6.67 ea MISC daily) EQL DUAL GEL INSOLES 5 RX/OTC WOMENS MISC VITALET PRO PLUS 3 QL(6.67 ea LANCETS MISC daily) EQL PUMICE 5 RX/OTC STONE/ROPE MISC VIVAGUARD INO CONTROL SOLUTION 5 EQL TOENAIL CLIPPER 5 RX/OTC LIQD MISC EXFOLIATING STONE RX/OTC VIVAGUARD LANCING 5 5 DEVICE MISC FILE MISC WALGREENS ADVANCED QL(6.67 ea FOAM TOE 5 RX/OTC TRAVELLANCETS 28G 3 daily) SEPARATORS MISC MISC FOOT COMFORT RX/OTC WALGREENS COMFORT QL(6.67 ea THERMAL ANKLE AND 5 ASSUREDLANCETS 3 daily) FOOT STABILIZER MISC MICRO THIN/33G MISC FOOT SLEEP SUPPORT 5 RX/OTC WALGREENS COMFORT QL(6.67 ea MISC ASSUREDLANCETS 3 daily) FOOT SMOOTHER DUAL 5 RX/OTC SUPER THIN/28G MISC SURFACE MISC FUTURO THERAPEUTIC RX/OTC WALGREENS LANCETS 3 QL(6.67 ea MISC daily) ARCH SUPPORT FOOT 5 MISC WALGREENS THIN 3 QL(6.67 ea LANCETS MISC daily) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GEL BALL OF FOOT 5 RX/OTC RA CUSHION INSOLES 5 RX/OTC CUSHIONS MISC WOMENS MISC GEL CORN 5 RX/OTC RA FOAM INSOLES 5 RX/OTC PROTECTORS MISC WOMENS MISC GEL INSOLES MENS 5 RX/OTC RA GEL HEEL CUSHIONS 5 RX/OTC MISC MENS MISC GEL INSOLES WOMENS 5 RX/OTC RA GEL TOE 5 RX/OTC MISC SEPARATORS MISC GEL TOE PROTECTOR 5 RX/OTC RA NAIL CLIPPER MISC 5 RX/OTC MISC RA PLANTAR FASCIITIS RX/OTC GEL TOE SEPARATORS 5 RX/OTC 5 MISC ARCH SLEEVE MISC RX/OTC GEL TOE SPACERS MISC 5 RX/OTC RA PUMICE STONE MISC 5 RA RENEWAL BARREL RX/OTC HEALTH 5 RX/OTC SLIPPERS/UNISEX MISC SPRINGTOENAIL NIPPER 5 MISC MEDICOOLS DIASOX 5 RX/OTC MISC RA TOENAIL CLIPPER 5 RX/OTC MISC MEMORY WORK/SPORT 5 RX/OTC INSOLES MISC SHOE HORN RX/OTC ODOR CONTROL RX/OTC DELUXE/CHROME FINISH 5 INSOLES 5 MISC MENS/WOMENS MISC SLEEP-N-HEEL NIGHT RX/OTC CONDITIONING HEEL 5 ODOR EATERS ULTRA 5 RX/OTC COMFORT MISC SLEEVES MISC PREVALON FOOT/LEG RX/OTC SLEEP-N-HEEL+ NIGHT RX/OTC STABILIZER WEDGE 5 CONDITIONING HEEL 5 MISC SLEEVES MISC RX/OTC SOCK AID DELUXE 5 RX/OTC PREVALON MISC 5 MOLDED MISC PREVALON PRESSURE RX/OTC SOFT FOAM TOE RX/OTC RELIEVING HEEL 5 SEPARATORSMEDIUM 5 PROTECTOR MISC MISC PREVALON PRESSURE RX/OTC SPENCO ARCH RX/OTC SUPPORT INSOLES SIZE 5 RELIEVING HEEL 5 PROTECTOR/PETITE 10/11 MENS MISC MISC SPENCO ARCH RX/OTC PREVALON PRESSURE RX/OTC SUPPORT INSOLES SIZE 5 12/13 MENS MISC RELIEVING HEEL 5 PROTECTOR/WEDGE SPENCO ARCH RX/OTC MISC SUPPORT INSOLES SIZE 5 8/9 MENS MISC PROFOOT PLANTAR 5 RX/OTC FASCIITIS MISC SPENCO COMFORT RX/OTC RX/OTC INSOLES SIZE 10/11 5 PUMICE STONE MISC 5 MENS MISC RA CUSHION INSOLES 5 RX/OTC MENS MISC

207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO COMFORT RX/OTC SPENCO GEL HEEL CUP RX/OTC INSOLES SIZE 12/13 5 SIZEMEDIUM/LARGE 5 MENS MISC MISC SPENCO COMFORT RX/OTC SPENCO GEL HEEL CUP RX/OTC INSOLES SIZE 14/15 5 SIZESMALL/MEDIUM 5 MENS MISC MISC SPENCO COMFORT RX/OTC SPENCO GEL HEEL 5 RX/OTC INSOLES SIZE 8/9 MENS 5 INSOLES ONE SIZE MISC MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO FOR HER RX/OTC SIZE 10/11 MENS MISC INSOLES SIZE 11/12 5 SPENCO GEL INSOLES 5 RX/OTC MISC SIZE 10/11-11/12 MISC SPENCO FOR HER RX/OTC SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 11/12 5 SIZE 12/13 MENS MISC TOTAL SUPPORT MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO FOR HER 5 RX/OTC SIZE 12/13 MISC INSOLES SIZE 3/4 MISC SPENCO GEL INSOLES 5 RX/OTC SPENCO FOR HER RX/OTC SIZE 14/15 MENS MISC INSOLES SIZE 3/4 TOTAL 5 SUPPORT MISC SPENCO GEL INSOLES 5 RX/OTC SIZE 14/15 MISC SPENCO FOR HER 5 RX/OTC INSOLES SIZE 5/6 MISC SPENCO GEL INSOLES 5 RX/OTC SIZE 3/4 MISC SPENCO FOR HER RX/OTC INSOLES SIZE 5/6 TOTAL 5 SPENCO GEL INSOLES 5 RX/OTC SUPPORT MISC SIZE 5/6 MISC SPENCO GEL INSOLES RX/OTC SPENCO FOR HER 5 RX/OTC 5 INSOLES SIZE 7/8 MISC SIZE 6/7-7/8 MISC SPENCO FOR HER RX/OTC SPENCO GEL INSOLES 5 RX/OTC INSOLES SIZE 7/8 TOTAL 5 SIZE 8/9 MENS MISC SUPPORT MISC SPENCO GEL INSOLES 5 RX/OTC SIZE 8/9-9/10 MISC SPENCO FOR HER 5 RX/OTC INSOLES SIZE 9/10 MISC SPENCO IRONMAN GEL 5 RX/OTC SPENCO FOR HER RX/OTC INSOLES LARGE MISC INSOLES SIZE 9/10 5 SPENCO IRONMAN GEL 5 RX/OTC TOTAL SUPPORT MISC INSOLES SMALL MISC SPENCO GEL ARCH RX/OTC SPENCO IRONMAN PLUS 5 RX/OTC INSOLES SIZE LARGE 5 INSOLES LARGE MISC MISC SPENCO IRONMAN PLUS 5 RX/OTC SPENCO GEL ARCH RX/OTC INSOLES SMALL MISC INSOLES SIZE MEDIUM 5 SPENCO KIDS COMFORT RX/OTC MISC INSOLES SIZE 3 TO 4-1/2 5 SPENCO GEL ARCH RX/OTC MISC INSOLES SIZE SMALL 5 SPENCO KIDS COMFORT RX/OTC MISC INSOLES SIZE 5 TO 6-1/2 5 MISC SPENCO GEL BALL OF 5 RX/OTC FOOT ONE SIZE MISC SPENCO KIDS COMFORT 5 RX/OTC INSOLES SIZE 7/8 MISC

208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO KIDS RX/OTC SPENCO POLYSORB RX/OTC POLYSORB INSOLES 5 INSOLES SIZE 14/15 5 SIZE 3 TO 4-1/2 MISC HIKER MISC SPENCO KIDS RX/OTC SPENCO POLYSORB RX/OTC POLYSORB INSOLES 5 INSOLES SIZE 14/15 5 SIZE 5 TO 6-1/2 MISC TOTAL SUPPORT MISC SPENCO KIDS RX/OTC SPENCO POLYSORB RX/OTC POLYSORB INSOLES 5 INSOLES SIZE 14/15 5 SIZE 7/8 MISC WALKER-RUNNER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 10/11- 5 INSOLES SIZE 3/4 5 11/12 CROSS-TRAINER CROSS-TRAINER MISC MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 3/4 HIKER 5 INSOLES SIZE 10/11- 5 MISC 11/12 HEAVY DUTY MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 3/4 TOTAL 5 INSOLES SIZE 10/11- 5 SUPPORT MISC 11/12 HIKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 3/4 5 INSOLES SIZE 10/11- 5 WALKER-RUNNER MISC 11/12 TOTAL SUPPORT SPENCO POLYSORB RX/OTC MISC INSOLES SIZE 5/6 5 SPENCO POLYSORB RX/OTC CROSS-TRAINER MISC INSOLES SIZE 10/11- 5 SPENCO POLYSORB RX/OTC 11/12 WALKER-RUNNER INSOLES SIZE 5/6 HEAVY 5 MISC DUTY MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 12/13 5 INSOLES SIZE 5/6 HIKER 5 CROSS-TRAINER MISC MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 12/13 5 INSOLES SIZE 5/6 TOTAL 5 HEAVY DUTY MISC SUPPORT MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 12/13 5 INSOLES SIZE 5/6 5 HIKER MISC WALKER-RUNNER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 12/13 5 INSOLES SIZE 6/7-7/8 5 TOTAL SUPPORT MISC CROSS-TRAINER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 12/13 5 INSOLES SIZE 6/7-7/8 5 WALKER-RUNNER MISC HEAVY DUTY MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 6/7-7/8 5 CROSS-TRAINER MISC HIKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 6/7-7/8 5 HEAVY DUTY MISC TOTAL SUPPORT MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO POLYSORB RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 6/7-7/8 5 INSOLES SIZE 5/6 DAY 5 WALKER-RUNNER MISC HIKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 8/9-9/10 5 INSOLES SIZE 6/7-7/8 5 CROSS-TRAINER MISC BACKPACKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 8/9-9/10 5 INSOLES SIZE 6/7-7/8 5 HEAVY DUTY MISC DAY HIKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 8/9-9/10 5 INSOLES SIZE 8/9-9/10 5 HIKER MISC BACKPACKER MISC SPENCO POLYSORB RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 8/9-9/10 5 INSOLES SIZE 8/9-9/10 5 TOTAL SUPPORT MISC DAY HIKER MISC SPENCO POLYSORB RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 8/9-9/10 5 INSOLES SIZE 10/11- 5 WALKER-RUNNER MISC 11/12 MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 10/11- 5 INSOLES SIZE 12/13 5 11/12 BACKPACKER MISC MISC SPENCO RX ARCH RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 10/11- 5 MISC 11/12 DAY HIKER MISC SPENCO RX ARCH 5 RX/OTC SPENCO POLYSORB OS RX/OTC INSOLES SIZE 3/4 MISC INSOLES SIZE 12/13 5 SPENCO RX ARCH 5 RX/OTC BACKPACKER MISC INSOLES SIZE 5/6 MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 12/13 DAY 5 INSOLES SIZE 6/7-7/8 5 HIKER MISC MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARCH RX/OTC INSOLES SIZE 14/15 5 INSOLES SIZE 8/9-9/10 5 BACKPACKER MISC MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 14/15 DAY 5 FOOTCRADLES SIZE 10 5 HIKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 3/4 5 FOOTCRADLES SIZE 11 5 BACKPACKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 3/4 DAY 5 FOOTCRADLES SIZE 12 5 HIKER MISC MENS MISC SPENCO POLYSORB OS RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 5/6 5 FOOTCRADLES SIZE 6 5 BACKPACKER MISC WOMENS MISC

210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO RX ARTHRITIS RX/OTC SPENCO RX HEEL RX/OTC FOOTCRADLES SIZE 7 5 INSOLES SIZE 12/13 5 WOMENS MISC MISC SPENCO RX ARTHRITIS RX/OTC SPENCO RX HEEL 5 RX/OTC FOOTCRADLES SIZE 8 5 INSOLES SIZE 5/6 MISC WOMENS MISC SPENCO RX HEEL RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 6/7-7/8 5 FOOTCRADLES SIZE 9 5 MISC MENS MISC SPENCO RX HEEL RX/OTC SPENCO RX ARTHRITIS RX/OTC INSOLES SIZE 8/9-9/10 5 FOOTCRADLES SIZE 9 5 MISC WOMENS MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX BALL OF 5 RX/OTC SIZE 10/11-11/12 MISC FOOT LARGE MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX BALL OF 5 RX/OTC SIZE 12/13 MISC FOOT MEDIUM MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX BALL OF 5 RX/OTC SIZE 14/15 MISC FOOT SMALL MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX DIABETIC RX/OTC SIZE 3/4 MISC SUPPORT SIZE 10 MENS 5 SPENCO RX INSOLES 5 RX/OTC MISC SIZE 5/6 MISC SPENCO RX DIABETIC RX/OTC SPENCO RX INSOLES 5 RX/OTC SUPPORT SIZE 11 MENS 5 SIZE 6/7-7/8 MISC MISC SPENCO RX INSOLES 5 RX/OTC SPENCO RX DIABETIC RX/OTC SIZE 8/9-9/10 MISC SUPPORT SIZE 12 MENS 5 MISC SPENCO RX ORTHOTIC RX/OTC ARCH SUPPORTS SIZE 5 SPENCO RX DIABETIC RX/OTC 10/11-11/12 MISC SUPPORT SIZE 6 5 WOMENS MISC SPENCO RX ORTHOTIC RX/OTC ARCH SUPPORTS SIZE 5 SPENCO RX DIABETIC RX/OTC 10/11-11/12 THINSOLE SUPPORT SIZE 7 5 MISC WOMENS MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX DIABETIC RX/OTC ARCH SUPPORTS SIZE 5 SUPPORT SIZE 8 5 12/13 MISC WOMENS MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX DIABETIC RX/OTC ARCH SUPPORTS SIZE 5 SUPPORT SIZE 9 MENS 5 12/13 THINSOLE MISC MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX DIABETIC RX/OTC ARCH SUPPORTS SIZE 5 SUPPORT SIZE 9 5 14/15 MISC WOMENS MISC SPENCO RX ORTHOTIC RX/OTC SPENCO RX HEEL RX/OTC ARCH SUPPORTS SIZE 5 INSOLES SIZE 10/11- 5 14/15 THINSOLE MISC 11/12 MISC SPENCO RX ORTHOTIC RX/OTC ARCH SUPPORTS SIZE 5 3/4 MISC

211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPENCO RX ORTHOTIC RX/OTC VALULINE PNEUMATIC RX/OTC 5 ARCH SUPPORTS SIZE SHORTLEG 5 3/4 THINSOLE MISC WALKER/LOW SPENCO RX ORTHOTIC RX/OTC TOP/MEDIUM MISC ARCH SUPPORTS SIZE 5 VALULINE PNEUMATIC RX/OTC 5/6 MISC SHORTLEG 5 SPENCO RX ORTHOTIC RX/OTC WALKER/LOW ARCH SUPPORTS SIZE 5 TOP/SMALL MISC 5/6 THINSOLE MISC VALULINE PNEUMATIC RX/OTC SPENCO RX ORTHOTIC RX/OTC SHORTLEG 5 ARCH SUPPORTS SIZE 5 WALKER/STANDARD 6/7-7/8 MISC TOP/LARGE MISC SPENCO RX ORTHOTIC RX/OTC VALULINE PNEUMATIC RX/OTC ARCH SUPPORTS SIZE 5 SHORTLEG 5 6/7-7/8 THINSOLE MISC WALKER/STANDARD TOP/MEDIUM MISC SPENCO RX ORTHOTIC RX/OTC ARCH SUPPORTS SIZE 5 VALULINE PNEUMATIC RX/OTC 8/9-9/10 MISC SHORTLEG 5 WALKER/STANDARD SPENCO RX ORTHOTIC RX/OTC TOP/SMALL MISC ARCH SUPPORTS SIZE 5 8/9-9/10 THINSOLE MISC VALULINE SHORT LEG 5 RX/OTC WALKER/LARGE MISC SPENCO SLIM FIT RX/OTC INSOLES SIZE 10/11 5 VALULINE SHORT LEG RX/OTC MENS MISC WALKER/LOW 5 TOP/LARGE MISC SPENCO SLIM FIT RX/OTC INSOLES SIZE 12/13 5 VALULINE SHORT LEG RX/OTC MENS MISC WALKER/LOW 5 TOP/MEDIUM MISC SPENCO SLIM FIT RX/OTC INSOLES SIZE 14/15 5 VALULINE SHORT LEG RX/OTC MENS MISC WALKER/LOW 5 TOP/SMALL MISC SPENCO SLIM FIT RX/OTC INSOLES SIZE 8/9 MENS 5 VALULINE SHORT LEG 5 RX/OTC MISC WALKER/MEDIUM MISC SPORT & WORK RX/OTC VALULINE SHORT LEG 5 RX/OTC CUSHION INSOLES 5 WALKER/SMALL MISC MENS SIZE 7-13 MISC VALULINE SHORT LEG RX/OTC RX/OTC WALKER/STANDARD 5 TOENAIL CLIPPER MISC 5 TOP/MEDIUM MISC VALULINE SHORT LEG RX/OTC TOENAIL CLIPPER/FILE 5 RX/OTC DELUXE MISC WALKER/STANDARD 5 TOP/SMALL MISC TOENAIL NIPPER MISC 5 RX/OTC VALULINE SHORT LEG RX/OTC VALULINE PNEUMATIC RX/OTC WALKER/STANDARD/LAR 5 GE MISC SHORTLEG 5 WALKER/LOW VALULINE SHORT LEG 5 RX/OTC TOP/LARGE MISC WALKER/XLARGE MISC VALULINE SHORT LEG 5 RX/OTC WALKER/XSMALL MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Misc. Devices GNP ALCOHOL SWABS 5 RX/OTC PADS ALCOH-GLOVE 5 RX/OTC CONTOURED WIPE PADS H-E-B INCONTROL 5 RX/OTC ALCOHOL PADS PADS ALCOH-WIPE 12" X 12" 5 SHEE HM STERILE ALCOHOL 5 RX/OTC PREP PADS PADS RX/OTC ALCOHOL PADS PADS 5 MEIJER ALCOHOL RX/OTC SWABS EXTRA-THICK 5 ALCOHOL PREP PADS 5 RX/OTC PADS PADS RX/OTC NOZIN NASAL SANITIZER 5 RX/OTC ALCOHOL PREPS PADS 5 PADS RX/OTC PHARMACIST CHOICE RX/OTC ALCOHOL SWABS PADS 5 ALCOHOL PRED PADS 5 PADS ALCOHOL SWABSTICK 5 RX/OTC PADS PHARMACIST CHOICE RX/OTC RX/OTC ALCOHOLPREP PADS 5 ALCOHOL WIPES PADS 5 PADS PRO COMFORT RX/OTC APLICARE ALCOHOL 5 RX/OTC 5 SWABSTICK PADS ALCOHOL PADS PADS PURE COMFORT RX/OTC BD SWABS SINGLE USE 5 RX/OTC BUTTERFLY PADS ALCOHOL PREPPADS 5 PADS BD SWABS SINGLE USE 5 RX/OTC PADS QC ALCOHOL SWABS 5 RX/OTC PADS CARETOUCH ALCOHOL 5 RX/OTC PREP PADS PADS RA ALCOHOL SWABS 5 RX/OTC CURITY ALCOHOL RX/OTC PADS PREPS/MEDIUM 2 PLY 5 REALITY SWABS PADS 5 RX/OTC PADS RELION ALCOHOL RX/OTC CURITY ALCOHOL 5 RX/OTC 5 SWABS PADS SWABS PADS SAPS CARE ALCOHOL RX/OTC CVS ALCOHOL PREP 5 RX/OTC 5 PADS PADS PREP PADS PADS RX/OTC SAPS HEALTH ALCOHOL 5 RX/OTC CVS PREP PADS PADS 5 PREPPADS PADS SAPS HEALTH CARE RX/OTC EASY COMFORT 5 RX/OTC ALCOHOL PADS PADS ALCOHOLPREP PADS 5 EASY TOUCH ALCOHOL RX/OTC PADS PREP PADS/MEDIUM 5 SB ALCOHOL PREP 5 RX/OTC PADS PADS PADS SHOPKO ALCOHOL RX/OTC EQL ALCOHOL SWABS 5 RX/OTC 5 PADS SWABS PADS SM ALCOHOL PREP RX/OTC FIFTY50 ALCOHOL PREP 5 RX/OTC 5 PADS PADS PADS PADS SURE COMFORT RX/OTC GLOBAL ALCOHOL PREP 5 RX/OTC EASEPADS PADS ALCOHOL PREP PADS 5 PADS

213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-PREP ALCOHOL 5 RX/OTC LUMINEUX RX/OTC PREP PADS PADS CLEAN/FRESH 5 TOOTHPASTE PSTE TGT ALCOHOL SWABS 5 RX/OTC PADS LUMINEUX KIDS 5 RX/OTC TRUE COMFORT RX/OTC TOOTHPASTE PSTE ALCOHOL PREP PADS 5 LUMINEUX SENSITIVITY 5 RX/OTC PADS TOOTHPASTE PSTE ULTICARE ALCOHOL RX/OTC 5 LUMINEUX WHITENING 5 RX/OTC SWABS PADS TOOTHPASTE PSTE ULTILET ALCOHOL 5 RX/OTC MI PASTE PLUS PSTE 5 RX/OTC SWABS PADS RX/OTC ULTRA-CARE ALCOHOL 5 RX/OTC MI PASTE PSTE 5 PREP PADS PADS WEBCOL ALCOHOL RX/OTC RA FLUORIDE 5 RX/OTC PREP LARGE 1 PLY 5 TOOTHPASTE PSTE PADS RA SENSITIVE RX/OTC WEBCOL ALCOHOL RX/OTC TOOTHPASTE/FLUORIDE 5 PREP LARGE 2 PLY 5 PSTE PADS RA WHITENING RX/OTC WEBCOL ALCOHOL RX/OTC TOOTHPASTE/FLUORIDE 5 PREP MEDIUM 2 PLY 5 PSTE PADS REMESENSE MISC 5 Oral Hygiene Products SENSITIVE TOOTHPASTE RX/OTC AQUAFRESH CAVITY RX/OTC EXTRA 5 PROTECTION SUGAR 5 WHITENING/FLUORIDE ACID PROTECTION PSTE MAX ST PSTE AQUAFRESH EXTREME 5 RX/OTC SENSITIVE RX/OTC CLEAN PSTE TOOTHPASTE/FLUORIDE 5 /MAXIMUM STRENGTH BIOTENE DRY MOUTH 5 RX/OTC GENTLEFORMULA PSTE PSTE SENSODYNE MAXIMUM RX/OTC BIOTENE DRY MOUTH 5 RX/OTC 5 PSTE STRENGTH PSTE SENSODYNE MAXIMUM RX/OTC CREST TARTAR 5 RX/OTC CONTROL PSTE STRENGTH/FLUORIDE 5 CREST TARTAR RX/OTC PSTE CONTROL/BAKING SODA 5 SENSODYNE PRONAMEL 5 RX/OTC TOOTHPASTE PSTE FRESHBREATH PSTE SENSODYNE PRONAMEL RX/OTC CREST TOOTHPASTE 5 RX/OTC 5 PSTE PSTE CREST RX/OTC Parenteral Therapy Supplies TOOTHPASTE/REGULAR 5 1ST TIER UNIFINE QL(5 ea daily); PSTE PENTIPS/MINI/31GX5MM 5 RX/OTC CREST RX/OTC MISC TOOTHPASTEREGULAR 5 1ST TIER UNIFINE QL(5 ea daily); PSTE PENTIPS29GX12MM 5 RX/OTC MISC

214 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNIFINE 5 QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily) PENTIPS31GX6MM MISC SYRINGE/U- 5 100/0.3ML/31GX5/16" 1ST TIER UNIFINE 5 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE 5 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC SYRINGE/U- 5 RX/OTC 100/0.5ML/29GX1/2" MISC 1ST TIER UNIFINE 5 QL(5 ea daily) PENTIPS33GX4MM MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 5 RX/OTC 1ST TIER UNIFINE QL(5 ea daily); 100/0.5ML/30GX5/16" PENTIPSPLUS 31GX8MM 5 RX/OTC MISC MISC ADVOCATE INSULIN QL(5 ea daily) 1ST TIER UNIFINE QL(5 ea daily); SYRINGE/U- 5 PENTIPSPLUS 32GX4MM 5 RX/OTC 100/0.5ML/31GX5/16" MISC MISC 1ST TIER UNIFINE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); PENTIPSPLUS 33GX4MM 5 SYRINGE/U- 5 RX/OTC MISC 100/1ML/29GX1/2" MISC 1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); PENTIPSPLUS/MINI/31GX 5 RX/OTC SYRINGE/U- 5 RX/OTC 5MM MISC 100/1ML/30GX5/16" MISC 1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) PENTIPSPLUS/ORIGINAL/ 5 RX/OTC SYRINGE/U- 5 29GX12MM MISC 100/1ML/31GX5/16" MISC 1ST TIER UNIFINE QL(5 ea daily) ASSURE ID INSULIN QL(5 ea daily); PENTIPSPLUS/ULTRA 5 SAFETYSYRINGE/U- 5 RX/OTC SHORT/31GX6MM MISC 100/0.5ML/29G X 1/2" ADVOCATE INSULIN PEN QL(5 ea daily) MISC NEEDLES 29GX12.7MM 5 ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 5 RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); 100/1ML/29G X 1/2" MISC NEEDLES 31GX5MM 5 RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily) MISC NEEDLES 30G X 3/16" 5 ADVOCATE INSULIN PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 5 RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 30G X 5/16" 5 RX/OTC ADVOCATE INSULIN PEN 5 QL(5 ea daily) MISC NEEDLES MISC ASSURE ID SAFETY PEN QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); NEEDLES 31G X 3/16" 5 RX/OTC SYRINGE/U- 5 RX/OTC MISC 100/0.3ML/29GX1/2" MISC AURORA PEN NEEDLES 5 QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/U- RX/OTC 5 AURORA PEN NEEDLES 5 QL(5 ea daily) 100/0.3ML/30GX5/16" 31G X6MM MISC MISC AURORA PEN NEEDLES 5 QL(5 ea daily); 31G X8MM MISC RX/OTC AURORA UNIFINE 5 QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

215 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AURORA UNIFINE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) PENTIPS/MINI/31GX3/16" 5 RX/OTC MICROFINE/U- 3 MISC 100/1ML/27G X 5/8" MISC AUTOPEN DEVI 5 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); MICROFINE/U- 3 RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) 100/1ML/28G X 1/2" MISC ULTRAFINE II/0.3ML/31G 3 BD INSULIN SYRINGE QL(5 ea daily); X 5/16" MISC SAFETYGLIDE/1ML/29G X 3 RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) 1/2" MISC ULTRAFINE II/0.5ML/31G 3 BD INSULIN SYRINGE 3 QL(5 ea daily); X 5/16" MISC SLIP TIP/U-100/1ML MISC RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/1ML/31G X 3 ULTRA-FINE/0.3ML/30G X 3 5/16" MISC 12.7MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 3 ULTRA-FINE/0.3ML/31G X 3 1/2" MISC 8MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 3 ULTRA-FINE/0.5ML/30G X 3 1/2" MISC 12.7MM MISC BD LO-DOSE INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE MICROFINE 3 RX/OTC ULTRA-FINE/0.5ML/31G X 3 IV/0.5ML/28G X 1/2" MISC 8MM MISC BD AUTOSHIELD 29G X 4 BD INSULIN SYRINGE QL(5 ea daily) 3/16" MISC ULTRA-FINE/1/2 3 UNIT/0.3ML/31G X 8MM BD AUTOSHIELD 29G X 4 QL(5 ea daily) 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD AUTOSHIELD DUO 3 QL(5 ea daily) 30G X 5MM MISC ULTRA-FINE/1ML/30G X 3 BD INSULIN SYRINGE QL(5 ea daily); 12.7MM MISC LUER-LOK/U-100/1ML 3 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRA-FINE/1ML/31G X 3 BD INSULIN SYRINGE QL(5 ea daily); 8MM MISC BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 3 RX/OTC 100/0.5ML/28G X 1/2" ULTRAFINE HALF- 3 MISC UNIT/0.3ML/31G X 5/16" BD INSULIN SYRINGE QL(5 ea daily) MISC MICROFINE IV/U- 3 BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/27G X 5/8" MISC ULTRAFINE/0.3ML/30G X 3 BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE IV/U- 3 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/28G X 1/2" MISC ULTRAFINE/0.3ML/31G X 3 BD INSULIN SYRINGE QL(5 ea daily); 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) MICROFINE/U- 3 RX/OTC 100/0.5ML/28G X 1/2" ULTRAFINE/0.5ML/30G X 3 MISC 1/2" MISC

216 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE/U- QL(5 ea daily) ULTRAFINE/0.5ML/31G X 3 500/0.5ML/31G X 6MM 3 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD PEN MINI MISC 5 RX/OTC ULTRAFINE/1ML/30G X 3 1/2" MISC BD PEN MISC 5 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily) ULTRAFINE/U- 3 RX/OTC 100/0.3ML/29G X 1/2" NEEDLE/MICRO/ULTRA- 3 MISC FINE/32G X 6MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily); NEEDLE/MINI/ULTRA- 3 RX/OTC ULTRAFINE/U- 3 RX/OTC 100/0.5ML/29G X 1/2" FINE/31G X 5MM MISC MISC BD PEN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/NANO/ULTRA- 3 RX/OTC ULTRAFINE/U- 3 RX/OTC FINE/32G X 4MM MISC 100/1ML/29G X 1/2" MISC BD PEN QL(5 ea daily) BD INSULIN QL(5 ea daily); NEEDLE/ORIGINAL/ULTR 3 SYRINGE/0.3ML/29G X 3 RX/OTC A-FINE/29G X 12.7MM 12.7MM MISC MISC BD INSULIN QL(5 ea daily); BD PEN QL(5 ea daily); SYRINGE/0.5ML/29G X 3 RX/OTC NEEDLE/SHORT/ULTRA- 3 RX/OTC 12.7MM MISC FINE/31G X 8MM MISC BD INSULIN QL(5 ea daily); BD SAFETY-GLIDE QL(5 ea daily); SYRINGE/1ML/27G X 3 RX/OTC INSULIN 3 RX/OTC 12.7MM MISC SYRINGE/0.5ML/29G X BD INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/1ML/29G X 3 RX/OTC BD SAFETY-LOK INSULIN QL(5 ea daily); 12.7MM MISC SYRINGE/PERM 3 RX/OTC BD INSULIN QL(5 ea daily) NEEDLE/UF/1ML/29G X 1/2" MISC SYRINGE/DETACHABLE 3 NEEDLE/U-100/1ML/25G BD SAFETYGLIDE QL(5 ea daily); X 1" MISC INSULIN 3 RX/OTC BD INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1/2" MISC SYRINGE/DETACHABLE 3 NEEDLE/U-100/1ML/25G BD SAFETYGLIDE RX/OTC X 5/8" MISC INSULIN 3 BD INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 15/64" MISC SYRINGE/DETACHABLE 3 NEEDLE/U-100/1ML/26G BD SAFETYGLIDE QL(5 ea daily) X 1/2" MISC INSULIN 3 SYRINGE/0.3ML/31G X BD INSULIN SYRINGE/U- 3 QL(5 ea daily); 100/1ML/27G X 1/2" MISC RX/OTC 5/16" MISC BD INSULIN SYRINGE/U- BD SAFETYGLIDE 100/2ML/27.5G X 5/8" 3 INSULIN 3 MISC SYRINGE/0.5ML/31G X 15/64" MISC

217 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SAFETYGLIDE CAREFINE PEN QL(5 ea daily) INSULIN 3 NEEDLES 31GX6MM NC SYRINGE/1ML/31G X MISC 15/64" MISC CAREFINE PEN QL(5 ea daily); BD SAFETYGLIDE QL(5 ea daily); NEEDLES 31GX8MM NC RX/OTC INSULIN 3 RX/OTC MISC SYSYRINGE/0.5ML/30G X CAREFINE PEN QL(5 ea daily); 5/16" MISC NEEDLES 32GX5MM NC RX/OTC BD VEO INSULIN MISC SYRINGE ULTR-FINE/U- 3 CAREFINE PEN QL(5 ea daily) 100/0.5ML/31G X 15/64" NEEDLES 32GX6MM NC MISC MISC BD VEO INSULIN RX/OTC CAREONE INSULIN QL(5 ea daily) SYRINGE ULTRA- 3 SYRINGES/0.3ML/30G X 5 AFINE/0.3ML/31G X 6MM 1/2" MISC MISC CAREONE INSULIN QL(5 ea daily) BD VEO INSULIN RX/OTC SYRINGES/0.3ML/31G X 5 SYRINGE ULTRA- 3 5/16" MISC FINE/0.3ML/31G X 6MM MISC CAREONE INSULIN QL(5 ea daily) SYRINGES/0.5ML/30G X 5 BD VEO INSULIN 1/2" MISC SYRINGE ULTRA- 3 FINE/0.5ML/31G X 6MM CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/31G X 5 5/16" MISC BD VEO INSULIN RX/OTC CAREONE INSULIN QL(5 ea daily) SYRINGE ULTRA- 3 FINE/1/2 UNIT/0.3ML/31G SYRINGES/1ML/30G X 5 X 6MM MISC 1/2" MISC BD VEO INSULIN CAREONE INSULIN QL(5 ea daily) SYRINGES/1ML/31GX5/16 5 SYRINGE ULTRA- 3 FINE/1ML/31G X 6MM " MISC MISC CAREONE UNIFINE QL(5 ea daily); BD VEO INSULIN RX/OTC PENTIPS 29GX12MM 5 RX/OTC MISC SYRINGE ULTRA-FINE/U- 3 100/0.3ML/31G X 15/64" CAREONE UNIFINE 5 QL(5 ea daily); MISC PENTIPS 31GX5MM MISC RX/OTC BD VEO INSULIN CAREONE UNIFINE 5 QL(5 ea daily) PENTIPS 31GX6MM MISC SYRINGE ULTRA-FINE/U- 3 100/1ML/31G X 15/64" CAREONE UNIFINE 5 QL(5 ea daily); MISC PENTIPS 31GX8MM MISC RX/OTC CAREFINE PEN NEEDLE NC QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); 32GX4MM MISC RX/OTC PENTIPS PEN NEEDLES 5 RX/OTC 32GX4MM MISC CAREFINE PEN NC QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC CAREONE UNIFINE QL(5 ea daily); CAREFINE PEN QL(5 ea daily); PENTIPS PLUS PEN 5 RX/OTC NEEDLES 30GX5/16" NC RX/OTC NEEDLES 29GX12MM MISC MISC

218 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN 5 RX/OTC COMFORT EZINSULIN 5 RX/OTC NEEDLES 31GX5MM SYRINGE/0.3ML/29G X MISC 1/2" MISC CAREONE UNIFINE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) PENTIPS PLUS PEN 5 COMFORT EZINSULIN 5 NEEDLES 31GX6MM SYRINGE/0.3ML/30G X MISC 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN 5 RX/OTC COMFORT EZINSULIN 5 RX/OTC NEEDLES 31GX8MM SYRINGE/0.3ML/30G X MISC 5/16" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PLUS PEN 5 RX/OTC COMFORT EZINSULIN 5 NEEDLES 32GX4MM SYRINGE/0.3ML/31G X MISC 5/16" MISC CARETOUCH INSULIN QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); SYRINGE/U-100/1ML/28G 5 COMFORT EZINSULIN 5 RX/OTC X 5/16" MISC SYRINGE/0.5ML/28G X CARETOUCH INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U-100/1ML/29G 5 CLEVER CHOICE QL(5 ea daily); X 5/16" MISC COMFORT EZINSULIN 5 RX/OTC CARETOUCH PEN QL(5 ea daily) SYRINGE/0.5ML/29G X NEEDLES 31G X 6 MM NC 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); COMFORT EZINSULIN 5 NEEDLES 31GX 5MM NC RX/OTC SYRINGE/0.5ML/30G X MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31GX 8MM NC RX/OTC COMFORT EZINSULIN 5 RX/OTC MISC SYRINGE/0.5ML/30G X 5/16" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 32GX 4MM NC RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 5 SYRINGE/0.5ML/31G X CARETOUCH PEN QL(5 ea daily); 5/16" MISC NEEDLES 32GX 5MM NC RX/OTC MISC CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 5 CEQUR SIMPLICITY 2U 5 RX/OTC SYRINGE/1.0ML/30G X DEVI 1/2" MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN RX/OTC 5 COMFORT EZINSULIN 5 RX/OTC PEN NEEDLES 31GX8MM SYRINGE/1ML/28G X 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 5 COMFORT EZINSULIN 5 RX/OTC PEN NEEDLES 33GX4MM SYRINGE/1ML/29G X 1/2" MISC MISC

219 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 5 RX/OTC COMFORT EZPEN 5 SYRINGE/1ML/30G X NEEDLES 33GX6MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 5 COMFORT EZPEN 5 SYRINGE/U- NEEDLES 33GX8MM 100/1ML/31GX5/16" MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN NEEDLE 5 QL(5 ea daily); COMFORT EZPEN 5 RX/OTC 32GX5/32" MISC RX/OTC NEEDLES 29GX12MM CLICKFINE PEN NEEDLE QL(5 ea daily) MISC UNIVERSAL/31GX1/4" 5 CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZPEN 5 RX/OTC CLICKFINE PEN NEEDLE QL(5 ea daily); NEEDLES 31GX5MM UNIVERSAL/31GX5/16" 5 RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN QL(5 ea daily) COMFORT EZPEN 5 NEEDLES 31G X 1/4" 5 NEEDLES 31GX6MM MISC MISC CLICKFINE PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31G X 5/16" 5 RX/OTC COMFORT EZPEN 5 RX/OTC MISC NEEDLES 31GX8MM MISC CLICKFINE PEN 5 QL(5 ea daily) NEEDLES/31GX1/4" MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE UNIVERSAL QL(5 ea daily); COMFORT EZPEN 5 RX/OTC NEEDLES 32GX4MM PEN NEEDLES 31GX5/16" 5 RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); INSULIN SYRINGE 5 RX/OTC COMFORT EZPEN 5 RX/OTC NEEDLES 32GX5MM 0.3ML/29G X 1/2" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE/0.3ML/30G X COMFORT EZPEN 5 NEEDLES 32GX6MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) INSULIN 5 SYRINGE/0.3ML/31G X COMFORT EZPEN 5 NEEDLES 32GX8MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE/0.5ML/29G X COMFORT EZPEN 5 NEEDLES 33GX4MM 1/2" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE/0.5ML/30G X COMFORT EZPEN 5 NEEDLES 33GX5MM 5/16" MISC MISC

220 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) INSULIN 5 SYRINGE U- 5 SYRINGE/0.5ML/31G X 100/0.5ML/31G X 5/16" 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE U-100/1ML/30G 5 SYRINGE/1ML/29G X 1/2" X 1/2" MISC MISC DROPLET INSULIN COMFORT ASSIST QL(5 ea daily); SYRINGE U-100/1ML/30G NC INSULIN 5 RX/OTC X 15/64" MISC SYRINGE/1ML/30G X DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE U-100/1ML/30G 5 RX/OTC COMFORT ASSIST QL(5 ea daily) X 5/16" MISC INSULIN 5 DROPLET INSULIN SYRINGE/1ML/31G X SYRINGE U-100/1ML/31G 5 5/16" MISC X 15/64" MISC DROPLET INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) SYRINGE U-100/0.3/31G 5 SYRINGE U-100/1ML/31G 5 X 5/16" MISC X 5/16" MISC DROPLET INSULIN QL(5 ea daily) DROPLET INSULIN SYRINGE U- 5 SYRINGE/U- 5 100/0.3ML/30G X 1/2" 100/0.5ML/31G X 15/64" MISC MISC DROPLET INSULIN DROPLET PEN NEEDLES 5 QL(5 ea daily) SYRINGE U- NC 29GX10MM MISC 100/0.3ML/30G X 15/64" MISC DROPLET PEN NEEDLES 5 QL(5 ea daily); 29GX12MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily); DROPLET PEN NEEDLES QL(5 ea daily); SYRINGE U- 5 RX/OTC 5 100/0.3ML/30G X 5/16" 31GX5MM MISC RX/OTC MISC DROPLET PEN NEEDLES 5 QL(5 ea daily) DROPLET INSULIN RX/OTC 31GX6MM MISC DROPLET PEN NEEDLES QL(5 ea daily); SYRINGE U- 5 5 100/0.3ML/31G X 15/64" 31GX8MM MISC RX/OTC MISC DROPLET PEN NEEDLES 5 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) 32G X 1/4" MISC SYRINGE U- 5 DROPLET PEN NEEDLES 5 QL(5 ea daily); 100/0.5ML/30G X 1/2" 32G X 3/16" MISC RX/OTC MISC DROPLET PEN NEEDLES 5 QL(5 ea daily) DROPLET INSULIN 32G X 5/16" MISC SYRINGE U- NC DROPLET PEN NEEDLES 5 QL(5 ea daily); 100/0.5ML/30G X 15/64" 32G X 5/32" MISC RX/OTC MISC DROPLET PEN NEEDLES 5 QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE U- 5 RX/OTC 100/0.5ML/30G X 5/16" DROPLET PEN NEEDLES 5 QL(5 ea daily); MISC 32GX5MM MISC RX/OTC DROPLET PEN NEEDLES 5 QL(5 ea daily) 32GX6MM MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

221 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES QL(5 ea daily) 5 EASY COMFORT PEN 5 QL(5 ea daily); 32GX8MM MISC NEEDLES31GX5/16" MISC RX/OTC DROPSAFE SAFETY PEN QL(5 ea daily); EASY COMFORT PEN 5 QL(5 ea daily); NEEDLES/31G X 5/16" 5 RX/OTC NEEDLES32GX5/32" MISC RX/OTC MISC EASY COMFORT PEN QL(5 ea daily) DROPSAFE SAFTEY PEN QL(5 ea daily) NEEDLES33G X 4MM 5 NEEDLES/31G X 1/4" 5 MISC MISC EASY COMFORT PEN QL(5 ea daily) DRUG MART UNIFINE 5 QL(5 ea daily); NEEDLES33G X 5MM 5 PENTIPS 31GX5MM MISC RX/OTC MISC DRUG MART UNIFINE QL(5 ea daily); EASY COMFORT PEN QL(5 ea daily) PENTIPS29G X 12MM 5 RX/OTC NEEDLES33G X 6MM 5 MISC MISC DRUG MART UNIFINE 5 QL(5 ea daily) EASY GLIDE PEN QL(5 ea daily) PENTIPS31GX6MM MISC NEEDLES 33G X 5/32" 5 MISC DRUG MART UNIFINE 5 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC EASY TOUCH 32GX5MM 5 QL(5 ea daily); MISC RX/OTC DRUG MART UNIFINE 5 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC EASY TOUCH 32GX6MM 5 QL(5 ea daily) DRUG MART UNIFINE QL(5 ea daily); MISC PENTIPSPLUS 32GX4MM 5 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN 5 RX/OTC EASY COMFORT INSULIN QL(5 ea daily); SYRINGE 1ML/29GX1/2" SYRINGE/0.5ML/30G X 5 RX/OTC MISC 5/16" MISC EASY TOUCH FLIPLOCK QL(5 ea daily) EASY COMFORT INSULIN QL(5 ea daily) SAFETY INSULIN 5 SYRINGE/0.5ML/31G X 5 SYRINGE 1ML/30GX1/2" 5/16" MISC MISC EASY COMFORT INSULIN QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily); SYRINGE/1ML/30G X 5 RX/OTC SAFETY INSULIN 5 RX/OTC 5/16" MISC SYRINGE 1ML/30GX5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 5 EASY TOUCH FLIPLOCK QL(5 ea daily) 5/16" MISC SAFETY INSULIN 5 SYRINGE 1ML/31GX5/16" EASY COMFORT INSULIN QL(5 ea daily) MISC SYRINGE/U- 5 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 5 RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 5 EASY TOUCH INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/0.3ML/31G X 5 5/16" MISC EASY COMFORT PEN 5 QL(5 ea daily) NEEDLES31GX1/4" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 5 RX/OTC EASY COMFORT PEN QL(5 ea daily); 1/2" MISC NEEDLES31GX3/16" 5 RX/OTC MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 5 RX/OTC 5/16" MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

222 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 5 RX/OTC SYRINGE/U-100/1ML/30G 5 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- 5 RX/OTC SYRINGE/U-100/1ML/31G 5 100/0.5ML/29G X 1/2" X 5/16" MISC MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLE 30G X 5/16" 5 RX/OTC SYRINGE/SAFETY/U- 5 RX/OTC MISC 100/0.5ML/30G X 5/16" EASY TOUCH PEN 5 QL(5 ea daily); MISC NEEDLES 29GX1/2" MISC RX/OTC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN 5 QL(5 ea daily) SYRINGE/SAFETY/U- 5 RX/OTC NEEDLES 31GX1/4" MISC 100/1ML/29G X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) NEEDLES 31GX5/16" 5 RX/OTC SYRINGE/SAFETY/U- 5 MISC 100/1ML/30G X 1/2" MISC EASY TOUCH PEN 5 QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) NEEDLES 32GX1/4" MISC SYRINGE/U- 5 100/0.3ML/30G X 1/2" EASY TOUCH PEN QL(5 ea daily); MISC NEEDLES 32GX3/16" 5 RX/OTC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN QL(5 ea daily); SYRINGE/U- 5 100/0.5ML/27G X 1/2" NEEDLES 32GX5/32" 5 RX/OTC MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily); NEEDLES/31G X 3/16" 5 RX/OTC SYRINGE/U- 5 RX/OTC 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH SAFETY EASY TOUCH INSULIN QL(5 ea daily) PEN NEEDLES/29G X 4 5MM MISC SYRINGE/U- 5 100/0.5ML/30G X 1/2" EASY TOUCH SAFETY QL(5 ea daily) MISC PEN NEEDLES/29G X 4 EASY TOUCH INSULIN QL(5 ea daily) 8MM MISC EASY TOUCH QL(5 ea daily); SYRINGE/U- 5 100/0.5ML/31G X 5/16" SHEATHLOCK SAFETY 5 RX/OTC MISC INSULIN SYRINGE EASY TOUCH INSULIN QL(5 ea daily); 1ML/29GX1/2" MISC SYRINGE/U-100/1ML/27G 5 RX/OTC EASY TOUCH QL(5 ea daily); X 1/2" MISC SHEATHLOCK SAFETY 5 RX/OTC EASY TOUCH INSULIN QL(5 ea daily); INSULIN SYRINGE SYRINGE/U-100/1ML/28G 5 RX/OTC 1ML/30GX5/16" MISC X 1/2" MISC EASY TOUCH QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SHEATHLOCK SAFETY 5 SYRINGE/U-100/1ML/29G 5 RX/OTC INSULIN SYRINGE X 1/2" MISC 1ML/31GX5/16" MISC

223 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily); SHEATHLOCK SAFETY 5 SYRINGE/0.3ML/29G X 5 RX/OTC SYRINGE 1ML/30GX1/2" 1/2" MISC MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 5 RX/OTC SYRINGE/0.3ML/31G X 5 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 5 SYRINGE/0.5ML/29G X 5 RX/OTC 5/16" MISC 1/2" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 5 RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC 1/2" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 5 RX/OTC SYRINGE/1ML/29G X 5 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 5 SYRINGE/1ML/30G X 5 RX/OTC 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 5 RX/OTC SYRINGE/U- 5 RX/OTC MISC 100/0.5ML/28G X 1/2" EQL INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 5 RX/OTC ELITE-THIN INSULIN 5/16" MISC SYRINGE/U- 5 EQL INSULIN QL(5 ea daily) 100/0.5ML/28G X 5/16" SYRINGE/1ML/31G X 5 MISC 5/16" MISC ELITE-THIN INSULIN QL(5 ea daily) EXCEL COMFORT POINT QL(5 ea daily) SYRINGE/U- 5 INSULIN PEN NEEDLES 5 100/0.5ML/29G X 5/16" 31G X 4MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN PEN NEEDLES 5 RX/OTC SYRINGE/U- 5 29G X 12MM MISC 100/0.5ML/31G X 5/16" MISC EXEL COMFORT POINT QL(5 ea daily) INSULIN PEN NEEDLES 5 ELITE-THIN INSULIN QL(5 ea daily); 31G X 6MM MISC SYRINGE/U-100/1ML/28G 5 RX/OTC X 1/2" MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN PEN NEEDLES 5 RX/OTC ELITE-THIN INSULIN QL(5 ea daily) 31G X 8MM MISC SYRINGE/U-100/1ML/28G 5 X 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN 5 RX/OTC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/U-100/1ML/29G 5 RX/OTC 1/2" MISC X 1/2" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE/U-100/1ML/31G 5 SYRINGE/0.3ML/30G X X 5/16" MISC 5/16" MISC

224 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 5 RX/OTC COMFORTINSULIN 5 SYRINGE/0.5ML/28G X SYRINGE/1ML/31G X 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); INSULIN 5 RX/OTC UNIFINE PENTIPS PEN 5 RX/OTC SYRINGE/0.5ML/29G X NEEDLES 32GX4MM 1/2" MISC MISC EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); INSULIN 5 RX/OTC UNIFINE PENTIPS PLUS 5 RX/OTC SYRINGE/0.5ML/30G X 31GX5MM MISC 5/16" MISC FREDS PHARMACY QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); UNIFINE PENTIPS PLUS 5 RX/OTC INSULIN 5 RX/OTC 31GX8MM MISC SYRINGE/1ML/28G X 1/2" FREESTYLE PRECISION QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/30G X 5/16" INSULIN 5 RX/OTC MISC SYRINGE/1ML/29G X 1/2" FREESTYLE PRECISION QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN 5 RX/OTC MISC SYRINGE/1ML/30G X FREESTYLE PRECISION QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 5 FIFTY50 PEN NEEDLES 5 QL(5 ea daily); 100/1ML/31G X 5/16" 31G X3/16" (5MM) MISC RX/OTC MISC FIFTY50 PEN NEEDLES 5 QL(5 ea daily); FREESTYLE PRECISION QL(5 ea daily); ) MISC 31G X5/16" (8MM RX/OTC INSULIN SYRINGES/U- 5 RX/OTC 100/1ML/30G X 5/16" FIFTY50 PEN NEEDLES 5 QL(5 ea daily); 31GX5MM MISC RX/OTC MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/31GX8MM 5 RX/OTC PEN NEEDLES 5 RX/OTC MISC 29GX12MM MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX4MM 5 RX/OTC PEN NEEDLES 31GX8MM 5 RX/OTC MISC MISC FIFTY50 PEN QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/32GX6MM 5 PEN NEEDLES 32GX4MM 5 RX/OTC MISC MISC FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASE INJECT QL(5 ea daily); PEN NEEEDLES 5 RX/OTC COMFORTINSULIN 5 SYRINGE/0.3ML/31G X 31GX5MM MISC 5/16" MISC GLOBAL EASY GLIDE QL(5 ea daily) FIFTY50 SUPERIOR QL(5 ea daily) INSULINSYRINGE/U- 5 100/0.3ML/31G X 5/16" COMFORTINSULIN 5 SYRINGE/0.5ML/31G X MISC 5/16" MISC

225 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL EASY GLIDE QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); 5 PEN NEEDLES 32GX4MM RX/OTC INSULIN SYRINGE/U- 5 RX/OTC MISC 100/1ML/30G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/29G X 1/2" INSULIN SYRINGE/U- 5 MISC 100/1ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 GLOBAL INSULIN QL(5 ea daily) 100/0.3ML/30G X 1/2" SYRINGE/U- 5 MISC 100/0.3ML/30G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLOBAL INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGES/U- 5 RX/OTC MISC 100/0.3ML/30GX5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 GLUCOPRO INSULIN QL(5 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/U- NC MISC 100/0.3ML/30G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/U- NC RX/OTC MISC 100/0.3ML/30G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE/U- NC MISC 100/0.3ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 GLUCOPRO INSULIN QL(5 ea daily) 100/0.5ML/30G X 1/2" SYRINGE/U- NC MISC 100/0.5ML/30G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U- NC RX/OTC MISC 100/0.5ML/30G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 GLUCOPRO INSULIN QL(5 ea daily) 100/0.5ML/31G X 5/16" SYRINGE/U- NC MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/28G X 1/2" MISC SYRINGE/U-100/1ML/30G NC GLOBAL INJECT EASE QL(5 ea daily); X 1/2" MISC INSULIN SYRINGE/U- 5 RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G NC RX/OTC GLOBAL INJECT EASE QL(5 ea daily) X 5/16" MISC INSULIN SYRINGE/U- 5 100/1ML/30G X 1/2" MISC

226 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/U-100/1ML/31G NC INSULIN 5 RX/OTC X 5/16" MISC SYRINGE/0.3ML/29G X GNP CLICKFINE PEN QL(5 ea daily); 1/2" MISC NEEDLEUNIVERSAL/31G 5 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); X5/16" MISC INSULIN 5 RX/OTC GNP CLICKFINE QL(5 ea daily) SYRINGE/0.3ML/30G X UNIVERSAL PEN 5 5/16" SHORT MISC NEEDLES 31GX1/4" MISC GNP ULTRA COMFORT QL(5 ea daily) GNP CLICKFINE QL(5 ea daily); INSULIN 5 SYRINGE/0.3ML/31G X UNIVERSAL PEN 5 RX/OTC NEEDLES 31GX5/16" 5/16" SHORT MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 5 RX/OTC SYRINGE/0.3ML/29G X 5 RX/OTC SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.3ML/30G X 5 RX/OTC INSULIN 5 RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X 1/2" MISC GNP INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 5 GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 5 RX/OTC SYRINGE/0.5ML/30G X GNP INSULIN QL(5 ea daily); 5/16" SHORT MISC SYRINGE/0.5ML/28G X 5 RX/OTC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily) INSULIN 5 GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X SYRINGE/0.5ML/29G X 5 RX/OTC 5/16" SHORT MISC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 5 RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC SYRINGE/1ML/28G X 1/2" 5/16" MISC MISC GNP INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.5ML/31G X 5 INSULIN 5 RX/OTC 5/16" MISC SYRINGE/1ML/29G X 1/2" GNP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 5 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN 5 RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/1ML/30G X SYRINGE/1ML/29G X 1/2" 5 RX/OTC 5/16" SHORT MISC MISC GNP ULTRA COMFORT QL(5 ea daily) GNP INSULIN QL(5 ea daily); INSULIN 5 SYRINGE/1ML/30G X 5 RX/OTC SYRINGE/1ML/31G X 5/16" MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily) H-E-B IN CONTROL PEN QL(5 ea daily); SYRINGE/1ML/31G X 5 NEEDLES 31GX5MM 5 RX/OTC 5/16" MISC MISC

227 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL PEN QL(5 ea daily) HEALTHY ACCENTS QL(5 ea daily); 5 NEEDLES 31GX6MM UNIFINE PENTIPS PEN 5 RX/OTC MISC NEEDLES 32GX4MM H-E-B IN CONTROL PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 5 RX/OTC HM ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/1ML/30G X 1/2" 5 H-E-B IN CONTROL PEN QL(5 ea daily); MISC NEEDLES/NANO/32GX4M 5 RX/OTC HM ULTICARE INSULIN QL(5 ea daily) M MISC SYRINGE/U- 5 H-E-B IN CONTROL QL(5 ea daily); 100/0.3ML/31G X 5/16" UNIFINEPENTIPS PLUS 5 RX/OTC MISC 31GX5MM MISC HUMAPEN LUXURA HD 5 RX/OTC H-E-B IN CONTROL QL(5 ea daily); DEVI UNIFINEPENTIPS PLUS 5 RX/OTC INPEN 100/BLUE/LILLY 5 RX/OTC 32GX4MM MISC DEVI H-E-B INCONTROL PEN QL(5 ea daily); INPEN 100/BLUE/NOVO 5 RX/OTC NEEDLES 29GX12MM 5 RX/OTC DEVI MISC INPEN 100/GRAY/LILLY 5 RX/OTC HEALTHWISE MINI PEN QL(5 ea daily) DEVI NEEDLES 31GX6MM 5 INPEN 100/GREY/NOVO 5 RX/OTC MISC DEVI HEALTHWISE PEN QL(5 ea daily); INPEN 100/PINK/LILLY 5 RX/OTC NEEDLES 29GX12MM 5 RX/OTC DEVI MISC INPEN 100/PINK/NOVO 5 RX/OTC HEALTHWISE SHORT QL(5 ea daily); DEVI PEN NEEDLES 31GX8MM 5 RX/OTC MISC INSULIN SYRINGE 5 QL(5 ea daily) 1ML/31G X1/4" MISC HEALTHWISE UNIFINE QL(5 ea daily); PENTIPS PEN NEEDLES 5 RX/OTC INSULIN QL(5 ea daily) 32GX4MM MISC SYRINGE/0.3ML/29G X 1" 5 MISC HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily); UNIFINE PENTIPS PEN 5 RX/OTC NEEDLES 29GX12MM SYRINGE/0.3ML/29G X 5 RX/OTC MISC 1/2" MISC HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 5 RX/OTC UNIFINE PENTIPS PEN 5 RX/OTC NEEDLES 31GX5MM 5/16" MISC MISC INSULIN QL(5 ea daily) HEALTHY ACCENTS QL(5 ea daily) SYRINGE/0.3ML/31G X 5 5/16" MISC UNIFINE PENTIPS PEN 5 NEEDLES 31GX6MM INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/27G X 5 HEALTHY ACCENTS QL(5 ea daily); 1/2" MISC INSULIN QL(5 ea daily); UNIFINE PENTIPS PEN 5 RX/OTC NEEDLES 31GX8MM SYRINGE/0.5ML/28G X 5 RX/OTC MISC 1/2" MISC

228 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 5 QL(5 ea daily); SYRINGE/0.5ML/30G X 5 100/1ML/29G X 1/2" MISC RX/OTC 1/2" MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily); 100/1ML/30G X 5/16" 5 RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC MISC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily) INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" 5 SYRINGE/0.5ML/31G X 5 MISC 5/16" MISC INSULIN SYRINGES 5 QL(5 ea daily) INSULIN QL(5 ea daily); 0.3ML/31G X 1/4" MISC SYRINGE/1ML/28G X 1/2" 5 RX/OTC INSULIN SYRINGES 5 QL(5 ea daily) MISC 0.5ML/31G X 1/4" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 5 RX/OTC SYRINGES/0.5ML/27GX1/ 5 MISC 2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 5 RX/OTC SYRINGES/0.5ML/28GX1/ 5 RX/OTC 5/16" MISC 2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 RX/OTC SYRINGES/0.5ML/29GX1/ 5 RX/OTC 0.3ML/30G X 5/16" MISC 2" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 SYRINGES/0.5ML/30GX5/ 5 RX/OTC 0.3ML/31G X 5/16" MISC 16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 5 RX/OTC SYRINGES/0.5ML/31GX 5 0.5ML/29G X 1/2" MISC 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 5 RX/OTC SYRINGES/0.5ML/31GX5/ 5 0.5ML/30G X 5/16" MISC 16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 SYRINGES/1ML/27GX/1/2" 5 RX/OTC 0.5ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 RX/OTC SYRINGES/1ML/27GX1/2" 5 RX/OTC 1ML/29G X 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 RX/OTC SYRINGES/1ML/28GX1/2" 5 RX/OTC 1ML/30G X 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 5 SYRINGES/1ML/29GX1/2" 5 RX/OTC 1ML/31G X 5/16" MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/0.3ML/29G X 1/2" 5 RX/OTC SYRINGES/1ML/30GX1/2" 5 MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/29G X 1/2" 5 RX/OTC MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

229 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) KMART VALU PLUS SYRINGES/1ML/31GX5/16 5 INSULIN 5 " MISC SYRINGE/0.5ML/29G MISC INSUPEN 29G X 12MM 5 QL(5 ea daily); MISC RX/OTC KMART VALU PLUS INSULIN INSUPEN 31G X 5MM 5 QL(5 ea daily); 5 MISC RX/OTC SYRINGE/0.5ML/30G MISC INSUPEN 31G X 8MM 5 QL(5 ea daily); MISC RX/OTC KMART VALU PLUS QL(5 ea daily); INSULIN 5 RX/OTC INSUPEN 32G X 4MM 5 QL(5 ea daily); SYRINGE/1ML/29G MISC MISC RX/OTC KMART VALU PLUS QL(5 ea daily); INSUPEN 33GX4MM MISC 5 QL(5 ea daily) INSULIN 5 RX/OTC SYRINGE/1ML/30G MISC INSUPEN PEN NEEDLES 5 QL(5 ea daily); 32G X4MM MISC RX/OTC KROGER INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 5 RX/OTC INSUPEN SENSITIVE 5 QL(5 ea daily) 1/2" MISC 32GX6MM MISC KROGER INSULIN QL(5 ea daily); INSUPEN SENSITIVE 5 QL(5 ea daily) SYRINGE/0.3ML/30G X 5 RX/OTC 32GX8MM MISC 5/16" MISC INSUPEN ULTRAFIN 5 QL(5 ea daily); KROGER INSULIN QL(5 ea daily) 29GX12MM MISC RX/OTC SYRINGE/0.3ML/31G X 5 INSUPEN ULTRAFIN 5 QL(5 ea daily); 5/16" MISC 30GX8MM MISC RX/OTC KROGER INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 5 QL(5 ea daily) SYRINGE/0.5ML/29G X 5 RX/OTC 31GX6MM MISC 1/2" MISC INSUPEN ULTRAFIN 5 QL(5 ea daily); KROGER INSULIN QL(5 ea daily); 31GX8MM MISC RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC KINRAY INSULIN QL(5 ea daily) 5/16" MISC SYRINGE PREFERRED 5 KROGER INSULIN QL(5 ea daily) PLUS/0.3ML/31G X 5/16" SYRINGE/0.5ML/31G X 5 MISC 5/16" MISC KINRAY INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGE PREFERRED 5 SYRINGE/1ML/29G X 1/2" 5 RX/OTC PLUS/0.5ML/31G X 5/16" MISC MISC KROGER INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 5 RX/OTC SYRINGE PREFERRED 5 5/16" MISC PLUS/1ML/31G X 5/16" KROGER INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X 5 KINRAY INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X 5 RX/OTC KROGER PEN NEEDLES 5 QL(5 ea daily); 1/2" MISC 29G X12MM MISC RX/OTC KMART VALU PLUS KROGER PEN NEEDLES 5 QL(5 ea daily); INSULIN 5 31G X8MM MISC RX/OTC SYRINGE/0.3ML/30G MISC KROGER PEN NEEDLES 5 QL(5 ea daily) 31GX1/4" MISC

230 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER PEN QL(5 ea daily) LEADER UNIFINE QL(5 ea daily); NEEDLES/33G X5/32" 5 PENTIPS NC RX/OTC MISC PLUS/SHORT/31GX5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X 5 RX/OTC LEADER UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS/MINI/31GX3/16" 5 RX/OTC LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 5 RX/OTC LEADER UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS/NANO/32GX5/32 5 RX/OTC LEADER INSULIN QL(5 ea daily) " MISC SYRINGE/0.3ML/31G X 5 LEADER UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS/PLUS/32GX5/32" 5 RX/OTC LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/28G X 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/29G X 5 RX/OTC LEADER INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.5ML/29G X 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/30G X 5 RX/OTC LEADER INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.3ML/31G X 5 LEADER INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X 5 LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X 5 RX/OTC LEADER INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/28G X 1/2" 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 5 LEADER INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/29G X 1/2" 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 5 RX/OTC LEADER INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 5 RX/OTC LEADER INSULIN QL(5 ea daily) 100/0.5ML/28G X 1/2" SYRINGE/1ML/31G X 5 MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- 5 RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 5 RX/OTC PLUS/MINI/31GX3/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U-100/1ML/28G 5 RX/OTC X 1/2" MISC PENTIPS NC RX/OTC PLUS/MINI/31GX3/16" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 5 RX/OTC LEADER UNIFINE QL(5 ea daily); X 1/2" MISC PENTIPS 5 RX/OTC LITETOUCH INSULIN QL(5 ea daily) PLUS/SHORT/31GX5/16" SYRINGE/U-100/1ML/31G 5 MISC X 5/16" MISC

231 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH PEN QL(5 ea daily) MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLES 29GX12.7MM 5 SYRINGE/U- NC RX/OTC MISC 100/0.5ML/28GX1/2" MISC LITETOUCH PEN QL(5 ea daily) MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLES 31G X 6MM 5 SYRINGE/U- NC RX/OTC MISC 100/1ML/28GX1/2" MISC LITETOUCH PEN QL(5 ea daily); MAXI-COMFORT SAFETY NEEDLES 31GX8MM 5 RX/OTC PEN NEEDLE/29G X 3/16" 4 SHORT MISC MISC LITETOUCH PEN QL(5 ea daily); MAXI-COMFORT SAFETY QL(5 ea daily) NEEDLES/31G X 3/16" 5 RX/OTC PEN NEEDLE/29G X 5/16" 4 MISC MISC LONGS INSULIN QL(5 ea daily) MAXICOMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 5 SYRINGES 27G X 1/2" 5 5/16" MISC MISC MAGELLAN INSULIN QL(5 ea daily); MEDIC INSULIN QL(5 ea daily); 5 SAFETY SYRINGE/U- 5 RX/OTC SYRINGE/0.3ML/30G X RX/OTC 100/0.3ML/29G X 1/2" 5/16" MISC MISC MEDIC INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 5 RX/OTC SAFETY SYRINGE/U- 5 RX/OTC 5/16" MISC 100/0.3ML/30G X 5/16" MEDICINE SHOPPE PEN QL(5 ea daily); MISC NEEDLES 29G X 12MM 5 RX/OTC MAGELLAN INSULIN QL(5 ea daily); MISC SAFETY SYRINGE/U- 5 RX/OTC MEDICINE SHOPPE PEN QL(5 ea daily) 100/0.5ML/29G X 1/2" NEEDLES 31G X 6MM 5 MISC MISC MAGELLAN INSULIN QL(5 ea daily); MEDICINE SHOPPE PEN QL(5 ea daily); SAFETY SYRINGE/U- 5 RX/OTC NEEDLES 31G X 8MM 5 RX/OTC 100/0.5ML/30G X 5/16" MISC MISC MEIJER PEN NEEDLES 5 QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); 29G X12MM MISC RX/OTC SAFETY SYRINGE/U- 5 RX/OTC 100/1ML/29G X 1/2" MISC MEIJER PEN NEEDLES 5 QL(5 ea daily) 31G X6MM MISC MAGELLAN INSULIN QL(5 ea daily); MEIJER PEN NEEDLES QL(5 ea daily); SAFETY SYRINGE/U- 5 RX/OTC 5 100/1ML/30G X 5/16" 31G X8MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily) MARATHON MEDICAL QL(5 ea daily); NEEDLE/33G X 4 MM 5 PENTIPS29GX12MM 5 RX/OTC MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily); 100/0.3ML/30G X 5/16" 5 RX/OTC MARATHON MEDICAL 5 QL(5 ea daily); PENTIPS31GX5MM MISC RX/OTC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MARATHON MEDICAL 5 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC 100/0.3ML/31G X 5/16" 5 MISC MARATHON MEDICAL 5 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC

232 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 100/1/2ML/30G X 5/16" 5 RX/OTC SYRINGE/SAFETY/PERM 5 RX/OTC MISC NEEDLE/0.3ML/29GX1/2" MM INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1/2ML/31G X 5/16" 5 MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/PERM 5 RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily); NEEDLE/0.5ML/29G X 1/2" 100/1ML/30G X 5/16" 5 RX/OTC MISC MISC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/SAFETY/PERM 5 RX/OTC 100/1ML/31G X 5/16" 5 NEEDLE/1ML/29G X 1/2" MISC MISC MONOJECT INSULIN QL(5 ea daily); MM PEN NEEDLES 31G X 5 QL(5 ea daily) 1/4" MISC SYRINGE/SOFTPACK/1M 5 RX/OTC L/27G X 1/2" MISC MM PEN NEEDLES 31G X 5 QL(5 ea daily); 3/16" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/SOFTPACK/U- 5 RX/OTC MM PEN NEEDLES 31G X 5 QL(5 ea daily); 100/0.5ML/28G X 1/2" 5/16" MISC RX/OTC MISC MM PEN NEEDLES 32G X 5 QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 5/32" MISC RX/OTC SYRINGE/U- 5 RX/OTC MONOJECT INSULIN 5 QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGE/1ML MISC RX/OTC MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 5 SYRINGE/U- 5 RX/OTC 5/16" MISC 100/0.5ML/30G X 5/16" MONOJECT INSULIN QL(5 ea daily) MISC SYRINGE/DETACH 5 MONOJECT INSULIN QL(5 ea daily); NEEDLE/1ML/25G X 5/8" SYRINGE/U-100/1ML/28G 5 RX/OTC MISC X 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/DETACH 5 RX/OTC SYRINGE/U-100/1ML/30G 5 RX/OTC NEEDLE/1ML/27G X 1/2" X 5/16" MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGEREGULAR LUER 5 RX/OTC SYRINGE/PERM 5 RX/OTC TIP/SOFTPACK/1ML MISC NEEDLE/1ML/28G X 1/2" MONOJECT ULTRA QL(5 ea daily); MISC COMFORT INSULIN 5 RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/PERM 5 RX/OTC 1/2" MISC NEEDLE/U-100/0.5ML/28G MONOJECT ULTRA QL(5 ea daily); X 1/2" MISC COMFORT INSULIN 5 RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X SYRINGE/SAFETY/PERM 5 RX/OTC 5/16" MISC NEEDLE/0.3ML/29G X 1/2" MONOJECT ULTRA QL(5 ea daily) MISC COMFORT INSULIN 5 SYRINGE/0.3ML/31G X 5/16" MISC

233 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); PC UNIFINE PENTIPS QL(5 ea daily) COMFORT INSULIN 5 RX/OTC 31G X6MM ULTRA 5 SYRINGE/0.5ML/28G X SHORT MISC 1/2" MISC PC UNIFINE PENTIPS 5 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 31G X8MM SHORT MISC RX/OTC COMFORT INSULIN RX/OTC 5 PEN NEEDLES 29G X 5 QL(5 ea daily); SYRINGE/0.5ML/29G X 12MM MISC RX/OTC 1/2" MISC PEN NEEDLES 29GX1/2" NC QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); MISC RX/OTC COMFORT INSULIN 5 RX/OTC SYRINGE/0.5ML/30G X PEN NEEDLES 30GX5/16" 5 QL(5 ea daily); 5/16" MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) PEN NEEDLES 30GX5MM 5 QL(5 ea daily) MISC COMFORT INSULIN 5 SYRINGE/0.5ML/31G X PEN NEEDLES 30GX8MM 5 QL(5 ea daily); 5/16" MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 31G X 1/4" NC QL(5 ea daily) SHORT MISC COMFORT INSULIN 5 RX/OTC SYRINGE/1ML/28G X 1/2" PEN NEEDLES 31G X 5 QL(5 ea daily); MISC 3/16" MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 31G X 5 QL(5 ea daily); COMFORT INSULIN 5 RX/OTC 5MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" PEN NEEDLES 31G X 5 QL(5 ea daily) MISC 6MM MISC MS INSULIN QL(5 ea daily) PEN NEEDLES 31G X 5 QL(5 ea daily); SYRINGE/0.3ML/31G X 5 8MM MISC RX/OTC 5/16" MISC PEN NEEDLES 31GX5/16" 5 QL(5 ea daily); MS INSULIN QL(5 ea daily) MISC RX/OTC SYRINGE/0.5ML/31G X 5 5/16" MISC PEN NEEDLES 31GX5/16" NC QL(5 ea daily); MISC RX/OTC MS INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 5 PEN NEEDLES 31GX6MM 5 QL(5 ea daily) 5/16" MISC (1/4") MISC PEN NEEDLES 31GX8MM QL(5 ea daily); NOVOFINE 32GX6MM NC QL(5 ea daily) 5 MISC (5/16") MISC RX/OTC PEN NEEDLES 31GX8MM QL(5 ea daily); NOVOFINE AUTOCOVER NC QL(5 ea daily); 5 30GX8MM MISC RX/OTC MISC RX/OTC PEN NEEDLES 32G X QL(5 ea daily); NOVOFINE PLUS NC QL(5 ea daily); 5 32GX4MM MISC RX/OTC 4MM MISC RX/OTC RX/OTC PEN NEEDLES 32G X 5 QL(5 ea daily); NOVOPEN ECHO DEVI 5 5MM MISC RX/OTC PEN NEEDLES 32G X QL(5 ea daily) NOVOTWIST 32GX5MM NC QL(5 ea daily); 5 MISC RX/OTC 6MM MISC PEN NEEDLES 32GX4MM QL(5 ea daily); PC UNIFINE PENTIPS 5 QL(5 ea daily); 5 29G X1/2" MISC RX/OTC MISC RX/OTC PEN NEEDLES 33G X QL(5 ea daily) PC UNIFINE PENTIPS 5 QL(5 ea daily); 5 31G X5MM MINI MISC RX/OTC 5/32" MISC

234 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTIPS 29G X 12MM NC QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 5 RX/OTC 100/0.3ML/29G X 1/2" PENTIPS 29GX12MM 5 QL(5 ea daily); MISC RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PENTIPS 31G X 5MM NC QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 5 RX/OTC 100/0.3ML/30G X 5/16" PENTIPS 31G X 8MM NC QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 31GX5MM MISC 5 INSULIN SYRINGE/U- 5 RX/OTC RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 31GX6MM MISC 5 QL(5 ea daily) MISC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 31GX8MM MISC 5 INSULIN SYRINGE/U- 5 RX/OTC RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 32G X 4MM NC QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 32GX4MM MISC 5 INSULIN SYRINGE/U- 5 RX/OTC RX/OTC 100/0.5ML/30G X 5/16" PRECISION SURE-DOSE QL(5 ea daily); MISC INSULIN NC RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/30G X INSULIN SYRINGE/U- 5 RX/OTC 5/16" MISC 100/1ML/28G X 1/2" MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); INSULIN NC RX/OTC INSULIN SYRINGE/U- 5 RX/OTC SYRINGE/0.5ML/28G X 100/1ML/29G X 1/2" MISC 1/2" MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC INSULIN NC RX/OTC 100/1ML/30G X 5/16" SYRINGE/0.5ML/29G X MISC 1/2" MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily) UNIFINE PENTIPS 29G X 5 RX/OTC INSULIN NC 12MM MISC SYRINGE/0.5ML/30G X PREFERRED PLUS QL(5 ea daily) 3/8" MISC UNIFINE PENTIPS 31G X 5 PRECISION SURE-DOSE QL(5 ea daily); 6MM ULTRA SHORT INSULIN NC RX/OTC MISC SYRINGE/1ML/28G X 1/2" PREFERRED PLUS QL(5 ea daily); MISC UNIFINE PENTIPS 31G X 5 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); 8MM SHORT MISC PLUSINSULIN NC RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/29G X UNIFINE PENTIPS 5 RX/OTC 1/2" MISC 32GX4MM MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); PLUSINSULIN RX/OTC NC UNIFINE 5 RX/OTC SYRINGE/1ML/29G X 1/2" PENTIPS/MINI/31GX5MM MISC MISC

235 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(5 ea daily) PX MINI PEN NEEDLES 5 QL(5 ea daily); SYRINGES/0.5ML/30G X 5 31GX5MM MISC RX/OTC 1/2" MISC PX PEN NEEDLE 5 QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGES/0.5ML/30G X 5 RX/OTC PX PEN NEEDLE 5 QL(5 ea daily); 5/16" MISC 31GX8MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) PX SHORTLENGTH PEN QL(5 ea daily); SYRINGES/0.5ML/31G X 5 NEEDLES/31GX8MM 5 RX/OTC 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) QC PEN NEEDLES 29G X 5 QL(5 ea daily); SYRINGES/1ML/30G X 5 12MM MISC RX/OTC 1/2" MISC QC PEN NEEDLES 31G X 5 QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily); 6MM MISC SYRINGES/1ML/30G X 5 RX/OTC 5/16" MISC QC PEN NEEDLES 31G X 5 QL(5 ea daily); 8MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) SYRINGES/1ML/31G X 5 QC UNIFINE PENTIPS 5 QL(5 ea daily); 5/16" MISC 32GX4MM MISC RX/OTC PRO COMFORT PEN QL(5 ea daily); RA INSULIN QL(5 ea daily); NEEDLES/31G X 8MM 5 RX/OTC SYRINGE/0.5ML/29G X NC RX/OTC MISC 1/2" MISC PRO COMFORT PEN QL(5 ea daily); RA INSULIN QL(5 ea daily); NEEDLES/32G X 4MM 5 RX/OTC SYRINGE/1ML/29G X 1/2" NC RX/OTC MISC MISC PRO COMFORT PEN QL(5 ea daily); RA INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/32G X 5MM 5 RX/OTC 100/0.5ML/30G X 5/16" NC RX/OTC MISC MISC PRO COMFORT PEN QL(5 ea daily) RA INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/32G X 6MM 5 100/1 ML/30G X 5/16" NC RX/OTC MISC MISC PRODIGY INSULIN QL(5 ea daily) RA PEN NEEDLES 31G X NC QL(5 ea daily); SYRING/U-100/0.3ML/31G 5 5MM3/16" MISC RX/OTC X 5/16" MISC RA PEN NEEDLES 31G X NC QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) 8MM5/16" MISC RX/OTC SYRINGE/1/2ML/31G X 5 REALITY INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- 5 RX/OTC PRODIGY INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/1ML/28G X 1/2" 5 RX/OTC MISC MISC REALITY INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC PURE COMFORT PEN 5 QL(5 ea daily) 5 NEEDLE 32G X8MM MISC 100/0.5ML/29G X 1/2" MISC PX EXTRA SHORT PEN QL(5 ea daily) NEEDLES 31GX6MM 5 REALITY INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G 5 RX/OTC X 1/2" MISC PX INSULIN SYRINGE/U- QL(5 ea daily) 100/0.5ML/30G X 1/2" 5 REALITY INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 5 RX/OTC X 1/2" MISC

236 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION INSULIN RELION INSULIN QL(5 ea daily); SYRINGE 0.5ML/31G X 3 SYRINGE/U- 5 RX/OTC 15/64" MISC 100/0.5ML/30G X 5/16" RELION INSULIN MISC SYRINGE 0.5ML/31G X NC RELION INSULIN QL(5 ea daily) 15/64" MISC SYRINGE/U- 5 RELION INSULIN 100/0.5ML/31G X 5/16" SYRINGE 3 MISC 1ML/31GX15/64" MISC RELION INSULIN RELION INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 5 SYRINGE/U-00/1ML/29G 5 RX/OTC MISC X 1/2" MISC RELION INSULIN QL(5 ea daily); RELION INSULIN SYRINGE/U-100/1ML/30G 5 RX/OTC SYRINGE/U- 5 X 5/16" MISC 100/0.3ML/29G MISC RELION INSULIN RELION INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 5 X 15/64" MISC SYRINGE/U- 5 RX/OTC 100/0.3ML/29G X 1/2" RELION INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 5 RELION INSULIN X 5/16" MISC SYRINGE/U- 5 RELION MINI PEN QL(5 ea daily) 100/0.3ML/30G MISC NEEDLES 31GX6MM 5 RELION INSULIN QL(5 ea daily); MISC SYRINGE/U- 5 RX/OTC RELION PEN NEEDLES 5 QL(5 ea daily); 100/0.3ML/30G X 5/16" 29GX12MM MISC RX/OTC MISC RELION PEN NEEDLES 5 QL(5 ea daily) RELION INSULIN RX/OTC 31GX6MM MISC SYRINGE/U- 5 RELION PEN NEEDLES 5 QL(5 ea daily); 100/0.3ML/31G X 15/64" 31GX8MM MISC RX/OTC MISC RELION PEN NEEDLES 5 QL(5 ea daily); RELION INSULIN RX/OTC 32GX4MM MISC RX/OTC SYRINGE/U- NC 100/0.3ML/31G X 15/64" RELION SHORT PEN 5 QL(5 ea daily); MISC NEEDLES31GX8MM MISC RX/OTC RELION INSULIN QL(5 ea daily) SAFESNAP INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 5 RX/OTC SYRINGE/U- 5 100/0.3ML/31G X 5/16" 5/16" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN SYRINGE/0.5ML/29G X 5 RX/OTC SYRINGE/U- 5 1/2" MISC 100/0.5ML/29G MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 5 RX/OTC 5/16" MISC SYRINGE/U- 5 RX/OTC 100/0.5ML/29G X 1/2" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 5 RX/OTC RELION INSULIN MISC SYRINGE/U- 5 100/0.5ML/30G MISC

237 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFESNAP INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 5 RX/OTC PENTIPS PEN 5 RX/OTC MISC NEEDLES/ORIGINAL/29G SAFETY INSULIN QL(5 ea daily); X12MM MISC SYRINGES 5 RX/OTC SHOPKO UNIFINE QL(5 ea daily); 0.5ML/29GX1/2" MISC PENTIPS PEN 5 RX/OTC SAFETY INSULIN QL(5 ea daily); NEEDLES/SHORT/31GX8 SYRINGES 5 RX/OTC MM MISC 0.5ML/30GX5/16" MISC SHOPKO UNIFINE QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); PENTIPS PLUS PEN 5 RX/OTC SYRINGES 1ML/27GX1/2" 5 RX/OTC NEEDLES/MICRO/REMOV MISC R/32GX4MM MISC SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); SYRINGES 1ML/29GX1/2" 5 RX/OTC PENTIPS PLUS PEN 5 RX/OTC MISC NEEDLES/MINI/REMOVE R/31GX5MM MISC SAFETY INSULIN QL(5 ea daily) SYRINGES 1ML/30GX1/2" 5 SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN 5 RX/OTC NEEDLES/REMOVER/29G SB INSULIN SYRINGE/U- QL(5 ea daily); X12MM MISC 100/0.5ML/29G X 1/2" 5 RX/OTC MISC SHOPKO UNIFINE QL(5 ea daily); PENTIPS PLUS PEN 5 RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/SHORT/REMO 100/0.5ML/29G X 1/2" NC RX/OTC VR/31GX8MM MISC MISC SURE COMFORT QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC 100/0.5ML/30G X 5/16" 5 RX/OTC 100/0.3ML/29G X 1/2" MISC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily) 100/0.5ML/30G X 5/16" NC RX/OTC INSULIN SYRINGE/U- 5 MISC 100/0.3ML/30G X 1/2" SB INSULIN SYRINGE/U- 5 QL(5 ea daily); MISC 100/1ML/29G X 1/2" MISC RX/OTC SURE COMFORT QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC 100/1ML/30G X 5/16" 5 RX/OTC 100/0.3ML/30G X 5/16" MISC MISC SB INSULIN SYRINGE/U- QL(5 ea daily) SURE COMFORT QL(5 ea daily) 100/1ML/31G X 5/16" 5 INSULIN SYRINGE/U- 5 MISC 100/0.3ML/31G X 5/16 SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PEN 5 RX/OTC SURE COMFORT QL(5 ea daily) NEEDLES/MICRO/32GX4 INSULIN SYRINGE/U- 5 MM MISC 100/0.3ML/31G X 5/16" SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PEN 5 RX/OTC SURE COMFORT QL(5 ea daily) NEEDLES/MINI/31GX5MM INSULIN SYRINGE/U- 5 MISC 100/0.3ML/31GX1/4" MISC

238 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC NEEDLES30GX5/16" 5 RX/OTC 100/0.5ML/28G X 1/2" SHORT MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE COMFORT QL(5 ea daily); NEEDLES31GX3/16" 5 RX/OTC INSULIN SYRINGE/U- 5 RX/OTC (5MM) MISC 100/0.5ML/29G X 1/2" SURE COMFORT PEN QL(5 ea daily); MISC NEEDLES31GX5/16" 5 RX/OTC SURE COMFORT QL(5 ea daily) (8MM) MISC INSULIN SYRINGE/U- 5 SURE COMFORT PEN 5 QL(5 ea daily); 100/0.5ML/30G X 1/2" NEEDLES32GX5/32" MISC RX/OTC MISC SURE COMFORT PEN 5 QL(5 ea daily) SURE COMFORT QL(5 ea daily); NEEDLES32GX6MM MISC INSULIN SYRINGE/U- 5 RX/OTC 100/0.5ML/30G X 5/16" SURE-FINE PEN QL(5 ea daily) MISC NEEDLES 29GX1/2" 5 12.7MM MISC SURE COMFORT QL(5 ea daily) SURE-FINE PEN QL(5 ea daily); INSULIN SYRINGE/U- 5 100/0.5ML/31G X 5/16 NEEDLES 31GX3/16" 5MM 5 RX/OTC MISC MISC SURE COMFORT QL(5 ea daily); SURE-FINE PEN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC NEEDLES 31GX5/16" 8MM 5 RX/OTC 100/1ML/28G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC SYRINGE/U- 5 RX/OTC 100/1ML/29G X 1/2" MISC 100/0.3ML/29G X 1/2" MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- 5 SURE-JECT INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U- 5 RX/OTC 100/0.3ML/30G X 5/16" SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 5 RX/OTC 100/1ML/30G X 5/16" SURE-JECT INSULIN QL(5 ea daily) MISC SYRINGE/U- 5 100/0.3ML/31G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 5 100/1ML/31G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 5 RX/OTC 100/0.5ML/28G X 1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN 5 SYRINGES/0.5ML/31G X SURE-JECT INSULIN QL(5 ea daily); 6MM MISC SYRINGE/U- 5 RX/OTC 100/0.5ML/29G X 1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGES/U- 5 100/1ML/31GX6MM MISC SURE-JECT INSULIN QL(5 ea daily); SYRINGE/U- 5 RX/OTC SURE COMFORT PEN QL(5 ea daily) 100/0.5ML/30G X 5/16" NEEDLES29GX1/2" 5 MISC 12.7MM MISC

239 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN SYRINGE/U- 5 SYRINGEU- 5 100/0.5ML/31G X 5/16" 100/0.5ML/31G X 15/64" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/28G 5 RX/OTC SYRINGEU- 5 X 1/2" MISC 100/0.5ML/31G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 5 RX/OTC TECHLITE INSULIN QL(5 ea daily); X 1/2" MISC SYRINGEU-100/1ML/29G 5 RX/OTC SURE-JECT INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/U-100/1ML/30G 5 RX/OTC TECHLITE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGEU-100/1ML/30G 5 SURE-JECT INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/U-100/1ML/31G 5 TECHLITE INSULIN QL(5 ea daily); X 5/16" MISC SYRINGEU-100/1ML/30G 5 RX/OTC TECHLITE INSULIN QL(5 ea daily); X 5/16" MISC SYRINGEU- 5 RX/OTC TECHLITE INSULIN 100/0.3ML/29G X 1/2" SYRINGEU-100/1ML/31G 5 MISC X 15/64" MISC TECHLITE INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) 5 SYRINGEU- 5 SYRINGEU-100/1ML/31G 100/0.3ML/30G X 1/2" X 5/16" MISC MISC TECHLITE PEN NEEDLES 5 QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); 29GX 10MM MISC SYRINGEU- RX/OTC 5 TECHLITE PEN NEEDLES 5 QL(5 ea daily); 100/0.3ML/30G X 5/16" 29GX 12 MM MISC RX/OTC MISC TECHLITE PEN NEEDLES 5 QL(5 ea daily); TECHLITE INSULIN RX/OTC 31GX 5MM MISC RX/OTC SYRINGEU- 5 100/0.3ML/31G X 15/64" TECHLITE PEN QL(5 ea daily); MISC NEEDLES/31GX 5MM 5 RX/OTC MISC TECHLITE INSULIN QL(5 ea daily) TECHLITE PEN QL(5 ea daily) SYRINGEU- 5 100/0.3ML/31G X 5/16" NEEDLES/31GX 6 MM 5 MISC MISC TECHLITE INSULIN QL(5 ea daily); TECHLITE PEN QL(5 ea daily); NEEDLES/31GX 8MM 5 RX/OTC SYRINGEU- 5 RX/OTC 100/0.5ML/29G X 1/2" MISC MISC TECHLITE PEN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) NEEDLES/32GX 4MM 5 RX/OTC MISC SYRINGEU- 5 100/0.5ML/30G X 1/2" TECHLITE PEN QL(5 ea daily) MISC NEEDLES/32GX 6MM 5 TECHLITE INSULIN QL(5 ea daily); MISC TECHLITE PEN QL(5 ea daily) SYRINGEU- 5 RX/OTC 100/0.5ML/30G X 5/16" NEEDLES/32GX 8MM 5 MISC MISC

240 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TODAYS HEALTH MINI QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); PEN NEEDLES 31G X 1/4" 5 COMFORT INSULIN RX/OTC MISC SYRINGE/U- 5 TODAYS HEALTH QL(5 ea daily); 100/0.5ML/29G X 1/2" ORIGINAL PEN NEEDLES 5 RX/OTC MISC 29G X 1/2" MISC TOPCARE ULTRA QL(5 ea daily); TODAYS HEALTH SHORT QL(5 ea daily); COMFORT INSULIN 5 RX/OTC PEN NEEDLES 31G X 5 RX/OTC SYRINGE/U-100/1ML/29G 5/16" MISC X 1/2" MISC TOPCARE CLICKFINE QL(5 ea daily) TRUE COMFORT INSULIN QL(5 ea daily) UNIVERSAL PEN EEDLES 5 SYRINGE/0.5ML/31G X 5 31GX1/4" MISC 5/16" MISC TOPCARE CLICKFINE QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily); UNIVERSAL PEN EEDLES 5 RX/OTC NEEDLES31G X 5MM 5 RX/OTC 31GX5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily); NEEDLES32G X 4MM 5 RX/OTC COMFORT INSULIN 5 RX/OTC SYRINGE/0.3ML/30G X MISC 5/16" MISC TRUEPLUS 5-BEVEL PEN RX/OTC TOPCARE ULTRA QL(5 ea daily) NEEDLES 31GX5MM NC MISC COMFORT INSULIN 5 SYRINGE/0.3ML/31G X TRUEPLUS 5-BEVEL PEN 5/16" MISC NEEDLES 31GX6MM NC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN 5 RX/OTC TRUEPLUS 5-BEVEL PEN RX/OTC SYRINGE/0.5ML/30G X NEEDLES 31GX8MM NC 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUEPLUS 5-BEVEL PEN RX/OTC NC COMFORT INSULIN 5 NEEDLES 32GX4MM SYRINGE/0.5ML/31G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- NC RX/OTC COMFORT INSULIN 5 RX/OTC 100/0.3ML/29G X 1/2" SYRINGE/1ML/30G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) SYRINGE/U- NC RX/OTC COMFORT INSULIN 5 100/0.3ML/30G X 5/16" SYRINGE/1ML/31G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- NC COMFORT INSULIN RX/OTC 100/0.3ML/31G X 5/16" SYRINGE/U- 5 MISC 100/0.3ML/29G X 1/2" TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U- NC RX/OTC 100/0.5ML/28G X 1/2" MISC

241 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- NC RX/OTC SYRINGE/0.3ML/29G X 5 RX/OTC 100/0.5ML/29G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 5 SYRINGE/U- NC RX/OTC 1/2" MISC 100/0.5ML/30G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 5 RX/OTC TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- NC ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/28G X 5 RX/OTC MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G NC RX/OTC SYRINGE/0.5ML/29G X 5 RX/OTC X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/29G NC RX/OTC SYRINGE/0.5ML/30G X 5 X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G NC RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC X 5/16" MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G NC SYRINGE/1ML/28G X 1/2" 5 RX/OTC X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 29GX12MM NC RX/OTC SYRINGE/1ML/29G X 1/2" 5 RX/OTC MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 31GX5MM NC RX/OTC SYRINGE/1ML/30G X 1/2" 5 MISC MISC TRUEPLUS PEN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX6MM NC SYRINGE/1ML/30G X 5 RX/OTC MISC 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX8MM NC RX/OTC SYRINGE/SHORT/0.3ML/3 5 RX/OTC MISC 0G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 32GX4MM NC RX/OTC SYRINGE/SHORT/0.3ML/3 5 MISC 1G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SAFETY 5 RX/OTC SYRINGE/SHORT/0.5ML/3 5 RX/OTC SYRINGE/0.5ML/29G X 0G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 5 SAFETY 5 RX/OTC 1G X 5/16" MISC SYRINGE/1ML/29G X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 5 RX/OTC G X 5/16" MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

242 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/SHORT/1ML/31 5 NEEDLES/31G X 5/16" 5 RX/OTC G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SYRINGE/U- 5 NEEDLES/32G X 4MM 5 RX/OTC 100/0.3ML/30G X 1/2" MISC MISC ULTICARE MICRO PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES/32G X 5/32" 5 RX/OTC SYRINGE/U- 5 MISC 100/0.3ML/31G X 5/16" ULTICARE MINI PEN QL(5 ea daily) MISC NEEDLES 31GX6MM 5 ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/U- 5 ULTICARE MINI PEN QL(5 ea daily) 100/0.5ML/30G X 1/2" NEEDLES ULTI-FINE IV 5 MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily) SYRINGE/U- 5 NEEDLES/31G X 6MM 5 100/0.5ML/31G X 5/16" MISC MISC ULTICARE MINI PEN 5 QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) NEEDLES31GX6MM MISC SYRINGE/U-100/1ML/30G 5 X 1/2" MISC ULTICARE PEN NEEDLES 5 QL(5 ea daily); 31GX 5MM/MINI MISC RX/OTC ULTICARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 5 ULTICARE PEN QL(5 ea daily) X 5/16" MISC NEEDLES/29GX 12.7MM 5 MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE SHORT PEN QL(5 ea daily); SYRINGEULTRAFINE U- 5 100/0.3ML/31G X 5/16" NEEDLES 31GX8MM 5 RX/OTC MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE SHORT PEN QL(5 ea daily); NEEDLES ULTI-FINE IV 5 RX/OTC SYRINGEULTRAFINE U- 5 100/0.5ML/31G X 5/16" MISC MISC ULTICARE SHORT PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES/31G X 8MM 5 RX/OTC MISC SYRINGEULTRAFINE U- 5 100/1ML/31G X 5/16" ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/31G X 5 ULTICARE MICRO PEN QL(5 ea daily); 1/4" MISC NEEDLES 31G X 8MM 5 RX/OTC ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/31G 5 ULTICARE MICRO PEN QL(5 ea daily); X1/4" MISC NEEDLES 32G X 4MM 5 RX/OTC ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/31G X 5 ULTICARE MICRO PEN QL(5 ea daily) 1/4" MISC NEEDLES/31G X 1/4" 5 ULTICARE U-100 INSULIN QL(5 ea daily) MISC SYRINGES/1ML/31G X 5 1/4" MISC

243 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN 5 QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SYRINGE 31X6MM MISC SYRINGE/U-100/1ML/30G 5 X 1/2" MISC ULTILET INSULIN 5 RX/OTC SYRINGE 31X6MM MISC ULTILET PEN NEEDLE 5 QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); 29GX12.7MM MISC SYRINGE/0.3ML/30G X 5 RX/OTC ULTILET PEN NEEDLE 5 QL(5 ea daily); 8MM MISC 31GX5MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily) ULTILET PEN NEEDLE 5 QL(5 ea daily); SYRINGE/0.3ML/31G X 5 31GX8MM MISC RX/OTC 8MM MISC ULTILET PEN NEEDLE 5 QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE/0.5ML/30G X 5 RX/OTC ULTILET PEN NEEDLE 5 QL(5 ea daily); 8MM MISC 32GX4MM/SHORT MISC RX/OTC ULTILET INSULIN QL(5 ea daily); ULTILET SHORT PEN QL(5 ea daily); SYRINGE/1ML/30G X 5 RX/OTC NEEDLES 31GX5/16" 5 RX/OTC 8MM MISC MISC ULTILET INSULIN QL(5 ea daily) ULTILET SHORT PEN 5 QL(5 ea daily); SYRINGE/1ML/31G X 5 NEEDLES31GX3/16" MISC RX/OTC 8MM MISC ULTILET U-100 INSULIN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SYRINGES/1ML/31G X 5 SYRINGE/SHORT/0.3ML/3 5 6MM MISC 0G X 12.7MM MISC ULTRA COMFORT QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC SYRINGE/SHORT/0.3ML/3 5 RX/OTC 100/0.3ML/30G X 5/16" 0G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 5 INSULIN SYRINGE/U- 5 RX/OTC 1G X 5/16" MISC 100/0.3ML/29G X 1/2" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 5 RX/OTC ULTRA-COMFORT QL(5 ea daily); 0G X 5/16" MISC INSULIN SYRINGE/U- 5 RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.3ML/30G X 5/16" SYRINGE/SHORT/0.5ML/3 5 MISC 1G X 5/16" MISC ULTRA-COMFORT QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 5 SYRINGE/SHORT/1ML/30 5 RX/OTC 100/0.3ML/31G X 5/16" G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE/SHORT/1ML/31 5 INSULIN SYRINGE/U- 5 RX/OTC G X 5/16" MISC 100/0.5ML/28G X 1/2" ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/U- 5 ULTRA-COMFORT QL(5 ea daily); 100/0.5ML/30G X 1/2" INSULIN SYRINGE/U- 5 RX/OTC MISC 100/0.5ML/29G X 1/2" ULTILET INSULIN MISC SYRINGE/U- 5 100/0.5ML/31GX6MM MISC 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

244 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC SYRINGE/U- NC RX/OTC 100/0.5ML/30G X 5/16" 100/1ML/29GX1/2" MISC MISC ULTRA-THIN II MINI PEN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) NEEEDLES/31GX3/16" NC RX/OTC INSULIN SYRINGE/U- 5 MISC 100/0.5ML/31G X 5/16" ULTRA-THIN II PEN NC QL(5 ea daily) MISC NEEDLES 29GX1/2" MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II PEN QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC NEEDLES/SHORT/31GX5/ NC RX/OTC 100/1ML/28G X 1/2" MISC 16" MISC ULTRA-COMFORT QL(5 ea daily); ULTRACARE PEN QL(5 ea daily) INSULIN SYRINGE/U- 5 RX/OTC NEEDLES/33G X 5/32" 5 100/1ML/29G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); UNIFINE PENTIPS 5 QL(5 ea daily); INSULIN SYRINGE/U- 5 RX/OTC 29GX12MM MISC RX/OTC 100/1ML/30G X 5/16" MISC UNIFINE PENTIPS NC QL(5 ea daily); 29GX12MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily) UNIFINE PENTIPS 31G X QL(5 ea daily); INSULIN SYRINGE/U- 5 5 100/1ML/31G X 5/16" 3/16" MISC RX/OTC MISC UNIFINE PENTIPS 5 QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC UNIFINE PENTIPS QL(5 ea daily) SYRINGE SHORT/U- NC RX/OTC 5 100/0.3ML/30GX5/16" 31GX6MM MISC MISC UNIFINE PENTIPS 5 QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE SHORT/U- NC UNIFINE PENTIPS 5 QL(5 ea daily); 100/0.3ML/31GX5/16" 32GX4MM MISC RX/OTC MISC UNIFINE PENTIPS 5 QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily); 32GX6MM MISC SYRINGE SHORT/U- RX/OTC NC UNIFINE PENTIPS 5 QL(5 ea daily) 100/0.5ML/30GX5/16" 33GX4MM MISC MISC UNIFINE PENTIPS PLUS 5 QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) 29GX12MM MISC RX/OTC SYRINGE SHORT/U- NC 100/0.5ML/31GX5/16" UNIFINE PENTIPS PLUS 5 QL(5 ea daily); MISC 31GX5MM MISC RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS NC QL(5 ea daily); SYRINGE SHORT/U- NC RX/OTC 31GX5MM MISC RX/OTC 100/1ML/30GX5/16" MISC UNIFINE PENTIPS PLUS 5 QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily) 31GX6MM MISC SYRINGE SHORT/U- NC UNIFINE PENTIPS PLUS NC QL(5 ea daily) 100/1ML/31GX5/16" MISC 31GX6MM MISC ULTRA-THIN II INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS 5 QL(5 ea daily); SYRINGE/U- NC RX/OTC 31GX8MM MISC RX/OTC 100/0.5ML/29GX1/2" MISC UNIFINE PENTIPS PLUS NC QL(5 ea daily); 31GX8MM MISC RX/OTC

245 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS PLUS 5 QL(5 ea daily); VIDA MIA UNIFINE QL(5 ea daily) 32GX4MM MISC RX/OTC PENTIPSMINI 31GX6MM 5 MISC UNIFINE PENTIPS PLUS NC QL(5 ea daily); 32GX4MM MISC RX/OTC VIDA MIA UNIFINE QL(5 ea daily); PENTIPSORIGINAL 5 RX/OTC UNIFINE PENTIPS PLUS 5 QL(5 ea daily) 33GX 5/32" MISC 29GX12MM MISC VIDA MIA UNIPFINE QL(5 ea daily); UNIFINE PENTIPS PLUS 5 QL(5 ea daily) 33GX4MM MISC PENTIPSSHORT 5 RX/OTC 31GX8MM MISC VALUE HEALTH INSULIN QL(5 ea daily); VP INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 5 RX/OTC 100/0.5ML/29G X 1/2" 100/0.3ML/29G X 1/2" 5 RX/OTC MISC MISC VALUE HEALTH INSULIN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily); SYRINGE/U-100/1ML/29G 5 RX/OTC PENTIPS PLUS 32GX4MM 5 RX/OTC X 1/2" MISC MISC VALUMARK PEN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily); NEEDLES 29GX12MM 5 RX/OTC PENTIPS 5 RX/OTC MISC PLUS/MINI/31GX5MM MISC VALUMARK PEN QL(5 ea daily) NEEDLES 31GX 6MM 5 WEGMANS UNIFINE QL(5 ea daily); MISC PENTIPS 5 RX/OTC PLUS/SHORT/31GX8MM VALUMARK PEN QL(5 ea daily); MISC NEEDLES 31GX 8MM 5 RX/OTC MISC WEGMANS UNIFINE QL(5 ea daily) PENTIPS PLUS/ULTRA 5 VANISHPOINT INSULIN QL(5 ea daily) SHORT/31GX6MM MISC SYRINGE/0.5ML/30G X 5 1/2" MISC MIGRAINE PRODUCTS - Drugs to Treat Migraine VANISHPOINT INSULIN Headaches SYRINGE/0.5ML/30G X 5 Calcitonin Gene-Related Peptide (CGRP) 3/16" MISC PA; SP VANISHPOINT INSULIN QL(5 ea daily); AIMOVIG SOAJ 4 SYRINGE/0.5ML/30G X 5 RX/OTC PA; SP 5/16" MISC AJOVY SOAJ 4 VANISHPOINT INSULIN QL(5 ea daily); 4 PA; SP SYRINGE/1ML/29G X 1/2" 5 RX/OTC AJOVY SOSY MISC EMGALITY SOAJ 4 PA; SP VANISHPOINT INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 5 EMGALITY SOSY 4 PA; SP 5/16" MISC VANISHPOINT INSULIN NURTEC TBDP 4 SYRINGE/1ML/30G X 5 3/16" MISC UBRELVY TABS 4 VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 5 RX/OTC VYEPTI SOLN NC 5/16" MISC Migraine Combinations VIDA MIA UNIFINE 5 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC

246 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAFERGOT TABS NC QL(0.3 ea (ergotamine w/ caffeine) AMERGE TABS 5 daily); AL(At (naratriptan hcl) least 18 yrs ergotamine w/ caffeine NC supp old) QL(0.2 ea ergotamine w/ caffeine tabs NC eletriptan hydrobromide 2 daily); AL(At tabs least 18 yrs MIGRAINE PACK THPK NC old) QL(0.3 ea MIGRANOW THPK NC FROVA TABS (frovatriptan 5 daily); AL(At succinate) least 18 yrs sumatriptan-naproxen NC QL(0.3 ea sodium tabs daily) old) QL(0.3 ea TREXIMET TABS 10 MG- NC QL(0.3 ea 60 MG daily) 2 daily); AL(At frovatriptan succinate tabs least 18 yrs TREXIMET TABS 500 MG- QL(0.3 ea old) 85 MG (sumatriptan- NC daily) QL(0.2 ea naproxen sodium) IMITREX SOLN NA 20 5 daily); AL(At Migraine Products - NSAIDs MG/ACT, 5 MG/ACT least 18 yrs (sumatriptan) CAMBIA PACK NC old) IMITREX SOLN SC 6 QL(0.134 ml Migraine Products MG/0.5ML (sumatriptan 5 daily,4 ml per D.H.E. 45 SOLN succinate) 30 days retail) (dihydroergotamine 4 IMITREX STATDOSE QL(0.134 ml mesylate) REFILL SOCT 4 MG/0.5ML 5 daily,4 ml per (sumatriptan succinate) 30 days retail) DIHYDROERGOTAMINE 5 MESYLATE CRYS XX IMITREX STATDOSE QL(0.134 ml REFILL SOCT 6 MG/0.5ML 5 daily) DIHYDROERGOTAMINE 5 MESYLATE POWD XX (sumatriptan succinate) IMITREX STATDOSE QL(0.134 ml dihydroergotamine 2 mesylate soln ij 1 mg/ml SYSTEM SOAJ 5 daily,4 ml per (sumatriptan succinate) 30 days retail) dihydroergotamine NC QL(0.27 ml mesylate soln na 4 mg/ml daily) IMITREX TABS OR 100 QL(0.3 ea MG, 25 MG, 50 MG 5 daily) dihydroergotamine NC (sumatriptan succinate) mesylate soln na 4 mg/ml QL(0.6 ea MAXALT TABS (rizatriptan 5 ERGOMAR SUBL 5 benzoate) daily); AL(At least 6 yrs old) ERGOTAMINE TARTRATE 5 POWD QL(0.4 ea MAXALT-MLT TBDP 5 daily); AL(At (rizatriptan benzoate) MIGRANAL SOLN QL(0.27 ml least 6 yrs old) (dihydroergotamine 5 daily) mesylate) QL(0.3 ea 2 daily); AL(At Serotonin Agonists naratriptan hcl tabs least 18 yrs QL(0.2 ea old) daily); AL(At almotriptan malate tabs 2 ST; QL(16 ea least 12 yrs ONZETRA XSAIL EXHP 4 per 30 days old) retail)

247 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.2 ea QL(0.2 ea RELPAX TABS (eletriptan 5 daily); AL(At ZOMIG TABS OR 2.5 MG, 5 daily); AL(At hydrobromide) least 18 yrs 5 MG (zolmitriptan) least 12 yrs old) old) REYVOW TABS 4 QL(0.2 ea ZOMIG ZMT TBDP 5 daily); AL(At QL(0.6 ea (zolmitriptan) least 12 yrs rizatriptan benzoate tabs 2 daily); AL(At old) 10 mg, 5 mg least 6 yrs old) MINERALS & ELECTROLYTES QL(0.4 ea rizatriptan benzoate tbdp 2 daily); AL(At 10 mg, 5 mg Bicarbonates least 6 yrs old) QL(0.2 ea NEUT SOLN 5 sumatriptan soln na 20 daily); AL(At 2 SODIUM ACETATE 5 mg/act, 5 mg/act least 18 yrs ANHYDROUS CRYS old) SODIUM ACETATE 5 RX/OTC QL(0.134 ml ANHYDROUS POWD sumatriptan succinate soaj 2 daily,4 ml per sc 4 mg/0.5ml, 6 mg/0.5ml 30 days retail) SODIUM ACETATE SOLN 5 2 MEQ/ML QL(0.134 ml sumatriptan succinate soct 2 daily,4 ml per sodium acetate soln 4 sc 4 mg/0.5ml 2 30 days retail) meq/ml SODIUM ACETATE sumatriptan succinate soct 2 QL(0.134 ml 5 sc 6 mg/0.5ml daily) TRIHYDRATE GRAN QL(0.134 ml SODIUM BICARBONATE 5 sumatriptan succinate soln 2 daily,4 ml per SOLN IJ 8.4 % sc 6 mg/0.5ml 30 days retail) sodium bicarbonate soln iv 2 7.5 %, 4.2 %, 8.4 % sumatriptan succinate sosy 2 QL(4 ml per 30 sc 6 mg/0.5ml days retail) SODIUM BICARBONATE 2 SOLN IV 8.4 % sumatriptan succinate tabs 2 QL(0.3 ea or 100 mg, 25 mg, 50 mg daily) SODIUM BICARBONATE/DEXTROS NC TOSYMRA SOLN NC E SOLN ST; QL(4 ml SODIUM LACTATE SOLN 5 ZEMBRACE SYMTOUCH 4 per 30 days SOAJ retail) THAM SOLN 5 QL(0.2 ea Calcium zolmitriptan tabs or 2.5 mg, 2 daily); AL(At 5 mg least 12 yrs old) CALCIFOL WAFR 5 QL(0.2 ea CALCIUM CARBONATE 5 RX/OTC EXTRA LIGHT POWD zolmitriptan tbdp or 2.5 mg, 2 daily); AL(At 5 mg least 12 yrs CALCIUM CARBONATE 5 RX/OTC old) HEAVY POWD QL(0.2 ea CALCIUM CARBONATE 5 RX/OTC ZOMIG SOLN NA 2.5 MG, 4 daily); AL(At LIGHT POWD 5 MG least 12 yrs old)

248 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCIUM CARBONATE 5 RX/OTC DEXTROSE 10%/NACL 5 POWD 0.2% SOLN calcium chloride (dihydrate) 2 DEXTROSE 5%/NACL 5 soln 0.3% SOLN CALCIUM CHLORIDE 5 dextrose in lactated ringers 2 ANHYDROUS GRAN soln CALCIUM CHLORIDE 5 dextrose w/ sodium 2 DIHYDRATE GRAN chloride soln CALCIUM CHLORIDE 5 DEXTROSE/SODIUM 2 DIHYDRATE POWD CHLORIDE SOLN CALCIUM CHLORIDE 5 ELLIOTTS B SOLN 5 SOLN IONOSOL-MB/DEXTROSE CALCIUM GLUCONATE 5 RX/OTC ANHYDROUS POWD 5% SOLN 20 MEQ/L-22 MEQ/L-23 MEQ/L-25 CALCIUM GLUCONATE 5 RX/OTC MONOHYDRATE POWD MEQ/L-3 MEQ/L-3 MEQ/L- 5 5 %, 20 MEQ/L-22 MEQ/L- CALCIUM GLUCONATE 5 RX/OTC 23 MEQ/L-25 MEQ/L-3 POWD XX MEQ/L-3 MMOLE/L-5 % CALCIUM GLUCONATE 2 ISOLYTE-P/DEXTROSE 5 SOLN IV 5% SOLN CALCIUM GLUCONATE 4 SOLN IV ISOLYTE-S PH 7.4 SOLN 5 calcium gluconate soln iv 2 ISOLYTE-S SOLN 5 CALCIUM KCL 0.15%/D5W/NACL 5 GLUCONATE/DEXTROSE NC 0.225% SOLN SOLN KCL 0.3%/D5W/NACL 5 CALCIUM 0.9% SOLN GLUCONATE/SODIUMCH NC LORIDE SOLN lactated ringer's soln 2 CALCIUM GLUCONATE/SODIUMCH NC NORMOSOL -R SOLN 5 LORIDE SOSY NORMOSOL-M IN D5W 5 SOLN CALCIUM LACTATE 5 PENTAHYDRATE POWD NORMOSOL-R IN D5W 5 SOLN CALCIUM PHOSPHATE 5 DIBASIC POWD NORMOSOL-R SOLN 5 CALCIUM PHOSPHATE 5 RX/OTC TRIBASIC POWD NORMOSOL-R/5% 5 DEXTROSE SOLN CALCIUM-FOLIC ACID 5 PLUS D WAFR parenteral electrolytes conc 2 Electrolyte Mixtures DEXTROSE PLASMA-LYTE A SOLN 5 5%/ELECTROLYTE #48 5 VIAFLEX SOLN PLASMA-LYTE-148 SOLN 5

249 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM CHLORIDE FLORIVA LIQD 5 /SODIUM CHLORIDE NC SOLN FLUORABON SOLN 5 potassium chloride in dextrose & sodium chloride 2 sodium fluoride chew or soln 0.25 mg, 0.5 mg, 1 mg, 2.2 6 mg potassium chloride in 2 dextrose soln sodium fluoride soln or 0.25 6 mg/drop, 0.125 mg/drop potassium chloride in nacl 2 soln sodium fluoride soln or 0.5 2 POTASSIUM mg/ml CHLORIDE/DEXTROSE 5 sodium fluoride tabs or 0.5 6 SOLN mg, 1 mg POTASSIUM Iodine Products CHLORIDE/DEXTROSE/L 5 ACTATED RINGERS iodine strong (lugol's) soln 2 SOLN Magnesium POTASSIUM CHLORIDE/LACTATED NC MAGNEBIND 400 TABS 5 RINGERS SOLN POTASSIUM MAGNESIUM RX/OTC CARBONATE HEAVY 5 CHLORIDE/LIDOCAINE NC HYDROCHLORIDE/DEXT POWD ROSE SOLN MAGNESIUM RX/OTC POTASSIUM CARBONATE LIGHT 5 POWD CHLORIDE/LIDOCAINE NC HYDROCHLORIDE/SODIU MAGNESIUM CHLORIDE 5 M CHLORIDE SOLN HEXAHYDRATE CRYS POTASSIUM MAGNESIUM CHLORIDE 5 RX/OTC POWD XX CHLORIDE/SODIUM 2 CHLORIDE SOLN 0.3 %- magnesium chloride soln ij 2 0.9 % POTASSIUM MAGNESIUM SULFATE IN CHLORIDE/SODIUM D5W SOLN (magnesium 5 CHLORIDE SOLN 0.9 %- sulfate in dextrose) 10 MEQ/100ML, 0.9 %-10 NC magnesium sulfate in 2 MEQ/500ML, 0.9 %-40 dextrose soln MEQ/250ML, 0.9 %-40 magnesium sulfate soln ij 2 MEQ/500ML 50 % POTASSIUM MAGNESIUM SULFATE CHLORIDE/SODIUMCHLO NC SOLN IV 1000 MG/1.6ML, RIDE SOLN 2000 MG/3.2ML, 3000 NC ringer's soln 2 MG/4.8ML, 4000 MG/6.4ML TPN ELECTROLYTES 5 magnesium sulfate soln iv CONC 2 gm/50ml, 20 gm/500ml, 4 2 Fluoride gm/100ml, 4 gm/50ml, 40 gm/1000ml

250 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGNESIUM SULFATE POTASSIUM SOLN IV 2 GM/50ML, 20 PHOSPHATES/DEXTROS NC GM/500ML, 4 GM/100ML, 5 E SOLN 4 GM/50ML, 40 POTASSIUM GM/1000ML (magnesium PHOSPHATES/SODIUM NC sulfate) CHLORIDE SOLN MAGNESIUM SODIUM SULFATE/DEXTROSE NC PHOSPHATE/DEXTROSE NC SOLN SOLN MAGNESIUM SODIUM SULFATE/LACTATED NC PHOSPHATE/SODIUM NC RINGERS SOLN CHLORIDE SOLN MAGNESIUM sodium phosphates SULFATE/SODIUMCHLOR NC (sodium phosphate dibasic 2 IDE SOLN & monobasic) soln Manganese SODIUM PHOSPHATES/DEXTROS NC manganese chloride soln 2 E SOLN manganese sulfate soln iv 2 Potassium Phosphate EFFER-K TBEF 5 GLYCOPHOS SOLN 5 K-TAB TBCR 10 MEQ 4 (potassium chloride) K-PHOS NEUTRAL TABS QL(8 ea daily) K-TAB TBCR 20 MEQ, 8 5 (pot phosphate monobasic 5 MEQ (potassium chloride) w/ sod phosphate dibasic & monobasic) potassium acetate soln iv 2 K-PHOS TABS 5 POTASSIUM ACETATE/SODIUMCHLO NC pot phosphate monobasic QL(8 ea daily) RIDE SOLN w/ sod phosphate dibasic & 2 potassium bicarb & chloride 2 monobasic tabs tbef POTASSIUM POTASSIUM 5 PHOSPHATE/DEXTROSE NC BICARBONATE GRAN XX SOLN POTASSIUM 5 POTASSIUM BICARBONATE POWD XX PHOSPHATE/SODIUM NC CHLORIDE SOLN potassium bicarbonate tbef 2 or 2 gm-2.5 gm, 25 meq potassium phosphates soln 224 mg/ml-236 mg/ml, 224 2 potassium chloride cpcr or 2 mg/ml-236 mg/ml 10 meq, 8 meq POTASSIUM POTASSIUM CHLORIDE 5 RX/OTC PHOSPHATES SOLN 45 GRAN XX MMOLE/15ML-71 NC potassium chloride MEQ/15ML, 224 MG/ML- microencapsulated crystals 2 236 MG/ML er tbcr potassium chloride pack or 2 20 meq 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

251 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM CHLORIDE 5 MULTITRACE-4 5 POWD XX PEDIATRIC SOLN POTASSIUM CHLORIDE MULTITRACE-4 SOLN 5 SOLN IV 0.4 MEQ/ML, 10 MEQ/100ML, 10 MULTITRACE-5 4 MEQ/50ML, 20 NC CONCENTRATE SOLN MEQ/100ML, 20 MEQ/50ML, 40 MULTITRACE-5 SOLN 5 MEQ/100ML selenious acid soln 40 2 potassium chloride soln iv 2 mcg/ml 2 meq/ml SELENIOUS ACID SOLN NC potassium chloride soln or 2 60 MCG/ML 20 %, 10 % THE LIQUILIFT TRACE NC potassium chloride tbcr or 2 KIT KIT 20 meq, 10 meq, 8 meq TRACE ELEMENTS 5 Sodium 4/PEDIATRIC SOLN trace minerals (cr-cu-mn- LIQUIVIDA HYDRATION NC 2 KIT KIT se-zn) soln sodium chloride flush soln 2 trace minerals (cr-cu-mn- 2 zn) soln SODIUM CHLORIDE 5 RX/OTC Zinc GRAN XX GALZIN CAPS 5 SODIUM CHLORIDE 5 POWD XX zinc chloride soln iv 2 SODIUM CHLORIDE 5 SOLN IJ 0.9 % ZINC SULFATE 5 RX/OTC GRANULAR POWD sodium chloride soln ij 0.9 NC % ZINC SULFATE 5 HEPTAHYDRATE GRAN sodium chloride soln ij 2.5 2 meq/ml, 0.9 % ZINC SULFATE 5 RX/OTC sodium chloride soln iv 3 HEPTAHYDRATE POWD %, 5 %, 23.4 %, 4 meq/ml, 2 ZINC SULFATE 5 RX/OTC 0.45 %, 0.9 % MONOHYDRATE POWD Trace Minerals ZINC SULFATE POWD XX 5 RX/OTC chromic chloride soln iv 2 ZINC SULFATE SOLN IV 1 2 MG/ML cupric chloride soln 2 zinc sulfate soln iv 1 mg/ml, 2 5 mg/ml CUPRIC SULFATE 5 PENTAHYDRATE GRAN zinc sulfate soln iv 3 mg/ml 5 CUPRIC SULFATE POWD 5 RX/OTC MISCELLANEOUS THERAPEUTIC CLASSES MULTITRACE-4 4 CONCENTRATE SOLN Chelating Agents MULTITRACE-4 5 CUPRIMINE CAPS 5 NEONATAL SOLN (penicillamine)

252 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPEN TITRATABS TABS 5 REVLIMID CAPS 4 PA; SP (penicillamine) PA; SP penicillamine caps or 5 THALOMID CAPS 4 penicillamine tabs or 5 Immunosuppressive Agents ASTAGRAF XL CP24 5 SYPRINE CAPS (trientine 5 PA; SP hcl) ATGAM INJ 5 trientine hcl caps 2 PA; SP AZASAN TABS 4 QL(3 ea daily) Continuous Renal Replacement Therapy (CRRT) AZATHIOPRINE POWD PHOXILLUM B22K4/0 NC 5 SOLN XX AZATHIOPRINE SOLR IJ PHOXILLUM BK4/2.5 NC NC SOLN 100 MG PRISMASOL B22GK 4/0 5 azathioprine tabs or 50 mg 2 SOLN CELLCEPT CAPS 4 PRISMASOL BGK 0/2.5 5 (mycophenolate mofetil) SOLN CELLCEPT PA PRISMASOL BGK 2/0 5 INTRAVENOUS SOLR 5 SOLN (mycophenolate mofetil hcl) PRISMASOL BGK 2/3.5 5 CELLCEPT SUSR 4 SOLN (mycophenolate mofetil) PRISMASOL BGK 4/0/1.2 5 CELLCEPT TABS 4 SOLN (mycophenolate mofetil) PRISMASOL BGK 4/2.5 5 cyclosporine caps or 100 2 SOLN mg, 25 mg PRISMASOL BK 0/0/1.2 5 cyclosporine modified (for 2 SOLN microemulsion) caps Enzymes cyclosporine modified (for 2 AMPHADASE SOLN NC microemulsion) soln cyclosporine soln iv 50 2 BROMELAIN 1200 GDU 5 RX/OTC mg/ml POWD ENVARSUS XR TB24 NC PA BROMELAIN POWD 5 RX/OTC everolimus PV CHYMOTRYPSIN ALPHA 5 (immunosuppressant) tabs 2 POWD 0.25 mg HYLENEX SOLN 5 everolimus PA; PV (immunosuppressant) tabs 2 VITRASE SOLN 5 0.5 mg, 0.75 mg IMURAN TABS 4 XIAFLEX SOLR 5 PA; SP (azathioprine) mycophenolate mofetil 2 Immunomodulators caps

253 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mycophenolate mofetil hcl 2 PA ZORTRESS TABS 0.25 PV solr MG (everolimus NC (immunosuppressant)) mycophenolate mofetil susr 2 ZORTRESS TABS 0.5 MG, PA; PV 2 mycophenolate mofetil tabs 2 0.75 MG (everolimus (immunosuppressant)) mycophenolate sodium PA 2 NC tbec ZORTRESS TABS 1 MG MYFORTIC TBEC 4 PA Irrigation Solutions (mycophenolate sodium) irrigation solutions, 2 NEORAL CAPS physiological soln (cyclosporine modified (for 4 lactated ringer's (irrigation) 2 microemulsion)) soln NEORAL SOLN (cyclosporine modified (for 4 ringer's irrigation soln 2 microemulsion)) water for irrigation, sterile 2 NULOJIX SOLR 5 PA; SP soln PROGRAF CAPS OR 0.5 Lymphatic Agents MG, 1 MG, 5 MG 5 SYLVANT SOLR 5 (tacrolimus) Misc Natural Products PROGRAF SOLN IV 5 5 PA MG/ML ACAI+SUPERFRUIT/GRE 5 EN TEA TABS RAPAMUNE SOLN 1 NC MG/ML (sirolimus) APPLE CIDER VINEGAR 5 RAPAMUNE TABS 0.5 DIET TABS MG, 1 MG, 2 MG 4 ARTHRI-FLEX 5 (sirolimus) ADVANTAGE TABS SANDIMMUNE CAPS OR BEAUTY & SKIN 5 100 MG, 25 MG 4 THERAPY TABS (cyclosporine) CHROMIUM PICOLINATE 5 SANDIMMUNE SOLN IV 5 FORTIFIED TABS 50 MG/ML (cyclosporine) CHROMIUM SANDIMMUNE SOLN OR 4 PICOLINATE/KELP/LECIT 5 100 MG/ML HIN/B-6/GRAPE FRUIT SIMULECT SOLR 5 EXTRACT TABS CHROMIUM XTRA TABS 5 sirolimus soln or 1 mg/ml 2 COMPLETE MENOPAUSE 5 sirolimus tabs or 0.5 mg, 1 2 HEALTH FORMULA TABS mg, 2 mg COMPLETE PROSTATE 5 tacrolimus caps or 0.5 mg, 2 HEALTHFORMULA TABS 1 mg, 5 mg CURCUMAX PRO TABS 5 THYMOGLOBULIN SOLR 5 CVS GLUCOSAMINE CHONDROITIN/MSM 5 TRIPLE STRENGTH TABS

254 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESTROMINERAL TABS 5 OSTEO BI-FLEX ADVANCED TRIPLE 5 FLEX-A-MIN DOUBLE STRENGTH TABS STRENGTH PLUS MSM 5 OSTEO BI-FLEX TABS ADVANCED WITH JOINT 5 FLEX-A-MIN SUPER SHIELD TABS GLUCOSAMINE 2000 5 OSTEO BI-FLEX JOINT PLUS TABS SHIELD FORMULA WITH 5 FLEX-A-MIN TRIPLE 5-LOXIN TABS STRENGTH/BONE 5 OSTEO BI-FLEX TRIPLE SHIELD PLUS VITAMINS STRENGTH WITH 5- 5 K2/D3 TABS LOXIN TABS FLEX-A-MIN TRIPLE OSTEO BI-FLEX/5-LOXIN 5 STRENGTH/JOINT FLEX 5 ADVANCED TABS PLUS VITAMIN D3 TABS PANTETHINE PLUS TABS 5 GINKGO BILOBA XTRA 5 TABS PINEAPPA TABS 5 GLUCOSAMINE CHONDROITIN COMPLEX 5 PMS FORMULA 5 PLUS MSM/TRIPLE INDOLPLEX TABS STRENGTH TABS POWER-V TABS 5 GLUCOSAMINE CHONDROITIN TRIPLE 5 PRO NUTRIENTS FRUIT 5 STRENGTH TABS & VEGGIE TABS HDL RX TABS 5 PYCNOGENOL COMPLEX 5 TABS HM GLUCOSAMINE QC GLUCOSAMINE & CHONDROITIN COMPLEX 5 CHONDROITIN TRIPLE 5 TABS STRENGTH/MSM TABS HOT FLASHEX TABS 5 R.N.A. - 180 TABS 5 LAXATIVE FORMULA 5 RA ESTROPLUS MAX 5 TABS STRENGTH TABS LYDIA PINKHAM TABS 5 RA GLUCOSAMINE CHONDROITIN/MSM 5 METABO-STYLE TABS 5 TABS RELAX & SLEEP TABS 5 misc natural products tabs 5 SEASONAL IC TABS 5 MISEFLEX-C TABS 5 SLEEP TONITE TABS 5 ORTHODIET TABS 5 SM GLUCOSAMINE OSTEO BI-FLEX CHONDROITIN COMPLEX 5 ADVANCED DOUBLE 5 TRIPLE STRENGTH TABS STRENGTH WITH JOINT SHIELD TABS TOTAL MEMORY & 5 FOCUS FORMULA TABS

255 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits URINOZINC PLUS TABS 5 ULTRABAG/DIANEAL LOW CALCIUM/1.5% 5 WABANA TABS 5 DEXTROSE SOLN ULTRABAG/DIANEAL Miscellaneous Therapeutic Classes LOW CALCIUM/2.5% 5 ADENOSINE-5- DEXTROSE SOLN MONOPHOSPHATE 5 ULTRABAG/DIANEAL POWD LOW CALCIUM/4.25% 5 DEXTROSE SOLN ADENOSINE-5- 5 TRIPHOSPHATE POWD ULTRABAG/DIANEAL PD- 5 2/1.5% DEXTROSE SOLN NEXAVIR SOLN 5 ULTRABAG/DIANEAL PD- 5 Organ Preservation Solutions 2/2.5% DEXTROSE SOLN VIASPAN-BELZER UW- ULTRABAG/DIANEAL PD- CSS COLD STORAGE 5 2/4.25% DEXTROSE 5 SOLN SOLN SOLN Peritoneal Dialysis Solutions Potassium Removing Agents LOKELMA PACK 4 DELFLEX-LC/1.5% 5 DEXTROSE SOLN sodium polystyrene 2 QL(454 gm per DELFLEX-LC/2.5% 5 sulfonate powd or fill retail) DEXTROSE SOLN sodium polystyrene DELFLEX-LC/4.25% 5 sulfonate susp or 15 2 DEXTROSE SOLN gm/60ml DELFLEX-SM/1.5% 5 sodium polystyrene DEXTROSE SOLN sulfonate susp re 30 2 DELFLEX-SM/2.5% 5 gm/120ml, 50 gm/200ml DEXTROSE SOLN 4 DIANEAL LOW VELTASSA PACK CALCIUM/1.5%DEXTROS 5 Prostaglandins E SOLN DIANEAL LOW alprostadil soln ij 2 CALCIUM/2.5%DEXTROS 5 PROSTIN VR PEDIATRIC 5 E SOLN SOLN (alprostadil) DIANEAL LOW CALCIUM/4.25%DEXTRO 5 Sclerosing Agents SE SOLN ASCLERA SOLN 5 DIANEAL PD-2/1.5% 5 DEXTROSE SOLN ETHAMOLIN SOLN 5 DIANEAL PD-2/2.5% 5 DEXTROSE SOLN POLYOXYL LAURYL NC ETHER SOLN DIANEAL PD-2/4.25% 5 DEXTROSE SOLN sodium tetradecyl sulfate 5 soln iv 3 % EXTRANEAL SOLN 5 SOTRADECOL SOLN 5 peritoneal dialysis solutions 5 soln VARITHENA FOAM 5

256 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Systemic Lupus Erythematosus Agents AQUORAL SOLN 5 RX/OTC BENLYSTA SOAJ SC 200 NC MG/ML artificial saliva lozg 5 RX/OTC BENLYSTA SOLR IV 120 5 PA; SP BIOTENE DRY MOUTH RX/OTC MG, 400 MG MOISTURIZING SPRAY 5 BENLYSTA SOSY SC 200 NC SOLN MG/ML BOCASAL PACK 5 MOUTH/THROAT/DENTAL AGENTS CAPHOSOL SOLN 5 RX/OTC Anesthetics Topical Oral benzocaine (dental) aero 2 RX/OTC cevimeline hcl caps 2 CVS DRY MOUTH SPRAY RX/OTC FIRST-MOUTHWASH BLM 5 5 SUSP SOLN EQL DRY MOUTH ORAL RX/OTC HURRICAINE AERO NC RX/OTC 5 (benzocaine (dental)) RINSE SOLN EVOXAC CAPS lidocaine hcl (mouth-throat) 2 QL(100 ml per 4 soln 2 % fill retail) (cevimeline hcl) lidocaine hcl (mouth-throat) 2 GELCLAIR GEL 5 soln 4 % RX/OTC Anti-infectives - Throat MOI-STIR SOLN 5 AMPHOTERICIN B POWD 5 MOUTH KOTE REMINT 5 RX/OTC XX 905 UNIT/MG, SOLN clotrimazole troc mt 2 MOUTH KOTE SOLN 5 RX/OTC nystatin (mouth-throat) QL(120 ml per 2 MUCOSITISRX PACK NC susp fill retail) ORAVIG TABS 5 NEUTRASAL PACK 5 Antiseptics - Mouth/Throat NUMOISYN LIQD 5 RX/OTC chlorhexidine gluconate 2 NUMOISYN LOZG 5 RX/OTC (mouth-throat) soln (artificial saliva) DEBACTEROL SOLN 5 ORAFATE PSTE 5 PERIDEX SOLN 5 ORAL RELIEF SPRAY RX/OTC (chlorhexidine gluconate FOR DRYMOUTH & 5 (mouth-throat)) DISCOMFORT SOLN Periodontal Products pilocarpine hcl (oral) tabs 5 2 QL(6 ea daily) ARESTIN MISC 5 PA; SP mg pilocarpine hcl (oral) tabs 2 Steroids - Mouth/Throat/Dental 7.5 mg triamcinolone acetonide 2 QL(5 gm per fill PROTHELIAL PSTE 5 (mouth) pste retail) Throat Products - Misc. RA DRY MOUTH SOLN 5 RX/OTC

257 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SALAGEN TABS 5 MG 4 QL(6 ea daily) b-complex w/ c & folic acid QL(1 ea daily); (pilocarpine hcl (oral)) tabs 1 mg-1 mg-1.5 mg-1.5 RX/OTC mg-1.7 mg-1.7 mg-10 mg- SALAGEN TABS 7.5 MG 4 (pilocarpine hcl (oral)) 10 mg-10 mg-10 mg-100 mg-100 mg-20 mg-20 mg- SALIVAMAX PACK 5 300 mcg-300 mcg-6 mcg-6 mcg, 1 mg-1 mg-1.5 mg- XEROSTOMIA RELIEF 5 RX/OTC 1.7 mg-20 mg-200 mg-30 SPRAY SOLN mcg-300 mcg-8 mg, 1 mg- NC MULTIVITAMINS 1.5 mg-1.7 mg-10 mg-10 mg-100 mg-20 mg-300 B-Complex Vitamins mcg-6 mcg, 1.5 mg-1.7 mg- 10 mg-10 mg-100 mg-1000 B-COMPLEX INJ NC mcg-20 mg-300 mcg-6 mcg, 1.5 mg-1.7 mg-10 b-complex vitamins inj 2 mg-100 mg-1000 mcg-150 mcg-20 mg-5 mg-6 mcg VITAMIN B COMPLEX/HYDROXOCO NC b-complex w/ c & folic acid BALAMIN INJ tabs 1 mg-1.5 mg-1.5 mg- 2 10 mg-20 mg-300 mcg-5 B-Complex w/ Folic Acid mg-50 mg-60 mg ACTRIVIT LIQD 5 RX/OTC b-complex w/ c & folic acid tabs 1 mg-1.5 mg-1.5 mg- NC b-complex w/ c & folic acid QL(1 ea daily); 10 mg-20 mg-300 mcg-5 caps 1 mg-1.5 mg-1.7 mg- 2 RX/OTC mg-50 mg-60 mg 10 mg-100 mg-150 mcg-20 b-complex w/ c & folic acid RX/OTC mg-5 mg-6 mcg tabs 1 mg-1.5 mg-1.7 mg- NC b-complex w/ c & folic acid QL(1 ea daily); 10 mg-10 mg-100 mg-20 tabs 0.006 mg-0.3 mg-1 RX/OTC mg-300 mcg-6 mcg mg-1.5 mg-1.7 mg-10 mg- b-complex w/ c-biotin- 2 10 mg-100 mg-20 mg, 0.01 minerals & folic acid tabs mcg-1 mg-1.5 mg-1.7 mg- 2 10 mg-10 mg-20 mg-300 DIALYVITE 3000 TABS 5 mcg-60 mg, 1 mg-1.5 mg- 1.7 mg-10 mg-10 mg-20 DIALYVITE 5000 TABS 5 mg-300 mcg-6 mcg-60 mg b-complex w/ c & folic acid RX/OTC DIALYVITE/ZINC TABS 5 tabs 0.5 mg-100 mg-15 2 mg-15 mg-18 mg-4 mg-5 FOLIC-K CAPS NC mcg-500 mg FOLICA-BE CAPS NC

FOLICA-V CAPS NC

NEPHPLEX RX TABS 5 NEPHRO-VITE RX TABS QL(1 ea daily); (b-complex w/ c & folic 5 RX/OTC acid) NUTRIVIT LIQD 5 RX/OTC

258 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RENATABS TABS 5 BIOTECT PLUS LIQD 5 RX/OTC

RENATABS WITH IRON 5 BURIED TREASURE RX/OTC MISC ACTIVE 55PLUS SENIOR 5 COMPLEX LIQD SUPERVITE LIQD 5 CENTRUM LIQD (multiple 5 RX/OTC VITAL-D RX TABS 5 vitamins w/ minerals) CORVITE TABS (multiple Bioflavonoid Products vitamins w/ minerals & folic 5 acid) ADRENAL C FORMULA 5 RX/OTC TABS DIALYVITE SUPREME D 5 TABS ADVANCED C PLUS 5 RX/OTC TABS EYE RX/OTC RX/OTC MULTIVITAMIN/LUTEIN 5 bioflavonoid products tabs 5 TABS RX/OTC PERIDIN-C TABS 5 RX/OTC FORTAVIT CAPS 5 (bioflavonoid products) RX/OTC Iron w/ Vitamins FORTAVIT LIQD 5 GERITOL COMPLETE 5 RX/OTC RX/OTC TABS (iron w/ vitamins) MULTI-VITE LIQD 5 iron w/ vitamins tabs 5 RX/OTC multiple vitamins w/ 2 minerals & folic acid tabs VITAFOL TABS (iron w/ 5 RX/OTC multiple vitamins w/ RX/OTC vitamins) minerals caps 0.33 mg-1 Multiple Vitamins & Fluoride-Folic Acid mg-1.3 mg-11.3 unit-113.3 mg-141.7 unit-15 mg-19 MULTIVITAMIN WITH NC mcg-19 mcg-2.3 mg-3.7 FLUORIDE CHEW mg-3964 unit-4.7 mcg-5.7 2 Multiple Vitamins w/ Calcium mcg-5.7 mg-56.7 mcg-56.7 mcg-56.7 mg-7.7 mg-75.7 ADVANCED AM/PM MISC 5 mg-75.7 mg, 1 mg-10 mcg- 10 mg-10 mg-150 mg-2 Multiple Vitamins w/ Minerals & Calcium-Folic mg-25 mg-4 mg-5 mg-50 FOLGARD OS TABS 5 unit-70 mg-80 mg-8000 unit multiple vitamins w/ RX/OTC TL G-FOL OS TABS 5 minerals caps 1 mg-10 mcg-10 mcg-1000 mcg-2 NC Multiple Vitamins w/ Minerals & Fluoride-Iron-Folic mg-2 mg-25 mg-3 mg-30 mg-30 mg-300 mcg-315 QUFLORA FE CHEW NC mg-32 mg-5 mg-6 mg-7 mg Multiple Vitamins w/ Minerals ALIVE MULTI-VITAMIN 5 RX/OTC LIQD BACMIN TABS 5 RX/OTC

BIOSUPP LIQD 5 RX/OTC

259 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC mg/15ml-15 mcg/15ml-15 minerals liqd 1.5 mg/15ml- mg/15ml-15 mg/15ml-150 1.7 mg/15ml-10 mg/15ml- mcg/15ml-2 mg/15ml-50 1000 unit/15ml-1300 mcg/15ml-50 mg/15ml-50 unit/15ml-150 mcg/15ml-2 mg/15ml-50 mg/15ml-50 mg/15ml-2 mg/15ml-20 mg/15ml-5000 unit/15ml- mg/15ml-25 mcg/15ml-25 800 mcg/15ml, 10 mg/5ml- mcg/15ml-3 mg/15ml-30 100 unit/5ml-12.5 mg/5ml- unit/15ml-300 mcg/15ml-6 2.5 unit/5ml-200 mcg/5ml- mcg/15ml-60 mg/15ml-9 225 mg/5ml-25 mcg/5ml-25 mg/15ml, 1.5 mg/15ml-1.7 mcg/5ml-250 mg/5ml-2500 mg/15ml-10 mg/15ml-1300 unit/5ml-5 mcg/5ml-5 unit/15ml-150 mcg/15ml-2 mg/5ml-7.5 mg/5ml-7.5 mg/15ml-2 mg/15ml-20 mg/5ml-75 mg/5ml-750 mg/15ml-25 mcg/15ml-25 mcg/5ml, 112.5 mcg/15ml- mcg/15ml-3 mg/15ml-30 15 mg/15ml-15 mg/15ml- unit/15ml-300 mcg/15ml- 150 mcg/15ml-18 400 unit/15ml-6 mcg/15ml- mcg/15ml-2.25 mg/15ml- 60 mg/15ml-9 mg/15ml, 1.5 2.55 mg/15ml-3 mg/15ml- mg/15ml-1.7 mg/15ml-10 300 mcg/15ml-37 mg/15ml- mg/15ml-150 mcg/15ml-2 45 mg/15ml-45 unit/15ml- mg/15ml-2 mg/15ml-20 5250 unit/15ml-600 mg/15ml-25 mcg/15ml-25 unit/15ml-75 mg/15ml-90 mcg/15ml-2500 unit/15ml-3 mg/15ml mg/15ml-30 unit/15ml-300 mcg/15ml-400 unit/15ml-6 5 mcg/15ml-60 mg/15ml-9 mg/15ml, 1.5 mg/15ml-1.7 mg/15ml-10 mg/15ml-150 mcg/15ml-2 mg/15ml-2 mg/15ml-20 mg/15ml-25 mcg/15ml-25 mcg/15ml-3 mg/15ml-30 unit/15ml-300 mcg/15ml-6 mcg/15ml-60 mg/15ml-9 mg/15ml, 1.5 mg/15ml-1.7 mg/15ml-10 mg/15ml-150 mcg/15ml-2 mg/15ml-2 mg/15ml-20 mg/15ml-25 mcg/15ml-250 mcg/15ml-3 mg/15ml-30 unit/15ml-300 mcg/15ml- 400 unit/15ml-6 mcg/15ml- 60 mg/15ml-9 mg/15ml, 1.5 mg/15ml-1.7 mg/15ml-10 mg/15ml-150 mcg/15ml-2 mg/15ml-2.5 mg/15ml-20 mg/15ml-25 mcg/15ml-25 mcg/15ml-2500 unit/15ml-3 mg/15ml-30 unit/15ml-300 mcg/15ml-400 unit/15ml-6 mcg/15ml-60 mg/15ml-9 mg/15ml, 10 mg/15ml-1000 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

260 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC NICAZEL TABS NC RX/OTC minerals tabs 0.05 mg-0.15 mg-1 mg-10 mg-100 mg-15 NUTRICAP TABS 5 RX/OTC mg-20 mcg-20 mg-20 mg- 25 mg-25 mg-3 mg-400 unit-50 mcg-50 mcg-50 OCUVEL CAPS 5 mg-500 mg-60 unit, 0.1 mg-0.15 mg-0.8 mg-100 ONEVITE TABS 5 mg-20 mg-20 mg-22.5 mg- RX/OTC 25 mg-25 mg-27 mg-3 mg- PROTECT PLUS CAPS 5 30 unit-5 mg-50 mcg-50 RX/OTC mg-500 mg-5000 unit, PROTECT PLUS NF LIQD 5 0.667 mg-1.667 mg- 133.333 mg-133.333 mg- REMEDIENT CAPS NC 133.333 unit-16.667 mcg- 16.667 mg-16.667 mg- REQ 49+ TABS 5 RX/OTC 16.667 mg-16.667 mg- 166.667 mg-1666.667 unit- SIDEROL TABS 5 RX/OTC 26.667 mg-3.333 mg- 33.333 mcg-333.333 mcg- STROVITE FORTE SYRP 333.333 mg-5 mcg-5 mg-5 1 MG/15ML-10 MG/15ML- mg-50 mcg-66.667 mg- 100 MG/15ML-15 66.667 mg-66.667 unit, 1 2 MG/15ML-15 MG/15ML- mg-1.25 mg-10 mg-125 150 MCG/15ML-17 mcg-125 mcg-125 unit-150 MG/15ML-20 MCG/15ML- mcg-25 mg-3.4 mg-35 mg- 20 MG/15ML-25 MG/15ML- 5 35 mg-35 mg-35 mg-35 3 MG/15ML-30 mg-400 mcg-400 unit-5 UNIT/15ML-300 MG/15ML- mg-500 mg-70 mcg-75 400 UNIT/15ML-4000 mcg, 1 mg-10 mg-100 unit- UNIT/15ML-5 MG/15ML-50 125 mg-200 unit-25 mg-25 MCG/15ML-50 MG/15ML- mg-25 mg-25 mg-300 mcg- 55 MCG/15ML 33 mg-50 mcg-50 mg-500 STROVITE FORTE TABS RX/OTC mg-5000 unit-60 mg, 1 mg- 0.1 MG-0.15 MG-0.8 MG- 10 mg-100 unit-125 mg- 10 MG-100 MG-1000 200 unit-25 mg-25 mg-25 UNIT-15 MG-20 MG-20 mg-25 mg-300 mcg-33 mg- MG-25 MCG-25 MG-25 5 50 mcg-50 mg-500 mg- MG-3 MG-3000 UNIT-50 5000 unit-80 mg, 100 mg- MCG-50 MCG-50 MG-500 1000 mcg-2.5 mg-20 mg- MG-60 UNIT (multiple 20 mg-20 mg-200 mcg-200 vitamins w/ minerals) mcg-25 mg-25 mg-400 RX/OTC unit-5 mg-50 mcg-50 mcg- STROVITE ONE TABS 5 50 mg-50 unit-500 mg- RX/OTC 5000 unit-66 mg SUPPORT LIQD 5 RX/OTC NEOVITE TABS NC SYNAGEX CAPS 5 RX/OTC NICADAN TABS NC SYNATEK CAPS 5 RX/OTC NICAZEL FORTE TABS NC THRIVITE 19 TABS 5

261 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UDAMIN SP TABS 5 pediatric multivitamins w/fl QL(1 ea daily); chew 0.25 mg-0.3 mg-1.05 AL(Up to 12 yrs VITAROCA PLUS TABS RX/OTC mg-1.05 mg-1.2 mg-13.5 old ) (multiple vitamins w/ 5 mg-15 unit-2500 unit-4.5 minerals) mcg-400 unit-60 mg, 0.25 mg-1.05 mg-1.05 mg-1.2 Multivitamins mg-13.5 mg-15 unit-2500 FOLIKA-V TABS NC unit-300 mcg-4.5 mcg-400 unit-60 mg, 0.3 mg-1 mg- GENICIN VITA-Q TABS NC 1.05 mg-1.05 mg-1.2 mg- 13.5 mg-15 unit-2500 unit- INFUVITE ADULT INJ 5 4.5 mcg-400 unit-60 mg, 1 2 mg-1.05 mg-1.05 mg-1.2 mg-13.5 mg-15 unit-2500 M.V.I. ADULT INJ 5 unit-300 mcg-4.5 mcg-400 unit-60 mg, 0.3 mg-0.5 mg- multiple vitamin inj 5 1.05 mg-1.05 mg-1.2 mg- 13.5 mg-15 unit-2500 unit- VITAXYME TABS NC 4.5 mcg-400 unit-60 mg, 0.5 mg-1.05 mg-1.05 mg- VITAZYME TABS NC 1.2 mg-13.5 mg-15 unit- 2500 unit-300 mcg-4.5 Ped MV w/ Fluoride mcg-400 unit-60 mg QL(50 ml per pediatric multivitamins w/fl QL(50 ml per fill retail); FLORIVA PLUS SOLN 5 soln 0.25 mg/ml-0.4 mg/ml- fill retail); AL(Up to 12 yrs 0.5 mg/ml-0.6 mg/ml-1500 AL(Up to 12 yrs old ) unit/ml-2 mcg/ml-35 mg/ml- old ) QL(1 ea daily); 400 unit/ml-5 unit/ml-8 MULTIVITAMIN/FLUORID 2 AL(Up to 12 yrs 2 E CHEW mg/ml, 0.4 mg/ml-0.5 old ) mg/ml-0.5 mg/ml-0.6 mg/ml-1500 unit/ml-2 mcg/ml-35 mg/ml-400 unit/ml-5 unit/ml-8 mg/ml QL(50 ml per pediatric vitamins acd w/ 6 fill retail); fluoride soln AL(Up to 12 yrs old ) POLY-VI-FLOR CHEW QL(6 ea per fill 0.25 MG-15 UNIT-200 retail) MCG-400 UNIT, 0.5 MG-15 5 UNIT-200 MCG-400 UNIT, 1 MG-15 UNIT-200 MCG- 400 UNIT POLY-VI-FLOR FS STRP 0.25 MG-0.4 MG-0.5 MG- 0.6 MG-200 MCG-400 UNIT-5 UNIT-8 MG, 0.4 NC MG-0.5 MG-0.5 MG-0.6 MG-200 MCG-400 UNIT-5 UNIT-8 MG

262 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLY-VI-FLOR FS STRP ped multivitamins w/fl & AL(Up to 12 yrs 0.4 MG-0.5 MG-0.6 MG-1 5 iron liqd 0.25 mg/ml-0.4 old ) MG-200 MCG-400 UNIT-5 mg/ml-0.5 mg/ml-0.6 UNIT-8 MG mg/ml-0.9 mcg/ml-1500 6 unit/ml-35 mg/ml-400 POLY-VI-FLOR SUSP 0.25 5 MG/ML-200 MCG/ML unit/ml-6 mg/ml-7.5 unit/ml- 8 mg/ml QL(1 ea daily); QUFLORA GUMMIES NC ped multivitamins w/fl & QL(50 ml per CHEW AL(Up to 12 yrs old ) iron soln 0.25 mg/ml-0.4 fill retail); mg/ml-0.5 mg/ml-0.6 6 AL(Up to 12 yrs QUFLORA PEDIATRIC QL(1 ea daily); mg/ml-10 mg/ml-1500 old ) CHEW 0.25 MG-1 MG-1.2 AL(Up to 12 yrs unit/ml-35 mg/ml-400 MG-1.3 MG-1.5 MG-100 old ) unit/ml-5 unit/ml-8 mg/ml MCG-108 MCG-1200 UNIT-15 MG-15 UNIT-4 POLY-VI-FLOR/IRON QL(6 ea per fill MCG-400 UNIT-5 MG-60 CHEW 0.5 MG-10 MG-15 5 retail) MG, 1 MG-1 MG-1.2 MG- UNIT-200 MCG-400 UNIT 1.3 MG-1.5 MG-100 MCG- 5 POLY-VI-FLOR/IRON 108 MCG-1200 UNIT-15 SUSP 0.25 MG/ML-200 5 MG-15 UNIT-4 MCG-400 MCG/ML-7 MG/ML UNIT-5 MG-60 MG, 0.5 QUFLORA FE PEDIATRIC NC MG-1 MG-1.2 MG-1.3 MG- LIQD 1.5 MG-100 MCG-108 MCG-1200 UNIT-15 MG- TL-FLUORIVITE CHEW 5 15 UNIT-4 MCG-400 UNIT- 5 MG-60 MG Ped Multiple Vitamins w/ Minerals QUFLORA PEDIATRIC QL(50 ml per pediatric multiple vitamin w/ 2 AL(Up to 12 yrs SOLN 0.25 MG/ML-0.4 fill retail); minerals & c liqd old ); RX/OTC MG/ML-0.5 MG/ML-0.6 AL(Up to 12 yrs pediatric multiple vitamin w/ 2 AL(Up to 12 yrs MG/ML-0.8 MG/ML-1 old ) minerals & c soln old ); RX/OTC MG/ML-10 MG/ML-1000 UNIT/ML-2 MCG/ML-35 Pediatric Multiple Vitamins & Minerals w/ Fluoride MCG/ML-35 MG/ML-400 FLORIVA CHEW 5 UNIT/ML-5 UNIT/ML-65 5 MCG/ML, 0.5 MG/ML-1 Pediatric Multiple Vitamins MG/ML-1 MG/ML-1 INFUVITE PEDIATRIC 5 MG/ML-1 MG/ML-1100 SOLN UNIT/ML-12 MG/ML-12 UNIT/ML-150 MCG/ML-2 M.V.I. PEDIATRIC SOLR 5 MG/ML-3 MCG/ML-400 UNIT/ML-45 MG/ML-81 Prenatal Vitamins MCG/ML ALIVE PRENATAL MULTI- TRI-VI-FLOR SUSP 5 VITAMIN/PLANT DHA NC CHEW TRI-VI-FLORO SUSP 5 ATABEX EC TBEC 5

Ped Multi Vitamins w/Fl & FE ATABEX OB TABS 5 ESCAVITE CHEW 5 AZESCHEW PRENATAL/POSTNATAL NC ESCAVITE D CHEW 5 CHEW 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

263 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZESCO TABS NC FOLET DHA THPK NC

BAL-CARE DHA MISC 5 FOLET ONE CAPS NC

C-NATE DHA CAPS 5 FOLIVANE-OB CAPS 5

CITRANATAL 90 DHA 4 HEMENATAL OB + DHA 5 MISC MISC CITRANATAL ASSURE 4 HEMENATAL OB TABS 5 MISC KOSHER PRENATAL CITRANATAL B-CALM 4 AL(Up to 45 yrs NC MISC old ) PLUS IRON TABS RX/OTC CITRANATAL BLOOM 4 M-NATAL PLUS TABS NC DHA MISC CITRANATAL BLOOM 4 MARNATAL-F CAPS 5 TABS QL(1 ea daily); AL(Up to 45 yrs MYNATAL ADVANCE 4 CITRANATAL DHA MISC 4 TABS AL(Up to 45 yrs old ) old ) CITRANATAL HARMONY 4 AL(Up to 45 yrs CAPS old ) MYNATAL CAPS 5 CITRANATAL MEDLEY 4 CAPS MYNATAL PLUS TABS 5 AL(Up to 45 yrs CITRANATAL RX TABS 4 QL(1 ea daily); old ) MYNATAL ULTRACAPLET 4 AL(Up to 45 yrs TABS QL(1 ea daily); old ) CO-NATAL FA TABS 5 AL(Up to 45 yrs MYNATAL-Z TABS 5 old ); RX/OTC COMPLETE NATAL DHA 5 MYNATE 90 PLUS TBCR 5 MISC QL(1 ea daily); NATACHEW CHEW 5 COMPLETENATE CHEW 4 AL(Up to 45 yrs old ) NATALVIT TABS 5 CONCEPT DHA CAPS 5 NATELLE ONE CAPS 5 CONCEPT OB CAPS 5 NEEVO DHA CAPS 5 CVS PRENATAL NC GUMMIES CHEW NEONATAL COMPLETE RX/OTC TABS 0.2 MG-1.84 MG-10 DOTHELLE DHA CAPS 5 MCG-10 MG-1000 MCG-12 MCG-120 MG-1200 MCG-2 NC DUET DHA 400 MISC 5 MG-2 MG-20 MG-200 MG- 25 MG-27 MG-3 MG-5 MG- DUET DHA BALANCED 5 9.2 MG MISC ENBRACE HR CAPS NC

264 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEONATAL COMPLETE QL(1 ea daily); ONE VITE WOMENS RX/OTC TABS 100 MG-1000 MCG- AL(Up to 45 yrs PRENATALVITAMIN PLUS NC 120 MG-1200 MCG-15 old ); RX/OTC TABS MG-150 MCG-18.4 MG-20 5 PNV OB+DHA MISC 5 AL(Up to 45 yrs MG-200 MG-25 MCG-29 old ) MG-3 MG-3 MG-3 MG-3 MG-30 MCG-7 MG-8 MCG QL(1 ea daily); PNV TABS 29-1 TABS 5 AL(Up to 45 yrs NEONATAL PLUS TABS NC RX/OTC old ) PNV-DHA+DOCUSATE 5 NESTABS ABC MISC 5 CAPS

NESTABS DHA MISC 5 PNV-OMEGA CAPS 5

NESTABS ONE CAPS NC PR NATAL 400 EC MISC 5

NESTABS TABS 5 PR NATAL 400 MISC 5

NEXA PLUS CAPS 5 PR NATAL 430 EC MISC 5

NIVA-PLUS TABS NC RX/OTC PR NATAL 430 MISC 5

O-CAL FA TABS NC RX/OTC PREGENNA TABS NC

O-CAL PRENATAL TABS 5 PREMESISRX TABS 5

OB COMPLETE ONE 5 PRENA 1 TRUE MISC 5 CAPS PRENA1 CHEW CHEW 5 OB COMPLETE PETITE 5 CAPS PRENA1 PEARL CPCR 5 OB COMPLETE PREMIER 5 TABS PRENAISSANCE CAPS 5 AL(Up to 45 yrs OB COMPLETE TABS 5 old ) PRENAISSANCE PLUS 5 CAPS OB COMPLETE/DHA 5 CAPS PRENARA CAPS NC OBSTETRIX DHA MISC 5 RX/OTC QL(1 ea daily); PRENATABS FA TABS 5 AL(Up to 45 yrs 5 RX/OTC OBSTETRIX EC TABS old ); RX/OTC OBSTETRIX ONE CAPS NC PRENATAL + COMPLETE MULTI/DHA/CHOLINE/FO NC OBTREX DHA MISC 5 RX/OTC LATE THPK PRENATAL + DHA THPK NC OBTREX TABS 5 RX/OTC

ONE A DAY PRENATAL NC CHEW

265 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 CHEW 1 QL(1 ea daily); prenatal vit w/ iron QL(1 ea daily); MG-100 MG-1000 UNIT-12 AL(Up to 45 yrs carbonyl-folic acid tabs 1 AL(Up to 45 yrs MCG-15 MG-20 MG-20 4 old ) mg-100 mg-120 mg-15 mg- old ) MG-200 MG-29 MG-3 MG- 150 mcg-20 mg-200 mg-29 2 3 MG-30 UNIT-400 UNIT-7 mg-3 mg-3 mg-3 mg-3 mg- MG 30 mcg-30 unit-400 unit- PRENATAL 19 TABS 1 QL(1 ea daily); 4000 unit-7 mg-8 mcg MG-100 MG-1000 UNIT-12 AL(Up to 45 yrs PRENATAL VITAMINS NC RX/OTC MCG-15 MG-20 MG-20 4 old ); RX/OTC PLUS LOW IRON TABS MG-200 MG-25 MG-29 prenatal without a w/ fe MG-3 MG-3 MG-30 UNIT- fumarate-l methylfolate-fa- 2 400 UNIT-7 MG dha caps PRENATAL ADULT GUMMY/DHA/FOLIC ACID NC PRENATAL-U CAPS 5 CHEW PRENATE AM TABS 5 QL(1 ea daily); PRENATAL PLUS IRON 5 TABS AL(Up to 45 yrs old ) PRENATE CHEW 5 PRENATAL PLUS TABS NC RX/OTC PRENATE DHA CAPS 5

PRENATAL TABS NC RX/OTC PRENATE ELITE TABS 5

QL(1 ea daily); PRENATE ENHANCE 5 prenatal vit w/ docusate- 2 AL(Up to 45 yrs CAPS iron carbonyl-folic acid tabs old ) PRENATE ESSENTIAL 5 prenatal vit w/ ferrous QL(1 ea daily); CAPS fumarate-folic acid chew 1 AL(Up to 45 yrs PRENATE MINI CAPS 5 mg-100 mg-1000 unit-12 2 old ) mcg-20 mg-20 mg-200 mg- 25 mg-29 mg-3 mg-3 mg- PRENATE PIXIE CAPS 5 30 unit-400 unit-6 mg-7 mg PRENATE RESTORE 5 prenatal vit w/ ferrous AL(Up to 45 yrs CAPS fumarate-folic acid tabs 1 old ) RX/OTC mg-1.8 mg-12 mcg-120 PRENATRIX TABS NC mg-2 mg-20 mg-200 mg-22 2 PRENATVITE COMPLETE NC mg-25 mg-25 mg-25 mg-28 TABS mg-3000 unit-4 mg-400 unit PRENATVITE PLUS TABS NC prenatal vit w/ ferrous fumarate-l methylfolate- 2 PRENATVITE RX TABS NC RX/OTC folic acid tabs RX/OTC prenatal vit w/ iron AL(Up to 45 yrs PREPLUS TABS NC carbonyl-folic acid tabs 1 old ) QL(1 ea daily); mg-1.25 mg-10 mg-10 mg- 2 PRETAB TABS 5 AL(Up to 45 yrs 10 mg-120 mg-15 mcg-15 old ); RX/OTC mg-2 mg-20 unit-2100 unit- 3.4 mg-315 unit-50 mg PRIMACARE CAPS NC

PROVIDA DHA CAPS NC

266 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROVIDA OB CAPS 5 TRISTART ONE CAPS NC

PUREFE OB PLUS CAPS 5 TRIVEEN-DUO DHA MISC 5

R-NATAL OB CAPS 5 ULTIMATECARE ONE 5 CAPS RELNATE DHA CAPS 5 VENA-BAL DHA MISC 5 QL(1 ea daily); QL(1 ea daily); SE-NATAL 19 CHEW 4 AL(Up to 45 yrs VIL-RX TABS 5 AL(Up to 45 yrs old ) old ) QL(1 ea daily); SE-NATAL 19 TABS 4 AL(Up to 45 yrs VINATE DHA RF CAPS 5 old ); RX/OTC VINATE II TABS 5 SELECT-OB CHEW 5 VINATE M TABS 5 SELECT-OB+DHA MISC 5 VINATE ONE TABS 5 TARON-BC MISC 5 VIRT-C DHA CAPS 5 TARON-C DHA CAPS 5 VIRT-NATE DHA CAPS 5 TARON-PREX CAPS 5 VIRT-PN DHA CAPS 4 THERANATAL CORE NC RX/OTC NUTRITION TABS VIRT-PN PLUS CAPS 5 QL(1 ea daily); THRIVITE RX TABS 5 AL(Up to 45 yrs VIRT-PN TABS 5 old ) VITAFOL FE+ CAPS 0.4 TL FOLATE TABS 5 MG-0.6 MG-1.6 MG-1.8 MG-1000 UNIT-1100 UNIT- TL-CARE DHA CAPS 5 15 MG-150 MCG-2 MG-2.5 NC MG-20 MG-20 UNIT-200 TL-SELECT CAPS 5 MG-25 MCG-25 MG-415 MG-60 MG-90 MG TRI-TABS DHA MISC 5 VITAFOL FE+ CPPK 0.4 MG-0.6 MG-1.6 MG-1.8 TRICARE PRENATAL 5 DHA ONE CAPS MG-1000 UNIT-1100 UNIT- 15 MG-150 MCG-2 MG-2.5 5 TRICARE PRENATAL NC MG-20 MG-20 UNIT-200 DHA ONE/FOLATE CAPS MG-25 MCG-25 MG-415 TRICARE TABS NC RX/OTC MG-50 MG-60 MG-90 MG VITAFOL GUMMIES NC TRINATAL RX 1 TABS 5 CHEW VITAFOL STRIPS FILM NC TRINAZ TABS NC VITAFOL ULTRA CAPS 5 TRISTART DHA CAPS NC

267 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAFOL-NANO TABS 5 ALLERWELL ALLERGY 4 RX/OTC FORMULA TABS VITAFOL-OB TABS 5 BILBERRY PLUS CAPS 5 RX/OTC

VITAFOL-OB+DHA MISC 5 BIOTIN PLUS KERATIN 4 RX/OTC TABS VITAFOL-ONE CAPS 5 BRAIN MIGHT/DHA & CO 4 RX/OTC Q10 TABS VITAMEDMD ONE 5 RX/QUATREFOLIC CAPS CAL-CO3Y CAPS 5 RX/OTC VITAMEDMD REDICHEW 5 RX/OTC RX CHEW CARDIOPRESS CAPS 5 VITAPEARL CPCR 5 CENTRUM 4 RX/OTC PERFORMANCE TABS VITATHELY/GINGER RX/OTC NC CENTRUM SPECIALIST 4 RX/OTC TABS ENERGY TABS VITATRUE MISC 5 CHOLASE CONTROL 5 RX/OTC CAPS VIVA DHA CAPS 5 COLLAGEN ULTRA CAPS 5 RX/OTC AL(Up to 45 yrs VOL-NATE TABS 4 old ) CVS HAIR/SKIN/NAILS 4 RX/OTC TABS VOL-PLUS TABS NC RX/OTC ELON MATRIX 5000 4 RX/OTC TABS QL(1 ea daily); VOL-TAB RX TABS 5 AL(Up to 45 yrs ELON MATRIX PLUS 4 RX/OTC old ) TABS ELON MATRIX 5000 RX/OTC VP-HEME OB + DHA 5 4 MISC COMPLETE TABS ELON MATRIX 4 RX/OTC VP-PNV-DHA CAPS 5 COMPLETE TABS WESTAB PLUS TABS NC RX/OTC ELON R3 TABS 4 RX/OTC

WESTGEL DHA CAPS NC GLUCO COR CAPS 5 RX/OTC

ZALVIT TABS NC GLYCOTROL CAPS 5 RX/OTC

ZATEAN-PN DHA CAPS 4 GLYCOTROL COMPLETE 5 RX/OTC CAPS ZATEAN-PN PLUS CAPS 5 GNP CENTURY ENERGY 4 RX/OTC METABOLISM TABS Specialty Vitamins Products GREEN SOURCE TABS 4 RX/OTC ADRENAL STRESS CALM 4 RX/OTC TABS HAIR FARE TABS 4 RX/OTC ADRENOID CAPS 5 RX/OTC HAIR NOURISHING 4 RX/OTC SUPPLEMENT TABS ADVANCED COLLAGEN 4 RX/OTC TABS

268 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHY HEART 4 RX/OTC specialty vitamins products RX/OTC COMPLEX TABS caps 1 mg-10 mcg-10 mg- RX/OTC 10 mg-10 mg-10 mg-100 HEART SAVIOR CAPS 5 mg-100 mg-15 mg-15 unit- RX/OTC 150 mg-25 mg-25 mg-25 5 HEART TABS TABS 4 mg-50 mg-50 mg-50 mg-50 RX/OTC mg, 100 mg-240 mcg-300 HM ESTROPLUS TABS 4 mcg-50 mg-50 mg-50 mg- 500 mg INULOSE BLOOD SUGAR 5 RX/OTC SUPPORT CAPS LIPIDSHIELD PLUS TABS 4 RX/OTC

LIPOTRIAD VISION 5 RX/OTC SUPPORT CAPS LIPOTRIAD VISION 5 RX/OTC SUPPORTPLUS CAPS LIPOTRIAD VISIONARY 5 RX/OTC CAPS LONGEVITY CAPS 5 RX/OTC

LONGEVITY PLUS CAPS 5 RX/OTC

M2 CALCIUM TABS 4 RX/OTC

METHYL-GUARD CAPS 5 RX/OTC

METHYL-GUARD PLUS 5 RX/OTC CAPS MG PLUS PROTEIN TABS 4 RX/OTC

MG-PLUS PROTEIN TABS 4 RX/OTC

MIL ADREGEN TABS 4 RX/OTC

MM BIOTIN/KERATIN 5 RX/OTC CAPS MPS CAPS 5 RX/OTC

NEW LIFE HAIR TABS 4 RX/OTC

RA EAR CARE TABS 4 RX/OTC

RETAINE VISION CAPS 5 RX/OTC

269 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits specialty vitamins products RX/OTC mg-50 mg-70 mcg-8.25 tabs 0.15 mg-10 mg-100 mg-80 mg-80 mg, 1.9 mg- mg-111 mcg-15 mg-15 mg- 12.5 mg-15 mg-18 mg-2 250 mg-30 mg-35 mg-400 mg-2.125 mg-2.5 mg-200 mcg-5 mg-5 unit-50 mg-6 mg-25 mg-2500 unit-30 mcg, 0.35 mg-0.75 mg- unit-300 mg-32 mg-400 0.85 mg-1 mg-1 mg-10 mcg-400 unit-50 mg-60 mcg-10 mg-100 mcg-12.5 mg-7.5 mcg-70 mcg-80 mcg-15 mcg-15 unit-16 mcg, 10 %-10 mg-100 mg- mcg-1750 unit-18.75 mcg- 100 mg-100 mg-100 mg-25 2.5 mcg-2.5 mg-20 mg-200 mg-25 mg-25 unit-30 mg- mcg-200 unit-3 mg-3.75 30 mg-40 mg-8 mcg, 10 mg-30 mg-32 mg-40 mg- mcg-10 mcg-10 mg-100 400 mg-5 mcg-5 mcg-5 mg-120 mcg-120 mg-15 mg-54 mg-60 mcg-75 mcg, mg-150 mcg-18 mcg-18 0.9 mg-10 mcg-10 mcg- mg-2 mg-25 mcg-4 mg-4 100 mg-11 mg-12 mg-120 mg-4.5 mg-40 mcg-40 mg- mcg-120 mg-150 mcg-18 40 mg-400 mcg-400 unit-48 mcg-18 mg-25 mcg-3500 mg-5 mcg-5.1 mg-50 mg- unit-4 mg-4 mg-4.5 mg-40 5000 unit-6 mg-60 mcg-60 mg-40 mg-400 mcg-400 mg-60 unit-70 mcg-72 mg- unit-48 mg-5 mcg-5.1 mg- 75 mcg-80 mg, 10 mg-10 50 mcg-50 mg-6 mg-60 mg-100 mg-12.5 mg-12.5 mcg-60 mg-60 unit-70 mg-125 mcg-150 mg-25 mcg-72 mg-75 mcg, 0.9 mg-25 mg-25 mg-25 mg-5 mcg-5 mg-5 mg-5 mg, 100 mg-10 mcg-10 mcg-100 2 mg-11 mg-12 mg-120 mcg- mcg-100 mg-15 unit-2 mg- 120 mg-150 mcg-18 mcg- 2 mg-5 mg-500 mcg-75 18 mg-25 mcg-3500 unit-4 mg-75 mg-9 mg, 100 mg- mg-4 mg-4.5 mg-40 mg-40 100 mg-125 mg-15 mg-150 mg-400 mcg-400 unit-48 mcg-18 mg-2 mg-250 mg- mg-5 mcg-5.1 mg-50 mcg- 400 mcg-400 mcg-5 mg-6 50 mg-6 mg-60 mcg-60 mcg mg-60 unit-70 mcg-72 mg- RX/OTC 75 mcg-80 mg, 1 mg-1 mg- SUPPORT-500 CAPS 5 1 mg-1.67 mg-1.67 mg- RX/OTC 1.67 mg-1.67 mg-10 mg-10 SYNERTROPIN CAPS 5 mg-1666.67 unit-2.5 mg- THERABETIC EYE 4 RX/OTC 2.67 mcg-237 mg-25 mg- HEALTH TABS 33.333 mg-33.333 unit- 37.5 mcg-4.167 mcg-4.167 THYMUS TABS OR 4 RX/OTC mg-40 mg-5 mg-5 unit-50 mg-66.67 mcg-8.333 mg- VITA-RX DIABETIC 5 RX/OTC 8.333 mg-8.333 mg-8.333 VITAMIN CAPS mg, 1.5 mg-100 mg-120 VITAMINS FOR THE HAIR 4 RX/OTC mcg-20 mg-20 mg-25 mcg- TABS 25 mg-30 unit-400 mcg-5 Vitamin Mixtures mg-5 mg-50 mcg-70 mcg- 80 mg-80 mg-800 unit, 1.5 COD LIVER OIL FOR KIDS 5 RX/OTC mg-100 mg-120 mcg-20 OIL mg-20 mg-25 mcg-25 mg- COD LIVER OIL OIL 5 RX/OTC 30 unit-400 mcg-5 mg-5 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

270 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS COD LIVER OIL OIL 5 RX/OTC cyclobenzaprine hcl tabs or 2 QL(3 ea daily) 10 mg, 5 mg NICOMIDE TABS NC cyclobenzaprine hcl tabs or NC 7.5 mg NORWEGIAN COD LIVER RX/OTC 5 CYCLOPHENE NC OIL OIL RAPIDPAQ CREA RX/OTC QC COD LIVER OIL OIL 5 CYCLOTENS REFILL PAK NC KIT RA COD LIVER OIL OIL 5 RX/OTC CYCLOTENS STARTER NC PAK KIT MUSCULOSKELETAL THERAPY AGENTS - ENOVARX- Drugs to Treat Spasms CYCLOBENZAPRINE HCL 5 Articular Cartilage Repair Therapy CREA CARTICEL IMPL 5 FIRST-BACLOFEN 1 NC SUSP SP MACI SHEE NC FIRST-BACLOFEN 5 NC SUSP Central Muscle Relaxants GABLOFEN SOLN 10000 ACTIVE- MCG/20ML, 40000 5 CYCLOBENZAPRINE KIT NC MCG/20ML CREA GABLOFEN SOLN 20000 5 MCG/20ML (baclofen) AMRIX CP24 NC QL(1 ea daily) (cyclobenzaprine hcl) GABLOFEN SOSY 10000 MCG/20ML, 20000 5 BACLOFEN POWD XX 5 MCG/20ML, 40000 baclofen soln it 20000 MCG/20ML, 50 MCG/ML mcg/20ml, 40 mg/20ml, 2 LIORESAL INTRATHECAL PA; SP 500 mcg/ml SOLN 0.05 MG/ML, 10 5 MG/5ML baclofen tabs or 10 mg, 20 2 mg, 5 mg LIORESAL INTRATHECAL SOLN 10 MG/20ML, 40 5 CARISOPRODOL POWD 5 XX MG/20ML (baclofen) QL(4 ea daily) carisoprodol tabs or 250 2 QL(3 ea daily) metaxalone tabs 400 mg NC mg metaxalone tabs 400 mg, QL(4 ea daily) carisoprodol tabs or 350 2 QL(4 ea daily) 2 mg 800 mg methocarbamol soln ij 1000 carisoprodol tabs or 350 NC QL(4 ea daily) 2 mg mg/10ml methocarbamol tabs or 500 CHLORZOXAZONE TABS NC 2 250 MG mg, 750 mg methocarbamol tabs or 500 chlorzoxazone tabs 375 NC NC mg, 500 mg, 750 mg mg, 750 mg ORPHENADRINE 5 chlorzoxazone tabs 500 mg 2 CITRATE POWD XX orphenadrine citrate soln ij cyclobenzaprine hcl cp24 NC QL(1 ea daily) 2 or 15 mg, 30 mg 30 mg/ml, 60 mg/2ml

271 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits orphenadrine citrate tb12 2 QL(2 ea daily) RYANODEX SUSR 5 or 100 mg OZOBAX SOLN NC Muscle Relaxant Combinations carisoprodol w/ aspirin & 2 QL(8 ea daily) ROBAXIN SOLN IJ 1000 5 codeine tabs MG/10ML (methocarbamol) carisoprodol w/ aspirin tabs 2 QL(8 ea daily) ROBAXIN TABS OR 500 4 MG (methocarbamol) CYCLO/GABA10/300 NC ROBAXIN-750 TABS 4 PACK THPK (methocarbamol) METAXALL CP KIT NC SKELAXIN TABS 4 QL(4 ea daily) (metaxalone) NOPIOID-LMC KIT THPK NC SOMA TABS 250 MG 5 QL(3 ea daily) (carisoprodol) NOPIOID-TC KIT THPK NC SOMA TABS 350 MG 5 QL(4 ea daily) (carisoprodol) NORGESIC FORTE TABS NC TABRADOL FUSEPAQ NC SUSP orphenadrine w/ aspirin & NC caff tabs TABRADOL RAPIDPAQ NC SUSP TIZANIDINE COMFORT 5 PAC MISC tizanidine hcl caps or 2 mg 2 NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus tizanidine hcl caps or 4 mg 2 QL(9 ea daily) Nasal Agent Combinations tizanidine hcl caps or 6 mg 2 QL(6 ea daily) azelastine hcl-fluticasone 2 QL(0.77 gm propionate susp daily) tizanidine hcl tabs or 4 mg, 2 2 mg DERMACINRX AZENASE NC PAK THPK ZANAFLEX CAPS 2 MG 5 (tizanidine hcl) DYMISTA SUSP QL(0.77 gm (azelastine hcl-fluticasone 4 daily) ZANAFLEX CAPS 4 MG 5 QL(9 ea daily) propionate) (tizanidine hcl) TICALAST KIT NC ZANAFLEX CAPS 6 MG 5 QL(6 ea daily) (tizanidine hcl) Nasal Agents - Misc. ZANAFLEX TABS 4 MG 5 (tizanidine hcl) ALZAIR ALLERGY BLOCKER NASAL SPRAY NC Direct Muscle Relaxants POWD DANTRIUM CAPS QL(4 ea daily) 4 DERMACINRX TICANASE NC (dantrolene sodium) PAK THPK DANTRIUM IV SOLR 5 (dantrolene sodium) TICASPRAY THPK NC dantrolene sodium caps or 2 QL(4 ea daily) Nasal Anesthetics 100 mg, 50 mg, 25 mg COCAINE NC dantrolene sodium solr iv 2 HYDROCHLORIDE SOLN 20 mg GOPRELTO SOLN NC

272 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUMBRINO SOLN NC ADRENALIN SOLN NA 0.1 5 % (epinephrine hcl (nasal)) Nasal Anti-infectives epinephrine hcl (nasal) soln 5 BACTROBAN NASAL 5 OINT PHENYLEPHRINE HCL 5 CRYS Nasal Antiallergy PHENYLEPHRINE HCL 5 RX/OTC azelastine hcl soln na 0.1 2 QL(1.2 ml POWD %, 0.15 %, 137 mcg/spray daily) PHENYLEPHRINE RX/OTC olopatadine hcl (nasal) soln 2 HYDROCHLORIDE POWD 5 XX PATANASE SOLN 5 PHENYLPROPANOLAMIN (olopatadine hcl (nasal)) E HYDROCHLORIDE USP 5 Nasal Anticholinergics POWD PSEUDOEPHEDRINE ipratropium bromide (nasal) 1 5 soln HCL CRYS Nasal Steroids PSEUDOEPHEDRINE 5 HCL POWD QL(1.67 gm BECONASE AQ SUSP NC daily) NEUROMUSCULAR AGENTS - Drugs to QL(0.6 ml Relax/Paralyze Muscles budesonide (nasal) susp 1 daily) ALS Agents flunisolide (nasal) soln 2 RADICAVA SOLN 5 PA; SP fluticasone propionate 2 QL(1.1 gm (nasal) susp daily); RX/OTC RILUTEK TABS (riluzole) 5 mometasone furoate 2 QL(1.22 gm riluzole tabs 2 (nasal) susp daily) NASONEX SUSP QL(1.22 gm TIGLUTIK SUSP NC (mometasone furoate 5 daily) (nasal)) Depolarizing Muscle Relaxants OMNARIS SUSP NC QL(0.42 gm daily) ANECTINE SOLN 5 QNASL AERS NC QUELICIN SOLN 5 (succinylcholine chloride) QNASL CHILDRENS NC SUCCINYLCHOLINE AERS CHLORIDE SOLN IJ 20 5 MG/ML SINUVA IMPL NC succinylcholine chloride triamcinolone acetonide 2 QL(1.2 ml soln ij 20 mg/ml, 200 2 (nasal) aero daily) mg/10ml XHANCE EXHU 5 QL(1.07 ml SUCCINYLCHOLINE daily) CHLORIDE SOSY IJ 100 NC MG/5ML, 140 MG/7ML, ZETONNA AERS NC QL(0.3 gm daily) 200 MG/10ML Sympathomimetic Decongestants

273 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUCCINYLCHOLINE ZOLGENSMA 10.1-10.5 5 PA; SP CHLORIDE SOSY IV 100 NC KG KIT MG/5ML, 140 MG/7ML, ZOLGENSMA 10.6-11.0 5 PA; SP 200 MG/10ML KG KIT Muscular Dystrophy Agents ZOLGENSMA 11.1-11.5 5 PA; SP KG KIT EXONDYS 51 SOLN 5 PA; SP ZOLGENSMA 11.6-12.0 5 PA; SP VYONDYS 53 SOLN NC KG KIT ZOLGENSMA 12.1-12.5 5 PA; SP Neuromuscular Blocking Agent - Neurotoxins KG KIT BOTOX SOLR 5 PA; SP ZOLGENSMA 12.6-13.0 5 PA; SP KG KIT PA; SP DYSPORT SOLR 5 ZOLGENSMA 13.1-13.5 5 PA; SP KG KIT PA; SP MYOBLOC SOLN 5 ZOLGENSMA 2.6-3.0 KG 5 PA; SP KIT XEOMIN SOLR 5 PA; SP ZOLGENSMA 3.1-3.5 KG 5 PA; SP KIT Nondepolarizing Muscle Relaxants ZOLGENSMA 3.6-4.0 KG 5 PA; SP atracurium besylate soln 2 KIT ZOLGENSMA 4.1-4.5 KG 5 PA; SP cisatracurium besylate soln KIT 200 mg/20ml, 10 mg/5ml, 2 20 mg/10ml ZOLGENSMA 4.6-5.0 KG 5 PA; SP KIT CISATRACURIUM BESYLATE SOSY 10 NC ZOLGENSMA 5.1-5.5 KG 5 PA; SP MG/5ML, 20 MG/10ML KIT ZOLGENSMA 5.6-6.0 KG PA; SP NIMBEX SOLN 5 5 (cisatracurium besylate) KIT ZOLGENSMA 6.1-6.5 KG 5 PA; SP pancuronium bromide soln 2 KIT ZOLGENSMA 6.6-7.0 KG PA; SP rocuronium bromide soln iv 2 5 100 mg/10ml, 50 mg/5ml KIT ROCURONIUM BROMIDE ZOLGENSMA 7.1-7.5 KG 5 PA; SP KIT SOSY IV 100 MG/10ML, NC 20 MG/2ML, 50 MG/5ML, ZOLGENSMA 7.6-8.0 KG 5 PA; SP 75 MG/7.5ML KIT vecuronium bromide solr iv 2 ZOLGENSMA 8.1-8.5 KG 5 PA; SP 10 mg, 20 mg KIT VECURONIUM BROMIDE NC ZOLGENSMA 8.6-9.0 KG 5 PA; SP SOSY IV 10 MG/10ML KIT VECURONIUM ZOLGENSMA 9.1-9.5 KG 5 PA; SP BROMIDE/SODIUM NC KIT CHLORIDE SOLN ZOLGENSMA 9.6-10.0 KG 5 PA; SP Spinal Muscular Atrophy Agents (SMA) KIT SPINRAZA SOLN 5 PA; SP NUTRIENTS

274 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Carbohydrates LIPO SOLN NC alcohol soln ij 98 % 2 LIPO-C SOLN NC DEXTROSE 20% SOLN 5 MIC/L-CARNITINE SOLN NC DEXTROSE 40% SOLN 5 Misc. Nutritional Substances DEXTROSE 50% SOLN 2 CARDIOVID PLUS CAPS 5

DEXTROSE ANHYDROUS 5 RX/OTC CYTOTINE POWD 5 RX/OTC POWD DEXTROSE 5 RX/OTC Protein-Carbohydrate-Lipid Combinations MONOHYDRATE POWD KABIVEN EMUL 5 DEXTROSE POWD XX 5 RX/OTC PERIKABIVEN EMUL 5 DEXTROSE SOLN IV 20 % 5 Proteins dextrose soln iv 250 mg/ml, 30 %, 50 %, 10 %, 70 %, 5 2 acetylcysteine (nutrient) 2 RX/OTC % caps RX/OTC DEXTROSE SOLN IV 50 % 2 ALANINE POWD 5 RX/OTC amino acid electrolyte 2 FRUCTOSE GRAN 5 infusion soln FRUCTOSE POWD 5 amino acid infusion soln 2 Lipids AMINO ACID SOLN NC CLINOLIPID EMUL NC amino acids caps 2 RX/OTC INTRALIPID EMUL 20 NC GM/100ML AMINOPROTECT SOLN NC INTRALIPID EMUL 30 5 AMINOSYN GM/100ML 7%/ELECTROLYTES 5 SOLN NEOKE MCT70 POWD NC RX/OTC

NUTRILIPID EMUL NC

OMEGAVEN EMUL NC

SMOFLIPID EMUL 5 Lipotropics CHOLINE BITARTRATE 5 POWD LECITHIN GRAN OR 5 RX/OTC

LECITHIN GRAN XX 5 RX/OTC

275 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMINOSYN II SOLN 1000 MG/100ML-170 MG/100ML-1018 MG/100ML-230 MG/100ML-1050 MG/100ML-253 MG/100ML-172 MG/100ML-255 MG/100ML-200 MG/100ML-33.3 MEQ/L- MG/100ML-270 340 MG/100ML-425 MG/100ML-298 MG/100ML-425 MG/100ML-300 MG/100ML-450 MG/100ML-38 MEQ/L-400 MG/100ML-561 MG/100ML-500 MG/100ML-595 MG/100ML-500 MG/100ML-61.1 MEQ/L- MG/100ML-530 614 MG/100ML-627 MG/100ML-660 MG/100ML-844 MG/100ML-700 MG/100ML-850 MG/100ML-71.8 MEQ/L- MG/100ML-865 722 MG/100ML-738 MG/100ML-893 MG/100ML MG/100ML-993 AMINOSYN II SOLN 1050 MG/100ML, 1000 MG/100ML-107.6 MEQ/L- MG/100ML-1018 1083 MG/100ML-1107 MG/100ML-1050 MG/100ML-1490 MG/100ML-172 MG/100ML-1500 MG/100ML-200 MG/100ML-1527 MG/100ML-270 MG/100ML-1575 MG/100ML-298 MG/100ML-258 MG/100ML-300 MG/100ML-300 5 MG/100ML-400 5 MG/100ML-405 MG/100ML-45.3 MEQ/L- MG/100ML-447 500 MG/100ML-500 MG/100ML-450 MG/100ML-530 MG/100ML-50 MEQ/L-600 MG/100ML-660 MG/100ML-750 MG/100ML-700 MG/100ML-750 MG/100ML-71.8 MEQ/L- MG/100ML-795 722 MG/100ML-738 MG/100ML-990 MG/100ML MG/100ML-993 (amino acid infusion) MG/100ML, 1000 MG/100ML-1018 AMINOSYN M SOLN 5 MG/100ML-1050 MG/100ML-172 AMINOSYN SOLN 5 MG/100ML-200 MG/100ML-270 AMINOSYN-HBC SOLN 5 MG/100ML-298 MG/100ML-300 AMINOSYN-PF 7% SOLN 5 MG/100ML-400 MG/100ML-500 AMINOSYN-PF SOLN 5 MG/100ML-500 MG/100ML-530 AMINOSYN-RF SOLN 5 MG/100ML-660 MG/100ML-700 BCAA SOLN NC MG/100ML-722 MG/100ML-738 CALM SOLN NC MG/100ML-993 MG/100ML, 146 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

276 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINIMIX CYTO CARN POWD NC RX/OTC 4.25%/DEXTROSE 10% 5 SOLN DL-ALANINE POWD 5 RX/OTC CLINIMIX 4.25%/DEXTROSE 25% 5 DL-LEUCINE POWD 5 RX/OTC SOLN CLINIMIX DL-METHIONINE POWD 5 RX/OTC 4.25%/DEXTROSE 5% 5 SOLN DL-PHENYLALANINE 5 RX/OTC POWD CLINIMIX 5%/DEXTROSE 5 15% SOLN ELCYS SOLN NC CLINIMIX 5%/DEXTROSE 5 20% SOLN FREAMINE HBC 6.9% 5 SOLN CLINIMIX 5%/DEXTROSE 5 25% SOLN FREAMINE III SOLN 5 CLINIMIX E 2.75%/DEXTROSE 10% 5 GABA SOLN NC SOLN RX/OTC CLINIMIX E GLUTAMINE POWD 5 2.75%/DEXTROSE 5% 5 SOLN GLUTATHIONE (L) SOLN NC CLINIMIX E RX/OTC 4.25%/DEXTROSE 10% 5 GLUTATHIONE POWD 5 SOLN GLUTATHIONE NC CLINIMIX E REDUCED SOLN 4.25%/DEXTROSE 25% 5 RX/OTC SOLN GLUTATHIONE-L POWD 5 CLINIMIX E GLUTATHIONE-L 5 RX/OTC 4.25%/DEXTROSE 5% 5 REDUCED POWD SOLN GLYCINE SOLN IJ NC CLINIMIX E 5%/DEXTROSE 15% 5 L-ALANINE POWD 5 RX/OTC SOLN CLINIMIX E L-ARGININE BASE POWD 5 RX/OTC 5%/DEXTROSE 20% 5 SOLN L-ARGININE NC CLINIMIX E HYDROCHLORIDE SOLN 5%/DEXTROSE 25% 5 L-ARGININE POWD 5 RX/OTC SOLN RX/OTC CLINIMIX N14G30E SOLN 5 L-CYSTINE POWD 5 RX/OTC CLINIMIX N9G15E SOLN 5 L-GLUTAMIC ACID POWD 5

CLINIMIX N9G20E SOLN 5 L-GLUTAMINE CRYS 5 RX/OTC cysteine hcl soln 2 L-GLUTAMINE POWD 5

277 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits L-HISTIDINE SYNTHAMIN 17 SOLN 5 MONOHYDROCHLORIDE 5 CRYS TAURINE LIQD XX 5 L-HISTIDINE MONOHYDROCHLORIDE 5 TAURINE POWD XX 5 MONOHYDRATE POWD L-HISTIDINE POWD 5 RX/OTC TAURINE SOLN IJ NC RX/OTC L-ISOLEUCINE POWD 5 RX/OTC THREONINE POWD 5

L-LEUCINE POWD 5 RX/OTC TRAVASOL SOLN 5

L-LYSINE NC TRI-AMINO SOLN NC HYDROCHLORIDE SOLN L-METHIONINE POWD 5 RX/OTC TROPHAMINE SOLN 5 TRYPTOPHAN CAPS 5 RX/OTC L-PHENYLALANINE 5 RX/OTC POWD TRYPTOPHAN POWD 5 RX/OTC L-PROLINE POWD 5 RX/OTC VALINE POWD 5 RX/OTC L-THREONINE CRYS 5 OPHTHALMIC AGENTS - Drugs to Treat the Eye L-TRYPTOPHAN CAPS 5 RX/OTC Artificial Tears and Lubricants L-TRYPTOPHAN POWD 5 RX/OTC LACRISERT INST 5 L-TYROSINE POWD 5 RX/OTC Beta-blockers - Ophthalmic L-VALINE CRYS 5 BETAGAN SOLN 5 (levobunolol hcl) RX/OTC L-VALINE POWD 5 betaxolol hcl (ophth) soln 2 RX/OTC LEUCINE POWD 5 BETIMOL SOLN 4 RX/OTC METHIONINE POWD 5 BETOPTIC-S SUSP 4 RX/OTC NEOKE ALCAR POWD NC carteolol hcl (ophth) soln 2

NEPHRAMINE SOLN 5 COMBIGAN SOLN 4 PHLEXY-10 CAPS 4 RX/OTC COSOPT PF SOLN (dorzolamide hcl-timolol 5 PREMASOL SOLN 5 maleate) COSOPT SOLN PROCALAMINE SOLN 5 (dorzolamide hcl-timolol 5 maleate) PROSOL SOLN 5 dorzolamide hcl-timolol 2 maleate soln

278 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISTALOL SOLN (timolol 5 cyclopentolate hcl soln op 2 2 maleate (ophth)) %, 1 % levobunolol hcl soln 2 homatropine hbr soln 2 metipranolol soln 2 ISOPTO ATROPINE SOLN 2 timolol maleate (ophth) 2 phenylephrine hcl 2 solg 0.25 %, 0.5 % (mydriatic) soln timolol maleate (ophth) 2 TROPICAMIDE POWD 5 soln 0.25 %, 0.5 % TROPICAMIDE/CYCLOPE timolol maleate (ophth) NC soln 0.5 % NTOLATE HYDROCHLORIDE/PHEN NC TIMOLOL/BRIMONIDE/DO NC RZOLAMIDE SOLN YLEPHRINE HYDRO SOLN TIMOLOL/BRIMONIDINE/ DORZOLAMIDE/LATANOP NC TROPICAMIDE/CYCLOPE ROST SOLN NTOLATE/PHENYLEPHRI NC NE SOLN TIMOLOL/DORZOLAMIDE/ NC LATANOPROST SOLN TROPICAMIDE/PHENYLE NC PHRINE SOLN TIMOLOL/LATANOPROST NC SOLN TROPICAMIDE/PROPARA CAINE/PHENYLEPHRINE/ NC TIMOPTIC OCUDOSE NC KETOROLAC SOLN SOLN 0.25 % TIMOPTIC OCUDOSE Miotics SOLN 0.5 % (timolol NC ISOPTO CARPINE SOLN 5 maleate (ophth)) (pilocarpine hcl) TIMOPTIC SOLN (timolol 5 MIOCHOL-E SOLR 5 maleate (ophth)) MIOSTAT SOLN 5 TIMOPTIC-XE SOLG 5 (timolol maleate (ophth)) PHOSPHOLINE IODIDE 5 Cycloplegic Mydriatics SOLR ATROPINE SULFATE pilocarpine hcl soln op 1 %, 2 MONOHYDRATE SOLN NC 2 %, 4 % OP Ophthalmic - Angiogenesis Inhibitors ATROPINE SULFATE 5 OINT OP 1 % BEOVU SOLN NC ATROPINE SULFATE 2 SOLN OP 1 % BEVACIZUMAB SOSY NC CYCLOGYL SOLN 0.5 % 5 QL(15 ml per PA; SP (cyclopentolate hcl) fill retail) EYLEA SOLN 4 CYCLOGYL SOLN 2 %, 1 5 4 PA; SP % (cyclopentolate hcl) EYLEA SOSY PA; SP CYCLOMYDRIL SOLN 5 LUCENTIS SOLN 4 PA; SP cyclopentolate hcl soln op 2 QL(15 ml per LUCENTIS SOSY 4 0.5 % fill retail)

279 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP QL(4 gm per fill MACUGEN SOLN 5 erythromycin (ophth) oint 2 retail) Ophthalmic Adrenergic Agents gatifloxacin (ophth) soln 2 ALPHAGAN P SOLN 0.1 % 4 gentamicin sulfate (ophth) 2 QL(4 gm per fill oint retail) ALPHAGAN P SOLN 0.15 4 % (brimonidine tartrate) gentamicin sulfate (ophth) 2 soln apraclonidine hcl soln 2 KLARITY-A SOLN NC QL(6 ml per 30 days retail) BRIMONIDE/DORZOLAMI NC DE P-F SOLN levofloxacin (ophth) soln 2 brimonidine tartrate soln op 2 0.15 %, 0.2 % MITOSOL KIT 5 IOPIDINE SOLN 0.5 % 5 (apraclonidine hcl) MOXEZA SOLN 5 (moxifloxacin hcl (ophth)) IOPIDINE SOLN 1 % 5 moxifloxacin hcl (ophth) 2 QL(3 ml per fill soln retail) SIMBRINZA SUSP 4 moxifloxacin hcl (ophth) 2 Ophthalmic Anti-infectives soln QL(6 ml per 30 MOXIFLOXACIN AZASITE SOLN 5 NC days retail) HYDROCHLORIDE SOLN MOXIFLOXACIN NC BACIGUENT OINT 2 HYDROCHLORIDE SOSY MOXIFLOXACIN bacitracin (ophthalmic) oint 2 HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN bacitracin-polymyxin b 2 QL(4 gm per fill (ophth) oint retail) MOXIFLOXACIN SOLN NC BESIVANCE SUSP 4 NATACYN SUSP 5 BETADINE OPHTHALMIC 5 PREP SOLN neomycin-bacitracin zn- 2 QL(4 gm per fill BLEPH-10 SOLN QL(15 ml per polymyxin oint retail) (sulfacetamide sodium 5 fill retail) neomycin-polymyxin- 2 QL(10 ml per (ophth)) gramicidin soln fill retail) CEFUROXIME NEOSPORIN SOLN QL(10 ml per SODIUM/SODIUMCHLORI NC (neomycin-polymyxin- 5 fill retail) DE SOLN gramicidin) OCUFLOX SOLN 5 QL(5 ml per fill CEFUROXIME SOSY NC (ofloxacin (ophth)) retail) QL(5 ml per fill CILOXAN OINT 4 ofloxacin (ophth) soln 2 retail) CILOXAN SOLN 5 polymyxin b-trimethoprim 2 QL(10 ml per (ciprofloxacin hcl (ophth)) soln fill retail) ciprofloxacin hcl (ophth) 2 POLYTRIM SOLN 5 QL(10 ml per soln (polymyxin b-trimethoprim) fill retail)

280 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POVIDONE IODINE SOLN 5 ALCAINE SOLN 5 (proparacaine hcl) sulfacetamide sodium 2 LIDOCAINE (ophth) oint HYDROCHLORIDE/EPINE NC PHRINE SOLN sulfacetamide sodium 2 QL(15 ml per (ophth) soln fill retail) LIDOCAINE QL(5 ml per fill HYDROCHLORIDE/PHEN tobramycin (ophth) soln 2 NC retail) YLEPHRINE HYDROCHLORIDE SOLN TOBREX OINT 5 LIDOCAINE HYDROCHLORIDE/PHEN TOBREX SOLN 5 QL(5 ml per fill NC (tobramycin (ophth)) retail) YLEPHRINE QL(8 ml per fill HYDROCHLORIDE SOSY trifluridine soln 2 retail) proparacaine hcl soln op 2 VIGAMOX SOLN 5 QL(3 ml per fill (moxifloxacin hcl (ophth)) retail) tetracaine hcl (ophth) soln 2 VIROPTIC SOLN 4 QL(8 ml per fill (trifluridine) retail) Ophthalmic Nerve Growth Factors PA; SP ZIRGAN GEL 5 OXERVATE SOLN 5 Ophthalmic Photodynamic Therapy Agents ZYMAXID SOLN 5 (gatifloxacin (ophth)) VISUDYNE SOLR 5 PA; SP Ophthalmic Gene Therapy Ophthalmic Photoenhancers LUXTURNA SUSP 5 PA; SP PHOTREXA VISCOUS NC Ophthalmic Immunomodulators SOSY PHOTREXA/PHOTREXA NC CEQUA SOLN NC VISCOUS KIT SOSY CYCLOSPORINE IN NC Ophthalmic Steroids KLARITY EMUL ALREX SUSP NC RESTASIS EMUL 4 QL(2 ml daily) bacitracin-poly-neomycin- 2 QL(4 gm per fill RESTASIS MULTIDOSE 4 QL(2 ml daily) hc oint retail) EMUL BLEPHAMIDE S.O.P. 5 Ophthalmic Integrin Antagonists OINT XIIDRA SOLN 4 BLEPHAMIDE SUSP 5

Ophthalmic Kinase Inhibitors dexamethasone sodium 2 QL(5 ml per fill phosphate (ophth) soln retail) RHOPRESSA SOLN 4 DEXAMETHASONE/MOXI NC FLOXACIN HCL SOLN ROCKLATAN SOLN 4 QL(0.09 ml daily) DEXAMETHASONE/MOXI FLOXACIN/KETOROLAC NC Ophthalmic Local Anesthetics SOLN AKTEN GEL 5 DEXTENZA INST NC

281 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXYCU SUSP NC neomycin-polymy- QL(5 ml per fill dexameth susp 0.1 %- 2 retail) DOUBLE PM SOLR NC 10000 unit/ml-3.5 mg/ml neomycin-polymyxin-hc 2 QL(8 ml per fill DUREZOL EMUL 4 (ophth) susp retail) OMNIPRED SUSP FLAREX SUSP NC (prednisolone acetate 5 (ophth)) fluorometholone (ophth) 2 PA; SP susp OZURDEX IMPL 5 FML FORTE SUSP 4 PRED FORTE SUSP (prednisolone acetate NC FML LIQUIFILM SUSP NC (ophth)) (fluorometholone (ophth)) PRED MILD SUSP 4 FML OINT 4 PRED-G S.O.P. OINT 5 GATIFLOXACIN- NC DEXAMETHASONE SOLN PRED-G SUSP 5 ILUVIEN IMPL 5 PA; SP prednisolone acetate 2 INVELTYS SUSP NC (ophth) susp PREDNISOLONE 5 KLARITY-B SOLN NC ACETATE P-F SUSP PREDNISOLONE KLARITY-L EMUL NC ACETATE/MOXIFLOXACI NC N SUSP LOTEMAX GEL NC PREDNISOLONE ACETATE/MOXIFLOXACI NC LOTEMAX OINT NC N/BROMFENAC SUSP PREDNISOLONE LOTEMAX SM GEL NC ACETATE/MOXIFLOXACI NC N/NEPAFENAC SUSP LOTEMAX SUSP NC (loteprednol etabonate) PREDNISOLONE ACETATE/NEPAFENAC NC loteprednol etabonate susp 2 SUSP PREDNISOLONE SODIUM MAXIDEX SUSP 4 PHOSPHATE SOLN OP 1 5 MAXITROL OINT 0.1 %- QL(5 gm per fill % PREDNISOLONE SODIUM 10000 UNIT/GM-3.5 5 retail) MG/GM (neomycin-polymy- PHOSPHATE/BROMFENA NC dexameth) C SOLN MAXITROL SUSP 0.1 %- QL(5 ml per fill PREDNISOLONE SODIUM PHOSPHATE/GATIFLOXA NC 10000 UNIT/ML-3.5 5 retail) MG/ML (neomycin-polymy- CIN SOLN dexameth) PREDNISOLONE SODIUM neomycin-polymy- QL(5 gm per fill PHOSPHATE/GATIFLOXA NC dexameth oint 0.1 %-10000 2 retail) CIN/BROMFENAC SOLN unit/gm-3.5 mg/gm 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

282 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISOLONE SODIUM HEALON GV SOLN 4 PHOSPHATE/MOXIFLOXA NC CIN SOLN HEALON PRO SOLN 4 PREDNISOLONE SODIUM PHOSPHATE/MOXIFLOXA NC HEALON SOLN 4 CIN/BROMFENAC SOLN PREDNISOLONE- NC HEALON5 PRO SOLN 4 GATIFLOXACIN SUSP HEALON5 SOLN 4 PREDNISOLONE/BROMF NC ENAC SUSP HYALURONIDASE SOLN NC PREDNISOLONE/GATIFL IO OXACIN/BROMFENAC NC SUSP MEMBRANEBLUE SOLN 4 PA; SP RETISERT IMPL 5 OMIDRIA SOLN 4 sulfacetamide sod- 2 prednisolone soln PROVISC SOLN 4 TOBRADEX OINT 4 QL(4 gm per fill retail) VISIONBLUE SOLN 4 TOBRADEX ST SUSP 4 Ophthalmics - Misc. ACULAR LS SOLN TOBRADEX SUSP QL(5 ml per fill (ketorolac tromethamine 5 (tobramycin- 5 retail) (ophth)) dexamethasone) ACULAR SOLN (ketorolac 5 tobramycin- 2 QL(5 ml per fill tromethamine (ophth)) dexamethasone susp retail) ACUVAIL SOLN 4 TRIAMCINOLONE/MOXIF NC LOXACIN HCL SUSP ALOCRIL SOLN 4 TRIESENCE SUSP 5 ALOMIDE SOLN 4 TRIPLE PMB SOLR NC QL(6 ml per fill azelastine hcl (ophth) soln 2 TRIPLE PMK SOLR NC retail) QL(0.4 ml AZOPT SUSP 4 YUTIQ IMPL NC daily) ST; QL(0.34 ml ZYLET SUSP NC QL(5 ml per fill BEPREVE SOLN 4 retail) daily) bromfenac sodium (ophth) 2 Ophthalmic Surgical Aids soln AMVISC PLUS SOLN 4 BROMSITE SOLN 4 AMVISC SOLN 4

BIOLON SOLN 4

GELFILM OP FILM 4

283 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.09 ml BSS PLUS SOLN 0.395 olopatadine hcl soln 0.2 % 2 MG/ML-0.433 MG/ML-2.19 daily); RX/OTC MG/ML-2.19 MG/ML-23 ophthalmic irrigation 2 MG/ML-3.85 MG/ML-4.6 5 solution - intraocular soln MG/ML-5 MG/ML-7.44 MG/ML (ophthalmic PATADAY SOLN 5 QL(0.09 ml irrigation solution - (olopatadine hcl) daily); RX/OTC intraocular) PATANOL SOLN 5 QL(0.34 ml BSS PLUS SOLN 0.395 (olopatadine hcl) daily); RX/OTC ST; QL(0.09 ml MG/ML-0.433 MG/ML-2.19 PAZEO SOLN 4 MG/ML-23 MG/ML-3.85 5 daily) MG/ML-4.6 MG/ML-5 PROLENSA SOLN 4 MG/ML-7.44 MG/ML BSS SOLN (ophthalmic TRUSOPT SOLN 5 QL(0.34 ml irrigation solution - 5 (dorzolamide hcl) daily) intraocular) ZERVIATE SOLN NC CHONDROITIN SULFATE NC SOLN Prostaglandins - Ophthalmic cromolyn sodium (ophth) QL(10 ml per QL(0.09 ml 2 bimatoprost soln op NC soln fill retail) daily) CYSTARAN SOLN 5 PA; QL(2.15 ml daily); SP DURYSTA IMPL NC diclofenac sodium (ophth) QL(0.09 ml 2 latanoprost soln op 2 soln daily) QL(0.34 ml dorzolamide hcl soln 2 LUMIGAN SOLN 4 ST; QL(0.09 ml daily) daily) DORZOLAMIDE HCL QL(0.34 ml 5 TRAVATAN Z SOLN 5 ST; QL(0.09 ml SOLN daily) (travoprost) daily) ELESTAT SOLN ST; QL(0.09 ml 5 travoprost soln 2 (epinastine hcl (ophth)) daily) EMADINE SOLN 4 VYZULTA SOLN 5 PA epinastine hcl (ophth) soln 2 XALATAN SOLN 5 QL(0.09 ml (latanoprost) daily) QL(3 ml per fill flurbiprofen sodium soln 2 retail) XELPROS EMUL NC ILEVRO SUSP 4 ZIOPTAN SOLN 5 ST; QL(1 ea daily) PA; SP JETREA SOLN 5 OTIC AGENTS - Drugs to Treat the Ear ketorolac tromethamine 2 Otic Agents - Miscellaneous (ophth) soln QL(15 ml per acetic acid (otic) soln 2 LASTACAFT SOLN 4 fill retail) Otic Anti-infectives NEVANAC SUSP 4 CETRAXAL SOLN QL(0.34 ml 5 olopatadine hcl soln 0.1 % 2 (ciprofloxacin hcl (otic)) daily); RX/OTC

284 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciprofloxacin hcl (otic) soln 2 oxytocin soln ij 2

FLOXIN OTIC SOLN NC OXYTOCIN/DEXTROSE NC (ofloxacin (otic)) SOLN ofloxacin (otic) soln 2 OXYTOCIN/DEXTROSE/L ACTATED RINGERS NC OTIPRIO SUSP NC SOLN OXYTOCIN/LACTATED NC Otic Combinations RINGERS SOLN OXYTOCIN/SODIUM NC CIPRO HC SUSP 5 CHLORIDE SOLN CIPRODEX SUSP PITOCIN SOLN (oxytocin) 5 (ciprofloxacin- NC dexamethasone) PASSIVE IMMUNIZING AND TREATMENT ciprofloxacin- 2 AGENTS - Antibody Drugs to Treat Low Immune dexamethasone susp System ciprofloxacin-fluocinolone NC QL(0.5 ea Antitoxins-Antivenins acetonide soln daily) ANASCORP SOLR 5 COLY-MYCIN S SUSP 5 ANAVIP SOLR 5 CORTISPORIN-TC SUSP 5 ANTIVENIN neomycin-polymyxin-hc 2 QL(10 ml per LATRODECTUS 5 (otic) soln fill retail) MACTANS KIT neomycin-polymyxin-hc 2 ANTIVENIN NORTH (otic) susp AMERICANCORAL 5 OTOVEL SOLN QL(0.5 ea SNAKE SOLR (ciprofloxacin-fluocinolone NC daily) acetonide) CROFAB SOLR 5 PRAMOTIC LIQD 5 Immune Serums Otic Steroids ASCENIV SOLN NC DERMOTIC OIL PA; SP (fluocinolone acetonide 5 BIVIGAM SOLN 5 (otic)) CARIMUNE 5 PA; SP NANOFILTERED SOLR fluocinolone acetonide 2 (otic) oil CUTAQUIG SOLN NC hydrocortisone w/acetic 2 QL(10 ml per acid soln fill retail) CUVITRU SOLN 1 OXYTOCICS - Drugs to Prevent/Control Uterine GM/5ML, 2 GM/10ML, 8 NC Bleeding GM/40ML CUVITRU SOLN 10 NC PA; SP Oxytocics GM/50ML, 4 GM/20ML methylergonovine maleate 2 CUVITRU SOLN 4 NC PA soln GM/20ML methylergonovine maleate 2 PA; SP tabs CYTOGAM INJ 5

285 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLEBOGAMMA DIF SOLN 5 PA; SP NABI-HB SOLN 5 PA; SP

GAMASTAN INJ 5 PA; SP OCTAGAM SOLN 5 PA; SP

GAMMAGARD LIQUID 5 PA; SP PANZYGA SOLN NC SOLN GAMMAGARD S/D IGA PA; SP PRIVIGEN SOLN 5 PA; SP LESS THAN 1MCG/ML 5 SOLR RHOGAM ULTRA- 5 PA; SP FILTERED PLUS SOSY GAMMAKED SOLN 1 NC PA; SP GM/10ML RHOPHYLAC SOSY 5 PA; SP GAMMAKED SOLN 10 PA; SP GM/100ML, 20 GM/200ML, 5 VARIZIG SOLN 5 5 GM/50ML PA; SP GAMMAPLEX SOLN 5 PA; SP WINRHO SDF SOLN 5

GAMUNEX-C SOLN 5 PA; SP XEMBIFY SOLN NC Monoclonal Antibodies HEPAGAM B SOLN 5 PA; SP SYNAGIS SOLN 5 PA; SP HIZENTRA SOLN 1 NC GM/5ML, 2 GM/10ML ZINPLAVA SOLN NC SP HIZENTRA SOLN 10 5 PA; SP GM/50ML, 4 GM/20ML Passive Immunizing Agents - Combinations HIZENTRA SOSY 1 HYQVIA KIT 5 PA; SP GM/5ML, 2 GM/10ML, 4 NC GM/20ML PENICILLINS - Drugs to Treat Bacterial Infections HYPERHEP B S/D SOLN 5 PA; SP Aminopenicillins HYPERRAB S/D SOLN 5 amoxicillin caps 2 HYPERRAB SOLN 1500 5 UNIT/5ML, 300 UNIT/ML amoxicillin chew 2 HYPERRAB SOLN 900 NC UNIT/3ML amoxicillin susr 2 HYPERRHO S/D MINI- 5 PA; SP amoxicillin tabs 2 DOSE SOSY PA; SP AMOXICILLIN 5 HYPERRHO S/D SOSY 5 TRIHYDRATE POWD HYPERTET S/D INJ 5 ampicillin caps 2

IMOGAM RABIES-HT 5 ampicillin sodium solr 2 SOLN QL(1 ea KEDRAB SOLN 5 MOXATAG TB24 5 daily,10 ea per fill retail) MICRHOGAM ULTRA- 5 PA; SP FILTEREDPLUS SOSY Natural Penicillins

286 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BICILLIN L-A SUSP 5 AUGMENTIN TABS 125 QL(20 ea per MG-875 MG, 125 MG-500 5 fill retail) PENICILLIN G MG (amoxicillin & pot clavulanate) POTASSIUM IN ISO- 5 OSMOTIC DEXTROSE AUGMENTIN XR TB12 QL(13.34 ea SOLN (amoxicillin & pot 5 daily) penicillin g potassium solr 2 clavulanate) BICILLIN C-R SUSP 5 PENICILLIN G PROCAINE 5 SUSP piperacillin sodium- 2 penicillin g sodium solr 2 tazobactam sodium solr UNASYN BULK PACK penicillin v potassium solr 2 SOLR (ampicillin & 5 sulbactam sodium) penicillin v potassium tabs 2 UNASYN SOLR (ampicillin 5 & sulbactam sodium) Penicillin Combinations ZOSYN SOLN 0.25 amoxicillin & pot QL(20 ea per GM/50ML-2 GM/50ML-5 %, clavulanate chew 200 mg- 2 fill retail) 0.375 GM/50ML-3 5 28.5 mg, 400 mg-57 mg GM/50ML-5 %, 0.5 amoxicillin & pot GM/100ML-4 GM/100ML-5 clavulanate susr 400 % ZOSYN SOLR 0.25 GM-2 mg/5ml-57 mg/5ml, 200 2 mg/5ml-28.5 mg/5ml, 250 GM, 0.375 GM-3 GM, 0.5 mg/5ml-62.5 mg/5ml, 42.9 GM-4 GM, 36 GM-4.5 GM 5 mg/5ml-600 mg/5ml (piperacillin sodium- amoxicillin & pot QL(30 ea per tazobactam sodium) clavulanate tabs 125 mg- 2 fill retail) Penicillinase-Resistant Penicillins 250 mg amoxicillin & pot QL(20 ea per dicloxacillin sodium caps 2 clavulanate tabs 125 mg- 2 fill retail) nafcillin sodium solr ij 1 gm, 2 875 mg, 125 mg-500 mg 2 gm amoxicillin & pot QL(13.34 ea NAFCILLIN SODIUM NC clavulanate tb12 1000 mg- 2 daily) SOLR IJ 10 GM 62.5 mg nafcillin sodium solr iv 1 2 ampicillin & sulbactam 2 gm, 10 gm, 2 gm sodium solr NAFCILLIN SOLN 5 AMPICILLIN-SULBACTAM 2 SOLR OXACILLIN SODIUM AUGMENTIN ES-600 SOLN IV 1 GM/50ML-1.5 5 SUSR (amoxicillin & pot 5 GM/50ML, 2 GM/50ML-300 clavulanate) MG/50ML AUGMENTIN SUSR 125 5 oxacillin sodium solr ij 1 2 MG/5ML-31.25 MG/5ML gm, 2 gm AUGMENTIN SUSR 250 oxacillin sodium solr iv 10 2 MG/5ML-62.5 MG/5ML 5 gm (amoxicillin & pot clavulanate) PHARMACEUTICAL ADJUVANTS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

287 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Alkalizing Agents FDC GREEN #3 POWD 5 RX/OTC TROLAMINE LIQD 5 RX/OTC FDC RED #3 POWD 5 RX/OTC Antimicrobial Agents FDC RED 40 POWD 5 RX/OTC BENZYL ALCOHOL LIQD 5 RX/OTC FDC YELLOW 5 5 RX/OTC CHLOROBUTANOL 5 ALUMINUM LAKE POWD ANHYDROUS POWD FDC YELLOW 6 POWD 5 RX/OTC CHLOROBUTANOL CRYS 5 FOOD COLOR BLACK 5 RX/OTC CHLOROBUTANOL 5 POWD POWD FOOD COLOR BLUE LIQD 5 METHYLPARABEN POWD 5 RX/OTC OR FOOD COLOR BLUE 5 RX/OTC METHYLPARABEN 5 POWD XX SODIUM POWD FOOD COLOR BROWN 5 RX/OTC POTASSIUM SORBATE 5 POWD GRAN FOOD COLOR GREEN 5 POTASSIUM SORBATE 5 LIQD POWD FOOD COLOR GREEN 5 RX/OTC PROPYLPARABEN POWD 5 RX/OTC POWD FOOD COLOR LIME 5 RX/OTC PROPYLPARABEN 5 GREEN POWD SODIUM POWD FOOD COLOR ORANGE 5 RX/OTC SORBIC ACID POWD 5 RX/OTC POWD Coloring Agents FOOD COLOR PINK LIQD 5 AMARANTH POWD 5 FOOD COLOR RED LIQD 5 BRILLIANT BLUE G 5 FOOD COLOR RED 5 RX/OTC POWD POWD EVANS BLUE POWD 5 FOOD COLOR VIOLET 5 POWD FD&C BLUE #2 POWD 5 RX/OTC FOOD COLOR WHITE 5 LIQD FD&C RED #40 POWD 5 RX/OTC FOOD COLOR YELLOW 5 LIQD FD&C YELLOW #5 POWD 5 RX/OTC FOOD COLOR YELLOW 5 RX/OTC POWD FD&C YELLOW #6 5 RX/OTC ALUMINUM LAKE POWD LISSAMINE GREEN B 5 POWD FDC BLUE 1 ALUMINUM 5 RX/OTC LAKE POWD QUINIZARIN GREEN SS 5 POWD FDC BLUE 1 POWD 5 RX/OTC SULPHAN BLUE POWD 5 FDC BLUE 2 POWD 5 RX/OTC

288 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRYPAN BLUE POWD 5 BEEF TYPE FLAVOR OS 5 RX/OTC LIQD Delivery Devices BEEF-ADE POWD 5 RX/OTC EXYDERM PTCH 5 BITTER STOP FLAVOR 5 RX/OTC LIQD Flavoring Agents BITTERNESS MASK 5 RX/OTC ALFALFA FLAVOR POWD 5 RX/OTC FLAVOR LIQD BITTERNESS REDUCING RX/OTC ALMOND OIL BITTER 5 RX/OTC 5 FLAVOR LIQD AGENT POWD RX/OTC BITTERNESS RX/OTC ANISE EXTRACT LIQD 5 SUPPRESSOR FLAVOR 5 RX/OTC LIQD ANISE FLAVOR OIL 5 BITTERNESS RX/OTC RX/OTC SUPRESSOR FLAVOR 5 APPLE FLAVOR LIQD 5 LIQD APPLE FLAVOR POWD 5 RX/OTC BLACKBERRY FLAVOR 5 RX/OTC LIQD APPLE FLAVOR WATER RX/OTC 5 BLUEBERRY FLAVOR 5 RX/OTC MISCIBLE POWD LIQD RX/OTC APRICOT FLAVOR LIQD 5 BUBBLE GUM 5 RX/OTC CONCENTRATE LIQD RX/OTC APRICOT FLAVOR POWD 5 BUBBLE GUM FLAVOR 5 RX/OTC LIQD BACON FLAVOR LIQD 5 RX/OTC BUBBLEGUM FLAVOR 5 RX/OTC LIQD BACON FLAVOR 5 RX/OTC NATURAL LIQD BUTTER FLAVOR LIQD 5 RX/OTC BANANA CONCENTRATE 5 RX/OTC LIQD BUTTER RUM FLAVOR 5 RX/OTC LIQD BANANA CREAM FLAVOR 5 RX/OTC LIQD BUTTERSCOTCH 5 RX/OTC FLAVOR LIQD BANANA CREME FLAVOR 5 RX/OTC LIQD CARAMEL FLAVOR LIQD 5 RX/OTC RX/OTC BANANA FLAVOR LIQD 5 CHEESE-ADE FLAVOR 5 RX/OTC POWD BEEF BRAISED NATURAL 5 RX/OTC FLAVOR LIQD CHEESECAKE FLAVOR 5 RX/OTC LIQD BEEF FLAVOR LIQD 5 RX/OTC CHERRY FLAVOR LIQD 5 RX/OTC BEEF FLAVOR POWD 5 RX/OTC CHERRY-ADE FLAVOR 5 RX/OTC POWD BEEF TYPE FLAVOR 5 RX/OTC NATURAL LIQD CHICKEN (GRILLED) 5 RX/OTC FLAVOR LIQD BEEF TYPE FLAVOR RX/OTC NATURALCHLORIDE 5 CHICKEN BROTH RX/OTC FREE LIQD FLAVOR SPRAY DRIED 5 POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

289 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHICKEN FLAVOR LIQD 5 RX/OTC FLAVOR RX/OTC CONCENTRATE/CHLORH 5 EXIDINE CONC CHICKEN FLAVOR OIL 5 RX/OTC SOLUBLE LIQD FLAVORX LIQD 5 RX/OTC CHICKEN FLAVOR POWD 5 RX/OTC GRAPE FLAVOR LIQD 5 RX/OTC CHICKEN FLAVOR 5 RX/OTC WATER MISCIBLE LIQD GRAPEFRUIT FLAVOR 5 RX/OTC PINK OIL CHICKEN ROASTED 5 RX/OTC CONCENTRATE LIQD GRILLED BEEF FLAVOR RX/OTC NATURAL OIL SOLUBLE 5 CHOCOLATE 5 RX/OTC CONCENTRATE CONC LIQD GRILLED CHICKEN RX/OTC CHOCOLATE FLAVOR 5 RX/OTC LIQD FLAVOR NATURAL OIL 5 MISCIBLE LIQD CHOCOLATE FLAVOR 5 RX/OTC POWD GUAVA FLAVOR LIQD 5 RX/OTC CHOCOLATE HAZELNUT 5 RX/OTC FLAVOR LIQD HAM FLAVOR LIQD 5 RX/OTC CHOCOLATE NATURAL & RX/OTC RX/OTC ARTIFICAL FLAVOR 5 HONEY FLAVOR LIQD 5 CONC KAHLUA FLAVOR LIQD 5 RX/OTC CINNAMON FLAVOR OIL 5 RX/OTC LEMON EXTRACT LIQD 5 RX/OTC COCONUT FLAVOR LIQD 5 RX/OTC LEMON FLAVOR LIQD 5 RX/OTC COFFEE FLAVOR LIQD 5 RX/OTC LEMON FLAVOR OIL 5 RX/OTC COLA FLAVOR LIQD 5 RX/OTC LEMONADE FLAVOR OIL 5 RX/OTC COTTON CANDY FLAVOR 5 RX/OTC LIQD LICORICE FLAVOR LIQD 5 RX/OTC CRAN-RASPBERRY 5 RX/OTC FLAVOR LIQD LIME FLAVOR OIL 5 RX/OTC CREME DE MENTHE 5 RX/OTC FLAVOR LIQD LIVER CONCENTRATE 5 RX/OTC LIQD CREME DE MENTHE 5 RX/OTC FLAVOR OIL LIVER FLAVOR LIQD 5 RX/OTC CREME DEMENTHE 5 RX/OTC FLAVOR LIQD LIVER FLAVOR POWD 5 RX/OTC ENGLISH TOFFEE 5 RX/OTC RX/OTC FLAVOR LIQD MANGO FLAVOR LIQD 5 EUCALYPTUS FLAVOR 5 RX/OTC RX/OTC OIL MANGO FLAVOR POWD 5 RX/OTC EUGENOL FLAVOR LIQD 5 MANGO FLAVOR 5 RX/OTC SWEETENED POWD RX/OTC FISH FLAVOR LIQD 5 MAPLE FLAVOR LIQD 5 RX/OTC

290 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MARSHMALLOW RX/OTC RASPBERRY FLAVOR 5 RX/OTC ARTIFICIAL FLAVOR 5 ARTIFICIAL CONC CONC RASPBERRY FLAVOR 5 RX/OTC MARSHMALLOW FLAVOR 5 RX/OTC LIQD LIQD RASPBERRY FLAVOR 5 RX/OTC MINT CHOCOLATE CHIP 5 RX/OTC POWD FLAVOR LIQD ROOT BEER FLAVOR 5 RX/OTC MOLASSES FLAVOR 5 RX/OTC LIQD POWD SARDINE FLAVOR LIQD 5 RX/OTC NATURAL CARAMEL 5 RX/OTC LIQD SHRIMP FLAVOR LIQD 5 RX/OTC ORANGE CONCENTRATE 5 RX/OTC LIQD SPEARMINT FLAVOR OIL 5 RX/OTC ORANGE CREAM 5 RX/OTC FLAVOR LIQD STEVIA GLYCERITE 5 RX/OTC LIQUID EXTRACT LIQD ORANGE FLAVOR LIQD 5 RX/OTC STRAWBERRY FLAVOR 5 RX/OTC LIQD ORANGE FLAVOR POWD 5 RX/OTC SUPER SYNERSWEET 5 RX/OTC FLAVOR POWD ORANGE OIL FLAVOR 5 RX/OTC LIQD SWEET CORN FLAVOR 5 RX/OTC CONCENTRATE CONC PASSION FRUIT FLAVOR 5 RX/OTC POWD SWEETENING 5 RX/OTC ENHANCER LIQD PASSION FRUIT FLAVOR 5 RX/OTC SWEETENED POWD SWEETENING RX/OTC ENHANCER/FLAVORX 5 PCCA SWEETNESS 5 RX/OTC ENHANCER LIQD LIQD RX/OTC PEACH FLAVOR LIQD 5 RX/OTC TANGERINE FLAVOR OIL 5 TANGERINE FLAVOR RX/OTC PEANUT BUTTER 5 RX/OTC 5 FLAVOR LIQD POWD TANGERINE FLAVOR RX/OTC PEANUT BUTTER 5 RX/OTC 5 FLAVOR OIL SWEETENED POWD RX/OTC PEPPERMINT FLAVOR 5 RX/OTC TEABERRY FLAVOR OIL 5 OIL TROPICAL PUNCH RX/OTC PINA COLADA FLAVOR 5 RX/OTC 5 LIQD FLAVOR LIQD RX/OTC PINEAPPLE FLAVOR 5 RX/OTC TUNA FLAVOR LIQD 5 LIQD TUNA FLAVOR POWD 5 RX/OTC PRALINES AND CREAM 5 RX/OTC FLAVOR LIQD RX/OTC TUNA TYPE FLAVOR OS 5 PUMPKIN FLAVOR LIQD 5 RX/OTC LIQD TUTTI FRUTTI 5 RX/OTC RASPBERRY 5 RX/OTC CONCENTRATE CONC CONCENTRATE CONC TUTTI FRUTTI FLAVOR 5 RX/OTC LIQD

291 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUTTI-FRUTTI FLAVOR RX/OTC 5 CAPSULE CONI-SNAP #1 5 RX/OTC LIQD BLUE/PINK CAPS VANILLA BUTTERNUT 5 RX/OTC CAPSULE CONI-SNAP #1 RX/OTC FLAVOR LIQD BLUE/POWDER BLUE 5 CAPS VANILLA FLAVOR LIQD 5 RX/OTC CAPSULE CONI-SNAP #1 5 RX/OTC VANILLIN FLAVOR POWD 5 RX/OTC BROWN/IVORY CAPS CAPSULE CONI-SNAP #1 RX/OTC VITAMIN/IRON MASKING 5 RX/OTC BROWN/LIGHT BROWN 5 AGENT FLAVOR LIQD CAPS WATERMELON FLAVOR RX/OTC 5 CAPSULE CONI-SNAP #1 5 RX/OTC LIQD CLEAR/CLEAR CAPS WILD CHERRY FLAVOR 5 RX/OTC CAPSULE CONI-SNAP #1 RX/OTC LIQD DARKGREEN/DARK 5 Gelatin Capsules (Empty) GREEN CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #0 5 RX/OTC CLEAR/CLEAR CAPS DARKGREEN/ORANGE 5 CAPS CAPSULE CONI-SNAP #0 RX/OTC DARK BLUE/DARK BLUE 5 CAPSULE CONI-SNAP #1 5 RX/OTC CAPS GREEN/YELLOW CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #0 5 RX/OTC GREEN/CLEAR CAPS LIGHT BLUE/WHITE 5 CAPS CAPSULE CONI-SNAP #0 RX/OTC LIGHT BLUE/WHITE 5 CAPSULE CONI-SNAP #1 5 RX/OTC CAPS LIGHT GREY/PINK CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #0 5 RX/OTC 5 PINK/PINK CAPS ORANGE CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #0 5 RX/OTC 5 RED/WHITE CAPS PINK/AQUA BLUE CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #0 5 RX/OTC 5 WHITE/WHITE CAPS PINK/CLEAR CAPS CAPSULE CONI-SNAP RX/OTC CAPSULE CONI-SNAP #1 5 RX/OTC #0/PURPLE/OPAQUE/CLE 5 PINK/PINK CAPS AR CAPS CAPSULE CONI-SNAP #1 5 RX/OTC PINK/WHITE CAPS CAPSULE CONI-SNAP 5 RX/OTC #00 CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #1 5 RX/OTC PINK/YELLOW CAPS CAPSULE CONI-SNAP 5 RX/OTC #00 WHITE/WHITE CAPS CAPSULE CONI-SNAP #1 5 RX/OTC CAPSULE CONI-SNAP RX/OTC PURPLE/PURPLE CAPS #000 CLEAR/CLEAR 5 CAPSULE CONI-SNAP #1 5 RX/OTC CAPS RED/BLUE CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #1 5 RX/OTC AQUABLUE/AQUA BLUE 5 RED/WHITE CAPS CAPS CAPSULE CONI-SNAP #1 5 RX/OTC WHITE CAPS CAPSULE CONI-SNAP #1 5 RX/OTC BLUE/BLUE CAPS

292 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #3 5 RX/OTC WHITE/CLEAR CAPS YELLOW/YELLOW CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC WHITE/GREEN CAPS BLACK/GREEN CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC YELLOW/GREEN CAPS CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC 5 CAPSULE CONI-SNAP #4 5 RX/OTC YELLOW/YELLOW CAPS WHITE CAPS CAPSULE CONI-SNAP #2 RX/OTC 5 CAPSULE EZEEFIT #0 5 RX/OTC CLEAR/CLEAR CAPS CLEAR CAPS CAPSULE CONI-SNAP #2 RX/OTC 5 CAPSULE EZEEFIT #00 5 RX/OTC WHITE CAPS CLEAR CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 CAPSULE SIZE 1 5 RX/OTC BLUE/CLEAR CAPS LACTOSE CAPS CAPSULE CONI-SNAP #3 RX/OTC DRCAPS SIZE 0 CLEAR 5 RX/OTC BROWN/LIGHT BLUE 5 CAPS CAPS DRCAPS SIZE 00 CLEAR 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC CAPS CLEAR/CLEAR CAPS DRCAPS SIZE 1 CLEAR 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC CAPS DARKGREY/PINK CAPS EMPTY CAPSULE #0 RED RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC TRANSLUCENT/WHITE 5 GRAY/YELLOW CAPS CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 EMPTY CAPSULE #00 5 RX/OTC GREEN/BLUE CAPS BLACK/RED CAPS CAPSULE CONI-SNAP #3 RX/OTC 5 EMPTY CAPSULE #00 5 RX/OTC MAROON/BLUE CAPS BLUE/WHITE CAPS CAPSULE CONI-SNAP #3 RX/OTC EMPTY CAPSULE #00 5 RX/OTC MINTGREEN/MINT 5 PINK/PINK CAPS GREEN CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC PURPLE//PURPLE CAPS OLIVE/CLEAR CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC PURPLE//WHITE CAPS ORANGE/ORANGE CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC RED/WHITE CAPS PINK/CLEAR CAPS EMPTY CAPSULE #00 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC YELLOW/YELLOW CAPS PINK/PINK CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC BLUE CAPS RED/CLEAR CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC CAPSULE CONI-SNAP #3 5 RX/OTC BLUE/WHITE CAPS RED/RED CAPS RX/OTC EMPTY CAPSULE SIZE 0 5 CAPSULE CONI-SNAP #3 5 RX/OTC CLEAR CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC CLEAR LOCKING CAPS CAPSULE CONI-SNAP #3 5 RX/OTC WHITE/WHITE CAPS

293 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC FUNCAPS LOCKING 5 YELLOW CAPS CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC YELLOW/OPAQUE 5 GREEN LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 00 RX/OTC GREEN/CLEAR CAPS BLUE/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 0 RX/OTC CAPS GREEN/CLEAR LOCKING 5 EMPTY CAPSULE SIZE 00 5 RX/OTC CAPS CLEAR CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 00 5 RX/OTC MAROON/OPAQUE 5 CLEAR LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 00 5 RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC DARK GREEN CAPS ORANGE CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC GREEN/OPAQUE 5 ORANGE/OPAQUE 5 LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC LIGGHT BLUE OPAQUE 5 PINK CAPS CAPS EMPTY CAPSULE SIZE 0 RX/OTC 5 EMPTY CAPSULE SIZE 00 5 RX/OTC PINK LOCKING CAPS ORANGE CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 00 RX/OTC PURPLE CAPS ORANGE/OPAQUE 5 EMPTY CAPSULE SIZE 0 RX/OTC LOCKING CAPS PURPLE/OPAQUE 5 EMPTY CAPSULE SIZE 00 5 RX/OTC LOCKING CAPS RED CAPS EMPTY CAPSULE SIZE 0 RX/OTC 5 EMPTY CAPSULE SIZE 00 5 RX/OTC PURPLE/WHITE CAPS WHITE CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC EMPTY CAPSULE SIZE 00 RX/OTC RED CAPS WHITE OPAQUE 5 LOCKING CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC RED/CLEAR CAPS EMPTY CAPSULE SIZE 5 RX/OTC 000 CLEAR CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC RED/WHITE CAPS EMPTY CAPSULE SIZE RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC 000 CLEAR LOCKING 5 RED/WHITE LOCKING 5 CAPS CAPS EMPTY CAPSULE SIZE RX/OTC 000 WHITE/OPAQUE 5 EMPTY CAPSULE SIZE 0 5 RX/OTC WHITE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 0 5 RX/OTC WHITE/CLEAR CAPS AQUABLUE 5 TRANSLUCENT CAPS EMPTY CAPSULE SIZE 0 5 RX/OTC WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE CAPS EMPTY CAPSULE SIZE 0 RX/OTC WHITE/OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS BLUE/CLEAR CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

294 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUE/OPAQUE LOCKING 5 GREEN/WHITE OPAQUE 5 CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/PINK CAPS GREEN/YELLOW CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/PINK LOCKING 5 GREY/PINK CAPS CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC IVORY CAPS BLUE/PINK 5 EMPTY CAPSULE SIZE 1 RX/OTC TRANSLUCENT CAPS LIGHT BLUE OPAQUE 5 EMPTY CAPSULE SIZE 1 RX/OTC CAPS BLUE/POWDER BLUE 5 EMPTY CAPSULE SIZE 1 RX/OTC CAPS MAROON TRANS/CLEAR 5 EMPTY CAPSULE SIZE 1 RX/OTC CAPS BLUE/RED OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS MINTGREEN CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE/WHITE CAPS ORANGE CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUETRANSLUCENT/PIN 5 ORANGE OPAQUE 5 K TRANSLUCENT CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 1 5 RX/OTC BROWN/IVORY CAPS ORANGE/CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC BROWN/IVORY OPAQUE 5 ORANGE/WHITE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC ORANGE/YELLOW CAPS CLEAR CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC PINK CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC PINK/CLEAR CAPS DARKGREEN CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC PINK/OPAQUE LOCKING 5 GREEN CAPS CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN CLEAR/YELLOW 5 PINK/POWDER BLUE 5 LOCKING CAPS CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN 5 PINK/WHITE CAPS TRANSLUCENT/YELLOW OPAQUE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC PINK/YELLOW CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN/ORANGE CAPS EMPTY CAPSULE SIZE 1 RX/OTC PINK/YELLOW OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS GREEN/WHITE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC POWDER BLUE CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

295 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC POWDER BLUE/OPAQUE 5 BLACK/GREEN CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC BLUE CAPS PURPLE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUE/CLEAR CAPS PURPLE/OPAQUE 5 EMPTY CAPSULE SIZE 3 5 RX/OTC LOCKING CAPS BLUE/WHITE CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC RED CAPS BLUEOPAQUE/CLEAR 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS RED/BLUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC CLEAR CAPS RED/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 3 5 RX/OTC CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC RED/WHITE CAPS DARKGREEN CAPS EMPTY CAPSULE SIZE 1 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC WHITE CAPS GRAY/PINK OPAQUE 5 EMPTY CAPSULE SIZE 1 RX/OTC LOCKING CAPS WHITE OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS GRAY/YELLOW OPAQUE 5 EMPTY CAPSULE SIZE 1 5 RX/OTC LOCKING CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN CAPS WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 1 5 RX/OTC GREEN/BLUE CAPS YELLOW CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 10 5 RX/OTC GREEN/BLUE LOCKING 5 CLEAR CAPS CAPS EMPTY CAPSULE SIZE 11 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC CLEAR CAPS GREEN/BLUE 5 TRANSLUCENT CAPS EMPTY CAPSULE SIZE 13 5 RX/OTC CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC GREY/PINK CAPS EMPTY CAPSULE SIZE 2 5 RX/OTC BLUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC GREY/YELLOW CAPS EMPTY CAPSULE SIZE 2 5 RX/OTC CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC LIGHT BLUE OPAQUE 5 EMPTY CAPSULE SIZE 2 5 RX/OTC CLEAR LOCKING CAPS CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 2 5 RX/OTC 5 GREEN CAPS MAROON/BLUE CAPS EMPTY CAPSULE SIZE 2 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC WHITE OPAQUE 5 MAROON/BLUE OPAQUE 5 LOCKING CAPS CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC MAROON/CLEAR CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

296 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 3 RX/OTC 5 EMPTY CAPSULE SIZE 3 5 RX/OTC MINT GREEN CAPS RED/WHITE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC OLIVE/CLEAR CAPS REDOPAQUE/CLEAR 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS OLIVE/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 3 5 RX/OTC CAPS WHITE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC ORANGE CAPS WHITE OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS ORANGE/OPAQUE 5 EMPTY CAPSULE SIZE 3 RX/OTC LOCKING CAPS WHITE OPAQUE/CLEAR 5 LOCKING CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC ORANGE/WHITE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC PINK CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC YELLOW CAPS PINK/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 3 RX/OTC CAPS YELLOW 5 EMPTY CAPSULE SIZE 3 RX/OTC OPAQUE/CLEAR PINK/POWDER BLUE 5 LOCKING CAPS CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC YELLOW/CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/WHITE CAPS EMPTY CAPSULE SIZE 3 RX/OTC YELLOW/OPAQUE 5 EMPTY CAPSULE SIZE 3 5 RX/OTC PINK/YELLOW CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 4 RX/OTC PINKOPAQUE/CLEAR 5 BLACK/GREEN OPAQUE 5 CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 4 5 RX/OTC PINKOPAQUE/CLEAR 5 BLUE/WHITE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 4 5 RX/OTC CLEAR CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC POWDER BLUE CAPS EMPTY CAPSULE SIZE 4 5 RX/OTC CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 3 5 RX/OTC PURPLE CAPS EMPTY CAPSULE SIZE 4 RX/OTC DARK BLUE/OPAQUE 5 EMPTY CAPSULE SIZE 3 5 RX/OTC PURPLE/CLEAR CAPS LOCKING CAPS EMPTY CAPSULE SIZE 4 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC 5 RED CAPS PURPLE CAPS EMPTY CAPSULE SIZE 4 RX/OTC EMPTY CAPSULE SIZE 3 5 RX/OTC RED/CLEAR CAPS PURPLE/OPAQUE 5 LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC RED/OPAQUE LOCKING 5 EMPTY CAPSULE SIZE 4 5 RX/OTC CAPS RED/WHITE CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

297 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 4 5 RX/OTC CHERRY CONCENTRATE 5 RX/OTC WHITE CAPS SYRP EMPTY CAPSULE SIZE 4 RX/OTC CHERRY SYRUP SYRP 5 RX/OTC WHITE/OPAQUE 5 LOCKING CAPS COLLODION FLEXIBLE 5 RX/OTC LIQD EMPTY CAPSULE SIZE 4 5 RX/OTC YELLOW CAPS COLLODION LIQD 5 RX/OTC EMPTY CAPSULE SIZE 5 5 RX/OTC CLEAR CAPS CORN SYRUP SYRP 5 EMPTY CAPSULE SIZE 7 5 RX/OTC CLEAR CAPS CUSTOM POLYGLYCOL 5 RX/OTC TROCHEBASE FLAK EMPTY GELATIN RX/OTC CAPSULE/SNAP 5 CUSTOM POLYGLYCOL 5 RX/OTC CLOSURE #0 CAPS TROCHEBASE WAX EMPTY GELATIN RX/OTC CVS DISTILLED WATER 5 RX/OTC CAPSULE/SNAP 5 LIQD CLOSURE #00 CAPS CVS PURIFIED WATER 5 RX/OTC EMPTY GELATIN RX/OTC LIQD CAPSULE/SNAP 5 DERMACINRX TOPICAL 5 RX/OTC CLOSURE #000 CAPS SOLUTION BASE SOLN EMPTY GELATIN RX/OTC DERMACINRX TSS BASE 5 RX/OTC CAPSULE/SNAP 5 SOLN CLOSURE #1 CAPS DISTILLATA DISTILLED 5 RX/OTC EMPTY GELATIN RX/OTC WATER LIQD CAPSULE/SNAP 5 RX/OTC CLOSURE #2 CAPS DISTILLED WATER LIQD 5 EMPTY GELATIN RX/OTC ETHYL ALCOHOL 200 5 RX/OTC CAPSULE/SNAP 5 PROOF SOLN CLOSURE #3 CAPS ETHYL ALCOHOL SOLN 5 RX/OTC EMPTY GELATIN RX/OTC CAPSULE/SNAP 5 FIXED OIL SUSPENSION 5 CLOSURE #4 CAPS LIQD Liquid Vehicles FLAVOR BLEND SUSP 5 RX/OTC ADA SHAMPOO SHAM 5 FLAVOR PLUS LIQD 5 RX/OTC ALCOHOL DEHYDRATED 5 RX/OTC SOLN FLAVOR SWEET SYRP 5 RX/OTC bacteriostatic sodium 2 chloride soln FLAVOR SWEET-SF 5 RX/OTC SYRP BACTERIOSTATIC WATER PARABENS 5 FOAMIL LIQD 5 SOLN FREEDOM PEG TROCHE 5 BASE GELATIN GUMMY 5 BASE POWD TROCHE GEL glycine diluent soln 2 PA; SP BLENDED SUSPENDING 5 RX/OTC COMPOUND SUSP GRAPE SYRUP SYRP 5 RX/OTC

298 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUM BASE GELATIN GEL 5 ORAL SYRUP FLAVORED 5 RX/OTC VEHICLE SYRP INFANT DRINKING 5 RX/OTC RX/OTC WATER LIQD ORAL SYRUP SF SYRP 5 LOZIBASE MISC 5 RX/OTC PCCA ACACIA SYRUP 5 BASE SYRP LOZIBASE S MISC 5 RX/OTC PCCA CUSTOM RX/OTC NATATROCHE HMP 5 MOUTH WASH-GP LIQD 5 BASE WAX PCCA CUSTOM TROCHE 5 RX/OTC MOUTHWASH-AF LIQD 5 BASE WAX PCCA FIXED OIL BASE 5 MOUTHWASH-OM LIQD 5 LIQD RX/OTC PCCA NATATROCHE 5 RX/OTC MX-SOL BLEND SF SUSP 5 BASE WAX RX/OTC PCCA POLYGLYCOL 5 MX-SOL BLEND SUSP 5 TROCHE POWD RX/OTC MX-SOL SF SYRP 5 PCCA PRACAMAC BASE 5 OIL RX/OTC MX-SOL SUSPEND SUSP 5 PCCA SWEET-SF SYRP 5 RX/OTC RX/OTC MX-SOL SYRP 5 PCCA SYRUP VEHICLE 5 RX/OTC SYRP NICE DISTILLED WATER 5 RX/OTC RX/OTC LIQD PCCA-PLUS SUSP 5 ORA-BLEND SF SUSP 5 RX/OTC PH 12 STERILE DILUENT PA; SP FORFLOLAN SOLN 5 ORA-BLEND SUSP 5 RX/OTC (glycine diluent) PROPYLENE GLYCOL 5 ORA-PLUS LIQD 5 RX/OTC SOLN EX RX/OTC ORA-SWEET SF SYRP 5 RX/OTC PURIFIED WATER LIQD 5 RX/OTC PX PURIFIED WATER 5 RX/OTC ORA-SWEET SYRP 5 LIQD RA CRYSTAL LAKE RX/OTC ORAL MIX DRY ALKA 5 RX/OTC 5 SF/CHERRY SUSR DISTILLEDWATER LIQD RASPBERRY SYRUP RX/OTC ORAL MIX DRY ALKA 5 RX/OTC 5 SF/UNFLAVORED SUSR SYRP ORAL MIX FLAVORED RX/OTC REGENT ALCOHOL SOLN 5 RX/OTC SUSPENDING VEHICLE 5 SUSP RHEOSPRAY LIQD 5 ORAL MIX SF SUSP 5 RX/OTC SALINE/PHENOL SOLN 5 ORAL SUSPEND LIQD 5 RX/OTC SERAQUA LIQD 5 ORAL SUSPENDING 5 RX/OTC COMPOUNDPLUS SUSP 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

299 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIMPLE SYRUP SYRP 5 RX/OTC TDM SOLUTION SOLN 5 RX/OTC

SOLVATECH PLUS SUSP 5 RX/OTC TECHNA 20 SF TROCHE RX/OTC BASEWITH BITTER-BLOC 5 FLAK SOLVATECH SWEET SF 5 RX/OTC SYRP TROCHE BASE NS POWD 5 SOLYDRA LIQD 5 TROCHE BASE POWD 5 SORBITOL SOLN XX 70 5 RX/OTC %, TROCHIBASE FLAK 5 RX/OTC SOSWEET SYRP 5 RX/OTC TROCHIBASE S CLASSIC 5 RX/OTC STERILE DILUENT FOR PA; SP FLAK FLOLAN SOLN (glycine 5 U-MILD SHAMPOO SHAM 5 diluent) STERILE DILUENT FOR PA; SP UNISPEND ANHYDROUS 5 RX/OTC TREPROSTINIL 5 SWEETENED SUSP INJECTION SOLN UNISPEND ANHYDROUS 5 RX/OTC SUSPENDRX WITH RX/OTC UNSWEETENED SUSP BITTER- 5 VERSAFREE SYRP 5 RX/OTC BLOC/SWEETENED SUSP VERSAPLUS SYRP 5 RX/OTC SUSPENDRX WITH RX/OTC VERSAPRO SHAMPOO BITTER- 5 5 BLOC/UNSWEETENED SHAM SUSP water for inject, bacteriostatic benzyl 2 SUSPENSION VEHICLE 5 RX/OTC SUSP alcohol soln SWEETENING RX/OTC water for injection, sterile 2 SUSPENDING 5 soln COMPOUND SYRP Non Gelatin Capsules (Empty) SYRPALTA SYRP 5 RX/OTC AR CAPS #1 CLEAR/ACID 5 RX/OTC RESISTANT CAPS SYRSPEND SF ALKA 5 RX/OTC SUSR CAPS 0 CLEAR DELAYED 5 RX/OTC RELEASE CAPS SYRSPEND SF LIQD 5 RX/OTC CAPSULE 0 CLEAR 5 RX/OTC VEGGIE CAPS SYRSPEND SF PH4 5 RX/OTC SUSR CAPSULE 0 CLEAR 5 RX/OTC VEGGIE LOCKING CAPS SYRSPEND SF SUSR 5 RX/OTC CAPSULE 00 CLEAR 5 RX/OTC VEGGIE LOCKING CAPS SYRUP NF SYRP 5 RX/OTC CAPSULE 1 CLEAR 5 RX/OTC VEGGIE CAPS SYRUP VEHICLE SF 5 RX/OTC SYRP CAPSULE 1 CLEAR 5 RX/OTC SYRUP VEHICLE SYRP 5 RX/OTC VEGGIE LOCKING CAPS CAPSULE 3 CLEAR 5 RX/OTC VEGGIE CAPS 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

300 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE 3 CLEAR 5 RX/OTC PH 4 BUFFER SOLN 5 VEGGIE LOCKING CAPS CAPSULE CONI-SNAP #0 RX/OTC PH 7 BUFFER SOLN 5 CLEAR/CLEAR VEGGIE 5 CAPS Pharmaceutical Excipients CAPSULE CONI-SNAP #1 RX/OTC RX/OTC CLEAR/CLEAR VEGGIE 5 ACACIA POWD 5 CAPS ACACIA SPRAY-DRIED 5 RX/OTC CAPSULE CONI-SNAP #3 RX/OTC POWD CLEAR/CLEAR VEGGIE 5 ASTRAGALUS ROOT 5 RX/OTC CAPS POWD EMPTY CAPSULE SIZE 1 RX/OTC VEGETABLE CLEAR 5 BACOCALMINE LIQD 5 CAPS BASE X FLAK 5 EMPTY VEGETABLE RX/OTC CAPSULE/SNAP 5 BEES WAX WAX 5 RX/OTC CLOSURE #0 CAPS EMPTY VEGETABLE RX/OTC BEESWAX WAX 5 RX/OTC CAPSULE/SNAP 5 CLOSURE #00 CAPS BENTONITE POWD 5 RX/OTC EMPTY VEGETABLE RX/OTC CAPSULE/SNAP 5 BITTER DRUG POWDER 5 RX/OTC CLOSURE #1 CAPS POWD RX/OTC VEGETABLE CAPSULE #0 5 RX/OTC BUFFER CREAM POWD 5 GREEN CAPS C10-C30 ALKYL RX/OTC VEGETABLE CAPSULE #0 5 RX/OTC WHITE CAPS ACRYLATE 5 CROSSPOLYMER POWD VEGETABLE CAPSULE 5 RX/OTC #00 WHITE CAPS CAPSUBLEND-H POWD 5 VEGETABLE CAPSULE #1 5 RX/OTC WHITE CAPS CAPSUBLEND-P POWD 5 VEGETABLE CAPSULE #2 5 RX/OTC WHITE CAPS CAPSUBLEND-S POWD 5 VEGETABLE CAPSULE #3 5 RX/OTC CARRAGEENAN POWD 5 WHITE CAPS RX/OTC VEGETABLE CAPSULE #4 5 RX/OTC CETYL ALCOHOL FLAK 5 WHITE CAPS Pharmaceutical Adjuvants Miscellanous CETYL ALCOHOL POWD 5 METER BUFFER PH 10 5 COCOA BUTTER 5 RX/OTC SOLN DEODORIZED MISC METER BUFFER PH 4 5 RX/OTC SOLN COCOA BUTTER MISC 5 METER BUFFER PH 7 5 COLLASIL OSA POWD 5 RX/OTC SOLN PH 10 BUFFER SOLN 5 EFFERVESCENT POWD 5

301 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMULGADE CM LIQD 5 LIPMAX SOLN 5

EMULSIFYING WAX WAX 5 LIQUIGEL COMPLEX 5 LIQD EMULSION 5 RX/OTC CONCENTRATE LIQD LOLLIBASE POWD 5 ETHYL ACETATE SOLN 5 LOLLIPOP BASE POWD 5 RX/OTC

F-MELT POWD 5 RX/OTC LOXORAL BASE POWD 5

FAGRON CAPFILL PRO 5 MAGNESIUM STEARATE 5 RX/OTC POWD POWD FAGRON DISPERSAPRO 5 MEDI-RDT BASE POWD 5 RX/OTC POWD RX/OTC MEDI-RDT KIT 5 FATTYBLEND MISC 5 (MULTIDOSE) KIT FIZZMIX BASE POWD 5 MEDI-RDT KIT KIT 5

FREEDOM LOLLIPOP 5 METHYLCELLULOSE GEL 5 BASE MISC METHYLCELLULOSE RX/OTC FREEDOM ODT BASE 5 RX/OTC 5 POWD POWD FREEDOM SIMPLECAP 5 MUCOLOX LIQD 5 POWDER POWD NATURAL BITTERNESS 5 RX/OTC GELATIN POWD 5 POWD RX/OTC GELATIN TYPE A POWD 5 NEXTOL SF MISC 5

GUM ARABIC MILLED 5 RX/OTC OLEIC ACID LIQD 5 POWD RX/OTC GUM ARABIC SPRAY- 5 RX/OTC PARAFFIN WAX 5 DRIED POWD PCCA CUSTOM RDT 5 RX/OTC KARAYA GUM GUM 5 RX/OTC POWDER POWD PCCA EMULSIFIX-205 LACTOSE ANHYDROUS 5 RX/OTC 5 POWD BASE LIQD PCCA LECITHIN LACTOSE HYDROUS 5 RX/OTC POWD ISOPROPYL PALMITATE 5 SOLN LACTOSE 5 RX/OTC MONOHYDRATE POWD PCCA LOXASPERSE 5 BASE POWD LACTOSE RX/OTC MONOHYDRATE 5 PCCA RAPID DISSOLVE RX/OTC SPRAYDRIED POWD TABLET POWDER BASE 5 POWD LACTOSE POWD 5 RX/OTC PCCA SORBITOL 5 LOLLIPOP BASE FLAK LECITHIN ISOPROPYL 5 PALMITATE SOLN PCCA XYLIFOS BASE 5 POWD 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

302 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLURONIC F127 POWD 5 RX/OTC STEARYL ALCOHOL 5 POWD RX/OTC PLURONIC GEL 5 SUPPOSI-PLEX R36 PLLT 5 RX/OTC

PLURONIC L64 LIQD 5 SUPPOSI-PLEX V33 PLLT 5 RX/OTC RX/OTC POLOX GEL 5 SUPPOSI-PURE MISC 5 RX/OTC RX/OTC POLOXAMER 188 POWD 5 SUPPOSIBLEND PLLT 5 RX/OTC RX/OTC POLOXAMER 407 POWD 5 SUPPOSITORY BLEND 5 RX/OTC PLLT POLYMATRIX POWDER 5 RX/OTC RX/OTC POWD SYNAPSIN POWD 5 POLYPEG SUPPOSITORY 5 RX/OTC RX/OTC BASE MISC TRAGACANTH POWD 5 RDT BASE POWD 5 RX/OTC UCARE POLYMER JR-400 5 RX/OTC POWD RX/OTC RDT-PLUS POWD 5 WAX PARAFFIN BEADS 5 RX/OTC WAX SEPINEO P 600 LIQD 5 WHITE BEES WAX WAX 5 RX/OTC RX/OTC SHEA BUTTER MISC 5 WHITE WAX PASTILLES 5 RX/OTC WAX SHEA BUTTER ORGANIC 5 RX/OTC MISC WHITE WAX WAX 5 RX/OTC SODIUM BENZOATE RX/OTC 5 WITEPSOL H15 BASE F 5 RX/OTC POWD PLLT SODIUM LAURYL 5 RX/OTC SULFATE POWD WITEPSOL H15 PLLT 5 SODIUM THIOSULFATE 5 RX/OTC PENTAHYDRATE CRYS WITEPSOL PLLT 5 SODIUM THIOSULFATE 5 WITEPSOL WAX 5 POWD XX RX/OTC SORBITOL CANDY BASE 5 XANTHAN GUM POWD 5 CRYS RX/OTC SORBITOL HARD CANDY 5 RX/OTC YELLOW WAX WAX 5 BASE-GRAPE MISC Placebos SPG SUPPOSI-BASE 5 RX/OTC PLLT PLACEBO #00 CAPS 5 STEARIC ACID FLAK 5 Semi Solid Vehicles RX/OTC STEARIC ACID POWD 5 1ST BASE CREA 5 RX/OTC STEARIC ACID TRIPLE RX/OTC 5 ADVANCED BASE PLUS 5 RX/OTC PRESSED POWD CREA STEARYL ALCOHOL 5 RX/OTC RX/OTC FLAK ALBA-DERM CREA 5 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

303 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALCOHOL BASE GEL GEL 5 BHRT BASE CREA 5 RX/OTC

ALPAWASH OINT 5 RX/OTC BRAVURA ALL-IN-ONE 5 RX/OTC CREA ALTADERM CREAM BASE 5 RX/OTC RX/OTC CREA CARBOGEL 940 GEL 5 ANHYDROUS BASE 5 CARBOHOL 940 GEL 5 RX/OTC CREA CARBOMER GEL 5 RX/OTC ANHYDROUS BASE OINT 5 AQUEOUS GEL ANHYDROUS CREAM 5 CARBOMER GEL 5 RX/OTC BASE CREA HYDROALCOHOLIC GEL ANHYDROUS GEL BASE 5 RX/OTC CELA BASE CREA 5 RX/OTC GEL APOTHEDERM CREA 5 RX/OTC CHEMSIL K-12 PSTE 5 RX/OTC APOTHESAR 2 CREA 5 RX/OTC CHEMSIL K-51 GEL 5

APOTHESAR CREA 5 RX/OTC CHEW-HESIVE OINT 5 RX/OTC CHRYSADERM DAY 5 RX/OTC APOTHESAR PLUS CREA 5 CREA APOTHESIL CREA 5 RX/OTC CHRYSADERM NIGHT 5 RX/OTC CREA ARBEM H-COSMETIC 5 RX/OTC RX/OTC CREA CLEODERM CREA 5 ARBEM LIPOPEN CREA 5 RX/OTC CLOVAGEL GEL 5 RX/OTC

ATREVIS HYDROGEL 5 RX/OTC CREAM BASE CREA 5 RX/OTC CREA CREAM BASE NIOSOMES AUXIPRO VANISHING 5 RX/OTC 5 CREAM CREA CREA RX/OTC CREAM CONCENTRATE 5 RX/OTC AZ CREAM CREA 5 CREA BASE A POLYETHYLENE 5 CREAM-HEAVY BASE 5 GLYCOL 1450 POWD NIOSOME CREA BASE C POLYETHYLENE 5 RX/OTC CUSTOM LIPOTHENE 110 5 RX/OTC GLYCOL 300 LIQD GEL BASE C POLYETHYLENE 5 RX/OTC CUSTOM LIPOTHENE 133 5 RX/OTC GLYCOL E 300 LIQD GEL BASE CREAM WITH 5 RX/OTC CUTIS PLUS CREA 5 RX/OTC LIPOSOME CREA DELBASE RX/OTC BASE D POLYETHYLENE 5 5 GLYCOL 4500 POWD COMPOUNDING OINT RX/OTC BASE PCCA CLARIFYING 5 RX/OTC DELIVRA SR CREA 5 CREA RX/OTC DERMASHIELD 5 RX/OTC BASE W301 CREA 5 HYDROGEL GEL 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

304 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIMETHIPAC GEL 5 RX/OTC HORMONE CREAM BASE 5 RX/OTC CREA DURABASE ADVANCED RX/OTC 5 HORMONE CREAM BASE 5 CREA NIOSOMES CREA DURABASE CREA 5 RX/OTC HORMONE CREAM- HEAVY BASENIOSOMES 5 EMOLIVAN CREA 5 RX/OTC CREA HRT BASE CREA 5 RX/OTC EMOLLIENT CREAM 5 RX/OTC BASE CREA HRT BASE FOR MEN GEL 5 EMOLLIENT CREAM 5 RX/OTC CREA HRT BOTANICAL BASE 5 RX/OTC ESPUMIL FOAM 5 CREA HRT BOTANICAL CREA 5 RX/OTC EXQUISITE HRT CREA 5 RX/OTC HRT CREAM BASE CREA 5 RX/OTC FAGRON LS PLUS CREA 5 RX/OTC HRT CREAM BASE 5 RX/OTC FAGRON NATURAL 5 RX/OTC WOMEN CREA CREAM CREA HRT ESSENTIAL CREAM 5 RX/OTC FAGRON SUPREME 5 RX/OTC CREA CREAM CREA HRT HEAVY CREA 5 RX/OTC FATTIBASE OINT 5 RX/OTC HRT NATURAL LOTION 5 FITALITE CREA 5 RX/OTC LOTN HYDROGEL GEL XX 5 RX/OTC FREEDOM ADAPTADERM 5 RX/OTC CREA HYDROPHILIC OINT 5 RX/OTC FREEDOM ADAPTADERM 5 RX/OTC GEL HYDROUS EMULSIFIED 5 RX/OTC BASE CREA FREEDOM CEPAPRO 5 RX/OTC GEL JELENE OINT 5 RX/OTC FREEDOM DERMA 5 RX/OTC SERUM CREA KRIS-ESTER 236 LIQD 5 FREEDOM DERMA-D 5 RX/OTC CREA KRISGEL 100 GEL 5 FREEDOM DERMA-N 5 RX/OTC CREA LANOLIN ALCOHOL WAX 5 FREEDOM SILOMAC RX/OTC 5 LANOLIN ANHYDROUS 5 RX/OTC ANHYDROUS GEL OINT GRX WHITE RX/OTC 5 LANOLIN ANHYDROUS- 5 RX/OTC PETROLATUM OINT GRX OINT RX/OTC H20 GEL BASE GEL 5 LANOLIN OIL XX 5 HORMONE CREAM BASE 5 RX/OTC RX/OTC BOTANICAL CREA lanolin oint ex 2

305 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lanolin oint xx 2 RX/OTC NOURIVAN ANTIOX 5 RX/OTC CREAM BASE CREA LECITHIN ORGANOGEL 5 RX/OTC RX/OTC GEL NOXI-K CREA 5 LIDOCAINE-PRILOCAINE- 5 OCCLUVAN OINT 5 RX/OTC CREAM BASE CREA RX/OTC OINTMENT BASE 5 LIP BALM BASE OINT 5 EMULSIFYING OINT LIPO CREAM BASE CREA 5 RX/OTC OLEABASE PLASTICIZED 5 RX/OTC OINT RX/OTC LIPOBASE CREA 5 OMNIBASE CREA 5 RX/OTC RX/OTC LIPOCREAM BASE CREA 5 P-SILOXAN DS CREA 5 RX/OTC

LIPOFOAM RX FOAM 5 PCCA ALADERM BASE 5 RX/OTC CREA RX/OTC LIPOGEL CR BASE GEL 5 PCCA ANHYDROUS 5 BASE OINT LIPOLAYER CREA 5 RX/OTC PCCA ANHYDROUS 5 RX/OTC LIPODERM BASE CREA LIPOPEN ABSORPTION 5 RX/OTC ENHANCING BASE CREA PCCA BASE 7542 CREA 5 RX/OTC LIPOPEN ANHYDROUS 5 LOTN PCCA BIOPEPTIDE BASE 5 RX/OTC CREA LIPOPEN ULTRA BASE 5 RX/OTC CREA PCCA CANNIDEX 5 RX/OTC CUSTOM BASE CREA LIPOSOMAL HEAVY 5 RX/OTC CREA PCCA COBASE #1 OINT 5 LIPOSOMAL REGULAR RX/OTC 5 PCCA COSMETIC HRT 5 RX/OTC CREA BASE CREA RX/OTC LIPOZYME CREA 5 PCCA CUSTOM LIPO- 5 RX/OTC MAX CREA LUBRAJEL NP GEL 5 RX/OTC PCCA ELLAGE CREA 5 MEDIBASE C LIQD 5 RX/OTC PCCA EMOLLIENT 5 RX/OTC CREAM BASE CREA MEDIDERM CREA 5 RX/OTC PCCA GELATIN BASE 5 OINT MEDIHOL BASE GEL 5 PCCA LIPODERM BASE 5 RX/OTC CREA MICRODERM BASE CREA 5 RX/OTC PCCA LIPODERM 5 RX/OTC MICROSOME BASE CREA 5 RX/OTC CUSTOM BASE CREA PCCA LIPODERM HMW 5 RX/OTC MULTIBASE CREA 5 RX/OTC GEL PCCA LIPOSOMIC BASE 5 RX/OTC NOURILITE CREA 5 RX/OTC FOR DRY SKIN CREA

306 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PCCA LIPOSOMIC BASE RX/OTC PENDERM CREA 5 RX/OTC FOR NORMAL SKIN 5 CREA PENSOMAL CREAM 5 RX/OTC CREA PCCA LIPOSOMIC BASE 5 RX/OTC FOR OILY SKIN CREA PENTAPHENE BASE 5 RX/OTC PCCA LIPOSOMIC BASE RX/OTC CREA FOR SENSITIVE SKIN 5 PERFORMAX SALT 5 RX/OTC CREA SUPPORTIVEBASE CREA PCCA MVC BASE CREA 5 RX/OTC PETROLATUM OINT 5 RX/OTC PCCA NATACREAM RX/OTC 5 PETROLATUM WHITE 5 RX/OTC CREA OINT PCCA OCCLUSADERM 5 RX/OTC PETROLEUM JELLY OINT 5 RX/OTC GEL RX/OTC PCCA PERME8 5 RX/OTC PFCB CREA 5 ANHYDROUS GEL PHARMABASE RX/OTC PCCA PLASTICIZED 5 RX/OTC 5 BASE OINT ANTIOXIDANT CREA PHARMABASE RX/OTC PCCA PLURONIC F127 5 5 BASE GEL COSMETIC CREA PHARMABASE RX/OTC PCCA POLOXAMER 407 5 GEL COSMETIC NATURAL 5 CREA PCCA POLYPEG BASE 5 RX/OTC OINT PHARMABASE HEAVY 5 RX/OTC CREA PCCA PRACASIL TM- 5 RX/OTC PLUS BASE CREA PHARMABASE LIGHT 5 RX/OTC CREA PCCA SPIRA-WASH 5 RX/OTC BASE GEL PHARMABASE VAGINAL 5 RX/OTC MOISTURIZING CREA PCCA VANISHING 5 RX/OTC CREAM LIGHT CREA PHYTOBASE CREA 5 RX/OTC PCCA VANISHING RX/OTC CREAM/LOTION BASE 5 PICODERM CREA 5 RX/OTC CREA PLASTIBASE OINT 5 RX/OTC PCCA VANPEN BASE 5 RX/OTC CREA PLASTICIZED BASE OINT 5 RX/OTC PCCA W06 ANHYDROUS 5 RX/OTC TOPICAL GEL PLO GEL - MEDIFLO KIT 5 KIT PCCA WAV CUSTOM 5 RX/OTC BASE CREA PLO GEL - MEDIFLO PRE- 5 RX/OTC PEG 300 LIQD 5 RX/OTC MIXED GEL PLO PREMIUM LECITHIN 5 RX/OTC PEG OINT 5 RX/OTC ORGANOGEL BASE GEL PLO TRANSDERMAL 5 RX/OTC PEG OINTMENT BASE 5 RX/OTC CREAM CREA OINT PLO ULTRAMAX GEL 5 RX/OTC PENCREAM CREA 5 RX/OTC

307 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLO20 BASE GEL 5 RX/OTC RA PETROLEUM JELLY 5 RX/OTC OINT RX/OTC PLO20 FLOWABLE GEL 5 REJUVACARE PLUS 5 RX/OTC CREA PLURONIC F127 GEL 5 RENEWCREAM HRT 5 RX/OTC CREA PNA-HRT BASE CREA 5 RX/OTC SA3 DERM CREA 5 RX/OTC POLYBASE OINT 5 RX/OTC SALT DURABLE CREAM 5 RX/OTC CREA POLYETHYLENE GLYCOL 5 1000 POWD SALT STABLE LS 5 RX/OTC ADVANCED CREA POLYETHYLENE GLYCOL 5 1450 FLAK SALTSTABLE LO CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 RX/OTC 1450 LIQD SANARE ADVANCED 5 RX/OTC SCAR THERAPY CREA POLYETHYLENE GLYCOL 5 1450 POWD SANARE SCAR THERAPY 5 RX/OTC CREA POLYETHYLENE GLYCOL 5 1500 POWD SCAR CARE BASE 5 RX/OTC ENHANCED GEL POLYETHYLENE GLYCOL 5 RX/OTC 300 LIQD SCAR CARE CREAM 5 RX/OTC CREA POLYETHYLENE GLYCOL 5 3350 GRAN XX SEDANARE CREA 5 RX/OTC POLYETHYLENE GLYCOL RX/OTC 5 SILOSOME 5 RX/OTC 3350 POWD XX TRANSDERMAL CREA POLYETHYLENE GLYCOL 5 RX/OTC RX/OTC 400 LIQD SILPROTEX PLUS CREA 5 POLYETHYLENE GLYCOL 5 RX/OTC 4500 POWD SIMPLGEL 30 GEL 5 POLYETHYLENE GLYCOL 5 SKYY DERM CREA 5 RX/OTC 600 LIQD RX/OTC POLYETHYLENE GLYCOL 5 SOLU-K GEL GEL 5 8000 GRAN RX/OTC POLYETHYLENE GLYCOL 5 RX/OTC STERA BASE CREA 5 8000 POWD SUSPENDIT GEL 5 RX/OTC POLYETHYLENE GLYCOL 5 8000BASE E OINT TDC MAX CREAM CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 RX/OTC BLEND OINT TERODERM CREA 5 RX/OTC POLYETHYLENE GLYCOL 5 NF POWD TERODERM-PLUS CREA 5 RX/OTC POLYMAC PROGEL GEL 5 RX/OTC TIGHTENING BASE CREA 5 RX/OTC Q-DERM CREA 5 RX/OTC TOMMY GEL GEL 5 RX/OTC

308 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRANSDERMAL PAIN 5 RX/OTC white petrolatum gel xx 2 RX/OTC BASE CREA RX/OTC WHITE PETROLATUM 5 RX/OTC U-BASE CREA 5 OINT EX ULTRADERM CREA 5 RX/OTC WILEY BASIC ELEMENTS 5 RX/OTC BHRTBASE CREA UNIVERSAL WATER GEL 5 WOUND CARE CREAM 5 RX/OTC GEL CREA RX/OTC V-MAX CREA 5 WOUND WASH BASE 5 RX/OTC GEL RX/OTC VANIBASE CREA 5 XCEL 100 CREA 5 RX/OTC RX/OTC VANISH-PEN CREA 5 XEMATOP BASE CREA 5 RX/OTC VANISHING CREAM RX/OTC 5 YELLOW PETROLATUM 5 RX/OTC BOTANICALBASE CREA OINT VANISHING CREAM RX/OTC 5 ZOE SCRIPTS 5 RX/OTC CREA IDEALBASE CREA VERSABASE CREA 5 ZOSIL PSTE 5 VERSABASE FOAM 5 FOAM Surfactants RX/OTC VERSABASE GEL 5 RX/OTC MYRJ 53 POWD 5 RX/OTC POLYOXYL 40 STEARATE 5 VERSABASE HRT GEL 5 PLLT POLYOXYL 40 STEARATE 5 RX/OTC VERSABASE LOTN 5 POWD VERSABASE SHAM 5 PROGESTINS - Hormone Replacement/Modifying Drugs RX/OTC VERSAPRO CREA EX 5 Progestins AYGESTIN TABS 5 VERSAPRO FOAM XX 5 (norethindrone acetate) RX/OTC VERSAPRO GEL XX 5 EC-RX PROGESTERONE NC 10% CREA VERSAPRO LOTN XX 5 EC-RX PROGESTERONE NC 20% CREA VERSATILE CREAM RX/OTC 5 hydroxyprogesterone 2 PA; SP BASE CREA caproate oil im VERSATILE RICH CREAM 5 RX/OTC MAKENA OIL IM 250 PA; SP BASE CREA MG/ML 5 VERSIGEL CREA 5 RX/OTC (hydroxyprogesterone caproate) RX/OTC VP DERMABASE CREA 5 MAKENA SOAJ SC 275 5 PA; SP MG/1.1ML WATER BASE GEL GEL 5

309 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits medroxyprogesterone XYREM SOLN 5 PA; SP acetate tabs or 10 mg, 2.5 2 mg, 5 mg Antidementia Agents MEGACE ES SUSP ARICEPT TABS (donepezil 5 QL(1 ea daily) (megestrol acetate 5 hydrochloride) (appetite)) donepezil hydrochloride 2 QL(1 ea daily) megestrol acetate 2 tabs (appetite) susp donepezil hydrochloride 2 QL(1 ea daily) NORETHINDRONE 5 tbdp ACETATE POWD XX EXELON PT24 13.3 5 norethindrone acetate tabs 2 MG/24HR (rivastigmine) or EXELON PT24 4.6 QL(1 ea daily) PROGESTERONE 10% NC MG/24HR, 9.5 MG/24HR 5 KIT CREA (rivastigmine) PROGESTERONE galantamine hydrobromide 2 QL(1 ea daily) COMPOUNDINGKIT NC cp24 16 mg, 24 mg, 8 mg CREA galantamine hydrobromide 2 QL(6 ml daily) progesterone micronized 2 QL(1 ea daily) soln 4 mg/ml caps or 100 mg galantamine hydrobromide 2 QL(2 ea daily) progesterone micronized 2 QL(0.6667 ea tabs 12 mg, 4 mg, 8 mg caps or 200 mg daily) memantine hcl cp24 14 mg, 2 progesterone oil im 2 21 mg, 28 mg, 7 mg memantine hcl soln 10 QL(10 ml daily) PROMETRIUM CAPS 100 QL(1 ea daily) 2 MG (progesterone 5 mg/5ml, 2 mg/ml micronized) memantine hcl tabs 2 PROMETRIUM CAPS 200 QL(0.6667 ea MG (progesterone 5 daily) memantine hcl tabs 10 mg, 2 QL(2 ea daily) micronized) 5 mg PROVERA TABS NAMENDA TABS 5 QL(2 ea daily) (medroxyprogesterone 5 (memantine hcl) acetate) NAMENDA TITRATION PAK TABS (memantine 5 PSYCHOTHERAPEUTIC AND NEUROLOGICAL hcl) AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions NAMENDA XR CP24 5 (memantine hcl) Agents for Chemical Dependency NAMENDA XR TITRATION 5 acamprosate calcium tbec 2 PACK CP24 NAMZARIC C4PK 4 ANTABUSE TABS 4 (disulfiram) NAMZARIC CP24 4 disulfiram tabs or 250 mg, 2 500 mg RAZADYNE ER CP24 QL(1 ea daily) 5 LUCEMYRA TABS NC (galantamine hydrobromide) Anti-Cataplectic Agents RAZADYNE TABS QL(2 ea daily) (galantamine 5 hydrobromide) 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

310 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits rivastigmine pt24 13.3 2 dimethyl fumarate cpdr or 2 PA; SP mg/24hr 120 mg, 240 mg rivastigmine pt24 4.6 2 QL(1 ea daily) dimethyl fumarate misc or 2 PA; SP mg/24hr, 9.5 mg/24hr SP rivastigmine tartrate caps 2 QL(2 ea daily) EXTAVIA KIT NC Combination Psychotherapeutics GILENYA CAPS 0.5 MG 4 PA; SP chlordiazepoxide- 2 PA; SP amitriptyline tabs glatiramer acetate sosy 2 olanzapine-fluoxetine hcl 2 PA; SP caps LEMTRADA SOLN 5 perphenazine-amitriptyline 2 QL(4 ea daily) MAVENCLAD TBPK 5 PA; SP tabs PA; SP SYMBYAX CAPS 5 MAYZENT TABS 4 (olanzapine-fluoxetine hcl) PA; SP Fibromyalgia Agents OCREVUS SOLN 5 QL(2 ea daily) SAVELLA TABS 5 PLEGRIDY SOPN NC SP SAVELLA TITRATION 5 QL(2 ea daily) SP PACK MISC PLEGRIDY SOSY NC Movement Disorder Drug Therapy PLEGRIDY STARTER NC SP PACK SOPN AUSTEDO TABS 4 PA; SP PLEGRIDY STARTER NC SP PACK SOSY INGREZZA CAPS 4 PA; SP REBIF REBIDOSE SOAJ 4 PA; SP INGREZZA CPPK 4 PA; SP REBIF REBIDOSE 4 PA; SP TITRATIONPACK SOAJ tetrabenazine tabs 2 PA; SP REBIF SOSY 4 PA; SP XENAZINE TABS NC PA; SP (tetrabenazine) REBIF TITRATION PACK 4 PA; SP Multiple Sclerosis Agents SOSY TECFIDERA CPDR PA; SP AMPYRA TB12 5 PA; SP 4 (dalfampridine) (dimethyl fumarate) PA; SP TECFIDERA STARTER PA; SP AUBAGIO TABS 4 PACK MISC (dimethyl 4 fumarate) AVONEX PEN AJKT NC SP TYSABRI CONC 4 PA; SP AVONEX PSKT NC SP VUMERITY CPDR 4 PA; SP BETASERON KIT NC SP ZEPOSIA 7-DAY NC STARTER PACK CPPK COPAXONE SOSY 4 PA; SP (glatiramer acetate) ZEPOSIA CAPS NC dalfampridine tb12 or 2 PA; SP

311 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZEPOSIA STARTER KIT NC HORIZANT TBCR 300 MG NC QL(2 ea daily) CPPK Postherpetic Neuralgia (PHN)/Neuropathic Pain HORIZANT TBCR 600 MG NC QL(1 ea daily) ACTIVE- NC PAC/GABAPENTIN THPK Smoking Deterrents bupropion hcl (smoking QL(2 ea daily) CONVENIENCE PAK NC 6 THPK deterrent) tb12 CHANTIX CONTINUING 6 QL(2 ea daily) GABACAINE THPK NC MONTHPAK TABS CHANTIX STARTING 6 GABAPAL THPK NC MONTH PAK TABS GPL PAK THPK NC CHANTIX TABS 6 QL(2 ea daily)

GRALISE TABS 4 PA NICODERM CQ PT24 6 QL(1 ea daily) (nicotine) LIDO GB-300 THPK NC NICORETTE GUM 5 (nicotine polacrilex) LIDOTIN THPK NC NICORETTE LOZG 5 (nicotine polacrilex) LIPRITIN II THPK NC NICORETTE MINI LOZG 5 (nicotine polacrilex) LIPRITIN THPK NC NICORETTE STARTER PA KIT GUM (nicotine 5 LYRICA CR TB24 NC polacrilex) nicotine polacrilex gum mt 6 PENTICAN THPK NC 2 mg, 4 mg PRILOPENTIN THPK NC nicotine polacrilex lozg mt 2 6 mg, 4 mg Premenstrual Dysphoric Disorder (PMDD) Agents nicotine pt24 6 QL(1 ea daily) fluoxetine hcl (pmdd) caps 2 PA; ST 10 mg, 20 mg NICOTINE TRANSDERMAL SYSTEM 6 fluoxetine hcl (pmdd) tabs NC 10 mg, 20 mg KIT NICOTROL INHALER SARAFEM TABS 5 6 (fluoxetine hcl (pmdd)) INHA Pseudobulbar Affect (PBA) Agents NICOTROL NS SOLN 6 QL(2 ea daily) NUEDEXTA CAPS 4 ZYBAN TB12 (bupropion 5 QL(2 ea daily) hcl (smoking deterrent)) Psychotherapeutic and Neurological Agents - Transthyretin Amyloidosis Agents ergoloid mesylates tabs or 2 ONPATTRO SOLN 5 PA; SP

ORAP TABS (pimozide) 5 TEGSEDI SOSY 4 PA; SP pimozide tabs 2 Vasomotor Symptom Agents Restless Leg Syndrome (RLS) Agents 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

312 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRISDELLE CAPS ESBRIET TABS 4 PA; SP (paroxetine mesylate 5 (vasomotor)) OFEV CAPS 4 PA; SP paroxetine mesylate 2 (vasomotor) caps Respiratory Agents - Misc. RESPIRATORY AGENTS - MISC. - Drugs to CUROSURF SUSP 5 Treat Lung Conditions Alpha-Proteinase Inhibitor (Human) INFASURF SUSP 5 ARALAST NP SOLR 1000 SP NC SURVANTA 5 MG INTRATRACHEAL SUSP ARALAST NP SOLR 500 5 PA; SP MG SULFONAMIDES - Drugs to Treat Bacterial Infections PA; SP GLASSIA SOLN 5 Sulfonamides PROLASTIN-C SOLN 1000 4 PA; 30 rtl lmt SULFADIAZINE POWD 5 MG/20ML day(s),; SP SULFADIAZINE SODIUM PROLASTIN-C SOLR 1000 NC SP 5 MG POWD ZEMAIRA SOLR NC SP SULFADIAZINE TABS 5 SULFAMETHOXAZOLE Cystic Fibrosis Agents 5 MICRO POWD KALYDECO PACK 5 PA; SP SULFAMETHOXAZOLE 5 POWD KALYDECO TABS 5 PA; SP SULFAPYRIDINE POWD 5 ORKAMBI PACK 5 PA; SP SULFATHIAZOLE POWD 5 ORKAMBI TABS 5 PA; SP SULFISOXIZOLE CRYS 5 PULMOZYME SOLN 4 PA; QL(5 ml daily); SP TETRACYCLINES - Drugs to Treat Bacterial Infections SYMDEKO TBPK 5 PA; SP Aminomethylcyclines PA; SP TRIKAFTA TBPK 5 NUZYRA SOLR 5 Pleural Sclerosing Agents NUZYRA TABS 5 SCLEROSOL 5 INTRAPLEURAL AERP Fluorocyclines STERILE TALC POWDER 5 SUSR XERAVA SOLR 50 MG 5 STERITALC POWD 5 Glycylcyclines Pulmonary Fibrosis Agents tigecycline solr 2 ESBRIET CAPS 4 PA; SP TIGECYCLINE SOLR NC

313 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYGACIL SOLR NC DOXYCYCLINE HYCLATE NC (tigecycline) TBEC OR 80 MG Tetracycline Combinations MINOCIN CAPS OR 50 NC MG (minocycline hcl) AVIDOXY DK KIT 5 MINOCIN SOLR IV 100 5 MG BENZODOX 30 KIT THPK NC minocycline hcl caps or 50 2 mg, 75 mg, 100 mg BENZODOX 60 KIT THPK NC minocycline hcl cp24 or NC PA Tetracyclines 135 mg, 45 mg, 90 mg MINOCYCLINE HCL ACTICLATE TABS NC 5 (doxycycline hyclate) POWD XX minocycline hcl tabs or 100 2 demeclocycline hcl tabs 2 mg, 50 mg, 75 mg DORYX MPC TBEC NC minocycline hcl tb24 or 105 mg, 115 mg, 55 mg, 65 mg, NC 80 mg DORYX TBEC 50 MG, 200 NC MG (doxycycline hyclate) minocycline hcl tb24 or 135 NC PA DORYX TBEC 80 MG NC mg, 45 mg, 90 mg MINOLIRA TB24 NC doxycycline (monohydrate) 2 caps 100 mg, 50 mg MORGIDOX 1X100MG KIT 5 doxycycline (monohydrate) NC caps 150 mg, 75 mg MORGIDOX 1X50MG KIT NC KIT doxycycline (monohydrate) 2 susr 25 mg/5ml MORGIDOX 2X100MG KIT 5 doxycycline (monohydrate) tabs 100 mg, 150 mg, 50 2 NUTRIDOX KIT 5 mg, 75 mg OXYTETRACYCLINE HCL doxycycline hyclate caps or 2 5 50 mg, 100 mg POWD DOXYCYCLINE HYCLATE NC SEYSARA TABS NC DR TBEC SOLODYN TB24 5 DOXYCYCLINE HYCLATE 5 (minocycline hcl) POWD XX TARGADOX TABS NC doxycycline hyclate solr iv 2 (doxycycline hyclate) 100 mg tetracycline hcl caps or 250 2 doxycycline hyclate tabs or 2 mg, 500 mg 100 mg, 20 mg VIBRAMYCIN CAPS 100 5 doxycycline hyclate tabs or NC MG (doxycycline hyclate) 50 mg, 150 mg, 75 mg VIBRAMYCIN SUSR 25 doxycycline hyclate tbec or NC MG/5ML (doxycycline 4 200 mg (monohydrate)) doxycycline hyclate tbec or VIBRAMYCIN SYRP 50 4 50 mg, 100 mg, 150 mg, 75 2 MG/5ML mg

314 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XIMINO CP24 (minocycline NC PA liothyronine sodium tabs or 2 hcl) 25 mcg, 5 mcg, 50 mcg THYROID AGENTS - Drugs to Regulate Thyroid NATURE-THROID NT-2.5 5 Hormones TABS Antithyroid Agents NATURE-THROID TABS 5

METHIMAZOLE POWD XX 5 SYNTHROID TABS 4 (levothyroxine sodium) methimazole tabs or 10 2 mg, 5 mg THYROID PORCINE 5 POWD propylthiouracil tabs or 2 THYROID POWD XX 0.23 5 %, TAPAZOLE TABS 4 (methimazole) thyroid tabs or 120 mg, 15 2 mg, 30 mg, 60 mg, 90 mg Thyroid Hormones TIROSINT CAPS 100 ARMOUR THYROID TABS MCG, 112 MCG, 125 MCG, 120 MG, 15 MG, 30 MG, 5 13 MCG, 137 MCG, 150 NC 60 MG, 90 MG (thyroid) MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 ARMOUR THYROID TABS 5 180 MG, 240 MG, 300 MG MCG, 88 MCG CYTOMEL TABS 5 TIROSINT-SOL SOLN NC (liothyronine sodium) LEVOTHYROXINE TRIOSTAT SOLN 5 SODIUM CAPS OR 100 (liothyronine sodium) MCG, 112 MCG, 125 WESTHROID TABS 5 MCG, 13 MCG, 137 MCG, NC 150 MCG, 175 MCG, 200 5 MCG, 25 MCG, 50 MCG, WP THYROID TABS 75 MCG, 88 MCG TOXOIDS LEVOTHYROXINE SODIUM SOLN IV 100 NC Toxoid Combinations MCG/5ML, 200 MCG/5ML, AL(At least 7 500 MCG/5ML ADACEL SUSP 6 yrs old - Up to LEVOTHYROXINE 64 yrs old) SODIUM SOLR IV 200 5 6 AL(At least 7 MCG (levothyroxine BOOSTRIX SUSP yrs old) sodium) AL(Up to 6 yrs levothyroxine sodium solr DAPTACEL SUSP 6 old ) iv 200 mcg, 100 mcg, 500 2 mcg DIPHTHERIA/TETANUS AL(Up to 6 yrs TOXOIDS ADSORBED 6 old ) levothyroxine sodium tabs PEDIATRIC SUSP or 300 mcg, 100 mcg, 112 AL(Up to 6 yrs mcg, 125 mcg, 137 mcg, 2 INFANRIX SUSP 6 150 mcg, 175 mcg, 200 old ) mcg, 25 mcg, 50 mcg, 75 AL(At least 4 mcg, 88 mcg KINRIX SUSP 6 yrs old - Up to 6 yrs old) liothyronine sodium soln iv 2 10 mcg/ml

315 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEDIARIX SUSP 6 AL(Up to 6 yrs dicyclomine hcl tabs 2 old ) PENTACEL SUSR 6 AL(Up to 4 yrs GLYCATE TABS NC old ) AL(At least 4 glycopyrrolate soln ij 0.2 QUADRACEL SUSP 6 yrs old - Up to mg/ml, 0.4 mg/2ml, 1 2 6 yrs old) mg/5ml, 4 mg/20ml AL(At least 7 GLYCOPYRROLATE TDVAX SUSP 6 yrs old) SOSY IJ 0.2 MG/ML, 0.4 NC MG/2ML, 0.6 MG/3ML, 1 AL(At least 7 TENIVAC INJ 6 MG/5ML yrs old) GLYCOPYRROLATE TETANUS/DIPHTHERIA AL(At least 7 SOSY IV 0.4 MG/2ML, 0.6 NC TOXOIDS-ADSORBED 6 yrs old) MG/3ML, 1 MG/5ML ADULT SUSP glycopyrrolate tabs or 1 2 ULCER DRUGS - Drugs to Treat Bowel, Intestine mg, 2 mg and Stomach Conditions GLYCOPYRROLATE NC Antispasmodics TABS OR 1.5 MG ATROPEN SOAJ 5 GLYRX-PF SOLN NC

ATROPINE SULFATE HYOSCYAMINE SULFATE 5 MONOHYDRATE POWD 5 POWD XX XX hyoscyamine sulfate soln ij 2 0.5 mg/ml ATROPINE SULFATE 5 POWD XX hyoscyamine sulfate tb12 2 QL(4 ea daily) or 0.375 mg atropine sulfate soln ij 0.4 2 mg/ml, 1 mg/ml, 8 mg/20ml ISOPROPAMIDE IODIDE 5 ATROPINE SULFATE POWD SOLN IJ 8 MG/20ML 5 LEVBID TB12 4 QL(4 ea daily) (atropine sulfate) (hyoscyamine sulfate) atropine sulfate sosy ij 0.25 LEVSIN SOLN 5 mg/5ml, 0.5 mg/5ml, 1 2 (hyoscyamine sulfate) mg/10ml methscopolamine bromide 2 ATROPINE SULFATE tabs or 2.5 mg, 5 mg SOSY IV 0.8 MG/2ML, 1 NC PROPANTHELINE 5 MG/2.5ML, 1.2 MG/3ML, 2 BROMIDE POWD XX MG/5ML propantheline bromide tabs 2 BELLADONNA/OPIUM 5 or SUPP SCOPOLAMINE HBR 5 BENTYL SOLN 5 POWD (dicyclomine hcl) SYMAX DUOTAB TBCR 5 CUVPOSA SOLN 5 H-2 Antagonists dicyclomine hcl caps 2 cimetidine hcl soln 2 QL(20 ml daily) dicyclomine hcl soln 2 CIMETIDINE 2 QL(20 ml daily) HYDROCHLORIDE SOLN 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

316 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CIMETIDINE POWD XX 5 ranitidine hcl soln ij 50 2 QL(2 ml daily) mg/2ml QL(4 ea daily); cimetidine tabs or 200 mg 2 ranitidine hcl syrp or 15 QL(20 ml daily) RX/OTC mg/ml, 150 mg/10ml, 75 2 cimetidine tabs or 300 mg 2 QL(4 ea daily) mg/5ml ranitidine hcl tabs or 150 2 QL(2 ea daily); cimetidine tabs or 400 mg 2 QL(2 ea daily) mg RX/OTC ranitidine hcl tabs or 300 2 QL(2 ea daily) cimetidine tabs or 800 mg 2 QL(1 ea daily) mg ZANTAC SOLN 25 MG/ML, 5 DEPRIZINE FUSEPAQ 5 25 MG/ML (ranitidine hcl) SUSR ZANTAC SOLN 50 5 QL(2 ml daily) famotidine in nacl soln 2 MG/2ML (ranitidine hcl) famotidine soln iv 20 Misc. Anti-Ulcer mg/2ml, 200 mg/20ml, 40 2 CARAFATE SUSP 1 NC mg/4ml GM/10ML (sucralfate) famotidine susr or 40 2 CARAFATE TABS 1 GM NC QL(4 ea daily) mg/5ml (sucralfate) QL(2 ea daily); famotidine tabs or 20 mg 2 RX/OTC SUCRALFATE POWD XX 5 famotidine tabs or 40 mg 2 sucralfate susp or 1 NC gm/10ml FAMOTIDINE/SODIUM NC QL(4 ea daily) CHLORIDE SOSY sucralfate tabs or 1 gm 2 NIZATIDINE CAPS 150 2 QL(2 ea daily) Proton Pump Inhibitors MG ACIPHEX SPRINKLE NC nizatidine caps 150 mg 2 QL(2 ea daily) CPSP 10 MG, 5 MG ACIPHEX TBEC NC QL(2 ea daily) nizatidine caps 300 mg 2 QL(1 ea daily) (rabeprazole sodium) PA; ST; QL(1 NIZATIDINE CAPS 300 4 QL(1 ea daily) DEXILANT CPDR 4 MG ea daily) nizatidine soln 15 mg/ml 2 QL(20 ml daily) ESOMEP-EZS KIT NC esomeprazole magnesium QL(1 ea daily); PEPCID SUSR 40 MG/5ML 5 2 (famotidine) cpdr 20 mg RX/OTC esomeprazole magnesium RX/OTC PEPCID TABS 20 MG 5 QL(2 ea daily); 2 (famotidine) RX/OTC cpdr 20 mg esomeprazole magnesium QL(1 ea daily) PEPCID TABS 40 MG 5 2 (famotidine) cpdr 40 mg esomeprazole magnesium ranitidine hcl caps or 150 2 QL(2 ea daily) 2 mg pack 10 mg, 20 mg, 40 mg esomeprazole sodium solr 2 ranitidine hcl caps or 300 2 QL(1 ea daily) mg ESOMEPRAZOLE 5 QL(1 ea daily) ranitidine hcl soln ij 1000 2 STRONTIUM CPDR mg/40ml, 150 mg/6ml

317 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESOMEPRAZOLE NC QL(1 ea daily) PREVACID CPDR 15 MG NC RX/OTC STRONTIUM CPDR (lansoprazole) FIRST-LANSOPRAZOLE 5 PREVACID CPDR 30 MG NC QL(1 ea daily) SUSP (lansoprazole) FIRST-OMEPRAZOLE 5 PREVACID SOLUTAB QL(1 ea daily); SUSP TBDD 15 MG NC RX/OTC (lansoprazole) lansoprazole cpdr or 15 mg 2 RX/OTC PREVACID SOLUTAB QL(1 ea daily) NC lansoprazole cpdr or 30 mg 2 QL(1 ea daily) TBDD 30 MG (lansoprazole) QL(1 ea daily); lansoprazole tbdd or 15 mg 2 5 RX/OTC PRILOSEC PACK lansoprazole tbdd or 30 mg 2 QL(1 ea daily) PROTONIX PACK OR 40 NC MG (pantoprazole sodium) NEXIUM 24HR CLEAR QL(1 ea daily); PROTONIX SOLR IV 40 5 MINIS CPDR 5 RX/OTC MG (pantoprazole sodium) (esomeprazole PROTONIX TBEC OR 20 QL(1 ea daily) magnesium) MG, 40 MG (pantoprazole NC NEXIUM 24HR CPDR QL(1 ea daily); sodium) (esomeprazole 5 RX/OTC RABEPRAZOLE SODIUM 5 magnesium) DR SPRINKLE CPSP NEXIUM CPDR 20 MG QL(1 ea daily); QL(2 ea daily) (esomeprazole NC RX/OTC rabeprazole sodium tbec 2 magnesium) Ulcer Drugs - Prostaglandins NEXIUM CPDR 40 MG QL(1 ea daily) (esomeprazole NC CYTOTEC TABS 4 QL(4 ea daily) magnesium) (misoprostol) misoprostol tabs or 100 QL(4 ea daily) NEXIUM I.V. SOLR 5 2 (esomeprazole sodium) mcg, 200 mcg NEXIUM PACK 10 MG, 20 Ulcer Therapy Combinations MG, 40 MG (esomeprazole NC amoxicillin-clarithromycin 2 magnesium) w/ lansoprazole misc NEXIUM PACK 2.5 MG, 5 NC MG HELIDAC THERAPY MISC NC OMEPRAZOLE + OMECLAMOX-PAK MISC 5 SYRSPEND SFALKA 5 SUSP omeprazole-sodium QL(1 ea daily); bicarbonate caps 1100 mg- 2 RX/OTC omeprazole cpdr or 10 mg, 2 40 mg 20 mg omeprazole-sodium QL(1 ea daily); pantoprazole sodium pack 2 or 40 mg bicarbonate caps 1100 mg- NC RX/OTC 20 mg pantoprazole sodium solr iv 2 40 mg omeprazole-sodium QL(1 ea daily) bicarbonate caps 1100 mg- NC pantoprazole sodium tbec 2 QL(1 ea daily) or 20 mg, 40 mg 40 mg omeprazole-sodium PREVACID 24HR CPDR 5 RX/OTC (lansoprazole) bicarbonate pack 1680 mg- NC 20 mg, 1680 mg-40 mg 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

318 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PYLERA CAPS 4 oxybutynin chloride tabs or 2 QL(3 ea daily) 5 mg TALICIA CPDR 5 oxybutynin chloride tb24 or 2 QL(2 ea daily) 10 mg, 15 mg, 5 mg ZEGERID CAPS 1100 MG- QL(1 ea daily); RX/OTC 20 MG (omeprazole- NC RX/OTC OXYTROL PTTW NC sodium bicarbonate) QL(1 ea daily) ZEGERID CAPS 1100 MG- QL(1 ea daily) solifenacin succinate tabs 2 40 MG (omeprazole- NC tolterodine tartrate cp24 2 2 QL(1 ea daily) sodium bicarbonate) mg, 4 mg ZEGERID OTC CAPS QL(1 ea daily); tolterodine tartrate tabs 1 2 QL(2 ea daily) (omeprazole-sodium 5 RX/OTC mg, 2 mg bicarbonate) ST; QL(1 ea TOVIAZ TB24 4 ZEGERID PACK 1680 MG- daily) 20 MG, 1680 MG-40 MG NC (omeprazole-sodium trospium chloride cp24 60 2 QL(1 ea daily) bicarbonate) mg trospium chloride tabs 20 2 URINARY ANTI-INFECTIVES - Drugs to Treat mg Bladder/Kidney Infections VESICARE TABS 5 QL(1 ea daily) Urinary Anti-infective Combinations (solifenacin succinate) methenamine-hyosc- Urinary Antispasmodics - Beta-3 Adrenergic methylene blue-sod phos- 2 phenyl sal caps MYRBETRIQ TB24 4 ST; QL(1 ea daily) Urinary Anti-infectives Urinary Antispasmodics - Cholinergic Agonists nitrofurantoin monohyd 2 macro caps bethanechol chloride tabs or 10 mg, 25 mg, 5 mg, 50 2 URINARY ANTISPASMODICS - Drugs to Treat mg Miscellaneous Bladder Spasms URECHOLINE TABS 4 Urinary Antispasmodic - Antimuscarinics (bethanechol chloride) darifenacin hydrobromide 2 QL(1 ea daily) Urinary Antispasmodics - Direct Muscle Relaxants tb24 flavoxate hcl tabs 2 DETROL LA CP24 NC QL(1 ea daily) (tolterodine tartrate) VACCINES DETROL TABS (tolterodine 5 QL(2 ea daily) tartrate) Bacterial Vaccines DITROPAN XL TB24 5 QL(2 ea daily) (oxybutynin chloride) ACTHIB SOLR 6 ENABLEX TB24 NC QL(1 ea daily) BCG VACCINE INJ 5 (darifenacin hydrobromide) ST BEXSERO SUSY 6 AL(At least 10 GELNIQUE GEL 5 yrs old) GELNIQUE PUMP GEL 5 ST BIOTHRAX SUSP 5 oxybutynin chloride syrp or 2 QL(16 ml daily) HIBERIX SOLR 6 5 mg/5ml

319 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MENACTRA INJ 6 FLUAD 2019-2020 SUSY 6

MENQUADFI INJ 6 FLUAD 2020-2021 SUSY 6

MENVEO SOLR 6 2 rtl MAX FLUAD QUADRIVALENT fill,365 rtl 6 PEDVAX HIB SUSP 6 INFLUENZA VACCINE day(s) supply,; FOR ADULTS PRSY AL(At least 65 yrs old) PNEUMOVAX 23 INJ 6 AL(At least 2 yrs old) FLUARIX QUADRIVALENT 6 2018-2019 SUSY PNEUMOVAX 23/1 DOSE 6 AL(At least 2 INJ yrs old) FLUARIX QUADRIVALENT 6 2019-2020 SUSY PREVNAR 13 SUSP 6 FLUARIX QUADRIVALENT AL(At least 10 6 TRUMENBA SUSY 6 2020-2021 SUSY yrs old) FLUBLOK AL(At least 18 TYPHIM VI SOLN 5 QUADRIVALENT 2018- 6 yrs old) 2019 SOSY VAXCHORA SUSR 5 FLUBLOK AL(At least 18 QUADRIVALENT 2019- 6 yrs old) VIVOTIF BERNA CPDR 5 2020 SOSY FLUBLOK AL(At least 18 VIVOTIF CPDR 5 QUADRIVALENT 2020- 6 yrs old) 2021 SOSY Viral Vaccines FLUCELVAX AL(At least 4 AFLURIA QUADRIVALENT 6 QUADRIVALENT 2018- 6 yrs old) 2018-2019 SUSY 2019 SUSP AFLURIA QUADRIVALENT 6 AL(Up to 3 yrs FLUCELVAX AL(At least 4 2019-2020 SUSY old ) QUADRIVALENT 2018- 6 yrs old) 2019 SUSY AFLURIA QUADRIVALENT 6 2019-2020 SUSY FLUCELVAX AL(At least 4 QUADRIVALENT 2019- 6 yrs old) AFLURIA QUADRIVALENT 6 2020-2021 SUSP 2020 SUSP FLUCELVAX AL(At least 4 AFLURIA QUADRIVALENT 6 AL(At least 3 2020-2021 SUSY yrs old) QUADRIVALENT 2019- 6 yrs old) 2020 SUSY AFLURIA QUADRIVALENT 6 AL(Up to 3 yrs 2020-2021 SUSY old ) FLUCELVAX AL(At least 4 QUADRIVALENT 2020- 6 yrs old) ENGERIX-B INJ IM 10 6 AL(Up to 19 yrs 2021 SUSP MCG/0.5ML old ) FLUCELVAX AL(At least 4 ENGERIX-B INJ IM 20 6 AL(At least 20 QUADRIVALENT 2020- 6 yrs old) MCG/ML yrs old) 2021 SUSY ENGERIX-B SUSP IJ 10 6 AL(Up to 19 yrs FLULAVAL MCG/0.5ML old ) QUADRIVALENT 2018- 6 ENGERIX-B SUSP IJ 20 6 AL(At least 20 2019 SUSY MCG/ML yrs old) FLULAVAL FLUAD 2018-2019 SUSY 6 QUADRIVALENT 2019- 6 2020 SUSY 1=Value Generics 2=Preferred Generic 3=Value Brand 4=Preferred Brand 5=Non-Preferred Brand or Generic 6=Prevention Drug $0 NC=Not Covered AL=Age Limit PA=Prior Authorization PV=Preventive Drugs QL=Quantity Limit SP=Specialty Drugs ST=Step Therapy RX/OTC=Prescription & Over-the-Counter

320 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLULAVAL IMOVAX RABIES 5 QUADRIVALENT 2020- 6 (H.D.C.V.) INJ 2021 SUSY IPOL INACTIVATED IPV 6 AL(At least 2 INJ FLUMIST 6 QUADRIVALENT SUSP yrs old - Up to 49 yrs old) IXIARO SUSP 5 FLUZONE HIGH-DOSE PF AL(At least 65 6 M-M-R II SOLR 6 AL(At least 1 2020-2021 SUSY yrs old) yrs old) FLUZONE AL(At least 1 QUADRIVALENT 2018- 6 PROQUAD SUSR 6 yrs old - Up to 2019 SUSP 12 yrs old) FLUZONE AL(Up to 3 yrs RABAVERT SUSR 5 QUADRIVALENT 2018- 6 old ) 2019 SUSY RECOMBIVAX HB SUSP 6 AL(At least 11 FLUZONE 10 MCG/ML yrs old) QUADRIVALENT 2018- 6 RECOMBIVAX HB SUSP 6 AL(At least 18 2019 SUSY 40 MCG/ML yrs old) FLUZONE RECOMBIVAX HB SUSP 5 6 AL(Up to 19 yrs QUADRIVALENT 2019- 6 MCG/0.5ML old ) 2020 SUSP ROTARIX SUSR 6 AL(Up to 1 yrs FLUZONE AL(Up to 3 yrs old ) QUADRIVALENT 2019- 6 old ) ROTATEQ SOLN 6 AL(Up to 1 yrs 2020 SUSY old ) FLUZONE SHINGRIX SUSR 6 AL(At least 50 QUADRIVALENT 2019- 6 yrs old) 2020 SUSY FLUZONE STAMARIL SUSR 5 QUADRIVALENT 2020- 6 2021 SUSP TWINRIX SUSP 6 AL(At least 18 yrs old) FLUZONE AL(At least 18 QUADRIVALENT 2020- 6 TWINRIX SUSY 6 2021 SUSY yrs old) AL(At least 9 AL(At least 1 VAQTA SUSP 25 6 yrs old - Up to GARDASIL 9 SUSP 6 yrs old - Up to UNIT/0.5ML 45 yrs old) 18 yrs old) AL(At least 19 AL(At least 9 VAQTA SUSP 50 UNIT/ML 6 GARDASIL 9 SUSY 6 yrs old - Up to yrs old) 45 yrs old) VARIVAX INJ 6 AL(At least 1 yrs old) HAVRIX SUSP 1440 6 AL(At least 19 ELU/ML yrs old) YF-VAX INJ 5 AL(At least 1 HAVRIX SUSP 720 6 AL(At least 50 ELU/0.5ML yrs old - Up to ZOSTAVAX SUSR 6 18 yrs old) yrs old) HEPLISAV-B SOLN 6 AL(At least 18 VAGINAL AND RELATED PRODUCTS yrs old) AL(At least 18 Miscellaneous Vaginal Products HEPLISAV-B SOSY 6 yrs old) INTRAROSA INST 5

321 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIMO-SAN GEL NC terconazole vaginal crea 2 QL(45 gm per 0.4 % fill retail) Spermicides terconazole vaginal crea 2 QL(20 gm per 0.8 % fill retail) ENCARE SUPP 6 terconazole vaginal supp 2 QL(3 ea per fill 80 mg retail) nonoxynol-9 gel 6 Vaginal Contraceptive - pH Modulators OPTIONS CONCEPTROL PHEXXI GEL NC VAGINAL 5 CONTRACEPTIVE GEL (nonoxynol-9) Vaginal Estrogens OPTIONS GYNOL II ESTRACE CREA VA 0.1 5 QL(1.434 gm VAGINALCONTRACEPTIV 6 MG/GM (estradiol vaginal) daily) E GEL estradiol vaginal crea 0.1 2 QL(1.434 gm mg/gm daily) SHUR-SEAL GEL 6 estradiol vaginal tabs 10 2 TODAY SPONGE MISC 6 mcg ESTRING RING 4 QL(1 ea per 90 VCF VAGINAL days retail) CONTRACEPTIVE FILM 6 FILM FEMRING RING 5 QL(1 ea per 90 days retail) VCF VAGINAL CONTRACEPTIVE FOAM 6 IMVEXXY MAINTENANCE NC FOAM PACK INST IMVEXXY STARTER NC Vaginal Anti-infectives PACK INST AVC CREA 5 PREMARIN CREA VA 4 QL(1.434 gm 0.625 MG/GM daily) CLEOCIN CREA VA 2 % QL(40 gm per VAGIFEM TABS (estradiol 5 (clindamycin phosphate 4 fill retail) vaginal) vaginal) Vaginal Progestins CLEOCIN SUPP VA 100 5 MG CRINONE GEL 4 clindamycin phosphate 2 QL(40 gm per vaginal crea fill retail) ENDOMETRIN INST 4 CLINDESSE CREA 5 FIRST-PROGESTERONE VGS 100 COMPOUNDING 5 GYNAZOLE-1 CREA 5 KIT SUPP METROGEL-VAGINAL QL(70 gm per FIRST-PROGESTERONE GEL (metronidazole 4 fill retail) VGS 200 5 vaginal) COMPOUNDING KIT SUPP QL(70 gm per metronidazole vaginal gel 2 fill retail) VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions miconazole nitrate vaginal 2 QL(3 ea per fill supp retail) Anaphylaxis Therapy Agents NUVESSA GEL NC ADRENALIN SOLN IJ 1 5 MG/ML

322 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADRENALIN SOLN IJ 30 AKOVAZ SOLN (ephedrine NC MG/30ML (epinephrine 5 sulfate (pressors)) (anaphylaxis)) BIORPHEN SOLN NC ADYPHREN AMP II KIT NC KIT DOBUTAMINE HCL SOLN 4 ADYPHREN AMP KIT KIT NC dobutamine in d5w soln 2 ADYPHREN II KIT NC dopamine hcl soln 2 ADYPHREN KIT KIT NC dopamine in d5w soln 2 AUVI-Q SOAJ 0.1 NC MG/0.1ML, 0.3 MG/0.3ML EMERPHED SOLN NC QL(2 ea per fill AUVI-Q SOAJ 0.15 5 ephedrine sulfate MG/0.15ML retail,4 ea per 2 30 days retail) (pressors) soln ij QL(2 ea per fill ephedrine sulfate 2 epinephrine (anaphylaxis) 2 retail,4 ea per (pressors) soln iv soaj 0.15 mg/0.15ml 30 days retail) EPHEDRINE SULFATE 5 SOLN IV 50 MG/ML epinephrine (anaphylaxis) 2 soaj 0.15 mg/0.3ml EPHEDRINE SULFATE QL(0.0667 ea SOSY IJ 25 MG/5ML, 50 NC epinephrine (anaphylaxis) 2 daily,4 ea per MG/10ML, 50 MG/5ML soaj 0.3 mg/0.3ml 22 days retail) EPHEDRINE SULFATE SOSY IV 25 MG/5ML, 250 NC epinephrine (anaphylaxis) 2 soln 30 mg/30ml MG/5ML EPHEDRINE EPINEPHRINE NC PROFESSIONAL KIT SULFATE/SODIUMCHLOR NC IDE SOSY EPINEPHRINESNAP-EMS NC KIT EPINEPHRINE HCL SOLN 5 EPINEPHRINESNAP-V NC KIT EPINEPHRINE HYDROCHLORIDE/DEXT NC QL(0.0667 ea ROSE SOLN daily,4 ea per EPIPEN 2-PAK SOAJ 4 EPINEPHRINE (epinephrine (anaphylaxis)) 22 days retail)2 rtl MAX fill,30 rtl HYDROCHLORIDE/DEXT NC day(s) supply, ROSE SOSY EPINEPHRINE EPIPEN-JR 2-PAK SOAJ 2 (epinephrine (anaphylaxis)) HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN EPISNAP KIT NC EPINEPHRINE HYDROCHLORIDE/SODIU NC SYMJEPI SOSY 4 M CHLORIDE SOSY Neurogenic Orthostatic Hypotension (NOH) - epinephrine soln ij 1 mg/ml 2 PA; SP NORTHERA CAPS 5 epinephrine soln ij 30 NC mg/30ml Vasopressors

323 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits epinephrine sosy ij 1 2 PHENYLEPHRINE mg/10ml HYDROCHLORIDE SOSY 5 IV 0.4 MG/10ML, 0.8 EPINEPHRINE SOSY IJ 1 5 MG/10ML MG/10ML, 1 MG/10ML PHENYLEPHRINE EPINEPHRINE/DEXTROS NC E SOLN HYDROCHLORIDE SOSY NC IV 0.5 MG/5ML EPINEPHRINE/SODIUM NC CHLORIDE SOLN PHENYLEPHRINE HYDROCHLORIDE SOSY NC EPINEPHRINE/SODIUM NC IV 0.5 MG/5ML-0.9 %, 0.9 CHLORIDE SOSY %-1 MG/10ML GIAPREZA SOLN NC PHENYLEPHRINE HYDROCHLORIDE/DEXT NC LEVOPHED SOLN 5 ROSE SOLN (norepinephrine bitartrate) PHENYLEPHRINE midodrine hcl tabs 2 HYDROCHLORIDE/SODIU NC M CHLORIDE SOLN NOREPHINEPHRINE BITARTRATE/SODIUM NC PHENYLEPHRINE CHLORIDE SOLN HYDROCHLORIDE/SODIU NC M CHLORIDE SOSY norepinephrine bitartrate 2 soln iv PHENYLEPHRINE/SODIU NC M CHLORIDE SOLN NOREPINEPHRINE BITARTRATE/DEXTROSE NC VAZCULEP SOLN SOLN (phenylephrine hcl 5 (pressors)) NOREPINEPHRINE BITARTRATE/DEXTROSE NC VITAMINS SOSY NOREPINEPHRINE Oil Soluble Vitamins BITARTRATE/SODIUM NC AQUASOL A 5 CHLORIDE SOLN PARENTERAL SOLN NOREPINEPHRINE BABY DDROPS LIQD 5 BITARTRATE/SODIUM NC CHLORIDE SOSY cholecalciferol caps or 400 2 AL(At least 65 unit yrs old) NOREPINEPHRINE/DEXT NC ROSE SOLN cholecalciferol chew or 400 2 AL(At least 65 unit yrs old) NOREPINEPHRINE/SODI NC UM CHLORIDE SOLN cholecalciferol liqd or 10 2 mcg/ml, 400 unit/ml NOREPINEPHRINE/SODI NC UM CHLORIDE SOSY cholecalciferol tabs or 400 5 AL(At least 65 unit yrs old) phenylephrine hcl 2 (pressors) soln D-VI-SOL LIQD 5 PHENYLEPHRINE (cholecalciferol) HYDROCHLORIDE SOLN DRISDOL CAPS 4 IV 10 MG/ML 5 (ergocalciferol) (phenylephrine hcl (pressors)) ERGOCAL CAPS NC

324 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ergocalciferol caps or 1.25 2 PYRIDOXINE HCL POWD 5 RX/OTC mg, 50000 unit XX ERGOCALCIFEROL 5 pyridoxine hcl soln ij 2 POWD XX SODIUM ASCORBATE MEPHYTON TABS 5 5 (phytonadione) GRAN SODIUM ASCORBATE RX/OTC phytonadione soln ij 1 2 5 mg/0.5ml, 10 mg/ml POWD RX/OTC phytonadione tabs or 5 mg 2 THIAMINE HCL POWD XX 5

VITAMIN D3 IMMUNE 5 thiamine hcl soln ij 2 HEALTH LIQD THIAMINE VITAMIN D3 LIQD OR 5 5 1200 UNIT/15ML MONONITRATE POWD VITAMIN E ACETATE 5 POWD 500 UNIT/GM, WHEAT GERM OIL 5 Water Soluble Vitamins AMINOBENZOIC ACID 5 POWD ASCOR SOLN NC

ASCORBIC ACID SOLN IJ 2 500 MG/ML ascorbic acid soln ij 500 2 mg/ml ASCORBIC ACID SOLN IV NC 15000 MG/30ML CALCIUM ASCORBATE 5 RX/OTC DIHYDRATE POWD CALCIUM ASCORBATE 5 RX/OTC POWD CALCIUM 5 RX/OTC PANTOTHENATE POWD NIACIN POWD 5 RX/OTC

NIACINAMIDE POWD 5 RX/OTC

NICOTINAMIDE POWD 5 RX/OTC

PARA-AMINOBENZOIC 5 ACID POWD PYRIDOXAL-5- NC PHOSPHATE SOLN

325 Index 1ST BASE 303 5-HYDROXY-L-TRYPTOPHAN ACCU-CHEK COMPACT PLUS 1ST MEDX-PATCH/LIDOCAINE 107 CLEAR CONTROL SOLUTION 136 5- (2 LEVELS) 191 1ST TIER UNIFINE METHYLTETRAHYDROFOLAT ACCU-CHEK FASTCLIX PENTIPS/MINI/31GX5MM 214 E 93 LANCETS 191 1ST TIER UNIFINE 5- ACCU-CHEK GUIDE 145 PENTIPS29GX12MM 214 METHYLTETRAHYDROFOLAT ACCU-CHEK GUIDE CONTROL 1ST TIER UNIFINE ECALCIUM 93 LEVEL1/LEVEL2 192 PENTIPS31GX6MM 215 5- ACCU-CHEK MULTICLIX 1ST TIER UNIFINE METHYLTETRAHYDROFOLIC LANCETS 192 PENTIPS31GX8MM 215 ACID/GLUCOSAMINE SALT ACCU-CHEK SAFE-T-PRO 1ST TIER UNIFINE 91 LANCETS 192 PENTIPS32GX4MM 215 6-AMINOCAPROIC ACID 77 ACCU-CHEK SAFE-T-PRO 1ST TIER UNIFINE 7-KETO DHEA 91 PLUSLANCETS 192 PENTIPS33GX4MM 215 ACCU-CHEK SMARTVIEW 1ST TIER UNIFINE 7T GUMMY ES 8 CONTROL 192 PENTIPSPLUS 31GX8MM 215 7TOPIC 138 ACCU-CHEK SMARTVIEW 1ST TIER UNIFINE 9-AMINOACRIDINE HCL 77 STRIPS 145 PENTIPSPLUS 32GX4MM 215 A-LIPOIC ACID (DL-THIOCTIC ACCU-CHEK SOFTCLIX 1ST TIER UNIFINE ACID) 77 LANCETS 192 PENTIPSPLUS 33GX4MM 215 A.A.G.C. KIT IN ACCUCAINE 136 1ST TIER UNIFINE TERODERM 123 ACCUPRIL 47 PENTIPSPLUS/MINI/31GX5MM abacavir sulfate 65 215 ACCURETIC 48 1ST TIER UNIFINE abacavir sulfate- ACCUTREND GLUCOSE 145 lamivudine 66 PENTIPSPLUS/ORIGINAL/29GX abacavir sulfate-lamivudine- ACCUTREND GLUCOSE 12MM 215 zidovudine 66 CONTROL 192 1ST TIER UNIFINE ACD FORMULA A 28 PENTIPSPLUS/ULTRA ABELCET 42 SHORT/31GX6MM 215 ABILIFY 64 ACD-A NOCLOT-50 28 1ST TIER UNILET ABILIFY MAINTENA 64 acebutolol hcl 70 COMFORTOUCH LANCETS ABILIFY MYCITE 64 ACEBUTOLOL HCL 70 28G 191 ACEPROMAZINE 1ST TIER UNILET abiraterone acetate 55 MALEATE 77 COMFORTOUCH LANCETS ABLYSINOL 75 ACESULFAME 30G 191 ABRAXANE 60 POTASSIUM 77 2,3-DIMERCAPTOSUCCINIC ACETADOTE 40 ACID(DMSA) 99 ABSORICA 118 acetaminophen 8 2-DEOXY-D-GLUCOSE 85 ABSORICA LD 118 2-DEOXY-D-GLUCOSE ABSTRAL 8 ACETAMINOPHEN 78 REAGANTGRADE 85 AC DERMAPEPTIDE 99 ACETAMINOPHEN CRYSTAL 2-METHOXYESTRADIOL 93 60MESH 78 ACACIA 301 acetaminophen w/ codeine 13 2ND SKIN BLISTER KIT 175 ACACIA SPRAY-DRIED 301 acetaminophen-caff-dihydrocod 2ND SKIN BLISTER PADS 175 ACAI+SUPERFRUIT/GREEN 13 2ND SKIN QUIKSTIK ADHESIVE TEA 254 acetaminophen-salicylamide- BANDAGES 175 acamprosate calcium 310 phenyltoloxamine 7 2ND SKIN QUIKSTIK ADHESIVE ACANYA 118 ACETARSONE 78 BANDAGES SPORT PACK 175 acarbose 34 ACETAZOLAMIDE 78 2ND SKIN SELF SEALING CUT ACARBOSE 77 acetazolamide 151 CLOSURE BANDAGE 175 ACCOLATE 23 acetazolamide sodium 151 4-AMINOBUTYRIC ACID 88 ACCU-CHEK AVIVA 191 ACETIC ACID 77 4-AMINOPYRIDINE 87 ACCU-CHEK AVIVA acetic acid 162 4-METHYLPYRAZOLE 87 PLUS 145 acetic acid (otic) 284 5-AMINOSALICYLIC ACID 159 ACCU-CHEK COMPACT PLUS 145 ACETIC ACID GLACIAL 77 5-FLUOROURACIL 87 ACETONE 105

Index 1 ACETYL DIPEPTIDE-1 ACTIVE INJECTION KIT BLM- ACYCLOVIR 78 CETYLESTER 78 1 113 acyclovir sodium 69 ACETYL HEXAPEPTIDE-8 78 ACTIVE INJECTION KIT acyclovir topical 128 ACETYL SALICYLIC ACID 8 BM 113 ACTIVE INJECTION KIT ACZONE 118,119 ACETYL-D-GLUCOSAMINE D 113 ADA SHAMPOO 298 78 ACTIVE INJECTION KIT ACETYL-L-CARNITINE DL 113 ADACEL 315 HYDROCHLORIDE 78 ACTIVE INJECTION KIT ADAGEN 3 ACETYLCHOLINE DLM 113 CHLORIDE 78 ADAKVEO 164 ACTIVE INJECTION KIT KET- ADALAT CC 72 ACETYLCYSTEINE 118 L 4 acetylcysteine 118 ACTIVE INJECTION KIT adapalene 119 acetylcysteine (antidote) 40 KETMARC-L 4 ADAPALENE 119 ACTIVE INJECTION KIT KL- acetylcysteine (nutrient) 275 adapalene-benzoyl 3 113 peroxide 119 ACIDOPHILUS ACTIVE INJECTION KIT ADAPALENE/BENZOYL LACTOBACILLUS 91 KM 113 PEROXIDE/CLINDAMYCIN ACIPHEX 317 ACTIVE INJECTION KIT 119 ACIPHEX SPRINKLE 317 L 113 ADAPALENE/BENZOYL acitretin 127 ACTIVE INJECTION KIT LM- PEROXIDE/NIACINAMIDE 119 2 171 ADASUVE 64 ACTEMRA 4 ACTIVE INJECTION KIT LM- ACTEMRA ACTPEN 4 DEP-1 113 ADCETRIS 54 ACTHAR 153 ACTIVE INJECTION KIT LM- ADCIRCA 75 DEP-2 113 ADDERALL 1 ACTHIB 319 ACTIVE INJECTION KIT M- ACTI-LANCE LANCETS 1 113 ADDERALL XR 1 28G 192 ACTIVE-CYCLOBENZAPRINE adefovir dipivoxil 68 ACTI-LANCE LITE SAFETY KIT 271 ADEMETIONINE DISULFATE LANCETS 28G 192 ACTIVE-KETOPROFEN TOSYLATE 78 ACTI-LANCE SPECIAL SAFETY KIT 123 ADEMPAS 75 LANCETS 17G 192 ACTIVE-PAC/GABAPENTIN ADENOCARD 21 ACTI-LANCE SPECIAL 312 SAFETYLANCETS 17G 192 ACTIVE-PREP KIT I 123 adenosine 22 ACTI-LANCE UNIVERSAL ACTIVE-PREP KIT II 123 ADENOSINE 22,78 SAFETY LANCETS 23G 192 ADENOSINE-5- ACTICLATE 314 ACTIVE-PREP KIT III 123 MONOPHOSPHATE 256 ACTICOAT FLEX 3 BARRIER ACTIVE-PREP KIT IV 123 ADENOSINE-5-TRIPHOSPHATE DRESSING 4"'X4" 141 ACTIVE-PREP KIT V 125 256 ACTIGALL 159 ACTIVE-TRAMADOL KIT 123 ADENOSYLCOBALAMIN 81 ACTIMARIS ALL-NATURAL ACTIVELLA 156 ADHANSIA XR 2 WOUND RINSE/ENERGIZED adhesive bandages 175 SINGLET OXYGEN 141 ACTONEL 152 ACTOPLUS MET 35 ADHESIVE BANDAGES ACTIMARIS WOUND GEL 141 ANTIBACTERIAL 175 ACTIMMUNE 59 ACTOPLUS MET XR 35 ADHESIVE BANDAGES ACTIPHYTE OF ALGAE GL 78 ACTOS 36 CLEAR 175 ACTIPHYTE OF ACTRIVIT 258 ADHESIVE BANDAGES CUCUMBER 81 ACUICYN ANTIMICROBIAL FLEXIBLE FABRIC 175 ACTIPHYTE OF IVY 89 ADHESIVE BANDAGES EYELID & EYELASH FOAM 175 ACTIPHYTE OF HYGIENE 139 ADHESIVE BANDAGES LEMONGRASS 105 ACUICYN DAILY EYELID & HEALTHAWARENESS 175 ACTIPHYTE OF SEA KELP 91 EYELASH CLEANSER 139 ADHESIVE BANDAGES HYPO- ACTIPHYTE OF SUGAR ACULAR 283 ALLERGENIC 175 KELP 91 ACULAR LS 283 ADHESIVE BANDAGES ACTIQ 8 ACUVAIL 283 PLASTIC 175 ACTIVE FE 166 acyclovir 69

Index 2 ADHESIVE BANDAGES ADVOCATE INSULIN PEN AFINITOR DISPERZ 57 SHEER 175 NEEDLES 31GX5MM 215 AFLURIA QUADRIVALENT ADHESIVE BANDAGES ADVOCATE INSULIN PEN 2018-2019 320 STRONGSTRIPS 175 NEEDLES 31GX8MM 215 AFLURIA QUADRIVALENT ADHESIVE BANDAGES WATER ADVOCATE INSULIN 2019-2020 320 SHIELD 175 SYRINGE/U- AFLURIA QUADRIVALENT ADHESIVE 100/0.3ML/29GX1/2" 215 2020-2021 320 PADS/LARGE/3"X4" 175 ADVOCATE INSULIN AFREZZA 37 ADHESIVE SYRINGE/U- PADS/MEDIUM/2"X3" 175 100/0.3ML/30GX5/16" 215 AFSTYLA 163 ADJUSTABLE LANCING ADVOCATE INSULIN AGAMATRIX AMP NO CODE DEVICE 192 SYRINGE/U- TEST STRIPS 145 ADLYXIN 36 100/0.3ML/31GX5/16" 215 AGAMATRIX CONTROL NORMAL& HIGH 192 ADLYXIN STARTER PACK 36 ADVOCATE INSULIN SYRINGE/U- AGAMATRIX CONTROL ADMELOG 36 100/0.5ML/29GX1/2" 215 SOLUTION LEVEL 2 192 ADMELOG SOLOSTAR 37 ADVOCATE INSULIN AGAMATRIX CONTROL ADRENAL C FORMULA 259 SYRINGE/U- SOLUTION LEVEL 4 192 AGAMATRIX JAZZ TEST ADRENAL STRESS CALM 268 100/0.5ML/30GX5/16" 215 ADVOCATE INSULIN STRIPS 145 ADRENALIN 322,323 SYRINGE/U- AGAMATRIX KEYNOTE TEST ADRENOCHROME 100/0.5ML/31GX5/16" 215 STRIPS 145 SEMICARBAZONE 81 ADVOCATE INSULIN AGAMATRIX PRESTO TEST ADRENOCORTICOTROPHIC SYRINGE/U- STRIPS 145 HORMONE 81 100/1ML/29GX1/2" 215 AGAMATRIX ULTRA-THIN ADRENOID 268 ADVOCATE INSULIN LANCETS 33G 192 ADVAIR DISKUS 24 SYRINGE/U- AGAR 78 100/1ML/30GX5/16" 215 AGGRENOX 164 ADVAIR HFA 24 ADVOCATE INSULIN ADVANCE INTUITION TEST AGRYLIN 164 SYRINGE/U- AIF #2 DRUG STRIPS 145 100/1ML/31GX5/16" 215 ADVANCE MICRO-DRAW PREPARATIONKIT 123 CONTROL LEVEL 1-2 192 ADVOCATE LANCETS 192 AIF #3 DRUG PREPARATION ADVANCE MICRO-DRAW ADVOCATE LANCETS KIT 123 NORMAL CONTROL 192 30G 192 AIMOVIG 246 ADVANCE MICRO-DRAW TEST ADVOCATE LANCING AIR FOAM INSOLES STRIPS 145 DEVICE 192 MENS 206 ADVANCED ALLERGY ADVOCATE RAPID-SAFE AIR FOAM INSOLES COLLECTION KIT 129 LANCING DEVICE 192 WOMENS 206 ADVANCED AM/PM 259 ADVOCATE REDI-CODE 145 AIRDUO RESPICLICK ADVANCED BASE PLUS 303 ADVOCATE REDI-CODE+ 113/14 24 TESTSTRIPS 145 AIRDUO RESPICLICK ADVANCED C PLUS 259 ADVOCATE SAFETY 232/14 24 ADVANCED COLLAGEN 268 LANCETS 192 AIRDUO RESPICLICK 55/1424 ADVOCATE SAFETY ADVANCED CURAD AQUA- AJOVY 246 PROTECT 176 LANCETS 26G 192 ADVANCED CURAD BLISTER- ADVOCATE TEST AKLIEF 119 CARE 176 STRIPS 145 AKOVAZ 323 ADVANCED CURAD COOL- ADYNOVATE 163 AKTEN 281 WRAP 176 ADYPHREN AMP II KIT 323 ADVANCED CURAD SOF- AKTIPAK 119 GEL 176 ADYPHREN AMP KIT 323 AKYNZEO 41 ADVANCED MOBILE LANCET ADYPHREN II 323 ALA SCALP 129 30G 192 ADYPHREN KIT 323 ALA-SCALP 129 ADVATE 163 ADZENYS ER 1 ALANINE 275 ADVOCATE INSULIN PEN ADZENYS XR-ODT 1 NEEDLES 215 ALASKAN RED ALGAE 78 ADVOCATE INSULIN PEN AEMCOLO 17 ALBA-DERM 303 NEEDLES 29GX12.7MM 215 AFINITOR 57 albendazole 17

Index 3 ALBENDAZOLE 78 ALIVE MULTI-VITAMIN 259 ALPHANATE/VON ALBENZA 17 ALIVE PRENATAL MULTI- WILLEBRANDFACTOR COMPLEX/HUMAN 163 albuterol sulfate 24 VITAMIN/PLANT DHA 263 ALIVIO PATCH 136 ALPHANINE SD 163 ALBUTEROL SULFATE 24 ALKERAN 52 alprazolam 21 albuterol sulfate 24 ALKYL BENZOATE C12- ALPRAZOLAM 78 ALBUTEROL SULFATE 24 15 78 ALPRAZOLAM INTENSOL 21 albuterol sulfate 24 ALL GEL BUNION TOE ALPROLIX 163 ALCAINE 281 SPREADER 206 ALLANTOIN 107 ALPROSTADIL 107 alclometasone dipropionate129 alprostadil 256 ALCOH-GLOVE CONTOURED ALLERWELL ALLERGY WIPE 213 FORMULA 268 ALREX 281 ALCOH-WIPE 12" X 12" 213 ALLEVYN GENTLE 141 ALTABAX 124 ALCOHOL 105 ALLEVYN PLUS CAVITY 176 ALTACE 47 alcohol 275 ALLEVYN THIN 176 ALTADERM CREAM BASE304 ALCOHOL BASE GEL 304 ALLOPURINOL 78 ALTERNATE SITE LANCING allopurinol 163 DEVICE 192 ALCOHOL DEHYDRATED 298 ALTOPREV 45 ALCOHOL PADS 213 allopurinol sodium 162 ALLZITAL 8 ALTRENO 119 ALCOHOL PREP PADS 213 ALTRENOGEST 78 ALCOHOL PREPS 213 ALMOND OIL 105 ALMOND OIL BITTER ALUMINUM ACETATE ALCOHOL SWABS 213 FLAVOR 289 BASIC 78 ALCOHOL SWABSTICK 213 ALMOND OIL SWEET 105 ALUMINUM CHLORIDE 139 ALCOHOL WIPES 139 ALUMINUM CHLORIDE almotriptan malate 247 ANHYDROUS 139 ALDACTAZIDE 151 ALOCANE EMERGENCY ALUMINUM CHLORIDE ALDACTONE 152 BURN MAXIMUM HEXAHYDRATE 139 ALDARA 134 STRENGTH 136 ALUMINUM ALOCRIL 283 ALDOSTERONE 78 CHLOROHYDRATE 78 ALOE VERA 78 ALUMINUM HYDROXIDE ALDURAZYME 154 ALOE VERA FREEZE DRIEDGEL 107 ALECENSA 57 DRIED 78 ALUMINUM POTASSIUM alendronate sodium 152 ALOE VERA LEAF 78 SULFATE 107 ALUMINUM SULFATE ALEVAMAX 138 alogliptin benzoate 36 HYDRATE 107 ALEVICYN ANTIPRURITIC alogliptin-metformin hcl 35 ALUNBRIG 57 GEL 138 ALEVICYN ANTIPRURITIC alogliptin-pioglitazone 35 ALVESCO 23 SG 138 ALOMIDE 283 ALZAIR ALLERGY BLOCKER ALEVICYN DERMAL ALOPRIM 163 NASAL SPRAY 272 SPRAY 141 ALORA 157 amantadine hcl 61 ALEVICYN PLUS 138 alosetron hcl 160 AMANTADINE HCL 78 ALFALFA FLAVOR 289 ALOXI 41 AMARANTH 288 alfentanil hcl 9 ALPAWASH 304 AMARYL 38 ALFENTANIL AMBIEN 169 HYDROCHLORIDE 9 ALPHA LIPOIC ACID 78 AMBIEN CR 169 ALFERON N 59 ALPHA-GPC 50% 88 AMBISOME 42 alfuzosin hcl 162 ALPHA-KETOGLUTARIC ACID 78 ambrisentan 74 ALGINIC ACID 78 ALPHA-LIPOIC ACID 3 amcinonide 129 ALIMTA 53 ALPHA-TOCOPHEROL 104 AMCINONIDE 129 ALINIA 18 ALPHAGAN P 280 AMD ANTIMICROBIAL ALIQOPA 57 FENESTRATED FOAM aliskiren fumarate 50 DRESSING 3.5"X3" 176

Index 4 AMD FOAM DRESSING amiodarone hcl 22 amphetamine- 4"X4" 176 AMIODARONE dextroamphetamine 1 AMD FOAM DRESSING HYDROCHLORIDE/DEXTROS amphotericin b 42 6"X6" 176 E 22 AMPHOTERICIN B 257 AMD FOAM AMITIZA 159 DRESSING/TOPSHEET ampicillin 286 4"X4" 176 amitriptyline hcl 34 ampicillin & sulbactam AMELUZ 126 AMITRIPTYLINE HCL 78 sodium 287 AMERGE 247 AMITRIPTYLINE ampicillin sodium 286 AMERIGEL WOUND HYDROCHLORIDE 78 AMPICILLIN-SULBACTAM 287 DRESSING 141 amlodipine besylate 72 AMPYRA 311 AMERIGEL WOUND AMLODIPINE BESYLATE 78 AMRIX 271 WASH 141 amlodipine besylate- AMVISC 283 AMICAR 168 atorvastatin calcium 74 AMVISC PLUS 283 AMIDATE 160 amlodipine besylate-benazepril hcl 48 AMYTAL SODIUM 169 AMIKACIN SULFATE 3 amlodipine besylate-olmesartan AMZEEQ 119 amikacin sulfate 3 medoxomil 48 amiloride & amlodipine besylate- ANACAINE 136 hydrochlorothiazide 151 valsartan 48 ANAFRANIL 34 AMILORIDE HCL 152 AMLODIPINE anagrelide hcl 164 amiloride hcl 152 BESYLATE/SYRSPEND SF ANAPROX DS 4 PH4 72 AMINO ACID 275 amlodipine-valsartan- ANASCORP 285 amino acid electrolyte hydrochlorothiazide 48 ANASTIA 136 infusion 275 AMMONIUM BROMIDE 107 anastrozole 55 amino acid infusion 275 AMMONIUM BROMIDE ANASTROZOLE 79 amino acids 275 ACS 107 ANAVIP 285 AMINOBENZOIC ACID 325 AMMONIUM CHLORIDE 107 ANCOBON 42 AMINOCAPROIC ACID 78 AMMONIUM HYDROXIDE 77 ANDEXXA 40 aminocaproic acid 168 AMMONIUM LACTATE 105 ANDRODERM 15 AMINOLEVULINIC ACID AMMONIUM LAURYL HCL 78 SULFATE 78 ANDROGEL 15 AMINOLEVULINIC ACID AMMONIUM MOLYBDATE ANDROGEL PUMP 15 HYDROCHLORIDE 78 TETRAHYDRATE 78 ANDROSTENEDIONE 79 AMINOLEVULINIC ACID AMMONIUM PHOSPHATE HYDROCHOLRIDE 78 DIBASIC 107 ANECTINE 273 AMINOPHYLLINE 25 AMMONIUM SULFATE 107 ANESTHESIA S/I-40 160 aminophylline 25 AMMONIUM ANESTHESIA S/I-40A 160 AMINOPHYLLINE TETRATHIOMOLYBDATE 79 ANESTHESIA S/I-40H 160 ANHYDROUS 25 AMMONUL 154 ANESTHESIA S/I-40S 160 AMINOPROPYL MENTHYL amoxapine 34 ANESTHESIA S/I-60 161 PHOSPHATE 78 amoxicillin 286 ANGELIQ 156 AMINOPROTECT 275 amoxicillin & pot AMINOSALICYLIC ACID 52 clavulanate 287 ANGIOMAX 28 AMINOSYN 276 AMOXICILLIN ANHYDROUS BASE 304 AMINOSYN TRIHYDRATE 286 ANHYDROUS CREAM 7%/ELECTROLYTES 275 amoxicillin-clarithromycin w/ BASE 304 lansoprazole 318 AMINOSYN II 276 ANHYDROUS GEL BASE 304 AMOXICILLIN/CLAVULANATE ANIMI-3 166 AMINOSYN M 276 POTASSIUM 4:1 79 AMINOSYN-HBC 276 AMPHADASE 253 ANIMI-3/VITAMIN D 166 AMINOSYN-PF 276 amphetamine 1 ANISE EXTRACT 289 AMINOSYN-PF 7% 276 amphetamine sulfate 1 ANISE FLAVOR 289 AMINOSYN-RF 276 ANISINDIONE 79

Index 5 ANJESO 4 APPLE FLAVOR WATER ARIXTRA 26 ANNOVERA 112 MISCIBLE 289 ARLACEL 165 88 apraclonidine hcl 280 ANORO ELLIPTA 24 armodafinil 2 aprepitant 41,42 ANTABUSE 310 ARMONAIR RESPICLICK APRICOT FLAVOR 289 ANTARA 45 113 23 APRISO 159 ARMONAIR RESPICLICK ANTHRALIN 127 APRIZIO PAK 136 232 23 ANTIBACTERIAL ARMONAIR RESPICLICK BANDAGES/EXTRA APRIZIO PAK II 136 55 23 LARGE 176 APTENSIO XR 2 ARMOUR THYROID 315 ANTIBACTERIAL CLEAR APTIOM 28 ADVANCED BANDAGES 176 ARNICA FLOWER 139 ANTIBACTERIAL CLEAR APTIVUS 66 ARNICA LG 79 BANDAGES 7/8"/SPOT 176 AQUA LANCE ADJUSTABLE ARNUITY ELLIPTA 23 LANCING DEVICE 192 ANTIBACTERIAL PLASTIC AROMASIN 55 BANDAGES 3/4"X3" 176 AQUACEL AG BURN 141 ANTICOAGULANT CITRATE AQUAFRESH CAVITY ARRANON 53 DEXTROSE SOLUTION A 28 PROTECTION SUGAR ACID arsenic trioxide 59 ANTICOAGULANT SODIUM PROTECTION 214 ARSENIC TRIOXIDE 79 CITRATE 26,28 AQUAFRESH EXTREME ARTHRI-FLEX ANTIMONY POTASSIUM CLEAN 214 ADVANTAGE 254 TARTRATE 79 AQUALANCE LANCETS ARTHROTEC 50 4 ANTIMONY TRICHLORIDE 79 ULTRA THIN 30G 192 ARTHROTEC 75 4 ANTIMONY TRISULFIDE 79 AQUASOL A PARENTERAL 324 articaine-epinephrine 171 ANTIPYRINE 79 AQUORAL 257 ANTIVENIN LATRODECTUS artificial saliva 257 MACTANS 285 AR CAPS #1 CLEAR/ACID ARTISS 168 RESISTANT 300 ANTIVENIN NORTH ARYMO ER 9 ARAKODA 51 AMERICANCORAL ARZERRA 54 SNAKE 285 ARALAST NP 313 ANUSOL-HC 16 ARANESP ALBUMIN ASACOL HD 159 ANZEMET 41 FREE 165 ASCENIV 285 APADAZ 13 ARAVA 7 ASCLERA 256 APEXICON E 129 ARAZLO 119 ASCOR 325 APIDRA 37 ARBEM H-COSMETIC 304 ASCORBIC ACID 79,325 APIDRA SOLOSTAR 37 ARBEM LIPOPEN 304 ascorbic acid 325 APLENZIN 32 ARBUTIN ALPHA 79 ASCORBIC ACID 325 APLICARE ALCOHOL ARCALYST 4 ASCORBIC ACID CASSAVE79 SWABSTICK 213 ARCAPTA NEOHALER 24 ASCORBYL PALMITATE 79 APOKYN 61 ARESTIN 257 ASMANEX HFA 23 APOMORPHINE HCL 79 ARGATROBAN 28 ASMANEX TWISTHALER 120 APOMORPHINE HCL argatroban 28 METERED DOSES 23 HEMIHYDRATE 79 ASMANEX TWISTHALER 14 APOMORPHINE ARGATROBAN 28 METERED DOSES 23 HYDROCHLORIDE 79 ARGATROBAN/SODIUM ASMANEX TWISTHALER 30 APOTHEDERM 304 CHLORIDE 28 METERED DOSES 23 ARGININE HCL 79 ASMANEX TWISTHALER 60 APOTHESAR 304 ARICEPT 310 METERED DOSES 23 APOTHESAR 2 304 ASMANEX TWISTHALER 7 ARIKAYCE 3 APOTHESAR PLUS 304 METERED DOSES 23 ARIMIDEX 55 APOTHESIL 304 ASPARAGINE MONOHYDRATE 79 APPLE CIDER VINEGAR aripiprazole 64,65 DIET 254 ARISTADA 65 ASPARLAS 59 APPLE FLAVOR 289 ARISTADA INITIO 65 aspirin 8

Index 6 ASPIRIN 8 ASSURE PRISM CONTROL ATROVENT HFA 23 aspirin 8 LEVEL 1/2 193 ATTAPULGITE ACTIVATED ASSURE PRISM MULTI TEST aspirin-dipyridamole 164 COLLODIAL 79 STRIPS 145 AUBAGIO 311 ASPIRIN/OMEPRAZOLE 164 ASSURE PRO CONTROL ASPIRIN/OMEPRAZOLE LEVEL1/2 193 AUGMENTIN 287 ER 164 ASSURE PRO TEST AUGMENTIN ES-600 287 ASSURE 3 CONTROL LEVEL STRIPS 145 AUGMENTIN XR 287 1/2 192 ASTAGRAF XL 253 AURORA LANCET SUPER ASSURE 3 TEST STRIPS 145 ASTERO 136 THIN30G 193 ASSURE 4 CONTROL LEVEL ASTRAGALUS ROOT 301 AURORA LANCET THIN 1/2 192 23G 193 ASTRINGYN 168 ASSURE 4 TEST STRIPS 145 AURORA PEN NEEDLES ASSURE COMFORT LANCETS ATABEX EC 263 29GX12MM 215 ULTRA THIN 28G 192 ATABEX OB 263 AURORA PEN NEEDLES 31G ASSURE DOSE NORMAL/HIGH ATACAND 47 X6MM 215 AURORA PEN NEEDLES 31G CONTROL 192 ATACAND HCT 48 ASSURE HAEMOLANCE PLUS X8MM 215 HIGH FLOW 18G 192 atazanavir sulfate 66 AURORA UNIFINE ASSURE HAEMOLANCE PLUS ATELVIA 152 PENTIPS/32GX5/32" 215 AURORA UNIFINE LOW FLOW 25G 192 ATENOLOL 70 ASSURE HAEMOLANCE PLUS PENTIPS/MINI/31GX3/16" 216 MICRO FLOW 28G 192 atenolol 70 AURYXIA 160 ASSURE HAEMOLANCE PLUS atenolol & chlorthalidone 48 AUSTEDO 311 NORMAL FLOW 21G 192 ATENOLOL/SYRSPEND SF AUTO-LANCET 193 ASSURE HAEMOLANCE PLUS PH4 70 PEDIATRIC BLADE 192 ATGAM 253 AUTO-LANCET MINI 193 AUTOLET IMPRESSION ASSURE ID INSULIN ATIVAN 21 SAFETYSYRINGE/U- LANCING DEVICE 193 100/0.5ML/29G X 1/2" 215 atomoxetine hcl 1 AUTOLET LANCING ASSURE ID INSULIN ATOPADERM 138 DEVICE 193 SAFETYSYRINGE/U- ATOPICLAIR 138 AUTOLET MINI 193 100/1ML/29G X 1/2" 215 AUTOLET PLUS 193 ASSURE ID SAFETY PEN atorvastatin calcium 45 NEEDLES 30G X 3/16" 215 ATORVASTATIN AUTOPEN 216 ASSURE ID SAFETY PEN CALCIUM 79 AUVI-Q 323 NEEDLES 30G X 5/16" 215 atovaquone 18 AUXIPRO VANISHING ASSURE ID SAFETY PEN ATOVAQUONE 79 CREAM 304 NEEDLES 31G X 3/16" 215 atovaquone-proguanil hcl 51 AVADERM 136 ASSURE II 145 atracurium besylate 274 AVALIDE 48 ASSURE II CHECK STRIP 145 ATRALIN 119 AVANDIA 36 ASSURE II CONTROL LEVEL AVAPRO 47 1 193 ATRAPRO ANTIPRURITIC ASSURE II CONTROL LEVEL HYDROGEL 141 AVAR 119 1/2 193 ATRAPRO CP 141 AVAR LS 119 ASSURE II TEST STRIPS 145 ATREVIS HYDROGEL 304 AVAR LS CLEANSER 119 ASSURE LANCE ATRIPLA 66 AVAR-E LS 119 LANCETS 193 ATROPEN 316 ASSURE LANCE LANCETS AVASTIN 54 ATROPINE AVC 322 21G 193 SULFATE 279,316 ASSURE LANCE PLUS atropine sulfate 316 AVEED 15 SAFETYLANCETS 25G 193 AVEIDAOXIA 140 ASSURE LANCE PLUS ATROPINE SULFATE 316 SAFETYLANCETS 30G 193 atropine sulfate 316 AVELOX 158 ASSURE LANCETS 193 ATROPINE SULFATE 316 AVENOVA 139 ASSURE PLATINUM TEST ATROPINE SULFATE AVICEL PH 101 STRIPS 145 MONOHYDRATE 279 MICROCRYSTALLINE CELLULOSE 81

Index 7 AVICEL PH 105 B-12 COMPLIANCE BALCOLTRA 111 MICROCRYSTALLINE INJECTIONKIT 165 balsalazide disodium 159 CELLULOSE 81 B-6 FOLIC ACID 166 BALSAM PERU & CASTOR AVIDOXY DK 314 B-COMPLEX 258 OIL 142 AVIPTADIL ACETATE 79 b-complex vitamins 258 BALVERSA 57 AVOCADO OIL 79 b-complex w/ c & folic BANANA CONCENTRATE 289 AVODART 162 acid 258 BANANA CREAM FLAVOR289 AVONEX 311 b-complex w/ c-biotin-minerals & folic acid 258 BANANA CREME FLAVOR289 AVONEX PEN 311 B-D INSULIN SYRINGE BANANA FLAVOR 289 AVSOLA 159 ULTRAFINE II/0.3ML/31G X BAND AID BUTTERFLY AVYCAZ 75 5/16" 216 CLOSURE MEDIUM 176 B-D INSULIN SYRINGE BAND-AID 177 AXIFOL 166 ULTRAFINE II/0.5ML/31G X AYGESTIN 309 5/16" 216 BAND-AID 1" 176 AYVAKIT 57 B-D INSULIN SYRINGE BAND-AID ALL-IN-ONE ADHESIVE GAUZE AZ CREAM 304 ULTRAFINE II/1ML/31G X 5/16" 216 PAD/LARGE 176 azacitidine 53 B-D INSULIN SYRINGE BAND-AID ALL-IN-ONE AZACTAM 19 ULTRAFINE/0.3ML/30G X ADHESIVE GAUZE AZACTAMIN ISO-OSMOTIC 1/2" 216 PAD/MEDIUM 176 DEXTROSE 19 B-D INSULIN SYRINGE BAND-AID BABY SHARK 176 AZASAN 253 ULTRAFINE/0.5ML/30G X BAND-AID BUTTERFLY CLOSURE LARGE 2-3/4" X AZASITE 280 1/2" 216 BABY DDROPS 324 1/2" 176 AZATHIOPRINE 253 BACIGUENT 280 BAND-AID CLEAR SPOTS azathioprine 253 7/8" 176 bacitracin 17 AZEDRA DOSIMETRIC 59 BAND-AID CLEAR STRIPS176 BACITRACIN 124 AZEDRA THERAPEUTIC 59 BAND-AID DISNEY bacitracin (ophthalmic) 280 PRINCESS 176 AZELAIC ACID 79 BACITRACIN BAND-AID EMOJI 176 azelaic acid 140 MICRONIZED 79 BAND-AID FLEXIBLE 176 AZELAIC BACITRACIN ZINC 124 BAND-AID FLEXIBLE ACID/NIACINAMIDE 119 bacitracin-poly-neomycin-hc FABRIC 176 AZELASTINE HCL 79 281 BAND-AID FLEXIBLE FABRIC1" azelastine hcl 273 bacitracin-polymyxin b X 3" 176 azelastine hcl (ophth) 283 (ophth) 280 BAND-AID FLEXIBLE azelastine hcl-fluticasone BACLOFEN 123,271 FABRICASSORTED 176 propionate 272 baclofen 271 BAND-AID FLEXIBLE FABRICEXTRA LARGE 176 AZELEX 119 BACMIN 259 BAND-AID FLEXIBLE AZESCHEW BACOCALMINE 301 FABRICFINGERTIP 176 PRENATAL/POSTNATAL 263 BACON FLAVOR 289 BAND-AID FLEXIBLE AZESCO 264 BACON FLAVOR FABRICKNUCKLE 176 AZILECT 63 NATURAL 289 BAND-AID FLEXIBLE AZITHROMYCIN 79 bacteriostatic sodium FABRICKNUCKLE & chloride 298 FINGERTIP 176 azithromycin 174 BAND-AID FLEXIBLE AZITHROMYCIN BACTERIOSTATIC WATER 298 FABRICTRAVEL PACK 176 DIHYDRATE 79 PARABENS BACTRIM 17 BAND-AID FROZEN 176 AZOPT 283 BACTRIM DS 17 BAND-AID GAUZE PADS AZOR 48 LARGE4" X 4" 176 BACTROBAN 124 aztreonam 19 BAND-AID GAUZE PADS BACTROBAN NASAL 273 SMALL2" X 2" 176 AZULFIDINE 159 BAL IN OIL 40 BAND-AID GLOW IN THE AZULFIDINE EN-TABS 159 DARK3/4" X 3" 176 BAL-CARE DHA 264

Index 8 BAND-AID HOT COLORS 3/4"X BAND-AID PLASTIC BASE C POLYETHYLENE 3" 176 STRIPS 177 GLYCOL E 300 304 BAND-AID HURT-FREE NON- BAND-AID QUILTVENT BASE CREAM WITH STICK PADS LARGE 3" X WATERPROOF PAD LARGE LIPOSOME 304 4" 176 2.875" X 4" 177 BASE D POLYETHYLENE BAND-AID HURT-FREE NON- BAND-AID SHEER COMFORT- GLYCOL 4500 304 STICK PADS MEDIUM 2" X FLEX 177 BASE FIVE COMPONENT 3" 177 BAND-AID SHEER NAPROXEN SODIUM MULTI- BAND-AID HYDRO SEAL ALL- STRIPS 177 PHASIC COMPOUND 4 PURPOSE 177 BAND-AID SHEER STRIPS BASE FOUR COMPONENT BAND-AID HYDRO SEAL 3/4" X 3" 177 GABAPENTIN MULTI-PHASIC BLISTER CUSHIONS MEDIUM BAND-AID SKIN-FLEX 177 COMPOUND 88 EXTREME 177 BAND-AID SPORT BASE G ALMOND OIL BAND-AID HYDRO SEAL STRIP/EXTRA WIDE 177 SWEET 105 BLISTER CUSHIONS BAND-AID STAR WARS 177 BASE GELATIN GUMMY SMALL 177 TROCHE 298 BAND-AID HYDRO SEAL BAND-AID SUPER STRIPS 177 BASE PCCA CLARIFYING 304 BLISTER CUSHIONS BAND-AID TOUGH BASE W301 304 VARIETY 177 STRIPS 177 BAND-AID HYDRO SEAL BASE X 301 BAND-AID TOUGH- BASIC FUCHSIN HCL 79 EXTRA LARGE 177 STRIPS 177 BAND-AID HYDRO SEAL BAND-AID TOUGH-STRIPS BAVENCIO 54 FINGERS 177 EXTRA LARGE 1-3/4" X BAND-AID HYDRO SEAL BAXDELA 158 4" 177 BAY OIL 105 LARGE 177 BAND-AID TOUGH-STRIPS BAND-AID INSIDE OUT 177 WATERPROOF 177 BAY RUM 105 BAND-AID ISLAND BAND-AID TOUGH-STRIPS BCAA 276 SURGICALDRESSING 4" X WATERPROOF/EXTRA BCG VACCINE 319 10" 177 LARGE 177 BD LO-DOSE INSULIN BAND-AID ISLAND BAND-AID VARIETY SYRINGE MICROFINE SURGICALDRESSING 4" X PACK 177 IV/0.5ML/28G X 1/2" 216 14" 177 BAND-AID WATER BLOCK BD AUTOSHIELD 29G X BAND-AID KLING ROLLED PLUS 178 3/16" 216 GAUZE LARGE 4" X 2.1 BAND-AID WATER BLOCK BD AUTOSHIELD 29G X YDS 177 PLUSFINGER CARE 178 5/16" 216 BAND-AID KLING ROLLED BAND-AID WATER BLOCK BD AUTOSHIELD DUO 30G X GAUZE LARGE 4" X 2.5 PLUSLARGE 178 5MM 216 YDS 177 BAND-AID/EXTRA BD INSULIN SYRINGE LUER- BAND-AID KLING ROLLED LARGE 178 LOK/U-100/1ML 216 GAUZE MEDIUM 3" X 2.1 BAND-AID/HELLO KITTY178 BD INSULIN SYRINGE YDS 177 BAND-AID/MICKEY MICROFINE IV/U- BAND-AID KLING ROLLED MOUSE 178 100/0.5ML/28G X 1/2" 216 GAUZE MEDIUM 3" X 2.5 BAND-AID/PRINCESS 178 BD INSULIN SYRINGE YDS 177 BANDAGES FABRIC MICROFINE IV/U-100/1ML/27G BAND-AID KLING ROLLED X 5/8" 216 GAUZE SMALL 2" X 2.5 KNUCKLE/FINGER 178 BANDAGES FABRIC STRIPS BD INSULIN SYRINGE YDS 177 MICROFINE IV/U-100/1ML/28G BAND-AID MEDICATED 3/4" 178 BANZEL 28 X 1/2" 216 STRIPS3/4" X 3" 177 BD INSULIN SYRINGE BAND-AID MICKEY BAQSIMI ONE PACK 36 MICROFINE/U-100/0.5ML/28G X MOUSE 177 BAQSIMI TWO PACK 36 1/2" 216 BAND-AID MIRASORB GAUZE BARACLUDE 68 BD INSULIN SYRINGE SPONGES LARGE 4" X 4" 177 MICROFINE/U-100/1ML/27G X BAND-AID NICKELODEON BASAGLAR KWIKPEN 37 5/8" 216 PAWPATROL 177 BASE A POLYETHYLENE BD INSULIN SYRINGE BAND-AID PLASTIC 177 GLYCOL 1450 304 MICROFINE/U-100/1ML/28G X BASE C POLYETHYLENE BAND-AID PLASTIC 1/2" 216 SHEER 177 GLYCOL 300 304

Index 9 BD INSULIN SYRINGE BD INSULIN BD SAFETYGLIDE INSULIN SAFETYGLIDE/1ML/29G X SYRINGE/DETACHABLE SYRINGE/0.3ML/31G X 1/2" 216 NEEDLE/U-100/1ML/25G X 5/16" 217 BD INSULIN SYRINGE SLIP 1" 217 BD SAFETYGLIDE INSULIN TIP/U-100/1ML 216 BD INSULIN SYRINGE/0.5ML/31G X BD INSULIN SYRINGE ULTRA- SYRINGE/DETACHABLE 15/64" 217 FINE/0.3ML/30G X 12.7MM216 NEEDLE/U-100/1ML/25G X BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE ULTRA- 5/8" 217 SYRINGE/1ML/31G X FINE/0.3ML/31G X 8MM 216 BD INSULIN 15/64" 218 BD INSULIN SYRINGE ULTRA- SYRINGE/DETACHABLE BD SAFETYGLIDE INSULIN FINE/0.5ML/30G X 12.7MM216 NEEDLE/U-100/1ML/26G X SYSYRINGE/0.5ML/30G X BD INSULIN SYRINGE ULTRA- 1/2" 217 5/16" 218 FINE/0.5ML/31G X 8MM 216 BD INSULIN SYRINGE/U- BD SWABS SINGLE USE 213 BD INSULIN SYRINGE ULTRA- 100/1ML/27G X 1/2" 217 BD SWABS SINGLE USE FINE/1/2 UNIT/0.3ML/31G X BD INSULIN SYRINGE/U- BUTTERFLY 213 8MM 216 100/2ML/27.5G X 5/8" 217 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE ULTRA- BD INSULIN SYRINGE/U- ULTR-FINE/U-100/0.5ML/31G X FINE/1ML/30G X 12.7MM 216 500/0.5ML/31G X 6MM 217 15/64" 218 BD INSULIN SYRINGE ULTRA- BD LANCET ULTRAFINE BD VEO INSULIN SYRINGE FINE/1ML/31G X 8MM 216 30G 193 ULTRA-AFINE/0.3ML/31G X BD INSULIN SYRINGE BD LANCET ULTRAFINE 6MM 218 ULTRAFINE HALF- 33G 193 BD VEO INSULIN SYRINGE UNIT/0.3ML/31G X 5/16" 216 BD MICROTAINER ULTRA-FINE/0.3ML/31G X BD INSULIN SYRINGE LANCETS 193 6MM 218 ULTRAFINE/0.3ML/30G X BD PEN 217 BD VEO INSULIN SYRINGE 1/2" 216 BD PEN MINI 217 ULTRA-FINE/0.5ML/31G X BD INSULIN SYRINGE 6MM 218 ULTRAFINE/0.3ML/31G X BD PEN NEEDLE/MICRO/ULTRA- BD VEO INSULIN SYRINGE 5/16" 216 ULTRA-FINE/1/2 BD INSULIN SYRINGE FINE/32G X 6MM 217 BD PEN UNIT/0.3ML/31G X 6MM 218 ULTRAFINE/0.5ML/30G X BD VEO INSULIN SYRINGE 1/2" 216 NEEDLE/MINI/ULTRA- FINE/31G X 5MM 217 ULTRA-FINE/1ML/31G X BD INSULIN SYRINGE 6MM 218 ULTRAFINE/0.5ML/31G X BD PEN NEEDLE/NANO/ULTRA- BD VEO INSULIN SYRINGE 5/16" 217 ULTRA-FINE/U-100/0.3ML/31G BD INSULIN SYRINGE FINE/32G X 4MM 217 BD PEN X 15/64" 218 ULTRAFINE/1ML/30G X BD VEO INSULIN SYRINGE 1/2" 217 NEEDLE/ORIGINAL/ULTRA- FINE/29G X 12.7MM 217 ULTRA-FINE/U-100/1ML/31G X BD INSULIN SYRINGE 15/64" 218 ULTRAFINE/U-100/0.3ML/29G X BD PEN 1/2" 217 NEEDLE/SHORT/ULTRA- BEAU RX 141 BD INSULIN SYRINGE FINE/31G X 8MM 217 BEAUTY & SKIN ULTRAFINE/U-100/0.5ML/29G X BD PUDENDAL/LOCAL THERAPY 254 1/2" 217 BLOCKTRAY 1% BECLOMETHASONE BD INSULIN SYRINGE LIDOCAINE 172 DIPROPIONATE 80 ULTRAFINE/U-100/1ML/29G X BD SAFETY-GLIDE INSULIN BECLOMETHASONE 1/2" 217 SYRINGE/0.5ML/29G X DIPROPIONATE BD INSULIN 1/2" 217 ANYDROUS 80 SYRINGE/0.3ML/29G X BD SAFETY-LOK INSULIN BECONASE AQ 273 12.7MM 217 SYRINGE/PERM BEEF BRAISED NATURAL BD INSULIN NEEDLE/UF/1ML/29G X FLAVOR 289 SYRINGE/0.5ML/29G X 1/2" 217 BEEF FLAVOR 289 12.7MM 217 BD SAFETYGLIDE INSULIN BEEF TYPE FLAVOR SYRINGE/0.3ML/29G X BD INSULIN SYRINGE/1ML/27G NATURAL 289 X 12.7MM 217 1/2" 217 BEEF TYPE FLAVOR BD INSULIN SYRINGE/1ML/29G BD SAFETYGLIDE INSULIN NATURALCHLORIDE SYRINGE/0.3ML/31G X X 12.7MM 217 FREE 289 15/64" 217 BEEF TYPE FLAVOR OS 289

Index 10 BEEF-ADE 289 BENZOIC ACID 125 BETAMETHASONE 80 BEES WAX 301 benzoin compound 139 BETAMETHASONE BEESWAX 301 BENZOIN GUM 80 ACETATE 80 BETAMETHASONE ACETATE BELBUCA 14 BENZOIN TINCTURE 140 MICRONIZED 80 BELEODAQ 57 BENZOIN TINCTURE BETAMETHASONE BELLADONNA 80 PLAIN 139 ACETATE/BETAMETHASONE BENZOLYL PEROXIDE 113 belladonna (bulk) 80 FORTE-HC 119 BETAMETHASONE BELLADONNA EXTRACT 80 benzonatate 117 COMBO 113 BELLADONNA/OPIUM 316 BENZOQUINONE (PARA) 80 BETAMETHASONE BELRAPZO 52 DIPROPIONATE 129 benzoyl peroxide 119 betamethasone dipropionate BELSOMRA 170 BENZOYL PEROXIDE 119 (topical) 129 BENACTYZINE benzoyl peroxide 119 betamethasone dipropionate HYDROCHLORIDE 80 BENZOYL PEROXIDE 119 augmented 129 benazepril & betamethasone sod phosphate & hydrochlorothiazide 48 BENZOYL PEROXIDE acetate 113 benazepril hcl 47 HYDROUS 119 BETAMETHASONE SODIUM benzoyl peroxide- PHOSPHATE 113 BENAZEPRIL HCL 80 erythromycin 120 BENAZEPRIL benzoyl peroxide- betamethasone valerate 129 HYDROCHLORIDE 80 hydrocortisone 120 BETAMETHASONE BENDAMUSTINE BENZOYL VALERATE 129 HYDROCHLORIDE 52 PEROXIDE/CLINDAMYCIN/NI BETANAPHTHOL 80 BENDEKA 52 ACINAMIDE 120 BETAPACE 71 BENEFIX 163 BENZOYL BETAPACE AF 71 PEROXIDE/CLINDAMYCIN/NI BENFOTIAMINE 80 ACINAMIDE/TRETINOIN 120 BETASERON 311 BENICAR 47 benztropine mesylate 61 betaxolol hcl 70 BENICAR HCT 49 BENZYL ALCOHOL 288 betaxolol hcl (ophth) 278 BENLYSTA 257 BENZYL BENZOATE 105 BETHANECHOL CHLORIDE 80 BENSAL HP 135 BEOVU 279 bethanechol chloride 319 BENTONITE 301 BEPREVE 283 BETHKIS 3 BENTYL 316 BERINERT 164 BETIMOL 278 BENZAC AC WASH 119 BESER 129 BETOPTIC-S 278 BENZACLIN 119 BESIVANCE 280 BEVACIZUMAB 279 BENZACLIN WITH PUMP 119 BESPONSA 54 BEVESPI AEROSPHERE 24 BENZALKONIUM BETA 1 KIT 113 CHLORIDE 65 BEVYXXA 26 BETA CAROTENE 80 BENZAMYCIN 119 bexarotene 59 BETA CYCLODEXTRIN 80 BENZEFOAM 119 BEXSERO 319 BETA GLUCAN 80 BENZEFOAM ULTRA 119 BEYAZ 111 BETA INJECT KIT 113 BENZEPRO 119 BHA 80 BETADINE OPHTHALMIC BENZETHONIUM BHRT BASE 304 CHLORIDE 80 PREP 280 BENZHYDROCODONE/ACETA BETAGAN 278 BHT 107 MINOPHEN 13 BETAHISTINE BI-EST 50:50 BENZNIDAZOLE 17 DIHYDROCHLORIDE 80 COMPOUNDINGKIT 157 BETAHISTINE HCL 80 BI-EST 50:50 BENZOCAINE 80 PROGESTERONE- benzocaine (dental) 257 BETAINE ANHYDROUS 80 TESTOSTERONE BENZOCAINE/LIDOCAINE/TET BETAINE HCL 80 COMPOUNDING KIT 157 RACAINE 136 BETALIDO 113 BI-EST 80:20 PROGESTERONE BENZODOX 30 KIT 314 BETALOAN SUIK 113 COMPOUNDING KIT 157 BENZODOX 60 KIT 314 bicalutamide 55

Index 11 BICILLIN C-R 287 BISACODYL 171 BORIC ACID 108 BICILLIN L-A 287 bisacodyl-peg 3350-pot BORIC ACID NF 108 BICNU 52 chloride-sod bicarb-sod BORON AMORPHOUS chloride 170 BIDIL 74 FINE 80 BISMUTH CITRATE 80 BORON CITRATE 80 BIEST/PROGESTERONE 157 BISMUTH BORTEZOMIB 57 BIIFENAC 1000 123 SUBCARBONATE 107 bosentan 75 BIIFENAC 500 123 BISMUTH SUBGALLATE 39 BOSULIF 57 BIJUVA 157 BISMUTH SUBNITRATE 107 BOSWELLIA SERRATA BIKTARVY 66 BISMUTH SUBSALICYLATE 108 EXTRACT 80 BILBERRY PLUS 268 bisoprolol & BOSWELLIA SERRATA BILTRICIDE 17 hydrochlorothiazide 49 EXTRACT65% 80 BOSWELLIA SERRATA BIMATOPROST 80 bisoprolol fumarate 70 EXTRACT70% 80 bimatoprost 284 BITTER DRUG BOTOX 274 BINOSTO 152 POWDER 301 BITTER ORANGE 80 BP VIT 3 166 BIO-STATIN 42 BITTER STOP FLAVOR 289 BPCO 142 bioflavonoid products 259 BITTERNESS MASK BRAFTOVI 57 BIOFREQUENCY FLAVOR 289 BRAIN MIGHT/DHA & CO INSOLES 206 BITTERNESS REDUCING Q10 268 BIOGUARD BARRIER AGENT 289 BRAVELLE 153 DRESSING/LARGE ROLL 178 BITTERNESS SUPPRESSOR BRAVURA ALL-IN-ONE 304 BIOGUARD GAUZE SPONGE FLAVOR 289 2"X2" 8 PLY 178 BITTERNESS SUPRESSOR BREO ELLIPTA 24 BIOGUARD GAUZE SPONGES FLAVOR 289 BRETYLIUM TOSYLATE 22 4"X4" 12 PLY 178 BIOGUARD ISLAND bivalirudin trifluoroacetate 28 BREVIBLOC 71 DRESSINGS4"X10" 178 BIVALIRUDIN/SODIUM BREVIBLOC PREMIXED 71 BIOGUARD ISLAND CHLORIDE 28 BREVIBLOC PREMIXED DRESSINGS4"X14" 178 BIVIGAM 285 DOUBLESTRENGTH 70 BIOGUARD ISLAND BLACKBERRY FLAVOR 289 BREVITAL SODIUM 161 DRESSINGS4"X5" 178 BLENDED SUSPENDING BRIDION 40 BIOGUARD NON-ADHERENT COMPOUND 298 BRIJ 35 96 DRESSINGS 3"X4" 178 bleomycin sulfate 56 BIOGUARD NON-ADHERENT BRIJ 700 96 BLEPH-10 280 DRESSINGS 3"X8" 178 BRIJ 93 96 BLEPHAMIDE 281 BIOLON 283 BRILINTA 164 BIORE HYDRATING BLEPHAMIDE S.O.P. 281 BRILLIANT BLUE G 288 MOISTURIZER 105 BLINCYTO 54 BRILLIANT GREEN 80 BIORPHEN 323 BLISTER RELIEF BIOSCANNER GLUCOSE TEST BANDAGE 178 BRIMONIDE/DORZOLAMIDE P- STRIPS 145 BLOOD GLUCOSE TEST F 280 BIOSUPP 259 STRIPS 145 BRIMONIDINE TARTRATE 80 BIOTECT PLUS 259 BLOOD GLUCOSE TEST brimonidine tartrate 280 STRIPS PREMIUM 145 BIOTENE DRY MOUTH 214 BRINEURA 154 BLOXIVERZ 51 BIOTENE DRY MOUTH BRISDELLE 313 GENTLEFORMULA 214 BLUE AGAVE ORGANIC 79 BRIVIACT 29 BIOTENE DRY MOUTH BLUEBERRY FLAVOR 289 BROMELAIN 253 MOISTURIZING SPRAY 257 BOCASAL 257 BIOTHRAX 319 BROMELAIN 1200 GDU 253 BONIVA 152 BROMFENAC SODIUM 80 BIOTIN 80 BONJESTA 41 BIOTIN PLUS KERATIN 268 bromfenac sodium (ophth) 283 BOOSTRIX 315 BROMHEXINE HCL 118 BIOTIN-D 80 BORDERED GAUZE 178 BISABOLOL ALPHA-L 80 bromocriptine mesylate 62

Index 12 BROMOCRIPTINE BUPIVACAINE BUTALBITAL/ASPIRIN/CAFFEIN MESYLATE 62 HYDROCHLORIDE 172 E 8 bromocriptine mesylate 62 BUPIVACAINE BUTISOL SODIUM 169 BROMPHENIRAMINE 43 HYDROCHLORIDE/DEXTROS butorphanol tartrate 15 E 172 BROMPHENIRAMINE BUPIVACAINE BUTORPHANOL MALEATE 43 HYDROCHLORIDE/SODIUM TARTRATE 15 BROMSITE 283 CHLORIDE 173 butorphanol tartrate 15 BROVANA 24 BUPIVACAINE BUTORPHANOL BRUKINSA 57 HYDROCHLORIDE/SODUM TARTRATE 81 BUTRANS 15 BRYHALI 129 CHLORIDE 173 BUPIVACAINE BUTTER FLAVOR 289 BSP 0820 113 HYDROCHLORIDEMONOHYD BUTTER RUM FLAVOR 289 BSS 284 RATE 173 BUTTERFLY CLOSURES 178 BSS PLUS 284 bupivacaine in dextrose 173 BUTTERSCOTCH BT INJECTION KIT 113 bupivacaine w/ epinephrine 172 FLAVOR 289 BUBBLE GUM BUTYL ALCOHOL 81 CONCENTRATE 289 BUPIVICAINE HYDROCHLORIDE/EPINEPHR BUTYLATED BUBBLE GUM FLAVOR 289 INE 172 HYDROXYANISOLE 81 BUBBLEGUM FLAVOR 289 BUPIVILOG KIT 113 BUTYLATED HYDROXYTOLUENE 108 BUCALSEP 65 BUPRENEX 14 BUTYLENE GLYCOL 81 BUDESONIDE 80 buprenorphine 15 BYDUREON 36 budesonide 113 BUPRENORPHINE 81 BYDUREON BCISE 36 budesonide (inhalation) 24 buprenorphine hcl 14 BYDUREON PEN 36 budesonide (nasal) 273 BUPRENORPHINE HCL 80 BYETTA 36 BUDESONIDE buprenorphine hcl-naloxone hcl MICRONIZED 80 dihydrate 15 BYNFEZIA PEN 156 budesonide-formoterol fumarate bupropion hcl 32 BYSTOLIC 71 dihydrate 24 BYVALSON 49 BUFFER CREAM 301 BUPROPION HCL 81 bupropion hcl (smoking C INDICUM EXTRACT/C BUFFERED LIDOCAINE SINESIS LEAF EXTRACT 81 HYDROCHLORIDE/SODIUM deterrent) 312 BUPROPION BICARBONATE 171 C-NATE DHA 264 BUFFERED HYDROCHLORIDE 81 C10-C30 ALKYL ACRYLATE LIDOCAINE/SODIUM BURIED TREASURE ACTIVE CROSSPOLYMER 301 55PLUS SENIOR BICARBONATE 171 cabergoline 156 COMPLEX 259 BUFFERED CABOMETYX 57 buspirone hcl 21 LIDOCAINE/SODIUMBICARBON CADIRAMD 136 ATE 172 BUSPIRONE HCL 81 CADUET 74 BUFLOMEDIL HCL 80 BUSPIRONE BULLSEYE MINI SAFETY HYDROCHLORIDE 81 CAFCIT 1 LANCETS 193 busulfan 52 CAFERGOT 247 BULLSEYE SAFETY BUSULFEX 52 caffeine & sodium benzoate 1 LANCETS 193 BUTALBITAL 81 CAFFEINE ANHYDROUS 1 bumetanide 151 butalbital-acetaminophen 8 caffeine citrate 1 BUMEX 151 butalbital-acetaminophen- CAFFEINE CITRATED 1 BUNAVAIL 14 caffeine 8 CAL-CO3Y 268 BUPHENYL 154 butalbital-acetaminophen- BUPIVACAINE caffeine w/ codeine 13 CALAMINE 140 FISIOPHARMA 172 butalbital-aspirin-caffeine 8 CALAN 72 BUPIVACAINE HCL 172 butalbital-aspirin-caffeine CALAN SR 72 bupivacaine hcl 172 w/cod 13 CALCIFOL 248 BUTALBITAL/ACETAMINOPH BUPIVACAINE HCL EN 8 CALCIPOTRIENE 81 MONOHYDRATE 172 calcipotriene 127

Index 13 CALCIPOTRIENE CALCIUM CANTHARIDIN 135 ANHYDROUS/CLOBETASOL GLUCONATE/SODIUMCHLOR CAPASTAT SULFATE 52 PROPIONATE 129 IDE 249 CALCIPOTRIENE CALCIUM capecitabine 53 MONOHYDRATE 81 GLYCEROPHOSPHATE 81 CAPEX 129 calcipotriene-betamethasone CALCIUM HYDROXIDE 108 CAPHOSOL 257 dipropionate 129 CALCIUM CAPLYTA 63 CALCIPOTRIOL 81 HYDROXYAPATITE 85 CAPRELSA 57 calcitonin (salmon) 153 CALCIUM L-5 CAPRYLIC ACID 81 CALCITRIOL 81 METHYLTETRAHYDROFOLAT E 93 CAPRYLIC/CAPRIC calcitriol 155 CALCIUM LACTATE TRIGLYCERIDE 81 calcitriol (topical) 127 PENTAHYDRATE 249 CAPRYLIC/CAPRIC CALCITRIOL IN ALMOND CALCIUM LEVULINATE TRIGLYCERIDES 82 OIL 81 DIHYDRATE 81 CAPS 0 CLEAR DELAYED CALCIUM ACETATE 81 CALCIUM OXIDE 81 RELEASE 300 calcium acetate (phosphate CALCIUM CAPSAICIN 136 binder) 160 PANTOTHENATE 325 CAPSAICIN PALMITATE 82 CALCIUM ALGINATE 81 CALCIUM PHOSPHATE CAPSICUM OLEORESIN 108 DIBASIC 249 CALCIUM AMINO ACID CAPSUBLEND-H 301 CHELATE 30% 81 CALCIUM PHOSPHATE TRIBASIC 249 CAPSUBLEND-P 301 CALCIUM ASCORBATE 325 CALCIUM PROPIONATE 81 CALCIUM ASCORBATE CAPSUBLEND-S 301 DIHYDRATE 325 CALCIUM PYRUVATE 81 CAPSULE 0 CLEAR CALCIUM CARBONATE 249 CALCIUM SACCHARIN 99 VEGGIE 300 CAPSULE 0 CLEAR VEGGIE CALCIUM CARBONATE EXTRA CALCIUM STEARATE 81 LOCKING 300 LIGHT 248 CALCIUM SULFATE 108 CAPSULE 00 CLEAR VEGGIE CALCIUM CARBONATE CALCIUM SULFATE LOCKING 300 HEAVY 248 ANHYDROUS 108 CAPSULE 1 CLEAR CALCIUM CARBONATE CALCIUM SULFATE VEGGIE 300 LIGHT 248 HEMIHYDRATE 108 CAPSULE 1 CLEAR VEGGIE CALCIUM CHLORIDE 249 CALCIUM THIOGLYCOLATE LOCKING 300 calcium chloride (dihydrate)249 TRIHYDRATE 81 CAPSULE 3 CLEAR CALCIUM CHLORIDE CALCIUM-FOLIC ACID PLUS VEGGIE 300 ANHYDROUS 81 D 249 CAPSULE 3 CLEAR VEGGIE CALCIUM CHLORIDE CALDOLOR 4 LOCKING 301 DIHYDRATE 249 CALLUS REMOVER 206 CAPSULE CONI-SNAP #0 CLEAR/CLEAR 292 CALCIUM CITRATE 81 CALLUS/CORN SHAVER206 CALCIUM CITRATE CAPSULE CONI-SNAP #0 CALLUS/CORN SHAVER CLEAR/CLEAR VEGGIE 301 TETRAHYDRATE 81 BLADES 206 CALCIUM DISODIUM CAPSULE CONI-SNAP #0 DARK VERSENATE 40 CALM 276 BLUE/DARK BLUE 292 CALQUENCE 57 CAPSULE CONI-SNAP #0 CALCIUM FOLINATE 91 GREEN/CLEAR 292 CALCIUM CAMBIA 247 CAPSULE CONI-SNAP #0 FRUCTOBORATE 81 CAMPATH 54 LIGHT BLUE/WHITE 292 CALCIUM GLUBIONATE 81 CAMPHOR 127 CAPSULE CONI-SNAP #0 CALCIUM GLUBIONATE CAMPTOSAR 61 PINK/PINK 292 MONOHYDRATE 81 CAPSULE CONI-SNAP #0 CALCIUM GLUCONATE 249 CANADIAN BALSAM 81 RED/WHITE 292 calcium gluconate 249 CANASA 159 CAPSULE CONI-SNAP #0 CANCIDAS 42 WHITE/WHITE 292 CALCIUM GLUCONATE CAPSULE CONI-SNAP ANHYDROUS 249 candesartan cilexetil 47 #0/PURPLE/OPAQUE/CLEAR CALCIUM GLUCONATE candesartan cilexetil- 292 MONOHYDRATE 249 hydrochlorothiazide 49 CAPSULE CONI-SNAP #00 CALCIUM CANNABIDIOL 81 CLEAR/CLEAR 292 GLUCONATE/DEXTROSE 249

Index 14 CAPSULE CONI-SNAP #00 CAPSULE CONI-SNAP #2 CARAFATE 317 WHITE/WHITE 292 CLEAR/CLEAR 293 CARAMEL FLAVOR 289 CAPSULE CONI-SNAP #000 CAPSULE CONI-SNAP #2 CLEAR/CLEAR 292 WHITE 293 CARBACHOL 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBAGLU 155 AQUABLUE/AQUA BLUE 292 BLUE/CLEAR 293 carbamazepine 29 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 BLUE/BLUE 292 BROWN/LIGHT BLUE 293 CARBAMAZEPINE 29 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 carbamazepine 29 BLUE/PINK 292 CLEAR/CLEAR 293 CARBAMIDE PEROXIDE 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBAPHEN 12 117 BLUE/POWDER BLUE 292 CLEAR/CLEAR VEGGIE 301 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBAPHEN 12 PED 117 BROWN/IVORY 292 DARKGREY/PINK 293 CARBATROL 29 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBAZOCHROME 82 BROWN/LIGHT BROWN 292 GRAY/YELLOW 293 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 carbidopa 61 CLEAR/CLEAR 292 GREEN/BLUE 293 CARBIDOPA 108 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBIDOPA CLEAR/CLEAR VEGGIE 301 MAROON/BLUE 293 ANHYDROUS 108 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 carbidopa-levodopa 62 DARKGREEN/DARK MINTGREEN/MINT carbidopa-levodopa-entacapone GREEN 292 GREEN 293 62 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBIMAZOLE 82 DARKGREEN/ORANGE 292 OLIVE/CLEAR 293 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 carbinoxamine maleate 43 GREEN/YELLOW 292 ORANGE/ORANGE 293 CARBINOXAMINE CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 MALEATE 43 LIGHT BLUE/WHITE 292 PINK/CLEAR 293 CARBOCAINE 173 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOGEL 940 304 LIGHT GREY/PINK 292 PINK/PINK 293 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOHOL 940 304 ORANGE 292 RED/CLEAR 293 CARBOMER 934P 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOMER 934P RESIN 82 PINK/AQUA BLUE 292 RED/RED 293 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOMER 940 82 PINK/CLEAR 292 WHITE/CLEAR 293 CARBOMER 941 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOMER GEL PINK/PINK 292 WHITE/WHITE 293 AQUEOUS 304 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBOMER GEL PINK/WHITE 292 YELLOW/YELLOW 293 HYDROALCOHOLIC 304 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 CARBOMER HOMOPOLYMER PINK/YELLOW 292 BLACK/GREEN 293 TYPE C 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 carboplatin 52 PURPLE/PURPLE 292 CLEAR/CLEAR 293 CARBOPOL 940 82 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 RED/BLUE 292 WHITE 293 CARBOPOL 940 NF 82 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #0 CARBOXYMETHYLCELLULOSE RED/WHITE 292 CLEAR 293 SODIUM 108 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #00 CARBOXYMETHYLCELLULOSE WHITE 292 CLEAR 293 SODIUM HIGH CAPSULE CONI-SNAP #1 CAPSULE SIZE 1 VISCOSITY 108 WHITE/CLEAR 293 LACTOSE 293 CARBOXYMETHYLCELLULOSE CAPSULE CONI-SNAP #1 captopril 47 SODIUM LOW VISCOSITY 108 CARBOXYMETHYLCELLULOSE WHITE/GREEN 293 CAPTOPRIL 82 CAPSULE CONI-SNAP #1 SODIUM MEDIUM YELLOW/GREEN 293 captopril & VISCOSITY 108 CAPSULE CONI-SNAP #1 hydrochlorothiazide 49 CARDENE IV 72 YELLOW/YELLOW 293 CARAC 126

Index 15 CARDIOCOM LANCING CAREFINE PEN NEEDLES CARESENS CONTROL A DEVICE 193 32GX5MM 218 SOLUTION 193 CARDIOPLEGIA DEL NIDO CAREFINE PEN NEEDLES CARESENS N BLOOD FORMULA 73 32GX6MM 218 GLUCOSETEST STRIPS 145 CARDIOPLEGIA INDUCTION CAREONE ADVANCED CARETOUCH ALCOHOL PREP HIGH POTASSIUM 74 LANCINGDEVICE 193 PADS 213 CARDIOPLEGIA INDUCTION CAREONE BLOOD GLUCOSE CARETOUCH BLOOD HIGH POTASSIUM/LOW TEST STRIPS/PREMIUM145 GLUCOSE TEST STRIPS 145 DEXTROSE 74 CAREONE BLOOD GLUCOSE CARETOUCH CONTROL CARDIOPLEGIA INDUCTION TEST STRIPS/VALUE 145 SOLUTION LEVEL 2 193 HIGH POTASSIUM/NON- CAREONE INSULIN CARETOUCH INSULIN ENRICHED 74 SYRINGES/0.3ML/30G X SYRINGE/U-100/1ML/28G X CARDIOPLEGIA INDUCTION 1/2" 218 5/16" 219 PLASMALYTE/HIGH CAREONE INSULIN CARETOUCH INSULIN POTASSIUM 74 SYRINGES/0.3ML/31G X SYRINGE/U-100/1ML/29G X CARDIOPLEGIA INDUCTION 5/16" 218 5/16" 219 PLASMALYTE/TROMETHAMINE CAREONE INSULIN CARETOUCH LANCING HIGH POTASSIU 74 SYRINGES/0.5ML/30G X DEVICEWITH EJECTOR 193 CARDIOPLEGIA 1/2" 218 CARETOUCH PEN NEEDLES MAINTENANCELOW CAREONE INSULIN 31G X 6 MM 219 DEXTROSE/LOW SYRINGES/0.5ML/31G X CARETOUCH PEN NEEDLES POTASSIUM 74 5/16" 218 31GX 5MM 219 CARDIOPLEGIA CAREONE INSULIN CARETOUCH PEN NEEDLES MAINTENANCELOW SYRINGES/1ML/30G X 31GX 8MM 219 POTASSIUM 74 1/2" 218 CARETOUCH PEN NEEDLES CARDIOPLEGIA CAREONE INSULIN 32GX 4MM 219 MAINTENANCELOW SYRINGES/1ML/31GX5/16" CARETOUCH PEN NEEDLES TROMETHAMINE/LOW 218 32GX 5MM 219 POTASSIUM 74 CAREONE LANCET CARETOUCH TWIST LANCETS CARDIOPLEGIA THIN 193 28G 193 MAINTENANCEPLASMALYTE/T CAREONE LANCET ULTRA CARETOUCH TWIST LANCETS ROMETHAMINE LOW THIN 193 30G 193 POTASSI 74 CAREONE UNIFINE PENTIPS CARETOUCH TWIST LANCETS CARDIOPLEGIA 29GX12MM 218 33G 193 REPERFUSATE/LOW CAREONE UNIFINE PENTIPS CARIMUNE POTASSIUM 74 31GX5MM 218 NANOFILTERED 285 CARDIOPLEGIC 74 CAREONE UNIFINE PENTIPS CARISOPRODOL 271 31GX6MM 218 carisoprodol 271 cardioplegic soln 74 CAREONE UNIFINE PENTIPS CARDIOPRESS 268 31GX8MM 218 carisoprodol w/ aspirin 272 CARDIOVID PLUS 275 CAREONE UNIFINE PENTIPS carisoprodol w/ aspirin & codeine 272 CARDIZEM 72 PEN NEEDLES 32GX4MM 218 CARMINE 82 CARDIZEM CD 72 CAREONE UNIFINE PENTIPS carmustine 52 CARDIZEM LA 72 PLUS PEN NEEDLES CARNAUBA WAX 82 CARDURA 48 29GX12MM 218 CAREONE UNIFINE PENTIPS CARNITINE (L) 91 CARDURA XL 162 PLUS PEN NEEDLES CARNITOR 155 CAREFINE PEN NEEDLE 31GX5MM 219 CARNITOR SF 155 32GX4MM 218 CAREONE UNIFINE PENTIPS CAREFINE PEN NEEDLES PLUS PEN NEEDLES CARNOSINE L 82 29GX1/2" 218 31GX6MM 219 CAROSPIR 152 CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPS CARPALAID EMPLOYEE 30GX5/16" 218 PLUS PEN NEEDLES SURVIVAL/LARGE 178 CAREFINE PEN NEEDLES 31GX8MM 219 CARPALAID EMPLOYEE 31GX6MM 218 CAREONE UNIFINE PENTIPS SURVIVAL/SMALL 178 CAREFINE PEN NEEDLES PLUS PEN NEEDLES CARPALAID PRACTIONER 31GX8MM 218 32GX4MM 219 PACK/LARGE 178

Index 16 CARPALAID PRACTIONER cefotaxime sodium 76 CENTANY 124 PACK/SMALL 178 cefotetan disodium 76 CENTANY AT 124 CARPALAID/LARGE 178 CEFOTETAN/DEXTROSE 76 CENTRATEX 166 CARPALAID/SMALL 178 cefoxitin sodium 76 CENTRUM 259 CARRAGEENAN 301 CEFOXITIN SODIUM 76 CENTRUM CARRAKLENZ 142 cefpodoxime proxetil 76 PERFORMANCE 268 CARRASMART 142 CENTRUM SPECIALIST cefprozil 76 CARRASMART FOAM 178 ENERGY 268 ceftazidime 76 CARRASYN HYDROGEL cephalexin 76 WOUND DRESSING 142 CEFTAZIDIME 82 CEQUA 281 CARRASYN V HYDROGEL CEFTAZIDIME/DEXTROSE CEQUR SIMPLICITY 2U 219 76 WOUNDDRESSING 142 CERACADE 138 carteolol hcl (ophth) 278 CEFTAZIDIME/SODIUM CARBONATE 82 CERAMAX 138 CARTICEL 271 CEFTRI-IM 76 CERAPHYL SLK 90 carvedilol 70 ceftriaxone sodium 76 CERDELGA 164 carvedilol phosphate 70 CEFTRIAXONE SODIUM 76 CEREBYX 31 CASCARA SAGRADA 171 ceftriaxone sodium 76 CERESIN WAX 82 CASODEX 55 CEFTRIAXONE SODIUM 82 CEREZYME 164 caspofungin acetate 42 ceftriaxone sodium in CESAMET 41 CASPOFUNGIN ACETATE 42 dextrose 76 CESIUM CHLORIDE 82 CASTOR OIL 106 CEFTRIAXONE/DEXTROSE 76 CETEARYL CATAPRES 48 ALCOHOL/CETEARETH-20 82 CEFTRISOL PLUS 76 CATAPRES-TTS-1 48 cetirizine hcl 43 CEFUROXIME 280 CATAPRES-TTS-2 48 CETOSTEARYL ALCOHOL 82 cefuroxime axetil 76 CATAPRES-TTS-3 48 CETRAXAL 284 cefuroxime sodium 76 CAYSTON 19 CETROTIDE 153 CEFUROXIME CBD4 FREEZE PUMP SODIUM/SODIUMCHLORIDE CETYL ALCOHOL 301 MAXIMUMSTRENGTH 136 280 CETYL ESTERS WAX 99 CEDAR LEAF OIL 106 CELA BASE 304 CETYL MYRISTOLEATE 82 cefaclor 76 CELACYN POST- CETYLCIDE-G 65 CEFACLOR ER 76 PROCEDURE PACK 142 CETYLEV 40 CELEBREX 4 cefadroxil 75 CETYLPYRIDINIUM CEFAZOLIN 76 celecoxib 5 CHLORIDE 82 CEFAZOLIN SODIUM 75 CELECOXIB 82 CETYLPYRIDINIUM cefazolin sodium 75 CELESTONE- CHLORIDEMONOHYDRATE SOLUSPAN 113 82 CEFAZOLIN SODIUM 75 CELEXA 32,33 cevimeline hcl 257 CEFAZOLIN SODIUM/DEXTROSE 75 CELLCEPT 253 CHANTIX 312 CEFAZOLIN SODIUM/SODIUM CELLCEPT CHANTIX CONTINUING CHLORIDE 75 INTRAVENOUS 253 MONTHPAK 312 CEFAZOLIN/SODIUM CELLULASE 82 CHANTIX STARTING MONTH CHLORIDE 76 CELLULOSE PAK 312 cefdinir 76 MICROCRYSTALLINE 82 CHARCOAL 40 cefditoren pivoxil 76 CELLULOSE PARTIALLY CHARCOAL ACTIVATED 40 DEPOLYMERIZED 82 CHEESE-ADE FLAVOR 289 CEFEPIME 77 CELLULOSE/CMC NA cefepime hcl 77 MICROCRYSTALLINE 82 CHEESECAKE FLAVOR 289 CEFEPIME/DEXTROSE 77 CELONTIN 32 CHEMET 39 cefixime 76 CEM-UREA 134 CHEMSIL K-12 304 CEFOTAN 76 CENFOL 166 CHEMSIL K-51 304

Index 17 CHEMSTRIP-K 145 CHLOROXINE 82 CHROMIUM CHENODAL 159 CHLOROXYLENOL 83 PICOLINATE/KELP/LECITHIN/B- 6/GRAPE FRUIT CHLORPHENIRAMINE CHERRY CONCENTRATE 298 EXTRACT 254 CHERRY FLAVOR 289 MALEATE 43 CHROMIUM chlorpromazine hcl 64 CHERRY SYRUP 298 POLYNICOTINATE 83 CHLORPROMAZINE HCL 83 CHROMIUM POTASSIUM CHERRY-ADE FLAVOR 289 chlorpropamide 38 SULFATE CHEW-HESIVE 304 chlorthalidone 152 DODECAHYDRATE 83 CHICKEN (GRILLED) CHROMIUM XTRA 254 CHLORZOXAZONE 271 FLAVOR 289 CHRYSADERM DAY 304 CHICKEN BROTH FLAVOR chlorzoxazone 271 SPRAY DRIED 289 CHOCOLATE CHRYSADERM NIGHT 304 CHICKEN FLAVOR 290 CONCENTRATE 290 CHRYSIN 83 CHICKEN FLAVOR OIL CHOCOLATE FLAVOR 290 CHYMOTRYPSIN ALPHA 253 SOLUBLE 290 CHOCOLATE HAZELNUT CIALIS 74 CHICKEN FLAVOR WATER FLAVOR 290 CICA-CARE 142 MISCIBLE 290 CHOCOLATE NATURAL & CHICKEN PROTEIN 82 ARTIFICAL FLAVOR 290 CICLODAN SOLUTION KIT 125 CHICKEN ROASTED CHOLASE CONTROL 268 ciclopirox 125 CONCENTRATE 290 CHOLBAM 158 CHILDRENS ADVIL 5 ciclopirox olamine 125 CHOLECAL DF 166 CHILDRENS MOTRIN 5 CICLOPIROX OLAMINE 125 CHOLECALCIFEROL 83 CHLOOXIA 129 CICLOPIROX cholecalciferol 324 OLAMINE/CLOBETASOL 128 CHLORAL HYDRATE 169 CHOLESTEROL 83 CICLOPIROX CHLORAMBUCIL 82 cholestyramine 44 OLAMINE/CLOBETASOL CHLORAMPHENICOL 82 PROPIONATE/SALICYLIC CHOLESTYRAMINE 83 CHLORAMPHENICOL ACID 128 PALMITATE 82 cholestyramine light 44 CICLOPIROX/SALICYLIC chloramphenicol sodium CHOLESTYRAMINE ACID 128 succinate 18 RESIN 83 cidofovir 68 chlordiazepoxide hcl 21 CHOLINE BITARTRATE 275 CIDOFOVIR ANHYDROUS 83 chlordiazepoxide-amitriptyline CHOLINE CHLORIDE 83 CIDOFOVIR DIHYDRATE 83 311 choline fenofibrate 45 CIFEREX 166 CHLORHEXIDINE DIACETATE CHOLINE MAGNESIUM CIFRAZOL 166 HYDRATE 82 TRISALICYLATE 83 CHLORHEXIDINE CHONDROITIN cilostazol 164 GLUCONATE 65 SULFATE 284 CILOXAN 280 chlorhexidine gluconate (mouth- CHONDROITIN SULFATE throat) 257 CIMDUO 66 SODIUM 83 CIMETIDINE 317 CHLOROACETIC ACID 129 CHORIONIC CHLOROBUTANOL 288 GONADOTROPIN 83 cimetidine 317 CHLOROBUTANOL CHORIONIC cimetidine hcl 316 ANHYDROUS 288 GONADOTROPIN(HUMAN) CIMETIDINE CHLOROFORM 106 83 HYDROCHLORIDE 316 CHLOROPHYLLIN SODIUM CHROMIC CHLORIDE 83 CIMETIDINE/LIDOCAINE/SALIC COPPER 82 chromic chloride 252 YLIC ACID 135 chloroprocaine hcl 174 CHROMIUM CHLORIDE 83 CIMZIA 159 CHLOROQUINE CHROMIUM CHLORIDE CIMZIA STARTER KIT 159 PHOSPHATE 51 HEXAHYDRATE cinacalcet hcl 155 chloroquine phosphate 51 REAGENT 83 CINNAMON BARK CASSIA 83 CHLOROTHIAZIDE 82 CHROMIUM PICOLINATE 83 CINNAMON FLAVOR 290 chlorothiazide 152 CHROMIUM PICOLINATE FORTIFIED 254 CINQAIR 22 chlorothiazide sodium 152 CINRYZE 164

Index 18 CINVANTI 42 CLARINEX-D 12 HOUR 117 CLEVER CHOICE COMFORT CIPRO 158 CLARITHROMYCIN 83 EZINSULIN SYRINGE/0.5ML/29G X CIPRO HC 285 clarithromycin 175 1/2" 219 CIPRO I.V.-IN D5W 158 CLEANLET LANCETS CLEVER CHOICE COMFORT CIPRODEX 285 28G 193 EZINSULIN CLEAR BANDAGES 178 CIPROFLOXACIN 83 SYRINGE/0.5ML/30G X CLEMASTINE 1/2" 219 ciprofloxacin 158 FUMARATE 43 CLEVER CHOICE COMFORT CIPROFLOXACIN HCL 83 clemastine fumarate 43 EZINSULIN ciprofloxacin hcl 158 CLEMIZOLE HCL 83 SYRINGE/0.5ML/30G X 5/16" 219 ciprofloxacin hcl (ophth) 280 CLENPIQ 170 CLEVER CHOICE COMFORT ciprofloxacin hcl (otic) 285 CLEOCIN 19,322 EZINSULIN ciprofloxacin in d5w 158 CLEOCIN PEDIATRIC SYRINGE/0.5ML/31G X ciprofloxacin-ciprofloxacin GRANULES 19 5/16" 219 hcl 158 CLEOCIN PHOSPHATE 19 CLEVER CHOICE COMFORT ciprofloxacin-dexamethasone CLEOCIN-T 120 EZINSULIN 285 SYRINGE/1.0ML/30G X ciprofloxacin-fluocinolone CLEODERM 304 1/2" 219 acetonide 285 CLEVER CHEK AUTO-CODE CLEVER CHOICE COMFORT CISAPRIDE TEST STRIPS 145 EZINSULIN SYRINGE/1ML/28G MONOHYDRATE 83 CLEVER CHEK AUTO-CODE X 1/2" 219 cisatracurium besylate 274 VOICE TEST STRIPS 145 CLEVER CHOICE COMFORT CLEVER CHEK LANCETS EZINSULIN SYRINGE/1ML/29G CISATRACURIUM ULTRATHIN 193 BESYLATE 274 X 1/2" 219 CLEVER CHEK LANCETS CLEVER CHOICE COMFORT cisplatin 53 ULTRATHIN 30G 193 EZINSULIN SYRINGE/1ML/30G CISPLATIN 53,83 CLEVER CHEK TEST X 5/16" 220 citalopram hydrobromide 33 STRIPS 145 CLEVER CHOICE COMFORT CITANEST FORTE CLEVER CHOICE AUTO- EZINSULIN SYRINGE/U- DENTAL 172 CODE PRO TEST 100/1ML/31GX5/16" 220 STRIPS 145 CITANEST PLAIN DENTAL173 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZLANCETS 21G 193 CITRANATAL 90 DHA 264 EZINSULIN PEN NEEDLES CLEVER CHOICE COMFORT CITRANATAL ASSURE 264 31GX8MM 219 EZLANCETS 23G 193 CITRANATAL B-CALM 264 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES EZLANCETS 28G 193 CITRANATAL BLOOM 264 33GX4MM 219 CLEVER CHOICE COMFORT CITRANATAL BLOOM CLEVER CHOICE COMFORT EZPEN NEEDLES DHA 264 EZINSULIN 29GX12MM 220 CITRANATAL DHA 264 SYRINGE/0.3ML/29G X CLEVER CHOICE COMFORT CITRANATAL HARMONY 264 1/2" 219 EZPEN NEEDLES CITRANATAL MEDLEY 264 CLEVER CHOICE COMFORT 31GX5MM 220 EZINSULIN CLEVER CHOICE COMFORT CITRANATAL RX 264 SYRINGE/0.3ML/30G X EZPEN NEEDLES CITRIC ACID 108 1/2" 219 31GX6MM 220 CITRIC ACID CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT ANHYDROUS 108 EZINSULIN EZPEN NEEDLES CITRIC ACID SYRINGE/0.3ML/30G X 31GX8MM 220 MONOHYDRATE 108 5/16" 219 CLEVER CHOICE COMFORT CITRONELLA OIL 106 CLEVER CHOICE COMFORT EZPEN NEEDLES CITRULLINE(L) 83 EZINSULIN 32GX4MM 220 SYRINGE/0.3ML/31G X CLEVER CHOICE COMFORT CITRUS BIOFLAVONOIDS 83 5/16" 219 EZPEN NEEDLES cladribine 53 CLEVER CHOICE COMFORT 32GX5MM 220 CLAFORAN 76 EZINSULIN CLEVER CHOICE COMFORT SYRINGE/0.5ML/28G X CLARINEX 43 EZPEN NEEDLES 1/2" 219 32GX6MM 220

Index 19 CLEVER CHOICE COMFORT clindamycin phosphate clobetasol propionate 130 EZPEN NEEDLES vaginal 322 CLOBETASOL 32GX8MM 220 clindamycin phosphate-benzoyl PROPIONATE 130 CLEVER CHOICE COMFORT peroxide 120 clobetasol propionate emollient EZPEN NEEDLES clindamycin phosphate-benzoyl base 130 33GX4MM 220 peroxide (refrigerate) 120 clobetasol propionate CLEVER CHOICE COMFORT clindamycin phosphate- emulsion 130 EZPEN NEEDLES tretinoin 120 CLOBETASOL PROPIONATE 33GX5MM 220 CLINDAMYCIN MICRONIZED USP 130 CLEVER CHOICE COMFORT PHOSPHATE/NIACINAMIDE CLOBETASOL EZPEN NEEDLES 120 PROPIONATE/LEVOCETIRIZIN 33GX6MM 220 CLINDAMYCIN E DIHYDROCHLORIDE 130 CLEVER CHOICE COMFORT PHOSPHATE/NIACINAMIDE/T CLOBETASOL EZPEN NEEDLES RETINOIN 120 PROPIONATE/NIACINAMIDE 33GX8MM 220 CLINDAMYCIN/NIACINAMIDE/ 130 CLEVER CHOICE MICRO SPIRONOLACTONE/TRETINO CLOBEX 130 TESTSTRIPS 146 IN 120 CLEVER CHOICE NO CODING CLINDAMYCIN/SODIUM clocortolone pivalate 130 TEST STRIPS 146 CHLORIDE 19 CLODAN KIT 130 CLEVER CHOICE TALK NO CLINDESSE 322 CLODERM 130 CODING TEST STRIPS 146 CLINIMIX 4.25%/DEXTROSE CLODERM PUMP 130 CLEVIPREX 72 10% 277 CLICKFINE PEN NEEDLE CLINIMIX 4.25%/DEXTROSE clofarabine 53 32GX5/32" 220 25% 277 CLOFAZIMINE 83 CLICKFINE PEN NEEDLE CLINIMIX 4.25%/DEXTROSE CLOLAR 53 UNIVERSAL/31GX1/4" 220 5% 277 CLOMIPHENE CITRATE 153 CLICKFINE PEN NEEDLE CLINIMIX 5%/DEXTROSE UNIVERSAL/31GX5/16" 220 15% 277 clomiphene citrate 153 CLICKFINE PEN NEEDLES 31G CLINIMIX 5%/DEXTROSE clomipramine hcl 34 X 1/4" 220 20% 277 CLOMIPRAMINE HCL 83 CLICKFINE PEN NEEDLES 31G CLINIMIX 5%/DEXTROSE X 5/16" 220 25% 277 clonazepam 28 CLICKFINE PEN CLINIMIX E 2.75%/DEXTROSE CLONAZEPAM 83 NEEDLES/31GX1/4" 220 10% 277 clonidine 48 CLICKFINE UNIVERSAL PEN CLINIMIX E 2.75%/DEXTROSE CLONIDINE HCL 48 NEEDLES 31GX5/16" 220 5% 277 CLIDINIUM BROMIDE 83 CLINIMIX E 4.25%/DEXTROSE clonidine hcl 48 10% 277 clonidine hcl (adhd) 1 CLIMARA 157 CLINIMIX E 4.25%/DEXTROSE CLIMARA PRO 157 clonidine hcl (analgesia) 8 25% 277 CLONIDINE CLIN SINGLE USE KIT 19 CLINIMIX E 4.25%/DEXTROSE HYDROCHLORIDE 48 CLINDACIN ETZ 120 5% 277 CLOPIDOGREL CLINIMIX E 5%/DEXTROSE BISULFATE 83 CLINDACIN PAC 120 15% 277 CLINDAGEL 120 CLINIMIX E 5%/DEXTROSE clopidogrel bisulfate 164 clindamycin hcl 19 20% 277 CLOPIDOGREL KIT 164 CLINIMIX E 5%/DEXTROSE CLINDAMYCIN HCL 83 clorazepate dipotassium 21 25% 277 CLOROTEKAL 174 CLINDAMYCIN HCL CLINIMIX N14G30E 277 MONOHYDRATE 83 CLORSULON 83 CLINIMIX N9G15E 277 clindamycin palmitate CLOTRIMAZOLE 125 hydrochloride 19 CLINIMIX N9G20E 277 clotrimazole 257 clindamycin phosphate 19 CLINOIN 120 clotrimazole (topical) 125 CLINDAMYCIN CLINOLIPID 275 PHOSPHATE 83 clotrimazole w/ clindamycin phosphate CLIOQUINOL 125 betamethasone 125 (topical) 120 clobazam 28 CLOVAGEL 304 clindamycin phosphate in CLOBETASOL 17 CLOVE OIL 106 d5w 19 PROPIONATE 130

Index 20 clozapine 64 COLLAGEN COMPEED SKIN PROTECTOR CLOZARIL 64 HYDROLYSATE 84 DRESSING/SMALL/STRIP 178 COLLAGEN ULTRA 268 COMPLERA 66 CO-ENZYME Q 10 108 COLLAGENASE 134 COMPLETE MENOPAUSE CO-NATAL FA 264 COLLASIL OSA 301 HEALTH FORMULA 254 CO-VERATROL 3 COMPLETE NATAL DHA 264 COLLODION 298 COAGADEX 163 COMPLETE PROSTATE COLLODION FLEXIBLE 298 COAGUCHEK LANCETS 193 HEALTHFORMULA 254 COLY-MYCIN M 20 COAL TAR 107 COMPLETENATE 264 COLY-MYCIN S 285 coal tar extract 141 COMTAN 61 COLYTE-FLAVOR CONCEPT DHA 264 COARTEM 51 PACKS 170 CONCEPT OB 264 COBALT GLUCONATE 83 COMBIGAN 278 CONCERTA 2 COBAMAMIDE 83 COMBIPATCH 157 CONDYLOX 135 COCAINE HCL 136 COMBIVENT RESPIMAT 24 CONSENSI 72 cocaine hcl 136 COMBIVIR 66 CONTOUR BLOOD GLUCOSE COCAINE COMETRIQ 57 HYDROCHLORIDE 272 TEST STRIPS 146 COMFORT ASSIST INSULIN CONTOUR NEXT BLOOD COCAMIDE DEA 83 SYRINGE 0.3ML/29G X GLUCOSE TEST 146 COCOA BUTTER 301 1/2" 220 CONTRAST ALLERGY PREMED COCOA BUTTER COMFORT ASSIST INSULIN PACK 113 DEODORIZED 301 SYRINGE/0.3ML/30G X CONVENIENCE PAK 312 COCONUT FLAVOR 290 5/16" 220 COMFORT ASSIST INSULIN CONZIP 9 COCONUT OIL 106 SYRINGE/0.3ML/31G X COOL BLOOD GLUCOSE TEST COD LIVER OIL 270 5/16" 220 STRIPS 146 COD LIVER OIL FOR KIDS270 COMFORT ASSIST INSULIN COOL CONTROL SOLUTION A 194 CODAR AR 117 SYRINGE/0.5ML/29G X 1/2" 220 COOL CONTROL SOLUTION CODEINE PHOSPHATE 9 COMFORT ASSIST INSULIN B 194 CODEINE SULFATE 9 SYRINGE/0.5ML/30G X COOLMAGIC 142 codeine sulfate 9 5/16" 220 COOLMAGIC TUBE SITE DRESSING 142 CODEINE SULFATE 9 COMFORT ASSIST INSULIN SYRINGE/0.5ML/31G X COPA ISLAND BORDERED COENZYME Q-10 3 5/16" 221 FOAM DRESSING 4"X4" 178 COENZYME Q10 108 COMFORT ASSIST INSULIN COPA ISLAND BORDERED COFFEE FLAVOR 290 SYRINGE/1ML/29G X FOAM DRESSING 6"X6" 178 1/2" 221 COPA PLUS HYDROPHILIC COGENTIN 61 COMFORT ASSIST INSULIN FOAM DRESSING 4"X4" 178 COLA FLAVOR 290 SYRINGE/1ML/30G X COPA PLUS HYDROPHILIC COLAZAL 159 5/16" 221 FOAM DRESSING 4"X8" 178 COPA PLUS HYDROPHILIC colchicine 163 COMFORT ASSIST INSULIN SYRINGE/1ML/31G X FOAM DRESSING 6"X6" 178 COLCHICINE 163 5/16" 221 COPASIL 99 colchicine w/ probenecid 162 COMFORT ASSURED COPAXONE 311 COLCRYS 163 LANCETS MICRO THIN COPIKTRA 57 33G 193 colesevelam hcl 44 COMFORT ASSURED COPPER GLUCONATE 84 COLESTID 44 LANCETS SUPER THIN COPPER GLYCINATE 84 COLESTID FLAVORED 44 28G 193 COPPER PEPTIDE 84 colestipol hcl 44 COMFORT LANCETS 193 CORAL CALCIUM 84 COLHIBIN 83 COMPEED SKIN PROTECTOR CORDARONE 22 colistimethate sodium 20 DRESSING/MEDIUM/OVAL CORDRAN 130 COLISTIMETHATE 178 COREG 70 SODIUM 84 COREG CR 70

Index 21 CORGARD 71 CREATINE ANHYDROUS 84 CUPRIMINE 252 CORIFACT 163 CREATINE CUPUACU BUTTER 84 CORLANOR 75 MONOHYDRATE 84 CURAD ACTI-FLEX FOAM CREATININE 84 CORLOPAM 50 7/8" 179 CREME DE MENTHE CURAD ACTI-FLEX FOAM CORN OIL 84 FLAVOR 290 ASSORTED 179 CORN STARCH 108 CREME DEMENTHE CURAD ADHESIVE BANDAGES CORN SYRUP 298 FLAVOR 290 FLEX ASSORTED 179 CURAD ADHESIVE BANDAGES CORTEF 113 CREON 151 CRESEMBA 42 FLEX FAMILY ASSORTED 179 CORTENEMA 16 CURAD COMFORT CORTIFOAM 16 CRESOL 84 FABRIC 179 CREST TARTAR CURAD GODZILLA 179 CORTISONE ACETATE 113 CONTROL 214 cortisone acetate 113 CURAD HOLD TITE TUBULAR CREST TARTAR STRETCH CORTISPORIN 124 CONTROL/BAKING SODA BANDAGE/LARGE/5YDS 179 TOOTHPASTE 214 CORTISPORIN-TC 285 CURAD JURASSIC PARK 179 CREST TOOTHPASTE 214 CORVERT 22 CURAD KID SIZE DINOSAUR CREST CORVITE 259 BANDAGES 179 TOOTHPASTE/REGULAR 21 CURAD NON-STICK PADS CORVITE 150 166 4 3"X4" 179 CORVITE FE 166 CREST CURAD NON-STICK PADS TOOTHPASTEREGULAR 21 WITHADHESIVE TABS CORZIDE 49 4 COSENTYX 127 3"X4" 179 CRESTOR 45 CURAD SENSITIVE SKIN COSENTYX SENSOREADY CRINONE 322 3/4" 179 PEN 127 CRIXIVAN 66 CURAD SENSITIVE SKIN COSMEGEN 56 ASSORTED FAMILY COSMOCIL CQ 96 CROFAB 285 PACK 179 COSOPT 278 cromolyn sodium 22 CURAD SENSITIVE SKIN EXTRA LARGE 179 COSOPT PF 278 CROMOLYN SODIUM 22 cromolyn sodium CURAD SENSITIVE SKIN COTELLIC 57 (mastocytosis) 159 SPOTS 179 COTEMPLA XR-ODT 2 cromolyn sodium (ophth) 284 CURAD WILD STYLES DESIGN- COTTON CANDY FLAVOR290 ITS 179 CROSCARMELLOSE CURAD WILD STYLES COTTONSEED OIL 106 SODIUM 84 TATTOO-U 179 COUMADIN 26 CROTAMITON 84 CURAFIL GEL WOUND COUMARIN 84 crotamiton 141 DRESSING 142 COVERLET STRIPS 178 CROTON OIL 84 CURCUMAX PRO 254 COVRSITE COVER CRUAD GAUZE PADS 4" X CURCUMIN 102 DRESSING 178 4" 179 CURCUMIN EXTRACT 102 COVRSITE PLUS COMPOSITE CRYOSERV 106 CURITY #10 BURN DRESSING 179 CRYSVITA 155 DRESSING/READY CUT COZAAR 47 CUBICIN 18 GAUZE/12"X12" 179 CURITY #10 BURN CRAN-RASPBERRY CUBICIN RF 18 FLAVOR 290 DRESSING/READY CUT CRANBERRY 84 CUCUMBER MELON 105 GAUZE/18"X18" 179 CRAYON BANDAGES CULTURELLE DIGESTIVE CURITY #10 BURN STRIPS 179 HEALTH WOMENS HEALTHY DRESSING/READY CUT CREAM BASE 304 BALANCE 39 GAUZE/36"X36" 179 cupric chloride 252 CURITY #10 GAUZE CREAM BASE NIOSOMES 304 CUPRIC CHLORIDE BOLT/OVAL CREAM CONCENTRATE 304 DIHYDRATE 84 FOLD/36"X300' 179 CREAM-HEAVY BASE CUPRIC SULFATE 252 CURITY ADHESIVE WOUND NIOSOME 304 CUPRIC SULFATE CLOSURE STRIPS 1/2"X4"179 CREATINE 84 PENTAHYDRATE 252

Index 22 CURITY ADHESIVE WOUND CURITY CURAD FLEXIBLE CURITY KERLIX BANDAGE CLOSURE STRIPS 1/4"X1- FABRIC ROLL/4-1/2"X144" 181 1/2" 179 BANDAGES/3/4" 180 CURITY KERLIX ROLL 4.5X4.1 CURITY ADHESIVE WOUND CURITY CURAD FLEXIBLE YARDS 181 CLOSURE STRIPS 1/4"X3"179 FABRIC CURITY MESH GAUZE CURITY ADHESIVE WOUND BANDAGES/ASSORTED 180 BANDAGEROLL 1"X30' 181 CLOSURE STRIPS 1/4"X4"179 CURITY CURAD NEON CURITY MESH GAUZE CURITY ADHESIVE WOUND STRIPSBANDAGES/3/4"/ASS BANDAGEROLL 2"X30' 181 CLOSURE STRIPS 1/8"X3"179 ORTED COLORS 180 CURITY MESH GAUZE CURITY ALCOHOL CURITY DRESSING BANDAGEROLL 3"X30' 181 PREPS/MEDIUM 2 PLY 213 SPONGES 4"X3" 6 PLY 180 CURITY MESH GAUZE CURITY ALCOHOL CURITY DRESSING BANDAGEROLL 4"X30' 181 SWABS 213 SPONGES 4"X4" 6 PLY 180 CURITY NON-ADHERENT CURITY ALL PURPOSE CURITY GAUZE PADS STRIPS 1/2"X12' 181 SPONGES 2"X2" 179 2"X2" 180 CURITY NON-ADHERENT CURITY ALL PURPOSE CURITY GAUZE PADS 2"X2" STRIPS 3"X8" 181 SPONGES 2"X2" 4PLY 179 12 PLY 180 CURITY NON-ADHERING CURITY ALL PURPOSE CURITY GAUZE PADS 4"X4" DRESSINGS 3"X8" 181 SPONGES 4 PLY 179 12 PLY 180 CURITY PLAIN PACKING CURITY ALL PURPOSE CURITY GAUZE SPONGE STRIP 181 SPONGES 4"X3" 4PLY 179 2"X2" 8 PLY 180 CURITY SODIUM CHLORIDE CURITY ALL PURPOSE CURITY GAUZE SPONGE DRESSING 6"X6-3/4" 142 SPONGES 4"X4" 179 2"X2"12 PLY 180 CURITY CURITY ALL PURPOSE CURITY GAUZE SPONGE SPONGES/CELLULOSEFILLED/ SPONGES 4"X4" 4PLY 179 4"X4" 12 PLY 180 2"X2" 181 CURITY ALL PURPOSE CURITY GAUZE SPONGE CURITY SPONGES 4"X4" 4PLY/SOFT 4"X4" 16 PLY 180 SPONGES/CELLULOSEFILLED/ POUCH 179 CURITY GAUZE SPONGE 4"X4" 181 CURITY AMD 4"X4" 8 PLY 180 CURITY STRETCH GAUZE ANTIMICROBIALGAUZE CURITY GAUZE SPONGE BANDAGE/1"X4.1YD 181 SPONGES 2"X2" 8 PLY 180 4"X4"16 PLY 180 CURITY STRETCH GAUZE CURITY AMD CURITY GAUZE SPONGE BANDAGE/2"X4.1YD 181 ANTIMICROBIALGAUZE 8"X4" 12 PLY 180 CURITY STRETCH GAUZE SPONGES 4"X4" 12 PLY 180 CURITY GAUZE SPONGE BANDAGE/3"X4.1YD 181 CURITY AMD 8"X4"12 PLY 180 CURITY STRETCH GAUZE ANTIMICROBIALPACKING CURITY GAUZE SPONGES BANDAGE/4"X4.1YD 181 STRIPS 1"X3' 180 4"X3"16 PLY 180 CURITY TELFA STERILE CURITY AMD CURITY GAUZE SPONGES ADHESIVE PADS/3"X4" 181 ANTIMICROBIALPACKING 4"X4" 12 PLY 180 CURITY TELFA STERILE NON- STRIPS 1/2"X3' 180 CURITY GAUZE SPONGES STICK PADS/3"X4" 181 CURITY AMD 4"X4" 8 PLY 180 CURITY TRIANGULAR ANTIMICROBIALPACKING CURITY HYPERTONIC BANDAGE 40"X40"X56" 181 STRIPS 1/4"X3' 180 SODIUMCHLORIDE PACKING CURITY WET DRESSING CURITY COVER SPONGE STRIP 1/2"X15' 142 8"X4" 181 4"X4" 180 CURITY IODOFORM CUROSURF 313 CURITY COVER SPONGES PACKING STRIP 181 CUSTOM LIPOTHENE 110 304 3"X4" 180 CURITY IODOFORM CURITY COVER SPONGES PACKING STRIP 1"X15' 180 CUSTOM LIPOTHENE 133 304 4"X3" 180 CURITY IODOFORM CUSTOM POLYGLYCOL CURITY COVER SPONGES PACKING STRIP TROCHEBASE 298 4"X4" 180 1/2"X15' 180 CUTAQUIG 285 CURITY CURAD ADHESIVE CURITY IODOFORM CUTIS PLUS 304 BANDAGES/3/4" PLASTIC 180 PACKING STRIP CUTIVATE 130 CURITY CURAD ADHESIVE 1/4"X15' 181 BANDAGES/3/4" SHEER 180 CURITY IODOFORM CUVITRU 285 CURITY CURAD ADHESIVE PACKING STRIP 2"X15' 181 CUVPOSA 316 BANDAGES/PLASTIC 180 CURITY KERLIX BANDAGE CVS ADHESIVE BANDAGES CURITY CURAD ADHESIVE ROLL/2-1/4"X108" 181 FOAM TOE SIZE 181 BANDAGES/SHEER 180

Index 23 CVS ADHESIVE GAUZE PAD CVS LANCETS MICRO THIN CYCLOPENTOLATE HCL 84 PREMIUM 4"X8" 181 33G 194 cyclopentolate hcl 279 CVS ADHESIVE PAD CVS LANCETS MICRO-THIN 4"X4" 181 33G 194 CYCLOPHENE RAPIDPAQ271 CVS ADHESIVE PAD CVS LANCETS cyclophosphamide 53 6"X6" 181 ORIGINAL 194 CYCLOPHOSPHAMIDE 84 CVS ADHESIVE PADS CVS LANCETS THIN CYCLOPHOSPHAMIDE 2.25"X3" 181 26G 194 MONOHYDRATE 84 CVS ADVANCED GEL CVS LANCETS ULTRA THIN ORTHOTICS/MENS 206 30G 194 cycloserine 52 CVS ADVANCED GLUCOSE CVS LANCETS ULTRA-THIN CYCLOSERINE 84 METER TEST STRIPS 146 30G 194 CYCLOSET 36 CVS ADVANCED HEALING CVS LANCING DEVICE 194 CYCLOSPORINE 84 PREMIUM CVS MANUKA HONEY cyclosporine 253 BANDAGES/SMALL 181 WOUND GEL 142 CVS ALCOHOL PREP CVS NON-STICK PADS CYCLOSPORINE A 84 PADS 213 3"X4" 182 CYCLOSPORINE IN CVS ANTI-BACTERIAL CVS NON-STICK PADS KLARITY 281 BANDAGES 181 3"X8" 182 cyclosporine modified (for CVS ANTI-BACTERIAL CVS PLASTIC microemulsion) 253 BANDAGES CHILDRENS 181 BANDAGES 182 CYCLOTENS REFILL PAK 271 CVS ANTI-BACTERIAL CVS PRENATAL CYCLOTENS STARTER BANDAGES GUMMIES 264 PAK 271 WATERPROOF 181 CVS PREP PADS 213 CVS ANTIBACTERIAL CYKLOKAPRON 168 BANDAGES/HEAVY DUTY CVS PURIFIED WATER 298 CYMBALTA 33 FABRIC 181 CVS SHEER cyproheptadine hcl 44 BANDAGES 182 CVS BUTTERFLY CYPROHEPTADINE HCL 84 CLOSURES 182 CVS SHEER BANDAGES CVS CLEAR BANDAGES 182 EXTRALARGE 182 CYRAMZA 54 CVS SPOT BANDAGE CVS COD LIVER OIL 271 CYSTADANE 155 SHEER 182 CYSTAGON 162 CVS DISTILLED WATER 298 CVS TUBULAR GAUZE 182 CVS DRY MOUTH SPRAY 257 CVS ULTRA THIN CYSTARAN 284 CVS FLEXIBLE FABRIC ANTI- LANCETS 194 CYSTEAMINE HCL 84 BACTERIAL BANDAGES 182 CYANOCOBALAMIN 84 cysteine hcl 277 CVS GAUZE PAD 8"X4" 182 cyanocobalamin 165 cytarabine 53 CVS GAUZE PADS 2"X2" 12- CYANOCOBALAMIN 165 CYTO CARN 277 PLY 182 CVS GAUZE PADS 4"X4" 12- cyanocobalamin- CYTO RALA 3 methylcobalamin 166 PLY 182 CYTOGAM 285 CVS GAUZE PADS STERILE CYANOKIT 40 CYTOMEL 315 4"X4" 12-PLY 182 CYCLANDELATE 84 CYTOTEC 318 CVS GLUCOSAMINE CYCLO/GABA10/300 CHONDROITIN/MSM TRIPLE PACK 272 CYTOTINE 275 STRENGTH 254 CYCLOBENZAPRINE 84 CYTOVENE 68 CVS GLUCOSE METER TEST CYCLOBENZAPRINE D-CARE 100X 172 STRIPS 146 HCL 84 D-CARE BLOOD CVS HAIR/SKIN/NAILS 268 cyclobenzaprine hcl 271 GLUCOSE 146 CVS IODINE TINCTURE 65 CYCLOBENZAPRINE D-CARE DM2 35 CVS ISOPROPYL HYDROCHLORIDE 84 D-MANNOSE 85 ALCOHOL 106 CYCLOGYL 279 D-RIBOSE 85 CVS ISOPROPYL ALCOHOL CYCLOMETHICONE 84 WIPES 140 D-RIBOSE REAGENT 85 CVS ISOPROPYL RUBBING CYCLOMYDRIL 279 D-VI-SOL 324 CYCLOPENTASILOXANE/PEG ALCOHOL 106 D-VITAMIN E SUCCINATE 104 CVS LANCETS 21G 194 /PPG-18/18 DIMETHICONE 84 D.H.E. 45 247

Index 24 dacarbazine 59 DELBASE DERMACEA GAUZE FLUFF DACOGEN 53 COMPOUNDING 304 ROLL 2"X3YD 182 DELESTROGEN 157 DERMACEA GAUZE FLUFF dactinomycin 56 DELFLEX-LC/1.5% ROLL 2.25"X3 YD 6 PLY 182 DAKLINZA 68 DEXTROSE 256 DERMACEA GAUZE FLUFF DALFAMPRIDINE 87 DELFLEX-LC/2.5% ROLL 3.4"X3-1/2YD 6PLY 182 DERMACEA GAUZE FLUFF dalfampridine 311 DEXTROSE 256 DELFLEX-LC/4.25% ROLL 3.4"X3.6 YD 6 PLY 182 DALIRESP 23 DEXTROSE 256 DERMACEA GAUZE FLUFF DALVANCE 18 DELFLEX-SM/1.5% ROLL 4-1/2"X4-1/8YD danazol 15 DEXTROSE 256 6PLY 182 DERMACEA GAUZE FLUFF DANAZOL 15 DELFLEX-SM/2.5% DEXTROSE 256 ROLL 4.5"X4.1 YD 6 PLY 182 DANTRIUM 272 DELIVRA SR 304 DERMACEA GAUZE ROLL DANTRIUM IV 272 2"X4-1/8YD 182 DELSTRIGO 66 DERMACEA GAUZE ROLL DANTROLENE SODIUM 85 DELUO ANTIMICROBIAL 3"X4-1/8YD 182 dantrolene sodium 272 WOUND& SKIN DERMACEA GAUZE ROLL DAPIPRAZOLE HCL 85 CLEANSER 142 4"X4-1/8YD 182 dapsone 19 DELZICOL 159 DERMACEA GAUZE ROLL DEMADEX 151 6"X4-1/8YD 182 DAPSONE 85,120 DERMACEA GAUZE SPONGE dapsone (topical) 120 DEMECARIUM BROMIDE 85 2"X2" 12 PLY 182 DAPSONE/NIACINAMIDE 120 demeclocycline hcl 314 DERMACEA GAUZE SPONGE DAPSONE/NIACINAMIDE/SPIR DEMEROL 9 2"X2" 8 PLY 182 ONOLACTONE 120 DEMSER 47 DERMACEA GAUZE SPONGE 4"X4" 12 PLY 182 DAPTACEL 315 DENATONIUM DERMACEA GAUZE SPONGE DAPTOMYCIN 18 BENZOATE 85 4"X4" 16 PLY 182 daptomycin 18 DENAVIR 128 DERMACEA GAUZE SPONGE DEOXIA 120 4"X4" 8 PLY 182 DARAPRIM 51 DERMACEA I.V. DRAIN darifenacin hydrobromide 319 DEOXYCHOLIC ACID 85 DEOXYCHOLIC ACID SPONGES 2"X2" 182 DERMACEA I.V. DRAIN DARZALEX 54 SODIUM 99 DARZALEX FASPRO 57 SPONGES 4"X4" 182 DEPACON 32 DERMACEA I.V. SPONGES daunorubicin hcl 56 DEPAKENE 32 2"X2" 182 DAUNORUBICIN DEPAKOTE 32 DERMACEA NON-ADHERENT HYDROCHLORIDE 56 DRESSING 3"X4" 182 DAURISMO 55 DEPAKOTE ER 32 DERMACEA NON-WOVEN DAYPRO 5 DEPAKOTE SPRINKLES 32 SPONGES 2"X2" 4 PLY 182 DERMACEA NON-WOVEN DAYTRANA 2 DEPEN TITRATABS 253 DEPO-ESTRADIOL 157 SPONGES 3"X4" 4 PLY 182 DAYVIGO 170 DERMACEA NON-WOVEN DDAVP 156 DEPO-MEDROL 113 SPONGES 3"X4" 6 PLY 182 DEBACTEROL 257 DEPO-PROVERA 55 DERMACEA NON-WOVEN DEPO-PROVERA SPONGES 4"X4" 4 PLY 182 decitabine 53 CONTRACEPTIVE 112 DERMACEA NON-WOVEN DECOLORIZED IODINE 65 DEPO-SUBQ PROVERA SPONGES 4"X4" 6 PLY 183 deferasirox 39 104 112 DERMACEA STRETCH DEPO-TESTOSTERONE 15 BANDAGE ROLL 2"X12' 183 deferiprone 39 DERMACEA STRETCH deferoxamine mesylate 40 DEPRIZINE FUSEPAQ 317 BANDAGE ROLL 3"X12' 183 DEHYDROCHOLIC ACID 85 DERMA-SMOOTHE/FS DERMACEA STRETCH BODY 130 BANDAGE ROLL 4"X12' 183 DEHYDROEPIANDROSTERON DERMA-SMOOTHE/FS E 108 DERMACEA STRETCH SCALP 130 BANDAGE ROLL 6"X12' 183 DEHYDROEPIANDROSTERON DERMACEA DRAIN E MICRONIZED 108 DERMACEA STRETCH SPONGES 4"X4" 182 BANDAGE2"X4-1/8YD 183

Index 25 DERMACEA STRETCH DERMACINRX SURGICAL desogestrel-ethinyl estradiol BANDAGE3"X4-1/8YD 183 PHARMAPAK 140 (triphasic) 111 DERMACEA STRETCH DERMACINRX THERAZOLE DESONATE 130 BANDAGE4"X4-1/8YD 183 PAK 125 desonide 130 DERMACEA STRETCH DERMACINRX TICANASE BANDAGE6"X12.3' 183 PAK 272 DESONIDE 131 DERMACEA STRETCH DERMACINRX TOPICAL DESOWEN 131 BANDAGE6"X4-1/8YD 183 SOLUTION BASE 298 DESOXIMETASONE 85,131 DERMACEA STRETCH DERMACINRX TSS BANDAGEROLL 3"X12' 183 BASE 298 desoximetasone 131 DERMACEA STRETCH DERMACINRX ZRM PAK136 DESOXYCORTICOSTERONE ACETATE 85 BANDAGEROLL 4"X12' 183 DERMADRESS DERMACEA STRETCH WATERPROOF COMPOSITE DESOXYN 1 BANDAGEROLL 6"X12' 183 DRESSING 183 desvenlafaxine 33 DERMACEA SUPER SPONGE DERMAGRAN HYDROGEL DESVENLAFAXINE ER 33 6"X6.75" 183 WOUNDDRESSING 142 desvenlafaxine succinate 33 DERMACEA TYPE VII GAUZE DERMAGRAN-B 2"X2" 12 PLY 183 HYDROPHILIC WOUND DETROL 319 DERMACEA TYPE VII GAUZE DRESSING 142 DETROL LA 319 2"X2" 8 PLY 183 DERMALEVIN ADHESIVE DEVILS CLAW 85 DERMACEA TYPE VII GAUZE FOAMDRESSING 4"X4" 183 4"X4" 12 PLY 183 DERMALEVIN ADHESIVE DEXABLISS 113 DERMACEA TYPE VII GAUZE FOAMDRESSING 6"X6" 183 DEXAMETHASONE 85 4"X4" 16 PLY 183 DERMASHIELD dexamethasone 114 DERMACEA TYPE VII GAUZE HYDROGEL 304 4"X4" 8 PLY 183 DEXAMETHASONE (LA) 113 DERMACEA X-RAY SPONGES DERMASORB HC 130 DEXAMETHASONE 10-DAY 4"X4" 16 PLY 183 DERMASORB TA 130 DOSE PACK 114 DERMACEA X-RAY SPONGES DERMASORB XM 134 DEXAMETHASONE 13-DAY 4"X8" 12 PLY 183 DERMASYN 142 DOSE PACK 114 DEXAMETHASONE DERMACEA X-RAY SPONGES dermatological products, 4"X8" 12PLY 183 ACETATE 85 DERMACEA X-RAY SPONGES misc. 138 DEXAMETHASONE ACETATE 4"X8" 16 PLY 183 DERMAZINC CREAM 128 ANHYDROUS 85 DERMACEA X-RAY SPONGES DERMAZYL 136 DEXAMETHASONE 4"X8" 24 PLY 183 DERMOTIC 285 ACETATE/DEXAMETHASONE DERMACINRX ANALGESIC PHOSPHATE 114 DERMULCERA 142 COMBOPAK 5 DEXAMETHASONE BASE 85 DERMACINRX AZENASE DESCOVY 66 DEXAMETHASONE PAK 272 DESFERAL 40 INTENSOL 114 DERMACINRX CINLONE-I desflurane 161 DEXAMETHASONE CPI 113 DESICCATED BEEF ISONICOTINATE 85 DERMACINRX DEXAMETHASONE SODIUM CLORHEXACIN 140 LIVER 85 DESIPRAMINE HCL 34 PHOSPHATE 85,114 DERMACINRX DUOPATCH dexamethasone sodium PHARMAPAK 136 desipramine hcl 34 phosphate 114 DERMACINRX ETHOXY desloratadine 44 DEXAMETHASONE SODIUM DIGLYCOL 84 DESMOPRESSIN PHOSPHATE 114 DERMACINRX INFLAMMATRAL ACETATE 85 dexamethasone sodium PAK 5 phosphate (ophth) 281 DERMACINRX LEXITRAL desmopressin acetate 156 desmopressin acetate DEXAMETHASONE SODIUM PHARMAPAK 123 PHOSPHATE/DEXTROSE 114 DERMACINRX NEUROTRAL spray 156 desmopressin acetate spray DEXAMETHASONE SODIUM PHARMAPAK 136 PHOSPHATE/SODIUM DERMACINRX PHN PAK 136 refrigerated 156 desogestrel & ethinyl CHLORIDE 114 DERMACINRX estradiol 111 DEXAMETHASONE/MOXIFLOX PUREFOLIX 166 desogestrel-ethinyl estradiol ACIN HCL 281 DERMACINRX SURGICAL (biphasic) 111 DEXAMETHASONE/MOXIFLOX COMBOPAK 140 ACIN/KETOROLAC 281

Index 26 DEXAMETHASONE/SODIUM DEXYCU 282 diazepam (anticonvulsant) 28 PHOSPHATE 114 DFS DR/MS/MENTH/CAP diazoxide 36 dexchlorpheniramine PAK 5 DIAZOXIDE 85 maleate 43 DFS/MS/MENTH/CAP DEXCHLORPHENIRAMINE PAK 123 DIBENZYLINE 47 MALEATE 85 DHEA 108 DIBUCAINE 86 DEXEDRINE 1 DHEA MICRONIZED 108 DIBUCAINE HCL 85 DEXERYL 138 DIAB 142 DIBUTYL SQUARATE 99 DEXILANT 317 DIAB DAILY CARE 142 DICHLORALPHENAZONE 86 DEXLIDO 114 DIAB F.D.G. FREEZE- DICHLOROACETIC ACID 86 DEXLIDO-M 114 DRIED 142 DICLAZURIL 86 DEXMEDETOMIDINE HCL 169 DIACOMIT 29 DICLEGIS 41 dexmedetomidine hcl 169 DIADIMAXIA 120 DICLO GEL PAK 123 dexmedetomidine hcl in sodium DIALYVITE 3000 258 DICLO GEL/XRYLIX chloride 169 DIALYVITE 5000 258 SHEETS 123 DEXMEDETOMIDINE HYDROCHLORIDE/DEXTROSE DIALYVITE SUPREME D 259 DICLOFENAC 5 MONOHYDRATE 169 DIALYVITE/ZINC 258 diclofenac epolamine 123 dexmethylphenidate hcl 2 DIAMINOPYRIDINE 85 diclofenac potassium 5 DEXONTO 0.4% 114 DIANEAL LOW diclofenac sodium 5 DEXOPIN 114 CALCIUM/1.5%DEXTROSE DICLOFENAC SODIUM 86 256 DEXPANTHENOL 85 diclofenac sodium (actinic DIANEAL LOW keratoses) 126 dexrazoxane hcl 60 CALCIUM/2.5%DEXTROSE diclofenac sodium (ophth) 284 DEXTENZA 281 256 diclofenac sodium (topical) 123 DEXTRAN 40000 85 DIANEAL LOW CALCIUM/4.25%DEXTROSE diclofenac sodium-capsaicin 5 DEXTRAN 75000 85 256 diclofenac sodium-capsaicin dextroamphetamine sulfate 1 DIANEAL PD-2/1.5% (topical) 123 DEXTROMETHORPHAN 85 DEXTROSE 256 DICLOFENAC DEXTROMETHORPHAN DIANEAL PD-2/2.5% SODIUM/HYALURONIC ACID HBR 117 DEXTROSE 256 SODIUM DEXTROMETHORPHAN HBR DIANEAL PD-2/4.25% SALT/NIACINAMIDE 126 MONOHYDRATE 117 DEXTROSE 256 diclofenac w/ misoprostol 5 DIAOXIA 120 DEXTROSE 275 DICLOFONO 123 DIASDIMAXIA 120 dextrose 275 DICLOPR 123 DIASOXIA 120 DEXTROSE 275 DICLOSTREAM 123 DIASTAT ACUDIAL 28 DEXTROSE 5%/ELECTROLYTE DICLOVIX 123 #48 VIAFLEX 249 DIASTAT PEDIATRIC 28 DICLOVIX M 123 DEXTROSE 10%/NACL DIASTIX 146 dicloxacillin sodium 287 0.2% 249 DIATHRIVE BLOOD DEXTROSE 20% 275 GLUCOSE TEST DICLOZOR 123 DEXTROSE 40% 275 STRIPS 146 DICOPANOL FUSEPAQ 43 DEXTROSE 5%/NACL DIATHRIVE GLUCOSE DICOPANOL RAPIDPAQ 43 CONTROL SOLUTION 194 0.3% 249 DICUMAROL 86 DEXTROSE 50% 275 DIATHRIVE LANCING DEVICE 194 dicyclomine hcl 316 DEXTROSE ANHYDROUS 275 DIATRUE PLUS BLOOD DICYCLOMINE dextrose in lactated ringers 249 GLUCOSE TEST HYDROCHLORIDE 86 DEXTROSE STRIPS 146 didanosine 66 MONOHYDRATE 275 diazepam 21 dextrose w/ sodium DIETHANOLAMINE 86 chloride 249 DIAZEPAM 21 DIETHYL PHTHALATE 86 DEXTROSE/SODIUM diazepam 21 DIETHYL-M-TOLUAMIDE 86 CHLORIDE 249 DIAZEPAM 85

Index 27 DIETHYLCARBAMAZINE DIMENHYDRINATE 41 DISOPHENOL 86 CITRATE 86 DIMENTHO 123 disopyramide phosphate 22 DIETHYLENE GLYCOL MONOETHYL ETHER 84 DIMERCAPTO-1- DISTILLATA DISTILLED DIETHYLENE GLYCOL PROPANESULFONIC ACID WATER 298 MONOETHYL ETHER NF 84 (DMPS) 108 DISTILLED WATER 298 DIETHYLPROPION DIMERCAPTO-1- DISULFIRAM 86 PROPANESULFONIC ACID HYDROCHLORIDE/TARTARIC disulfiram 310 ACID 86 SODIUM SALT 108 DIMERCAPTOPROPANE DITHOL 123 DIETHYLSTILBESTROL 86 SULFONATE DMPS 39 DITROPAN XL 319 DIFFERIN 120 DIMERCAPTOPROPANE- DIURIL 152 DIFICID 175 SULFONATE (2,3) divalproex sodium 32 DIFIL-G FORTE 23 SODIUM 108 DIMERCAPTOSUCCINIC DIVALPROEX SODIUM 86 diflorasone diacetate 131 ACID 99 DIVIGEL 157 DIFLUCAN 42 DIMETHIPAC 305 DIVISTA 166 DIFLUNISAL 8 DIMETHYL FUMARATE 86 DL-3-HYDROXYBUTYRIC diflunisal 8 dimethyl fumarate 311 ACIDSODIUM 99 DIFMETIOXRIME 125 DIMETHYL SILOXANE DL-ALANINE 277 DIGIFAB 40 HYDROXYALKYL- DL-ALPHA LIPOIC ACID 79 TERMINATED 86 digoxin 73 DL-LEUCINE 277 DIMETHYL SULFONE 93 DIGOXIN 86 DL-MALIC ACID 93 DIMETHYL SULFOXIDE 106 DIGOXIN MICRONIZED 86 DL-METHIONINE 277 DIMETHYLACETAMIDE 86 DIHYDROCODEINE DL-PANTHENOL 96 BITARTRATE 86 DIMETHYLAMINOETHANOL DIHYDROERGOTAMINE (DEANOL) 86 DL-PANTHENOL ALCOHOL96 MESYLATE 247 DIMETHYLGLYCINE HCL 86 DL-PHENYLALANINE 277 dihydroergotamine DIMOXIA 120 DMAE BITARTRATE 86 mesylate 247 DINITROCHLOROBENZENE DMT SUIK 114 DIHYDROXYACETONE (1,3) 108 DOBUTAMINE HCL 323 DIMER 86 DIOSGENIN 86 DIINDOLYLMETHANE 86 dobutamine in d5w 323 DIOSMIN 86 DIIODO-L-THYRONINE 3,5 86 DOCETAXEL 60 DIOVAN 47 DILANTIN 31 docetaxel 60 DIOVAN HCT 49 DILANTIN INFATABS 31 DOCETAXEL 60 DIOXYBENZONE 86 DILANTIN-125 31 docetaxel 60 DIPENTUM 159 DILATRATE SR 20 DOCETAXEL 60 diphenhydramine hcl 43 DILAUDID 9 DOCETAXEL (NON-ALCOHOL DIPHENHYDRAMINE HCL43 FORMULA) 60 diltiazem hcl 72 diphenhydramine hcl 43 DOCOSANOL 86 DILTIAZEM HCL 72 DIPHENIDOL DOCUSATE SODIUM 171 diltiazem hcl 72 HYDROCHLORIDE 86 DOCUSATE SODIUM/SODIUM DILTIAZEM HCL 86 diphenoxylate w/ atropine 39 BENZOATE 108 diltiazem hcl coated beads 72 DIPHENYLCYCLOPROPENON dofetilide 22 diltiazem hcl extended release E 86 DIPHTHERIA/TETANUS DOLOPHINE 9 beads 72 DOLOTRANZ 136 DILTIAZEM TOXOIDS ADSORBED HYDROCHLORIDE 72 PEDIATRIC 315 donepezil hydrochloride 310 DILTIAZEM DIPRIVAN 161 dopamine hcl 323 HYDROCHLORIDE/DEXTROSE DIPROLENE 131 DOPAMINE 72 DIPROLENE AF 131 HYDROCHLORIDE 86 DILTIAZEM dopamine in d5w 323 HYDROCHLORIDE/SODIUM DIPYRIDAMOLE 86 CHLORIDE 72 dipyridamole 164 DOPRAM 1

Index 28 DOPTELET 165 DRAXACE LOTION DROPLET PEN NEEDLES DORAL 169 CLEANSER 121 31GX6MM 221 DRCAPS SIZE 0 CLEAR 293 DROPLET PEN NEEDLES doripenem 18 DRCAPS SIZE 00 31GX8MM 221 DORYX 314 CLEAR 293 DROPLET PEN NEEDLES 32G DORYX MPC 314 DRCAPS SIZE 1 CLEAR 293 X 1/4" 221 DROPLET PEN NEEDLES 32G dorzolamide hcl 284 DRISDOL 324 X 3/16" 221 DORZOLAMIDE HCL 284 DRITHO-CREME HP 127 DROPLET PEN NEEDLES 32G dorzolamide hcl-timolol DRIXECE 121 X 5/16" 221 maleate 278 DROPLET PEN NEEDLES 32G DORZOLAMIDE DRIZALMA SPRINKLE 33 X 5/32" 221 HYDROCHLORIDE 86 dronabinol 41 DROPLET PEN NEEDLES DOTHELLE DHA 264 DROPERIDOL 21 32GX4MM 221 DOUBLE AIR FOAM INSOLES DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES MENS 206 U-100/0.3/31G X 5/16" 221 32GX5MM 221 DOUBLE AIR FOAM INSOLES DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES WOMENS 206 U-100/0.3ML/30G X 1/2" 221 32GX6MM 221 DOUBLE PM 282 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32GX8MM 222 DOUBLEDEX 114 U-100/0.3ML/30G X 15/64" 221 DROPSAFE SAFETY PEN DOVATO 66 DROPLET INSULIN SYRINGE NEEDLES/31G X 5/16" 222 DOVONEX 127 U-100/0.3ML/30G X 5/16"221 DROPSAFE SAFTEY PEN DOW CORNING 1501 DROPLET INSULIN SYRINGE NEEDLES/31G X 1/4" 222 drospirenone-ethinyl FLUID 86 U-100/0.3ML/31G X estradiol 111 DOW CORNING 200 99 15/64" 221 DROPLET INSULIN SYRINGE drospirenone-ethinyl estradiol- doxazosin mesylate 48 U-100/0.5ML/30G X 1/2" 221 levomefolate calcium 111 DOXAZOSIN MESYLATE 86 DROPLET INSULIN SYRINGE DROXIA 164 doxepin hcl 34 U-100/0.5ML/30G X DRUG MART ADJUSTABLE DOXEPIN HCL 86 15/64" 221 LANCING DEVICE 194 DROPLET INSULIN SYRINGE DRUG MART LANCETS doxepin hcl (antipruritic) 127 U-100/0.5ML/30G X 5/16"221 THIN 194 doxepin hcl (sleep) 169 DROPLET INSULIN SYRINGE DRUG MART ON-THE-GO DOXEPIN U-100/0.5ML/31G X 5/16"221 LANCETS GENTLE 30G 194 HYDROCHLORIDE 86 DROPLET INSULIN SYRINGE DRUG MART UNIFINE PENTIPS doxercalciferol 155 U-100/1ML/30G X 1/2" 221 31GX5MM 222 DROPLET INSULIN SYRINGE DRUG MART UNIFINE DOXIL 56 U-100/1ML/30G X 15/64" 221 PENTIPS29G X 12MM 222 doxorubicin hcl 56 DROPLET INSULIN SYRINGE DRUG MART UNIFINE doxorubicin hcl liposomal 56 U-100/1ML/30G X 5/16" 221 PENTIPS31GX6MM 222 DRUG MART UNIFINE doxycycline (monohydrate) 314 DROPLET INSULIN SYRINGE U-100/1ML/31G X 15/64" 221 PENTIPS31GX8MM 222 doxycycline (rosacea) 140 DROPLET INSULIN SYRINGE DRUG MART UNIFINE doxycycline hyclate 314 U-100/1ML/31G X 5/16" 221 PENTIPS32GX4MM 222 DOXYCYCLINE HYCLATE 314 DROPLET INSULIN DRUG MART UNIFINE SYRINGE/U-100/0.5ML/31G X PENTIPSPLUS 32GX4MM 222 doxycycline hyclate 314 15/64" 221 DRUG MART UNILET DOXYCYCLINE HYCLATE 314 DROPLET LANCETS ULTRA LANCETSSUPER THIN DOXYCYCLINE HYCLATE THIN 30G 194 30G 194 DR 314 DROPLET LANCING DRUG MART UNILET DOXYCYCLINE DEVICE 194 LANCETSULTRA THIN MONOHYDRATE 86 DROPLET PEN NEEDLES 28G 194 DOXYLAMINE SUCCINATE 43 29GX10MM 221 DRUG MART UNILET MICRO doxylamine-pyridoxine 41 DROPLET PEN NEEDLES THIN LANCETS 33G 194 29GX12MM 221 DRYMAX EXTRA 183 DRAKKAR NOIR 105 DROPLET PEN NEEDLES DRYSOL 140 DRAXACE 121 31GX5MM 221 DS PREP PAK 123

Index 29 DST PLUS PAK 123 DUZALLO 162 EASY COMFORT PEN DSUVIA 9 DXEVO 11-DAY 114 NEEDLES31GX1/4" 222 EASY COMFORT PEN DUAC 121 DYANAVEL XR 1 NEEDLES31GX3/16" 222 DUAKLIR PRESSAIR 24 DYAZIDE 151 EASY COMFORT PEN DUAL COMPLEX FORMULA 1 DYCLONINE HCL 87 NEEDLES31GX5/16" 222 KIT 123 DYCLONINE EASY COMFORT PEN DUAVEE 157 HYDROCHLORIDE 87 NEEDLES32GX5/32" 222 EASY COMFORT PEN DUET DHA 400 264 DYMISTA 272 NEEDLES33G X 4MM 222 DUET DHA BALANCED 264 DYNABAC 5.0 123 EASY COMFORT PEN DUETACT 35 DYPHYLLINE 87 NEEDLES33G X 5MM 222 DUEXIS 5 dyphylline-guaifenesin 23 EASY COMFORT PEN NEEDLES33G X 6MM 222 DULERA 24 DYRENIUM 152 EASY GLIDE PEN NEEDLES duloxetine hcl 33 DYSPORT 274 33G X 5/32" 222 DULOXETINE HCL 86 DYURAL-40 114 EASY GRIP CALLUS DULOXETINE REMOVER 206 DYURAL-80 114 EASY MINI EJECT LANCING HYDROCHLORIDE 86 DYURAL-L 114 DUO-CARE CONTROL DEVICE 194 EASY MINI LANCING SOLUTION 194 DYURAL-LM 114 DEVICE 194 DUO-CARE TEST STRIPS 146 E-Z JECT LANCETS 194 EASY PLUS II BLOOD DUOBRII 131 E-Z JECT LANCETS 21G194 GLUCOSE TEST 146 DUODOTE 39 E-Z JECT LANCETS EASY STEP TEST STRIPS146 COLOR 194 EASY TALK BLOOD GLUCOSE DUOPA 62 E-Z JECT LANCETS SUPER DUPIXENT 134 TEST STRIPS 146 THIN 30G 194 EASY TOUCH 32GX5MM 222 DURABASE 305 E-Z JECT LANCETS THIN EASY TOUCH 32GX6MM 222 DURABASE ADVANCED 305 26G 194 E-ZJECT LANCETS MICRO- EASY TOUCH ALCOHOL PREP DURACHOL 166 THIN 33G 194 PADS/MEDIUM 213 DURACLON 8 E.E.S. GRANULES 175 EASY TOUCH CONTROL DURAGESIC 9 EASY COMFORT ALCOHOL SOLUTION/HIGH & LOW 194 EASY TOUCH FLIPLOCK DURASAFE PADS 213 SPINAL/EPIDURALTRAY/1% EASY COMFORT INSULIN SAFETY INSULIN SYRINGE XYLOCAINE/19GX36"CLOSE SYRINGE/0.5ML/30G X 1ML/29GX1/2" 222 5/16" 222 EASY TOUCH FLIPLOCK CATH 173 SAFETY INSULIN SYRINGE DURASAFE EASY COMFORT INSULIN SYRINGE/0.5ML/31G X 1ML/30GX1/2" 222 SPINAL/EPIDURALTRAY/1% EASY TOUCH FLIPLOCK XYLOCAINE/19GX36"OPEN 5/16" 222 EASY COMFORT INSULIN SAFETY INSULIN SYRINGE CATH 173 1ML/30GX5/16" 222 DURASAFE SYRINGE/1ML/30G X 5/16" 222 EASY TOUCH FLIPLOCK SPINAL/EPIDURALTRAY/1% SAFETY INSULIN SYRINGE XYLOCAINE/20GX36"CLOSE EASY COMFORT INSULIN SYRINGE/1ML/31G X 1ML/31GX5/16" 222 CATH 173 EASY TOUCH GLUCOSE TEST DURASAFE 5/16" 222 EASY COMFORT INSULIN STRIPS 146 SPINAL/EPIDURALTRAY/1% EASY TOUCH INSULIN XYLOCAINE/20GX36"OPEN SYRINGE/U-100/0.5ML/30G X 1/2" 222 SYRINGE/0.3ML/30G X CATH 173 5/16" 222 DUREZOL 282 EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G X EASY TOUCH INSULIN DURLAZA 164 1/2" 222 SYRINGE/0.3ML/31G X DURYSTA 284 EASY COMFORT 5/16" 222 EASY TOUCH INSULIN DUTASTERIDE 87 LANCETS 194 EASY COMFORT LANCETS SYRINGE/0.5ML/29G X dutasteride 162 30G/PULL TOP 194 1/2" 222 dutasteride-tamsulosin hcl 162 EASY COMFORT LANCETS DUTOPROL 49 30G/THIN TOP 194

Index 30 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SAFETY SYRINGE/0.5ML/30G X 28G/PRESSURE LANCETS28G/PRESSURE 5/16" 222 ACTIVATED 194 ACTIVATED 195 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SAFETY PEN SYRINGE/1ML/30G X 28G/PULL-TOP 195 NEEDLES/29G X 5MM 223 5/16" 223 EASY TOUCH LANCETS EASY TOUCH SAFETY PEN EASY TOUCH INSULIN 28G/TWIST 195 NEEDLES/29G X 8MM 223 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 100/0.5ML/29G X 1/2" 223 30G/BUTTON-ACTIVATED SAFETY INSULIN SYRINGE EASY TOUCH INSULIN 195 1ML/29GX1/2" 223 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 100/0.5ML/30G X 5/16" 223 30G/PRESSURE SAFETY INSULIN SYRINGE EASY TOUCH INSULIN ACTIVATED 195 1ML/30GX5/16" 223 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 100/1ML/29G X 1/2" 223 30G/PULL-TOP 195 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN EASY TOUCH LANCETS 1ML/31GX5/16" 223 SYRINGE/SAFETY/U- 30G/TWIST 195 EASY TOUCH SHEATHLOCK 100/1ML/30G X 1/2" 223 EASY TOUCH LANCETS SAFETY SYRINGE EASY TOUCH INSULIN 32G/PRESSURE 1ML/30GX1/2" 224 SYRINGE/U-100/0.3ML/30G X ACTIVATED 195 EASY TRAK BLOOD GLUCOSE 1/2" 223 EASY TOUCH LANCETS TEST STRIPS 146 EASY TOUCH INSULIN 32G/PULL-TOP 195 EASY TRAK II BLOOD SYRINGE/U-100/0.5ML/27G X EASY TOUCH LANCETS GLUCOSE TEST STRIPS 146 1/2" 223 32G/TWIST 195 EASY TWIST & CAP EASY TOUCH INSULIN EASY TOUCH LANCETS LANCETS 195 SYRINGE/U-100/0.5ML/28G X 33G/TWIST 195 EASYGLUCO 146 1/2" 223 EASY TOUCH LANCING EASYGLUCO PLUS 146 EASY TOUCH INSULIN DEVICE/EJECTOR 195 EASY TOUCH PEN NEEDLE EASYGLUCO PLUS CONTROL SYRINGE/U-100/0.5ML/30G X SOLUTION LEVEL 1 195 1/2" 223 30G X 5/16" 223 EASY TOUCH PEN NEEDLES EASYMAX 15 GLUCOSE EASY TOUCH INSULIN CONTROL SOLUTION LEVEL SYRINGE/U-100/0.5ML/31G X 29GX1/2" 223 EASY TOUCH PEN NEEDLES 1/LEVEL 2 195 5/16" 223 EASYMAX 15 GLUCOSE EASY TOUCH INSULIN 31GX1/4" 223 EASY TOUCH PEN NEEDLES CONTROL SOLUTION/LEVEL SYRINGE/U-100/1ML/27G X 2/LEVEL 3 195 1/2" 223 31GX5/16" 223 EASY TOUCH PEN NEEDLES EASYMAX 15 LEVEL 2 EASY TOUCH INSULIN GLUCOSE CONTROL SYRINGE/U-100/1ML/28G X 32GX1/4" 223 EASY TOUCH PEN NEEDLES SOLUTION 195 1/2" 223 EASYMAX 15 TEST EASY TOUCH INSULIN 32GX3/16" 223 EASY TOUCH PEN NEEDLES STRIPS 146 SYRINGE/U-100/1ML/29G X EASYMAX GLUCOSE 1/2" 223 32GX5/32" 223 EASY TOUCH PEN CONTROL SOLUTION EASY TOUCH INSULIN NORMAL/LOW 195 SYRINGE/U-100/1ML/30G X NEEDLES/31G X 3/16" 223 EASY TOUCH SAFETY EASYMAX GLUCOSE 1/2" 223 CONTROL EASY TOUCH INSULIN LANCETS21G/PRESSURE ACTIVATED 195 SOLUTION/NORMAL-HIGH SYRINGE/U-100/1ML/31G X 195 5/16" 223 EASY TOUCH SAFETY EASY TOUCH LANCETS LANCETS23G/PRESSURE EASYMAX TEST STRIPS 146 21G/PRESSURE ACTIVATED 195 EASYPRO BLOOD GLUCOSE ACTIVATED 194 EASY TOUCH SAFETY TEST STRIPS 146 EASY TOUCH LANCETS LANCETS26G/BUTTON EASYPRO PLUS 146 23G/PRESSURE ACTIVATED 195 EC- RX DHEA 4% 3 EASY TOUCH SAFETY ACTIVATED 194 EC-NAPROSYN 5 EASY TOUCH LANCETS LANCETS26G/PRESSURE 26G/PRESSURE ACTIVATED 195 EC-RX DHEA 10% 3 ACTIVATED 194 EASY TOUCH SAFETY EC-RX ESTRADIOL 0.4% 157 LANCETS28G/BUTTON EASY TOUCH LANCETS EC-RX ESTRADIOL 0.6% 157 26G/PULL-TOP 194 ACTIVATED 195

Index 31 EC-RX PROGESTERONE ELAPRASE 155 ELITE-THIN INSULIN 10% 309 ELCYS 277 SYRINGE/U-100/1ML/29G X EC-RX PROGESTERONE 1/2" 224 20% 309 ELELYSO 164 ELITE-THIN INSULIN EC-RX TESTOSTERONE ELEMENT COMPACT SYRINGE/U-100/1ML/31G X 0.2% 15 CONTROL SOLUTION LEVEL 5/16" 224 EC-RX TESTOSTERONE 2 195 ELITEK 60 0.4% 15 ELEMENT COMPACT EC-RX TESTOSTERONE CONTROL SOLUTION LEVEL ELIXOPHYLLIN 25 10% 15 3 195 ELLA 112 EC-RX TESTOSTERONE ELEMENT COMPACT TEST ELLENCE 57 20% 15 STRIPS 146 ELLIOTTS B 249 ECEOXIA 121 ELEMENT TEST STRIPS146 ELLZIA PAK 131 ECONASIL 125 ELESTAT 284 ELMIRON 162 ECONAZOLE NITRATE 87 ELESTRIN 157 ELOCON 131 econazole nitrate 125 ELETONE 138 ELOCTATE 163 ECONAZOLE ELETONE TWINPACK 138 ELON MATRIX 5000 268 NITRATE/NIACINAMIDE 125 eletriptan hydrobromide 247 ECOTRIN 8 ELON MATRIX PLUS 268 ELIDEL 135 ECOTRIN REGULAR ELON MATRIX 5000 STRENGTH 8 ELIGARD 55 COMPLETE 268 ECOZA 125 ELIMITE 141 ELON MATRIX COMPLETE 268 EDARBI 48 ELIQUIS 26 ELON R3 268 EDARBYCLOR 49 ELIQUIS STARTER PACK 26 ELZONRIS 59 EDECRIN 151 ELITE-THIN INSULIN SYRINGE/0.3ML/31G X EMADINE 284 EDETATE ACID 108 5/16" 224 EMBEDA 9 EDETATE CALCIUM ELITE-THIN INSULIN EMBRACE BLOOD GLUCOSE DISODIUM 40 SYRINGE/0.5ML/29G X TEST STRIPS 146 EDETATE DISODIUM 109 1/2" 224 EMBRACE EVO BLOOD EDETATE DISODIUM ELITE-THIN INSULIN GLUCOSETEST STRIPS 146 DIHYDRATE 108 SYRINGE/0.5ML/30G X EMBRACE LANCETS ULTRA EDETATE TETRASODIUM 5/16" 224 THIN 30G 195 TETRAHYDRATE 109 ELITE-THIN INSULIN EMBRACE LANCING DEVICE EDLUAR 169 SYRINGE/1ML/29G X WITH EJECTOR 195 EDROPHONIUM 5/16" 224 EMBRACE PRO BLOOD CHLORIDE 87 ELITE-THIN INSULIN GLUCOSETEST STRIPS 146 EDURANT 66 SYRINGE/1ML/30G X EMBRACE PRO GLUCOSE 5/16" 224 CONTROL SOLUTION 195 efavirenz 66 ELITE-THIN INSULIN EMBRACE TALK BLOOD efavirenz-emtricitabine-tenofovir SYRINGE/U-100/0.5ML/28G X GLUCOSE TEST STRIPS 146 disoproxil fumarate 66 1/2" 224 EMCYT 55 efavirenz-lamivudine-tenofovir ELITE-THIN INSULIN disoproxil fumarate 66 SYRINGE/U-100/0.5ML/28G X EMEND 42 EFFER-K 251 5/16" 224 EMEND TRIPACK 42 EFFERVESCENT 301 ELITE-THIN INSULIN EMERPHED 323 EFFEXOR XR 33 SYRINGE/U-100/0.5ML/29G X EMFLAZA 114 5/16" 224 EFFIENT 164 ELITE-THIN INSULIN EMGALITY 246 EFUDEX 126 SYRINGE/U-100/0.5ML/31G X EMOLIVAN 305 EGCG 88 5/16" 224 EMOLLIENT CREAM 305 ELITE-THIN INSULIN EMOLLIENT CREAM EGRIFTA 154 SYRINGE/U-100/1ML/28G X EGRIFTA SV 154 BASE 305 1/2" 224 EMPLICITI 54 EHA LOTION 136 ELITE-THIN INSULIN EMPRICAINE II 136 EHA LOTION 4% 136 SYRINGE/U-100/1ML/28G X 5/16" 224

Index 32 EMPTY CAPSULE #0 RED EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 TRANSLUCENT/WHITE 293 WHITE 294 BLUE/PINK LOCKING 295 EMPTY CAPSULE #00 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 BLACK/RED 293 WHITE/CLEAR 294 BLUE/PINK EMPTY CAPSULE #00 EMPTY CAPSULE SIZE 0 TRANSLUCENT 295 BLUE/WHITE 293 WHITE/OPAQUE 294 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE #00 EMPTY CAPSULE SIZE 0 BLUE/POWDER BLUE 295 PINK/PINK 293 WHITE/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE #00 LOCKING 294 BLUE/RED OPAQUE PURPLE//PURPLE 293 EMPTY CAPSULE SIZE 0 LOCKING 295 EMPTY CAPSULE #00 YELLOW 294 EMPTY CAPSULE SIZE 1 PURPLE//WHITE 293 EMPTY CAPSULE SIZE 0 BLUE/WHITE 295 EMPTY CAPSULE #00 YELLOW/OPAQUE EMPTY CAPSULE SIZE 1 RED/WHITE 293 LOCKING 294 BLUETRANSLUCENT/PINK EMPTY CAPSULE #00 EMPTY CAPSULE SIZE 00 TRANSLUCENT 295 YELLOW/YELLOW 293 BLUE/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 LOCKING 294 BROWN/IVORY 295 BLUE 293 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 CLEAR 294 BROWN/IVORY OPAQUE BLUE/WHITE 293 EMPTY CAPSULE SIZE 00 LOCKING 295 EMPTY CAPSULE SIZE 0 CLEAR LOCKING 294 EMPTY CAPSULE SIZE 1 CLEAR 293 EMPTY CAPSULE SIZE 00 CLEAR 295 EMPTY CAPSULE SIZE 0 DARK GREEN 294 EMPTY CAPSULE SIZE 1 CLEAR LOCKING 293 EMPTY CAPSULE SIZE 00 CLEAR LOCKING 295 EMPTY CAPSULE SIZE 0 GREEN/OPAQUE EMPTY CAPSULE SIZE 1 FUNCAPS LOCKING 294 LOCKING 294 DARKGREEN 295 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 GREEN LOCKING 294 LIGGHT BLUE OPAQUE 294 GREEN 295 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 GREEN/CLEAR 294 ORANGE 294 GREEN CLEAR/YELLOW EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 LOCKING 295 GREEN/CLEAR LOCKING 294 ORANGE/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 LOCKING 294 GREEN MAROON/OPAQUE EMPTY CAPSULE SIZE 00 TRANSLUCENT/YELLOW LOCKING 294 RED 294 OPAQUE 295 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 ORANGE 294 WHITE 294 GREEN/ORANGE 295 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 ORANGE/OPAQUE WHITE OPAQUE GREEN/WHITE 295 LOCKING 294 LOCKING 294 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 000 GREEN/WHITE OPAQUE PINK 294 CLEAR 294 LOCKING 295 EMPTY CAPSULE SIZE 0 PINK EMPTY CAPSULE SIZE 000 EMPTY CAPSULE SIZE 1 LOCKING 294 CLEAR LOCKING 294 GREEN/YELLOW 295 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 000 EMPTY CAPSULE SIZE 1 PURPLE 294 WHITE/OPAQUE GREY/PINK 295 EMPTY CAPSULE SIZE 0 LOCKING 294 EMPTY CAPSULE SIZE 1 PURPLE/OPAQUE EMPTY CAPSULE SIZE 1 IVORY 295 LOCKING 294 AQUABLUE EMPTY CAPSULE SIZE 1 LIGHT EMPTY CAPSULE SIZE 0 TRANSLUCENT 294 BLUE OPAQUE 295 PURPLE/WHITE 294 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 BLUE 294 MAROON TRANS/CLEAR 295 RED 294 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 BLUE/CLEAR 294 MINTGREEN 295 RED/CLEAR 294 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 BLUE/OPAQUE ORANGE 295 RED/WHITE 294 LOCKING 295 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 ORANGE OPAQUE RED/WHITE LOCKING 294 BLUE/PINK 295 LOCKING 295

Index 33 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 ORANGE/CLEAR 295 BLUE 296 OLIVE/CLEAR 297 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 ORANGE/WHITE 295 CLEAR 296 OLIVE/OPAQUE LOCKING297 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 ORANGE/YELLOW 295 CLEAR LOCKING 296 ORANGE 297 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 PINK 295 GREEN 296 ORANGE/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 2 LOCKING 297 PINK/CLEAR 295 WHITE OPAQUE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 LOCKING 296 ORANGE/WHITE 297 PINK/OPAQUE LOCKING 295 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 BLACK/GREEN 296 PINK 297 PINK/POWDER BLUE 295 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 BLUE 296 PINK/CLEAR 297 PINK/WHITE 295 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 BLUE/CLEAR 296 PINK/OPAQUE LOCKING 297 PINK/YELLOW 295 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 BLUE/WHITE 296 PINK/POWDER BLUE 297 PINK/YELLOW OPAQUE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 LOCKING 295 BLUEOPAQUE/CLEAR PINK/WHITE 297 EMPTY CAPSULE SIZE 1 LOCKING 296 EMPTY CAPSULE SIZE 3 POWDER BLUE 295 EMPTY CAPSULE SIZE 3 PINK/YELLOW 297 EMPTY CAPSULE SIZE 1 CLEAR 296 EMPTY CAPSULE SIZE 3 POWDER BLUE/OPAQUE EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR 297 LOCKING 296 CLEAR LOCKING 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR PURPLE 296 DARKGREEN 296 LOCKING 297 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 PURPLE/OPAQUE GRAY/PINK OPAQUE POWDER BLUE 297 LOCKING 296 LOCKING 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 PURPLE 297 RED 296 GRAY/YELLOW OPAQUE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 LOCKING 296 PURPLE/CLEAR 297 RED/BLUE 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 GREEN 296 RED 297 RED/OPAQUE LOCKING 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 GREEN/BLUE 296 RED/CLEAR 297 RED/WHITE 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 GREEN/BLUE LOCKING 296 RED/OPAQUE LOCKING 297 VEGETABLE CLEAR 301 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 GREEN/BLUE RED/WHITE 297 WHITE 296 TRANSLUCENT 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 REDOPAQUE/CLEAR WHITE OPAQUE GREY/PINK 296 LOCKING 297 LOCKING 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 GREY/YELLOW 296 WHITE 297 WHITE/CLEAR 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 LIGHT BLUE OPAQUE 296 WHITE OPAQUE WHITE/OPAQUE 296 EMPTY CAPSULE SIZE 3 LOCKING 297 EMPTY CAPSULE SIZE 1 MAROON/BLUE 296 EMPTY CAPSULE SIZE 3 YELLOW 296 EMPTY CAPSULE SIZE 3 WHITE OPAQUE/CLEAR EMPTY CAPSULE SIZE 10 MAROON/BLUE LOCKING 297 CLEAR 296 OPAQUE 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 11 EMPTY CAPSULE SIZE 3 WHITE/CLEAR 297 CLEAR 296 MAROON/CLEAR 296 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 13 EMPTY CAPSULE SIZE 3 WHITE/OPAQUE 297 CLEAR 296 MINT GREEN 297 EMPTY CAPSULE SIZE 3 YELLOW 297

Index 34 EMPTY CAPSULE SIZE 3 EMPTY VEGETABLE ENROFLOXACIN 87 YELLOW OPAQUE/CLEAR CAPSULE/SNAP CLOSURE ENSTILAR 131 LOCKING 297 #0 301 EMPTY CAPSULE SIZE 3 EMPTY VEGETABLE entacapone 61 YELLOW/CLEAR 297 CAPSULE/SNAP CLOSURE entecavir 68 EMPTY CAPSULE SIZE 3 #00 301 ENTEREG 160 YELLOW/OPAQUE EMPTY VEGETABLE LOCKING 297 CAPSULE/SNAP CLOSURE ENTOCORT EC 114 EMPTY CAPSULE SIZE 4 #1 301 ENTRESTO 74 BLACK/GREEN OPAQUE EMSAM 32 ENTTY SPRAY 138 LOCKING 297 emtricitabine 66 ENTYVIO 159 EMPTY CAPSULE SIZE 4 BLUE/WHITE 297 emtricitabine-tenofovir ENVARSUS XR 253 EMPTY CAPSULE SIZE 4 disoproxil fumarate 66 ENZADYNE 151 EMTRIVA 66 CLEAR 297 EPANED 47 EMPTY CAPSULE SIZE 4 EMU OIL 87 EPCLUSA 68 CLEAR LOCKING 297 EMULGADE CM 302 EMPTY CAPSULE SIZE 4 DARK EPHEDRINE HCL 24 EMULSIFYING WAX 302 BLUE/OPAQUE LOCKING 297 EPHEDRINE SULFATE 25,323 EMPTY CAPSULE SIZE 4 EMULSION ephedrine sulfate CONCENTRATE 302 PURPLE 297 (pressors) 323 EMPTY CAPSULE SIZE 4 EMULSION SB 138 EPHEDRINE PURPLE/OPAQUE EMVERM 17 SULFATE/SODIUMCHLORIDE LOCKING 297 ENABLEX 319 323 EMPTY CAPSULE SIZE 4 EPICERAM 138 RED/WHITE 297 enalapril maleate 47 EMPTY CAPSULE SIZE 4 ENALAPRIL MALEATE 87 EPICYN 140 WHITE 298 enalapril maleate & EPIDIOLEX 29 EMPTY CAPSULE SIZE 4 hydrochlorothiazide 49 EPIDUO 121 WHITE/OPAQUE enalaprilat 47 LOCKING 298 EPIDUO FORTE 121 EMPTY CAPSULE SIZE 4 ENBRACE HR 264 EPIFOAM 131 YELLOW 298 ENBREL 7 epinastine hcl (ophth) 284 EMPTY CAPSULE SIZE 5 ENBREL MINI 7 EPINEPHRINE 109 CLEAR 298 ENBREL SURECLICK 7 EMPTY CAPSULE SIZE 7 epinephrine 323,324 CLEAR 298 ENCARE 322 EPINEPHRINE 324 EMPTY GELATIN ENDARI 164 epinephrine (anaphylaxis) 323 CAPSULE/SNAP CLOSURE ENDOMETRIN 322 #0 298 EPINEPHRINE BASE 109 EMPTY GELATIN ENGERIX-B 320 EPINEPHRINE CAPSULE/SNAP CLOSURE ENGLISH TOFFEE BITARTRATE 87 #00 298 FLAVOR 290 EPINEPHRINE HCL 323 EMPTY GELATIN ENHERTU 54 epinephrine hcl (nasal) 273 CAPSULE/SNAP CLOSURE ENOVARX-AMITRIPTYLINE EPINEPHRINE #000 298 79 HYDROCHLORIDE/DEXTROSE EMPTY GELATIN ENOVARX-BACLOFEN 123 323 CAPSULE/SNAP CLOSURE ENOVARX- EPINEPHRINE #1 298 CYCLOBENZAPRINE HYDROCHLORIDE/SODIUM EMPTY GELATIN HCL 271 CHLORIDE 323 CAPSULE/SNAP CLOSURE ENOVARX-DICLOFENAC EPINEPHRINE #2 298 SODIUM 123 PROFESSIONAL 323 EMPTY GELATIN ENOVARX-IBUPROFEN 124 EPINEPHRINE/DEXTROSE CAPSULE/SNAP CLOSURE ENOVARX-LIDOCAINE 324 #3 298 HCL 136 EPINEPHRINE/SODIUM EMPTY GELATIN ENOVARX-NAPROXEN 124 CHLORIDE 324 CAPSULE/SNAP CLOSURE EPINEPHRINESNAP-EMS 323 #4 298 ENOVARX-TRAMADOL 123 EPINEPHRINESNAP-V 323 enoxaparin sodium 26

Index 35 EPIPEN 2-PAK 323 EQL GAUZE PADS EQL SUPER THIN LANCETS EPIPEN-JR 2-PAK 323 2"X2"/SMALL 184 30G 195 EQL GAUZE PADS EQL THIN LANCETS 26G 195 epirubicin hcl 57 4"X4"/LARGE 184 EQL TOENAIL CLIPPER 206 EPISNAP 323 EQL GENTLE STRIPS 184 EQL VARIETY PACK EPIVIR 66 EQL HEAVY DUTY ADHESIVEBANDAGES 184 EPIVIR HBV 68 BANDAGES EXTRA LONG EQUAPAX/ATORVASTATIN 3/4"X4-3/4" 184 eplerenone 50 CALCIUM/COQ10 45 EQL HEAVY DUTY FABRIC EQUAPAX/IBUPROFEN/MINRE EPOGEN 165 STRIPS MULTI- X 4 epoprostenol sodium 74 PURPOSE 184 EQUETRO 63 eprosartan mesylate 48 EQL HEAVY DUTY FABRIC STRIPS/EXTRA LARGE 184 ERAXIS 42 EPSOM SALT 171 EQL INSULIN ERBITUX 54 EPZICOM 66 SYRINGE/0.3ML/29G X ERGOCAL 324 EQ BLOOD GLUCOSE TEST 1/2" 224 ergocalciferol 325 STRIPS 146 EQL INSULIN EQ FLEXIBLE FABRIC SYRINGE/0.3ML/30G X ERGOCALCIFEROL 325 BANDAGES/ANTIBACTERIAL 5/16" 224 ERGOLOID MESYLATES 87 183 EQL INSULIN ergoloid mesylates 312 EQ STRONG STRIPS SYRINGE/0.3ML/31G X BANDAGES/ANTIBACTERIAL 5/16" 224 ERGOMAR 247 183 EQL INSULIN ERGOTAMINE TARTRATE247 EQL ADHESIVE PADS SYRINGE/0.5ML/29G X ergotamine w/ caffeine 247 LARGE 183 1/2" 224 ERIVEDGE 55 EQL ADHESIVE PADS EQL INSULIN MEDIUM 183 SYRINGE/0.5ML/30G X ERLEADA 55 EQL ADVANCED HEALING 5/16" 224 erlotinib hcl 57 ADHESIVE BANDAGES 183 EQL INSULIN ERTACZO 125 SYRINGE/0.5ML/31G X EQL ALCOHOL SWABS 213 ertapenem sodium 18 EQL ANIMAL PRINT 5/16" 224 STRIPS 184 EQL INSULIN ERWINAZE 59 EQL ANTIBACTERIAL SYRINGE/1ML/29G X ERYGEL 121 FABRICSTRIPS 184 1/2" 224 ERYPED 200 175 EQL INSULIN EQL BUTTERFLY ERYPED 400 175 CLOSURES 184 SYRINGE/1ML/30G X EQL COLOR LANCETS 5/16" 224 ERYTHROCIN 21G 195 EQL INSULIN LACTOBIONATE 175 EQL COLOR LANCETS MICRO SYRINGE/1ML/31G X ERYTHROMYCIN 175 THIN 33G 195 5/16" 224 erythromycin (acne aid) 121 EQL DRY MOUTH ORAL EQL PLASTIC STRIPS 184 erythromycin (ophth) 280 RINSE 257 EQL PLASTIC STRIPS MULTI- erythromycin base 175 EQL DUAL GEL INSOLES PURPOSE 184 WOMENS 206 EQL PUMICE ERYTHROMYCIN EQL FIRST AID STONE/ROPE 206 ESTOLATE 87 ANTISEPTICBANDAGES 184 EQL SHEER SPOTS ERYTHROMYCIN EQL FLEXIBLE FABRIC SMALL 184 ETHYLSUCCINATE 175 erythromycin BANDAGES 184 EQL SHEER STRIPS 184 EQL FLEXIBLE FABRIC ethylsuccinate 175 EQL SHEER STRIPS EXTRA erythromycin stearate 175 BANDAGES MULTI- LARGE 184 PURPOSE 184 EQL SHEER STRIPS MULTI- ESBRIET 313 EQL FLEXIBLE FABRIC PURPOSE 184 ESCAVITE 263 BANDAGES/EXTRA EQL STERILE NON-STICK ESCAVITE D 263 LARGE 184 PADS 3"X4"/LARGE 184 escitalopram oxalate 33 EQL FLEXIBLE FABRIC EQL STRIPS 184 BANDAGES/KNUCKLE & ESGIC 8 FINGERTIP 184 EQL STRONG STRIPS EQL FLEXIBLE FOAM WATERPROOF 184 ESKATA 128 STRIPS 184 esmolol hcl 71

Index 36 esmolol hcl-sodium chloride 71 ethambutol hcl 52 EVEKEO ODT 1 ESMOLOL ETHAMOLIN 256 EVENCARE + BLOOD HYDROCHLORIDE 71 ETHER 106 GLUCOSETEST STRIP 146 ESMOLOL HYDROCHLORIDE EVENCARE BLOOD GLUCOSE INWATER 71 ETHINYL ESTRADIOL 157 TEST STRIP 146 ESMOLOL HYDROCHLORIDE ethosuximide 32 EVENCARE CONTROL INWATER DOUBLE ETHOSUXIMIDE 87 SOLUTION 195 STRENGTH 71 EVENCARE G2 GLUCOSE ETHOXIA 121 ESOMEP-EZS 317 CONTROL SOLUTION/LOW- ETHOXY DIGLYCOL 84 esomeprazole magnesium 317 HIGH 196 ETHOXY ETHOXY ETHANOL EVENCARE G2 TEST esomeprazole sodium 317 REAGENT 84 STRIPS 146 ESOMEPRAZOLE ETHYL ACETATE 302 EVENCARE G3 GLUCOSE STRONTIUM 317 ETHYL ALCOHOL 106 CONTROL SOLUTION/LOW- ESPUMIL 305 HIGH 196 ETHYL ALCOHOL 190 ESSENTRA WIPES 9X9" EVENCARE G3 TEST PROOF 106 STRIPS 146 CLEANROOM ETHYL ALCOHOL 200 SUPPLIES/PRESATURATED EVENCARE MINI BLOOD PROOF 298 GLUCOSE TEST STRIPS 147 140 ETHYL ALCOHOL SDA-40B estazolam 169 EVENCARE PROVIEW BLOOD 190 PROOF 106 GLUCOSE TEST STRIPS 147 ESTRACE 157,322 ethyl chloride 136 EVENITY 153 ESTRADIOL 87 ETHYL CHLORIDE/FINE everolimus 57 estradiol 157 STREAM 136 ETHYL CHLORIDE/MEDIUM everolimus estradiol & norethindrone STREAM 136 (immunosuppressant) 253 acetate 157 ETHYL OLEATE 87 EVISTA 154 ESTRADIOL BENZOATE 87 EVOCLIN 121 ESTRADIOL ETHYL VANILLIN 87 CONCENTRATE 87 ETHYLCELLULOSE 87 EVOLUTION AUTOCODE 147 ESTRADIOL CYPIONATE 87 ETHYLENEDIAMINE 87 EVOMELA 53 ESTRADIOL ETHYLPARABEN 105 EVOTAZ 66 HEMIHYDRATE 87 ethynodiol diacet & eth EVOXAC 257 ESTRADIOL MICRONIZED 87 estrad 111 EVZIO 40 estradiol vaginal 322 ETHYOL 60 EXACTECH R-S-G TEST ESTRADIOL VALERATE 87 etidronate disodium 153 STRIPS 147 estradiol valerate 157 etodolac 5 EXACTECH TEST STRIPS 147 ESTRING 322 ETOMIDATE 87 EXALGO 9 ESTRIOL 87 etomidate 161 EXCEL COMFORT POINT etonogestrel-ethinyl INSULIN PEN NEEDLES 31G X ESTRIOL CONCENTRATE 87 4MM 224 estradiol 112 ESTRIOL MICRONIZED 87 EXCEL-GEL 142 ETOPOPHOS 60 ESTRIOL ULTRA EXCILON AMD MICRONIZED 87 etoposide 60 ANTIMICROBIALDRAIN ESTRIOL-PROGESTERONE ETOPOSIDE 87 SPONGES 4"X4" 6 PLY 184 COMPOUNDING KIT 157 EUCALYPTOL 87 EXCILON AMD ESTROGEL 157 EUCALYPTUS FLAVOR 290 ANTIMICROBIALNON-WOVEN ESTROMINERAL 255 SPONGES 4"X4" 6 PLY 184 EUCALYPTUS OIL 106 ESTRONE 87 EXCILON DRAIN SPONGE EUCRISA 140 4"X4" 184 ESTRONE CONCENTRATE 87 EUGENOL 106 EXCILON DRAIN SPONGES ESTROSTEP FE 111 4"X4" 6 PLY 184 EUGENOL FLAVOR 290 eszopiclone 169 EXCILON I.V. SPONGES 2"X2" 6 EURAX 141 PLY 184 ethacrynate sodium 151 EVAMIST 158 EXEL COMFORT POINT ethacrynic acid 151 EVANS BLUE 288 INSULIN PEN NEEDLES 29G X ETHAMBUTOL HCL 52 12MM 224 EVEKEO 1

Index 37 EXEL COMFORT POINT EZ SMART BLOOD GLUCOSE FC2 FEMALE CONDOM 191 INSULIN PEN NEEDLES 31G X TEST STRIPS 147 FD&C BLUE #2 288 6MM 224 EZ SMART PLUS BLOOD EXEL COMFORT POINT GLUCOSE TEST FD&C RED #40 288 INSULIN PEN NEEDLES 31G X STRIPS 147 FD&C YELLOW #5 288 8MM 224 EZ-LETS LANCETS 21G 196 FD&C YELLOW #6 ALUMINUM EXEL COMFORT POINT EZ-LETS LANCETS 26G LAKE 288 INSULIN SYRINGE/0.3ML/29G X SUPER-SOFT 196 FDC BLUE 1 288 1/2" 224 EZ-LETS LANCETS 28G FDC BLUE 1 ALUMINUM EXEL COMFORT POINT ULTRA-SOFT 196 LAKE 288 INSULIN SYRINGE/0.3ML/30G X EZ-LETS LANCETS 30G 196 FDC BLUE 2 288 5/16" 224 EXEL COMFORT POINT EZALLOR SPRINKLE 45 FDC GREEN #3 288 INSULIN SYRINGE/0.5ML/28G X ezetimibe 46 FDC RED #3 288 1/2" 225 ezetimibe-simvastatin 44 FDC RED 40 288 EXEL COMFORT POINT F-MELT 302 FDC YELLOW 5 ALUMINUM INSULIN SYRINGE/0.5ML/29G X LAKE 288 1/2" 225 FABIOR 121 EXEL COMFORT POINT FABRAZYME 155 FDC YELLOW 6 288 INSULIN SYRINGE/0.5ML/30G X FABRIC fe fum-iron polysacch complex-fa- 5/16" 225 BANDAGES/ASSORTED 184 b complex-c-zn-mn-cu 166 fe fumarate-vitamin c-vitamin EXEL COMFORT POINT FAGRON CAPFILL PRO 302 INSULIN SYRINGE/1ML/28G X b12-folic acid 166 FAGRON febuxostat 163 1/2" 225 DISPERSAPRO 302 EXEL COMFORT POINT FAGRON LS PLUS 305 FEIBA 163 INSULIN SYRINGE/1ML/29G X felbamate 31 1/2" 225 FAGRON NATURAL EXEL COMFORT POINT CREAM 305 FELBATOL 31 INSULIN SYRINGE/1ML/30G X FAGRON SUPREME FELDENE 5 CREAM 305 5/16" 225 felodipine 72 FALESSA 111 EXELDERM 125 FEMARA 55 famciclovir 69 EXELON 310 FEMHRT LOW DOSE 157 FAMCICLOVIR 87 exemestane 55 FEMRING 322 FAMOTIDINE 88 EXFOLIATING STONE FENBENDAZOLE 88 FILE 206 famotidine 317 fenofibrate 45 EXFORGE 49 famotidine in nacl 317 EXFORGE HCT 49 FAMOTIDINE/SODIUM FENOFIBRATE 45 EXJADE 39 CHLORIDE 317 fenofibrate 45 EXODERM 125 FANAPT 63 FENOFIBRATE 88 FANAPT TITRATION EXONDYS 51 274 fenofibrate micronized 45 PACK 63 FENOFIBRIC ACID 45 EXPAREL 173 FANATREX FUSEPAQ 29 fenofibric acid 45 EXQUISITE HRT 305 FARESTON 55 FENOGLIDE 45 EXTAVIA 311 FARXIGA 38 FENOPROFEN CALCIUM 5 EXTINA 125 FARYDAK 57 fenoprofen calcium 5 EXTRANEAL 256 FASENRA 22 FENOPROFEN CALCIUM 5 EXU-DRY NON-PERMEABLE FASENRA PEN 22 SHEET 36"X72" 142 fenoprofen calcium 5 FASLODEX 55 EXU-DRY PERMEABLE FENORTHO 5 QUILTED 36"X72" 142 FATTIBASE 305 FENSOLVI 154 EXYDERM 289 FATTYBLEND 302 fentanyl 9 EYE MULTIVITAMIN/LUTEIN FAVIPIRAVIR 70 259 fentanyl citrate 9 FAZACLO 64 EYLEA 279 FENTANYL CITRATE 9 FBL KIT 124 EZ SMART BLOOD GLUCOSE fentanyl citrate 9 LANCETS 196 FC FEMALE CONDOM 191

Index 38 FENTANYL CITRATE 9 FERROUS FUMARATE 88 FIFTY50 SUPERIOR fentanyl citrate 9 ferrous fumarate w/ b12-vit c-fa- COMFORTINSULIN ifc 166 SYRINGE/0.5ML/31G X FENTANYL 225 CITRATE/BUPIVACAINE ferrous fumarate-fa-b complex- 5/16" c-zn-mg-mn-cu 166 FIFTY50 SUPERIOR HCL/SODIUM CHLORIDE 13 COMFORTINSULIN FENTANYL ferrous fumarate-folic acid 166 SYRINGE/1ML/31G X CITRATE/BUPIVACAINE 5/16" 225 HYDROCHLORIDE 13 FERROUS GLUCONATE 88 FERROUS GLUCONATE FIFTY50 UNILET LANCETS FENTANYL 196 CITRATE/BUPIVACAINE DIHYDRATE 88 33G HYDROCHLORIDE/SODIUM FERROUS SULFATE 168 FINACEA 140 CHLORIDE 13 ferrous sulfate 168 FINASTERIDE 88 FENTANYL FERROUS SULFATE finasteride 162 CITRATE/BUPIVICAINE ANHYDROUS 168 FINE 30 196 HCL/SODIUM CHLORIDE 13 FERROUS SULFATE FINGERSTIX LANCETS 196 FENTANYL HEPTAHYDRATE 168 CITRATE/BUPIVICAINE FINTEPLA 29 FERULIC ACID 88 HYDROCHLORIDE/SODIUM FIORICET 8 FETROJA 77 CHLORIDE 13 FIORICET/CODEINE 14 FENTANYL CITRATE/NACL 9 FETZIMA 34 FENTANYL FETZIMA TITRATION FIORINAL 8 CITRATE/ROPIVACAINE PACK 34 FIORINAL/CODEINE #3 14 HYDROCHLORIDE 13 FEVERFEW 88 FIRAZYR 164 FENTANYL FEXOFENADINE HCL 88 FIRDAPSE 51 CITRATE/ROPIVACAINE HYDROCHLORIDE/SODIUM FIASP 37 FIRMAGON 55 CHLORIDE 13 FIASP FLEXTOUCH 37 FIRST - METOPROLOL 71 FENTANYL CITRATE/SODIUM FIASP PENFILL 37 FIRST-ATENOLOL 71 CHLORIDE 9 FIBRICOR 45 FIRST-BACLOFEN 1 271 FENTANYL/BUPIVACAINE/NAC L 14 FIBRYGA 163 FIRST-BACLOFEN 5 271 FENTORA 10 FIFTY50 ALCOHOL PREP FIRST-LANSOPRAZOLE 318 PADS 213 FER-IN-SOL 168 FIRST-METRONIDAZOLE FIFTY50 GLUCOSE TEST 100 17 FERAHEME 168 STRIP 2.0 147 FIRST-METRONIDAZOLE FERIVA 21/7 166 FIFTY50 PEN NEEDLES 31G 50 17 FERIVAFA 166 X3/16" (5MM) 225 FIRST-MOUTHWASH BLM 257 FIFTY50 PEN NEEDLES 31G FERRALET 90 166 X5/16" (8MM) 225 FIRST-OMEPRAZOLE 318 FERRAPLUS 90 166 FIFTY50 PEN NEEDLES FIRST-PROGESTERONE VGS FERRIC AMMONIUM 31GX5MM 225 100 COMPOUNDING KIT 322 CITRATE 88 FIFTY50 PEN FIRST-PROGESTERONE VGS FERRIC CHLORIDE NEEDLES/31GX8MM 225 200 COMPOUNDING KIT 322 HEXAHYDRATE 88 FIFTY50 PEN FIRST-VANCOMYCIN 25 18 FERRIC NEEDLES/32GX4MM 225 FIRST-VANCOMYCIN 50 18 FIFTY50 PEN PYROPHOSPHATE 105 FIRVANQ 18 FERRIC SUBSULFATE 88 NEEDLES/32GX6MM 225 FISH FLAVOR 290 FERRIC SULFATE FIFTY50 SAFETY SEAL HYDRATE 88 LANCETS 30G 196 FITALITE 305 FIFTY50 SAFETY SEAL FIXED OIL SUSPENSION 298 FERRIPROX 40 LANCETS 32G 196 FERRIPROX TWICE-A-DAY 40 FIFTY50 SUPERIOR FIZZMIX BASE 302 FERRLECIT 168 COMFORTINSULIN FLAGYL 17 FERRO-PLEX HEMATINIC 166 SYRINGE/0.3ML/31G X FLAREX 282 5/16" 225 FERROTRIN 166 FLAVOR BLEND 298 FERROUS BISGLYCINATE FLAVOR CHELATE 88 CONCENTRATE/CHLORHEXIDI NE 290

Index 39 FLAVOR PLUS 298 FLUBLOK QUADRIVALENT FLUORESCEIN SODIUM 109 FLAVOR SWEET 298 2018-2019 320 fluorometholone (ophth) 282 FLUBLOK QUADRIVALENT FLAVOR SWEET-SF 298 2019-2020 320 FLUOROPLEX 126 FLAVORX 290 FLUBLOK QUADRIVALENT fluorouracil 53 flavoxate hcl 319 2020-2021 320 FLUOROURACIL 88 FLUCELVAX QUADRIVALENT FLEBOGAMMA DIF 286 2018-2019 320 fluorouracil (topical) 127 flecainide acetate 22 FLUCELVAX QUADRIVALENT FLUOVIX 131 FLECTOR 124 2019-2020 320 FLUOVIX PLUS 131 FLEX-A-MIN DOUBLE FLUCELVAX QUADRIVALENT fluoxetine hcl 33 2020-2021 320 STRENGTH PLUS MSM 255 FLUOXETINE HCL 88 FLEX-A-MIN SUPER fluconazole 42 GLUCOSAMINE 2000 FLUCONAZOLE 88 fluoxetine hcl (pmdd) 312 FLUOXETINE PLUS 255 fluconazole in nacl 42 FLEX-A-MIN TRIPLE HYDROCHLORIDE 33 STRENGTH/BONE SHIELD FLUCONAZOLE/IBUPROFEN/I fluphenazine decanoate 64 TRACONAZOLE/TERBINAFIN PLUS VITAMINS K2/D3 255 E HYDROCHLORIDE 125 FLUPHENAZINE FLEX-A-MIN TRIPLE DECANOATE 88 flucytosine 42 STRENGTH/JOINT FLEX PLUS fluphenazine hcl 64 FLUCYTOSINE 88 VITAMIN D3 255 flurandrenolide 131 FLEXIBLE FABRIC fludarabine phosphate 53 flurazepam hcl 169 BANDAGES 184 FLUDROCORTISONE FLEXIBLE FABRIC ACETATE 117 FLURBIPROFEN 5 BANDAGESASSORTED 184 fludrocortisone acetate 117 flurbiprofen 5 FLEXIN 136 FLULAVAL QUADRIVALENT flurbiprofen sodium 284 FLEXIZOL COMBIPAK 5 2018-2019 320 flutamide 55 FLEXZAN 4 X 8 184 FLULAVAL QUADRIVALENT FLUTICASONE FLIBANSERIN 88 2019-2020 320 PROPIONATE 88 FLULAVAL QUADRIVALENT FLOLAN 74 2020-2021 321 fluticasone propionate 131 FLOLIPID 45 FLUMADINE 69 fluticasone propionate FLOMAX 162 (nasal) 273 flumazenil 40 fluticasone-salmeterol 25 FLORAJEN ACIDOPHILUS 39 FLUMAZENIL 88 fluvastatin sodium 45 FLORAJEN WOMEN 39 FLUMIST fluvoxamine maleate 33 FLORIVA 250 QUADRIVALENT 321 flunisolide (nasal) 273 FLUZONE HIGH-DOSE PF 2020- FLORIVA PLUS 262 2021 321 FLUNISOLIDE FLUZONE QUADRIVALENT FLOVENT DISKUS 24 ANHYDROUS 24 FLOVENT HFA 24 2018-2019 321 FLUNIXIN MEGLUMINE 88 FLUZONE QUADRIVALENT FLOXIN OTIC 285 fluocinolone acetonide 131 2019-2020 321 floxuridine 53 FLUOCINOLONE FLUZONE QUADRIVALENT FLOXURIDINE 88 ACETONIDE 131 2020-2021 321 FLUAD 2018-2019 320 fluocinolone acetonide FML 282 (otic) 285 FML FORTE 282 FLUAD 2019-2020 320 FLUOCINOLONE FLUAD 2020-2021 320 ACETONIDE/NIACINAMIDE FML LIQUIFILM 282 FLUAD QUADRIVALENT 131 FOAM TOE SEPARATORS206 INFLUENZA VACCINE FOR fluocinonide 131 FOAMIL 298 ADULTS 320 FLUOCINONIDE 131 FOCALIN 2 FLUARIX QUADRIVALENT fluocinonide emulsified FOCALIN XR 2 2018-2019 320 131 FLUARIX QUADRIVALENT base FOLET DHA 264 FLUOPAR 131 2019-2020 320 FOLET ONE 264 FLUORABON 250 FLUARIX QUADRIVALENT FOLGARD OS 259 2020-2021 320 FLUORESCEIN 109 FOLGARD RX 166

Index 40 FOLI-D 166 FORA D40/G31 BLOOD fosaprepitant dimeglumine 42 FOLIC + B12 166 GLUCOSE TEST FOSCAVIR 68 STRIPS 147 folic acid 165 FORA G20 BLOOD GLUCOSE fosinopril sodium 47 FOLIC ACID 165 TEST STRIPS 147 fosinopril sodium & folic acid 165 FORA G30/PREMIUM V10 hydrochlorothiazide 49 BLOOD GLUCOSE TEST fosphenytoin sodium 31 folic acid-cholecalciferol 166 STRIPS 147 FOSRENOL 160 folic acid-vitamin b6-vitamin FORA GD20 TEST b12 166 STRIPS 147 FRAGMIN 26 FOLIC D3 166 FORA GD50 BLOOD FREAMINE HBC 6.9% 277 FOLIC-K 258 GLUCOSE TEST FREAMINE III 277 FOLICA-BE 258 STRIPS 147 FREDS PHARMACY AUTOLET FORA GTEL BLOOD FOLICA-V 258 LANCING DEVICE 196 GLUCOSE TEST FREDS PHARMACY UNIFINE FOLIKA-D 166 STRIPS 147 PENTIPS PEN NEEDLES FOLIKA-V 262 FORA LANCETS 196 32GX4MM 225 FOLITE 167 FORA LANCING DEVICE196 FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM 225 FOLIVANE-F 167 FORA LANCING DEVICE/CLEARCAP 196 FREDS PHARMACY UNIFINE FOLIVANE-OB 264 FORA TN'G/TN'G VOICE PENTIPS PLUS 31GX8MM 225 FOLIVANE-PLUS 167 BLOOD GLUCOSE TEST FREDS PHARMACY UNILET FOLIXAPURE 167 STRIPS 147 LANCETS SUPER THIN 30G 196 FOLLISTIM AQ 153 FORA V10 BLOOD GLUCOSE TEST STRIPS 147 FREDS PHARMACY UNILET FOLOTYN 53 FORA V12 BLOOD GLUCOSE LANCETS ULTRA THIN FOLTRATE 167 TEST STRIPS 147 28G 196 FOLVITE FE 167 FORA V20 BLOOD GLUCOSE FREEDOM ADAPTADERM 305 fomepizole 40 TEST STRIPS 147 FREEDOM CEPAPRO 305 FORA V30A BLOOD FREEDOM DERMA fondaparinux sodium 26 GLUCOSE TEST SERUM 305 FOOD COLOR BLACK 288 STRIPS 147 FREEDOM DERMA-D 305 FORACARE GD40 147 FOOD COLOR BLUE 288 FREEDOM DERMA-N 305 FOOD COLOR BROWN 288 FORACARE PREMIUM V10 TESTSTRIPS 147 FREEDOM ESTERDERM 84 FOOD COLOR GREEN 288 FORACARE TEST N GO TEST FREEDOM LOLLIPOP FOOD COLOR LIME STRIPS 147 BASE 302 GREEN 288 FORANE 161 FREEDOM ODT BASE 302 FOOD COLOR ORANGE 288 FORFIVO XL 32 FREEDOM PEG TROCHE FOOD COLOR PINK 288 BASE 298 formaldehyde 65 FOOD COLOR RED 288 FREEDOM SILOMAC FORMALDEHYDE 65 ANHYDROUS 305 FOOD COLOR VIOLET 288 FORMOTEROL FREEDOM SIMPLECAP FOOD COLOR WHITE 288 FUMARATE 88 POWDER 302 FOOD COLOR YELLOW 288 FORSKOLIN 88 FREESTYLE CONTROL FOOT COMFORT THERMAL SOLUTION 196 FORTAMET 35 FREESTYLE CONTROL ANKLE AND FOOT FORTAVIT 259 STABILIZER 206 SOLUTION HIGH/LOW 196 FREESTYLE INSULINX FOOT SLEEP SUPPORT 206 FORTAZ 76 FORTEO 153 BLOODGLUCOSE TEST 147 FOOT SMOOTHER DUAL FREESTYLE INSULINX SURFACE 206 FORTESTA 15 BLOODGLUCOSE TEST FORA BLOOD GLUCOSE TEST FORTISCARE BLOOD STRIPS 147 STRIPS 147 GLUCOSETEST STRIP 147 FREESTYLE LANCETS 196 FORA D15G BLOOD GLUCOSE FOSAMAX 153 TEST STRIPS 147 FREESTYLE LITE TEST FORA D20 BLOOD GLUCOSE FOSAMAX PLUS D 153 STRIPS 147 TEST STRIPS 147 fosamprenavir calcium 66

Index 41 FREESTYLE PRECISION GABAPENTIN/NAPROXEN GEBAUERS PAIN EASE 136 INSULIN SYRINGE/U- SOD MULTI-PHASIC GEBAUERS SPRAY AND 100/0.5ML/30G X 5/16" 225 TRANSDERMAL CMPD STRETCH 136 FREESTYLE PRECISION KIT 124 GEL BALL OF FOOT INSULIN SYRINGE/U- GABITRIL 31 CUSHIONS 207 100/0.5ML/31G X 5/16" 225 GABLOFEN 271 GEL CORN FREESTYLE PRECISION GALACTOSE 88 PROTECTORS 207 INSULIN SYRINGE/U- GEL INSOLES MENS 207 100/1ML/31G X 5/16" 225 GALAFOLD 155 FREESTYLE PRECISION galantamine GEL INSOLES WOMENS 207 INSULIN SYRINGES/U- hydrobromide 310 GEL TOE PROTECTOR 207 100/1ML/30G X 5/16" 225 GALZIN 252 GEL TOE SEPARATORS 207 FREESTYLE PRECISION NEO GEL TOE SPACERS 207 BLOOD GLUCOSE TEST GAMASTAN 286 STRIPS 147 GAMMA-AMINOBUTYRIC GEL-FLOW 168 FREESTYLE TEST ACID 88 GELATIN 302 GAMMAGARD LIQUID 286 STRIPS 147 GELATIN TYPE A 302 FREESTYLE UNISTICK II GAMMAGARD S/D IGA LESS LANCETS 196 THAN 1MCG/ML 286 GELCLAIR 257 FRESENIUS PROPOVEN GAMMAKED 286 GELFILM OP 283 2% 161 GAMMAPLEX 286 GELFOAM-JMI POWDER FRESH LINEN KIT 168 FRAGRANCE 105 GAMUNEX-C 286 GELFOAM-JMI SPONGE FROTEK 124 GANCICLOVIR 68 KIT 168 FROVA 247 ganciclovir sodium 68 GELNIQUE 319 frovatriptan succinate 247 ganirelix acetate 153 GELNIQUE PUMP 319 FRUCTOSE 275 GANIRELIX ACETATE 154 GEMCITABINE 54 FULLERS EARTH 109 GARDASIL 9 321 gemcitabine hcl 54 FULPHILA 165 GARDENIA FRAGRANCE 88 GEMCITABINE GASTROCROM 159 HYDROCHLORIDE 54 fulvestrant 55 GEMFIBROZIL 45 gatifloxacin (ophth) 280 FUMARIC ACID 77 gemfibrozil 45 FUNGIMEZ 125 GATIFLOXACIN SESQUIHYDRATE 88 GEMZAR 54 FURADANTIN 20 GATIFLOXACIN- GEN7T 136 FURAZOLIDONE 88 DEXAMETHASONE 282 GEN7T PLUS 136 GATTEX 160 FUROSEMIDE 151 GENADUR 138 GAUZE BANDAGE 3" 184 furosemide 151,152 GENADUR KIT 138 FUROSEMIDE/SODIUM GAUZE BANDAGE/2" X CHLORIDE 152 4YDS 184 GENERESS FE 111 FUSILEV 60 GAUZE DRESSING GENICIN VITA-D 167 FUSION PLUS 167 4"X4" 184 GENICIN VITA-Q 262 GAUZE PADS 2"X2" 184 FUSION SPRINKLES 167 GENISTEIN 88 FUTURO THERAPEUTIC ARCH GAUZE PADS 4"X4" 185 GENOTROPIN 154 SUPPORT FOOT 206 GAUZE PADS 4"X4" 12 PLY 184 GENOTROPIN MINIQUICK154 FUZEON 66 GAUZE SPONGE TYPE VII gentamicin in saline 3 FYCOMPA 28 MEDI-PAK 2"X2" 8PLY 185 gentamicin sulfate 3 G-MYCO NAIL 125 GAUZE SPONGES 4"X4" 12 GENTAMICIN SULFATE 124 GABA 277 PLY 185 GAUZE STRETCH BANDAGE gentamicin sulfate (ophth) 280 GABACAINE 312 3"X2.5YD 185 gentamicin sulfate (topical) 124 GABAPAL 312 GAZYVA 54 GENTEEL BUTTERFLY TOUCH gabapentin 29 GE100 BLOOD GLUCOSE LANCETS 196 GABAPENTIN 88 TESTSTRIPS 147 GENTEEL LANCING GEBAUERS INSTANT DEVICE/BUFF BLACK 196 ICE 136

Index 42 GENTEEL LANCING GILPHEX TR 117 GLOBAL INJECT EASE INSULIN DEVICE/BUTTERFLY GILTUSS TR 117 SYRINGE/U-100/0.5ML/31G X BLUE 196 5/16" 226 GENTEEL LANCING GINGER 88 GLOBAL INJECT EASE INSULIN DEVICE/GLORIOUS GINGER ROOT 109 SYRINGE/U-100/1ML/28G X GOLD 196 GINKGO BILOBA XTRA 255 1/2" 226 GENTEEL LANCING GLOBAL INJECT EASE INSULIN DEVICE/PLAYFUL GINSENG (AMERICAN) 79 SYRINGE/U-100/1ML/29G X PURPLE 196 GINSENG ROOT 88 1/2" 226 GENTEEL LANCING GLASSIA 313 GLOBAL INJECT EASE INSULIN DEVICE/PRECIOUS glatiramer acetate 311 SYRINGE/U-100/1ML/30G X PLATINUM 196 1/2" 226 GENTEEL LANCING GLEEVEC 57 GLOBAL INJECT EASE INSULIN DEVICE/PRINCESS PINK 196 GLEOSTINE 53 SYRINGE/U-100/1ML/30G X GENTEEL LANCING GLIADEL WAFER 53 5/16" 226 DEVICE/STATELY SILVER196 glimepiride 38 GLOBAL INJECT EASE INSULIN GENTEEL LANCING SYRINGE/U-100/1ML/31G X DEVICE/WILLOWY WHITE 196 GLIPIZIDE 38 5/16" 226 GENTIAN VIOLET 125 glipizide 38 GLOBAL INJECT EASE GENTLE ADHESIVE glipizide-metformin hcl 35 LANCETS 28G 197 BANDAGES/EXTRA GLOBAL ALCOHOL PREP GLOBAL INJECT EASE LARGE 185 EASEPADS 213 LANCETS 30G 197 GENTLE-LET GP GLOBAL EASE INJECT PEN GLOBAL INSULIN SYRINGE/U- LANCETS 196 NEEDLES 29GX12MM 225 100/0.3ML/30G X 1/2" 226 GENTLE-LET LANCETS GLOBAL EASE INJECT PEN GLOBAL INSULIN SYRINGES/U- GENERAL PURPOSE NEEDLES 31GX8MM 225 100/0.3ML/30GX5/16" 226 STYLE/FINE POINT 196 GLOBAL EASE INJECT PEN GLOBAL LANCING GENTLE-LET LANCETS NEEDLES 32GX4MM 225 DEVICE 197 GENERAL PURPOSE GLOBAL EASE INJECT PEN GLOPERBA 163 STYLE/MEDIUM POINT 196 NEEEDLES 31GX5MM 225 GLUCAGEN HYPOKIT 36 GENTLE-LET LANCETS GLOBAL EASY GLIDE GLUCAGON EMERGENCY SAFETY STYLE/FINE INSULINSYRINGE/U- KIT 36 POINT 196 100/0.3ML/31G X 5/16" 225 GLUCAGON EMERGENCY KIT GENTLE-LET LANCETS GLOBAL EASY GLIDE PEN FOR LOW BLOOD SUGAR 36 SAFETY STYLE/MEDIUM NEEDLES 32GX4MM 226 GLUCO COR 268 POINT 196 GLOBAL INJECT EASE GLUCO PERFECT 3 TEST GENULTIMATE TEST INSULIN SYRINGE/U- STRIPS 147 STRIPS 147 100/0.3ML/29G X 1/2" 226 GLUCOCARD 01 CONTROL GENVOYA 66 GLOBAL INJECT EASE SOLUTION GEODON 63 INSULIN SYRINGE/U- NORMAL/HIGH 197 100/0.3ML/30G X 1/2" 226 GERANIUM NATURAL 106 GLUCOCARD 01 SENSOR GLOBAL INJECT EASE PLUS 147 GERANIUM OIL 106 INSULIN SYRINGE/U- GLUCOCARD 01 SENSOR GERITOL COMPLETE 259 100/0.3ML/30G X 5/16" 226 PLUSTEST STRIPS 148 GERMALL PLUS 87 GLOBAL INJECT EASE GLUCOCARD EXPRESSION INSULIN SYRINGE/U- BLOOD GLUCOSE TEST GERMANIUM 100/0.3ML/31G X 5/16" 226 SESQUIOXIDE 109 STRIPS 148 GLOBAL INJECT EASE GLUCOCARD EXPRESSION GHRP-2/GHRP- INSULIN SYRINGE/U- 6/SERMORELINACETATE 154 CONTROL SOLUTION LEVEL GHRP-2/SERMORELIN 100/0.5ML/28G X 1/2" 226 1 197 GLOBAL INJECT EASE GLUCOCARD SHINE CONTROL ACETATE 154 INSULIN SYRINGE/U- GHT TEST STRIPS 147 SOLUTION LEVEL 1 197 100/0.5ML/29G X 1/2" 226 GLUCOCARD SHINE TEST GIALAX 171 GLOBAL INJECT EASE STRIPS 148 GIAPREZA 324 INSULIN SYRINGE/U- GLUCOCARD VITAL TEST GILENYA 311 100/0.5ML/30G X 1/2" 226 STRIPS 148 GLOBAL INJECT EASE GLUCOCARD X-SENSOR 148 GILOTRIF 57 INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 226

Index 43 GLUCOCOM LANCETS GLUCOTROL XL 38 GLYXAMBI 35 28G 197 GLUMETZA 35 GNP ADHESIVE PADS 3" X GLUCOCOM LANCETS GLUTAMINE 277 4" 185 30G 197 GNP ALCOHOL SWABS 213 GLUCOCOM LANCETS GLUTARALDEHYDE 65 33G 197 GLUTARALDEHYDE IN GNP BORIC ACID 109 GLUCOCOM TEST WATER 89 GNP CENTURY ENERGY STRIPS 148 GLUTATHIONE 277 METABOLISM 268 GLUCONAVII BLOOD GNP CLEAR STRIPS 185 GLUTATHIONE (L) 277 GLUCOSETEST STRIPS 148 GNP CLICKFINE PEN GLUCONOLACTONE 89 GLUTATHIONE NEEDLEUNIVERSAL/31GX5/16" REDUCED 277 GLUCOPHAGE 35 227 GLUTATHIONE-L 277 GNP CLICKFINE UNIVERSAL GLUCOPHAGE XR 35 GLUTATHIONE-L PEN NEEDLES 31GX1/4" 227 GLUCOPRO INSULIN REDUCED 277 GNP CLICKFINE UNIVERSAL SYRINGE/U-100/0.3ML/30G X GLYBURIDE 38 PEN NEEDLES 31GX5/16" 227 1/2" 226 glyburide 38 GNP EASY TOUCH CONTROL GLUCOPRO INSULIN SOLUTION HIGH/LOW 197 SYRINGE/U-100/0.3ML/30G X glyburide micronized 38 GNP EASY TOUCH GLUCOSE 5/16" 226 glyburide-metformin 35 TEST STRIPS 148 GLUCOPRO INSULIN GLYCATE 316 GNP EUCALYPTUS OIL 106 SYRINGE/U-100/0.3ML/31G X GNP INSULIN 5/16" 226 GLYCERIN 106 GLUCOPRO INSULIN GLYCERINE 106 SYRINGE/0.3ML/29G X 1/2" 227 SYRINGE/U-100/0.5ML/30G X GLYCEROL FORMAL 106 1/2" 226 GNP INSULIN GLYCEROL SYRINGE/0.3ML/30G X GLUCOPRO INSULIN MONOOLEATE 89 SYRINGE/U-100/0.5ML/30G X 5/16" 227 GLYCERYL GNP INSULIN 5/16" 226 MONOSTEARATE 89 GLUCOPRO INSULIN SYRINGE/0.3ML/31G X GLYCINE 162 5/16" 227 SYRINGE/U-100/0.5ML/31G X GNP INSULIN 5/16" 226 glycine (gu irrigant) 162 GLUCOPRO INSULIN GLYCINE (L) 162 SYRINGE/0.5ML/28G X SYRINGE/U-100/1ML/30G X 1/2" 227 glycine diluent 298 GNP INSULIN 1/2" 226 GLYCINE SOYA GLUCOPRO INSULIN SYRINGE/0.5ML/29G X PROTEIN 106 1/2" 227 SYRINGE/U-100/1ML/30G X GNP INSULIN 5/16" 226 GLYCOFUROL 89 GLUCOPRO INSULIN GLYCOLIC ACID 77 SYRINGE/0.5ML/30G X GLYCOLIC ACID 70% HIGH 5/16" 227 SYRINGE/U-100/1ML/31G X GNP INSULIN 5/16" 227 PURITY 128 GLUCOSAMINE CHONDROITIN SYRINGE/0.5ML/31G X GLYCOPHOS 251 5/16" 227 COMPLEX PLUS MSM/TRIPLE GLYCOPYRROLATE 89 GNP INSULIN STRENGTH 255 GLUCOSAMINE CHONDROITIN glycopyrrolate 316 SYRINGE/1ML/28G X 1/2" 227 TRIPLE STRENGTH 255 GLYCOPYRROLATE 316 GNP INSULIN SYRINGE/1ML/29G X 1/2" 227 GLUCOSAMINE glycopyrrolate 316 89 GNP INSULIN HYDROCHLORIDE GLYCOPYRROLATE 316 SYRINGE/1ML/30G X GLUCOSAMINE SULFATE 89 GLYCOSAMINOGLYCANS 8 5/16" 227 GLUCOSAMINE SULFATE 9 GNP INSULIN POTASSIUM CHLORIDE 89 SYRINGE/1ML/31G X GLUCOSAMINE SULFATE GLYCOTROL 268 GLYCOTROL 5/16" 227 SODIUM CHLORIDE 89 GNP IODIDES TINCTURE 65 GLUCOSE CONTROL COMPLETE 268 SOLUTION 197 GLYCYRRHIZIC ACID 89 GNP IODINE TINCTURE 65 GLUCOSE METER TEST GLYNASE 38 GNP ISOPROPYL STRIPS ADVANCED 148 GLYRX-PF 316 ALCOHOL 106 GLUCOTROL 38 GNP ISOPROPYL ALCOHOL GLYSET 34 WIPES 140

Index 44 GNP LANCETS 197 GOJJI BLOOD GLUCOSE GREEN TEA 87 GNP LANCETS 21G 197 TESTSTRIPS/GOJJI STERILE GREEN TEA OIL LANCETS 30G 148 GNP LANCETS MICRO THIN FRAGRANCE 89 GOJJI LANCING GRILLED BEEF FLAVOR 33G 197 DEVICE/CLEAR CAP 197 GNP LANCETS SUPER THIN NATURAL OIL SOLUBLE 290 GOLD SODIUM GRILLED CHICKEN FLAVOR 30G 197 THIOMALATE 89 GNP LANCETS THIN 197 NATURAL OIL MISCIBLE 290 GOLYTELY 170 GRISEOFULVIN 89 GNP LANCETS THIN 26G 197 GONAL-F 153 GRISEOFULVIN GNP MICRO THIN LANCETS MICRONIZED 89 33G 197 GONAL-F RFF 153 GNP PLASTIC STRIPS GONAL-F RFF griseofulvin microsize 42 3/4" 185 REDIJECT 153 griseofulvin ultramicrosize 42 GNP SHEER STRIPS 185 GONITRO 20 GRX WHITE GNP SHEER STRIPS GOODSENSE COLOR PETROLATUM 305 ASSORTED 185 LANCETS MICRO-THIN 33G GRX WOUND 142 GNP SUPER STRIP UNIVERSAL 197 GUAIACOL 106 GOODSENSE IODINE 65 WATERSEALBANDAGES 185 GUAIFENESIN 118 GNP SUPER THIN GOODSENSE ISOPROPYL LANCETS/30G 197 ALCOHOL 106 guaifenesin-codeine 117 GNP ULTRA COMFORT GOODSENSE LANCETS GUANABENZ ACETATE 89 INSULIN SYRINGE/0.3ML/29G X MICRO-THIN 33G 197 GUANETHIDINE 1/2" 227 GOODSENSE LANCETS HEMISULFATE 89 GNP ULTRA COMFORT MICRO-THIN 33G guanfacine hcl 48 INSULIN SYRINGE/0.3ML/30G X UNIVERSAL 197 5/16" SHORT 227 GOODSENSE LANCETS guanfacine hcl (adhd) 2 GNP ULTRA COMFORT ULTRA-THIN 26G GUANIDINE HCL 51 INSULIN SYRINGE/0.3ML/31G X UNIVERSAL 197 GUANIDINEACETIC ACID 89 5/16" SHORT 227 GOODSENSE LANCETS GUAR GUM 89 GNP ULTRA COMFORT ULTRA-THIN 30G 197 INSULIN SYRINGE/0.5ML/28G X GOODSENSE LANCETS GUARANA SEED EXTRACT89 1/2" 227 ULTRA-THIN 30G GUAVA FLAVOR 290 GNP ULTRA COMFORT UNIVERSAL 197 GUM ARABIC MILLED 302 INSULIN SYRINGE/0.5ML/29G X GOODSENSE LANCING GUM ARABIC SPRAY- 1/2" 227 DEVICE 197 DRIED 302 GNP ULTRA COMFORT GOODSENSE PREMIUM GUM BASE GELATIN 299 INSULIN SYRINGE/0.5ML/30G X BLOOD GLUCOSE TEST 5/16" SHORT 227 STRIPS 148 GVOKE HYPOPEN 1-PACK 36 GNP ULTRA COMFORT GOPRELTO 272 GVOKE HYPOPEN 2-PACK 36 INSULIN SYRINGE/0.5ML/31G X GORDOFILM 135 GVOKE PFS 36 5/16" SHORT 227 GORDONS UREA 134 GYMNEMA SYLVESTRIS GNP ULTRA COMFORT LEAF 89 INSULIN SYRINGE/1ML/28G X GPL PAK 312 GYNAZOLE-1 322 1/2" 227 GRALISE 312 GNP ULTRA COMFORT H-E-B IN CONTROL PEN INSULIN SYRINGE/1ML/29G X GRAMICIDIN D 89 NEEDLES 31GX5MM 227 1/2" 227 granisetron hcl 41 H-E-B IN CONTROL PEN GNP ULTRA COMFORT GRANIX 165 NEEDLES 31GX6MM 228 H-E-B IN CONTROL PEN INSULIN SYRINGE/1ML/30G X GRAPE FLAVOR 290 5/16" SHORT 227 NEEDLES 31GX8MM 228 GNP ULTRA COMFORT GRAPE SEED 89 H-E-B IN CONTROL PEN INSULIN SYRINGE/1ML/31G X GRAPE SYRUP 298 NEEDLES/NANO/32GX4MM 5/16" SHORT 227 GRAPEFRUIT FLAVOR 228 PINK 290 H-E-B IN CONTROL GOCOVRI 62 UNIFINEPENTIPS PLUS GOJJI BLOOD GLUCOSE GRAPESEED 89 31GX5MM 228 TESTSTRIPS 148 GREEN SOAP 89 H-E-B IN CONTROL GREEN SOURCE 268 UNIFINEPENTIPS PLUS 32GX4MM 228

Index 45 H-E-B INCONTROL HCG 153 HEMETAB 167 ADVANCEDLANCING HDL RX 255 HEMOCYTE PLUS 167 DEVICE 197 H-E-B INCONTROL ALCOHOL HEALON 283 HEMOFIL M 163 PADS 213 HEALON GV 283 HEPAGAM B 286 H-E-B INCONTROL LANCETS HEALON PRO 283 heparin (porcine) in sodium MICRO THIN 33G 197 HEALON5 283 chloride 26 H-E-B INCONTROL LANCETS HEPARIN LOCK FLUSH 26 SUPER THIN 30G 197 HEALON5 PRO 283 H-E-B INCONTROL LANCETS HEALTH CARE LANCING heparin sod (porcine) in d5w 26 ULTRA THIN 28G 197 DEVICE 197 HEPARIN SODIUM 26,89 H-E-B INCONTROL PEN HEALTH heparin sodium (porcine) 26 NEEDLES 29GX12MM 228 SLIPPERS/UNISEX 207 heparin sodium (porcine) lock H20 GEL BASE 305 HEALTHWISE MINI PEN flush 26 HAEGARDA 164 NEEDLES 31GX6MM 228 heparin sodium (porcine) lock HEALTHWISE PEN NEEDLES HAEMOLANCE 197 flush & nacl lock flush 26 29GX12MM 228 HEPARIN SODIUM/D5W 26 HAEMOLANCE LOW FLOW HEALTHWISE SHORT PEN LANCETS 197 NEEDLES 31GX8MM 228 HEPARIN HAEMOLANCE PLUS 197 HEALTHWISE UNIFINE SODIUM/DEXTROSE 26 PENTIPS PEN NEEDLES HEPARIN SODIUM/NACL HAEMOLANCE PLUS HIGH 0.45% 26,27 FLOW 197 32GX4MM 228 HEALTHY ACCENTS HEPARIN SODIUM/SODIUM HAEMOLANCE PLUS LOW CHLORIDE 27 FLOW 197 AUTOLET IMPRESSION HEPARIN SODIUM/SODIUM LANCING DEVICE 198 HAEMOLANCE PLUS MAX CHLORIDE 0.9% 27 FLOW 197 HEALTHY ACCENTS UNIFINE HEPARIN/SODIUM PENTIPS PEN NEEDLES HAEMOLANCE PLUS CHLORIDE 28 PEDIATRIC FLOW 197 29GX12MM 228 HEPES 89 HAIR FARE 268 HEALTHY ACCENTS UNIFINE HAIR NOURISHING PENTIPS PEN NEEDLES HEPLISAV-B 321 SUPPLEMENT 268 31GX5MM 228 HEPMED 28 HALAVEN 61 HEALTHY ACCENTS UNIFINE HEPSERA 69 PENTIPS PEN NEEDLES halcinonide 131 31GX6MM 228 HEPTAMINOL 89 HALCION 170 HEALTHY ACCENTS UNIFINE HERCEPTIN 54 HALDOL 63 PENTIPS PEN NEEDLES HERCEPTIN HYLECTA 57 31GX8MM 228 HALDOL DECANOATE 100 63 HEALTHY ACCENTS UNIFINE HERZUMA 54 HALDOL DECANOATE 50 63 PENTIPS PEN NEEDLES HETLIOZ 170 halobetasol propionate 131 32GX4MM 228 HIBERIX 319 HALOBETASOL HEALTHY ACCENTS UNILET HIPREX 20 LANCETS SUPER THIN PROPIONATE 131 HISTAMINE PHOSPHATE 89 HALOG 132 30G 198 HEALTHY HEART HIZENTRA 286 haloperidol 64 COMPLEX 269 HM ADHESIVE BANDAGES HALOPERIDOL 89 HEART SAVIOR 269 ANTIBACTERIAL 185 haloperidol decanoate 64 HEART TABS 269 HM ADHESIVE BANDAGES ANTIBACTERIAL/SHEER 185 HALOPERIDOL HECTOROL 155 DECANOATE 89 HM ADHESIVE BANDAGES HELIDAC THERAPY 318 haloperidol lactate 64 ANTIBACTERIAL/SHEER/XL HELIXATE FS 163 185 HALUCORT 138 HEMANGEOL 71 HM ADHESIVE PADS HAM FLAVOR 290 ANTIBACTERIAL/SHEER 185 HARMONY BLOOD GLUCOSE HEMATOGEN FA 167 HM BORIC ACID 109 TEST STRIPS 148 HEMATOXYLIN 89 HM BUTTERFLY HARVONI 68,69 HEMATRON-AF 167 CLOSURES 185 HAVRIX 321 HEMENATAL OB 264 HM CASTOR OIL 106 HAWTHORN BERRY 89 HEMENATAL OB + DHA 264 HM ESTROPLUS 269

Index 46 HM FABRIC ADHESIVE HUMALOG JUNIOR HYALURONIC ACID BANDAGES ADVANCED KWIKPEN 37 SODIUM/NIACINAMIDE/TACRO ANTIBACTERIAL 185 HUMALOG KWIKPEN 37 LIMUS 135 HM GLUCOSAMINE HUMALOG MIX 50/50 37 HYALURONIC ACID 255 CHONDROITIN COMPLEX HUMALOG MIX 50/50 SODIUM/NIACINAMIDE/TRETIN OIN 121 HM IODIDES TINCTURE 65 KWIKPEN 37 HYALURONIDASE 89 HM IODINE TINCTURE 65 HUMALOG MIX 75/25 37 HM ISOPROPYL RUBBING HUMALOG MIX 75/25 HYCAMTIN 61 ALCOHOL 106 KWIKPEN 37 HYCLODEX 140 HM ISOPRPYL RUBBING HUMAN CHORIONIC hydralazine hcl 50 ALCOHOL 106 GONADOTROPIN 84 HYDRALAZINE HCL 89 HM NON-STICK PADS 3" X HUMAPEN LUXURA HD 228 4" 185 HYDRAZINE SULFATE 90 HUMATE-P 163 HM STERILE ALCOHOL PREP HYDREA 59 PADS 213 HUMATROPE 154 HYDRO 35 134 HM STERILE PADS 185 HUMATROPE COMBO HYDRO 40 FOAM 134 HM STERILE PADS 2"X2" 185 PACK 154 HYDROCELL ADHESIVE HM ULTICARE INSULIN HUMIRA 4 HUMIRA PEDIATRIC CROHNS DRESSING 4"X4" 185 SYRINGE/1ML/30G X 1/2" 228 HYDROCELL ADHESIVE HM ULTICARE INSULIN DISEASE STARTER PACK 4 DRESSING 6"X6" 185 SYRINGE/U-100/0.3ML/31G X HUMIRA PEN 4 HYDROCELL DRESSING 5/16" 228 HUMIRA PEN-CD/UC/HS 4"X4" 185 homatropine hbr 279 STARTER 4 HYDROCELL DRESSING HOMATROPINE HUMIRA PEN-PS/UV 6"X6" 185 METHYLBROMIDE 109 STARTER 4 HYDROCHLORIC ACID 77 HONEY ALMOND HUMULIN 70/30 37 FRAGRANCE 89 HUMULIN 70/30 hydrochlorothiazide 152 HONEY FLAVOR 290 KWIKPEN 37 HYDROCHLOROTHIAZIDE HUMULIN N 37 152 HORIZANT 312 hydrochlorothiazide 152 HORMONE CREAM BASE 305 HUMULIN N KWIKPEN 37 HYDROCODONE HORMONE CREAM BASE HUMULIN R 37 BITARTRATE 90 BOTANICAL 305 HUMULIN R U-500 HYDROCODONE HORMONE CREAM BASE (CONCENTRATED) 37 BITARTRATE/ACETAMINOPHE NIOSOMES 305 HUMULIN R U-500 N 14 HORMONE CREAM-HEAVY KWIKPEN 37 HYDROCODONE BASENIOSOMES 305 HUPERZINE SERRATE A 89 BITARTRATE/GUAIFENESIN HOT FLASHEX 255 HURRICAINE 257 118 HPR 138 HW EMBRACE PRO BLOOD hydrocodone polistirex- HPR PLUS 138 GLUCOSE TEST chlorpheniramine polistirex 118 STRIPS 148 hydrocodone w/ HPR PLUS HYDROGEL homatropine 117 KIT 139 HW EMBRACE TALK BLOOD hydrocodone- HPR PLUS/MB GLUCOSE TEST acetaminophen 14 STRIPS 148 HYDROGEL 134 hydrocodone-ibuprofen 14 HRT BASE 305 HY-VEE LANCETS 198 hydrocortisone 114 HRT BASE FOR MEN 305 HY-VEE THIN LANCETS 198 HYDROCORTISONE 132 HRT BOTANICAL 305 HYALUCIL-4 127 hydrocortisone (intrarectal) 16 HRT BOTANICAL BASE 305 HYALURONATE SODIUM 89 hydrocortisone (rectal) 16 HRT CREAM BASE 305 hyaluronate sodium HRT CREAM BASE (emollient) 134 hydrocortisone (topical) 132 WOMEN 305 HYALURONIC ACID HYDROCORTISONE HYDROLYZED 89 ACETATE 132 HRT ESSENTIAL CREAM 305 HYALURONIC ACID HYDROCORTISONE ACETATE HRT HEAVY 305 SODIUM 89 MICRONIZED 132 HRT NATURAL LOTION 305 HYALURONIC ACID SODIUM HUMALOG 37 SALT 89

Index 47 HYDROCORTISONE HYDROMORPHONE HCL 10 hydroxyprogesterone ACETATE/LIDOCAINE hydromorphone hcl 10 caproate 309 HYDROCHLORIDE 132 hydroxyprogesterone caproate hydrocortisone butyrate 132 HYDROMORPHONE HCL 10 (antineoplastic) 55 HYDROCORTISONE hydromorphone hcl 10 HYDROXYPROPYL BUTYRATE 132 HYDROMORPHONE CELLULOSE 90 hydrocortisone butyrate HCL/SODIUMCHLORIDE 10 HYDROXYPROPYL hydrophilic lipo base 132 HYDROMORPHONE CELLULOSE 150-400 CPS 90 HYDROCORTISONE HYDROCHLORIDE 10 HYDROXYPROPYL HEMISUCCINATE HYDROMORPHONE CELLULOSE 1500 CPS 90 MONOHYDRATE 90 HYDROCHLORIDE/ SODIUM HYDROXYPROPYL HYDROCORTISONE CHLORIDE 10 CELLULOSE 1500-3000 MICRONIZED 132 HYDROMORPHONE CPS 90 hydrocortisone valerate 132 HYDROCHLORIDE/BUPIVACA HYDROXYPROPYL INE HYDROCHLORIDE 14 CELLULOSE 4000-6500 hydrocortisone w/acetic CPS 90 acid 285 HYDROMORPHONE HYDROCHLORIDE/BUPIVACA HYDROXYPROPYL HYDROCORTISONE/IODOQUIN CELLULOSE 75-100 CPS 90 OL/KETOCONAZOLE 125 INE HYDROCHLORIDE/SODIUM HYDROXYPROPYL HYDROCORTISONE/KETOCON METHYLCELLULOSE 90 AZOLE 125 14 HYDROMORPHONE HYDROXYPROPYL-BETA- HYDROFERA BLUE FOAM CYCLODEXTRIN 90 DRESSING 2"X2" 142 HYDROCHLORIDE/ROPIVAC AINE HYDROCHLORIDE 14 HYDROXYQUINOLINE HYDROFERA BLUE FOAM SULFATE 95 DRESSING 4"X4" 142 HYDROMORPHONE HYDROFERA BLUE FOAM HYDROCHLORIDE/ROPIVAC HYDROXYTRYPTOPHAN 109 DRESSING 6"X6" 142 AINE/SODIUM CHLORIDE14 HYDROXYTRYPTOPHAN L- HYDROFERA BLUE FOAM HYDROMORPHONE 5 109 DRESSING/MOISTURE HYDROCHLORIDE/SODIUM hydroxyurea 59 RETENTIVE FILM/2-1/4X8 142 CHLORIDE 10,11 HYDROXYUREA 90 HYDROMORPHONE/SODIUM HYDROFERA BLUE FOAM hydroxyzine hcl 21 DRESSING/MOISTURE CHLORIDE 11 RETENTIVE FILM/4"X4" 142 HYDROPHILIC 305 HYDROXYZINE HCL 90 HYDROFERA BLUE FOAM HYDROQUINONE 140 hydroxyzine pamoate 21 DRESSING/MOISTURE HYDROUS EMULSIFIED HYDROXYZINE PAMOATE 21 RETENTIVE FILM/ISLAND 142 BASE 305 HYDROFERA BLUE FOAM HYLAGUARD 139 HYDROXOCOBALAMIN 90 HYLAMIX 139 DRESSING/MOISTURE hydroxocobalamin RETENTIVE/OSTOMY/2.5" acetate 165 HYLATOPIC PLUS 139 142 HYDROXOCOBALAMIN HYLENEX 253 HYDROFERA BLUE FOAM HYDROCHLORIDE 90 DRESSING/TUNNELING/9MM HYLINATE 134 HYDROXYAMPHETAMINE HYOPHEN 17 142 HYDROBROMIDE 90 HYDROFERA BLUE HEAVY hydroxychloroquine sulfate 51 HYOSCYAMINE SULFATE 316 DRAINAGE 4"X4" 143 hyoscyamine sulfate 316 HYDROFERA BLUE HEAVY HYDROXYCHLOROQUINE DRAINAGE 6"X6" 143 SULFATE 90 HYPER-SAL 118 HYDROFERA BLUE READY HYDROXYETHYL HYPERHEP B S/D 286 CELLULOSE 90 FOAMDRESSING HYPERRAB 286 2.5"X2.5" 143 HYDROXYETHYL HYDROFERA BLUE READY CELLULOSE 100 CPS 90 HYPERRAB S/D 286 FOAMDRESSING 4"X5" 143 HYDROXYETHYL HYPERRHO S/D 286 HYDROFERA BLUE READY CELLULOSE 4500-6500 HYPERRHO S/D MINI- FOAMDRESSING 8"X8" 143 CPS 90 DOSE 286 HYDROFLUORIC ACID 90 HYDROXYETHYL HYPERSAL 118 CELLULOSE 5000 CPS 90 HYDROGEL 143 HYDROXYETHYL HYPERTET S/D 286 hydrogen peroxide 65 METHACRYLATE 90 HYPOCYN 140 hydromorphone hcl 10 HYDROXYPROGESTERONE HYPROMELLOSE CAPROATE 90 100000CPS 90

Index 48 HYPROMELLOSE 4000 MPA- IMIPRAMINE HCL 34 INFED 168 S 90 imipramine hcl 34 INFINITY BLOOD GLUCOSE HYPROMELLOSE 4000CPS90 imipramine pamoate 34 TEST STRIPS 148 HYPROMELLOSE METHOCEL INFINITY VOICE 148 IMIQUIMOD 91 K100M 90 INFLAMMA-K KIT 124 HYPROMELLOSE TYPE imiquimod 134 2910 90 INFLAMMATION REDUCTION IMIQUIMOD/LEVOCETIRIZINE PACK 5 HYQVIA 286 DIHYDROCHLORIDE/NIACINA INFLATHERM 5 HYSINGLA ER 11 MIDE 127 IMIQUIMOD/LEVOCETIRIZINE INFLECTRA 159 HYZAAR 49 DIHYDROCHLORIDE/TRETIN INFUGEM 54 ibandronate sodium 153 OIN 127 INFUMORPH 200 11 IBRANCE 57 IMITREX 247 INFUMORPH 500 11 IBU 600-EZS 5 IMITREX STATDOSE INFUVITE ADULT 262 IBUPAK 5 REFILL 247 IMITREX STATDOSE INFUVITE PEDIATRIC 263 IBUPROFEN 5 SYSTEM 247 INGREZZA 311 ibuprofen 5 IMLYGIC 61 INJECTAFER 168 IBUPROFEN COMFORT IMODIUM A-D 39 PAC 5 INLYTA 58 IMOGAM RABIES-HT 286 ibuprofen lysine 5 INNOPRAN XL 71 IMOVAX RABIES ibutilide fumarate 22 (H.D.C.V.) 321 INOSITOL 91 ICAR-C PLUS 167 IMPAVIDO 17 INOSITOL HEXANICOTINATE 91 icatibant acetate 164 IMPOYZ 132 INOVA 121 ICHTHAMMOL 140 IMURAN 253 INOVA 4/1 ACNE CONTROL ICLUSIG 58 IMVEXXY MAINTENANCE THERAPY 121 icosapent ethyl 44 PACK 322 INOVA 8/2 ACNE CONTROL ICY HOT LIDOCAINE PLUS IMVEXXY STARTER THERAPY 121 MENTHOL 136 PACK 322 INPEN 100/BLUE/LILLY 228 IN TOUCH BLOOD GLUCOSE IDAMYCIN PFS 57 TEST STRIPS 148 INPEN 100/BLUE/NOVO 228 idarubicin hcl 57 IN TOUCH GLUCOSE INPEN 100/GRAY/LILLY 228 IDEBENONE 90 CONTROLSOLUTION 198 INPEN 100/GREY/NOVO 228 IDELVION 163 IN TOUCH LANCING INPEN 100/PINK/LILLY 228 DEVICE 198 IDHIFA 58 IN TOUCH STERILE INPEN 100/PINK/NOVO 228 IDOXURIDINE 91 LANCETS30G 198 INREBIC 58 IFEX 53 INBRIJA 62 INSPRA 50 ifosfamide 53 INCRELEX 154 INSULIN ASPART IFOSFAMIDE 53 INCRUSE ELLIPTA 23 PROTAMINE/INSULIN ASPART 37 IGLUCOSE BLOOD GLUCOSE indapamide 152 INSULIN ASPART TEST STRIPS 148 INDERAL LA 71 PROTAMINE/INSULIN ASPART ILARIS 4 INDERAL XL 71 FLEXPEN 37 ILEVRO 284 INDOCIN 5 INSULIN LISPRO 37 ILIDERM 139 INDOCYANINE GREEN 91 INSULIN LISPRO JUNIOR KWIKPEN 37 ILUMYA 127 INDOLE-3-CARBINOL 91 ILUVIEN 282 INSULIN LISPRO KWIKPEN 37 indomethacin 5 INSULIN LISPRO imatinib mesylate 58 INDOMETHACIN 5 PROTAMINE/INSULIN LISPRO IMBRUVICA 58 indomethacin sodium 5 KWIKPEN 37 INSULIN SYRINGE 1ML/31G IMFINZI 54 INFANRIX 315 IMIDUREA 91 X1/4" 228 INFANT DRINKING INSULIN SYRINGE/0.3ML/29G X IMIOXIA 125 WATER 299 1" 228 imipenem-cilastatin 18 INFASURF 313

Index 49 INSULIN SYRINGE/0.3ML/29G X INSULIN INTRASITE GEL 1/2" 228 SYRINGES/0.5ML/29GX1/2" APPLIPAK 143 INSULIN SYRINGE/0.3ML/30G X 229 INTRON A 59 5/16" 228 INSULIN INTUNIV 2 INSULIN SYRINGE/0.3ML/31G X SYRINGES/0.5ML/30GX5/16" 5/16" 228 229 INULOSE BLOOD SUGAR INSULIN SYRINGE/0.5ML/27G X INSULIN SUPPORT 269 1/2" 228 SYRINGES/0.5ML/31GX INVANZ 18 INSULIN SYRINGE/0.5ML/28G X 5/16" 229 INVEGA 63 1/2" 228 INSULIN INVEGA SUSTENNA 63 INSULIN SYRINGE/0.5ML/30G X SYRINGES/0.5ML/31GX5/16" INVEGA TRINZA 63 1/2" 229 229 INSULIN SYRINGE/0.5ML/30G X INSULIN INVELTYS 282 5/16" 229 SYRINGES/1ML/27GX/1/2" INVIRASE 66 INSULIN SYRINGE/0.5ML/31G X 229 INVOKAMET 35 5/16" 229 INSULIN INSULIN SYRINGE/1ML/28G X SYRINGES/1ML/27GX1/2" INVOKAMET XR 35 1/2" 229 229 INVOKANA 38 INSULIN SYRINGE/1ML/29G X INSULIN IODIDES TINCTURE 65 1/2" 229 SYRINGES/1ML/28GX1/2" IODINE 91 INSULIN SYRINGE/1ML/30G X 229 5/16" 229 INSULIN IODINE RESUBLIMED 91 INSULIN SYRINGE/NEEDLE SYRINGES/1ML/29GX1/2" IODINE STRONG 91 0.3ML/30G X 5/16" 229 229 iodine strong (lugol's) 250 INSULIN SYRINGE/NEEDLE INSULIN 0.3ML/31G X 5/16" 229 SYRINGES/1ML/30GX1/2" iodine strong (lugol's) (bulk) 91 INSULIN SYRINGE/NEEDLE 229 IODINE TINCTURE 65 0.5ML/29G X 1/2" 229 INSULIN IODINE TINCTURE MILD 65 INSULIN SYRINGE/NEEDLE SYRINGES/1ML/31GX5/16" IODOFORM 109 0.5ML/30G X 5/16" 229 230 IODOQUINOL 3 INSULIN SYRINGE/NEEDLE INSUPEN 29G X 12MM 230 0.5ML/31G X 5/16" 229 IONOSOL-MB/DEXTROSE INSULIN SYRINGE/NEEDLE INSUPEN 31G X 5MM 230 5% 249 1ML/29G X 1/2" 229 INSUPEN 31G X 8MM 230 IONSYS 11 INSULIN SYRINGE/NEEDLE INSUPEN 32G X 4MM 230 1ML/30G X 5/16" 229 IOPANOIC ACID 91 INSULIN SYRINGE/NEEDLE INSUPEN 33GX4MM 230 IOPIDINE 280 1ML/31G X 5/16" 229 INSUPEN PEN NEEDLES 32G IPAMORELIN ACETATE 154 X4MM 230 INSULIN SYRINGE/U- IPOL INACTIVATED IPV 321 100/0.3ML/29G X 1/2" 229 INSUPEN SENSITIVE INSULIN SYRINGE/U- 32GX6MM 230 IPRATROPIUM BROMIDE 23 100/0.5ML/29G X 1/2" 229 INSUPEN SENSITIVE ipratropium bromide 23 INSULIN SYRINGE/U- 32GX8MM 230 ipratropium bromide (nasal)273 100/1ML/29G X 1/2" 229 INSUPEN ULTRAFIN 29GX12MM 230 IPRATROPIUM BROMIDE INSULIN SYRINGE/U- MONOHYDRATE 23 100/1ML/30G X 5/16" 229 INSUPEN ULTRAFIN INSULIN SYRINGE/U- 30GX8MM 230 ipratropium-albuterol 25 100/1ML/31G X 5/16" 229 INSUPEN ULTRAFIN irbesartan 48 INSULIN SYRINGES 0.3ML/31G 31GX6MM 230 irbesartan-hydrochlorothiazide X 1/4" 229 INSUPEN ULTRAFIN 49 INSULIN SYRINGES 0.5ML/31G 31GX8MM 230 IRESSA 58 X 1/4" 229 INTEGRA F 167 irinotecan hcl 61 INSULIN INTEGRA PLUS 167 iron combinations 167 SYRINGES/0.5ML/27GX1/2" INTELENCE 66 229 iron polysaccharide complex-vit INSULIN INTERMEZZO 170 b12-folic acid 167 SYRINGES/0.5ML/28GX1/2" INTRALIPID 275 iron w/ vitamins 259 229 INTRAROSA 321 iron-docusate-b12-folic acid-vit c- vit e-copper-biotin 167

Index 50 iron-folic acid-vitamin c-vitamin ivermectin 17 K-PHOS NO 2 161 b6-vitamin b12-zinc 167 IVERMECTIN 91,140 K-TAB 251 iron-vitamin c-vitamin b12-folic acid 167 ivermectin (rosacea) 140 K.B.G.L. IN TERODERM CREAM 124 IROSPAN 24/6 167 IVERMECTIN/METRONIDAZO KABIVEN 275 irrigation solutions, LE/NIACINAMIDE 140 physiological 254 IXEMPRA KIT 61 KADCYLA 54 IS 24/6 167 IXIARO 321 KADIAN 11 ISENTRESS 66 IXINITY 163 KAHLUA FLAVOR 290 ISENTRESS HD 66 J & J ADHESIVE LARGE 185 KALBITOR 164 isoflurane 161 J & J GAUZE 2"X2" 8 KALETRA 67 ISOLYTE-P/DEXTROSE PLY 185 KALYDECO 313 5% 249 J & J GAUZE 4"X4" 12 PLY 185 KAMDOY 139 ISOLYTE-S 249 J & J GAUZE 4"X4" 8 KANAMYCIN SULFATE 91 ISOLYTE-S PH 7.4 249 PLY 185 KANJINTI 54 ISOMETHEPTENE J & J GAUZE SPONGES 12- MUCATE 91 PLY 4" X 4" 185 KANUMA 155 ISONIAZID 52 J & J GAUZE SPONGES 16- KAOLIN 39 isoniazid 52 PLY 4" X 4" 185 KAOLIN COLLOIDAL 39 J & J GAUZE SPONGES 8- KAPSPARGO SPRINKLE 71 ISONIAZID 52 PLY4" X 4" 185 isoniazid 52 J & J NON-STICK PADS KAPVAY 2 ISOPROPAMIDE IODIDE 316 100LARGE 185 KARAYA GUM 302 ISOPROPANOL 106 JADENU 40 KARBINAL ER 43 ISOPROPYL ALCOHOL 106 JADENU SPRINKLE 40 KATERZIA 73 isopropyl alcohol 106 JAKAFI 58 KAZANO 35 ISOPROPYL ALCOHOL JALYN 162 KCL 0.15%/D5W/NACL WIPES 140 JANUMET 35 0.225% 249 ISOPROPYL MYRISTATE 91 KCL 0.3%/D5W/NACL JANUMET XR 35 0.9% 249 ISOPROPYL PALMITATE 106 JANUVIA 36 KEDRAB 286 isoproterenol hcl 25 JARDIANCE 38 KEFLEX 76 ISOPROTERENOL HCL 91 JASMINE FRAGRANCE 91 KELARX 141 ISOPTO ATROPINE 279 JATENZO 15 KENALOG 132 ISOPTO CARPINE 279 JELENE 305 KENALOG-10 114 ISORDIL TITRADOSE 20 JELMYTO 57 KENALOG-40 114 ISOSORBIDE 91 JENTADUETO 35 KENALOG-80 114 isosorbide dinitrate 20 JENTADUETO XR 35 KENDALL AMORPHOUS isosorbide mononitrate 20 JETREA 284 HYDROGEL WOUND ISOTRETINOIN 91 JEVTANA 61 DRESSING 143 KENDALL HYDROGEL isotretinoin 121 JIVI 163 IMPREGNATED GAUZE ISOXSUPRINE HCL 91 JOJOBA OIL 91 2"X2" 143 isradipine 72 JORNAY PM 2 KENDALL HYDROGEL ISTALOL 279 JTT PHYSICIANS KIT 114 IMPREGNATED GAUZE 4"X4" 143 ISTODAX (OVERFILL) 58 JUBLIA 125 KENDALL HYDROGEL ISTURISA 152 JULUCA 66 IMPREGNATED GAUZE ISUPREL 25 JUNIPER TAR 106 4"X8" 143 ITHOXIA 121 KENDALL HYDROGEL WOUND JUXTAPID 46 DRESSING 3" DISK 143 itraconazole 42,43 JYNARQUE 156 KENDALL HYDROGEL WOUND ITRACONAZOLE 91 K-PHOS 251 DRESSING 4-3/4" DISK 143 IV NOVICE PACK 136 K-PHOS NEUTRAL 251

Index 51 KENDALL HYDROPHILIC FOAM KERLIX GAUZE ROLL SMALL KETOROLAC DRESSING 4"X8" 185 2.25"X 3YD 6 PLY 186 TROMETHAMINE 91 KENDALL HYDROPHILIC KERLIX SPONGES 4" X 4" 12 ketorolac tromethamine FOAMDRESSING 2"X2" 185 PLY 186 (ophth) 284 KENDALL HYDROPHILIC KERLIX SPONGES 4" X 4" 16 KETOROLAC FOAMDRESSING 4"X4" 185 PLY 186 TROMETHAMINE/BUPIVACAIN KENDALL HYDROPHILIC KERLIX SUPER SPONGES E FOAMDRESSING 6"X6" 185 MEDIUM 6"X6-3/4" 186 HYDROCHLORIDE/KETAMINE KENDALL HYDROPHILIC KERLIX SUPER SPONGES HY 6 FOAMPLUS DRESSING MEDIUM 6"X6.75" 186 KETOSTIX 148 2"X2" 185 KERLIX X-RAY DETECTABLE KENDALL ZINC CALCIUM PACKING SPONGE 4- KETOTIFEN FUMARATE 91 ALGINATE DRESSING 1/2"X22" 186 KETOTIFEN HYDROGEN 2"X2" 143 KERLIX X-RAY DETECTABLE FUMARATE 91 KENDALL ZINC CALCIUM SPONGES EXTRA LARGE 1- KEVEYIS 151 ALGINATE DRESSING 5/8" 186 KEVZARA 4 4"X4" 143 KERYDIN 125 KEYTRUDA 54 KENDALL ZINC CALCIUM KETALAR 161 ALGINATE DRESSING KHAPZORY 60 4"X8" 143 KETAMINE HCL 91 KHEDEZLA 34 KENDALL ZINC CALCIUM ketamine hcl 161 KINERET 4 ALGINATE DRESSING ROPE KETAMINE KINETIN 91 12" 143 HYDROCHLORIDE 161 KEPIVANCE 60 KETAMINE KINNEY LANCETS 198 KEPPRA 29 HYDROCHLORIDE/ROPIVAC KINNEY THIN LANCETS 198 AINE KINRAY INSULIN SYRINGE KEPPRA XR 29 HYDROCHLORIDE/KETOROL PREFERRED PLUS/0.3ML/31G KERAGEL 143 AC T 6 X 5/16" 230 KERAGELT 143 KETAMINE KINRAY INSULIN SYRINGE KERALAC 134 HYDROCHLORIDE/SODIUM PREFERRED PLUS/0.5ML/31G CHLORIDE 161 X 5/16" 230 KERALYT 135 ketoconazole 43 KINRAY INSULIN SYRINGE KERALYT SCALP 135 KETOCONAZOLE 109 PREFERRED PLUS/1ML/31G X KERAMATRIX REPLICINE 5/16" 230 10CMX10CM 143 ketoconazole (topical) 125 KINRAY INSULIN KERAMATRIX REPLICINE KETODAN KIT 125 SYRINGE/0.5ML/29G X 5CMX5CM 143 KETONE 148 1/2" 230 KERLIX AMD KETONE TEST STRIPS 148 KINRIX 315 ANTIMICROBIALBANDAGE KETOPHENE KISQALI 58 ROLL 4-1/2"X12.3YD 6 KISQALI FEMARA 200 PLY 185 RAPIDPAQ 124 ketoprofen 6 DOSE 57 KERLIX AMD KISQALI FEMARA 400 ANTIMICROBIALSUPER KETOPROFEN 91 DOSE 57 SPONGES 186 KETOPROFEN KISQALI FEMARA 600 KERLIX BANDAGE ROLL 2- MICRONIZED 91 DOSE 57 1/4"X9' 6PLY 186 KETOPROFEN ULTRA KITABIS PAK 3 KERLIX BANDAGE ROLL 3- MICRONIZED 91 7/16"X3-3/16' 6PLY 186 KETOROCAINE-L 6 KIVIK 139 KERLIX BANDAGE ROLL 4- KETOROCAINE-LM 6 KIWI FRAGRANCE 91 1/2"X4-1/8YD 6PLY 186 KLARITY-A 280 KERLIX BANDAGE ROLL 4- KETOROLAC 2% GEL 124 1/2"X9.3' 8PLY 186 ketorolac tromethamine 6 KLARITY-B 282 KERLIX BANDAGE ROLL/6 KETOROLAC KLARITY-L 282 PLY/MEDIUM 186 TROMETHAMINE 6 KLARON 121 KERLIX GAUZE ROLL LARGE ketorolac tromethamine 6 4.5"X 4.1YD 6 PLY 186 KLING FLUFF 186 KERLIX GAUZE ROLL KETOROLAC KLING FLUFF SPONGE MEDIUM3.4"X3.6YD 6 PLY186 TROMETHAMINE 6 6X6.75 186 ketorolac tromethamine 6 KLONOPIN 28

Index 52 KMART VALU PLUS INSULIN KROGER INSULIN L-CARNITINE 92 SYRINGE/0.3ML/30G 230 SYRINGE/1ML/30G X L-CARNOSINE 84 KMART VALU PLUS INSULIN 5/16" 230 SYRINGE/0.5ML/29G 230 KROGER INSULIN L-CITRULLINE 84 KMART VALU PLUS INSULIN SYRINGE/1ML/31G X L-CYSTEINE 84 SYRINGE/0.5ML/30G 230 5/16" 230 L-CYSTEINE HCL KMART VALU PLUS INSULIN KROGER LANCETS 198 MONOHYDRATE 84 SYRINGE/1ML/29G 230 L-CYSTINE 277 KMART VALU PLUS INSULIN KROGER LANCETS 21G 198 SYRINGE/1ML/30G 230 KROGER LANCETS MICRO L-GLUTAMIC ACID 277 THIN33G 198 L-GLUTAMIC ACID HCL 151 KOATE 163 KROGER LANCETS SUPER KOATE-DVI 163 L-GLUTAMIC ACID THIN 198 MONOSODIUM 93 KROGER LANCETS KOGENATE FS 163 L-GLUTAMINE 277 KOJIC ACID 109 THIN 198 KROGER LANCETS THIN L-HISTIDINE 278 KOMBIGLYZE XR 35 26G 198 L-HISTIDINE KORLYM 36 KROGER LANCETS MONOHYDROCHLORIDE 278 KOSELUGO 58 ULTRATHIN30G 198 L-HISTIDINE KOSHER PRENATAL PLUS KROGER LANCING MONOHYDROCHLORIDE IRON 264 DEVICE 198 MONOHYDRATE 278 KROGER PEN NEEDLES 29G KOVALTRY 163 L-ISOLEUCINE 278 X12MM 230 L-LEUCINE 278 KRINTAFEL 51 KROGER PEN NEEDLES 31G KRIS-ESTER 236 305 X8MM 230 L-LYSINE HCL 92 L-LYSINE KRISGEL 100 305 KROGER PEN NEEDLES 31GX1/4" 230 HYDROCHLORIDE 278 KRISTALOSE 171 KROGER PEN NEEDLES/33G L-LYSINE KROGER AUTOLET LANCING X5/32" 231 MONOHYDROCHLORIDE 92 DEVICE 198 KROGER PREMIUM BLOOD L-MENTHOL 109 KROGER BLOOD GLUCOSE GLUCOSE TEST L-METHIONINE 278 TESTSTRIPS 148 STRIPS 148 L-METHYLFOLATE KROGER HEALTHPRO KROGER TEST STRIPS 148 GLUCOSECONTROL CALCIUM 92 SOLUTION/HIGH/LOW 198 KRYSTEXXA 163 L-ORNITHINE KROGER HEALTHPRO KUDZU ROOT 91 HYDROCHLORIDE 95 GLUCOSETEST STRIPS 148 KUVAN 155 L-PHENYLALANINE 278 KROGER HEALTHPRO TWIST KYLEENA 112 L-PROLINE 278 LANCETS/26G 198 KYMRIAH 55 L-SELENOMETHIONINE 92 KROGER INSULIN L-SELENOMETHIONINE SYRINGE/0.3ML/29G X KYNMOBI 62 BLEND 92 1/2" 230 KYPROLIS 58 KROGER INSULIN L-SERINE 99 L-5- L-THREONINE 278 SYRINGE/0.3ML/30G X METHYLTETRAHYDROFOLIC 5/16" 230 ACID CALCIUM 91 L-TRYPTOPHAN 278 KROGER INSULIN L-TYROSINE 278 SYRINGE/0.3ML/31G X L-ALANINE 277 5/16" 230 L-ARGININE 277 L-VALINE 278 KROGER INSULIN L-ARGININE BASE 277 L.E.T. 136 SYRINGE/0.5ML/29G X L-ARGININE HCL 79 labetalol hcl 70 1/2" 230 KROGER INSULIN L-ARGININE LABETALOL HCL 92 SYRINGE/0.5ML/30G X HYDROCHLORIDE 277 LABETALOL L-ASPARAGINE 5/16" 230 HYDROCHLORIDE 70 KROGER INSULIN MONOHYDRATE 105 LABETALOL SYRINGE/0.5ML/31G X L-ASPARTIC ACID 109 HYDROCHLORIDE/DEXTROSE 5/16" 230 L-ASPARTIC ACID SODIUM 70 KROGER INSULIN MONOHYDRATE 99 LABETALOL SYRINGE/1ML/29G X 1/2" 230 L-ASPARTIC ACID SODIUM HYDROCHLORIDE/SODIUM SALT 99 CHLORIDE 70

Index 53 LAC-HYDRIN 134 LANCETS 30G/TWIST LAURETH-9 LACRISERT 278 TOP 198 POLIDOCANOL 92 LANCETS 31G TWIST LAURIC ACID 92 LACTASE 5000 92 TOP 198 LAVARE WOUND WASH 143 lactated ringer's 249 LANCETS 33G UNIVERSAL LAVENDER OIL 106 lactated ringer's (irrigation) 254 DESIGN 198 LANCETS MICRO THIN LAVENDER OIL LACTIC ACID 77 33G 198 FRAGRANCE 106 lactic acid (ammonium LANCETS SAFETY SEAL LAVENDER OIL NATURAL 106 lactate) 134 21G 198 LAXATIVE FORMULA 255 LACTIC ACID RACEMIC 77 LANCETS SAFETY SEAL LAZANDA 11 lactic acid w/ vitamin e 134 26G 198 LACTIC LANCETS SAFETY SEAL LDO PLUS 136 ACID/NIACINAMIDE 140 28G 198 LEAD ACETATE lactobacillus 39 LANCETS SAFETY SEAL TRIHYDRATE 109 30G 198 LEAD TETROXIDE 92 LACTOSE 302 LANCETS SUPER THIN LEADER ADVANCED LANCING LACTOSE ANHYDROUS 302 28G 198 DEVICE 199 LACTOSE HYDROUS 302 LANCETS THIN 198 LEADER INSULIN LACTOSE LANCETS TWIST TOP 198 SYRINGE/0.3ML/29G X MONOHYDRATE 302 LANCETS ULTRA FINE 198 1/2" 231 LACTOSE MONOHYDRATE LEADER INSULIN SPRAYDRIED 302 LANCETS ULTRA THIN 198 SYRINGE/0.3ML/30G X LACTULOSE 171 LANCETS ULTRA THIN 5/16" 231 30G 198 LEADER INSULIN lactulose 171 LANCETSBULLSEYE SYRINGE/0.3ML/31G X lactulose (encephalopathy) 160 SAFETY 198 5/16" 231 LAMICTAL 29 LANCING DEVICE 199 LEADER INSULIN LAMICTAL CHEWABLE LANCING DEVICE SYRINGE/0.5ML/28G X DISPERSIBLE 29 ADJUSTABLE 199 1/2" 231 LAMICTAL ODT 29 LANOLIN 305 LEADER INSULIN LAMICTAL STARTER/NOT lanolin 305 SYRINGE/0.5ML/29G X 1/2" 231 TAKING CARBAMAZEPINE 29 LANOLIN ALCOHOL 305 LAMICTAL STARTER/TAKING LEADER INSULIN CARBAMAZEPINE/NOT TAKING LANOLIN ANHYDROUS 305 SYRINGE/0.5ML/30G X VALPROATE 29 LANOLIN ANHYDROUS- 5/16" 231 LAMICTAL STARTER/TAKING GRX 305 LEADER INSULIN VALPROATE 29 LANOXIN 73 SYRINGE/0.5ML/31G X 5/16" 231 LAMICTAL XR 29 LANOXIN PEDIATRIC 73 LEADER INSULIN lamivudine 67 LANSOPRAZOLE 92 SYRINGE/1ML/28G X 1/2" 231 lamivudine (hbv) 69 lansoprazole 318 LEADER INSULIN lamivudine-zidovudine 67 lanthanum carbonate 160 SYRINGE/1ML/29G X 1/2" 231 LEADER INSULIN lamotrigine 30 LANTUS 37 SYRINGE/1ML/30G X LAMOTRIGINE 92 LANTUS SOLOSTAR 37 5/16" 231 LANCET DEVICE LANZO 199 LEADER INSULIN ADJUSTABLE 198 lapatinib ditosylate 58 SYRINGE/1ML/31G X LANCET DEVICE WITH 5/16" 231 EJECTOR 198 LARTRUVO 54 LEADER UNIFINE PENTIPS LANCETS 198 LASIX 152 PLUS/MINI/31GX3/16" 231 LANCETS 26G TWIST LASTACAFT 284 LEADER UNIFINE PENTIPS TOP 198 PLUS/SHORT/31GX5/16" 231 LATANOPROST 92 LEADER UNIFINE LANCETS 28G 198 latanoprost 284 PENTIPS/MINI/31GX3/16" 231 LANCETS 30G 198 LATRIX XM 134 LEADER UNIFINE LANCETS 30G TWIST LATUDA 63 PENTIPS/NANO/32GX5/32" TOP 198 231

Index 54 LEADER UNIFINE levalbuterol hcl 25 levothyroxine sodium 315 PENTIPS/PLUS/32GX5/32" LEVALBUTEROL HCL 92 LEVOTHYROXINE SODIUM 231 levalbuterol tartrate 25 (T4) 92 LECITHIN 99 LEVSIN 316 LEVAMISOLE HCL 56 LECITHIN ISOPROPYL LEVULAN KERASTICK 127 PALMITATE 302 LEVAQUIN 158 LEXAPRO 33 LECITHIN ORGANOGEL 306 LEVATIO PATCH 137 LEXETTE 132 LECITHIN SOYA 99 LEVBID 316 LEXIVA 67 LEDIPASVIR/SOFOSBUVIR LEVEMIR 37 69 LEXIXRYL 124 LEVEMIR FLEXTOUCH 37 leflunomide 7 LIALDA 159 LEVETIRACETAM 30 LEFLUNOMIDE 92 LIBERTY GLUCOSE CONTROL levetiracetam 30 LEMON EXTRACT 290 MID 199 LEVETIRACETAM 92 LIBERTY MEDICAL LANCETS LEMON FLAVOR 290 levetiracetam in sodium 30G 199 LEMONADE FLAVOR 290 chloride 30 LIBERTY MINI LANCING LEMTRADA 311 LEVICYN 139 DEVICE 199 LENVIMA 10 MG DAILY LEVICYN DERMAL LIBERTY NEXT GENERATION DOSE 58 SPRAY 143 BLOOD GLUCOSE TEST STRIPS 148 LENVIMA 12MG DAILY LEVIGOLT 137 DOSE 58 LIBERTY TEST STRIPS 148 levobunolol hcl 279 LENVIMA 14 MG DAILY LIBTAYO 54 LEVOCARNITINE 92 DOSE 58 LICART 124 LENVIMA 18 MG DAILY levocarnitine (metabolic DOSE 58 modifiers) 155 LICORICE LENVIMA 20 MG DAILY levocetirizine DEGLYCYRRHIZINATED 92 DOSE 58 dihydrochloride 44 LICORICE FLAVOR 290 LENVIMA 24 MG DAILY LEVOCETIRIZINE LICORICE ROOT 109 DOSE 58 DIHYDROCHLORIDE 92 LIDO GB-300 312 LENVIMA 4 MG DAILY LEVODOPA 62 LIDOCAINE 92 DOSE 58 levofloxacin 158 LENVIMA 8 MG DAILY lidocaine 137 DOSE 58 levofloxacin (ophth) 280 LIDOCAINE AND LENZAPATCH 136 LEVOFLOXACIN TETRACAINECREAM 137 HEMIHYDRATE 92 LESCOL XL 45 LIDOCAINE BASE 92 levofloxacin in d5w 158 LETAIRIS 75 LIDOCAINE HCL 22,92 LEVOLEUCOVORIN 60 letrozole 56 lidocaine hcl 137 levoleucovorin calcium 60 lidocaine hcl (cardiac) 22 LETROZOLE 92 LEVOMEFOLATE LETS KIT 172 CALCIUM 92 lidocaine hcl (local anesth.) 173 LEUCINE 278 levonorgestrel & eth lidocaine hcl (mouth-throat) 257 leucovorin calcium 60 estradiol 111 LIDOCAINE HCL levonorgestrel (emergency MONOHYDRATE 92 LEUCOVORIN CALCIUM 92 oc) 112 LIDOCAINE HCL- LEUKERAN 53 levonorgestrel-eth estradiol HYDROCORTISONE ACETATE LEUKINE 165 (triphasic) 111 WITH ALOE 16 levonorgestrel-ethinyl estradiol LIDOCAINE LEUKOSTRIP 1/2"X4" 186 (91-day) 111 HCL/DEXTROSE 173 LEUKOSTRIP 1/4"X3" 186 levonorgestrel-ethinyl estradiol LIDOCAINE LEUKOSTRIP 1/4"X4" 186 (continuous) 111 HYDROCHLORIDE 137,173 LEUKOSTRIP 1/8"X1-1/2" 186 LEVOPHED 324 LIDOCAINE HYDROCHLORIDE/DEXTROSE leuprolide acetate 56 levorphanol tartrate 11 LEVORPHANOL 22 LEUPROLIDE ACETATE 92 LIDOCAINE TARTRATE 92 LEUPROLIDE LEVOTHYROXINE HYDROCHLORIDE/EPINEPHRI ACETATE/BUPIVACAINE SODIUM 92,315 NE 281 HYDROCHLORIDE 56

Index 55 LIDOCAINE LIFESCAN UNISTIK II LIPOTRIAD VISION HYDROCHLORIDE/EPINEPHRI LANCETS 199 SUPPORTPLUS 269 NE/TETRACAINE LILETTA 112 LIPOTRIAD VISIONARY 269 HYDROCHLORIDE 137 LIME FLAVOR 290 LIPOZYME 306 LIDOCAINE HYDROCHLORIDE/PHENYLEP LIME OIL 106 LIPRITIN 312 HRINE HYDROCHLORIDE 281 LIMONENE 92 LIPRITIN II 312 LIDOCAINE LINCOCIN 19 LIQUIGEL COMPLEX 302 HYDROCHLORIDE/SODIUM lincomycin hcl 19 LIQUIVIDA HYDRATION BICARBONATE 172 LINCOMYCIN HCL 92 KIT 252 LIDOCAINE lisinopril 47 HYDROCHLORIDE/SODIUM lindane 141 LISINOPRIL 92 CHLORIDE 172 linezolid 19 lidocaine in d5w 22 lisinopril & linezolid in sodium chloride19 hydrochlorothiazide 49 lidocaine w/ epinephrine 172 LINOLEIC ACID 92 LISSAMINE GREEN B 288 lidocaine-hydrocortisone acetate 132 LINSEED OIL RAW 106 LITE TOUCH LANCETS 199 lidocaine-hydrocortisone acetate LINZESS 160 LITE TOUCH LANCING (rectal) 16 LIORESAL PEN 199 lidocaine-menthol 137 INTRATHECAL 271 LITETOUCH INSULIN LIOTHYRONINE 92 SYRINGE/0.3ML/29G X lidocaine-prilocaine 137 1/2" 231 LIDOCAINE-PRILOCAINE- LIOTHYRONINE SODIUM 92 LITETOUCH INSULIN CREAM BASE 306 liothyronine sodium 315 SYRINGE/0.3ML/30G X lidocaine-transparent LIOTHYRONINE SODIUM 5/16" 231 dressing 137 (T3) 92 LITETOUCH INSULIN LIDOCAINE/TETRACAINE 137 LIP BALM BASE 306 SYRINGE/0.3ML/31G X LIDOCIDEX I 114 LIPACTIVE INCA INCHI 5/16" 231 LIDOCILONE I 114 WO 91 LITETOUCH INSULIN LIPIDSHIELD PLUS 269 SYRINGE/0.5ML/30G X LIDODERM 137 5/16" 231 LIDODOSE 137 LIPITOR 45,46 LITETOUCH INSULIN LIDODOSE PEDIATRIC BULK LIPMAX 302 SYRINGE/0.5ML/31G X PACK 137 LIPO 275 5/16" 231 LIDOLOG KIT 114 LIPO CREAM BASE 306 LITETOUCH INSULIN LIDOMAR 172 SYRINGE/1ML/30G X LIPO-B 167 5/16" 231 LIDOMARK 1/5 173 LIPO-C 275 LITETOUCH INSULIN LIDOPIN 137 LIPOBASE 306 SYRINGE/U-100/0.5ML/28G X LIDOPROFEN 124 1/2" 231 LIPOCREAM BASE 306 LITETOUCH INSULIN LIDOPURE PATCH 137 LIPOFEN 45 SYRINGE/U-100/0.5ML/29G X LIDORX 137 LIPOFOAM RX 306 1/2" 231 LIDOSOL-HC 132 LIPOGEL CR BASE 306 LITETOUCH INSULIN LIDOSTREAM 137 SYRINGE/U-100/1ML/28G X LIPOIC ACID 79 1/2" 231 LIDOTHOL 137 LIPOIC ACID/DL-ALPHA (DL- LITETOUCH INSULIN LIDOTIN 312 THIOCTIC ACID) 79 SYRINGE/U-100/1ML/29G X LIDOTRAL 137 LIPOLAYER 306 1/2" 231 LIDOTRANS 5 PAK 137 LIPOPEN ABSORPTION LITETOUCH INSULIN ENHANCING BASE 306 SYRINGE/U-100/1ML/31G X LIDOTREX 137 LIPOPEN ANHYDROUS 306 5/16" 231 LIDOVEX 137 LIPOPEN ULTRA BASE 306 LITETOUCH LANCETS MICRO LIDOVIX 6 THIN 33G 199 LIPOSOMAL HEAVY 306 LITETOUCH PEN NEEDLES LIDTOPIC MAX 137 LIPOSOMAL REGULAR 306 29GX12.7MM 232 LIFESCAN UNISTIK 2 DEEP LIPOTRIAD VISION LITETOUCH PEN NEEDLES PENETRATION 199 SUPPORT 269 31G X 6MM 232

Index 56 LITETOUCH PEN NEEDLES lopinavir-ritonavir 67 LUMINEUX WHITENING 31GX8MM SHORT 232 LOPRESSOR 71 TOOTHPASTE 214 LITETOUCH PEN LUMIZYME 155 LOPRESSOR HCT 49 NEEDLES/31G X 3/16" 232 LUMOXITI 54 LITHIUM 63 LOPROX 125 LUNESTA 170 lithium carbonate 63 LOPROX KIT 126 LUPANETA PACK 154 LOPROX SHAMPOO 126 LITHIUM CARBONATE 63 LUPRON DEPOT (1- lithium carbonate 63 LORATADINE 92 MONTH) 56 LITHIUM CITRATE lorazepam 21 LUPRON DEPOT (3- TETRAHYDRATE 92 LORAZEPAM 92 MONTH) 56 LUPRON DEPOT (4- LITHOBID 63 LORAZEPAM/DEXTROSE 21 LITHOSTAT 162 MONTH) 56 LORAZEPAM/SODIUM LUPRON DEPOT (6- LIVALO 46 CHLORIDE 21 MONTH) 56 LIVE BETTER ADVANCED LORBRENA 58 LUPRON DEPOT-PED (1- LANCING DEVICE 199 LORTAB 14 MONTH) 154 LIVE BETTER LANCET losartan potassium 48 LUPRON DEPOT-PED (3- SUPERTHIN 30G 199 MONTH) 154 losartan potassium & LIVE BETTER LANCET LUTATHERA 59 ULTRATHIN 28G 199 hydrochlorothiazide 49 LUTEIN 92 LIVER CONCENTRATE 290 LOSEASONIQUE 111 LUXAMEND 143 LIVER FLAVOR 290 LOTEMAX 282 LUXIQ 132 LMR PLUS 137 LOTEMAX SM 282 LUXTURNA 281 LO LOESTRIN FE 111 LOTENSIN 47 LUZU 126 LOCOID 132 LOTENSIN HCT 49 LYDEXA 137 LOCOID LIPOCREAM 132 loteprednol etabonate 282 LYDIA PINKHAM 255 LOCUST BEAN GUM 85 LOTREL 49 LYNPARZA 58 LODINE 6 LOTRISONE 126 LYRICA 30 LODOSYN 61 LOTRONEX 160 LYRICA CR 312 LOKELMA 256 lovastatin 46 LYSINE HCL 93 LOLLIBASE 302 LOVAZA 44 LYSODREN 56 LOLLIPOP BASE 302 LOVENOX 28 LYSTEDA 168 LOMOTIL 39 loxapine succinate 64 LYUMJEV 37 LONGEVITY 269 LOXORAL BASE 302 LYUMJEV KWIKPEN 37 LONGEVITY PLUS 269 LOYON 139 LONGS INSULIN LOZIBASE 299 M-M-R II 321 SYRINGE/0.5ML/31G X LOZIBASE S 299 M-NATAL PLUS 264 5/16" 232 LT INJECTION KIT 114 M.V.I. ADULT 262 LONGS LANCETS M.V.I. PEDIATRIC 263 STANDARD 199 LUBRAJEL NP 306 LONGS LANCETS THIN 199 LUCEMYRA 310 M2 CALCIUM 269 LONGS LANCETS ULTRA LUCENTIS 279 MACA ROOT 93 THIN 199 LUGOLS STRONG MACADAMIA NUT OIL 106 LONHALA MAGNAIR REFILL IODINE 65 MACI 271 KIT 23 luliconazole 126 LONHALA MAGNAIR STARTER MACROBID 20 KIT 23 LUMIGAN 284 MACRODANTIN 20 LONSURF 57 LUMINEUX CLEAN/FRESH MACUGEN 280 TOOTHPASTE 214 loperamide hcl 39 LUMINEUX KIDS MAFENIDE ACETATE 93 LOPERAMIDE HCL 39 TOOTHPASTE 214 mafenide acetate 128 LOPERAMIDE LUMINEUX SENSITIVITY MAGELLAN INSULIN SAFETY HYDROCHLORIDE 39 TOOTHPASTE 214 SYRINGE/U-100/0.3ML/29G X LOPID 45 1/2" 232

Index 57 MAGELLAN INSULIN SAFETY MAGNESIUM SULFATE MARINOL 41 SYRINGE/U-100/0.3ML/30G X HEPTAHYDRATE 171 MARLIDO KIT 172 5/16" 232 MAGNESIUM SULFATE IN MAGELLAN INSULIN SAFETY D5W 250 MARLIDO-25 172 SYRINGE/U-100/0.5ML/29G X magnesium sulfate in MARNATAL-F 264 1/2" 232 dextrose 250 MARPLAN 32 MAGELLAN INSULIN SAFETY MAGNESIUM SYRINGE/U-100/0.5ML/30G X SULFATE/DEXTROSE 251 MARQIBO 61 5/16" 232 MAGNESIUM MARSHMALLOW ARTIFICIAL MAGELLAN INSULIN SAFETY SULFATE/LACTATED FLAVOR 291 SYRINGE/U-100/1ML/29G X RINGERS 251 MARSHMALLOW FLAVOR 291 1/2" 232 MAGNESIUM MARVONA SUIK 172 MAGELLAN INSULIN SAFETY SULFATE/SODIUMCHLORIDE MAS CARE-PAK 115 SYRINGE/U-100/1ML/30G X 251 5/16" 232 MAGNESIUM MATULANE 60 MAGNASWEET 110 79 TRISILICATE 17 MAVENCLAD 311 MAGNESIUM TRISILICATE MAVYRET 69 MAGNASWEET 135 79 HYDRATE 17 MAXALT 247 MAGNEBIND 400 250 MAKENA 309 MAXALT-MLT 247 MAGNESIUM ALUMINUM MALARONE 51 SILICATE 93 MAXFE 167 malathion 141 MAGNESIUM AMINO ACID MAXI-COMFORT INSULIN CHELLATE 20% 93 MALEIC ACID 93 SYRINGE/U- MAGNESIUM ASCORBATE 93 MALIC ACID 93 100/0.5ML/28GX1/2" 232 MAGNESIUM BISGLYCINATE MALTODEXTRIN 93 MAXI-COMFORT INSULIN CHELATE 93 SYRINGE/U-100/1ML/28GX1/2" MAGNESIUM BISGLYCINATE MANDELIC ACID 93 232 DIHYDRATE 93 manganese chloride 251 MAXI-COMFORT SAFETY PEN MAGNESIUM CARBONATE MANGANESE CHLORIDE NEEDLE/29G X 3/16" 232 HEAVY 250 TETRAHYDRATE 93 MAXI-COMFORT SAFETY PEN MAGNESIUM CARBONATE MANGANESE NEEDLE/29G X 5/16" 232 LIGHT 250 GLUCONATE 93 MAXICOMFORT INSULIN MAGNESIUM CHLORIDE 250 MANGANESE SULFATE 93 SYRINGES 27G X 1/2" 232 magnesium chloride 250 manganese sulfate 251 MAXIDEX 282 MAGNESIUM CHLORIDE MANGO FLAVOR 290 MAXIPIME 77 HEXAHYDRATE 250 MANGO FLAVOR MAXITROL 282 MAGNESIUM CITRATE 93 SWEETENED 290 MAXZIDE 151 MAGNESIUM CITRATE MANNITOL 109 MAXZIDE-25 151 TRIBASIC 93 mannitol 152 MAGNESIUM GLUCONATE 93 MAYZENT 311 MAPLE FLAVOR 290 MAGNESIUM GLYCINATE 93 MB HYDROGEL 139 maprotiline hcl 32 MAGNESIUM HYDROXIDE 93 MEBENDAZOLE 17 MARATHON MEDICAL MECAMYLAMINE HCL 93 MAGNESIUM MALATE 93 PENTIPS29GX12MM 232 MAGNESIUM OXIDE MARATHON MEDICAL MECHLORETHAMINE HCL 93 HEAVY 16 PENTIPS31GX5MM 232 MECLIZINE HCL 41 MAGNESIUM OXIDE LIGHT 16 MARATHON MEDICAL meclizine hcl 41 MAGNESIUM PHOSPHATE PENTIPS31GX8MM 232 MECLIZINE HCL DIBASIC TRIHYDRATE 93 MARATHON MEDICAL MONOHYDRATE 41 PENTIPS32GX4MM 232 MAGNESIUM SALICYLATE 93 meclofenamate sodium 6 MARBETA-25 115 MAGNESIUM STEARATE 302 MECLOFENAMATE SODIUM 6 MARBETA-L 115 MAGNESIUM SULFATE 171 MECLOFENOXATE MARCAINE 173 magnesium sulfate 250 HYDROCHLORIDE 93 MARCAINE SPINAL 173 MAGNESIUM SULFATE 250 MEDI-DERM 135 MARCAINE/EPINEPHRINE MEDI-DERM-RX 135 magnesium sulfate 250 172 MEDI-DERM/L 137 MAGNESIUM SULFATE 251 MARDEX-25 115

Index 58 MEDI-DERM/L-RX 137 MEDISENSE THIN MEIJER ALCOHOL SWABS MEDI-PATCH RX 137 LANCETS 199 EXTRA-THICK 213 MEDIUM CHAIN MEIJER BLOOD GLUCOSE MEDI-PATCH/LIDOCAINE 137 TRIGLYCERIDES 93 TESTSTRIPS 148 MEDI-RDT BASE 302 MEDLANCE PLUS EXTRA MEIJER COLOR LANCETS MEDI-RDT KIT 302 LANCETS 21G 199 UNIVERSAL 33G 200 MEDI-RDT KIT MEDLANCE PLUS MEIJER ESSENTIAL BLOOD (MULTIDOSE) 302 LANCETS 199 GLUCOSE TEST STRIPS 148 MEDLANCE PLUS LANCETS MEDIBASE C 306 MEIJER LANCETS 200 LITE 25G 199 MEIJER LANCETS THIN 200 MEDIC INSULIN MEDLANCE PLUS LITE SYRINGE/0.3ML/30G X LANCETS 25G 199 MEIJER LANCETS 5/16" 232 MEDLANCE PLUS SPECIAL UNIVERSAL21G 200 MEDIC INSULIN LANCETS 0.8MM 199 MEIJER LANCETS SYRINGE/0.5ML/30G X MEDLANCE PLUS UNIVERSAL30G 200 5/16" 232 SUPERLITE 30G 199 MEIJER LANCETS MEDICHOICE PRE-SET MEDLANCE PLUS UNIVERSAL33G 200 SAFETY LANCET DUAL SUPERLITE 30G/COMFORT MEIJER PEN NEEDLES 29G USE 199 MAX 199 X12MM 232 MEDICHOICE PRE-SET MEDLANCE PLUS MEIJER PEN NEEDLES 31G SAFETY LANCET LOW UNIVERSAL LANCETS X6MM 232 MEIJER PEN NEEDLES 31G FLOW 199 21G 199 MEDICHOICE PRE-SET X8MM 232 MEDLANCE PLUS/LITE MEIJER PREMIUM BLOOD SAFETY LANCET MEDIUM 25G 200 GLUCOSE TEST STRIPS 148 FLOW 199 MEDLANCE/EXTRA 200 MEDICHOICE PRE-SET MEIJER SUPER THIN SAFETY LANCET MODERATE MEDLANCE/LITE 200 LANCETS 200 FLOW 199 MEDLANCE/UNIVERSAL200 MEIJER TRUETEST BLOOD MEDICHOICE SAFETY MEDPURA ALCOHOL GLUCOSE TEST STRIPS 149 LANCETEXTRA 199 PADS 140 MEIJER TRUETRACK BLOOD MEDICHOICE SAFETY MEDROL 115 GLUCOSE TEST STRIPS 149 MEKINIST 58 LANCETNORMAL 199 MEDROL DOSEPAK 115 MEDICINE SHOPPE PEN MEKTOVI 58 MEDROLOAN II SUIK 115 NEEDLES 29G X 12MM 232 MELATONIN 109 MEDICINE SHOPPE PEN MEDROLOAN SUIK 115 meloxicam 6 NEEDLES 31G X 6MM 232 MEDROX-RX 135 MEDICINE SHOPPE PEN MEDROXYPROGESTERONE MELOXICAM 94 NEEDLES 31G X 8MM 232 ACETATE 93 melphalan 53 MEDICOOLS DIASOX 207 medroxyprogesterone melphalan hcl 53 MEDIDERM 306 acetate 310 memantine hcl 310 medroxyprogesterone acetate MEDIHOL BASE 306 MEMANTINE MEDIHONEY (contraceptive) 112 MEDROXYPROGESTERONE HYDROCHLORIDE 94 WOUND/BURNDRESSING 143 MEMBRANEBLUE 283 MEDIPORE + PAD SOFT ACETATE MICRONIZED 93 MEDROXYPROGESTERONE MEMORY WORK/SPORT CLOTH ADHESIVE WOUND INSOLES 207 DRESSING 6"X6" 186 ACETATE YAM 93 MEDISENSE GLUCOSE MEDROXYPROGESTERONE MENACTRA 320 KETONECONTROL SOLUTION MICRONIZED 93 MENADIONE 94 1-LOW,1-MED,1 HIGH 199 mefenamic acid 6 MENADIONE SODIUM MEDISENSE GLUCOSE MEFENAMIC ACID 6 BISULFITE 109 KETONECONTROL SOLUTION mefloquine hcl 51 MENEST 158 1-NORMAL 199 MENOPUR 153 MEDISENSE HIGH/LOW MEGACE ES 310 CONTROL SOLUTION 199 MEGESTROL ACETATE 56 MENOSTAR 158 MEDISENSE HIGH/MID/LOW megestrol acetate 56 MENQUADFI 320 CONTROL SOLUTION 199 megestrol acetate MENTHO-CAINE KIT 137 MEDISENSE MID CONTROL (appetite) 310 MENTHOL 109 SOLUTION 199 MEGLUMINE 94 MENTHOL-L 109

Index 59 MENVEO 320 METHADOSE 11 METHYL ALCOHOL 106 MEPERIDINE HCL 11 METHADOSE SUGAR- METHYL FOLATE 94 meperidine hcl 11 FREE 11 METHYL METHACRYLATE MEPERIDINE methamphetamine hcl 1 CROSSPOLYMER 94 HYDROCHLORIDE/SODIUM METHANESULFONIC METHYL SALICYLATE 136 CHLORIDE 11 ACID 94 METHYL SULFONE 94 METHANOL 106 MEPHYTON 325 METHYL-GUARD 269 METHAZOLAMIDE 151 MEPIVACAINE HCL 173 METHYL-GUARD PLUS 269 methazolamide 151 mepivacaine hcl 173 METHYLCELLULOSE 302 METHENAMINE 109 meprobamate 21 METHYLCOBALAMIN 94,165 methenamine hippurate 20 MEPRON 18 methyldopa 48 MEPSEVII 155 methenamine mandelate 20 methyldopa & MEQUINOL 94 METHENAMINE hydrochlorothiazide 49 MANDELATE 109 METHYLENE BLUE 109 mercaptopurine 54 methenamine-hyosc-methylene MERCAPTOPURINE 94 blue-sod phos-phenyl sal 18 methylene blue (antidote) 40 MERCAPTOPURINE methenamine-hyoscamine- METHYLENE BLUE MONOHYDRATE 94 methylene blue-sodium TRIHYDRATE 109 meropenem 18 phosphate 18 METHYLENE CHLORIDE 94 MEROPENEM/SODIUM METHIMAZOLE 315 methylergonovine maleate 285 CHLORIDE 18 methimazole 315 METHYLIN 2 MERREM 18 METHIONINE 278 METHYLMETHACRYLATE mesalamine 159 METHIONINE/INOSITOL/CHO CROSSPOLYMER (310) 94 MESALAMINE 159 LINE/CYANOCOBALAMIN METHYLPARABEN 288 167 mesalamine 159,160 METHYLPARABEN METHITEST 15 SODIUM 288 mesalamine w/ cleanser 160 METHOCARBAMOL 94 methylphenidate hcl 2 mesna 60 methocarbamol 271 METHYLPHENIDATE HCL 94 MESNEX 60 METHOCEL E4M 90 METHYLPHENIDATE MESTINON 51 METHOCEL E4M HYDROCHLORIDE ER 2 MESTINON TIMESPAN 51 PREMIUM 90 METHYLPREDNISOLONE 115 METABO-STYLE 255 METHOCEL E4M PREMIUM methylprednisolone 115 METACRESOL ACETATE 94 CR 90 METHYLPREDNISOLONE METHOCEL K100 METAPROTERENOL ACETATE 115 PREMIUM 90 methylprednisolone acetate115 SULFATE 25 METHOCEL K100M metaproterenol sulfate 25 METHYLPREDNISOLONE PREMIUM 90 ACETATE/BUPIVACAINE METASTRON 59 METHOHEXITAL HYDROCHLORIDE 115 METAXALL CP 272 SODIUM 161 methylprednisolone sod metaxalone 271 METHOTREXATE 4 succ 115 METER BUFFER PH 10 301 methotrexate sodium 54 METHYLPREDNISOLONE/LIDO METHOXSALEN 140 CAINE 115 METER BUFFER PH 4 301 METHYLSULFONYLMETHANE METER BUFFER PH 7 301 methoxsalen rapid 127 94 METHOXYAMINE methyltestosterone 15 metformin hcl 35,36 HYDROCHLORIDE 94 METFORMIN HCL 94 METHOXYETHANOL 94 METHYLTESTOSTERONE 15 METHACHOLINE METHSCOPOLAMINE METHYLTETRAHYDROFOLATE CHLORIDE 94 BROMIDE 94 CALCIUM 94 METHACRYLIC ACID methscopolamine METHYSERGIDE COPOLYMER TYPE A 94 bromide 316 MALEATE 94 methadone hcl 11 METHSCOPOLAMINE metipranolol 279 METHADONE HCL 11 NITRATE 94 METOCLOPRAMIDE HCL 159 methadone hcl 11 methyclothiazide 152 metoclopramide hcl 159

Index 60 METOCLOPRAMIDE HCL MICORT-HC 132 MIL ADREGEN 269 MONOHYDRATE 159 MICRHOGAM ULTRA- MILK THISTLE 94 METOCLOPRAMIDE FILTEREDPLUS 286 MILLIPRED 115 HYDROCHLORIDE 159 MICROCRYSTALLINE METOCLOPRAMIDE ODT 159 CELLULOSE NF 101 85 MILLIPRED DP 115 metolazone 152 MICROCRYSTALLINE milrinone lactate 73 metoprolol & CELLULOSE NF 105 85 milrinone lactate in dextrose 73 hydrochlorothiazide 49 MICROCYN 143 MIMYX 139 MICROCYN SKIN AND metoprolol succinate 71 MINASTRIN 24 FE 111 METOPROLOL SUCCINATE WOUND HYDROGEL 143 ER/HYDROCHLOROTHIAZIDE MICRODERM BASE 306 MINERAL OIL 171 49 MICRODOT CONTROL mineral oil 171 METOPROLOL TARTRATE 71 SOLUTIONHIGH/LOW 200 MINERAL OIL HEAVY 171 metoprolol tartrate 71 MICRODOT PEN MINERAL OIL LIGHT 171 NEEDLE/33G X 4 MM 232 METOPROLOL TARTRATE 71 MICRODOT TEST MINI LANCING DEVICE 200 metoprolol tartrate 71 STRIPS 149 MINIPRESS 48 METROCREAM 140 MICRODOT XTRA TEST MINIVELLE 158 STRIPS 149 METROGEL 140 MINOCIN 314 MICROLET LANCETS 200 METROGEL-VAGINAL 322 minocycline hcl 314 MICROLET NEXT 200 METROLOTION 140 MINOCYCLINE HCL 314 MICROPLEGIA MSA/MSG 74 metronidazole 17 minocycline hcl 314 MICROSOME BASE 306 METRONIDAZOLE 17 MICROTAINER SAFETY MINOLIRA 314 metronidazole 17 FLOW minoxidil 50 METRONIDAZOLE 94 LANCET/STERILE/SINGLE- MINOXIDIL 109 metronidazole (topical) 140,141 USE 200 MINT CHOCOLATE CHIP METRONIDAZOLE MICROVIX LP 137 FLAVOR 291 BENZOATE 94 MICROZIDE 152 MIOCHOL-E 279 METRONIDAZOLE MIDAZOLAM 94 MIOSTAT 279 BENZOATE/SYRSPEND SF MIDAZOLAM HCL 170 MIRALAX MIX-IN PAX 171 PH4 17 metronidazole in nacl 17 midazolam hcl 170 MIRAPEX 62 MIDAZOLAM metronidazole vaginal 322 MIRAPEX ER 62 HYDROCHLORIDE 170 MIRASORB SPONGES 2" X metyrosine 47 MIDAZOLAM 2" 186 mexiletine hcl 22 HYDROCHLORIDE/DEXTROS MIRASORB SPONGES 4" X MEXILETINE E 170 4" 186 HYDROCHLORIDE 94 MIDAZOLAM MIRCERA 165 MG PLUS PROTEIN 269 HYDROCHLORIDE/SODIUM CHLORIDE 170 MIRCETTE 111 MG-PLUS PROTEIN 269 MIDAZOLAM/KETAMINE MIRENA 112 MI PASTE 214 HYDROCHLORIDE/ONDANSE mirtazapine 32 MI PASTE PLUS 214 TRON MIRTAZAPINE 94 HYDROCHLORIDE 169 MIACALCIN 153 MIDAZOLAM/SODIUM MIRVASO 141 MIC/L-CARNITINE 275 CHLORIDE 170 misc natural products 255 micafungin sodium 42 MIDAZOLAM/SYRSPEND SF MISEFLEX-C 255 PH4 170 MICARDIS 48 MISOPROSTOL 94 midodrine hcl 324 MICARDIS HCT 49 misoprostol 318 miglitol 34 MICONAZOLE 43 MISOPROSTOL-HPMC 94 miglustat 164 MICONAZOLE NITRATE 126 MITIGARE 163 MIGRAINE PACK 247 miconazole nitrate vaginal 322 mitomycin 57 MIGRANAL 247 miconazole-zinc oxide-white MITOMYCIN 57,94 petrolatum 126 MIGRANOW 247

Index 61 MITOSOL 280 MONOETHANOLAMINE 94 MONOJECT INSULIN MITOTANE 94 MONOJECT BONE MARROW SYRINGE/U-100/1ML/30G X 5/16" 233 mitoxantrone hcl 57 BIOPSY TRAY/BIOP ASPIR NEEDLE 11GX4" 174 MONOJECT INSULIN MKO MELT DOSE PACK 169 MONOJECT BONE MARROW SYRINGEREGULAR LUER MLK F1 KIT 115 BIOPSY TRAY/BIOP ASPIR TIP/SOFTPACK/1ML 233 MONOJECT ULTRA COMFORT MLK F2 KIT 115 NEEDLE 8GX4" 174 MONOJECT BONE MARROW INSULIN SYRINGE/0.3ML/29G X MLK F3 KIT 115 BIOPSY TRAY/STERNAL- 1/2" 233 MLK F4 KIT 115 ILIAC NEEDLE 16G 174 MONOJECT ULTRA COMFORT MLP A-1 115 MONOJECT INSULIN INSULIN SYRINGE/0.3ML/30G X 5/16" 233 MM BIOTIN/KERATIN 269 SYRINGE/1ML 233 MONOJECT INSULIN MONOJECT ULTRA COMFORT MM EASY TOUCH GLUCOSE SYRINGE/1ML/31G X INSULIN SYRINGE/0.3ML/31G X TEST STRIPS 149 5/16" 233 MM INSULIN SYRINGE/U- 5/16" 233 MONOJECT INSULIN MONOJECT ULTRA COMFORT 100/0.3ML/30G X 5/16" 232 SYRINGE/DETACH INSULIN SYRINGE/0.5ML/28G X MM INSULIN SYRINGE/U- 1/2" 234 100/0.3ML/31G X 5/16" 232 NEEDLE/1ML/25G X 5/8" 233 MONOJECT INSULIN MONOJECT ULTRA COMFORT MM INSULIN SYRINGE/U- INSULIN SYRINGE/0.5ML/29G X 100/1/2ML/30G X 5/16" 233 SYRINGE/DETACH NEEDLE/1ML/27G X 1/2" 233 1/2" 234 MM INSULIN SYRINGE/U- MONOJECT ULTRA COMFORT 100/1/2ML/31G X 5/16" 233 MONOJECT INSULIN SYRINGE/PERM INSULIN SYRINGE/0.5ML/30G X MM INSULIN SYRINGE/U- 5/16" 234 100/1ML/30G X 5/16" 233 NEEDLE/1ML/28G X 1/2" 233 MONOJECT INSULIN MONOJECT ULTRA COMFORT MM INSULIN SYRINGE/U- INSULIN SYRINGE/0.5ML/31G X 100/1ML/31G X 5/16" 233 SYRINGE/PERM NEEDLE/U- 100/0.5ML/28G X 1/2" 233 5/16" 234 MM LANCING DEVICE 200 MONOJECT INSULIN MONOJECT ULTRA COMFORT MM PEN NEEDLES 31G X SYRINGE/SAFETY/PERM INSULIN SYRINGE/1ML/28G X 1/4" 233 NEEDLE/0.3ML/29G X 1/2" 234 MM PEN NEEDLES 31G X 1/2" 233 MONOJECT ULTRA COMFORT 3/16" 233 MONOJECT INSULIN INSULIN SYRINGE/1ML/29G X MM PEN NEEDLES 31G X SYRINGE/SAFETY/PERM 1/2" 234 5/16" 233 NEEDLE/0.3ML/29GX1/2" MONOLET LANCETS 200 MM PEN NEEDLES 32G X 233 MONOLET OPD LANCETS200 5/32" 233 MONOJECT INSULIN MM TWIST LANCETS 200 MONOLETTOR SAFETY SYRINGE/SAFETY/PERM LANCETS 200 MOBIC 6 NEEDLE/0.5ML/29G X MONONINE 163 modafinil 2 1/2" 233 MONSELS FERRIC MODERIBA 1200 DOSE MONOJECT INSULIN SUBSULFATE 168 SYRINGE/SAFETY/PERM PACK 69 montelukast sodium 23 moexipril hcl 47 NEEDLE/1ML/29G X 1/2" 233 MONOJECT INSULIN MONTELUKAST SODIUM 94 MOI-STIR 257 SYRINGE/SOFTPACK/1ML/27 MORANTEL TARTRATE 94 MOLASSES FLAVOR 291 G X 1/2" 233 MORGIDOX 1X100MG 314 MOLESKIN FOAM MONOJECT INSULIN PADDING 186 SYRINGE/SOFTPACK/U- MORGIDOX 1X50MG KIT 314 molindone hcl 64 100/0.5ML/28G X 1/2" 233 MORGIDOX 2X100MG 314 MONOJECT INSULIN MORPHABOND ER 11 MOLYBDENUM 94 SYRINGE/U-100/0.3ML/30G X MOMETASONE FUROATE 94 5/16" 233 morphine sulfate 11 mometasone furoate 132 MONOJECT INSULIN MORPHINE SULFATE 11,12 mometasone furoate SYRINGE/U-100/0.5ML/30G X morphine sulfate 12 (nasal) 273 5/16" 233 MORPHINE SULFATE 12 MONOJECT INSULIN MONISTAT SOOTHING CARE morphine sulfate 12 ITCH RELIEF 132 SYRINGE/U-100/1ML/28G X MONOBENZONE 94 1/2" 233 MORPHINE SULFATE 12 MONOCLATE-P 163 morphine sulfate 12

Index 62 morphine sulfate beads 11 MULPLETA 165 MYDAYIS 1 morphine sulfate for continuous MULTAQ 22 MYFORTIC 254 microinfusion 11 MULTI-LANCET DEVICE 200 MYGLUCOHEALTH BLOOD MORPHINE MULTI-SPECIALTY KIT 115 GLUCOSE TEST 149 SULFATE/DEXTROSE 12 MYGLUCOHEALTH CONTROL MORPHINE SULFATE/SODIUM MULTI-VITE 259 LOW/NORMAL/HIGH 200 CHLORIDE 12 MULTIBASE 306 MYGLUCOHEALTH MGH MOTEGRITY 158 MULTIGEN 167 SOFTLANCE LANCETS 30G 200 MOTOFEN 39 MULTIGEN FOLIC 167 MYLERAN 53 MOUTH KOTE 257 MULTIGEN PLUS 167 MYLOTARG 54 MOUTH KOTE REMINT 257 multiple vitamin 262 MYNATAL 264 MOUTH WASH-GP 299 multiple vitamins w/ MOUTHWASH-AF 299 minerals 260,261 MYNATAL ADVANCE 264 MOUTHWASH-OM 299 multiple vitamins w/ minerals & MYNATAL PLUS 264 folic acid 259 MOVANTIK 160 MYNATAL ULTRACAPLET 264 MULTITRACE-4 252 MYNATAL-Z 264 MOVIPREP 170 MULTITRACE-4 MOXATAG 286 CONCENTRATE 252 MYNATE 90 PLUS 264 MOXEZA 280 MULTITRACE-4 MYOBLOC 274 MOXIFLOXACIN 280 NEONATAL 252 MYRBETRIQ 319 MULTITRACE-4 MYRJ 53 309 MOXIFLOXACIN PEDIATRIC 252 HYDROCHLORIDE/SODIUM MULTITRACE-5 252 MYSOLINE 30 HYDROCHLORIDE 158 MYTESI 39 MOXIFLOXACIN HCL 94 MULTITRACE-5 CONCENTRATE 252 MYXREDLIN 37 moxifloxacin hcl 158 MULTIVITAMIN WITH N-ACETYL-L-CARNOSINE 95 moxifloxacin hcl (ophth) 280 FLUORIDE 259 N-ACETYL-L-CYSTEINE 118 MOXIFLOXACIN MULTIVITAMIN/FLUORIDE HYDROCHLORIDE 158 262 NABI-HB 286 MOXIFLOXACIN MUPIROCIN 95 nabumetone 6 HYDROCHLORIDE/SODIUM mupirocin 124 NABUMETONE 95 CHLORIDE 280 mupirocin calcium NADH 95 MOXISYLYTE HCL 95 (topical) 124 NADOLOL 71 MOZOBIL 168 MURI-LUBE 171 nadolol 71 MPD SAFETY LANCET MUSTARGEN 53 21G/1.8MM 200 nadolol & MPD SAFETY LANCET MVASI 54 bendroflumethiazide 49 28G/1.8MM 200 MX-SOL 299 NAFCILLIN 287 MPD SAFETY LANCET MX-SOL BLEND 299 nafcillin sodium 287 30G/1.8MM 200 MX-SOL BLEND SF 299 NAFCILLIN SODIUM 287 MPD SAFETY LANCETS 23G/1.8MM 200 MX-SOL SF 299 nafcillin sodium 287 MPS 269 MX-SOL SUSPEND 299 naftifine hcl 126 MS CONTIN 12 MYALEPT 155 NAFTIN 126 MS INSULIN MYAMBUTOL 52 NAGLAZYME 155 SYRINGE/0.3ML/31G X MYCAMINE 42 nalbuphine hcl 15 5/16" 234 MS INSULIN MYCO NAIL 126 NALBUPHINE HCL 95 SYRINGE/0.5ML/31G X MYCO-NAIL 126 NALFON 6 5/16" 234 MYCOBUTIN 52 NALOCET 14 MS INSULIN SYRINGE/1ML/31G mycophenolate mofetil 253 naloxone hcl 40 X 5/16" 234 mycophenolate mofetil MTX SUPPORT 167 NALOXONE HCL 95 hcl 254 NALOXONE HCL MUCOLOX 302 mycophenolate sodium 254 DIHYDRATE 95 MUCOSITISRX 257

Index 63 NALOXONE HYDROCHLORIDE NATURAL CARAMEL 291 NERLYNX 58 DIHYDRATE 95 NATURAL MIXED NESACAINE 174 NALTREXONE 40 TOCOPHEROLS30% 102 NESACAINE-MPF 174 naltrexone hcl 40 NATURE-THROID 315 NESINA 36 NALTREXONE HCL 95 NATURE-THROID NT- NESTABS 265 NALTREXONE 2.5 315 HYDROCHLORIDE 95 NAVELBINE 61 NESTABS ABC 265 NAMENDA 310 NAYZILAM 28 NESTABS DHA 265 NAMENDA TITRATION NEBUPENT 17 NESTABS ONE 265 PAK 310 NEBUSAL 118 NETTLE LEAF 95 NAMENDA XR 310 NEEVO DHA 264 NEUAC KIT 121 NAMENDA XR TITRATION PACK 310 nefazodone hcl 33 NEULASTA 165 NAMZARIC 310 NEMBUTAL SODIUM 169 NEULASTA ONPRO KIT 165 NANDROLONE NEO-SYNALAR 124 NEUPOGEN 165 DECANOATE 95 NEO-SYNALAR KIT 124 NEUPRO 62 NANDROLONE NEURAPTINE 123 DECANOATE/TESTOSTERONE NEOCERA 139 CYPIONATE/TESTOSTERONE NEOKE ALCAR 278 NEURCAINE 137 ENA 15 NEOKE MCT70 275 NEURIN-SL 167 NAPHAZOLINE HCL 95 NEOKE RA LIPOIC 3 NEURONTIN 30 NAPRELAN 6 neomycin sulfate 3 NEUT 248 NAPRO 15% COMPOUNDING NEOMYCIN SULFATE 124 NEUTEK 2TEK CONTROL KIT 124 neomycin-bacitracin zn- SOLUTIONS 200 NAPROSYN 6 polymyxin 280 NEUTEK 2TEK TEST NAPROXEN 6 neomycin-polymy- STRIPS 149 naproxen 6 dexameth 282 NEUTRASAL 257 NAPROXEN COMFORT PAC 6 neomycin-polymyxin-gramicidin NEVANAC 284 280 nevirapine 67 NAPROXEN SODIUM 6 neomycin-polymyxin-hc naproxen sodium 6 (ophth) 282 NEW LIFE HAIR 269 naproxen-esomeprazole neomycin-polymyxin-hc NEXA PLUS 265 magnesium 6 (otic) 285 NEXAVAR 58 naratriptan hcl 247 neomycin/polymyxin b gu 162 NEXAVIR 256 NARCAN 40 NEONATAL NEXCARE ABSOLUTE COMPLETE 264,265 NARDIL 32 WATERPROOF PAD 186 NEONATAL PLUS 265 NEXCARE ABSOLUTE NAROPIN 174 NEOPROFEN 6 WATERPROOF PREMIUM NASCOBAL 165 NEORAL 254 ADHESIVE PAD 2- NASONEX 273 3/8"X45" 186 NEOSALUS 139 NATACHEW 264 NEXCARE ACTIVE BRIGHTS NEOSALUS CP 139 BANDAGES ASSORTED 186 NATACYN 280 NEOSPORIN 280 NEXCARE ACTIVE SPORT NATALVIT 264 neostigmine methylsulfate 51 FOAM BANDAGES 1-1/8" X NATAPRES 105 3" 186 NEOSTIGMINE NEXCARE ACTIVE SPORT NATAZIA 111 METHYLSULFATE 51,95 FOAM BANDAGES nateglinide 38 NEOTUSS PLUS 118 ASSORTED 186 NATELLE ONE 264 NEOVITE 261 NEXCARE ACTIVE SPORT NATESTO 15 NEPAFENAC 95 FOAM BANDAGES KNEE/ELBOW 186 NATPARA 153 NEPHPLEX RX 258 NEXCARE ADHESIVE NATRECOR 75 NEPHRAMINE 278 DRESSING/PAD WATERPROOF NATROBA 141 NEPHRO-VITE RX 258 6" X 6" 186 NATURAL BITTERNESS 302 NEPHRON FA 167 NEXCARE COMFORT FABRIC BANDAGES 3/4" X 3" 186

Index 64 NEXCARE COMFORT FABRIC NEXIUM 24HR CLEAR NICOTINAMIDE ADENINE BANDAGES ASSORTED 187 MINIS 318 DINUCLEOTIDE 95 NEXCARE COMFORT FABRIC NEXIUM I.V. 318 NICOTINAMIDE ADENINE BANDAGES NEXLETOL 44 DINUCLEOTIDE (NAD) 95 KNEE/ELBOW 187 nicotine 312 NEXLIZET 44 NEXCARE HEAVY DUTY NICOTINE POLACRILEX 95 CLEAR& TOUGH BANDAGES NEXPLANON 112 nicotine polacrilex 312 ASSORTED 187 NEXTERONE 22 NEXCARE HEAVY DUTY NICOTINE TARTRATE 95 NEXTOL SF 302 CLEAR& TOUGH BANDAGES NICOTINE TRANSDERMAL KNEE/ELBOW 187 NIACIN 325 SYSTEM 312 NEXCARE HEAVY DUTY niacin (antihyperlipidemic) 46 NICOTROL INHALER 312 FLEXIBLE FABRIC BANDAGES NIACINAMIDE 325 NICOTROL NS 312 1-1/8"X3" 187 NIACINAMIDE/SPIRONOLACT NEXCARE HEAVY DUTY nifedipine 73 ONE 121 FLEXIBLE FABRIC BANDAGES NIACINAMIDE/SPIRONOLACT NIFEREX 167 ASSORTED 187 ONE/TRETINOIN 121 NILANDRON 56 NEXCARE HEAVY DUTY NIACINAMIDE/SULFACETAMI FLEXIBLE FABRIC BANDAGES nilutamide 56 DE SODIUM NIMBEX 274 KNEE/ELBOW 187 MONOHYDRATE 121 NEXCARE NON-STICK PADS NIACINAMIDE/TACROLIMUS nimodipine 73 3"X 4" 187 MONOHYDRATE 135 NIMODIPINE 95 NEXCARE PREMIUM NIACINAMIDE/TAZAROTENE NINLARO 58 ADHESIVEGAUZE PAD 6" X 121 6" 187 NIACINAMIDE/TRETINOIN NIPENT 60 NEXCARE SOFT 'N FLEX 121 NIPRIDE RTU 51 BANDAGES 187 NIACINAMIDE/TRIAMCINOLO nisoldipine 73 NEXCARE TATTOO NE ACETONIDE 132 WATERPROOF BANDAGES 1- NITHIODOTE 39 NIAOULI 106 1/16" X 2-1/4" 187 nitisinone 155 NIASPAN 46 NEXCARE TATTOO NITRIC ACID 77 WATERPROOF NICADAN 261 NITRO-BID 20 BANDAGES/EINSTEINS 1- nicardipine hcl 73 NITRO-DUR 20 1/16"X2-1/4" 187 NICARDIPINE NEXCARE TATTOO HYDROCHLORIDE 73 nitrofurantoin 20 WATERPROOF NICARDIPINE NITROFURANTOIN 95 BANDAGES/NEMO 1-1/16" X 2- HYDROCHLORIDE/DEXTROS 1/4" 187 NITROFURANTOIN E 73 ANHYDROUS 95 NEXCARE TATTOO NICARDIPINE WATERPROOF nitrofurantoin macrocrystal 20 HYDROCHLORIDE/SODIUM nitrofurantoin monohyd BANDAGES/POOH 1-1/16" X 2- CHLORIDE 73 1/4" 187 macro 20 NEXCARE TATTOO NICAZEL 261 NITROFURAZONE 128 WATERPROOF NICAZEL FORTE 261 nitroglycerin 20 NICE DISTILLED BANDAGES/PRINCESS 1-1/16" NITROGLYCERIN 21 X 2-1/4" 187 WATER 299 NEXCARE WATERPROOF NICE PURE BAKING nitroglycerin 21 BANDAGES 187 SODA 99 nitroglycerin in d5w 20 NEXCARE WATERPROOF NICLOSAMIDE 95 NITROLINGUAL BANDAGES 1-1/16" X 2- NICODERM CQ 312 PUMPSPRAY 21 1/4" 187 NITROMIST 21 NEXCARE WATERPROOF NICOMIDE 271 BANDAGES ASSORTED 187 NICORETTE 312 NITROPRESS 51 NEXCARE WATERPROOF NICORETTE MINI 312 nitroprusside sodium 51 BANDAGES NICORETTE STARTER NITROSTAT 21 KNEE/ELBOW 187 KIT 312 NITYR 155 NEXIUM 318 NICOTINAMIDE 325 NIVA-PLUS 265 NEXIUM 24HR 318 NIVATOPIC PLUS 139

Index 65 NIVESTYM 165 norgestimate-ethinyl estradiol NOVOLIN N FLEXPEN 37 NIZATIDINE 317 (triphasic) 111 NOVOLIN N FLEXPEN norgestrel & ethinyl nizatidine 317 RELION 37 estradiol 111 NOVOLIN N RELION 38 NIZATIDINE 317 NORITATE 141 NOVOLIN R 38 nizatidine 317 NORMOSOL -R 249 NOVOLIN R FLEXPEN 38 NIZORAL 126 NORMOSOL-M IN D5W 249 NOVOLIN R FLEXPEN NOCDURNA 156 NORMOSOL-R 249 RELION 38 NOCTIVA 156 NORMOSOL-R IN D5W 249 NOVOLIN R RELION 38 NON-STICK PADS 3"X4" 187 NORMOSOL-R/5% NOVOLOG FLEXPEN nonoxynol-9 322 DEXTROSE 249 SOPN 38 NOPIOID-LMC KIT 272 NORPACE 22 NOVOLOG MIX 70/30 38 NOVOLOG MIX 70/30 NOPIOID-TC KIT 272 NORPACE CR 22 NORPRAMIN 34 PREFILLED FLEXPEN 38 NORCO 14 NOVOLOG MIX 70/30 NORDITROPIN FLEXPRO 154 NORTHERA 323 PREFILLED FLEXPEN norelgestromin-ethinyl nortriptyline hcl 34 SUPN 38 estradiol 112 NORTRIPTYLINE HCL 34 NOVOLOG MIX 70/30 SUSP38 NOREPHINEPHRINE nortriptyline hcl 34 NOVOLOG PENFILL SOCT 38 BITARTRATE/SODIUM NOVOLOG SOLN 38 CHLORIDE 324 NORVASC 73 NOREPINEPHRINE NORVIR 67 NOVOPEN ECHO 234 BITARTRATE 95 NORWEGIAN COD LIVER NOVOSEVEN RT 163 norepinephrine bitartrate 324 OIL 271 NOVOTWIST 32GX5MM 234 NOREPINEPHRINE NOURIANZ 61 NOXAFIL 43 BITARTRATE/DEXTROSE 324 NOURILITE 306 NOREPINEPHRINE NOXI-K 306 NOURISIL 99 NOXIFOL-D 167 BITARTRATE/SODIUM NOURIVAN ANTIOX CREAM CHLORIDE 324 BASE 306 NOXIPAK 132 NOREPINEPHRINE/DEXTROSE NOVA MAX GLUCOSE TEST NOZIN NASAL SANITIZER 213 324 NOREPINEPHRINE/SODIUM STRIPS 149 NP #2 DRUG PREPARATION NOVA MAX PLUS GLU/KET KIT 124 CHLORIDE 324 CONTROL SOLUTION- norethin acet & estrad-fe 111 NPLATE 165 MID 200 NU GAUZE 4PLY 4"X4" 187 NORETHINDRONE 95 NOVA SAFETY LANCETS norethindrone & eth 23G 200 NU GAUZE GENERAL-USE estradiol 111 NOVA SAFETY LANCETS SPONGES 4"X4" 4 PLY 187 norethindrone & ethinyl estradiol- 28G 200 NU GAUZE PACKING STRIPS fe 111 NOVA SUREFLEX PLAIN 1/2" X 5 YDS 187 norethindrone LANCETS 200 NU GAUZE UTERINE (contraceptive) 113 NOVA SUREFLEX LANCING PACKINGSTRIPS IODOFORM norethindrone acet & eth DEVICE 200 8" X 10 YDS 187 estra 111 NU-GEL COLLAGEN WOUND NOVAREL 153 DRESSING 143 NORETHINDRONE NOVOFINE 32GX6MM 234 ACETATE 310 NUBEQA 56 NOVOFINE AUTOCOVER NUCALA 22 norethindrone acetate 310 30GX8MM 234 norethindrone acetate-ethinyl NOVOFINE PLUS NUCARACLINPAK 121 estradiol 157 32GX4MM 234 NUCARARXPAK 121 norethindrone acetate-ethinyl NOVOLIN 70/30 37 estradiol-fe 111 NUCORT 132 norethindrone-eth estradiol NOVOLIN 70/30 NUCYNTA 12 FLEXPEN 37 (triphasic) 111 NOVOLIN 70/30 FLEXPEN NUCYNTA ER 12 NORGESIC FORTE 272 RELION 37 NUDERMRXPAK 120 127 norgestimate-ethinyl NOVOLIN 70/30 RELION 37 NUDERMRXPAK 60 127 estradiol 111 NOVOLIN N 38 NUDROXIPAK 7

Index 66 NUDROXIPAK DSDR-50 6 OB COMPLETE/DHA 265 OLUX 132 NUDROXIPAK DSDR-75 7 OBIZUR 163 OLUX-E 132 NUDROXIPAK E-400 7 OBSTETRIX DHA 265 OMECLAMOX-PAK 318 NUDROXIPAK I-800 7 OBSTETRIX EC 265 OMEGA-3 RX COMPLETE 44 NUDROXIPAK M-15 7 OBSTETRIX ONE 265 omega-3-acid ethyl esters 44 NUDROXIPAK N-500 7 OBTREX 265 OMEGA-3/D-3 WELLNESS NUEDEXTA 312 OBTREX DHA 265 PACK 44 OMEGAVEN 275 NUFERA 167 OCALIVA 158 OMEPRAZOLE 95 NULOJIX 254 OCCLUVAN 306 omeprazole 318 NULYTELY 171 OCREVUS 311 OMEPRAZOLE + SYRSPEND NULYTELY/FLAVOR OCTAGAM 286 SFALKA 318 PACKS 171 OCTINOXATE 95 omeprazole-sodium NUMBONEX 137 octreotide acetate 156 bicarbonate 318 NUMBRINO 273 OCTYL STEARATE 95 OMIDRIA 283 NUMOISYN 257 OCUFLOX 280 OMNARIS 273 NUPLAZID 63 OCUVEL 261 OMNIBASE 306 NURTEC 246 ODEFSEY 67 OMNIPRED 282 NUSRUGEPAK SURGICAL ODOMZO 55 OMNITROPE 154 PREP/CAREPAK 140 ON CALL EXPRESS BLOOD NUSURGEPAK SURGICAL ODOR CONTROL INSOLES MENS/WOMENS 207 GLUCOSE TEST STRIPS 149 PREP/CAREPAK 140 ON CALL EXPRESS GLUCOSE NUTRASEB 128 ODOR EATERS ULTRA COMFORT 207 CONTROL SOLUTION 200 NUTRICAP 261 OFEV 313 ON CALL LANCETS 200 NUTRIDOX 314 ON CALL LANCING OFIRMEV 8 NUTRILIPID 275 DEVICE 200 ofloxacin 158 ON CALL PLUS BLOOD NUTRIVIT 258 ofloxacin (ophth) 280 GLUCOSE TEST 149 NUVAIL 139 ofloxacin (otic) 285 ON CALL PLUS GLUCOSE NUVAKAAN II 137 CONTROL LEVEL 1/2 200 OGIVRI 55 NUVARING 112 ON CALL PLUS LANCETS 200 OIL-ALMOND SWEET 107 NUVESSA 322 ON CALL PLUS LANCING OIL-COCONUT 107 DEVICE 200 NUVIGIL 2,3 OINTMENT BASE ON CALL VIVID BLOOD NUWIQ 163 EMULSIFYING 306 GLUCOSE TEST 149 NUZYRA 313 olanzapine 64 ON CALL VIVID BLOOD NYLIDRIN GLUCOSE TEST STRIPS 149 olanzapine-fluoxetine hcl 311 ON CALL VIVID GLUCOSE HYDROCHLORIDE 74 OLEABASE CONTROL LEVEL 1/2 200 NYMALIZE 73 PLASTICIZED 306 ONCASPAR 59 nystatin 42 OLEIC ACID 302 ondansetron 41 NYSTATIN 95 OLIVE OIL 107 ondansetron hcl 41 nystatin (mouth-throat) 257 olmesartan medoxomil 48 ONDANSETRON HCL 95 OLMESARTAN nystatin (topical) 126 ONDANSETRON HCL NYSTATIN FOREIGN 95 MEDOXOMIL 95 olmesartan medoxomil- DIHYDRATE 95 nystatin-triamcinolone 126 amlodipine-hydrochlorothiazide ONDANSETRON O-CAL FA 265 50 HYDROCHLORIDE/DEXTROSE olmesartan medoxomil- 41 O-CAL PRENATAL 265 ONDANSETRON hydrochlorothiazide 50 OB COMPLETE 265 HYDROCHLORIDE/SODIUM olopatadine hcl 284 OB COMPLETE ONE 265 CHLORIDE 41 olopatadine hcl (nasal) 273 OB COMPLETE PETITE 265 ONE A DAY PRENATAL 265 OLUMIANT 4 ONE DROP BLOOD GLUCOSE OB COMPLETE PREMIER 265 TEST STRIPS 149

Index 67 ONE VITE WOMENS ORA-BLEND SF 299 orphenadrine w/ aspirin & PRENATALVITAMIN PLUS 265 ORA-PLUS 299 caff 272 ONETOUCH CLUB LANCETS ORTHO DF 167 ORA-SWEET 299 FINE POINT 201 ORTHO MICRONOR 113 ONETOUCH DELICA LANCETS ORA-SWEET SF 299 ORTHO TRI-CYCLEN 112 EXTRA FINE 33G 201 ORABLOC 172 ONETOUCH DELICA LANCETS ORTHO TRI-CYCLEN LO 111 ORACEA 141 FINE 30G 201 ORTHO-CYCLEN 112 ONETOUCH DELICA LANCING ORACIT 161 ORTHO-FOLIC 167 DEVICE 201 ORAFATE 257 ONETOUCH DELICA PLUS ORAL MIX DRY ALKA ORTHO-NOVUM 1/35 112 LANCING DEVICE 201 SF/CHERRY 299 ORTHO-NOVUM 7/7/7 112 ONETOUCH FINEPOINT ORAL MIX DRY ALKA ORTHODIET 255 LANCETS 201 SF/UNFLAVORED 299 oseltamivir phosphate 69 ONETOUCH ULTRA 149 ORAL MIX FLAVORED ONETOUCH ULTRA SUSPENDING VEHICLE 299 OSELTAMIVIR PHOSPHATE 95 CONTROL 201 ORAL MIX SF 299 OSENI 35 ONETOUCH ULTRASOFT ORAL RELIEF SPRAY FOR LANCETS 201 DRYMOUTH & OSMOLEX ER 62 ONETOUCH VERIO MID DISCOMFORT 257 OSMOPREP 171 CONTROL SOLUTION 201 ONETOUCH VERIO TEST ORAL SUSPEND 299 OSPHENA 154 STRIPS 149 ORAL SUSPENDING OSTEO BI-FLEX ADVANCED ONEVITE 261 COMPOUNDPLUS 299 DOUBLE STRENGTH WITH ORAL SYRUP FLAVORED JOINT SHIELD 255 ONEXTON 121 VEHICLE 299 OSTEO BI-FLEX ADVANCED ONFI 28 ORAL SYRUP SF 299 TRIPLE STRENGTH 255 ONGLYZA 36 ORANGE OSTEO BI-FLEX ADVANCED ONIVYDE 61 CONCENTRATE 291 WITH JOINT SHIELD 255 ORANGE CREAM OSTEO BI-FLEX JOINT SHIELD ONPATTRO 312 FLAVOR 291 FORMULA WITH 5-LOXIN 255 ONTRUZANT 55 ORANGE FLAVOR 291 OSTEO BI-FLEX TRIPLE ONYCHO-MED 126 STRENGTH WITH 5- ORANGE OIL FLAVOR 291 LOXIN 255 ONZETRA XSAIL 247 ORAP 312 OSTEO BI-FLEX/5-LOXIN OPANA 12 ORAPRED ODT 115 ADVANCED 255 OPDIVO 55 ORAVIG 257 OTEZLA 7 ophthalmic irrigation solution - ORBACTIV 18 OTIPRIO 285 intraocular 284 ORENCIA 7 OTOVEL 285 opium tincture 39 ORENCIA CLICKJECT 7 OTREXUP 4 OPSUMIT 75 ORENITRAM 74 OVACE PLUS 128 OPTIFOAM 187 OVACE PLUS WASH 128 OPTIONS CONCEPTROL ORFADIN 155 VAGINAL ORGANIC COCONUT OVACE WASH 128 CONTRACEPTIVE 322 OIL 107 OVEEZA 167 OPTIONS GYNOL II ORIAHNN 157 OVIDE 141 VAGINALCONTRACEPTIVE ORIGANUM 95 OVIDREL 153 322 ORILISSA 154 OPTIUM TEST STRIPS 149 OXACILLIN SODIUM 287 ORKAMBI 313 OPTIUMEZ TEST STRIPS 149 oxacillin sodium 287 ORLISTAT 95 OPTUMRX BLOOD GLUCOSE OXALIC ACID DIHYDRATE 77 TEST 149 ORMECA 127 oxaliplatin 53 OPTUMRX GLUCOSE ORNITHINE OXANDROLONE 95 CONTROL LEVEL 1/2 201 HYDROCHLORIDE 95 OPURITY B12/FOLIC ORPHENADRINE oxaprozin 7 ACID 167 CITRATE 271 OXAYDO 12 ORA-BLEND 299 orphenadrine citrate 271,272 oxazepam 21

Index 68 OXBRYTA 165 P-CARE K80 115 PARAFORMALDEHYDE 96 oxcarbazepine 30 P-CARE K80G 115 PARAGARD INTRAUTERINE OXERVATE 281 P-CARE K80MX 115 COPPER CONTRACEPTIVE T380A 112 oxiconazole nitrate 126 P-CARE M 174 paregoric 39 OXISTAT 126 P-CARE MG 172 parenteral electrolytes 249 OXSORALEN ULTRA 127 P-CARE X 174 paricalcitol 155 OXTELLAR XR 30 P-SILOXAN DS 306 PARLODEL 62 OXYBENZONE 109 paclitaxel 61 PARNATE 32 OXYBUTININ CHLORIDE 95 PADCEV 55 paromomycin sulfate 3 OXYBUTYNIN CHLORIDE 96 PAINGO KFT 137 PAROMOMYCIN SULFATE 96 oxybutynin chloride 319 paliperidone 63 paroxetine hcl 33 oxycodone hcl 12 PALMAROSA OIL 96 paroxetine mesylate OXYCODONE HCL 12 PALMERS COCOA BUTTER (vasomotor) 313 oxycodone hcl 12 FORMULA SCAR PARSABIV 155 SERUM 141 oxycodone w/ PALMITAMIDE MEA PASER 52 acetaminophen 14 (PMEA) 96 PASSION FRUIT FLAVOR 291 oxycodone-aspirin 14 PALMITOYL PENTAPEPTIDE- PASSION FRUIT FLAVOR oxycodone-ibuprofen 14 3 96 SWEETENED 291 OXYCODONE/ACETAMINOPHE PALMITOYL TRIPEPTIDE- PATADAY 284 N 14 3 96 PATANASE 273 palonosetron hcl 41 OXYCONTIN 12 PATANOL 284 OXYMETAZOLINE HCL 96 PALONOSETRON HYDROCHLORIDE 41 PAXIL 33 oxymorphone hcl 12 PALYNZIQ 155 PAXIL CR 33 OXYTETRACYCLINE DIHYDRATE 96 PAMELOR 34 PAZEO 284 OXYTETRACYCLINE HCL 314 pamidronate disodium 153 PC LANCETS SUPER THIN 30G 201 OXYTOCIN 96 PAMIDRONATE DISODIUM 153 PC UNIFINE PENTIPS 29G oxytocin 285 X1/2" 234 pamidronate disodium 153 OXYTOCIN/DEXTROSE 285 PC UNIFINE PENTIPS 31G PANCREATIN 96 OXYTOCIN/DEXTROSE/LACTA X5MM MINI 234 TED RINGERS 285 PANCREAZE 151 PC UNIFINE PENTIPS 31G OXYTOCIN/LACTATED pancuronium bromide 274 X6MM ULTRA SHORT 234 PC UNIFINE PENTIPS 31G RINGERS 285 PANDEL 133 OXYTOCIN/SODIUM X8MM SHORT 234 CHLORIDE 285 PANRETIN 127 PCCA ACACIA SYRUP BASE 299 OXYTROL 319 PANTETHINE PLUS 255 PANTHENOL 96 PCCA ALADERM BASE 306 OZEMPIC 36 PCCA ANHYDROUS OZOBAX 272 PANTOPRAZOLE SODIUM 96 BASE 306 PCCA ANHYDROUS LIPODERM OZURDEX 282 pantoprazole sodium 318 P-CARE 100MX 172 BASE 306 PANZYGA 286 PCCA BASE 7542 306 P-CARE D40 115 PAPAIN 96 PCCA BIOPEPTIDE BASE 306 P-CARE D40G 115 PAPAVERINE HCL 74 PCCA CANNIDEX CUSTOM P-CARE D40MX 115 papaverine hcl 74 BASE 306 P-CARE D80 115 PAPAVERINE PCCA COBASE #1 306 P-CARE D80G 115 HYDROCHLORIDE 74 PCCA COSMETIC HRT P-CARE D80MX 115 PARA-AMINOBENZOIC BASE 306 ACID 325 PCCA CUSTOM LIPO- P-CARE K40 115 PARACHLOROPHENOL 96 MAX 306 P-CARE K40G 115 PARAFFIN 302 PCCA CUSTOM NATATROCHE P-CARE K40MX 115 HMP BASE 299

Index 69 PCCA CUSTOM RDT PCCA T3 SODIUM PEN NEEDLES 29GX1/2" 234 POWDER 302 DILUTION 93 PEN NEEDLES 30GX5/16" 234 PCCA CUSTOM TROCHE PCCA T4 SODIUM BASE 299 DILUTION 93 PEN NEEDLES 30GX5MM 234 PCCA DMAE COMPLEX 87 PCCA VANISHING CREAM PEN NEEDLES 30GX8MM 234 PCCA ELLAGE 306 LIGHT 307 PEN NEEDLES 31G X 1/4" PCCA VANISHING SHORT 234 PCCA EMOLLIENT CREAM CREAM/LOTION BASE 307 BASE 306 PEN NEEDLES 31G X PCCA EMULSIFIX-205 PCCA VANPEN BASE 307 3/16" 234 BASE 302 PCCA W06 ANHYDROUS PEN NEEDLES 31G X 5MM 234 PCCA FIXED OIL BASE 299 TOPICAL 307 PCCA WAV CUSTOM PEN NEEDLES 31G X PCCA GELATIN BASE 306 BASE 307 6MM 234 PCCA LECITHIN ISOPROPYL PCCA XYLIFOS BASE 302 PEN NEEDLES 31G X PALMITATE 302 8MM 234 PCCA-PLUS 299 PCCA LIPODERM BASE 306 PEN NEEDLES 31GX5/16" 234 PCCA LIPODERM CUSTOM PCP 100 171 PEN NEEDLES 31GX6MM BASE 306 PEACH FLAVOR 291 (1/4") 234 PCCA LIPODERM HMW 306 PEANUT BUTTER PEN NEEDLES 31GX8MM 234 PCCA LIPOSOMIC BASE FOR FLAVOR 291 PEN NEEDLES 31GX8MM DRY SKIN 306 PEANUT OIL 107 (5/16") 234 PCCA LIPOSOMIC BASE FOR PEANUTS BANDAGES 187 PEN NEEDLES 32G X NORMAL SKIN 307 PECTIN 39 4MM 234 PCCA LIPOSOMIC BASE FOR PEN NEEDLES 32G X OILY SKIN 307 ped multivitamins w/fl & 5MM 234 PCCA LIPOSOMIC BASE FOR iron 263 PEN NEEDLES 32G X SENSITIVE SKIN 307 PEDIAPRED 115 6MM 234 PCCA LOXASPERSE PEDIARIX 316 PEN NEEDLES 32GX4MM 234 BASE 302 pediatric multiple vitamin w/ PEN NEEDLES 33G X PCCA MVC BASE 307 minerals & c 263 5/32" 234 PCCA NATACREAM 307 pediatric multivitamins PENCREAM 307 w/fl 262 PCCA NATATROCHE PENDERM 307 BASE 299 pediatric vitamins acd w/ fluoride 262 PENICILLAMINE 96 PCCA OCCLUSADERM 307 PEDIZOLPAK 126 penicillamine 253 PCCA PERME8 ANHYDROUS 307 PEDVAX HIB 320 penicillin g potassium 287 PCCA PLASTICIZED PEG 307 PENICILLIN G POTASSIUM IN BASE 307 PEG 300 307 ISO-OSMOTIC DEXTROSE 287 PCCA PLURONIC F127 peg 3350-kcl-sod bicarb-sod BASE 307 chloride-sod sulfate 171 PENICILLIN G PROCAINE 287 PCCA POLOXAMER 407 307 peg 3350-potassium chloride- penicillin g sodium 287 PCCA POLYGLYCOL sod bicarbonate-sod penicillin v potassium 287 TROCHE 299 chloride 171 PENLAC NAIL LACQUER 126 PCCA POLYPEG BASE 307 PEG 400 PENLEN 139 PCCA PRACAMAC BASE 299 MONOSTEARATE 96 PCCA PRACASIL TM-PLUS PEG OINTMENT BASE 307 PENNSAID 124 BASE 307 PEG-40 CASTOR OIL 96 PENNYROYAL OIL 96 PCCA RAPID DISSOLVE PEGANONE 31 PENSOMAL CREAM 307 TABLET POWDER BASE 302 PCCA SORBITOL LOLLIPOP PEGASYS 69 PENTACEL 316 BASE 302 PEGASYS PROCLICK 69 PENTAM 300 17 PCCA SPIRA-WASH BASE307 PEGINTRON 69 pentamidine isethionate 17 PCCA SWEET-SF 299 PEMAZYRE 58 PENTAPHENE BASE 307 PCCA SWEETNESS PEN NEEDLES 29G X PENTASA 160 ENHANCER 291 12MM 234 pentazocine w/ naloxone 15 PCCA SYRUP VEHICLE 299

Index 70 PENTETATE CALCIUM perphenazine-amitriptyline PHARMACY COUNTER TRISODIUM 40 311 LANCETS 201 PENTETATE ZINC PERSERIS 63 PHENAZOPYRIDINE HCL 162 TRISODIUM 40 PERTZYE 151 phenazopyridine hcl 162 PENTICAN 312 PERUVIAN BALSAM 107 phenelzine sulfate 32 PENTIPS 29G X 12MM 235 PETROLATUM 307 PHENELZINE SULFATE 96 PENTIPS 29GX12MM 235 PETROLATUM WHITE 307 PHENERGAN 44 PENTIPS 31G X 5MM 235 PETROLEUM JELLY 307 PHENINDIONE 96 PENTIPS 31G X 8MM 235 PEUCEDANUM OSTRUTHIUM PHENIRAMINE MALEATE 96 PENTIPS 31GX5MM 235 EXTRACT 96 phenobarbital 169 PENTIPS 31GX6MM 235 PEXEVA 33 PHENOBARBITAL 169 PENTIPS 31GX8MM 235 PF-LIDOCAINE phenobarbital 169 PENTIPS 32G X 4MM 235 HYDROCHLORIDE 174 PFCB 307 PHENOBARBITAL PENTIPS 32GX4MM 235 SODIUM 169 PH 10 BUFFER 301 PENTOBARBITAL phenobarbital sodium 169 PH 12 STERILE DILUENT SODIUM 169 PHENOL 65 pentobarbital sodium 169 FORFLOLAN 299 PHENOLSULFONIC ACID 96 PENTOSAN POLYSULFATE PH 4 BUFFER 301 SODIUM 96 PH 7 BUFFER 301 phenoxybenzamine hcl 47 PENTOSAN POLYSULFATE PHARMABASE PHENOXYBENZAMINE SODIUM DR 162 ANTIOXIDANT 307 HCL 96 PENTOXIFYLLINE 96 PHARMABASE PHENOXYETHANOL 96 pentoxifylline 164 COSMETIC 307 PHENTERMINE PHARMABASE COSMETIC HYDROCHLORIDE 96 PENTYLENE GLYCOL 96 NATURAL 307 phentolamine mesylate 47 PENTYLENETETRAZOLE 96 PHARMABASE HEAVY 307 PHENTOLAMINE PEPCID 317 PHARMABASE LIGHT 307 MESYLATE 96 PEPPERMINT FLAVOR 291 PHARMABASE VAGINAL PHENYL SALICYLATE 96 PEPPERMINT OIL 107 MOISTURIZING 307 PHENYLBUTAZONE 7 PHARMACIST CHOICE PEPSIN 151 ALCOHOL PRED PADS 213 PHENYLEPHRINE HCL 273 PERCOCET 14 PHARMACIST CHOICE phenylephrine hcl PERFECT LANCETS 30G 201 ALCOHOLPREP PADS 213 (mydriatic) 279 PHARMACIST CHOICE phenylephrine hcl PERFECT PRESSURE (pressors) 324 ACTIVATED SAFETY LANCETS AUTOCODE BLOOD GLUCOSE TEST PHENYLEPHRINE 28G 201 HYDROCHLORIDE 273,324 PERFLUORODECALIN 96 STRIPS 149 PHARMACIST CHOICE NO PHENYLEPHRINE PERFORMAX SALT CODING BLOOD GLUCOSE HYDROCHLORIDE/DEXTROSE SUPPORTIVEBASE 307 TEST STRIPS 149 324 PERFOROMIST 25 PHARMACIST CHOICE PHENYLEPHRINE PERGOLIDE MESYLATE 96 ULTRA THIN LANCETS 201 HYDROCHLORIDE/SODIUM CHLORIDE 324 PERIDEX 257 PHARMACIST CHOICE ULTRA THIN LANCETS phenylephrine w/ dm-gg 118 PERIDIN-C 259 28G 201 PHENYLEPHRINE/SODIUM PERIKABIVEN 275 PHARMACIST CHOICE CHLORIDE 324 perindopril erbumine 47 ULTRA THIN LANCETS PHENYLETHYL ALCOHOL 96 peritoneal dialysis solutions 256 30G 201 PHENYLETHYLAMINE HCL 97 PHARMACIST CHOICE PHENYLMERCURIC PERJETA 55 ULTRA THIN LANCETS permethrin 141 ACETATE 109 31G 201 PHENYLMERCURIC PHARMACIST CHOICE PERMETHRIN TECHNICAL 96 NITRATE 109 perphenazine 64 ULTRA THIN LANCETS PHENYLPROPANOLAMINE 33G 201 PERPHENAZINE 96 HYDROCHLORIDE USP 273

Index 71 PHENYLTOLOXAMINE pimozide 312 PLEXION CLEANSING DIHYDROGEN CITRATE 97 PINA COLADA FLAVOR 291 CLOTHS 121 PHENYTEK 31 PLIAGLIS 137 pindolol 71 phenytoin 31 PLIXDA 121 PINE BARK EXTRACT 97 PHENYTOIN 97 PLO GEL - MEDIFLO KIT 307 PINE NEEDLE OIL 97 PHENYTOIN SODIUM 31 PLO GEL - MEDIFLO PRE- PINE OIL 107 phenytoin sodium 31 MIXED 307 PINE TAR 107 PLO PREMIUM LECITHIN phenytoin sodium extended 31 PINEAPPA 255 ORGANOGEL BASE 307 PHEODOYO 126 PLO TRANSDERMAL PINEAPPLE EXTRACT 97 PHESGO 57 CREAM 307 PINEAPPLE FLAVOR 291 PHEXXI 322 PLO ULTRAMAX 307 PINENE (L-ALPHA) 93 PHEYO 126 PLO20 BASE 308 pioglitazone hcl 36 PHLAG SPRAY 139 PLO20 FLOWABLE 308 pioglitazone hcl- PLURONIC 303 PHLEXY-10 278 glimepiride 35 PHOSLYRA 160 pioglitazone hcl-metformin PLURONIC F127 303 PHOSPHATIDYLCHOLINE 97 hcl 35 PLURONIC L64 303 piperacillin sodium-tazobactam PMS FORMULA PHOSPHATIDYLSERINE 99 sodium 287 INDOLPLEX 255 PHOSPHOLINE IODIDE 279 PIPERAZINE CITRATE 17 PMX-1184 SILICONE 99 PHOSPHORIC ACID 77 PIPERINE 97 PNA-HRT BASE 308 PHOTOFRIN 60 PIQRAY 200MG DAILY PNEUMOVAX 23 320 PHOTREXA VISCOUS 281 DOSE 58 PIQRAY 250MG DAILY PNEUMOVAX 23/1 DOSE 320 PHOTREXA/PHOTREXA PNV OB+DHA 265 VISCOUS KIT 281 DOSE 58 PIQRAY 300MG DAILY PHOXILLUM B22K4/0 253 PNV TABS 29-1 265 DOSE 58 PNV-DHA+DOCUSATE 265 PHOXILLUM BK4/2.5 253 PIRACETAM 97 PNV-OMEGA 265 PHYSICIANS EZ USE B-12 piroxicam 7 COMPLIANCE KIT 165 POCKETCHEM EZ BLOOD PHYSICIANS EZ USE JOINT PIROXICAM 7 GLUCOSE TEST STRIPS 149 TUNNEL AND TRIGGER 115 PITOCIN 285 POCKETCHEM EZ CONTROL PHYSICIANS EZ USE M- PLACEBO #00 303 LEVEL 1 201 PRED 115 POD-CARE 100C 116 PLAN B ONE-STEP 112 PHYSOSTIGMINE POD-CARE 100CG 116 SALICYLATE 40 PLAQUENIL 51 POD-CARE 100CMX 116 PHYTIC ACID IN WATER 97 PLASMA-LYTE A 249 POD-CARE 100K 116 PHYTOBASE 307 PLASMA-LYTE-148 249 POD-CARE 100KG 116 PHYTONADIONE 97 PLASTIBASE 307 POD-CARE 100KMX 116 phytonadione 325 PLASTIC ADHESIVE PODOCON 25 IN BENZOIN PICATO 127 BANDAGES 3/4" 187 PLASTIC BANDAGES TINCTURE 135 PICO SINGLE USE 3/4" 187 PODOFILOX 97 NEGATIVEPRESSURE WOUND THERAPY SYSTEM 143 PLASTICIZED BASE 307 podofilox 135 PICODERM 307 PLAVIX 164 PODOPHYLLUM RESIN 135 PIFELTRO 67 PLEGISOL 74 POINT OF CARE KM 116 PILOCARPINE HCL 109 PLEGRIDY 311 POINT OF CARE L.2 116 pilocarpine hcl 279 PLEGRIDY STARTER POINT OF CARE L.5 116 PACK 311 pilocarpine hcl (oral) 257 POINT OF CARE LM DEP PLENVU 171 2 116 PILOCARPINE NITRATE 109 PLEXION 121 POINT OF CARE LM-2.2 172 pimecrolimus 135 PLEXION CLEANSER 121 POINT OF CARE LM-2.5 172 PIMOBENDAN 97 POLIVY 55

Index 72 POLOX 303 POLYTRIM 280 potassium chloride POLOXAMER 188 303 POLYVINYL ALCOHOL 97 microencapsulated crystals er 251 POLOXAMER 407 303 POLYVINYLPYRROLIDONE K- POTASSIUM POLY-PREP 171 30 97 250 POLYVINYLPYRROLIDONE K- CHLORIDE/DEXTROSE POLY-VI-FLOR 262,263 POTASSIUM 90 97 CHLORIDE/DEXTROSE/LACTA POLY-VI-FLOR FS 262,263 POMALYST 56 TED RINGERS 250 POLY-VI-FLOR/IRON 263 POMEGRANATE SEED 97 POTASSIUM POLYBASE 308 PONAZURIL 97 CHLORIDE/LACTATED POLYETHYLENE GLYCOL PORTRAZZA 55 RINGERS 250 1000 308 POTASSIUM POLYETHYLENE GLYCOL posaconazole 43 CHLORIDE/LIDOCAINE 1450 308 pot & sod citrates w/citric HYDROCHLORIDE/DEXTROSE POLYETHYLENE GLYCOL ac 161 250 1500 308 pot phosphate monobasic w/ POTASSIUM POLYETHYLENE GLYCOL sod phosphate dibasic & CHLORIDE/LIDOCAINE 300 308 monobasic 251 HYDROCHLORIDE/SODIUM polyethylene glycol 3350 171 POTASH SULFURATED CHLORIDE 250 LUMP 109 POLYETHYLENE GLYCOL POTASSIUM 3350 308 POTASSIUM ACETATE 97 CHLORIDE/SODIUM POLYETHYLENE GLYCOL potassium acetate 251 CHLORIDE 250 400 308 POTASSIUM POTASSIUM POLYETHYLENE GLYCOL ACETATE/SODIUMCHLORIDE CHLORIDE/SODIUMCHLORIDE 4500 308 251 250 POLYETHYLENE GLYCOL POTASSIUM ALUM 109 POTASSIUM CITRATE 161 600 105 POTASSIUM potassium citrate POLYETHYLENE GLYCOL ASPARTATE 97 (alkalinizer) 161 8000 308 POTASSIUM AZELAOYL POTASSIUM CITRATE POLYETHYLENE GLYCOL DIGLYCINATE 97 MONOHYDRATE 161 8000BASE E 308 POTASSIUM BENZOATE 97 potassium citrate-citric acid 161 POLYETHYLENE GLYCOL POTASSIUM GLUCONATE BLEND 308 potassium bicarb & chloride 251 ANHYDROUS 109 POLYETHYLENE GLYCOL POTASSIUM HYDROXIDE 77 NF 308 POTASSIUM POLYHEXAMETHYLENE BICARBONATE 251 POTASSIUM IODIDE 97 BIGUANIDE 97 potassium bicarbonate 251 POTASSIUM POLYMAC PROGEL 308 POTASSIUM METABISULFITE 97 POLYMATRIX POWDER 303 BITARTRATE 109 POTASSIUM NITRATE 109 POTASSIUM BROMIDE 109 POTASSIUM POLYMEM FILM DOT 187 POTASSIUM PERCHLORATE 110 POLYMEM NON-ADHESIVE CARBONATE 109 POTASSIUM PAD 187 potassium chloride 251 PERMANGANATE 97 POLYMYXIN B SULFATE 20 POTASSIUM PHOSPHATE POTASSIUM CHLORIDE 251 polymyxin b sulfate 20 DIBASIC 97 potassium chloride 251 polymyxin b-trimethoprim 280 POTASSIUM PHOSPHATE POTASSIUM CHLORIDE 252 DIBASIC ANHYDROUS 97 POLYOX WSR-301 105 potassium chloride 252 POTASSIUM PHOSPHATE POLYOXYL 40 STEARATE309 MONOBASIC 97 POTASSIUM CHLORIDE POTASSIUM POLYOXYL LAURYL /SODIUM CHLORIDE 250 ETHER 256 PHOSPHATE/DEXTROSE 251 potassium chloride in POTASSIUM POLYPEG SUPPOSITORY dextrose 250 BASE 303 potassium chloride in dextrose PHOSPHATE/SODIUM CHLORIDE 251 POLYSORBATE 20 107 & sodium chloride 250 POLYSORBATE 40 107 potassium chloride in potassium phosphates 251 nacl 250 POTASSIUM POLYSORBATE 60 107 PHOSPHATES 251 POLYSORBATE 80 107

Index 73 POTASSIUM PRECISION GLUCOSE PREDNISOLONE PHOSPHATES/DEXTROSE CONTROLSOLUTION (TRI- ACETATE 116 251 LEVEL/HI/LO/NORMAL) 201 prednisolone acetate POTASSIUM PRECISION GLUCOSE (ophth) 282 PHOSPHATES/SODIUM KETONECONTROL PREDNISOLONE ACETATE P- CHLORIDE 251 SOLUTION 1-LOW, 1- F 282 POTASSIUM SODIUM HIGH 201 PREDNISOLONE TARTRATE 97 PRECISION ACETATE/MOXIFLOXACIN POTASSIUM SORBATE 288 GLUCOSE/KETONECONTROL 282 POTASSIUM SULFATE 97 SOLUTIONS 1-HI 1-LO 201 PREDNISOLONE PRECISION PCX 149 ACETATE/MOXIFLOXACIN/BRO POTELIGEO 55 PRECISION PCX PLUS TEST MFENAC 282 POVIDONE 97 STRIPS 149 PREDNISOLONE POVIDONE IODINE 281 PRECISION POINT OF CARE ACETATE/MOXIFLOXACIN/NEP AFENAC 282 POVIDONE K-30 97 TEST STRIPS 149 PRECISION QID TEST PREDNISOLONE POVIDONE-IODINE 97 STRIPS 149 ACETATE/NEPAFENAC 282 POWDER SCENT PRECISION SOF-TACT TEST PREDNISOLONE FRAGRANCE 97 STRIPS 149 ANHYDROUS 116 POWER-V 255 PRECISION SURE-DOSE PREDNISOLONE SODIUM PR BENZOYL PEROXIDE 121 INSULIN SYRINGE/0.3ML/30G PHOSPHATE 116 prednisolone sodium PR CREAM 139 X 5/16" 235 PRECISION SURE-DOSE phosphate 116 PR NATAL 400 265 INSULIN SYRINGE/0.5ML/28G PREDNISOLONE SODIUM PR NATAL 400 EC 265 X 1/2" 235 PHOSPHATE 282 PRECISION SURE-DOSE PREDNISOLONE SODIUM PR NATAL 430 265 PHOSPHATE, USP 116 PR NATAL 430 EC 265 INSULIN SYRINGE/0.5ML/29G X 1/2" 235 PREDNISOLONE SODIUM PRADAXA 28 PRECISION SURE-DOSE PHOSPHATE/BROMFENAC PRALIDOXIME CHLORIDE 40 INSULIN SYRINGE/0.5ML/30G 282 PREDNISOLONE SODIUM PRALINES AND CREAM X 3/8" 235 PRECISION SURE-DOSE PHOSPHATE/GATIFLOXACIN FLAVOR 291 282 PRALUENT 47 INSULIN SYRINGE/1ML/28G X 1/2" 235 PREDNISOLONE SODIUM pramipexole dihydrochloride 62 PRECISION SURE-DOSE PHOSPHATE/GATIFLOXACIN/B PRAMOTIC 285 PLUSINSULIN ROMFENAC 282 SYRINGE/0.3ML/29G X PREDNISOLONE SODIUM PRAMOX GEL 137 PHOSPHATE/MOXIFLOXACIN PRAMOXINE HCL 138 1/2" 235 PRECISION SURE-DOSE 283 PRANDIN 38 PLUSINSULIN PREDNISOLONE SODIUM PRASTERA 4 SYRINGE/1ML/29G X PHOSPHATE/MOXIFLOXACIN/B 1/2" 235 ROMFENAC 283 prasterone micronized 110 PREDNISOLONE- prasugrel hcl 164 PRECISION THINS GP LANCET 201 GATIFLOXACIN 283 PRAVACHOL 46 PRECISION XTRA BLOOD PREDNISOLONE/BROMFENAC GLUCOSE TEST 283 pravastatin sodium 46 PREDNISOLONE/GATIFLOXACI STRIPS 149 PRAXBIND 40 N/BROMFENAC 283 praziquantel 17 PRECOSE 34 PREDNISOLONEUSP, PRAZIQUANTEL 97 PRED FORTE 282 MICRONIZED ANHYDROUS 116 prazosin hcl 48 PRED MILD 282 PREDNISONE 116 PRAZOSIN PRED-G 282 HYDROCHLORIDE 48 PRED-G S.O.P. 282 prednisone 116 PRE & POST SX POUCH 140 prednicarbate 133 PREDNISONE INTENSOL 116 PRECEDEX 170 PREDNISOLONE 116 PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X PRECISION GLUCOSE prednisolone 116 CONTROL 201 1/2" 235

Index 74 PREFERRED PLUS INSULIN PRENA 1 TRUE 265 PRESSURE ACTIVATED SYRINGE/U-100/0.3ML/30G X PRENA1 CHEW 265 SAFETYLANCET 21G 201 5/16" 235 PRESTALIA 50 PRENA1 PEARL 265 PREFERRED PLUS INSULIN PRETAB 266 SYRINGE/U-100/0.5ML/28G X PRENAISSANCE 265 PRETOMANID 52 1/2" 235 PRENAISSANCE PLUS 265 PREFERRED PLUS INSULIN PREVACID 318 PRENARA 265 SYRINGE/U-100/0.5ML/29G X PREVACID 24HR 318 PRENATABS FA 265 1/2" 235 PREVACID SOLUTAB 318 PREFERRED PLUS INSULIN PRENATAL 266 SYRINGE/U-100/0.5ML/30G X PRENATAL + COMPLETE PREVALON 207 5/16" 235 MULTI/DHA/CHOLINE/FOLAT PREVALON FOOT/LEG PREFERRED PLUS INSULIN E 265 STABILIZER WEDGE 207 SYRINGE/U-100/1ML/28G X PRENATAL + DHA 265 PREVALON PRESSURE 1/2" 235 RELIEVING HEEL PREFERRED PLUS INSULIN PRENATAL 19 266 PROTECTOR 207 SYRINGE/U-100/1ML/29G X PRENATAL ADULT PREVALON PRESSURE 1/2" 235 GUMMY/DHA/FOLIC RELIEVING HEEL PREFERRED PLUS INSULIN ACID 266 PROTECTOR/PETITE 207 SYRINGE/U-100/1ML/30G X PRENATAL PLUS 266 PREVALON PRESSURE 5/16" 235 PRENATAL PLUS IRON 266 RELIEVING HEEL PREFERRED PLUS LANCETS prenatal vit w/ docusate-iron PROTECTOR/WEDGE 207 COLORED 21G 201 carbonyl-folic acid 266 PREVIDOLRX ANALGESIC PREFERRED PLUS LANCETS prenatal vit w/ ferrous fumarate- PAK 7 SUPER THIN 30G 201 folic acid 266 PREVNAR 13 320 PREFERRED PLUS LANCETS prenatal vit w/ ferrous fumarate- PREVYMIS 68 THIN 26G 201 l methylfolate-folic acid 266 PREZCOBIX 67 PREFERRED PLUS UNIFINE prenatal vit w/ iron carbonyl- PENTIPS 29G X 12MM 235 folic acid 266 PREZISTA 67 PREFERRED PLUS UNIFINE PRENATAL VITAMINS PLUS PRIALT 8 PENTIPS 31G X 6MM ULTRA LOW IRON 266 PRIFTIN 52 SHORT 235 prenatal without a w/ fe PRILO PATCH 138 PREFERRED PLUS UNIFINE fumarate-l methylfolate-fa- PENTIPS 31G X 8MM dha 266 PRILOCAINE 98 SHORT 235 PRENATAL-U 266 PRILOCAINE HCL 97 PREFERRED PLUS UNIFINE PENTIPS 32GX4MM 235 PRENATE 266 PRILOCAINE HCLUSP 98 PREFERRED PLUS UNIFINE PRENATE AM 266 PRILOCAINE HYDROCHLORIDE 98 PENTIPS/MINI/31GX5MM 235 PRENATE DHA 266 PRILOPENTIN 312 PREFEST 157 PRENATE ELITE 266 PRILOSEC 318 pregabalin 30 PRENATE ENHANCE 266 PRILOVIXIL 138 PREGABALIN 97 PRENATE ESSENTIAL 266 PRIMACARE 266 PREGENNA 265 PRENATE MINI 266 PRIMAPORE 11-3/4"X4" 187 PREGNENOLONE 110 PRENATE PIXIE 266 PREGNENOLONE PRIMAPORE 13-3/4"X4" 188 PRENATE RESTORE 266 MICRONIZED 110 PRIMAPORE 2-7/8"X2" 188 PRENATRIX 266 PREGNYL W/DILUENT PRIMAPORE 4"X3-1/8" 188 BENZYLALCOHOL/NACL 153 PRENATVITE PREMARIN 158,322 COMPLETE 266 PRIMAPORE 6"X3-1/8" 188 PREMASOL 278 PRENATVITE PLUS 266 PRIMAPORE 8"X4" 188 PREMESISRX 265 PRENATVITE RX 266 primaquine phosphate 51 PREMIUM BLOOD GLUCOSE PREPIV SUPPLY 138 PRIMAQUINE PHOSPHATE 51 TEST STRIPS 149 PREPLUS 266 PRIMAXIN IV 18 PREMIUM SCAR PATCH 138 PREPOPIK 171 primidone 30 PREMPHASE 157 PRESERA 139 PRIMIDONE 98 PREMPRO 157 PRIMLEV 14

Index 75 PRIMSOL 17 PRO-C-DURE 5 KIT 116 PROFILNINE 163 PRINIVIL 47 PRO-C-DURE 6 KIT 116 PROFILNINE SD 163 PRISMASOL B22GK 4/0 253 PROAIR DIGIHALER 25 PROFLAVINE PRISMASOL BGK 0/2.5 253 PROAIR HFA 25 HEMISULFATE 98 PROFOOT PLANTAR PRISMASOL BGK 2/0 253 PROAIR RESPICLICK 25 FASCIITIS 207 PRISMASOL BGK 2/3.5 253 probenecid 163 PROGESTERONE 98 PRISMASOL BGK 4/0/1.2 253 PROBICHEW 39 progesterone 310 PRISMASOL BGK 4/2.5 253 PROBIOTIC 39 PROGESTERONE 10% PRISMASOL BK 0/0/1.2 253 PROBIOTIC GOLD EXTRA KIT 310 PROGESTERONE PRISTIQ 34 STRENGTH 39 PROBUPHINE IMPLANT COMPOUNDINGKIT 310 PRIVIGEN 286 KIT 15 PROGESTERONE PRIZOPAK II 138 PROCAINAMIDE HCL 22 CONCENTRATE 98 PRIZOTRAL 138 PROGESTERONE procainamide hcl 22 MICRONIZED 98 PRIZOTRAL II 138 PROCAINE HCL 174 progesterone micronized 310 PRO COMFORT ALCOHOL PROCALAMINE 278 PROGESTERONE PADS 213 MICRONIZED (SOY) 98 PRO COMFORT INSULIN PROCARBAZINE HCL 98 PROCARDIA 73 PROGESTERONE SYRINGES/0.5ML/30G X MICRONIZED (YAM) 98 1/2" 236 PROCARDIA XL 73 PROGESTERONE PRO COMFORT INSULIN prochlorperazine 64 MICRONIZED PREMIUM 98 SYRINGES/0.5ML/30G X PROGESTERONE MILLED 98 5/16" 236 prochlorperazine edisylate 64 PRO COMFORT INSULIN PROCHLORPERAZINE PROGESTERONE ULTRA SYRINGES/0.5ML/31G X EDISYLATE 98 MICRONIZED 98 5/16" 236 PROCHLORPERAZINE PROGESTERONE PRO COMFORT INSULIN MALEATE 64 WETTABLE 98 SYRINGES/1ML/30G X prochlorperazine maleate 64 PROGESTERONE WETTABLE (YAM) 98 1/2" 236 PROCRIT 165 PROGLYCEM 36 PRO COMFORT INSULIN PROCTOCORT 16 SYRINGES/1ML/30G X PROGRAF 254 PROCTOFOAM HC 16 5/16" 236 PROLASTIN-C 313 PRO COMFORT INSULIN PROCYSBI 162 PROLATE 14 SYRINGES/1ML/31G X PRODIGEN 39 PROLENSA 284 5/16" 236 PRODIGY INSULIN PRO COMFORT LANCETS SYRING/U-100/0.3ML/31G X PROLEUKIN 60 30G 201 5/16" 236 PROLIA 153 PRO COMFORT LANCETS PRODIGY INSULIN 31G 201 PROMACTA 165 SYRINGE/1/2ML/31G X PROMAZINE HCL 98 PRO COMFORT PEN 5/16" 236 NEEDLES/31G X 8MM 236 PRODIGY INSULIN PROMELLA IN PREBIOTIC 39 PRO COMFORT PEN SYRINGE/1ML/28G X promethazine & NEEDLES/32G X 4MM 236 1/2" 236 phenylephrine 118 PRO COMFORT PEN PRODIGY LANCING NEEDLES/32G X 5MM 236 promethazine hcl 44 DEVICE 201 PROMETHAZINE HCL 98 PRO COMFORT PEN PRODIGY NO CODING 236 NEEDLES/32G X 6MM BLOOD GLUCOSE TEST promethazine w/codeine 118 PRO NUTRIENTS FRUIT & promethazine-dm 118 VEGGIE 255 STRIPS 149 PRO VOICE V8/V9 BLOOD PRODIGY PRESSURE promethazine-phenylephrine- GLUCOSE TEST STRIPS 149 ACTIVATED SAFETY codeine 118 LANCETS 201 PROMETHAZINE/PHENYLEPHR PRO-C-DURE 1 KIT 116 PRODIGY SAFETY INE 118 PRO-C-DURE 2 KIT 116 LANCETS 201 PROMETRIUM 310 PRO-C-DURE 3 KIT 116 PRODIGY TWIST TOP PROMISEB 128 LANCETS 201 PRO-C-DURE 4 KIT 116 PROMISEB COMPLETE 128

Index 76 propafenone hcl 22 PROXI-STRIP 1/4" X 4" 188 PX PEN NEEDLE PROPANEDIOL 98 PROXI-STRIPS 1/2"X4" 188 29GX12MM 236 PX PEN NEEDLE PROPANTHELINE PROZAC 33 31GX8MM 236 BROMIDE 316 PRUCLAIR 139 PX PURIFIED WATER 299 propantheline bromide 316 PRUDOXIN 127 PX SHORTLENGTH PEN PROPARACAINE HCL 98 PRUMYX 139 NEEDLES/31GX8MM 236 proparacaine hcl 281 pseudoephed-bromphen- PX SUPERSTRIP 1" X 3" 188 PROPIONIC ACID 98 dm 118 PYCNOGENOL COMPLEX 255 propofol 161 pseudoephed-cpm w/ PYLERA 319 PROPOFOL 161 hydrocod 118 PSEUDOEPHEDRINE PYRANTEL PAMOATE 98 propranolol & HCL 273 pyrazinamide 52 hydrochlorothiazide 50 PSORCON 133 PYRAZINAMIDE 52 propranolol hcl 71 PSS SELECT GP PYRIDIUM 162 PROPRANOLOL HCL 71 LANCETS 201 pyridostigmine bromide 51,52 propranolol hcl 71,72 PSS SELECT SAFETY LANCETS 202 PYRIDOSTIGMINE PROPYL GALLATE 98 BROMIDE 98 PROPYLENE GLYCOL 98 PSYLLIUM HUSK 98 PYRIDOXAL-5-PHOSPHATE PROPYLENE GLYCOL PTS PANELS GLUCOSE 325 MONOSTEARATE 98 TEST 149 PYRIDOXAL-5-PHOSPHATE PROPYLPARABEN 288 PULLULAN 98 MONOHYDRATE 98 PROPYLPARABEN PULMICORT 24 PYRIDOXINE HCL 325 SODIUM 288 PULMICORT FLEXHALER24 pyridoxine hcl 325 PROPYLTHIOURACIL 98 PULMOZYME 313 PYRILAMINE MALEATE 43 propylthiouracil 315 PUMICE (FLOUR) 110 pyrimethamine 51 PROQUAD 321 PUMICE STONE 207 PYRIMETHAMINE 98 PROSCAR 162 PUMPKIN FLAVOR 291 PYRIMETHAMINE/LEUCOVORI PROSOL 278 PURE COMFORT ALCOHOL N 51 PROSTAGLANDIN E1 110 PREPPADS 213 PYROGALLIC ACID 135 PURE COMFORT PEN PROSTAGLANDIN E2 87 PYROGALLOL 110 NEEDLE 32G X8MM 236 PYRUVIC ACID 110 PROSTIN VR PEDIATRIC 256 PUREFE OB PLUS 267 Q-DERM 308 PROTAMINE SULFATE 98 PUREFE PLUS 167 QBRELIS 47 PROTECT PLUS 261 PURIFIED WATER 299 PROTECT PLUS NF 261 QBREXZA 140 PURIXAN 54 QC ADVANCED LANCING PROTEXA 134 PUSH BUTTON SAFETY DEVICE 202 PROTHELIAL 257 LANCETS 21G 202 QC ALCOHOL SWABS 213 PROTONIX 318 PUSH BUTTON SAFETY LANCETS 28G 202 QC ALL PURPOSE PROTOPAM CHLORIDE 40 PX ADVANCED LANCING DRESSINGS4"X4" 188 PROTOPIC 135 DEVICE 202 QC BORDER ISLAND GAUZE PAD 2"X2" 188 protriptyline hcl 34 PX EXTRA SHORT PEN NEEDLES 31GX6MM 236 QC BORIC ACID 110 PROVAD 39 PX INSULIN SYRINGE/U- QC CASTOR OIL 107 PROVAYBLUE 40 100/0.5ML/30G X 1/2" 236 QC COD LIVER OIL 271 PROVENGE 55 PX LANCET AUTO QC GLUCOSAMINE & INJECTOR 202 CHONDROITIN TRIPLE PROVENTIL HFA 25 PX LANCETS ULTRA STRENGTH/MSM 255 PROVERA 310 THIN 202 PROVIDA DHA 266 PX LANCETS ULTRA THIN QC IODIDES TINCTURE 65 PROVIDA OB 267 28G 202 QC IODINE TINCTURE 65 PX MINI PEN NEEDLES QC LANCETS SUPER PROVIGIL 3 31GX5MM 236 THIN 202 PROVISC 283

Index 77 QC LANCETS ULTRA quinapril-hydrochlorothiazide RA BANDAGES FLEXIBLE THIN 202 50 FABRIC NON STICK QC NON-ADHERENT PADS QUINIDINE GLUCONATE 22 3/4"X3" 188 3"X4" 188 quinidine gluconate 22 RA BANDAGES FLEXIBLE QC PEN NEEDLES 29G X FABRIC NON STICK EXTRA 12MM 236 quinidine sulfate 22 LARGE 188 QC PEN NEEDLES 31G X QUINIDINE SULFATE 110 RA BANDAGES FLEXIBLE 6MM 236 QUINIDINE SULFATE FOAM 188 QC PEN NEEDLES 31G X DIHYDRATE 110 RA 8MM 236 QUININE HCL 98 BANDAGES/CLEAR/ASSORTED QC STERILE PADS 188 quinine sulfate 51 188 QC SWEET OIL 107 RA BANDAGES/EXTRA LONG QUININE SULFATE 51 FABRIC/HEAVY DUTY 188 QC UNIFINE PENTIPS QUININE SULFATE RA BANDAGES/STRONG- 32GX4MM 236 DIHYDRATE 51 QC UNILET LANCETS STRIPS/EXTRA LARGE 188 28G/ULTRA THIN 202 QUINIXIL 133 RA BORIC ACID 110 QC UNILET LANCETS QUINIZARIN GREEN SS 288 RA BUTTERFLY 33G/MICRO THIN 202 QUINOSONE 133 BANDAGES/MEDIUM 188 QINLOCK 58 QUINTET AC BLOOD RA COD LIVER OIL 271 QMIIZ ODT 7 GLUCOSETEST STRIPS 149 RA CONFORMED BANDAGE 188 QNASL 273 QUINTET BLOOD GLUCOSE TEST STRIPS 149 RA CRYSTAL LAKE QNASL CHILDRENS 273 QUINTET GLUCOSE DISTILLEDWATER 299 QTERN 35 CONTROL/HIGH/NORMAL RA CUSHION INSOLES QUADRACEL 316 202 MENS 207 QUTENZA 138 RA CUSHION INSOLES QUADRAMET 59 WOMENS 207 QUALAQUIN 51 QUZYTTIR 44 RA DRESSING SPONGES QUARTETTE 112 QVAR REDIHALER 24 4"X4" 188 RA DRY MOUTH 257 QUATERNIUM-15 98 R-NATAL OB 267 RA E-ZJECT COLOR quazepam 170 R.N.A. - 180 255 RA ADHESIVE LANCETSMICRO-THIN QUDEXY XR 30 BANDAGES 188 33G 202 QUELICIN 273 RA ADHESIVE BANDAGES RA E-ZJECT LANCETS FLEXIBLE 188 28G 202 QUERCETIN DIHYDRATE 98 RA E-ZJECT LANCETS THIN QUESTRAN 45 RA ADHESIVE BANDAGES FLEXIBLE FOAM 188 26G 202 QUESTRAN LIGHT 45 RA ADHESIVE BANDAGES RA E-ZJECT LANCETS THIN quetiapine fumarate 64 PLASTIC 188 28G 202 RA E-ZJECT LANCETS QUFLORA FE 259 RA ADHESIVE BANDAGES SHEER 188 ULTRATHIN 30G 202 QUFLORA FE PEDIATRIC 263 RA ADHESIVE PADS 2- RA EAR CARE 269 QUFLORA GUMMIES 263 1/4"X3" 188 RA ESTROPLUS MAX QUFLORA PEDIATRIC 263 RA ADHESIVE PADS STRENGTH 255 QUICKTEK CONTROL 3"X4" 188 RA FIRST AID ADVANCED SOLUTION 202 RA ALCOHOL SWABS 213 ANTIBACTERIAL QUICKTEK TEST STRIPS 149 RA ALL PURPOSE WATERPROOF STRONG STRIPS 188 QUILLICHEW ER 3 DRESSINGS4"X4" 188 RA BANDAGES CLEAR 188 RA FIRST AID CLEAR SPOT QUILLIVANT XR 3 7/8" 188 RA BANDAGES FLEXIBLE RA FIRST AID FLEXIBLE QUINACRINE FABRIC ASSORTED DIHYDROCHLORIDE 51 FABRIC ADHESIVE SIZES 188 BANDAGE 188 QUINACRINE RA BANDAGES FLEXIBLE DIHYDROCHLORIDE FABRIC EXTRA LARGE 188 RA FIRST AID IODINE 65 DIHYDRATE 51 RA BANDAGES FLEXIBLE RA FIRST AID NON-STICK QUINACRINE HCL 51 FABRIC HEAVY DUTY 188 PADS 188 quinapril hcl 47 RA FIRST AID SHEER ADHESIVE BANDAGE 189

Index 78 RA FLUORIDE rabeprazole sodium 318 RDT-PLUS 303 TOOTHPASTE 214 RABEPRAZOLE SODIUM DR READYLANCE SAFETY RA FOAM INSOLES SPRINKLE 318 LANCETS/21G/2.2MM 202 WOMENS 207 RACEPINEPHRINE HCL 98 READYLANCE SAFETY RA GAUZE BANDAGE 189 RADIACARE POST LANCETS/23G/1.8MM 202 RA GAUZE SPONGES HEALING 143 READYLANCE SAFETY 4"X4" 189 RADIADRES GEL LANCETS/26G/1.8MM 202 RA GEL HEEL CUSHIONS SHEET 143 READYLANCE SAFETY MENS 207 RADIAGEL 143 LANCETS/28G/1.8MM 202 RA GEL TOE READYLANCE SAFETY SEPARATORS 207 RADIAPLEXRX 143 LANCETS/30G/1.6MM 202 RA GLUCOSAMINE RADICAVA 273 READYSHARP ANESTHETICS CHONDROITIN/MSM 255 RADIOGARDASE 40 +BETAMETHASONE 116 RA INSULIN READYSHARP ANESTHETICS SYRINGE/0.5ML/29G X raloxifene hcl 154 +DEXAMETHASONE 116 1/2" 236 ramelteon 170 READYSHARP ANESTHETICS RA INSULIN SYRINGE/1ML/29G ramipril 47 +KETOROLAC 7 X 1/2" 236 RANEXA 20 READYSHARP ANESTHETICS RA INSULIN SYRINGE/U- +METHYLPREDNISOLONE 100/0.5ML/30G X 5/16" 236 RANITIDINE HCL 98 80 116 RA INSULIN SYRINGE/U-100/1 ranitidine hcl 317 READYSHARP ML/30G X 5/16" 236 RANITIDINE BETAMETHASONE 116 RA ISOPROPYL ALCOHOL HYDROCHLORIDE 98 READYSHARP WIPES 140 ranolazine 20 DEXAMETHASONE 116 RA LANCING DEVICE 202 RAPAFLO 162 READYSHARP KETOROLAC 7 READYSHARP RA NAIL CLIPPER 207 RAPAMUNE 254 RA PEN NEEDLES 31G X LIDOCAINE 174 5MM3/16" 236 RAPESEED OIL 98 READYSHARP-A 172 RA PEN NEEDLES 31G X RAPIVAB 69 READYSHARP-K 116 8MM5/16" 236 rasagiline mesylate 63 REALITY INSULIN SYRINGE/U- RA PETROLEUM JELLY 308 RASAGILINE MESYLATE 98 100/0.5ML/28G X 1/2" 236 RA PLANTAR FASCIITIS ARCH RASPBERRY REALITY INSULIN SYRINGE/U- SLEEVE 207 CONCENTRATE 291 100/0.5ML/29G X 1/2" 236 RA PUMICE STONE 207 RASPBERRY FLAVOR 291 REALITY INSULIN SYRINGE/U- 100/1ML/28G X 1/2" 236 RA RENEWAL BARREL RASPBERRY FLAVOR SPRINGTOENAIL NIPPER 207 REALITY INSULIN SYRINGE/U- ARTIFICIAL 291 100/1ML/29G X 1/2" 236 RA SENSITIVE RASPBERRY SYRUP 299 TOOTHPASTE/FLUORIDE REALITY LANCETS 202 214 RASUVO 4 REALITY SWABS 213 RA SHEER ADHESIVE RAUWOLFIA REALITY TRIGGER LARGE 189 SERPENTINA 99 LANCETS 202 RA STERILE PADS 2"X2" 189 RAVICTI 155 REBETOL 69 RA STERILE PADS 4"X4" 189 RAY-TEC X-RAY DETECTABLESPONGES 4" X REBIF 311 RA STRONG STRIPS REBIF REBIDOSE 311 BANDAGES 189 4" 16 PLY 189 RA STRONG STRIPS RAY-TEC X-RAY REBIF REBIDOSE BANDAGES NON-STICK 189 DETECTABLESPONGES 8" X TITRATIONPACK 311 RA SUPER STRIP 1"X3" 189 4" 12 PLY 189 REBIF TITRATION PACK 311 RAY-TEC X-RAY REBLOZYL 165 RA TOENAIL CLIPPER 207 DETECTABLESPONGES 8" X RA TRUETEST STRIPS 149 4" 16 PLY 189 RECARBRIO 18 RA TUBULAR RAYALDEE 155 RECEDO 141 GAUZE/FINGER 189 RAYOS 116 RECK 172 RA WHITENING RECLAST 153 TOOTHPASTE/FLUORIDE RAZADYNE 310 214 RAZADYNE ER 310 RECOMBINATE 163 RABAVERT 321 RDT BASE 303 RECOMBIVAX HB 321

Index 79 RECOTHROM 168 RELION INSULIN SYRINGE/U- RELION ULTIMA TEST RECOTHROM SPRAY KIT 168 100/0.3ML/30G X 5/16" 237 STRIPS 150 RELION INSULIN SYRINGE/U- RELION ULTRA THIN RECOTHROM/SPRAY 100/0.3ML/31G X 15/64" 237 LANCETS30G 202 APPLICATOR KIT 168 RELION INSULIN SYRINGE/U- RELION ULTRA THIN PLUS RECTIV 16 100/0.3ML/31G X 5/16" 237 LANCETS 32G 202 RECURA 126 RELION INSULIN SYRINGE/U- RELION ULTRA THIN PLUS RED YEAST RICE 99 100/0.5ML/29G 237 LANCETS 33G 202 RED YEAST RICE RELION INSULIN SYRINGE/U- RELISTOR 160 EXTRACT 99 100/0.5ML/29G X 1/2" 237 RELNATE DHA 267 RELION INSULIN SYRINGE/U- REFUAH PLUS BLOOD RELPAX 248 GLUCOSETEST STRIPS 149 100/0.5ML/30G 237 REFUAH PLUS GLUCOSE RELION INSULIN SYRINGE/U- REMDESIVIR 70 CONTROL SOLUTION 202 100/0.5ML/30G X 5/16" 237 REMEDIENT 261 RELION INSULIN SYRINGE/U- REGENECARE 143 100/0.5ML/31G X 5/16" 237 REMERON 32 REGENT ALCOHOL 299 RELION INSULIN SYRINGE/U- REMERON SOLTAB 32 REGLAN 159 100/1ML/30G 237 REMESENSE 214 REGONOL 52 RELION INSULIN SYRINGE/U- REMICADE 160 100/1ML/30G X 5/16" 237 REGRANEX 143 RELION INSULIN SYRINGE/U- remifentanil hcl 12 REJUVACARE PLUS 308 100/1ML/31G X 15/64" 237 REMIFENTANIL RELAFEN DS 7 RELION INSULIN SYRINGE/U- HYDROCHLORIDE/SODIUM 100/1ML/31G X 5/16" 237 CHLORIDE 13 RELAX & SLEEP 255 RELION KETONE 150 REMIGEN CREAM 139 RELEASE NON-ADHERING DRESSING 4" X 3" 189 RELION KETONE TEST REMODULIN 74 STRIPS 150 RENACIDIN 162 RELENZA DISKHALER 70 RELION LANCETS MICRO- RELEXXII 3 THIN33G 202 RENAGEL 160 RELIAMED SELF-ADHESIVE RELION LANCETS RENATABS 259 DRESSING RETENTION STANDARD 21G 202 RENATABS WITH IRON 259 RELION LANCETS THIN SHEET 189 RENEWCREAM HRT 308 RELION 2-IN-1 LANCET 26G 202 DEVICES 30G 202 RELION LANCETS ULTRA- RENFLEXIS 160 RELION 2-IN-1 LANCING THIN30G 202 RENOVAGE 102 DEVICE 25G 202 RELION LANCING RENOVO 138 RELION 2-IN-1 LANCING DEVICE 202 DEVICE 30G 202 RELION MINI PEN NEEDLES RENVELA 160 RELION ALCOHOL 31GX6MM 237 repaglinide 38 SWABS 213 RELION PEN NEEDLES repaglinide-metformin hcl 35 29GX12MM 237 RELION ALL-IN-ONE REPATHA 47 COMPACTBLOOD GLUCOSE RELION PEN NEEDLES TESTING SYSTEM 202 31GX6MM 237 REPATHA PUSHTRONEX RELION BLOOD GLUCOSE RELION PEN NEEDLES SYSTEM 47 TESTSTRIPS 150 31GX8MM 237 REPATHA SURECLICK 47 RELION CONFIRM/MICRO RELION PEN NEEDLES REPHRESH PRO-B 39 TEST STRIPS 150 32GX4MM 237 REQ 49+ 261 RELION INSULIN SYRINGE RELION PREMIER BLOOD 0.5ML/31G X 15/64" 237 GLUCOSE TEST REQUIP 62 RELION INSULIN SYRINGE STRIPS 150 REQUIP XL 62 1ML/31GX15/64" 237 RELION PRIME BLOOD RESCRIPTOR 67 GLUCOSE TEST RELION INSULIN SYRINGE/U- RESERPINE 48 00/1ML/29G X 1/2" 237 STRIPS 150 RELION INSULIN SYRINGE/U- RELION SHORT PEN RESERVAPAK KIT 3 100/0.3ML/29G 237 NEEDLES31GX8MM 237 RESERVAPAK PLUS KIT 3 RELION INSULIN SYRINGE/U- RELION ULTIMA BLOOD RESORCINOL 110 100/0.3ML/29G X 1/2" 237 GLUCOSE TEST RELION INSULIN SYRINGE/U- STRIPS 150 resorcinol-sulfur 121 100/0.3ML/30G 237 RESTASIS 281

Index 80 RESTASIS MULTIDOSE 281 REVITADERM WOUND RIGHTEST GS300 BLOOD RESTORA RX 39 CARE 144 GLUCOSE TEST STRIPS 150 REVLIMID 253 RIGHTEST GS550 BLOOD RESTORA SPRINKLES 39 REXALL BLOOD GLUCOSE GLUCOSE TEST STRIPS 150 RESTORE CONTACT TEST STRIPS 150 RILUTEK 273 LAYER/NON-ADHERENT REXALL LANCETS ULTRA riluzole 273 2"X2" 189 THIN 203 RESTORE DUO ABSORBENT rimantadine hydrochloride 70 REXAPHENAC 124 DRESSING 4"X5" 189 RIMSO-50 162 REXASIL PATCH/VITAMIN E RESTORE FOAM DRESSING ringer's 250 BORDERED 4"X4" 189 KIT 144 RESTORE FOAM DRESSING REXULTI 65 ringer's irrigation 254 BORDERED 6"X6" 189 REYATAZ 67 RINVOQ 4 RESTORE FOAM DRESSING REYVOW 248 RIOMET 36 NON-BORDERED 4"X4" 189 RESTORE FOAM DRESSING REZAMID 122 RIOMET ER 36 NON-BORDERED 6"X6" 189 REZESOL 122 risedronate sodium 153 RESTORE HYDROGEL RHEOSPRAY 299 RISPERDAL 63 DRESSING 144 RISPERDAL CONSTA 63 RESTORE LITE FOAM RHOFADE 141 DRESSING NON-BORDERED RHOGAM ULTRA-FILTERED risperidone 63 4"X5" 189 PLUS 286 RITALIN 3 RESTORE LITE FOAM RHOPHYLAC 286 RITALIN LA 3 DRESSING NON-BORDERED RHOPRESSA 281 ritonavir 67 6"X6" 189 RIASTAP 163 RESTORE ODOR ABSORBING RITUXAN 55 DRESSING 4"X4" 189 RIAX 122 RITUXAN HYCELA 57 RESTORE TRIO ABSORBENT RIBASPHERE 69 rivastigmine 311 DRESSING 4"X5" 189 RIBASPHERE RIBAPAK 69 rivastigmine tartrate 311 RESTORIL 170 ribavirin 70 RESVERATROL 99 RIXUBIS 164 RIBAVIRIN 99 rizatriptan benzoate 248 RESVERATROL 98% 99 ribavirin (hepatitis c) 69 RESVERATROL 98+% 99 ROBAXIN 272 RIBOFLAVIN 99 ROBAXIN-750 272 RETACRIT 166 RIBOFLAVIN-5-PHOSPHATE RETAINE VISION 269 SODIUM 99 ROCALTROL 155 RETEVMO 58 RIBOFLAVIN-5-PHOSPHATE ROCKLATAN 281 SODIUM ANHYDROUS 99 RETIN-A 121 ROCURONIUM BROMIDE 99 RIBOSE (D) 87 RETIN-A MICRO 121,122 rocuronium bromide 274 RIDAURA 4 RETIN-A MICRO PUMP 122 ROCURONIUM BROMIDE 274 rifabutin 52 RETINALDEHYDE 99 ROMIDEPSIN 58 RIFADIN 52 RETINOIC ACID 122 RONIDAZOLE 99 RIFAMATE 52 RETINOIC ACID-ALL ROOT BEER FLAVOR 291 TRANS 122 rifampin 52 ROPIDEX 116 RETINOL MOLECULAR RIFAMPIN 99 ropinirole hydrochloride 62 FILM 104 RIFAMPIN/SYRSPEND SF ropivacaine hcl 174 RETISERT 283 PH4 52 ROPIVACAINE RETROVIR 67 RIFATER 52 HYDROCHLORIDE 99,174 RETROVIR IV INFUSION 67 RIFAXIMIN 99 ROPIVACAINE REVATIO 75 RIGHTEST GD500 LANCING HYDROCHLORIDE/CLONIDINE DEVICE 203 HYDROCHLORIDE/KETOROLA REVCOVI 155 RIGHTEST GL300 C 172 REVEAL BLOOD GLUCOSE LANCETS 203 ROPIVACAINE TEST 150 RIGHTEST GS100 BLOOD HYDROCHLORIDE/SODIUM REVESTA 167 GLUCOSE TEST CHLORIDE 174 STRIPS 150 ROSADAN KIT 141

Index 81 ROSE BENGAL B 99 SAFESNAP INSULIN SALICYLIC ROSE OIL 107 SYRINGE/0.3ML/30G X ACID/SULFACETAMIDE 5/16" 237 SODIUM MONOHYDRATE 122 ROSEMARY OIL 107 SAFESNAP INSULIN SALIMEZ FORTE 135 ROSIN LUMP 110 SYRINGE/0.5ML/29G X SALINE/PHENOL 299 rosuvastatin calcium 46 1/2" 237 SAFESNAP INSULIN SALISOL 135 ROTARIX 321 SYRINGE/0.5ML/30G X SALITECH 135 ROTATEQ 321 5/16" 237 SALIVAMAX 258 SAFESNAP INSULIN ROWASA 160 salsalate 8 ROXICET 14 SYRINGE/1ML/28G X 1/2" 237 SALSALATE 100 ROXICODONE 13 SAFESNAP INSULIN SALT DURABLE CREAM 308 ROXIFOL-D 167 SYRINGE/1ML/29G X SALT STABLE LS ROXYBOND 13 1/2" 238 ADVANCED 308 ROZEREM 170 SAFETY INSULIN SYRINGES SALTSTABLE LO 308 0.5ML/29GX1/2" 238 ROZLYTREK 58 SAFETY INSULIN SYRINGES SALVAX 135 RRB PAK 133 0.5ML/30GX5/16" 238 SALVAX DUO PLUS 135 RTD WOUND CARE SAFETY INSULIN SYRINGES SAMSCA 156 DRESSING2" X 2" 144 1ML/27GX1/2" 238 SANARE ADVANCED SCAR RTD WOUND CARE SAFETY INSULIN SYRINGES THERAPY 308 DRESSING4" X 4" 144 1ML/29GX1/2" 238 SANARE SCAR THERAPY 308 RTD WOUND CARE SAFETY INSULIN SYRINGES DRESSING4" X 5" 144 1ML/30GX1/2" 238 SANCUSO 41 RUBIDIUM CHLORIDE 99 SAFETY LANCET SANDIMMUNE 254 21G/PRESSURE SANDOSTATIN 156 RUBRACA 58 ACTIVATED 203 rufinamide 30 SANDOSTATIN LAR SAFETY LANCET DEPOT 156 28G/PRESSURE RUTIN 99 SANTYL 134 RUXIENCE 55 ACTIVATED 203 SAFETY LANCETS 203 SAPHRIS 64 RUZURGI 52 SAFETY LANCETS 21G 203 sapropterin dihydrochloride 155 RYANODEX 272 SAFETY LANCETS 28G 203 SAPS CARE ALCOHOL PREP RYBELSUS 36 PADS 213 SAFETY LET LANCETS 203 RYDAPT 58 SAPS HEALTH ALCOHOL SAFETY SEAL LANCETS PREPPADS 213 RYNODERM 134 28G 203 SAPS HEALTH CARE RYTARY 62 SAFETY SEAL LANCETS ALCOHOLPREP PADS 213 RYTHMOL SR 22 30G 203 SAPS HEALTH TWIST TOP RYVENT 43 SAFFLOWER OIL 107 LANCETS 30G 203 SAFYRAL 112 SAPSCARE TWIST TOP SA3 DERM 308 LANCETS 30G 203 SAGE LEAF 99 SABRIL 31 SARAFEM 312 SAIZEN 154 SACCHARIN CALCIUM 99 SARCLISA 55 SAIZENPREP SAFE-T-LANCE LOW FLOW SARDINE FLAVOR 291 25G 203 RECONSTITUTIONKIT 154 SAFE-T-LANCE NORMAL SALAGEN 258 SASSAFRAS OIL 107 FLOW21G 203 SALEX 135 SAVAYSA 26 SAFE-T-LANCE PLUS SALEX CREAM 135 SAVELLA 311 SAFETYLANCET HIGH SALEX LOTION 135 SAVELLA TITRATION FLOW 203 PACK 311 SALICYLIC ACID 99,100 SAFE-T-LANCE PLUS SAW PALMETTO BERRY 100 SAFETYLANCET LOW salicylic acid 135 SB ALCOHOL PREP FLOW 203 salicylic acid w/ cleanser 135 SAFE-T-LANCE PLUS PADS 213 SAFETYLANCET NORMAL SB INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 238 FLOW 203

Index 82 SB INSULIN SYRINGE/U- SEMPREX-D 118 SHINGRIX 321 100/0.5ML/30G X 5/16" 238 SENNA 100 SHOE HORN SB INSULIN SYRINGE/U- SENSIPAR 155 DELUXE/CHROME FINISH207 100/1ML/29G X 1/2" 238 SHOPKO ALCOHOL SB INSULIN SYRINGE/U- SENSITIVE TOOTHPASTE SWABS 213 100/1ML/30G X 5/16" 238 EXTRA SHOPKO AUTOLET LANCING SB INSULIN SYRINGE/U- WHITENING/FLUORIDE MAX DEVICE 203 100/1ML/31G X 5/16" 238 ST 214 SHOPKO ON-THE-GO SB LANCETS THIN 203 SENSITIVE COMFORTLANCETS 30G 203 SB LANCETS ULTRA TOOTHPASTE/FLUORIDE/MA SHOPKO UNIFINE PENTIPS THIN 203 XIMUM STRENGTH 214 PEN SCALACORT DK 133 SENSODYNE MAXIMUM NEEDLES/MICRO/32GX4MM STRENGTH 214 SCAR CARE BASE 238 SENSODYNE MAXIMUM SHOPKO UNIFINE PENTIPS ENHANCED 308 STRENGTH/FLUORIDE 214 SCAR CARE CREAM 308 PEN NEEDLES/MINI/31GX5MM SENSODYNE 238 scar treatment products 141 PRONAMEL 214 SHOPKO UNIFINE PENTIPS SCARCIN GEL 141 SENSODYNE PRONAMEL PEN FRESHBREATH 214 NEEDLES/ORIGINAL/29GX12M SCARCIN ROLL-ON 141 SENSORCAINE- SCARLET RED 100 M 238 MPF/EPINEPHRINE 172 SHOPKO UNIFINE PENTIPS SCARSILK GEL 141 SEPICALM VG 104 PEN SCARZEN SKIN REPAIR 133 SEPINEO P 600 303 NEEDLES/SHORT/31GX8MM SCENESSE 140 SERAQUA 299 238 SCLEROSOL SEREVENT DISKUS 25 SHOPKO UNIFINE PENTIPS PLUS PEN INTRAPLEURAL 313 SERMORELIN ACETATE100 scopolamine 41 NEEDLES/MICRO/REMOVR/32 SERNIVO 133 GX4MM 238 SCOPOLAMINE HBR 316 SEROQUEL 64 SHOPKO UNIFINE PENTIPS SE-NATAL 19 267 PLUS PEN SEROQUEL XR 64 SEASONAL IC 255 NEEDLES/MINI/REMOVER/31G SEROSTIM 154 X5MM 238 SEASONIQUE 112 SEROTONIN HCL 100 SHOPKO UNIFINE PENTIPS SEBUDERM 139 sertraline hcl 33 PLUS PEN SECONAL SODIUM 169 NEEDLES/REMOVER/29GX12M SERTRALINE HCL 100 SECRETIN-MANNITOL 100 M 238 SESAME OIL 107 SHOPKO UNIFINE PENTIPS SECUADO 64 sevelamer carbonate 160 PLUS PEN SEDANARE 308 sevelamer hcl 160 NEEDLES/SHORT/REMOVR/31 SEEBRI NEOHALER 23 GX8MM 238 sevoflurane 161 SEGLUROMET 35 SHOPKO UNILET LANCETS SEYSARA 314 SUPER THIN 30G 203 SELECT-LITE LANCING SFROWASA 160 SHOPKO UNILET LANCETS DEVICE 203 ULTRA THIN 28G 203 SELECT-OB 267 SHARK CARTILAGE 100 SHOWER FRESH SELECT-OB+DHA 267 SHEA BUTTER 303 FRAGRANCE 100 selegiline hcl 63 SHEA BUTTER SHRIMP FLAVOR 291 ORGANIC 303 SHUR-SEAL 322 SELEGILINE HCL 63 SHEER ADHESIVE selenious acid 252 BANDAGES 189 SIBERIAN GINSENG 100 SELENIOUS ACID 252 SHEER ADHESIVE SIDE BUTTON SAFETY LANCET21G 203 SELENIUM SULFIDE 100 BANDAGES 3/4" X 3" 189 SHEER BANDAGES 189 SIDEKICK BLOOD GLUCOSE selenium sulfide 128 SYSTEM 203 SHEER BANDAGES 3/4" 189 SIDEROL 261 SELENIUM YEAST 100 SHEER SELRX 128 BANDAGES/ASSORTED 189 SIGNIFOR 156 SELZENTRY 67 SHEER BANDAGES/EX- SIGNIFOR LAR 156 SEMGLEE 38 LARGE 189 SIKLOS 165

Index 83 SIL-K PAD/LARGE 144 SINGULAIR 23 SM SIL-K PAD/MEDIUM 144 SINUVA 273 BANDAGES/CLEAR/ASSORTED 190 SIL-K PAD/SMALL 144 SIROLIMUS 100 SM SILA III 133 sirolimus 254 BANDAGES/FLEXIBLE/ASSORT SILALITE PAK 133 SIRTURO 52 ED 190 SILDENAFIL CITRATE 100 SITAVIG 69 SM BENZOIN TINCTURE 140 sildenafil citrate (pulmonary SIVEXTRO 19 SM BORIC ACID 110 hypertension) 75 SKELAXIN 272 SM GAUZE PADS 2"X2" 190 SILENOR 169 SKINTEGRITY SM GAUZE PADS 4"X4" 190 SILICA GEL 110 HYDROGEL 144 SM GLUCOSAMINE SILICA GEL SKLICE 141 CHONDROITIN COMPLEX ULTRAMICRONIZED 110 SKYLA 112 TRIPLE STRENGTH 255 SILICON DIOXIDE 110 SM HYPO-ALLERGENIC SKYRIZI 127 SILICON DIOXIDE (SYLOID 244 BANDAGES 190 FP) 110 SKYY DERM 308 SM IODIDES TINCTURE 65 SILICONE BLEND SLEEP TONITE 255 SM IODINE TINCTURE 65 CUSTOM 100 SLEEP-N-HEEL NIGHT SM ISOPROPYL SILICONE ELASTOMER CONDITIONING HEEL ALCOHOL 107 BLEND 100 SLEEVES 207 SM ISOPROPYL ALCOHOL SILICONE FLUID 556 100 SLEEP-N-HEEL+ NIGHT RUBBING 107 silicone-vitamin e 144 CONDITIONING HEEL SM MICRO THIN LANCETS SILIPAC 141 SLEEVES 207 33G 203 SLYND 113 SM ROLLED GAUZE BANDAGE SILIQ 127 SM ADHESIVE PADS 2"X4.1YD 190 silodosin 162 2"X3" 189 SM ROLLED GAUZE BANDAGE SILOSOME SM ADHESIVE PADS 3"X4.1YD 190 TRANSDERMAL 308 3"X4" 189 SM STERILE PADS 190 SILPROTEX PLUS 308 SM ALCOHOL PREP SM STERILE PADS 2"X2" 190 SILVADENE 129 PADS 213 SM STRONG STRIPS 190 SM BANDAGE ROLL SILVER NITRATE 129 4.5"X144" 189 SM STURDY STRIP FABRIC silver nitrate-potassium SM BANDAGES CLEAR BANDAGES 1"X3" 190 nitrate 129 SPOTS 189 SM SWEET OIL 107 SILVER PROTEIN MILD 65 SM BANDAGES FABRIC SM TRUEDRAW LANCING SILVER SULFADIAZINE 100 3/4" 189 DEVICE 203 SM BANDAGES FABRIC SMART DIABETES VANTAGE silver sulfadiazine 129 EXTRALARGE 189 LANCING DEVICE 203 SIMBRINZA 280 SM BANDAGES FABRIC SMART SENSE COLOR SIMETHICONE 158 KNUCKLE/FINGERTIP 190 LANCETS UNIVERSAL SIMPLE DIAGNOSTICS SM BANDAGES FOAM 190 33G 203 LANCING DEVICE 203 SM BANDAGES FOAM EXTRA SMART SENSE PREMIUM LARGE 190 BLOODGLUCOSE STRIPS150 SIMPLE SYRUP 300 SMART SENSE STANDARD SIMPLGEL 30 308 SM BANDAGES PLASTIC 190 LANCETS UNIVERSAL SIMPONI 4 SM BANDAGES SHEER 190 21G 203 SIMPONI ARIA 4 SMART SENSE SUPER THIN SM BANDAGES SHEER LANCETS UNIVERSAL SIMULECT 254 EXTRA LARGE 190 30G 203 SIMVASTATIN 46 SM BANDAGES STRONG SMART SENSE THIN STRIPS 1" 190 LANCETSUNIVERSAL simvastatin 46 SM BANDAGES SIMVASTATIN 100 26G 203 WATERSHIELD 190 SMART SENSE VALUE BLOOD SINCALIDE IN MANNITOL 100 SM GLUCOSE STRIPS 150 SINEMET 62 BANDAGES/ANTIBACTERIAL SMARTEST BLOOD GLUCOSE 190 SINEMET CR 62 TEST STRIPS 150 SINGLE-LET 203

Index 84 SMARTEST CONTROL SODIUM CHLORITE 100 SODIUM SOLUTIONMEDIUM 203 SODIUM CITRATE 26 PHENYLBUTYRATE 101 SMARTEST LANCETS sodium phenylbutyrate 156 28G 203 SODIUM CITRATE ANHYDROUS 161 SODIUM PHOSPHATE SMOFLIPID 275 SODIUM CITRATE DIBASIC 101 SOCK AID DELUXE DIHYDRATE 100 SODIUM PHOSPHATE MOLDED 207 SODIUM CITRATE LOCK DIBASICANHYDROUS 101 sod benzoate & sod FLUSH 26 SODIUM PHOSPHATE phenylacetate 155 SODIUM DIBASICDIHYDRATE 101 SODIUM 4- CITRATE/GENTAMICIN 28 SODIUM PHOSPHATE AMINOSALICYLATEDIHYDRAT SODIUM COCOYL DIBASICDRIED 101 E 79 GLUTAMATE 100 SODIUM PHOSPHATE SODIUM ACETATE 248 SODIUM DIBASICHEPTAHYDRATE sodium acetate 248 DEHYDROACETATE 100 101 SODIUM SODIUM PHOSPHATE SODIUM ACETATE MONOBASIC 101 ANHYDROUS 248 DEOXYCHOLATE 100 SODIUM DIACETATE 100 SODIUM PHOSPHATE SODIUM ACETATE MONOBASIC SODIUM TRIHYDRATE 100 ANHYDROUS 101 SODIUM ALGINATE 100 DICHLOROACETATE 100 SODIUM PHOSPHATE SODIUM ASCORBATE 325 SODIUM DIURIL 152 TRIBASIC 101 SODIUM BENZOATE 303 SODIUM EDECRIN 152 SODIUM SODIUM sodium ferric gluconate PHOSPHATE/DEXTROSE 251 BICARBONATE 16,248 complex in sucrose 168 SODIUM PHOSPHATE/SODIUM SODIUM FLUORIDE 100 CHLORIDE 251 sodium bicarbonate 248 sodium phosphates (sodium SODIUM sodium fluoride 250 phosphate dibasic & BICARBONATE/DEXTROSE SODIUM monobasic) 251 248 FLUOROPHOSPHATE 100 SODIUM SODIUM BISULFITE 100 SODIUM GLUCONATE 100 PHOSPHATES/DEXTROSE SODIUM BITARTRATE SODIUM HYALURONATE 90 251 MONOHYDRATE 100 SODIUM HYALURONATE sodium polystyrene SODIUM BORATE 77 (INJECTION GRADE) 90 sulfonate 256 SODIUM BORATE SODIUM HYDROXIDE 77 SODIUM PROPIONATE 101 DECAHYDRATE 77 SODIUM IODIDE 100 SODIUM PYROPHOSPHATE SODIUM BROMIDE 110 ANHYDROUS 105 SODIUM L-ASPARTATE 100 SODIUM BUTYRATE 110 SODIUM PYRROLIDONE SODIUM LACTATE 100 CARBOXYLATE 101 SODIUM CACODYLATE 110 SODIUM LAURETH SODIUM SALICYLATE 8 SODIUM CAPRATE 100 SULFATE 100 SODIUM SELENITE 101 SODIUM CAPYRLATE FOOD SODIUM LAURYL GRADE 100 SULFATE 303 SODIUM STEARATE 101 SODIUM CARBONATE SODIUM SODIUM STEARYL ANHYDROUS 77 METABISULFITE 101 FUMARATE 101 SODIUM CARBONATE SODIUM METABISULFITE SODIUM SUCCINATE 101 MONOHYDRATE 77 ANHYDROUS 101 SODIUM SULFACETAMIDE SODIUM SODIUM MOLYBDATE 101 WASH 128 CARBOXYMETHYLCELLULOSE SODIUM SODIUM MEDIUM VISCOSITY 110 MONOFLUOROPHOSPHATE SULFACETAMIDE/SULFUR SODIUM CHLORIDE 252 101 122 sodium chloride 252 SODIUM NITRATE ACS 101 SODIUM sodium chloride (gu SULFACETAMIDE/SULFUR SODIUM NITRITE 40 CLEANSER IN UREA 122 irrigant) 162 SODIUM OLEATE 101 SODIUM SULFATE 110 sodium chloride (inhalant) 118 SODIUM PERBORATE SODIUM SULFITE 110 sodium chloride flush 252 MONOHYDRATE 110 SODIUM CHLORIDE/SODIUM SODIUM PERBORATE SODIUM SULFITE ANHYDROUS 110 BICARBONATE 110 TETRAHYDRATE 110

Index 85 SODIUM TARTRATE SORBIC ACID 288 SPENCO COMFORT INSOLES DIHYDRATE 101 SORBITAN SIZE 12/13 MENS 208 SODIUM TETRADECYL MONOLAURATE 101 SPENCO COMFORT INSOLES SULFATE 101 SORBITAN SIZE 14/15 MENS 208 sodium tetradecyl sulfate 256 MONOOLEATE 101 SPENCO COMFORT INSOLES SODIUM THIOSULFATE 40 SORBITAN SIZE 8/9 MENS 208 SPENCO FOR HER INSOLES sodium thiosulfate 40 MONOPALMITATE 101 SORBITAN MONOPALMITATE SIZE 11/12 208 SODIUM THIOSULFATE BASE I 101 SPENCO FOR HER INSOLES PENTAHYDRATE 303 SORBITAN SIZE 11/12 TOTAL SODIUM VALPROATE 104 MONOSTEARATE 101 SUPPORT 208 SODIUM-L-ASCORBYL-2- SORBITOL 162,300 SPENCO FOR HER INSOLES SIZE 3/4 208 PHOSPHATE DIHYDRATE 101 SORBITOL CANDY SOF-SET ADHESIVE SPENCO FOR HER INSOLES BASE 303 SIZE 3/4 TOTAL PATCH 190 SORBITOL HARD CANDY SOF-WICK 4"X4" 190 SUPPORT 208 BASE-GRAPE 303 SPENCO FOR HER INSOLES SOF-WIK 190 SORBITOL-MANNITOL 162 SIZE 5/6 208 SOFOSBUVIR/VELPATASVIR SORBITOL/MANNITOL SPENCO FOR HER INSOLES 69 IRRIGATION 162 SIZE 5/6 TOTAL SOFT FOAM TOE SORESPOT BLISTER & SKIN SUPPORT 208 SEPARATORSMEDIUM 207 PROTECTION SPENCO FOR HER INSOLES SOLARAVIX 127 BANDAGES 190 SIZE 7/8 208 SOLARTEK GLUCOSE SORIATANE 127 SPENCO FOR HER INSOLES CONTROLSOLUTIONS 203 SORILUX 127 SIZE 7/8 TOTAL solifenacin succinate 319 SOSWEET 300 SUPPORT 208 SOLIQUA 100/33 35 SPENCO FOR HER INSOLES sotalol hcl 72 SIZE 9/10 208 SOLIRIS 164 sotalol hcl (afib/afl) 72 SPENCO FOR HER INSOLES SOLODYN 314 SOTALOL SIZE 9/10 TOTAL SOLOSEC 3 HYDROCHLORIDE 72 SUPPORT 208 SOLOSITE 144 SOTRADECOL 256 SPENCO GEL ARCH INSOLES SIZE LARGE 208 SOLTAMOX 56 SOTYLIZE 72 SPENCO GEL ARCH INSOLES SOLU-CORTEF 116 SOVALDI 69 SIZE MEDIUM 208 SOLU-K GEL 308 SOYABEAN CASEIN DIGEST SPENCO GEL ARCH INSOLES MEDIUM 101 SIZE SMALL 208 SOLU-MEDROL 116,117 SOYBEAN OIL 107 SPENCO GEL BALL OF FOOT SOLU-PREF 28 SPAN 80 101 ONE SIZE 208 SOLUPAK 138 SPENCO GEL HEEL CUP SPEARMINT 107 SOLUS V2 AUDIBLE TEST150 SIZEMEDIUM/LARGE 208 SPEARMINT FLAVOR 291 SPENCO GEL HEEL CUP SOLUS V2 LANCING SIZESMALL/MEDIUM 208 DEVICE 204 SPEARMINT OIL 107 specialty vitamins SPENCO GEL HEEL INSOLES SOLUS V2 PRESSURE ONE SIZE 208 ACTIVATED SAFETY LANCETS products 269,270 SPENCO ADHESIVE KNIT SPENCO GEL INSOLES SIZE 28G 204 10/11 MENS 208 SOLUS V2 TWIST LANCETS 3"X5" 190 SPENCO ARCH SUPPORT SPENCO GEL INSOLES SIZE 30G 204 10/11-11/12 208 SOLVATECH PLUS 300 INSOLES SIZE 10/11 SPENCO GEL INSOLES SIZE MENS 207 208 SOLVATECH SWEET SF 300 SPENCO ARCH SUPPORT 12/13 SOLYDRA 300 SPENCO GEL INSOLES SIZE INSOLES SIZE 12/13 12/13 MENS 208 SOMA 272 MENS 207 SPENCO GEL INSOLES SIZE SOMATULINE DEPOT 156 SPENCO ARCH SUPPORT 14/15 208 INSOLES SIZE 8/9 SOMAVERT 154 SPENCO GEL INSOLES SIZE MENS 207 14/15 MENS 208 SOOLANTRA 141 SPENCO COMFORT INSOLES SPENCO GEL INSOLES SIZE SOOTHEE 138 SIZE 10/11 MENS 207 3/4 208

Index 86 SPENCO GEL INSOLES SIZE SPENCO POLYSORB SPENCO POLYSORB INSOLES 5/6 208 INSOLES SIZE 14/15 HEAVY SIZE 8/9-9/10 HEAVY SPENCO GEL INSOLES SIZE DUTY 209 DUTY 210 6/7-7/8 208 SPENCO POLYSORB SPENCO POLYSORB INSOLES SPENCO GEL INSOLES SIZE INSOLES SIZE 14/15 SIZE 8/9-9/10 HIKER 210 8/9 MENS 208 HIKER 209 SPENCO POLYSORB INSOLES SPENCO GEL INSOLES SIZE SPENCO POLYSORB SIZE 8/9-9/10 TOTAL 8/9-9/10 208 INSOLES SIZE 14/15 TOTAL SUPPORT 210 SPENCO IRONMAN GEL SUPPORT 209 SPENCO POLYSORB INSOLES INSOLES LARGE 208 SPENCO POLYSORB SIZE 8/9-9/10 WALKER- SPENCO IRONMAN GEL INSOLES SIZE 14/15 RUNNER 210 INSOLES SMALL 208 WALKER-RUNNER 209 SPENCO POLYSORB OS SPENCO IRONMAN PLUS SPENCO POLYSORB INSOLES SIZE 10/11-11/12 INSOLES LARGE 208 INSOLES SIZE 3/4 CROSS- BACKPACKER 210 SPENCO IRONMAN PLUS TRAINER 209 SPENCO POLYSORB OS INSOLES SMALL 208 SPENCO POLYSORB INSOLES SIZE 10/11-11/12 DAY SPENCO KIDS COMFORT INSOLES SIZE 3/4 HIKER 210 INSOLES SIZE 3 TO 4-1/2 208 HIKER 209 SPENCO POLYSORB OS SPENCO KIDS COMFORT SPENCO POLYSORB INSOLES SIZE 12/13 INSOLES SIZE 5 TO 6-1/2 208 INSOLES SIZE 3/4 TOTAL BACKPACKER 210 SPENCO KIDS COMFORT SUPPORT 209 SPENCO POLYSORB OS INSOLES SIZE 7/8 208 SPENCO POLYSORB INSOLES SIZE 12/13 DAY SPENCO KIDS POLYSORB INSOLES SIZE 3/4 WALKER- HIKER 210 INSOLES SIZE 3 TO 4-1/2 209 RUNNER 209 SPENCO POLYSORB OS SPENCO KIDS POLYSORB SPENCO POLYSORB INSOLES SIZE 14/15 INSOLES SIZE 5 TO 6-1/2 209 INSOLES SIZE 5/6 CROSS- BACKPACKER 210 SPENCO KIDS POLYSORB TRAINER 209 SPENCO POLYSORB OS INSOLES SIZE 7/8 209 SPENCO POLYSORB INSOLES SIZE 14/15 DAY SPENCO POLYSORB INSOLES INSOLES SIZE 5/6 HEAVY HIKER 210 SIZE 10/11-11/12 CROSS- DUTY 209 SPENCO POLYSORB OS TRAINER 209 SPENCO POLYSORB INSOLES SIZE 3/4 SPENCO POLYSORB INSOLES INSOLES SIZE 5/6 BACKPACKER 210 SIZE 10/11-11/12 HEAVY HIKER 209 SPENCO POLYSORB OS DUTY 209 SPENCO POLYSORB INSOLES SIZE 3/4 DAY SPENCO POLYSORB INSOLES INSOLES SIZE 5/6 TOTAL HIKER 210 SIZE 10/11-11/12 HIKER 209 SUPPORT 209 SPENCO POLYSORB OS SPENCO POLYSORB INSOLES SPENCO POLYSORB INSOLES SIZE 5/6 SIZE 10/11-11/12 TOTAL INSOLES SIZE 5/6 WALKER- BACKPACKER 210 SUPPORT 209 RUNNER 209 SPENCO POLYSORB OS SPENCO POLYSORB INSOLES SPENCO POLYSORB INSOLES SIZE 5/6 DAY SIZE 10/11-11/12 WALKER- INSOLES SIZE 6/7-7/8 HIKER 210 RUNNER 209 CROSS-TRAINER 209 SPENCO POLYSORB OS SPENCO POLYSORB INSOLES SPENCO POLYSORB INSOLES SIZE 6/7-7/8 SIZE 12/13 CROSS- INSOLES SIZE 6/7-7/8 HEAVY BACKPACKER 210 TRAINER 209 DUTY 209 SPENCO POLYSORB OS SPENCO POLYSORB INSOLES SPENCO POLYSORB INSOLES SIZE 6/7-7/8 DAY SIZE 12/13 HEAVY DUTY 209 INSOLES SIZE 6/7-7/8 HIKER 210 SPENCO POLYSORB INSOLES HIKER 209 SPENCO POLYSORB OS SIZE 12/13 HIKER 209 SPENCO POLYSORB INSOLES SIZE 8/9-9/10 SPENCO POLYSORB INSOLES INSOLES SIZE 6/7-7/8 TOTAL BACKPACKER 210 SIZE 12/13 TOTAL SUPPORT 209 SPENCO POLYSORB OS SUPPORT 209 SPENCO POLYSORB INSOLES SIZE 8/9-9/10 DAY SPENCO POLYSORB INSOLES INSOLES SIZE 6/7-7/8 HIKER 210 SIZE 12/13 WALKER- WALKER-RUNNER 210 SPENCO RX ARCH INSOLES RUNNER 209 SPENCO POLYSORB SIZE 10/11-11/12 210 SPENCO POLYSORB INSOLES INSOLES SIZE 8/9-9/10 SPENCO RX ARCH INSOLES SIZE 14/15 CROSS- CROSS-TRAINER 210 SIZE 12/13 210 TRAINER 209 SPENCO RX ARCH INSOLES SIZE 14/15 210

Index 87 SPENCO RX ARCH INSOLES SPENCO RX HEEL INSOLES SPENCO RX ORTHOTIC ARCH SIZE 3/4 210 SIZE 10/11-11/12 211 SUPPORTS SIZE 6/7-7/8 SPENCO RX ARCH INSOLES SPENCO RX HEEL INSOLES THINSOLE 212 SIZE 5/6 210 SIZE 12/13 211 SPENCO RX ORTHOTIC ARCH SPENCO RX ARCH INSOLES SPENCO RX HEEL INSOLES SUPPORTS SIZE 8/9-9/10 212 SIZE 6/7-7/8 210 SIZE 5/6 211 SPENCO RX ORTHOTIC ARCH SPENCO RX ARCH INSOLES SPENCO RX HEEL INSOLES SUPPORTS SIZE 8/9-9/10 SIZE 8/9-9/10 210 SIZE 6/7-7/8 211 THINSOLE 212 SPENCO RX ARTHRITIS SPENCO RX HEEL INSOLES SPENCO SLIM FIT INSOLES FOOTCRADLES SIZE 10 SIZE 8/9-9/10 211 SIZE 10/11 MENS 212 MENS 210 SPENCO RX INSOLES SIZE SPENCO SLIM FIT INSOLES SPENCO RX ARTHRITIS 10/11-11/12 211 SIZE 12/13 MENS 212 FOOTCRADLES SIZE 11 SPENCO RX INSOLES SIZE SPENCO SLIM FIT INSOLES MENS 210 12/13 211 SIZE 14/15 MENS 212 SPENCO RX ARTHRITIS SPENCO RX INSOLES SIZE SPENCO SLIM FIT INSOLES FOOTCRADLES SIZE 12 14/15 211 SIZE 8/9 MENS 212 MENS 210 SPENCO RX INSOLES SIZE SPG SUPPOSI-BASE 303 SPENCO RX ARTHRITIS 3/4 211 spinosad 141 FOOTCRADLES SIZE 6 SPENCO RX INSOLES SIZE WOMENS 210 5/6 211 SPINRAZA 274 SPENCO RX ARTHRITIS SPENCO RX INSOLES SIZE SPIRIVA HANDIHALER 23 FOOTCRADLES SIZE 7 6/7-7/8 211 SPIRIVA RESPIMAT 23 WOMENS 211 SPENCO RX INSOLES SIZE SPENCO RX ARTHRITIS 8/9-9/10 211 SPIRONOLACTONE 152 FOOTCRADLES SIZE 8 SPENCO RX ORTHOTIC spironolactone 152 WOMENS 211 ARCH SUPPORTS SIZE spironolactone & SPENCO RX ARTHRITIS 10/11-11/12 211 hydrochlorothiazide 151 FOOTCRADLES SIZE 9 SPENCO RX ORTHOTIC SPIRULINA 101 MENS 211 ARCH SUPPORTS SIZE SPORANOX 43 SPENCO RX ARTHRITIS 10/11-11/12 THINSOLE 211 FOOTCRADLES SIZE 9 SPENCO RX ORTHOTIC SPORANOX PULSEPAK 43 WOMENS 211 ARCH SUPPORTS SIZE SPORT & WORK CUSHION SPENCO RX BALL OF FOOT 12/13 211 INSOLES MENS SIZE 7-13212 LARGE 211 SPENCO RX ORTHOTIC SPRAVATO 56MG DOSE 32 SPENCO RX BALL OF FOOT ARCH SUPPORTS SIZE 12/13 SPRAVATO 84MG DOSE 32 THINSOLE 211 MEDIUM 211 SPRITAM 30 SPENCO RX BALL OF FOOT SPENCO RX ORTHOTIC SMALL 211 ARCH SUPPORTS SIZE SPRIX 7 SPENCO RX DIABETIC 14/15 211 SPRYCEL 58 SUPPORT SIZE 10 MENS 211 SPENCO RX ORTHOTIC SQUALANE 101 SPENCO RX DIABETIC ARCH SUPPORTS SIZE 14/15 SUPPORT SIZE 11 MENS 211 THINSOLE 211 SQUARIC ACID 101 SPENCO RX DIABETIC SPENCO RX ORTHOTIC SQUARIC ACID IN SUPPORT SIZE 12 MENS 211 ARCH SUPPORTS SIZE BUTANOL 101 SPENCO RX DIABETIC 3/4 211 SSKI 118 SUPPORT SIZE 6 SPENCO RX ORTHOTIC ST JOHNS WORT 101 WOMENS 211 ARCH SUPPORTS SIZE 3/4 STALEVO 100 62 SPENCO RX DIABETIC THINSOLE 212 SUPPORT SIZE 7 SPENCO RX ORTHOTIC STALEVO 125 62 WOMENS 211 ARCH SUPPORTS SIZE STALEVO 150 62 SPENCO RX DIABETIC 5/6 212 STALEVO 200 62 SUPPORT SIZE 8 SPENCO RX ORTHOTIC WOMENS 211 ARCH SUPPORTS SIZE 5/6 STALEVO 50 62 SPENCO RX DIABETIC THINSOLE 212 STALEVO 75 62 SUPPORT SIZE 9 MENS 211 SPENCO RX ORTHOTIC STAMARIL 321 SPENCO RX DIABETIC ARCH SUPPORTS SIZE 6/7- STANNOUS CHLORIDE SUPPORT SIZE 9 7/8 212 DIHYDRATE 101 WOMENS 211 STANNOUS FLUORIDE 110

Index 88 STANOZOLOL 102 STRATTERA 2 sulfacetamide sodium STARCH 110 STRAWBERRY FLAVOR 291 (acne) 122 sulfacetamide sodium STARLIX 38 STRENSIQ 156 (ophth) 281 stavudine 67 STREPTOMYCIN sulfacetamide sodium w/ STEARIC ACID 303 SULFATE 3 sulfur 122 STEARIC ACID TRIPLE streptomycin sulfate 3 sulfacetamide sodium-sulfur in PRESSED 303 STRETCH GAUZE urea vehicle 122 sulfacetamide sodium-sulfur w/ STEARYL ALCOHOL 303 BANDAGE 190 STRIANT 15 skin cleanser 122 STEGLATRO 38 sulfacetamide sodium-sulfur- STRIBILD 67 STEGLUJAN 35 sunscreen 122 STRIVERDI RESPIMAT 25 STELARA 127 SULFADIAZINE 313 STROMECTOL 17 STERA BASE 308 SULFADIAZINE SODIUM 313 STERI-STRIP 1 7/8" X STRONTIUM CHLORIDE 102 SULFADIMETHOXINE 102 1/2"/DRESSING 2 3/8" X 1 STRONTIUM CHLORIDE SR- SULFAMERAZINE 102 7/8" 190 89 59 STRONTIUM NITRATE 110 SULFAMETHOXAZOLE 313 STERI-STRIP 1" X 5" 190 SULFAMETHOXAZOLE STERI-STRIP 1/2" X 2" 190 STROVITE FORTE 261 MICRO 313 STERI-STRIP 1/2" X 4 " 190 STROVITE ONE 261 sulfamethoxazole-trimethoprim STERI-STRIP 1/4" X 1 1/2" 190 SUBLOCADE 15 18 SULFAMYLON 129 STERI-STRIP 1/4" X 3" 190 SUBOXONE 15 SULFANILAMIDE 110 STERI-STRIP 1/4" X 4" 190 SUBSYS 13 SULFAPYRIDINE 313 STERI-STRIP 1/8" X 3" 190 SUCCIMER DMSA 102 SULFASALAZINE 160 STERILANCE TL 204 SUCCINIC ACID 102 STERILE BANDAGE ROLL SUCCINYLCHOLINE sulfasalazine 160 2.25"X3YD 190 CHLORIDE 102,273 SULFATHIAZOLE 313 STERILE DILUENT FOR succinylcholine chloride 273 SULFISOXIZOLE 313 FLOLAN 300 SUCCINYLCHOLINE SULFOSALICYLIC ACID STERILE DILUENT FOR CHLORIDE 273 DIHYDRATE 102 TREPROSTINIL SUCCINYLCHOLINE SULFUR 102 INJECTION 300 CHLORIDEDIHYDRATE 102 STERILE GAUZE PADS SUCRAID 151 SULFUR PRECIPITATED 102 2"X2" 190 SUCRALFATE 317 SULFUR SUBLIMED 102 STERILE PADS 2"X2" 190 sucralfate 317 SULFURATED LIME 141 STERILE PADS 4"X4" 190 SUCROSE 110 SULFURIC ACID 77 STERILE TALC POWDER 313 SUCROSE SULINDAC 7 STERITALC 313 CONFECTIONERS 110 sulindac 7 STEVIA EXTRACT 102 SUCROSE SULPHAN BLUE 288 OCTAACETATE 102 STEVIA GLYCERITE LIQUID SULPIRIDE 102 EXTRACT 291 SUCROSE POWDERED STEVIA POWDER CONFECTIONERS 110 SUMADAN KIT 122 EXTRACT 102 SUFENTANIL CITRATE 13 SUMADAN WASH 122 STEVIOL GLYCOSIDES 102 sufentanil citrate 13 SUMADAN XLT 122 STEVIOSIDE 102 SUFENTANIL CITRATE 102 SUMATRIPTAN 102 STIMATE 156 SULAR 73 sumatriptan 248 STIMULEN 144 sulconazole nitrate 126 SUMATRIPTAN STIOLTO RESPIMAT 25 SULFACETAMIDE 102 SUCCINATE 102 sulfacetamide sod- sumatriptan succinate 248 STIVARGA 58 sumatriptan-naproxen STRATA CTX 139 prednisolone 283 sulfacetamide sodium 128 sodium 247 STRATA GRT 144 SULFACETAMIDE SUMAXIN 122 STRATA XRT 139 SODIUM 128 SUMAXIN CP KIT 122

Index 89 SUMAXIN WASH 122 SURE COMFORT INSULIN SURE RESULT O3D3 SUN BURNT PLUS PAIN SYRINGE/U-100/0.5ML/30G X SYSTEM 44 RELIEF 138 5/16" 239 SURE-FINE PEN NEEDLES SUNOSI 2 SURE COMFORT INSULIN 29GX1/2" 12.7MM 239 SYRINGE/U-100/0.5ML/31G X SURE-FINE PEN NEEDLES SUPER SYNERSWEET 5/16 239 31GX3/16" 5MM 239 FLAVOR 291 SURE COMFORT INSULIN SURE-FINE PEN NEEDLES SUPER THIN LANCETS 204 SYRINGE/U-100/1ML/28G X 31GX5/16" 8MM 239 SUPEROXIDE 1/2" 239 SURE-JECT INSULIN DISMUTASE 102 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X SUPERVITE 259 SYRINGE/U-100/1ML/29G X 1/2" 239 SUPPORT 261 1/2" 239 SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X SUPPORT-500 270 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16" 239 SUPPOSI-PLEX R36 303 1/2" 239 SURE-JECT INSULIN SUPPOSI-PLEX V33 303 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X SUPPOSI-PURE 303 SYRINGE/U-100/1ML/30G X 5/16" 239 5/16" 239 SURE-JECT INSULIN SUPPOSIBLEND 303 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X SUPPOSITORY BLEND 303 SYRINGE/U-100/1ML/31G X 1/2" 239 SUPPRELIN LA 154 5/16" 239 SURE-JECT INSULIN SUPRANE 161 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X SYRINGES/0.5ML/31G X 1/2" 239 SUPRAX 76,77 6MM 239 SURE-JECT INSULIN SUPREME II HIGH/LOW SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X CONTROL SOLUTION 204 SYRINGES/U- 5/16" 239 SUPREME TEST STRIPS 150 100/1ML/31GX6MM 239 SURE-JECT INSULIN SUPREP BOWEL PREP SURE COMFORT LANCETS SYRINGE/U-100/0.5ML/31G X KIT 171 18G 204 5/16" 240 SURE COMFORT ALCOHOL SURE COMFORT LANCETS SURE-JECT INSULIN PREP PADS 213 21G 204 SYRINGE/U-100/1ML/28G X SURE COMFORT INSULIN SURE COMFORT LANCETS 1/2" 240 SYRINGE/U-100/0.3ML/29G X 23G 204 SURE-JECT INSULIN 1/2" 238 SURE COMFORT LANCETS SYRINGE/U-100/1ML/29G X SURE COMFORT INSULIN 28G 204 1/2" 240 SYRINGE/U-100/0.3ML/30G X SURE COMFORT LANCETS SURE-JECT INSULIN 1/2" 238 30G 204 SYRINGE/U-100/1ML/30G X SURE COMFORT INSULIN SURE COMFORT LANCING 5/16" 240 SYRINGE/U-100/0.3ML/30G X PEN 204 SURE-JECT INSULIN 5/16" 238 SURE COMFORT PEN SYRINGE/U-100/1ML/31G X SURE COMFORT INSULIN NEEDLES29GX1/2" 5/16" 240 SYRINGE/U-100/0.3ML/31G X 12.7MM 239 SURE-LANCE FLAT 5/16 238 SURE COMFORT PEN LANCETS 204 SURE COMFORT INSULIN NEEDLES30GX5/16" SURE-LANCE LANCETS SYRINGE/U-100/0.3ML/31G X SHORT 239 26G 204 5/16" 238 SURE COMFORT PEN SURE-LANCE THIN LANCETS SURE COMFORT INSULIN NEEDLES31GX3/16" 28G 204 SYRINGE/U- (5MM) 239 SURE-LANCE ULTRA THIN 100/0.3ML/31GX1/4" 238 SURE COMFORT PEN LANCETS 204 SURE COMFORT INSULIN NEEDLES31GX5/16" SURE-PEN 204 SYRINGE/U-100/0.5ML/28G X (8MM) 239 SURE-PREP ALCOHOL PREP 1/2" 239 SURE COMFORT PEN PADS 214 SURE COMFORT INSULIN NEEDLES32GX5/32" 239 SURE-TEST EASYPLUS MINI SYRINGE/U-100/0.5ML/29G X SURE COMFORT PEN BLOOD GLUCOSE TEST 1/2" 239 NEEDLES32GX6MM 239 STRIPS 150 SURE COMFORT INSULIN SURE EDGE BLOOD SURE-TOUCH LANCETS SYRINGE/U-100/0.5ML/30G X GLUCOSE TEST UNIVERSAL 204 1/2" 239 STRIPS 150 SURECHEK BLOOD GLUCOSE TEST STRIPS 150

Index 90 SURELITE LANCETS 204 SYNAGIS 286 TALC 110 SURESEAL 190 SYNALAR 133 TALICIA 319 SURESEAL EXTRA SYNALAR CREAM KIT 133 TALIVA 167 LARGE 190 SYNALAR OINTMENT TALTZ 128 SURESEAL LARGE 190 KIT 133 TALZENNA 59 SURESTEP GLUCOSE SYNALAR TS 133 TAMIFLU 70 CONTROL 204 SYNAPRYN FUSEPAQ 13 SURESTEP GLUCOSE tamoxifen citrate 56 SYNAPSIN 303 CONTROLSOLUTION 204 TAMOXIFEN CITRATE 102 SURGICAL GAUZE SYNAREL 154 tamsulosin hcl 162 SPONGE 190 SYNATEK 261 TANDEM F 168 SURMONTIL 34 SYNDROS 41 SURVANTA TANDEM PLUS 168 SYNERA 138 INTRATRACHEAL 313 TANGERINE FLAVOR 291 SUSPENDIT 308 SYNERCID 20 TANGERINE FLAVOR SUSPENDRX WITH BITTER- SYNERDERM 139 SWEETENED 291 BLOC/SWEETENED 300 SYNERTROPIN 270 TANNIC ACID 140 SUSPENDRX WITH BITTER- SYNJARDY 35 TANZEUM 36 BLOC/UNSWEETENED 300 SUSPENSION VEHICLE 300 SYNJARDY XR 35 TAPAZOLE 315 SUSTIVA 67 SYNRIBO 60 TARCEVA 59 SUSTOL 41 SYNTHAMIN 17 278 TARDEOXIA 122 SUTENT 58 SYNTHROID 315 TARDIMAXIA 122 SUVICORT 139 SYNVEXIA TC 138 TARGADOX 314 SWEET CORN FLAVOR SYPRINE 253 TARGRETIN 60,127 CONCENTRATE 291 SYRPALTA 300 TARKA 50 SWEET OIL 107 SYRSPEND SF 300 TARON FORTE 168 SWEETENING SYRSPEND SF ALKA 300 TARON-BC 267 ENHANCER 291 SWEETENING SYRSPEND SF PH4 300 TARON-C DHA 267 ENHANCER/FLAVORX 291 SYRUP NF 300 TARON-PREX 267 SWEETENING SUSPENDING SYRUP VEHICLE 300 TAROXIA 122 COMPOUND 300 SX1 MEDICATED POST- SYRUP VEHICLE SF 300 TARTARIC ACID 77 OPERATIVE SYSTEM 138 TABLOID 54 TASIGNA 59 SYLATRON 60 TABRADOL FUSEPAQ 272 TASMAR 61 SYLVANT 254 TABRADOL RAPIDPAQ 272 TAURINE 278 SYMAX DUOTAB 316 TABRECTA 58 tavaborole 126 SYMBICORT 25 TACHOSIL 169 TAXOL 61 SYMBYAX 311 TACLONEX 133 TAXOTERE 61 SYMDEKO 313 TACROLIMUS 102 TAYTULLA 112 SYMFI 67 tacrolimus 254 TAZAROTENE 102 SYMFI LO 67 tacrolimus (topical) 135 tazarotene 128 SYMJEPI 323 TACROLIMUS TAZICEF 77 SYMLINPEN 120 34 MONOHYDRATE 102 TAZORAC 128 tadalafil 74 SYMLINPEN 60 34 TAZVERIK 59 TADALAFIL 102 TDC MAX CREAM 308 SYMPAZAN 28 tadalafil (pulmonary SYMPROIC 160 hypertension) 75 TDM SOLUTION 300 SYMTUZA 67 TAFINLAR 58 TDVAX 316 SYN-AKE 87 TAGRISSO 58 TEA COCOYL GLUTAMINE 102 SYNAGEX 261 TAKHZYRO 164 TEA TREE OIL 102

Index 91 TEABERRY FLAVOR 291 TEFLARO 77 TELFA NON-ADHERENT PAD TECENTRIQ 55 TEGADERM CONTACT PREPACK 8"X3" 191 TELFA NON-ADHERENT PADS TECFIDERA 311 LAYER/NON-ADHERENT 3"X4" 191 PREPACK 3"X4" 191 TECFIDERA STARTER TEGADERM CONTACT telmisartan 48 PACK 311 LAYER/NON-ADHERENT telmisartan-amlodipine 50 TECHLITE AST LANCETS 204 3"X8" 191 telmisartan-hydrochlorothiazide TECHLITE INSULIN SYRINGEU- TEGADERM FILM 50 100/0.3ML/29G X 1/2" 240 TRANSPARENT temazepam 170 TECHLITE INSULIN SYRINGEU- DRESS/FRAME STYLE 1- 100/0.3ML/30G X 1/2" 240 3/4"X1-3/4" 191 TEMIXYS 67 TECHLITE INSULIN SYRINGEU- TEGADERM FOAM TEMODAR 53 100/0.3ML/30G X 5/16" 240 DRESSING 2"X2" 191 TEMOVATE 133 TECHLITE INSULIN SYRINGEU- TEGADERM FOAM temozolomide 53 100/0.3ML/31G X 15/64" 240 DRESSING 4"X4" 191 TECHLITE INSULIN SYRINGEU- TEGADERM FOAM temsirolimus 59 100/0.3ML/31G X 5/16" 240 DRESSING 4"X8" 191 TENDEROL UNDERCAST TECHLITE INSULIN SYRINGEU- TEGADERM FOAM PADDING 2"X4 YD 191 100/0.5ML/29G X 1/2" 240 DRESSING ROLL 4"X24"191 TENDEROL UNDERCAST TECHLITE INSULIN SYRINGEU- TEGADERM HYDROGEL PADDING 3"X4 YD 191 100/0.5ML/30G X 1/2" 240 WOUND FILLER 144 TENDEROL UNDERCAST TECHLITE INSULIN SYRINGEU- TEGRETOL 30 PADDING 4"X4 YD 191 100/0.5ML/30G X 5/16" 240 TENDEROL UNDERCAST TECHLITE INSULIN SYRINGEU- TEGRETOL-XR 30 PADDING 6"X4 YD 191 100/0.5ML/31G X 15/64" 240 TEGSEDI 312 TENIPOSIDE 61 TECHLITE INSULIN SYRINGEU- TEKTURNA 50 100/0.5ML/31G X 5/16" 240 TENIVAC 316 TECHLITE INSULIN SYRINGEU- TEKTURNA HCT 50 tenofovir disoproxil fumarate 67 100/1ML/29G X 1/2" 240 TELCARE BLOOD GLUCOSE TENORETIC 100 50 TEST STRIPS 150 TECHLITE INSULIN SYRINGEU- TENORETIC 50 50 100/1ML/30G X 1/2" 240 TELCARE GLUCOSE TECHLITE INSULIN SYRINGEU- CONTROL SOLUTION LEVEL TENORMIN 71 100/1ML/30G X 5/16" 240 1/2 204 TEPADINA 53 TELFA ADHESIVE DRESSING TECHLITE INSULIN SYRINGEU- TEPEZZA 154 100/1ML/31G X 15/64" 240 3"X4" 191 TECHLITE INSULIN SYRINGEU- TELFA AMD ADHESIVE terazosin hcl 48 100/1ML/31G X 5/16" 240 BANDAGE 2"X3.75" 191 terbinafine hcl 42 TECHLITE LANCETS 204 TELFA AMD ANTIMICROBIAL TERBINAFINE HCL 102 ISLAND DRESSING TECHLITE LANCETS 30G 204 4"X5" 191 TERBUTALINE SULFATE 25 TECHLITE PEN NEEDLES 29GX TELFA AMD ANTIMICROBIAL terbutaline sulfate 25 10MM 240 ISLAND terconazole vaginal 322 TECHLITE PEN NEEDLES 29GX DRESSING4"X8" 191 12 MM 240 TELFA AMD ANTIMICROBIAL TERIPARATIDE 153 TECHLITE PEN NEEDLES 31GX NON-ADHERENT PAD TERODERM 308 5MM 240 3"X8" 191 TERODERM-PLUS 308 TECHLITE PEN NEEDLES/31GX TELFA ISLAND DRESSING TERPIN HYDRATE 118 5MM 240 4"X10" 191 TECHLITE PEN NEEDLES/31GX TELFA ISLAND DRESSING TERPIN HYDRATE 6 MM 240 4"X14" 191 MONOHYDRATE 118 TECHLITE PEN NEEDLES/31GX TELFA ISLAND DRESSING TESSALON PERLES 117 8MM 240 4"X5" 191 TESTIM 16 TECHLITE PEN NEEDLES/32GX TELFA ISLAND DRESSING TESTONE CIK 16 4MM 240 4"X8" 191 TECHLITE PEN NEEDLES/32GX TELFA NON-ADHERENT TESTOPEL 16 6MM 240 DRESSING 3"X4" 191 testosterone 16 TECHLITE PEN NEEDLES/32GX TELFA NON-ADHERENT PAD TESTOSTERONE 16 8MM 240 3"X8" 191 TECHNA 20 SF TROCHE testosterone 16 BASEWITH BITTER-BLOC 300 TESTOSTERONE 103

Index 92 TESTOSTERONE TGT BLOOD GLUCOSE TEST THROMBIN-JMI SYRINGE COMPOUNDINGKIT 16 STRIPS PREMIUM 150 SPRAY KIT 169 TESTOSTERONE TGT LANCET MICRO THIN THROMBIN-JMI W/DIL CONCENTRATE 102 33G 204 SPRAYPUMP ACTUATOR 169 TESTOSTERONE TGT LANCET THIN 26G 204 THROMBOGEN 169 CYPIONATE 16 TGT LANCET ULTRA THIN THYMOGLOBULIN 254 testosterone cypionate 16 30G 204 THYMOL 110 TESTOSTERONE TGT LANCING DEVICE 204 THYMOL IODIDE 110 CYPIONATE 102 THALOMID 253 TESTOSTERONE THYMUS 103 THAM 248 CYPIONATE/TESTOSTERONE THYROID 103,315 PROPIONATE 16 THE LIQUILIFT TRACE TESTOSTERONE KIT 252 thyroid 315 ENANTHATE 16 THEANINE 103 THYROID PORCINE 315 testosterone enanthate 16 THEO-24 25 tiagabine hcl 31 TESTOSTERONE THEOBROMINE 103 TIAZAC 73 MICRONIZED 103 TIBSOVO 59 TESTOSTERONE MICRONIZED theophylline 25 (SOY) 102 THEOPHYLLINE TICALAST 272 TESTOSTERONE MICRONIZED ANHYDROUS 110 TICARCILLIN (YAM) 102 THEOPHYLLINE DISODIUM/CLAVULANATE TESTOSTERONE MICRONIZED ETHYLENEDIAMINE EP 25 POTASSIUM 103 SOY 103 THEOPHYLLINE/D5W 25 TICASPRAY 272 TESTOSTERONE MICRONIZED THERABETIC EYE TICE BCG 60 YAM 103 HEALTH 270 TIGAN 41 TESTOSTERONE NON- THERAGAUZE 191 tigecycline 313 MICRONIZED SOY 103 THERAHONEY 144 TESTOSTERONE TIGECYCLINE 313 PROPIONATE 16 THERANATAL CORE TETANUS/DIPHTHERIA NUTRITION 267 TIGHTENING BASE 308 TOXOIDS-ADSORBED THIABENDAZOLE 17 TIGLUTIK 273 ADULT 316 THIAMINE HCL 325 TIKOSYN 22 tetrabenazine 311 thiamine hcl 325 TIMOLOL MALEATE 72 TETRACAINE 103 THIAMINE timolol maleate 72 TETRACAINE HCL 103 MONONITRATE 325 timolol maleate (ophth) 279 tetracaine hcl 174 THIMEROSAL 65 TIMOLOL/BRIMONIDE/DORZOL tetracaine hcl (ophth) 281 THINLETS GP LANCETS204 AMIDE 279 TIMOLOL/BRIMONIDINE/DORZ TETRACYCLINE HCL 124 THIOGUANINE 103 THIOLA 162 OLAMIDE/LATANOPROST tetracycline hcl 314 279 TETRACYCLINE THIOLA EC 162 TIMOLOL/DORZOLAMIDE/LATA HYDROCHLORIDE 124 thioridazine hcl 64 NOPROST 279 TETRAHYDRO-L-BIOPTERIN THIORIDAZINE HCL 103 TIMOLOL/LATANOPROST DIHYDROCHLORIDE 103 THIOSALICYLIC ACID 279 TETRAHYDROBIOPTERIN SODIUMSALT 102 TIMOPTIC 279 DIHYDROCHLORIDE 103 TETRAHYDROBIOPTERIN thiotepa 53 TIMOPTIC OCUDOSE 279 HYDROCHLORIDE 103 THIOTEPA 103 TIMOPTIC-XE 279 TETRAHYDROCURCUMINOIDS thiothixene 65 TINDAMAX 17 (THC) 103 THREONINE 278 tinidazole 17 TETRAHYDROZOLINE HCL 103 THRIVITE 19 261 TINIDAZOLE 110 TETRIX 139 THRIVITE RX 267 TINOGARD TL 81 TEXACORT 133 THROMBIN-JMI TIOPRONIN 103 DILUENT 169 TIROSINT 315 TGT ALCOHOL SWABS 214 THROMBIN-JMI TGT BLOOD GLUCOSE TEST EPISTAXIS 169 TIROSINT-SOL 315 STRIPS 150 TISSEEL 169

Index 93 TISSEEL VH 169 tolbutamide 38 topotecan hcl 61 TITANIUM DIOXIDE 103 tolcapone 61 TOPPER DRESSING TIVICAY 67 tolmetin sodium 7 SPONGES 191 TOPPER DRESSING SPONGES TIVICAY PD 67 TOLNAFTATE 126 4"X4" 191 TIVORBEX 7 TOLSURA 43 TOPROL XL 71 TIZANIDINE COMFORT tolterodine tartrate 319 toremifene citrate 56 PAC 272 TOLTRAZURIL 103 TORISEL 59 TIZANIDINE HCL 103 TOLU BALSAM 103 TORONOVA II SUIK 7 tizanidine hcl 272 TOLUIDINE BLUE O 103 TORONOVA SUIK 7 TL FOLATE 267 tolvaptan 156 torsemide 152 TL G-FOL OS 259 TOMMY GEL 308 TOSYMRA 248 TL-CARE DHA 267 TOPAMAX 30,31 TOTAL MEMORY & FOCUS TL-FLUORIVITE 263 TOPAMAX SPRINKLE 30 FORMULA 255 TL-SELECT 267 TOPCARE CLICKFINE TOTECT 60 TOBI 3 UNIVERSAL PEN EEDLES TOUJEO MAX SOLOSTAR 38 TOBI PODHALER 3 31GX1/4" 241 TOUJEO SOLOSTAR 38 TOBRADEX 283 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES TOVET KIT 133 TOBRADEX ST 283 31GX5/16" 241 TOVIAZ 319 tobramycin 3 TOPCARE LANCETS MICRO- TPN ELECTROLYTES 250 TOBRAMYCIN 103 THIN 33G 204 TRACE ELEMENTS TOPCARE ULTRA COMFORT tobramycin (ophth) 281 4/PEDIATRIC 252 INSULIN SYRINGE/0.3ML/30G trace minerals (cr-cu-mn-se- TOBRAMYCIN SULFATE 3 X 5/16" 241 zn) 252 tobramycin sulfate 3,4 TOPCARE ULTRA COMFORT trace minerals (cr-cu-mn- tobramycin- INSULIN SYRINGE/0.3ML/31G zn) 252 dexamethasone 283 X 5/16" 241 TRACLEER 75 TOBREX 281 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/30G TRADJENTA 36 TOCOPHERYL ACID TRAGACANTH 303 SUCCINATED-ALPHA 104 X 5/16" 241 TOPCARE ULTRA COMFORT TOCOTRIENOLS 103 tramadol hcl 13 INSULIN SYRINGE/0.5ML/31G TRAMADOL HCL 103 TODAY SPONGE 322 X 5/16" 241 TODAYS HEALTH ADVANCED TOPCARE ULTRA COMFORT TRAMADOL LANCING DEVICE 204 INSULIN SYRINGE/1ML/30G X HYDROCHLORIDE 103 TODAYS HEALTH MINI PEN 5/16" 241 tramadol-acetaminophen 14 NEEDLES 31G X 1/4" 241 TOPCARE ULTRA COMFORT trandolapril 47 TODAYS HEALTH ORIGINAL INSULIN SYRINGE/1ML/31G X trandolapril-verapamil hcl 50 PEN NEEDLES 29G X 1/2" 241 5/16" 241 TODAYS HEALTH SHORT PEN TOPCARE ULTRA COMFORT TRANEXAMIC ACID 103 NEEDLES 31G X 5/16" 241 INSULIN SYRINGE/U- tranexamic acid 168 TODAYS HEALTH SUPER 100/0.3ML/29G X 1/2" 241 TRANEXAMIC ACID/SODIUM THINLANCETS 30G 204 TOPCARE ULTRA COMFORT CHLORIDE 168 TODAYS HEALTH ULTRA INSULIN SYRINGE/U- TRANILAST 103 THINLANCETS 28G 204 100/0.5ML/29G X 1/2" 241 TRANSDERM SCOP 41 TOENAIL CLIPPER 212 TOPCARE ULTRA COMFORT TRANSDERM-SCOP 41 TOENAIL CLIPPER/FILE INSULIN SYRINGE/U- DELUXE 212 100/1ML/29G X 1/2" 241 TRANSDERMAL PAIN BASE 309 TOENAIL NIPPER 212 TOPICORT 133 TRANXENE T 21 TOFRANIL 34 TOPIDEX 117 tranylcypromine sulfate 32 TOLAK 127 topiramate 31 TRANZAREL 138 tolazamide 38 TOPIRAMATE 103 TRAVASOL 278 TOLAZOLINE topotecan hcl 61 TRAVATAN Z 284 HYDROCHLORIDE 103 TOPOTECAN HCL 61

Index 94 TRAVEL LANCETS 30G 204 TRIAMCINOLONE TRILOSTANE 104 TRAVEL LANCETS ADVANCED ACETONIDEUSP, TRIMEPRAZINE 28G 204 MICRONIZED 133 TARTRATE 104 travoprost 284 TRIAMCINOLONE trimethobenzamide hcl 41 DIACETATE 117 TRAZIMERA 55 TRIAMCINOLONE TRIMETHOBENZAMIDE TRAZODONE HCL 33 DIACETATE HCL 104 TRIMETHOPRIM 17 trazodone hcl 33 MICRONIZED 117 TRIAMCINOLONE trimethoprim 17 TREANDA 53 HEXACETONIDE 103 trimipramine maleate 34 TRECATOR 52 TRIAMCINOLONE/MOXIFLOX TRIMIPRAMINE MALEATE 34 TRELEGY ELLIPTA 25 ACIN HCL 283 TRIMO-SAN 322 TRELSTAR MIXJECT 56 TRIAMCINOLONEUSP, MICRONIZED 103 TRINATAL RX 1 267 TREMFYA 128 TRIAMSIL COMBIPAK 133 TRINAZ 267 treprostinil 74 TRIAMSIL MULTIPAK 133 TRINTELLIX 33 TRESIBA 38 triamterene 152 TRIOSTAT 315 TRESIBA FLEXTOUCH 38 TRIAMTERENE 152 TRIOXSALEN 104 tretinoin 122 triamterene & TRIPELENNAMINE HCL 43 TRETINOIN 122 hydrochlorothiazide 151 TRIPLE COMPLEX FORMULA TRETINOIN (ALL-TRANS TRIANEX 133 3KIT 124 RETINOIC ACID) 122 triazolam 170 TRIPLE PMB 283 tretinoin (chemotherapy) 60 TRIBENZOR 50 TRIPLE PMK 283 tretinoin microsphere 122 TRICARE 267 TRIPROLIDINE HCL 104 TRETTEN 164 TRICARE PRENATAL DHA TRIPTODUR 154 TREXALL 54 ONE 267 TRISENOX 60 TREXIMET 247 TRICARE PRENATAL DHA ONE/FOLATE 267 TRISTART DHA 267 TRI-AMINO 278 TRICHLORMETHIAZIDE 103 TRISTART ONE 267 TRI-CHLOR 129 TRICHLOROACETIC TRITON X-100 96 TRI-NORINYL 28 112 ACID 103 TRIUMEQ 67 TRI-TABS DHA 267 TRICITRASOL 28 TRIVEEN-DUO DHA 267 TRI-VI-FLOR 263 TRICLOSAN 103 TRIXYLITRAL 124 TRI-VI-FLORO 263 TRICOR 45 TRIZIVIR 68 TRIACETIN 103 TRIDESILON 134 TROCHE BASE 300 TRIAMCINOLONE 103 trientine hcl 253 TROCHE BASE NS 300 TRIAMCINOLONE TRIESENCE 283 ACETONIDE 117 TRIETHANOLAMINE LAURYL TROCHIBASE 300 triamcinolone acetonide 117 SULFATE 103 TROCHIBASE S CLASSIC 300 TRIAMCINOLONE TRIETHYL CITRATE 103 TRODELVY 55 ACETONIDE 117,133 TRIFERIC 168 TROGARZO 68 triamcinolone acetonide (mouth) 257 trifluoperazine hcl 64 TROKENDI XR 31 triamcinolone acetonide trifluridine 281 TROLAMINE 288 (nasal) 273 TRIGLIDE 45 TROMETHAMINE 104 triamcinolone acetonide (topical) 133 trihexyphenidyl hcl 61 TROPHAMINE 278 TRIAMCINOLONE ACETONIDE TRIJARDY XR 35 TROPICAL PUNCH PF 117 TRIKAFTA 313 FLAVOR 291 TROPICAMIDE 279 triamcinolone acetonide- TRILEPTAL 31 dimethicone-silicone 133 TROPICAMIDE/CYCLOPENTOL TRIAMCINOLONE TRILIPIX 45 ATE ACETONIDE/BUPIVACAINE TRILOAN II SUIK 117 HYDROCHLORIDE/PHENYLEP HYDROCHLORIDE 117 TRILOAN SUIK 117 HRINE HYDRO 279

Index 95 TROPICAMIDE/CYCLOPENTOL TRUEPLUS INSULIN TRYPTOPHAN 278 ATE/PHENYLEPHRINE 279 SYRINGE/U-100/0.5ML/30G X TUDORZA PRESSAIR 23 TROPICAMIDE/PHENYLEPHRIN 5/16" 242 E 279 TRUEPLUS INSULIN TUKYSA 59 TROPICAMIDE/PROPARACAIN SYRINGE/U-100/0.5ML/31G X TUNA FLAVOR 291 E/PHENYLEPHRINE/KETOROL 5/16" 242 TUNA TYPE FLAVOR OS 291 AC 279 TRUEPLUS INSULIN TURALIO 59 TROPOLONE 104 SYRINGE/U-100/1ML/28G X TURMERIC 104 trospium chloride 319 1/2" 242 TRUEPLUS INSULIN TURMERIC ROOT 104 TRUE COMFORT ALCOHOL SYRINGE/U-100/1ML/29G X PREP PADS 214 TURPENTINE SPIRITS 136 TRUE COMFORT INSULIN 1/2" 242 TRUEPLUS INSULIN TUSSICAPS 118 SYRINGE/0.5ML/31G X SYRINGE/U-100/1ML/30G X TUSSIONEX PENNKINETIC 5/16" 241 EXTENDED RELEASE 118 TRUE COMFORT PEN 5/16" 242 TRUEPLUS INSULIN TUSSLIN PEDIATRIC 118 NEEDLES31G X 5MM 241 TRUE COMFORT PEN SYRINGE/U-100/1ML/31G X TUTTI FRUTTI NEEDLES32G X 4MM 241 5/16" 242 CONCENTRATE 291 TRUE COMFORT TWIST TOP TRUEPLUS LANCETS TUTTI FRUTTI FLAVOR 291 LANCETS 30G 204 26G 205 TUTTI-FRUTTI FLAVOR 292 TRUEPLUS LANCETS TRUE FOCUS SELF TUXARIN ER 118 MONITORING BLOOD 28G 205 TRUEPLUS LANCETS 28G GLUCOSE TEST STRIPS 150 TUZISTRA XR 118 TRUE METRIX BLOOD SUPER THIN 205 TWINRIX 321 TRUEPLUS LANCETS GLUCOSETEST STRIPS 150 TWIRLA 112 TRUE METRIX SELF 30G 205 TRUEPLUS LANCETS 30G TWYNSTA 50 MONITORING BLOOD ULTRA THIN 205 TYBLUME 112 GLUCOSE STRIPS 150 TRUEPLUS LANCETS TRUECONTROL GLUCOSE TYBOST 68 33G 205 CONTROL LEVEL 0 204 TRUEPLUS LANCETS 33G TYGACIL 314 TRUECONTROL GLUCOSE MICRO THIN 205 TYKERB 59 CONTROL LEVEL 1 204 TRUEPLUS PEN NEEDLES TRUEDRAW LANCING TYLENOL/CODEINE #3 14 29GX12MM 242 DEVICE 204 TRUEPLUS PEN NEEDLES TYLENOL/CODEINE #4 14 TRUEPLUS 5-BEVEL PEN 31GX5MM 242 TYLOSIN TARTRATE 104 NEEDLES 31GX5MM 241 TRUEPLUS PEN NEEDLES TRUEPLUS 5-BEVEL PEN TYLOXAPOL 104 31GX6MM 242 NEEDLES 31GX6MM 241 TRUEPLUS PEN NEEDLES TYMLOS 153 TRUEPLUS 5-BEVEL PEN 31GX8MM 242 TYPHIM VI 320 NEEDLES 31GX8MM 241 TRUEPLUS PEN NEEDLES TRUEPLUS 5-BEVEL PEN TYSABRI 311 32GX4MM 242 TYVASO 74 NEEDLES 32GX4MM 241 TRUEPLUS SAFETY TRUEPLUS INSULIN LANCETS 28G 205 TYVASO REFILL 74 SYRINGE/U-100/0.3ML/29G X TYVASO STARTER 74 1/2" 241 TRUETEST STRIPS 150 TRUEPLUS INSULIN TRUETRACK BLOOD U-BASE 309 SYRINGE/U-100/0.3ML/30G X GLUCOSE TEST 150 U-MILD SHAMPOO 300 5/16" 241 TRUETRACK TEST 150 UBIDECARENONE 110 TRUEPLUS INSULIN TRULANCE 158 UBIQUINOL 104 SYRINGE/U-100/0.3ML/31G X TRULICITY 36 5/16" 241 UBRELVY 246 TRUEPLUS INSULIN TRUMENBA 320 UCARE POLYMER JR-400 303 SYRINGE/U-100/0.5ML/28G X TRUSOPT 284 UCERIS 16,117 1/2" 241 TRUVADA 68 TRUEPLUS INSULIN UDAMIN SP 262 SYRINGE/U-100/0.5ML/29G X TRUXIMA 55 UDENYCA 166 1/2" 242 TRYPAN BLUE 289 ULESFIA 141 TRYPSIN 104 ULORIC 163

Index 96 ULTANE 161 ULTICARE INSULIN ULTICARE U-100 INSULIN ULTI-LANCE AUTOMATIC/ SYRINGE/U-100/0.3ML/30G X SYRINGES/0.3ML/31G X CLEAR TIP 205 1/2" 243 1/4" 243 ULTICARE ALCOHOL ULTICARE INSULIN ULTICARE U-100 INSULIN SWABS 214 SYRINGE/U-100/0.3ML/31G X SYRINGES/0.3ML/31G ULTICARE INSULIN SAFETY 5/16" 243 X1/4" 243 SYRINGE/0.5ML/29G X ULTICARE INSULIN ULTICARE U-100 INSULIN 1/2" 242 SYRINGE/U-100/0.5ML/30G X SYRINGES/0.5ML/31G X ULTICARE INSULIN SAFETY 1/2" 243 1/4" 243 SYRINGE/1ML/29G X 1/2" 242 ULTICARE INSULIN ULTICARE U-100 INSULIN ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X SYRINGES/1ML/31G X SYRINGE/0.3ML/29G X 5/16" 243 1/4" 243 1/2" 242 ULTICARE INSULIN ULTILET ALCOHOL ULTICARE INSULIN SYRINGE/U-100/1ML/30G X SWABS 214 SYRINGE/0.3ML/30G X 1/2" 243 ULTILET CLASSIC 1/2" 242 ULTICARE INSULIN LANCETS 205 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X ULTILET INSULIN SYRINGE SYRINGE/0.3ML/30G X 5/16" 243 31X6MM 244 5/16" 242 ULTICARE INSULIN ULTILET INSULIN ULTICARE INSULIN SYRINGEULTRAFINE U- SYRINGE/0.3ML/30G X SYRINGE/0.5ML/28G X 100/0.3ML/31G X 5/16" 243 8MM 244 1/2" 242 ULTICARE INSULIN ULTILET INSULIN ULTICARE INSULIN SYRINGEULTRAFINE U- SYRINGE/0.3ML/31G X SYRINGE/0.5ML/29G X 100/0.5ML/31G X 5/16" 243 8MM 244 1/2" 242 ULTICARE INSULIN ULTILET INSULIN ULTICARE INSULIN SYRINGEULTRAFINE U- SYRINGE/0.5ML/30G X SYRINGE/0.5ML/30G X 100/1ML/31G X 5/16" 243 8MM 244 1/2" 242 ULTICARE MICRO PEN ULTILET INSULIN ULTICARE INSULIN NEEDLES 31G X 8MM 243 SYRINGE/1ML/30G X 8MM244 SYRINGE/0.5ML/30G X ULTICARE MICRO PEN ULTILET INSULIN 5/16" 242 NEEDLES 32G X 4MM 243 SYRINGE/1ML/31G X 8MM244 ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/1ML/28G X 1/2" 242 NEEDLES/31G X 1/4" 243 SYRINGE/SHORT/0.3ML/30G X ULTICARE INSULIN ULTICARE MICRO PEN 12.7MM 244 SYRINGE/1ML/29G X 1/2" 242 NEEDLES/31G X 5/16" 243 ULTILET INSULIN ULTICARE INSULIN ULTICARE MICRO PEN SYRINGE/SHORT/0.3ML/30G X SYRINGE/1ML/30G X 1/2" 242 NEEDLES/32G X 4MM 243 5/16" 244 ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/1ML/30G X NEEDLES/32G X 5/32" 243 SYRINGE/SHORT/0.3ML/31G X 5/16" 242 ULTICARE MINI PEN 5/16" 244 ULTICARE INSULIN NEEDLES 31GX6MM 243 ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X ULTICARE MINI PEN SYRINGE/SHORT/0.5ML/30G X 5/16" 242 NEEDLES ULTI-FINE IV 243 5/16" 244 ULTICARE INSULIN ULTICARE MINI PEN ULTILET INSULIN SYRINGE/SHORT/0.3ML/31G X NEEDLES/31G X 6MM 243 SYRINGE/SHORT/0.5ML/31G X 5/16" 242 ULTICARE MINI PEN 5/16" 244 ULTICARE INSULIN NEEDLES31GX6MM 243 ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X ULTICARE PEN NEEDLES SYRINGE/SHORT/1ML/30G X 5/16" 242 31GX 5MM/MINI 243 5/16" 244 ULTICARE INSULIN ULTICARE PEN ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X NEEDLES/29GX 12.7MM 243 SYRINGE/SHORT/1ML/31G X 5/16" 242 ULTICARE SHORT PEN 5/16" 244 ULTICARE INSULIN NEEDLES 31GX8MM 243 ULTILET INSULIN SYRINGE/U- SYRINGE/SHORT/1ML/30G X ULTICARE SHORT PEN 100/0.5ML/30G X 1/2" 244 5/16" 242 NEEDLES ULTI-FINE IV 243 ULTILET INSULIN SYRINGE/U- ULTICARE INSULIN ULTICARE SHORT PEN 100/0.5ML/31GX6MM 244 SYRINGE/SHORT/1ML/31G X NEEDLES/31G X 8MM 243 ULTILET INSULIN SYRINGE/U- 5/16" 243 100/1ML/30G X 1/2" 244 ULTILET LANCETS 205

Index 97 ULTILET LANCETS 33G 205 ULTRA-COMFORT INSULIN ULTRABAG/DIANEAL PD- ULTILET PEN NEEDLE SYRINGE/U-100/1ML/29G X 2/4.25% DEXTROSE 256 29GX12.7MM 244 1/2" 245 ULTRACARE PEN ULTILET PEN NEEDLE ULTRA-COMFORT INSULIN NEEDLES/33G X 5/32" 245 31GX5MM 244 SYRINGE/U-100/1ML/30G X ULTRACET 14 ULTILET PEN NEEDLE 5/16" 245 ULTRADERM 309 ULTRA-COMFORT INSULIN 31GX8MM 244 ULTRAM 13 ULTILET PEN NEEDLE SYRINGE/U-100/1ML/31G X 32GX4MM 244 5/16" 245 ULTRASAL-ER 135 ULTILET PEN NEEDLE ULTRA-THIN II AUTO ULTRATRAK PRO CONTROL 32GX4MM/SHORT 244 LANCET 205 SOLUTION 2 LEVELS 205 ULTILET SAFETY LANCETS ULTRA-THIN II INSULIN ULTRATRAK PRO TEST 21G X 2.2MM 205 SYRINGE SHORT/U- STRIPS 150 ULTILET SAFETY LANCETS 100/0.3ML/30GX5/16" 245 ULTRATRAK ULTIMATE 23G 205 ULTRA-THIN II INSULIN CONTROL SOLUTION 2 ULTILET SHORT PEN SYRINGE SHORT/U- LEVELS 205 NEEDLES 31GX5/16" 244 100/0.3ML/31GX5/16" 245 ULTRATRAK ULTIMATE TEST ULTILET SHORT PEN ULTRA-THIN II INSULIN STRIPS 150 NEEDLES31GX3/16" 244 SYRINGE SHORT/U- ULTRAVATE 134 ULTILET U-100 INSULIN 100/0.5ML/30GX5/16" 245 UNASYN 287 SYRINGES/1ML/31G X ULTRA-THIN II INSULIN 6MM 244 SYRINGE SHORT/U- UNASYN BULK PACK 287 ULTIMA TEST STRIPS 150 100/0.5ML/31GX5/16" 245 UNDECYLENIC ACID 107 ULTRA-THIN II INSULIN ULTIMATECARE ONE 267 UNIFINE PENTIPS SYRINGE SHORT/U- 29GX12MM 245 ULTIVA 13 100/1ML/30GX5/16" 245 UNIFINE PENTIPS 31G X ULTRA COMFORT INSULIN ULTRA-THIN II INSULIN 3/16" 245 SYRINGE/U-100/0.3ML/30G X SYRINGE SHORT/U- UNIFINE PENTIPS 5/16" 244 100/1ML/31GX5/16" 245 31GX5MM 245 ULTRA-CARE ALCOHOL PREP ULTRA-THIN II INSULIN UNIFINE PENTIPS PADS 214 SYRINGE/U- 31GX6MM 245 ULTRA-CARE LANCETS 100/0.5ML/29GX1/2" 245 UNIFINE PENTIPS 30G 205 ULTRA-THIN II INSULIN 31GX8MM 245 ULTRA-COMFORT INSULIN SYRINGE/U- UNIFINE PENTIPS SYRINGE/U-100/0.3ML/29G X 100/1ML/29GX1/2" 245 32GX4MM 245 1/2" 244 ULTRA-THIN II LANCETS UNIFINE PENTIPS ULTRA-COMFORT INSULIN 28G 205 32GX6MM 245 SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II LANCETS UNIFINE PENTIPS 5/16" 244 30G 205 33GX4MM 245 ULTRA-COMFORT INSULIN ULTRA-THIN II MINI PEN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.3ML/31G X NEEEDLES/31GX3/16" 245 29GX12MM 245 5/16" 244 ULTRA-THIN II PEN NEEDLES UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN 29GX1/2" 245 31GX5MM 245 SYRINGE/U-100/0.5ML/28G X ULTRA-THIN II PEN UNIFINE PENTIPS PLUS 1/2" 244 NEEDLES/SHORT/31GX5/16" 31GX6MM 245 ULTRA-COMFORT INSULIN 245 UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/29G X ULTRABAG/DIANEAL LOW 31GX8MM 245 1/2" 244 CALCIUM/1.5% UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN DEXTROSE 256 32GX4MM 246 SYRINGE/U-100/0.5ML/30G X ULTRABAG/DIANEAL LOW UNIFINE PENTIPS PLUS 33GX 5/16" 245 CALCIUM/2.5% 5/32" 246 ULTRA-COMFORT INSULIN DEXTROSE 256 UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/31G X ULTRABAG/DIANEAL LOW 33GX4MM 246 5/16" 245 CALCIUM/4.25% UNILET COMFORTOUCH ULTRA-COMFORT INSULIN DEXTROSE 256 LANCET 205 SYRINGE/U-100/1ML/28G X ULTRABAG/DIANEAL PD- UNILET EXCELITE 205 1/2" 245 2/1.5% DEXTROSE 256 UNILET EXCELITE II 205 ULTRABAG/DIANEAL PD- 2/2.5% DEXTROSE 256 UNILET G.P. LANCET 205

Index 98 UNILET G.P. SUPERLITE UREA PEROXIDE 85 VALUE HEALTH INSULIN LANCET 205 URECHOLINE 319 SYRINGE/U-100/1ML/29G X UNILET GP 28 ULTRA 1/2" 246 THIN 205 URESOL 134 VALUE PLUS LANCETS UNILET LANCET 205 URIDINE 104 STANDARD 21G 206 UNILET LANCETS MICRO- URIMAR-T 18 VALUE PLUS LANCETS SUPERTHIN 30G 206 THIN33G 205 URINOZINC PLUS 256 UNILET LANCETS SUPER- VALUE PLUS LANCETS THIN THIN30G 205 UROCIT-K 10 161 26G 206 UNILET LANCETS ULTRA-THIN UROCIT-K 15 161 VALUE PLUS LANCING 28G 205 UROCIT-K 5 162 DEVICE 206 VALULINE PNEUMATIC UNILET SUPERLITE UROGESIC-BLUE 18 LANCET 205 SHORTLEG WALKER/LOW UNISPEND ANHYDROUS UROXATRAL 162 TOP/LARGE 212 SWEETENED 300 URSO 250 159 VALULINE PNEUMATIC SHORTLEG WALKER/LOW UNISPEND ANHYDROUS URSO FORTE 159 UNSWEETENED 300 TOP/MEDIUM 212 URSODIOL 104 UNISTIK 3 GENTLE 205 VALULINE PNEUMATIC UNISTIK PRO SAFETY LANCET ursodiol 159 SHORTLEG WALKER/LOW 21G 205 URSODIOL/SYRSPEND SF TOP/SMALL 212 UNISTIK PRO SAFETY LANCET PH4 159 VALULINE PNEUMATIC 25G 205 UTA 18 SHORTLEG WALKER/STANDARD UNISTIK PRO SAFETY LANCET UTIBRON NEOHALER 25 28G 205 TOP/LARGE 212 UNISTIK SAFETY LANCETS UTOPIC 134 VALULINE PNEUMATIC 28G 205 V-MAX 309 SHORTLEG UNISTIK SAFETY LANCETS VABOMERE 18 WALKER/STANDARD TOP/MEDIUM 212 30G 205 VACUSTIM BLACK 144 UNISTIK TOUCH SAFETY VALULINE PNEUMATIC LANCETS 21G 205 VACUSTIM SILVER 144 SHORTLEG UNISTIK TOUCH SAFETY VAGIFEM 322 WALKER/STANDARD LANCETS 23G 205 valacyclovir hcl 69 TOP/SMALL 212 UNISTIK TOUCH SAFETY VALULINE SHORT LEG LANCETS 28G 205 VALACYCLOVIR HCL 104 WALKER/LARGE 212 UNISTIK TOUCH SAFETY VALACYCLOVIR VALULINE SHORT LEG LANCETS 30G 205 HYDROCHLORIDE 104 WALKER/LOW UNISTRIP1 GENERIC 150 VALCHLOR 127 TOP/LARGE 212 VALCYTE 68 VALULINE SHORT LEG UNITUXIN 55 WALKER/LOW UNIVERSAL 1 LANCETS VALERIAN ROOT 104 TOP/MEDIUM 212 THIN26G 205 valganciclovir hcl 68 VALULINE SHORT LEG UNIVERSAL 1 LANCETS ULTRA VALINE 278 WALKER/LOW THIN 30G 205 VALIUM 21 TOP/SMALL 212 UNIVERSAL 1 VALULINE SHORT LEG LANCETS/33G/MICRO-THIN valproate sodium 32 WALKER/MEDIUM 212 206 VALPROATE SODIUM 104 VALULINE SHORT LEG UNIVERSAL WATER GEL 309 valproic acid 32 WALKER/SMALL 212 VALULINE SHORT LEG UPTRAVI 75 valrubicin 57 URALISS 134 WALKER/STANDARD valsartan 48 TOP/MEDIUM 212 URAMAXIN 134 valsartan-hydrochlorothiazide VALULINE SHORT LEG URE-K 134 50 WALKER/STANDARD UREA 104 VALSTAR 57 TOP/SMALL 212 VALTOCO 28 VALULINE SHORT LEG urea 134 WALKER/STANDARD/LARGE UREA 134 VALTREX 69 212 urea 134 VALUE HEALTH INSULIN VALULINE SHORT LEG SYRINGE/U-100/0.5ML/29G X WALKER/XLARGE 212 urea in lactic acid vehicle 134 1/2" 246

Index 99 VALULINE SHORT LEG VANISHPOINT INSULIN VECURONIUM WALKER/XSMALL 212 SYRINGE/1ML/29G X BROMIDE/SODIUM VALUMARK LANCET SUPER 5/16" 246 CHLORIDE 274 THIN 30G 206 VANISHPOINT INSULIN VEGETABLE CAPSULE #0 VALUMARK LANCET ULTRA SYRINGE/1ML/30G X GREEN 301 THIN 28G 206 3/16" 246 VEGETABLE CAPSULE #0 VALUMARK PEN NEEDLES VANISHPOINT INSULIN WHITE 301 29GX12MM 246 SYRINGE/1ML/30G X VEGETABLE CAPSULE #00 VALUMARK PEN NEEDLES 5/16" 246 WHITE 301 31GX 6MM 246 VANOS 134 VEGETABLE CAPSULE #1 VALUMARK PEN NEEDLES WHITE 301 31GX 8MM 246 VANTAS 56 VEGETABLE CAPSULE #2 VANADIUM 104 VAPRISOL 156 WHITE 301 VANADYL SULFATE VAQTA 321 VEGETABLE CAPSULE #3 HYDRATE 104 VARDENAFIL WHITE 301 VANCOCIN 18 HYDROCHLORIDE 104 VEGETABLE CAPSULE #4 VARDIMAXIA 122 WHITE 301 VANCOCIN HCL 18 VEINPUNCTURE PX1 VANCOMYCIN 19 VARITHENA 256 PHLEBOTOMY SYSTEM 138 vancomycin hcl 18 VARIVAX 321 VEKLURY 70 VANCOMYCIN HCL 18 VARIZIG 286 VELCADE 59 vancomycin hcl 18,19 VAROPHEN 124 VELETRI 74 VANCOMYCIN HCL 104 VAROXIA 123 VELPHORO 160 VANCOMYCIN HCL + VARUBI 42 VELTASSA 256 SYRSPENDSF PH4 18 VASCEPA 44 VELTIN 123 VANCOMYCIN VASCUDERM HYDROGEL VEMLIDY 69 HYDROCHLORIDE 19,104 WOUNDDRESSING 144 VENA-BAL DHA 267 VANCOMYCIN VASERETIC 50 HYDROCHLORIDE/DEXTROSE VASHE SKIN/WOUND/BURN VENCLEXTA 55 19 CLEANSING 144 VENCLEXTA STARTING VANCOMYCIN VASHE WOUND PACK 55 HYDROCHLORIDE/SODIUM THERAPY 144 VENELEX 144 CHLORIDE 19 VASOPRESSIN/DEXTROSE VENIPUNCTURE CPI 138 VANCOSOL PACK 19 156 VANIBASE 309 VASOPRESSIN/SODIUM venlafaxine hcl 34 VANILLA BUTTERNUT CHLORIDE 156 VENOFER 168 FLAVOR 292 VASOSTRICT 156 VENTAVIS 74 VANILLA FLAVOR 292 VASOTEC 47 VENTOLIN HFA 25 VANILLIN 104 VAXCHORA 320 verapamil hcl 73 VANILLIN FLAVOR 292 VAZCULEP 324 VERAPAMIL HCL 73 VANISH-PEN 309 VCF VAGINAL verapamil hcl 73 VANISHING CREAM 309 CONTRACEPTIVE FILM 322 VERASENS BLOOD GLUCOSE VANISHING CREAM VCF VAGINAL TEST STRIPS 151 BOTANICALBASE 309 CONTRACEPTIVE VERASENS GLUCOSE VANISHPOINT INSULIN FOAM 322 CONTROLLEVEL 1 206 SYRINGE/0.5ML/30G X VECAMYL 50 VERDESO 134 1/2" 246 VECTIBIX 55 VEREGEN 123 VANISHPOINT INSULIN VECTICAL 128 SYRINGE/0.5ML/30G X VERELAN 73 VECURONIUM VERELAN PM 73 3/16" 246 BROMIDE 104 VANISHPOINT INSULIN VERIPRED 20 117 vecuronium bromide 274 SYRINGE/0.5ML/30G X VERSABASE 309 5/16" 246 VECURONIUM VANISHPOINT INSULIN BROMIDE 274 VERSABASE FOAM 309 SYRINGE/1ML/29G X 1/2" 246 VERSABASE HRT 309 VERSACLOZ 64

Index 100 VERSAFREE 300 VINATE II 267 VITAMIN A PALMITATE 104 VERSAPLUS 300 VINATE M 267 VITAMIN B VERSAPRO 309 VINATE ONE 267 COMPLEX/HYDROXOCOBALA MIN 258 VERSAPRO SHAMPOO 300 vinblastine sulfate 61 VITAMIN B12/FOLIC ACID 168 VERSATILE CREAM BASE309 vincristine sulfate 61 VITAMIN D3 85,325 VERSATILE RICH CREAM vinorelbine tartrate 61 VITAMIN D3 IMMUNE BASE 309 VINPOCETINE 104 HEALTH 325 VERSIGEL 309 VIOKACE 151 VITAMIN DEFICIENCY VERZENIO 59 INJECTABLE SYSTEM- VIRACEPT 68 VESICARE 319 B12 165 VIRAMUNE 68 VEXASYN 144 VITAMIN E 104 VIRAMUNE XR 68 VFEND 43 VITAMIN E ACETATE 104,325 VIRASAL 135 VFEND IV 43 VITAMIN E SUCCINATE 104 VIRAZOLE 70 VIASPAN-BELZER UW-CSS VITAMIN K2 95 COLD STORAGE SOLN 256 VIREAD 68 VITAMIN/IRON MASKING VIBATIV 19 VIROPTIC 281 AGENT FLAVOR 292 VIBERZI 160 VIRT-C DHA 267 VITAMINS FOR THE HAIR 270 VIBRAMYCIN 314 VIRT-FEFA PLUS 168 VITAPEARL 268 VICTORIAS SECRET VIRT-NATE DHA 267 VITAROCA PLUS 262 VANILLALACE 105 VIRT-PN 267 VITATHELY/GINGER 268 VICTOZA 36 VIRT-PN DHA 267 VITATRUE 268 VIDA MIA AUTOLET VITAXYME 262 LANCINGDEVICE 206 VIRT-PN PLUS 267 VIDA MIA UNIFINE VISBIOME 39 VITAZYME 262 PENTIPS32GX4MM 246 VISIONBLUE 283 VITRAKVI 59 VIDA MIA UNIFINE VISTARIL 21 VITRASE 253 PENTIPSMINI 31GX6MM 246 VIDA MIA UNIFINE VISTOGARD 40 VIVA DHA 268 PENTIPSORIGINAL VISUDYNE 281 VIVAGUARD INO BLOOD GLUCOSE TEST STRIPS 151 29GX12MM 246 VITA-RX DIABETIC VIDA MIA UNILET LANCETS VIVAGUARD INO CONTROL VITAMIN 270 SOLUTION 206 SUPER THIN 30G 206 VITAFOL 259 VIDA MIA UNILET LANCETS VIVAGUARD LANCING ULTRA THIN 28G 206 VITAFOL FE+ 267 DEVICE 206 VIDA MIA UNIPFINE VITAFOL GUMMIES 267 VIVELLE-DOT 158 PENTIPSSHORT VITAFOL STRIPS 267 VIVITROL 40 31GX8MM 246 VITAFOL ULTRA 267 VIVLODEX 7 VIDARABINE 104 VITAFOL-NANO 268 VIVOTIF 320 VIDAZA 54 VITAFOL-OB 268 VIVOTIF BERNA 320 VIDEX EC 68 VITAFOL-OB+DHA 268 VIZIMPRO 59 VIDEXPEDIATRIC 68 VITAFOL-ONE 268 VOCAL POINT BLOOD VIEKIRA PAK 69 GLUCOSE TEST STRIPS 151 VITAL-D RX 259 vigabatrin 31 VOGELXO 16 VITALET PRO LANCETS 206 VOGELXO PUMP 16 VIGAMOX 281 VITALET PRO PLUS VIIBRYD 33 LANCETS 206 VOL-NATE 268 VIIBRYD STARTER PACK 33 VITAMEDMD ONE VOL-PLUS 268 VIL-RX 267 RX/QUATREFOLIC 268 VOL-TAB RX 268 VITAMEDMD REDICHEW VIMIZIM 156 RX 268 VOLTAREN 124 VIMOVO 7 VITAMEZ 168 VOPAC GB 124 VIMPAT 31 VITAMIN A 104 VOPAC KT 124 VINATE DHA RF 267 VITAMIN A ACETATE 104 VORAXAZE 60

Index 101 voriconazole 43 WATERSHIELD WATER- WOUND WASH BASE 309 VORICONAZOLE 104 RESISTANT BANDAGES191 WP THYROID 315 WAVESENSE PRESTO TEST VOSEVI 69 STRIPS 151 WPR PLUS WOUND HEALING SYSTEM 138 VOTRIENT 59 WAX PARAFFIN BEADS 303 XADAGO 63 VP DERMABASE 309 WEBCOL ALCOHOL PREP XALATAN 284 VP FC KIT 124 LARGE 1 PLY 214 WEBCOL ALCOHOL PREP XALIX 135 VP GKL KIT 124 LARGE 2 PLY 214 XALKORI 59 VP INSULIN SYRINGE/U- WEBCOL ALCOHOL PREP 100/0.3ML/29G X 1/2" 246 MEDIUM 2 PLY 214 XANAX 21 VP-HEME OB + DHA 268 WEGMANS UNIFINE PENTIPS XANAX XR 21 VP-PNV-DHA 268 PLUS 32GX4MM 246 XANTHAN GUM 303 VPRIV 164 WEGMANS UNIFINE PENTIPS XARELTO 26 PLUS/MINI/31GX5MM 246 VRAYLAR 63 WEGMANS UNIFINE PENTIPS XARELTO STARTER PACK 26 VSL#3 DS 39 PLUS/SHORT/31GX8MM246 XATMEP 54 VUMERITY 311 WEGMANS UNIFINE PENTIPS XCEL 100 309 PLUS/ULTRA VUSION 126 SHORT/31GX6MM 246 XCOPRI 31 VYEPTI 246 WELCHOL 45 XELJANZ 4 VYNDAMAX 75 WELLBUTRIN SR 32 XELJANZ XR 4 VYNDAQEL 75 WELLBUTRIN XL 32 XELODA 54 VYONDYS 53 274 WESTAB PLUS 268 XELPROS 284 VYTORIN 44 WESTGEL DHA 268 XEMATOP BASE 309 VYVANSE 1 WESTHROID 315 XEMBIFY 286 VYXEOS 57 WHEAT GERM 325 XENAZINE 311 VYZULTA 284 WHEY PROTEIN ISOLATE XENLETA 20 WA-001 EXPERIMENTAL INSTANIZED 104 XEOMIN 274 SOILSURFACTANT 107 WHITE BEES WAX 303 XEPI 125 WABANA 256 WHITE KIDNEY BEAN XERAC AC 140 WAKIX 2 EXTRACT 105 XERALUX 139 WALGREENS ADVANCED white petrolatum 309 TRAVELLANCETS 28G 206 WHITE PETROLATUM 309 XERAVA 313 WALGREENS COMFORT WHITE WAX 303 XERESE 128 ASSUREDLANCETS MICRO WHITE WAX PASTILLES 303 XERMELO 160 THIN/33G 206 XEROFORM NON-OCCLUSIVE WALGREENS COMFORT WHITE WILLOW BARK 105 OIL EMULSION GAUZE STRIP ASSUREDLANCETS SUPER WILATE 164 5"X9" 144 THIN/28G 206 WILD CHERRY FLAVOR 292 XEROFORM NON-OCCLUSIVE WALGREENS LANCETS 206 WILEY BASIC ELEMENTS OIL EMULSION PATCH WALGREENS THIN BHRTBASE 309 2"X2" 144 LANCETS 206 WINRHO SDF 286 XEROFORM NON-OCCLUSIVE WALGREENS ULTRA THIN OIL EMULSION LANCETS 206 WITCH HAZEL 90 STRIP/OVERWRAP 1"X8" 144 warfarin sodium 26 WITEPSOL 303 XEROFORM NON-OCCLUSIVE WARFARIN SODIUM WITEPSOL H15 303 ROLL 144 CLATHRATEFORM 26 WITEPSOL H15 BASE F 303 XEROFORM OCCLUSIVE WATER BASE GEL 309 PETROLATUM GAUZE ROLL WOUND CARE CREAM 309 water for inject, bacteriostatic 4"X9' 144 benzyl alcohol 300 WOUND DEBRIDEMENT144 XEROFORM OCCLUSIVE water for injection, sterile 300 WOUND GEL 144 PETROLATUM GAUZE STRIP 1"X8" 144 water for irrigation, sterile 254 WOUND GEL SPRAY 144 XEROFORM OCCLUSIVE WATERMELON FLAVOR 292 WOUND TREATMENT PETROLATUM GAUZE STRIP KIT 191 5"X9" 144

Index 102 XEROFORM OCCLUSIVE XURIDEN 156 ZARONTIN 32 PETROLATUM GAUZE XYLAZINE ZARXIO 166 STRIP/OVERWRAP 1"X8" 144 HYDROCHLORIDE 105 ZATEAN-PN DHA 268 XEROFORM OCCLUSIVE XYLITOL 105 PETROLATUM GAUZE ZATEAN-PN PLUS 268 XYLITOL NF 105 STRIP/OVERWRAP 5"X9" 144 ZAVARA 168 XEROFORM OCCLUSIVE XYLOCAINE 174 ZAVESCA 164 PETROLTUM GAUZE PATCH XYLOCAINE-MPF 174 ZEAXANTHIN 105 2"X2" 144 XYLOCAINE- XEROFORM OCCLUSIVE MPF/EPINEPHRINE 172 ZEGERID 319 PETROLTUM GAUZE PATCH XYLOCAINE/EPINEPHRINE ZEGERID OTC 319 4"X4" 144 172 ZEJULA 59 XEROSTOMIA RELIEF XYLOMETAZOLINE HCL 105 SPRAY 258 ZELAC 39 XYLOMETAZOLINE XGEVA 153 HYDROCHLORIDE 105 ZELAPAR 63 XHANCE 273 XYNTHA 164 ZELBORAF 59 XIAFLEX 253 XYNTHA SOLOFUSE 164 ZELNORM 160 XIFAXAN 17 XYOSTED 16 ZEMAIRA 313 XIGDUO XR 35 XYREM 310 ZEMBRACE SYMTOUCH 248 XIIDRA 281 XYZAL ALLERGY 24HR ZEMDRI 4 XILAPAK 134 CHILDRENS 44 ZEMPLAR 156 XIMINO 315 YASMIN 28 112 ZENEVIX 138 XOFIGO 59 YAZ 112 ZENPEP 151 XOFLUZA 70 YBUPHEN 7 ZEPATIER 69 XOLAIR 23 YEAST EXTRACT 105 ZEPOSIA 311 XOLEGEL 126 YELLOW PETROLATUM 309 ZEPOSIA 7-DAY STARTER XOLEGEL COREPAK 126 YELLOW WAX 303 PACK 311 XOLEGEL DUO/HEAD & YERVOY 55 ZEPOSIA STARTER KIT 312 SHOULDERS 126 YESCARTA 55 ZEPZELCA 53 XOLEGEL DUO/XOLEX 126 YF-VAX 321 ZERBAXA 75 XOPENEX 25 YLANG-YLANG OIL ZERIT 68 XOPENEX CONCENTRATE 25 FRAGRANCE 85 ZERVIATE 284 XOPENEX HFA 25 YOHIMBINE HCL 105 ZESTORETIC 50 XOSPATA 59 YONDELIS 53 ZESTRIL 47 XPOVIO 100 MG ONCE YONSA 56 ZETIA 46 WEEKLY 56 YOSPRALA 164 ZETONNA 273 XPOVIO 40 MG ONCE YUPELRI 23 WEEKLY 56 ZEVALIN Y-90 55 XPOVIO 40 MG TWICE YUTIQ 283 ZEYOCAINE 138 WEEKLY 56 ZACARE 4% KIT 123 ZIAC 50 XPOVIO 60 MG ONCE ZACARE 8% KIT 123 WEEKLY 56 ZIAGEN 68 XPOVIO 60 MG TWICE ZACLIR CLEANSING 123 ZIANA 123 WEEKLY 56 zafirlukast 23 zidovudine 68 XPOVIO 80 MG ONCE zaleplon 170 WEEKLY 56 ZIEXTENZO 166 XPOVIO 80 MG TWICE ZALTRAP 54 ZILACAINE PATCH 138 WEEKLY 56 ZALVIT 268 zileuton 23 XRYLIDERM 138 ZANABIN ANTIPRURITIC ZILRETTA 117 XRYLIX 124 HYDROGEL 144 ZANAFLEX 272 ZILXI 141 XTAMPZA ER 13 ZANOSAR 53 ZINC ACETATE 105 XTANDI 56 ZANTAC 317 ZINC CHLORIDE 105 XULTOPHY 100/3.6 35

Index 103 zinc chloride 252 ZOLGENSMA 12.6-13.0 ZYBAN 312 ZINC CITRATE KG 274 ZYCLARA 134 ZOLGENSMA 13.1-13.5 DIHYDRATE 105 ZYCLARA PUMP 135 ZINC GLUCONATE 105 KG 274 ZOLGENSMA 2.6-3.0 KG 274 ZYDELIG 59 ZINC MONOMETHIONINE 105 ZOLGENSMA 3.1-3.5 KG 274 ZYFLO 23 ZINC OXIDE 105 ZOLGENSMA 3.6-4.0 KG 274 ZYFLO CR 23 ZINC PICOLINATE 105 ZOLGENSMA 4.1-4.5 KG 274 ZYKADIA 59 ZINC PYRITHIONE 98 ZOLGENSMA 4.6-5.0 KG 274 ZYLET 283 ZINC SULFATE 252 ZOLGENSMA 5.1-5.5 KG 274 ZYLOPRIM 163 zinc sulfate 252 ZYMAXID 281 ZINC SULFATE ZOLGENSMA 5.6-6.0 KG 274 GRANULAR 252 ZOLGENSMA 6.1-6.5 KG 274 ZYPITAMAG 46 ZINC SULFATE ZOLGENSMA 6.6-7.0 KG 274 ZYPREXA 64 HEPTAHYDRATE 252 ZOLGENSMA 7.1-7.5 KG 274 ZYPREXA RELPREVV 64 ZINC SULFATE MONOHYDRATE 252 ZOLGENSMA 7.6-8.0 KG 274 ZYPREXA ZYDIS 64 ZINC UNDECYLENATE 105 ZOLGENSMA 8.1-8.5 KG 274 ZYTIGA 56 ZINECARD 60 ZOLGENSMA 8.6-9.0 KG 274 ZYVOX 20 ZINGO 174 ZOLGENSMA 9.1-9.5 KG 274 ZINPLAVA 286 ZOLGENSMA 9.6-10.0 KG 274 ZIOPTAN 284 ZOLINZA 59 ziprasidone hcl 63 ZOLMITRIPTAN 105 ziprasidone mesylate 63 zolmitriptan 248 ZIPSOR 7 ZOLOFT 33 ZIRABEV 54 zolpidem tartrate 170 ZIRCONIUM OXIDE 105 ZOLPIMIST 170 ZIRGAN 281 ZOMACTON 154 ZITHRANOL 128 ZOMETA 153 ZITHROMAX 174,175 ZOMIG 248 ZITHROMAX TRI-PAK 175 ZOMIG ZMT 248 ZITHROMAX Z-PAK 175 ZONALON 127 ZOCOR 46 ZONEGRAN 31 ZOE SCRIPTS IDEALBASE 309 zonisamide 31 ZOFRAN 41 ZONISAMIDE 105 ZOLADEX 56 ZONTIVITY 164 zoledronic acid 153 ZORBTIVE 154 ZOLEDRONIC ACID 153 ZORTRESS 254 zoledronic acid 153 ZORVOLEX 7 ZOLEDRONIC ACID 153 ZOSIL 309 ZOLGENSMA 10.1-10.5 ZOSTAVAX 321 KG 274 ZOSYN 287 ZOLGENSMA 10.6-11.0 KG 274 ZOVIRAX 69,128 ZOLGENSMA 11.1-11.5 ZTLIDO 138 KG 274 ZUBSOLV 15 ZOLGENSMA 11.6-12.0 ZULRESSO 32 KG 274 ZOLGENSMA 12.1-12.5 ZUPLENZ 41 KG 274 ZURAMPIC 163

Index 104