Comprehensive PREFERRED DRUG LIST

Buckeye Health Plan

PAGE 1 Buckeye Health Plan Pharmacy Program

Buckeye Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and cost effective drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Buckeye covers prescription medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The Pharmacy program covers all medically necessary Medicaid covered drugs. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section provides an overview of the Buckeye pharmacy program. For more detailed information, please visit our website at www.buckeyehealthplan.com. The following program covers both the Covered Families & Children (CFC) and Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled inBuckeye.

Plan Preferred Drug List

The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes all drugs available without PA, drugs that require PA, and those agents that have the restrictions of Step Therapy (ST). The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacy Director, Buckeye Clinical Pharmacists, and several Ohio primary care physicians, pharmacists, and specialists. The PDL does not:

o Require or prohibit the prescribing or dispensing of any medication o Substitute for the independent professional judgment of the physician/clinician or pharmacist, or o Relieve the physician/clinician or pharmacist of any obligation to the patient or others

Envolve Pharmacy Solutions

Buckeye works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL list require a PA and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Follow these guidelines for efficient processing of your authorization requests:

1. Complete the Buckeye Health Plan/Envolve Pharmacy Solutions form: MedicationPrior Authorization Request Form. 2. Fax to Envolve Pharmacy Solutions at1-877-386-4695. 3. Once approved, Envolve Pharmacy Solutions notifies the prescriber byfax. 4. If the clinical information provided does not explain the medical necessity for the requested PA medication, Envolve Pharmacy Solutions will deny the request and offer PDL alternatives to the prescriber by fax. 5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply of medication by calling 1-800-681-5632. Prior Authorization Process

The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will require PA and those are listed on the PDL with “PA” noted in the Requirements/Limits column. In addition, all name brand drugs not listed on the PDL list will require prior authorization. If a request for authorization is needed the information should be submitted by your physician/clinician to Envolve Pharmacy Solutions on the Buckeye Health Plan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. This form should be faxed to Envolve Pharmacy Solutions at 1-877-386-4695. This document is located on the Buckeye website at www.buckeyehealthplan.com. Buckeye will cover the medication if it is determined that:

1. There is a medical reason you need the specificmedication. 2. Depending on the medication, other medications on the PDL have not worked.

All reviews are performed by a licensed healthcare professional using the criteria established by the Buckeye P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. The P&T committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and thatPDL medications will be appropriate to treat the vast majority of medical conditions. A phone or fax-in process is available for PA requests.

Envolve Pharmacy Solutions Contact Information: Prior Authorization Fax 1-877-386- 4695; Prior Authorization Phone 1-866-399-0928

Mailing Address: 2425 W Shaw Ave, Fresno, CA 93711

When calling, please have patient information, including Medicaid number, complete diagnosis, medication history and current medications readily available. Envolve Pharmacy Solutions will provide a decision to the request by fax or phone within 24 hours. When incomplete information is received to support medical necessity of a drug requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy claims processing system will be changed to allow the specific member to receive this specific drug. If the request is denied, information about the denial will be provided to the clinician. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the pharmacist should attempt to contact the clinician to request a change to a product included in the PDL. Phone Numbers for Buckeye Health Plan Member Services

The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members cannot be assisted if they call the PA toll-free number. Buckeye Member Services may be reached at 1-866-246-4358 (TTY 1-800-750-0750).

Transition Period

For members new to Buckeye, Medicaid covered drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership with Buckeye. This will allow you and your doctor time to consider other medications that do not require PA and to learn the steps to getting PA. After 90 days, if a drug you are receiving requires PA, your provider will need to submit a PA to Envolve Pharmacy Solutions. Buckeye’s PDL identifies the drugs that will require PA. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at 1-866-246-4358 (TTY 1-800-750- 0750).

72-Hour Emergency Supply Policy

State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72- hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call the Envolve Pharmacy Solutions Pharmacy Help Desk at 1-800-681-5632 for a prescription override to submit the 72-hour medication supply for payment.

Step Therapy

Some medications listed on the Buckeye PDL may require specific medications to be used before you can receive the step therapy medication. If Buckeye has a record that the required medication was tried first the ST medications are automatically covered. If Buckeye does not have a record that the required medication was tried, you or your physician/clinician may be required to provide additional information. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Dispensing Limits, Quantity Limits, and Age Limits

Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance. For most medications, a total of 75 percent (75%) of the days supplied must have elapsed before the prescription can be refilled. That means a prescription for these medications can be filled after 25 days. For some narcotic pain medications, a total of 90 percent (90%) of the days supplied must have elapsed before the next fill of the narcotic pain medication can be obtained. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. Buckeye may limit how much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If you require a medication that does not appear on the PDL, you or your physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Buckeye requires:

o Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or

o Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeuticcategory with comparable labeled indications); or

o Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

All reviews are performed by a licensed healthcare professional using the criteria established by the Buckeye P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process.

Appropriate Use and Safety Edits

Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Point-of-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Buckeye website at www.buckeyehealthplan.com.

DUR (Drug Utilization Review) Programs Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews prescribing retrospectively to review for both safety and efficacy. Buckeye will work with Envolve Pharmacy Solutions to review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. Buckeye will continue to monitor for issues going forward and take action as needed. Mandatory Generic Substitution

When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA. We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need the particular brand name drug. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L- thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin.

Over-The-Counter Medications

The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.

Filling a Prescription

You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription and your Buckeye ID card. Please visit the Buckeye website at www.buckeyehealthplan.com to access the Buckeye PDL, important forms, and provider/member information 24 hours a day, seven days a week.

Mail Order Program

Buckeye Health Plan offers a 90 day supply (3 month supply) of maintenance medications by mail. These drugs are used to treat long-term conditions or illnesses. You can find a list of covered maintenance medications in the Maintenance Drug Pharmacy Program document located on the Buckeye website at www.buckeyehealthplan.com. Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call Homescripts at 1-800-785- 4197.

Buckeye Health Plan Pharmacy Program - Additional Information Working with Our Pharmacy Benefit Managers

Buckeye works with two Pharmacy Benefit Managers (PBMs). Acaria Health is the preferred provider of biopharmaceuticals and injectables for Buckeye. Envolve Pharmacy Solutions administers all other prescribed drugs. Certain drugs require PA to be approved for payment by Buckeye. These include:

o Some Buckeye drugs listed on the PDL with “PA” in the Requirements/Limits column o Most injectables including Procrit, Neulasta andNeupogen. AcariaHealth – Biopharmaceuticals and Injectables

AcariaHealth is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require PA to be approved for payment. All reviews are performed by a licensed healthcare professional using the criteria established by the Buckeye P&T Committee. Buckeye provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the Buckeye website at www.buckeyehealthplan.com. Follow these guidelines for the most efficient processing of your authorization requests. Providers can request that AcariaHealth deliver the specialty drug to the office/member. If you want AcariaHealth to deliver the specialty drug to the office/member:

1. Fax the AcariaHealth PA form to 1-855-678-6976 forPA. 2. If approved, AcariaHealth will contact the provider or member for deliveryconfirmation.

Pharmacy and Therapeutics Committee

The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacy Director, Buckeye Clinical Pharmacists, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update the PDL accordingly based on the results of both the Buckeye P&T Committee and the requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification when changes are made to the list of drugs that require PA.

Unapproved Use of Preferred Medication

Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs are not eligible for coverage.

Benefit Exclusions

The following drug categories are not part of the Buckeye PDL and are not covered by the 72- hour emergency supply policy: - Fertility enhancing drugs - Anorexia, weight loss, or weight gain drugs - Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective - Infusion therapy and supplies - Drugs and other agents used for cosmetic purposes or for hairgrowth - Erectile dysfunction drugs prescribed to treatimpotence

DESI drugs products and known related drug products are defined as less than effective by the FDA because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. State programs may allow coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL.

Newly Approved Products

We review new drugs for safety and effectiveness prior to considering adding them to the Buckeye PDL. During this review period, access to these medications will be considered through the PA review process. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Medical Benefits

The following drugs and medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy:

1. Members will receive vaccines as a medical benefit under physician reimbursement iflisted the vaccine covered under the vaccines for children program. 2. Cosmetic-Botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a PA from Buckeye. 3. Blood and blood products. 4. Those specialty injectable drugs available as a medical benefit. Most injectables requirePA from Buckeye.

Prescribers who request medical prior authorizations at Envolve Pharmacy Solutions will be redirected to contact Buckeye Health Plan as applicable.

DME/Home Health Benefits

The following medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy:

1. Enteral products 2. Nebulizers 3. Medical supplies

Injectable Drugs

Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and Depo-Provera IM are covered by Buckeye and some individual products may require PA or have other limits (i.e., QL, AL). Most other injectables require PA.

Coordinated Services Program

Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services Program, or CSP. CSP members may need to select one pharmacy to get medications filled, select one doctor to write their scripts, or both depending on the CSP enrollment. While in CSP, the member will still be able to get all medically necessary Medicaid-covered health care services. However, the member must use the selected pharmacy or doctor for pharmacy services. Members enrolled in the CSP program will also be offered enrollment in Care Management to help better coordinate the member’s needs. Care Managers will work with the CSP members, to help make sure all their needs are met. Except in an emergency, the member should contact their PCP before seeing other doctors. By knowing the complete medical history, the PCP can take better care of the patient.

We help keep you informed

The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current Buckeye PDL can be downloaded from our website at www.buckeyehealthplan.com.

Contacts for Pharmacy Appeals/Grievances

Members: In the event that a member disagrees with the decision regarding coverage of a medication, the member may file an appeal with Buckeye by calling Buckeye Member Services at 1- 866-246-4358 (TTY 1-800-750-0750).

Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to Buckeye in writing to the Appeals Department at the following address:

Buckeye Health Plan 4349 Easton Way, Suite 300 Columbus, Ohio 43219

A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a member by calling Buckeye at 1-866-246-4356 ext. 24084 (TTY 1- 800-750-0750). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be possible. Abbreviations

The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column: AL: Age Limit APA: Advanced Prior Authorization--an automated prior authorization process to determine whether clinical criteria is met. If clinical criteria is not fully met, an electronic or manual prior authorization will still need to be done. MP: Maintenance Product--a medication used to treat long-term conditions or illnesses. Your plan allows 90 day supplies of Maintenance Products. PA: Prior Authorization QL: Quantity Limit RX/OTC: These drugs are made in both prescription form and Over-the-counter (OTC) form. ST: Step Therapy SP: Specialty Medication Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- dextroamphetamine sulfate F PA OBESITY/ANOREXIANTS - Drugs to Treat soln 5 mg/5ml ADHD, Sleep and Eating Disorders QL(2 ea daily); dextroamphetamine sulfate F AL(At least 3 Amphetamines tabs 5 mg, 10 mg yrs old) ADDERALL TABS (Use QL(2 ea daily); Amphetamine- *** AL(At least 3 methamphetamine hcl tabs F PA Dextroamphetamine) yrs old) PROCENTRA SOLN (Use PA ADDERALL XR CP24 (Use QL(1 ea daily); Dextroamphetamine *** Amphetamine- *** AL(At least 6 Sulfate) Dextroamphetamine) yrs old) VYVANSE CAPS F ST; QL(1 ea amphetamine- QL(1 ea daily); daily) dextroamphetamine cp24 AL(At least 6 5mg-5mg-5mg-5mg, yrs old) ZENZEDI TABS F PA 2.5mg-2.5mg-2.5mg- Analeptics 2.5mg, 7.5mg-7.5mg- F 7.5mg-7.5mg, 1.25mg- 1.25mg-1.25mg-1.25mg, caffeine citrate soln F 3.75mg-3.75mg-3.75mg- 3.75mg, 6.25mg-6.25mg- Attention-Deficit/Hyperactivity Disorder (ADHD) 6.25mg-6.25mg F ST; AL(At least atomoxetine hcl caps 6 yrs old) amphetamine- QL(2 ea daily); dextroamphetamine tabs AL(At least 3 clonidine hcl (adhd) tb12 F 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- PA; QL(1 ea 2.5mg, 7.5mg-7.5mg- guanfacine hcl (adhd) tb24 F daily); AL(At 7.5mg-7.5mg, 1.25mg- least 6 yrs old) 1.25mg-1.25mg-1.25mg, F PA; QL(1 ea 3.75mg-3.75mg-3.75mg- INTUNIV TB24 (Use *** Guanfacine HCl (ADHD)) daily); AL(At 3.75mg, 1.875mg- least 6 yrs old) 1.875mg-1.875mg- KAPVAY TB12 (Use *** 1.875mg, 3.125mg- Clonidine HCl (ADHD)) 3.125mg-3.125mg- 3.125mg STRATTERA CAPS (Use *** ST; AL(At least Atomoxetine HCl) 6 yrs old) DESOXYN TABS (Use *** PA Methamphetamine HCl) Stimulants - Misc. DEXEDRINE CP24 10 MG, QL(2 ea daily); armodafinil tabs F PA 15 MG (Use *** AL(At least 6 Dextroamphetamine yrs old) CONCERTA TBCR 18 MG, QL(1 ea daily); Sulfate) 27 MG, 54 MG (Use *** AL(At least 6 DEXEDRINE CP24 5 MG QL(1 ea daily); Methylphenidate HCl) yrs old) (Use Dextroamphetamine *** AL(At least 6 QL(2 ea daily); CONCERTA TBCR 36 MG *** Sulfate) yrs old) (Use Methylphenidate HCl) AL(At least 6 QL(2 ea daily); yrs old) dextroamphetamine sulfate F AL(At least 6 PA cp24 10 mg, 15 mg DAYTRANA PTCH F yrs old) QL(1 ea daily); dexmethylphenidate hcl PA; QL(1 ea dextroamphetamine sulfate F AL(At least 6 cp24 5 mg, 10 mg, 15 mg, daily) cp24 5 mg F yrs old) 20 mg, 25 mg, 30 mg, 35 mg, 40 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

0 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); PROVIGIL TABS (Use *** PA dexmethylphenidate hcl F AL(At least 6 ) tabs 5 mg, 10 mg, 2.5 mg Modafinil yrs old) QUILLIVANT XR SUSR F PA QL(2 ea daily); FOCALIN TABS (Use *** AL(At least 6 Dexmethylphenidate HCl) RITALIN LA CP24 (Use *** PA yrs old) Methylphenidate HCl) FOCALIN XR CP24 (Use *** PA; QL(1 ea RITALIN TABS 10 MG, 20 QL(3 ea daily); Dexmethylphenidate HCl) daily) MG (Use Methylphenidate *** AL(At least 3 QL(1 ea daily); HCl) yrs old) METADATE CD CPCR *** AL(At least 6 (Use Methylphenidate HCl) QL(6 ea daily); yrs old) RITALIN TABS 5 MG (Use *** Methylphenidate HCl) AL(At least 3 yrs old) METHYLIN SOLN (Use *** Methylphenidate HCl) ALLERGENIC EXTRACTS/BIOLOGICALS MISC methylphenidate hcl chew F PA 5 mg, 10 mg, 2.5 mg Allergenic Extracts methylphenidate hcl cp24 PA PA 10 mg, 20 mg, 30 mg, 40 F GRASTEK SUBL F mg ORALAIR ADULT SAMPLE F PA; SP methylphenidate hcl cpcr QL(1 ea daily); KIT SUBL 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 ORALAIR ADULT F PA; SP mg, 50 mg, 60 mg yrs old) STARTER PACK SUBL methylphenidate hcl soln 5 F PA; SP mg/5ml, 10 mg/5ml ORALAIR SUBL F QL(3 ea daily); RAGWITEK SUBL F PA methylphenidate hcl tabs F AL(At least 3 10 mg, 20 mg yrs old) ALTERNATIVE MEDICINES QL(6 ea daily); methylphenidate hcl tabs 5 F AL(At least 3 mg Alternative Medicine - A's yrs old) ALPHA LIPOIC ACID F QL(2 ea daily); CAPS 300 MG methylphenidate hcl tbcr 10 F AL(At least 6 mg, 20 mg, 36 mg yrs old) Alternative Medicine - C's QL(1 ea daily); CHEW Q CHEW F methylphenidate hcl tbcr 18 F AL(At least 6 mg, 27 mg, 54 mg yrs old) CO Q-10 CHEW F METHYLPHENIDATE QL(1 ea daily) coenzyme q10 PA HYDROCHLORIDE ER F TB24 18 MG, 27 MG, 54 (ubidecarenone) caps 30 F MG mg, 100 mg METHYLPHENIDATE QL(2 ea daily) coenzyme q10 HYDROCHLORIDE ER F (ubidecarenone) caps 50 F TB24 36 MG mg Alternative Medicine - G's modafinil tabs F PA ginger (zingiber officinalis) F QL(4 ea daily) caps NUVIGIL TABS (Use *** PA Armodafinil) Alternative Medicine - M's

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits melatonin caps 5 mg F ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint MELATONIN LIQD 1 F Conditions MG/4ML, 2.5 MG/10ML Anti-TNF-alpha - Monoclonal Antibodies melatonin tabs 1 mg, 300 F mcg HUMIRA PEDIATRIC PA; SP CROHNS DISEASE F melatonin tabs 3 mg, 5 mg F QL(1 ea daily) STARTER PACK PSKT PA; SP Alternative Medicine - U HUMIRA PEN PNKT F CYTO-Q MAX LIQD F HUMIRA PEN-CD/UC/HS F PA; SP STARTER PNKT QH LIQD F HUMIRA PEN-PS/UV F PA; SP STARTER PNKT Alternative Medicine Combinations HUMIRA PSKT F PA; SP LIQ-10 SYRP F SIMPONI SOAJ F PA; SP melatonin-pyridoxine tabs F SIMPONI SOSY F PA; SP AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Antirheumatic - Enzyme Inhibitors Aminoglycosides XELJANZ TABS 5 MG F PA; SP ARIKAYCE SUSP F PA; SP Antirheumatic Antimetabolites PA; SP BETHKIS NEBU F METHOTREXATE TABS F PA; SP KITABIS PAK NEBU F OTREXUP SOAJ F PA; SP neomycin sulfate tabs F RASUVO SOAJ F PA; SP paromomycin sulfate caps F PA Gold Compounds RIDAURA CAPS F TOBI NEBU (Use *** PA; SP Tobramycin) Interleukin-1 Blockers TOBI PODHALER CAPS F PA; SP ARCALYST SOLR F PA; SP TOBRAMYCIN NEBU F PA; SP Interleukin-1 Receptor Antagonist (IL-1Ra) PA; SP tobramycin nebu F KINERET SOSY F PA; SP TOBRAMYCIN SULFATE PA SOLN 10 MG/ML, 40 F Interleukin-6 Receptor Inhibitors MG/ML ACTEMRA ACTPEN SOAJ F PA; SP tobramycin sulfate soln 40 PA mg/ml, 80 mg/2ml, 1.2 F ACTEMRA SOSY F PA; SP gm/30ml Nonsteroidal Anti-inflammatory Agents (NSAIDs) tobramycin sulfate solr 1.2 F PA gm

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL CAPS (Use *** MP FENOPROFEN CALCIUM F PA Ibuprofen) CAPS 400 MG ADVIL MIGRAINE CAPS *** MP fenoprofen calcium tabs F (Use Ibuprofen) 600 mg ADVIL TABS (Use *** MP FENORTHO CAPS F PA Ibuprofen) MP ALEVE ARTHRITIS TABS *** QL(2 ea daily); flurbiprofen tabs F (Use Naproxen Sodium) MP MP ALEVE TABS (Use *** QL(2 ea daily); ibuprofen caps 200 mg F Naproxen Sodium) MP ibuprofen chew 100 mg F MP ANAPROX DS TABS (Use *** MP Naproxen Sodium) ibuprofen susp 100 mg/5ml F RX/OTC; MP CELEBREX CAPS 400 MG *** PA (Use Celecoxib) ibuprofen susp 40 mg/ml, F MP CELEBREX CAPS 50 MG, PA; QL(2 ea 50 mg/1.25ml 100 MG, 200 MG (Use *** daily) ibuprofen tabs 100 mg, 200 MP Celecoxib) mg, 400 mg, 600 mg, 800 F celecoxib caps 400 mg F PA mg INDOCIN SUPP F celecoxib caps 50 mg, 100 F PA; QL(2 ea mg, 200 mg daily) INDOCIN SUSP F CHILDRENS ADVIL SUSP *** RX/OTC; MP (Use Ibuprofen) indomethacin caps F MP CHILDRENS MOTRIN *** RX/OTC; MP SUSP (Use Ibuprofen) indomethacin cpcr F MP DAYPRO TABS (Use *** MP Oxaprozin) INFANTS ADVIL SUSP *** MP (Use Ibuprofen) diclofenac potassium tabs F MP ketoprofen caps 50 mg, 75 F MP mg diclofenac sodium tb24 F MP KETOPROFEN CAPS 50 F MP MG, 75 MG diclofenac sodium tbec F MP KETOPROFEN ER CP24 F DUEXIS TABS F PA QL(20 ea per EC-NAPROSYN TBEC QL(2 ea daily); *** ketorolac tromethamine F 30 days retail); (Use Naproxen) MP tabs or 10 mg AL(At least 17 yrs old) EC-NAPROXEN TBEC *** QL(2 ea daily); (Use Naproxen) MP LODINE TABS (Use *** MP Etodolac) etodolac caps F MP MECLOFENAMATE F etodolac tabs F MP SODIUM CAPS mefenamic acid caps F PA etodolac tb24 F MP meloxicam tabs F MP FELDENE CAPS (Use *** MP Piroxicam)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOBIC TABS (Use *** MP VIMOVO TBEC F PA Meloxicam) MOTRIN INFANTS MP ZIPSOR CAPS F PA DROPS SUSP (Use *** Ibuprofen) ZORVOLEX CAPS F PA nabumetone tabs F MP Phosphodiesterase 4 (PDE4) Inhibitors PA NALFON CAPS 400 MG F OTEZLA TABS F PA; SP

NALFON TABS 600 MG *** PA; SP (Use Fenoprofen Calcium) OTEZLA TBPK F NAPRELAN TB24 375 MG, PA Pyrimidine Synthesis Inhibitors 500 MG (Use Naproxen *** ARAVA TABS (Use *** QL(1 ea daily); Sodium) Leflunomide) MP NAPRELAN TB24 750 MG F PA QL(1 ea daily); leflunomide tabs F MP NAPROSYN SUSP (Use *** MP Naproxen) Selective Costimulation Modulators PA; SP NAPROSYN TABS (Use *** MP ORENCIA SOLR F Naproxen) PA; SP naproxen sodium tabs 220 F QL(2 ea daily); ORENCIA SOSY F mg MP Soluble Tumor Necrosis Factor Receptor Agents naproxen sodium tabs 275 F MP mg, 550 mg ENBREL SOLR F PA; SP naproxen sodium tb24 375 F PA mg, 500 mg ENBREL SOSY F PA; SP naproxen susp 125 mg/5ml F MP ENBREL SURECLICK F PA; SP SOAJ naproxen tabs 250 mg, 375 F MP mg, 500 mg ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions naproxen tbec 375 mg, 500 F QL(2 ea daily); mg MP Analgesic Combinations MP oxaprozin tabs F acetaminophen-caffeine F tabs piroxicam caps F MP aspirin-acetaminophen- F caffeine tabs PONSTEL CAPS (Use *** PA Mefenamic Acid) butalbital-acetaminophen F tabs 325mg-50mg MP sulindac tabs F butalbital-acetaminophen- PA caffeine caps 300mg- F TOLMETIN SODIUM F PA; MP CAPS 400 MG 50mg-40mg butalbital-acetaminophen- QL(4 ea daily) TOLMETIN SODIUM TABS F PA; MP 200 MG caffeine caps 325mg- F 50mg-40mg TOLMETIN SODIUM TABS F PA 600 MG butalbital-acetaminophen- QL(4 ea daily) caffeine tabs 325mg-50mg- F 40mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits butalbital-aspirin-caffeine F QL(4 ea daily) acetaminophen tbcr or 650 F caps mg ESGIC TABS (Use QL(4 ea daily) acetaminophen tbdp or 80 F Butalbital-Acetaminophen- *** mg Caffeine) NORTEMP INFANTS F EXCEDRIN EXTRA SUSP STRENGTH TABS (Use *** TRIAMINIC FEVER Aspirin-Acetaminophen- REDUCERPAIN F Caffeine) RELIEVER CHILDRENS EXCEDRIN MENSTRUAL SYRP COMPLETE TABS (Use *** TRIAMINIC FEVER Aspirin-Acetaminophen- REDUCERPAIN F Caffeine) RELIEVER INFANTS EXCEDRIN MIGRAINE SYRP TABS (Use Aspirin- *** TYLENOL 8 HOUR Acetaminophen-Caffeine) ARTHRITISPAIN TBCR *** EXCEDRIN TENSION (Use Acetaminophen) HEADACHE TABS (Use *** TYLENOL 8 HOUR TBCR *** Acetaminophen-Caffeine) (Use Acetaminophen) FIORICET CAPS (Use PA TYLENOL CHILDRENS Butalbital-Acetaminophen- *** CHEWABLES/PAIN + *** Caffeine) FEVER CHEW (Use FIORINAL CAPS (Use *** QL(4 ea daily) Acetaminophen) Butalbital-Aspirin-Caffeine) TYLENOL CHILDRENS *** TENCON TABS 325MG- F SUSP (Use 50MG Acetaminophen) Analgesics Other TYLENOL EXTRA STRENGTH TABS (Use *** acetaminophen caps or F Acetaminophen) 500 mg acetaminophen chew or 80 TYLENOL INFANTS F PAIN+FEVER SUSP (Use *** mg, 160 mg Acetaminophen) acetaminophen elix or 160 F TYLENOL INFANTS SUSP *** mg/5ml, 80 mg/2.5ml (Use Acetaminophen) acetaminophen liqd or 160 mg/5ml, 500 mg/15ml, F TYLENOL SORE THROAT DAYTIME LIQD (Use *** 1000 mg/30ml Acetaminophen) acetaminophen soln or 160 F TYLENOL TABS (Use *** mg/5ml, 650 mg/20.3ml, Acetaminophen) 325 mg/10.15ml Salicylates acetaminophen supp re F QL(12 ea per 120 mg, 325 mg, 650 mg 30 days retail) aspirin buffered (cal carb- F acetaminophen susp or mag carb-mag oxide) tabs 160 mg/5ml, 80 mg/0.8ml, F aspirin chew or 81 mg F 80 mg/2.5ml ASPIRIN SUPP RE 120 QL(12 ea per acetaminophen tabs or 325 F mg, 500 mg MG, 200 MG, 300 MG, 600 F 30 days retail) MG

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aspirin supp re 300 mg, F QL(12 ea per Smart PA: 600 mg 30 days retail) Opioid Naive MED=30mg/ aspirin tabs or 325 mg F Subacute CODEINE SULFATE TABS MED=60mg aspirin tbec or 81 mg, 324 F 30 MG (Use Codeine *** mg, 325 mg, 500 mg ) and Max 7 day Sulfate supply/Rx;QL(2 BUFFERIN TABS (Use ea daily); AL(At Aspirin Buffered (Cal Carb- *** least 12 yrs Mag Carb-Mag Oxide)) old) choline & mag salicylate F PA Smart PA: liqd Opioid Naive diflunisal tabs F MP MED=30mg/ Subacute ECOTRIN MAXIMUM codeine sulfate tabs 30 mg, F MED=60mg STRENGTH TBEC (Use *** 60 mg and Max 7 day Aspirin) supply/Rx;QL(2 ECOTRIN REGULAR ea daily); AL(At STRENGTH TBEC (Use *** least 12 yrs Aspirin) old) Smart salsalate tabs F CONZIP CP24 F PA;AL(At least 18 yrs old) ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Smart PA: Opioid Naive Opioid Agonists MED=30mg/ Smart PA: DEMEROL TABS (Use *** Subacute Opioid Naive Meperidine HCl) MED=60mg MED=30mg/ and Max 7 day ABSTRAL SUBL F Subacute supply/Rx;QL(6 MED=60mg ea daily) and Max 7 day Smart PA: supply/Rx Opioid Naive Smart PA: MED=30mg/ Opioid Naive DILAUDID LIQD 1 MG/ML *** Subacute MED=30mg/ (Use Hydromorphone HCl) MED=60mg ACTIQ LPOP (Use *** and Max 7 day ) Subacute Fentanyl Citrate MED=60mg supply/Rx;QL(8 and Max 7 day 0 ml daily) supply/Rx Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ DILAUDID TABS 2 MG, 4 Subacute MED=30mg/ MG, 8 MG (Use *** Subacute ) MED=60mg Hydromorphone HCl and Max 7 day CODEINE SULFATE TABS F MED=60mg 15 MG, 60 MG and Max 7 day supply/Rx;QL(8 supply/Rx;QL(2 ea daily) ea daily); AL(At Smart least 12 yrs DOLOPHINE TABS 10 MG *** PA;QL(10 ea (Use Methadone HCl) old) daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DOLOPHINE TABS 5 MG *** Smart PA;QL(4 KADIAN CP24 200 MG F Smart PA (Use Methadone HCl) ea daily) Smart Smart PA: DURAGESIC PT72 (Use *** Opioid Naive Fentanyl) PA;QL(0.34 ea daily) MED=30mg/ Smart PA: LAZANDA SOLN F Subacute Opioid Naive MED=60mg fentanyl citrate lpop bu 200 MED=30mg/ and Max 7 day mcg, 400 mcg, 600 mcg, F Subacute supply/Rx 800 mcg, 1200 mcg, 1600 MED=60mg Smart PA: mcg and Max 7 day Opioid Naive MED=30mg/ supply/Rx levorphanol tartrate tabs 2 F Subacute Smart mg fentanyl pt72 F PA;QL(0.34 ea MED=60mg daily) and Max 7 day supply/Rx Smart PA: Opioid Naive Smart PA: MED=30mg/ Opioid Naive FENTORA TABS F Subacute MED=30mg/ MEPERIDINE HCL SOLN F Subacute MED=60mg 50 MG/5ML and Max 7 day MED=60mg supply/Rx and Max 7 day supply/Rx Smart PA: Opioid Naive Smart PA: MED=30mg/ Opioid Naive MED=30mg/ hydromorphone hcl liqd or F Subacute 1 mg/ml MED=60mg MEPERIDINE HCL TABS F Subacute and Max 7 day 50 MG MED=60mg supply/Rx;QL(8 and Max 7 day 0 ml daily) supply/Rx;QL(6 ea daily) Smart PA: Opioid Naive Smart PA: MED=30mg/ Opioid Naive HYDROMORPHONE HCL F Subacute MED=30mg/ SUPP RE 3 MG MED=60mg meperidine hcl tabs 50 mg, F Subacute and Max 7 day 100 mg MED=60mg supply/Rx and Max 7 day supply/Rx;QL(6 Smart PA: ea daily) Opioid Naive MED=30mg/ Smart methadone hcl conc 10 F PA;QL(10 ml hydromorphone hcl tabs or F Subacute mg/ml 2 mg, 4 mg, 8 mg MED=60mg daily) and Max 7 day Smart methadone hcl soln 10 F PA;QL(60 ml supply/Rx;QL(8 mg/5ml ea daily) daily) KADIAN CP24 10 MG, 20 Smart PA METHADONE HCL SOLN Smart 10 MG/5ML (Use *** PA;QL(60 ml MG, 30 MG, 50 MG, 60 *** MG, 80 MG, 100 MG (Use Methadone HCl) daily) Morphine Sulfate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart Smart PA: methadone hcl soln 5 F PA;QL(30 ml Opioid Naive mg/5ml daily) MED=30mg/ METHADONE HCL SOLN Smart MORPHINE SULFATE F Subacute 5 MG/5ML (Use *** PA;QL(30 ml TABS OR 15 MG, 30 MG MED=60mg Methadone HCl) daily) and Max 7 day supply/Rx;QL(6 Smart ea daily) methadone hcl tabs 10 mg F PA;QL(10 ea daily) morphine sulfate tbcr or 15 Smart PA;QL(3 mg, 30 mg, 60 mg, 100 mg, F ea daily) Smart PA;QL(4 methadone hcl tabs 5 mg F 200 mg ea daily) MS CONTIN TBCR (Use *** Smart PA;QL(3 Smart Morphine Sulfate) ea daily) METHADOSE CONC (Use *** Methadone HCl) PA;QL(10 ml daily) NUCYNTA ER TB12 F Smart PA METHADOSE SUGAR- Smart FREE CONC (Use *** PA;QL(10 ml Smart PA: Methadone HCl) daily) Opioid Naive MED=30mg/ morphine sulfate cp24 or Smart PA NUCYNTA TABS F Subacute 10 mg, 20 mg, 30 mg, 50 F MED=60mg mg, 60 mg, 80 mg, 100 mg and Max 7 day MORPHINE SULFATE ER F Smart PA supply/Rx CP24 Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ OPANA TABS (Use *** MED=30mg/ Oxymorphone HCl) Subacute Subacute MED=60mg morphine sulfate soln or 10 F MED=60mg and Max 7 day mg/5ml, 20 mg/5ml and Max 7 day supply/Rx supply/Rx;QL(5 Smart PA: 00 ml per 30 Opioid Naive days retail) MED=30mg/ Subacute Smart PA: oxycodone hcl caps 5 mg F Opioid Naive MED=60mg MED=30mg/ and Max 7 day Subacute supply/Rx;QL(6 morphine sulfate soln or 20 F MED=60mg ea daily) mg/ml, 100 mg/5ml and Max 7 day Smart PA: supply/Rx;QL(2 Opioid Naive 40 ml per fill MED=30mg/ retail) oxycodone hcl conc 100 F Subacute Smart PA: mg/5ml MED=60mg Opioid Naive and Max 7 day MED=30mg/ supply/Rx;QL(6 MORPHINE SULFATE Subacute ml daily) SUPP RE 5 MG, 10 MG, F MED=60mg OXYCODONE HCL ER F Smart PA 20 MG, 30 MG and Max 7 day T12A supply/Rx;QL(2 4 ea per fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ MED=30mg/ oxycodone hcl soln 5 F Subacute Subacute mg/5ml MED=60mg F MED=60mg and Max 7 day tramadol hcl tabs 50 mg and Max 7 day supply/Rx supply/Rx;QL(8 Smart PA: ea daily); AL(At Opioid Naive least 18 yrs MED=30mg/ old) oxycodone hcl tabs 5 mg, F Subacute Smart 10 mg, 15 mg, 20 mg, 30 MED=60mg tramadol hcl tb24 100 mg, F PA;AL(At least mg 200 mg, 300 mg and Max 7 day 18 yrs old) supply/Rx;QL(6 Smart PA: ea daily) Opioid Naive OXYCODONE Smart PA MED=30mg/ HYDROCHLORIDE ER F Subacute T12A ULTRAM TABS (Use *** MED=60mg Smart PA Tramadol HCl) and Max 7 day OXYCONTIN T12A F supply/Rx;QL(8 Smart PA: ea daily); AL(At Opioid Naive least 18 yrs MED=30mg/ old) oxymorphone hcl tabs F Subacute Opioid Combinations MED=60mg Smart PA: and Max 7 day Opioid Naive supply/Rx MED=30mg/ OXYMORPHONE Smart PA Subacute HYDROCHLORIDE ER F acetaminophen w/ codeine F MED=60mg TB12 soln 120mg/5ml-12mg/5ml and Max 7 day Smart PA: supply/Rx;QL(3 Opioid Naive 0 ml daily); MED=30mg/ AL(At least 12 yrs old) ROXICODONE TABS (Use *** Subacute Oxycodone HCl) MED=60mg Smart PA: and Max 7 day Opioid Naive supply/Rx;QL(6 MED=30mg/ ea daily) acetaminophen w/ codeine Subacute Smart PA: tabs 300mg-15mg, 300mg- F MED=60mg and Max 7 day Opioid Naive 30mg, 300mg-60mg MED=30mg/ supply/Rx;QL(6 SUBSYS LIQD F Subacute ea daily); AL(At MED=60mg least 12 yrs and Max 7 day old) supply/Rx Smart TRAMADOL HCL ER F CP24 PA;AL(At least 18 yrs old)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ ASPIRIN-CAFFEINE- MED=30mg/ F Subacute Subacute DIHYDROCODEINE CAPS FIORINAL/CODEINE #3 MED=60mg MED=60mg CAPS (Use Butalbital- *** and Max 7 day Aspirin-Caffeine w/Cod) and Max 7 day supply/Rx supply/Rx;QL(4 Smart PA: ea daily); AL(At Opioid Naive least 12 yrs MED=30mg/ old) butalbital-acetaminophen- Subacute Smart PA: caffeine w/ codeine caps F MED=60mg Opioid Naive 300mg-50mg-40mg-30mg and Max 7 day HYDROCODONE MED=30mg/ supply/Rx;AL(A BITARTRATE/ACETAMIN F Subacute t least 12 yrs OPHEN SOLN MED=60mg old) and Max 7 day Smart PA: supply/Rx Opioid Naive Smart PA: MED=30mg/ Opioid Naive Subacute hydrocodone- MED=30mg/ butalbital-acetaminophen- MED=60mg F Subacute caffeine w/ codeine caps F acetaminophen soln and Max 7 day 10mg/15ml-325mg/15ml MED=60mg 325mg-50mg-40mg-30mg supply/Rx;QL(4 and Max 7 day ea daily); AL(At supply/Rx least 12 yrs Smart PA: old) Opioid Naive Smart PA: hydrocodone- MED=30mg/ acetaminophen soln Opioid Naive F Subacute MED=30mg/ 2.5mg/5ml-108mg/5ml, MED=60mg 5mg/10ml-217mg/10ml, Subacute and Max 7 day 7.5mg/15ml-325mg/15ml butalbital-aspirin-caffeine F MED=60mg supply/Rx;QL(1 w/cod caps and Max 7 day 80 ml daily) supply/Rx;QL(4 Smart PA: ea daily); AL(At Opioid Naive least 12 yrs MED=30mg/ old) hydrocodone- Subacute acetaminophen tabs 10mg- F Smart PA: MED=60mg Opioid Naive 325mg and Max 7 day MED=30mg/ supply/Rx;QL(6 FIORICET/CODEINE Subacute ea daily) CAPS (Use Butalbital- *** MED=60mg Smart PA: Acetaminophen-Caffeine and Max 7 day w/ Codeine) hydrocodone- Opioid Naive supply/Rx;AL(A acetaminophen tabs 5mg- MED=30mg/ t least 12 yrs 300mg, 10mg-300mg, F Subacute old) 2.5mg-325mg, 7.5mg- MED=60mg 300mg and Max 7 day supply/Rx

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ MED=30mg/ hydrocodone- Subacute NORCO TABS 5MG- Subacute acetaminophen tabs 5mg- F 325MG (Use Hydrocodone- *** MED=60mg ) MED=60mg 325mg and Max 7 day Acetaminophen and Max 7 day supply/Rx;QL(1 supply/Rx;QL(1 2 ea daily) 2 ea daily) Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ MED=30mg/ hydrocodone- Subacute NORCO TABS 7.5MG- Subacute acetaminophen tabs F 325MG (Use Hydrocodone- *** MED=60mg ) MED=60mg 7.5mg-325mg and Max 7 day Acetaminophen and Max 7 day supply/Rx;QL(8 supply/Rx;QL(8 ea daily) ea daily) Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ oxycodone w/ MED=30mg/ hydrocodone-ibuprofen F Subacute F Subacute tabs acetaminophen tabs MED=60mg 2.5mg-325mg MED=60mg and Max 7 day and Max 7 day supply/Rx supply/Rx Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ oxycodone w/ MED=30mg/ IBUDONE TABS (Use *** ) Subacute acetaminophen tabs 5mg- F Subacute Hydrocodone-Ibuprofen MED=60mg 325mg, 10mg-325mg, MED=60mg and Max 7 day 7.5mg-325mg and Max 7 day supply/Rx supply/Rx;QL(6 Smart PA: ea daily) Opioid Naive Smart PA: MED=30mg/ Opioid Naive LORTAB ELIX F Subacute MED=30mg/ MED=60mg oxycodone-aspirin tabs F Subacute and Max 7 day MED=60mg supply/Rx and Max 7 day Smart PA: supply/Rx Opioid Naive Smart PA: Opioid Naive NORCO TABS 10MG- MED=30mg/ *** Subacute MED=30mg/ 325MG (Use Hydrocodone- OXYCODONE/ACETAMIN Subacute Acetaminophen) MED=60mg F and Max 7 day OPHEN SOLN MED=60mg supply/Rx;QL(6 and Max 7 day ea daily) supply/Rx;QL(3 0 ml daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ OXYCODONE/IBUPROFE MED=30mg/ F Subacute Subacute N TABS tramadol-acetaminophen F MED=60mg MED=60mg tabs and Max 7 day and Max 7 day supply/Rx supply/Rx;AL(A Smart PA: t least 18 yrs Opioid Naive old) PERCOCET TABS 2.5MG- MED=30mg/ Smart PA: 325MG (Use Oxycodone *** Subacute Opioid Naive w/ Acetaminophen) MED=60mg MED=30mg/ and Max 7 day Subacute supply/Rx TYLENOL/CODEINE #3 MED=60mg TABS (Use Acetaminophen *** Smart PA: w/ Codeine) and Max 7 day Opioid Naive supply/Rx;QL(6 PERCOCET TABS 5MG- MED=30mg/ ea daily); AL(At 325MG, 10MG-325MG, Subacute least 12 yrs 7.5MG-325MG (Use *** old) Oxycodone w/ MED=60mg ) and Max 7 day Smart PA: Acetaminophen supply/Rx;QL(6 Opioid Naive ea daily) MED=30mg/ Smart PA: Subacute TYLENOL/CODEINE #4 MED=60mg Opioid Naive TABS (Use Acetaminophen *** MED=30mg/ w/ Codeine) and Max 7 day PRIMLEV TABS F Subacute supply/Rx;QL(6 MED=60mg ea daily); AL(At and Max 7 day least 12 yrs supply/Rx old) Smart PA: Smart PA: Opioid Naive Opioid Naive MED=30mg/ MED=30mg/ REPREXAIN TABS (Use *** Subacute Subacute Hydrocodone-Ibuprofen) ULTRACET TABS (Use *** MED=60mg Tramadol-Acetaminophen) MED=60mg and Max 7 day and Max 7 day supply/Rx supply/Rx;AL(A t least 18 yrs Smart PA: old) Opioid Naive MED=30mg/ Smart PA: SYNALGOS-DC CAPS F Subacute Opioid Naive MED=60mg XODOL TABS (Use MED=30mg/ and Max 7 day Hydrocodone- *** Subacute supply/Rx Acetaminophen) MED=60mg and Max 7 day supply/Rx

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: QL and daily buprenorphine hcl- dose limit;AL(At Opioid Naive naloxone hcl dihydrate subl F MED=30mg/ least 16 yrs 8mg-2mg, 2mg-0.5mg ZAMICET SOLN F Subacute old) MED=60mg buprenorphine ptwk td 5 Smart PA and Max 7 day mcg/hr, 10 mcg/hr, 15 F supply/Rx mcg/hr, 20 mcg/hr Opioid Partial Agonists BUPRENORPHINE PTWK Smart PA Smart PA TD 5 MCG/HR, 10 F BELBUCA FILM F MCG/HR, 15 MCG/HR, 20 QL and daily MCG/HR, 7.5 MCG/HR Smart PA: F dose limit;AL(At BUNAVAIL FILM least 16 yrs Opioid Naive old) MED=30mg/ Smart PA: Subacute butorphanol tartrate soln na F MED=60mg Opioid Naive 10 mg/ml MED=30mg/ and Max 7 day BUPRENEX SOLN (Use *** supply/Rx;AL(A ) Subacute Buprenorphine HCl MED=60mg t least 18 yrs and Max 7 day old) supply/Rx BUTRANS PTWK 5 Smart PA Smart PA: MCG/HR, 10 MCG/HR, 15 *** Opioid Naive MCG/HR, 20 MCG/HR MED=30mg/ (Use Buprenorphine) buprenorphine hcl soln ij F Subacute BUTRANS PTWK 7.5 F Smart PA 0.3 mg/ml MED=60mg MCG/HR and Max 7 day Smart PA: supply/Rx Opioid Naive MED=30mg/ QL and daily pentazocine w/ naloxone F Subacute dose limit; tabs naloxone MED=60mg and Max 7 day buprenorphine hcl subl sl 2 F combo req. mg, 8 mg unless supply/Rx contraindicated PA; PA ;AL(At least 16 PROBUPHINE IMPLANT F Required;QL(4 yrs old) KIT IMPL ea per 180 QL and daily days retail); SP buprenorphine hcl- dose limit;QL(1 PA Required;1 naloxone hcl dihydrate film F ea daily); AL(At rtl MAX fill,28 rtl 4mg-1mg, 2mg-0.5mg least 16 yrs SUBLOCADE SOSY 3 day(s) supply,; old) AL(At least 18 QL and daily yrs old); SP buprenorphine hcl- dose limit;QL(2 QL and daily naloxone hcl dihydrate film F ea daily); AL(At SUBOXONE FILM 4MG- dose limit;QL(1 8mg-2mg, 12mg-3mg least 16 yrs 1MG, 2MG-0.5MG (Use F ea daily); AL(At old) Buprenorphine HCl- Naloxone HCl Dihydrate) least 16 yrs old)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL and daily testosterone cypionate soln QL(4 ml per 30 SUBOXONE FILM 8MG- F dose limit;QL(2 im 200 mg/ml days retail) 2MG, 12MG-3MG (Use F Buprenorphine HCl- ea daily); AL(At testosterone gel 1 %, 1.62 PA Naloxone HCl Dihydrate) least 16 yrs %, 10 mg/act, 50 mg/5gm, old) 25 mg/2.5gm, 40.5 F QL and daily mg/2.5gm, 20.25 dose limit;AL(At mg/1.25gm ZUBSOLV SUBL F least 16 yrs TESTOSTERONE GEL 1 PA old) %, 50 MG/5GM, 25 F ANDROGENS-ANABOLIC - Drugs to Regulate MG/2.5GM Hormones TESTOSTERONE PUMP F PA GEL Anabolic Steroids PA ANADROL-50 TABS F PA testosterone soln 30 mg/act F TESTRED CAPS (Use PA OXANDRIN TABS (Use *** PA *** Oxandrolone) Methyltestosterone) PA oxandrolone tabs F PA VOGELXO GEL F PA Androgens VOGELXO PUMP GEL F ANDRODERM PT24 F QL(1 ea daily) ANORECTAL AGENTS - Rectal Drugs to Treat Pain, Swelling and Itching ANDROGEL GEL (Use *** PA Testosterone) Intrarectal Steroids CORTENEMA ENEM (Use ANDROGEL PUMP GEL *** PA (Use Testosterone) Hydrocortisone *** (Intrarectal)) ANDROID CAPS (Use *** PA Methyltestosterone) CORTIFOAM FOAM F PA AXIRON SOLN (Use *** PA Testosterone) hydrocortisone (intrarectal) F enem danazol caps F Rectal Combinations DEPO-TESTOSTERONE QL(4 ml per 30 ANALPRAM-HC LOTN F QL(62 ml per SOLN (Use Testosterone *** days retail) 30 days retail) Cypionate) phenylephrine-shark liver F QL(12 ea per FORTESTA GEL (Use *** PA oil-cocoa butter supp 30 days retail) Testosterone) phenylephrine-shark liver QL(31 gm per METHITEST TABS F PA oil-mineral oil-petrolatum F 30 days retail) oint METHYLTESTOSTERONE PA F pramoxine-phenylephrine- F CAPS glycerin-petrolatum crea STRIANT MISC F PA PREPARATION H CREA (Use Pramoxine- *** TESTIM GEL (Use *** PA Phenylephrine-Glycerin- Testosterone) Petrolatum) TESTOSTERONE QL(4 ml per 30 CYPIONATE SOLN IM 200 F days retail) MG/ML ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREPARATION H alum & mag hydrox- TOTABLES PAIN RELIEF simethicone susp CREA (Use Pramoxine- *** 400mg/5ml-40mg/5ml- Phenylephrine-Glycerin- 400mg/5ml, 400mg/5ml- F Petrolatum) 400mg/5ml-40mg/5ml- 40mg/5ml-400mg/5ml- Rectal Local Anesthetics 400mg/5ml dibucaine (rectal) oint F aluminum hydroxide-mag F carb susp NUPERCAINAL OINT (Use *** Dibucaine (Rectal)) aluminum hydroxide-mag F trisil chew pramoxine hcl (rectal) foam F GAVISCON SUSP (Use PROCTOFOAM FOAM Aluminum Hydroxide-Mag *** (Use Pramoxine HCl *** Carb) (Rectal)) HYVEE ADVANCED ANTACID MAXIMUM Rectal Steroids STRENGTH SUSP (Use *** ANUSOL-HC CREA (Use *** Alum & Mag Hydrox- Hydrocortisone (Rectal)) Simethicone) hydrocortisone (rectal) crea F PA Antacids - Aluminum Salts 1 % ALUMINUM HYDROXIDE F hydrocortisone (rectal) crea F SUSP OR 2.5 % PROCTOCORT CREA PA Antacids - Bicarbonate (Use Hydrocortisone *** sodium bicarbonate F QL(100 ea per (Rectal)) (antacid) tabs 30 days retail) Vasodilating Agents Antacids - Calcium Salts PA calcium carbonate (antacid) F RECTIV OINT F chew calcium carbonate (antacid) F ANTACIDS tabs Antacid Combinations CALCIUM CARBONATE F alum & mag hydrox- QL(744 ml per TABS 648 MG TUMS CHEW (Use simethicone liqd F 30 days retail) 200mg/5ml-20mg/5ml- Calcium Carbonate *** 200mg/5ml (Antacid)) alum & mag hydrox- TUMS LASTING EFFECTS CHEW (Use Calcium *** simethicone liqd F 400mg/5ml-40mg/5ml- Carbonate (Antacid)) 400mg/5ml Antacids - Magnesium Salts alum & mag hydrox- QL(744 ml per simethicone susp 30 days retail) magnesium oxide tabs F 200mg/5ml-20mg/5ml- 200mg/5ml, 200mg/5ml- F ANTHELMINTICS - Drugs to Treat Worm 200mg/5ml-20mg/5ml- Infections 20mg/5ml-200mg/5ml- Anthelmintics 200mg/5ml albendazole tabs F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALBENZA TABS (Use *** PA BACTRIM TABS (Use Albendazole) Sulfamethoxazole- *** Trimethoprim) BILTRICIDE TABS (Use *** PA Praziquantel) sulfamethoxazole- F QL(1 ea per 14 trimethoprim susp EMVERM CHEW F days retail) sulfamethoxazole- F trimethoprim tabs ivermectin tabs F PA Antiprotozoal Agents PA praziquantel tabs F ALINIA SUSR F PA Limit 1 fill per PA pyrantel pamoate susp F Month;QL(60 ALINIA TABS F ml per fill retail) atovaquone susp F REESES PINWORM F QL(16 ea per MEDICINE TABS fill retail) MEPRON SUSP (Use *** STROMECTOL TABS (Use *** PA Atovaquone) Ivermectin) Glycopeptides ANTI-INFECTIVE AGENTS - MISC. - Drugs to QL(300 ml per FIRVANQ SOLR F Treat Bacterial Infections fill retail) Anti-infective Agents - Misc. VANCOCIN HCL CAPS QL(4 ea daily) 125 MG (Use Vancomycin *** FLAGYL CAPS 375 MG *** PA (Use Metronidazole) HCl) FLAGYL TABS 250 MG, VANCOCIN HCL CAPS QL(8 ea daily) 500 MG (Use *** 250 MG (Use Vancomycin *** Metronidazole) HCl) vancomycin hcl caps or QL(4 ea daily) metronidazole caps 375 F PA F mg 125 mg vancomycin hcl caps or QL(8 ea daily) metronidazole tabs 250 F F mg, 500 mg 250 mg PA vancomycin hcl solr iv 1 F QL(14 ea per NEBUPENT SOLR F gm, 1000 mg fill retail) PRIMSOL SOLN F PA vancomycin hcl solr iv 500 F QL(14 ea per mg 30 days retail) TINDAMAX TABS (Use *** PA Leprostatics Tinidazole) dapsone tabs F tinidazole tabs F PA Lincosamides F trimethoprim tabs CLEOCIN CAPS OR 150 PA MG, 300 MG (Use *** TRIMPEX SOLN F Clindamycin HCl) XIFAXAN TABS F PA CLEOCIN CAPS OR 75 *** PA MG (Use Clindamycin HCl) Anti-infective Misc. - Combinations CLEOCIN PEDIATRIC QL(300 ml per BACTRIM DS TABS (Use GRANULES SOLR (Use *** fill retail) Sulfamethoxazole- *** Clindamycin Palmitate Trimethoprim) Hydrochloride) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin hcl caps 150 F NITRO-DUR PT24 0.1 MP mg, 300 mg MG/HR, 0.2 MG/HR, 0.4 *** PA MG/HR, 0.6 MG/HR (Use clindamycin hcl caps 75 mg F Nitroglycerin) NITRO-DUR PT24 0.3 PA clindamycin palmitate F QL(300 ml per F hydrochloride solr fill retail) MG/HR, 0.8 MG/HR Oxazolidinones nitroglycerin cpcr or 9 mg, F MP 2.5 mg, 6.5 mg PA linezolid susr F nitroglycerin pt24 td 0.1 MP PA mg/hr, 0.2 mg/hr, 0.4 F linezolid tabs F mg/hr, 0.6 mg/hr nitroglycerin soln tl 0.4 PA; MP SIVEXTRO TABS F PA; QL(6 ea F per fill retail) mg/spray nitroglycerin subl sl 0.3 mg, MP ZYVOX SUSR (Use *** PA F Linezolid) 0.4 mg, 0.6 mg NITROLINGUAL PA; MP ZYVOX TABS (Use *** PA Linezolid) PUMPSPRAY SOLN (Use *** Nitroglycerin) ANTIANGINAL AGENTS - Drugs to Treat Chest Pain NITROSTAT SUBL (Use *** MP Nitroglycerin) Antianginals-Other ANTIANXIETY AGENTS - Drugs to Treat Anxiety RANEXA TB12 (Use *** PA Ranolazine) Antianxiety Agents - Misc. PA QL(4 ea daily); ranolazine tb12 F buspirone hcl tabs 15 mg F MP Nitrates buspirone hcl tabs 30 mg, F QL(3 ea daily); DILATRATE SR CPCR F PA 7.5 mg MP buspirone hcl tabs 5 mg, 10 F QL(6 ea daily); ISORDIL TITRADOSE F mg MP TABS 40 MG hydroxyzine hcl syrp 10 F ISORDIL TITRADOSE MP mg/5ml TABS 5 MG (Use *** Isosorbide Dinitrate) hydroxyzine hcl tabs 10 F MP mg, 25 mg, 50 mg ISOSORBIDE DINITRATE MP F HYDROXYZINE ER TBCR F PAMOATE CAPS 100 MG ISOSORBIDE DINITRATE MP F hydroxyzine pamoate caps TABS 30 MG F 25 mg isosorbide dinitrate tabs 5 MP F hydroxyzine pamoate caps MP mg, 10 mg, 20 mg F 50 mg isosorbide mononitrate F QL(2 ea daily); tabs 10 mg, 20 mg MP meprobamate tabs F isosorbide mononitrate F QL(1 ea daily); VISTARIL CAPS 25 MG tb24 30 mg, 60 mg, 120 mg MP (Use Hydroxyzine *** NITRO-BID OINT F Pamoate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VISTARIL CAPS 50 MG MP Smart PA: (Use Hydroxyzine *** Concurrent Pamoate) Benzodiazepin F e + Opioid Use Benzodiazepines chlordiazepoxide hcl caps within 90-days Smart PA: NOT Concurrent Allowed;QL(4 ALPRAZOLAM INTENSOL F Benzodiazepin ea daily) CONC e + Opioid Use Smart PA: within 90-days Concurrent NOT Allowed Benzodiazepin Smart PA: clorazepate dipotassium F e + Opioid Use Concurrent tabs within 90-days Benzodiazepin NOT alprazolam tabs 0.25 mg, F e + Opioid Use Allowed;QL(3 0.5 mg, 1 mg, 2 mg within 90-days ea daily) NOT Smart PA: Allowed;QL(4 Concurrent ea daily) F Benzodiazepin PA; Smart PA: diazepam conc or 5 mg/ml e + Opioid Use Concurrent within 90-days alprazolam tb24 0.5 mg, 1 F Benzodiazepin NOT Allowed mg, 2 mg, 3 mg e + Opioid Use within 90-days Smart PA: Concurrent NOT Allowed DIAZEPAM SOLN OR 5 F Benzodiazepin PA; Smart PA: MG/5ML e + Opioid Use Concurrent within 90-days alprazolam tbdp 0.25 mg, F Benzodiazepin NOT Allowed 0.5 mg, 1 mg, 2 mg e + Opioid Use within 90-days Smart PA: Concurrent NOT Allowed Benzodiazepin Smart PA: diazepam tabs or 2 mg, 5 F e + Opioid Use Concurrent mg, 10 mg within 90-days Benzodiazepin NOT ATIVAN TABS 0.5 MG, 2 *** e + Opioid Use Allowed;QL(4 MG (Use Lorazepam) within 90-days ea daily) NOT PA; Smart PA: Allowed;QL(3 Concurrent ea daily) F Benzodiazepin Smart PA: lorazepam conc 2 mg/ml e + Opioid Use Concurrent within 90-days Benzodiazepin NOT Allowed ATIVAN TABS 1 MG (Use *** e + Opioid Use Smart PA: Lorazepam) within 90-days Concurrent NOT Benzodiazepin Allowed;QL(4 e + Opioid Use ea daily) lorazepam tabs 0.5 mg, 2 F mg within 90-days NOT Allowed;QL(3 ea daily)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: PA; Smart PA: Concurrent Concurrent Benzodiazepin XANAX XR TB24 (Use *** Benzodiazepin F e + Opioid Use Alprazolam) e + Opioid Use lorazepam tabs 1 mg within 90-days within 90-days NOT NOT Allowed Allowed;QL(4 ea daily) ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms Smart PA: Concurrent Antiarrhythmics Type I-A Benzodiazepin disopyramide phosphate F MP oxazepam caps 10 mg, 15 F e + Opioid Use caps mg, 30 mg within 90-days NORPACE CAPS (Use F MP NOT Disopyramide Phosphate) Allowed;QL(4 ea daily) NORPACE CR CP12 F Smart PA: Concurrent quinidine gluconate tbcr F Benzodiazepin QUINIDINE SULFATE F OXAZEPAM CAPS 10 MG, F e + Opioid Use TABS 30 MG within 90-days NOT Antiarrhythmics Type I-B Allowed;QL(4 MEXILETINE HCL CAPS F MP ea daily) 150 MG, 200 MG, 250 MG Smart PA: mexiletine hcl caps 200 F MP Concurrent mg, 250 mg Benzodiazepin Antiarrhythmics Type I-C TRANXENE T TABS (Use *** e + Opioid Use Clorazepate Dipotassium) within 90-days flecainide acetate tabs F MP NOT Allowed;QL(3 propafenone hcl cp12 225 F PA; MP ea daily) mg, 325 mg, 425 mg Smart PA: propafenone hcl tabs 150 F MP Concurrent mg, 225 mg, 300 mg Benzodiazepin RYTHMOL SR CP12 (Use *** PA; MP VALIUM TABS (Use *** e + Opioid Use Propafenone HCl) Diazepam) within 90-days NOT Antiarrhythmics Type III Allowed;QL(4 amiodarone hcl tabs 100 F PA; MP ea daily) mg Smart PA: amiodarone hcl tabs 200 F MP Concurrent mg, 400 mg Benzodiazepin dofetilide caps F XANAX TABS (Use *** e + Opioid Use Alprazolam) within 90-days MULTAQ TABS F PA; QL(2 ea NOT daily) Allowed;QL(4 ea daily) TIKOSYN CAPS (Use *** Dofetilide)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIASTHMATIC AND BRONCHODILATOR Selective Phosphodiesterase 4 (PDE4) Inhibitors AGENTS - Drugs to Treat Lung Conditions DALIRESP TABS 500 F PA Anti-Inflammatory Agents MCG cromolyn sodium nebu F QL(8 ml daily) Steroid Inhalants PA; QL(9 gm Antiasthmatic - Monoclonal Antibodies AEROSPAN AERS F per 30 days retail) DUPIXENT SOSY F PA; SP ALVESCO AERS F PA FASENRA SOSY F PA; SP ASMANEX TWISTHALER PA 120 METERED DOSES F XOLAIR SOSY 150 F PA; SP MG/ML, 75 MG/0.5ML AEPB Bronchodilators - Anticholinergics ASMANEX TWISTHALER PA 14 METERED DOSES F ATROVENT HFA AERS F AEPB ASMANEX TWISTHALER PA INCRUSE ELLIPTA AEPB F QL(30 ea per 30 days retail) 30 METERED DOSES F AEPB INCRUSE ELLIPTA AEPB F QL(7 ea per 30 days retail) ASMANEX TWISTHALER PA 60 METERED DOSES F QL(375 ml per ipratropium bromide soln F AEPB 25 days retail) ASMANEX TWISTHALER PA SPIRIVA HANDIHALER F ST; QL(30 ea 7 METERED DOSES F CAPS per fill retail) AEPB TUDORZA PRESSAIR F QL(1 ea per 30 QL(120 ml per AEPB days retail) budesonide (inhalation) F 30 days retail); Leukotriene Modulators susp AL(Up to 8 yrs old ) ACCOLATE TABS (Use *** PA Zafirlukast) FLOVENT DISKUS AEPB QL(2 ea daily) F montelukast sodium chew QL(1 ea daily); 100 MCG/BLIST, 250 F MCG/BLIST 4 mg, 5 mg MP montelukast sodium pack 4 QL(1 ea daily) FLOVENT DISKUS AEPB F F 50 MCG/BLIST mg QL(1 ea daily); FLOVENT HFA AERO 110 F QL(12 gm per montelukast sodium tabs F MCG/ACT, 220 MCG/ACT fill retail) 10 mg MP SINGULAIR CHEW 4 MG, QL(1 ea daily); FLOVENT HFA AERO 44 F QL(10.6 gm per MCG/ACT fill retail) 5 MG (Use Montelukast *** MP Sodium) PULMICORT FLEXHALER F PA AEPB SINGULAIR PACK 4 MG *** QL(1 ea daily) (Use Montelukast Sodium) QL(120 ml per PULMICORT SUSP (Use *** 30 days retail); SINGULAIR TABS 10 MG *** QL(1 ea daily); Budesonide (Inhalation)) AL(Up to 8 yrs (Use Montelukast Sodium) MP old ) PA zafirlukast tabs F PA; QL(17.4 QVAR AERS F gm per fill ZYFLO TABS F PA retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(21.6 METAPROTERENOL QL(30 ml daily) QVAR REDIHALER AERB F gm per fill SULFATE SYRP 10 F retail) MG/5ML Sympathomimetics METAPROTERENOL F QL(60 ea per SULFATE TABS 10 MG, ADVAIR DISKUS AEPB 20 MG (Use Fluticasone- *** fill retail) Salmeterol) PERFOROMIST NEBU F PA PA; QL(12 gm ADVAIR HFA AERO F per fill retail) PROAIR HFA AERS (Use *** Albuterol Sulfate) albuterol sulfate aers in F 108 mcg/act PROVENTIL HFA AERS *** (Use Albuterol Sulfate) ALBUTEROL SULFATE F ER TB12 SEREVENT DISKUS F QL(60 ea per AEPB 30 days retail) albuterol sulfate nebu in F QL(12.5 ml 0.083 % daily) STRIVERDI RESPIMAT F PA AERS albuterol sulfate nebu in F 0.5 % SYMBICORT AERO F QL(11 gm per fill retail) albuterol sulfate nebu in F QL(375 ml per 0.63 mg/3ml, 1.25 mg/3ml 30 days retail) terbutaline sulfate tabs F MP albuterol sulfate syrp or 2 F PA mg/5ml TRELEGY ELLIPTA AEPB F albuterol sulfate tabs or 2 F Limit 1 package mg, 4 mg VENTOLIN HFA AERS *** (Use Albuterol Sulfate) per Claim, 2 per Month albuterol sulfate tb12 or 4 F mg, 8 mg VOSPIRE ER TB12 (Use *** ANORO ELLIPTA AEPB F PA Albuterol Sulfate) XOPENEX PA ARCAPTA NEOHALER F PA CONCENTRATE NEBU *** CAPS (Use Levalbuterol HCl) PA BREO ELLIPTA AEPB F XOPENEX HFA AERO F PA PA BROVANA NEBU F XOPENEX NEBU (Use *** PA Levalbuterol HCl) COMBIVENT RESPIMAT F QL(4 gm per 30 AERS days retail) Xanthines ELIXOPHYLLIN ELIX F DULERA AERO F QL(13 gm per 30 days retail) QL(60 ea per THEO-24 CP24 F fluticasone-salmeterol aepb F fill retail) theophylline soln 80 F QL(475 ml per ipratropium-albuterol soln F QL(12 ml daily) mg/15ml fill retail); MP theophylline tb12 100 mg, F MP levalbuterol hcl nebu F PA 200 mg, 300 mg levalbuterol tartrate aero F PA theophylline tb12 450 mg F theophylline tb24 400 mg, F MP 600 mg

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 3 fills at ANTICOAGULANTS - Blood Thinners RETAIL per Coumarin Anticoagulants 180 days;QL(6 enoxaparin sodium soln sc F ml per 7 days COUMADIN TABS (Use F MP 40 mg/0.4ml retail)3 rtl MAX Warfarin Sodium) fill,180 rtl warfarin sodium tabs F MP day(s) supply,; SP Direct Factor Xa Inhibitors Limit 3 fills at RETAIL per ELIQUIS STARTER PACK F QL(4 ea daily) TABS 180 days;QL(9 QL(4 ea daily) enoxaparin sodium soln sc F ml per 7 days ELIQUIS TABS F 60 mg/0.6ml retail)3 rtl MAX fill,180 rtl QL(1 ea day(s) supply,; XARELTO TABS 10 MG F daily,35 ea per SP 180 days retail) Limit 3 fills at XARELTO TABS 15 MG F QL(2 ea daily) RETAIL per 180 XARELTO TABS 20 MG F QL(1 ea daily) days;QL(12 ml enoxaparin sodium soln sc F per 7 days Heparins And Heparinoid-Like Agents 80 mg/0.8ml, 120 mg/0.8ml retail)3 rtl MAX fill,180 rtl ARIXTRA SOLN (Use *** PA; SP Fondaparinux Sodium) day(s) supply,; Limit 3 fills at SP RETAIL per fondaparinux sodium soln F PA; SP 180 days;QL(42 ml FRAGMIN SOLN F PA; SP enoxaparin sodium soln ij F per 7 days 300 mg/3ml retail)3 rtl MAX heparin sodium (porcine) F fill,180 rtl soln day(s) supply,; Limit 3 fills at SP RETAIL per Limit 3 fills at 180 RETAIL per LOVENOX SOLN IJ 300 days;QL(42 ml 180 MG/3ML (Use Enoxaparin *** per 7 days days;QL(14 ml Sodium) retail)3 rtl MAX enoxaparin sodium soln sc F per 7 days fill,180 rtl 100 mg/ml, 150 mg/ml retail)3 rtl MAX day(s) supply,; fill,180 rtl SP day(s) supply,; Limit 3 fills at SP RETAIL per Limit 3 fills at 180 RETAIL per LOVENOX SOLN SC 100 days;QL(14 ml 180 days;QL(5 MG/ML, 150 MG/ML (Use *** per 7 days Enoxaparin Sodium) retail)3 rtl MAX enoxaparin sodium soln sc F ml per 7 days 30 mg/0.3ml retail)3 rtl MAX fill,180 rtl fill,180 rtl day(s) supply,; day(s) supply,; SP SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 3 fills at Smart PA: RETAIL per Concurrent 180 days;QL(5 Benzodiazepin LOVENOX SOLN SC 30 *** ml per 7 days clonazepam tabs 0.5 mg, 1 F e + Opioid Use MG/0.3ML (Use within 90-days Enoxaparin Sodium) retail)3 rtl MAX mg, 2 mg fill,180 rtl NOT day(s) supply,; Allowed;QL(4 SP ea daily) Limit 3 fills at PA; Smart PA: RETAIL per Concurrent 180 days;QL(6 clonazepam tbdp 0.125 Benzodiazepin LOVENOX SOLN SC 40 mg, 0.25 mg, 0.5 mg, 1 mg, F *** ml per 7 days e + Opioid Use MG/0.4ML (Use 2 mg within 90-days Enoxaparin Sodium) retail)3 rtl MAX fill,180 rtl NOT Allowed day(s) supply,; QL(1 ea per fill SP DIASTAT ACUDIAL GEL F retail); AL(At Limit 3 fills at least 2 yrs old) RETAIL per QL(1 ea per fill 180 days;QL(9 DIASTAT PEDIATRIC GEL F retail); AL(At LOVENOX SOLN SC 60 ml per 7 days MG/0.6ML (Use *** least 2 yrs old) Enoxaparin Sodium) retail)3 rtl MAX fill,180 rtl QL(1 ea per fill diazepam (anticonvulsant) F retail); AL(At day(s) supply,; gel SP least 2 yrs old) Limit 3 fills at QL(1 ea per fill DIAZEPAM GEL RE 20 F retail); AL(At RETAIL per MG, 2.5 MG 180 least 2 yrs old) LOVENOX SOLN SC 80 days;QL(12 ml QL(1 ea per fill DIAZEPAM RECTAL GEL F retail); AL(At MG/0.8ML, 120 MG/0.8ML *** per 7 days GEL (Use Enoxaparin Sodium) retail)3 rtl MAX least 2 yrs old) fill,180 rtl Smart PA: day(s) supply,; Concurrent SP Benzodiazepin Thrombin Inhibitors KLONOPIN TABS (Use *** e + Opioid Use Clonazepam) within 90-days PRADAXA CAPS F PA NOT Allowed;QL(4 ANTICONVULSANTS - Drugs to Treat Seizures ea daily) ONFI SUSP (Use *** PA AMPA Glutamate Receptor Antagonists Clobazam) PA FYCOMPA TABS F ONFI TABS (Use *** PA Clobazam) Anticonvulsants - Benzodiazepines Anticonvulsants - Misc. PA clobazam susp F APTIOM TABS F PA PA clobazam tabs F BANZEL SUSP F PA; SP

BANZEL TABS F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbamazepine chew F MP lamotrigine chew 5 mg, 25 F MP mg MP carbamazepine cp12 F lamotrigine kit F PA MP carbamazepine susp F lamotrigine tabs 25 mg, F MP 100 mg, 150 mg, 200 mg carbamazepine tabs F MP lamotrigine tb24 25 mg, 50 ST; QL(1 ea mg, 100 mg, 200 mg, 250 F daily) carbamazepine tb12 F MP mg, 300 mg lamotrigine tbdp 25 mg, 50 F PA CARBATROL CP12 (Use F MP mg, 100 mg, 200 mg Carbamazepine) levetiracetam soln 100 F QL(16 ml EPIDIOLEX SOLN F PA; SP mg/ml, 500 mg/5ml daily); MP levetiracetam tabs 250 mg, QL(4 ea daily); gabapentin caps 100 mg, F QL(9 ea daily); F 300 mg, 400 mg MP 750 mg, 1000 mg MP QL(6 ea daily); gabapentin soln 250 F MP levetiracetam tabs 500 mg F mg/5ml, 300 mg/6ml MP QL(6 ea daily); levetiracetam tb24 500 mg, ST; MP gabapentin tabs 600 mg F F MP 750 mg QL(4 ea daily); PA gabapentin tabs 800 mg F LYRICA CAPS F MP MYSOLINE TABS (Use *** MP KEPPRA SOLN 100 QL(16 ml Primidone) MG/ML (Use *** daily); MP Levetiracetam) NEURONTIN CAPS 100 QL(9 ea daily); MG, 300 MG, 400 MG (Use *** MP KEPPRA TABS 250 MG, QL(4 ea daily); Gabapentin) 750 MG, 1000 MG (Use *** MP Levetiracetam) NEURONTIN SOLN 250 *** MP MG/5ML (Use Gabapentin) KEPPRA TABS 500 MG *** QL(6 ea daily); (Use Levetiracetam) MP NEURONTIN TABS 600 *** QL(6 ea daily); MG (Use Gabapentin) MP KEPPRA XR TB24 (Use *** ST; MP Levetiracetam) NEURONTIN TABS 800 *** QL(4 ea daily); MG (Use Gabapentin) MP LAMICTAL CHEWABLE MP DISPERSIBLE CHEW (Use *** oxcarbazepine susp F MP Lamotrigine) MP LAMICTAL ODT KIT F PA oxcarbazepine tabs F LAMICTAL ODT TBDP 25 PA POTIGA TABS F PA MG, 50 MG, 100 MG, 200 *** MG (Use Lamotrigine) primidone tabs F MP LAMICTAL TABS (Use *** MP PA Lamotrigine) QUDEXY XR CS24 F PA LAMICTAL XR KIT F TEGRETOL SUSP (Use F MP Carbamazepine) LAMICTAL XR TB24 25 ST; QL(1 ea TEGRETOL TABS (Use F MP MG, 50 MG, 100 MG, 200 *** daily) Carbamazepine) MG, 250 MG, 300 MG (Use Lamotrigine) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL-XR TB12 (Use F MP FELBATOL TABS (Use *** Carbamazepine) Felbamate) TOPAMAX SPRINKLE QL(6 ea daily); GABA Modulators CPSP 15 MG (Use *** MP ) GABITRIL TABS 12 MG, Topiramate 16 MG (Use Tiagabine *** TOPAMAX SPRINKLE QL(8 ea daily); HCl) CPSP 25 MG (Use *** MP ) GABITRIL TABS 2 MG, 4 *** MP Topiramate MG (Use Tiagabine HCl) TOPAMAX TABS 100 MG *** QL(4 ea daily); ) SABRIL PACK (Use *** PA; SP (Use Topiramate MP Vigabatrin) TOPAMAX TABS 200 MG *** QL(3 ea daily); ) SABRIL TABS (Use *** PA; SP (Use Topiramate MP Vigabatrin) TOPAMAX TABS 25 MG, *** QL(6 ea daily); 50 MG (Use Topiramate) MP tiagabine hcl tabs 12 mg, F 16 mg QL(6 ea daily); topiramate cpsp 15 mg F tiagabine hcl tabs 2 mg, 4 MP MP F mg QL(8 ea daily); topiramate cpsp 25 mg F PA; SP MP vigabatrin pack F PA TOPIRAMATE ER CS24 F vigabatrin tabs F PA; SP QL(4 ea daily); topiramate tabs 100 mg F MP Hydantoins QL(3 ea daily); DILANTIN CAPS 100 MG MP topiramate tabs 200 mg F MP (Use Phenytoin Sodium F Extended) topiramate tabs 25 mg, 50 F QL(6 ea daily); mg MP DILANTIN CAPS 30 MG F TRILEPTAL SUSP (Use MP *** DILANTIN INFATABS F MP Oxcarbazepine) CHEW (Use Phenytoin) TRILEPTAL TABS (Use MP *** DILANTIN-125 SUSP (Use F MP Oxcarbazepine) Phenytoin) PA TROKENDI XR CP24 F PEGANONE TABS F PA VIMPAT SOLN F PA PHENYTEK CAPS (Use MP Phenytoin Sodium F VIMPAT TABS F PA Extended) phenytoin chew F MP ZONEGRAN CAPS (Use *** MP Zonisamide) phenytoin sodium extended F MP zonisamide caps F MP caps MP Carbamates phenytoin susp F felbamate susp F Succinimides CELONTIN CAPS F PA felbamate tabs F ethosuximide caps F MP FELBATOL SUSP (Use *** Felbamate) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ethosuximide soln F MP REMERON SOLTAB TBDP *** QL(1 ea daily) 45 MG (Use Mirtazapine) ZARONTIN CAPS (Use MP F REMERON TABS 15 MG *** QL(3 ea daily); Ethosuximide) (Use Mirtazapine) MP ZARONTIN SOLN (Use MP F REMERON TABS 30 MG *** QL(1.5 ea Ethosuximide) (Use Mirtazapine) daily); MP Valproic Acid REMERON TABS 45 MG *** QL(1 ea daily); (Use Mirtazapine) MP DEPAKENE CAPS (Use F MP Valproic Acid) Antidepressants - Misc. DEPAKOTE ER TB24 (Use *** MP PA Divalproex Sodium) APLENZIN TB24 F DEPAKOTE SPRINKLES MP bupropion hcl tabs 75 mg, F QL(3 ea daily); CSDR (Use Divalproex *** 100 mg MP Sodium) QL(4 ea daily); bupropion hcl tb12 100 mg F DEPAKOTE TBEC (Use *** MP MP Divalproex Sodium) QL(3 ea daily); bupropion hcl tb12 150 mg F divalproex sodium csdr F MP MP QL(2 ea daily); bupropion hcl tb12 200 mg F divalproex sodium tb24 F MP MP bupropion hcl tb24 150 mg F QL(3 ea daily) divalproex sodium tbec F MP BUPROPION PA valproic acid caps or F MP HYDROCHLORIDE ER F (XL) TB24 ANTIDEPRESSANTS - Drugs to Treat PA Depression FORFIVO XL TB24 F Limit 2 fills per Alpha-2 Receptor Antagonists (Tetracyclics) MAPROTILINE HCL TABS F QL(3 ea daily); month mirtazapine tabs 15 mg F MP WELLBUTRIN SR TB12 QL(4 ea daily); QL(1.5 ea 100 MG (Use Bupropion *** MP mirtazapine tabs 30 mg F daily); MP HCl) QL(1 ea daily); WELLBUTRIN SR TB12 QL(3 ea daily); mirtazapine tabs 45 mg F MP 150 MG (Use Bupropion *** MP HCl) QL(1 ea daily) mirtazapine tabs 7.5 mg F WELLBUTRIN SR TB12 QL(2 ea daily); QL(3 ea daily) 200 MG (Use Bupropion *** MP mirtazapine tbdp 15 mg F HCl) QL(1.5 ea WELLBUTRIN XL TB24 QL(3 ea daily) mirtazapine tbdp 30 mg F *** daily) (Use Bupropion HCl) mirtazapine tbdp 45 mg F QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 9 MG/24HR F PA REMERON SOLTAB TBDP *** QL(3 ea daily) 15 MG (Use Mirtazapine) MARPLAN TABS F PA REMERON SOLTAB TBDP *** QL(1.5 ea 30 MG (Use Mirtazapine) daily) NARDIL TABS (Use *** Phenelzine Sulfate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARNATE TABS (Use *** fluoxetine hcl tabs 60 mg F PA Tranylcypromine Sulfate) FLUOXETINE F PA phenelzine sulfate tabs F HYDROCHLORIDE TABS tranylcypromine sulfate F FLUOXETINE PA tabs HYDROCHLORIDE TABS *** (Use Fluoxetine HCl) Selective Serotonin Reuptake Inhibitors (SSRIs) fluvoxamine maleate cp24 PA CELEXA TABS 10 MG QL(4 ea daily); F (Use Citalopram *** AL(At least 6 100 mg, 150 mg Hydrobromide) yrs old); MP fluvoxamine maleate tabs F QL(3 ea daily) 100 mg CELEXA TABS 20 MG QL(2 ea daily); (Use Citalopram *** MP fluvoxamine maleate tabs F QL(2 ea daily) Hydrobromide) 25 mg, 50 mg CELEXA TABS 40 MG QL(1 ea daily); LEXAPRO TABS 10 MG *** QL(2 ea daily); (Use Citalopram *** MP (Use Escitalopram Oxalate) MP Hydrobromide) LEXAPRO TABS 20 MG *** QL(1 ea daily); (Use Escitalopram Oxalate) MP citalopram hydrobromide F soln 10 mg/5ml LEXAPRO TABS 5 MG *** QL(4 ea daily); QL(4 ea daily); (Use Escitalopram Oxalate) MP citalopram hydrobromide F AL(At least 6 tabs 10 mg paroxetine hcl tabs 10 mg, F yrs old); MP 20 mg, 30 mg, 40 mg citalopram hydrobromide F QL(2 ea daily); 1 rtl MAX fill,30 tabs 20 mg MP paroxetine hcl tb24 12.5 F rtl day(s) mg, 37.5 mg supply, citalopram hydrobromide F QL(1 ea daily); tabs 40 mg MP paroxetine hcl tb24 25 mg F escitalopram oxalate soln 5 F ST mg/5ml PAXIL CR TB24 12.5 MG, 1 rtl MAX fill,30 37.5 MG (Use Paroxetine *** rtl day(s) escitalopram oxalate tabs F QL(2 ea daily); 10 mg MP HCl) supply, PAXIL CR TB24 25 MG escitalopram oxalate tabs F QL(1 ea daily); *** 20 mg MP (Use Paroxetine HCl) PAXIL SUSP 10 MG/5ML F QL(40 ml daily) escitalopram oxalate tabs 5 F QL(4 ea daily); mg MP PAXIL TABS 10 MG, 20 FLUOXETINE DR CPDR F PA MG, 30 MG, 40 MG (Use *** Paroxetine HCl) fluoxetine hcl caps 10 mg, F QL(4 ea daily); 20 mg MP PEXEVA TABS F PA QL(2 ea daily); PROZAC CAPS 10 MG, 20 *** QL(4 ea daily); fluoxetine hcl caps 40 mg F AL(At least 7 MG (Use Fluoxetine HCl) MP yrs old); MP QL(2 ea daily); fluoxetine hcl soln 20 QL(120 ml per PROZAC CAPS 40 MG *** AL(At least 7 F (Use Fluoxetine HCl) mg/5ml 30 days retail) yrs old); MP QL(1 ea daily); sertraline hcl conc 20 F fluoxetine hcl tabs 10 mg F AL(At least 7 mg/ml yrs old); MP QL(2 ea daily); sertraline hcl tabs 100 mg F fluoxetine hcl tabs 20 mg F QL(4 ea daily) MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sertraline hcl tabs 25 mg, F QL(4 ea daily); KHEDEZLA TB24 F PA 50 mg MP PRISTIQ TB24 (Use PA ZOLOFT CONC 20 MG/ML *** *** (Use Sertraline HCl) Desvenlafaxine Succinate) venlafaxine hcl cp24 150 QL(2 ea daily); ZOLOFT TABS 100 MG *** QL(2 ea daily); F (Use Sertraline HCl) MP mg MP venlafaxine hcl cp24 37.5 QL(4 ea daily); ZOLOFT TABS 25 MG, 50 *** QL(4 ea daily); F MG (Use Sertraline HCl) MP mg MP QL(5 ea daily); Serotonin Modulators venlafaxine hcl cp24 75 mg F MP NEFAZODONE HCL TABS F 100 MG, 150 MG venlafaxine hcl tabs 25 mg, F 50 mg, 100 mg nefazodone hcl tabs 50 F mg, 250 mg venlafaxine hcl tabs 75 mg, F MP 37.5 mg NEFAZODONE F HYDROCHLORIDE TABS venlafaxine hcl tb24 75 mg, F QL(1 ea daily) 150 mg, 225 mg, 37.5 mg QL(2 ea daily) trazodone hcl tabs 300 mg F Tricyclic Agents trazodone hcl tabs 50 mg, F MP amitriptyline hcl tabs F 100 mg, 150 mg PA; QL(1 ea AMOXAPINE TABS F daily); AL(At TRINTELLIX TABS F least 18 yrs ANAFRANIL CAPS (Use *** PA old) Clomipramine HCl) PA VIIBRYD TABS F PA; QL(1 ea clomipramine hcl caps F daily) desipramine hcl tabs 10 Serotonin-Norepinephrine Reuptake Inhibitors mg, 50 mg, 75 mg, 100 mg, F QL(2 ea daily); 150 mg CYMBALTA CPEP (Use *** Duloxetine HCl) AL(At least 7 QL(2 ea daily) yrs old); MP desipramine hcl tabs 25 mg F DESVENLAFAXINE ER F PA doxepin hcl caps 10 mg, 25 TB24 50 MG, 100 MG mg, 50 mg, 75 mg, 100 mg, F desvenlafaxine succinate F PA 150 mg tb24 DOXEPIN HCL CAPS 150 F QL(2 ea daily); MG duloxetine hcl cpep 20 mg, F AL(At least 7 30 mg, 60 mg yrs old); MP doxepin hcl conc 10 mg/ml F EFFEXOR XR CP24 150 QL(2 ea daily); *** ELAVIL TABS (Use *** MG (Use Venlafaxine HCl) MP Amitriptyline HCl) EFFEXOR XR CP24 37.5 QL(4 ea daily); *** F MG (Use Venlafaxine HCl) MP imipramine hcl tabs imipramine pamoate caps QL(3 ea daily) EFFEXOR XR CP24 75 *** QL(5 ea daily); F MG (Use Venlafaxine HCl) MP 100 mg QL(2 ea daily) FETZIMA CP24 F PA imipramine pamoate caps F 125 mg, 150 mg FETZIMA TITRATION PA F imipramine pamoate caps F QL(1 ea daily) PACK C4PK 75 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea NORPRAMIN TABS 10 MG *** alogliptin-pioglitazone tabs F (Use Desipramine HCl) daily); MP NORPRAMIN TABS 25 MG *** QL(2 ea daily) DUETACT TABS (Use PA (Use Desipramine HCl) Pioglitazone HCl- *** Glimepiride) nortriptyline hcl caps 10 F mg, 25 mg, 50 mg, 75 mg glipizide-metformin hcl tabs F MP nortriptyline hcl soln 10 F QL(20 ml daily) mg/5ml GLUCOVANCE TABS (Use *** MP Glyburide-Metformin) NORTRIPTYLINE HCL F QL(20 ml daily) SOLN 10 MG/5ML glyburide-metformin tabs F MP PAMELOR CAPS (Use *** Nortriptyline HCl) INVOKAMET TABS F PA protriptyline hcl tabs 10 mg F JANUMET TABS F PA SURMONTIL CAPS (Use *** PA PA Trimipramine Maleate) JANUMET XR TB24 F TOFRANIL TABS (Use *** PA; QL(2 ea Imipramine HCl) daily); AL(At trimipramine maleate caps F PA JENTADUETO TABS F least 18 yrs old); AGE QL(0 ANTIDIABETICS - Drugs to Regulate Blood to 90, 90 ea) PA; QL(2 ea Sugar JENTADUETO XR TB24 F daily) Alpha-Glucosidase Inhibitors KAZANO TABS *** PA; QL(2 ea acarbose tabs F QL(3 ea daily) daily); MP PA; QL(2 ea GLYSET TABS (Use *** PA KOMBIGLYZE XR TB24 F Miglitol) daily) PA OSENI TABS *** QL(1 ea daily); miglitol tabs F MP pioglitazone hcl-glimepiride PA PRECOSE TABS (Use *** QL(3 ea daily) F Acarbose) tabs Antidiabetic - Amylin Analogs pioglitazone hcl-metformin F QL(2 ea daily); hcl tabs MP PA; QL(11 ml SYMLINPEN 120 SOPN F per 30 days REPAGLINIDE/METFORM PA retail) IN HYDROCHLORIDE F TABS PA; QL(6 ml SYMLINPEN 60 SOPN F per 30 days Biguanides retail) FORTAMET TB24 (Use *** PA Antidiabetic Combinations Metformin HCl) ACTOPLUS MET TABS QL(2 ea daily); GLUCOPHAGE TABS 500 *** QL(4 ea daily); (Use Pioglitazone HCl- *** MP MG (Use Metformin HCl) MP Metformin HCl) GLUCOPHAGE TABS 850 MP PA MG, 1000 MG (Use *** ACTOPLUS MET XR TB24 F Metformin HCl) alogliptin-metformin hcl F PA; QL(2 ea tabs daily); MP ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPHAGE XR TB24 QL(4 ea daily); GLUCOSE CHEW 4GM- F 500 MG (Use Metformin *** MP 6MG, 4GM-4GM-6MG HCl) GLUCOSE INSTANT F GLUCOPHAGE XR TB24 QL(3 ea daily); ENERGY CHEW 750 MG (Use Metformin *** MP GNP GLUCOSE CHEW 4 F QL(50 ea per HCl) GM 30 days retail) GLUMETZA TB24 (Use PA *** GNP GLUCOSE CHEW F Metformin HCl) 4GM-6MG QL(4 ea daily); metformin hcl tabs 500 mg F GNP QUICK DISSOLVE F QL(50 ea per MP GLUCOSE CHEW 30 days retail) metformin hcl tabs 850 mg, MP F GOODSENSE GLUCOSE F 1000 mg CHEW QL(4 ea daily); metformin hcl tb24 500 mg F MP HM GLUCOSE CHEW F metformin hcl tb24 500 mg, F PA HY-VEE GLUCOSE CHEW F 1000 mg QL(3 ea daily); PA; SP metformin hcl tb24 750 mg F KORLYM TABS F MP KROGER GLUCOSE F Diabetic Other CHEW QL(50 ea per BD GLUCOSE CHEW F LEADER GLUCOSE F 30 days retail) CHEW CVS GLUCOSE CHEW 4 F QL(50 ea per LEADER QUICK QL(50 ea per GM 30 days retail) DISSOLVE GLUCOSE F 30 days retail) CVS GLUCOSE CHEW F CHEW 4GM-6MG LONGS GLUCOSE CHEW F DEX4 CHEW F MEIJER GLUCOSE CHEW F DEX4 FAST ACTING F GLUCOSE CHEW PREFERRED PLUS F DEX4 NATURALS CHEW F GLUCOSE CHEW PROGLYCEM SUSP F PA DEX4 POUCH PACK F CHEW PX GLUCOSE CHEW F DEX4 QUICK DISSOLVE F QL(50 ea per GLUCOSE CHEW 30 days retail) RA GLUCOSE CHEW F dextrose (diabetic use) gel F RELION GLUCOSE CHEW F Limit 1 SM GLUCOSE CHEW 4 QL(50 ea per GLUCAGEN HYPOKIT F package per F SOLR claim, 1 claim GM 30 days retail) per month SM GLUCOSE CHEW F Limit 1 4GM-6MG GLUCAGON package per F SMART SENSE F EMERGENCY KIT KIT claim, 1 claim GLUCOSE CHEW per month GLUCOSE CHEW 4 GM F QL(50 ea per 30 days retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SMART SENSE PA; QL(1.8 ml VICTOZA SOPN F GLUCOSE TABLETS F daily) CHEW Insulin Sensitizing Agents TGT GLUCOSE CHEW F ACTOS TABS (Use *** QL(1 ea daily); Pioglitazone HCl) MP UP & UP GLUCOSE F CHEW AVANDIA TABS F PA; QL(1 ea daily); MP VALUE PLUS GLUCOSE F QL(1 ea daily); CHEW pioglitazone hcl tabs F MP WALGREENS GLUCOSE F QL(50 ea per CHEW 4 GM 30 days retail) Insulin QL(40 ml per WALGREENS GLUCOSE F ADMELOG SOLN F CHEW 4GM-6MG 30 days retail) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ADMELOG SOLOSTAR F QL(30 ml per SOPN 30 days retail) QL(1 ea daily); alogliptin benzoate tabs F MP AFREZZA POWD F PA JANUVIA TABS F PA APIDRA SOLN F NESINA TABS (Use *** Alogliptin Benzoate) APIDRA SOLOSTAR F SOPN ONGLYZA TABS F PA BASAGLAR KWIKPEN F QL(30 ml per SOPN 30 days retail) TRADJENTA TABS F PA; MP FIASP FLEXTOUCH F SOPN Incretin Mimetic Agents (GLP-1 Receptor PA; QL(4 ea FIASP SOLN F per 28 days HUMALOG JUNIOR F QL(30 ml per BYDUREON PEN PEN F retail); AL(At KWIKPEN SOPN 30 days retail) least 18 yrs old) HUMALOG KWIKPEN F QL(30 ml per SOPN 100 UNIT/ML 30 days retail) PA; QL(4 ea per 28 days HUMALOG KWIKPEN F BYDUREON SRER F retail); AL(At SOPN 200 UNIT/ML least 18 yrs HUMALOG MIX 50/50 F QL(30 ml per old) KWIKPEN SUPN 30 days retail) PA; QL(2 ml HUMALOG MIX 50/50 F QL(40 ml per per 30 days SUSP 30 days retail) BYETTA SOPN 10 F retail); AL(At MCG/0.04ML HUMALOG MIX 75/25 F QL(30 ml per least 18 yrs KWIKPEN SUPN 30 days retail) old) HUMALOG MIX 75/25 F QL(40 ml per PA; QL(1 ml SUSP 30 days retail) per 30 days BYETTA SOPN 5 QL(30 ml per F retail); AL(At HUMALOG SOCT F MCG/0.02ML least 18 yrs 30 days retail) old) HUMALOG SOLN F QL(40 ml per 30 days retail) TANZEUM PEN F PA HUMULIN 70/30 KWIKPEN F QL(30 ml per SUPN 30 days retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(40 ml per NOVOLOG PENFILL QL(30 ml per HUMULIN 70/30 SUSP F F 30 days retail) SOCT 30 days retail) HUMULIN N KWIKPEN QL(30 ml per F NOVOLOG SOLN F QL(40 ml per SUPN 30 days retail) 30 days retail) QL(40 ml per TOUJEO MAX SOLOSTAR PA HUMULIN N SUSP F F 30 days retail) SOPN QL(40 ml per TOUJEO SOLOSTAR PA HUMULIN R SOLN F F 30 days retail) SOPN HUMULIN R U-500 F TRESIBA FLEXTOUCH F PA (CONCENTRATED) SOLN SOPN HUMULIN R U-500 F Meglitinide Analogues KWIKPEN SOPN QL(3 ea daily); nateglinide tabs F INSULIN LISPRO F QL(30 ml per MP KWIKPEN SOPN 30 days retail) PRANDIN TABS (Use *** PA INSULIN LISPRO SOLN F QL(40 ml per Repaglinide) 30 days retail) repaglinide tabs F PA LANTUS SOLOSTAR *** SOPN STARLIX TABS (Use *** QL(3 ea daily); LEVEMIR FLEXTOUCH F PA; QL(2 ml Nateglinide) MP SOPN daily) Sodium-Glucose Co-Transporter 2 (SGLT2) LEVEMIR SOLN F PA INVOKANA TABS F PA; MP NOVOLIN 70/30 FLEXPEN F QL(30 ml per RELION SUPN 30 days retail) JARDIANCE TABS F PA; QL(1 ea daily) NOVOLIN 70/30 FLEXPEN F QL(30 ml per SUPN 30 days retail) Sulfonylureas AMARYL TABS 1 MG, 2 QL(4 ea daily); NOVOLIN 70/30 RELION F QL(40 ml per *** SUSP 30 days retail) MG (Use Glimepiride) MP AMARYL TABS 4 MG (Use QL(2 ea daily); NOVOLIN 70/30 SUSP F QL(40 ml per *** 30 days retail) Glimepiride) MP CHLORPROPAMIDE NOVOLIN N RELION F QL(40 ml per F SUSP 30 days retail) TABS QL(4 ea daily); NOVOLIN N SUSP F QL(40 ml per glimepiride tabs 1 mg, 2 mg F 30 days retail) MP QL(2 ea daily); NOVOLIN R RELION F QL(40 ml per glimepiride tabs 4 mg F SOLN 30 days retail) MP MP NOVOLIN R SOLN F QL(40 ml per glipizide tabs F 30 days retail) glipizide tb24 F MP NOVOLOG FLEXPEN F QL(30 ml per SOPN 30 days retail) GLUCOTROL TABS (Use *** MP NOVOLOG MIX 70/30 QL(30 ml per Glipizide) PREFILLED FLEXPEN F 30 days retail) SUPN GLUCOTROL XL TB24 *** MP (Use Glipizide) NOVOLOG MIX 70/30 F QL(40 ml per SUSP 30 days retail) glyburide micronized tabs F MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits glyburide tabs F MP bismuth subsalicylate susp F 525 mg/15ml GLYNASE TABS (Use MP *** bismuth subsalicylate tabs F Glyburide Micronized) 262 mg TOLAZAMIDE TABS F CHILDRENS PROBIOTIC F RX/OTC PEARLS CAPS TOLBUTAMIDE TABS F CULTURELLE RX/OTC ADVANCED IMMUNE F ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs DEFENSE CAPS to Treat Diarrhea CULTURELLE PRO-WELL F RX/OTC Antidiarrheal - Chloride Channel Antagonists CAPS PA CVS ADULT 50+ F RX/OTC MYTESI TBEC F PROBIOTIC CAPS Antidiarrheal/Probiotic Agents - Misc. CVS ADULT PROBIOTIC F RX/OTC CAPS ACIDOPHILUS CAPS F RX/OTC CVS DIGESTIVE F RX/OTC PROBIOTIC CAPS ACIDOPHILUS HIGH- F RX/OTC POTENCY CAPS CVS MOOD SUPPORT F RX/OTC PROBIOTIC CAPS ACIDOPHILUS PEARLS F RX/OTC CAPS CVS PROBIOTIC CAPS F RX/OTC ACIDOPHILUS F RX/OTC PROBIOTIC BLEND CAPS CVS PROBIOTIC RX/OTC F ACIDOPHILUS SUPER RX/OTC MAXIMUM STRENGTH F CAPS PROBIOTIC CAPS ACIDOPHILUS/GOAT RX/OTC CVS PROBIOTIC PEARLS F RX/OTC F EXTRA STRENGTH CAPS MILK CAPS ADVANCED PROBIOTIC RX/OTC CVS SENIOR PROBIOTIC F RX/OTC F CAPS 10 CAPS DAILY PROBIOTIC CAPS F RX/OTC ADVANCED PROBIOTIC F RX/OTC CAPS DIFF-STAT CAPS F RX/OTC ALIGN CAPS F RX/OTC DIGESTIVE ADVANTAGE F RX/OTC ALIGN EXTRA F RX/OTC CAPS STRENGTH CAPS DIGESTIVE ADVANTAGE RX/OTC ALOE 10000 & F RX/OTC LACTOSE DEFENSE F PROBIOTICS CAPS FORMULA CAPS BACID CAPS F RX/OTC EQ PROBIOTIC RX/OTC DIGESTIVE SYSTEM F BIOHM PROBIOTIC F RX/OTC SUPPORT CAPS SUPPLEMENT CAPS EQL DAILY PROBIOTIC F RX/OTC BIOHM PROBIOTIC RX/OTC CAPS SUPPLEMENT/VITAMIN C F EQL PROBIOTIC COLON RX/OTC CAPS F SUPPORT CAPS bismuth subsalicylate chew F 262 mg FLORA VANCE CAPS F RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLORAJEN ACIDOPHILUS F PHILLIPS COLON F RX/OTC CAPS HEALTH CAPS FLORAJEN BIFIDOBLEND F RX/OTC PREORBOTIC CAPS F RX/OTC CAPS RX/OTC PRO-BIOTIC BLEND F RX/OTC FLORAJEN3 CAPS F CAPS FLORAJEN4KIDS CAPS F RX/OTC PRO-FLORA IMMUNE F RX/OTC CAPS FORTIFY DAILY RX/OTC F PROBIOMAX DAILY DF F RX/OTC PROBIOTIC CAPS CAPS GNP ACIDOPHILUS HIGH F RX/OTC PROBIOTIC & RX/OTC POTENCY CAPS ACIDOPHILUS FORMULA F EXTRA STRENGTH CAPS GNP PROBIOTIC COLON F RX/OTC SUPPORT CAPS PROBIOTIC + OMEGA-3 F RX/OTC CAPS HIGH POTENCY F RX/OTC PROBIOTIC CAPS PROBIOTIC RX/OTC F HM ACIDOPHILUS CAPS F RX/OTC ACIDOPHILUS BEADS CAPS RX/OTC LACTO-PECTIN CAPS F PROBIOTIC F RX/OTC ACIDOPHILUS CAPS lactobacillus caps F PROBIOTIC ADVANCED F RX/OTC ULTRAPOTENCY CAPS lactobacillus tabs F PROBIOTIC CAPS F RX/OTC RX/OTC MEGA PROBIOTIC CAPS F PROBIOTIC CAPS F META BIOTIC/BIO- RX/OTC F PROBIOTIC COLON F RX/OTC ACTIVE 12 CAPS SUPPORT CAPS NATRUL PROBIOTIC F RX/OTC PROBIOTIC RX/OTC CAPS COMPLEX/ACIDOPHILUS F PEARLS IC CAPS F RX/OTC CAPS RX/OTC PEPTO BISMOL TABS PROBIOTIC DAILY CAPS F (Use Bismuth *** PROBIOTIC GOLD EXTRA F Subsalicylate) STRENGTH CAPS PEPTO-BISMOL CHEW PROBIOTIC MATURE F RX/OTC 262 MG (Use Bismuth *** ADULT CAPS Subsalicylate) PROBIOTIC PEARLS F RX/OTC PEPTO-BISMOL ADVANTAGE CAPS INSTACOOL CHEW (Use *** Bismuth Subsalicylate) PROBIOTIC PEARLS F RX/OTC CAPS PEPTO-BISMOL MAX STRENGTH SUSP (Use *** PROBIOTIC+TURMERIC F RX/OTC Bismuth Subsalicylate) EXTRACT CAPS PEPTO-BISMOL TO-GO PROBIOTIC-10 CAPS F RX/OTC CHEW (Use Bismuth *** Subsalicylate) PROBIOTIC-10 ULTIMATE F RX/OTC CAPS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRODIGEN CAPS F RX/OTC IMODIUM MULTI- SYMPTOM RELIEF TABS *** PROVAD CAPS F RX/OTC (Use Loperamide- Simethicone) RA PROBIOTIC COLON RX/OTC F F CARE CAPS KALA TABS loperamide-simethicone RA PROBIOTIC F RX/OTC F COMPLEX CAPS tabs RA PROBIOTIC RX/OTC Antiperistaltic Agents DIGESTIVE SUPPORT F diphenoxylate w/ atropine F CAPS tabs RA PROBIOTIC MAXIMUM RX/OTC F DIPHENOXYLATE/ATROP F STRENGTH CAPS INE LIQD REPHRESH PRO-B CAPS F IMODIUM A-D CAPS 2 MG *** QL(8 ea daily); (Use Loperamide HCl) RX/OTC RX/OTC RESTORA CAPS F IMODIUM A-D LIQD 1 RX/OTC MG/7.5ML (Use *** RISAQUAD CAPS F Loperamide HCl) RX/OTC IMODIUM A-D TABS 2 MG *** QL(8 ea daily) RISAQUAD-2 CAPS F (Use Loperamide HCl) LOMOTIL TABS (Use SD PROBIOTIC-10 F RX/OTC *** COMPLEXULTRA CAPS Diphenoxylate w/ Atropine) QL(8 ea daily); SM ACIDOPHILUS F RX/OTC loperamide hcl caps 2 mg F PEARLS CAPS RX/OTC loperamide hcl liqd 1 QL(40 ml daily) F RX/OTC F SUPER PROBIOTIC CAPS mg/5ml SUPER PROBIOTIC RX/OTC loperamide hcl liqd 1 F DIGESTIVE SUPPORT F mg/7.5ml CAPS loperamide hcl susp 1 F TRUBIOTICS CAPS F RX/OTC mg/7.5ml loperamide hcl tabs 2 mg F QL(8 ea daily) TRUNATURE DIGESTIVE F RX/OTC PROBIOTIC CAPS MOTOFEN TABS F PA ULTRAFLORA IMMUNE F RX/OTC HEALTH CAPS opium tincture tinc F PA VISBIOME PROBIOTIC F RX/OTC HIGH POTENCY CAPS PAREGORIC TINC F PA VSL#3 CAPS F RX/OTC ANTIDOTES AND SPECIFIC ANTAGONISTS ZELAC CAPS F RX/OTC Antidotes - Chelating Agents Antidiarrheal/Probiotic Combinations CHEMET CAPS F ACIDOPHILUS/CITRUS F PECTIN TABS deferasirox tbso F PA; SP

EXJADE TBSO (Use *** PA; SP Deferasirox) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERRIPROX TABS F PA; SP ZOFRAN ODT TBDP (Use *** QL(2 ea daily) Ondansetron) PA; SP JADENU TABS F ZOFRAN SOLN 4 MG/5ML *** QL(50 ml per (Use Ondansetron HCl) 30 days retail) Antidotes and Specific Antagonists ZOFRAN TABS 4 MG, 8 QL(2 ea daily) MG (Use Ondansetron *** SM IPECAC SYRUP SYRP F HCl) VISTOGARD PACK F ZUPLENZ FILM F PA Opioid Antagonists Antiemetics - Anticholinergic PA QL(24 ea per EVZIO SOAJ F dimenhydrinate tabs F fill retail) NALOXONE HCL SOCT QL(24 ea per F DRAMAMINE CHEW F 0.4 MG/ML fill retail) naloxone hcl soln 0.4 F DRAMAMINE TABS (Use *** QL(24 ea per mg/ml, 4 mg/10ml Dimenhydrinate) fill retail) NALOXONE HCL SOSY 2 F QL(4 ml per 90 MG/2ML days retail) meclizine hcl chew 25 mg F naltrexone hcl tabs F meclizine hcl tabs 25 mg, F RX/OTC 12.5 mg NARCAN LIQD F QL(2 ea per 60 PA days retail) scopolamine pt72 F VIVITROL SUSR F TIGAN CAPS (Use *** Trimethobenzamide HCl) ANTIEMETICS - Drugs to Treat Nausea and TRANSDERM SCOP PT72 F PA Vomiting 5-HT3 Receptor Antagonists TRANSDERM-SCOP PT72 F PA PA ANZEMET TABS F TRANSDERM-SCOP PT72 *** PA (Use Scopolamine) granisetron hcl tabs F PA trimethobenzamide hcl F caps ondansetron hcl soln ij 4 F mg/2ml, 40 mg/20ml Antiemetics - Miscellaneous ondansetron hcl soln or 4 F QL(50 ml per CESAMET CAPS F PA mg/5ml 30 days retail) DICLEGIS TBEC 10MG- PA ondansetron hcl tabs or 24 F QL(1 ea per 14 F mg days retail) 10MG ondansetron hcl tabs or 4 F QL(2 ea daily) dronabinol caps F mg, 8 mg EMETROL SOLN (Use ONDANSETRON F HYDROCHLORIDE SOLN Fructose-Dextrose- *** Phosphoric Acid) ondansetron tbdp F QL(2 ea daily) fructose-dextrose- F phosphoric acid liqd SANCUSO PTCH F PA fructose-dextrose- F phosphoric acid soln

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MARINOL CAPS (Use *** fluconazole susr 40 mg/ml F Dronabinol) Substance P/Neurokinin 1 (NK1) Receptor fluconazole tabs 100 mg, F 200 mg PA aprepitant caps F QL(2 ea per fill fluconazole tabs 150 mg F retail) EMEND CAPS (Use PA *** QL(3 ea per 14 Aprepitant) fluconazole tabs 50 mg F days retail) EMEND TRIPACK CAPS *** PA (Use Aprepitant) itraconazole caps F PA

ANTIFUNGALS - Drugs to Treat Fungal Infections itraconazole soln F PA Antifungals ketoconazole tabs F QL(1 ea daily) ANCOBON CAPS (Use *** PA Flucytosine) NOXAFIL SUSP F PA flucytosine caps F PA NOXAFIL TBEC F PA GRIS-PEG TABS (Use *** Griseofulvin Ultramicrosize) ONMEL TABS F PA griseofulvin microsize susp F SPORANOX CAPS (Use *** PA Itraconazole) griseofulvin microsize tabs F SPORANOX PULSEPAK *** PA CAPS (Use Itraconazole) griseofulvin ultramicrosize F tabs SPORANOX SOLN (Use *** PA QL(1 ea Itraconazole) LAMISIL TABS (Use *** daily,90 ea per Terbinafine HCl) VFEND SUSR (Use *** PA 120 days retail) Voriconazole) QL(6 ea daily) nystatin tabs F VFEND TABS (Use *** PA Voriconazole) QL(1 ea PA terbinafine hcl tabs F daily,90 ea per voriconazole susr F 120 days retail) voriconazole tabs F PA Imidazole-Related Antifungals DIFLUCAN SUSR 10 *** QL(70 ml per ANTIHISTAMINES - Drugs to Treat Allergies MG/ML (Use Fluconazole) fill retail) Antihistamines - Alkylamines DIFLUCAN SUSR 40 *** MG/ML (Use Fluconazole) CHLOR-TRIMETON ALLERGY TBCR (Use *** DIFLUCAN TABS 100 MG, *** 200 MG (Use Fluconazole) Chlorpheniramine Maleate) CHLOR-TRIMETON SYRP DIFLUCAN TABS 150 MG *** QL(2 ea per fill (Use Fluconazole) retail) 2 MG/5ML (Use *** Chlorpheniramine Maleate) DIFLUCAN TABS 50 MG *** QL(3 ea per 14 (Use Fluconazole) days retail) CHLOR-TRIMETON TABS QL(120 ea per QL(70 ml per 4 MG (Use *** fill retail) fluconazole susr 10 mg/ml F fill retail) Chlorpheniramine Maleate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chlorpheniramine maleate F SILPHEN COUGH SYRP F QL(240 ml per syrp 2 mg/5ml fill retail) chlorpheniramine maleate F QL(120 ea per TAVIST ALLERGY TABS *** QL(2 ea daily) tabs 4 mg fill retail) (Use Clemastine Fumarate) chlorpheniramine maleate F Antihistamines - Non-Sedating tbcr 12 mg ALLEGRA ALLERGY DEXCHLORPHENIRAMIN F CHILDRENS SUSP (Use *** E MALEATE SOLN Fexofenadine HCl) ED CHLORPED LIQD F ALLEGRA ALLERGY TABS (Use Fexofenadine *** RYCLORA SOLN F HCl) cetirizine hcl caps 10 mg F Antihistamines - Ethanolamines ALER-DRYL TABS F QL(4 ea daily) cetirizine hcl chew 5 mg, 10 F QL(1 ea daily) mg BENADRYL ALLERGY QL(4 ea daily) QL(240 ml per CAPS (Use *** cetirizine hcl soln 1 mg/ml, F fill retail); 5 mg/5ml Diphenhydramine HCl) RX/OTC BENADRYL ALLERGY QL(240 ml per CHILDRENS CHEW 12.5 cetirizine hcl syrp 1 mg/ml, F fill retail); *** 5 mg/5ml MG (Use Diphenhydramine RX/OTC HCl) cetirizine hcl tabs 5 mg, 10 F QL(1 ea daily) BENADRYL ALLERGY QL(240 ml per mg CHILDRENS LIQD 12.5 fill retail) *** CLARINEX SYRP 0.5 F PA MG/5ML (Use MG/ML Diphenhydramine HCl) CLARINEX TABS 5 MG *** PA BENADRYL ALLERGY QL(4 ea daily) (Use Desloratadine) TABS (Use *** Diphenhydramine HCl) CLARITIN ALLERGY QL(240 ml per CHILDRENS SYRP (Use *** fill retail) carbinoxamine maleate F PA Loratadine) tabs CLARITIN CAPS 10 MG *** clemastine fumarate tabs F QL(2 ea daily) (Use Loratadine) 1.34 mg CLARITIN CHEW 5 MG *** CLEMASTINE FUMARATE F TABS 2.68 MG CLARITIN CHEW 5 MG *** diphenhydramine hcl caps F QL(4 ea daily) (Use Loratadine) 25 mg, 50 mg CLARITIN CHILDRENS *** diphenhydramine hcl chew F CHEW (Use Loratadine) 12.5 mg CLARITIN REDITABS QL(1 ea daily) QL(240 ml per TBDP 10 MG (Use *** diphenhydramine hcl elix F fill retail); 12.5 mg/5ml Loratadine) RX/OTC CLARITIN REDITABS F PA diphenhydramine hcl liqd QL(240 ml per TBDP 5 MG 25 mg/10ml, 50 mg/20ml, F fill retail) CLARITIN SYRP 5 *** QL(240 ml per 12.5 mg/5ml MG/5ML (Use Loratadine) fill retail) diphenhydramine hcl tabs F QL(4 ea daily) 25 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLARITIN TABS 10 MG *** QL(1 ea daily) Antihistamines - Piperidines (Use Loratadine) cyproheptadine hcl syrp F DESLORATADINE ODT F PA TBDP cyproheptadine hcl tabs F desloratadine tabs F PA ANTIHYPERLIPIDEMICS - Drugs to Treat High fexofenadine hcl susp F Cholesterol Antihyperlipidemics - Combinations fexofenadine hcl tabs F ezetimibe-simvastatin tabs F ST levocetirizine F ST; RX/OTC dihydrochloride tabs VYTORIN TABS (Use *** ST Ezetimibe-Simvastatin) loratadine caps 10 mg F Antihyperlipidemics - Misc. loratadine chew 5 mg F KYNAMRO SOSY F PA; SP QL(240 ml per loratadine soln 5 mg/5ml F LOVAZA CAPS (Use *** PA fill retail) Omega-3-acid Ethyl Esters) QL(240 ml per loratadine syrp 5 mg/5ml F omega-3-acid ethyl esters F PA fill retail) caps QL(1 ea daily) loratadine tabs 10 mg F VASCEPA CAPS F PA QL(1 ea daily) loratadine tbdp 10 mg F Bile Acid Sequestrants XYZAL ALLERGY 24HR ST; RX/OTC cholestyramine light pack F MP TABS (Use Levocetirizine *** Dihydrochloride) cholestyramine light powd F MP XYZAL TABS (Use ST; RX/OTC Levocetirizine *** cholestyramine pack F MP Dihydrochloride) cholestyramine powd F MP ZYRTEC ALLERGY CAPS *** (Use Cetirizine HCl) colesevelam hcl pack F PA ZYRTEC ALLERGY TABS *** QL(1 ea daily) (Use Cetirizine HCl) PA ZYRTEC CHILDRENS QL(240 ml per colesevelam hcl tabs F ALLERGY SOLN (Use *** fill retail); COLESTID FLAVORED *** PA; MP Cetirizine HCl) RX/OTC GRAN (Use Colestipol HCl) Antihistamines - Phenothiazines COLESTID FLAVORED *** PA; MP PACK (Use Colestipol HCl) promethazine hcl soln or F AL(At least 2 6.25 mg/5ml yrs old) COLESTID GRAN 5 GM *** PA; MP QL(12 ea per (Use Colestipol HCl) promethazine hcl supp re F fill retail); AL(At COLESTID PACK 5 GM PA; MP 25 mg, 50 mg, 12.5 mg *** least 2 yrs old) (Use Colestipol HCl) promethazine hcl syrp or F AL(At least 2 COLESTID TABS 1 GM *** MP 6.25 mg/5ml yrs old) (Use Colestipol HCl) promethazine hcl tabs or F AL(At least 2 colestipol hcl gran 5 gm F PA; MP 25 mg, 50 mg, 12.5 mg yrs old)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits colestipol hcl pack 5 gm F PA; MP TRICOR TABS (Use *** PA; MP Fenofibrate) MP colestipol hcl tabs 1 gm F TRIGLIDE TABS F QL(1 ea daily); MP QUESTRAN LIGHT POWD MP *** TRILIPIX CPDR (Use *** PA (Use Cholestyramine Light) Choline Fenofibrate) QUESTRAN PACK (Use *** MP Cholestyramine) HMG CoA Reductase Inhibitors PA QUESTRAN POWD (Use *** MP ALTOPREV TB24 F Cholestyramine) atorvastatin calcium tabs F MP WELCHOL PACK (Use *** PA 10 mg, 20 mg Colesevelam HCl) atorvastatin calcium tabs F QL(1 ea daily); WELCHOL TABS (Use *** PA 40 mg, 80 mg MP Colesevelam HCl) CRESTOR TABS (Use *** ST; QL(1 ea Fibric Acid Derivatives Rosuvastatin Calcium) daily) PA ANTARA CAPS F fluvastatin sodium caps F PA PA choline fenofibrate cpdr F fluvastatin sodium tb24 F PA FENOFIBRATE CAPS 50 PA; MP F LESCOL XL TB24 (Use *** PA MG, 150 MG Fluvastatin Sodium) fenofibrate micronized caps F QL(1 ea daily); LIPITOR TABS 10 MG, 20 MP 134 mg, 200 mg MP MG (Use Atorvastatin *** Calcium) fenofibrate micronized caps F PA 43 mg, 130 mg LIPITOR TABS 40 MG, 80 QL(1 ea daily); MG (Use Atorvastatin *** MP fenofibrate micronized caps F QL(2 ea daily); 67 mg MP Calcium) QL(1 ea daily); PA fenofibrate tabs 160 mg F LIVALO TABS F MP lovastatin tabs 10 mg, 20 QL(1 ea daily); FENOFIBRATE TABS 160 F QL(1 ea daily); F MG MP mg MP QL(2 ea daily); fenofibrate tabs 48 mg, 145 F PA; MP lovastatin tabs 40 mg F mg MP QL(3 ea daily); PRAVACHOL TABS (Use QL(1 ea daily); fenofibrate tabs 54 mg F *** MP Pravastatin Sodium) MP QL(1 ea daily); PA pravastatin sodium tabs F FENOFIBRIC ACID TABS F MP ST; QL(1 ea FIBRICOR TABS F PA rosuvastatin calcium tabs F daily) QL(2 ea daily); gemfibrozil tabs F simvastatin tabs 5 mg, 10 F QL(1 ea daily); MP mg, 20 mg, 40 mg MP PA; MP PA; QL(1 ea LIPOFEN CAPS F simvastatin tabs 80 mg F daily); MP LOFIBRA CAPS (Use *** QL(1 ea daily); ZOCOR TABS 5 MG, 10 QL(1 ea daily); Fenofibrate Micronized) MP MG, 20 MG, 40 MG (Use *** MP LOPID TABS (Use *** QL(2 ea daily); Simvastatin) Gemfibrozil) MP ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOCOR TABS 80 MG (Use *** PA; QL(1 ea LOTENSIN TABS 40 MG *** QL(2 ea daily); Simvastatin) daily); MP (Use Benazepril HCl) MP Intestinal Cholesterol Absorption Inhibitors moexipril hcl tabs F ezetimibe tabs F ST perindopril erbumine tabs F ZETIA TABS (Use *** ST Ezetimibe) PRINIVIL TABS (Use *** MP Lisinopril) Microsomal Triglyceride Transfer Protein (MTP) quinapril hcl tabs F MP JUXTAPID CAPS F PA; SP QL(2 ea daily); ramipril caps F Nicotinic Acid Derivatives MP trandolapril tabs 1 mg, 2 QL(1 ea daily); niacin (antihyperlipidemic) F F tbcr mg MP QL(2 ea daily); MP trandolapril tabs 4 mg F NIACIN TABS 500 MG F MP MP NIACOR TABS F VASOTEC TABS (Use *** QL(2 ea daily); Enalapril Maleate) MP NIASPAN TBCR (Use *** ZESTRIL TABS (Use *** MP Niacin (Antihyperlipidemic)) Lisinopril) ANTIHYPERTENSIVES - Drugs to Treat High Agents for Pheochromocytoma Blood Pressure DEMSER CAPS F PA; SP ACE Inhibitors ACCUPRIL TABS (Use *** MP Angiotensin II Receptor Antagonists Quinapril HCl) ATACAND TABS (Use *** ACEON TABS (Use *** Candesartan Cilexetil) Perindopril Erbumine) AVAPRO TABS (Use *** QL(1 ea daily); ALTACE CAPS (Use *** QL(2 ea daily); Irbesartan) MP Ramipril) MP BENICAR TABS (Use ST QL(2 ea daily); *** benazepril hcl tabs 40 mg F Olmesartan Medoxomil) MP candesartan cilexetil tabs F benazepril hcl tabs 5 mg, F QL(1 ea daily); 10 mg, 20 mg MP COZAAR TABS (Use *** QL(1 ea daily); QL(3 ea daily); Losartan Potassium) MP captopril tabs F MP DIOVAN TABS (Use *** QL(1 ea daily); QL(2 ea daily); Valsartan) MP enalapril maleate tabs F MP EPROSARTAN F PA MESYLATE TABS EPANED SOLN F QL(1 ea daily); QL(1 ea daily); irbesartan tabs F fosinopril sodium tabs F MP MP QL(1 ea daily); losartan potassium tabs F lisinopril tabs F MP MP MICARDIS TABS (Use *** QL(1 ea daily) LOTENSIN TABS 10 MG, QL(1 ea daily); Telmisartan) 20 MG (Use Benazepril *** MP ST HCl) olmesartan medoxomil tabs F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits telmisartan tabs F QL(1 ea daily) benazepril & F QL(1 ea daily); hydrochlorothiazide tabs MP QL(1 ea daily); valsartan tabs F BENICAR HCT TABS (Use ST MP Olmesartan Medoxomil- *** Antiadrenergic Antihypertensives Hydrochlorothiazide) bisoprolol & QL(1 ea daily); CARDURA TABS (Use *** MP F Doxazosin Mesylate) hydrochlorothiazide tabs MP candesartan cilexetil- CATAPRES TABS (Use *** MP F Clonidine HCl) hydrochlorothiazide tabs CAPTOPRIL/HYDROCHL QL(2 ea daily); clonidine hcl tabs F MP OROTHIAZIDE TABS F MP 25MG-15MG, 25MG- doxazosin mesylate tabs or F MP 1 mg, 2 mg, 4 mg, 8 mg 25MG, 50MG-15MG MP CAPTOPRIL/HYDROCHL QL(3 ea daily); guanfacine hcl tabs F OROTHIAZIDE TABS F MP 50MG-25MG methyldopa tabs F MP CLORPRES TABS F PA MINIPRESS CAPS (Use *** MP Prazosin HCl) CORZIDE TABS 40MG- MP 5MG (Use Nadolol & *** prazosin hcl caps F Bendroflumethiazide) MP CORZIDE TABS 80MG- F terazosin hcl caps F 5MG Antihypertensive Combinations DIOVAN HCT TABS (Use QL(1 ea daily); Valsartan- *** MP ACCURETIC TABS (Use QL(2 ea daily) Hydrochlorothiazide) Quinapril- *** Hydrochlorothiazide) DUTOPROL TB24 25MG- F QL(1 ea daily); 12.5MG MP amlodipine besylate- F QL(1 ea daily); benazepril hcl caps MP DUTOPROL TB24 50MG- F QL(1 ea daily) 12.5MG, 100MG-12.5MG amlodipine besylate- F ST olmesartan medoxomil tabs EDARBYCLOR TABS F PA amlodipine besylate- ST F enalapril maleate & F QL(2 ea daily); valsartan tabs hydrochlorothiazide tabs MP amlodipine-valsartan- F ST EXFORGE HCT TABS ST hydrochlorothiazide tabs (Use Amlodipine-Valsartan- *** ATACAND HCT TABS Hydrochlorothiazide) (Use Candesartan Cilexetil- *** EXFORGE TABS (Use ST Hydrochlorothiazide) Amlodipine Besylate- *** atenolol & chlorthalidone F QL(2 ea daily); Valsartan) tabs MP fosinopril sodium & F QL(1 ea daily); AVALIDE TABS (Use QL(1 ea daily); hydrochlorothiazide tabs MP Irbesartan- *** MP HYZAAR TABS (Use QL(1 ea daily); Hydrochlorothiazide) Losartan Potassium & *** MP AZOR TABS (Use ST Hydrochlorothiazide) Amlodipine Besylate- *** irbesartan- F QL(1 ea daily); Olmesartan Medoxomil) hydrochlorothiazide tabs MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lisinopril & F MP TARKA TBCR (Use hydrochlorothiazide tabs Trandolapril-Verapamil *** LOPRESSOR HCT TABS QL(2 ea daily); HCl) (Use Metoprolol & *** MP TEKTURNA HCT TABS F PA Hydrochlorothiazide) losartan potassium & F QL(1 ea daily); telmisartan-amlodipine tabs F hydrochlorothiazide tabs MP LOTENSIN HCT TABS QL(1 ea daily); telmisartan- F QL(1 ea daily) (Use Benazepril & *** MP hydrochlorothiazide tabs Hydrochlorothiazide) TENORETIC 100 TABS QL(2 ea daily); LOTREL CAPS (Use QL(1 ea daily); (Use Atenolol & *** MP Amlodipine Besylate- *** MP Chlorthalidone) Benazepril HCl) TENORETIC 50 TABS QL(2 ea daily); (Use Atenolol & *** MP METHYLDOPA/HYDROCH F LOROTHIAZIDE TABS Chlorthalidone) trandolapril-verapamil hcl metoprolol & F QL(2 ea daily); F hydrochlorothiazide tabs MP tbcr METOPROLOL QL(1 ea daily); TRANDOLAPRIL/VERAPA F MIL HCL ER TBCR SUCCINATE F MP ER/HYDROCHLOROTHIA TRIBENZOR TABS (Use ST ZIDE TB24 25MG-12.5MG Olmesartan Medoxomil- *** METOPROLOL QL(1 ea daily) Amlodipine- SUCCINATE Hydrochlorothiazide) ER/HYDROCHLOROTHIA F TWYNSTA TABS (Use *** ZIDE TB24 50MG-12.5MG, Telmisartan-Amlodipine) 100MG-12.5MG valsartan- F QL(1 ea daily); hydrochlorothiazide tabs MP METOPROLOL/HYDROCH F QL(1 ea daily); LOROTHIAZIDE TABS MP VASERETIC TABS (Use QL(2 ea daily); MICARDIS HCT TABS QL(1 ea daily) Enalapril Maleate & *** MP (Use Telmisartan- *** Hydrochlorothiazide) Hydrochlorothiazide) ZESTORETIC TABS (Use MP Lisinopril & *** moexipril- F QL(2 ea daily) hydrochlorothiazide tabs Hydrochlorothiazide) ZIAC TABS (Use Bisoprolol QL(1 ea daily); nadolol & F *** bendroflumethiazide tabs & Hydrochlorothiazide) MP NADOLOL/BENDROFLUM F Antihypertensives - Misc. ETHIAZIDE TABS PA; SP olmesartan medoxomil- ST VECAMYL TABS F amlodipine- F Direct Renin Inhibitors hydrochlorothiazide tabs aliskiren fumarate tabs F PA olmesartan medoxomil- F ST hydrochlorothiazide tabs TEKTURNA TABS 150 F PA PROPRANOLOL/HYDROC F QL(2 ea daily); MG, 300 MG HLOROTHIAZIDE TABS MP TEKTURNA TABS 150 PA quinapril- F QL(2 ea daily) MG, 300 MG (Use Aliskiren *** hydrochlorothiazide tabs Fumarate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Selective Aldosterone Receptor Antagonists quinine sulfate caps F eplerenone tabs F ANTIMYASTHENIC/CHOLINERGIC AGENTS INSPRA TABS (Use *** Eplerenone) Antimyasthenic/Cholinergic Agents Vasodilators FIRDAPSE TABS F PA; SP MP hydralazine hcl tabs F GUANIDINE HCL TABS F PA QL(10 ea minoxidil tabs 10 mg F MESTINON SYRP (Use *** daily); MP Pyridostigmine Bromide) QL(3 ea daily); minoxidil tabs 2.5 mg F MESTINON TABS (Use *** MP Pyridostigmine Bromide) ANTIMALARIALS - Drugs to Treat Malaria MESTINON TIMESPAN (Parasitic Infections) TBCR (Use Pyridostigmine *** Antimalarial Combinations Bromide) pyridostigmine bromide atovaquone-proguanil hcl F PA F tabs soln pyridostigmine bromide COARTEM TABS F QL(24 ea per F fill retail) tabs MALARONE TABS (Use *** PA pyridostigmine bromide tbcr F Atovaquone-Proguanil HCl) ANTIMYCOBACTERIAL AGENTS - Drugs to Antimalarials Treat Tuberculosis (Bacterial Infections) CHLOROQUINE PHOSPHATE TABS 250 F Anti TB Combinations MG RIFAMATE CAPS F PA chloroquine phosphate F QL(1 ea daily) tabs 500 mg RIFATER TABS F PA PA; SP DARAPRIM TABS F Antimycobacterial Agents hydroxychloroquine sulfate F MP cycloserine caps F PA tabs MP mefloquine hcl tabs F ethambutol hcl tabs F ISONIAZID SYRP 50 F MP MEFLOQUINE HCL TABS F MG/5ML PLAQUENIL TABS (Use MP isoniazid tabs 100 mg, 300 F MP Hydroxychloroquine *** mg Sulfate) MYAMBUTOL TABS (Use *** MP primaquine phosphate tabs F Ethambutol HCl) MYCOBUTIN CAPS (Use *** PRIMAQUINE Rifabutin) PHOSPHATE TABS (Use *** PA Primaquine Phosphate) PASER PACK F QUALAQUIN CAPS (Use *** PA Quinine Sulfate) PRIFTIN TABS F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyrazinamide tabs F methotrexate sodium soln ij 1 gm/40ml, 50 mg/2ml, 250 F rifabutin caps F mg/10ml METHOTREXATE RIFADIN CAPS (Use *** SODIUM SOLN IJ 250 F Rifampin) MG/10ML rifampin caps F methotrexate sodium tabs F or 2.5 mg PA SIRTURO TABS F PURIXAN SUSP F

TRECATOR TABS F TABLOID TABS F PA; SP

ANTINEOPLASTICS AND ADJUNCTIVE TREXALL TABS F THERAPIES - Drugs to Treat Cancer Alkylating Agents XELODA TABS (Use *** PA; SP Capecitabine) ALKERAN TABS (Use *** Melphalan) Antineoplastic - Antibodies PA; SP cyclophosphamide caps 25 F ADCETRIS SOLR F mg, 50 mg CYCLOPHOSPHAMIDE LIBTAYO SOLN F PA; SP CAPS 25 MG, 50 MG (Use *** Cyclophosphamide) LUMOXITI SOLR F PA; SP GLEOSTINE CAPS F UNITUXIN SOLN F PA; SP HEXALEN CAPS F PA ZEVALIN Y-90 KIT F PA; SP LEUKERAN TABS F Antineoplastic - Cellular Immunotherapy melphalan tabs F PROVENGE SUSP F PA; SP

MUSTARGEN SOLR F PA; SP Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS F PA; SP MYLERAN TABS F PA; SP TEMODAR CAPS OR 5 PA; SP ERIVEDGE CAPS F MG, 20 MG, 100 MG, 140 *** MG, 180 MG, 250 MG (Use Antineoplastic - Hormonal and Related Agents Temozolomide) abiraterone acetate tabs F PA; SP 250 mg TEMODAR SOLR IV 100 F PA; SP MG anastrozole tabs F temozolomide caps F PA; SP ARIMIDEX TABS (Use *** Anastrozole) Antimetabolites AROMASIN TABS (Use *** ST; SP capecitabine tabs F PA; SP Exemestane) QL(1 ea daily) mercaptopurine tabs F bicalutamide tabs F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CASODEX TABS (Use *** QL(1 ea daily) AFINITOR TABS F PA; SP Bicalutamide) PA; SP EMCYT CAPS F PA; SP BORTEZOMIB SOLR F PA; SP ERLEADA TABS F PA; SP BOSULIF TABS F PA; SP exemestane tabs F ST; SP CALQUENCE CAPS F PA; SP FARESTON TABS (Use *** PA CAPRELSA TABS F Toremifene Citrate) PA; SP FEMARA TABS (Use *** PA COMETRIQ KIT F Letrozole) COPIKTRA CAPS F PA; SP flutamide caps F PA; SP PA; QL(41.67 COTELLIC TABS F HYDROXYPROGESTERO ml daily); AL(At NE CAPROATE SOLN IM F erlotinib hcl tabs F PA; SP 1.25 GM/5ML least 16 yrs old); SP GILOTRIF TABS F PA; SP letrozole tabs F PA GLEEVEC TABS (Use *** PA; SP LYSODREN TABS F SP Imatinib Mesylate) PA; SP megestrol acetate susp F IBRANCE CAPS F PA; SP megestrol acetate tabs F ICLUSIG TABS F IDHIFA TABS F PA; SP NILANDRON TABS (Use *** PA Nilutamide) imatinib mesylate tabs F PA; SP nilutamide tabs F PA IMBRUVICA CAPS 140 F PA; SP tamoxifen citrate tabs F MP MG PA IMBRUVICA TABS 140 PA; QL(1 ea toremifene citrate tabs F MG, 280 MG, 420 MG, 560 F daily) MG XTANDI CAPS F PA; SP INLYTA TABS F PA; SP ZYTIGA TABS (Use *** PA; SP Abiraterone Acetate) JAKAFI TABS F PA; SP Antineoplastic - Immunomodulators LORBRENA TABS F PA; SP POMALYST CAPS F PA; SP LYNPARZA TABS F PA; SP Antineoplastic Combinations PA; SP RITUXAN HYCELA SOLN F PA; SP MEKINIST TABS F PA; SP Antineoplastic Enzyme Inhibitors NEXAVAR TABS F PA; SP AFINITOR DISPERZ TBSO F NINLARO CAPS F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPRYCEL TABS F PA; SP INTRON A SOLN F PA; SP

STIVARGA TABS F PA; SP INTRON A SOLR F PA; SP

SUTENT CAPS F PA; SP INTRON A W/DILUENT F PA; SP SOLR PA; SP TAFINLAR CAPS F MATULANE CAPS F PA; SP PA; SP TALZENNA CAPS F PHOTOFRIN SOLR F PA; SP TARCEVA TABS (Use *** PA; SP PA; SP Erlotinib HCl) PROLEUKIN SOLR F TASIGNA CAPS F PA; SP SYLATRON KIT F PA; SP

TYKERB TABS F PA; SP TARGRETIN CAPS (Use *** PA; SP Bexarotene) PA; SP VERZENIO TABS F tretinoin (chemotherapy) F PA; SP caps PA; SP VITRAKVI CAPS F TRISENOX SOLN F PA; SP PA; SP VITRAKVI SOLN F Chemotherapy Adjuncts PA; SP VIZIMPRO TABS F PA; SP KEPIVANCE SOLR F

VOTRIENT TABS F PA; SP Chemotherapy Rescue/Antidote Agents KHAPZORY SOLR F PA; SP XOSPATA TABS F PA; SP LEUCOVORIN CALCIUM F ZELBORAF TABS F PA; SP TABS OR 10 MG, 15 MG leucovorin calcium tabs or F ZOLINZA CAPS F PA; SP 5 mg, 25 mg Mitotic Inhibitors ZYDELIG TABS F PA; SP ETOPOSIDE CAPS F SP Antineoplastic Radiopharmaceuticals F PA; SP AZEDRA DOSIMETRIC F PA MARQIBO SUSP SOLN Topoisomerase I Inhibitors AZEDRA THERAPEUTIC F PA SOLN HYCAMTIN CAPS F PA; SP Antineoplastics Misc. ANTIPARKINSON AND RELATED THERAPY ACTIMMUNE SOLN F PA; SP AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Adjuvants bexarotene caps F PA; SP carbidopa tabs F PA HYDREA CAPS (Use *** Hydroxyurea) LODOSYN TABS (Use *** PA Carbidopa) hydroxyurea caps F Antiparkinson Anticholinergics ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benztropine mesylate tabs F MP PARLODEL TABS (Use *** Bromocriptine Mesylate) trihexyphenidyl hcl elix 0.4 F QL(16.7 ml pramipexole QL(3 ea daily); mg/ml daily); MP dihydrochloride tabs 0.125 F AL(At least 18 mg, 0.25 mg, 0.75 mg, 0.5 yrs old) trihexyphenidyl hcl tabs 2 F MP mg, 5 mg mg, 1 mg, 1.5 mg Antiparkinson COMT Inhibitors pramipexole PA dihydrochloride tb24 0.375 F COMTAN TABS (Use *** mg, 0.75 mg, 3 mg, 1.5 mg, Entacapone) 4.5 mg entacapone tabs F REQUIP TABS 0.25 MG QL(6 ea daily); (Use Ropinirole *** MP TASMAR TABS (Use *** PA Hydrochloride) Tolcapone) REQUIP TABS 0.5 MG, 1 QL(3 ea daily); tolcapone tabs F PA MG, 2 MG (Use Ropinirole *** MP Hydrochloride) Antiparkinson Dopaminergics REQUIP TABS 3 MG, 4 QL(6 ea daily) amantadine hcl caps 100 F MP MG (Use Ropinirole *** mg Hydrochloride) amantadine hcl syrp 50 MP F REQUIP TABS 5 MG (Use *** QL(3 ea daily) mg/5ml Ropinirole Hydrochloride) amantadine hcl tabs 100 PA; MP F REQUIP XL TB24 (Use *** PA mg Ropinirole Hydrochloride) bromocriptine mesylate F ropinirole hydrochloride F QL(6 ea daily); caps tabs 0.25 mg MP bromocriptine mesylate F ropinirole hydrochloride F QL(3 ea daily); tabs tabs 0.5 mg, 1 mg, 2 mg MP carbidopa-levodopa tabs MP ropinirole hydrochloride F QL(6 ea daily) 10mg-100mg, 25mg- F tabs 3 mg, 4 mg 100mg, 25mg-250mg ropinirole hydrochloride F QL(3 ea daily) carbidopa-levodopa tbcr MP tabs 5 mg 25mg-100mg, 50mg- F ropinirole hydrochloride PA 200mg tb24 2 mg, 4 mg, 6 mg, 8 F carbidopa-levodopa tbdp PA; MP mg, 12 mg 10mg-100mg, 25mg- F SINEMET CR TBCR (Use *** MP 100mg, 25mg-250mg Carbidopa-Levodopa) CARBIDOPA/LEVODOPA/ PA F SINEMET TABS (Use *** MP ENTACAPONE TABS Carbidopa-Levodopa) MIRAPEX ER TB24 (Use PA PA Pramipexole *** STALEVO 100 TABS F Dihydrochloride) F PA MIRAPEX TABS (Use QL(3 ea daily); STALEVO 125 TABS Pramipexole *** AL(At least 18 PA Dihydrochloride) yrs old) STALEVO 150 TABS F PARLODEL CAPS (Use *** STALEVO 200 TABS F PA Bromocriptine Mesylate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 50 TABS F PA VRAYLAR CAPS F PA

STALEVO 75 TABS F PA VRAYLAR CPPK F PA Antiparkinson Monoamine Oxidase Inhibitors QL(2 ea daily); F AZILECT TABS ( ziprasidone hcl caps AL(At least 18 Use *** PA yrs old) Rasagiline Mesylate) Benzisoxazoles ELDEPRYL CAPS (Use *** MP Selegiline HCl) FANAPT TABS F PA rasagiline mesylate tabs F PA FANAPT TITRATION F PA PACK TABS selegiline hcl caps F MP INVEGA SUSTENNA F PA selegiline hcl tabs F MP SUSY INVEGA TB24 (Use *** PA ZELAPAR TBDP F PA Paliperidone) INVEGA TRINZA SUSY F PA ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to Treat Mood Disorders paliperidone tb24 F PA Antimanic Agents RISPERDAL CONSTA F PA lithium carbonate caps 150 F SUSR mg, 300 mg, 600 mg QL(2 ea daily); LITHIUM CARBONATE RISPERDAL M-TAB TBDP *** (Use Risperidone) AL(At least 5 CAPS 150 MG, 600 MG F yrs old) (Use Lithium Carbonate) QL(4 ml daily); lithium carbonate tabs 300 RISPERDAL SOLN 1 *** AL(At least 5 F MG/ML (Use Risperidone) mg yrs old) lithium carbonate tbcr 300 F RISPERDAL TABS 0.25 QL(4 ea daily); mg, 450 mg MG, 0.5 MG, 1 MG, 2 MG, *** AL(At least 5 LITHIUM SOLN F 3 MG, 4 MG (Use yrs old) Risperidone) LITHOBID TBCR (Use F Lithium Carbonate) RISPERIDONE ODT TBDP F Antipsychotics - Misc. QL(4 ml daily); PA risperidone soln 1 mg/ml F AL(At least 5 EQUETRO CP12 F yrs old) GEODON CAPS OR 20 QL(2 ea daily); risperidone tabs 0.25 mg, QL(4 ea daily); MG, 40 MG, 60 MG, 80 MG *** AL(At least 18 0.5 mg, 1 mg, 2 mg, 3 mg, F AL(At least 5 (Use Ziprasidone HCl) yrs old) 4 mg yrs old) LATUDA TABS 20 MG, 40 F PA; QL(1 ea risperidone tbdp 0.25 mg F MG, 60 MG, 120 MG daily) PA; QL(2 ea QL(2 ea daily); LATUDA TABS 80 MG F risperidone tbdp 0.5 mg, 1 F AL(At least 5 daily) mg, 2 mg, 3 mg, 4 mg yrs old) NUPLAZID TABS 17 MG F PA; QL(2 ea daily) Butyrophenones

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALDOL DECANOATE QL(4 ea daily); *** olanzapine tabs or 5 mg, F AL(At least 10 100 SOLN (Use 2.5 mg Haloperidol Decanoate) yrs old) HALDOL DECANOATE 50 olanzapine tbdp or 5 mg, F PA; QL(1 ea SOLN (Use Haloperidol *** 10 mg, 15 mg, 20 mg daily) Decanoate) quetiapine fumarate tabs QL(2 ea daily); haloperidol decanoate soln F 25 mg, 50 mg, 100 mg, 200 F AL(At least 10 mg, 300 mg, 400 mg yrs old) haloperidol lactate conc F quetiapine fumarate tb24 PA; QL(1 ea 50 mg, 150 mg, 200 mg, F daily) haloperidol tabs 0.5 mg, 1 F QL(3 ea daily) 300 mg, 400 mg mg, 10 mg SAPHRIS SUBL 5 MG, 10 F PA haloperidol tabs 2 mg, 5 F MG mg, 20 mg QL(2 ea daily); SEROQUEL TABS (Use *** Dibenzapines Quetiapine Fumarate) AL(At least 10 yrs old) CLOZAPINE ODT TBDP F PA SEROQUEL XR TB24 (Use *** PA; QL(1 ea QL(9 ea daily); Quetiapine Fumarate) daily) clozapine tabs 100 mg F AL(At least 18 VERSACLOZ SUSP F PA yrs old) QL(3 ea daily); ZYPREXA RELPREVV F PA clozapine tabs 25 mg, 50 F AL(At least 18 SUSR mg, 200 mg yrs old) ZYPREXA TABS OR 10 QL(2 ea daily); MG, 7.5 MG (Use *** AL(At least 10 clozapine tbdp 25 mg, 100 F PA mg, 12.5 mg Olanzapine) yrs old) QL(9 ea daily); ZYPREXA TABS OR 15 QL(1 ea daily); CLOZARIL TABS 100 MG *** MG, 20 MG (Use *** AL(At least 10 (Use Clozapine) AL(At least 18 yrs old) Olanzapine) yrs old) QL(3 ea daily); ZYPREXA TABS OR 5 QL(4 ea daily); CLOZARIL TABS 25 MG *** AL(At least 18 MG, 2.5 MG (Use *** AL(At least 10 (Use Clozapine) yrs old) Olanzapine) yrs old) ZYPREXA ZYDIS TBDP PA; QL(1 ea FAZACLO TBDP 150 MG, F PA *** 200 MG (Use Olanzapine) daily) FAZACLO TBDP 25 MG, PA Dihydroindolones 100 MG, 12.5 MG (Use *** MOLINDONE F PA Clozapine) HYDROCHLORIDE TABS loxapine succinate caps 10 F QL(4 ea daily) mg, 25 mg, 50 mg Phenothiazines QL(3 ea daily) loxapine succinate caps 5 F chlorpromazine hcl tabs F mg fluphenazine decanoate F QL(2 ea daily); soln olanzapine tabs or 10 mg, F AL(At least 10 7.5 mg yrs old) FLUPHENAZINE HCL F CONC OR 5 MG/ML QL(1 ea daily); olanzapine tabs or 15 mg, F AL(At least 10 FLUPHENAZINE HCL 20 mg F yrs old) ELIX OR 2.5 MG/5ML

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUPHENAZINE HCL QL(90 ml per F formaldehyde soln F SOLN IJ 2.5 MG/ML fill retail) fluphenazine hcl tabs or 1 F hydrogen peroxide soln F mg, 5 mg, 10 mg, 2.5 mg QL(4 ea daily) HYDROGEN PEROXIDE F perphenazine tabs F SOLN prochlorperazine maleate F Chlorine Antiseptics tabs chlorhexidine gluconate F QL(946 ml per prochlorperazine supp F liqd fill retail) HIBICLENS LIQD (Use *** QL(946 ml per thioridazine hcl tabs F QL(3 ea daily) Chlorhexidine Gluconate) fill retail) Iodine Antiseptics trifluoperazine hcl tabs F QL(3 ea daily) BETADINE SKIN QL(15200 ml Quinolinone Derivatives CLEANSER SOLN (Use *** per fill retail) PA; QL(1 ea Povidone-Iodine) ABILIFY MAINTENA PRSY F per 24 days BETADINE SOLN (Use *** QL(3800 ml per retail) Povidone-Iodine) fill retail) PA; QL(1 ea BETADINE SURGICAL QL(15200 ml ABILIFY MAINTENA SRER F per 24 days SCRUB SOLN (Use *** per fill retail) retail) Povidone-Iodine) QL(200 gm per PA; SP povidone-iodine oint 10 % F ABILIFY MYCITE TABS F fill retail) QL(3800 ml per ABILIFY TABS (Use *** PA; QL(1 ea povidone-iodine soln 10 % F Aripiprazole) daily) fill retail) QL(15200 ml PA; QL(750 ml povidone-iodine soln 7.5 % F aripiprazole soln 1 mg/ml F per 30 days per fill retail) retail) aripiprazole tabs 2 mg, 5 PA; QL(1 ea ANTIVIRALS - Drugs to Treat Viral Infections mg, 10 mg, 15 mg, 20 mg, F daily) Antiretrovirals 30 mg abacavir sulfate soln 20 F QL(30 ml daily) aripiprazole tbdp 10 mg, 15 F PA; AL(At least mg/ml mg 6 yrs old) abacavir sulfate tabs 300 F QL(2 ea daily) ARISTADA PRSY 441 F PA mg MG/1.6ML, 662 MG/2.4ML abacavir sulfate-lamivudine F QL(1 ea daily) ARISTADA PRSY 882 PA; tabs MG/3.2ML, 1064 F MG/3.9ML abacavir sulfate- F QL(2 ea daily) lamivudine-zidovudine tabs REXULTI TABS F PA APTIVUS CAPS 250 MG F QL(4 ea daily) Thioxanthenes APTIVUS SOLN 100 F QL(10 ml daily) thiothixene caps F QL(3 ea daily) MG/ML atazanavir sulfate caps F QL(2 ea daily) ANTISEPTICS & DISINFECTANTS ATRIPLA TABS F Antiseptics & Disinfectants

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIVIR TABS (Use *** QL(2 ea daily) INVIRASE TABS 500 MG F QL(4 ea daily) Lamivudine-Zidovudine) QL(1 ea daily) ISENTRESS CHEW 100 F QL(6 ea daily) COMPLERA TABS F MG CRIXIVAN CAPS 200 MG F QL(9 ea daily) ISENTRESS CHEW 25 MG F QL(12 ea daily)

CRIXIVAN CAPS 400 MG F QL(6 ea daily) ISENTRESS PACK 100 F QL(2 ea daily) MG ST; QL(1 ea DELSTRIGO TABS F ISENTRESS TABS 400 F QL(2 ea daily) daily) MG DESCOVY TABS F JULUCA TABS F QL(1 ea daily) didanosine cpdr F QL(1 ea daily) KALETRA SOLN 400MG/5ML-100MG/5ML *** EDURANT TABS F QL(1 ea daily) (Use Lopinavir-Ritonavir) KALETRA TABS 100MG- F QL(4 ea daily) efavirenz caps 200 mg F QL(1 ea daily) 25MG KALETRA TABS 200MG- F QL(6 ea daily) efavirenz caps 50 mg F QL(2 ea daily) 50MG QL(30 ml daily) efavirenz tabs 600 mg F QL(1 ea daily) lamivudine soln 10 mg/ml F QL(2 ea daily) EMTRIVA CAPS 200 MG F QL(1 ea daily) lamivudine tabs 150 mg F QL(1 ea daily) EMTRIVA SOLN 10 F lamivudine tabs 300 mg F MG/ML lamivudine-zidovudine tabs F QL(2 ea daily) EPIVIR SOLN 10 MG/ML *** QL(30 ml daily) (Use Lamivudine) LEXIVA SUSP 50 MG/ML F QL(56 ml daily) EPIVIR TABS 150 MG *** QL(2 ea daily) (Use Lamivudine) LEXIVA TABS 700 MG QL(4 ea daily) EPIVIR TABS 300 MG *** QL(1 ea daily) (Use Fosamprenavir *** (Use Lamivudine) Calcium) EPZICOM TABS (Use QL(1 ea daily) Abacavir Sulfate- *** lopinavir-ritonavir soln F Lamivudine) nevirapine susp 50 mg/5ml F QL(40 ml daily) EVOTAZ TABS F QL(1 ea daily) nevirapine tabs 200 mg F QL(2 ea daily) fosamprenavir calcium tabs F QL(4 ea daily) nevirapine tb24 100 mg F QL(3 ea daily) GENVOYA TABS F QL(1 ea daily) nevirapine tb24 400 mg F QL(1 ea daily) INTELENCE TABS 200 F QL(2 ea daily) MG NORVIR CAPS 100 MG F QL(12 ea daily) INTELENCE TABS 25 MG, F QL(4 ea daily) 100 MG NORVIR SOLN 80 MG/ML F QL(15 ml daily) INVIRASE CAPS 200 MG F QL(10 ea daily) NORVIR TABS 100 MG *** QL(12 ea daily) (Use Ritonavir)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ODEFSEY TABS F tenofovir disoproxil F QL(1 ea daily) fumarate tabs QL(1 ea daily) PIFELTRO TABS F TIVICAY TABS 50 MG F PREZCOBIX TABS F QL(1 ea daily) QL(1 ea daily); TRIUMEQ TABS F AL(At least 18 PREZISTA SUSP 100 F QL(12 ml daily) yrs old) MG/ML TRIZIVIR TABS (Use QL(2 ea daily) PREZISTA TABS 150 MG F QL(3 ea daily) Abacavir Sulfate- *** Lamivudine-Zidovudine) PREZISTA TABS 75 MG, F QL(2 ea daily) PA; SP 600 MG TROGARZO SOLN F PREZISTA TABS 800 MG F QL(1 ea daily) TRUVADA TABS 150MG- 100MG, 200MG-133MG, F RESCRIPTOR TABS 100 F QL(12 ea daily) 250MG-167MG MG TRUVADA TABS 300MG- F QL(1 ea daily) RESCRIPTOR TABS 200 F QL(6 ea daily) 200MG MG QL(1 ea daily); RETROVIR CAPS 100 MG *** QL(6 ea daily) TYBOST TABS F AL(At least 18 (Use Zidovudine) yrs old) RETROVIR SYRP 50 *** QL(60 ml daily) VIDEX EC CPDR 125 MG F QL(1 ea daily) MG/5ML (Use Zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) VIDEX EC CPDR 200 MG, QL(1 ea daily) 200 MG, 300 MG (Use *** 250 MG, 400 MG (Use *** Atazanavir Sulfate) Didanosine) QL(6 ea daily) VIDEXPEDIATRIC SOLR 2 F QL(20 ml daily) REYATAZ PACK 50 MG F GM QL(12 ea daily) ritonavir tabs F VIDEXPEDIATRIC SOLR 4 F GM SELZENTRY TABS 150 F QL(2 ea daily) QL(9 ea daily) MG VIRACEPT TABS 250 MG F QL 2 per VIRACEPT TABS 625 MG F QL(4 ea daily) SELZENTRY TABS 25 F MG, 75 MG day;QL(2 ea daily) VIRAMUNE SUSP 50 *** QL(40 ml daily) MG/5ML (Use Nevirapine) SELZENTRY TABS 300 F QL(4 ea daily) MG VIRAMUNE TABS 200 MG *** QL(2 ea daily) (Use Nevirapine) stavudine caps F QL(2 ea daily) VIRAMUNE XR TB24 100 *** QL(3 ea daily) STRIBILD TABS F PA; QL(1 ea MG (Use Nevirapine) daily) VIRAMUNE XR TB24 400 *** QL(1 ea daily) SUSTIVA CAPS 200 MG *** QL(1 ea daily) MG (Use Nevirapine) (Use Efavirenz) VIREAD POWD 40 MG/GM F SUSTIVA CAPS 50 MG *** QL(2 ea daily) (Use Efavirenz) VIREAD TABS 150 MG, F QL(1 ea daily) 200 MG, 250 MG SUSTIVA TABS 600 MG *** QL(1 ea daily) (Use Efavirenz)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIREAD TABS 300 MG QL(1 ea daily) LEDIPASVIR/SOFOSBUVI F PA; QL(1 ea (Use Tenofovir Disoproxil *** R TABS daily); SP Fumarate) MAVYRET TABS F PA; QL(3 ea ZERIT CAPS 15 MG, 20 QL(2 ea daily) daily); SP MG, 30 MG, 40 MG (Use *** MODERIBA 1200 DOSE F PA; SP Stavudine) PACK TABS QL(80 ml daily) ZERIT SOLR 1 MG/ML F MODERIBA 800 DOSE F PA; SP PACK TABS ZIAGEN SOLN 20 MG/ML *** QL(30 ml daily) PA; SP (Use Abacavir Sulfate) OLYSIO CAPS F ZIAGEN TABS 300 MG QL(2 ea daily) *** PEGASYS PROCLICK F PA; SP (Use Abacavir Sulfate) SOLN QL(6 ea daily) zidovudine caps 100 mg F PEGASYS SOLN F PA; SP QL(60 ml daily) zidovudine syrp 50 mg/5ml F PEGINTRON KIT F PA; SP zidovudine tabs 300 mg F QL(2 ea daily) REBETOL CAPS 200 MG PA; SP (Use Ribavirin (Hepatitis *** CMV Agents C)) REBETOL SOLN 40 PA; SP VALCYTE TABS (Use *** QL(2 ea daily) F Valganciclovir HCl) MG/ML valganciclovir hcl tabs F QL(2 ea daily) RIBASPHERE RIBAPAK F PA; SP TABS 400 MG, 600 MG Hepatitis Agents RIBASPHERE TABS F PA; SP adefovir dipivoxil tabs F PA ribavirin (hepatitis c) caps F PA; SP BARACLUDE SOLN 0.05 F PA MG/ML ribavirin (hepatitis c) tabs F PA; SP BARACLUDE TABS 0.5 *** PA MG, 1 MG (Use Entecavir) SOFOSBUVIR/VELPATAS F PA; QL(1 ea VIR TABS daily); SP COPEGUS TABS (Use *** PA; SP Ribavirin (Hepatitis C)) SOVALDI TABS F PA; SP PA entecavir tabs F Herpes Agents QL(50 ea per EPCLUSA TABS F PA; QL(1 ea acyclovir caps 200 mg F daily); SP 30 days retail) QL(400 ml per EPIVIR HBV SOLN 5 F PA acyclovir susp 200 mg/5ml F MG/ML 30 days retail) EPIVIR HBV TABS 100 PA acyclovir tabs 400 mg F QL(3 ea daily) MG (Use Lamivudine *** QL(50 ea per (HBV)) acyclovir tabs 800 mg F PA; QL(1 ea 30 days retail) HARVONI TABS F daily); SP famciclovir tabs F HEPSERA TABS (Use *** PA Adefovir Dipivoxil) SITAVIG TABS F PA lamivudine (hbv) tabs F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits valacyclovir hcl tabs 1 gm, F QL(21 ea per Limit 1 Fill per 1000 mg 30 days retail) TAMIFLU CAPS 45 MG, 75 180 MG (Use Oseltamivir *** days;QL(10 ea valacyclovir hcl tabs 500 F QL(60 ea per mg 30 days retail) Phosphate) per 30 days retail) VALTREX TABS 1 GM *** QL(21 ea per (Use Valacyclovir HCl) 30 days retail) Limit 1 Fill per TAMIFLU SUSR 6 MG/ML 180 VALTREX TABS 500 MG *** QL(60 ea per (Use Oseltamivir *** days;QL(120 (Use Valacyclovir HCl) 30 days retail) Phosphate) ml per 30 days ZOVIRAX CAPS OR 200 *** QL(50 ea per retail) MG (Use Acyclovir) 30 days retail) BETA BLOCKERS - Drugs to Treat High Blood ZOVIRAX SUSP OR 200 *** QL(400 ml per Pressure MG/5ML (Use Acyclovir) 30 days retail) Alpha-Beta Blockers ZOVIRAX TABS OR 400 *** QL(3 ea daily) MG (Use Acyclovir) carvedilol phosphate cp24 F PA ZOVIRAX TABS OR 800 *** QL(50 ea per MG (Use Acyclovir) 30 days retail) carvedilol tabs 12.5 mg, F QL(3 ea daily); 6.25 mg, 3.125 mg MP Influenza Agents QL(4 ea daily); carvedilol tabs 25 mg F FLUMADINE TABS (Use QL(20 ea per MP Rimantadine *** 10 days retail) Hydrochloride) COREG CR CP24 (Use *** PA Carvedilol Phosphate) Limit 1 Fill per 180 COREG TABS 12.5 MG, QL(3 ea daily); oseltamivir phosphate caps F days;QL(20 ea 6.25 MG, 3.125 MG (Use *** MP or 30 mg per 30 days Carvedilol) retail) COREG TABS 25 MG (Use *** QL(4 ea daily); Limit 1 Fill per Carvedilol) MP QL(3 ea daily); 180 labetalol hcl tabs 100 mg F oseltamivir phosphate caps F days;QL(10 ea MP or 45 mg, 75 mg per 30 days QL(6 ea daily); labetalol hcl tabs 200 mg F retail) MP Limit 1 Fill per QL(8 ea daily); labetalol hcl tabs 300 mg F 180 MP oseltamivir phosphate susr F days;QL(120 or 6 mg/ml ml per 30 days Beta Blockers Cardio-Selective retail) acebutolol hcl caps F MP QL(20 ea per RELENZA DISKHALER F QL(2 ea daily); AEPB fill retail); AL(At atenolol tabs F least 5 yrs old) MP QL(1 ea daily) rimantadine hydrochloride F QL(20 ea per betaxolol hcl tabs F tabs 10 days retail) QL(1 ea daily); bisoprolol fumarate tabs F Limit 1 Fill per MP TAMIFLU CAPS 30 MG 180 (Use Oseltamivir *** days;QL(20 ea BYSTOLIC TABS F PA Phosphate) per 30 days retail) LOPRESSOR TABS 100 QL(4.5 ea MG (Use Metoprolol *** daily); MP Tartrate)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPRESSOR TABS 50 QL(4 ea daily); propranolol hcl tabs 10 mg, MP MG (Use Metoprolol *** MP 20 mg, 40 mg, 60 mg, 80 F Tartrate) mg QL(2 ea daily); QL(2 ea daily); metoprolol succinate tb24 F sotalol hcl (afib/afl) tabs F 200 mg MP MP metoprolol succinate tb24 F QL(4 ea daily); sotalol hcl tabs F MP 25 mg, 50 mg, 100 mg MP TIMOLOL MALEATE TABS MP metoprolol tartrate tabs 100 F QL(4.5 ea F mg daily); MP 10 MG, 20 MG MP metoprolol tartrate tabs 25 F QL(4 ea daily); timolol maleate tabs 5 mg F mg, 50 mg MP CALCIUM CHANNEL BLOCKERS - Drugs to TENORMIN TABS (Use *** QL(2 ea daily); Atenolol) MP Treat High Blood Pressure TOPROL XL TB24 200 MG *** QL(2 ea daily); Calcium Channel Blockers (Use Metoprolol Succinate) MP ADALAT CC TB24 30 MG, *** QL(1 ea daily); TOPROL XL TB24 25 MG, QL(4 ea daily); 90 MG (Use Nifedipine) MP 50 MG, 100 MG (Use *** MP ADALAT CC TB24 60 MG *** QL(2 ea daily); Metoprolol Succinate) (Use Nifedipine) MP ZEBETA TABS (Use QL(1 ea daily); QL(1 ea daily); *** amlodipine besylate tabs F Bisoprolol Fumarate) MP MP Beta Blockers Non-Selective CALAN SR TBCR (Use *** QL(2 ea daily); Verapamil HCl) MP BETAPACE AF TABS (Use *** QL(2 ea daily); Sotalol HCl (AFIB/AFL)) MP CALAN TABS (Use *** QL(3 ea daily); Verapamil HCl) MP BETAPACE TABS (Use *** MP Sotalol HCl) CARDIZEM CD CP24 120 QL(1 ea daily); MG, 180 MG, 300 MG (Use MP CORGARD TABS (Use *** QL(2 ea daily); *** Nadolol) MP Diltiazem HCl Coated PA Beads) HEMANGEOL SOLN F CARDIZEM CD CP24 240 QL(2 ea daily); MG (Use Diltiazem HCl *** MP INDERAL LA CP24 (Use *** QL(2 ea daily); Propranolol HCl) MP Coated Beads) PA CARDIZEM CD CP24 360 MP INDERAL XL CP24 F MG (Use Diltiazem HCl *** Coated Beads) INNOPRAN XL CP24 F PA CARDIZEM LA TB24 120 F QL(2 ea daily); MG nadolol tabs F MP CARDIZEM LA TB24 180 MP MG, 240 MG, 300 MG, 360 F MP pindolol tabs MG, 420 MG (Use *** propranolol hcl cp24 60 QL(2 ea daily); Diltiazem HCl Coated mg, 80 mg, 120 mg, 160 F MP Beads) mg CARDIZEM TABS 30 MG, QL(4 ea daily) PROPRANOLOL HCL MP 120 MG (Use Diltiazem *** SOLN 20 MG/5ML, 40 F HCl) MG/5ML CARDIZEM TABS 60 MG *** QL(3 ea daily); (Use Diltiazem HCl) MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORVASC TABS (Use QL(1 ea daily); DILT-XR CP24 F QL(1 ea daily); *** MP Amlodipine Besylate) MP diltiazem hcl coated beads QL(1 ea daily); NYMALIZE SOLN F PA cp24 120 mg, 180 mg, 300 F MP mg PROCARDIA CAPS (Use *** QL(4 ea daily); Nifedipine) MP diltiazem hcl coated beads F QL(2 ea daily); cp24 240 mg MP PROCARDIA XL TB24 30 QL(1 ea daily); MG, 90 MG (Use *** MP diltiazem hcl coated beads F MP cp24 360 mg Nifedipine) diltiazem hcl coated beads MP PROCARDIA XL TB24 60 *** QL(2 ea daily); tb24 180 mg, 240 mg, 300 F MG (Use Nifedipine) MP mg, 360 mg, 420 mg SULAR TB24 (Use *** PA Nisoldipine) diltiazem hcl cp12 60 mg, F QL(2 ea daily); 90 mg, 120 mg MP TIAZAC CP24 120 MG, QL(1 ea daily); 180 MG, 300 MG, 360 MG, MP diltiazem hcl cp24 120 mg, F QL(1 ea daily); *** 180 mg MP 420 MG (Use Diltiazem HCl QL(2 ea daily); Extended Release Beads) diltiazem hcl cp24 240 mg F MP TIAZAC CP24 240 MG QL(2 ea daily); diltiazem hcl extended QL(1 ea daily); (Use Diltiazem HCl *** MP Extended Release Beads) release beads cp24 120 F MP mg, 180 mg, 300 mg, 360 verapamil hcl cp24 100 mg, F QL(2 ea daily); mg, 420 mg 200 mg MP diltiazem hcl extended QL(2 ea daily); verapamil hcl cp24 120 mg, F QL(1 ea daily); release beads cp24 240 F MP 180 mg, 240 mg, 300 mg MP mg VERAPAMIL HCL ER F QL(2 ea daily); CP24 100 MG MP diltiazem hcl tabs 30 mg, F QL(4 ea daily) 90 mg, 120 mg VERAPAMIL HCL ER F QL(1 ea daily); QL(3 ea daily); CP24 300 MG MP diltiazem hcl tabs 60 mg F MP VERAPAMIL HCL SR F QL(1 ea daily); QL(1 ea daily); CP24 MP felodipine tb24 F MP verapamil hcl tabs 40 mg, F QL(3 ea daily); 80 mg, 120 mg MP isradipine caps F PA verapamil hcl tbcr 120 mg, F QL(2 ea daily); nicardipine hcl caps F QL(3 ea daily) 180 mg, 240 mg MP VERELAN CP24 120 MG, QL(1 ea daily); nifedipine caps 10 mg, 20 F QL(4 ea daily); 180 MG, 240 MG (Use *** MP mg MP Verapamil HCl) nifedipine tb24 30 mg, 90 QL(1 ea daily); F VERELAN CP24 360 MG F QL(1 ea daily); mg MP MP QL(2 ea daily); nifedipine tb24 60 mg F VERELAN PM CP24 100 F QL(2 ea daily); MP MG MP PA nimodipine caps F VERELAN PM CP24 200 *** QL(2 ea daily); MG (Use Verapamil HCl) MP PA NISOLDIPINE ER TB24 F VERELAN PM CP24 300 F QL(1 ea daily); MG MP nisoldipine tb24 F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIOTONICS - Drugs to Treat Heart Failure TYVASO REFILL SOLN F PA; SP and Abnormal Heart Rhythm PA; SP Cardiac Glycosides TYVASO SOLN F DIGOXIN SOLN 0.05 F MP PA; SP MG/ML TYVASO STARTER SOLN F digoxin tabs 0.125 mg, MP VELETRI SOLR F PA; SP 0.25 mg, 125 mcg, 250 F mcg VENTAVIS SOLN F PA; SP LANOXIN TABS 125 MCG, F MP 250 MCG (Use Digoxin) Pulmonary Hypertension - Endothelin Receptor LANOXIN TABS 62.5 F PA ambrisentan tabs F PA; SP MCG, 187.5 MCG CARDIOVASCULAR AGENTS - MISC. - Drugs to bosentan tabs F PA; SP Treat Heart and Circulation Conditions LETAIRIS TABS (Use *** PA; SP Cardiovascular Agents Misc. - Combinations Ambrisentan) amlodipine besylate- F PA PA; SP atorvastatin calcium tabs OPSUMIT TABS F BIDIL TABS F PA TRACLEER TABS 125 PA; SP MG, 62.5 MG (Use *** CADUET TABS (Use PA Bosentan) Amlodipine Besylate- *** PA; SP Atorvastatin Calcium) TRACLEER TBSO 32 MG F Impotence Agents Pulmonary Hypertension - Phosphodiesterase BI-MIX SOLR F PA; SP ADCIRCA TABS (Use PA; SP Tadalafil (Pulmonary *** SUPER BI-MIX SOLR F PA; SP Hypertension)) REVATIO SOLN IV 10 PA; SP PA; SP SUPER TRI-MIX SOLR F MG/12.5ML (Use Sildenafil *** Citrate (Pulmonary TRI-MIX SOLR F PA; SP Hypertension)) REVATIO SUSR OR 10 F PA; SP Peripheral Vasodilators MG/ML inositol niacinate caps F REVATIO TABS OR 20 PA; SP MG (Use Sildenafil Citrate *** Prostaglandin Vasodilators (Pulmonary Hypertension)) PA; SP sildenafil citrate (pulmonary F PA; SP epoprostenol sodium solr F hypertension) soln sildenafil citrate (pulmonary PA; SP FLOLAN SOLR (Use *** PA; SP F Epoprostenol Sodium) hypertension) tabs tadalafil (pulmonary PA; SP F PA; SP F ORENITRAM TBCR hypertension) tabs REMODULIN SOLN (Use *** PA; SP Pulmonary Hypertension - Sol Guanylate Cyclase Treprostinil) ADEMPAS TABS F PA; SP treprostinil soln F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per CEPHALOSPORINS - Drugs to Treat Bacterial cefdinir caps 300 mg F Infections fill retail) cefdinir susr 125 mg/5ml, QL(100 ml per Cephalosporins - 1st Generation F 250 mg/5ml fill retail) QL(20 ea per cefadroxil caps 500 mg F fill retail) CEFDITOREN PIVOXIL F PA TABS 200 MG, 400 MG cefadroxil susr 250 mg/5ml, F QL(100 ml per 500 mg/5ml fill retail) cefixime caps F PA QL(10 ea per cefadroxil tabs 1 gm F PA fill retail) cefixime susr F cephalexin caps 250 mg, F PA 500 mg cefpodoxime proxetil susr F cephalexin caps 750 mg F PA cefpodoxime proxetil tabs F PA PA cephalexin susr 125 F CEFTIBUTEN CAPS F mg/5ml, 250 mg/5ml PA CEPHALEXIN TABS 250 F PA CEFTIBUTEN SUSR F MG, 500 MG Limit 1 fill per KEFLEX CAPS 250 MG, *** 500 MG (Use Cephalexin) ceftriaxone sodium solr F Month;QL(3 ea per fill retail) KEFLEX CAPS 750 MG *** PA (Use Cephalexin) SPECTRACEF TABS F PA Cephalosporins - 2nd Generation SUPRAX CAPS 400 MG *** PA (Use Cefixime) cefaclor caps 250 mg, 500 F mg SUPRAX CHEW 100 MG, F PA 200 MG CEFACLOR ER TB12 F PA SUPRAX SUSR 100 PA CEFACLOR SUSR 125 MG/5ML, 200 MG/5ML *** MG/5ML, 250 MG/5ML, F (Use Cefixime) 375 MG/5ML SUPRAX SUSR 500 PA QL(200 ml per F cefprozil susr 125 mg/5ml F MG/5ML fill retail) QL(100 ml per CHEMICALS cefprozil susr 250 mg/5ml F fill retail) Bulk Chemicals - H's cefprozil tabs 250 mg, 500 QL(20 ea per F HYDROXYPROGESTERO F mg fill retail) NE CAPROATE POWD XX CEFTIN SUSR F QL(100 ml per fill retail) CONTRACEPTIVES - Drugs to Prevent Pregnancy QL(20 ea per cefuroxime axetil tabs F fill retail) Combination Contraceptives - Oral Cephalosporins - 3rd Generation BEYAZ TABS (Use PA Drospirenone-Ethinyl *** CEDAX CAPS F PA Estradiol-Levomefolate Calcium) PA CEDAX SUSR F BREVICON-28 TABS (Use MP Norethindrone & Eth *** Estradiol) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYCLESSA TABS (Use MP LOESTRIN 1.5/30-21 MP Desogestrel-Ethinyl *** TABS (Use Norethindrone *** Estradiol (Triphasic)) Acet & Eth Estra) DESOGEN TABS (Use MP LOESTRIN 1/20-21 TABS MP Desogestrel & Ethinyl *** (Use Norethindrone Acet & *** Estradiol) Eth Estra) desogestrel & ethinyl F MP LOESTRIN FE 1.5/30 MP estradiol tabs TABS (Use Norethin Acet & *** Estrad-Fe) desogestrel-ethinyl F MP estradiol (biphasic) tabs LOESTRIN FE 1/20 TABS MP (Use Norethin Acet & *** desogestrel-ethinyl F MP estradiol (triphasic) tabs Estrad-Fe) LOSEASONIQUE TABS PA drospirenone-ethinyl F QL(1 ea daily); estradiol tabs 3mg-0.02mg MP (Use Levonorgestrel- *** Ethinyl Estradiol (91-Day)) drospirenone-ethinyl F MP estradiol tabs 3mg-0.03mg MINASTRIN 24 FE CHEW PA (Use Norethin Acet & *** drospirenone-ethinyl PA Estrad-Fe) estradiol-levomefolate F calcium tabs MIRCETTE TABS (Use MP Desogestrel-Ethinyl *** ESTROSTEP FE TABS Estradiol (Biphasic)) (Use Norethindrone *** Acetate-Ethinyl Estradiol- NATAZIA TABS F PA Fe) NECON 1/50-28 TABS F MP ethynodiol diacet & eth F MP estrad tabs NECON 10/11-28 TABS F MP FALESSA KIT F PA norethin acet & estrad-fe F PA FEMCON FE CHEW (Use chew 75mg-20mcg-1mg Norethindrone & Ethinyl *** Estradiol-Fe) norethin acet & estrad-fe F tabs 75mg-20mcg-1mg GENERESS FE CHEW (Use Norethindrone & *** norethin acet & estrad-fe MP Ethinyl Estradiol-Fe) tabs 75mg-20mcg-1mg, F 75mg-30mcg-1.5mg levonorgestrel & eth F MP estradiol tabs norethindrone & eth F MP estradiol tabs levonorgestrel-eth estradiol F MP (triphasic) tabs norethindrone & ethinyl F estradiol-fe chew 1 rtl pack lmt levonorgestrel-ethinyl F amt,91 rtl pack norethindrone acet & eth MP estradiol (91-day) tabs F lmt day(s), estra tabs norethindrone acetate- levonorgestrel-ethinyl F PA F estradiol (91-day) tabs ethinyl estradiol-fe tabs norethindrone-eth estradiol MP levonorgestrel-ethinyl F PA F estradiol (continuous) tabs (triphasic) tabs PA norgestimate-ethinyl F MP LO LOESTRIN FE TABS F estradiol (triphasic) tabs

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norgestimate-ethinyl F YAZ TABS (Use QL(1 ea daily); estradiol (triphasic) tabs Drospirenone-Ethinyl *** MP Estradiol) norgestimate-ethinyl F MP estradiol tabs Combination Contraceptives - Transdermal norgestrel & ethinyl QL(2 ea daily); F norelgestromin-ethinyl F QL(3 ea per fill estradiol tabs MP estradiol ptwk retail) NORINYL 1+35 TABS (Use MP XULANE PTWK *** QL(3 ea per fill Norethindrone & Eth *** retail) Estradiol) Combination Contraceptives - Vaginal MP OGESTREL TABS F QL(1 ea per fill NUVARING RING F ORTHO TRI-CYCLEN LO retail) TABS (Use Norgestimate- *** Copper Contraceptives - IUD Ethinyl Estradiol PARAGARD PA; SP (Triphasic)) INTRAUTERINE COPPER F ORTHO TRI-CYCLEN MP CONTRACEPTIVE T380A TABS (Use Norgestimate- *** IUD Ethinyl Estradiol (Triphasic)) Emergency Contraceptives QL(4 ea per ORTHO-CYCLEN TABS MP ELLA TABS F (Use Norgestimate-Ethinyl *** 365 days retail) Estradiol) Limit 4 per ORTHO-NOVUM 1/35 MP levonorgestrel (emergency F year;QL(1 ea TABS (Use Norethindrone *** oc) tabs per 21 days & Eth Estradiol) retail) Limit 4 per ORTHO-NOVUM 7/7/7 MP PLAN B ONE-STEP TABS TABS (Use Norethindrone- *** (Use Levonorgestrel *** year;QL(1 ea Eth Estradiol (Triphasic)) (Emergency OC)) per 21 days retail) OVCON-35 TABS (Use MP Norethindrone & Eth *** Progestin Contraceptives - IUD Estradiol) KYLEENA IUD 19.5 MG F PA; SP QUARTETTE TABS (Use PA Levonorgestrel-Ethinyl *** Progestin Contraceptives - Injectable Estradiol (91-Day)) DEPO-PROVERA QL(1 ml per 91 SAFYRAL TABS (Use PA CONTRACEPTIVE SUSP *** days retail) Drospirenone-Ethinyl *** (Use Medroxyprogesterone Estradiol-Levomefolate Acetate (Contraceptive)) Calcium) DEPO-PROVERA QL(1 ml per fill SEASONIQUE TABS (Use 1 rtl pack lmt CONTRACEPTIVE SUSY *** retail) Levonorgestrel-Ethinyl *** amt,91 rtl pack (Use Medroxyprogesterone Estradiol (91-Day)) lmt day(s), Acetate (Contraceptive)) TRI-NORINYL 28 TABS MP DEPO-SUBQ PROVERA F QL(1 ml per fill (Use Norethindrone-Eth *** 104 SUSY retail) Estradiol (Triphasic)) medroxyprogesterone QL(1 ml per 91 YASMIN 28 TABS (Use MP acetate (contraceptive) F days retail) Drospirenone-Ethinyl *** susp Estradiol)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits medroxyprogesterone QL(1 ml per fill MILLIPRED TABS 5 MG F acetate (contraceptive) F retail) susy ORAPRED ODT TBDP PA Progestin Contraceptives - Oral (Use Prednisolone Sodium *** Phosphate) norethindrone F (contraceptive) tabs PEDIAPRED SOLN (Use Prednisolone Sodium *** ORTHO MICRONOR Phosphate) TABS (Use Norethindrone *** (Contraceptive)) prednisolone sodium PA phosphate soln or 10 F CORTICOSTEROIDS - Steroid Hormone Drugs to mg/5ml Treat Systemic Swelling Conditions prednisolone sodium QL(150 ml per Glucocorticosteroids phosphate soln or 20 F fill retail) mg/5ml CORTEF TABS (Use *** Hydrocortisone) prednisolone sodium phosphate soln or 5 F CORTISONE ACETATE F TABS mg/5ml, 15 mg/5ml prednisolone sodium PA dexamethasone elix 0.5 F mg/5ml phosphate tbdp or 10 mg, F 15 mg, 30 mg DEXAMETHASONE F INTENSOL CONC prednisolone soln F dexamethasone sodium QL(150 ml per phosphate soln ij 4 mg/ml, F 30 days retail) PREDNISOLONE SOLN F 20 mg/5ml, 120 mg/30ml prednisolone syrp F DEXAMETHASONE SOLN F 0.5 MG/5ML PREDNISONE INTENSOL F dexamethasone tabs 0.75 CONC mg, 0.5 mg, 4 mg, 6 mg, F PREDNISONE SOLN 5 F 1.5 mg MG/5ML DEXAMETHASONE TABS F prednisone tabs 1 mg, 5 F 1 MG, 2 MG mg, 10 mg, 20 mg, 2.5 mg PA; SP EMFLAZA TABS F PREDNISONE TABS 50 F MG hydrocortisone tabs F PREDNISONE TBPK 5 F MG, 10 MG MEDROL DOSEPAK TBPK *** (Use Methylprednisolone) VERIPRED 20 SOLN (Use QL(150 ml per Prednisolone Sodium *** fill retail) MEDROL TABS (Use *** Phosphate) Methylprednisolone) Mineralocorticoids methylprednisolone tabs F fludrocortisone acetate tabs F methylprednisolone tbpk F COUGH/COLD/ALLERGY - Drugs to Treat MILLIPRED SOLN 10 PA Cough, Cold and Allergy Symptoms MG/5ML (Use *** Prednisolone Sodium Antitussives Phosphate) benzonatate caps 100 mg F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzonatate caps 150 mg F PA ACTICON SOLN F PA

Limit 1 fill per ACTINEL LIQD F F Month;QL(20 benzonatate caps 200 mg ea per 30 days ACTINEL PEDIATRIC F retail) LIQD DELSYM COUGH QL(240 ml per ADVIL COLD & SINUS CHILDRENS SUER (Use 6 days retail) *** TABS (Use *** Dextromethorphan Pseudoephedrine- Polistirex) Ibuprofen) DELSYM SUER (Use QL(240 ml per ALLEGRA-D 12 HOUR Dextromethorphan *** 6 days retail) ALLERGY & Polistirex) CONGESTION TB12 (Use *** Fexofenadine- dextromethorphan hbr caps F 15 mg Pseudoephedrine) ALLEGRA-D 24 HOUR dextromethorphan hbr liqd F 15 mg/5ml, 15 mg/15ml ALLERGY & CONGESTION TB24 (Use *** dextromethorphan hbr liqd F QL(240 ml per 7.5 mg/5ml 6 days retail) Fexofenadine- Pseudoephedrine) dextromethorphan hbr syrp F 15 mg/5ml BENADRYL-D ALLERGY & SINUS CHILDRENS SOLN *** dextromethorphan F QL(240 ml per (Use Diphenhydramine- polistirex suer 6 days retail) Phenylephrine) hydrocodone w/ AL(At least 18 homatropine syrp 5mg/5ml- F yrs old) BIONEL LIQD F 1.5mg/5ml BIONEL PEDIATRIC LIQD F hydrocodone w/ PA; AL(At least homatropine tabs 5mg- F 18 yrs old) 1.5mg BIOSPEC DMX LIQD F ROBITUSSIN CHILDRENS Limit 1 fill per COUGH LONG-ACTING F brompheniramine & F Month;QL(120 SYRP phenyleph elix ml per 30 days ROBITUSSIN LINGERING retail) Limit 1 fill per COLDLONG-ACTING *** COUGHGELS CAPS (Use brompheniramine & F Month;QL(120 Dextromethorphan HBr) pseudoeph elix ml per 30 days retail) TESSALON PERLES *** CAPS (Use Benzonatate) Limit 1 fill per TRIAMINIC LONG ACTING QL(240 ml per brompheniramine & F Month;QL(120 COUGH LIQD (Use *** 6 days retail) pseudoeph liqd ml per 30 days Dextromethorphan HBr) retail) QL(240 ml per VICKS DAYQUIL COUGH BROTAPP DM LIQD F LIQD (Use *** fill retail) Dextromethorphan HBr) CAPCOF SYRP F Cough/Cold/Allergy Combinations CAPMIST DM TABS F acetaminophen w/ dm liqd F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPRON DM LIQD F PA COMTREX COLD & COUGH MAXIMUM STRENGTH TABS (Use cetirizine-pseudoephedrine F QL(2 ea daily) *** tb12 Dextromethorphan- CHERACOL PLUS LIQD QL(240 ml per Phenylephrine- (Use Dextromethorphan- *** fill retail) Acetaminophen) Guaifenesin) COMTREX COLD & CHERACOL-D COUGH QL(240 ml per COUGH NIGHTTIME MAXIMUM STRENGTH LIQD (Use *** fill retail) *** Dextromethorphan- TABS (Use Phenylephrine- Guaifenesin) Chlorpheniramine-DM w/ APAP) chlorpheniramine & F phenylephrine liqd CONEX COLD/ALLERGY F PA SOLN chlorpheniramine & F phenylephrine tabs CORICIDIN HBP COLD & FLU TABS (Use *** chlorpheniramine & F Chlorpheniramine- pseudoeph tabs Acetaminophen) chlorpheniramine- F DAY TIME MULTI- acetaminophen tabs SYMPTOM COLD/FLU chlorpheniramine- PA RELIEF CAPS (Use *** phenylephrine- Dextromethorphan- acetaminophen misc 2mg- F Phenylephrine- 325mg-5mg, 2mg-2mg- Acetaminophen) 325mg-325mg-5mg-5mg, chlorpheniramine- DECON-A ELIX F phenylephrine- acetaminophen tabs 2mg- F DECON-A LIQD F 325mg-5mg, 2mg-2mg- dextromethorphan- 325mg-325mg-5mg-5mg acetaminophen- F CLARINEX-D 12 HOUR F PA chlorpheniramine susp TB12 dextromethorphan- CLARITIN-D 12 HOUR QL(2 ea daily) doxylamine-acetaminophen F TB12 (Use Loratadine & *** liqd Pseudoephedrine) dextromethorphan- CLARITIN-D 24 HOUR QL(1 ea daily) guaifenesin caps 10mg- F TB24 (Use Loratadine & *** 200mg Pseudoephedrine) dextromethorphan- QL(240 ml per CLEAR COUGH PM guaifenesin liqd 10mg/5ml- fill retail) MULTI-SYMPTOM LIQD 100mg/5ml, 10mg/5ml- (Use Dextromethorphan- *** 200mg/5ml, 20mg/10ml- Doxylamine- 200mg/10ml, 20mg/10ml- F Acetaminophen) 400mg/10ml, 15mg/7.5ml- 150mg/7.5ml, 10mg/5ml- COLD & FLU RELIEF F NIGHTTIME D LIQD 10mg/5ml-100mg/5ml- 100mg/5ml

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- DIMETAPP MULTI- QL(237 ml per guaifenesin liqd 5mg/5ml- SYMPTOM COLD & FLU F fill retail) 100mg/5ml, 30mg/5ml- LIQD 200mg/5ml, 20mg/20ml- F DIMETAPP MULTI- 400mg/20ml, 30mg/5ml- SYMPTOM COLD RELIEF 30mg/5ml-200mg/5ml- CHILDRENS LIQD (Use *** 200mg/5ml Phenylephrine- dextromethorphan- QL(240 ml per Brompheniramine-DM) guaifenesin soln 10mg/5ml- fill retail) F diphenhydramine- F 100mg/5ml, 20mg/10ml- phenylephrine liqd 200mg/10ml diphenhydramine- F dextromethorphan- QL(240 ml per phenylephrine soln guaifenesin syrp fill retail) 10mg/5ml-100mg/5ml, F diphenhydramine- 10mg/5ml-10mg/5ml- phenylephrine- 100mg/5ml-100mg/5ml acetaminophen liqd 12.5mg/10ml-325mg/10ml- dextromethorphan- 5mg/10ml, 12.5mg/15ml- F guaifenesin tabs 20mg- F 325mg/15ml-5mg/15ml, 400mg, 20mg-20mg- 12.5mg/15ml-12.5mg/15ml- 400mg-400mg 325mg/15ml-325mg/15ml- dextromethorphan- QL(2 ea 10%-5mg/15ml-5mg/15ml guaifenesin tb12 30mg- F daily,210 ea diphenhydramine- QL(237 ml per 600mg per fill retail) phenylephrine- fill retail) dextromethorphan- acetaminophen liqd F guaifenesin tb12 60mg- F 6.25mg/5ml-160mg/5ml- 1200mg 2.5mg/5ml dextromethorphan- doxylamine-dm liqd F phenylephrine- F acetaminophen caps ED A-HIST LIQD (Use dextromethorphan- Chlorpheniramine & *** phenylephrine- F Phenylephrine) acetaminophen liqd QL(240 ml per ED BRON GP LIQD F dextromethorphan- 6 days retail) phenylephrine- F fexofenadine- F acetaminophen tabs pseudoephedrine tb12 DIABETIC TUSSIN F fexofenadine- F COLD/FLU CAPS pseudoephedrine tb24 DIMETAPP COLD & Limit 1 fill per GLENMAX PEB LIQD F ALLERGY ELIX (Use *** Month;QL(120 Brompheniramine & ml per 30 days GNP DAY TIME MUCUS Phenyleph) retail) RELIEFDM LIQD (Use *** DIMETAPP DM COLD & Dextromethorphan- Guaifenesin) COUGH LIQD (Use *** Phenylephrine- guaifenesin-codeine soln F Brompheniramine-DM) 100mg/5ml-10mg/5ml DIMETAPP LONG ACTING QL(240 ml per guaifenesin-codeine soln F PA COUGH PLUS COLD F fill retail) 100mg/5ml-6.3mg/5ml SYRP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits guaifenesin-codeine syrp F MUCINEX DM MAXIMUM 100mg/5ml-10mg/5ml STRENGTH TB12 (Use *** LITTLE REMEDIES FOR Dextromethorphan- COLDSMULTI SYMPTOM F Guaifenesin) LIQD MUCINEX DM TB12 (Use QL(2 ea Dextromethorphan- *** daily,210 ea LOHIST-D LIQD F QL(240 ml per fill retail) Guaifenesin) per fill retail) loratadine & QL(2 ea daily) MUCINEX FAST-MAX pseudoephedrine tb12 F COLD & SINUS LIQD (Use 5mg-120mg Phenylephrine- *** Acetaminophen- loratadine & QL(1 ea daily) Guaifenesin) pseudoephedrine tb24 F 10mg-240mg, 10mg-10mg- MUCINEX FAST-MAX PA; QL(266 ml 240mg-240mg COLD FLU& SORE per fill retail) THROAT CLEAR & COOL *** M-CLEAR WC SOLN F PA LIQD (Use Phenylephrine- DM-GG w/ APAP) PA M-END PE LIQD F MUCINEX FAST-MAX PA; QL(266 ml MUCINEX CHILDRENS PA; QL(266 ml COLD FLU& SORE per fill retail) COLD COUGH & SORE per fill retail) THROAT LIQD (Use *** THROAT LIQD (Use *** Phenylephrine-DM-GG w/ Phenylephrine-DM-GG w/ APAP) APAP) MUCINEX FAST-MAX PA; QL(266 ml MUCINEX CHILDRENS PA; QL(266 ml COLD/FLU LIQD (Use *** per fill retail) MULTI-SYMPTOM COLD per fill retail) Phenylephrine-DM-GG w/ & FEVER LIQD (Use *** APAP) Phenylephrine-DM-GG w/ MUCINEX FAST-MAX PA; QL(266 ml APAP) SEVERE COLD LIQD (Use *** per fill retail) MUCINEX CHILDRENS Phenylephrine-DM-GG w/ APAP) MULTI-SYMPTOM COLD *** LIQD (Use Phenylephrine MUCINEX FAST-MAX w/ DM-GG) SEVERE CONGESTION & MUCINEX CONGESTION COUGH CLEAR & COOL *** LIQD (Use Phenylephrine & COUGH CHILDRENS *** LIQD (Use Phenylephrine w/ DM-GG) w/ DM-GG) MUCINEX FAST-MAX SEVERE CONGESTION & MUCINEX COUGH FOR F *** KIDS PACK COUGH LIQD (Use Phenylephrine w/ DM-GG) MUCINEX D MAXIMUM QL(2 ea daily) MUCINEX STUFFY NOSE STRENGTH TB12 (Use *** Pseudoephedrine- & COLD CHILDRENS *** Guaifenesin) LIQD (Use Phenylephrine- Guaifenesin) MUCINEX D TB12 (Use QL(210 ea per Pseudoephedrine- *** fill retail) NORTUSS-EX LIQD F Guaifenesin) phenylephrine w/ F acetaminophen tabs phenylephrine w/ dm-gg F liqd ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phenylephrine w/ dm-gg F phenylephrine-doxylamine- syrp dextromethorphan- F phenylephrine- acetaminophen liqd acetaminophen- phenylephrine-guaifenesin F guaifenesin liqd F liqd 650mg/20ml-400mg/20ml- PHENYLEPHRINE/GUAIF F 10mg/20ml ENESIN LIQD phenylephrine- PA acetaminophen- PHENYLHISTINE DH LIQD F guaifenesin tabs 325mg- F PA 200mg-5mg, 325mg- PRO-RED AC SYRP F 325mg-200mg-200mg- QL(240 ml per 5mg-5mg promethazine & F 5 days retail); phenylephrine- F phenylephrine soln AL(At least 2 brompheniramine-dm elix yrs old) phenylephrine- F QL(240 ml per brompheniramine-dm liqd promethazine w/codeine F fill retail); AL(At soln least 18 yrs phenylephrine-chlorphen- F dm liqd old) phenylephrine- QL(240 ml per chlorpheniramine-dm w/ F promethazine w/codeine F fill retail); AL(At apap susp syrp least 18 yrs phenylephrine- old) chlorpheniramine-dm w/ F QL(240 ml per apap tabs promethazine-dm soln F fill retail); AL(At QL(240 ml per least 2 yrs old) phenylephrine-dm liqd F fill retail) QL(240 ml per QL(240 ml per promethazine-dm syrp F fill retail); AL(At phenylephrine-dm soln F fill retail) least 2 yrs old) phenylephrine-dm-gg w/ PA; QL(266 ml QL(240 ml per apap liqd 10mg/10ml- per fill retail) promethazine- F fill retail); AL(At phenylephrine-codeine syrp least 18 yrs 325mg/10ml-200mg/10ml- F 5mg/10ml, 20mg/20ml- old) 650mg/20ml-400mg/20ml- QL(240 ml per 10mg/20ml PROMETHAZINE/PHENYL F 5 days retail); phenylephrine-dm-gg w/ EPHRINE SYRP AL(At least 2 apap liqd 10mg/15ml- yrs old) QL(240 ml per 325mg/15ml-200mg/15ml- F 5mg/15ml, 20mg/30ml- PROMETHAZINE/PHENYL F fill retail); AL(At 650mg/30ml-400mg/30ml- EPHRINE/CODEINE SYRP least 18 yrs 10mg/30ml old) phenylephrine-dm-gg w/ pseudoephed-bromphen- F QL(240 ml per apap tabs 10mg-325mg- dm syrp fill retail) 200mg-5mg, 10mg-10mg- F pseudoephedrine w/ *** 325mg-325mg-200mg- codeine-gg soln 200mg-5mg-5mg pseudoephedrine w/ F QL(240 ml per codeine-gg soln 6 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pseudoephedrine w/ dm-gg F QL(240 ml per ROBITUSSIN PEAK COLD liqd 6 days retail) MULTI-SYMPTOM COLD *** LIQD (Use Phenylephrine pseudoephedrine- F QL(240 ml per chlorphen-dm liqd fill retail) w/ DM-GG) pseudoephedrine- QL(240 ml per ROBITUSSIN TO GO guaifenesin syrp F fill retail) COUGH &COLD CF LIQD *** 30mg/5ml-100mg/5ml (Use Phenylephrine w/ DM- GG) pseudoephedrine- QL(240 ml per guaifenesin tabs 40mg- F SCOT-TUSSIN DM LIQD F 400mg fill retail) pseudoephedrine- QL(2 ea daily) SCOT-TUSSIN LIQD (Use guaifenesin tb12 120mg- F Pheniramine-PE w/ Sod *** 1200mg Salicylate & Caffeine Citrate) pseudoephedrine- QL(210 ea per guaifenesin tb12 60mg- F fill retail) SCOT-TUSSIN SENIOR F 600mg LIQD PA pseudoephedrine-ibuprofen F SEMPREX-D CAPS F tabs THERAFLU SEVERE PX DAYTIME MULTI- F SYMPTOM CAPS COLD NIGHTTIME TABS (Use Phenylephrine- *** PX NITETIME MULTI- F Chlorpheniramine-DM w/ SYMPTOM CAPS APAP) REFENESEN CHEST TRIAMINIC COLD & QL(240 ml per CONGESTION & PAIN F COUGH DAY TIME F fill retail) RELIEF PE TABS CHILDRENS SYRP RESPAIRE-30 CAPS F TRIAMINIC FLU COUGH & F FEVER SYRP ROBITUSSIN CHILDRENS F triprolidine & F COUGH & COLD CF LIQD pseudoephedrine tabs ROBITUSSIN CHILDRENS COUGH/COLD LONG- F TUSNEL LIQD F ACTING LIQD ROBITUSSIN NIGHTTIME TUSNEL PEDIATRIC LIQD F COUGH LONG-ACTING F TYLENOL CHILDRENS DM CHILDRENS LIQD PLUS FLU SUSP (Use ROBITUSSIN PEAK COLD QL(240 ml per Phenylephrine- *** COUGH+ CHEST fill retail) Chlorpheniramine-DM w/ CONGESTION DM MAX *** APAP) STRENGTH LIQD (Use TYLENOL CHILDRENS Dextromethorphan- PLUS MULTI-SYMPTOM Guaifenesin) COLD SUSP (Use *** ROBITUSSIN PEAK COLD QL(240 ml per Phenylephrine- DM SYRP (Use *** fill retail) Chlorpheniramine-DM w/ Dextromethorphan- APAP) Guaifenesin)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL COLD & FLU Expectorants SEVERE TABS (Use *** Limit 1 fill per Phenylephrine-DM-GG w/ guaifenesin liqd 100 ) F Month;QL(240 APAP mg/5ml, 200 mg/10ml, 400 ml per 6 days mg/20ml TYLENOL COLD & HEAD PA retail) SEVERE CONGESTION Limit 1 fill per TABS (Use Phenylephrine- *** guaifenesin soln 100 F Month;QL(240 Acetaminophen- mg/5ml, 200 mg/10ml, 300 ml per 6 days Guaifenesin) mg/15ml retail) TYLENOL COLD MAX Limit 1 fill per LIQD (Use Month;QL(240 Dextromethorphan- *** guaifenesin syrp 100 F mg/5ml, 200 mg/10ml ml per 6 days Phenylephrine- retail) Acetaminophen) PA TYLENOL COLD MULTI- guaifenesin tabs 200 mg F SYMPTOM NIGHTTIME guaifenesin tabs 400 mg F LIQD (Use Phenylephrine- *** Doxylamine- Dextromethorphan- guaifenesin tb12 1200 mg F QL(2 ea daily) Acetaminophen) Limit 1 fill per TYLENOL COLD MULTI- F Month;QL(40 SYMPTOM SEVERE guaifenesin tb12 600 mg ea per 30 days DAYTIME LIQD (Use *** retail) Phenylephrine-DM-GG w/ APAP) MUCINEX FOR KIDS F PA PACK TYLENOL COLD/COUGH/RUNNYNO MUCINEX MAXIMUM QL(2 ea daily) STRENGTH TB12 (Use *** SE CHILDRENS SUSP *** (Use Dextromethorphan- Guaifenesin) Acetaminophen- Limit 1 fill per Chlorpheniramine) MUCINEX TB12 (Use *** Month;QL(40 TYLENOL SINUS SEVERE PA Guaifenesin) ea per 30 days retail) TABS (Use Phenylephrine- *** Acetaminophen- SSKI SOLN F Guaifenesin) TYLENOL WARMING Misc. Respiratory Inhalants COUGH & SEVER sodium chloride (inhalant) F QL(240 ml per CONGESTION DAYTIME *** aers 0.9 % fill retail) LIQD (Use Phenylephrine- DM-GG w/ APAP) sodium chloride (inhalant) F nebu 0.9 %, 3 %, 10 % VICKS DAYQUIL MUCUS F CONTROL DM LIQD Mucolytics VICKS NYQUIL COUGH acetylcysteine soln F LIQD (Use Doxylamine- *** DM) DERMATOLOGICALS - Drugs to Treat Skin ZYRTEC-D QL(2 ea daily) Conditions ALLERGY/CONGESTION *** Acne Products TB12 (Use Cetirizine- Pseudoephedrine)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea BENZOYL PEROXIDE 8% F PA; RX/OTC *** daily); AL(At GEL ABSORICA CAPS least 12 yrs old) benzoyl peroxide bar 10 % F ACANYA GEL (Use PA BENZOYL PEROXIDE F QL(340.2 gm Clindamycin Phosphate- *** CLEANSER LIQD per fill retail) Benzoyl Peroxide) BENZOYL PEROXIDE F QL(340.2 gm ACNE MEDICATION 10 F CLEANSER LOTN per fill retail) LOTN benzoyl peroxide crea 10 F ACNE MEDICATION 5 F %, 2.5 % LOTN benzoyl peroxide foam 5.3 F PA; RX/OTC adapalene crea 0.1 % F PA % benzoyl peroxide foam 9.8 F PA adapalene gel 0.3 % F PA % benzoyl peroxide gel 10 % F RX/OTC ADAPALENE LOTN 0.1 % F PA BENZOYL PEROXIDE F AKTIPAK PACK F PA GEL 2.5 %

ATRALIN GEL (Use *** PA benzoyl peroxide gel 5 % F Tretinoin) QL(237 gm per AVAR LS CLEANSER PA benzoyl peroxide liqd 10 % F fill retail); LIQD (Use Sulfacetamide *** RX/OTC Sodium w/ Sulfur) QL(204 gm per benzoyl peroxide liqd 4 % F AVAR LS PADS F PA fill retail) PA benzoyl peroxide liqd 5 %, F RX/OTC AVAR PADS F 2.5 % QL(340.2 gm PA benzoyl peroxide liqd 6 % F AZELEX CREA F per fill retail) BENZAC AC WASH LIQD *** RX/OTC benzoyl peroxide liqd 7 % F PA (Use Benzoyl Peroxide) BENZACLIN GEL (Use PA benzoyl peroxide misc 6 % F PA; RX/OTC Clindamycin Phosphate- *** Benzoyl Peroxide) PA; QL(46.6 benzoyl peroxide- F gm per fill BENZACLIN WITH PUMP PA erythromycin gel retail) GEL (Use Clindamycin *** Phosphate-Benzoyl BP CLEANSING WASH F PA Peroxide) EMUL BENZAMYCIN GEL (Use PA; QL(46.6 BPO CREAMY WASH F PA Benzoyl Peroxide- *** gm per fill COMPLETEPACK KIT Erythromycin) retail) BPO GEL 4 % F RX/OTC BENZEFOAM FOAM (Use *** PA; RX/OTC Benzoyl Peroxide) BPO GEL 8 % F PA; RX/OTC BENZEFOAM ULTRA PA FOAM (Use Benzoyl *** Peroxide)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEAN & CLEAR ERYGEL GEL (Use *** QL(60 gm per ADVANTAGE 3-IN-1 F Erythromycin (Acne Aid)) fill retail) EXFOLIATING CLEANSER QL(60 gm per erythromycin (acne aid) gel F LOTN fill retail) CLEOCIN-T GEL (Use erythromycin (acne aid) F PA Clindamycin Phosphate *** pads (Topical)) erythromycin (acne aid) F CLEOCIN-T LOTN (Use soln Clindamycin Phosphate *** (Topical)) EVOCLIN FOAM (Use PA Clindamycin Phosphate *** CLEOCIN-T SOLN (Use (Topical)) Clindamycin Phosphate *** (Topical)) FABIOR FOAM F PA CLEOCIN-T SWAB (Use PA INOVA 4/1 ACNE F PA Clindamycin Phosphate *** CONTROL THERAPY KIT (Topical)) INOVA 8/2 ACNE F PA CLINDAGEL GEL *** CONTROL THERAPY KIT INOVA KIT F PA clindamycin phosphate F PA (topical) foam PA; QL(2 ea clindamycin phosphate F F daily); AL(At (topical) gel isotretinoin caps least 12 yrs clindamycin phosphate F old) (topical) lotn KLARON LOTN (Use QL(236 ml per clindamycin phosphate F Sulfacetamide Sodium *** fill retail) (topical) soln (Acne)) clindamycin phosphate F PA NEUAC KIT KIT F PA (topical) swab NEUTROGENA ON-THE- CLINDAMYCIN *** PHOSPHATE GEL SPOT ACNE TREATMENT *** CREA (Use Benzoyl clindamycin phosphate- F PA benzoyl peroxide gel Peroxide) PANOXYL LIQD (Use RX/OTC clindamycin phosphate- F PA *** tretinoin gel Benzoyl Peroxide) DESQUAM-X WASH LIQD QL(237 gm per PANOXYL-4 CREAMY QL(204 gm per 10 % (Use Benzoyl *** fill retail); WASH LIQD (Use Benzoyl *** fill retail) Peroxide) RX/OTC Peroxide) DESQUAM-X WASH LIQD RX/OTC RA DAYLOGIC ACNE 5 % (Use Benzoyl *** FOAMINGWASH F Peroxide) MAXIMUM STRENGTH FOAM DIFFERIN CREA 0.1 % *** PA (Use Adapalene) QL(20 gm per RETIN-A CREA 0.025 %, fill retail); DIFFERIN GEL 0.3 % (Use PA 0.05 %, 0.1 % (Use *** *** Tretinoin) AL(Up to 35 yrs Adapalene) old ) DIFFERIN LOTN 0.1 % F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(15 gm per SUMAXIN PADS (Use PA RETIN-A GEL 0.01 % (Use *** fill retail); Sulfacetamide Sodium w/ *** Tretinoin) AL(Up to 35 yrs Sulfur) old ) SUMAXIN TS SUSP (Use PA RETIN-A GEL 0.025 % *** AL(Up to 35 yrs Sulfacetamide Sodium w/ *** (Use Tretinoin) old ) Sulfur) RETIN-A MICRO GEL (Use *** PA SUMAXIN WASH LIQD PA Tretinoin Microsphere) (Use Sulfacetamide *** RETIN-A MICRO PUMP PA Sodium w/ Sulfur) GEL 0.04 %, 0.1 % (Use *** QL(20 gm per Tretinoin Microsphere) tretinoin crea 0.025 %, 0.05 F fill retail); %, 0.1 % AL(Up to 35 yrs RETIN-A MICRO PUMP F PA GEL 0.08 % old ) SODIUM QL(60 gm per QL(15 gm per fill retail); SULFACETAMIDE/SULFU F fill retail) tretinoin gel 0.01 % F R LOTN AL(Up to 35 yrs old ) SODIUM QL(30 gm per AL(Up to 35 yrs SULFACETAMIDE/SULFU F fill retail) tretinoin gel 0.025 % F R SUSP old ) PA SSS 10-5 FOAM F PA tretinoin gel 0.05 % F PA sulfacetamide sodium F QL(236 ml per tretinoin microsphere gel F (acne) lotn fill retail) VELTIN GEL F PA sulfacetamide sodium w/ F PA sulfur crea 5%-10% ZIANA GEL (Use PA sulfacetamide sodium w/ F PA Clindamycin Phosphate- *** sulfur emul 1%-10% Tretinoin) sulfacetamide sodium w/ F QL(340.2 gm sulfur emul 5%-10% per fill retail) Agents for External Genital and Perianal Warts sulfacetamide sodium w/ PA VEREGEN OINT F PA sulfur liqd 4%-9%, 2%- F 10%, 4.5%-9% Analgesics - Topical sulfacetamide sodium w/ PA ICY HOT PAIN RELIEVING sulfur pads 4%-10%, 4%- F GEL GEL (Use Menthol *** 4%-10%-10% (Topical Analgesic)) menthol (topical analgesic) sulfacetamide sodium w/ F PA F sulfur susp 4%-8% gel sulfacetamide sodium- F PA Anti-inflammatory Agents - Topical sulfur w/ skin cleanser kit DICLOFENAC F PA SUMADAN KIT KIT (Use PA EPOLAMINE PTCH Sulfacetamide Sodium- *** PA; Limit 2 Sulfur w/ Skin Cleanser) tubes (200 SUMADAN WASH LIQD PA diclofenac sodium (topical) F grams) per (Use Sulfacetamide *** gel 1 % month;QL(6.68 Sodium w/ Sulfur) gm daily) PA SUMAXIN CP KIT KIT F diclofenac sodium (topical) F PA soln 1.5 % ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLECTOR PTCH F PA NEOSPORIN ORIGINAL QL(907.8 gm OINT (Use Neomycin- *** per fill retail) PA; Limit 2 Bacitracin-Polymyxin) VOLTAREN GEL (Use tubes (200 NEOSPORIN PLUS PAIN QL(15 gm per Diclofenac Sodium *** grams) per RELIEF MAXIMUM 30 days retail) (Topical)) month;QL(6.68 STRENGTH CREA (Use *** gm daily) Neomycin-Polymyxin w/ Antibiotics - Topical Pramoxine) PA POLYSPORIN OINT (Use *** QL(144 gm per ALTABAX OINT F Bacitracin-Polymyxin B) fill retail) BACIGUENT OINT (Use *** Antifungals - Topical Bacitracin (Topical)) ALEVAZOL OINT F PA bacitracin (topical) oint F ALOE VESTA QL(2712 gm QL(30 gm per bacitracin zinc oint F ANTIFUNGAL OINT (Use *** per fill retail) fill retail) Miconazole Nitrate QL(144 gm per (Topical)) bacitracin-polymyxin b oint F fill retail) ALOE VESTA CLEAR QL(2712 gm BACTROBAN CREA (Use QL(30 gm per ANTIFUNGAL OINT (Use *** per fill retail) Mupirocin Calcium *** fill retail) Miconazole Nitrate (Topical)) (Topical)) AZOLEN TINCTURE QL(29.57 ml CENTANY OINT F QL(30 gm per F fill retail) SOLN per fill retail) RX/OTC CORTISPORIN CREA F PA butenafine hcl crea F QL(100 gm per PA ciclopirox gel 0.77 % F CORTISPORIN OINT F fill retail) gentamicin sulfate (topical) F QL(60 gm per ciclopirox olamine crea F crea fill retail) QL(60 ml per gentamicin sulfate (topical) F QL(60 gm per ciclopirox olamine susp F oint fill retail) fill retail) PA mupirocin calcium (topical) F QL(30 gm per ciclopirox sham 1 % F crea fill retail) QL(6.6 ml per MUPIROCIN CREA F QL(30 gm per ciclopirox soln 8 % F fill retail) fill retail) QL(30 gm per QL(113 gm per mupirocin oint F fill retail) clotrimazole (topical) crea F fill retail); RX/OTC PA NEO-SYNALAR CREA F QL(60 ml per clotrimazole (topical) soln F fill retail); neomycin-bacitracin- F QL(907.8 gm polymyxin oint per fill retail) RX/OTC clotrimazole w/ QL(45 gm per neomycin-bacitracin- F QL(56 gm per F polymyxin-pramoxine oint fill retail) betamethasone crea 30 days retail) clotrimazole w/ QL(30 ml per neomycin-polymyxin w/ F QL(15 gm per F pramoxine crea 30 days retail) betamethasone lotn 30 days retail) QL(30 gm per econazole nitrate crea F fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERTACZO CREA F PA LOTRIMIN ULTRA CREA F RX/OTC

EXELDERM CREA F PA LOTRIMIN ULTRA CREA *** RX/OTC (Use Butenafine HCl) EXELDERM SOLN F PA LOTRISONE CREA (Use QL(45 gm per Clotrimazole w/ *** 30 days retail) EXTINA FOAM (Use *** PA Betamethasone) Ketoconazole (Topical)) MENTAX CREA F RX/OTC FUNGOID TINCTURE F QL(29.57 ml SOLN per fill retail) MICATIN CREA (Use *** GENTIAN VIOLET SOLN F Miconazole Nitrate (Topical)) GNP GENTIAN VIOLET F miconazole nitrate (topical) F SOLN crea PA; QL(8 ml miconazole nitrate (topical) F QL(2712 gm JUBLIA SOLN F per 30 days oint per fill retail) retail) miconazole nitrate (topical) QL(1020 gm QL(60 gm per F ketoconazole (topical) crea F powd per fill retail) fill retail) MICONAZOLE PA PA ketoconazole (topical) foam F NITRATE/ZINC F OXIDE/WHITE ketoconazole (topical) F QL(120 ml per PETROLATUM OINT sham fill retail) naftifine hcl crea F PA LAMISIL ADVANCED GEL F QL(12 gm per fill retail) NAFTIN CREA 2 % (Use *** PA Naftifine HCl) LAMISIL AT CREA (Use *** QL(42 gm per Terbinafine HCl (Topical)) fill retail) NAFTIN GEL 1 %, 2 % F PA LAMISIL AT JOCK ITCH QL(42 gm per CREA (Use Terbinafine *** fill retail) NIZORAL A-D SHAM F HCl (Topical)) NIZORAL SHAM (Use QL(120 ml per LAMISIL AT SPRAY SOLN F QL(125 ml per *** fill retail) Ketoconazole (Topical)) fill retail) QL(30 gm per LOPROX CREA (Use *** nystatin (topical) crea F Ciclopirox Olamine) fill retail) QL(30 gm per LOPROX SHAMPOO *** PA nystatin (topical) oint F SHAM (Use Ciclopirox) fill retail) QL(60 gm per LOPROX SUSP (Use *** QL(60 ml per nystatin-triamcinolone crea F Ciclopirox Olamine) fill retail) fill retail) QL(60 gm per QL(113 gm per nystatin-triamcinolone oint F LOTRIMIN AF CREA (Use *** fill retail) Clotrimazole (Topical)) fill retail); RX/OTC oxiconazole nitrate crea F PA LOTRIMIN AF FOR HER QL(113 gm per CREA (Use Clotrimazole *** fill retail); OXISTAT CREA (Use *** PA (Topical)) RX/OTC Oxiconazole Nitrate) LOTRIMIN AF JOCK ITCH QL(113 gm per OXISTAT LOTN F PA CREA (Use Clotrimazole *** fill retail); (Topical)) RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENLAC NAIL LACQUER *** QL(6.6 ml per diphenhydramine-zinc QL(30 gm per SOLN (Use Ciclopirox) fill retail) acetate crea 0.1%-0.1%- F fill retail) 2%-2%, 0.1%-2% terbinafine hcl (topical) F QL(42 gm per crea fill retail) diphenhydramine-zinc F acetate crea 0.1%-1% TINACTIN AERP (Use *** QL(138 gm per Tolnaftate) fill retail) diphenhydramine-zinc F acetate liqd 0.1%-2% TINACTIN CREA (Use *** QL(30 gm per Tolnaftate) fill retail) ITCH RELIEF CREA F TINACTIN DEODORANT *** QL(138 gm per AERP (Use Tolnaftate) fill retail) Antineoplastic or Premalignant Lesion Agents - TINACTIN JOCK ITCH *** QL(138 gm per CARAC CREA F AERP (Use Tolnaftate) fill retail) diclofenac sodium (actinic PA TINACTIN JOCK ITCH *** QL(30 gm per F CREA (Use Tolnaftate) fill retail) keratoses) gel EFUDEX CREA (Use QL(40 gm per TINACTIN POWD (Use *** QL(113 gm per *** Tolnaftate) fill retail) Fluorouracil (Topical)) 30 days retail) QL(138 gm per PA tolnaftate aerp F FLUOROPLEX CREA F fill retail) QL(30 gm per QL(40 gm per tolnaftate crea F fluorouracil (topical) crea F fill retail) 30 days retail) QL(151 ml per FLUOROURACIL CREA tolnaftate liqd F F fill retail) 0.5 % QL(113 gm per FLUOROURACIL SOLN 2 QL(10 ml per tolnaftate powd F F fill retail) %, 5 % 30 days retail) QL(151 ml per PA tolnaftate soln F PANRETIN GEL F fill retail) PICATO GEL F PA VUSION OINT F PA SOLARAZE GEL (Use PA XOLEGEL GEL F PA Diclofenac Sodium (Actinic *** Keratoses)) Antihistamines-Topical PA; SP BENADRYL EXTRA QL(30 gm per VALCHLOR GEL F STRENGTH CREA (Use *** fill retail) Antipruritics - Topical Diphenhydramine-Zinc QL(222 ml per Acetate) camphor & menthol lotn F fill retail) BENADRYL ITCH doxepin hcl (antipruritic) PA STOPPING CREA (Use *** F Diphenhydramine-Zinc crea Acetate) DOXEPIN *** HYDROCHLORIDE CREA diphenhydramine hcl F (topical) crea PRUDOXIN CREA F PA diphenhydramine hcl F (topical) gel SARNA LOTN (Use *** QL(222 ml per Camphor & Menthol) fill retail) diphenhydramine hcl F (topical) soln ZONALON CREA ***

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZONALON CREA F PA HEAD & SHOULDERS CLASSICCLEAN/NORMAL *** Antipsoriatics SHAM (Use Pyrithione Zinc) PA acitretin caps F HEAD & SHOULDERS QL(120 gm per DRY SCALP 2 IN 1 SHAM *** calcipotriene crea F fill retail) (Use Pyrithione Zinc) PA calcipotriene oint F OVACE PLUS LOTN F QL(60 ml per OVACE PLUS WASH GEL PA calcipotriene soln F fill retail) (Use Sulfacetamide *** Sodium) DOVONEX CREA (Use *** QL(120 gm per Calcipotriene) fill retail) OVACE PLUS WASH LIQD (Use Sulfacetamide *** DRITHO-CREME HP F Sodium) CREA OVACE WASH LIQD (Use *** methoxsalen rapid caps F PA Sulfacetamide Sodium) OXSORALEN ULTRA PA pyrithione zinc sham F CAPS (Use Methoxsalen *** QL(355 ml per Rapid) salicylic acid & sulfur sham F fill retail) SORIATANE CAPS (Use *** PA Acitretin) SEBULEX SHAM (Use *** QL(355 ml per Salicylic Acid & Sulfur) fill retail) PA SORILUX FOAM F QL(420 ml per selenium sulfide lotn 1 % F QL(120 gm per fill retail) QL(120 ml per F fill retail); selenium sulfide lotn 2.5 % F tazarotene crea AL(Up to 21 yrs fill retail) old ) QL(420 ml per selenium sulfide sham 1 % F QL(240 gm per fill retail) fill retail); TAZORAC CREA 0.05 % F SELSUN BLUE DAILY QL(420 ml per AL(Up to 21 yrs LOTN (Use Selenium *** fill retail) old ) Sulfide) QL(120 gm per SELSUN BLUE LOTN (Use *** QL(420 ml per TAZORAC CREA 0.1 % *** fill retail); Selenium Sulfide) fill retail) (Use Tazarotene) AL(Up to 21 yrs SELSUN BLUE QL(420 ml per old ) MEDICATED LOTN (Use *** fill retail) QL(200 gm per Selenium Sulfide) TAZORAC GEL 0.05 %, F fill retail); SELSUN BLUE QL(420 ml per 0.1 % AL(Up to 21 yrs MOISTURIZING LOTN *** fill retail) old ) (Use Selenium Sulfide) PA; SP TREMFYA SOPN F sulfacetamide sodium gel F PA ex Antiseborrheic Products sulfacetamide sodium liqd F HEAD & SHOULDERS ex 2IN1 CLASSIC *** CLEAN/NORMAL SHAM Antivirals - Topical QL(5 gm per fill (Use Pyrithione Zinc) acyclovir topical crea F retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 gm per QL(50 gm per acyclovir topical oint F betamethasone 30 days retail) dipropionate augmented F fill retail) oint DENAVIR CREA F PA betamethasone valerate F XERESE CREA F PA crea 0.1 % betamethasone valerate F PA ZOVIRAX CREA EX 5 % *** QL(5 gm per fill foam 0.12 % (Use Acyclovir Topical) retail) betamethasone valerate F ZOVIRAX OINT EX 5 % *** QL(30 gm per lotn 0.1 % (Use Acyclovir Topical) 30 days retail) betamethasone valerate F Burn Products oint 0.1 % PA mafenide acetate pack F PA CAPEX SHAM F clobetasol propionate crea QL(60 gm per SILVADENE CREA (Use *** F Silver Sulfadiazine) 0.05 % fill retail) clobetasol propionate F QL(60 gm per silver sulfadiazine crea F emollient base crea fill retail) SULFAMYLON CREA 85 F clobetasol propionate F PA MG/GM emulsion foam SULFAMYLON PACK 5 % PA *** clobetasol propionate foam F PA (Use Mafenide Acetate) 0.05 % Corticosteroids - Topical clobetasol propionate gel F QL(60 gm per 0.05 % fill retail) alclometasone dipropionate F PA crea clobetasol propionate liqd F PA 0.05 % alclometasone dipropionate F PA oint clobetasol propionate lotn F PA QL(60 gm per 0.05 % AMCINONIDE CREA F fill retail) clobetasol propionate oint F QL(60 gm per 0.05 % fill retail) AMCINONIDE LOTN F PA clobetasol propionate sham F PA 0.05 % AMCINONIDE OINT F PA clobetasol propionate soln F QL(50 ml per APEXICON E CREA F PA 0.05 % fill retail) CLOBEX LIQD (Use *** PA AUGMENTED QL(50 gm per Clobetasol Propionate) BETAMETHASONE F fill retail) CLOBEX LOTN (Use *** PA DIPROPIONATE GEL Clobetasol Propionate) betamethasone 1 rtl pack lmt F CLOBEX SHAM (Use *** PA dipropionate (topical) crea per fill, Clobetasol Propionate) betamethasone QL(60 ml per F CLOCORTOLONE F PA dipropionate (topical) lotn fill retail) PIVALATE CREA betamethasone F CLOCORTOLONE F PA dipropionate (topical) oint PIVALATE PUMP CREA betamethasone QL(50 gm per PA dipropionate augmented F fill retail) CLODAN KIT KIT F gel

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLODERM CREA F PA fluocinolone acetonide crea F PA; QL(60 gm 0.01 % per fill retail) PA CLODERM PUMP CREA F fluocinolone acetonide crea F PA; QL(120 gm 0.025 % per fill retail) CORDRAN TAPE 4 PA F fluocinolone acetonide oint F PA; QL(120 gm MCG/SQCM 0.025 % per fill retail) CUTIVATE LOTN (Use PA *** fluocinolone acetonide soln F PA Fluticasone Propionate) 0.01 % DERMATOP OINT (Use PA QL(120 gm per *** fluocinonide crea 0.05 % F Prednicarbate) fill retail) PA DESONATE GEL F fluocinonide crea 0.1 % F PA PA; QL(60 gm desonide crea F fluocinonide emulsified F QL(60 gm per per fill retail) base crea fill retail) PA; QL(118 ml QL(60 gm per desonide lotn F fluocinonide gel 0.05 % F per fill retail) fill retail) PA; QL(60 gm QL(60 gm per desonide oint F fluocinonide oint 0.05 % F per fill retail) fill retail) DESOWEN CREA (Use PA; QL(60 gm QL(60 ml per *** fluocinonide soln 0.05 % F Desonide) per fill retail) fill retail) DESOWEN LOTN (Use PA; QL(118 ml *** fluticasone propionate crea F QL(60 gm per Desonide) per fill retail) 0.05 % fill retail) desoximetasone crea 0.05 QL(300 gm per F fluticasone propionate lotn F PA % fill retail) 0.05 % desoximetasone crea 0.25 PA; QL(200 gm F fluticasone propionate oint F QL(60 gm per % per fill retail) 0.005 % fill retail) desoximetasone gel 0.05 PA; QL(60 gm F halobetasol propionate F PA % per fill retail) crea 0.05 % desoximetasone liqd 0.25 PA F halobetasol propionate oint F PA % 0.05 % desoximetasone oint 0.25 F PA; QL(100 gm PA % per fill retail) HALOG CREA F DIFLORASONE F QL(60 gm per PA DIACETATE CREA fill retail) HALOG OINT F QL(60 gm per hydrocortisone (topical) diflorasone diacetate oint F F fill retail) crea 0.5 % DIPROLENE OINT (Use QL(50 gm per QL(454 gm per *** hydrocortisone (topical) F fill retail); Betamethasone fill retail) crea 1 % Dipropionate Augmented) RX/OTC ELOCON CREA (Use *** QL(50 gm per hydrocortisone (topical) F QL(120 gm per Mometasone Furoate) fill retail) crea 2.5 % 30 days retail) ELOCON OINT (Use *** QL(45 gm per hydrocortisone (topical) lotn F QL(120 ml per Mometasone Furoate) fill retail) 1 % fill retail) EPIFOAM FOAM F hydrocortisone (topical) lotn F QL(118 ml per 2.5 % fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone (topical) F QL(56 gm per MONISTAT SOOTHING QL(454 gm per oint 0.5 % fill retail) CARE ITCH RELIEF CREA *** fill retail); QL(60 gm per (Use Hydrocortisone RX/OTC hydrocortisone (topical) F 30 days retail); (Topical)) oint 1 % RX/OTC OLUX FOAM (Use *** PA Clobetasol Propionate) hydrocortisone (topical) F oint 2.5 % OLUX-E FOAM (Use PA Clobetasol Propionate *** hydrocortisone acetate F (topical) crea Emulsion) PA hydrocortisone butyrate F PANDEL CREA F crea prednicarbate crea F PA hydrocortisone butyrate F PA hydrophilic lipo base crea PREDNICARBATE CREA F PA hydrocortisone butyrate F oint PREDNICARBATE OINT F PA hydrocortisone butyrate F soln PSORCON CREA F QL(60 gm per fill retail) hydrocortisone valerate F QL(60 gm per crea fill retail) SYNALAR CREA 0.025 % PA; QL(120 gm (Use Fluocinolone *** per fill retail) hydrocortisone valerate F PA oint Acetonide) SYNALAR OINT 0.025 % PA; QL(120 gm hydrocortisone-aloe vera F QL(224 gm per crea fill retail) (Use Fluocinolone *** per fill retail) KENALOG AERS (Use PA Acetonide) Triamcinolone Acetonide *** SYNALAR SOLN 0.01 % PA (Topical)) (Use Fluocinolone *** Acetonide) LOCOID CREA (Use *** Hydrocortisone Butyrate) TEMOVATE CREA (Use *** QL(60 gm per LOCOID LIPOCREAM PA Clobetasol Propionate) fill retail) TEMOVATE OINT (Use QL(60 gm per CREA (Use Hydrocortisone *** *** Butyrate Hydrophilic Lipo Clobetasol Propionate) fill retail) Base) TEXACORT SOLN F PA LOCOID OINT (Use *** Hydrocortisone Butyrate) TOPICORT CREA 0.05 % *** QL(300 gm per (Use Desoximetasone) fill retail) LOCOID SOLN (Use *** Hydrocortisone Butyrate) TOPICORT CREA 0.25 % *** PA; QL(200 gm (Use Desoximetasone) per fill retail) LUXIQ FOAM (Use *** PA Betamethasone Valerate) TOPICORT GEL 0.05 % *** PA; QL(60 gm QL(50 gm per (Use Desoximetasone) per fill retail) mometasone furoate crea F fill retail) TOPICORT LIQD 0.25 % *** PA QL(45 gm per (Use Desoximetasone) mometasone furoate oint F fill retail) TOPICORT OINT 0.25 % *** PA; QL(100 gm (Use Desoximetasone) per fill retail) mometasone furoate soln F PA triamcinolone acetonide F PA (topical) aers 0.147 mg/gm

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(120 gm per QL(480 ml per triamcinolone acetonide F urea lotn 10 % F (topical) crea 0.025 % 30 days retail) fill retail) triamcinolone acetonide F urea lotn 40 % F (topical) crea 0.1 % triamcinolone acetonide F QL(15 gm per Emollients (topical) crea 0.5 % fill retail) A + D PERSONAL CARE F triamcinolone acetonide QL(60 ml per LOTION LOTN (topical) lotn 0.025 %, 0.1 F fill retail) % ALBOLENE CREA F triamcinolone acetonide QL(454 gm per F ALOE AFTERSUN F (topical) oint 0.025 % fill retail) LOTION LOTN triamcinolone acetonide F (topical) oint 0.1 % AMLACTIN ULTRA CREA F AQUA GLYCOLIC FACE triamcinolone acetonide F QL(15 gm per F (topical) oint 0.5 % fill retail) CREAM CREA AQUA GLYCOLIC HAND & TRIDESILON CREA (Use *** PA; QL(60 gm F Desonide) per fill retail) BODYLOTION LOTN ULTRAVATE CREA (Use *** PA AQUA LACTEN LOTN F Halobetasol Propionate) AQUADERM ULTRAVATE OINT (Use *** PA Halobetasol Propionate) TREATMENT/MOISTURIZ F ER LOTN VANOS CREA (Use *** PA Fluocinonide) AQUAMED LOTN F WESTCORT OINT (Use *** PA Hydrocortisone Valerate) AQUAPHILIC OINT F QL(10896 gm per fill retail) Diaper Rash Products AQUAPHOR ADVANCED F QL(10896 gm diaper rash products oint F THERAPY BABY OINT per fill retail) AQUAPHOR ADVANCED F QL(10896 gm Emollient/Keratolytic Agents THERAPY OINT per fill retail) ATRAC-TAIN CREA (Use QL(1704 gm *** AQUAPHOR OINT F QL(10896 gm Urea) per fill retail) per fill retail) URE-K CREA F PA AVEENO ACTIVE NATURALS DAILY F QL(1704 gm MOISTURIZING BODY urea crea 10 % F per fill retail) YOGURT LOTN urea crea 20 % F AVEENO ACTIVE NATURALS DAILY F RX/OTC MOISTURIZING BODY urea crea 40 % F YOGURT/APRICO LOTN urea crea 50 % F PA AVEENO ACTIVE NATURALS ECZEMA *** THERAPY CREA (Use urea in zinc undecylenate- F PA lactic acid vehicle emul Colloidal Oatmeal) UREA IN ZINC PA UNDECYLENATE/LACTIC F ACID VEHICLE EMUL

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVEENO ACTIVE BOUDREAUXS BABY QL(10896 gm NATURALS ECZEMA *** BUTT SMOOTH DRY SKIN F per fill retail) THERAPY HAND CREA OINT (Use Colloidal Oatmeal) CAM LOTN F AVEENO ACTIVE NATURALS SKIN RELIEF F CERAVE AM SPF 30 F MOISTURE REPAIR LOTN CREA CERAVE CREA F AVEENO BABY ECZEMA THERAPY CREA (Use *** Colloidal Oatmeal) CERAVE LOTN F AVEENO DAILY CERAVE PM LOTN F MOISTURIZINGSPF 15 F LOTN CERAVE RENEWING SA F CREA AVEENO INTENSE F RELIEF HAND CREA CERAVE SA RENEWING F AVEENO POSITIVELY LOTN AGELESSFIRMING BODY F CETAPHIL DAILY LOTN ADVANCE ULTRA F AVEENO POSITIVELY HYDRATING LOTN AGELESSSKIN F CETAPHIL DAILY FACIAL F STRENGTHENING BODY MOISTURIZER LOTN CREAM CREA CETAPHIL AVEENO POSITIVELY DERMACONTROL F AGELESSSKIN F MOISTURIZER/SPF 30 STRENGTHENING HAND LOTN CREAM CREA CETAPHIL AVEENO POSITIVELY MOISTURIZING CREA *** NOURISHING 24-HOUR F (Use Emollient) ULTRA-HYDRATING CETAPHIL F CREA MOISTURIZING LOTN AVEENO POSITIVELY F CETAPHIL F RADIANT LOTN RESTORADERM LOTN AVEENO POSITIVELY CETAPHIL THERAPEUTIC F RADIANTOVERNIGHT F HAND CREA HYDRATING FACIAL MOISTURI CREA CLN FACIAL MOISTURIZER F AVEENO STRESS RELIEF F NOURISHING LOTN MOISTURIZING LOTN COCOA BUTTER HAND & F BASLE CREA F BODYLOTION LOTN

BETA CARE CREA F COCOA BUTTER LOTN F COCONUT OIL BEAUTY F BETA CARE LOTN F CREA BETA XMA CREA F colloidal oatmeal crea F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS DAILY ULTRA F EMOLLIA-LOTION LOTN F MOISTURELOTION LOTN CVS MOISTURIZING F emollient crea F CREAM CREA DAILY CONDITIONING F QL(10896 gm emollient lotn 1.25 %, F TREATMENT OINT per fill retail) emollient oint QL(10896 gm DAILY MOISTURIZING F 0.16gm/30gm- F per fill retail) LOTN 300mg/30gm- DERMABASEOIL IN F 100unit/30gm, 41 %, 52 %, WATER CREA EPILYT LOTN F DERMAIDE ALOE CREA F EQ THERAPEUTIC DRY F DERMAL THERAPY SKIN CREA EXTRA STRENGTH BODY F EQ THERAPEUTIC LOTION LOTN MOISTURIZING CREAM F DERMAL THERAPY FACE CREA CAREMOISTURIZING F EQL ADVANCED LOTION LOTN RECOVERY SKIN CARE F DERMAL THERAPY FOOT F LOTN MASSAGE LOTN EQL MOISTURIZING F DERMAL THERAPY HAND CREAM CREA ELBOW & KNEE CREAM F EQL ULTRA LOTN MOISTURIZING DAILY F DERMAL THERAPY HEEL F LOTION LOTN CARE LOTN DERMEND EUCERIN BABY LOTN F MOISTURIZING BRUISE F EUCERIN CALMING FORMULA CREA DAILY MOISTURIZER *** DHEA CREA F CREA (Use Emollient) EUCERIN DAILY DIABETIDERM CREA F PROTECTION/SPF 30 F LOTN DIABETIDERM FOOT F EUCERIN INTENSIVE F REJUVENATING CREA REPAIR LOTN DIABETIDERM HAND & F EUCERIN INTENSIVE F BODY LOTN REPAIRHAND CREA DIABETIDERM LOTN F EUCERIN LOTN F DMAE CREA F EUCERIN ORIGINAL HEALINGSOOTHING F DML FORTE CREA F REPAIR LOTN EUCERIN PLUS CREA F DROXY CREAM CREA F EUCERIN PLUS LOTN F ELON SKIN REPAIR F SYSTEM CREA EMOLLIA-CREME CREA F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCERIN GOLD BOND ULTIMATE F PROFESSIONAL REPAIR F SOFTENING LOTN RICH FEEL LOTN GOLD BOND ULTIMATE F EUCERIN SKIN CALMING SOOTHING CREA DAILY MOISTURIZING *** GOLD BOND ULTIMATE F CREA (Use Emollient) SOOTHING LOTN EUCERIN SMOOTHING REPAIRADVANCED F GRX VITAMIN E LOTN F FORMULA LOTN HYDRASYN25 CREA F GENTLE CREA F HYDRAZONE LOTION F GNP ADVANCED F LOTN RECOVERY LOTN HYDRO-LAN CREA F GOLD BOND MEDICATED BODYLOTION EXTRA F STRENGTH LOTN J & J BURN CREAM CREA F GOLD BOND MEDICATED F KERADAN CREA F BODYLOTION LOTN GOLD BOND ULTIMATE KERI ADVANCED DIABETICS DRY SKIN F MOISTURE THERAPY F RELIEF LOTN LOTN GOLD BOND ULTIMATE KERI BASIC ESSENTIALS F DIABETICS' DRY RELIEF F LOTN LOTN KERI LONG LASTING F CREA GOLD BOND ULTIMATE F HEALING CREA KERI NOURISHING SHEA F BUTTER LOTN GOLD BOND ULTIMATE F HEALING LOTN KERI ORIGINAL LOTN F GOLD BOND ULTIMATE F QL(10896 gm HEALING OINT per fill retail) KERI OVERNIGHT LOTN F GOLD BOND ULTIMATE F LOTN KERI RENEWAL MILK F BODY LOTN GOLD BOND ULTIMATE F OVERNIGHT LOTN KERI RENEWAL SKIN F FIRMING LOTN GOLD BOND ULTIMATE F PROTECTION LOTN KERI RENEWAL STRETCH MARK F GOLD BOND ULTIMATE F MINIMIZER LOTN RESTORING LOTN KERI SENSITIVE SKIN F GOLD BOND ULTIMATE LOTN ROUGH& BUMPY SKIN F CREA LAC-HYDRIN CREA (Use QL(385 gm per Lactic Acid (Ammonium *** fill retail); GOLD BOND ULTIMATE Lactate)) RX/OTC SHEERRIBBONS F PEARLRADIANCE LOTN LAC-HYDRIN LOTN (Use QL(1368 ml per Lactic Acid (Ammonium *** fill retail); GOLD BOND ULTIMATE Lactate)) RX/OTC SHEERRIBBONS F SILKSOFTNESS LOTN

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAC-HYDRIN TWELVE QL(1368 ml per MEDELA TENDER CARE F LOTN (Use Lactic Acid *** fill retail); LANOLIN CREA (Ammonium Lactate)) RX/OTC MEDERMA AG FACE F QL(385 gm per CREAM CREA lactic acid (ammonium F fill retail); lactate) crea 12 % MEDERMA AG HAND & F RX/OTC BODY LOTION LOTN QL(1368 ml per MEDERMA STRETCH lactic acid (ammonium F fill retail); F lactate) lotn 12 % MARKS THERAPY CREA RX/OTC MOISTURIZING CREAM F lactic acid (ammonium F CREA lactate) lotn 5 % MOTHERS FRIEND CREA F LACTINOL HX CREA F LADY ESTHER 4 MOTHERS FRIEND LOTN F PURPOSE FACE CREAM F CREA MSM SKIN LOTION LOTN F QL(10896 gm LANAPHILIC OINT F NEOSPORIN ECZEMA per fill retail) ESSENTIALS CREA (Use *** Colloidal Oatmeal) LANOLOR CREA F NEUTROGENA BODY LEADER FINGER CREAM F LIGHT SESAME F CREA FORMULA LOTN LUBRIDERM ADVANCED F NEUTROGENA HAND F THERAPY LOTN CREA LUBRIDERM DAILY NEUTROGENA MOISTURE/NORMAL TO F HAND/NORWEGIANFOR F DRY SKIN LOTN MULA/FAST ABSORBING LUBRIDERM DAILY CREA MOISTURESHEA + F NEUTROGENA HEALTHY F CALMING LAVENDER SKIN CREA JASMINE LOTN NEUTROGENA HEALTHY F LUBRIDERM INTENSE F SKIN FACE SPF 15 LOTN SKIN REPAIR LOTN NEUTROGENA LUBRIDERM LOTN F MOISTURE SENSITIVE F SKIN LOTN LUBRIDERM MENS 3-IN-1 F NISEKO HYDRATING LOTN FACIAL MOISTURIZER F LUBRIDERM SERIOUSLY F CREA SENSITIVE LOTN NIVEA CREA F LUBRIDERM SKIN NOURISHINGWITH SHEA F NIVEA EXTRA ENRICHED F AND COCOA BUTTERS LOTION LOTN LOTN NIVEA EXTRA ENRICHED F LUBRISOFT LOTN F LOTN NIVEA GENTLE BODY F MAXAM LOTN F EXFOLIATOR LOTN

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVEA LIGHT CREA F RESTA CREA F

NIVEA LIGHT LOTN F RESTA LITE LOTN F

NIVEA LOTN F RISABAL-PH CREA F

NIVEA ORIGINAL LOTN F ROC DEEP WRINKLE F SERUM LOTN NIVEA ORIGINAL F ROC MULTI CORREXION MOISTURE LOTN 5 IN1 RESTORING EYE F NIVEA SOFT CREA F CREAM CREA ROC MULTI CORREXION NIVEA VISAGE CREA F 5 IN1 RESTORING NIGHT F CREAM CREA NIVEA VISAGE INNER ROC RETINOL F BEAUTY NIGHTTIME F CORREXION CREA RENEWAL CREA ROC RETINOL F NIVEA VISAGE LOTN F CORREXION MAX CREA ROC RETINOL NUTRADERM ADVANCED F CORREXION NIGHT F FORMULA LOTN CREA NUTRADERM CREA F ROC RETINOL CORREXION SENSITIVE F NUTRADERM LOTN F EYE CREA ROC RETINOL OINTMENT BASE OINT F QL(10896 gm per fill retail) CORREXION SENSITIVE F NIGHT CREA PEN-KERA CREA F ROSE MILK LOTN F PENTRAVAN CREA F SKIN REPAIR LOTN F PENTRAVAN PLUS CREA F SOOTHE & COOL QL(454 gm per MOISTURIZING BODY F PETROLATUM OINT F LOTION WITH ALOE fill retail) LOTN PRETTY FEET & HANDS F SOOTHE & COOL SKIN CREA CREAMWITH ALOE & F RA ADVANCED HEALING F QL(10896 gm VITAMINS A, D & E CREA OINT per fill retail) RA DAYLOGIC HEALING SORBOLENE CREA F DRY SKIN THERAPY F SPECIAL CARE CREAM F LOTN CREA RA GENTLE SKIN CREAM F ST IVES SWISS CREA FORMULA 24HOUR F RA RENEWAL DRY SKIN F MOISTURE LOTN THERAPY LOTN STUDIO 35 EXTRA RADIAGUARD F MOISTURIZING LOTION F ADVANCED LOTN LOTN

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STUDIO 35 Immunosuppressive Agents - Topical F MOISTURIZING SKIN PA; QL(30 gm CREA ELIDEL CREA (Use *** Pimecrolimus) per 30 days SWEEN CREAM CREA F retail) PA; QL(30 gm THERABETIC SKIN CARE F pimecrolimus crea F per 30 days LOTN retail) THERAPEUTIC F PA; QL(30 gm MOISTURIZING CREA PROTOPIC OINT 0.03 % *** per 30 days THERAPLEX F (Use Tacrolimus (Topical)) retail); AL(At HYDROLOTION LOTN least 2 yrs old) UDDERLY SMOOTH F PA; QL(30 gm CREA per 30 days PROTOPIC OINT 0.1 % *** retail); AL(At UDDERLY SMOOTH F (Use Tacrolimus (Topical)) EXTRA CARE CREA least 16 yrs old) UDDERLY SMOOTH F EXTRA CARE20 CREA PA; QL(30 gm tacrolimus (topical) oint F per 30 days VANICREAM CREA F 0.03 % retail); AL(At least 2 yrs old) VANICREAM LITE LOTN F PA; QL(30 gm per 30 days VELVACHOL CREA F tacrolimus (topical) oint 0.1 F retail); AL(At % least 16 yrs VITAMIN E WITH F PANTHENOL CREA old) Keratolytic/Antimitotic Agents vitamins a & d (topical) oint F CLEAR AWAY ONE STEP WIBI LOTN F WARTREMOVER PADS *** (Use Salicylic Acid) ZIMS CRACK CREME F CLEAR AWAY PLANTAR DAYTIME CREA SYSTEM PADS (Use *** Enzymes - Topical Salicylic Acid) PA CLEAR AWAY WART SANTYL OINT F REMOVER SYSTEM *** PADS (Use Salicylic Acid) TBC AERS F PA COMPOUND W FREEZE Immunomodulating Agents - Topical OFF WART REMOVAL F SYSTEM AERO ALDARA CREA (Use *** PA Imiquimod) COMPOUND W LIQD (Use *** Salicylic Acid) PA imiquimod crea F COMPOUND W MAXIMUM QL(14 gm per PA STRENGTH GEL (Use *** fill retail) IMIQUIMOD PUMP CREA F Salicylic Acid) PA ZYCLARA CREA F PA CONDYLOX GEL F

ZYCLARA PUMP CREA F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORN REMOVER ONE BENGAY ULTRA STEP PADS (Use Salicylic *** STRENGTH CREA (Use *** Acid) Camphor-Menthol-Methyl CORN REMOVER Salicylate) WATERPROOF PADS *** camphor-menthol-methyl F (Use Salicylic Acid) salicylate crea DERMAREST PSORIASIS F liniments & rubs oint F GEL menthol-methyl salicylate F KERALYT GEL 3 % F (liniments) crea KERALYT GEL 6 % (Use *** menthol-methyl salicylate F Salicylic Acid) (liniments) oint podofilox soln F MOBISYL CREA (Use *** Trolamine Salicylate) SALEX CREAM KIT (Use PA *** MYOFLEX CREA (Use *** Salicylic Acid w/ Cleanser) Trolamine Salicylate) SALEX LOTION KIT (Use PA *** SPORTSCREME CREA *** Salicylic Acid w/ Cleanser) (Use Trolamine Salicylate) SALEX SHAM (Use *** TIGER BALM PAIN F Salicylic Acid) RELIEVING PTCH QL(14 gm per salicylic acid gel 17 % F fill retail) trolamine salicylate crea F salicylic acid gel 6 % F ZIKS ARTHRITIS PAIN F QL(56.6 gm per RELIEF CREA fill retail) salicylic acid liqd 17 % F Local Anesthetics - Topical ARTHRITIS PAIN QL(60 gm per SALICYLIC ACID LOTION F PA F KIT RELIEVING CREA fill retail) AVEENO ANTI-ITCH F salicylic acid pads 40 % F LOTN salicylic acid sham 6 % F benzocaine-triclosan aero F QL(15 ml per CALADRYL LOTN (Use salicylic acid soln 17 % F *** fill retail) Pramoxine-Calamine) PA CAPSAGEL EXTRA F QL(60 gm per salicylic acid w/ cleanser kit F STRENGTH GEL fill retail) Liniments CAPSAGEL GEL F QL(60 gm per fill retail) ASPERCREME/ALOE CREA (Use Trolamine *** CAPSAGEL MAXIMUM F QL(30 gm per Salicylate) STRENGTH GEL fill retail) BENGAY GREASELESS capsaicin crea 0.025 % F CREA (Use Menthol- *** QL(56.6 gm per Methyl Salicylate capsaicin crea 0.1 % F (Liniments)) fill retail) CAPZASIN QUICK RELIEF F GEL

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPZASIN-HP CREA (Use *** QL(56.6 gm per pramoxine-zinc acetate lotn F Capsaicin) fill retail) QL(42.5 gm per 1 rtl pack lmt CAPZASIN-P CREA F PREDATOR CREA (Use *** fill retail) Lidocaine HCl) amt,30 rtl pack lmt day(s), CASTIVA WARMING F QL(113 gm per LOTN fill retail) Misc. Dermatological Products DERMOPLAST AERO F QL(473 ml per 5 DAY LIQD F fill retail); RX/OTC DERMOPLAST PAIN F RELIEVINGSPRAY AERO QL(473 ml per dermatological products, QL(31 gm per F fill retail); dibucaine oint F misc. liqd 30 days retail) RX/OTC ITCH-X GEL F QL(473 ml per DIABETIDERM MASSAGE F fill retail); STIMULATOR LIQD QL(1 gm RX/OTC lidocaine crea 4 % F daily,120 gm QL(473 ml per per fill retail) GENADUR LIQD F fill retail); QL(453.6 gm RX/OTC lidocaine hcl crea 3 % F per fill retail); QL(473 ml per RX/OTC JOBST IT STAYS/ROLL- F fill retail); ON LIQD 1 rtl pack lmt RX/OTC lidocaine hcl crea 4 % F amt,30 rtl pack QL(473 ml per lmt day(s), KERASAL FUNGAL NAIL F fill retail); RENEWAL LIQD QL(100 ml per RX/OTC lidocaine hcl gel 2 % F fill retail) QL(473 ml per QL(100 ml per NAIL SCRUB LIQD F fill retail); lidocaine hcl gel 2 % F fill retail); RX/OTC RX/OTC QL(473 ml per REMOVE ADHESIVE PA; QL(1 ea F fill retail); lidocaine ptch 5 % F REMOVER LIQD daily) RX/OTC QL(30 gm per QL(473 ml per lidocaine-prilocaine crea F fill retail) THUM LIQD F fill retail); RX/OTC lidocaine-prilocaine kit F Misc. Topical lidocaine-transparent QL(5676 ml per F 4-N-1 CREA F dressing kit fill retail) LIDODERM PTCH (Use PA; QL(1 ea *** A+D FIRST AID OINT F QL(10896 ml Lidocaine) daily) per fill retail) QL(1 gm QL(10896 ml LMX 4 CREA (Use *** ABSORBASE OINT F Lidocaine) daily,120 gm per fill retail) per fill retail) LMX 4 PLUS KIT (Use ACUWASH LIQD F Lidocaine-Transparent *** ALOE VESTA DAILY QL(11328 ml Dressing) MOISTURIZER LOTN (Use *** per fill retail) pramoxine-calamine lotn F Dimethicone (Topical)) ALOE VESTA F QL(10896 ml PROTECTIVE OINT per fill retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALOE VESTA SKIN QL(11328 ml BOUDREAUXS BUTT CONDITIONER LOTN *** per fill retail) BATH BODYWASH & F (Use Dimethicone SHAMPOO LIQD (Topical)) BOUDREAUXS BUTT F QL(2712 gm aluminum hydroxide oint ex F PASTE OINT per fill retail) CALAMINE LOTN F aluminum sulfate & calcium F acetate pack CARA-KLENZ SOLN F AMEDA TRIPLE ZERO F LANOLIN CREA CARRINGTON MOISTURE F QL(10896 gm BARRIER CREA per fill retail) AMERIDERM F QL(10896 ml PERISHIELD OINT per fill retail) CARRINGTON MOISTURE F QL(10896 gm BARRIER/ZINC CREA per fill retail) AQUA GLYCOLIC FACIAL F CLEANSER LIQD CERAVE FOAMING F AQUA GLYCOLIC FACIAL CLEANSER LIQD SHAMPOO & BODY F CERAVE HYDRATING F CLEANSER LIQD CLEANSER LIQD QL(10896 ml AQUA GLYCOLIC TONER F CERAVE OINT F LIQD per fill retail) AQUAPHOR LIP REPAIR F QL(10896 ml CETAKLENZ LIQD F OINT per fill retail) ASC LOTIONIZED CETAPHIL ANTIMICROBIAL SKIN F DERMACONTROL FOAM F CLEANSER LIQD WASH LIQD CETAPHIL GENTLE AVEENO BABY CALMING F F COMFORT BATH LIQD CLEANSER LIQD AVEENO BABY CETAPHIL LIQD F CLEANSING THERAPY F MOISTURIZING WASH CETAPHIL F LIQD RESTORADERM LIQD AVEENO POSITIVELY CHAPSTICK OVERNIGHT F QL(10896 ml OINT per fill retail) NOURISHING F ANTIOXIDANT INFUSED CHAPSTICK ULTRA QL(10896 ml BODY WASH LIQD MOISTUREDAYTIME F per fill retail) AVEENO POSITIVELY FORMULA OINT RADIANT60 SECOND IN- F CHAPSTICK QL(10896 ml SHOWER FACIAL LIQD ULTRASMOOTH FORTIFY F per fill retail) OINT BASIS CLEANSER EXTRA F DRY LIQD CHAPSTICK QL(10896 ml ULTRASMOOTH F per fill retail) BASIS CLEANSER F NORMAL/DRY LIQD NOURISH OINT CHAPSTICK QL(10896 ml BASIS CLEANSER F SENSITIVE LIQD ULTRASMOOTH F per fill retail) REJUVENATE OINT BASIS FACIAL F QL(10896 gm MOISTURIZER CREA per fill retail) CHAPSTICK QL(10896 ml ULTRASMOOTH SOOTHE F per fill retail) BASIS OVERNIGHT CREA F QL(10896 gm per fill retail) OINT ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEAN & CLEAR COLEMAN INSECT Limit 1 package ESSENTIALSFOAMING F REPELLENT/SPORTSME *** per Claim, 2 FACIAL CLEANSER LIQD N AERO per Month CLEAN & CLEAR QL(5676 ml per COOL BOTTOMS CREA F FOAMING FACIAL F fill retail) CLEANSER SENSITIVE CRITIC-AID CLEAR QL(10896 ml SKIN LIQD MOISTUREBARRIER F per fill retail) CLEAN & CLEAR OINT MORNING BURST F Limit 1 package DETOXIFYING FACIAL CUTTER AERO *** per Claim, 2 CLEANSER LIQD per Month CLEAN & CLEAR Limit 1 package MORNING BURST FACIAL F CUTTER ALL FAMILY *** AERO per Claim, 2 CLEANSER LIQD per Month CLEAN & CLEAR Limit 1 package MORNING BURST CUTTER BACKWOODS *** F AERO per Claim, 2 HYDRATING FACIAL per Month CLEANSER LIQD Limit 1 package CLEAN & CLEAR NIGHT CUTTER BACKWOODS *** per Claim, 2 DRY AERO RELAXING DEEP F per Month CLEANING FACE WASH LIQD Limit 1 package CUTTER DRY AERO *** per Claim, 2 CLEANSING EYELID F per Month PADS PADS Limit 1 package CLN BODY WASH CUTTER SKINSATIONS *** AERO per Claim, 2 GENTLE NON-DRYING F per Month LIQD Limit 1 package CLN FACIAL CLEANSER CUTTER SPORT AERO *** per Claim, 2 MOISTURE BALANCING F per Month LIQD CVS CLEANSING EYELID F CLN HAND & FOOT WIPES PADS WASH DEEP CLEANSING F LIQD Limit 1 package CVS INSECT REPELLENT *** per Claim, 2 AERO CLN SPORT WASH HIGH F per Month PERFORMANCE LIQD CVS ISOPROPYL F RX/OTC CLN SPORTWASH LIQD F ALCOHOL WIPES MISC CVS SALINE WOUND F QL(7200 ml per COLEMAN 100 MAX Limit 1 WASH SOLN fill retail) INSECT *** package per REPELLENT/CONTINUOU Claim, 2 per CVS TOTAL HOME Limit 1 package S SPRAY AERO Month INSECT REPELLENT *** per Claim, 2 AERO per Month Limit 1 COLEMAN INSECT QL(10896 ml *** package per DERMADROX OINT F REPELLENT/HIGH & DRY Claim, 2 per per fill retail) AERO Month DERMAGRAN OINT (Use *** QL(2712 gm Aluminum Hydroxide) per fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMAGRAN SKIN QL(2712 gm GERI-WASH LIQD F PROTECTANT OINT (Use *** per fill retail) Aluminum Hydroxide) GNP ISOPROPYL F RX/OTC QL(11328 ml ALCOHOL WIPES MISC dimethicone (topical) lotn F per fill retail) GNP SALINE WOUND F QL(7200 ml per DOMEBORO PACK (Use WASH SOLN fill retail) Aluminum Sulfate & *** GOLD BOND ULTIMATE Calcium Acetate) DEEP MOISTURE BODY F WASH EXFOLIATING DRYSOL SOLN F LIQD EQL BODY GOLD BOND ULTIMATE WASH/SENSITIVE SKIN F DEEP MOISTURE BODY F LIQD WASH HEALING LIQD EQL BODY WASH/SHEA F GOLD BOND ULTIMATE BUTTER LIQD DEEP MOISTURE BODY F WASH SENSITIVE/OAT EQL CLEAR HAND SOAP F REFILL LIQD EXT LIQD EQL INVIGORATING GOLD BOND ULTIMATE MAKEUP REMOVER F DEEP MOISTURE BODY F TOWELETTES PADS WASH SOFTENING/SHEA LIQD EQL LIQUID HAND SOAP F LIQD GRX ASC LOTIONIZED ANTIMICROBIAL SKIN F EQL LIQUID HAND SOAP F CLEANSER LIQD REFILL LIQD HM EYELID WIPES PADS F EQL MAKEUP REMOVER F TOWELETTES PADS QL(10896 gm HYDROCERIN CREA F EQL SKIN ASTRINGENT F per fill retail) LIQD ESSENTRA WIPES 9X9" RX/OTC IONIL LIQD F CLEANROOM F ISOPROPYL ALCOHOL F RX/OTC SUPPLIES/PRESATURAT WIPES MISC ED MISC KP GENTLE SKIN F EUCERIN ADVANCED F CLEANSER LIQD CLEANSING LIQD LAN-O-SOOTHE CREA F EUCERIN CREA (Use Skin *** QL(10896 gm Protectants, Misc.) per fill retail) LANSINOH LANOLIN F EUCERIN SKIN CALMING F MINIS NIPPLE CREA BODYWASH LIQD LANSINOH LANOLIN F EYE-SCRUB PADS F NIPPLE CREA LANTISEPTIC SKIN F QL(10896 ml EYESCRUB LIQD F PROTECTANT OINT per fill retail) MEDERMA AG BODY FREE & CLEAR FOR F F SENSITIVE SKIN LIQD CLEANSER LIQD MEDERMA AG FACIAL GERI PROTECT OINT F QL(10896 ml F per fill retail) CLEANSER LIQD

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDERMA AG FACIAL F Limit 1 package TONER LIQD OFF DEEP WOODS AERO *** per Claim, 2 per Month MEIJER CALAMINE LOTN F Limit 1 package OFF DEEP WOODS DRY *** per Claim, 2 NATURES WASH PLUS F AERO LIQD per Month NEOSPORIN LIP HEALTH QL(10896 ml Limit 1 package OFF DEEP WOODS DRY F per Claim, 2 OVERNIGHT RENEWAL F per fill retail) AERO THERAPY OINT per Month QL(5676 ml per Limit 1 package NEUTRAPHOR CREA F OFF DEEP WOODS *** fill retail) SPORTSMEN AERO per Claim, 2 per Month NEUTRAPHORUS REX F QL(5676 ml per CREA fill retail) Limit 1 package OFF FAMILYCARE *** per Claim, 2 NEUTROGENA DEEP SMOOTH & DRY AERO CLEAN FACIAL F per Month CLEANSER LIQD Limit 1 package OFF SMOOTH & DRY *** per Claim, 2 NEUTROGENA FRESH AERO FOAMINGCLEANSER F per Month QL(10896 ml LIQD PALOMAR E OINT F NEUTROGENA MAKEUP per fill retail) REMOVERCLEANSING F PERI-WASH LIQD F TOWELETTES PADS PETROLEUM JELLY LIP QL(10896 ml NIVEA VISAGE FOAMING F F FACIAL LIQD TREATMENT OINT per fill retail) NIVEA VISAGE PHARMACIST CHOICE RX/OTC MOISTURIZING TONER F ALCOHOL PRED PADS F LIQD PADS PROSHIELD PLUS SKIN QL(5676 ml per NOBLE MYSTIQUE BODY F F CLEANSER LIQD PROTECTANT CREA fill retail) OCUSOFT BABY EYELID PURPOSE GENTLE F & EYELASH CLEANSER F CLEANING WASH LIQD PADS QC CALAMINE LOTN F OCUSOFT EYELID F CLEANSINGPADS PADS RA ISOPROPYL F RX/OTC ALCOHOL WIPES MISC OCUSOFT LID SCRUB F PADS RA MAKEUP REMOVER F EYELIDWIPES XL PADS OCUSOFT LID SCRUB F PLUS PADS RA RENEWAL QL(10896 ml Limit 1 ADVANCED HEALING F per fill retail) package per OINT OFF ACTIVE AERO *** Claim, 2 per RA SALINE WOUND F QL(7200 ml per Month WASH SOLN fill retail) Limit 1 REFRESH CLEANSER F LIQD F package per OFF DEEP WOODS AERO Claim, 2 per REHYLA HAIR + BODY F Month CLEANSER LIQD

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REHYLA WASH LIQD F SALJET RINSE SOLN F QL(7200 ml per fill retail) REMEDY CLEAR-AID QL(10896 ml F SALJET SOLN F QL(7200 ml per OINT per fill retail) fill retail) REMEDY FOAMING Limit 1 package BODY SAWYER INSECT *** F REPELLENT AERO per Claim, 2 CLEANER/OLIVAMINE per Month LIQD SAWYER INSECT Limit 1 package REMEDY NUTRASHIELD QL(5676 ml per F REPELLENT *** per Claim, 2 CREA fill retail) CONTROLLED RELEASE per Month LOTN REMEDY SKIN REPAIR F QL(946 ml per CREA fill retail) SENSI-CARE F QL(10896 gm Limit 1 MOISTURIZING CREA per fill retail) package per REPEL FAMILY AERO *** SENSI-CARE SEPTI-SOFT F Claim, 2 per CONENTRATE LIQD Month QL(10896 gm skin protectants, misc. crea F Limit 1 per fill retail) REPEL FAMILY DRY package per *** skin protectants, misc. oint F QL(10896 ml AERO Claim, 2 per 0.5%-6.3%-70%, 51.1 %, per fill retail) Month Limit 1 SM CALAMINE LOTN F REPEL HUNTERS *** package per FORMULA AERO Claim, 2 per soap & cleansers liqd F Month SOOTHE & COOL FREE F QL(10896 ml Limit 1 MEDSEPTIC OINT per fill retail) REPEL SPORTSMEN *** package per AERO Claim, 2 per SOOTHE & COOL FREE QL(10896 ml Month MOISTURE BARRIER F per fill retail) OINT Limit 1 SOOTHE & COOL FREE QL(10896 ml REPEL SPORTSMEN DRY *** package per F AERO Claim, 2 per SKIN PASTE OINT per fill retail) Month SOOTHE & COOL QL(10896 ml Limit 1 MOISTURE BARRIER F per fill retail) OINT REPEL SPORTSMEN *** package per MAX AERO Claim, 2 per SOOTHE & COOL QL(10896 ml Month PROTECT MOISTURE F per fill retail) Limit 1 BARRIER OINT SOOTHE & COOL REPEL SPORTSMEN *** package per MAX LOTN Claim, 2 per SHAMPOO ANDBODY F Month WASH WITH ALOE LIQD SORBIDON HYDRATE QL(10896 gm F F RISAMINE OINT CREA per fill retail) ROC MAX RESURFACING F STAPHSCRUB LIQD F FACIAL CLEANSER LIQD QL(7200 ml per SUMMERS EVE SAFE WASH SOLN F fill retail) CLEANSING F WASH/SENSITIVE SKIN SALINE WOUND WASH F QL(7200 ml per SOLN fill retail) LIQD

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUMMERS EVE NIGHT- METROCREAM CREA QL(45 gm per *** TIME CLEANSING F (Use Metronidazole 30 days retail) WASH/SENSITIVE SKIN (Topical)) LIQD METROGEL GEL (Use *** PA SURE COMFORT RX/OTC Metronidazole (Topical)) ALCOHOL PREP PADS F METROLOTION LOTN PADS (Use Metronidazole *** SYSTANE LID WIPES F (Topical)) PADS metronidazole (topical) F QL(45 gm per TENA SKIN-CARING F crea 0.75 % 30 days retail) BODY WASH LIQD PA; QL(45 gm metronidazole (topical) gel F per 31 days TENA SKIN-CARING F 0.75 % WASH CREAM LIQD retail) TRIPLE PASTE OINT F metronidazole (topical) gel F PA 1 % TRIPLE PASTE SP OINT F metronidazole (topical) lotn F 0.75 % Limit 1 MIRVASO GEL F PA ULTRATHON INSECT F package per REPELLENT 8 AERO Claim, 2 per PA Month NORITATE CREA F Limit 1 ORACEA CPDR F PA ULTRATHON INSECT F package per REPELLENT LOTN Claim, 2 per Month Scabicides & Pediculicides QL(454 gm per crotamiton lotn F witch hazel-glycerin pads F fill retail) ELIMITE CREA (Use QL(360 gm per WOUND WASH SALINE F QL(7200 ml per *** SOLN fill retail) Permethrin) fill retail) QL(60 gm per zinc oxide (topical) crea 13 F EURAX CREA F % fill retail) EURAX LOTN (Use QL(454 gm per zinc oxide (topical) oint 20 F QL(500 gm per *** % fill retail) Crotamiton) fill retail) QL(1 ml per 14 zinc oxide (topical) oint 40 F KLOUT SHAM F % days retail) Poison Ivy Products LICEMD GEL F poison ivy treatments misc F LICIDE TREATMENT KIT F KIT ZANFEL MISC (Use *** Poison Ivy Treatments) LINDANE SHAM F PA Rosacea Agents Limit 2 fills per PA malathion lotn F month;QL(59 azelaic acid gel F ml per fill retail) DOXYCYCLINE CPDR F PA NATROBA SUSP F FINACEA GEL (Use PA *** NIX CREME RINSE LIQD *** Azelaic Acid) (Use Permethrin)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 fills per DHS TAR GEL SHAM (Use *** OVIDE LOTN (Use *** ) Malathion) month;QL(59 Coal Tar Extract ml per fill retail) DHS TAR SHAM (Use Coal *** permethrin aero xx 0.5 % F Tar Extract) NEUTROGENA T/GEL QL(360 gm per permethrin crea ex 5 % F SHAM (Use Coal Tar *** fill retail) Extract) permethrin liqd ex 1 % F NEUTROGENA T/GEL STUBBORN ITCH QL(240 ml per *** permethrin lotn ex 1 % F CONTROL SHAM (Use fill retail) Coal Tar Extract) pyrethrins-piperonyl F THERAPLEX T SHAM *** QL(473 ml per butoxide liqd (Use Coal Tar Extract) fill retail) pyrethrins-piperonyl F Wound Care Products butoxide sham QL(3000 ml per pyrethrins-piperonyl ACTIMARIS WOUND GEL F GEL fill retail); butoxide-permethrin-nit F RX/OTC remover kit QL(3000 ml per RA LICE SOLUTION KIT AMERIGEL WOUND F F DRESSING GEL fill retail); KIT RX/OTC RID AERO (Use *** QL(3000 ml per Permethrin) ATRAPRO ANTIPRURITIC F HYDROGEL GEL fill retail); RID COMPLETE LICE RX/OTC ELIMINATION KIT (Use QL(4260 ml per Pyrethrins-Piperonyl *** ATRAPRO DERMAL F SPRAY LIQD fill retail); Butoxide-Permethrin-Nit RX/OTC Remover) QL(3000 ml per RID ESSENTIAL LICE F CARRASMART GEL F fill retail); ELIMINATION KIT KIT RX/OTC RID LIQD (Use Pyrethrins- *** QL(3000 ml per Piperonyl Butoxide) CARRASYN HYDROGEL F fill retail); WOUND DRESSING GEL SCHOOLTIME SHAMPOO F QL(1 ml per 14 RX/OTC SHAM days retail) CARRASYN V QL(3000 ml per SPINOSAD SUSP F HYDROGEL F fill retail); WOUNDDRESSING GEL RX/OTC ULESFIA LOTN F PA QL(3000 ml per COLLATYL GEL F fill retail); Tar Products RX/OTC coal tar extract sham 0.5 % F COMFEEL PASTE PSTE F QL(2040 ml per fill retail) QL(473 ml per coal tar extract sham 1 % F QL(3000 ml per fill retail) CURAD GERM SHIELD F fill retail); GEL QL(480 ml per RX/OTC coal tar extract sham 2.5 % F fill retail) QL(3000 ml per CURAFIL GEL WOUND F fill retail); DENOREX THERAPEUTIC QL(480 ml per DRESSING GEL 2-IN-1 SHAM (Use Coal *** fill retail) RX/OTC Tar Extract)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3000 ml per LIDOTREX GEL F PA CVS MANUKA HONEY F fill retail); WOUND GEL GEL RX/OTC MEDIHONEY QL(3000 ml per QL(3000 ml per WOUND/BURNDRESSING F fill retail); CVS SILVER GEL GEL F fill retail); GEL RX/OTC RX/OTC MEDIHONEY QL(2040 ml per DERMAGRAN QL(3000 ml per WOUND/BURNDRESSING F fill retail) HYDROGEL F fill retail); PSTE WOUNDDRESSING GEL RX/OTC QL(4260 ml per DERMAGRAN-B QL(3000 ml per MICROCYN LIQD F fill retail); HYDROPHILIC WOUND F fill retail); RX/OTC DRESSING GEL RX/OTC MICROKLENZ QL(4260 ml per QL(3000 ml per ANTISEPTIC WOUND F fill retail); DERMASYN GEL F fill retail); CLEANSER LIQD RX/OTC RX/OTC QL(4260 ml per NEXCARE WOUND F fill retail); QL(3000 ml per CLEANSER LIQD DIAB DAILY CARE GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per NU-GEL COLLAGEN F fill retail); QL(3000 ml per WOUND DRESSING GEL DIAB F.D.G. FREEZE- F fill retail); RX/OTC DRIED GEL RX/OTC QL(3000 ml per QL(3000 ml per PROTYL AG GEL F fill retail); DIAB GEL F fill retail); RX/OTC RX/OTC QL(4260 ml per PURACYN PLUS DUO- F fill retail); QL(3000 ml per CARE LIQD EXCEL-GEL GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per PURILON GEL F fill retail); GRX WOUND GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per RADIAGEL GEL F fill retail); HYDROGEL AG GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per RADIAPLEXRX GEL F fill retail); HYDROGEL GEL F fill retail); RX/OTC RX/OTC REGENECARE GEL F PA QL(3000 ml per INTRASITE GEL F PA APPLIPAK GEL fill retail); REGRANEX GEL F RX/OTC KENDALL AMORPHOUS QL(3000 ml per REMEDY 4-IN-1 BODY QL(4260 ml per HYDROGEL WOUND F fill retail); CLEANSER/FOAMER F fill retail); DRESSING GEL RX/OTC LIQD RX/OTC QL(3000 ml per QL(4260 ml per RESTA WOUND F fill retail); KERAGEL GEL F fill retail); CLEANSER LIQD RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per RESTORE HYDROGEL F fill retail); KERAGELT GEL F fill retail); DRESSING GEL RX/OTC RX/OTC ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REVITADERM WOUND QL(3000 ml per TRIAD HYDROPHILIC F QL(2040 ml per F fill retail); WOUND DRESSING PSTE fill retail) CARE GEL RX/OTC QL(3000 ml per QL(4260 ml per VASCUDERM HYDROGEL F WOUNDDRESSING GEL fill retail); SAF-CLENS AF LIQD F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per VEXASYN GEL F fill retail); SAF-GEL GEL F fill retail); RX/OTC RX/OTC WOUN'DRES COLLAGEN QL(3000 ml per F SEA-CLENS WOUND QL(4260 ml per HYDROGEL WOUND fill retail); F fill retail); DRESSING GEL RX/OTC CLEANSER LIQD RX/OTC QL(4260 ml per QL(4260 ml per WOUND CLEANSER LIQD F fill retail); SHUR-CLENS LIQD F fill retail); RX/OTC RX/OTC QL(4260 ml per QL(3000 ml per wound cleansers liqd F fill retail); SILVASORB GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(3000 ml per WOUND GEL GEL F fill retail); SILVERMED GEL F fill retail); RX/OTC RX/OTC QL(3000 ml per QL(4260 ml per WOUND GEL SPRAY GEL F fill retail); SILVERMED LIQD F fill retail); RX/OTC RX/OTC QL(4260 ml per QL(3000 ml per WOUND WASH LIQD F fill retail); SKINTEGRITY F RX/OTC HYDROGEL GEL fill retail); RX/OTC ZANABIN ANTIPRURITIC QL(3000 ml per QL(4260 ml per F fill retail); SKINTEGRITY WOUND F HYDROGEL GEL RX/OTC LIQD fill retail); RX/OTC QL(3000 ml per DIAGNOSTIC PRODUCTS SOLOSITE GEL F fill retail); Diagnostic Drugs RX/OTC GLUCAGEN DIAGNOSTIC F Limit 1 fill per QL(3000 ml per SOLR Month SP ANTIPRURITIC GEL F fill retail); RX/OTC Diagnostic Tests QL(3000 ml per ACCU-CHEK GUIDE *** RX/OTC SPECTRAGEL GEL F fill retail); STRP RX/OTC QL(100 ea per ALBUSTIX STRP F QL(3000 ml per 30 days retail) STIMULEN GEL F fill retail); BLOOD GLUCOSE TEST *** RX/OTC RX/OTC STRIPS STRP QL(3000 ml per CARETOUCH BLOOD RX/OTC TEGADERM HYDROGEL F fill retail); WOUND FILLER GEL GLUCOSE TEST STRIPS *** RX/OTC STRP QL(3000 ml per CHEK-STIX COMBO PAK QL(100 ea per THERAHONEY GEL F fill retail); URINALYSIS CONTROL F fill retail) RX/OTC STRP ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHEK-STIX CONTROL F QL(100 ea per FORA GTEL BLOOD STRP fill retail) KETONE TEST STRIPS *** QL(1 ea STRP CHEMSTRIP -10 WITH SG F GOODSENSE PREMIUM RX/OTC STRP daily,30 ea per 30 days retail) BLOOD GLUCOSE TEST *** QL(1 ea STRIPS STRP CHEMSTRIP 10 MD STRP F daily,30 ea per QL(1 ea 30 days retail) HEMA-COMBISTIX STRP F daily,30 ea per QL(1 ea 30 days retail) CHEMSTRIP 2 GP F HW EMBRACE PRO RX/OTC STRIPS STRP daily,30 ea per 30 days retail) BLOOD GLUCOSE TEST *** QL(1 ea STRIPS STRP CHEMSTRIP 5 OB STRP F daily,30 ea per HW EMBRACE TALK RX/OTC 30 days retail) BLOOD GLUCOSE TEST *** QL(1 ea STRIPS STRP CHEMSTRIP 7 STRP F daily,30 ea per INFINITY VOICE STRP *** RX/OTC 30 days retail) QL(100 ea per QL(1 ea KETO-DIASTIX STRP F CHEMSTRIP 9 STRIPS F 30 days retail) STRP daily,30 ea per 30 days retail) KETOCARE STRP F QL(100 ea per fill retail) CHEMSTRIP UGK STRP F QL(100 ea per 30 days retail) KETONE TEST STRIPS *** STRP CHEMSTRIP-K STRP F QL(100 ea per fill retail) KETOSTIX STRP F QL(100 ea per fill retail) CHEMSTRIP-MICRAL F QL(100 ea per STRP 30 days retail) QL(1 ea QL(1 ea LABSTIX STRP F daily,30 ea per COMBISTIX STRP F daily,30 ea per 30 days retail) 30 days retail) QL(1 ea MULTISTIX 10 SG STRP F daily,30 ea per CONTOUR NEXT BLOOD *** RX/OTC GLUCOSE TEST STRP 30 days retail) CVS ADVANCED RX/OTC QL(1 ea GLUCOSE METER TEST *** MULTISTIX 5 STRP F daily,30 ea per STRIPS STRP 30 days retail) QL(1 ea CVS KETONE CARE F QL(100 ea per STRP 30 days retail) MULTISTIX 7 STRP F daily,30 ea per 30 days retail) DIASTIX STRP F QL(30 ea per 30 days retail) QL(1 ea DIATHRIVE BLOOD RX/OTC MULTISTIX 8 SG STRP F daily,30 ea per GLUCOSE TEST STRIPS *** 30 days retail) STRP QL(1 ea EMBRACE TALK BLOOD RX/OTC MULTISTIX 9 SG STRP F daily,30 ea per GLUCOSE TEST STRIPS *** 30 days retail) STRP QL(1 ea FORA GTEL BLOOD RX/OTC MULTISTIX 9 STRP F daily,30 ea per GLUCOSE TEST STRIPS *** 30 days retail) STRP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea INSULIN MULTISTIX STRP F daily,30 ea per USERS 30 days retail) LIMITED TO NOVA MAX PLUS QL(1 ea daily) 150 PER 30 TRUETEST BLOOD DAYS, NON- KETONE TESTSTRIPS F GLUCOSE TEST STRIPS F STRP STRP INSULIN USERS ONE DROP BLOOD RX/OTC LIMITED TO GLUCOSE TEST STRIPS *** 100 PER 90 STRP DAYS;RX/OTC PRO VOICE V8/V9 RX/OTC INSULIN BLOOD GLUCOSE TEST *** USERS STRIPS STRP LIMITED TO PTS PANELS KETONE *** QL(1 ea daily) 150 PER 30 TEST STRP TRUETEST BLOOD F DAYS, NON- GLUCOSE TEST STRP INSULIN PTS PANELS KETONE F QL(1 ea daily) TEST STRP USERS LIMITED TO RELION KETONE STRP *** 100 PER 90 DAYS;RX/OTC RELION KETONE TEST *** STRIPS STRP INSULIN RELION PREMIER RX/OTC USERS BLOOD GLUCOSE TEST *** LIMITED TO STRIPS STRP 150 PER 30 TRUETEST STRIPS STRP F DAYS, NON- TRUE FOCUS SELF RX/OTC INSULIN MONITORING BLOOD *** USERS GLUCOSE TEST STRIPS LIMITED TO STRP 100 PER 90 INSULIN DAYS;RX/OTC USERS INSULIN LIMITED TO USERS 150 PER 30 TRUE METRIX BLOOD LIMITED TO GLUCOSETEST STRIPS F DAYS, NON- 150 PER 30 INSULIN STRP TRUETRACK BLOOD F DAYS, NON- USERS GLUCOSE TEST STRP INSULIN LIMITED TO USERS 100 PER 90 LIMITED TO DAYS;RX/OTC 100 PER 90 INSULIN DAYS;RX/OTC USERS INSULIN LIMITED TO USERS 150 PER 30 TRUE METRIX SELF LIMITED TO MONITORING BLOOD F DAYS, NON- 150 PER 30 INSULIN GLUCOSE STRIPS STRP TRUETRACK TEST STRP F DAYS, NON- USERS INSULIN LIMITED TO USERS 100 PER 90 LIMITED TO DAYS;RX/OTC 100 PER 90 DAYS;RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea DIURETICS - Drugs to Treat Heart, Circulation URISTIX 4 STRP F daily,30 ea per Conditions and Blood Pressure 30 days retail) Carbonic Anhydrase Inhibitors QL(1 ea URISTIX STRP F daily,30 ea per acetazolamide cp12 F MP 30 days retail) acetazolamide tabs F MP UTI HOME TEST TEST F QL(30 ea per 30 days retail) DIAMOX CP12 (Use *** MP DIETARY PRODUCTS/DIETARY MANAGEMENT Acetazolamide) PRODUCTS methazolamide tabs F Dietary Management Products NEPTAZANE TABS (Use *** CHOLEXMAX POWD F Methazolamide) CHOLEXTRA T/F POWD F Diuretic Combinations ALDACTAZIDE TABS MP PA L-METHYL-MC NAC TABS F 25MG-25MG (Use *** Spironolactone & METAFOLBIC PLUS TABS F PA Hydrochlorothiazide) ALDACTAZIDE TABS F PA NEOKE BCAA4 POWD F 50MG-50MG amiloride & F QL(1 ea daily) DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide tabs Enzymes DYAZIDE CAPS (Use MP Digestive Enzymes Triamterene & *** CREON CPEP PA Hydrochlorothiazide) 114000UNIT-36000UNIT- F MAXZIDE TABS (Use MP 180000UNIT Triamterene & *** CREON CPEP 9500UNIT- Hydrochlorothiazide) 3000UNIT-15000UNIT, MAXZIDE-25 TABS (Use MP 19000UNIT-6000UNIT- Triamterene & *** 30000UNIT, 38000UNIT- F Hydrochlorothiazide) 12000UNIT-60000UNIT, spironolactone & F MP 76000UNIT-24000UNIT- hydrochlorothiazide tabs 120000UNIT triamterene & F MP LACTAID FAST ACT TABS *** hydrochlorothiazide caps (Use Lactase) triamterene & F MP LACTAID TABS (Use *** hydrochlorothiazide tabs Lactase) Loop Diuretics lactase tabs F bumetanide tabs F MP PANCREAZE CPEP F BUMEX TABS (Use *** MP Bumetanide) SUCRAID SOLN F PA; SP DEMADEX TABS 10 MG *** QL(1 ea daily); ZENPEP CPEP F (Use Torsemide) MP DEMADEX TABS 20 MG *** QL(2 ea daily) (Use Torsemide) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDECRIN TABS (Use *** PA Bone Density Regulators Ethacrynic Acid) ACTONEL TABS (Use *** PA ethacrynic acid tabs F PA Risedronate Sodium) ALENDRONATE SODIUM F QL(10.8 ml furosemide soln 10 mg/ml F MP SOLN 70 MG/75ML daily); MP alendronate sodium tabs QL(0.15 ea FUROSEMIDE SOLN 8 F MP F MG/ML 35 mg, 70 mg daily); MP ALENDRONATE SODIUM QL(1 ea daily); furosemide tabs 20 mg, 40 F MP F mg, 80 mg TABS 40 MG MP alendronate sodium tabs 5 QL(1 ea daily); LASIX TABS (Use *** MP F Furosemide) mg, 10 mg MP ATELVIA TBEC (Use PA torsemide tabs 20 mg, 100 F QL(2 ea daily) *** mg Risedronate Sodium) BONIVA TABS (Use PA torsemide tabs 5 mg, 10 F QL(1 ea daily); *** mg MP Ibandronate Sodium) QL(3.7 ml per calcitonin (salmon) soln F Potassium Sparing Diuretics fill retail) ALDACTONE TABS (Use MP *** ETIDRONATE DISODIUM F PA Spironolactone) TABS QL(4 ea daily) amiloride hcl tabs F FORTEO SOLN F PA; SP MP spironolactone tabs F FOSAMAX PLUS D TABS F PA Thiazides and Thiazide-Like Diuretics FOSAMAX TABS (Use *** QL(0.15 ea Alendronate Sodium) daily); MP CHLOROTHIAZIDE TABS F QL(2 ea daily); 250 MG MP ibandronate sodium tabs F PA QL(4 ea daily); chlorothiazide tabs 500 mg F MP MIACALCIN SOLN F QL(2 ml per fill retail) chlorthalidone tabs F MP risedronate sodium tabs F PA DIURIL SUSP F PA risedronate sodium tbec F PA hydrochlorothiazide caps F MP Fertility Regulators MP hydrochlorothiazide tabs F CHORIONIC F PA; SP GONADOTROPIN SOLR indapamide tabs F MP HCG SOLR F PA; SP METHYCLOTHIAZIDE F PA TABS NOVAREL SOLR F PA; SP metolazone tabs F MP PREGNYL W/DILUENT PA; SP BENZYLALCOHOL/NACL F MICROZIDE CAPS (Use *** MP SOLR Hydrochlorothiazide) Growth Hormone Receptor Antagonists ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and SOMAVERT SOLR F PA; SP Regulate Hormones ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Growth Hormones Metabolic Modifiers GENOTROPIN MINIQUICK F PA; SP BRINEURA KIT F PA SOLR PA; SP BUPHENYL TABS (Use *** PA; SP GENOTROPIN SOLR F Sodium Phenylbutyrate) HUMATROPE COMBO F PA; SP calcitriol caps F PACK SOLR HUMATROPE SOLR F PA; SP calcitriol soln F PA; SP NORDITROPIN FLEXPRO F PA; SP CARBAGLU TABS F SOLN CARNITOR SF SOLN (Use QL(30 ml daily) NUTROPIN AQ NUSPIN F PA; SP 10 SOLN Levocarnitine (Metabolic *** Modifiers)) NUTROPIN AQ NUSPIN F PA; SP 20 SOLN CARNITOR SOLN 1 QL(30 ml daily) GM/10ML (Use *** NUTROPIN AQ NUSPIN 5 F PA; SP Levocarnitine (Metabolic SOLN Modifiers)) OMNITROPE SOLN F PA; SP CARNITOR TABS 330 MG QL(3 ea daily); (Use Levocarnitine *** RX/OTC OMNITROPE SOLR F PA; SP (Metabolic Modifiers)) cinacalcet hcl tabs F PA; SP SAIZEN CLICK.EASY F PA; SP SOLR doxercalciferol caps F PA SAIZEN SOLR F PA; SP HECTOROL CAPS (Use *** PA SAIZENPREP PA; SP Doxercalciferol) RECONSTITUTIONKIT F SOLR KANUMA SOLN F PA; SP PA; SP SEROSTIM SOLR F KUVAN TBSO F PA; SP PA; SP ZOMACTON SOLR F levocarnitine (metabolic F QL(30 ml daily) modifiers) soln 1 gm/10ml ZORBTIVE SOLR F PA; SP levocarnitine (metabolic F QL(3 ea daily); modifiers) tabs 330 mg RX/OTC Hormone Receptor Modulators MEPSEVII SOLN F PA; SP EVISTA TABS (Use *** QL(1 ea daily) Raloxifene HCl) NITYR TABS F PA; SP raloxifene hcl tabs F QL(1 ea daily) ORFADIN CAPS F PA; SP Insulin-Like Growth Factors (Somatomedins) PA INCRELEX SOLN F PA; SP paricalcitol caps F PA; SP LHRH/GnRH Agonist Analog Pituitary REVCOVI SOLN F PA; SP SYNAREL SOLN F ROCALTROL CAPS (Use *** Calcitriol) TRIPTODUR SRER F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROCALTROL SOLN (Use *** ACTIVELLA TABS 0.1MG- PA; QL(1 ea Calcitriol) 0.5MG (Use Estradiol & *** daily) Norethindrone Acetate) SENSIPAR TABS (Use *** PA; SP Cinacalcet HCl) ACTIVELLA TABS 0.5MG- PA PA; SP 1MG (Use Estradiol & *** sodium phenylbutyrate tabs F Norethindrone Acetate) PA ZEMPLAR CAPS (Use *** PA ANGELIQ TABS F Paricalcitol) PA Posterior Pituitary Hormones CLIMARA PRO PTWK F DDAVP SOLN NA 0.01 % F QL(5 ml per fill retail) COMBIPATCH PTTW F DDAVP SOLN NA 0.01 % QL(5 ml per fill PA (Use Desmopressin *** retail) DUAVEE TABS F Acetate Spray) estradiol & norethindrone F PA; QL(1 ea DDAVP TABS OR 0.1 MG, QL(6 ea daily) acetate tabs 0.1mg-0.5mg daily) 0.2 MG (Use *** estradiol & norethindrone F PA Desmopressin Acetate) acetate tabs 0.5mg-1mg desmopressin acetate F QL(5 ml per fill FEMHRT LOW DOSE spray refrigerated soln retail) TABS (Use Norethindrone *** Acetate-Ethinyl Estradiol) desmopressin acetate F QL(5 ml per fill spray soln retail) norethindrone acetate- F desmopressin acetate tabs F QL(6 ea daily) ethinyl estradiol tabs PREMPHASE TABS F PA STIMATE SOLN F PA; SP PREMPRO TABS F Prolactin Inhibitors cabergoline tabs F PA Estrogens Limit 8 patches per Somatostatic Agents ALORA PTTW F PA; SP month;QL(0.3 octreotide acetate soln F ea daily); MP Limit 4 patches SANDOSTATIN SOLN *** PA; SP (Use Octreotide Acetate) CLIMARA PTWK (Use *** per PA; SP Estradiol) month;QL(0.15 SIGNIFOR SOLN F ea daily); MP DIVIGEL GEL 0.25 PA Vasopressin Receptor Antagonists MG/0.25GM, 0.5 F JYNARQUE TABS 15 MG, F PA MG/0.5GM, 1 MG/GM 30 MG ESTRACE TABS OR 0.5 MP SAMSCA TABS F PA MG, 1 MG, 2 MG (Use *** Estradiol) ESTROGENS - Hormone Replacement/Modifying estradiol pttw td 0.0375 Limit 8 patches Drugs mg/24hr, 0.025 mg/24hr, F per Estrogen Combinations 0.075 mg/24hr, 0.05 month;QL(0.3 mg/24hr, 0.1 mg/24hr ea daily); MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estradiol ptwk td 0.025 Limit 4 patches FACTIVE TABS F PA mg/24hr, 0.075 mg/24hr, per 0.05 mg/24hr, 0.06 F month;QL(0.15 QL(1 ea mg/24hr, 0.1 mg/24hr, 37.5 ea daily); MP LEVAQUIN TABS (Use *** Levofloxacin) daily,14 ea per mcg/24hr fill retail) estradiol tabs or 0.5 mg, 1 MP F levofloxacin soln iv 25 F PA mg, 2 mg mg/ml ESTROPIPATE TABS 0.75 QL(1 ea daily); F levofloxacin soln or 25 F PA MG, 1.5 MG MP mg/ml ESTROPIPATE TABS 3 F QL(2 ea daily); QL(1 ea MG MP levofloxacin tabs or 250 F daily,14 ea per mg, 500 mg, 750 mg fill retail) EVAMIST SOLN F PA moxifloxacin hcl tabs F PA MENEST TABS F PA QL(56 ea per ofloxacin tabs F Limit 8 patches fill retail) MINIVELLE PTTW (Use *** per Estradiol) month;QL(0.3 GASTROINTESTINAL AGENTS - MISC. - ea daily); MP Miscellaneous Gastrointestinal Drugs PREMARIN TABS OR QL(1 ea daily) Antiflatulents 0.625 MG, 0.45 MG, 0.3 F GAS-X CHEW (Use *** MG, 0.9 MG, 1.25 MG Simethicone) Limit 8 patches GAS-X EXTRA VIVELLE-DOT PTTW (Use *** per STRENGTH CHEW (Use *** Estradiol) month;QL(0.3 Simethicone) ea daily); MP MYLICON INFANTS GAS QL(31 ml per FLUOROQUINOLONES - Drugs to Treat Bacterial RELIEF SUSP (Use *** 30 days retail) Infections Simethicone) Fluoroquinolones MYLICON SUSP (Use *** QL(31 ml per Simethicone) 30 days retail) AVELOX TABS (Use *** PA Moxifloxacin HCl) simethicone chew 80 mg, F 125 mg CIPRO SUSR 5 F PA GM/100ML simethicone liqd 20 F QL(31 ml per mg/0.3ml, 40 mg/0.6ml 30 days retail) CIPRO SUSR 500 PA MG/5ML (Use *** simethicone susp 20 F QL(31 ml per Ciprofloxacin) mg/0.3ml, 40 mg/0.6ml 30 days retail) CIPRO TABS 250 MG, 500 Bile Acid Synthesis Disorder Agents MG (Use Ciprofloxacin *** CHOLBAM CAPS F PA; QL(5 ea HCl) daily); SP CIPROFLOXACIN ER F PA Farnesoid X Receptor (FXR) Agonists TB24 OCALIVA TABS F PA; SP CIPROFLOXACIN HCL F QL(6 ea per fill TABS 100 MG retail) Gallstone Solubilizing Agents ciprofloxacin hcl tabs 250 F mg, 500 mg, 750 mg ACTIGALL CAPS (Use *** MP Ursodiol) ciprofloxacin susr or 250 F PA mg/5ml, 500 mg/5ml ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHENODAL TABS F PA; SP DIPENTUM CAPS F PA

URSO 250 TABS (Use *** QL(7 ea daily); GIAZO TABS F PA Ursodiol) MP LIALDA TBEC (Use URSO FORTE TABS (Use *** MP *** Ursodiol) Mesalamine) QL(60 ml daily) ursodiol caps 300 mg F MP mesalamine enem re 4 gm F QL(7 ea daily); mesalamine supp re 1000 PA ursodiol tabs 250 mg F F MP mg ursodiol tabs 500 mg F MP mesalamine tbec or 1.2 gm F Gastrointestinal Antiallergy Agents mesalamine tbec or 800 *** mg cromolyn sodium F PA (mastocytosis) conc mesalamine tbec or 800 F QL(3 ea daily) mg GASTROCROM CONC PA (Use Cromolyn Sodium *** mesalamine w/ cleanser kit F PA (Mastocytosis)) PA; SP Gastrointestinal Chloride Channel Activators REMICADE SOLR F AMITIZA CAPS F PA ROWASA KIT (Use *** PA Mesalamine w/ Cleanser) Gastrointestinal Stimulants SFROWASA ENEM F metoclopramide hcl soln F sulfasalazine tabs F MP metoclopramide hcl tabs F sulfasalazine tbec F MP METOCLOPRAMIDE ODT F PA TBDP Intestinal Acidifiers lactulose (encephalopathy) REGLAN TABS (Use *** F Metoclopramide HCl) soln Inflammatory Bowel Agents Irritable Bowel Syndrome (IBS) Agents APRISO CP24 F PA alosetron hcl tabs F PA LINZESS CAPS 145 MCG, PA; SP AZULFIDINE EN-TABS *** MP F TBEC (Use Sulfasalazine) 290 MCG LOTRONEX TABS (Use PA AZULFIDINE TABS (Use *** MP *** Sulfasalazine) Alosetron HCl) balsalazide disodium caps F QL(9 ea daily) Phosphate Binder Agents calcium acetate (phosphate F CANASA SUPP (Use *** PA binder) caps Mesalamine) calcium acetate (phosphate F RX/OTC CIMZIA KIT F PA; SP binder) tabs ELIPHOS TABS (Use RX/OTC COLAZAL CAPS (Use *** QL(9 ea daily) Balsalazide Disodium) Calcium Acetate *** (Phosphate Binder))

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOSRENOL CHEW (Use *** PA potassium citrate-citric acid PA; RX/OTC Lanthanum Carbonate) soln 1100mg/5ml- PA 334mg/5ml, 1100mg/5ml- F lanthanum carbonate chew F 1100mg/5ml-334mg/5ml- 334mg/5ml PHOSLYRA SOLN F PA POTASSIUM PA PA CITRATE/SODIUMCITRAT F RENAGEL TABS 400 MG F E/CITRIC ACID SOLN RENAGEL TABS 800 MG *** PA QL(500 ml per (Use Sevelamer HCl) sodium citrate & citric acid F 30 days retail); soln RX/OTC RENVELA PACK (Use *** PA Sevelamer Carbonate) TRICITRATES SOLN F PA RENVELA TABS (Use *** PA Sevelamer Carbonate) UROCIT-K 10 TBCR (Use PA Potassium Citrate *** sevelamer carbonate pack F (Alkalinizer)) PA UROCIT-K 15 TBCR (Use PA sevelamer carbonate tabs F Potassium Citrate *** (Alkalinizer)) sevelamer hcl tabs F PA UROCIT-K 5 TBCR (Use Potassium Citrate *** SEVELAMER F PA HYDROCHLORIDE TABS (Alkalinizer)) VELPHORO CHEW F PA Cystinosis Agents CYSTAGON CAPS F PA; SP Short Bowel Syndrome (SBS) Agents GATTEX KIT F PA; SP Genitourinary Irrigants acetic acid soln F PA GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive F PA Organs and Urinary System glycine (gu irrigant) soln Acidifiers neomycin/polymyxin b gu F PA soln K-PHOS NO 2 TABS F PA NEOMYCIN/POLYMYXIN F PA B SULFATES SOLN Alkalinizers NEOSPORIN GU PA PA CYTRA-3 SYRP F IRRIGANT SOLN (Use *** Neomycin/Polymyxin B pot & sod citrates w/citric F PA GU) ac soln RENACIDIN SOLN F PA potassium citrate F PA (alkalinizer) tbcr 15 meq sodium chloride (gu F potassium citrate irrigant) soln (alkalinizer) tbcr 540 mg, F SORBITOL SOLN IR 3 %, F PA 1080 mg 3.3 % potassium citrate-citric acid F PA pack 3300mg-1002mg Interstitial Cystitis Agents ELMIRON CAPS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Prostatic Hypertrophy Agents allopurinol tabs F MP PA alfuzosin hcl tb24 F QL(6 ea per fill AVODART CAPS ( F retail); AL(At Use *** PA colchicine tabs least 16 yrs Dutasteride) old) CARDURA XL TB24 F PA COLCHICINE TABS *** PA dutasteride caps F QL(6 ea per fill retail); AL(At COLCRYS TABS F dutasteride-tamsulosin hcl F PA least 16 yrs caps old) QL(1 ea daily); finasteride tabs F PA MP ULORIC TABS F FLOMAX CAPS (Use QL(2 ea daily); *** ZYLOPRIM TABS (Use *** MP Tamsulosin HCl) MP Allopurinol) JALYN CAPS (Use PA Uricosurics Dutasteride-Tamsulosin *** HCl) probenecid tabs F PROSCAR TABS (Use *** QL(1 ea daily); Finasteride) MP HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders RAPAFLO CAPS 4 MG F PA Antihemophilic Products RAPAFLO CAPS 4 MG, 8 *** PA ADVATE SOLR 250 UNIT, PA; SP MG (Use Silodosin) 500 UNIT, 1000 UNIT, F silodosin caps F PA 1500 UNIT, 2000 UNIT, 3000 UNIT QL(2 ea daily); tamsulosin hcl caps F ALPHANATE/VON PA; SP MP WILLEBRANDFACTOR F COMPLEX/HUMAN SOLR UROXATRAL TB24 (Use *** PA Alfuzosin HCl) ALPHANINE SD SOLR F PA; SP Urinary Analgesics ALPROLIX SOLR F PA; SP phenazopyridine hcl tabs F BENEFIX KIT 3000 UNIT F PA; SP PYRIDIUM TABS (Use *** Phenazopyridine HCl) COAGADEX SOLR F PA; SP Urinary Stone Agents PA; SP LITHOSTAT TABS F PA ELOCTATE SOLR F PA; SP THIOLA TABS F PA FEIBA SOLR F PA; SP GOUT AGENTS - Drugs to Treat Gout HELIXATE FS KIT F Gout Agent Combinations HEMLIBRA SOLN F PA; SP colchicine w/ probenecid F PA; SP tabs HUMATE-P SOLR F Gout Agents ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IXINITY SOLR 250 UNIT, PA; SP aspirin-dipyridamole cp12 F PA 500 UNIT, 1000 UNIT, F 2000 UNIT, 3000 UNIT BRILINTA TABS F QL(2 ea daily) JIVI SOLR F PA; SP CABLIVI KIT F PA; SP KOGENATE FS BIO-SET PA; SP F QL(2 ea daily); KIT cilostazol tabs F MP KOGENATE FS KIT F PA; SP clopidogrel bisulfate tabs F MP MONOCLATE-P KIT F PA; SP dipyridamole tabs F MP MONONINE SOLR F PA; SP EFFIENT TABS (Use *** PA Prasugrel HCl) NUWIQ KIT F PA; SP PLAVIX TABS (Use *** MP NUWIQ SOLR F PA; SP Clopidogrel Bisulfate) prasugrel hcl tabs F PA REBINYN SOLR F PA; SP ZONTIVITY TABS F PA RECOMBINATE SOLR F PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat RIXUBIS SOLR F PA; SP Blood Disorders Agents for Gaucher Disease TRETTEN SOLR F PA; SP CERDELGA CAPS F PA; SP Bradykinin B2 Receptor Antagonists PA; SP FIRAZYR SOLN F PA; SP miglustat caps F ZAVESCA CAPS (Use *** PA; SP Complement Inhibitors Miglustat) PA; SP ULTOMIRIS SOLN F Agents for Sickle Cell Anemia Hematorheologic Agents DROXIA CAPS F MP pentoxifylline tbcr F ENDARI PACK F PA; SP Plasma Kallikrein Inhibitors Cobalamins PA; SP KALBITOR SOLN F B-12 LOZG F PA; SP TAKHZYRO SOLN F B-12 TABS F Platelet Aggregation Inhibitors cyanocobalamin soln ij F QL(10 ml per 1000 mcg/ml 270 days retail) AGGRENOX CP12 (Use *** PA Aspirin-Dipyridamole) cyanocobalamin subl sl F 1000 mcg AGRYLIN CAPS (Use *** Anagrelide HCl) cyanocobalamin tabs or 100 mcg, 250 mcg, 500 F anagrelide hcl caps F mcg, 1000 mcg, 2000 mcg

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyanocobalamin tbcr or F B-12 1000 SUBL F 1000 mcg NASCOBAL SOLN F PA BIFERA TABS F Folic Acid/Folates cobalamine combinations F subl RX/OTC; MP folic acid tabs 1 mg F fe fum-iron polysacch PA F QL(1 ea daily) complex-fa-b complex-c- folic acid tabs 400 mcg, F zn-mn-cu caps 800 mcg fe fumarate-vitamin c- F PA Hematopoietic Growth Factors vitamin b12-folic acid caps ARANESP ALBUMIN F PA; SP FREE SOLN FEOSOL BIFERA TABS F ARANESP ALBUMIN F PA; SP FERRALET 90 TABS F PA FREE SOSY PA EPOGEN SOLN F PA; SP FERRAPLUS 90 TABS F ferrous fumarate w/ b12-vit PA F PA; SP F GRANIX SOLN c-fa-ifc caps GRANIX SOSY F PA; SP ferrous fumarate-fa-b QL(1 ea daily) complex-c-zn-mg-mn-cu F LEUKINE SOLR F PA; SP tabs ferrous fumarate-folic acid F PA NEULASTA ONPRO KIT F PA; SP tabs PSKT FOCALGIN DSS TABS F PA NEULASTA SOSY F PA; SP FOLGARD TABS F NEUPOGEN SOLN F PA; SP folic acid-vitamin b6-vitamin F NEUPOGEN SOSY F PA; SP b12 tabs HEMATOGEN FA CAPS F PA NIVESTYM SOLN F PA; SP iron polysaccharide NIVESTYM SOSY F PA; SP complex-vit b12-folic acid F caps PROCRIT SOLN 2000 PA; SP UNIT/ML, 3000 UNIT/ML, MULTIGEN FOLIC TABS F PA 4000 UNIT/ML, 10000 F UNIT/ML, 20000 UNIT/ML, MULTIGEN PLUS TABS F PA 40000 UNIT/ML MULTIGEN TABS F PA PROMACTA PACK F PA; SP NEPHRON FA TABS F PA PROMACTA TABS F PA; SP NOVAFERRUM 125 LIQD F UDENYCA SOSY F PA; SP

ZARXIO SOSY F PA; SP Hematopoietic Mixtures ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TANDEM PLUS CAPS PA ferrous sulfate tbec 325 mg F MP (Use Fe Fum-Iron *** Polysacch Complex-FA-B HEMOCYTE TABS (Use *** QL(2 ea daily) Complex-C-Zn-Mn-Cu) Ferrous Fumarate) PA TARON FORTE CAPS F IRON CHEWS PEDIATRIC F CHEW Iron IRON SLOW RELEASE F TBCR carbonyl iron tabs F IRON TBCR F FEOSOL NATURAL RELEASE TABS (Use *** NOVAFERRUM 50 CAPS F Carbonyl Iron) polysaccharide iron QL(1 ea daily) FEOSOL TABS (Use *** F Ferrous Sulfate Dried) complex caps FER-IN-SOL SOLN (Use *** PROFE CAPS F Ferrous Sulfate) QL(2 ea daily) SLOW FE TBCR (Use *** FERRETTS TABS F Ferrous Sulfate) ferrous fumarate tabs F QL(2 ea daily) HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders ferrous gluconate tabs 27 F mg, 240 mg, 324 mg Hemostatics - Systemic AMICAR TABS 1000 MG PA; SP FERROUS GLUCONATE F *** TABS 324 MG (Use Aminocaproic Acid) AMICAR TABS 500 MG *** QL(24 ea per ferrous sulfate dried tabs F (Use Aminocaproic Acid) fill retail); SP aminocaproic acid tabs F PA; SP ferrous sulfate dried tbcr F 1000 mg aminocaproic acid tabs 500 QL(24 ea per ferrous sulfate elix 220 F F mg/5ml mg fill retail); SP Limit 1 fill per FERROUS SULFATE LIQD F 220 MG/5ML Month;QL(30 LYSTEDA TABS (Use ea per 5 days ferrous sulfate soln 15 F *** mg/ml Tranexamic Acid) retail); AL(At least 12 yrs FERROUS SULFATE F old) SYRP 300 MG/5ML Limit 1 fill per ferrous sulfate tabs 28 mg F Month;QL(30 ea per 5 days tranexamic acid tabs F ferrous sulfate tabs 65 mg, F MP retail); AL(At 325 mg least 12 yrs FERROUS SULFATE F old) TBCR 140 MG HYPNOTICS/SEDATIVES/SLEEP DISORDER ferrous sulfate tbcr 45 mg, F AGENTS 50 mg, 142 mg, 47.5 mg Antihistamine Hypnotics FERROUS SULFATE F TBEC 324 MG diphenhydramine hcl F (sleep) caps 50 mg

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diphenhydramine hcl F QL(1 ea daily) Smart PA: (sleep) tabs 25 mg Concurrent Benzodiazepin diphenhydramine hcl F estazolam tabs F (sleep) tabs 50 mg e + Opioid Use within 90-days doxylamine succinate F NOT Allowed (sleep) tabs PA NYTOL MAXIMUM eszopiclone tabs F STRENGTH TABS (Use *** Diphenhydramine HCl Smart PA: (Sleep)) Concurrent Benzodiazepin UNISOM SLEEPGELS e + Opioid Use FLURAZEPAM HCL CAPS F CAPS (Use *** within 90-days Diphenhydramine HCl NOT (Sleep)) Allowed;QL(1 UNISOM SLEEPTABS ea daily) TABS (Use Doxylamine *** Smart PA: Succinate (Sleep)) Concurrent Barbiturate Hypnotics Benzodiazepin HALCION TABS (Use *** e + Opioid Use BUTISOL SODIUM TABS F PA Triazolam) within 90-days NOT phenobarbital elix F Allowed;QL(1 ea daily) phenobarbital soln F INTERMEZZO SUBL (Use *** PA Zolpidem Tartrate) phenobarbital tabs F LUNESTA TABS (Use *** PA Eszopiclone) SECONAL SODIUM CAPS F PA Smart PA: Hypnotics - Tricyclic Agents Concurrent Benzodiazepin SILENOR TABS F PA e + Opioid Use midazolam hcl soln ij 5 F within 90-days mg/5ml, 25 mg/5ml Non-Barbiturate Hypnotics NOT Allowed;QL(10 AMBIEN CR TBCR (Use *** PA Zolpidem Tartrate) ml per 30 days retail) AMBIEN TABS (Use *** QL(1 ea daily) Zolpidem Tartrate) Smart PA: PA; Smart PA: Concurrent Concurrent Benzodiazepin Benzodiazepin e + Opioid Use DORAL TABS F midazolam hcl soln ij 5 F within 90-days e + Opioid Use mg/ml within 90-days NOT NOT Allowed Allowed;QL(6 ml per 84 days EDLUAR SUBL F PA retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA: Smart PA: Concurrent Concurrent Benzodiazepin Benzodiazepin midazolam hcl soln ij 5 e + Opioid Use e + Opioid Use mg/ml, 10 mg/10ml, 50 F within 90-days temazepam caps 15 mg, F within 90-days mg/10ml NOT 30 mg NOT Allowed;QL(20 Allowed;QL(1 ml per 30 days ea daily); AL(At retail) least 18 yrs Smart PA: old) Concurrent PA; Smart PA: Benzodiazepin Concurrent midazolam hcl soln ij 5 e + Opioid Use temazepam caps 7.5 mg, F Benzodiazepin mg/ml, 2 mg/2ml, 10 F within 90-days 22.5 mg e + Opioid Use mg/2ml NOT within 90-days Allowed;QL(4 NOT Allowed ml per 30 days Smart PA: retail) Concurrent PA; Smart PA: Benzodiazepin Concurrent e + Opioid Use triazolam tabs F midazolam hcl syrp or 2 F Benzodiazepin within 90-days mg/ml e + Opioid Use NOT within 90-days Allowed;QL(1 NOT Allowed ea daily) PA; Smart PA: ST; QL(2 ea zaleplon caps 10 mg F Concurrent daily) Benzodiazepin ST; QL(1 ea QUAZEPAM TABS F zaleplon caps 5 mg F e + Opioid Use daily) within 90-days NOT Allowed zolpidem tartrate subl sl 3.5 F PA mg, 1.75 mg Smart PA: Concurrent zolpidem tartrate tabs or 5 F QL(1 ea daily) Benzodiazepin mg, 10 mg e + Opioid Use zolpidem tartrate tbcr or F PA 12.5 mg, 6.25 mg RESTORIL CAPS 15 MG, *** within 90-days 30 MG (Use Temazepam) NOT ZOLPIMIST SOLN F PA Allowed;QL(1 ea daily); AL(At Orexin Receptor Antagonists least 18 yrs old) BELSOMRA TABS 5 MG, F PA 10 MG, 20 MG PA; Smart PA: Concurrent Selective Melatonin Receptor Agonists RESTORIL CAPS 7.5 MG, Benzodiazepin 22.5 MG (Use *** HETLIOZ CAPS F PA; SP Temazepam) e + Opioid Use within 90-days PA NOT Allowed ROZEREM TABS F SONATA CAPS 10 MG *** ST; QL(2 ea (Use Zaleplon) daily) LAXATIVES - Bowel Treatment Drugs SONATA CAPS 5 MG (Use *** ST; QL(1 ea Bulk Laxatives Zaleplon) daily) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENEFIBER FOR METAMUCIL POWD 48.57 *** CHILDREN POWD (Use *** % (Use Psyllium) Wheat Dextrin) methylcellulose (laxative) F BENEFIBER POWD (Use *** powd Wheat Dextrin) methylcellulose (laxative) F calcium polycarbophil tabs F QL(10 ea daily) tabs CITRUCEL FIBER psyllium caps F LAXATIVE POWD (Use *** Methylcellulose (Laxative)) psyllium powd F CITRUCEL TABS (Use *** wheat dextrin powd F Methylcellulose (Laxative)) CVS NATURAL FIBER F Laxative Combinations SUPPLEMENT PACK bisacodyl-peg 3350-pot EVAC POWD (Use *** chloride-sod bicarb-sod F Psyllium) chloride kit FIBERCON TABS (Use *** QL(10 ea daily) PA Calcium Polycarbophil) CLENPIQ SOLN F COLYTE-FLAVOR PACKS QL(4000 ml per HYDROCIL INSTANT F PACK SOLR (Use PEG 3350-KCl- *** fill retail) Sod Bicarb-Sod Chloride- HYDROCIL INSTANT *** POWD (Use Psyllium) Sod Sulfate) GOLYTELY SOLR KONSYL DAILY FIBER F PACK 100 % 227.1GM-21.5GM-5.53GM- F 2.82GM-6.36GM KONSYL DAILY FIBER POWD 100 % (Use *** GOLYTELY SOLR 236GM- QL(4000 ml per Psyllium) 22.74GM-5.86GM-2.97GM- fill retail) 6.74GM (Use PEG 3350- *** KONSYL DAILY FIBER F KCl-Sod Bicarb-Sod POWD 60.3 % Chloride-Sod Sulfate) KONSYL ORIGINAL MOVIPREP SOLR 100GM- PA FORMULADAILY FIBER *** 7.5GM-2.691GM-1.015GM- F POWD (Use Psyllium) 5.9GM-4.7GM KONSYL POWD F NULYTELY/FLAVOR PACKS SOLR (Use PEG KONSYL-D POWD F 3350-Potassium Chloride- *** Sod Bicarbonate-Sod METAMUCIL CAPS 0.52 *** Chloride) GM (Use Psyllium) peg 3350-kcl-sod bicarb- QL(4000 ml per METAMUCIL sod chloride-sod sulfate F fill retail) MULTIHEALTH FIBER F solr SINGLES PACK peg 3350-potassium METAMUCIL ORIGINAL chloride-sod bicarbonate- F TEXTURE POWD (Use *** sod chloride solr Psyllium) PREPOPIK PACK F PA METAMUCIL PACK 28 % F sennosides-docusate F QL(4 ea daily) sodium tabs ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENOKOT S TABS (Use QL(4 ea daily) FLEET ENEMA SIX PACK Sennosides-Docusate *** ENEM (Use Sodium *** Sodium) Phosphates) SUPREP BOWEL PREP F PA FLEET PEDIATRIC ENEM *** KIT SOLN (Use Sodium Phosphates) Laxatives - Miscellaneous magnesium citrate soln F glycerin (laxative) supp F QL(992 ml per magnesium hydroxide susp F 30 days retail) GLYCERIN ADULT SUPP *** (Use Glycerin (Laxative)) MILK OF MAGNESIA F CONCENTRATE SUSP KRISTALOSE PACK 10 *** PA GM (Use Lactulose) ORAL SALINE LAXATIVE F SOLN KRISTALOSE PACK 20 F PA GM OSMOPREP TABS F PA lactulose pack 10 gm F PA PEDIA-LAX CHEW OR 400 F MG lactulose soln 10 gm/15ml, F 20 gm/30ml sodium phosphates enem F MIRALAX PACK (Use *** RX/OTC Polyethylene Glycol 3350) sodium phosphates soln F MIRALAX POWD (Use *** QL(34 gm Polyethylene Glycol 3350) daily); RX/OTC Stimulant Laxatives QL(12 ea per PEDIA-LAX SUPP RE 1 bisacodyl supp re 10 mg F GM (Use Glycerin *** fill retail) (Laxative)) bisacodyl tbec or 5 mg F QL(1 ea daily) PEDIA-LAX SUPP RE 2.8 F GM DULCOLAX SUPP RE 10 *** QL(12 ea per MG (Use Bisacodyl) fill retail) polyethylene glycol 3350 F RX/OTC pack DULCOLAX TBEC OR 5 *** QL(1 ea daily) MG (Use Bisacodyl) polyethylene glycol 3350 F QL(34 gm powd daily); RX/OTC EX-LAX CHEW (Use *** Sennosides) SORBITOL SOLN OR 70 F % EX-LAX TABS (Use *** Sennosides) Lubricant Laxatives FLEET BISACODYL ENEM F FLEET OIL ENEM (Use *** Mineral Oil) SENNA SYRP F KONDREMUL EMUL F sennosides chew F mineral oil enem re 100 %, F sennosides liqd F mineral oil oil or 100 %, F RX/OTC 99.9 %, sennosides syrp F Saline Laxatives sennosides tabs F FLEET ENEMA ENEM *** (Use Sodium Phosphates)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENOKOT TABS (Use *** ZITHROMAX SUSR 100 QL(15 ml per Sennosides) MG/5ML (Use *** fill retail) Azithromycin) Surfactant Laxatives ZITHROMAX SUSR 200 QL(60 ml per COLACE CAPS (Use *** QL(3 ea daily) *** ) MG/5ML (Use fill retail) Docusate Sodium Azithromycin) COLACE CLEAR CAPS *** QL(6 ea per fill (Use Docusate Sodium) ZITHROMAX TABS 250 *** MG (Use Azithromycin) retail) docusate calcium caps F ZITHROMAX TABS 500 *** QL(4 ea daily) MG (Use Azithromycin) docusate sodium caps 100 F QL(3 ea daily) mg, 250 mg ZITHROMAX TABS 600 *** QL(8 ea per 28 MG (Use Azithromycin) days retail) docusate sodium caps 50 F mg ZITHROMAX TRI-PAK *** QL(4 ea daily) TABS (Use Azithromycin) docusate sodium liqd 50 F mg/5ml, 150 mg/15ml ZITHROMAX Z-PAK TABS *** QL(6 ea per fill (Use Azithromycin) retail) docusate sodium syrp 60 F mg/15ml ZMAX SUSR F PA docusate sodium tabs 100 F mg Clarithromycin clarithromycin susr 125 F QL(100 ml per DOCUSOL MINI ENEM F mg/5ml fill retail) CLARITHROMYCIN SUSR QL(100 ml per DOCUSOL PLUS MINI- F F ENEMA ENEM 125 MG/5ML fill retail) ENEMEEZ MINI ENEM F clarithromycin susr 250 F mg/5ml ENEMEEZ PLUS ENEM F CLARITHROMYCIN SUSR F 250 MG/5ML PEDIA-LAX LIQD OR 50 F clarithromycin tabs 250 mg, F QL(28 ea per MG/15ML 500 mg fill retail) MACROLIDES - Drugs to Treat Bacterial QL(14 ea per clarithromycin tb24 500 mg F Infections fill retail) Azithromycin Erythromycins AZITHROMYCIN PACK 1 F QL(2 ea per fill E.E.S. 400 TABS F GM retail) E.E.S. GRANULES SUSR azithromycin susr 100 F QL(15 ml per mg/5ml fill retail) (Use Erythromycin *** Ethylsuccinate) azithromycin susr 200 F QL(60 ml per mg/5ml fill retail) ERY-TAB TBEC F QL(6 ea per fill azithromycin tabs 250 mg F retail) ERYPED 200 SUSR (Use Erythromycin *** azithromycin tabs 500 mg F QL(4 ea daily) Ethylsuccinate) QL(8 ea per 28 ERYPED 400 SUSR (Use azithromycin tabs 600 mg F days retail) Erythromycin *** Ethylsuccinate) ZITHROMAX PACK 1 GM F QL(2 ea per fill retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERYTHROCIN STEARATE F AGAMATRIX JAZZ *** RX/OTC TABS WIRELESS 2 KIT erythromycin base cpep F AGAMATRIX PRESTO KIT *** RX/OTC erythromycin base tabs F BAYER CONTOUR RX/OTC BLOOD GLUCOSE *** erythromycin MONITORING SYSTEM ethylsuccinate susr 200 F KIT mg/5ml, 400 mg/5ml BAYER CONTOUR LINK RX/OTC ERYTHROMYCIN 2.4 BLOOD GLUCOSE *** ETHYLSUCCINATE TABS F MONITORING SYSTEM 400 MG KIT PCE TBEC F BD LATITUDE DIABETES RX/OTC MANAGEMENT SYSTEM *** Fidaxomicin KIT PA BD LOGIC BLOOD *** RX/OTC DIFICID TABS F GLUCOSE MONITOR KIT BIOTEL CARE RX/OTC MEDICAL DEVICES AND SUPPLIES CONNECTED BLOOD *** GLUCOSE MONITORING Diabetic Supplies SYSTEM KIT ACCU-CHEK AVIVA *** RX/OTC BLOOD GLUCOSE RX/OTC CONNECT KIT MONITORINGSYSTEM *** ACCU-CHEK AVIVA PLUS *** RX/OTC KIT KIT BLOOD GLUCOSE RX/OTC ACCU-CHEK GUIDE KIT *** RX/OTC MONITORINGSYSTEM *** PREMIUM KIT ACCU-CHEK GUIDE ME RX/OTC *** BLOOD GLUCOSE *** RX/OTC KIT SYSTEM PAK KIT ACCU-CHEK NANO *** RX/OTC CAREONE BLOOD RX/OTC SMARTVIEW KIT GLUCOSE MONITORING *** ADVANCE INTUITION RX/OTC SYSTEM/PREMIUM KIT BLOOD GLUCOSE *** CAREONE BLOOD RX/OTC MONITORING SYSTEM GLUCOSE MONITORING *** KIT SYSTEM/VALUE KIT ADVANCED MOBILE F QL(200 ea per CARETOUCH BLOOD RX/OTC LANCET 30G MISC 30 days retail) GLUCOSE MONITORING *** ADVOCATE BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** CLEVER CHEK BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** ADVOCATE BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** CLEVER CHOICE MICRO RX/OTC SYSTEM/TALKING KIT BLOODGLUCOSE *** ADVOCATE REDI-CODE+/ *** RX/OTC MONITORING SYSTEM TALKING KIT KIT ADVOCATE REDI- *** RX/OTC CONTOUR BLOOD RX/OTC CODE/TALKING KIT GLUCOSE MONITORING *** SYSTEM KIT ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONTOUR NEXT BLOOD RX/OTC EASY TOUCH RX/OTC *** GLUCOSE MONITORING HEALTHPRO GLUCOSE *** SYSTEM KIT MONITORING SYSTEM CONTOUR NEXT EZ RX/OTC KIT BLOOD GLUCOSE *** EASY TRAK BLOOD RX/OTC MONITORING SYSTEM GLUCOSE MONITORING *** KIT SYSTEM KIT CONTOUR NEXT LINK RX/OTC EASYMAX L BLOOD *** RX/OTC BLOOD GLUCOSE *** GLUCOSE SYSTEM KIT MONITORING SYSTEM EASYMAX N BLOOD *** RX/OTC KIT GLUCOSE SYSTEM KIT CONTOUR NEXT LINK RX/OTC EASYMAX NG SELF- RX/OTC WIRELESS BLOOD *** MONITORING BLOOD *** GLUCOSE MONITORING GLUCOSE SYSTEM KIT SY KIT EASYMAX V BLOOD RX/OTC COOL BLOOD GLUCOSE *** RX/OTC GLUCOSE *** MONITORING KIT KIT SYSTEM/TALKING KIT CVS ADVANCED *** RX/OTC EASYMAX V2 SELF- RX/OTC GLUCOSE METER KIT MONITORING BLOOD *** D-CARE GLUCOMETER RX/OTC GLUCOSE KIT/GLUCOSE TEST *** SYSTEM/SPEAKING KIT STRIPS KIT EASYPLUS R13N SELF- RX/OTC DIATHRIVE BLOOD *** MONITORING BLOOD *** GLUCOSE METER DEVI GLUCOSE SYSTEM KIT DIATHRIVE GLUCOSE EASYPLUS V SELF- RX/OTC *** CONTROL SOLUTION MONITORING BLOOD *** LIQD GLUCOSE SYSTEM/SPEAKING KIT DIATHRIVE LANCETS F QL(200 ea per ULTRA THIN 30G MISC 30 days retail) EASYPRO BLOOD RX/OTC DRUG MART UNILET QL(200 ea per GLUCOSE MONITORING *** MICRO THIN LANCETS F 30 days retail) SYSTEM KIT 33G MISC EASYPRO PLUS KIT *** RX/OTC EASY COMFORT LANCETS TWIST TOP *** ELEMENT AUTOCODE *** RX/OTC MISC SYSTEM KIT EASY PLUS BLOOD RX/OTC EMBRACE EVO BLOOD RX/OTC GLUCOSE MONITORING *** GLUCOSE MONITORING *** SYSTEM KIT KIT KIT EASY STEP BLOOD RX/OTC EMBRACE TALK BLOOD GLUCOSE MONITOR *** GLUCOSE MONITOR *** STARTER KIT KIT DEVI EASY TALK BLOOD RX/OTC EMBRACE TALK BLOOD RX/OTC GLUCOSE MONITORING *** GLUCOSE MONITORING *** SYSTEM/TALKING KIT SYSTEM KIT EASY TOUCH GLUCOSE RX/OTC EMBRACE TALK MONITORING SYSTEM *** GLUCOSE CONTROL *** KIT SOLUTION HIGH SOLN

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMBRACE TALK GLUCOCARD 01-MINI RX/OTC *** GLUCOSE CONTROL BLOOD GLUCOSE *** SOLUTION LOW SOLN MONITORING SYSTEM KIT FIFTY50 GLUCOSE *** RX/OTC METER 2.0 KIT GLUCOCARD RX/OTC FORA G20 BLOOD RX/OTC EXPRESSION AUDIO- GLUCOSE MONITORING *** ENABLED BLOOD *** SYSTEM KIT GLUCOSE MONITORING KIT FORA GTEL BLOOD GLUCOCARD SHINE RX/OTC GLUCOSE MONITORING *** SYSTEM/MULTI- CONNEX BLOOD *** FUNCTIONAL DEVI GLUCOSE MONITORING SYSTEM KIT FORA TN'G VOICE RX/OTC GLUCOCARD SHINE RX/OTC BLOOD GLUCOSE *** MONITORING SYSTEM EXPRESS BLOOD *** KIT GLUCOSE MONITORING SYSTEM KIT FORA V30A BLOOD RX/OTC GLUCOSE MONITORING *** GLUCOCARD SHINE KIT *** RX/OTC SYSTEM KIT FORTISCARE SELF- RX/OTC GLUCOCARD VITAL RX/OTC MONITORING BLOOD *** BLOOD GLUCOSE *** GLUCOSE SYSTEM KIT MONITORING SYSTEM BLACK KIT FREESTYLE FREEDOM *** RX/OTC KIT GLUCOCARD VITAL RX/OTC BLOOD GLUCOSE *** FREESTYLE FREEDOM *** RX/OTC MONITORING SYSTEM LITE KIT BLUE KIT FREESTYLE INSULINX RX/OTC GLUCOCARD VITAL RX/OTC BLOODGLUCOSE *** BLOOD GLUCOSE *** MONITORING SYSTEM MONITORING SYSTEM KIT KIT FREESTYLE PRECISION RX/OTC GLUCOCARD VITAL RX/OTC NEO BLOOD GLUCOSE *** BLOOD GLUCOSE *** MONITORING SYSTEM MONITORING SYSTEM KIT PINK KIT FREESTYLE SIDEKICK II RX/OTC *** GLUCOCARD X-METER *** RX/OTC VALUEPACK KIT KIT GE100 BLOOD GLUCOSE RX/OTC GLUCOCOM BLOOD RX/OTC MONITORING SYSTEM *** GLUCOSE MONITORING *** KIT SYSTEM KIT GENTEEL BUTTERFLY *** GLUCOCOM BLOOD RX/OTC TOUCH LANCETS MISC GLUCOSE MONITORING *** GHT BLOOD GLUCOSE RX/OTC SYSTEM VALUE KIT KIT MONITORING SYSTEM *** GLUCONAVII BLOOD RX/OTC KIT GLUCOSEMONITORING *** GLUCOCARD 01 BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** SYSTEM KIT

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOODSENSE LANCETS QL(200 ea per MEIJER ESSENTIAL RX/OTC F MICRO-THIN 33G 30 days retail) BLOOD GLUCOSE *** UNIVERSAL MISC MONITORING SYSTEM GOODSENSE LANCETS QL(200 ea per KIT ULTRA-THIN 26G F 30 days retail) MEIJER PREMIUM RX/OTC UNIVERSAL MISC BLOOD GLUCOSE *** GOODSENSE PREMIUM RX/OTC MONITORING KIT KIT BLOODGLUCOSE *** MEIJER TRUE2GO RX/OTC MONITORING SYSTEM BLOOD GLUCOSE *** KIT MONITORING SYSTEM HW EMBRACE PRO KIT BLOOD GLUCOSE *** MEIJER TRUERESULT RX/OTC METER DEVI BLOOD GLUCOSE *** HW EMBRACE TALK MONITORING SYSTEM BLOOD GLUCOSE *** KIT MONITOR DEVI MEIJER TRUETRACK RX/OTC HW EMBRACE TALK RX/OTC BLOOD GLUCOSE *** MONITORING KIT KIT BLOOD GLUCOSE *** MONITORING SYSTEM MICRODOT BLOOD RX/OTC KIT GLUCOSE MONITORING *** IBG STAR BLOOD RX/OTC SYSTEM KIT *** GLUCOSE MONITORING MM EASY TOUCH BLOOD *** RX/OTC SYSTEM KIT GLUCOSE METER KIT IGLUCOSE BLOOD RX/OTC MPD SAFETY LANCET *** GLUCOSE MOITORING *** 21G/1.8MM MISC SYSTEM KIT MPD SAFETY LANCET *** INFINITY BLOOD RX/OTC 28G/1.8MM MISC GLUCOSE MONITORING *** MPD SAFETY LANCET *** SYSTEM KIT 30G/1.8MM MISC INFINITY BLOOD RX/OTC MPD SAFETY LANCETS *** GLUCOSE MONITORING *** 23G/1.8MM MISC SYSTEM/STARTER KIT KIT MYGLUCOHEALTH RX/OTC BLOOD GLUCOSE *** INFINITY VOICE KIT *** RX/OTC MONITORING SYSTEM KIT INFINITY VOICE LEVEL 2 *** NOVA MAX BLOOD RX/OTC LIQD GLUCOSE MONITORING *** KROGER BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** PA KIT KIT OMNIPOD 5 PACK MISC F KROGER PREMIUM RX/OTC OMNIPOD DASH 5 PACK F PA BLOOD GLUCOSE *** MISC MONITORING KIT KIT OMNIPOD DASH SYSTEM F PA LDR BLOOD GLUCOSE *** RX/OTC KIT TRUETEST KIT KIT OMNIPOD STARTER KIT F PA MEIJER BLOOD RX/OTC KIT GLUCOSE MONITORING *** KIT KIT ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ON CALL EXPRESS RX/OTC OPTUMRX BLOOD RX/OTC BLOOD GLUCOSE *** GLUCOSE MONITORING *** MONITORING SYSTEM SYSTEM KIT KIT PARADIGM LINK BLOOD *** RX/OTC ON CALL PLUS BLOOD *** RX/OTC GLUCOSE MONITOR KIT GLUCOSE METER KIT PHARMACIST CHOICE RX/OTC ON CALL PLUS BLOOD RX/OTC AUTOCODE BLOOD *** GLUCOSE MONITORING *** GLUCOSE MONITORING SYSTEM KIT SYSTEM KIT ON CALL VIVID BLOOD *** RX/OTC POCKETCHEM EZ RX/OTC GLUCOSE METER KIT BLOOD GLUCOSE *** ON CALL VIVID BLOOD RX/OTC MONITORING SYSTEM GLUCOSE MONITORING *** KIT SYSTEM KIT PRECISION LINK KIT *** RX/OTC ON CALL VIVID PAL RX/OTC BLOOD GLUCOSE *** PRECISION XTRA KIT *** RX/OTC METER KIT ONE DROP BLOOD RX/OTC PRO VOICE V8 BLOOD GLUCOSE MONITORING *** GLUCOSE MONITORING *** SYSTEM KIT SYSTEM DEVI RX/OTC PRO VOICE V9 BLOOD ONETOUCH ULTRA 2 KIT *** GLUCOSE MONITORING *** SYSTEM DEVI ONETOUCH ULTRA MINI *** RX/OTC KIT PRODIGY AUTOCODE RX/OTC BLOOD GLUCOSE ONETOUCH ULTRALINK *** RX/OTC *** SYSTEM (DEC) KIT MONITORING SYSTEM KIT ONETOUCH ULTRALINK *** RX/OTC SYSTEM (HEX) KIT PRODIGY AUTOCODE RX/OTC BLOOD GLUCOSE *** ONETOUCH VERIO FLEX RX/OTC MONITORING/TALKING BLOOD GLUCOSE *** KIT MONITORING SYSTEM KIT PRODIGY POCKET RX/OTC BLOOD GLUCOSE *** ONETOUCH VERIO IQ RX/OTC METER KIT KIT BLOOD GLUCOSE *** MONITORING SYSTEM PRODIGY VOICE BLOOD RX/OTC KIT GLUCOSE METER KIT *** KIT ONETOUCH VERIO KIT *** RX/OTC PUSH BUTTON SAFETY *** LANCETS 28G MISC ONETOUCH VERIO SYNC RX/OTC RX/OTC BLOODGLUCOSE *** QUICKTEK KIT *** MONITORING SYSTEM KIT RA TRUE2GO BLOOD RX/OTC OPTIUM BLOOD RX/OTC GLUCOSEMONITORING *** GLUCOSE MONITORING *** SYSTEM KIT SYSTEM KIT RA TRUERESULT BLOOD *** RX/OTC GLUCOSE MONITOR KIT OPTUMRX BLOOD *** RX/OTC GLUCOSE METER KIT

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REFUAH PLUS BLOOD RX/OTC SMARTEST PERSONA *** RX/OTC GLUCOSEMONITORING *** STARTERKIT KIT SYSTEM KIT SMARTEST PRONTO *** RX/OTC RELION CONFIRM RX/OTC STARTERKIT KIT BLOOD GLUCOSE *** SMARTEST PROTEGE *** RX/OTC MONITORING SYSTEM STARTERKIT KIT KIT SOLUS V2 AUDIBLE RX/OTC RELION MICRO BLOOD RX/OTC BLOOD GLUCOSE *** GLUCOSE MONITORING *** MANAGEMENT SYSTEM SYSTEM KIT KIT RELION PREMIER RX/OTC SURECHEK BLOOD RX/OTC COMPACT BLOOD *** GLUCOSE MONITORING *** GLUCOSE MONITORING SYSTEM STARTER KIT SYSTEM KIT KIT RELION ULTIMA BLOOD RX/OTC TELCARE BLOOD RX/OTC GLUCOSE MONITORING *** GLUCOSE MONITORING *** SYSTEM KIT SYSTEM KIT REVEAL BLOOD *** RX/OTC TGT BLOOD GLUCOSE RX/OTC GLUCOSE MONITOR KIT METER MONITORING *** REXALL BLOOD RX/OTC SYSTEM KIT GLUCOSE MONITORING *** TGT BLOOD GLUCOSE RX/OTC SYSTEM KIT MONITORING SYSTEM *** RIGHTEST GM100 RX/OTC KIT BLOOD GLUCOSE *** TGT BLOOD GLUCOSE RX/OTC MONITORING SYSTEM MONITORING SYSTEM *** KIT PREMIUM KIT RIGHTEST GM300 RX/OTC TRUE COMFORT TWIST *** BLOOD GLUCOSE *** TOP LANCETS 30G MISC MONITORING SYSTEM KIT TRUE FOCUS BLOOD GLUCOSESELF *** RIGHTEST GM550 RX/OTC MONITORING METER BLOOD GLUCOSE *** DEVI MONITORING SYSTEM KIT TRUE METRIX AIR RX/OTC BLOOD GLUCOSE *** SAPS HEALTH CARE METER/BLUETOOTH TWIST TOP LANCETS *** SMART KIT MISC TRUE METRIX AIR RX/OTC SMART SENSE PREMIUM RX/OTC W/BLUETOOTH SMART *** BLOODGLUCOSE *** KIT MONITORING SYSTEM KIT TRUE METRIX BLOOD *** RX/OTC GLUCOSEMETER KIT SMART SENSE VALUE RX/OTC TRUE METRIX GO RX/OTC BLOODGLUCOSE *** MONITORING SYSTEM BLOOD GLUCOSE *** KIT METER KIT TRUE2GO BLOOD RX/OTC SMARTEST EJECT *** RX/OTC STARTER KIT KIT GLUCOSE MONITORING *** SYSTEM KIT

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUECONTROL QL(3 ea per ALCOHOL PADS PADS *** RX/OTC GLUCOSE CONTROL F 270 days retail) LEVEL 0 LIQD ALCOHOL PREP PADS *** RX/OTC TRUECONTROL QL(3 ea per PADS GLUCOSE CONTROL F 270 days retail) SAPS HEALTH CARE RX/OTC LEVEL 1 LIQD ALCOHOLPREP PADS *** PADS TRUEPLUS SAFETY *** LANCETS 28G MISC TRUE COMFORT RX/OTC TRUERESULT BLOOD RX/OTC ALCOHOL PREP PADS *** GLUCOSEMONITORING *** PADS SYSTEM KIT ULTRA-CARE ALCOHOL *** RX/OTC TRUERESULT BLOOD RX/OTC PREP PADS PADS GLUCOSEMONITORING *** Parenteral Therapy Supplies SYSTEM/NO CODING KIT 1ST TIER UNIFINE *** TRUETEST GLUCOSE F QL(3 ea per PENTIPS32GX6MM MISC CONTROLLEVEL 1 LIQD 270 days retail) 1ST TIER UNIFINE *** TRUETEST GLUCOSE F QL(3 ea per PENTIPS33GX4MM MISC CONTROLLEVEL 2 LIQD 270 days retail) 1ST TIER UNIFINE TRUETEST GLUCOSE F QL(3 ea per PENTIPSPLUS 33GX4MM *** CONTROLLEVEL 3 LIQD 270 days retail) MISC TRUETRACK BLOOD RX/OTC ASSURE ID SAFETY PEN GLUCOSE MONITORING *** NEEDLES 30G X 5/16" *** SYSTEM KIT MISC TRUETRACK SMART *** RX/OTC ASSURE ID SAFETY PEN RX/OTC SYSTEM KIT NEEDLES 31G X 3/16" *** ULTRA THIN LANCETS *** MISC 31G MISC BD PEN NEEDLE/NANO RX/OTC ULTRA TRAK PRO RX/OTC 2ND GEN/32G X 5/32" *** BLOOD GLUCOSE *** MISC MONITORING SYSTEM CLICKFINE PEN RX/OTC KIT NEEDLES 31G X 3/16" *** ULTRA-CARE LANCETS *** MISC 30G MISC CLICKFINE PEN RX/OTC UNISTIK PRO SAFETY *** NEEDLES 31G X 8MM *** LANCET 21G MISC MISC UNISTIK PRO SAFETY *** CLICKFINE PEN RX/OTC LANCET 25G MISC NEEDLES 32G X 5/32" *** MISC UNISTIK PRO SAFETY *** LANCET 28G MISC COMFORT EZ *** RX/OTC VERASENS BLOOD RX/OTC MICRO/32G X 4MM MISC GLUCOSE MONITORING *** COMFORT EZ *** RX/OTC SYSTEM KIT SHORT/31G X 8MM MISC RX/OTC WAVESENSE AMP KIT *** COMFORT EZ/31G X 5MM *** RX/OTC MISC WAVESENSE KEYNOTE RX/OTC *** COMFORT EZ/31G X 6MM *** RX/OTC KIT MISC Misc. Devices ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES *** RX/OTC HEALTHWISE MICRON RX/OTC 31GX5MM MISC PEN NEEDLES/32G X *** 5/32" MISC DROPLET PEN NEEDLES *** RX/OTC 31GX8MM MISC HEALTHWISE SHORT RX/OTC PEN NEEDLES/31G X *** DROPLET PEN NEEDLES F QL(5 ea daily) 32G X 1/4" MISC 3/16" MISC HEALTHWISE SHORT RX/OTC DROPLET PEN NEEDLES F QL(5 ea daily); 32G X 3/16" MISC RX/OTC PEN NEEDLES/31G X *** 5/16" MISC DROPLET PEN NEEDLES F QL(5 ea daily) 32G X 5/16" MISC HM ULTICARE SHORT RX/OTC PEN NEEDLES 31GX8MM *** DROPLET PEN NEEDLES F QL(5 ea daily); MISC 32G X 5/32" MISC RX/OTC LITETOUCH INSULIN PEN RX/OTC DROPLET PEN NEEDLES *** RX/OTC NEEDLES/32G X *** 32GX4MM MISC 4MM/MINI MISC DROPSAFE SAFETY PEN RX/OTC LITETOUCH PEN RX/OTC NEEDLES/31G X 5/16" *** NEEDLES 31G X *** MISC 6MM/ULTRA SHORT DROPSAFE SAFTEY PEN RX/OTC MISC NEEDLES/31G X 1/4" *** LITETOUCH PEN RX/OTC MISC NEEDLES/31G X *** EASY GLIDE PEN 5MM/MINI MISC NEEDLES 33G X 5/32" *** LITETOUCH PEN RX/OTC MISC NEEDLES/31G X *** EASY TOUCH PEN QL(5 ea daily) 8MM/SHORT MISC NEEDLE 30G X 5/16" F MM PEN NEEDLES 31G X *** QL(5 ea daily); MISC 3/16" MISC RX/OTC GOODSENSE CLICKFINE RX/OTC MM PEN NEEDLES 31G X *** QL(5 ea daily); SAFETY PEN *** 5/16" MISC RX/OTC NEEDLE/31G X 3/16" MISC MM PEN NEEDLES 32G X *** QL(5 ea daily); 5/32" MISC RX/OTC GOODSENSE PEN RX/OTC TRUE COMFORT PEN RX/OTC NEEDLE/PENFINE *** CLASSIC/31G X 3/16" NEEDLES31G X 5MM *** MISC MISC GOODSENSE PEN RX/OTC TRUE COMFORT PEN RX/OTC NEEDLES31G X 6MM *** NEEDLE/PENFINE *** CLASSIC/31G X 5/16" MISC MISC TRUE COMFORT PEN RX/OTC GOODSENSE PEN NEEDLES32G X 4MM *** NEEDLE/PENFINE *** MISC CLASSIC/32G X 1/4" MISC TRUEPLUS 5-BEVEL PEN RX/OTC GOODSENSE PEN RX/OTC NEEDLES 29GX12.7MM *** MISC NEEDLE/PENFINE *** CLASSIC/32G X 5/32" TRUEPLUS 5-BEVEL PEN RX/OTC MISC NEEDLES 31GX5MM *** MISC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS 5-BEVEL PEN RX/OTC ULTRACARE PEN NEEDLES 31GX6MM *** NEEDLES/33G X 5/32" *** MISC MISC TRUEPLUS 5-BEVEL PEN RX/OTC UNIFINE PENTIPS *** NEEDLES 31GX8MM *** 32GX6MM MISC MISC UNIFINE PENTIPS *** TRUEPLUS 5-BEVEL PEN RX/OTC 33GX4MM MISC NEEDLES 32GX4MM *** UNIFINE PENTIPS PLUS *** MISC 33GX4MM MISC ULTICARE MICRO PEN RX/OTC NEEDLES/31G X 1/4" *** MIGRAINE PRODUCTS - Drugs to Treat Migraine MISC Headaches ULTICARE MICRO PEN RX/OTC Migraine Combinations NEEDLES/31G X 5/16" *** CAFERGOT TABS (Use *** MISC Ergotamine w/ Caffeine) ULTICARE MICRO PEN RX/OTC ergotamine w/ caffeine tabs F NEEDLES/32G X 4MM *** MISC MIGERGOT SUPP F PA ULTICARE MICRO PEN RX/OTC NEEDLES/32G X 5/32" *** sumatriptan-naproxen F PA MISC sodium tabs 85mg-500mg ULTICARE MINI PEN RX/OTC TREXIMET TABS 85MG- PA NEEDLES/31G X 6MM *** 500MG (Use Sumatriptan- *** MISC Naproxen Sodium) ULTICARE MINI PEN Migraine Products - Monoclonal Antibodies NEEDLES/32G X 1/4" *** PA; SP MISC AJOVY SOSY F ULTICARE SHORT PEN RX/OTC PA; SP NEEDLES/31G X 8MM *** EMGALITY SOAJ F MISC EMGALITY SOSY F PA; SP ULTRACARE PEN RX/OTC NEEDLES/31G X 1/4" *** Migraine Products MISC D.H.E. 45 SOLN (Use ULTRACARE PEN RX/OTC Dihydroergotamine *** NEEDLES/31G X 3/16" *** Mesylate) MISC dihydroergotamine F ULTRACARE PEN RX/OTC mesylate soln NEEDLES/31G X 5/16" *** MISC MIGRANAL SOLN F ULTRACARE PEN NEEDLES/32G X 1/14" *** Serotonin Agonists MISC almotriptan malate tabs F PA ULTRACARE PEN RX/OTC NEEDLES/32G X 3/16" *** QL(9 ea per 30 MISC AMERGE TABS (Use *** days retail); Naratriptan HCl) AL(At least 18 ULTRACARE PEN RX/OTC yrs old) NEEDLES/32G X 5/32" *** MISC ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AXERT TABS (Use *** PA QL(12 ea per Almotriptan Malate) rizatriptan benzoate tabs 5 F 30 days retail); mg, 10 mg AL(At least 6 eletriptan hydrobromide F PA tabs yrs old) rizatriptan benzoate tbdp 5 PA; QL(0.4 ea FROVA TABS (Use *** PA F Frovatriptan Succinate) mg, 10 mg daily) QL(6 ea per 30 frovatriptan succinate tabs F PA F days retail); sumatriptan soln AL(At least 12 IMITREX SOLN NA 5 QL(6 ea per 30 days retail); yrs old) MG/ACT, 20 MG/ACT (Use *** QL(3 ml per 30 Sumatriptan) AL(At least 12 yrs old) sumatriptan succinate soaj F days retail); QL(2.5 ml per sc 4 mg/0.5ml AL(At least 12 IMITREX SOLN SC 6 30 days retail); yrs old) MG/0.5ML (Use *** QL(2 ml per 30 Sumatriptan Succinate) AL(At least 12 yrs old) sumatriptan succinate soaj F days retail); IMITREX STATDOSE QL(3 ml per 30 sc 6 mg/0.5ml AL(At least 12 yrs old) REFILL SOCT 4 MG/0.5ML *** days retail); (Use Sumatriptan AL(At least 12 QL(3 ml per 30 Succinate) yrs old) sumatriptan succinate soct F days retail); IMITREX STATDOSE QL(2 ml per 30 sc 4 mg/0.5ml AL(At least 12 yrs old) REFILL SOCT 6 MG/0.5ML *** days retail); (Use Sumatriptan AL(At least 12 QL(2 ml per 30 Succinate) yrs old) sumatriptan succinate soct F days retail); IMITREX STATDOSE QL(3 ml per 30 sc 6 mg/0.5ml AL(At least 12 yrs old) SYSTEM SOAJ 4 *** days retail); MG/0.5ML (Use AL(At least 12 QL(2.5 ml per Sumatriptan Succinate) yrs old) sumatriptan succinate soln F 30 days retail); IMITREX STATDOSE QL(2 ml per 30 sc 6 mg/0.5ml AL(At least 12 SYSTEM SOAJ 6 days retail); yrs old) *** QL(3 ml per 30 MG/0.5ML (Use AL(At least 12 SUMATRIPTAN Sumatriptan Succinate) yrs old) F days retail); SUCCINATE SOSY SC 6 AL(At least 12 QL(9 ea per 30 MG/0.5ML IMITREX TABS OR 25 MG, days retail); yrs old) 50 MG, 100 MG (Use *** QL(9 ea per 30 Sumatriptan Succinate) AL(At least 12 yrs old) sumatriptan succinate tabs F days retail); QL(12 ea per or 25 mg, 50 mg, 100 mg AL(At least 12 yrs old) MAXALT TABS (Use *** 30 days retail); Rizatriptan Benzoate) AL(At least 6 zolmitriptan tabs F PA yrs old) PA MAXALT-MLT TBDP (Use *** PA; QL(0.4 ea zolmitriptan tbdp F Rizatriptan Benzoate) daily) QL(9 ea per 30 ZOMIG SOLN NA 2.5 MG F PA days retail); naratriptan hcl tabs F AL(At least 12 AL(At least 18 ZOMIG SOLN NA 5 MG F yrs old) yrs old) ZOMIG TABS OR 5 MG, PA RELPAX TABS (Use *** PA *** Eletriptan Hydrobromide) 2.5 MG (Use Zolmitriptan)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOMIG ZMT TBDP (Use *** PA CALCIUM TABS F Zolmitriptan) CALTRATE 600+D PLUS MINERALS & ELECTROLYTES MINERALS CHEW (Use *** Calcium Carbonate-Vitamin Calcium D w/ Minerals) CALCI-CHEW CHEW F CITRACAL + D3 MAXIMUM TABS (Use *** CALCIONATE SYRP F Calcium Citrate-Vitamin D) calcium carbonate tabs 500 CITRACAL MAXIMUM mg, 600 mg, 1250 mg, F TABS (Use Calcium *** 1500 mg Citrate-Vitamin D) CITRACAL calcium carbonate- F cholecalciferol chew PETITES/VITAMIND TABS *** (Use Calcium Citrate- calcium carbonate- F Vitamin D) cholecalciferol tabs MAGNEBIND 300 TABS F calcium carbonate-vitamin F d caps 600mg-200unit OS-CAL ULTRA TABS F calcium carbonate-vitamin F d chew 600mg-400unit oyster shell tabs F calcium carbonate-vitamin d tabs 125unit-250mg, RA OYSTER SHELL 125unit-500mg, 125unit- CALCIUM/VITAMIN D F 600mg, 200unit-500mg, TABS 250mg-125unit, 500mg- F 125unit, 500mg-200unit, RISACAL-D TABS F 500mg-400unit, 600mg- VIACTIV CALCIUM PLUS F 125unit, 500mg-500mg- D CHEW 200unit-200unit calcium carbonate-vitamin QL(62 ea per Electrolyte Mixtures d tabs 200unit-600mg, F 31 days retail) CERASPORT EX1 SOLN F 400unit-600mg, 600mg- 200unit, 600mg-400unit CERASPORT SOLN F calcium carbonate-vitamin F d w/ minerals chew ENFAMIL ENFALYTE F SOLN CALCIUM CITRATE TABS F 200 MG EQUALYTE SOLN (Use *** Oral Electrolytes) calcium citrate tabs 200 F mg, 950 mg HYDRALYTE FREEZER F POPS SOLN calcium citrate-vitamin d F tabs HYDRALYTE SOLN F CALCIUM GLUCONATE F TABS OR 500 MG lactated ringer's soln F PA

CALCIUM LACTATE TABS F oral electrolytes soln F CALCIUM SOFT CHEWS F CHEW

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEDIALYTE ADVANCED MAGOX 400 TABS (Use CARE SOLN (Use Oral *** Magnesium Oxide (Mg *** Electrolytes) Supplement)) PEDIALYTE FREEZER NU-MAG TBEC F POPS SOLN (Use Oral *** Electrolytes) SLOW-MAG TBEC F PEDIALYTE SINGLES SOLN (Use Oral *** Mineral Combinations Electrolytes) ADVANCED PEDIALYTE SOLN (Use *** CALCIUM/VITAMIND/MAG F Oral Electrolytes) NESIUM TABS Fluoride BONE DENSITY BUILDER F TABS FLUOR-A-DAY CHEW F PA CAL MAG ZINC +D3 TABS F FLURA-DROPS SOLN F CAL-MAG-ZINC-D TABS F sodium fluoride chew 0.25 F mg, 0.5 mg, 1 mg, 2.2 mg CAL-MAG-ZINC-D3 TABS F sodium fluoride soln 0.125 F mg/drop, 0.5 mg/ml CALCIUM/MAGNESIUM/ZI F NC TABS SODIUM FLUORIDE TABS F 1 MG CALCIUM/MAGNESIUM/ZI F NC/VITAMIN D3 TABS Magnesium CITRACAL PLUS TABS F MAG-TAB SR TBCR (Use *** Magnesium Lactate) CVS CALCIUM MAG64 TBEC F CITRATE+D/MAGNESIUM F TABS PA MAGNEBIND 400 TABS F FEM-CAL CITRATE TABS F

MAGNESIUM CAPS F MULTI MEGA MINERALS F TABS MAGNESIUM multiple minerals w/ F GLUCONATE TABS 500 F vitamins tabs MG MULTISOURCE CALCIUM magnesium gluconate tabs F MAGNESIUM & D F 500 mg, 27.5 mg FORMULA TABS magnesium lactate tbcr F NATRUL-CAL TABS F magnesium oxide (mg supplement) tabs 250 mg, F PROSTEON TABS F 500 mg, 241.3 mg THERACAL D2000 TABS F magnesium oxide (mg F QL(2 ea daily) supplement) tabs 400 mg THERACAL D4000 TABS F MAGNESIUM OXIDE F CAPS THERACAL RAPID F REPLETION TABS MAGNESIUM TABS F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Phosphate potassium chloride soln or F MP 10 %, 20 % K-PHOS NEUTRAL TABS QL(8 ea daily) (Use Pot Phosphate potassium chloride tbcr or 8 F MP Monobasic w/ Sod *** meq, 10 meq Phosphate Dibasic & Zinc Monobasic) GALZIN CAPS F PA K-PHOS TABS F PA PHOS-NAK POWDER zinc sulfate caps 220 mg F CONCENTRATE PACK *** ZINC SULFATE CAPS 50 F (Use Potassium & Sodium MG Phosphates) pot phosphate monobasic QL(8 ea daily) zinc tabs F w/ sod phosphate dibasic & F monobasic tabs MISCELLANEOUS THERAPEUTIC CLASSES potassium & sodium F Chelating Agents phosphates pack CUPRIMINE CAPS (Use *** PA Potassium Penicillamine) PA EFFER-K TBEF F DEPEN TITRATABS TABS F 250 MG EFFERVESCENT PA PA POTASSIUM/CHLORIDE F penicillamine caps 250 mg F TBEF Fecal Incontinence Bulking Agents K-TAB TBCR 10 MEQ (Use *** MP Potassium Chloride) SOLESTA GEL F PA; SP MP K-TAB TBCR 8 MEQ F Immunomodulators KLOR-CON M15 TBCR F REVLIMID CAPS F PA; SP

KLOR-CON/25 PACK F THALOMID CAPS F PA; SP potassium bicarb & F PA Immunosuppressive Agents chloride tbef ASTAGRAF XL CP24 F PA; SP potassium bicarbonate tbef F ATGAM INJ F PA; SP potassium chloride cpcr or F MP 10 meq PA; QL(3 ea AZASAN TABS F potassium chloride cpcr or F QL(1 ea daily); daily) 8 meq MP azathioprine tabs F QL(3 ea daily) POTASSIUM CHLORIDE F MP ER TBCR CELLCEPT CAPS 250 MG QL(6 ea daily) potassium chloride MP (Use Mycophenolate *** microencapsulated crystals F Mofetil) er tbcr CELLCEPT SUSR 200 MG/ML (Use *** potassium chloride pack or F 20 meq Mycophenolate Mofetil)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELLCEPT TABS 500 MG QL(6 ea daily) SANDIMMUNE CAPS OR (Use Mycophenolate *** 25 MG, 100 MG (Use F Mofetil) Cyclosporine) cyclosporine caps or 25 F SANDIMMUNE SOLN OR F PA mg, 100 mg 100 MG/ML cyclosporine modified (for F sirolimus soln F microemulsion) caps cyclosporine modified (for F sirolimus tabs F microemulsion) soln CYCLOSPORINE F tacrolimus caps F MODIFIED CAPS ZORTRESS TABS 0.25 F PA ENVARSUS XR TB24 F PA MG, 0.75 MG, 0.5 MG Irrigation Solutions GAMIFANT SOLN F PA; SP lactated ringer's (irrigation) F PA IMURAN TABS (Use *** QL(3 ea daily) soln Azathioprine) water for irrigation, sterile F mycophenolate mofetil F QL(6 ea daily) soln caps 250 mg Lymphatic Agents mycophenolate mofetil susr F 200 mg/ml SYLVANT SOLR F PA; SP mycophenolate mofetil tabs F QL(6 ea daily) 500 mg Potassium Removing Agents KAYEXALATE POWD (Use QL(454 gm per mycophenolate sodium F QL(3 ea daily) tbec 180 mg Sodium Polystyrene *** fill retail) Sulfonate) mycophenolate sodium F QL(4 ea daily) tbec 360 mg sodium polystyrene F QL(454 gm per sulfonate powd fill retail) MYFORTIC TBEC 180 MG QL(3 ea daily) (Use Mycophenolate *** sodium polystyrene F Sodium) sulfonate susp MYFORTIC TBEC 360 MG QL(4 ea daily) Systemic Lupus Erythematosus Agents (Use Mycophenolate *** BENLYSTA SOAJ F PA; SP Sodium) NEORAL CAPS (Use BENLYSTA SOSY F PA; SP Cyclosporine Modified (For *** Microemulsion)) MOUTH/THROAT/DENTAL AGENTS NEORAL SOLN (Use Cyclosporine Modified (For *** Anesthetics Topical Oral Microemulsion)) ANBESOL MAXIMUM PROGRAF CAPS OR 0.5 STRENGTH GEL (Use *** MG, 1 MG, 5 MG (Use *** Benzocaine (Dental)) Tacrolimus) ANBESOL MAXIMUM RAPAMUNE SOLN (Use *** STRENGTH LIQD (Use *** Sirolimus) Benzocaine (Dental)) RAPAMUNE TABS (Use *** BABY ANBESOL GEL *** Sirolimus) (Use Benzocaine (Dental))

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzocaine (dental) gel F ORAVIG TABS F PA benzocaine (dental) liqd F Antiseptics - Mouth/Throat CHERACOL SORE benzocaine (dental) pste F THROAT LIQD (Use *** Phenol (Antiseptic)) benzocaine (dental) soln F chlorhexidine gluconate F (mouth-throat) soln benzocaine-menthol F (mouth-throat) lozg PAIN-A-LAY LIQD (Use *** CEPACOL DUAL RELIEF Phenol (Antiseptic)) SORETHROAT SPRAY F PERIDEX SOLN (Use LIQD Chlorhexidine Gluconate *** CEPACOL SORE THROAT (Mouth-Throat)) EXTRA STRENGTH LOZG *** phenol (antiseptic) liqd F (Use Benzocaine-Menthol (Mouth-Throat)) Dental Products CEPACOL SORE THROAT F PREVIDENT 5000 LOZG 2.1MG-10MG BOOSTER PLUS PSTE *** CEPACOL SORE THROAT (Use Sodium Fluoride (Dental)) LOZG 3.6MG-15MG (Use *** Benzocaine-Menthol PREVIDENT 5000 DRY QL(60 ml per (Mouth-Throat)) MOUTH GEL (Use Sodium *** 30 days retail) CEPACOL SORE THROAT Fluoride (Dental)) MAXIMUM NUMBING F PREVIDENT 5000 ORTHO LOZG DEFENSE PSTE (Use *** CHLORASEPTIC LOZG Sodium Fluoride (Dental)) (Use Benzocaine-Menthol *** PREVIDENT 5000 PLUS (Mouth-Throat)) CREA (Use Sodium *** CHLORASEPTIC SORE Fluoride (Dental)) THROAT/LIQUID CENTER *** PREVIDENT FLUORIDE QL(60 ml per LOZG (Use Benzocaine- GEL (Use Sodium Fluoride *** 30 days retail) Menthol (Mouth-Throat)) (Dental)) HURRICAINE ONE SOLN *** PREVIDENT RINSE SOLN (Use Benzocaine (Dental)) (Use Sodium Fluoride *** (Dental)) HURRICAINE SOLN (Use *** Benzocaine (Dental)) sodium fluoride (dental) F crea dt 1.1 % lidocaine hcl (mouth-throat) F QL(100 ml per soln fill retail) sodium fluoride (dental) gel F QL(60 ml per dt 1.1 % 30 days retail) ORAMAGIC PLUS SUSR F sodium fluoride (dental) F Anti-infectives - Throat pste dt 1.1 % sodium fluoride (dental) F clotrimazole lozg F soln mt 0.2 % clotrimazole troc F stannous fluoride conc F RX/OTC nystatin (mouth-throat) F Steroids - Mouth/Throat/Dental susp ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits triamcinolone acetonide F QL(5 gm per fill QL(900 ml per (mouth) pste retail) XEROSTOMIA RELIEF F SPRAY SOLN fill retail); RX/OTC Throat Products - Misc. QL(900 ml per MULTIVITAMINS AQUORAL SOLN F fill retail); RX/OTC B-Complex w/ Folic Acid BIOTENE DRY MOUTH QL(900 ml per b-complex w/ c & folic acid RX/OTC MOISTURIZING SPRAY F fill retail); tabs 15mg-100mg-15mg- SOLN RX/OTC 18mg-5mcg-0.5mg-4mg- QL(900 ml per 500mg, 18mg-5mg-45mg- CAPHOSOL SOLN F fill retail); 10mg-10mcg-400mcg- RX/OTC 5mg-250mg, 15mg-50mg- 10.2mg-10mg-6mcg- cevimeline hcl caps F PA 400mcg-5mg-300mg, 15mg-50mg-10.2mg-10mg- QL(900 ml per 400mcg-300mcg-5mg- CVS DRY MOUTH SPRAY F fill retail); SOLN 300mg, 25mg-5mg-10mg- RX/OTC 250mcg-5mg-400mcg- QL(900 ml per 300mcg-5mg-120mg, 5mg- EQL DRY MOUTH ORAL F 25mg-20mg-15mcg- RINSE SOLN fill retail); RX/OTC 100mg-400mcg-30mcg- 2mg-150mg, 5mg-25mg- EVOXAC CAPS (Use *** PA Cevimeline HCl) 50mg-5mg-37.5mcg- 200mcg-15mcg-5mg- QL(900 ml per 150mg, 50mg-50mg-50mg- MOI-STIR SOLN F fill retail); 50mg-50mcg-400mcg- F RX/OTC 50mcg-50mg-500mg, QL(900 ml per 50mg-50mg-50mg-50mg- MOUTHKOTE SOLN F fill retail); 50mcg-50mg-400mcg- RX/OTC 50mcg-500mg, 100mg- QL(900 ml per 5.5mg-25mg-20mg-15mcg- NUMOISYN LIQD F fill retail); 400mcg-30mcg-2mg- RX/OTC 150mg, 25mg-5.5mg- ORAL RELIEF SPRAY QL(900 ml per 25mg-20mg-100mcg- FOR DRYMOUTH & F fill retail); 400mcg-1000mcg-5mg- DISCOMFORT SOLN RX/OTC 60mg, 30unit-10mg- 100mg-10mg-20mg- pilocarpine hcl (oral) tabs 5 F QL(6 ea daily) 12mcg-400mcg-45mcg- mg 5mg-500mg, 25mg-100mg- pilocarpine hcl (oral) tabs F 5.5mg-25mg-20mg- 7.5 mg 100mcg-400mcg-1000mcg- QL(900 ml per 5mg-60mg, 30unit-100mg- RA DRY MOUTH SOLN F fill retail); 10mg-1mg-20mg-1mg- RX/OTC 1mg-10mg-12mcg- 400mcg-45mcg-5mg- SALAGEN TABS 5 MG QL(6 ea daily) 500mg (Use Pilocarpine HCl *** (Oral)) b-complex w/ c & folic acid RX/OTC tabs 6mcg-1.5mg-10mg- *** SALAGEN TABS 7.5 MG 20mg-1.7mg-1mg-300mcg- (Use Pilocarpine HCl *** 10mg-100mg (Oral))

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MILCO-B-FORTE TABS RX/OTC EQL PRENATAL F QL(1 ea daily); (Use B-Complex w/ C & F FORMULA TABS MP Folic Acid) EXTRA-VIRT PLUS DHA F PA SM B-COMPLEX/VITAMIN F RX/OTC CAPS C TABS EZFE FORTE CAPS F Prenatal Vitamins PA ACTIVE OB CAPS F PA FOCALGIN 90 DHA MISC F PA ATABEX OB TABS F PA FOCALGIN CA MISC F PA BAL-CARE DHA MISC F PA FOLCAL DHA CAPS F PA FOLCAPS OMEGA 3 F PA CALCIUM PNV CAPS F CAPS PA CALNA TABS F FOLIVANE-OB CAPS F GNP DAILY PRENATAL CITRANATAL 90 DHA F PA F MISC MISC QL(1 ea daily); CITRANATAL ASSURE F PA GNP PRENATAL TABS F MISC MP GOODSENSE PRENATAL QL(1 ea daily); CITRANATAL BLOOM F PA F DHA MISC VITAMINS TABS MP PA HEMENATAL OB + DHA F PA CITRANATAL DHA MISC F MISC HEMENATAL OB TABS PA CITRANATAL HARMONY F PA CAPS 6MG-65MCG-28MG- PA 0.8MG-250MCG-10UNIT- CITRANATAL RX TABS F 4.5MG-1.5MG-10MG- F 17MG-1.6MG-12MCG- CLASSIC PRENATAL F QL(1 ea daily); TABS MP 400UNIT-1MG-30MCG- 50MG CO-NATAL FA TABS F QL(1 ea daily) HM ONE DAILY F PRENATAL COMBO MISC COMPLETE NATAL DHA F PA MISC HM PRENATAL TABS F QL(1 ea daily); MP COMPLETENATE CHEW F QL(1 ea daily) INATAL GT TABS F QL(1 ea daily) CONCEPT DHA CAPS F PA INFANATE BALANCE F PA CAPS CONCEPT OB CAPS F PA KP PRENATAL F QL(1 ea daily); MULTIVITAMINS TABS MP CVS PRENATAL TABS F QL(1 ea daily); MP KPN PRENATAL TABS F CVS WOMENS F PRENATAL+DHA MISC LEVOMEFOLATE DHA F PA CAPS DOTHELLE DHA CAPS F PA M-NATAL PLUS TABS F QL(1 ea daily); RX/OTC; MP ENFAMIL EXPECTA MISC F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); OB COMPLETE PETITE PA M-VIT TABS F F RX/OTC; MP CAPS MACNATAL CN DHA F PA OB COMPLETE PREMIER F PA CAPS TABS MARNATAL-F CAPS F PA OBSTETRIX DHA MISC F RX/OTC

MULTI PRENATAL TABS F QL(1 ea daily); OBTREX DHA MISC F RX/OTC MP ONE-A-DAY WOMENS MYNATAL ADVANCE F QL(1 ea daily) F TABS PRENATAL MISC PA PRENATAL FORMULA F MYNATAL CAPS F TABS MYNATAL PLUS TABS F QL(1 ea daily) PERRY PRENATAL CAPS F

MYNATAL ULTRACAPLET F QL(1 ea daily) PNV FERROUS TABS FUMARATE/DOCUSATE/F F OLIC ACID TABS MYNATAL-Z TABS F QL(1 ea daily) PNV FOLIC ACID + IRON F QL(1 ea daily); MYNATE 90 PLUS TBCR F QL(1 ea daily) MULTIVITAMIN TABS RX/OTC; MP PNV OB+DHA MISC F PA NAT-RUL PRENATAL F QL(1 ea daily); VITAMINS TABS MP PNV PRENATAL PLUS F QL(1 ea daily); NATALVIT TABS F QL(1 ea daily) MULTIVITAMIN TABS RX/OTC; MP PNV TABS 29-1 TABS F MP NATELLE ONE CAPS F PA PNV-DHA CAPS F PA NEEVO DHA CAPS F PA PNV-DHA+DOCUSATE F PA NEONATAL PLUS TABS F QL(1 ea daily); CAPS RX/OTC; MP PNV-OMEGA CAPS F PA NEONATAL VITAMIN F QL(1 ea daily); TABS MP PNV-SELECT TABS PA NESTABS ABC MISC F PA 600MCG-10UNIT- 150MCG-2500UNIT-2MG- PA 15MG-30MG-3MG-120MG- F NESTABS DHA MISC F 27MG-6MG-20MG-3.4MG- PA 12MCG-400UNIT- NEXA PLUS CAPS F 400MCG-300MCG-20MG- QL(1 ea daily); 80MG NIVA-PLUS TABS F RX/OTC; MP PNV-TOTAL CAPS F PA NUTRICION PORVIDA F TABS PNV-VP-U CAPS F QL(1 ea daily) O-CAL FA TABS F QL(1 ea daily); RX/OTC; MP PR NATAL 400 EC MISC F PA

O-CAL PRENATAL TABS F PR NATAL 400 MISC F PA OB COMPLETE ONE F PA PA CAPS PR NATAL 430 EC MISC F ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PR NATAL 430 MISC F PA PRENATAL MULTIVITAMIN + DHA F MISC PRE-NATAL FORMULA F TABS PRENATAL F PREFERAOB ONE CAPS F PA MULTIVITAMIN PLUS DHA MISC PA PRENAISSANCE CAPS F PRENATAL F QL(1 ea daily); MULTIVITAMIN TABS MP PRENAISSANCE PLUS PA F PRENATAL ONE DAILY F QL(1 ea daily); CAPS TABS MP MP PRENATABS RX TABS F PRENATAL PLUS IRON F MP TABS PRENATAL + DHA THPK F PRENATAL PLUS TABS F QL(1 ea daily); RX/OTC; MP PRENATAL 19 CHEW QL(1 ea daily) 30UNIT-1000UNIT-20MG- PRENATAL TABS 11UNIT- QL(1 ea daily); 3MG-200MG-29MG-7MG- 263MG-25MG-1.5MG- MP 15MG-3MG-12MCG- 27MG-4000UNIT-18MG- 1.7MG-4MCG-400UNIT- 400UNIT-1MG-20MG- F 100MG, 1000UNIT- 0.8MG-2.6MG-100MG, 400UNIT-20MG-25MG- 30UNIT-4000UNIT-25MG- 3MG-200MG-29MG-7MG- 1.8MG-200MG-28MG- 6MG-3MG-12MCG-1MG- 20MG-1.7MG-8MCG- 30UNIT-20MG-100MG 400UNIT-0.8MG-2.6MG- 120MG, 30UNIT-25MG- PRENATAL 19 TABS 1.8MG-200MG-28MG- 1000UNIT-30UNIT-20MG- 20MG-1.7MG-4000UNIT- 25MG-3MG-200MG-29MG- 8MCG-400UNIT-800MCG- 15MG-3MG-7MG-12MCG- 2.6MG-120MG, 30UNIT- 400UNIT-20MG-1MG- 4000UNIT-25MG-1.8MG- 100MG, 30UNIT- F 200MG-28MG-20MG- F 1000UNIT-20MG-25MG- 1.7MG-8MCG-400UNIT- 3MG-200MG-29MG-7MG- 800MCG-2.6MG-120MG, 15MG-3MG-12MCG- 4000UNIT-30UNIT-200MG- 400UNIT-1MG-20MG- 25MG-1.8MG-28MG- 100MG 20MG-1.7MG-8MCG- PRENATAL AND IRON F 400UNIT-800MCG-2.6MG- TABS 120MG, 4000UNIT- 30UNIT-25MG-1.8MG- PRENATAL COMPLETE F TABS 200MG-28MG-20MG- 1.7MG-8MCG-400UNIT- PRENATAL FORMULA A- F FREE TABS 800MCG-2.6MG-120MG, 160MG-11UNIT-200MG- PRENATAL FORTE TABS F 25MG-1.84MG-27MG- 4000UNIT-18MG-1.7MG- PRENATAL LOW IRON F QL(1 ea daily); 4MCG-400UNIT-800MCG- TABS MP 2.6MG-100MG PRENATAL MULTI +DHA F CAPS

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 22MG- QL(1 ea daily); PRETAB TABS F QL(1 ea daily) 2MG-25MG-1.84MG- RX/OTC; MP 200MG-27MG-4000UNIT- F PROVIDA OB CAPS F PA 20MG-3MG-12MCG- 400UNIT-1MG-10MG- PA 120MG PUREFE OB PLUS CAPS F PRENATAL TABS PX PRENATAL F QL(1 ea daily); 4000UNIT-200MG- MULTIVITAMINS TABS MP 11UNIT-27MG-25MG- F QC PRENATAL TABS F QL(1 ea daily); 1.84MG-18MG-1.7MG- MP 4MCG-400UNIT-0.8MG- 2.6MG-100MG R-NATAL OB CAPS F PA PRENATAL VITAMIN & F QL(1 ea daily); MINERAL TABS MP RA ONE DAILY MISC F PRENATAL VITAMIN F QL(1 ea daily); RA PRENATAL QL(1 ea daily); TABS MP FORMULA/FOLICACID F MP TABS PRENATAL F QL(1 ea daily); VITAMIN/IRON TABS MP RA PRENATAL TABS F QL(1 ea daily); MP PRENATAL VITAMINS F QL(1 ea daily); PLUS LOW IRON TABS RX/OTC; MP RIGHT STEP PRENATAL F QL(1 ea daily); TABS MP PRENATAL VITAMINS F QL(1 ea daily); TABS MP RULAVITE DHA CAPS F PA PRENATAL+DHA MISC F SE-NATAL 19 CHEW QL(1 ea daily) QL(1 ea daily) 30UNIT-1000UNIT-100MG- PRENATAL-U CAPS F 20MG-3MG-200MG-29MG- F PRENATE DHA CAPS PA 7MG-15MG-3MG-12MCG- 18MG-600MCG-40UNIT- 400UNIT-1MG-20MG 300MG-50MG-155MG- F SE-NATAL 19 TABS 25MCG-400UNIT- 30UNIT-1000UNIT-20MG- 400MCG-26MG-90MG 25MG-200MG-29MG-7MG- F 15MG-3MG-12MCG- PRENATE ENHANCE F PA CAPS 400UNIT-3MG-20MG- 1MG-100MG PRENATE ESSENTIAL F PA CAPS SELECT-OB CHEW PA PRENATE ESSENTIAL PA 1700UNIT-29MG-30UNIT- CAPS 29MG-600MCG- 15MG-25MG-1.6MG- F 40MG-10UNIT-150MCG- 15MG-1.8MG-5MCG- 300MG-50MG-145MG- F 400UNIT-1MG-2.5MG- 13MCG-220UNIT- 60MG 400MCG-280MCG-26MG- SELECT-OB+DHA MISC PA 90MG 250MG-29MG-30UNIT- PA 15MG-25MG-1.6MG- F PRENATE PIXIE CAPS F 20MG-1700UNIT-15MG- 1.8MG-5MCG-400UNIT- PRENATE RESTORE F PA 1MG-2.5MG-60MG CAPS SM ONE DAILY F PREPLUS TABS F QL(1 ea daily); PRENATAL MISC RX/OTC; MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA SM PRENATAL VITAMINS F QL(1 ea daily); VIRT NATE TABS F TABS MP QL(1 ea daily) TARON-C DHA CAPS F PA VIRT-ADVANCE TABS F PA TARON-PREX CAPS F PA VIRT-C DHA CAPS F PA THERANATAL CORE F QL(1 ea daily); VIRT-PN DHA CAPS F NUTRITION TABS RX/OTC; MP PA THRIVITE 19 TABS F VIRT-PN PLUS CAPS F MP VIRT-PN TABS 600MCG- PA THRIVITE RX TABS F 10UNIT-150MCG- 2500UNIT-2MG-15MG- TL-CARE DHA CAPS F PA 30MG-3MG-120MG-27MG- F 6MG-20MG-3.4MG- TL-SELECT CAPS F PA 12MCG-400UNIT- 400MCG-300MCG-20MG- TRI-TABS DHA MISC F PA 80MG PA TRIADVANCE TABS F QL(1 ea daily) VIRT-SELECT CAPS F VIRT-VITE GT TABS F QL(1 ea daily) TRICARE PRENATAL F PA DHA ONE CAPS VITAFOL ULTRA CAPS F PA TRICARE TABS F QL(1 ea daily); RX/OTC; MP VITAFOL-NANO TABS F PA TRINATAL GT TABS F QL(1 ea daily) VITAFOL-OB TABS F QL(1 ea daily) TRINATAL RX 1 TABS F QL(1 ea daily) VOL-NATE TABS F PA TRINATE TABS F PA QL(1 ea daily); VOL-PLUS TABS F TRIVEEN-DUO DHA MISC F PA RX/OTC; MP VOL-TAB RX TABS F MP ULTIMATECARE ONE F PA CAPS VP-CH PLUS CAPS F PA VEMAVITE-PRX 2 CAPS F PA VP-HEME OB + DHA MISC F PA VENA-BAL DHA MISC F PA VP-HEME OB TABS 6MG- PA VIL-RX TABS F MP 65MCG-28MG-0.8MG- 250MCG-10UNIT-4.5MG- F VINATE DHA RF CAPS F PA 1.5MG-10MG-17MG- 1.6MG-12MCG-400UNIT- VINATE II TABS F PA 1MG-30MCG-50MG VP-HEME ONE CAPS F PA VINATE M TABS F QL(1 ea daily) WEGMANS COMPLETE F VINATE ONE TABS F QL(1 ea daily) PRENATAL+DHA MISC ZATEAN-CH CAPS F PA

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZATEAN-PN DHA CAPS F PA metaxalone tabs F PA

ZATEAN-PN PLUS CAPS F PA methocarbamol tabs F

MUSCULOSKELETAL THERAPY AGENTS - orphenadrine citrate tb12 F QL(2 ea daily) Drugs to Treat Spasms PARAFON FORTE DSC *** Central Muscle Relaxants TABS (Use Chlorzoxazone) AMRIX CP24 (Use PA *** ROBAXIN TABS (Use *** Cyclobenzaprine HCl) Methocarbamol) baclofen soln it 40 PA; SP ROBAXIN-750 TABS (Use *** mg/20ml, 500 mcg/ml, F Methocarbamol) 20000 mcg/20ml SKELAXIN TABS (Use *** PA baclofen tabs or 10 mg, 20 F MP Metaxalone) mg SOMA TABS 250 MG (Use *** PA carisoprodol tabs 250 mg F PA Carisoprodol) PA; QL(4 ea SOMA TABS 350 MG (Use PA; QL(4 ea carisoprodol tabs 350 mg F *** daily) Carisoprodol) daily) tizanidine hcl caps 2 mg, 4 PA CHLORZOXAZONE TABS F PA F 375 MG, 750 MG mg, 6 mg tizanidine hcl tabs 2 mg, 4 CHLORZOXAZONE TABS F F 500 MG mg ZANAFLEX CAPS 2 MG, 4 PA cyclobenzaprine hcl cp24 F PA 15 mg, 30 mg MG, 6 MG (Use Tizanidine *** HCl) cyclobenzaprine hcl tabs F QL(3 ea daily) 10 mg ZANAFLEX TABS 4 MG *** (Use Tizanidine HCl) cyclobenzaprine hcl tabs 5 F mg Direct Muscle Relaxants DANTRIUM CAPS (Use cyclobenzaprine hcl tabs F PA *** 7.5 mg Dantrolene Sodium) FEXMID TABS (Use *** PA dantrolene sodium caps F Cyclobenzaprine HCl) GABLOFEN SOLN 10000 PA; SP Muscle Relaxant Combinations MCG/20ML, 20000 F carisoprodol w/ aspirin & F PA; AL(At least MCG/20ML, 40000 codeine tabs 12 yrs old) MCG/20ML carisoprodol w/ aspirin tabs F PA GABLOFEN SOLN 20000 *** PA; SP MCG/20ML (Use Baclofen) NASAL AGENTS - SYSTEMIC AND TOPICAL - LIORESAL INTRATHECAL PA; SP Drugs to treat the Nose or Sinus SOLN 0.05 MG/ML, 10 F MG/5ML, 10 MG/20ML, 40 Nasal Agent Combinations MG/20ML, 2000 MCG/ML DYMISTA SUSP F PA LIORESAL INTRATHECAL PA; SP SOLN 40 MG/20ML, 500 *** Nasal Agents - Misc. MCG/ML (Use Baclofen) AYR NASAL DROPS F LORZONE TABS F PA SOLN

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(16 ml per AYR NASAL MIST fluticasone propionate ALLERGY &SINUS F 30 days retail); F (nasal) susp HYPERTONIC SALINE RX/OTC SOLN PA; QL(17 gm mometasone furoate F per 30 days OCEAN NASAL SPRAY *** QL(480 ml per (nasal) susp 50 mcg/act SOLN (Use Saline) fill retail) retail) saline gel F QL(17 ml per 30 days retail); NASACORT ALLERGY F AL(At least 2 saline soln 0.65%-0.002%, F QL(480 ml per 24HR AERO 0.65 % fill retail) yrs old); RX/OTC Nasal Anti-infectives QL(17 ml per NASACORT ALLERGY BACTROBAN NASAL F 30 days retail); OINT 24HR AERO (Use *** AL(At least 2 Triamcinolone Acetonide Nasal Antiallergy (Nasal)) yrs old); ASTEPRO SOLN (Use QL(30 ml per RX/OTC *** QL(17 ml per Azelastine HCl) fill retail) NASACORT ALLERGY QL(30 ml per 30 days retail); azelastine hcl soln F 24HR CHILDRENS AERO fill retail) *** AL(At least 2 (Use Triamcinolone yrs old); Acetonide (Nasal)) cromolyn sodium (nasal) F QL(26 ml per RX/OTC aers 30 days retail) NASONEX SUSP (Use PA; QL(17 gm NASALCROM AERS (Use *** QL(26 ml per Mometasone Furoate *** per 30 days Cromolyn Sodium (Nasal)) 30 days retail) (Nasal)) retail) PA olopatadine hcl (nasal) soln F OMNARIS SUSP F PA PATANASE SOLN (Use *** PA PA Olopatadine HCl (Nasal)) QNASL AERS F Nasal Anticholinergics RHINOCORT AQUA SUSP *** PA; RX/OTC (Use Budesonide (Nasal)) ipratropium bromide (nasal) F soln QL(17 ml per 30 days retail); Nasal Steroids triamcinolone acetonide F AL(At least 2 (nasal) aero BECONASE AQ SUSP F PA yrs old); RX/OTC PA; RX/OTC budesonide (nasal) susp F ZETONNA AERS F PA FLONASE ALLERGY QL(16 ml per Sympathomimetic Decongestants RELIEF CHILDRENS *** 30 days retail); SUSP (Use Fluticasone RX/OTC ADRENALIN SOLN F Propionate (Nasal)) FLONASE ALLERGY QL(16 ml per AFRIN 12 HOUR SOLN *** (Use Oxymetazoline HCl) RELIEF SUSP (Use *** 30 days retail); Fluticasone Propionate RX/OTC AFRIN ALL NIGHT (Nasal)) NODRIP SOLN (Use *** Oxymetazoline HCl) FLONASE SENSIMIST F PA SUSP AFRIN CHILDRENS SOLN F FLUNISOLIDE SOLN F QL(25 ml per 30 days retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFRIN NASAL SPRAY pseudoephedrine hcl liqd F SOLN (Use Oxymetazoline *** 15 mg/5ml HCl) pseudoephedrine hcl tabs F AFRIN NODRIP EXTRA 30 mg, 60 mg MOISTURIZING SOLN *** pseudoephedrine hcl tb12 F QL(62 ea per (Use Oxymetazoline HCl) 120 mg 30 days retail) AFRIN NODRIP ORIGINAL SOLN (Use Oxymetazoline *** SUDAFED 24 HOUR TB24 F HCl) SUDAFED CHILDRENS AFRIN NODRIP SEVERE LIQD (Use *** CONGESTION SOLN (Use *** Pseudoephedrine HCl) Oxymetazoline HCl) SUDAFED CONGESTION AFRIN NODRIP SINUS TABS (Use *** SOLN (Use Oxymetazoline *** Pseudoephedrine HCl) HCl) SUDAFED NASAL AFRIN SINUS SOLN (Use *** DECONGESTANT Oxymetazoline HCl) MAXIMUM STRENGTH *** TABS (Use AFRIN SOLN (Use *** Oxymetazoline HCl) Pseudoephedrine HCl) SUDAFED PE QL(120 ml per DRISTAN SPRAY SOLN *** (Use Oxymetazoline HCl) CHILDRENS NASAL F fill retail) DURATION 12 HOUR DECONGESTANT SOLN SOLN (Use Oxymetazoline *** SUDAFED PE QL(24 ea per HCl) CONGESTION TABS (Use *** fill retail) Phenylephrine HCl (Oral)) DURATION SPRAY SOLN *** (Use Oxymetazoline HCl) VICKS SINEX 12 HOUR LITTLE NOSES DECONGESTANT SOLN *** DECONGESTANTNOSE F (Use Oxymetazoline HCl) DROPS SOLN VICKS SINEX MOISTURIZING SOLN *** NASAL DECONGESTANT F LIQD (Use Oxymetazoline HCl) VICKS SINEX SEVERE NASAL DECONGESTANT F SYRP NASALDECONGESTANT *** SOLN (Use Oxymetazoline NEO-SYNEPHRINE COLD HCl) & SINUS EXTRA SOLN *** (Use Phenylephrine HCl) VICKS SINEX SEVERE SOLN (Use Oxymetazoline *** NEO-SYNEPHRINE COLD HCl) & SINUS MILD SOLN (Use *** Phenylephrine HCl) VICKS SINEX SOLN (Use *** Oxymetazoline HCl) NEO-SYNEPHRINE COLD F & SINUS REGULAR SOLN NEUROMUSCULAR AGENTS - Drugs to Relax/Paralyze Muscles oxymetazoline hcl soln F ALS Agents phenylephrine hcl (oral) QL(24 ea per F RILUTEK TABS (Use *** PA tabs fill retail) Riluzole) phenylephrine hcl soln na F PA 0.25 %, 1 % riluzole tabs F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIGLUTIK SUSP F PA; SP GENTEAL TEARS MODERATEPF SOLN *** (Use Dextran 70- NUTRIENTS Hypromellose) Carbohydrates glycerin-hypromellose- polyethylene glycol 400 F POLYCOSE LIQD F soln HYPOTEARS SOLN F QL(31 ml per POLYCOSE POWD F 30 days retail) Misc. Nutritional Substances hypromellose (ophth) soln F docosahexaenoic acid F caps ISOPTO TEARS SOLN F omega-3 fatty acids caps F LACRISERT INST F PA omega-3 fatty acids cpdr F MOISTURE EYES SOLN (Use Propylene Glycol- *** Proteins Glycerin) ARGININE TABS F polyethylene glycol- propylene glycol (ophth) F arginine tabs F soln QL(31 ml per polyvinyl alcohol soln F OPHTHALMIC AGENTS - Drugs to Treat the Eye 30 days retail) polyvinyl alcohol-povidone F Artificial Tears and Lubricants (ophth) soln QL(4 gm per fill artificial tear ointment oint F propylene glycol (ophth) F retail) soln artificial tear solution soln F propylene glycol-glycerin F soln carboxymethylcellulose F REFRESH LIQUIGEL GEL sodium (ophth) gel (Use *** carboxymethylcellulose F Carboxymethylcellulose sodium (ophth) soln Sodium (Ophth)) carboxymethylcellulose- F REFRESH OPTIVE F glycerin soln SENSITIVE SOLN dextran 70-hypromellose F REFRESH OPTIVE SOLN soln (Use *** Carboxymethylcellulose- GENTEAL MILD SOLN F Glycerin) GENTEAL MILD TO REFRESH REPAIR SOLN MODERATE SOLN (Use *** (Use *** Hypromellose (Ophth)) Carboxymethylcellulose- Glycerin) GENTEAL SEVERE GEL F REFRESH TEARS SOLN GENTEAL TEARS (Use *** Carboxymethylcellulose MODERATE PF SOLN *** (Use Dextran 70- Sodium (Ophth)) Hypromellose) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYSTANE COMPLETE dorzolamide hcl-timolol QL(10 ml per SOLN (Use Propylene *** maleate soln 2%-0.5%, F 30 days retail) Glycol (Ophth)) 22.3mg/ml-6.8mg/ml SYSTANE OVERNIGHT dorzolamide hcl-timolol PA THERAPY LUBRICANT F maleate soln 22.3mg/ml- F EYE GEL 6.8mg/ml SYSTANE SOLN (Use DORZOLAMIDE QL(10 ml per Polyethylene Glycol- *** HCL/TIMOLOL MALEATE F 30 days retail) Propylene Glycol (Ophth)) SOLN SYSTANE ULTRA HOME ISTALOL SOLN F PA & AWAY PACK SOLN (Use *** Polyethylene Glycol- ISTALOL SOLN (Use *** PA Propylene Glycol (Ophth)) Timolol Maleate (Ophth)) SYSTANE ULTRA SOLN QL(15 ml per levobunolol hcl soln F (Use Polyethylene Glycol- *** 30 days retail) Propylene Glycol (Ophth)) METIPRANOLOL SOLN F PA TEARS NATURALE PM QL(42 gm per OINT (Use White *** fill retail) timolol maleate (ophth) solg F QL(5 ml per fill Petrolatum-Mineral Oil) 0.25 %, 0.5 % retail) VISINE TEARS SOLN (Use timolol maleate (ophth) soln F QL(15 ml per Glycerin-Hypromellose- *** 0.25 %, 0.5 % fill retail) Polyethylene Glycol 400) timolol maleate (ophth) soln F PA white petrolatum-mineral oil F QL(42 gm per 0.5 % oint fill retail) TIMOLOL MALEATE QL(5 ml per fill Beta-blockers - Ophthalmic OPHTHALMIC GEL F retail) FORMING SOLG BETAGAN SOLN (Use *** QL(15 ml per Levobunolol HCl) 30 days retail) TIMOPTIC OCUDOSE F QL(60 ea per QL(15 ml per SOLN fill retail) betaxolol hcl (ophth) soln F fill retail) TIMOPTIC SOLN (Use *** QL(15 ml per Timolol Maleate (Ophth)) fill retail) BETIMOL SOLN F QL(15 ml per 30 days retail) TIMOPTIC-XE SOLG 0.25 QL(5 ml per fill PA % (Use Timolol Maleate *** retail) BETOPTIC-S SUSP F (Ophth)) Limit 1 fill per TIMOPTIC-XE SOLG 0.25 QL(5 ml per fill carteolol hcl (ophth) soln F F Month %, 0.5 % retail) CARTEOLOL HCL SOLN F Limit 1 fill per Cycloplegic Mydriatics Month ATROPINE SULFATE F COMBIGAN SOLN F PA OINT OP 1 % ATROPINE SULFATE F COSOPT PF SOLN (Use PA SOLN OP 1 % Dorzolamide HCl-Timolol *** Maleate) CYCLOGYL SOLN 0.5 % *** QL(15 ml per (Use Cyclopentolate HCl) 30 days retail) COSOPT SOLN (Use QL(10 ml per Dorzolamide HCl-Timolol *** 30 days retail) CYCLOGYL SOLN 1 % *** Maleate) (Use Cyclopentolate HCl) CYCLOGYL SOLN 2 % *** QL(15 ml per (Use Cyclopentolate HCl) fill retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYCLOMYDRIL SOLN F PA AZASITE SOLN F PA cyclopentolate hcl soln 0.5 QL(15 ml per QL(4 gm per 30 F BACITRACIN OINT F % 30 days retail) days retail) cyclopentolate hcl soln 1 % F bacitracin-polymyxin b F QL(4 gm per 30 (ophth) oint days retail) QL(15 ml per cyclopentolate hcl soln 2 % F PA fill retail) BESIVANCE SUSP F homatropine hbr soln F BLEPH-10 SOLN (Use QL(15 ml per Sulfacetamide Sodium *** 30 days retail) ISOPTO ATROPINE SOLN F (Ophth)) QL(3.5 gm per CILOXAN OINT F MYDRIACYL SOLN (Use *** fill retail) Tropicamide) CILOXAN SOLN (Use *** QL(10 ml per tropicamide soln F Ciprofloxacin HCl (Ophth)) fill retail) ciprofloxacin hcl (ophth) F QL(10 ml per Miotics soln fill retail) ISOPTO CARPINE SOLN *** erythromycin (ophth) oint F (Use Pilocarpine HCl) PA PHOSPHOLINE IODIDE F PA gatifloxacin (ophth) soln F SOLR GENTAK OINT F QL(4 gm per 30 pilocarpine hcl soln F days retail) Ophthalmic - Angiogenesis Inhibitors gentamicin sulfate (ophth) F QL(4 gm per 30 oint days retail) BEVACIZUMAB SOSY F PA; SP gentamicin sulfate (ophth) F QL(30 ml per soln fill retail) LUCENTIS SOSY F PA; SP levofloxacin (ophth) soln F PA Ophthalmic Adrenergic Agents MOXEZA SOLN 0.5 % F PA ALPHAGAN P SOLN 0.1 % F PA moxifloxacin hcl (ophth) F QL(3 ml per fill ALPHAGAN P SOLN 0.15 PA soln 0.5 % retail) % (Use Brimonidine *** Tartrate) NATACYN SUSP F PA apraclonidine hcl soln F PA neomycin-bacitracin zn- F QL(4 gm per 30 polymyxin oint days retail) brimonidine tartrate soln F PA 0.15 % NEOMYCIN/POLYMYXIN/ F QL(10 ml per GRAMICIDIN SOLN 30 days retail) brimonidine tartrate soln F QL(15 ml per 0.2 % fill retail) NEOSPORIN SOLN (Use QL(10 ml per Neomycin-Polymyxin- *** 30 days retail) IOPIDINE SOLN 0.5 % *** PA Gramicidin) (Use Apraclonidine HCl) OCUFLOX SOLN (Use *** QL(10 ml per IOPIDINE SOLN 1 % F Ofloxacin (Ophth)) 30 days retail) QL(10 ml per PA ofloxacin (ophth) soln F SIMBRINZA SUSP F 30 days retail) Ophthalmic Anti-infectives ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits polymyxin b-trimethoprim F QL(10 ml per tetrahydrozoline w/ zinc F soln fill retail) sulfate soln POLYTRIM SOLN (Use *** QL(10 ml per VISINE SOLN (Use QL(30 ml per Polymyxin B-Trimethoprim) fill retail) Tetrahydrozoline HCl *** fill retail) (Ophth)) sulfacetamide sodium F QL(15 ml per (ophth) soln 30 days retail) Ophthalmic Immunomodulators SULFACETAMIDE F QL(4 gm per 30 PA SODIUM OINT OP days retail) RESTASIS EMUL 0.05 % F QL(5 ml per 30 tobramycin (ophth) soln F RESTASIS MULTIDOSE F PA days retail) EMUL 0.05 % TOBREX OINT F Ophthalmic Local Anesthetics ALCAINE SOLN (Use *** PA TOBREX SOLN (Use *** QL(5 ml per 30 Proparacaine HCl) Tobramycin (Ophth)) days retail) proparacaine hcl soln F PA TRIFLURIDINE SOLN F QL(8 ml per 30 days retail) PA QL(8 ml per 30 tetracaine hcl (ophth) soln F trifluridine soln F days retail) Ophthalmic Nerve Growth Factors VIGAMOX SOLN (Use *** QL(3 ml per fill Moxifloxacin HCl (Ophth)) retail) OXERVATE SOLN F PA; SP VIROPTIC SOLN (Use *** QL(8 ml per 30 Trifluridine) days retail) Ophthalmic Steroids PA ZIRGAN GEL F PA ALREX SUSP F bacitracin-poly-neomycin- ZYMAXID SOLN (Use *** PA F Gatifloxacin (Ophth)) hc oint BLEPHAMIDE S.O.P. F Ophthalmic Decongestants OINT naphazoline w/ BLEPHAMIDE SUSP F QL(10 ml per pheniramine soln 0.025%- F fill retail) 0.3% DEXAMETHASONE naphazoline w/ QL(15 ml per SODIUM PHOSPHATE F pheniramine soln 0.027%- F 30 days retail) SOLN OP 0.1 % 0.315% PA NAPHCON-A SOLN (Use DUREZOL EMUL F Naphazoline w/ *** fluorometholone (ophth) F QL(15 ml per Pheniramine) susp fill retail) OPCON-A SOLN (Use QL(15 ml per PA Naphazoline w/ *** 30 days retail) FML FORTE SUSP F Pheniramine) FML LIQUIFILM SUSP QL(15 ml per phenylephrine hcl (ophth) F PA (Use Fluorometholone *** fill retail) soln 10 % (Ophth)) phenylephrine hcl (ophth) QL(5 ml per 30 F FML OINT F QL(4 gm per 30 soln 2.5 % days retail) days retail) tetrahydrozoline hcl (ophth) F QL(30 ml per PA soln fill retail) LOTEMAX GEL F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTEMAX SUSP (Use *** PA SULFACETAMIDE QL(10 ml per Loteprednol Etabonate) SODIUM/PREDNISOLONE F 30 days retail) PA SODIUM PHOSPHATE loteprednol etabonate susp F SOLN MAXIDEX SUSP F PA TOBRADEX OINT F QL(4 gm per 30 days retail) MAXITROL OINT QL(4 gm per 30 F PA 10000UNIT/GM- days retail) TOBRADEX ST SUSP 3.5MG/GM-0.1% (Use *** TOBRADEX SUSP (Use QL(10 ml per Neomycin-Polymy- Tobramycin- *** fill retail) Dexameth) Dexamethasone) MAXITROL SUSP QL(10 ml per tobramycin- F QL(10 ml per 10000UNIT/ML-3.5MG/ML- *** 30 days retail) dexamethasone susp fill retail) 0.1% (Use Neomycin- PA Polymy-Dexameth) YUTIQ IMPL F neomycin-polymy- QL(4 gm per 30 ZYLET SUSP F PA dexameth oint F days retail) 10000unit/gm-3.5mg/gm- 0.1% Ophthalmics - Misc. neomycin-polymy- QL(10 ml per ACULAR LS SOLN (Use Ketorolac Tromethamine *** dexameth susp F 30 days retail) 10000unit/ml-3.5mg/ml- (Ophth)) 0.1% ACULAR SOLN (Use QL(10 ml per NEOMYCIN/POLYMYXIN/ QL(15 ml per Ketorolac Tromethamine *** fill retail) HYDROCORTISONE F 30 days retail) (Ophth)) SUSP ACUVAIL SOLN F PA OMNIPRED SUSP (Use QL(15 ml per Prednisolone Acetate *** fill retail) ST; QL(5 ml (Ophth)) ALOCRIL SOLN F per 30 days retail) PA; SP OZURDEX IMPL F ST; QL(10 ml ALOMIDE SOLN F per 30 days PRED FORTE SUSP F QL(15 ml per fill retail) retail) QL(6 ml per 30 PRED MILD SUSP F QL(10 ml per azelastine hcl (ophth) soln F 30 days retail) days retail) PA AZOPT SUSP F QL(15 ml per PRED-G S.O.P. OINT F fill retail) bromfenac sodium (ophth) PA PRED-G SUSP F QL(5 ml per fill F retail) soln PA PREDNISOLONE F QL(15 ml per BROMFENAC SOLN F ACETATE P-F SUSP fill retail) cromolyn sodium (ophth) QL(10 ml per PREDNISOLONE F QL(15 ml per F ACETATE SUSP fill retail) soln fill retail) PREDNISOLONE SODIUM QL(15 ml per diclofenac sodium (ophth) F QL(3 ml per 30 PHOSPHATE SOLN OP 1 F 30 days retail) soln days retail) % DORZOLAMIDE HCL F QL(10 ml per SOLN 30 days retail) sulfacetamide sod- F QL(10 ml per prednisolone soln 30 days retail) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml per LATANOPROST SOLN QL(5 ml per 30 dorzolamide hcl soln F F 30 days retail) 0.005 % days retail) ELESTAT SOLN (Use *** PA LUMIGAN SOLN F PA Epinastine HCl (Ophth)) PA EMADINE SOLN F PA RESCULA SOLN F PA XALATAN SOLN (Use *** QL(5 ml per 30 epinastine hcl (ophth) soln F Latanoprost) days retail) FLURBIPROFEN SODIUM F QL(5 ml per 30 SOLN days retail) OTIC AGENTS - Drugs to Treat the Ear QL(5 ml per 30 flurbiprofen sodium soln F Otic Agents - Miscellaneous days retail) QL(15 ml per acetic acid (otic) soln F ILEVRO SUSP F PA 30 days retail) ACETIC ACID/ALUMINUM F ketorolac tromethamine F ACETATE SOLN (ophth) soln 0.4 % carbamide peroxide (otic) F QL(15 ml per ketorolac tromethamine F QL(10 ml per soln 30 days retail) (ophth) soln 0.5 % fill retail) DEBROX SOLN (Use *** QL(15 ml per ketotifen fumarate (ophth) F QL(240 ml per Carbamide Peroxide (Otic)) 30 days retail) soln fill retail) Otic Anti-infectives LASTACAFT SOLN F PA CETRAXAL SOLN F PA MURO 128 OINT (Use QL(7 gm per fill Sodium Chloride *** retail) CIPROFLOXACIN SOLN F PA Hypertonic) OT 0.2 % MURO 128 SOLN (Use QL(30 ml per FLOXIN OTIC SOLN (Use *** QL(10 ml per Sodium Chloride *** fill retail) Ofloxacin (Otic)) fill retail) ) QL(10 ml per Hypertonic ofloxacin (otic) soln F fill retail) olopatadine hcl soln F PA Otic Combinations PATADAY SOLN (Use *** PA PA Olopatadine HCl) CIPRO HC SUSP F PROLENSA SOLN F PA QL(7.5 ml per fill retail)1 rtl CIPRODEX SUSP F sodium chloride hypertonic F QL(7 gm per fill MAX fill,30 rtl oint retail) day(s) supply, sodium chloride hypertonic F QL(30 ml per PA soln fill retail) COLY-MYCIN S SUSP F CORTANE-B AQUEOUS QL(10 ml per TRUSOPT SOLN (Use *** QL(10 ml per F Dorzolamide HCl) 30 days retail) SOLN fill retail) ZADITOR SOLN (Use QL(240 ml per CORTANE-B-OTIC SOLN QL(15 ml per Ketotifen Fumarate *** fill retail) (Use Pramoxine-HC- *** fill retail) (Ophth)) Chloroxylenol) Prostaglandins - Ophthalmic neomycin-polymyxin-hc F QL(10 ml per (otic) soln fill retail) QL(5 ml per 30 latanoprost soln 0.005 % F days retail) neomycin-polymyxin-hc F QL(20 ml per (otic) susp 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OTICIN HC NR SOLN (Use QL(15 ml per GAMUNEX-C SOLN F PA; SP Pramoxine-HC- *** fill retail) Chloroxylenol) HEPAGAM B SOLN F PA; SP pramoxine-hc-chloroxylenol F QL(15 ml per soln fill retail) HIZENTRA SOLN F PA; SP Otic Steroids HYPERRHO S/D MINI- F PA; SP DERMOTIC OIL (Use QL(20 ml per DOSE SOSY Fluocinolone Acetonide *** fill retail); AL(At PA; SP (Otic)) least 2 yrs old) HYPERRHO S/D SOSY F QL(20 ml per MICRHOGAM ULTRA- PA; SP fluocinolone acetonide F fill retail); AL(At F (otic) oil FILTEREDPLUS SOSY least 2 yrs old) OCTAGAM SOLN F PA; SP hydrocortisone w/acetic F QL(20 ml per acid soln 30 days retail) PANZYGA SOLN F PA; SP OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding PRIVIGEN SOLN F PA; SP Oxytocics RHOGAM ULTRA- F PA; SP methylergonovine maleate F FILTERED PLUS SOSY tabs RHOPHYLAC SOSY F PA; SP PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune WINRHO SDF SOLN F PA; SP System Immune Serums Monoclonal Antibodies PA; SP BIVIGAM SOLN F PA; SP SYNAGIS SOLN F

CARIMUNE F PA; SP PENICILLINS - Drugs to Treat Bacterial Infections NANOFILTERED SOLR CUVITRU SOLN F PA; SP Aminopenicillins amoxicillin caps 250 mg, F CYTOGAM INJ F PA; SP 500 mg AMOXICILLIN CHEW 125 F FLEBOGAMMA DIF SOLN F PA; SP MG, 250 MG amoxicillin susr 125 GAMASTAN INJ F PA; SP mg/5ml, 200 mg/5ml, 250 F mg/5ml, 400 mg/5ml GAMASTAN S/D INJ F PA; SP amoxicillin tabs 500 mg F PA GAMMAGARD LIQUID F PA; SP SOLN amoxicillin tabs 875 mg F GAMMAGARD S/D IGA PA; SP ampicillin caps 250 mg, LESS THAN 1MCG/ML F F 500 mg SOLR AMPICILLIN CAPS 500 PA; SP F GAMMAKED SOLN F MG PA; SP AMPICILLIN SUSR 125 F GAMMAPLEX SOLN F MG/5ML, 250 MG/5ML

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOXATAG TB24 F PA AUGMENTIN TABS QL(30 ea per 500MG-125MG (Use *** fill retail) Natural Penicillins Amoxicillin & Pot Clavulanate) penicillin v potassium solr F 125 mg/5ml, 250 mg/5ml AUGMENTIN TABS QL(20 ea per 875MG-125MG (Use *** fill retail) PENICILLIN V Amoxicillin & Pot POTASSIUM SOLR 125 F Clavulanate) MG/5ML, 250 MG/5ML AUGMENTIN XR TB12 QL(40 ea per penicillin v potassium tabs F (Use Amoxicillin & Pot *** 30 days retail) 250 mg, 500 mg Clavulanate) Penicillin Combinations Penicillinase-Resistant Penicillins amoxicillin & pot QL(100 ml per clavulanate susr F fill retail) dicloxacillin sodium caps F 200mg/5ml-28.5mg/5ml amoxicillin & pot QL(150 ml per PHARMACEUTICAL ADJUVANTS clavulanate susr F fill retail) 250mg/5ml-62.5mg/5ml Internal Vehicle Ingredients/Agents amoxicillin & pot QL(200 ml per SIMPLYTHICK EASY MIX F QL(6000 ml per clavulanate susr F fill retail) GEL fill retail) QL(6000 ml per 400mg/5ml-57mg/5ml SIMPLYTHICK GEL F amoxicillin & pot QL(400 ml per fill retail) clavulanate susr F fill retail) starch-maltodextrin F 600mg/5ml-42.9mg/5ml (thickening) powd amoxicillin & pot QL(30 ea per THICK-IT ORIGINAL clavulanate tabs 250mg- F fill retail) POWD (Use Starch- *** 125mg, 500mg-125mg Maltodextrin (Thickening)) amoxicillin & pot QL(20 ea per Liquid Vehicles clavulanate tabs 875mg- F fill retail) BLENDED SUSPENDING F RX/OTC 125mg COMPOUND SUSP amoxicillin & pot QL(40 ea per CVS DISTILLED WATER F RX/OTC clavulanate tb12 1000mg- F 30 days retail) LIQD 62.5mg CVS PURIFIED WATER F RX/OTC AMOXICILLIN/CLAVULAN F QL(20 ea per LIQD ATE POTASSIUM CHEW fill retail) DISTILLATA DISTILLED F RX/OTC AMOXICILLIN/CLAVULAN QL(40 ea per WATER LIQD ATE POTASSIUM ER F 30 days retail) TB12 DISTILLED WATER LIQD F RX/OTC AUGMENTIN ES-600 QL(400 ml per RX/OTC SUSR (Use Amoxicillin & *** fill retail) FLAVOR BLEND SUSP F Pot Clavulanate) FLAVOR PLUS LIQD F RX/OTC AUGMENTIN SUSR F QL(150 ml per 125MG/5ML-31.25MG/5ML fill retail) FLAVOR SWEET SYRP F RX/OTC AUGMENTIN SUSR QL(150 ml per 250MG/5ML-62.5MG/5ML fill retail) *** FLAVOR SWEET-SF F RX/OTC (Use Amoxicillin & Pot SYRP Clavulanate) glycine diluent soln F PA; SP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GRAPE SYRUP SYRP F RX/OTC PX PURIFIED WATER F RX/OTC LIQD RX/OTC MX-SOL BLEND SF SUSP F RA CRYSTAL LAKE F RX/OTC DISTILLEDWATER LIQD RX/OTC MX-SOL BLEND SUSP F SOLVATECH PLUS SUSP F RX/OTC RX/OTC MX-SOL SF SYRP F SOLVATECH SWEET SF F RX/OTC SYRP RX/OTC MX-SOL SUSPEND SUSP F STERILE DILUENT FOR PA; SP FLOLAN SOLN (Use *** MX-SOL SYRP F RX/OTC Glycine Diluent) STERILE DILUENT FOR PA; SP NICE DISTILLED WATER F RX/OTC LIQD TREPROSTINIL F INJECTION SOLN RX/OTC ORA-BLEND SF SUSP F SUSPENDRX WITH RX/OTC RX/OTC BITTER- F ORA-BLEND SUSP F BLOC/SWEETENED RX/OTC SUSP ORA-PLUS LIQD F SUSPENDRX WITH RX/OTC RX/OTC BITTER- F ORA-SWEET SF SYRP F BLOC/UNSWEETENED SUSP ORA-SWEET SYRP F RX/OTC SUSPENSION VEHICLE F RX/OTC ORAL MIX FLAVORED RX/OTC SUSP SUSPENDING VEHICLE F SWEETENING RX/OTC SUSP SUSPENDING F COMPOUND SYRP ORAL MIX SF SUSP F RX/OTC SYRPALTA SYRP F RX/OTC ORAL SUSPEND LIQD F RX/OTC SYRSPEND SF LIQD F RX/OTC ORAL SUSPENDING F RX/OTC COMPOUNDPLUS SUSP SYRUP VEHICLE SF F RX/OTC SYRP ORAL SYRUP FLAVORED F RX/OTC VEHICLE SYRP SYRUP VEHICLE SYRP F RX/OTC ORAL SYRUP SF SYRP F RX/OTC VERSAFREE SYRP F RX/OTC PCCA SWEET-SF SYRP F RX/OTC VERSAPLUS SYRP F RX/OTC PCCA SYRUP VEHICLE F RX/OTC SYRP Semi Solid Vehicles RX/OTC PCCA-PLUS SUSP F 1ST BASE CREA F RX/OTC PH 12 STERILE DILUENT PA; SP ADVANCED BASE PLUS F RX/OTC FORFLOLAN SOLN (Use *** CREA Glycine Diluent) ALBA-DERM CREA F RX/OTC PURIFIED WATER LIQD F RX/OTC ALTADERM CREAM BASE F RX/OTC CREA ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APOTHESAR 2 CREA F RX/OTC FITALITE CREA F RX/OTC

APOTHESAR PLUS CREA F RX/OTC FREEDOM ADAPTADERM F RX/OTC CREA RX/OTC APOTHESIL CREA F FREEDOM DERMA F RX/OTC SERUM CREA ARBEM H-COSMETIC RX/OTC F FREEDOM DERMA-D F RX/OTC CREA CREA RX/OTC ARBEM LIPOPEN CREA F FREEDOM DERMA-N F RX/OTC CREA ATREVIS HYDROGEL F RX/OTC CREA HYDROPHILIC OINT F RX/OTC AUXIPRO VANISHING RX/OTC F HYDROPHILIC F CREAM CREA PETROLATUM OINT RX/OTC AZ CREAM CREA F HYDROUS EMULSIFIED F RX/OTC BASE CREA BASE PCCA CLARIFYING F RX/OTC CREA LANOLIN ANHYDROUS F RX/OTC OINT BASE W301 CREA F RX/OTC LANOLIN ANHYDROUS- F RX/OTC GRX OINT BRAVURA ALL-IN-ONE F RX/OTC CREA lanolin oint F RX/OTC CELA BASE CREA F RX/OTC LIPO CREAM BASE CREA F RX/OTC CHRYSADERM DAY F RX/OTC CREA LIPOPEN ABSORPTION F RX/OTC ENHANCING BASE CREA CHRYSADERM NIGHT F RX/OTC CREA LIPOPEN ULTRA BASE F RX/OTC CREA CREAM BASE CREA F RX/OTC LIPOSOMAL HEAVY F RX/OTC CREA CREAM CONCENTRATE F RX/OTC CREA LIPOSOMAL REGULAR F RX/OTC CREA CUTIS PLUS CREA F RX/OTC MEDIDERM CREA F RX/OTC DELBASE F RX/OTC COMPOUNDING OINT MICRODERM BASE CREA F RX/OTC EMOLIVAN CREA F RX/OTC MICROSOME BASE CREA F RX/OTC EMOLLIENT CREAM F RX/OTC BASE CREA MULTIBASE CREA F RX/OTC EMOLLIENT CREAM F RX/OTC RX/OTC CREA NOURILITE CREA F RX/OTC FAGRON LS PLUS CREA F NOURIVAN ANTIOX F RX/OTC CREAM BASE CREA FAGRON NATURAL F RX/OTC RX/OTC CREAM CREA NOXI-K CREA F FAGRON SUPREME F RX/OTC RX/OTC CREAM CREA OCCLUVAN OINT F ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P-SILOXAN DS CREA F RX/OTC PHARMABASE RX/OTC COSMETIC NATURAL F CREA PCCA ALADERM BASE F RX/OTC CREA PHARMABASE HEAVY F RX/OTC CREA PCCA ANHYDROUS F RX/OTC LIPODERM BASE CREA PHARMABASE LIGHT F RX/OTC PCCA BASE 7542 CREA F RX/OTC CREA PHARMABASE VAGINAL F RX/OTC PCCA BIOPEPTIDE BASE F RX/OTC MOISTURIZING CREA CREA PHYTOBASE CREA F RX/OTC PCCA COSMETIC HRT F RX/OTC BASE CREA PICODERM CREA F RX/OTC PCCA EMOLLIENT F RX/OTC CREAM BASE CREA PNA-HRT BASE CREA F RX/OTC PCCA LIPODERM BASE F RX/OTC CREA Q-DERM CREA F RX/OTC PCCA LIPODERM F RX/OTC CUSTOM BASE CREA REJUVACARE PLUS F RX/OTC CREA PCCA MVC BASE CREA F RX/OTC SA3 DERM CREA F RX/OTC PCCA NATACREAM F RX/OTC CREA SALT DURABLE CREAM F RX/OTC CREA PCCA PRACASIL TM- F RX/OTC PLUS BASE CREA SALT STABLE LS F RX/OTC ADVANCED CREA PCCA VANISHING F RX/OTC CREAM LIGHT CREA SALTSTABLE LO CREA F RX/OTC PCCA VANISHING RX/OTC SANARE ADVANCED F RX/OTC CREAM/LOTION BASE F SCAR THERAPY CREA CREA SANARE SCAR THERAPY F RX/OTC PCCA VANPEN BASE F RX/OTC CREA CREA SCAR CARE CREAM F RX/OTC PENCREAM CREA F RX/OTC CREA RX/OTC PENDERM CREA F RX/OTC SEDANARE CREA F RX/OTC PENSOMAL CREAM F RX/OTC SILPROTEX PLUS CREA F CREA SKYY DERM CREA F RX/OTC PENTAPHENE BASE F RX/OTC CREA STERA BASE CREA F RX/OTC PERFORMAX SALT F RX/OTC SUPPORTIVEBASE CREA TERODERM CREA F RX/OTC PFCB CREA F RX/OTC TERODERM-PLUS CREA F RX/OTC PHARMABASE F RX/OTC ANTIOXIDANT CREA TIGHTENING BASE CREA F RX/OTC PHARMABASE F RX/OTC COSMETIC CREA ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits U-BASE CREA F RX/OTC medroxyprogesterone F MP acetate tabs ULTRADERM CREA F RX/OTC MEGACE ES SUSP (Use PA Megestrol Acetate *** V-MAX CREA F RX/OTC (Appetite)) megestrol acetate F PA VANIBASE CREA F RX/OTC (appetite) susp norethindrone acetate tabs F VANISH-PEN CREA F RX/OTC progesterone micronized F QL(60 ea per VANISHING CREAM F RX/OTC caps 30 days retail) BOTANICALBASE CREA PROMETRIUM CAPS (Use *** QL(60 ea per VANISHING CREAM F RX/OTC Progesterone Micronized) 30 days retail) CREA PROVERA TABS (Use MP VERSAPRO CREA F RX/OTC Medroxyprogesterone *** Acetate) VERSATILE CREAM F RX/OTC BASE CREA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and VERSATILE RICH CREAM F RX/OTC BASE CREA Emotional Conditions Agents for Chemical Dependency VERSIGEL CREA F RX/OTC acamprosate calcium tbec F PA VP DERMABASE CREA F RX/OTC ANTABUSE TABS (Use *** WOUND CARE CREAM F RX/OTC Disulfiram) CREA disulfiram tabs F XCEL 100 CREA F RX/OTC Anti-Cataplectic Agents XEMATOP BASE CREA F RX/OTC XYREM SOLN F PA; SP ZOE SCRIPTS F RX/OTC IDEALBASE CREA Antidementia Agents PROGESTINS - Hormone Replacement/Modifying ARICEPT TABS 23 MG PA Drugs (Use Donepezil *** Hydrochloride) Progestins ARICEPT TABS 5 MG, 10 QL(31 ea per AYGESTIN TABS (Use *** MG (Use Donepezil *** 31 days retail) Norethindrone Acetate) Hydrochloride) hydroxyprogesterone QL(4 ml per 28 F donepezil hydrochloride F PA caproate oil im 250 mg/ml days retail) tabs 23 mg MAKENA OIL IM 250 QL(4 ml per 28 donepezil hydrochloride F QL(31 ea per MG/ML (Use F days retail) tabs 5 mg, 10 mg 31 days retail) Hydroxyprogesterone donepezil hydrochloride F QL(31 ea per Caproate) tbdp 5 mg, 10 mg 31 days retail) QL(4.4 ml per EXELON PT24 (Use PA MAKENA SOAJ SC 275 F *** MG/1.1ML 28 days retail); Rivastigmine) SP galantamine hydrobromide F QL(1 ea daily) cp24 8 mg, 16 mg, 24 mg ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GALANTAMINE QL(6 ml daily) Fibromyalgia Agents HYDROBROMIDE SOLN 4 F PA; QL(2 ea MG/ML SAVELLA TABS F daily) galantamine hydrobromide F QL(2 ea daily) tabs 4 mg, 8 mg, 12 mg PA; QL(55 ea SAVELLA TITRATION F per 365 days PACK MISC memantine hcl cp24 14 F PA; QL(2 ea retail) mg, 21 mg, 28 mg daily) Movement Disorder Drug Therapy memantine hcl cp24 7 mg F PA INGREZZA CAPS 80 MG F PA; SP memantine hcl soln 2 F PA; QL(2 ml mg/ml daily) tetrabenazine tabs F PA; SP memantine hcl tabs F PA XENAZINE TABS (Use *** PA; SP Tetrabenazine) memantine hcl tabs 5 mg, F 10 mg Multiple Sclerosis Agents AMPYRA TB12 (Use PA; SP NAMENDA TABS (Use *** *** Memantine HCl) Dalfampridine) NAMENDA TITRATION PA AUBAGIO TABS F PA; SP PAK TABS (Use *** Memantine HCl) AVONEX KIT F PA; SP NAMENDA XR CP24 14 PA; QL(2 ea MG, 21 MG, 28 MG (Use *** daily) AVONEX PEN AJKT F PA; SP Memantine HCl) PA; SP NAMENDA XR CP24 7 MG *** PA AVONEX PSKT F (Use Memantine HCl) BETASERON KIT F PA; SP NAMENDA XR TITRATION F PA PACK CP24 COPAXONE SOSY (Use *** PA; SP RAZADYNE ER CP24 (Use QL(1 ea daily) Glatiramer Acetate) Galantamine *** Hydrobromide) dalfampridine tb12 F PA; SP RAZADYNE TABS (Use QL(2 ea daily) PA; SP Galantamine *** EXTAVIA KIT F Hydrobromide) GILENYA CAPS 0.5 MG F PA; SP rivastigmine pt24 F PA glatiramer acetate sosy F PA; SP rivastigmine tartrate caps F QL(2 ea daily) PLEGRIDY SOPN F PA; SP Combination Psychotherapeutics PA; SP CHLORDIAZEPOXIDE/AMI F PLEGRIDY SOSY F TRIPTYLINE TABS PLEGRIDY STARTER PA; SP olanzapine-fluoxetine hcl F PA F caps PACK SOPN PLEGRIDY STARTER PA; SP PERPHENAZINE/AMITRIP F F TYLINE TABS PACK SOSY SYMBYAX CAPS (Use PA REBIF REBIDOSE SOAJ F PA; SP Olanzapine-Fluoxetine *** HCl) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF REBIDOSE F PA; SP NICODERM CQ PT24 14 QL(1 ea daily) TITRATIONPACK SOAJ MG/24HR, 21 MG/24HR *** (Use Nicotine) REBIF SOSY F PA; SP NICODERM CQ PT24 7 *** MG/24HR (Use Nicotine) REBIF TITRATION PACK F PA; SP SOSY NICORETTE GUM 2 MG, 4 QL(24 ea daily) *** TECFIDERA CPDR F PA; SP MG (Use Nicotine Polacrilex) TECFIDERA STARTER F PA; SP NICORETTE LOZG 2 MG, QL(20 ea daily) PACK MISC 4 MG (Use Nicotine *** Postherpetic Neuralgia (PHN)/Neuropathic Pain Polacrilex) PA NICORETTE MINI LOZG *** QL(20 ea daily) GRALISE STARTER MISC F (Use Nicotine Polacrilex) PA NICORETTE STARTER QL(24 ea daily) GRALISE TABS F KIT GUM (Use Nicotine *** Polacrilex) Premenstrual Dysphoric Disorder (PMDD) Agents nicotine polacrilex gum 2 F QL(24 ea daily) FLUOXETINE CAPS F QL(124 ea per mg, 4 mg 30 days retail) nicotine polacrilex lozg 2 F QL(20 ea daily) Pseudobulbar Affect (PBA) Agents mg, 4 mg PA NUEDEXTA CAPS F nicotine pt24 14 mg/24hr, F QL(1 ea daily) 21 mg/24hr Psychotherapeutic and Neurological Agents - nicotine pt24 7 mg/24hr F ERGOLOID MESYLATES F PA TABS NICOTINE QL(56 ea per TRANSDERMAL SYSTEM F fill retail) ORAP TABS (Use *** Pimozide) KIT NICOTROL INHALER F QL(504 ea per PIMOZIDE TABS F INHA fill retail) Restless Leg Syndrome (RLS) Agents NICOTROL NS SOLN F QL(120 ml per 30 days retail) PA HORIZANT TBCR F ZYBAN TB12 (Use QL(2 ea daily) Bupropion HCl (Smoking *** Smoking Deterrents Deterrent)) bupropion hcl (smoking F QL(2 ea daily) deterrent) tb12 Transthyretin Amyloidosis Agents Limit 180 days TEGSEDI SOSY F PA; SP CHANTIX CONTINUING F MONTHPAK TABS supply per 365 days Vasomotor Symptom Agents Limit 180 days BRISDELLE CAPS (Use PA Paroxetine Mesylate *** CHANTIX STARTING F supply per 365 MONTH PAK TABS days;QL(53 ea (Vasomotor)) per fill retail) paroxetine mesylate F PA Limit 180 days (vasomotor) caps CHANTIX TABS F supply per 365 RESPIRATORY AGENTS - MISC. - Drugs to days Treat Lung Conditions Cystic Fibrosis Agents ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KALYDECO PACK 50 MG, F PA; SP minocycline hcl tb24 45 PA 75 MG mg, 55 mg, 65 mg, 80 mg, F PA; SP 90 mg, 105 mg, 115 mg, KALYDECO TABS 150 MG F 135 mg MONODOX CAPS 100 MG ORKAMBI PACK 100MG- F PA 125MG, 150MG-188MG (Use Doxycycline *** (Monohydrate)) ORKAMBI TABS 100MG- F PA; SP 125MG, 200MG-125MG MONODOX CAPS 75 MG PA PA; SP (Use Doxycycline *** PULMOZYME SOLN F (Monohydrate)) PA; SP SOLODYN TB24 (Use *** PA SYMDEKO TBPK F Minocycline HCl) Pulmonary Fibrosis Agents tetracycline hcl caps F PA; SP OFEV CAPS F VIBRAMYCIN CAPS 100 MG (Use Doxycycline *** SULFONAMIDES - Drugs to Treat Bacterial Hyclate) Infections VIBRAMYCIN SUSR 25 PA Sulfonamides MG/5ML (Use Doxycycline *** (Monohydrate)) SULFADIAZINE TABS F PA VIBRAMYCIN SYRP 50 F PA TETRACYCLINES - Drugs to Treat Bacterial MG/5ML Infections THYROID AGENTS - Drugs to Regulate Thyroid Tetracyclines Hormones demeclocycline hcl tabs F PA Antithyroid Agents methimazole tabs F MP doxycycline (monohydrate) F caps 50 mg, 100 mg propylthiouracil tabs F MP doxycycline (monohydrate) F PA caps 75 mg, 150 mg TAPAZOLE TABS (Use *** MP Methimazole) doxycycline (monohydrate) F PA susr 25 mg/5ml Thyroid Hormones doxycycline (monohydrate) F ARMOUR THYROID TABS tabs 50 mg, 100 mg 15 MG, 30 MG, 60 MG, 90 F doxycycline (monohydrate) F PA MG, 120 MG (Use Thyroid) tabs 75 mg, 150 mg ARMOUR THYROID TABS F doxycycline hyclate caps F 180 MG, 240 MG, 300 MG 50 mg, 100 mg CYTOMEL TABS (Use *** MP doxycycline hyclate tabs 20 F Liothyronine Sodium) mg, 100 mg levothyroxine sodium tabs F MP doxycycline hyclate tbec 75 F PA mg, 100 mg, 150 mg liothyronine sodium tabs F MP MINOCIN CAPS (Use *** Minocycline HCl) NATURE-THROID TABS F minocycline hcl caps 50 F mg, 75 mg, 100 mg SYNTHROID TABS (Use F MP Levothyroxine Sodium) ***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits thyroid tabs F hyoscyamine sulfate tabs *** or 0.125 mg THYROLAR-1 TABS F hyoscyamine sulfate tabs F or 0.125 mg THYROLAR-1/2 TABS F hyoscyamine sulfate tb12 F QL(4 ea daily) or 0.375 mg THYROLAR-1/4 TABS F hyoscyamine sulfate tbdp *** or 0.125 mg THYROLAR-2 TABS F hyoscyamine sulfate tbdp F or 0.125 mg THYROLAR-3 TABS F LEVBID TB12 (Use *** QL(4 ea daily) TIROSINT CAPS 13 MCG, PA Hyoscyamine Sulfate) 25 MCG, 50 MCG, 75 MCG, 88 MCG, 100 MCG, F LEVSIN SOLN F 112 MCG, 125 MCG, 137 methscopolamine bromide F PA MCG, 150 MCG tabs WESTHROID TABS F PROPANTHELINE F QL(4 ea daily) BROMIDE TABS WP THYROID TABS F ROBINUL FORTE TABS *** QL(4 ea daily) (Use Glycopyrrolate) ULCER DRUGS - Drugs to Treat Bowel, Intestine ROBINUL TABS (Use *** QL(4 ea daily) and Stomach Conditions Glycopyrrolate) Antispasmodics SYMAX DUOTAB TBCR F BELLADONNA/OPIUM F PA SUPP H-2 Antagonists BENTYL CAPS (Use *** Dicyclomine HCl) CIMETIDINE HCL SOLN F CUVPOSA SOLN F PA cimetidine tabs 200 mg F RX/OTC dicyclomine hcl caps 10 mg F cimetidine tabs 300 mg, F 400 mg, 800 mg dicyclomine hcl soln 10 F QL(496 ml per mg/5ml 30 days retail) famotidine susr 40 mg/5ml F dicyclomine hcl tabs 20 mg F famotidine tabs 10 mg, 40 F mg glycopyrrolate tabs or 1 F QL(4 ea daily) RX/OTC mg, 2 mg famotidine tabs 20 mg F nizatidine caps 150 mg, PA hyoscyamine sulfate elix or F F 0.125 mg/5ml 300 mg NIZATIDINE SOLN 15 PA hyoscyamine sulfate soln F F or 0.125 mg/ml MG/ML PEPCID AC MAXIMUM RX/OTC hyoscyamine sulfate subl sl F 0.125 mg STRENGTH TABS (Use *** Famotidine) hyoscyamine sulfate subl sl *** 0.125 mg PEPCID AC TABS (Use *** Famotidine)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEPCID SUSR 40 MG/5ML *** EQ OMEPRAZOLE TBEC F QL(1 ea daily) (Use Famotidine) QL(1 ea daily) PEPCID TABS 20 MG (Use *** RX/OTC EQL OMEPRAZOLE TBEC F Famotidine) esomeprazole magnesium QL(2 ea daily); PEPCID TABS 40 MG (Use *** F Famotidine) cpdr 20 mg RX/OTC QL(2 ea daily) esomeprazole magnesium F PA ranitidine hcl caps 150 mg F cpdr 40 mg QL(1 ea daily) FIRST-LANSOPRAZOLE F QL(300 ml per ranitidine hcl caps 300 mg F SUSP fill retail) ranitidine hcl syrp 15 QL(40 ml daily) QL(300 ml per F mg/ml, 75 mg/5ml, 150 FIRST-OMEPRAZOLE F fill retail); mg/10ml SUSP AL(Up to 2 yrs old ) ranitidine hcl tabs 150 mg F RX/OTC GNP OMEPRAZOLE F QL(1 ea daily) ranitidine hcl tabs 300 mg F TBEC HM OMEPRAZOLE TBEC F QL(1 ea daily) ranitidine hcl tabs 75 mg F QL(2 ea daily) KLS OMEPRAZOLE TBEC F QL(1 ea daily) TAGAMET HB TABS (Use *** RX/OTC Cimetidine) QL(4 ea daily); lansoprazole cpdr 15 mg F ZANTAC 150 MAXIMUM RX/OTC RX/OTC STRENGTH TABS (Use *** QL(2 ea daily) Ranitidine HCl) lansoprazole cpdr 30 mg F ZANTAC 75 TABS (Use *** QL(2 ea daily) lansoprazole tbdp 15 mg, F QL(1 ea daily) Ranitidine HCl) 30 mg ZANTAC TABS 150 MG *** RX/OTC NEXIUM 24HR CLEAR QL(2 ea daily); (Use Ranitidine HCl) MINIS CPDR (Use *** RX/OTC Esomeprazole Magnesium) ZANTAC TABS 300 MG *** (Use Ranitidine HCl) NEXIUM 24HR CPDR (Use *** QL(2 ea daily); Esomeprazole Magnesium) RX/OTC Misc. Anti-Ulcer CARAFATE SUSP 1 QL(420 ml per NEXIUM CPDR 20 MG QL(2 ea daily); F (Use Esomeprazole *** RX/OTC GM/10ML fill retail) Magnesium) CARAFATE TABS 1 GM *** (Use Sucralfate) NEXIUM CPDR 40 MG PA (Use Esomeprazole *** sucralfate tabs F Magnesium) NEXIUM PACK 10 MG, 20 F PA Proton Pump Inhibitors MG, 40 MG ACIPHEX SPRINKLE F PA QL(300 ml per CPSP OMEPRAZOLE + F fill retail); SYRSPEND SFALKA AL(Up to 2 yrs ACIPHEX TBEC (Use *** PA SUSP Rabeprazole Sodium) old ) CVS OMEPRAZOLE TBEC F QL(1 ea daily) omeprazole cpdr 10 mg F QL(1 ea daily) QL(2 ea daily); DEXILANT CPDR F PA; ST omeprazole cpdr 20 mg F RX/OTC

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omeprazole cpdr 40 mg F QL(2 ea daily) misoprostol tabs F omeprazole magnesium F Ulcer Therapy Combinations cpdr amoxicillin-clarithromycin F PA OMEPRAZOLE TBEC 20 F QL(1 ea daily) w/ lansoprazole misc MG famotidine-calcium pantoprazole sodium tbec F QL(1 ea daily) carbonate-magnesium F 20 mg hydroxide chew pantoprazole sodium tbec F QL(2 ea daily) PA 40 mg OMECLAMOX-PAK MISC F PREVACID 24HR CPDR *** QL(4 ea daily); omeprazole-sodium QL(2 ea daily); (Use Lansoprazole) RX/OTC bicarbonate caps 20mg- F RX/OTC 1100mg PREVACID CPDR 15 MG *** QL(4 ea daily); (Use Lansoprazole) RX/OTC omeprazole-sodium PA bicarbonate caps 40mg- F PREVACID CPDR 30 MG *** QL(2 ea daily) (Use Lansoprazole) 1100mg omeprazole-sodium PREVACID SOLUTAB *** QL(1 ea daily) TBDP (Use Lansoprazole) bicarbonate pack 20mg- F 1680mg, 40mg-1680mg QL(1 ea daily) PRILOSEC OTC TBEC F PEPCID COMPLETE PA CHEW (Use Famotidine- *** PRILOSEC PACK F Calcium Carbonate- PA Magnesium Hydroxide) PROTONIX PACK 40 MG F PREVPAC MISC (Use PA PROTONIX TBEC 20 MG QL(1 ea daily) Amoxicillin-Clarithromycin *** (Use Pantoprazole *** w/ Lansoprazole) Sodium) PYLERA CAPS F PA PROTONIX TBEC 40 MG QL(2 ea daily) (Use Pantoprazole *** ZEGERID CAPS 20MG- QL(2 ea daily); Sodium) 1100MG (Use Omeprazole- *** RX/OTC QL(1 ea daily) Sodium Bicarbonate) PX OMEPRAZOLE TBEC F ZEGERID CAPS 40MG- PA QL(1 ea daily) 1100MG (Use Omeprazole- *** RA OMEPRAZOLE TBEC F Sodium Bicarbonate) rabeprazole sodium tbec F PA ZEGERID OTC CAPS (Use QL(2 ea daily); Omeprazole-Sodium *** RX/OTC Bicarbonate) SB OMEPRAZOLE TBEC F QL(1 ea daily) ZEGERID PACK 20MG- QL(1 ea daily) SM OMEPRAZOLE TBEC F 1680MG, 40MG-1680MG *** (Use Omeprazole-Sodium SW OMEPRAZOLE TBEC F QL(1 ea daily) Bicarbonate) URINARY ANTI-INFECTIVES - Drugs to Treat TGT OMEPRAZOLE TBEC F QL(1 ea daily) Bladder/Kidney Infections Ulcer Drugs - Prostaglandins Urinary Anti-infective Combinations PA CYTOTEC TABS (Use *** HYOPHEN TABS F Misoprostol)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methenamine-hyosc- PA nitrofurantoin susp F QL(40 ml daily) methylene blue-benzoic F acid-phenyl sal tabs URINARY ANTISPASMODICS - Drugs to Treat methenamine-hyosc- PA Miscellaneous Bladder Spasms methylene blue-sod phos- phenyl sal caps 40.8mg- F Urinary Antispasmodic - Antimuscarinics 0.12mg-36mg-120mg- darifenacin hydrobromide F PA 10mg tb24 methenamine-hyosc- DETROL LA CP24 (Use *** methylene blue-sod phos- Tolterodine Tartrate) phenyl sal tabs 40.8mg- DETROL TABS (Use *** PA 0.12mg-32.4mg-81mg- F Tolterodine Tartrate) 10.8mg, 40.8mg-0.12mg- DITROPAN XL TB24 (Use *** QL(2 ea daily); 36.2mg-81.6mg-10.8mg, Oxybutynin Chloride) MP 40.8mg-36.2mg-0.12mg- 81.6mg-10.8mg ENABLEX TB24 (Use *** PA Darifenacin Hydrobromide) methenamine-hyoscamine- PA methylene blue-sodium F GELNIQUE GEL F PA phosphate caps PA methenamine-hyoscamine- PA GELNIQUE PUMP GEL F methylene blue-sodium F phosphate tabs oxybutynin chloride syrp 5 F QL(16.6 ml mg/5ml daily); MP UROGESIC-BLUE TABS PA oxybutynin chloride tabs 5 QL(3 ea daily); (Use Methenamine- *** F Hyoscamine-Methylene mg MP Blue-Sodium Phosphate) oxybutynin chloride tb24 5 F QL(2 ea daily); mg, 10 mg, 15 mg MP UTA CAPS F PA OXYTROL FOR WOMEN F PA; RX/OTC PTTW Urinary Anti-infectives OXYTROL PTTW F PA; RX/OTC FURADANTIN SUSP (Use *** QL(40 ml daily) Nitrofurantoin) solifenacin succinate tabs F PA HIPREX TABS (Use *** PA Methenamine Hippurate) tolterodine tartrate cp24 2 F MACROBID CAPS (Use mg, 4 mg Nitrofurantoin Monohyd *** tolterodine tartrate tabs 1 F PA Macro) mg, 2 mg MACRODANTIN CAPS PA (Use Nitrofurantoin *** TOVIAZ TB24 F Macrocrystal) trospium chloride cp24 60 F PA methenamine hippurate F PA mg tabs trospium chloride tabs 20 F QL(2 ea daily) methenamine mandelate F mg tabs VESICARE TABS (Use *** PA nitrofurantoin macrocrystal F Solifenacin Succinate) caps Urinary Antispasmodics - Cholinergic Agonists nitrofurantoin monohyd F macro caps bethanechol chloride tabs F MP

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Use MP URECHOLINE TABS ( *** VARIVAX INJ F AL(At least 18 Bethanechol Chloride) yrs old) Urinary Antispasmodics - Direct Muscle Relaxants QL(1 ea per 999 days flavoxate hcl tabs F ZOSTAVAX SUSR F retail); AL(At least 50 yrs VACCINES old) Bacterial Vaccines VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones PNEUMOVAX 23 INJ F AL(At least 18 yrs old) Spermicides QL(12 ea per PNEUMOVAX 23/1 DOSE F AL(At least 18 ENCARE SUPP F INJ yrs old) fill retail) QL(25.5 gm per PREVNAR 13 SUSP F AL(At least 18 nonoxynol-9 gel F yrs old) fill retail) Viral Vaccines OPTIONS CONCEPTROL QL(25.5 gm per VAGINAL fill retail) AL(At least 18 *** ENGERIX-B INJ F CONTRACEPTIVE GEL yrs old) (Use Nonoxynol-9) AL(At least 18 ENGERIX-B SUSP F OPTIONS GYNOL II QL(81 gm per yrs old) VAGINALCONTRACEPTIV F fill retail) limit 0.5 per E GEL 180 days;1 rtl QL(24 gm per SHUR-SEAL GEL F FLUMIST pack lmt fill retail) F amt,180 rtl QUADRIVALENT SUSP pack lmt VCF VAGINAL day(s),; AL(At CONTRACEPTIVE FILM F least 9 yrs old) FILM VCF VAGINAL QL(17 gm per GARDASIL 9 SUSP F AL(At least 9 yrs old) CONTRACEPTIVE FOAM F fill retail) FOAM GARDASIL 9 SUSY F AL(At least 9 yrs old) Vaginal Anti-infectives CLEOCIN CREA VA 2 % GARDASIL SUSP F AL(At least 9 yrs old) (Use Clindamycin *** Phosphate Vaginal) HAVRIX SUSP F CLEOCIN SUPP VA 100 F PA MG M-M-R II INJ F AL(At least 18 yrs old) clindamycin phosphate F AL(At least 18 vaginal crea RECOMBIVAX HB SUSP F yrs old) CLINDESSE CREA F QL(2 ea per 999 days clotrimazole vaginal crea 1 F QL(45 gm per SHINGRIX SUSR F retail); AL(At % 30 days retail) least 50 yrs clotrimazole vaginal crea 2 F QL(31 gm per old) % 30 days retail) VAQTA SUSP F GYNAZOLE-1 CREA F

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GYNE-LOTRIMIN 3 CREA *** QL(31 gm per ESTRACE CREA VA 0.1 QL(43 gm per (Use Clotrimazole Vaginal) 30 days retail) MG/GM (Use Estradiol *** 30 days retail) Vaginal) GYNE-LOTRIMIN CREA *** QL(45 gm per (Use Clotrimazole Vaginal) 30 days retail) estradiol vaginal crea 0.1 F QL(43 gm per METROGEL-VAGINAL QL(70 gm per mg/gm 30 days retail) GEL (Use Metronidazole *** 30 days retail) estradiol vaginal tabs 10 F Vaginal) mcg QL(70 gm per PA metronidazole vaginal gel F ESTRING RING F 30 days retail) QL(3 ea per 30 PA MICONAZOLE 3 SUPP F FEMRING RING F days retail) PREMARIN CREA VA QL(43 gm per miconazole nitrate vaginal F QL(45 gm per F crea 2 %, 4 % 30 days retail) 0.625 MG/GM 30 days retail) VAGIFEM TABS (Use miconazole nitrate vaginal F QL(24 gm per *** kit fill retail) Estradiol Vaginal) Vaginal Progestins miconazole nitrate vaginal F QL(1 ea per fill kit retail) CRINONE GEL F AL(At least 14 yrs old) miconazole nitrate vaginal F QL(7 ea per 30 supp 100 mg days retail) FIRST-PROGESTERONE AL(At least 14 MONISTAT 1 COMBO QL(1 ea per fill VGS 100 COMPOUNDING F yrs old) PACK KIT (Use *** retail) KIT SUPP Miconazole Nitrate Vaginal) FIRST-PROGESTERONE AL(At least 14 MONISTAT 1 DAY OR QL(1 ea per fill VGS 200 F yrs old) COMPOUNDING KIT NIGHT COMBO PACK KIT *** retail) (Use Miconazole Nitrate SUPP Vaginal) VASOPRESSORS - Drugs to Treat Heart and MONISTAT 3 QL(24 gm per Circulation Conditions COMBINATION PACK KIT *** fill retail) (Use Miconazole Nitrate Anaphylaxis Therapy Agents Vaginal) PA; Limit 1 fill (2 pens) per MONISTAT 3 CREA (Use *** QL(45 gm per Miconazole Nitrate Vaginal) 30 days retail) month; 4 pens AUVI-Q SOAJ 0.15 F per year;QL(2 MONISTAT 7 SIMPLY QL(45 gm per MG/0.15ML ea per fill CURE CREA (Use *** 30 days retail) retail,4 ea per Miconazole Nitrate Vaginal) 365 days retail) TERAZOL 7 CREA (Use *** AUVI-Q SOAJ 0.3 *** Terconazole Vaginal) MG/0.3ML TERCONAZOLE CREA F PA; Limit 1 fill (2 pens) per terconazole vaginal crea F month; 4 pens epinephrine (anaphylaxis) F per year;QL(2 soaj 0.15 mg/0.15ml terconazole vaginal supp F ea per fill retail,4 ea per tioconazole vaginal oint F 365 days retail) Vaginal Estrogens

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 fill (2 cholecalciferol chew 400 F pens) per unit, 1000 unit month; 4 pens epinephrine (anaphylaxis) cholecalciferol liqd 400 F F per year;QL(2 unit/ml, 5000 unit/ml soaj 0.15 mg/0.3ml ea per fill retail,4 ea per cholecalciferol tabs 25 365 days retail) mcg, 400 unit, 1000 unit, F 2000 unit, 5000 unit epinephrine (anaphylaxis) *** soaj 0.3 mg/0.3ml D-VI-SOL LIQD (Use *** Cholecalciferol) Limit 1 fill (2 pens) per DRISDOL CAPS (Use *** Ergocalciferol) epinephrine (anaphylaxis) F month; 4 pens soaj 0.3 mg/0.3ml per year;QL(4 ergocalciferol caps F ea per 365 days retail) ergocalciferol soln F EPINEPHRINE SOAJ 0.3 *** MG/0.3ML KEY-E CHEW F QL(62 ea per 30 days retail) EPIPEN 2-PAK SOAJ (Use *** Epinephrine (Anaphylaxis)) MEPHYTON TABS (Use *** Phytonadione) EPIPEN-JR 2-PAK SOAJ *** phytonadione tabs F Neurogenic Orthostatic Hypotension (NOH) - REPLESTA WAFR F NORTHERA CAPS 100 F PA; QL(3 ea MG, 200 MG daily); SP VITAMIN D3 LIQD F NORTHERA CAPS 300 F PA; QL(6 ea MG daily); SP vitamin e caps 100 unit, F QL(62 ea per Vasopressors 200 unit, 400 unit 30 days retail) VITAMIN E CHEW 400 F QL(62 ea per EPINEPHRINE HCL SOLN *** UNIT 30 days retail) vitamin e soln 50 unit/ml, EPINEPHRINE HCL SOLN F F 1 MG/ML 15 unit/0.3ml epinephrine soln 1 mg/ml *** Water Soluble Vitamins ascorbic acid chew or midodrine hcl tabs F 250mg, 500mg, 250 mg, F 500 mg, 7.5mg-500mg VITAMINS ascorbic acid tabs or QL(100 ea per 500mg, 1000mg, 250 mg, 30 days retail) Oil Soluble Vitamins 500 mg, 1000 mg, 10mg- 500mg, 37mg-500mg, F cholecalciferol caps 1000 F QL(100 ea per unit, 2000 unit fill retail) 37mg-1000mg, 14mg- 25mg-500mg, 25mg-35mg- cholecalciferol caps 400 F unit, 10000 unit 500mg ascorbic acid tbcr or cholecalciferol caps 5000 F QL(2 ea daily) unit 500mg, 500 mg, 16mg- F 25mg-500mg cholecalciferol caps 50000 F QL(8 ea per 30 unit days retail) B-1 TABS F QL(100 ea per 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

161 Drug Requirements/ Drug Name Tier Limits biotin caps F

BIOTIN FORTE TABS F biotin tabs F niacin cpcr 250 mg, 500 F mg niacin tabs 100 mg, 250 F mg, 500 mg niacin tbcr 250 mg, 500 F mg, 750 mg NIACIN TR TBCR F pyridoxine hcl tabs F QL(100 ea per riboflavin tabs F 30 days retail) SLO-NIACIN TBCR (Use *** Niacin) QL(100 ea per thiamine hcl tabs F 30 days retail) QL(100 ea per thiamine mononitrate tabs F 30 days retail)

***GENERIC or alternate product is required Ohio Buckeye Medicaid Updated June 1, 2019

162 Index 1ST BASE 149 ACIDOPHILUS HIGH- ADRENALIN 139 1ST TIER UNIFINE POTENCY 34 ADVAIR DISKUS 22 ACIDOPHILUS PEARLS 34 PENTIPS32GX6MM 123 ADVAIR HFA 22 1ST TIER UNIFINE ACIDOPHILUS PROBIOTIC PENTIPS33GX4MM 123 BLEND 34 ADVANCE INTUITION BLOOD 1ST TIER UNIFINE ACIDOPHILUS SUPER GLUCOSE MONITORING PENTIPSPLUS 33GX4MM 123 PROBIOTIC 34 SYSTEM 117 4-N-1 89 ACIDOPHILUS/CITRUS ADVANCED BASE PLUS 149 ADVANCED 5 DAY 89 PECTIN 36 ACIDOPHILUS/GOAT CALCIUM/VITAMIND/MAGNESI A + D PERSONAL CARE MILK 34 UM 128 LOTION 81 ACIPHEX 157 ADVANCED MOBILE LANCET A+D FIRST AID 89 ACIPHEX SPRINKLE 157 30G 117 abacavir sulfate 52 ADVANCED PROBIOTIC 34 acitretin 77 abacavir sulfate-lamivudine 52 ADVANCED PROBIOTIC 10 34 ACNE MEDICATION 10 71 abacavir sulfate-lamivudine- ADVATE 108 ACNE MEDICATION 5 71 zidovudine 52 ADVIL 4 ABILIFY 52 ACTEMRA 3 ADVIL COLD & SINUS 64 ABILIFY MAINTENA 52 ACTEMRA ACTPEN 3 ADVIL MIGRAINE 4 ABILIFY MYCITE 52 ACTICON 64 ADVOCATE BLOOD GLUCOSE abiraterone acetate 46 ACTIGALL 105 MONITORING SYSTEM 117 ABSORBASE 89 ACTIMARIS WOUND GEL 96 ADVOCATE BLOOD GLUCOSE ABSORICA 71 ACTIMMUNE 48 MONITORING SYSTEM/TALKING 117 ABSTRAL 7 ACTINEL 64 ADVOCATE REDI-CODE+/ acamprosate calcium 152 ACTINEL PEDIATRIC 64 TALKING 117 ACANYA 71 ACTIQ 7 ADVOCATE REDI- acarbose 30 ACTIVE OB 133 CODE/TALKING 117 AEROSPAN 21 ACCOLATE 21 ACTIVELLA 104 AFINITOR 47 ACCU-CHEK AVIVA ACTONEL 102 AFINITOR DISPERZ 47 CONNECT 117 ACTOPLUS MET 30 ACCU-CHEK AVIVA PLUS 117 AFREZZA 32 ACTOPLUS MET XR 30 ACCU-CHEK GUIDE 98 AFRIN 140 ACTOS 32 ACCU-CHEK GUIDE ME 117 AFRIN 12 HOUR 139 ACULAR 145 ACCU-CHEK NANO AFRIN ALL NIGHT SMARTVIEW 117 ACULAR LS 145 NODRIP 139 ACCUPRIL 42 ACUVAIL 145 AFRIN CHILDRENS 139 ACCURETIC 43 ACUWASH 89 AFRIN NASAL SPRAY 140 acebutolol hcl 56 acyclovir 55 AFRIN NODRIP EXTRA ACEON 42 acyclovir topical 77 MOISTURIZING 140 AFRIN NODRIP ORIGINAL140 ADALAT CC 57 acetaminophen 6 AFRIN NODRIP SEVERE acetaminophen w/ codeine 10 adapalene 71 CONGESTION 140 acetaminophen w/ dm 64 ADAPALENE 71 AFRIN NODRIP SINUS 140 acetaminophen-caffeine 5 ADCETRIS 46 AFRIN SINUS 140 acetazolamide 101 ADCIRCA 59 AGAMATRIX JAZZ WIRELESS acetic acid 107 ADDERALL 1 2 117 AGAMATRIX PRESTO 117 acetic acid (otic) 146 ADDERALL XR 1 ACETIC ACID/ALUMINUM adefovir dipivoxil 55 AGGRENOX 109 ACETATE 146 ADEMPAS 59 AGRYLIN 109 acetylcysteine 70 ADMELOG 32 AJOVY 125 ACIDOPHILUS 34 ADMELOG SOLOSTAR 32 AKTIPAK 71 ALBA-DERM 149

Index 1 albendazole 16 alogliptin-metformin hcl 30 amitriptyline hcl 29 ALBENZA 17 alogliptin-pioglitazone 30 AMLACTIN ULTRA 81 ALBOLENE 81 ALOMIDE 145 amlodipine besylate 57 ALBUSTIX 98 ALORA 104 amlodipine besylate-atorvastatin albuterol sulfate 22 alosetron hcl 106 calcium 59 amlodipine besylate-benazepril ALBUTEROL SULFATE ER 22 ALPHA LIPOIC ACID 2 hcl 43 ALCAINE 144 ALPHAGAN P 143 amlodipine besylate-olmesartan alclometasone dipropionate 78 ALPHANATE/VON medoxomil 43 amlodipine besylate- ALCOHOL PADS 123 WILLEBRANDFACTOR COMPLEX/HUMAN 108 valsartan 43 ALCOHOL PREP PADS 123 ALPHANINE SD 108 amlodipine-valsartan- hydrochlorothiazide 43 ALDACTAZIDE 101 alprazolam 19 AMOXAPINE 29 ALDACTONE 102 ALPRAZOLAM INTENSOL19 amoxicillin 147 ALDARA 87 ALPROLIX 108 AMOXICILLIN 147 ALENDRONATE SODIUM 102 ALREX 144 amoxicillin 147 alendronate sodium 102 ALTABAX 74 ALENDRONATE SODIUM 102 amoxicillin & pot ALTACE 42 clavulanate 148 alendronate sodium 102 ALTADERM CREAM amoxicillin-clarithromycin w/ ALER-DRYL 39 BASE 149 lansoprazole 158 ALEVAZOL 74 ALTOPREV 41 AMOXICILLIN/CLAVULANATE POTASSIUM 148 ALEVE 4 alum & mag hydrox- simethicone 16 AMOXICILLIN/CLAVULANATE ALEVE ARTHRITIS 4 ALUMINUM HYDROXIDE 16 POTASSIUM ER 148 alfuzosin hcl 108 amphetamine- aluminum hydroxide 90 ALIGN 34 dextroamphetamine 1 aluminum hydroxide-mag ampicillin 147 ALIGN EXTRA STRENGTH 34 carb 16 AMPICILLIN 147 ALINIA 17 aluminum hydroxide-mag AMPYRA 153 aliskiren fumarate 44 trisil 16 aluminum sulfate & calcium AMRIX 138 ALKERAN 46 acetate 90 ANADROL-50 15 ALLEGRA ALLERGY 39 ALVESCO 21 ANAFRANIL 29 ALLEGRA ALLERGY amantadine hcl 49 CHILDRENS 39 anagrelide hcl 109 AMARYL 33 ALLEGRA-D 12 HOUR ANALPRAM-HC 15 AMBIEN 112 ALLERGY & CONGESTION 64 ANAPROX DS 4 ALLEGRA-D 24 HOUR AMBIEN CR 112 anastrozole 46 ALLERGY & CONGESTION 64 ambrisentan 59 allopurinol 108 ANBESOL MAXIMUM AMCINONIDE 78 STRENGTH 130 almotriptan malate 125 AMEDA TRIPLE ZERO ANCOBON 38 ALOCRIL 145 LANOLIN 90 ANDRODERM 15 ALOE 10000 & AMERGE 125 ANDROGEL 15 PROBIOTICS 34 AMERIDERM ALOE AFTERSUN LOTION 81 PERISHIELD 90 ANDROGEL PUMP 15 ALOE VESTA ANTIFUNGAL74 AMERIGEL WOUND ANDROID 15 ALOE VESTA CLEAR DRESSING 96 ANGELIQ 104 ANTIFUNGAL 74 AMICAR 111 ANORO ELLIPTA 22 ALOE VESTA DAILY amiloride & MOISTURIZER 89 hydrochlorothiazide 101 ANTABUSE 152 ALOE VESTA PROTECTIVE89 amiloride hcl 102 ANTARA 41 ALOE VESTA SKIN aminocaproic acid 111 ANUSOL-HC 16 CONDITIONER 90 amiodarone hcl 20 ANZEMET 37 alogliptin benzoate 32 AMITIZA 106 APEXICON E 78

Index 2 APIDRA 32 AROMASIN 46 ATRAPRO ANTIPRURITIC APIDRA SOLOSTAR 32 ARTHRITIS PAIN HYDROGEL 96 ATRAPRO DERMAL APLENZIN 27 RELIEVING 88 artificial tear ointment 141 SPRAY 96 APOTHESAR 2 150 ATREVIS HYDROGEL 150 artificial tear solution 141 APOTHESAR PLUS 150 ASC LOTIONIZED ATRIPLA 52 APOTHESIL 150 ANTIMICROBIAL SKIN ATROPINE SULFATE 142 apraclonidine hcl 143 CLEANSER 90 ATROVENT HFA 21 aprepitant 38 ascorbic acid 162 AUBAGIO 153 APRISO 106 ASMANEX TWISTHALER 120 AUGMENTED METERED DOSES 21 APTIOM 24 BETAMETHASONE ASMANEX TWISTHALER 14 DIPROPIONATE 78 APTIVUS 52 METERED DOSES 21 AUGMENTIN 148 AQUA GLYCOLIC FACE ASMANEX TWISTHALER 30 CREAM 81 METERED DOSES 21 AUGMENTIN ES-600 148 AQUA GLYCOLIC FACIAL ASMANEX TWISTHALER 60 AUGMENTIN XR 148 CLEANSER 90 METERED DOSES 21 AUVI-Q 161 AQUA GLYCOLIC HAND & ASMANEX TWISTHALER 7 AUXIPRO VANISHING BODYLOTION 81 METERED DOSES 21 CREAM 150 AQUA GLYCOLIC SHAMPOO & ASPERCREME/ALOE 88 AVALIDE 43 BODY CLEANSER 90 aspirin 6 AQUA GLYCOLIC TONER 90 AVANDIA 32 ASPIRIN 6 AQUA LACTEN 81 AVAPRO 42 aspirin 7 AQUADERM AVAR 71 aspirin buffered (cal carb-mag TREATMENT/MOISTURIZER AVAR LS 71 81 carb-mag oxide) 6 aspirin-acetaminophen- AVAR LS CLEANSER 71 AQUAMED 81 caffeine 5 AVEENO ACTIVE NATURALS AQUAPHILIC 81 ASPIRIN-CAFFEINE- DAILY MOISTURIZING BODY AQUAPHOR 81 DIHYDROCODEINE 11 YOGURT 81 AQUAPHOR ADVANCED aspirin-dipyridamole 109 AVEENO ACTIVE NATURALS THERAPY 81 ASSURE ID SAFETY PEN DAILY MOISTURIZING BODY AQUAPHOR ADVANCED NEEDLES 30G X 5/16" 123 YOGURT/APRICO 81 THERAPY BABY 81 ASSURE ID SAFETY PEN AVEENO ACTIVE NATURALS AQUAPHOR LIP REPAIR 90 NEEDLES 31G X 3/16" 123 ECZEMA THERAPY 81 ASTAGRAF XL 129 AVEENO ACTIVE NATURALS AQUORAL 132 ECZEMA THERAPY HAND 82 ARANESP ALBUMIN ASTEPRO 139 AVEENO ACTIVE NATURALS FREE 110 ATABEX OB 133 SKIN RELIEF MOISTURE ARAVA 5 ATACAND 42 REPAIR 82 ARBEM H-COSMETIC 150 ATACAND HCT 43 AVEENO ANTI-ITCH 88 ARBEM LIPOPEN 150 atazanavir sulfate 52 AVEENO BABY CALMING COMFORT BATH 90 ARCALYST 3 ATELVIA 102 AVEENO BABY CLEANSING ARCAPTA NEOHALER 22 atenolol 56 THERAPY MOISTURIZING ARGININE 141 atenolol & chlorthalidone 43 WASH 90 arginine 141 AVEENO BABY ECZEMA ATGAM 129 THERAPY 82 ARICEPT 152 ATIVAN 19 AVEENO DAILY ARIKAYCE 3 atomoxetine hcl 1 MOISTURIZINGSPF 15 82 ARIMIDEX 46 atorvastatin calcium 41 AVEENO INTENSE RELIEF HAND 82 aripiprazole 52 atovaquone 17 AVEENO POSITIVELY ARISTADA 52 atovaquone-proguanil hcl 45 AGELESSFIRMING BODY 82 ARIXTRA 23 ATRAC-TAIN 81 AVEENO POSITIVELY armodafinil 1 AGELESSSKIN ATRALIN 71 STRENGTHENING BODY ARMOUR THYROID 155 CREAM 82

Index 3 AVEENO POSITIVELY B-12 109 BECONASE AQ 139 AGELESSSKIN B-12 1000 110 BELBUCA 14 STRENGTHENING HAND b-complex w/ c & folic CREAM 82 BELLADONNA/OPIUM 156 AVEENO POSITIVELY acid 132 BELSOMRA 113 BABY ANBESOL 130 NOURISHING 24-HOUR ULTRA- BENADRYL ALLERGY 39 HYDRATING 82 BACID 34 BENADRYL ALLERGY AVEENO POSITIVELY BACIGUENT 74 CHILDRENS 39 NOURISHING ANTIOXIDANT BACITRACIN 143 BENADRYL EXTRA INFUSED BODY WASH 90 bacitracin (topical) 74 STRENGTH 76 AVEENO POSITIVELY BENADRYL ITCH RADIANT 82 bacitracin zinc 74 STOPPING 76 AVEENO POSITIVELY bacitracin-poly-neomycin-hc BENADRYL-D ALLERGY & RADIANT60 SECOND IN- 144 SINUS CHILDRENS 64 SHOWER FACIAL 90 bacitracin-polymyxin b 74 benazepril & AVEENO POSITIVELY bacitracin-polymyxin b hydrochlorothiazide 43 RADIANTOVERNIGHT (ophth) 143 benazepril hcl 42 HYDRATING FACIAL MOISTURI 82 baclofen 138 BENEFIBER 114 AVEENO STRESS RELIEF BACTRIM 17 BENEFIBER FOR MOISTURIZING 82 BACTRIM DS 17 CHILDREN 114 AVELOX 105 BACTROBAN 74 BENEFIX 108 AVODART 108 BACTROBAN NASAL 139 BENGAY GREASELESS 88 AVONEX 153 BENGAY ULTRA BAL-CARE DHA 133 STRENGTH 88 AVONEX PEN 153 balsalazide disodium 106 BENICAR 42 AXERT 126 BANZEL 24 BENICAR HCT 43 AXIRON 15 BARACLUDE 55 BENLYSTA 130 AYGESTIN 152 BASAGLAR KWIKPEN 32 BENTYL 156 AYR NASAL DROPS 138 BASE PCCA BENZAC AC WASH 71 AYR NASAL MIST ALLERGY CLARIFYING 150 &SINUS HYPERTONIC BASE W301 150 BENZACLIN 71 SALINE 139 BASIS CLEANSER EXTRA BENZACLIN WITH PUMP 71 AZ CREAM 150 DRY 90 BENZAMYCIN 71 AZASAN 129 BASIS CLEANSER BENZEFOAM 71 NORMAL/DRY 90 AZASITE 143 BASIS CLEANSER BENZEFOAM ULTRA 71 azathioprine 129 SENSITIVE 90 benzocaine (dental) 131 AZEDRA DOSIMETRIC 48 BASIS FACIAL benzocaine-menthol (mouth- AZEDRA THERAPEUTIC 48 MOISTURIZER 90 throat) 131 BASIS OVERNIGHT 90 benzocaine-triclosan 88 azelaic acid 95 BASLE 82 benzonatate 63,64 azelastine hcl 139 BAYER CONTOUR BLOOD benzoyl peroxide 71 azelastine hcl (ophth) 145 GLUCOSE MONITORING BENZOYL PEROXIDE 71 AZELEX 71 SYSTEM 117 benzoyl peroxide 71 AZILECT 50 BAYER CONTOUR LINK 2.4 BENZOYL PEROXIDE 8% 71 AZITHROMYCIN 116 BLOOD GLUCOSE MONITORING SYSTEM 117 BENZOYL PEROXIDE azithromycin 116 BD GLUCOSE 31 CLEANSER 71 AZOLEN TINCTURE 74 BD LATITUDE DIABETES benzoyl peroxide- AZOPT 145 MANAGEMENT erythromycin 71 AZOR 43 SYSTEM 117 benztropine mesylate 49 BD LOGIC BLOOD GLUCOSE BESIVANCE 143 AZULFIDINE 106 MONITOR 117 AZULFIDINE EN-TABS 106 BD PEN NEEDLE/NANO 2ND BETA CARE 82 B-1 162 GEN/32G X 5/32" 123 BETA XMA 82

Index 4 BETADINE 52 BLENDED SUSPENDING BUMEX 101 BETADINE SKIN COMPOUND 148 BUNAVAIL 14 BLEPH-10 143 CLEANSER 52 BUPHENYL 103 BETADINE SURGICAL BLEPHAMIDE 144 BUPRENEX 14 SCRUB 52 BLEPHAMIDE S.O.P. 144 buprenorphine 14 BETAGAN 142 BLOOD GLUCOSE betamethasone dipropionate MONITORINGSYSTEM 117 BUPRENORPHINE 14 (topical) 78 BLOOD GLUCOSE buprenorphine hcl 14 betamethasone dipropionate MONITORINGSYSTEM buprenorphine hcl-naloxone hcl augmented 78 PREMIUM 117 dihydrate 14 betamethasone valerate 78 BLOOD GLUCOSE SYSTEM bupropion hcl 27 BETAPACE 57 PAK 117 bupropion hcl (smoking BETAPACE AF 57 BLOOD GLUCOSE TEST deterrent) 154 STRIPS 98 BETASERON 153 BUPROPION BONE DENSITY HYDROCHLORIDE ER (XL) 27 betaxolol hcl 56 BUILDER 128 buspirone hcl 18 betaxolol hcl (ophth) 142 BONIVA 102 butalbital-acetaminophen 5 BORTEZOMIB 47 bethanechol chloride 159 butalbital-acetaminophen- BETHKIS 3 bosentan 59 caffeine 5 BETIMOL 142 BOSULIF 47 butalbital-acetaminophen- BETOPTIC-S 142 BOUDREAUXS BABY BUTT caffeine w/ codeine 11 SMOOTH DRY SKIN 82 butalbital-aspirin-caffeine 6 BEVACIZUMAB 143 BOUDREAUXS BUTT BATH butalbital-aspirin-caffeine bexarotene 48 BODYWASH & w/cod 11 BEYAZ 60 SHAMPOO 90 butenafine hcl 74 BI-MIX 59 BOUDREAUXS BUTT PASTE 90 BUTISOL SODIUM 112 bicalutamide 46 BP CLEANSING WASH 71 butorphanol tartrate 14 BIDIL 59 BPO 71 BUTRANS 14 BIFERA 110 BPO CREAMY WASH BYDUREON 32 BILTRICIDE 17 COMPLETEPACK 71 BYDUREON PEN 32 BIOHM PROBIOTIC BRAVURA ALL-IN-ONE 150 BYETTA 32 SUPPLEMENT 34 BREO ELLIPTA 22 BIOHM PROBIOTIC BYSTOLIC 56 SUPPLEMENT/VITAMIN C 34 BREVICON-28 60 cabergoline 104 BIONEL 64 BRILINTA 109 CABLIVI 109 BIONEL PEDIATRIC 64 brimonidine tartrate 143 CADUET 59 BIOSPEC DMX 64 BRINEURA 103 CAFERGOT 125 BIOTEL CARE CONNECTED BRISDELLE 154 caffeine citrate 1 BLOOD GLUCOSE BROMFENAC 145 CAL MAG ZINC +D3 128 MONITORING SYSTEM 117 bromfenac sodium CAL-MAG-ZINC-D 128 BIOTENE DRY MOUTH (ophth) 145 MOISTURIZING SPRAY 132 bromocriptine mesylate 49 CAL-MAG-ZINC-D3 128 biotin 163 brompheniramine & CALADRYL 88 BIOTIN FORTE 163 phenyleph 64 CALAMINE 90 bisacodyl 115 brompheniramine & CALAN 57 pseudoeph 64 bisacodyl-peg 3350-pot chloride- CALAN SR 57 sod bicarb-sod chloride 114 BROTAPP DM 64 CALCI-CHEW 127 bismuth subsalicylate 34 BROVANA 22 CALCIONATE 127 bisoprolol & budesonide (inhalation) 21 calcipotriene 77 hydrochlorothiazide 43 budesonide (nasal) 139 bisoprolol fumarate 56 calcitonin (salmon) 102 BUFFERIN 7 BIVIGAM 147 calcitriol 103 bumetanide 101 CALCIUM 127

Index 5 calcium acetate (phosphate CAPZASIN QUICK CARRINGTON MOISTURE binder) 106 RELIEF 88 BARRIER/ZINC 90 CALCIUM CARBONATE 16 CAPZASIN-HP 89 CARTEOLOL HCL 142 calcium carbonate 127 CAPZASIN-P 89 carteolol hcl (ophth) 142 calcium carbonate (antacid) 16 CARA-KLENZ 90 carvedilol 56 calcium carbonate- CARAC 76 carvedilol phosphate 56 cholecalciferol 127 CARAFATE 157 CASODEX 47 calcium carbonate-vitamin d 127 CARBAGLU 103 CASTIVA WARMING 89 calcium carbonate-vitamin d w/ carbamazepine 25 CATAPRES 43 minerals 127 carbamide peroxide (otic) 146 CEDAX 60 CALCIUM CITRATE 127 CARBATROL 25 cefaclor 60 calcium citrate 127 carbidopa 48 CEFACLOR 60 calcium citrate-vitamin d 127 carbidopa-levodopa 49 CEFACLOR ER 60 CALCIUM GLUCONATE 127 CARBIDOPA/LEVODOPA/ENT cefadroxil 60 CALCIUM LACTATE 127 ACAPONE 49 cefdinir 60 carbinoxamine maleate 39 CALCIUM PNV 133 CEFDITOREN PIVOXIL 60 carbonyl iron 111 calcium polycarbophil 114 cefixime 60 carboxymethylcellulose sodium CALCIUM SOFT CHEWS 127 cefpodoxime proxetil 60 CALCIUM/MAGNESIUM/ZINC (ophth) 141 128 carboxymethylcellulose-glycerin cefprozil 60 CALCIUM/MAGNESIUM/ZINC/VI 141 CEFTIBUTEN 60 TAMIN D3 128 CARDIZEM 57 CEFTIN 60 CALNA 133 CARDIZEM CD 57 ceftriaxone sodium 60 CALQUENCE 47 CARDIZEM LA 57 cefuroxime axetil 60 CALTRATE 600+D PLUS CARDURA 43 CELA BASE 150 MINERALS 127 CARDURA XL 108 CELEBREX 4 CAM 82 CAREONE BLOOD GLUCOSE camphor & menthol 76 MONITORING celecoxib 4 camphor-menthol-methyl SYSTEM/PREMIUM 117 CELEXA 28 salicylate 88 CAREONE BLOOD GLUCOSE CELLCEPT 129,130 CANASA 106 MONITORING CELONTIN 26 SYSTEM/VALUE 117 candesartan cilexetil 42 CARETOUCH BLOOD CENTANY 74 candesartan cilexetil- GLUCOSE MONITORING CEPACOL DUAL RELIEF hydrochlorothiazide 43 SYSTEM 117 SORETHROAT SPRAY 131 CAPCOF 64 CARETOUCH BLOOD CEPACOL SORE THROAT131 capecitabine 46 GLUCOSE TEST STRIPS 98 CEPACOL SORE THROAT CAPEX 78 CARIMUNE EXTRA STRENGTH 131 NANOFILTERED 147 CEPACOL SORE THROAT CAPHOSOL 132 carisoprodol 138 MAXIMUM NUMBING 131 CAPMIST DM 64 carisoprodol w/ aspirin 138 cephalexin 60 CAPRELSA 47 carisoprodol w/ aspirin & CEPHALEXIN 60 CAPRON DM 65 codeine 138 CERASPORT 127 CAPSAGEL 88 CARNITOR 103 CERASPORT EX1 127 CAPSAGEL EXTRA CARNITOR SF 103 CERAVE 82 STRENGTH 88 CARRASMART 96 CERAVE AM SPF 30 82 CAPSAGEL MAXIMUM CARRASYN HYDROGEL STRENGTH 88 CERAVE FOAMING FACIAL WOUND DRESSING 96 capsaicin 88 CLEANSER 90 CARRASYN V HYDROGEL CERAVE HYDRATING captopril 42 WOUNDDRESSING 96 CLEANSER 90 CARRINGTON MOISTURE CAPTOPRIL/HYDROCHLOROT CERAVE PM 82 HIAZIDE 43 BARRIER 90 CERAVE RENEWING SA 82

Index 6 CERAVE SA RENEWING 82 CHEMSTRIP-MICRAL 99 CHORIONIC CERDELGA 109 CHENODAL 106 GONADOTROPIN 102 CHRYSADERM DAY 150 CESAMET 37 CHERACOL PLUS 65 CHRYSADERM NIGHT 150 CETAKLENZ 90 CHERACOL SORE ciclopirox 74 CETAPHIL 90 THROAT 131 CETAPHIL DAILY ADVANCE CHERACOL-D COUGH 65 ciclopirox olamine 74 ULTRA HYDRATING 82 CHEW Q 2 cilostazol 109 CETAPHIL DAILY FACIAL CHILDRENS ADVIL 4 CILOXAN 143 MOISTURIZER 82 CHILDRENS MOTRIN 4 cimetidine 156 CETAPHIL DERMACONTROL FOAM WASH 90 CHILDRENS PROBIOTIC CIMETIDINE HCL 156 CETAPHIL DERMACONTROL PEARLS 34 CIMZIA 106 CHLOR-TRIMETON 38 MOISTURIZER/SPF 30 82 cinacalcet hcl 103 CETAPHIL GENTLE CHLOR-TRIMETON CLEANSER 90 ALLERGY 38 CIPRO 105 CETAPHIL MOISTURIZING 82 CHLORASEPTIC 131 CIPRO HC 146 CETAPHIL CHLORASEPTIC SORE CIPRODEX 146 RESTORADERM 82 THROAT/LIQUID ciprofloxacin 105 CENTER 131 CETAPHIL THERAPEUTIC CIPROFLOXACIN 146 HAND 82 chlordiazepoxide hcl 19 cetirizine hcl 39 CHLORDIAZEPOXIDE/AMITRI CIPROFLOXACIN ER 105 cetirizine-pseudoephedrine 65 PTYLINE 153 CIPROFLOXACIN HCL 105 CETRAXAL 146 chlorhexidine gluconate 52 ciprofloxacin hcl 105 chlorhexidine gluconate cevimeline hcl 132 ciprofloxacin hcl (ophth) 143 (mouth-throat) 131 citalopram hydrobromide 28 CHANTIX 154 CHLOROQUINE CHANTIX CONTINUING PHOSPHATE 45 CITRACAL + D3 MAXIMUM 127 MONTHPAK 154 chloroquine phosphate 45 CITRACAL MAXIMUM 127 CHANTIX STARTING MONTH CHLOROTHIAZIDE 102 PAK 154 CITRACAL CHAPSTICK OVERNIGHT 90 chlorothiazide 102 PETITES/VITAMIND 127 CHAPSTICK ULTRA chlorpheniramine & CITRACAL PLUS 128 MOISTUREDAYTIME phenylephrine 65 CITRANATAL 90 DHA 133 chlorpheniramine & FORMULA 90 CITRANATAL ASSURE 133 CHAPSTICK ULTRASMOOTH pseudoeph 65 chlorpheniramine maleate 39 CITRANATAL BLOOM FORTIFY 90 DHA 133 CHAPSTICK ULTRASMOOTH chlorpheniramine- NOURISH 90 acetaminophen 65 CITRANATAL DHA 133 CHAPSTICK ULTRASMOOTH chlorpheniramine- CITRANATAL HARMONY 133 REJUVENATE 90 phenylephrine-acetaminophen CITRANATAL RX 133 65 CHAPSTICK ULTRASMOOTH CITRUCEL 114 SOOTHE 90 chlorpromazine hcl 51 CITRUCEL FIBER CHEK-STIX COMBO PAK CHLORPROPAMIDE 33 URINALYSIS CONTROL 98 LAXATIVE 114 chlorthalidone 102 CHEK-STIX CONTROL 99 CLARINEX 39 CHLORZOXAZONE 138 CHEMET 36 CLARINEX-D 12 HOUR 65 CHOLBAM 105 CHEMSTRIP -10 WITH SG 99 clarithromycin 116 cholecalciferol 162 CHEMSTRIP 10 MD 99 CLARITHROMYCIN 116 cholestyramine 40 CHEMSTRIP 2 GP STRIPS 99 clarithromycin 116 cholestyramine light 40 CHEMSTRIP 5 OB 99 CLARITHROMYCIN 116 CHOLEXMAX 101 CHEMSTRIP 7 99 clarithromycin 116 CHOLEXTRA T/F 101 CHEMSTRIP 9 STRIPS 99 CLARITIN 39 choline & mag salicylate 7 CLARITIN ALLERGY CHEMSTRIP UGK 99 choline fenofibrate 41 CHILDRENS 39 CHEMSTRIP-K 99 CLARITIN CHILDRENS 39

Index 7 CLARITIN REDITABS 39 clindamycin hcl 18 CLOZARIL 51 CLARITIN-D 12 HOUR 65 clindamycin palmitate CO Q-10 2 CLARITIN-D 24 HOUR 65 hydrochloride 18 CO-NATAL FA 133 CLINDAMYCIN CLASSIC PRENATAL 133 PHOSPHATE 72 COAGADEX 108 CLEAN & CLEAR ADVANTAGE clindamycin phosphate coal tar extract 96 3-IN-1 EXFOLIATING (topical) 72 COARTEM 45 CLEANSER 72 clindamycin phosphate CLEAN & CLEAR vaginal 160 cobalamine combinations 110 ESSENTIALSFOAMING FACIAL clindamycin phosphate-benzoyl COCOA BUTTER 82 CLEANSER 91 peroxide 72 COCOA BUTTER HAND & CLEAN & CLEAR FOAMING clindamycin phosphate- BODYLOTION 82 FACIAL CLEANSER SENSITIVE tretinoin 72 COCONUT OIL BEAUTY 82 SKIN 91 CLINDESSE 160 CLEAN & CLEAR MORNING CODEINE SULFATE 7 CLN BODY WASH GENTLE codeine sulfate 7 BURST DETOXIFYING FACIAL NON-DRYING 91 CLEANSER 91 CLN FACIAL CLEANSER coenzyme q10 CLEAN & CLEAR MORNING MOISTURE BALANCING 91 (ubidecarenone) 2 BURST FACIAL CLEANSER91 CLN FACIAL MOISTURIZER COLACE 116 CLEAN & CLEAR MORNING NOURISHING 82 COLACE CLEAR 116 BURST HYDRATING FACIAL CLN HAND & FOOT WASH COLAZAL 106 CLEANSER 91 DEEP CLEANSING 91 CLEAN & CLEAR NIGHT CLN SPORT WASH HIGH colchicine 108 RELAXING DEEP CLEANING PERFORMANCE 91 COLCHICINE 108 FACE WASH 91 CLN SPORTWASH 91 colchicine w/ probenecid 108 CLEANSING EYELID PADS 91 clobazam 24 COLCRYS 108 CLEAR AWAY ONE STEP WARTREMOVER 87 clobetasol propionate 78 COLD & FLU RELIEF CLEAR AWAY PLANTAR clobetasol propionate emollient NIGHTTIME D 65 SYSTEM 87 base 78 COLEMAN 100 MAX INSECT CLEAR AWAY WART clobetasol propionate REPELLENT/CONTINUOUS REMOVER SYSTEM 87 emulsion 78 SPRAY 91 CLEAR COUGH PM MULTI- CLOBEX 78 COLEMAN INSECT SYMPTOM 65 REPELLENT/HIGH & DRY 91 CLOCORTOLONE COLEMAN INSECT PIVALATE 78 clemastine fumarate 39 REPELLENT/SPORTSMEN 91 CLEMASTINE FUMARATE 39 CLOCORTOLONE PIVALATE PUMP 78 colesevelam hcl 40 CLENPIQ 114 CLODAN KIT 78 COLESTID 40 CLEOCIN 17,160 CLODERM 79 COLESTID FLAVORED 40 CLEOCIN PEDIATRIC colestipol hcl 40,41 GRANULES 17 CLODERM PUMP 79 CLEOCIN-T 72 clomipramine hcl 29 COLLATYL 96 CLEVER CHEK BLOOD clonazepam 24 colloidal oatmeal 82 GLUCOSE MONITORING clonidine hcl 43 COLY-MYCIN S 146 SYSTEM 117 COLYTE-FLAVOR PACKS 114 CLEVER CHOICE MICRO clonidine hcl (adhd) 1 BLOODGLUCOSE clopidogrel bisulfate 109 COMBIGAN 142 MONITORING SYSTEM 117 clorazepate dipotassium 19 COMBIPATCH 104 CLICKFINE PEN NEEDLES 31G CLORPRES 43 COMBISTIX 99 X 3/16" 123 COMBIVENT RESPIMAT 22 CLICKFINE PEN NEEDLES 31G clotrimazole 131 X 8MM 123 clotrimazole (topical) 74 COMBIVIR 53 CLICKFINE PEN NEEDLES 32G clotrimazole vaginal 160 COMETRIQ 47 X 5/32" 123 clotrimazole w/ COMFEEL PASTE 96 CLIMARA 104 betamethasone 74 COMFORT EZ MICRO/32G X CLIMARA PRO 104 clozapine 51 4MM 123 CLINDAGEL 72 CLOZAPINE ODT 51 COMFORT EZ SHORT/31G X 8MM 123

Index 8 COMFORT EZ/31G X 5MM 123 CORN REMOVER CVS ADULT 50+ COMFORT EZ/31G X 6MM 123 WATERPROOF 88 PROBIOTIC 34 CORTANE-B AQUEOUS 146 CVS ADULT PROBIOTIC 34 COMPLERA 53 CORTANE-B-OTIC 146 CVS ADVANCED GLUCOSE COMPLETE NATAL DHA 133 CORTEF 63 METER 118 COMPLETENATE 133 CVS ADVANCED GLUCOSE CORTENEMA 15 COMPOUND W 87 METER TEST STRIPS 99 COMPOUND W FREEZE OFF CORTIFOAM 15 CVS CALCIUM WART REMOVAL SYSTEM 87 CORTISONE ACETATE 63 CITRATE+D/MAGNESIUM 128 CVS CLEANSING EYELID COMPOUND W MAXIMUM CORTISPORIN 74 STRENGTH 87 WIPES 91 CORZIDE 43 CVS DAILY ULTRA COMTAN 49 COSOPT 142 MOISTURELOTION 83 COMTREX COLD & COUGH COSOPT PF 142 CVS DIGESTIVE MAXIMUM STRENGTH 65 PROBIOTIC 34 COMTREX COLD & COUGH COTELLIC 47 CVS DISTILLED WATER 148 NIGHTTIME MAXIMUM COUMADIN 23 STRENGTH 65 CVS DRY MOUTH SPRAY 132 COZAAR 42 CONCEPT DHA 133 CVS GLUCOSE 31 CREAM BASE 150 CONCEPT OB 133 CVS INSECT REPELLENT 91 CREAM CONCENTRATE150 CONCERTA 1 CVS ISOPROPYL ALCOHOL CREON 101 WIPES 91 CONDYLOX 87 CRESTOR 41 CVS KETONE CARE 99 CONEX COLD/ALLERGY 65 CVS MANUKA HONEY WOUND CONTOUR BLOOD GLUCOSE CRINONE 161 CRITIC-AID CLEAR GEL 97 MONITORING SYSTEM 117 CVS MOISTURIZING MOISTUREBARRIER 91 CONTOUR NEXT BLOOD CREAM 83 GLUCOSE MONITORING CRIXIVAN 53 CVS MOOD SUPPORT SYSTEM 118 cromolyn sodium 21 PROBIOTIC 34 CONTOUR NEXT BLOOD cromolyn sodium CVS NATURAL FIBER GLUCOSE TEST 99 (mastocytosis) 106 SUPPLEMENT 114 CONTOUR NEXT EZ BLOOD cromolyn sodium (nasal) 139 CVS OMEPRAZOLE 157 GLUCOSE MONITORING SYSTEM 118 cromolyn sodium (ophth) 145 CVS PRENATAL 133 CONTOUR NEXT LINK BLOOD crotamiton 95 CVS PROBIOTIC 34 GLUCOSE MONITORING CULTURELLE ADVANCED CVS PROBIOTIC MAXIMUM SYSTEM 118 IMMUNE DEFENSE 34 STRENGTH 34 CONTOUR NEXT LINK CULTURELLE PRO-WELL34 CVS PROBIOTIC PEARLS WIRELESS BLOOD GLUCOSE CUPRIMINE 129 EXTRA STRENGTH 34 MONITORING SY 118 CVS PURIFIED WATER 148 CONZIP 7 CURAD GERM SHIELD 96 CVS SALINE WOUND COOL BLOOD GLUCOSE CURAFIL GEL WOUND WASH 91 MONITORING KIT 118 DRESSING 96 CVS SENIOR PROBIOTIC 34 CUTIS PLUS 150 COOL BOTTOMS 91 CVS SILVER GEL 97 COPAXONE 153 CUTIVATE 79 CVS TOTAL HOME INSECT COPEGUS 55 CUTTER 91 REPELLENT 91 COPIKTRA 47 CUTTER ALL FAMILY 91 CVS WOMENS PRENATAL+DHA 133 CORDRAN 79 CUTTER BACKWOODS 91 CUTTER BACKWOODS cyanocobalamin 109 COREG 56 DRY 91 CYCLESSA 61 COREG CR 56 CUTTER DRY 91 cyclobenzaprine hcl 138 CORGARD 57 CUTTER SKINSATIONS 91 CYCLOGYL 142 CORICIDIN HBP COLD & CUTTER SPORT 91 FLU 65 CYCLOMYDRIL 143 CORN REMOVER ONE CUVITRU 147 cyclopentolate hcl 143 STEP 88 CUVPOSA 156 cyclophosphamide 46 CYCLOPHOSPHAMIDE 46

Index 9 cycloserine 45 DEMSER 42 desmopressin acetate 104 cyclosporine 130 DENAVIR 78 desmopressin acetate CYCLOSPORINE DENOREX THERAPEUTIC 2- spray 104 MODIFIED 130 IN-1 96 desmopressin acetate spray cyclosporine modified (for DEPAKENE 27 refrigerated 104 DESOGEN 61 microemulsion) 130 DEPAKOTE 27 CYMBALTA 29 desogestrel & ethinyl DEPAKOTE ER 27 cyproheptadine hcl 40 estradiol 61 DEPAKOTE SPRINKLES 27 desogestrel-ethinyl estradiol CYSTAGON 107 DEPEN TITRATABS 129 (biphasic) 61 CYTO-Q MAX 3 DEPO-PROVERA desogestrel-ethinyl estradiol CYTOGAM 147 CONTRACEPTIVE 62 (triphasic) 61 CYTOMEL 155 DEPO-SUBQ PROVERA DESONATE 79 CYTOTEC 158 104 62 desonide 79 DEPO-TESTOSTERONE 15 CYTRA-3 107 DESOWEN 79 DERMABASEOIL IN desoximetasone 79 D-CARE GLUCOMETER WATER 83 KIT/GLUCOSE TEST DESOXYN 1 DERMADROX 91 STRIPS 118 DESQUAM-X WASH 72 DERMAGRAN 91 D-VI-SOL 162 DESVENLAFAXINE ER 29 D.H.E. 45 125 DERMAGRAN HYDROGEL WOUNDDRESSING 97 desvenlafaxine succinate 29 DAILY CONDITIONING DERMAGRAN SKIN TREATMENT 83 DETROL 159 PROTECTANT 92 DETROL LA 159 DAILY MOISTURIZING 83 DERMAGRAN-B DAILY PROBIOTIC 34 HYDROPHILIC WOUND DEX4 31 dalfampridine 153 DRESSING 97 DEX4 FAST ACTING GLUCOSE 31 DALIRESP 21 DERMAIDE ALOE 83 DERMAL THERAPY EXTRA DEX4 NATURALS 31 danazol 15 STRENGTH BODY DEX4 POUCH PACK 31 DANTRIUM 138 LOTION 83 DEX4 QUICK DISSOLVE dantrolene sodium 138 DERMAL THERAPY FACE GLUCOSE 31 dapsone 17 CAREMOISTURIZING dexamethasone 63 LOTION 83 DARAPRIM 45 DERMAL THERAPY FOOT DEXAMETHASONE 63 darifenacin hydrobromide 159 MASSAGE 83 dexamethasone 63 DAURISMO 46 DERMAL THERAPY HAND DEXAMETHASONE 63 DAY TIME MULTI-SYMPTOM ELBOW & KNEE CREAM 83 DEXAMETHASONE COLD/FLU RELIEF 65 DERMAL THERAPY HEEL INTENSOL 63 CARE 83 DAYPRO 4 dexamethasone sodium DERMAREST PSORIASIS 88 phosphate 63 DAYTRANA 1 DERMASYN 97 DEXAMETHASONE SODIUM DDAVP 104 dermatological products, PHOSPHATE 144 DEBROX 146 misc. 89 DEXCHLORPHENIRAMINE DECON-A 65 DERMATOP 79 MALEATE 39 DEXEDRINE 1 deferasirox 36 DERMEND MOISTURIZING DELBASE BRUISE FORMULA 83 DEXILANT 157 COMPOUNDING 150 DERMOPLAST 89 dexmethylphenidate hcl 1,2 DELSTRIGO 53 DERMOPLAST PAIN dextran 70-hypromellose 141 DELSYM 64 RELIEVINGSPRAY 89 dextroamphetamine sulfate 1 DERMOTIC 147 DELSYM COUGH dextromethorphan hbr 64 DESCOVY 53 CHILDRENS 64 dextromethorphan polistirex 64 DEMADEX 101 desipramine hcl 29 dextromethorphan- demeclocycline hcl 155 desloratadine 40 acetaminophen-chlorpheniramine DEMEROL 7 DESLORATADINE ODT 40 65

Index 10 dextromethorphan-doxylamine- diclofenac sodium (topical) 73 diphenhydramine-phenylephrine acetaminophen 65 dicloxacillin sodium 148 66 dextromethorphan-guaifenesin diphenhydramine-phenylephrine- 65,66 dicyclomine hcl 156 acetaminophen 66 dextromethorphan- didanosine 53 diphenhydramine-zinc phenylephrine-acetaminophen DIFF-STAT 34 acetate 76 66 DIFFERIN 72 diphenoxylate w/ atropine 36 dextrose (diabetic use) 31 DIPHENOXYLATE/ATROPINE DIFICID 117 DHEA 83 36 DIFLORASONE DIPROLENE 79 DHS TAR 96 DIACETATE 79 DHS TAR GEL 96 diflorasone diacetate 79 dipyridamole 109 DIAB 97 DIFLUCAN 38 disopyramide phosphate 20 DIAB DAILY CARE 97 DISTILLATA DISTILLED diflunisal 7 WATER 148 DIAB F.D.G. FREEZE- DIGESTIVE ADVANTAGE 34 DRIED 97 DISTILLED WATER 148 DIGESTIVE ADVANTAGE disulfiram 152 DIABETIC TUSSIN LACTOSE DEFENSE COLD/FLU 66 FORMULA 34 DITROPAN XL 159 DIABETIDERM 83 DIGOXIN 59 DIURIL 102 DIABETIDERM FOOT divalproex sodium 27 REJUVENATING 83 digoxin 59 DIABETIDERM HAND & dihydroergotamine DIVIGEL 104 BODY 83 mesylate 125 DMAE 83 DIABETIDERM MASSAGE DILANTIN 26 DML FORTE 83 STIMULATOR 89 DILANTIN INFATABS 26 docosahexaenoic acid 141 DIAMOX 101 DILANTIN-125 26 docusate calcium 116 diaper rash products 81 DILATRATE SR 18 docusate sodium 116 DIASTAT ACUDIAL 24 DILAUDID 7 DOCUSOL MINI 116 DIASTAT PEDIATRIC 24 DILT-XR 58 DOCUSOL PLUS MINI- DIASTIX 99 diltiazem hcl 58 ENEMA 116 DIATHRIVE BLOOD GLUCOSE diltiazem hcl coated beads 58 dofetilide 20 METER 118 DIATHRIVE BLOOD GLUCOSE diltiazem hcl extended release DOLOPHINE 7,8 TEST STRIPS 99 beads 58 DOMEBORO 92 DIATHRIVE GLUCOSE dimenhydrinate 37 donepezil hydrochloride 152 DIMETAPP COLD & CONTROL SOLUTION 118 DORAL 112 DIATHRIVE LANCETS ULTRA ALLERGY 66 THIN 30G 118 DIMETAPP DM COLD & DORZOLAMIDE HCL 145 diazepam 19 COUGH 66 dorzolamide hcl 146 DIMETAPP LONG ACTING DIAZEPAM 19 dorzolamide hcl-timolol COUGH PLUS COLD 66 maleate 142 diazepam 19 DIMETAPP MULTI-SYMPTOM DORZOLAMIDE HCL/TIMOLOL DIAZEPAM 24 COLD & FLU 66 MALEATE 142 diazepam (anticonvulsant) 24 DIMETAPP MULTI-SYMPTOM DOTHELLE DHA 133 COLD RELIEF DIAZEPAM RECTAL GEL 24 CHILDRENS 66 DOVONEX 77 dibucaine 89 dimethicone (topical) 92 doxazosin mesylate 43 dibucaine (rectal) 16 DIOVAN 42 doxepin hcl 29 DICLEGIS 37 DIOVAN HCT 43 DOXEPIN HCL 29 DICLOFENAC EPOLAMINE 73 DIPENTUM 106 doxepin hcl 29 diclofenac potassium 4 diphenhydramine hcl 39 doxepin hcl (antipruritic) 76 diclofenac sodium 4 diphenhydramine hcl DOXEPIN diclofenac sodium (actinic (sleep) 111,112 HYDROCHLORIDE 76 keratoses) 76 diphenhydramine hcl doxercalciferol 103 diclofenac sodium (ophth) 145 (topical) 76 DOXYCYCLINE 95

Index 11 doxycycline (monohydrate) 155 DYMISTA 138 ED A-HIST 66 doxycycline hyclate 155 E.E.S. 400 116 ED BRON GP 66 doxylamine succinate E.E.S. GRANULES 116 ED CHLORPED 39 (sleep) 112 EASY COMFORT LANCETS EDARBYCLOR 43 doxylamine-dm 66 TWIST TOP 118 EDECRIN 102 DRAMAMINE 37 EASY GLIDE PEN NEEDLES EDLUAR 112 DRISDOL 162 33G X 5/32" 124 EASY PLUS BLOOD EDURANT 53 DRISTAN SPRAY 140 GLUCOSE MONITORING efavirenz 53 DRITHO-CREME HP 77 SYSTEM 118 EASY STEP BLOOD EFFER-K 129 dronabinol 37 EFFERVESCENT DROPLET PEN NEEDLES GLUCOSE MONITOR STARTER KIT 118 POTASSIUM/CHLORIDE 129 31GX5MM 124 EFFEXOR XR 29 DROPLET PEN NEEDLES EASY TALK BLOOD 31GX8MM 124 GLUCOSE MONITORING EFFIENT 109 DROPLET PEN NEEDLES 32G SYSTEM/TALKING 118 EFUDEX 76 EASY TOUCH GLUCOSE X 1/4" 124 ELAVIL 29 DROPLET PEN NEEDLES 32G MONITORING SYSTEM 118 X 3/16" 124 EASY TOUCH HEALTHPRO ELDEPRYL 50 DROPLET PEN NEEDLES 32G GLUCOSE MONITORING ELEMENT AUTOCODE X 5/16" 124 SYSTEM 118 SYSTEM 118 DROPLET PEN NEEDLES 32G EASY TOUCH PEN NEEDLE ELESTAT 146 X 5/32" 124 30G X 5/16" 124 EASY TRAK BLOOD eletriptan hydrobromide 126 DROPLET PEN NEEDLES ELIDEL 87 32GX4MM 124 GLUCOSE MONITORING DROPSAFE SAFETY PEN SYSTEM 118 ELIMITE 95 NEEDLES/31G X 5/16" 124 EASYMAX L BLOOD ELIPHOS 106 GLUCOSE SYSTEM 118 DROPSAFE SAFTEY PEN ELIQUIS 23 NEEDLES/31G X 1/4" 124 EASYMAX N BLOOD drospirenone-ethinyl GLUCOSE SYSTEM 118 ELIQUIS STARTER PACK 23 estradiol 61 EASYMAX NG SELF- ELIXOPHYLLIN 22 drospirenone-ethinyl estradiol- MONITORING BLOOD ELLA 62 GLUCOSE SYSTEM 118 levomefolate calcium 61 ELMIRON 107 DROXIA 109 EASYMAX V BLOOD GLUCOSE ELOCON 79 DROXY CREAM 83 SYSTEM/TALKING 118 ELOCTATE 108 DRUG MART UNILET MICRO EASYMAX V2 SELF- THIN LANCETS 33G 118 ELON SKIN REPAIR MONITORING BLOOD SYSTEM 83 DRYSOL 92 GLUCOSE SYSTEM/SPEAKING 118 EMADINE 146 DUAVEE 104 EMBRACE EVO BLOOD DUETACT 30 EASYPLUS R13N SELF- MONITORING BLOOD GLUCOSE MONITORING DUEXIS 4 GLUCOSE SYSTEM 118 KIT 118 DULCOLAX 115 EASYPLUS V SELF- EMBRACE TALK BLOOD GLUCOSE MONITOR 118 DULERA 22 MONITORING BLOOD GLUCOSE EMBRACE TALK BLOOD duloxetine hcl 29 SYSTEM/SPEAKING 118 GLUCOSE MONITORING DUPIXENT 21 EASYPRO BLOOD GLUCOSE SYSTEM 118 DURAGESIC 8 MONITORING SYSTEM 118 EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 99 DURATION 12 HOUR 140 EASYPRO PLUS 118 EMBRACE TALK GLUCOSE DURATION SPRAY 140 EC-NAPROSYN 4 CONTROL SOLUTION DUREZOL 144 EC-NAPROXEN 4 HIGH 118 econazole nitrate 74 EMBRACE TALK GLUCOSE dutasteride 108 CONTROL SOLUTION dutasteride-tamsulosin hcl 108 ECOTRIN MAXIMUM STRENGTH 7 LOW 119 DUTOPROL 43 ECOTRIN REGULAR EMCYT 47 DYAZIDE 101 STRENGTH 7 EMEND 38

Index 12 EMEND TRIPACK 38 EPOGEN 110 ERYPED 400 116 EMETROL 37 epoprostenol sodium 59 ERYTHROCIN STEARATE 117 EMFLAZA 63 EPROSARTAN erythromycin (acne aid) 72 EMGALITY 125 MESYLATE 42 erythromycin (ophth) 143 EPZICOM 53 EMOLIVAN 150 erythromycin base 117 EQ OMEPRAZOLE 157 EMOLLIA-CREME 83 erythromycin EQ PROBIOTIC DIGESTIVE EMOLLIA-LOTION 83 ethylsuccinate 117 SYSTEM SUPPORT 34 ERYTHROMYCIN emollient 83 EQ THERAPEUTIC DRY ETHYLSUCCINATE 117 EMOLLIENT CREAM 150 SKIN 83 escitalopram oxalate 28 EQ THERAPEUTIC EMOLLIENT CREAM ESGIC 6 BASE 150 MOISTURIZING CREAM 83 EQL ADVANCED RECOVERY esomeprazole magnesium 157 EMSAM 27 SKIN CARE 83 ESSENTRA WIPES 9X9" EMTRIVA 53 EQL BODY WASH/SENSITIVE CLEANROOM EMVERM 17 SKIN 92 SUPPLIES/PRESATURATED ENABLEX 159 EQL BODY WASH/SHEA 92 BUTTER 92 estazolam 112 enalapril maleate 42 EQL CLEAR HAND SOAP enalapril maleate & REFILL 92 ESTRACE 104,161 hydrochlorothiazide 43 EQL DAILY PROBIOTIC 34 estradiol 104,105 ENBREL 5 EQL DRY MOUTH ORAL estradiol & norethindrone ENBREL SURECLICK 5 RINSE 132 acetate 104 ENCARE 160 EQL INVIGORATING MAKEUP estradiol vaginal 161 REMOVER ENDARI 109 ESTRING 161 TOWELETTES 92 ESTROPIPATE 105 ENEMEEZ MINI 116 EQL LIQUID HAND SOAP 92 ENEMEEZ PLUS 116 EQL LIQUID HAND SOAP ESTROSTEP FE 61 ENFAMIL ENFALYTE 127 REFILL 92 eszopiclone 112 ENFAMIL EXPECTA 133 EQL MAKEUP REMOVER ethacrynic acid 102 TOWELETTES 92 ethambutol hcl 45 ENGERIX-B 160 EQL MOISTURIZING enoxaparin sodium 23 CREAM 83 ethosuximide 26 EQL OMEPRAZOLE 157 ethynodiol diacet & eth entacapone 49 estrad 61 entecavir 55 EQL PRENATAL FORMULA 133 ETIDRONATE DISODIUM 102 ENVARSUS XR 130 EQL PROBIOTIC COLON etodolac 4 EPANED 42 SUPPORT 34 ETOPOSIDE 48 EPCLUSA 55 EQL SKIN ASTRINGENT 92 EUCERIN 83 EPIDIOLEX 25 EQL ULTRA MOISTURIZING EUCERIN ADVANCED EPIFOAM 79 DAILY LOTION 83 CLEANSING 92 EQUALYTE 127 EPILYT 83 EUCERIN BABY 83 EQUETRO 50 epinastine hcl (ophth) 146 EUCERIN CALMING DAILY ergocalciferol 162 MOISTURIZER 83 EPINEPHRINE 162 ERGOLOID EUCERIN DAILY epinephrine 162 MESYLATES 154 PROTECTION/SPF 30 83 epinephrine ergotamine w/ caffeine 125 EUCERIN INTENSIVE REPAIR 83 (anaphylaxis) 161,162 ERIVEDGE 46 EPINEPHRINE HCL 162 EUCERIN INTENSIVE ERLEADA 47 REPAIRHAND 83 EPIPEN 2-PAK 162 erlotinib hcl 47 EUCERIN ORIGINAL EPIPEN-JR 2-PAK 162 ERTACZO 75 HEALINGSOOTHING EPIVIR 53 REPAIR 83 ERY-TAB 116 EPIVIR HBV 55 EUCERIN PLUS 83 ERYGEL 72 eplerenone 45 EUCERIN PROFESSIONAL ERYPED 200 116 REPAIR RICH FEEL 84

Index 13 EUCERIN SKIN CALMING FANAPT 50 FERROUS GLUCONATE 111 BODYWASH 92 FANAPT TITRATION ferrous sulfate 111 EUCERIN SKIN CALMING PACK 50 FERROUS SULFATE 111 DAILY MOISTURIZING 84 FARESTON 47 EUCERIN SMOOTHING ferrous sulfate 111 FASENRA 21 REPAIRADVANCED FERROUS SULFATE 111 FORMULA 84 FAZACLO 51 ferrous sulfate 111 EURAX 95 fe fum-iron polysacch complex- FERROUS SULFATE 111 EVAC 114 fa-b complex-c-zn-mn-cu 110 fe fumarate-vitamin c-vitamin ferrous sulfate 111 EVAMIST 105 b12-folic acid 110 FERROUS SULFATE 111 EVISTA 103 FEIBA 108 ferrous sulfate 111 EVOCLIN 72 felbamate 26 ferrous sulfate dried 111 EVOTAZ 53 FELBATOL 26 FETZIMA 29 EVOXAC 132 FELDENE 4 FETZIMA TITRATION PACK29 EVZIO 37 felodipine 58 FEXMID 138 EX-LAX 115 FEM-CAL CITRATE 128 fexofenadine hcl 40 EXCEDRIN EXTRA FEMARA 47 STRENGTH 6 fexofenadine-pseudoephedrine EXCEDRIN MENSTRUAL FEMCON FE 61 66 COMPLETE 6 FEMHRT LOW DOSE 104 FIASP 32 EXCEDRIN MIGRAINE 6 FEMRING 161 FIASP FLEXTOUCH 32 EXCEDRIN TENSION FENOFIBRATE 41 FIBERCON 114 HEADACHE 6 fenofibrate 41 FIBRICOR 41 EXCEL-GEL 97 FENOFIBRATE 41 FIFTY50 GLUCOSE METER EXELDERM 75 2.0 119 fenofibrate 41 EXELON 152 FINACEA 95 fenofibrate micronized 41 exemestane 47 finasteride 108 FENOFIBRIC ACID 41 EXFORGE 43 FIORICET 6 FENOPROFEN CALCIUM 4 EXFORGE HCT 43 FIORICET/CODEINE 11 fenoprofen calcium 4 EXJADE 36 FIORINAL 6 FENORTHO 4 EXTAVIA 153 FIORINAL/CODEINE #3 11 fentanyl 8 EXTINA 75 FIRAZYR 109 fentanyl citrate 8 EXTRA-VIRT PLUS DHA 133 FIRDAPSE 45 FENTORA 8 EYE-SCRUB 92 FIRST-LANSOPRAZOLE 157 FEOSOL 111 EYESCRUB 92 FIRST-OMEPRAZOLE 157 FEOSOL BIFERA 110 ezetimibe 42 FIRST-PROGESTERONE VGS FEOSOL NATURAL ezetimibe-simvastatin 40 100 COMPOUNDING KIT 161 RELEASE 111 FIRST-PROGESTERONE VGS EZFE FORTE 133 FER-IN-SOL 111 200 COMPOUNDING KIT 161 FABIOR 72 FERRALET 90 110 FIRVANQ 17 FACTIVE 105 FERRAPLUS 90 110 FITALITE 150 FAGRON LS PLUS 150 FERRETTS 111 FLAGYL 17 FAGRON NATURAL FERRIPROX 37 FLAVOR BLEND 148 CREAM 150 FAGRON SUPREME ferrous fumarate 111 FLAVOR PLUS 148 CREAM 150 ferrous fumarate w/ b12-vit c-fa- FLAVOR SWEET 148 FALESSA 61 ifc 110 FLAVOR SWEET-SF 148 ferrous fumarate-fa-b complex- famciclovir 55 c-zn-mg-mn-cu 110 flavoxate hcl 160 famotidine 156 ferrous fumarate-folic FLEBOGAMMA DIF 147 famotidine-calcium carbonate- acid 110 flecainide acetate 20 magnesium hydroxide 158 ferrous gluconate 111 FLECTOR 74

Index 14 FLEET BISACODYL 115 flurbiprofen sodium 146 FOSAMAX PLUS D 102 FLEET ENEMA 115 flutamide 47 fosamprenavir calcium 53 FLEET ENEMA SIX PACK 115 fluticasone propionate 79 fosinopril sodium 42 FLEET OIL 115 fluticasone propionate fosinopril sodium & FLEET PEDIATRIC 115 (nasal) 139 hydrochlorothiazide 43 fluticasone-salmeterol 22 FOSRENOL 107 FLOLAN 59 fluvastatin sodium 41 FRAGMIN 23 FLOMAX 108 fluvoxamine maleate 28 FREE & CLEAR FOR FLONASE ALLERGY SENSITIVE SKIN 92 RELIEF 139 FML 144 FREEDOM ADAPTADERM 150 FLONASE ALLERGY RELIEF FML FORTE 144 FREEDOM DERMA CHILDRENS 139 FML LIQUIFILM 144 FLONASE SENSIMIST 139 SERUM 150 FOCALGIN 90 DHA 133 FREEDOM DERMA-D 150 FLORA VANCE 34 FOCALGIN CA 133 FREEDOM DERMA-N 150 FLORAJEN ACIDOPHILUS 35 FOCALGIN DSS 110 FREESTYLE FREEDOM 119 FLORAJEN BIFIDOBLEND 35 FOCALIN 2 FREESTYLE FREEDOM FLORAJEN3 35 FOCALIN XR 2 LITE 119 FLORAJEN4KIDS 35 FREESTYLE INSULINX FOLCAL DHA 133 FLOVENT DISKUS 21 BLOODGLUCOSE FOLCAPS OMEGA 3 133 MONITORING SYSTEM 119 FLOVENT HFA 21 FOLGARD 110 FREESTYLE PRECISION NEO FLOXIN OTIC 146 folic acid 110 BLOOD GLUCOSE MONITORING SYSTEM 119 fluconazole 38 folic acid-vitamin b6-vitamin flucytosine 38 FREESTYLE SIDEKICK II b12 110 VALUEPACK 119 fludrocortisone acetate 63 FOLIVANE-OB 133 FROVA 126 FLUMADINE 56 fondaparinux sodium 23 frovatriptan succinate 126 FLUMIST QUADRIVALENT160 FORA G20 BLOOD GLUCOSE fructose-dextrose-phosphoric FLUNISOLIDE 139 MONITORING SYSTEM 119 FORA GTEL BLOOD acid 37 fluocinolone acetonide 79 GLUCOSE MONITORING FUNGOID TINCTURE 75 fluocinolone acetonide SYSTEM/MULTI-FUNCTIONAL FURADANTIN 159 (otic) 147 119 furosemide 102 fluocinonide 79 FORA GTEL BLOOD FUROSEMIDE 102 fluocinonide emulsified base 79 GLUCOSE TEST STRIPS 99 FORA GTEL BLOOD KETONE furosemide 102 FLUOR-A-DAY 128 TEST STRIPS 99 FYCOMPA 24 fluorometholone (ophth) 144 FORA TN'G VOICE BLOOD gabapentin 25 GLUCOSE MONITORING FLUOROPLEX 76 GABITRIL 26 FLUOROURACIL 76 SYSTEM 119 FORA V30A BLOOD GABLOFEN 138 fluorouracil (topical) 76 GLUCOSE MONITORING galantamine hydrobromide 152 FLUOXETINE 154 SYSTEM 119 GALANTAMINE FLUOXETINE DR 28 FORFIVO XL 27 HYDROBROMIDE 153 fluoxetine hcl 28 formaldehyde 52 galantamine hydrobromide 153 FLUOXETINE FORTAMET 30 GALZIN 129 HYDROCHLORIDE 28 FORTEO 102 GAMASTAN 147 fluphenazine decanoate 51 FORTESTA 15 GAMASTAN S/D 147 FLUPHENAZINE HCL 51,52 FORTIFY DAILY GAMIFANT 130 fluphenazine hcl 52 PROBIOTIC 35 GAMMAGARD LIQUID 147 FLURA-DROPS 128 FORTISCARE SELF- GAMMAGARD S/D IGA LESS FLURAZEPAM HCL 112 MONITORING BLOOD THAN 1MCG/ML 147 GLUCOSE SYSTEM 119 GAMMAKED 147 flurbiprofen 4 FOSAMAX 102 FLURBIPROFEN SODIUM 146 GAMMAPLEX 147

Index 15 GAMUNEX-C 147 glipizide 33 glyburide 34 GARDASIL 160 glipizide-metformin hcl 30 glyburide micronized 33 GARDASIL 9 160 GLUCAGEN glyburide-metformin 30 GAS-X 105 DIAGNOSTIC 98 glycerin (laxative) 115 GLUCAGEN HYPOKIT 31 GAS-X EXTRA GLYCERIN ADULT 115 GLUCAGON EMERGENCY STRENGTH 105 glycerin-hypromellose- GASTROCROM 106 KIT 31 GLUCOCARD 01 BLOOD polyethylene glycol 400 141 gatifloxacin (ophth) 143 GLUCOSE MONITORING glycine (gu irrigant) 107 GATTEX 107 SYSTEM 119 glycine diluent 148 GAVISCON 16 GLUCOCARD 01-MINI BLOOD glycopyrrolate 156 GLUCOSE MONITORING GE100 BLOOD GLUCOSE GLYNASE 34 MONITORING SYSTEM 119 SYSTEM 119 GLUCOCARD EXPRESSION GLYSET 30 GELNIQUE 159 AUDIO-ENABLED BLOOD GNP ACIDOPHILUS HIGH GELNIQUE PUMP 159 GLUCOSE POTENCY 35 gemfibrozil 41 MONITORING 119 GNP ADVANCED GENADUR 89 GLUCOCARD SHINE 119 RECOVERY 84 GNP DAILY PRENATAL 133 GENERESS FE 61 GLUCOCARD SHINE CONNEX BLOOD GLUCOSE GNP DAY TIME MUCUS GENOTROPIN 103 MONITORING SYSTEM 119 RELIEFDM 66 GENOTROPIN MINIQUICK103 GLUCOCARD SHINE GNP GENTIAN VIOLET 75 GENTAK 143 EXPRESS BLOOD GLUCOSE GNP GLUCOSE 31 gentamicin sulfate (ophth) 143 MONITORING SYSTEM 119 GNP ISOPROPYL ALCOHOL GLUCOCARD VITAL BLOOD WIPES 92 gentamicin sulfate (topical) 74 GLUCOSE MONITORING GENTEAL MILD 141 SYSTEM 119 GNP OMEPRAZOLE 157 GENTEAL MILD TO GLUCOCARD VITAL BLOOD GNP PRENATAL 133 MODERATE 141 GLUCOSE MONITORING GNP PROBIOTIC COLON GENTEAL SEVERE 141 SYSTEM BLACK 119 SUPPORT 35 GENTEAL TEARS MODERATE GLUCOCARD VITAL BLOOD GNP QUICK DISSOLVE PF 141 GLUCOSE MONITORING GLUCOSE 31 GENTEAL TEARS SYSTEM BLUE 119 GNP SALINE WOUND MODERATEPF 141 GLUCOCARD VITAL BLOOD WASH 92 GENTEEL BUTTERFLY TOUCH GLUCOSE MONITORING GOLD BOND MEDICATED LANCETS 119 SYSTEM PINK 119 BODYLOTION 84 GLUCOCARD X-METER 119 GOLD BOND MEDICATED GENTIAN VIOLET 75 BODYLOTION EXTRA GENTLE 84 GLUCOCOM BLOOD GLUCOSE MONITORING STRENGTH 84 GENVOYA 53 SYSTEM 119 GOLD BOND ULTIMATE 84 GEODON 50 GLUCOCOM BLOOD GOLD BOND ULTIMATE DEEP GERI PROTECT 92 GLUCOSE MONITORING MOISTURE BODY WASH SYSTEM VALUE KIT 119 EXFOLIATING 92 GERI-WASH 92 GLUCONAVII BLOOD GOLD BOND ULTIMATE DEEP GHT BLOOD GLUCOSE GLUCOSEMONITORING MOISTURE BODY WASH MONITORING SYSTEM 119 SYSTEM 119 HEALING 92 GIAZO 106 GLUCOPHAGE 30 GOLD BOND ULTIMATE DEEP GILENYA 153 MOISTURE BODY WASH GLUCOPHAGE XR 31 SENSITIVE/OAT EXT 92 GILOTRIF 47 GLUCOSE 31 GOLD BOND ULTIMATE DEEP ginger (zingiber officinalis) 2 GLUCOSE INSTANT MOISTURE BODY WASH glatiramer acetate 153 ENERGY 31 SOFTENING/SHEA 92 GLEEVEC 47 GLUCOTROL 33 GOLD BOND ULTIMATE GLUCOTROL XL 33 DIABETICS DRY SKIN GLENMAX PEB 66 RELIEF 84 GLEOSTINE 46 GLUCOVANCE 30 GOLD BOND ULTIMATE glimepiride 33 GLUMETZA 31 DIABETICS' DRY RELIEF 84

Index 16 GOLD BOND ULTIMATE GRIS-PEG 38 HEMOCYTE 111 HEALING 84 griseofulvin microsize 38 HEPAGAM B 147 GOLD BOND ULTIMATE OVERNIGHT 84 griseofulvin ultramicrosize 38 heparin sodium (porcine) 23 GOLD BOND ULTIMATE GRX ASC LOTIONIZED HEPSERA 55 PROTECTION 84 ANTIMICROBIAL SKIN HETLIOZ 113 GOLD BOND ULTIMATE CLEANSER 92 RESTORING 84 GRX VITAMIN E 84 HEXALEN 46 GOLD BOND ULTIMATE GRX WOUND 97 HIBICLENS 52 ROUGH& BUMPY SKIN 84 HIGH POTENCY GOLD BOND ULTIMATE guaifenesin 70 PROBIOTIC 35 SHEERRIBBONS guaifenesin-codeine 66 HIPREX 159 PEARLRADIANCE 84 guanfacine hcl 43 HIZENTRA 147 GOLD BOND ULTIMATE guanfacine hcl (adhd) 1 SHEERRIBBONS HM ACIDOPHILUS 35 SILKSOFTNESS 84 GUANIDINE HCL 45 HM EYELID WIPES 92 GOLD BOND ULTIMATE GYNAZOLE-1 160 HM GLUCOSE 31 SOFTENING 84 GYNE-LOTRIMIN 161 GOLD BOND ULTIMATE HM OMEPRAZOLE 157 SOOTHING 84 GYNE-LOTRIMIN 3 161 HM ONE DAILY PRENATAL GOLYTELY 114 HALCION 112 COMBO 133 GOODSENSE CLICKFINE HALDOL DECANOATE HM PRENATAL 133 SAFETY PEN NEEDLE/31G X 100 51 HM ULTICARE SHORT PEN 3/16" 124 HALDOL DECANOATE 50 51 NEEDLES 31GX8MM 124 GOODSENSE GLUCOSE 31 halobetasol propionate 79 homatropine hbr 143 GOODSENSE LANCETS HALOG 79 HORIZANT 154 MICRO-THIN 33G haloperidol 51 HUMALOG 32 UNIVERSAL 120 haloperidol decanoate 51 HUMALOG JUNIOR GOODSENSE LANCETS KWIKPEN 32 ULTRA-THIN 26G haloperidol lactate 51 HUMALOG KWIKPEN 32 UNIVERSAL 120 HARVONI 55 GOODSENSE PEN HUMALOG MIX 50/50 32 NEEDLE/PENFINE HAVRIX 160 HUMALOG MIX 50/50 CLASSIC/31G X 3/16" 124 HCG 102 KWIKPEN 32 GOODSENSE PEN HEAD & SHOULDERS 2IN1 HUMALOG MIX 75/25 32 NEEDLE/PENFINE CLASSIC HUMALOG MIX 75/25 CLASSIC/31G X 5/16" 124 CLEAN/NORMAL 77 KWIKPEN 32 GOODSENSE PEN HEAD & SHOULDERS HUMATE-P 108 NEEDLE/PENFINE CLASSICCLEAN/NORMAL HUMATROPE 103 CLASSIC/32G X 1/4" 124 77 GOODSENSE PEN HEAD & SHOULDERS DRY HUMATROPE COMBO NEEDLE/PENFINE SCALP 2 IN 1 77 PACK 103 CLASSIC/32G X 5/32" 124 HEALTHWISE MICRON PEN HUMIRA 3 GOODSENSE PREMIUM NEEDLES/32G X 5/32" 124 HUMIRA PEDIATRIC CROHNS BLOOD GLUCOSE TEST HEALTHWISE SHORT PEN DISEASE STARTER PACK 3 STRIPS 99 NEEDLES/31G X 3/16" 124 HUMIRA PEN 3 GOODSENSE PREMIUM HEALTHWISE SHORT PEN HUMIRA PEN-CD/UC/HS BLOODGLUCOSE NEEDLES/31G X 5/16" 124 STARTER 3 MONITORING SYSTEM 120 HECTOROL 103 HUMIRA PEN-PS/UV GOODSENSE PRENATAL HELIXATE FS 108 STARTER 3 VITAMINS 133 HEMA-COMBISTIX 99 HUMULIN 70/30 33 GRALISE 154 HEMANGEOL 57 HUMULIN 70/30 KWIKPEN 32 GRALISE STARTER 154 HEMATOGEN FA 110 HUMULIN N 33 granisetron hcl 37 HEMENATAL OB 133 HUMULIN N KWIKPEN 33 GRANIX 110 HEMENATAL OB + DHA 133 HUMULIN R 33 GRAPE SYRUP 149 HUMULIN R U-500 HEMLIBRA 108 GRASTEK 2 (CONCENTRATED) 33

Index 17 HUMULIN R U-500 HYDROGEN PEROXIDE 52 IMITREX STATDOSE KWIKPEN 33 hydromorphone hcl 8 SYSTEM 126 HURRICAINE 131 IMODIUM A-D 36 HYDROMORPHONE HCL 8 HURRICAINE ONE 131 IMODIUM MULTI-SYMPTOM hydromorphone hcl 8 HW EMBRACE PRO BLOOD RELIEF 36 GLUCOSE METER 120 HYDROPHILIC 150 IMURAN 130 HW EMBRACE PRO BLOOD HYDROPHILIC INATAL GT 133 PETROLATUM 150 GLUCOSE TEST STRIPS 99 INCRELEX 103 HW EMBRACE TALK BLOOD HYDROUS EMULSIFIED GLUCOSE MONITOR 120 BASE 150 INCRUSE ELLIPTA 21 HW EMBRACE TALK BLOOD hydroxychloroquine sulfate 45 indapamide 102 GLUCOSE MONITORING HYDROXYPROGESTERONE INDERAL LA 57 SYSTEM 120 CAPROATE 47,60 INDERAL XL 57 HW EMBRACE TALK BLOOD hydroxyprogesterone GLUCOSE TEST STRIPS 99 caproate 152 INDOCIN 4 HY-VEE GLUCOSE 31 hydroxyurea 48 indomethacin 4 HYCAMTIN 48 hydroxyzine hcl 18 INFANATE BALANCE 133 hydralazine hcl 45 HYDROXYZINE INFANTS ADVIL 4 HYDRALYTE 127 PAMOATE 18 INFINITY BLOOD GLUCOSE HYDRALYTE FREEZER hydroxyzine pamoate 18 MONITORING SYSTEM 120 POPS 127 HYOPHEN 158 INFINITY BLOOD GLUCOSE HYDRASYN25 84 MONITORING hyoscyamine sulfate 156 SYSTEM/STARTER KIT 120 HYDRAZONE LOTION 84 HYPERRHO S/D 147 INFINITY VOICE 99 HYDREA 48 HYPERRHO S/D MINI- INFINITY VOICE LEVEL 2 120 HYDRO-LAN 84 DOSE 147 HYPOTEARS 141 INGREZZA 153 HYDROCERIN 92 INLYTA 47 hydrochlorothiazide 102 hypromellose (ophth) 141 HYVEE ADVANCED ANTACID INNOPRAN XL 57 HYDROCIL INSTANT 114 MAXIMUM STRENGTH 16 inositol niacinate 59 HYDROCODONE HYZAAR 43 BITARTRATE/ACETAMINOPHE INOVA 72 N 11 ibandronate sodium 102 INOVA 4/1 ACNE CONTROL hydrocodone w/ IBG STAR BLOOD GLUCOSE THERAPY 72 homatropine 64 MONITORING SYSTEM 120 INOVA 8/2 ACNE CONTROL hydrocodone- IBRANCE 47 THERAPY 72 acetaminophen 11,12 IBUDONE 12 INSPRA 45 hydrocodone-ibuprofen 12 ibuprofen 4 INSULIN LISPRO 33 hydrocortisone 63 ICLUSIG 47 INSULIN LISPRO KWIKPEN 33 hydrocortisone (intrarectal) 15 ICY HOT PAIN RELIEVING INTELENCE 53 hydrocortisone (rectal) 16 GEL 73 INTERMEZZO 112 hydrocortisone (topical) 79 IDHIFA 47 INTRASITE GEL APPLIPAK 97 hydrocortisone acetate IGLUCOSE BLOOD GLUCOSE INTRON A 48 MOITORING SYSTEM 120 (topical) 80 INTRON A W/DILUENT 48 hydrocortisone butyrate 80 ILEVRO 146 INTUNIV 1 hydrocortisone butyrate imatinib mesylate 47 INVEGA 50 hydrophilic lipo base 80 IMBRUVICA 47 INVEGA SUSTENNA 50 hydrocortisone valerate 80 imipramine hcl 29 hydrocortisone w/acetic INVEGA TRINZA 50 imipramine pamoate 29 acid 147 INVIRASE 53 imiquimod 87 hydrocortisone-aloe vera 80 INVOKAMET 30 IMIQUIMOD PUMP 87 HYDROGEL 97 INVOKANA 33 IMITREX 126 HYDROGEL AG 97 IONIL 92 hydrogen peroxide 52 IMITREX STATDOSE REFILL 126 IOPIDINE 143

Index 18 ipratropium bromide 21 JYNARQUE 104 KETOPROFEN 4 ipratropium bromide (nasal)139 K-PHOS 129 KETOPROFEN ER 4 ipratropium-albuterol 22 K-PHOS NEUTRAL 129 ketorolac tromethamine 4 irbesartan 42 K-PHOS NO 2 107 ketorolac tromethamine irbesartan-hydrochlorothiazide K-TAB 129 (ophth) 146 KETOSTIX 99 43 KADIAN 8 IRON 111 ketotifen fumarate (ophth) 146 KALA 36 IRON CHEWS PEDIATRIC 111 KEY-E 162 KALBITOR 109 iron polysaccharide complex-vit KHAPZORY 48 KALETRA 53 b12-folic acid 110 KHEDEZLA 29 IRON SLOW RELEASE 111 KALYDECO 155 KINERET 3 ISENTRESS 53 KANUMA 103 KITABIS PAK 3 ISONIAZID 45 KAPVAY 1 KLARON 72 isoniazid 45 KAYEXALATE 130 KLONOPIN 24 ISOPROPYL ALCOHOL KAZANO 30 KLOR-CON M15 129 WIPES 92 KEFLEX 60 KLOR-CON/25 129 ISOPTO ATROPINE 143 KENALOG 80 ISOPTO CARPINE 143 KENDALL AMORPHOUS KLOUT 95 ISOPTO TEARS 141 HYDROGEL WOUND KLS OMEPRAZOLE 157 ISORDIL TITRADOSE 18 DRESSING 97 KOGENATE FS 109 ISOSORBIDE DINITRATE 18 KEPIVANCE 48 KOGENATE FS BIO-SET 109 isosorbide dinitrate 18 KEPPRA 25 KOMBIGLYZE XR 30 ISOSORBIDE DINITRATE KEPPRA XR 25 KONDREMUL 115 ER 18 KERADAN 84 KONSYL 114 isosorbide mononitrate 18 KERAGEL 97 KONSYL DAILY FIBER 114 isotretinoin 72 KERAGELT 97 KONSYL ORIGINAL isradipine 58 KERALYT 88 FORMULADAILY FIBER 114 ISTALOL 142 KERASAL FUNGAL NAIL KONSYL-D 114 ITCH RELIEF 76 RENEWAL 89 KORLYM 31 KERI ADVANCED MOISTURE ITCH-X 89 KP GENTLE SKIN THERAPY 84 CLEANSER 92 itraconazole 38 KERI BASIC ESSENTIALS84 KP PRENATAL ivermectin 17 KERI LONG LASTING 84 MULTIVITAMINS 133 IXINITY 109 KERI NOURISHING SHEA KPN PRENATAL 133 J & J BURN CREAM 84 BUTTER 84 KRISTALOSE 115 JADENU 37 KERI ORIGINAL 84 KROGER BLOOD GLUCOSE JAKAFI 47 KERI OVERNIGHT 84 MONITORING KIT 120 KROGER GLUCOSE 31 JALYN 108 KERI RENEWAL MILK BODY 84 KROGER PREMIUM BLOOD JANUMET 30 KERI RENEWAL SKIN GLUCOSE MONITORING JANUMET XR 30 FIRMING 84 KIT 120 JANUVIA 32 KERI RENEWAL STRETCH KUVAN 103 MARK MINIMIZER 84 JARDIANCE 33 KYLEENA 62 KERI SENSITIVE SKIN 84 JENTADUETO 30 KYNAMRO 40 KETO-DIASTIX 99 JENTADUETO XR 30 L-METHYL-MC NAC 101 KETOCARE 99 JIVI 109 labetalol hcl 56 ketoconazole 38 JOBST IT STAYS/ROLL-ON 89 LABSTIX 99 ketoconazole (topical) 75 JUBLIA 75 LAC-HYDRIN 84 KETONE TEST STRIPS 99 JULUCA 53 LAC-HYDRIN TWELVE 85 ketoprofen 4 JUXTAPID 42 LACRISERT 141

Index 19 LACTAID 101 LATUDA 50 LICEMD 95 LACTAID FAST ACT 101 LAZANDA 8 LICIDE TREATMENT KIT 95 lactase 101 LDR BLOOD GLUCOSE lidocaine 89 lactated ringer's 127 TRUETEST KIT 120 lidocaine hcl 89 LEADER FINGER CREAM 85 lactated ringer's (irrigation) 130 lidocaine hcl (mouth-throat) 131 LEADER GLUCOSE 31 lactic acid (ammonium lidocaine-prilocaine 89 LEADER QUICK DISSOLVE lactate) 85 lidocaine-transparent LACTINOL HX 85 GLUCOSE 31 LEDIPASVIR/SOFOSBUVIR dressing 89 LACTO-PECTIN 35 55 LIDODERM 89 lactobacillus 35 leflunomide 5 LIDOTREX 97 lactulose 115 LESCOL XL 41 LINDANE 95 lactulose (encephalopathy) 106 LETAIRIS 59 linezolid 18 LADY ESTHER 4 PURPOSE letrozole 47 liniments & rubs 88 FACE CREAM 85 LEUCOVORIN CALCIUM 48 LINZESS 106 LAMICTAL 25 LIORESAL INTRATHECAL 138 LAMICTAL CHEWABLE leucovorin calcium 48 DISPERSIBLE 25 LEUKERAN 46 liothyronine sodium 155 LAMICTAL ODT 25 LEUKINE 110 LIPITOR 41 LAMICTAL XR 25 levalbuterol hcl 22 LIPO CREAM BASE 150 LAMISIL 38 levalbuterol tartrate 22 LIPOFEN 41 LAMISIL ADVANCED 75 LEVAQUIN 105 LIPOPEN ABSORPTION ENHANCING BASE 150 LAMISIL AT 75 LEVBID 156 LIPOPEN ULTRA BASE 150 LAMISIL AT JOCK ITCH 75 LEVEMIR 33 LIPOSOMAL HEAVY 150 LAMISIL AT SPRAY 75 LEVEMIR FLEXTOUCH 33 LIPOSOMAL REGULAR 150 lamivudine 53 levetiracetam 25 LIQ-10 3 lamivudine (hbv) 55 levobunolol hcl 142 lisinopril 42 levocarnitine (metabolic lamivudine-zidovudine 53 lisinopril & lamotrigine 25 modifiers) 103 levocetirizine hydrochlorothiazide 44 LAN-O-SOOTHE 92 dihydrochloride 40 LITETOUCH INSULIN PEN LANAPHILIC 85 NEEDLES/32G X levofloxacin 105 4MM/MINI 124 lanolin 150 levofloxacin (ophth) 143 LITETOUCH PEN NEEDLES LANOLIN ANHYDROUS 150 LEVOMEFOLATE DHA 133 31G X 6MM/ULTRA LANOLIN ANHYDROUS- levonorgestrel & eth SHORT 124 GRX 150 estradiol 61 LITETOUCH PEN LANOLOR 85 levonorgestrel (emergency NEEDLES/31G X oc) 62 5MM/MINI 124 LANOXIN 59 LITETOUCH PEN LANSINOH LANOLIN MINIS levonorgestrel-eth estradiol (triphasic) 61 NEEDLES/31G X NIPPLE 92 8MM/SHORT 124 LANSINOH LANOLIN levonorgestrel-ethinyl estradiol NIPPLE 92 (91-day) 61 LITHIUM 50 levonorgestrel-ethinyl estradiol lithium carbonate 50 lansoprazole 157 (continuous) 61 LITHIUM CARBONATE 50 lanthanum carbonate 107 levorphanol tartrate 8 lithium carbonate 50 LANTISEPTIC SKIN levothyroxine sodium 155 PROTECTANT 92 LITHOBID 50 LEVSIN 156 LANTUS SOLOSTAR 33 LITHOSTAT 108 LEXAPRO 28 LASIX 102 LITTLE NOSES LASTACAFT 146 LEXIVA 53 DECONGESTANTNOSE latanoprost 146 LIALDA 106 DROPS 140 LIBTAYO 46 LITTLE REMEDIES FOR LATANOPROST 146 COLDSMULTI SYMPTOM 67

Index 20 LIVALO 41 LOVAZA 40 magnesium lactate 128 LMX 4 89 LOVENOX 23,24 magnesium oxide 16 LMX 4 PLUS 89 loxapine succinate 51 MAGNESIUM OXIDE 128 LO LOESTRIN FE 61 LUBRIDERM 85 magnesium oxide (mg LOCOID 80 LUBRIDERM ADVANCED supplement) 128 MAGOX 400 128 LOCOID LIPOCREAM 80 THERAPY 85 LUBRIDERM DAILY MAKENA 152 LODINE 4 MOISTURE/NORMAL TO DRY MALARONE 45 LODOSYN 48 SKIN 85 malathion 95 LOESTRIN 1.5/30-21 61 LUBRIDERM DAILY MOISTURESHEA + CALMING MAPROTILINE HCL 27 LOESTRIN 1/20-21 61 LAVENDER JASMINE 85 MARINOL 38 LOESTRIN FE 1.5/30 61 LUBRIDERM INTENSE SKIN MARNATAL-F 134 LOESTRIN FE 1/20 61 REPAIR 85 MARPLAN 27 LOFIBRA 41 LUBRIDERM MENS 3-IN- 1 85 MARQIBO 48 LOHIST-D 67 LUBRIDERM SERIOUSLY MATULANE 48 LOMOTIL 36 SENSITIVE 85 MAVYRET 55 LONGS GLUCOSE 31 LUBRIDERM SKIN NOURISHINGWITH SHEA MAXALT 126 loperamide hcl 36 AND COCOA BUTTERS 85 MAXALT-MLT 126 loperamide-simethicone 36 LUBRISOFT 85 MAXAM 85 LOPID 41 LUCENTIS 143 MAXIDEX 145 lopinavir-ritonavir 53 LUMIGAN 146 MAXITROL 145 LOPRESSOR 56,57 LUMOXITI 46 MAXZIDE 101 LOPRESSOR HCT 44 LUNESTA 112 MAXZIDE-25 101 LOPROX 75 LUXIQ 80 meclizine hcl 37 LOPROX SHAMPOO 75 LYNPARZA 47 MECLOFENAMATE SODIUM 4 loratadine 40 LYRICA 25 MEDELA TENDER CARE loratadine & LYSODREN 47 LANOLIN 85 pseudoephedrine 67 LYSTEDA 111 MEDERMA AG BODY lorazepam 19,20 CLEANSER 92 LORBRENA 47 M-CLEAR WC 67 MEDERMA AG FACE LORTAB 12 M-END PE 67 CREAM 85 M-M-R II 160 MEDERMA AG FACIAL LORZONE 138 CLEANSER 92 losartan potassium 42 M-NATAL PLUS 133 MEDERMA AG FACIAL losartan potassium & M-VIT 134 TONER 93 hydrochlorothiazide 44 MACNATAL CN DHA 134 MEDERMA AG HAND & BODY LOSEASONIQUE 61 MACROBID 159 LOTION 85 LOTEMAX 144 MEDERMA STRETCH MARKS MACRODANTIN 159 THERAPY 85 LOTENSIN 42 mafenide acetate 78 MEDIDERM 150 LOTENSIN HCT 44 MAG-TAB SR 128 MEDIHONEY loteprednol etabonate 145 MAG64 128 WOUND/BURNDRESSING 97 LOTREL 44 MAGNEBIND 300 127 MEDROL 63 LOTRIMIN AF 75 MAGNEBIND 400 128 MEDROL DOSEPAK 63 LOTRIMIN AF FOR HER 75 medroxyprogesterone MAGNESIUM 128 acetate 152 LOTRIMIN AF JOCK ITCH 75 magnesium citrate 115 medroxyprogesterone acetate LOTRIMIN ULTRA 75 MAGNESIUM (contraceptive) 62 LOTRISONE 75 GLUCONATE 128 mefenamic acid 4 LOTRONEX 106 magnesium gluconate 128 mefloquine hcl 45 lovastatin 41 magnesium hydroxide 115 MEFLOQUINE HCL 45

Index 21 MEGA PROBIOTIC 35 METAFOLBIC PLUS 101 methylprednisolone 63 MEGACE ES 152 METAMUCIL 114 METHYLTESTOSTERONE 15 megestrol acetate 47 METAMUCIL MULTIHEALTH METIPRANOLOL 142 megestrol acetate FIBER SINGLES 114 metoclopramide hcl 106 METAMUCIL ORIGINAL (appetite) 152 METOCLOPRAMIDE ODT 106 MEIJER BLOOD GLUCOSE TEXTURE 114 MONITORING KIT 120 METAPROTERENOL metolazone 102 MEIJER CALAMINE 93 SULFATE 22 metoprolol & MEIJER ESSENTIAL BLOOD metaxalone 138 hydrochlorothiazide 44 GLUCOSE MONITORING metformin hcl 31 metoprolol succinate 57 SYSTEM 120 methadone hcl 8 METOPROLOL SUCCINATE MEIJER GLUCOSE 31 ER/HYDROCHLOROTHIAZIDE METHADONE HCL 8 44 MEIJER PREMIUM BLOOD methadone hcl 9 GLUCOSE MONITORING metoprolol tartrate 57 KIT 120 METHADONE HCL 9 METOPROLOL/HYDROCHLOR MEIJER TRUE2GO BLOOD methadone hcl 9 OTHIAZIDE 44 GLUCOSE MONITORING METHADOSE 9 METROCREAM 95 SYSTEM 120 METHADOSE SUGAR- METROGEL 95 MEIJER TRUERESULT BLOOD FREE 9 METROGEL-VAGINAL 161 GLUCOSE MONITORING methamphetamine hcl 1 SYSTEM 120 METROLOTION 95 MEIJER TRUETRACK BLOOD methazolamide 101 metronidazole 17 GLUCOSE MONITORING methenamine hippurate 159 metronidazole (topical) 95 KIT 120 methenamine mandelate 159 metronidazole vaginal 161 MEKINIST 47 methenamine-hyosc-methylene MEXILETINE HCL 20 melatonin 3 blue-benzoic acid-phenyl mexiletine hcl 20 MELATONIN 3 sal 159 methenamine-hyosc-methylene MIACALCIN 102 melatonin 3 blue-sod phos-phenyl sal 159 MICARDIS 42 melatonin-pyridoxine 3 methenamine-hyoscamine- MICARDIS HCT 44 meloxicam 4 methylene blue-sodium MICATIN 75 melphalan 46 phosphate 159 methimazole 155 MICONAZOLE 3 161 memantine hcl 153 METHITEST 15 miconazole nitrate (topical) 75 MENEST 105 methocarbamol 138 miconazole nitrate vaginal 161 MENTAX 75 METHOTREXATE 3 MICONAZOLE NITRATE/ZINC menthol (topical analgesic) 73 methotrexate sodium 46 OXIDE/WHITE menthol-methyl salicylate PETROLATUM 75 (liniments) 88 METHOTREXATE MICRHOGAM ULTRA- MEPERIDINE HCL 8 SODIUM 46 FILTEREDPLUS 147 methotrexate sodium 46 meperidine hcl 8 MICROCYN 97 methoxsalen rapid 77 MEPHYTON 162 MICRODERM BASE 150 methscopolamine meprobamate 18 MICRODOT BLOOD GLUCOSE bromide 156 MONITORING SYSTEM 120 MEPRON 17 METHYCLOTHIAZIDE 102 MICROKLENZ ANTISEPTIC MEPSEVII 103 methylcellulose (laxative) 114 WOUND CLEANSER 97 mercaptopurine 46 methyldopa 43 MICROSOME BASE 150 mesalamine 106 METHYLDOPA/HYDROCHLO MICROZIDE 102 mesalamine w/ cleanser 106 ROTHIAZIDE 44 midazolam hcl 112,113 methylergonovine MESTINON 45 maleate 147 midodrine hcl 162 MESTINON TIMESPAN 45 METHYLIN 2 MIGERGOT 125 META BIOTIC/BIO-ACTIVE methylphenidate hcl 2 miglitol 30 12 35 METHYLPHENIDATE miglustat 109 METADATE CD 2 HYDROCHLORIDE ER 2 MIGRANAL 125

Index 22 MILCO-B-FORTE 133 MONISTAT 7 SIMPLY MUCINEX FAST-MAX COLD MILK OF MAGNESIA CURE 161 FLU& SORE THROAT 67 CONCENTRATE 115 MONISTAT SOOTHING CARE MUCINEX FAST-MAX COLD MILLIPRED 63 ITCH RELIEF 80 FLU& SORE THROAT CLEAR & MONOCLATE-P 109 COOL 67 MINASTRIN 24 FE 61 MONODOX 155 MUCINEX FAST-MAX mineral oil 115 COLD/FLU 67 MONONINE 109 MINIPRESS 43 MUCINEX FAST-MAX SEVERE montelukast sodium 21 COLD 67 MINIVELLE 105 morphine sulfate 9 MUCINEX FAST-MAX SEVERE MINOCIN 155 CONGESTION & COUGH 67 MORPHINE SULFATE 9 minocycline hcl 155 MUCINEX FAST-MAX SEVERE morphine sulfate 9 minoxidil 45 CONGESTION & COUGH MORPHINE SULFATE ER 9 CLEAR & COOL 67 MIRALAX 115 MOTHERS FRIEND 85 MUCINEX FOR KIDS 70 MIRAPEX 49 MOTOFEN 36 MUCINEX MAXIMUM MIRAPEX ER 49 STRENGTH 70 MOTRIN INFANTS DROPS 5 MIRCETTE 61 MUCINEX STUFFY NOSE & MOUTHKOTE 132 COLD CHILDRENS 67 mirtazapine 27 MOVIPREP 114 MULTAQ 20 MIRVASO 95 MOXATAG 148 MULTI MEGA MINERALS 128 misoprostol 158 MULTI PRENATAL 134 MM EASY TOUCH BLOOD MOXEZA 143 GLUCOSE METER 120 moxifloxacin hcl 105 MULTIBASE 150 MM PEN NEEDLES 31G X moxifloxacin hcl (ophth) 143 MULTIGEN 110 3/16" 124 MPD SAFETY LANCET MULTIGEN FOLIC 110 MM PEN NEEDLES 31G X 21G/1.8MM 120 5/16" 124 MULTIGEN PLUS 110 MPD SAFETY LANCET multiple minerals w/ MM PEN NEEDLES 32G X 28G/1.8MM 120 5/32" 124 vitamins 128 MPD SAFETY LANCET MULTISOURCE CALCIUM MOBIC 5 30G/1.8MM 120 MPD SAFETY LANCETS MAGNESIUM & D MOBISYL 88 FORMULA 128 23G/1.8MM 120 modafinil 2 MULTISTIX 100 MS CONTIN 9 MODERIBA 1200 DOSE MULTISTIX 10 SG 99 PACK 55 MSM SKIN LOTION 85 MULTISTIX 5 99 MODERIBA 800 DOSE MUCINEX 70 PACK 55 MUCINEX CHILDRENS COLD MULTISTIX 7 99 moexipril hcl 42 COUGH & SORE MULTISTIX 8 SG 99 moexipril-hydrochlorothiazide THROAT 67 MULTISTIX 9 99 44 MUCINEX CHILDRENS MULTISTIX 9 SG 99 MOI-STIR 132 MULTI-SYMPTOM COLD 67 MUPIROCIN 74 MOISTURE EYES 141 MUCINEX CHILDRENS MULTI-SYMPTOM COLD & mupirocin 74 MOISTURIZING CREAM 85 FEVER 67 mupirocin calcium (topical) 74 MOLINDONE MUCINEX CONGESTION & HYDROCHLORIDE 51 COUGH CHILDRENS 67 MURO 128 146 mometasone furoate 80 MUCINEX COUGH FOR MUSTARGEN 46 mometasone furoate KIDS 67 MX-SOL 149 (nasal) 139 MUCINEX D 67 MX-SOL BLEND 149 MONISTAT 1 COMBO MUCINEX D MAXIMUM MX-SOL BLEND SF 149 PACK 161 STRENGTH 67 MONISTAT 1 DAY OR NIGHT MUCINEX DM 67 MX-SOL SF 149 COMBO PACK 161 MUCINEX DM MAXIMUM MX-SOL SUSPEND 149 MONISTAT 3 161 STRENGTH 67 MYAMBUTOL 45 MONISTAT 3 COMBINATION MUCINEX FAST-MAX COLD & MYCOBUTIN 45 PACK 161 SINUS 67 mycophenolate mofetil 130

Index 23 mycophenolate sodium 130 NASACORT ALLERGY NEOMYCIN/POLYMYXIN/GRAM MYDRIACYL 143 24HR 139 ICIDIN 143 NASACORT ALLERGY 24HR NEOMYCIN/POLYMYXIN/HYDR MYFORTIC 130 CHILDRENS 139 OCORTISONE 145 MYGLUCOHEALTH BLOOD NASAL NEONATAL PLUS 134 GLUCOSE MONITORING DECONGESTANT 140 NEONATAL VITAMIN 134 SYSTEM 120 NASALCROM 139 NEORAL 130 MYLERAN 46 NASCOBAL 110 NEOSPORIN 143 MYLICON 105 NASONEX 139 MYLICON INFANTS GAS NEOSPORIN ECZEMA NAT-RUL PRENATAL ESSENTIALS 85 RELIEF 105 VITAMINS 134 MYNATAL 134 NEOSPORIN GU NATACYN 143 IRRIGANT 107 MYNATAL ADVANCE 134 NATALVIT 134 NEOSPORIN LIP HEALTH MYNATAL PLUS 134 NATAZIA 61 OVERNIGHT RENEWAL THERAPY 93 MYNATAL ULTRACAPLET 134 nateglinide 33 MYNATAL-Z 134 NEOSPORIN ORIGINAL 74 NATELLE ONE 134 NEOSPORIN PLUS PAIN MYNATE 90 PLUS 134 NATROBA 95 RELIEF MAXIMUM MYOFLEX 88 NATRUL PROBIOTIC 35 STRENGTH 74 MYSOLINE 25 NATRUL-CAL 128 NEPHRON FA 110 MYTESI 34 NATURE-THROID 155 NEPTAZANE 101 nabumetone 5 NATURES WASH PLUS 93 NESINA 32 nadolol 57 NEBUPENT 17 NESTABS ABC 134 nadolol & NECON 1/50-28 61 NESTABS DHA 134 bendroflumethiazide 44 NEUAC KIT 72 NADOLOL/BENDROFLUMETHIA NECON 10/11-28 61 ZIDE 44 NEEVO DHA 134 NEULASTA 110 naftifine hcl 75 NEFAZODONE HCL 29 NEULASTA ONPRO KIT 110 NAFTIN 75 nefazodone hcl 29 NEUPOGEN 110 NAIL SCRUB 89 NEFAZODONE NEURONTIN 25 NALFON 5 HYDROCHLORIDE 29 NEUTRAPHOR 93 NALOXONE HCL 37 NEO-SYNALAR 74 NEUTRAPHORUS REX 93 naloxone hcl 37 NEO-SYNEPHRINE COLD & NEUTROGENA BODY LIGHT SINUS EXTRA 140 SESAME FORMULA 85 NALOXONE HCL 37 NEO-SYNEPHRINE COLD & NEUTROGENA DEEP CLEAN naltrexone hcl 37 SINUS MILD 140 FACIAL CLEANSER 93 NAMENDA 153 NEO-SYNEPHRINE COLD & NEUTROGENA FRESH NAMENDA TITRATION SINUS REGULAR 140 FOAMINGCLEANSER 93 PAK 153 NEOKE BCAA4 101 NEUTROGENA HAND 85 NAMENDA XR 153 neomycin sulfate 3 NEUTROGENA NAMENDA XR TITRATION neomycin-bacitracin zn- HAND/NORWEGIANFORMULA/ PACK 153 polymyxin 143 FAST ABSORBING 85 naphazoline w/ neomycin-bacitracin-polymyxin NEUTROGENA HEALTHY pheniramine 144 74 SKIN 85 NAPHCON-A 144 neomycin-bacitracin-polymyxin- NEUTROGENA HEALTHY SKIN pramoxine 74 FACE SPF 15 85 NAPRELAN 5 neomycin-polymy- NEUTROGENA MAKEUP NAPROSYN 5 dexameth 145 REMOVERCLEANSING naproxen 5 neomycin-polymyxin w/ TOWELETTES 93 pramoxine 74 NEUTROGENA MOISTURE naproxen sodium 5 neomycin-polymyxin-hc SENSITIVE SKIN 85 naratriptan hcl 126 (otic) 146 NEUTROGENA ON-THE-SPOT NARCAN 37 neomycin/polymyxin b gu 107 ACNE TREATMENT 72 NARDIL 27 NEOMYCIN/POLYMYXIN B NEUTROGENA T/GEL 96 SULFATES 107

Index 24 NEUTROGENA T/GEL NITYR 103 norgestimate-ethinyl estradiol STUBBORN ITCH NIVA-PLUS 134 (triphasic) 61 CONTROL 96 norgestrel & ethinyl estradiol 62 nevirapine 53 NIVEA 85 NIVEA EXTRA NORINYL 1+35 62 NEXA PLUS 134 ENRICHED 85 NORITATE 95 NEXAVAR 47 NIVEA EXTRA ENRICHED NORPACE 20 NEXCARE WOUND LOTION 85 NORPACE CR 20 CLEANSER 97 NIVEA GENTLE BODY NEXIUM 157 EXFOLIATOR 85 NORPRAMIN 30 NEXIUM 24HR 157 NIVEA LIGHT 86 NORTEMP INFANTS 6 NEXIUM 24HR CLEAR NIVEA ORIGINAL 86 NORTHERA 162 MINIS 157 NIVEA ORIGINAL nortriptyline hcl 30 NIACIN 42 MOISTURE 86 NORTRIPTYLINE HCL 30 niacin 163 NIVEA SOFT 86 NORTUSS-EX 67 niacin (antihyperlipidemic) 42 NIVEA VISAGE 86 NORVASC 58 NIACIN TR 163 NIVEA VISAGE FOAMING FACIAL 93 NORVIR 53 NIACOR 42 NIVEA VISAGE INNER NOURILITE 150 NIASPAN 42 BEAUTY NIGHTTIME NOURIVAN ANTIOX CREAM nicardipine hcl 58 RENEWAL 86 BASE 150 NIVEA VISAGE NOVA MAX BLOOD GLUCOSE NICE DISTILLED WATER 149 MOISTURIZING TONER 93 MONITORING SYSTEM 120 NICODERM CQ 154 NIVESTYM 110 NOVA MAX PLUS KETONE NICORETTE 154 NIX CREME RINSE 95 TESTSTRIPS 100 NOVAFERRUM 125 110 NICORETTE MINI 154 nizatidine 156 NOVAFERRUM 50 111 NICORETTE STARTER NIZATIDINE 156 KIT 154 NOVAREL 102 NIZORAL 75 nicotine 154 NOVOLIN 70/30 33 nicotine polacrilex 154 NIZORAL A-D 75 NOBLE MYSTIQUE BODY NOVOLIN 70/30 FLEXPEN 33 NICOTINE TRANSDERMAL NOVOLIN 70/30 FLEXPEN SYSTEM 154 CLEANSER 93 nonoxynol-9 160 RELION 33 NICOTROL INHALER 154 NOVOLIN 70/30 RELION 33 NICOTROL NS 154 NORCO 12 NORDITROPIN NOVOLIN N 33 nifedipine 58 FLEXPRO 103 NOVOLIN N RELION 33 NILANDRON 47 norelgestromin-ethinyl NOVOLIN R 33 nilutamide 47 estradiol 62 NOVOLIN R RELION 33 norethin acet & estrad-fe 61 nimodipine 58 NOVOLOG 33 NINLARO 47 norethindrone & eth estradiol 61 NOVOLOG FLEXPEN 33 NISEKO HYDRATING FACIAL norethindrone & ethinyl NOVOLOG MIX 70/30 33 85 MOISTURIZER estradiol-fe 61 NOVOLOG MIX 70/30 nisoldipine 58 norethindrone PREFILLED FLEXPEN 33 NISOLDIPINE ER 58 (contraceptive) 63 NOVOLOG PENFILL 33 NITRO-BID 18 norethindrone acet & eth estra 61 NOXAFIL 38 NITRO-DUR 18 norethindrone acetate 152 NOXI-K 150 nitrofurantoin 159 norethindrone acetate-ethinyl NU-GEL COLLAGEN WOUND nitrofurantoin macrocrystal 159 estradiol 104 DRESSING 97 nitrofurantoin monohyd norethindrone acetate-ethinyl NU-MAG 128 macro 159 estradiol-fe 61 NUCYNTA 9 nitroglycerin 18 norethindrone-eth estradiol NUCYNTA ER 9 (triphasic) 61 NITROLINGUAL NUEDEXTA 154 PUMPSPRAY 18 norgestimate-ethinyl estradiol 62 NULYTELY/FLAVOR NITROSTAT 18 PACKS 114

Index 25 NUMOISYN 132 OFF FAMILYCARE SMOOTH ON CALL VIVID BLOOD NUPERCAINAL 16 & DRY 93 GLUCOSE MONITORING OFF SMOOTH & DRY 93 SYSTEM 121 NUPLAZID 50 ofloxacin 105 ON CALL VIVID PAL BLOOD NUTRADERM 86 GLUCOSE METER 121 NUTRADERM ADVANCED ofloxacin (ophth) 143 ondansetron 37 FORMULA 86 ofloxacin (otic) 146 ondansetron hcl 37 NUTRICION PORVIDA 134 OGESTREL 62 ONDANSETRON NUTROPIN AQ NUSPIN OINTMENT BASE 86 HYDROCHLORIDE 37 10 103 olanzapine 51 ONE DROP BLOOD GLUCOSE NUTROPIN AQ NUSPIN MONITORING SYSTEM 121 20 103 olanzapine-fluoxetine hcl 153 ONE DROP BLOOD GLUCOSE NUTROPIN AQ NUSPIN 5 103 olmesartan medoxomil 42 TEST STRIPS 100 NUVARING 62 olmesartan medoxomil- ONE-A-DAY WOMENS amlodipine-hydrochlorothiazide PRENATAL 134 NUVIGIL 2 44 ONETOUCH ULTRA 2 121 NUWIQ 109 olmesartan medoxomil- ONETOUCH ULTRA MINI 121 hydrochlorothiazide 44 NYMALIZE 58 ONETOUCH ULTRALINK nystatin 38 olopatadine hcl 146 SYSTEM (DEC) 121 nystatin (mouth-throat) 131 olopatadine hcl (nasal) 139 ONETOUCH ULTRALINK nystatin (topical) 75 OLUX 80 SYSTEM (HEX) 121 ONETOUCH VERIO 121 nystatin-triamcinolone 75 OLUX-E 80 OLYSIO 55 ONETOUCH VERIO FLEX NYTOL MAXIMUM BLOOD GLUCOSE STRENGTH 112 OMECLAMOX-PAK 158 MONITORING SYSTEM 121 O-CAL FA 134 omega-3 fatty acids 141 ONETOUCH VERIO IQ BLOOD O-CAL PRENATAL 134 omega-3-acid ethyl esters 40 GLUCOSE MONITORING OB COMPLETE ONE 134 SYSTEM 121 omeprazole 157,158 ONETOUCH VERIO SYNC OB COMPLETE PETITE 134 OMEPRAZOLE 158 BLOODGLUCOSE OB COMPLETE PREMIER 134 OMEPRAZOLE + SYRSPEND MONITORING SYSTEM 121 OBSTETRIX DHA 134 SFALKA 157 ONFI 24 OBTREX DHA 134 omeprazole magnesium 158 ONGLYZA 32 OCALIVA 105 omeprazole-sodium ONMEL 38 bicarbonate 158 OCCLUVAN 150 OMNARIS 139 OPANA 9 OCEAN NASAL SPRAY 139 OMNIPOD 5 PACK 120 OPCON-A 144 OCTAGAM 147 OMNIPOD DASH 5 opium tincture 36 octreotide acetate 104 PACK 120 OPSUMIT 59 OCUFLOX 143 OMNIPOD DASH OPTIONS CONCEPTROL OCUSOFT BABY EYELID & SYSTEM 120 VAGINAL EYELASH CLEANSER 93 OMNIPOD STARTER CONTRACEPTIVE 160 OCUSOFT EYELID KIT 120 OPTIONS GYNOL II CLEANSINGPADS 93 OMNIPRED 145 VAGINALCONTRACEPTIVE OCUSOFT LID SCRUB 93 OMNITROPE 103 160 OCUSOFT LID SCRUB ON CALL EXPRESS BLOOD OPTIUM BLOOD GLUCOSE PLUS 93 GLUCOSE MONITORING MONITORING SYSTEM 121 OPTUMRX BLOOD GLUCOSE ODEFSEY 54 SYSTEM 121 ON CALL PLUS BLOOD METER 121 OFEV 155 GLUCOSE METER 121 OPTUMRX BLOOD GLUCOSE OFF ACTIVE 93 ON CALL PLUS BLOOD MONITORING SYSTEM 121 OFF DEEP WOODS 93 GLUCOSE MONITORING ORA-BLEND 149 OFF DEEP WOODS DRY 93 SYSTEM 121 ORA-BLEND SF 149 ON CALL VIVID BLOOD OFF DEEP WOODS ORA-PLUS 149 GLUCOSE METER 121 SPORTSMEN 93 ORA-SWEET 149

Index 26 ORA-SWEET SF 149 oxandrolone 15 PARAGARD INTRAUTERINE ORACEA 95 oxaprozin 5 COPPER CONTRACEPTIVE T380A 62 oral electrolytes 127 oxazepam 20 PAREGORIC 36 ORAL MIX FLAVORED OXAZEPAM 20 paricalcitol 103 SUSPENDING VEHICLE 149 oxcarbazepine 25 ORAL MIX SF 149 PARLODEL 49 OXERVATE 144 ORAL RELIEF SPRAY FOR PARNATE 28 DRYMOUTH & oxiconazole nitrate 75 paromomycin sulfate 3 DISCOMFORT 132 OXISTAT 75 paroxetine hcl 28 ORAL SALINE LAXATIVE 115 OXSORALEN ULTRA 77 paroxetine mesylate ORAL SUSPEND 149 oxybutynin chloride 159 (vasomotor) 154 ORAL SUSPENDING oxycodone hcl 9,10 PASER 45 COMPOUNDPLUS 149 PATADAY 146 ORAL SYRUP FLAVORED OXYCODONE HCL ER 9 VEHICLE 149 OXYCODONE PATANASE 139 ORAL SYRUP SF 149 HYDROCHLORIDE ER 10 PAXIL 28 oxycodone w/ ORALAIR 2 acetaminophen 12 PAXIL CR 28 ORALAIR ADULT SAMPLE oxycodone-aspirin 12 PCCA ALADERM BASE 151 KIT 2 OXYCODONE/ACETAMINOPH PCCA ANHYDROUS LIPODERM ORALAIR ADULT STARTER EN 12 BASE 151 PACK 2 OXYCODONE/IBUPROFEN PCCA BASE 7542 151 ORAMAGIC PLUS 131 13 PCCA BIOPEPTIDE BASE 151 ORAP 154 OXYCONTIN 10 PCCA COSMETIC HRT ORAPRED ODT 63 oxymetazoline hcl 140 BASE 151 ORAVIG 131 oxymorphone hcl 10 PCCA EMOLLIENT CREAM BASE 151 ORENCIA 5 OXYMORPHONE PCCA LIPODERM BASE 151 ORENITRAM 59 HYDROCHLORIDE ER 10 OXYTROL 159 PCCA LIPODERM CUSTOM ORFADIN 103 BASE 151 ORKAMBI 155 OXYTROL FOR WOMEN 159 PCCA MVC BASE 151 orphenadrine citrate 138 oyster shell 127 PCCA NATACREAM 151 ORTHO MICRONOR 63 OZURDEX 145 PCCA PRACASIL TM-PLUS ORTHO TRI-CYCLEN 62 P-SILOXAN DS 151 BASE 151 PA PRENATAL PCCA SWEET-SF 149 ORTHO TRI-CYCLEN LO 62 FORMULA 134 PCCA SYRUP VEHICLE 149 ORTHO-CYCLEN 62 PAIN-A-LAY 131 PCCA VANISHING CREAM ORTHO-NOVUM 1/35 62 paliperidone 50 LIGHT 151 ORTHO-NOVUM 7/7/7 62 PALOMAR E 93 PCCA VANISHING CREAM/LOTION BASE 151 OS-CAL ULTRA 127 PAMELOR 30 PCCA VANPEN BASE 151 oseltamivir phosphate 56 PANCREAZE 101 PCCA-PLUS 149 OSENI 30 PANDEL 80 PCE 117 OSMOPREP 115 PANOXYL 72 PEARLS IC 35 OTEZLA 5 PANOXYL-4 CREAMY OTICIN HC NR 147 WASH 72 PEDIA-LAX 115,116 OTREXUP 3 PANRETIN 76 PEDIALYTE 128 pantoprazole sodium 158 PEDIALYTE ADVANCED OVACE PLUS 77 CARE 128 OVACE PLUS WASH 77 PANZYGA 147 PEDIALYTE FREEZER OVACE WASH 77 PARADIGM LINK BLOOD POPS 128 GLUCOSE MONITOR 121 PEDIALYTE SINGLES 128 OVCON-35 62 PARAFON FORTE DSC 138 OVIDE 96 PEDIAPRED 63 OXANDRIN 15 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 114

Index 27 peg 3350-potassium chloride-sod PH 12 STERILE DILUENT PHILLIPS COLON HEALTH 35 bicarbonate-sod chloride 114 FORFLOLAN 149 PHOS-NAK POWDER PEGANONE 26 PHARMABASE CONCENTRATE 129 PEGASYS 55 ANTIOXIDANT 151 PHOSLYRA 107 PHARMABASE PEGASYS PROCLICK 55 COSMETIC 151 PHOSPHOLINE IODIDE 143 PEGINTRON 55 PHARMABASE COSMETIC PHOTOFRIN 48 PEN-KERA 86 NATURAL 151 PHYTOBASE 151 PENCREAM 151 PHARMABASE HEAVY 151 phytonadione 162 PENDERM 151 PHARMABASE LIGHT 151 PICATO 76 PHARMABASE VAGINAL penicillamine 129 MOISTURIZING 151 PICODERM 151 penicillin v potassium 148 PHARMACIST CHOICE PIFELTRO 54 PENICILLIN V ALCOHOL PRED PADS 93 pilocarpine hcl 143 POTASSIUM 148 PHARMACIST CHOICE pilocarpine hcl (oral) 132 penicillin v potassium 148 AUTOCODE BLOOD pimecrolimus 87 PENLAC NAIL LACQUER 76 GLUCOSE MONITORING SYSTEM 121 PIMOZIDE 154 PENSOMAL CREAM 151 phenazopyridine hcl 108 pindolol 57 PENTAPHENE BASE 151 phenelzine sulfate 28 pioglitazone hcl 32 pentazocine w/ naloxone 14 phenobarbital 112 pioglitazone hcl-glimepiride 30 pentoxifylline 109 phenol (antiseptic) 131 pioglitazone hcl-metformin PENTRAVAN 86 phenylephrine hcl 140 hcl 30 PENTRAVAN PLUS 86 phenylephrine hcl (ophth) 144 piroxicam 5 PEPCID 157 phenylephrine hcl (oral) 140 PLAN B ONE-STEP 62 PEPCID AC 156 phenylephrine w/ PLAQUENIL 45 PEPCID AC MAXIMUM acetaminophen 67 PLAVIX 109 STRENGTH 156 phenylephrine w/ dm-gg 67 PLEGRIDY 153 PEPCID COMPLETE 158 phenylephrine-acetaminophen- PLEGRIDY STARTER PEPTO BISMOL 35 guaifenesin 68 PACK 153 PEPTO-BISMOL 35 phenylephrine- PNA-HRT BASE 151 PEPTO-BISMOL brompheniramine-dm 68 phenylephrine-chlorphen-dm PNEUMOVAX 23 160 INSTACOOL 35 PNEUMOVAX 23/1 DOSE 160 PEPTO-BISMOL MAX 68 STRENGTH 35 phenylephrine- PNV FERROUS chlorpheniramine-dm w/ FUMARATE/DOCUSATE/FOLIC PEPTO-BISMOL TO-GO 35 apap 68 ACID 134 PERCOCET 13 phenylephrine-dm 68 PNV FOLIC ACID + IRON PERFORMAX SALT phenylephrine-dm-gg w/ MULTIVITAMIN 134 SUPPORTIVEBASE 151 apap 68 PNV OB+DHA 134 PERFOROMIST 22 phenylephrine-doxylamine- PNV PRENATAL PLUS PERI-WASH 93 dextromethorphan- MULTIVITAMIN 134 PERIDEX 131 acetaminophen 68 PNV TABS 29-1 134 phenylephrine-guaifenesin 68 perindopril erbumine 42 PNV-DHA 134 phenylephrine-shark liver oil- PNV-DHA+DOCUSATE 134 permethrin 96 cocoa butter 15 perphenazine 52 phenylephrine-shark liver oil- PNV-OMEGA 134 PERPHENAZINE/AMITRIPTYLIN mineral oil-petrolatum 15 PNV-SELECT 134 E 153 PHENYLEPHRINE/GUAIFENE PNV-TOTAL 134 SIN 68 PERRY PRENATAL 134 PNV-VP-U 134 PHENYLHISTINE DH 68 PETROLATUM 86 POCKETCHEM EZ BLOOD PETROLEUM JELLY LIP PHENYTEK 26 GLUCOSE MONITORING TREATMENT 93 phenytoin 26 SYSTEM 121 PEXEVA 28 phenytoin sodium podofilox 88 PFCB 151 extended 26 poison ivy treatments 95

Index 28 POLYCOSE 141 PRAVACHOL 41 PRENATAL LOW IRON 135 polyethylene glycol 3350 115 pravastatin sodium 41 PRENATAL MULTI +DHA 135 polyethylene glycol-propylene praziquantel 17 PRENATAL glycol (ophth) 141 prazosin hcl 43 MULTIVITAMIN 135 polymyxin b-trimethoprim 144 PRENATAL MULTIVITAMIN + PRE-NATAL FORMULA 135 polysaccharide iron DHA 135 complex 111 PRECISION LINK 121 PRENATAL MULTIVITAMIN POLYSPORIN 74 PRECISION XTRA 121 PLUS DHA 135 PRENATAL ONE DAILY 135 POLYTRIM 144 PRECOSE 30 PRENATAL PLUS 135 polyvinyl alcohol 141 PRED FORTE 145 polyvinyl alcohol-povidone PRED MILD 145 PRENATAL PLUS IRON 135 (ophth) 141 PRED-G 145 PRENATAL VITAMIN 136 PRENATAL VITAMIN & POMALYST 47 PRED-G S.O.P. 145 PONSTEL 5 MINERAL 136 PREDATOR 89 PRENATAL pot & sod citrates w/citric VITAMIN/IRON 136 ac 107 prednicarbate 80 pot phosphate monobasic w/ sod PREDNICARBATE 80 PRENATAL VITAMINS 136 phosphate dibasic & prednisolone 63 PRENATAL VITAMINS PLUS LOW IRON 136 monobasic 129 PREDNISOLONE 63 potassium & sodium PRENATAL+DHA 136 phosphates 129 PREDNISOLONE ACETATE 145 PRENATAL-U 136 potassium bicarb & chloride129 PREDNISOLONE ACETATE P- PRENATE DHA 136 potassium bicarbonate 129 F 145 PRENATE ENHANCE 136 potassium chloride 129 prednisolone sodium PRENATE ESSENTIAL 136 phosphate 63 POTASSIUM CHLORIDE PRENATE PIXIE 136 ER 129 PREDNISOLONE SODIUM potassium chloride PHOSPHATE 145 PRENATE RESTORE 136 microencapsulated crystals PREDNISONE 63 PREORBOTIC 35 er 129 prednisone 63 PREPARATION H 15 potassium citrate PREDNISONE 63 PREPARATION H TOTABLES (alkalinizer) 107 PREDNISONE INTENSOL 63 PAIN RELIEF 16 potassium citrate-citric acid 107 PREPLUS 136 POTASSIUM PREFERAOB ONE 135 CITRATE/SODIUMCITRATE/CIT PREFERRED PLUS PREPOPIK 114 RIC ACID 107 GLUCOSE 31 PRETAB 136 POTIGA 25 PREGNYL W/DILUENT PRETTY FEET & HANDS 86 BENZYLALCOHOL/NACL 10 povidone-iodine 52 2 PREVACID 158 PR NATAL 400 134 PREMARIN 105,161 PREVACID 24HR 158 PR NATAL 400 EC 134 PREMPHASE 104 PREVACID SOLUTAB 158 PR NATAL 430 135 PREMPRO 104 PREVIDENT 5000 BOOSTER PLUS 131 PR NATAL 430 EC 134 PRENAISSANCE 135 PREVIDENT 5000 DRY PRADAXA 24 PRENAISSANCE PLUS 135 MOUTH 131 pramipexole dihydrochloride 49 PRENATABS RX 135 PREVIDENT 5000 ORTHO DEFENSE 131 pramoxine hcl (rectal) 16 PRENATAL 135,136 PREVIDENT 5000 PLUS 131 pramoxine-calamine 89 PRENATAL + DHA 135 PREVIDENT FLUORIDE 131 pramoxine-hc-chloroxylenol PRENATAL 19 135 147 PREVIDENT RINSE 131 PRENATAL AND IRON 135 pramoxine-phenylephrine- PREVNAR 13 160 PRENATAL COMPLETE 135 glycerin-petrolatum 15 PREVPAC 158 pramoxine-zinc acetate 89 PRENATAL FORMULA A- PREZCOBIX 54 PRANDIN 33 FREE 135 PREZISTA 54 prasugrel hcl 109 PRENATAL FORTE 135

Index 29 PRIFTIN 45 PROBUPHINE IMPLANT propylthiouracil 155 PRILOSEC 158 KIT 14 PROSCAR 108 PROCARDIA 58 PRILOSEC OTC 158 PROSHIELD PLUS SKIN PROCARDIA XL 58 primaquine phosphate 45 PROTECTANT 93 PROCENTRA 1 PROSTEON 128 PRIMAQUINE PHOSPHATE 45 prochlorperazine 52 PROTONIX 158 primidone 25 prochlorperazine maleate 52 PROTOPIC 87 PRIMLEV 13 PROCRIT 110 protriptyline hcl 30 PRIMSOL 17 PROCTOCORT 16 PROTYL AG 97 PRINIVIL 42 PROCTOFOAM 16 PROVAD 36 PRISTIQ 29 PRODIGEN 36 PROVENGE 46 PRIVIGEN 147 PRODIGY AUTOCODE PRO VOICE V8 BLOOD PROVENTIL HFA 22 BLOOD GLUCOSE PROVERA 152 GLUCOSE MONITORING MONITORING SYSTEM 121 SYSTEM 121 PRODIGY AUTOCODE PROVIDA OB 136 PRO VOICE V8/V9 BLOOD BLOOD GLUCOSE PROVIGIL 2 GLUCOSE TEST STRIPS 100 MONITORING/TALKING 121 PROZAC 28 PRO VOICE V9 BLOOD PRODIGY POCKET BLOOD GLUCOSE MONITORING GLUCOSE METER KIT 121 PRUDOXIN 76 SYSTEM 121 PRODIGY VOICE BLOOD pseudoephed-bromphen-dm 68 PRO-BIOTIC BLEND 35 GLUCOSE METER KIT 121 pseudoephedrine hcl 140 PRO-FLORA IMMUNE 35 PROFE 111 pseudoephedrine w/ codeine- PRO-RED AC 68 progesterone micronized 152 gg 68 PROAIR HFA 22 PROGLYCEM 31 pseudoephedrine w/ dm-gg 69 probenecid 108 PROGRAF 130 pseudoephedrine-chlorphen-dm 69 PROBIOMAX DAILY DF 35 PROLENSA 146 pseudoephedrine-guaifenesin PROBIOTIC 35 PROLEUKIN 48 69 PROBIOTIC & ACIDOPHILUS PROMACTA 110 pseudoephedrine-ibuprofen 69 FORMULA EXTRA promethazine & PSORCON 80 STRENGTH 35 phenylephrine 68 psyllium 114 PROBIOTIC + OMEGA-3 35 promethazine hcl 40 PTS PANELS KETONE PROBIOTIC ACIDOPHILUS 35 promethazine w/codeine 68 TEST 100 PROBIOTIC ACIDOPHILUS PULMICORT 21 BEADS 35 promethazine-dm 68 PROBIOTIC ADVANCED promethazine-phenylephrine- PULMICORT FLEXHALER 21 ULTRAPOTENCY 35 codeine 68 PULMOZYME 155 PROBIOTIC COLON PROMETHAZINE/PHENYLEP PURACYN PLUS DUO- SUPPORT 35 HRINE 68 CARE 97 PROBIOTIC PROMETHAZINE/PHENYLEP HRINE/CODEINE 68 PUREFE OB PLUS 136 COMPLEX/ACIDOPHILUS 35 PURIFIED WATER 149 PROBIOTIC DAILY 35 PROMETRIUM 152 PROBIOTIC GOLD EXTRA propafenone hcl 20 PURILON 97 STRENGTH 35 PROPANTHELINE PURIXAN 46 PROBIOTIC MATURE BROMIDE 156 PURPOSE GENTLE CLEANING ADULT 35 proparacaine hcl 144 WASH 93 PROBIOTIC PEARLS 35 propranolol hcl 57 PUSH BUTTON SAFETY LANCETS 28G 121 PROBIOTIC PEARLS PROPRANOLOL HCL 57 ADVANTAGE 35 PX DAYTIME MULTI- PROBIOTIC+TURMERIC propranolol hcl 57 SYMPTOM 69 EXTRACT 35 PROPRANOLOL/HYDROCHL PX GLUCOSE 31 PROBIOTIC-10 35 OROTHIAZIDE 44 PX NITETIME MULTI- PROBIOTIC-10 ULTIMATE 35 propylene glycol (ophth) 141 SYMPTOM 69 propylene glycol-glycerin 141 PX OMEPRAZOLE 158

Index 30 PX PRENATAL RA LICE SOLUTION KIT 96 REBINYN 109 MULTIVITAMINS 136 RA MAKEUP REMOVER RECOMBINATE 109 PX PURIFIED WATER 149 EYELIDWIPES XL 93 RECOMBIVAX HB 160 PYLERA 158 RA OMEPRAZOLE 158 RECTIV 16 pyrantel pamoate 17 RA ONE DAILY 136 REESES PINWORM pyrazinamide 46 RA OYSTER SHELL MEDICINE 17 pyrethrins-piperonyl butoxide96 CALCIUM/VITAMIN D 127 REFENESEN CHEST pyrethrins-piperonyl butoxide- RA PRENATAL 136 CONGESTION & PAIN RELIEF permethrin-nit remover 96 RA PRENATAL PE 69 PYRIDIUM 108 FORMULA/FOLICACID 136 REFRESH CLEANSER 93 RA PROBIOTIC COLON REFRESH LIQUIGEL 141 pyridostigmine bromide 45 CARE 36 pyridoxine hcl 163 RA PROBIOTIC REFRESH OPTIVE 141 pyrithione zinc 77 COMPLEX 36 REFRESH OPTIVE RA PROBIOTIC DIGESTIVE SENSITIVE 141 Q-DERM 151 SUPPORT 36 REFRESH REPAIR 141 QC CALAMINE 93 RA PROBIOTIC MAXIMUM REFRESH TEARS 141 QC PRENATAL 136 STRENGTH 36 REFUAH PLUS BLOOD RA RENEWAL ADVANCED QH 3 GLUCOSEMONITORING HEALING 93 QNASL 139 RA RENEWAL DRY SKIN SYSTEM 122 QUALAQUIN 45 THERAPY 86 REGENECARE 97 QUARTETTE 62 RA SALINE WOUND REGLAN 106 WASH 93 QUAZEPAM 113 REGRANEX 97 RA TRUE2GO BLOOD REHYLA HAIR + BODY QUDEXY XR 25 GLUCOSEMONITORING CLEANSER 93 QUESTRAN 41 SYSTEM 121 REHYLA WASH 94 QUESTRAN LIGHT 41 RA TRUERESULT BLOOD GLUCOSE MONITOR 121 REJUVACARE PLUS 151 quetiapine fumarate 51 rabeprazole sodium 158 RELENZA DISKHALER 56 QUICKTEK 121 RADIAGEL 97 RELION CONFIRM BLOOD QUILLIVANT XR 2 RADIAGUARD GLUCOSE MONITORING quinapril hcl 42 ADVANCED 86 SYSTEM 122 quinapril-hydrochlorothiazide RADIAPLEXRX 97 RELION GLUCOSE 31 44 RAGWITEK 2 RELION KETONE 100 quinidine gluconate 20 raloxifene hcl 103 RELION KETONE TEST QUINIDINE SULFATE 20 STRIPS 100 ramipril 42 RELION MICRO BLOOD quinine sulfate 45 RANEXA 18 GLUCOSE MONITORING QVAR 21 ranitidine hcl 157 SYSTEM 122 QVAR REDIHALER 22 RELION PREMIER BLOOD ranolazine 18 GLUCOSE TEST STRIPS 100 R-NATAL OB 136 RAPAFLO 108 RELION PREMIER COMPACT RA ADVANCED HEALING 86 RAPAMUNE 130 BLOOD GLUCOSE RA CRYSTAL LAKE rasagiline mesylate 50 MONITORING SYSTEM 122 DISTILLEDWATER 149 RELION ULTIMA BLOOD RA DAYLOGIC ACNE RASUVO 3 GLUCOSE MONITORING FOAMINGWASH MAXIMUM RAZADYNE 153 SYSTEM 122 STRENGTH 72 RAZADYNE ER 153 RELPAX 126 RA DAYLOGIC HEALING DRY REBETOL 55 REMEDY 4-IN-1 BODY SKIN THERAPY 86 CLEANSER/FOAMER 97 REBIF 154 RA DRY MOUTH 132 REMEDY CLEAR-AID 94 RA GENTLE SKIN CREAM 86 REBIF REBIDOSE 153 REMEDY FOAMING BODY RA GLUCOSE 31 REBIF REBIDOSE CLEANER/OLIVAMINE 94 RA ISOPROPYL ALCOHOL TITRATIONPACK 154 REMEDY NUTRASHIELD 94 REBIF TITRATION PACK154 WIPES 93 REMEDY SKIN REPAIR 94

Index 31 REMERON 27 REXULTI 52 rivastigmine 153 REMERON SOLTAB 27 REYATAZ 54 rivastigmine tartrate 153 REMICADE 106 RHINOCORT AQUA 139 RIXUBIS 109 REMODULIN 59 RHOGAM ULTRA-FILTERED rizatriptan benzoate 126 REMOVE ADHESIVE PLUS 147 ROBAXIN 138 RHOPHYLAC 147 REMOVER 89 ROBAXIN-750 138 RENACIDIN 107 RIBASPHERE 55 ROBINUL 156 RENAGEL 107 RIBASPHERE RIBAPAK 55 ROBINUL FORTE 156 RENVELA 107 ribavirin (hepatitis c) 55 ROBITUSSIN CHILDRENS repaglinide 33 riboflavin 163 COUGH & COLD CF 69 REPAGLINIDE/METFORMIN RID 96 ROBITUSSIN CHILDRENS HYDROCHLORIDE 30 RID COMPLETE LICE COUGH LONG-ACTING 64 REPEL FAMILY 94 ELIMINATION 96 ROBITUSSIN CHILDRENS REPEL FAMILY DRY 94 RID ESSENTIAL LICE COUGH/COLD LONG- ACTING 69 REPEL HUNTERS ELIMINATION KIT 96 RIDAURA 3 ROBITUSSIN LINGERING FORMULA 94 COLDLONG-ACTING REPEL SPORTSMEN 94 rifabutin 46 COUGHGELS 64 REPEL SPORTSMEN DRY 94 RIFADIN 46 ROBITUSSIN NIGHTTIME REPEL SPORTSMEN MAX 94 RIFAMATE 45 COUGH LONG-ACTING DM CHILDRENS 69 REPHRESH PRO-B 36 rifampin 46 ROBITUSSIN PEAK COLD REPLESTA 162 RIFATER 45 COUGH+ CHEST CONGESTION REPREXAIN 13 RIGHT STEP DM MAX STRENGTH 69 REQUIP 49 PRENATAL 136 ROBITUSSIN PEAK COLD RIGHTEST GM100 BLOOD DM 69 REQUIP XL 49 GLUCOSE MONITORING ROBITUSSIN PEAK COLD RESCRIPTOR 54 SYSTEM 122 MULTI-SYMPTOM COLD 69 RESCULA 146 RIGHTEST GM300 BLOOD ROBITUSSIN TO GO COUGH GLUCOSE MONITORING &COLD CF 69 RESPAIRE-30 69 SYSTEM 122 ROC DEEP WRINKLE RESTA 86 RIGHTEST GM550 BLOOD SERUM 86 RESTA LITE 86 GLUCOSE MONITORING ROC MAX RESURFACING RESTA WOUND SYSTEM 122 FACIAL CLEANSER 94 CLEANSER 97 RILUTEK 140 ROC MULTI CORREXION 5 IN1 RESTASIS 144 riluzole 140 RESTORING EYE CREAM 86 ROC MULTI CORREXION 5 IN1 RESTASIS MULTIDOSE 144 rimantadine hydrochloride 56 RESTORING NIGHT RESTORA 36 RISABAL-PH 86 CREAM 86 RESTORE HYDROGEL RISACAL-D 127 ROC RETINOL CORREXION 86 DRESSING 97 RISAMINE 94 RESTORIL 113 ROC RETINOL CORREXION RISAQUAD 36 RETIN-A 72,73 MAX 86 RISAQUAD-2 36 ROC RETINOL CORREXION RETIN-A MICRO 73 risedronate sodium 102 NIGHT 86 RETIN-A MICRO PUMP 73 ROC RETINOL CORREXION RISPERDAL 50 RETROVIR 54 SENSITIVE EYE 86 RISPERDAL CONSTA 50 ROC RETINOL CORREXION REVATIO 59 RISPERDAL M-TAB 50 SENSITIVE NIGHT 86 REVCOVI 103 risperidone 50 ROCALTROL 103 REVEAL BLOOD GLUCOSE ropinirole hydrochloride 49 MONITOR 122 RISPERIDONE ODT 50 REVITADERM WOUND RITALIN 2 ROSE MILK 86 CARE 98 RITALIN LA 2 rosuvastatin calcium 41 REVLIMID 129 ritonavir 54 ROWASA 106 REXALL BLOOD GLUCOSE ROXICODONE 10 MONITORING SYSTEM 122 RITUXAN HYCELA 47

Index 32 ROZEREM 113 SAWYER INSECT sevelamer hcl 107 RULAVITE DHA 136 REPELLENT 94 SEVELAMER SAWYER INSECT RYCLORA 39 HYDROCHLORIDE 107 REPELLENT CONTROLLED SFROWASA 106 RYTHMOL SR 20 RELEASE 94 SHINGRIX 160 SA3 DERM 151 SB OMEPRAZOLE 158 SHUR-CLENS 98 SABRIL 26 SCAR CARE CREAM 151 SHUR-SEAL 160 SAF-CLENS AF 98 SCHOOLTIME SHAMPOO96 SIGNIFOR 104 SAF-GEL 98 scopolamine 37 sildenafil citrate (pulmonary SAFE WASH 94 SCOT-TUSSIN 69 hypertension) 59 SAFYRAL 62 SCOT-TUSSIN DM 69 SILENOR 112 SAIZEN 103 SCOT-TUSSIN SENIOR 69 silodosin 108 SAIZEN CLICK.EASY 103 SD PROBIOTIC-10 SILPHEN COUGH 39 COMPLEXULTRA 36 SAIZENPREP SILPROTEX PLUS 151 RECONSTITUTIONKIT 103 SE-NATAL 19 136 SILVADENE 78 SALAGEN 132 SEA-CLENS WOUND CLEANSER 98 SILVASORB 98 SALEX 88 SEASONIQUE 62 silver sulfadiazine 78 SALEX CREAM 88 SEBULEX 77 SILVERMED 98 SALEX LOTION 88 SECONAL SODIUM 112 SIMBRINZA 143 salicylic acid 88 SEDANARE 151 simethicone 105 salicylic acid & sulfur 77 SELECT-OB 136 SIMPLYTHICK 148 SALICYLIC ACID LOTION 88 SELECT-OB+DHA 136 SIMPLYTHICK EASY MIX 148 salicylic acid w/ cleanser 88 selegiline hcl 50 SIMPONI 3 saline 139 selenium sulfide 77 simvastatin 41 SALINE WOUND WASH 94 SELSUN BLUE 77 SINEMET 49 SALJET 94 SELSUN BLUE DAILY 77 SINEMET CR 49 SALJET RINSE 94 SELSUN BLUE SINGULAIR 21 salsalate 7 MEDICATED 77 sirolimus 130 SALT DURABLE CREAM 151 SELSUN BLUE SALT STABLE LS MOISTURIZING 77 SIRTURO 46 ADVANCED 151 SELZENTRY 54 SITAVIG 55 SALTSTABLE LO 151 SEMPREX-D 69 SIVEXTRO 18 SAMSCA 104 SENNA 115 SKELAXIN 138 SANARE ADVANCED SCAR sennosides 115 skin protectants, misc. 94 THERAPY 151 sennosides-docusate SKIN REPAIR 86 SANARE SCAR THERAPY 151 sodium 114 SKINTEGRITY HYDROGEL 98 SANCUSO 37 SENOKOT 116 SKINTEGRITY WOUND 98 SANDIMMUNE 130 SENOKOT S 115 SKYY DERM 151 SANDOSTATIN 104 SENSI-CARE SLO-NIACIN 163 SANTYL 87 MOISTURIZING 94 SENSI-CARE SEPTI-SOFT SLOW FE 111 SAPHRIS 51 CONENTRATE 94 SLOW-MAG 128 SAPS HEALTH CARE SENSIPAR 104 ALCOHOLPREP PADS 123 SM ACIDOPHILUS PEARLS 36 SAPS HEALTH CARE TWIST SEREVENT DISKUS 22 SM B-COMPLEX/VITAMIN TOP LANCETS 122 SEROQUEL 51 C 133 SARNA 76 SEROQUEL XR 51 SM CALAMINE 94 SAVELLA 153 SEROSTIM 103 SM GLUCOSE 31 SAVELLA TITRATION sertraline hcl 28,29 SM IPECAC SYRUP 37 PACK 153 sevelamer carbonate 107 SM OMEPRAZOLE 158

Index 33 SM ONE DAILY SOOTHE & COOL FREE STAPHSCRUB 94 PRENATAL 136 MEDSEPTIC 94 starch-maltodextrin SM PRENATAL VITAMINS 137 SOOTHE & COOL FREE (thickening) 148 SMART SENSE GLUCOSE 31 MOISTURE BARRIER 94 STARLIX 33 SOOTHE & COOL FREE SKIN SMART SENSE GLUCOSE PASTE 94 stavudine 54 TABLETS 32 SOOTHE & COOL MOISTURE STERA BASE 151 SMART SENSE PREMIUM BARRIER 94 BLOODGLUCOSE STERILE DILUENT FOR SOOTHE & COOL FLOLAN 149 MONITORING SYSTEM 122 MOISTURIZING BODY SMART SENSE VALUE STERILE DILUENT FOR LOTION WITH ALOE 86 TREPROSTINIL BLOODGLUCOSE SOOTHE & COOL PROTECT MONITORING SYSTEM 122 INJECTION 149 MOISTURE BARRIER 94 STIMATE 104 SMARTEST EJECT STARTER SOOTHE & COOL SHAMPOO KIT 122 ANDBODY WASH WITH STIMULEN 98 SMARTEST PERSONA ALOE 94 STIVARGA 48 STARTERKIT 122 SOOTHE & COOL SKIN SMARTEST PRONTO STRATTERA 1 CREAMWITH ALOE & STRIANT 15 STARTERKIT 122 VITAMINS A, D & E 86 SMARTEST PROTEGE SORBIDON HYDRATE 94 STRIBILD 54 STARTERKIT 122 STRIVERDI RESPIMAT 22 soap & cleansers 94 SORBITOL 107,115 STROMECTOL 17 sodium bicarbonate SORBOLENE 86 (antacid) 16 STUDIO 35 EXTRA SORIATANE 77 MOISTURIZING LOTION 86 sodium chloride (gu SORILUX 77 irrigant) 107 STUDIO 35 MOISTURIZING SKIN 87 sodium chloride (inhalant) 70 sotalol hcl 57 SUBLOCADE 14 sodium chloride hypertonic 146 sotalol hcl (afib/afl) 57 SUBOXONE 14,15 sodium citrate & citric acid 107 SOVALDI 55 SUBSYS 10 sodium fluoride 128 SP ANTIPRURITIC 98 SUCRAID 101 SODIUM FLUORIDE 128 SPECIAL CARE CREAM 86 sucralfate 157 sodium fluoride (dental) 131 SPECTRACEF 60 SUDAFED 24 HOUR 140 sodium phenylbutyrate 104 SPECTRAGEL 98 SUDAFED CHILDRENS 140 sodium phosphates 115 SPINOSAD 96 SUDAFED CONGESTION 140 sodium polystyrene SPIRIVA HANDIHALER 21 sulfonate 130 spironolactone 102 SUDAFED NASAL DECONGESTANT MAXIMUM SODIUM spironolactone & SULFACETAMIDE/SULFUR STRENGTH 140 hydrochlorothiazide 101 SUDAFED PE CHILDRENS 73 SPORANOX 38 SOFOSBUVIR/VELPATASVIR NASAL DECONGESTANT 140 55 SPORANOX PULSEPAK 38 SUDAFED PE CONGESTION 140 SOLARAZE 76 SPORTSCREME 88 SPRYCEL 48 SULAR 58 SOLESTA 129 sulfacetamide sod- solifenacin succinate 159 SSKI 70 prednisolone 145 SOLODYN 155 SSS 10-5 73 sulfacetamide sodium 77 SOLOSITE 98 ST IVES SWISS FORMULA SULFACETAMIDE 24HOUR MOISTURE 86 SOLUS V2 AUDIBLE BLOOD SODIUM 144 GLUCOSE MANAGEMENT STALEVO 100 49 sulfacetamide sodium (acne)73 SYSTEM 122 STALEVO 125 49 sulfacetamide sodium SOLVATECH PLUS 149 STALEVO 150 49 (ophth) 144 SOLVATECH SWEET SF 149 STALEVO 200 49 sulfacetamide sodium w/ sulfur 73 SOMA 138 STALEVO 50 50 sulfacetamide sodium-sulfur w/ SOMAVERT 102 STALEVO 75 50 skin cleanser 73 SONATA 113 stannous fluoride 131

Index 34 SULFACETAMIDE SYLATRON 48 TASMAR 49 SODIUM/PREDNISOLONE SYLVANT 130 TAVIST ALLERGY 39 SODIUM PHOSPHATE 145 SULFADIAZINE 155 SYMAX DUOTAB 156 tazarotene 77 sulfamethoxazole-trimethoprim SYMBICORT 22 TAZORAC 77 17 SYMBYAX 153 TBC 87 SULFAMYLON 78 SYMDEKO 155 TEARS NATURALE PM 142 sulfasalazine 106 SYMLINPEN 120 30 TECFIDERA 154 sulindac 5 SYMLINPEN 60 30 TECFIDERA STARTER SUMADAN KIT 73 SYNAGIS 147 PACK 154 TEGADERM HYDROGEL SUMADAN WASH 73 SYNALAR 80 WOUND FILLER 98 sumatriptan 126 SYNALGOS-DC 13 TEGRETOL 25 sumatriptan succinate 126 SYNAREL 103 TEGRETOL-XR 26 SUMATRIPTAN SYNTHROID 155 TEGSEDI 154 SUCCINATE 126 SYRPALTA 149 sumatriptan succinate 126 TEKTURNA 44 sumatriptan-naproxen SYRSPEND SF 149 TEKTURNA HCT 44 sodium 125 SYRUP VEHICLE 149 TELCARE BLOOD GLUCOSE SUMAXIN 73 SYRUP VEHICLE SF 149 MONITORING SYSTEM 122 SUMAXIN CP KIT 73 SYSTANE 142 telmisartan 43 SUMAXIN TS 73 SYSTANE COMPLETE 142 telmisartan-amlodipine 44 telmisartan-hydrochlorothiazide SUMAXIN WASH 73 SYSTANE LID WIPES 95 44 SUMMERS EVE CLEANSING SYSTANE OVERNIGHT temazepam 113 WASH/SENSITIVE SKIN 94 THERAPY LUBRICANT SUMMERS EVE NIGHT-TIME EYE 142 TEMODAR 46 CLEANSING WASH/SENSITIVE SYSTANE ULTRA 142 TEMOVATE 80 SKIN 95 SYSTANE ULTRA HOME & temozolomide 46 SUPER BI-MIX 59 AWAY PACK 142 TENA SKIN-CARING BODY SUPER PROBIOTIC 36 TABLOID 46 WASH 95 SUPER PROBIOTIC DIGESTIVE tacrolimus 130 TENA SKIN-CARING WASH CREAM 95 SUPPORT 36 tacrolimus (topical) 87 TENCON 6 SUPER TRI-MIX 59 tadalafil (pulmonary SUPRAX 60 hypertension) 59 tenofovir disoproxil fumarate 54 SUPREP BOWEL PREP TAFINLAR 48 TENORETIC 100 44 KIT 115 TAGAMET HB 157 TENORETIC 50 44 SURE COMFORT ALCOHOL PREP PADS 95 TAKHZYRO 109 TENORMIN 57 SURECHEK BLOOD GLUCOSE TALZENNA 48 TERAZOL 7 161 MONITORING SYSTEM TAMIFLU 56 terazosin hcl 43 STARTER KIT 122 tamoxifen citrate 47 terbinafine hcl 38 SURMONTIL 30 terbinafine hcl (topical) 76 SUSPENDRX WITH BITTER- tamsulosin hcl 108 BLOC/SWEETENED 149 TANDEM PLUS 111 terbutaline sulfate 22 SUSPENDRX WITH BITTER- TANZEUM 32 TERCONAZOLE 161 BLOC/UNSWEETENED 149 TAPAZOLE 155 terconazole vaginal 161 SUSPENSION VEHICLE 149 TARCEVA 48 TERODERM 151 SUSTIVA 54 TARGRETIN 48 TERODERM-PLUS 151 SUTENT 48 TARKA 44 TESSALON PERLES 64 SW OMEPRAZOLE 158 TARON FORTE 111 TESTIM 15 SWEEN CREAM 87 TARON-C DHA 137 testosterone 15 SWEETENING SUSPENDING COMPOUND 149 TARON-PREX 137 TESTOSTERONE 15 TASIGNA 48 testosterone 15

Index 35 TESTOSTERONE THYROLAR-1/4 156 tolnaftate 76 CYPIONATE 15 THYROLAR-2 156 tolterodine tartrate 159 testosterone cypionate 15 THYROLAR-3 156 TOPAMAX 26 TESTOSTERONE PUMP 15 tiagabine hcl 26 TOPAMAX SPRINKLE 26 TESTRED 15 TIAZAC 58 TOPICORT 80 tetrabenazine 153 TIGAN 37 topiramate 26 tetracaine hcl (ophth) 144 TIGER BALM PAIN TOPIRAMATE ER 26 tetracycline hcl 155 RELIEVING 88 TOPROL XL 57 tetrahydrozoline hcl (ophth) 144 TIGHTENING BASE 151 toremifene citrate 47 tetrahydrozoline w/ zinc TIGLUTIK 141 torsemide 102 sulfate 144 TIKOSYN 20 TEXACORT 80 TOUJEO MAX SOLOSTAR 33 TIMOLOL MALEATE 57 TGT BLOOD GLUCOSE METER TOUJEO SOLOSTAR 33 timolol maleate 57 MONITORING SYSTEM 122 TOVIAZ 159 TGT BLOOD GLUCOSE timolol maleate (ophth) 142 TRACLEER 59 MONITORING SYSTEM 122 TIMOLOL MALEATE TGT BLOOD GLUCOSE OPHTHALMIC GEL TRADJENTA 32 MONITORING SYSTEM FORMING 142 tramadol hcl 10 PREMIUM 122 TIMOPTIC 142 TRAMADOL HCL ER 10 TGT GLUCOSE 32 TIMOPTIC OCUDOSE 142 tramadol-acetaminophen 13 TGT OMEPRAZOLE 158 TIMOPTIC-XE 142 trandolapril 42 THALOMID 129 TINACTIN 76 trandolapril-verapamil hcl 44 THEO-24 22 TINACTIN DEODORANT 76 TRANDOLAPRIL/VERAPAMIL theophylline 22 TINACTIN JOCK ITCH 76 HCL ER 44 THERABETIC SKIN CARE 87 TINDAMAX 17 tranexamic acid 111 THERACAL D2000 128 tinidazole 17 TRANSDERM SCOP 37 THERACAL D4000 128 tioconazole vaginal 161 TRANSDERM-SCOP 37 THERACAL RAPID TIROSINT 156 TRANXENE T 20 REPLETION 128 tranylcypromine sulfate 28 THERAFLU SEVERE COLD TIVICAY 54 NIGHTTIME 69 tizanidine hcl 138 trazodone hcl 29 THERAHONEY 98 TL-CARE DHA 137 TRECATOR 46 THERANATAL CORE TL-SELECT 137 TRELEGY ELLIPTA 22 NUTRITION 137 TREMFYA 77 THERAPEUTIC TOBI 3 MOISTURIZING 87 TOBI PODHALER 3 treprostinil 59 THERAPLEX TOBRADEX 145 TRESIBA FLEXTOUCH 33 HYDROLOTION 87 TOBRADEX ST 145 tretinoin 73 THERAPLEX T 96 TOBRAMYCIN 3 tretinoin (chemotherapy) 48 thiamine hcl 163 tobramycin 3 tretinoin microsphere 73 thiamine mononitrate 163 tobramycin (ophth) 144 TRETTEN 109 THICK-IT ORIGINAL 148 TOBRAMYCIN SULFATE 3 TREXALL 46 THIOLA 108 tobramycin sulfate 3 TREXIMET 125 thioridazine hcl 52 tobramycin- TRI-MIX 59 thiothixene 52 dexamethasone 145 TRI-NORINYL 28 62 THRIVITE 19 137 TOBREX 144 TRI-TABS DHA 137 THRIVITE RX 137 TOFRANIL 30 TRIAD HYDROPHILIC WOUND THUM 89 TOLAZAMIDE 34 DRESSING 98 thyroid 156 TOLBUTAMIDE 34 TRIADVANCE 137 THYROLAR-1 156 triamcinolone acetonide tolcapone 49 (mouth) 132 THYROLAR-1/2 156 TOLMETIN SODIUM 5

Index 36 triamcinolone acetonide TROKENDI XR 26 TRUERESULT BLOOD (nasal) 139 trolamine salicylate 88 GLUCOSEMONITORING triamcinolone acetonide SYSTEM/NO CODING 123 (topical) 80,81 tropicamide 143 TRUETEST BLOOD GLUCOSE TRIAMINIC COLD & COUGH trospium chloride 159 TEST 100 DAY TIME CHILDRENS 69 TRUBIOTICS 36 TRUETEST BLOOD GLUCOSE TRIAMINIC FEVER TRUE COMFORT ALCOHOL TEST STRIPS 100 REDUCERPAIN RELIEVER PREP PADS 123 TRUETEST GLUCOSE CHILDRENS 6 TRUE COMFORT PEN CONTROLLEVEL 1 123 TRIAMINIC FEVER NEEDLES31G X 5MM 124 TRUETEST GLUCOSE REDUCERPAIN RELIEVER TRUE COMFORT PEN CONTROLLEVEL 2 123 INFANTS 6 NEEDLES31G X 6MM 124 TRUETEST GLUCOSE TRIAMINIC FLU COUGH & TRUE COMFORT PEN CONTROLLEVEL 3 123 FEVER 69 NEEDLES32G X 4MM 124 TRUETEST STRIPS 100 TRIAMINIC LONG ACTING TRUE COMFORT TWIST TOP TRUETRACK BLOOD COUGH 64 LANCETS 30G 122 GLUCOSE MONITORING triamterene & TRUE FOCUS BLOOD SYSTEM 123 hydrochlorothiazide 101 GLUCOSESELF MONITORING TRUETRACK BLOOD triazolam 113 METER 122 GLUCOSE TEST 100 TRIBENZOR 44 TRUE FOCUS SELF TRUETRACK SMART TRICARE 137 MONITORING BLOOD SYSTEM 123 TRICARE PRENATAL DHA GLUCOSE TEST TRUETRACK TEST 100 ONE 137 STRIPS 100 TRUNATURE DIGESTIVE TRUE METRIX AIR BLOOD TRICITRATES 107 PROBIOTIC 36 GLUCOSE TRUSOPT 146 TRICOR 41 METER/BLUETOOTH TRUVADA 54 TRIDESILON 81 SMART 122 TUDORZA PRESSAIR 21 trifluoperazine hcl 52 TRUE METRIX AIR W/BLUETOOTH SMART 122 TUMS 16 TRIFLURIDINE 144 TRUE METRIX BLOOD TUMS LASTING EFFECTS 16 trifluridine 144 GLUCOSEMETER 122 TUSNEL 69 TRIGLIDE 41 TRUE METRIX BLOOD TUSNEL PEDIATRIC 69 trihexyphenidyl hcl 49 GLUCOSETEST STRIPS 100 TRUE METRIX GO BLOOD TWYNSTA 44 TRILEPTAL 26 GLUCOSE METER 122 TYBOST 54 TRILIPIX 41 TRUE METRIX SELF TYKERB 48 trimethobenzamide hcl 37 MONITORING BLOOD GLUCOSE STRIPS 100 TYLENOL 6 trimethoprim 17 TRUE2GO BLOOD GLUCOSE TYLENOL 8 HOUR 6 trimipramine maleate 30 MONITORING SYSTEM 122 TYLENOL 8 HOUR TRUECONTROL GLUCOSE TRIMPEX 17 ARTHRITISPAIN 6 CONTROL LEVEL 0 123 TRINATAL GT 137 TRUECONTROL GLUCOSE TYLENOL CHILDRENS 6 TRINATAL RX 1 137 CONTROL LEVEL 1 123 TYLENOL CHILDRENS TRINATE 137 TRUEPLUS 5-BEVEL PEN CHEWABLES/PAIN + FEVER6 TYLENOL CHILDRENS PLUS TRINTELLIX 29 NEEDLES 29GX12.7MM 124 TRUEPLUS 5-BEVEL PEN FLU 69 TRIPLE PASTE 95 NEEDLES 31GX5MM 124 TYLENOL CHILDRENS PLUS TRIPLE PASTE SP 95 TRUEPLUS 5-BEVEL PEN MULTI-SYMPTOM COLD 69 triprolidine & NEEDLES 31GX6MM 125 TYLENOL COLD & FLU pseudoephedrine 69 TRUEPLUS 5-BEVEL PEN SEVERE 70 TRIPTODUR 103 NEEDLES 31GX8MM 125 TYLENOL COLD & HEAD TRUEPLUS 5-BEVEL PEN SEVERE CONGESTION 70 TRISENOX 48 NEEDLES 32GX4MM 125 TYLENOL COLD MAX 70 TRIUMEQ 54 TRUEPLUS SAFETY TYLENOL COLD MULTI- TRIVEEN-DUO DHA 137 LANCETS 28G 123 SYMPTOM NIGHTTIME 70 TRIZIVIR 54 TRUERESULT BLOOD TYLENOL COLD MULTI- GLUCOSEMONITORING SYMPTOM SEVERE TROGARZO 54 SYSTEM 123 DAYTIME 70

Index 37 TYLENOL ULTRACARE PEN URSO FORTE 106 COLD/COUGH/RUNNYNOSE NEEDLES/31G X 3/16" 125 ursodiol 106 CHILDRENS 70 ULTRACARE PEN TYLENOL EXTRA NEEDLES/31G X 5/16" 125 UTA 159 STRENGTH 6 ULTRACARE PEN UTI HOME TEST 101 TYLENOL INFANTS 6 NEEDLES/32G X 1/14" 125 V-MAX 152 ULTRACARE PEN TYLENOL INFANTS VAGIFEM 161 PAIN+FEVER 6 NEEDLES/32G X 3/16" 125 valacyclovir hcl 56 TYLENOL SINUS SEVERE 70 ULTRACARE PEN NEEDLES/32G X 5/32" 125 TYLENOL SORE THROAT VALCHLOR 76 ULTRACARE PEN VALCYTE 55 DAYTIME 6 NEEDLES/33G X 5/32" 125 TYLENOL WARMING COUGH & ULTRACET 13 valganciclovir hcl 55 SEVER CONGESTION VALIUM 20 DAYTIME 70 ULTRADERM 152 TYLENOL/CODEINE #3 13 ULTRAFLORA IMMUNE valproic acid 27 TYLENOL/CODEINE #4 13 HEALTH 36 valsartan 43 ULTRAM 10 valsartan-hydrochlorothiazide TYVASO 59 ULTRATHON INSECT 44 TYVASO REFILL 59 REPELLENT 95 VALTREX 56 TYVASO STARTER 59 ULTRATHON INSECT VALUE PLUS GLUCOSE 32 REPELLENT 8 95 U-BASE 152 VANCOCIN HCL 17 ULTRAVATE 81 UDDERLY SMOOTH 87 UNIFINE PENTIPS vancomycin hcl 17 UDDERLY SMOOTH EXTRA 32GX6MM 125 VANIBASE 152 CARE 87 UNIFINE PENTIPS UDDERLY SMOOTH EXTRA VANICREAM 87 33GX4MM 125 CARE20 87 UNIFINE PENTIPS PLUS VANICREAM LITE 87 UDENYCA 110 33GX4MM 125 VANISH-PEN 152 ULESFIA 96 UNISOM SLEEPGELS 112 VANISHING CREAM 152 ULORIC 108 UNISOM SLEEPTABS 112 VANISHING CREAM ULTICARE MICRO PEN UNISTIK PRO SAFETY BOTANICALBASE 152 NEEDLES/31G X 1/4" 125 LANCET 21G 123 VANOS 81 ULTICARE MICRO PEN UNISTIK PRO SAFETY VAQTA 160 NEEDLES/31G X 5/16" 125 LANCET 25G 123 VARIVAX 160 ULTICARE MICRO PEN UNISTIK PRO SAFETY NEEDLES/32G X 4MM 125 LANCET 28G 123 VASCEPA 40 ULTICARE MICRO PEN UNITUXIN 46 VASCUDERM HYDROGEL NEEDLES/32G X 5/32" 125 WOUNDDRESSING 98 ULTICARE MINI PEN UP & UP GLUCOSE 32 VASERETIC 44 NEEDLES/31G X 6MM 125 URE-K 81 VASOTEC 42 ULTICARE MINI PEN urea 81 NEEDLES/32G X 1/4" 125 VCF VAGINAL urea in zinc undecylenate-lactic CONTRACEPTIVE FILM 160 ULTICARE SHORT PEN acid vehicle 81 NEEDLES/31G X 8MM 125 VCF VAGINAL UREA IN ZINC CONTRACEPTIVE FOAM 160 ULTIMATECARE ONE 137 UNDECYLENATE/LACTIC VECAMYL 44 ULTOMIRIS 109 ACID VEHICLE 81 VELETRI 59 ULTRA THIN LANCETS URECHOLINE 160 VELPHORO 107 31G 123 URISTIX 101 ULTRA TRAK PRO BLOOD VELTIN 73 URISTIX 4 101 GLUCOSE MONITORING VELVACHOL 87 SYSTEM 123 UROCIT-K 10 107 VEMAVITE-PRX 2 137 ULTRA-CARE ALCOHOL PREP UROCIT-K 15 107 VENA-BAL DHA 137 PADS 123 UROCIT-K 5 107 ULTRA-CARE LANCETS venlafaxine hcl 29 UROGESIC-BLUE 159 30G 123 VENTAVIS 59 ULTRACARE PEN UROXATRAL 108 VENTOLIN HFA 22 NEEDLES/31G X 1/4" 125 URSO 250 106

Index 38 verapamil hcl 58 VIRACEPT 54 VRAYLAR 50 VERAPAMIL HCL ER 58 VIRAMUNE 54 VSL#3 36 VERAPAMIL HCL SR 58 VIRAMUNE XR 54 VUSION 76 VERASENS BLOOD GLUCOSE VIREAD 54,55 VYTORIN 40 MONITORING SYSTEM 123 VIROPTIC 144 VYVANSE 1 VEREGEN 73 VIRT NATE 137 WALGREENS GLUCOSE 32 VERELAN 58 VIRT-ADVANCE 137 warfarin sodium 23 VERELAN PM 58 VIRT-C DHA 137 water for irrigation, sterile 130 VERIPRED 20 63 VIRT-PN 137 WAVESENSE AMP 123 VERSACLOZ 51 VIRT-PN DHA 137 WAVESENSE KEYNOTE 123 VERSAFREE 149 VIRT-PN PLUS 137 WEGMANS COMPLETE VERSAPLUS 149 VIRT-SELECT 137 PRENATAL+DHA 137 VERSAPRO 152 WELCHOL 41 VIRT-VITE GT 137 VERSATILE CREAM BASE152 VISBIOME PROBIOTIC HIGH WELLBUTRIN SR 27 VERSATILE RICH CREAM POTENCY 36 WELLBUTRIN XL 27 BASE 152 VISINE 144 WESTCORT 81 VERSIGEL 152 VISINE TEARS 142 WESTHROID 156 VERZENIO 48 VISTARIL 18,19 wheat dextrin 114 VESICARE 159 VISTOGARD 37 white petrolatum-mineral oil 142 VEXASYN 98 VITAFOL ULTRA 137 WIBI 87 VFEND 38 VITAFOL-NANO 137 WINRHO SDF 147 VIACTIV CALCIUM PLUS D 127 VITAFOL-OB 137 witch hazel-glycerin 95 VIBRAMYCIN 155 VITAMIN D3 162 WOUN'DRES COLLAGEN vitamin e 162 HYDROGEL WOUND VICKS DAYQUIL COUGH 64 DRESSING 98 VICKS DAYQUIL MUCUS VITAMIN E 162 WOUND CARE CREAM 152 CONTROL DM 70 vitamin e 162 WOUND CLEANSER 98 VICKS NYQUIL COUGH 70 VITAMIN E WITH VICKS SINEX 140 PANTHENOL 87 wound cleansers 98 VICKS SINEX 12 HOUR vitamins a & d (topical) 87 WOUND GEL 98 DECONGESTANT 140 VITRAKVI 48 WOUND GEL SPRAY 98 VICKS SINEX WOUND WASH 98 MOISTURIZING 140 VIVELLE-DOT 105 WOUND WASH SALINE 95 VICKS SINEX SEVERE 140 VIVITROL 37 VICKS SINEX SEVERE VIZIMPRO 48 WP THYROID 156 NASALDECONGESTANT 140 VOGELXO 15 XALATAN 146 VICTOZA 32 VOGELXO PUMP 15 XANAX 20 VIDEX EC 54 VOL-NATE 137 XANAX XR 20 VIDEXPEDIATRIC 54 VOL-PLUS 137 XARELTO 23 vigabatrin 26 VOL-TAB RX 137 XCEL 100 152 VIGAMOX 144 VOLTAREN 74 XELJANZ 3 VIIBRYD 29 voriconazole 38 XELODA 46 VIL-RX 137 VOSPIRE ER 22 XEMATOP BASE 152 VIMOVO 5 VOTRIENT 48 XENAZINE 153 VIMPAT 26 VP DERMABASE 152 XERESE 78 VINATE DHA RF 137 VP-CH PLUS 137 XEROSTOMIA RELIEF VINATE II 137 SPRAY 132 VP-HEME OB 137 XIFAXAN 17 VINATE M 137 VP-HEME OB + DHA 137 XODOL 13 VINATE ONE 137 VP-HEME ONE 137 XOLAIR 21

Index 39 XOLEGEL 76 ZIAGEN 55 ZYLET 145 XOPENEX 22 ZIANA 73 ZYLOPRIM 108 XOPENEX CONCENTRATE 22 zidovudine 55 ZYMAXID 144 XOPENEX HFA 22 ZIKS ARTHRITIS PAIN ZYPREXA 51 XOSPATA 48 RELIEF 88 ZYPREXA RELPREVV 51 ZIMS CRACK CREME XTANDI 47 DAYTIME 87 ZYPREXA ZYDIS 51 XULANE 62 zinc 129 ZYRTEC ALLERGY 40 XYREM 152 zinc oxide (topical) 95 ZYRTEC CHILDRENS XYZAL 40 ALLERGY 40 zinc sulfate 129 ZYRTEC-D XYZAL ALLERGY 24HR 40 ZINC SULFATE 129 ALLERGY/CONGESTION 70 YASMIN 28 62 ziprasidone hcl 50 ZYTIGA 47 YAZ 62 ZIPSOR 5 ZYVOX 18 YUTIQ 145 ZIRGAN 144 ZADITOR 146 ZITHROMAX 116 zafirlukast 21 ZITHROMAX TRI-PAK 116 zaleplon 113 ZITHROMAX Z-PAK 116 ZAMICET 14 ZMAX 116 ZANABIN ANTIPRURITIC ZOCOR 41,42 HYDROGEL 98 ZOE SCRIPTS ZANAFLEX 138 IDEALBASE 152 ZANFEL 95 ZOFRAN 37 ZANTAC 157 ZOFRAN ODT 37 ZANTAC 150 MAXIMUM ZOLINZA 48 STRENGTH 157 zolmitriptan 126 ZANTAC 75 157 ZOLOFT 29 ZARONTIN 27 zolpidem tartrate 113 ZARXIO 110 ZOLPIMIST 113 ZATEAN-CH 137 ZOMACTON 103 ZATEAN-PN DHA 138 ZOMIG 126 ZATEAN-PN PLUS 138 ZOMIG ZMT 127 ZAVESCA 109 ZONALON 76 ZEBETA 57 ZONEGRAN 26 ZEGERID 158 zonisamide 26 ZEGERID OTC 158 ZONTIVITY 109 ZELAC 36 ZORBTIVE 103 ZELAPAR 50 ZORTRESS 130 ZELBORAF 48 ZORVOLEX 5 ZEMPLAR 104 ZOSTAVAX 160 ZENPEP 101 ZOVIRAX 56,78 ZENZEDI 1 ZUBSOLV 15 ZERIT 55 ZUPLENZ 37 ZESTORETIC 44 ZYBAN 154 ZESTRIL 42 ZYCLARA 87 ZETIA 42 ZYCLARA PUMP 87 ZETONNA 139 ZYDELIG 48 ZEVALIN Y-90 46 ZYFLO 21 ZIAC 44

Index 40